C0 ns ti Pation Nursing intervention Nursing diagnosis | Out come ‘Alteration in Bowel { Elimination: The pationt will: (Constipation) | &- pass soft Related To: | formed stool by ] sounds qhouss. + Malnutrition ‘and 2% day(s). | 4- Assess bowel elimination qhours. | 4 | + Asses factors responsible for constipation: | 4&- Assess abdomen for distention, bowel | -Metabolicend | a. Patient wi sions [Scrat |e reece | disorders erpalize and | 7 sedentary Iesiylé blavative abuse 4-Sensory/motor | understanding | , gebiitation Gisordere fofmethod for’ |“ teck of trefivacy Baste ee | preventing Immobilty and/or treating | #- Promote corrective measures Inadequate diet ‘pati a review dally routine constipation. d + 1 provide privacyitime Irregular provide comfort evacuation pattern a encourage adequalé exercise iT + Promote adequate dietaryifuid intake. Patient f , kes: = Fluids: ~ Fiber foods: ‘4-Pain (upon luke defecation) + Initiate bowel program to promote defecation. + Consult dietitian. #- Pregnancy 4 Surgery #-Lack of privacy 4 Dehydration As evidenced by: Major: Hard formed ! stool andior - defecation occurs fewer than three times per week. Minor: ‘&- Decreased bowel sounds. Reported | * - feeling of rectal fullness or pressure ‘around rectum, Staining and pain on defecation. #- Palpable impaction. CamSeanner + ne sualNursing diagn Alteration in ‘| Bowel Elimination: (Diarrhea) Related To: ‘- Inflammation of bowels Colon mucosa ulceration & Fecal impaction * Gastric bypass Infant - breast fed *- Decreased sphincter reflexes Allergies 4- Medications = Stress/anxiety 4- Tube feedings 4- Decreased tolerance to dietary program: As evidenced by: Major: #- Loose ligt stools and/or: ‘#- Frequency Minor: Out come ‘The patient will: - Have elimination resembles that of patient's normal stool/pattern. - Patient and will verbalize methods for treating diarrhea, ‘Urgency * ‘Cramping/abdominal pain Hyperactive bowel sounds Increase of fluidity ‘or volume of stools preventing and/or ion, bowel sounds, ‘&- Assess abdomen for distent pain q hours. \dentify factors that contribute to diarrhea: #- Record color, odor, amount and frequency of stool. #- Instruct patient in pattern that closer | #5" ‘medication usage SIS of diarrhea to watch for requiring m attention discontinuing solids offer clear liqu vedical CamSeanner sine sualane ma confusion. # Decreased serumm albumin, r Nursing diagnosis Out come Nursing intervention Evaluation Alteration = Nutrition: Less Than | The patient Assess and document patient's dietary Body Requirements | will: history, patters of ingestion, intolerance to (anemia) #-Experience | foods. Related To’ adeugate - Assess patient likes and distikes. Inform 4- Dysphasia nutrition dietary. 3 Hi ‘»- Teach techniques to maintain adequate = “sna disorders a oral nutritional Palen stimulate appetite: ~ Anorexia intake, + Allergy 4- Experience 4- administerfinstruct pt. on good oral 4- Burns an increase in hygiene before and after feedings #- Cancer the amount or 2 maintain pleasant environment for - Chemotherapy type of nutrients patient 2- Chemical ingested. i ren a 4 Determine proper denture fit and profice By |e Sawratt lke as necessary . + Increase social contact with meals by: ‘#- Depression 4 Plan care so that unpleasant/painful #- Infection tests/x’'s don't take place before meals. *- Inability to obtain ‘ Medicate pt. for pain 2 hrs before meals per food physician's orders. # Lack of mowledge Consult with dietitian are: of adequate nutrition A celtic cout #- Nausea and 2. change in food consistency vomiting 3- spacing meals *- Radiation Therapy 4- provision of high caloric supplements #- Social isolation gta i supplementation ‘2. Stress 6- food intolerances/preferences T- extra fluids on tray 8- dietetic teaching, fooc Major: 8- therapeutic diet restrictions: + Reported inadequate food intake less than 4+. strengthening exercises recommended daily 2- prosthetic devices allowance with or without 3 avoid ewallowin weight loss and/or actual eee or potential metabolic needs in excess of intake. anor 4- be sure pt. is alert and responsive Weight 10% to 20% or before eating more below ideal for 2- sit upright 60-90 degrees for 15-20 helght and frame. min, before, during & after eating #: Teohycardia on 3- decrease distractions minimal exercise and 4- demonstrate patience by providing bradycardia at rest. specific directions until finished” Muscle weakness and ‘ 5- assure — good = mouth care tendemess. #:Weigh patient q at am/p.m. Mental irritability or CamSeanner + ne sualNursing diagnosis | Out come elevation body temperature more than normal body (Ayperthermia) Related To: *- CNS Pathology 4- Dehydration #- Exposure to heat/sun ‘Impaired physical environment 4 Infection 4- Inflammation 4- Peripheral neuropathy related to injury 4- Vigorous activity ‘As evidenced by: Major: 4 Temperature over 37.8 C (100 F) orally, or 38.8 Co1F) rectally. Minor: 4- Flushed skin 4 Warm to touch # Increased respiratory rate # Tachycardia . Shivering/goose pimples Dehydration The patient will= 4- Maintain normal body temperature Nursing intervention 4 Assess temperature q hours: ‘&- Assess possible etiology of increased temperature. #- Encourage fluids when indicated. ‘2s. Administer antipyretics per physician's order. - Remove excess clothing or blankets. + 4- Provide air condition/fan if appropriate. Evaluation CamSeanner + ne sual\ aa) Pe they iA Nursing diagnosis Alteration body temperature less than The patient body normal will: (Hypothermia) - Maintain Related To: normal body +- CNS pathology temperature. 4 Decreased ability to shiver 4- Exposure to the cold +- Impaired physical environment As evidenced by: Major: 4- Reduction in body temperature below 35 C (95 F) orally, or 35.5 C (96 F) rectally. *- Cool skin 4- Moderate pallor #- Shivering (mild) Minor: + Mental confusion/drowsiness/restle ssness 4- Decreased pulse and respirations Nursing intervention Evaluation ‘&- Assess temperature q hours. 4- Asses for possible etiology of hypothermia. 4- Keep room temperature between 70-74 F. #- Apply extra blankets. 4- Use warming blanket per physician's order to maintain normal body temperature. &- Provide intravenous solutions through a blood warmer per physician's order. 4- Rewarm patient gradually to prevent complications of rapid rewarming. 4- Teach patient to avoid extremes of cold weather and to dress adequately when exposed to cold. CamSeanner sine sualChest pan , Nursing diagnosis Out come Nursing intervention Evaluation ALTER IN ‘The patient will; | 4- Assess for causative factors asssociated: Comfort: #- Verbalize 1-Activity 2-Stress Chest Pain relieficontrol of | 3-Eating 4-Bowel Related To: | pain. elimination ‘&-Myocardial | #- Verbalize 5-Previous angina attack Inferction 4 Unstable Angina Coronary Artery Disease ‘Chest Trauma ‘®- Stress Anxiety od Musculoskeletal Disorders Pulmonary, Myocardial contusion causative factors | 4- Assess characterizing of chest pain. associated with | Location o- Intensity (Scale 1-10) 0- Duration chest pain. | - Quality o- Radiation | 4- Review history of previous pain experienced by patient and compare to current experience. 4- Instruct patient to report pain immediately. - Continuous EKG monitoring; note and record patiern during pain. Obtain STAT 12-lead EKG per policy for acute changes noted on continuous monitor. - Provide a quiet, restful environment. 4- As per physician order, administer IV analgesics in small increments until pain is relieved or maximum dose is achieved. Monitor BP during administration of pain meds. Assess pt. response to pain medication and notify physician if pain is not controlled or pt. experiences adverse reaction (decreased BP, HA, distress). 4- Administer nitroglycerine as ordered by physician, Monitor as stated above. +- Administer supplemental oxygen as ordered by physician. *- Assist with ADL's to reduce cardiac stressors. ‘&- Assist in eliminating causative factors as identified by patient assessment: As evidenced by: Major: ®- Person reports or demonstrates a discomfort. Minor: #- Increased BP & Diaphoresis *- Dilated pupils + Restlessness + Facial mask of pain - (Crying/moaning #- Short of breath * Anxiety CamSeanner + ine pusE aluation, Nursing diagnosis | Out come The patient Fluid Volume wil &- Asses) brane and skin ee mc Demonstrate | 1-Moistness of mucous mera! Related To: adequate fluid turgor and chart findings. Excessive urinary | balance A-E.B. 2-Intake and output q hours. ae Eta ee 3.Orthostatic hypotension QD. hie . ‘Balanced intake 4- Daily weights each am/pm using same h and output. scale, b Abnormal ‘aNormal lab value 5. Labs: HCT, BUN, Specific gravity, rainage simprovedskin | Sodium, Other: tugor i : ‘®- Encourage fluid intake of ce/day; . ‘- Assist patient with drinking if necessary. #- Explore patient's understanding of etiologic: factors and provide necessary teaching. 4- Excessive emesis. #- Difficulty in swallowing. 4- Medication: - Hemorthage #- Fever + Bums ‘As evidenced by: Major: %- Output greater than intake. #- Dry skin/mucous membranes. Minor: #- Increased serum sodium. 4 Increased pulse from baseline. *- Decreased or excessive urine output. - Concentrated urine, & Urinary frequency .#- Decreased fluid intake. 4- Poor skin tugor. + hirst/nausea/anorexia, CamSeanner + ne sual= acantas Nursing intervention Evaluation The patient Alteration in 4 Monitor I & O, including patterns of urinary Patterns of ee - Mor Uri - Be incontinence. ar continent at @- Instruct to start and stop stream during urination. Ask physician for pelvic floor exercises Order and teach as follows: x (# of times). - Limit fluids 2 No fluids after: 4 Awaken patient @ Provide urinal/be access. #- Place call light within reach at all time: * Provide comfort measures (sitz baths: warm perinea soaks as needed Eliminatin: (Incontinence) all times. # Be continent during waking hours, Related To: - Congenital 3 hours prior to bedtime. at night to void at: or hours. edpan/bedside commode in easy urinary tract: #- Drug therapy - Environmental barriers to bathroom #- Estrogen deficiency + Inability to communicate needs oy Lack of privacy 4 Loss of perineal tissue tone #- Neurogenic disorder or injury enlargement 4- Stress/fear As evidenced by: Major: ‘4 Urgency followed by incontinence. - Other: CamSeanner + ne sualNursing diagnosis Alteration in (Retention) Related To: *- Anxiety &- Fecal impaction *- Flaccid bladder *- Medications *- Packing #- Stones 4 Weak or absent sensory and/or motor impulses As evidenced by: Major: #- Bladder distention (not related to acute, reversible etiology). *- Distention with small frequent voids or dribbling (overflow incontinence). #- 100 ml or more residual of urine. Minor: *- The individual states that it feels as though the bladder is not ‘empty after _ voiding. Out come The patient will - Void in the amount of: - Have urine residual less than 30ce. - Verbalize knowledge of signs and symptoms of infection Nursing intervention - Palpate bladder for distention q hours or after each void. & Monitor I & O. 2. Attempt to stimulate relaxation of urethral sphincter by: 4- running water providing warm water for patient to place hand/fingers in 4- Provide privacy. physician orde - Intermittent straight cath q hours per CamSeanner + ne sual— | oa a Nursing diagnosis | Out come Nursing intervention i ‘Anxiety 4- Assist patient to reduce present level of | Related To: ‘The patient will: | anxiety by: *- \actual pain #- Demonstrate a 1-Provide reassurance and comfort #- Disease decrease in anxiety.: 2-Stay with person. * 1-A reduction in 3-Don't make demands or request any Invasive/noninvasive | presenting decisions. procedure: physiological, 4-Speak slowly and calmly. ‘*- Loss of emotional, and/or Attend to physical symptoms. Describe significant other cognitive symptoms: Threat to self- | manifestations of 6- Give clear, concise explanations concept anxiety. regarding impending procedures. ‘As evidenced by: | 2-Verbalization of 7-Focus on present situation. Major: relief of anxiety. $:Identify and reinforce coping strategies [Physiological] + patient has used in the past. ‘a Elevated BP, P, R | Discuss/demonstrate | _ 9-Discuss advantages and disadvantages of #- Insomnia effective coping ing coping methods. #- Restlessnes mechanisms for 10-Discuss alternate strategies for handling * Dry mouth dealing with anxiety. (Bg.: exercise, relaxation techniques and #-Dilated pupils | anxiety. exercises, stress management classes, directed 4 Frequent conversation (by nurse), assertiveness training) urination 11-Set limits on manipulation or irrational 4 Diamhea demands. [Emotional] 12-Help establish short term goals that can be - Patient complains attained. of apprehension, 13-Reinforce positive responses. nervousness, tension 14-Initiate health teaching and referrals as [Cognitive] indicated:, Inability to concentrate - Orientation to past Blocking of thoughts, hyperattentiveness CamSeanner + ne sualNursing diagnosis, Out come b@l seYés Nursing intervention Impaired Skin Integrity Related To: +- Bums of - - Decreased sensation 4-Immobility 4- Malnutrition - Pressure ulcer - Puritus 4 Stoma problems: As evidenced by: Major: #- Disruption of epidermal and dermal tissue. Minor: 4 Denuded skin. #- Erythema. #-Lesions. The patient will: 4-Maintain or develop clean and intact skin %- Inspect and chart skin integrity qhrs Do wound care/dressing change as ordered. Describe: : #- Provide measures to decrease pressure/irritation to skin: 1 fleece pad 1 egg crate mattress keep skin clean and dry 4- Turn end reposition qhrs. - Up in chair for minutes q. 4 Gently massage bony prominences and pressure points with lotion q. #- Maintain adequate nutrition and hydration. 4- Change incontinent pad ASAP after voiding or defecation. &- Expose skin to air if indicated. #- Initiate health teaching and referrals as indicated, List: &- Keep nails short. &- Mittens to decrease skin breakdown from scratching, (These are considered a restraint in some facilities. Get an order first.) CamSeanner + ne sualNursing diagnosis | Out come Nursing intervention Evaluation Ineffective Airway Clearance The patient will: | 4- Assess respiratory rate, depth, rythm, effort, Related To: *- Maintain and breath sounds q hours. *- Artificial airway patent airway *- Position: HOB elevated degrees. #- Excessive or thick | A-E.B.: 4- Promote optimum level of activity for best secretions Clear breath | possible lung expansion: Inability to cough | sounds or breath a Ambulate q for min. effectively sounds consistent Chair q for min. *- Infection with own nTum/reposition q + baseline. - Suction q hours (and pm) per: Obstruction/restriction | m Respirations Nasal o Oral o Pain easy and un- Tracheal . labored. #- Encourage fluids when indicated. As evidenced by: a Normal resp. Major: rate. #- Ineffective cough. # Inability to remove ss airway secretions. Minor: #- Abnormal breath sounds. #- Abnormal respiratory rate, rythm, depth ‘camScanner 1 Us tualNursing Out come Nursing intervention Evaluation Sleep Pattern Disturbance Related To: - Impaired oxygen transport %- Impaired elimination ‘Impaired metabolism *- Immobility *- #- Lack of exercise #- Anxiety response *- Life-style disruptions As evidenced by: Major: #- Difficulty falling or remaining asleep Minor: *- Fatigue on awakening or *- Medication Hospitalization The patient will: &-Demonstrate | #- Explore with patient potential contributing an optimal factors. balance of rest - Maintain bedtime routine per patient and activity preference. AEB. hours of 1 Likes to go to bed. uninterrupted o Prefers quiet sleep at night. 1 Darkness Remain awake | a Night light during the day. o Music ‘&- Takes sleeping pill as ordered by a physician %- Provide comfort measures to induce sleep: o Back rub 5 Herbal tea-warm milk 1 Pillows for support 1 Bedtime snack when appropriate. o Pain medication if needed. *- Limit nighttime fluids to: - Void before retiring. ‘*- Coordinate treatment/meds to limit interruptions during sleep period. : *- Limit the amount and length of daytime sleeping: #- Increase daytime activity: CamSeanner + ne sual—— ‘Nursing Out come ‘Nursing intervention diagnosis Evaluation Social Isolation %- Encourage patient to verbalize feelings. Related To: The patient will: | &- Assist to identify causative and contributing Death of s/o | #- Identify the | factors. *- Divorce reasons for 4%. Assist to reduce or eliminate causative and ‘#- Substance his/her feelings of | contributing factors: abuse isolation. 4. Assist to identify diversional activities. (See - Illness: 4. Identify ways | Diversional Activity Deficit) Aseyidenced | of increasing +- Initiate referrals as needed or increase social by: meaningful relationships: Major: relationships. *- Expressed | #- Identify feelings of appropriate unexplained —_| diversional dread or activities. abandonment *- Desire for more contact ‘with people Minor: *- Time passing slowly 4. Inability to concentrate and make decisions #- Feelings of uselessness ‘. &- Doubts . about ability to surviv ga CamSeanner + ne sualNursing diagnosis 1-Infection related to microorganism invasion into the body. Out come Pt with infection or wound infected ‘Nursing intervention Evaluation | Wash hands before and after each patient care | “The patient The patient will | activity. be free of 2- Obtain blood, sputum, urine and wound cultures | remains free infection as upon initial suspicion of onset of sepsis of signs or evidenced by 3- Use strict aseptic technique when handling symptoms of negative cultures. | invasive lines and equipment. line - infections; 4- Initiate broad spectrum antibiotics early and change to narrow spectrum when culture results are known 2- Nursing Diagnosis: Decreased cardiac output related to abnormal inflammation, The patient will _ | 1- Assess patient’s HR, BP and hemodynamic exhibit signs of _ | parameters every hour and after interventions. adequate *HR remains perfusion: : 60-100 *MAP>65 | 2- Obtain serum lactate levels. beats/min. mmHg. it R *MAP > 65 *HR 60-100 | 3- Administer fluid resuscitation to maintain MAP > | mmHg. beats/min. 65 mmHg and CVP 8-12. 4- Administer vasopressors if necessary to maintain MAP > 65 mmilg. 5- Administer drotrecogin alfa (XIGRIS) therapy for patients at high risk of death. CamSeanner + ne sualPt with liver disease Nursing intervention Narsing Out come diagnosis Evaluation A TPtiseble | Ineffective | Prwill verbalize | 1. Explain disease process in acute liver fai to seck early management | abasic 2. Educate pt. regarding etiology regarding treatment for of alteration in | understanding | rationale for treatments. potential healthy liver | ofcare needed} 3. Explain and promote abstinence from alcohol electrolyte functioning, | for acute liver _ | consumption. disturbances, failure. 4, Educate pt on S&S to report such as bruising | malnutrition bleeding, increased ascites and lack of adequate | and hypoglycemi nutrition. CamSeanner + ne sualDyspnea | 9. Medications (riarcotics, sedatives, | analgesics) . 10. Neuromuscular sirment (eg. MS, Guillain-Barre) 11. Surgery or trauma 12. Pain 43. Other: As evidenced by: 1. Change: respiratory rate or pattern from baseline. 2. Changes in pulse (rate, rythm). 3. Orthopnea 4. Tachypnea 5. Hyperpnea 6. Splinted, guarded respirations, 3. Absence of diminished breath sounds. 4. Other:, 5. Increase activity as tolerated to promote maximum diaphragmatic excursion: 6. Other: di agnosis Expected Nursing intervention Evaluatic outcome ‘ n Ineffective Breathing | The patientwill: |], Assess color, respiratory | The patient Patterns rate, depth, effort, rhythm and | is complete breath sounds q__hours. | imet related to : 2. 1, Demonstrat | 3, Position to facilitate | 4. Allergic response ean effective | optimum breathing patterns: 2. Anesthesia PSR, rate, depth, 3. Aspiration Be ced | 4, COPD AEB: © HOB el d | 5. Decreased lung ps SOE EMSs meh j compliance a 4— 6. Fatigue 7. History of smoking 2. Color pink! 8. immobility absence of 4. Cough and deep breath q cyanosis. hours. CamSeanner + ne sualPatient with Acute Renal Failure Nursing Out come Nursing intervention diagnosis Evaluation A-Deficient- | he patient will | 1- Monitor HR, BP and hemodynamic Fluid Volume | exhibit signs of | parameters every hour. related to adequate hypovolemia | perfusion: 2- Monitor daily weights. *normal MAP 70 or greater 3+ Assess for signs and symptoms of “urine output | intravascular volurhe depletion if urine output of 30 cc/br decreases. Consider common causes of *HR 60-100 | decreased cardiac output. bpm. 4- Promptly plan for administration of fluids to increase intravascular fluid volume. 5- Assess patient for signs and symptoms of fluid volume overload. 6- Administer norepinephrine to improve renal perfusion if fluid challenges do not improve MAP to 70 or greater. 7- Consult a nephrologist if patient does not respond to volume resuscitation. The patient will | 1- Monitor HR, BP, hemodynamic pressures and exhibit signs of | urine output hourly. optimal fluid 2- Monitor daily weights and maintain accurate I volume status: &0 ‘normal MAP_ | 3- Assess for possible causes of fluid volume (70-100) excess. 4- Avoid administration of drugs known to cause nephrotoxicity: NSAIDS, amino glycosides, cephalosporin's, contrast media, ACE inhibitors. 5- Restrict total fluid intake from all sources. 6- Concentrate IV medication infusions. 7- Prepare for continuous renal replacement therapy if output does not improve. ‘camScanner + Lis taalAcutely Il Burn Patient diagnosis 1-Impaired —_} The client will Skin Integrity | achieve optimal related to burn | wound healing as injury manifested by wound closure and no evidence of infection. Nursing Out come Nursing intervention 1-During the first 24-48 of injury continually assess the injury for evidence of adequate perfusion, edema and depth of injury. Check capillary refill, pulses (via palpation or Doppler ultrasound) every hour or as ordered. 2- Change burn dressing using the topicals and dressing materials ordered, at the prescribed frequency. 3- Frequently reassess the integrity of the dressing. Reinforce dressing as needed. Monitor for change in amount, type, odor and frequency of drainage and need for reinforcement. 4- With each dressing change maintain sterile technique. 5-With each dressing change observe the bum area for evidence of healing (i.e. sloughing of burn scar, bleeding, “budding” evidence of new skin cell regeneration and wound closure). 6- With each dressing change closely observe the bum wound for evidence of infection (i.e. foul smelling drainage, green or purulent drainage, if the burn has been grafted-evidence that the graft is sloughing and pulling away from the wound bed). Alert the practitioner to any changes in the bun wound, Obtain cultures as needed to confirm infection. Consult with practitioner about need to =) Evaluation change burn topical or consider graft or re- grafting area. CamSeanner + ee pusOut come 1- Request a consult with registered dietician when patient is admitted to assess nutritional status as soon as possible, develop nutritional goals and nutritional plan. The patient will achieve optimal nutritional status as evidenced by wound healing, weight stability and laboratory results (i.e. albumin, electrolytes, pre- albumin) within normal limits. Nutrition less than body Tequirements 2. Encourage the patient to eat a balance diet, but emphasize that protein is essential to wound healing and recovery. increased metabolic needs following burn injury. 3- Ifthe patient has burns on their face, hands, or mouth; try modifications to their food to make the food easier and more palatable to ingest. Consult with PT/OT as needed to implement strategies to help the patient eat and gain a sense of independence with eating. 4- Check patient's weight per unit recommendations. Some units do weekly, twice weekly or daily weights for at risk or high-risk patients. 5- Check laboratory work per dietary or unit protocol. 6- Keep accurate +O and/or calorie counts. 7- Consider the need for tube feeding or TPN if patient cannot take in the nutrients needed by mouth, Camseanner se sual Nursing intervention EvaluationNursing diagnosis Nursing intervention Evaluation b 1- Assess patient's pain and comfort level Patient's pain and | frequently. Assess pain prior to procedures, anxiety and during and after procedures and at intervals of overall comfort | rest. Use self-report scales as much as possible, level will be well | or 2s able to considering patient’s age, acuity and managed using a_| level of consciousness. combination of narcotic and non- | 2- Pre-mediate the patient for dressing changes narcotic and any type of burn therapy. 3- Alteration in Comfort rit Burn Injury and Treatment interventions and adjunct 3-Consider anxiety as a component of comfort alternative therapies (ic. | 4- Consider altemative methods to control pain music therapy, | and anxiety. Some options are: distraction, reiki, relaxation, relaxation, reiki massage, music therapy, ete. etc). When appropriate and feasible have the bum patient participate in their own burn care and therapy, to allow a sense of contiol. Sometimes family presence and involvement can help the patient cope beiter with pain 5-Consider that pain as a result of burn injuries will transition fiom acute to chronie pain. Consider both narcotic and non-narcotic medications, as well as adjunct therapies to help the patient. - 6- Consider itch as a component of comfort management. Apply emollients as needed, Consider diphenhydramine or loratadine if itch interferes with sleep or causes the patient to re- ‘open wound due to scratching. 7- If the patient's pain cannot be adequately managed consider request a consult to a pain specialist. CamSeanner + ne sualNursing diagnosis Out come | Nursing intervention Evaluation i Airway Clearance, Ineffective Related Factors: Decreased energy and fatigue -Ineffective cough -Tracheobronchial Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by infection clear lung -Tracheobronchial | sounds, eupnoea, obstruction and ability to (including foreign | effectively cough body aspiration) —_| up secretions tracheobronchial | after treatments secretions and deep breaths. -Impaired respiratory muscle function -Trauma Defining Characteristics -Abnormal breath sounds (crackles, thonchi, wheezes) Changes in - -~respiratory rate or depth -Cough Hypoxemia/eyanosis Dyspnea (i) Assess airway for patency. Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest. (i) Auscultate lungs for presence of normal or adventitious breath sounds, as in the following: + Decreased or absent breath sounds © May indicate presence of mucous plug or other major airway obstruction. + Wheezing © May indicate increasing airway resistance. + Coarse sounds © May indicate presence of fluid along larger airways. (i) Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, position for breathing, Abnormality indicates respiratory compromise. (i) Assess changes in mental status. Increasing lethargy, confusion, restlessness, and/or irritability can be early signs of cerebral hypoxia. (i) Assess changes in vital signs and temperature. Tachycardia and hypertension may be related to increased work of breathing. Fever may develop in response to retained secretions/atelectasis. (i Assess cough for effectiveness and productivity. Consider possible causes for ineffective cough: respiratoi CamSeanner + ne sualNursing diagnosis} Out come Knowledge Deficit Related To: #- New diagnosis: *- Language differences: &- Hospitalization *- Diagnostic test: *- Surgical procedure: &- Medications: *- Pregnancy As evidenced by: Major: #- Verbalizes a deficiency in knowledge or skill . &- Requests information. &- Expresses and inaccurate perception of health status. Does not correctly perform a desired or prescribed health behavior. Minor: #- Lack of integration of treatment plans into daily activities. *- Exhibits or expresses psychological alteration, (anxiety, depression) resulting from misinformation or lack of information, ‘The patient will: &- Describe disease process, causes, factors contributing to symptoms. #- Describe procedure(s) for disease or symptom control. 4- Identify needed alterations in lifestyle. Knowle dae Defiel Nursing intervention 4- Assess patient's readiness to learn by assessing emotional respose to illness: ‘Acceptance - Anger - Anxiety-Denial - ‘4. Allow person to work through and express intense emotions prior to teaching, 4. Examine patient's health beliefs: - Assess patient's desire to learn. ‘&- Assess preferred learning mode: Auditory- Group- Onetoone- Visual &- Assess literacy level. +. Provide health teaching and referrals: #- Plan and share necessity of learning outcomes with patient - s/o. 4- Evaluate patient - s/o behaviors as evidence that Jearning outcomes have been achieved: CamSeanner + ne sual* Assess for causative factors. * Provide opportunities to relearn or ‘adapt to ity. & Teach patient to use affected extremity 19 accomplish tasks &, Consistent bathing routing at am/pm every day, Provide as much privacy as possible by Pulling curtains and closing doors. + Provide equipment within easy reach, ‘®- Encourage independence. Reinforce success for task accomplished.= Self Gre Defveil [DvesSin) Nursing Out come Nursing intervention diagnosis Evaluation Self Care The patient will: 4. Allow sufficient time for dressing and _ Deficit: #- Demonstrate undressing, since the task may be tiring, painful, Dressing and _} increased ability to | and difficult. Grooming dress/groom self. | #- Promote independence in dressing through Related To: *- Demonstrate continual and unaided practice. . * ability to cope with | #- Choose clothing that is loose fitting, with Neuromuscular | the necessity of wide sleeves and pant legs, and front fasteners. impaitment: having someone 4- Lay clothes out in the order in which they will &- Impaired else assist him/her | be needed to dress. } visual actuity | in performing the | #- Avoid placing clothing to blind side if patient #-Immobility | task. has field cut, until patient is visually a &- Weakness | 4-Demonstrate | accommodated to surroundings; encourage %-Decreased | ability to learn patient fo turn head to scan entire visual field. level of how to use - Consult/refer to PT/OT for teaching, consciousness | adaptive devices to | application of prosthetics. ‘As evidenced | facilitate optimal | #- Provide dressing aids as necessary (dressing independence in | stick, swedish reacher, zipper pull, button-hook, the task of long handled shoehorn, shoe fasteners adapted &-Impaired | dressing/grooming. | with elastic laces, velcro closures, flip back ability to put on tongues). or take off - Plan for person to learn and demonstrate one clothing. part of an activity before progressing further. 4- Unable to - Make consistent dressing/grooming routine to obtain or provide a structured program to decrease replace article confusion. of clothing. #- Unable to fasten clothing. - Unable to 7 groom self satisfactorily CamSeanner + ne sualLmPaives physical mode Ly Nursing ; Out come Nursing intervention diagnosis Evaluatio Impaired 4 Assess symmetry, strength, and degree of Physical Mobility Related To: 4 Amputation = Cardiovascular *- External devices *- Impaired balance + Limited The patient will: *- Maintain or increase strength and endurance of upper/lower limbs AE.B.: * Will not develop complications of velactive ROM exercises as ordered by physician q to :( body part). ; #- Position in proper alignment and reposition q hrs - Encourage isometric exercises when indicated. 4- Up in chair minutes q. 4- Check/teach proper use/function of adaptive equipment. je progressive mobilization ‘4- Demonstrate use of adaptive ROM device(s) to = increase mobility. Musculoskeletal | Device: impairment fa Neuromuscular impairment Pain + Surgical procedure + Trauma As evidenced by: Major: + Inability to move purposefully within the environment, CamSeanner + ine pusTl lit represents the NAND/A-approved nusingdizpnosesforclin- + Risk for ismpaured pareny were om ical use and testing. Sexual dysfunction Pattern 1. Exchanging + Inemrupted f farnly proceses * Imbalanced nutrition: requ + Caregiver role strain, ee testy eames © Rie for career lene gots * feidk for imbalanced nutrition: More than body requirements On one + Risk for infection 2 tneffective sexuality partemns © Risk for imbalanced body temperature i it + Hypothermia : Pattern 4. Valuing = Hyperthermia ppiritual distress ‘Ineffective thermoregulation + Risk for: acieual well-being, Austonomic dysreflexia > Readiness for enbanced =piti + Tsk for autonomic dysrefiesis Pattern 5. Choosing = Constipation 2 Ineffective coping = Perceived constipation 2 fropaired adjustinent + Diarthea « Defenstve coping + Bowel incontinence «Ineffective denial 2 Rick for constipation 1 Disabled family coping 2 Impaired ucimary elimination 2 Compromised family coping 2 Stress urinary incontinence 1 (otdinees for enhanced family coping 2 Reflex urinary incontinence 1 Readiness for enhanced community Coping Urge urinary incontinence 2 Ineffective community coping + Functional urinary incontinence « Ineffective therapeutic repimen managemert Total urinary incontinence 2 Noncompliance. (speci! © Rise for urge urinary incontinence Fee family therapeutic regimen manage < Urinary retention 7 1 iSfiective community thecapantic regimen a Sere2yre dame perfusion (specify type renal, cerebral, cardio- 1 Erie thetapeutic regimen management pulmonary, gastrointestinal, petip 2 Decisional conflict (specify) «Risk for imbalanced fluid volume 1 Health cecking behaviors (specify) 1 Excess fluid volume + Deficient fluid volume Pattern 6. Moving 2 Risk for defient Buid volume + Impaired physical mobility . + Decrened cardiac output 5 ik a er ar : pare 5 + perioperstive- positioning injury 2 ep ey derence Liopaired walling 1 [hetieve breathing pattern 1 impaired wheelchair mobility = Impaired spontancous vententilation _ + Impaiced transfer, ability > iol vendilatory weaning, response + Impaired bed mobility 1 Rok forinjury 2 Activity intolerance 1 Risk for alle" = Fatigue 1 Risk for suffocation + Rise for activity intolerance = Risk for poisoning © Disturbed sleep pattern = Risk for trauma deprivation 1 Risk for aspiration + Deficient diversional activity Risk for dinuse syndrome + Impaired home maintenance Ineffective health maintenance sure fecovery Feeding self-care a cba ct ees Effective bressefecding + Ineffective infant feeding patteria ‘ Bathing/hypiene self-care deficit : ing self-care deficit : self-care deficit : fprowth and development ++ Risk for disorganized infant behavior +. Disorganized infant behavior CamSeanner + ne sual¢ iadines for eohancsl axgatbel infsen behavior = Wandering” i Pattern 7. Perceiving * Chronic pain « Disturbed body image anaes # Chronic low self esteem * Dysfnnetlonal pdeving + Situational low selfesteem + Anticiparory grieving + Risk for simztional low selEesteem”™ ° Chronic somo ‘ » Disturbed personal identity + Risk for other-directed violence * Dismbed sensory perception (pec: viel auditory kinetic, * Sfmuttion® uutatory, tale, olfaaocy) + Risk for sefsauilation eee + Risk for self-directed violence : ee + Risk for suic>" antiase + Posttraurca syndrome © Risk far powerlessness* * Rape-traumma syndrome + Rape-trauma syndrome: Compound reaction Pattem 8. Rrowng, . ae Sleatrescin ‘Deficient knoveledge (epeciy + Risk for post * Imprized environmental interpretation syndrome Damen se Ge » Acute confusion “© Death anxiery + Chronic confusion Os » Disturbed chonght processes «+ Intpaired memory os ‘oe additions to tzonomy. Nonh Amaican Nursing Diagnosis Asocatioa. (2001). Nacwing diagnasis: Definitions and oe ing lantng. Clesifcerien 2001-2002. oi CamSeanner + ne sualGlucose Fa Urea 9 - ye Cholesterol, Triglyceride 4202 pa. HDL Ssh tall Jy fd sh - LDL 2th) pote Jy fad Direct Asa) T. Proteins 4- Albumin £.3 - ¥.4 - Phosphoras © - Sodium Vi. - VT Potassium °.¢ - TA -- Magnesium ¥.°° - 1% Tron Vs - 75 TIBC €: D. xylose 3+ After 1h - Sg or: Calcium \+ ALT (SGPT) RBCX-£.Y > pal GSI 3136 milion/mm3 35S a 4.2-5.4 million / mm3 SLY! Hemoglobin YA - V¥.2 Ghasllmg% Sill = 12.5 - 16 ee eu! Haematocrit »sSill% ev - £¥ - CeiygS shag! 37-47% “ey! -- youl Oly Sli slad / mm3 eee VV alu % =) Caeeall % Platelets £°* Reticulocyte Y ESR N- + 3,83 zB Coagulation Time ) + ptrombin Time \+ CamSeanner + ine sual