Nursing Diagnosis
Content
Nursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction
Long Term Goal: Patient will maintain a patent airway
Short Term Goals / Outcomes: Patients lungs sounds will be clear to auscultate Patient will be free of dyspnea Patient will demonstrate correct coughing and deep breathing techniques Intervention Assess airway for patency by asking the patient to state his name. Inspect the mouth, neck and position of trachea for potential obstruction. Auscultate lungs for presence of normal or adventitious lung sounds. Rationale Evaluation
Maintaining an airway is always top priority Patient is able to state their name especially in patients who may have experienced without difficulty. trauma to the airway. If a patient can articulate an answer, their airway is patent. Foreign materials or blood in the mouth, hematoma of the neck or tracheal deviation can all mean airway obstruction. No foreign objects, blood in mouth noted. Neck is free of hematoma. Trachea is midline.
Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.
Patient’s lungs sounds are clear to auscultation throughout all lobes.
Assess respiratory quality, rate, depth, effort and pattern.
Patient is free of signs of distress.
Assess for mental status changes.
Increasing lethargy, confusion, restlessness and / Patient is awake, alert and oriented or irritability can be early signs of cerebral X3. hypoxia. Tachycardia and hypertension occur with Patient is normotensive with heart
Assess changes in
vital signs. Monitor arterial blood gases (ABGs). Administer supplemental oxygen.
increased work of breathing. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs.
rate 60 – 100 bpm. ABGs show PaCO2 between 35-45 and PaO2 between 80 – 100. Patient is receiving oxygen. SaO2 via pulse oximetry is 90 – 100%.
Position Patient with Promotes better lung expansion and improved head of bed 45 gas exchange. degrees (if tolerated). Assist Patient with Assist patient to improve lung expansion, the coughing and deep productivity of the cough and mobilize breathing techniques secretions. (positioning, incentive spirometry, frequent position changes). Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). If a patient is unable to maintain an adequate airway, an artificial airway will be required to promote oxygenation and ventilation; and prevent aspiration.
Patient’s rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.
Artificial airway is placed and maintained without complications.
Confirm placement of Complications such as esophageal and right main stem intubations can occur during the artificial airway. insertion. Artificial airway placement should be confirmed by CO2 detector, equal bilateral breath sounds and a chest x-ray. If maxillofacial trauma is present: 1. position the patient for The patient with maxillofacial trauma is usually more comfortable sitting up. Any time there is trauma to the maxillofacial area there is the possibility of a compromised airway.
CO2 detector changes color, bilateral breath sounds are audible equally and artificial airway is at the tip of the carina on x-ray.
Patient exhibits normal respiratory rate and depth in sitting position. Patient is free of wheezing, stridor and facial edema.
optimal Noting swelling is important as a baseline for airway comparison later. clearance and constant assessment of airway patency 2. note the degree of swelling to the face and amount of blood loss 3. prepare the patient for definitive treatment If neck trauma is present: 1. assess for potential hemorrhage and disruption of the larynx or trachea 2. prepare the patient for CT scan Teach patient correct coughing and Deep breathing techniques. Weak, shallow breathing and coughing is ineffective in removing secretions. Patient is able to demonstrate correct coughing and breathing techniques. Hemorrhage or disruption of the larynx and trachea can be seen as hoarseness in speech, palpable crepitus, pain with swallowing or coughing, or hemoptysis. The neck should be also assessed for ecchymosis, abrasions, or loss of thyroid prominence. Laryngeal injuries are most definitely diagnosed by CT scans as soft tissue neck films are not sensitive to these injuries. Patient is free of signs of hemorrhage or disruption. CT scan reveals no injury to the larynx.
Nursing Diagnosis
Long Term Goal Patient will maintain optimal gas
Impaired Gas Exchange r/t altered oxygen supply Short Term Goals / Outcomes: Patient will maintain normal arterial blood gas (ABGs). Patient will be awake and alert. Patient will demonstrate a normal depth, rate and pattern of respirations. Interventions Assess respirations: quality, rate, pattern, depth and breathing effort. Rationale Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. Absence of ventilation, asymmetric breath sounds, dyspnea with accessory muscle use, dullness on chest percussion and gross chest wall instability (i.e. flail chest or sucking chest wound) all require immediate attention.
exchange
Evaluation Patient is free of signs of distress. ABGs show PaCO2 between 35-45 Pts respirations are of a normal rate and depth.
Assess for lifethreatening problems. (i.e. resp arrest, flail chest, sucking chest wound). Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation. Assess for signs of hypoxemia. Monitor vital signs.
Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities.
Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax.
Patient’s lungs sounds are clear to auscultate throughout all lobes.
Tachycardia, restlessness, diaphoresis, headache, Patient is free of signs of hypoxia. lethargy and confusion are all signs of hypoxemia. Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue. Patient is normotensive with heart rate 60 – 100 bpm and respiratory rate 10-20.
Assess for changes in orientation and behavior. Monitor ABGs.
Restlessness is an early sign of Patient is awake, alert and hypoxia. Mentation gets worse as hypoxia oriented X3. increases due to lack of blood supply to the brain. Increasing PaCO2 and decreasing PaO2 are signs of ABGs show PaCO2 between 35-45 respiratory failure. and PaO2 between 80 – 100. Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. SaO2 via pulse oximetry remains at 90 – 100%.
Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis. Provide supplemental oxygen, via 100% O2 non-rebreather mask. Prepare the patient for intubation.
Lack of oxygen delivery to the tissues will result in Patient is free of cyanosis. cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.
Early supplemental oxygen is essential in all Patient is receiving 100% trauma patients since early mortality is associated oxygen. SaO2 via pulse oximetry is with inadequate delivery of oxygenated blood to 90 – 100%. the brain and vital organs. Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient. Treatment needs to focus on the underlying problem that leads to the respiratory failure. Artificial airway is placed and maintained without complications.
Treat the underlying injuries with appropriate interventions. If rib fractures exist: 1. Assess for paradoxical chest movements. 2. Provide adequate
Appropriate injury specific treatment has been started.
Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a life-threatening complication of rib fractures that requires mechanical ventilation and aggressive pulmonary care. Pain relief is essential to enhance coughing and deep breathing.
No paradoxical movements are noted. Patient reports pain as <3 on 0-10 scale. Bilateral breath sounds present in all lobes.
pain 3. relief. Assess breath sounds. If Pneumothorax or Hemothorax exist: 1. obtain chest x-ray
Absence of bilateral breath sounds in the presence of a flail chest, indicates a pneumo/hemo thorax.
Chest tube is placed and connected to 20cm wall suction with good 2. prepare for tidaling and no air leak or SQ insertion of a A three sided dressing gives the accumulated air a emphysema noted. way to escape, thereby decreasing thoracic chest tube Three-sided dressing pressure and preventing a tension If open maintained. No further Pneumothorax. A chest tube must then be Pneumothorax exists cardiopulmonary decompensation inserted. place a dressing that noted in patient. is taped on three sides for temporary management. Position patient with Promotes better lung expansion and improved head of bed 45 gas exchange. degrees (if tolerated). Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest). Suction patient as needed. Promotes alveolar expansion and prevents alveolar collapse. Splinting helps reduce pain and optimizes deep breathing and coughing efforts. Patient’s rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.
A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax. A chest tube decreases the thoracic pressure and re-inflates the lung tissue.
Suctioning aides to remove secretions from the airway and optimizes gas exchange.
Patient suctioned for moderate amount of thin yellow secretion. Lung sounds clear after suctioning.
Hyperoxygenate patient with 100% before and after suctioning. Keep suctioning to 10-15 seconds. Pace activities and provide rest periods to prevent fatigue.
Prevents alteration in oxygenation during suctioning.
Patient’s SaO2 remained >90% during suctioning.
Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.
No changes to cardiopulmonary status noted during activity. Patients SaO2 remains >90% during activities.
Nursing Diagnosis Deficient Fluid Volume r/t active fluid loss due to bleeding
Long Term Goal Patient will maintain adequate fluid and electrolyte balance.
Short Term Goals / Outcomes: Patient will maintain urine output >30cc/hr. Patient will be normotensive with heart rate 60 -100bpm. Patient will demonstrate normal skin turgor. Interventions Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate. Rationale If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 – 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular. Cool, pale, diaphoretic skin suggests ineffective circulation due to hypovolemia. Active fluid and/or blood loss adds to Hypovolemic state and must be accounted for when replacing fluids. Evaluation All pulses palpable, strong and regular.
Assess skin color and temperature. Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding.
Skin pink, warm and dry.
All external bleeding controlled.
Monitor vital signs. (T,P,R,B/P)
Sinus tachycardia may occur with hypovolemia to maintain cardiac output. Hypotension is a hallmark of hypovolemia. Febrile states decrease body fluids through perspiration and increase respiratory rate. Greater than 10 mmHg drop signifies that circulating volume is reduced by 20%. Greater that 20 – 30 mmHg drop signifies blood volume is decreased by 40%. Abnormally flattened jugular veins and distant heart tones are signs of ineffective circulation. Loss of consciousness accompanies ineffective circulating blood volume to the brain.
Vital signs within normal limits.
Monitor blood pressure for orthostatic changes.
No orthostatic changes noted when patient placed from supine to Fowlers position.
Auscultate heart tones and inspect jugular veins.
S1, S2 audible. No flattening or distention of jugular vein noted.
Assess mental status.
Awake, alert and oriented X3.
Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes. Assess color and amount of urine.
Dry mucous membranes and tenting of the Normal skin turgor. Mucous skin are signs of hypovolemia. The sternum membranes pink and moist. and inner thigh should be used for skin turgor due to loss of elasticity with aging.
Concentrated urine and output <30cc for two consecutive hours indicate insufficient circulating volume.
Urine clear, yellow. Output at least 30cc/hr.
Monitor serum electrolytes and urine osmolality.
Elevated hemoglobin, Hematocrit and blood All lab values within normal urea nitrogen (BUN) accompany a fluid ranges. deficit. Urine specific-gravity is also increased. All values decrease with inadequate All pressures within normal circulating volume. Hemodynamic stability ranges. is the goal of fluid replacements. Monitoring of hemodynamic
Monitor hemodynamic pressures: central venous pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge
pressure (PCWP), if available. Initiate two large bore intravenous catheters (IVs) and start intravenous fluid replacements as ordered.
pressures can guide fluid replacements.
14 -16 gauge catheters are preferred in case fluids need to be given rapidly. Parenteral fluids are necessary to restore volume. Lactated Ringers is usually the fluid of choice due to its isotonic properties and close resemblance to the electrolyte composition of plasma. Blood and blood products will be necessary for active blood loss. If there is no time to wait for cross matching, Type O blood may be transfused.
Two large bore IVs started, lactated ringers infusing as per physician orders without complications.
Obtain a serum specimen for type and cross matCh Administer blood and blood products as ordered. During treatment monitor for signs of fluid overload.
Type and cross sent. Type specific blood infusing as per physician orders.
Due to large amounts of fluids administered No signs of overload noted with rapidly, circulatory overload can occur. fluid replacements. Headache, flushed skin, tachycardia, venous distention, elevated hemodynamic pressures (CVP, PCWP), increased blood pressure, dyspnea, crackles, tachypnea and cough are all signs of overload. Central venous line and arterial line inserted without difficulty.
Assist the physician with Provides for more effective fluid insertion of a central venous replacements and accurate monitoring of line and arterial line if hemodynamic picture. indicated.
Nursing Diagnosis Acute Pain r/t trauma
Long Term Goal Patient will be free of pain
Short Term Goals / Outcomes: Patient will report pain less than 3 on 0-10 scale. Patient’s vital signs will be within normal limits.
Interventions Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors. Monitor vital signs.
Rationale A good assessment of pain will help in the treatment and ongoing management of pain.
Evaluation Patient reports pain as 3 or less on 0-10 scale; intermittent and sharp in incision area.
Tachycardia, elevated blood pressure, tachypnea and Vital signs within fever may accompany pain. normal limits. Some patients may verbally deny pain when it is still present. Restlessness, inability to focus, frowning, grimacing and guarding of the area may be nonverbal signs of acute pain. Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration. No non-verbal signs of pain noted.
Assess for non-verbal signs of pain.
Give analgesics as ordered and evaluate the effectiveness.
Analgesics given as ordered. Patient reports satisfactory pain relief after administration. Patient states “I want some relief. I know some pain will still exist.” No complications of analgesia noted.
Assess the patient’s expectations of pain relief.
Some patients are content with reduction in pain, others may expect complete elimination. This effects the patient’s perception of the effectiveness of treatment. Excessive sedation and respiratory depression are severe side effects that need reported immediately and may require discontinuation of medication. Urinary retention, nausea/vomiting and constipation can also occur with narcotic use and need reported and treated.
Assess for complications to analgesics, especially respiratory depression.
Anticipate the need for The most effective way to deal with pain is to pain relief and respond prevent it. Early intervention can decrease the total
Patient reports pain as
immediately to complaints of pain.
amount of analgesic required. Quick response decreases the patient’s anxiety regarding having their needs met and demonstrates caring.
soon as it starts.
Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation. Institute nonpharmacological approached to pain (detraction, relaxation exercises, music therapy, etc.). If patient is on patient controlled analgesia (PCA): 1. Dedicate an IV line for PCA only.
Outside sources of stress, anxiety and lack of sleep all Patient appears relaxed, is sleeping may exaggerate the patient’s perception of pain. throughout the night.
Non-pharmacological approaches help distract the patient from the pain. The goal is to reduce tension and thereby reduce pain.
Patient is relaxing by use of nonpharmacological technique of choice.
Drug interaction may occur, if dedicated line is not possible consult pharmacist before mixing drugs.
2. Assess pain relief and the The patient and significant others must understand amount of pain that the patient is the only one who should control the patient is the PCA. requesting. 3. Educate patient and significant others on correct use of PCA. If the patient is receiving epidural analgesia: These symptoms indicate an allergic response, or improper catheter placement. Labeling of tubing is necessary to prevent
PCA infusing without complications. Patient and family understand If demands for the drug are frequent the basal or purpose and use of lock-out dose may need to be increased to cover the PCA. Patient is getting patient’s pain. adequate pain relief If demands for the drug are very low, the patient may with current dose. need further education of use of the PCA.
All tubing labeled. No signs of allergic reaction or catheter
1. Assess for numbness, tingling in extremities; and a metallic taste in the mouth. 2. Label all tubing clearly. For PCA and epidural analgesia: 1. Keep Narcan readily available. 2. Place “No additional analgesia” sign over head of bed.
inadvertent administration of fluids or drugs in the epidural space. Catheter migration or improper administration through the catheter can result in life-threatening complications.
migration noted.
In event of respiratory depression reversal agent must be available. This prevents inadvertent analgesia overdosing.
Narcan on unit if needed. Sign placed in room for safety.
Nursing Diagnosis Risk For Infection r/t inadequate primary defenses
Long Term Goal Patient will be free of infection
Short Term Goals / Outcomes: Patient will maintain normal vital signs. Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes. Interventions Rationale Evaluation Patient has midline thoracic incision, Foley, chest tube and peripheral IV access.
Assess for presence of risk Represent a break in body’s first line of factors: open wounds, defense. abrasions; indwelling catheters; drains; artificial airways; and venous access devices. Monitor white blood count Normal WBC is 4-11 mm3. Rising WBC
Patient’s WBC are within
(WBC).
indicates the body’s attempt to combat pathogens. Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.
the normal range.
Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection.
All areas are without signs of infection.
Monitor temperature and the In the first 24-48 hours fever up to 38 Temperature is less than presence of sweating and chills. degrees C (100.4F) is related to the stress of 37.7C. No sweating or surgery. After 48 hours fever above 37.7C chills present. (99.8F) suggests infection. High fever with sweating and chills suggests septicemia. Monitor the color of respiratory Yellow or yellow-green sputum indicates a secretions. respiratory infection. Monitor the appearance of urine. Patient coughs up only thin clear secretions.
Cloudy, foul-smelling urine, with sediments Urine is clear yellow indicates a urinary tract or bladder with no sediments. infection. Strict asepsis is necessary to prevent crosscontamination and nosocomial infections. No further infections are noted.
Maintain strict aseptic technique with all dressing changes; tubes, drains and catheter care; and venous access devices.
Wash hands and teach others to Hand washing reduces the risk of wash hands before and after transmitting pathogens from one area of the body to another as well as from one patient care. patient to another. Encourage fluid intake of 2000ml – 3000ml of water per day (unless contraindicated). Fluids promote frequent emptying of the bladder, reducing stasis of urine and risk of urinary tract and bladder infections.
No further infections are noted.
Patient drinks 2000 3000 ml of fluid. No presence of urinary tract or bladder infections.
Encourage intake of protein and Optimal nutritional status promotes wound Wounds are well calorie rich foods. Provide healing. approximated. enteral feeding in patients who
are NPO. Encourage coughing and deep breathing. Reduces stasis of pulmonary secretions, reducing the risk of pneumonia. Patient coughs up thin clear secretions.
Administer and teach the use of All agents are either toxic to the pathogens WBC within normal limits. No further antimicrobial drugs as ordered. or retard the pathogen’s growth. Ideally medications should be selected based on a infections noted. culture from the infected area. A broadspectrum agent may be started until culture reports are available.
Nursing Diagnosis Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased arterial flow & cerebral edema
Long Term Goal Patient will maintain optimal tissue perfusion to vital organs
Short Term Goals / Outcomes: Patient will maintain strong peripheral pulses. Patient will report absence of chest pain. Patient will be awake, alert and oriented. Patient will maintain normal arterial blood gases (ABGs). Patient will maintain normal urine output. Patient will maintain normal bowel sounds. Interventions Assess each area for signs of decreased tissue perfusion. Rationale Early detection facilitates prompt, effective treatment. Signs may be: Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool to touch; mottling; prolonged capillary refill Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, abnormal ABGs, angina Renal: decreased output, hematuria, elevated BUN/creatinine ratio No signs of decreased perfusion noted. Evaluation
GI: decreased or absent bowel sounds; nausea; abdominal pain / distention Cerebral: restless, change in mentation seizure activity, papillary changes and decrease reaction to light Monitor vital signs for Adequate perfusion to vital organs is essential. A optimal cardiac output. mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion. Administer fluids and blood products as ordered. Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage. All vital signs within normal limits.
Fluids infusing. Vital signs, urine output and mentation all within normal limits. Heparin infusing. PTT within therapeutic range.
Anticipate the need for possible antithrombolytic therapy. Assess for compartment syndrome if peripheral circulation is impaired (pain, palor, pulselessness, paralysis, parathesia). Administer oxygen as prescribed. Titrate oxygen based on continuous pulse oximetry levels.
If an obstruction to the area has developed an embolectomy, heparinzation, or thrombolytic therapy may be necessary to restore flow and prevent ischemia Compartment syndrome develops as the tissue swells and the fascial covering over the muscles can not yield to the pressure. Blood flow to the extremity is drastically reduced. An emergent fasciotomy may need to be performed to restore flow.
No signs of compartment syndrome noted.
Oxygen saturates circulating hemoglobin and Patient receiving increases the effectiveness of blood that reached the oxygen. Pulse ischemic tissues. Thus improving tissue perfusion. Oximetry 90 – 100%.
Monitor ABGs, Metabolic acidosis and hypoxia indicate that tissues especially for metabolic are not adequately being perfused. acidosis and hypoxia. If Patient complains of NTG causes vasodilation, decreases preload and afterload and thus improves perfusion to the
ABGs within normal limits.
NTG administer. Patient
angina; 1. administer nitroglycerin (NTG) sublingually. If cerebral perfusion is compromised: 1. Ensure proper functioning of intracranial pressure (ICP) catheter if present.
myocardium.
reports relief of angina.
Promotes venous outflow from brain and helps reduce pressure.
Patient awake and alert with no change in mentation. No seizures noted
Straining, coughing, neck or hip flexion and lying supine may increase ICP and further reduce blood 2. Elevate head of flow. bed 30 -45 Reduces the risk of seizures, which may result from degrees. cerebral edema or ischemia. 3. Avoid measures that may trigger increased ICP 4. Administer anticonvulsants as needed.
ASSESSMENT
DIAGNOSIS
INFERENCE
PLANNING
INTERVENTI ON INDEPENDEN T Monitor vital signs as well as central venous pressure.
RATIONALE
EVALUATIO N After 4 hours of nursing interventio ns, the Patient was able to demonstrat e stabilized fluid volume as evidenced by balanced intake and output (I&O) and vital signs within client’s normal range.
SUBJECTIVE:
“Namamanas ang paa ko”(My feet are swelling) as verbalized by the patient.
Excess fluid volume related to compromis ed regulatory mechanism
OBJECTIVE:
Restlessn ess Fatigue Edema on lower extremitie s
V/S taken as follows
T: 36.9˚C
Excessive fluid volume in the blood. This fluid excess usually results from compromis ed regulatory mechanism s for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It can also be caused by too much intake of sodium from foods, intravenous (IV) solutions, medication s, or
After 4 hours of nursing interventio ns, the Patient will demonstrat e stabilized fluid volume as evidenced by balanced intake and output (I&O) and vital signs within client’s normal range.
Tachycar dia and hyperten sion are common manifest ations. Crackle sounds and extra heart sounds are indicative of fluid excess, possibly resulting in rapid develop ment of pulmonar y edema. Decrease d renal perfusion , cardiac insufficie ncy, and fluid shifts may cause
Auscultat e lung and heart sounds.
Maintain adequat e I&O. Note decrease d urinary output
P: 102 R: 20 BP: 110/ 80
diagnostic contrast dyes. The excess fluid, mainly salt and water, builds up in different body locations and can lead to swelling in the legs and arms (peripheral edema), and/or fluid in the abdomen (ascites).
and positive fluid balance on 24hour calculati ons.
decrease urinary output and edema formatio n. One liter of fluid retention equals a weight gain of 1 kilogram. Pulmonar y fluid shifts potentat e respirato ry complicat ions. Gravity improves lung expansio n.
Weigh as indicated . Be alert for sudden weight gain.
Encourag e coughing and deep breathin g exercises .
Maintain semifowler’s position.
Reduce pressure and friction on edemato us tissue.
Turn or repositio n, and provide skin care at regular intervals.
Encourag e bed rest.
Limited cardiac reserves results in fatigue and activity intoleran ce.
Caregiver Role Strain - Evaluation, Interventions, Documentation 9:23 PM Posted by Pak Mantri
Desired Outcomes/Evaluation Criteria—Client Will: • Identify resources within self to deal with situation. • Provide opportunity for care receiver to deal with situation in own way. • Express more realistic understanding and expectations of the care receiver. • Demonstrate behavior/lifestyle changes to cope with and/or resolve problematic factors. • Report improved general well-being, ability to deal with situation.
Actions/Interventions NURSING PRIORITY NO. 1. To assess degree of impaired function: • Inquire about/observe physical condition of care receiver and surroundings as appropriate. • Assess caregiver’s current state of functioning (e.g., hours of sleep, nutritional intake, personal appearance, demeanor).
• Determine use of prescription/over-the-counter (OTC) drugs, alcohol to deal with situation. • Identify safety issues concerning caregiver and receiver. • Assess current actions of caregiver and how they are received by care receiver (e.g., caregiver may be trying to be helpful but is not perceived as helpful; may be too protective or may have unrealistic expectations of care receiver). May lead to misunderstanding and conflict. • Note choice/frequency of social involvement and recreational activities. • Determine use/effectiveness of resources and support systems.
NURSING PRIORITY NO. 2. To identify the causative/contributing factors relating to the impairment: • Note presence of high-risk situations (e.g., elderly client with total self-care dependence, or family with several small children with one child requiring extensive assistance due to physical condition/developmental delays). May necessitate role reversal resulting in added stress or place excessive demands on parenting skills. • Determine current knowledge of the situation, noting misconceptions, lack of information.May interfere with caregiver/ care receiver response to illness/condition. • Identify relationship of caregiver to care receiver (e.g., spouse/lover, parent/child, sibling, friend). • Ascertain proximity of caregiver to care receiver. • Note physical/mental condition, complexity of therapeutic regimen of care receiver. • Determine caregiver’s level of responsibility, involvement in and anticipated length of care. • Ascertain developmental level/abilities and additional responsibilities of caregiver. • Use assessment tool, such as Burden Interview, when appropriate, to further determine caregiver’s abilities. • Identify individual cultural factors and impact on caregiver. Helps clarify expectations of caregiver/receiver, family, and community. • Note co-dependency needs/enabling behaviors of caregiver. • Determine availability/use of support systems and resources. • Identify presence/degree of conflict between caregiver/care receiver/family. • Determine preillness/current behaviors that may be interfering with the care/recovery of the care receiver.
NURSING PRIORITY NO. 3. To assist caregiver in identifying feelings and in beginning to deal with problems: • Establish a therapeutic relationship, conveying empathy and unconditional positive regard. • Acknowledge difficulty of the situation for the caregiver/ family. • Discuss caregiver’s view of and concerns about situation. • Encourage caregiver to acknowledge and express feelings. Discuss normalcy of the reactions without using false reassurance. • Discuss caregiver’s/family members’ life goals, perceptions and expectations of self to clarify unrealistic thinking and identify potential areas of flexibility or compromise. • Discuss impact of and ability to handle role changes necessitated by situation.
NURSING PRIORITY NO. 4. To enhance caregiver’s ability to deal with current situation: • Identify strengths of caregiver and care receiver. • Discuss strategies to coordinate caregiving tasks and other responsibilities (e.g., employment, care of children/dependents, housekeeping activities). • Facilitate family conference to share information and develop plan for involvement in care activities as appropriate. • Identify classes and/or needed specialists (e.g., first aid/CPR classes, enterostomal/physical therapist). • Determine need for/sources of additional resources (e.g., financial, legal, respite care). • Provide information and/or demonstrate techniques for dealing with acting out/violent or disoriented behavior. Enhances safety of caregiver and receiver. • Identify equipment needs/resources, adaptive aids to enhance the independence and safety of the care receiver. • Provide contact person/case manager to coordinate care, provide support, assist with problemsolving.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Assist caregiver to plan for changes that may be necessary (e.g., home care providers, eventual placement in long-term care facility). • Discuss/demonstrate stress management techniques and importance of self-nurturing (e.g., pursuing self-development interests, personal needs, hobbies, and social activities). • Encourage involvement in support group. • Refer to classes/other therapies as indicated. • Identify available 12-step program when indicated to provide tools to deal with enabling/codependent behaviors that impair level of function. • Refer to counseling or psychotherapy as needed. • Provide bibliotherapy of appropriate references for self-paced learning and encourage discussion of information.
Documentation Focus ASSESSMENT/REASSESSMENT • Assessment findings, functional level/degree of impairment, caregiver’s understanding/perception of situation. • Identified risk factors. PLANNING • Plan of care and individual responsibility for specific activities. • Needed resources, including type and source of assistive devices/durable equipment. • Teaching plan. IMPLEMENTATION/EVALUATION • Caregiver/receiver response to interventions/teaching and actions performed. • Identification of inner resources, behavior/lifestyle changes to be made. • Attainment/progress toward desired outcome(s). • Modifications to plan of care. DISCHARGE PLANNING
• Plan for continuation/follow-through of needed changes. • Referrals for assist ASSESSMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: “eto nga at hianng hina siya, hindi naniya magalaw angright side niya” As stated by the significant other OBJECTIVE:-grade of 0 in the level of functioning-paraesthesia in the right side of thebody-0/5 muscle strength in theRUE-1/5 muscle strength in the RLE-impaired coordination-inability to purposefully move body part IMPAIREDPHYSICALMOBILITY r t neuromuscular involvement (right sided paraesthesia) abed inability to purposefully move body parts. HPN, age, alcohol, smoking ↓Thrombus formation in the blood vessel ↓Obstruction to the flow of blood↓ metabolic acidosis, an aerobic respiration ↓Destruction of neurons↓ DISCHARGEPLAN: After 2 week of Nursing Intervention the client will be able to move and do minimal task such as:-go to the toilet with minimal assistance- ambulate moderately-eat without assistance-do tooth brushing without assistance SHORT TERM: After 1 week of Nursing Intervention the Significant other will be able to verbalize understanding of *Observe movement when client is unaware of observation*schedule activities with adequate rest periods during the day* encourage energy conserving techniques for rising ADLs*encourage adequate intake of fluids and nutritious foods like: fruits and vegetables.*Plan for progressive increase of activity level/ participation in exercise, training as tolerated by the client, such as:-performing ROM*to note any in congruencies w/reports or abilities*to reduce fatigue and increase comfort.*limit fatigue and maximize participation*maximize energy production and aides in fast recovery.*Helps to minimize frustrations and rechanneled energy .DISCHARGE PLAN: After 2 week of Nursing Intervention the client had been able to move and do minimal task such as:-go to the toilet with minimal assistance-ambulate moderately-eat without assistance-do tooth brushing without assistance SHORT TERM: After 1 week of Nursing Intervention the Significant other had been able to verbalize understanding of the situation and /evaluation.
Long Term Goal: Patient will maintain a patent airway
Short Term Goals / Outcomes: Patients lungs sounds will be clear to auscultate Patient will be free of dyspnea Patient will demonstrate correct coughing and deep breathing techniques Intervention Assess airway for patency by asking the patient to state his name. Inspect the mouth, neck and position of trachea for potential obstruction. Auscultate lungs for presence of normal or adventitious lung sounds. Rationale Evaluation
Maintaining an airway is always top priority Patient is able to state their name especially in patients who may have experienced without difficulty. trauma to the airway. If a patient can articulate an answer, their airway is patent. Foreign materials or blood in the mouth, hematoma of the neck or tracheal deviation can all mean airway obstruction. No foreign objects, blood in mouth noted. Neck is free of hematoma. Trachea is midline.
Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.
Patient’s lungs sounds are clear to auscultation throughout all lobes.
Assess respiratory quality, rate, depth, effort and pattern.
Patient is free of signs of distress.
Assess for mental status changes.
Increasing lethargy, confusion, restlessness and / Patient is awake, alert and oriented or irritability can be early signs of cerebral X3. hypoxia. Tachycardia and hypertension occur with Patient is normotensive with heart
Assess changes in
vital signs. Monitor arterial blood gases (ABGs). Administer supplemental oxygen.
increased work of breathing. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs.
rate 60 – 100 bpm. ABGs show PaCO2 between 35-45 and PaO2 between 80 – 100. Patient is receiving oxygen. SaO2 via pulse oximetry is 90 – 100%.
Position Patient with Promotes better lung expansion and improved head of bed 45 gas exchange. degrees (if tolerated). Assist Patient with Assist patient to improve lung expansion, the coughing and deep productivity of the cough and mobilize breathing techniques secretions. (positioning, incentive spirometry, frequent position changes). Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). If a patient is unable to maintain an adequate airway, an artificial airway will be required to promote oxygenation and ventilation; and prevent aspiration.
Patient’s rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.
Artificial airway is placed and maintained without complications.
Confirm placement of Complications such as esophageal and right main stem intubations can occur during the artificial airway. insertion. Artificial airway placement should be confirmed by CO2 detector, equal bilateral breath sounds and a chest x-ray. If maxillofacial trauma is present: 1. position the patient for The patient with maxillofacial trauma is usually more comfortable sitting up. Any time there is trauma to the maxillofacial area there is the possibility of a compromised airway.
CO2 detector changes color, bilateral breath sounds are audible equally and artificial airway is at the tip of the carina on x-ray.
Patient exhibits normal respiratory rate and depth in sitting position. Patient is free of wheezing, stridor and facial edema.
optimal Noting swelling is important as a baseline for airway comparison later. clearance and constant assessment of airway patency 2. note the degree of swelling to the face and amount of blood loss 3. prepare the patient for definitive treatment If neck trauma is present: 1. assess for potential hemorrhage and disruption of the larynx or trachea 2. prepare the patient for CT scan Teach patient correct coughing and Deep breathing techniques. Weak, shallow breathing and coughing is ineffective in removing secretions. Patient is able to demonstrate correct coughing and breathing techniques. Hemorrhage or disruption of the larynx and trachea can be seen as hoarseness in speech, palpable crepitus, pain with swallowing or coughing, or hemoptysis. The neck should be also assessed for ecchymosis, abrasions, or loss of thyroid prominence. Laryngeal injuries are most definitely diagnosed by CT scans as soft tissue neck films are not sensitive to these injuries. Patient is free of signs of hemorrhage or disruption. CT scan reveals no injury to the larynx.
Nursing Diagnosis
Long Term Goal Patient will maintain optimal gas
Impaired Gas Exchange r/t altered oxygen supply Short Term Goals / Outcomes: Patient will maintain normal arterial blood gas (ABGs). Patient will be awake and alert. Patient will demonstrate a normal depth, rate and pattern of respirations. Interventions Assess respirations: quality, rate, pattern, depth and breathing effort. Rationale Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. Absence of ventilation, asymmetric breath sounds, dyspnea with accessory muscle use, dullness on chest percussion and gross chest wall instability (i.e. flail chest or sucking chest wound) all require immediate attention.
exchange
Evaluation Patient is free of signs of distress. ABGs show PaCO2 between 35-45 Pts respirations are of a normal rate and depth.
Assess for lifethreatening problems. (i.e. resp arrest, flail chest, sucking chest wound). Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation. Assess for signs of hypoxemia. Monitor vital signs.
Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities.
Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax.
Patient’s lungs sounds are clear to auscultate throughout all lobes.
Tachycardia, restlessness, diaphoresis, headache, Patient is free of signs of hypoxia. lethargy and confusion are all signs of hypoxemia. Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue. Patient is normotensive with heart rate 60 – 100 bpm and respiratory rate 10-20.
Assess for changes in orientation and behavior. Monitor ABGs.
Restlessness is an early sign of Patient is awake, alert and hypoxia. Mentation gets worse as hypoxia oriented X3. increases due to lack of blood supply to the brain. Increasing PaCO2 and decreasing PaO2 are signs of ABGs show PaCO2 between 35-45 respiratory failure. and PaO2 between 80 – 100. Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. SaO2 via pulse oximetry remains at 90 – 100%.
Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis. Provide supplemental oxygen, via 100% O2 non-rebreather mask. Prepare the patient for intubation.
Lack of oxygen delivery to the tissues will result in Patient is free of cyanosis. cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.
Early supplemental oxygen is essential in all Patient is receiving 100% trauma patients since early mortality is associated oxygen. SaO2 via pulse oximetry is with inadequate delivery of oxygenated blood to 90 – 100%. the brain and vital organs. Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient. Treatment needs to focus on the underlying problem that leads to the respiratory failure. Artificial airway is placed and maintained without complications.
Treat the underlying injuries with appropriate interventions. If rib fractures exist: 1. Assess for paradoxical chest movements. 2. Provide adequate
Appropriate injury specific treatment has been started.
Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a life-threatening complication of rib fractures that requires mechanical ventilation and aggressive pulmonary care. Pain relief is essential to enhance coughing and deep breathing.
No paradoxical movements are noted. Patient reports pain as <3 on 0-10 scale. Bilateral breath sounds present in all lobes.
pain 3. relief. Assess breath sounds. If Pneumothorax or Hemothorax exist: 1. obtain chest x-ray
Absence of bilateral breath sounds in the presence of a flail chest, indicates a pneumo/hemo thorax.
Chest tube is placed and connected to 20cm wall suction with good 2. prepare for tidaling and no air leak or SQ insertion of a A three sided dressing gives the accumulated air a emphysema noted. way to escape, thereby decreasing thoracic chest tube Three-sided dressing pressure and preventing a tension If open maintained. No further Pneumothorax. A chest tube must then be Pneumothorax exists cardiopulmonary decompensation inserted. place a dressing that noted in patient. is taped on three sides for temporary management. Position patient with Promotes better lung expansion and improved head of bed 45 gas exchange. degrees (if tolerated). Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest). Suction patient as needed. Promotes alveolar expansion and prevents alveolar collapse. Splinting helps reduce pain and optimizes deep breathing and coughing efforts. Patient’s rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.
A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax. A chest tube decreases the thoracic pressure and re-inflates the lung tissue.
Suctioning aides to remove secretions from the airway and optimizes gas exchange.
Patient suctioned for moderate amount of thin yellow secretion. Lung sounds clear after suctioning.
Hyperoxygenate patient with 100% before and after suctioning. Keep suctioning to 10-15 seconds. Pace activities and provide rest periods to prevent fatigue.
Prevents alteration in oxygenation during suctioning.
Patient’s SaO2 remained >90% during suctioning.
Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.
No changes to cardiopulmonary status noted during activity. Patients SaO2 remains >90% during activities.
Nursing Diagnosis Deficient Fluid Volume r/t active fluid loss due to bleeding
Long Term Goal Patient will maintain adequate fluid and electrolyte balance.
Short Term Goals / Outcomes: Patient will maintain urine output >30cc/hr. Patient will be normotensive with heart rate 60 -100bpm. Patient will demonstrate normal skin turgor. Interventions Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate. Rationale If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 – 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular. Cool, pale, diaphoretic skin suggests ineffective circulation due to hypovolemia. Active fluid and/or blood loss adds to Hypovolemic state and must be accounted for when replacing fluids. Evaluation All pulses palpable, strong and regular.
Assess skin color and temperature. Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding.
Skin pink, warm and dry.
All external bleeding controlled.
Monitor vital signs. (T,P,R,B/P)
Sinus tachycardia may occur with hypovolemia to maintain cardiac output. Hypotension is a hallmark of hypovolemia. Febrile states decrease body fluids through perspiration and increase respiratory rate. Greater than 10 mmHg drop signifies that circulating volume is reduced by 20%. Greater that 20 – 30 mmHg drop signifies blood volume is decreased by 40%. Abnormally flattened jugular veins and distant heart tones are signs of ineffective circulation. Loss of consciousness accompanies ineffective circulating blood volume to the brain.
Vital signs within normal limits.
Monitor blood pressure for orthostatic changes.
No orthostatic changes noted when patient placed from supine to Fowlers position.
Auscultate heart tones and inspect jugular veins.
S1, S2 audible. No flattening or distention of jugular vein noted.
Assess mental status.
Awake, alert and oriented X3.
Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes. Assess color and amount of urine.
Dry mucous membranes and tenting of the Normal skin turgor. Mucous skin are signs of hypovolemia. The sternum membranes pink and moist. and inner thigh should be used for skin turgor due to loss of elasticity with aging.
Concentrated urine and output <30cc for two consecutive hours indicate insufficient circulating volume.
Urine clear, yellow. Output at least 30cc/hr.
Monitor serum electrolytes and urine osmolality.
Elevated hemoglobin, Hematocrit and blood All lab values within normal urea nitrogen (BUN) accompany a fluid ranges. deficit. Urine specific-gravity is also increased. All values decrease with inadequate All pressures within normal circulating volume. Hemodynamic stability ranges. is the goal of fluid replacements. Monitoring of hemodynamic
Monitor hemodynamic pressures: central venous pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge
pressure (PCWP), if available. Initiate two large bore intravenous catheters (IVs) and start intravenous fluid replacements as ordered.
pressures can guide fluid replacements.
14 -16 gauge catheters are preferred in case fluids need to be given rapidly. Parenteral fluids are necessary to restore volume. Lactated Ringers is usually the fluid of choice due to its isotonic properties and close resemblance to the electrolyte composition of plasma. Blood and blood products will be necessary for active blood loss. If there is no time to wait for cross matching, Type O blood may be transfused.
Two large bore IVs started, lactated ringers infusing as per physician orders without complications.
Obtain a serum specimen for type and cross matCh Administer blood and blood products as ordered. During treatment monitor for signs of fluid overload.
Type and cross sent. Type specific blood infusing as per physician orders.
Due to large amounts of fluids administered No signs of overload noted with rapidly, circulatory overload can occur. fluid replacements. Headache, flushed skin, tachycardia, venous distention, elevated hemodynamic pressures (CVP, PCWP), increased blood pressure, dyspnea, crackles, tachypnea and cough are all signs of overload. Central venous line and arterial line inserted without difficulty.
Assist the physician with Provides for more effective fluid insertion of a central venous replacements and accurate monitoring of line and arterial line if hemodynamic picture. indicated.
Nursing Diagnosis Acute Pain r/t trauma
Long Term Goal Patient will be free of pain
Short Term Goals / Outcomes: Patient will report pain less than 3 on 0-10 scale. Patient’s vital signs will be within normal limits.
Interventions Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors. Monitor vital signs.
Rationale A good assessment of pain will help in the treatment and ongoing management of pain.
Evaluation Patient reports pain as 3 or less on 0-10 scale; intermittent and sharp in incision area.
Tachycardia, elevated blood pressure, tachypnea and Vital signs within fever may accompany pain. normal limits. Some patients may verbally deny pain when it is still present. Restlessness, inability to focus, frowning, grimacing and guarding of the area may be nonverbal signs of acute pain. Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration. No non-verbal signs of pain noted.
Assess for non-verbal signs of pain.
Give analgesics as ordered and evaluate the effectiveness.
Analgesics given as ordered. Patient reports satisfactory pain relief after administration. Patient states “I want some relief. I know some pain will still exist.” No complications of analgesia noted.
Assess the patient’s expectations of pain relief.
Some patients are content with reduction in pain, others may expect complete elimination. This effects the patient’s perception of the effectiveness of treatment. Excessive sedation and respiratory depression are severe side effects that need reported immediately and may require discontinuation of medication. Urinary retention, nausea/vomiting and constipation can also occur with narcotic use and need reported and treated.
Assess for complications to analgesics, especially respiratory depression.
Anticipate the need for The most effective way to deal with pain is to pain relief and respond prevent it. Early intervention can decrease the total
Patient reports pain as
immediately to complaints of pain.
amount of analgesic required. Quick response decreases the patient’s anxiety regarding having their needs met and demonstrates caring.
soon as it starts.
Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation. Institute nonpharmacological approached to pain (detraction, relaxation exercises, music therapy, etc.). If patient is on patient controlled analgesia (PCA): 1. Dedicate an IV line for PCA only.
Outside sources of stress, anxiety and lack of sleep all Patient appears relaxed, is sleeping may exaggerate the patient’s perception of pain. throughout the night.
Non-pharmacological approaches help distract the patient from the pain. The goal is to reduce tension and thereby reduce pain.
Patient is relaxing by use of nonpharmacological technique of choice.
Drug interaction may occur, if dedicated line is not possible consult pharmacist before mixing drugs.
2. Assess pain relief and the The patient and significant others must understand amount of pain that the patient is the only one who should control the patient is the PCA. requesting. 3. Educate patient and significant others on correct use of PCA. If the patient is receiving epidural analgesia: These symptoms indicate an allergic response, or improper catheter placement. Labeling of tubing is necessary to prevent
PCA infusing without complications. Patient and family understand If demands for the drug are frequent the basal or purpose and use of lock-out dose may need to be increased to cover the PCA. Patient is getting patient’s pain. adequate pain relief If demands for the drug are very low, the patient may with current dose. need further education of use of the PCA.
All tubing labeled. No signs of allergic reaction or catheter
1. Assess for numbness, tingling in extremities; and a metallic taste in the mouth. 2. Label all tubing clearly. For PCA and epidural analgesia: 1. Keep Narcan readily available. 2. Place “No additional analgesia” sign over head of bed.
inadvertent administration of fluids or drugs in the epidural space. Catheter migration or improper administration through the catheter can result in life-threatening complications.
migration noted.
In event of respiratory depression reversal agent must be available. This prevents inadvertent analgesia overdosing.
Narcan on unit if needed. Sign placed in room for safety.
Nursing Diagnosis Risk For Infection r/t inadequate primary defenses
Long Term Goal Patient will be free of infection
Short Term Goals / Outcomes: Patient will maintain normal vital signs. Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes. Interventions Rationale Evaluation Patient has midline thoracic incision, Foley, chest tube and peripheral IV access.
Assess for presence of risk Represent a break in body’s first line of factors: open wounds, defense. abrasions; indwelling catheters; drains; artificial airways; and venous access devices. Monitor white blood count Normal WBC is 4-11 mm3. Rising WBC
Patient’s WBC are within
(WBC).
indicates the body’s attempt to combat pathogens. Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.
the normal range.
Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection.
All areas are without signs of infection.
Monitor temperature and the In the first 24-48 hours fever up to 38 Temperature is less than presence of sweating and chills. degrees C (100.4F) is related to the stress of 37.7C. No sweating or surgery. After 48 hours fever above 37.7C chills present. (99.8F) suggests infection. High fever with sweating and chills suggests septicemia. Monitor the color of respiratory Yellow or yellow-green sputum indicates a secretions. respiratory infection. Monitor the appearance of urine. Patient coughs up only thin clear secretions.
Cloudy, foul-smelling urine, with sediments Urine is clear yellow indicates a urinary tract or bladder with no sediments. infection. Strict asepsis is necessary to prevent crosscontamination and nosocomial infections. No further infections are noted.
Maintain strict aseptic technique with all dressing changes; tubes, drains and catheter care; and venous access devices.
Wash hands and teach others to Hand washing reduces the risk of wash hands before and after transmitting pathogens from one area of the body to another as well as from one patient care. patient to another. Encourage fluid intake of 2000ml – 3000ml of water per day (unless contraindicated). Fluids promote frequent emptying of the bladder, reducing stasis of urine and risk of urinary tract and bladder infections.
No further infections are noted.
Patient drinks 2000 3000 ml of fluid. No presence of urinary tract or bladder infections.
Encourage intake of protein and Optimal nutritional status promotes wound Wounds are well calorie rich foods. Provide healing. approximated. enteral feeding in patients who
are NPO. Encourage coughing and deep breathing. Reduces stasis of pulmonary secretions, reducing the risk of pneumonia. Patient coughs up thin clear secretions.
Administer and teach the use of All agents are either toxic to the pathogens WBC within normal limits. No further antimicrobial drugs as ordered. or retard the pathogen’s growth. Ideally medications should be selected based on a infections noted. culture from the infected area. A broadspectrum agent may be started until culture reports are available.
Nursing Diagnosis Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased arterial flow & cerebral edema
Long Term Goal Patient will maintain optimal tissue perfusion to vital organs
Short Term Goals / Outcomes: Patient will maintain strong peripheral pulses. Patient will report absence of chest pain. Patient will be awake, alert and oriented. Patient will maintain normal arterial blood gases (ABGs). Patient will maintain normal urine output. Patient will maintain normal bowel sounds. Interventions Assess each area for signs of decreased tissue perfusion. Rationale Early detection facilitates prompt, effective treatment. Signs may be: Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool to touch; mottling; prolonged capillary refill Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, abnormal ABGs, angina Renal: decreased output, hematuria, elevated BUN/creatinine ratio No signs of decreased perfusion noted. Evaluation
GI: decreased or absent bowel sounds; nausea; abdominal pain / distention Cerebral: restless, change in mentation seizure activity, papillary changes and decrease reaction to light Monitor vital signs for Adequate perfusion to vital organs is essential. A optimal cardiac output. mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion. Administer fluids and blood products as ordered. Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage. All vital signs within normal limits.
Fluids infusing. Vital signs, urine output and mentation all within normal limits. Heparin infusing. PTT within therapeutic range.
Anticipate the need for possible antithrombolytic therapy. Assess for compartment syndrome if peripheral circulation is impaired (pain, palor, pulselessness, paralysis, parathesia). Administer oxygen as prescribed. Titrate oxygen based on continuous pulse oximetry levels.
If an obstruction to the area has developed an embolectomy, heparinzation, or thrombolytic therapy may be necessary to restore flow and prevent ischemia Compartment syndrome develops as the tissue swells and the fascial covering over the muscles can not yield to the pressure. Blood flow to the extremity is drastically reduced. An emergent fasciotomy may need to be performed to restore flow.
No signs of compartment syndrome noted.
Oxygen saturates circulating hemoglobin and Patient receiving increases the effectiveness of blood that reached the oxygen. Pulse ischemic tissues. Thus improving tissue perfusion. Oximetry 90 – 100%.
Monitor ABGs, Metabolic acidosis and hypoxia indicate that tissues especially for metabolic are not adequately being perfused. acidosis and hypoxia. If Patient complains of NTG causes vasodilation, decreases preload and afterload and thus improves perfusion to the
ABGs within normal limits.
NTG administer. Patient
angina; 1. administer nitroglycerin (NTG) sublingually. If cerebral perfusion is compromised: 1. Ensure proper functioning of intracranial pressure (ICP) catheter if present.
myocardium.
reports relief of angina.
Promotes venous outflow from brain and helps reduce pressure.
Patient awake and alert with no change in mentation. No seizures noted
Straining, coughing, neck or hip flexion and lying supine may increase ICP and further reduce blood 2. Elevate head of flow. bed 30 -45 Reduces the risk of seizures, which may result from degrees. cerebral edema or ischemia. 3. Avoid measures that may trigger increased ICP 4. Administer anticonvulsants as needed.
ASSESSMENT
DIAGNOSIS
INFERENCE
PLANNING
INTERVENTI ON INDEPENDEN T Monitor vital signs as well as central venous pressure.
RATIONALE
EVALUATIO N After 4 hours of nursing interventio ns, the Patient was able to demonstrat e stabilized fluid volume as evidenced by balanced intake and output (I&O) and vital signs within client’s normal range.
SUBJECTIVE:
“Namamanas ang paa ko”(My feet are swelling) as verbalized by the patient.
Excess fluid volume related to compromis ed regulatory mechanism
OBJECTIVE:
Restlessn ess Fatigue Edema on lower extremitie s
V/S taken as follows
T: 36.9˚C
Excessive fluid volume in the blood. This fluid excess usually results from compromis ed regulatory mechanism s for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It can also be caused by too much intake of sodium from foods, intravenous (IV) solutions, medication s, or
After 4 hours of nursing interventio ns, the Patient will demonstrat e stabilized fluid volume as evidenced by balanced intake and output (I&O) and vital signs within client’s normal range.
Tachycar dia and hyperten sion are common manifest ations. Crackle sounds and extra heart sounds are indicative of fluid excess, possibly resulting in rapid develop ment of pulmonar y edema. Decrease d renal perfusion , cardiac insufficie ncy, and fluid shifts may cause
Auscultat e lung and heart sounds.
Maintain adequat e I&O. Note decrease d urinary output
P: 102 R: 20 BP: 110/ 80
diagnostic contrast dyes. The excess fluid, mainly salt and water, builds up in different body locations and can lead to swelling in the legs and arms (peripheral edema), and/or fluid in the abdomen (ascites).
and positive fluid balance on 24hour calculati ons.
decrease urinary output and edema formatio n. One liter of fluid retention equals a weight gain of 1 kilogram. Pulmonar y fluid shifts potentat e respirato ry complicat ions. Gravity improves lung expansio n.
Weigh as indicated . Be alert for sudden weight gain.
Encourag e coughing and deep breathin g exercises .
Maintain semifowler’s position.
Reduce pressure and friction on edemato us tissue.
Turn or repositio n, and provide skin care at regular intervals.
Encourag e bed rest.
Limited cardiac reserves results in fatigue and activity intoleran ce.
Caregiver Role Strain - Evaluation, Interventions, Documentation 9:23 PM Posted by Pak Mantri
Desired Outcomes/Evaluation Criteria—Client Will: • Identify resources within self to deal with situation. • Provide opportunity for care receiver to deal with situation in own way. • Express more realistic understanding and expectations of the care receiver. • Demonstrate behavior/lifestyle changes to cope with and/or resolve problematic factors. • Report improved general well-being, ability to deal with situation.
Actions/Interventions NURSING PRIORITY NO. 1. To assess degree of impaired function: • Inquire about/observe physical condition of care receiver and surroundings as appropriate. • Assess caregiver’s current state of functioning (e.g., hours of sleep, nutritional intake, personal appearance, demeanor).
• Determine use of prescription/over-the-counter (OTC) drugs, alcohol to deal with situation. • Identify safety issues concerning caregiver and receiver. • Assess current actions of caregiver and how they are received by care receiver (e.g., caregiver may be trying to be helpful but is not perceived as helpful; may be too protective or may have unrealistic expectations of care receiver). May lead to misunderstanding and conflict. • Note choice/frequency of social involvement and recreational activities. • Determine use/effectiveness of resources and support systems.
NURSING PRIORITY NO. 2. To identify the causative/contributing factors relating to the impairment: • Note presence of high-risk situations (e.g., elderly client with total self-care dependence, or family with several small children with one child requiring extensive assistance due to physical condition/developmental delays). May necessitate role reversal resulting in added stress or place excessive demands on parenting skills. • Determine current knowledge of the situation, noting misconceptions, lack of information.May interfere with caregiver/ care receiver response to illness/condition. • Identify relationship of caregiver to care receiver (e.g., spouse/lover, parent/child, sibling, friend). • Ascertain proximity of caregiver to care receiver. • Note physical/mental condition, complexity of therapeutic regimen of care receiver. • Determine caregiver’s level of responsibility, involvement in and anticipated length of care. • Ascertain developmental level/abilities and additional responsibilities of caregiver. • Use assessment tool, such as Burden Interview, when appropriate, to further determine caregiver’s abilities. • Identify individual cultural factors and impact on caregiver. Helps clarify expectations of caregiver/receiver, family, and community. • Note co-dependency needs/enabling behaviors of caregiver. • Determine availability/use of support systems and resources. • Identify presence/degree of conflict between caregiver/care receiver/family. • Determine preillness/current behaviors that may be interfering with the care/recovery of the care receiver.
NURSING PRIORITY NO. 3. To assist caregiver in identifying feelings and in beginning to deal with problems: • Establish a therapeutic relationship, conveying empathy and unconditional positive regard. • Acknowledge difficulty of the situation for the caregiver/ family. • Discuss caregiver’s view of and concerns about situation. • Encourage caregiver to acknowledge and express feelings. Discuss normalcy of the reactions without using false reassurance. • Discuss caregiver’s/family members’ life goals, perceptions and expectations of self to clarify unrealistic thinking and identify potential areas of flexibility or compromise. • Discuss impact of and ability to handle role changes necessitated by situation.
NURSING PRIORITY NO. 4. To enhance caregiver’s ability to deal with current situation: • Identify strengths of caregiver and care receiver. • Discuss strategies to coordinate caregiving tasks and other responsibilities (e.g., employment, care of children/dependents, housekeeping activities). • Facilitate family conference to share information and develop plan for involvement in care activities as appropriate. • Identify classes and/or needed specialists (e.g., first aid/CPR classes, enterostomal/physical therapist). • Determine need for/sources of additional resources (e.g., financial, legal, respite care). • Provide information and/or demonstrate techniques for dealing with acting out/violent or disoriented behavior. Enhances safety of caregiver and receiver. • Identify equipment needs/resources, adaptive aids to enhance the independence and safety of the care receiver. • Provide contact person/case manager to coordinate care, provide support, assist with problemsolving.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Assist caregiver to plan for changes that may be necessary (e.g., home care providers, eventual placement in long-term care facility). • Discuss/demonstrate stress management techniques and importance of self-nurturing (e.g., pursuing self-development interests, personal needs, hobbies, and social activities). • Encourage involvement in support group. • Refer to classes/other therapies as indicated. • Identify available 12-step program when indicated to provide tools to deal with enabling/codependent behaviors that impair level of function. • Refer to counseling or psychotherapy as needed. • Provide bibliotherapy of appropriate references for self-paced learning and encourage discussion of information.
Documentation Focus ASSESSMENT/REASSESSMENT • Assessment findings, functional level/degree of impairment, caregiver’s understanding/perception of situation. • Identified risk factors. PLANNING • Plan of care and individual responsibility for specific activities. • Needed resources, including type and source of assistive devices/durable equipment. • Teaching plan. IMPLEMENTATION/EVALUATION • Caregiver/receiver response to interventions/teaching and actions performed. • Identification of inner resources, behavior/lifestyle changes to be made. • Attainment/progress toward desired outcome(s). • Modifications to plan of care. DISCHARGE PLANNING
• Plan for continuation/follow-through of needed changes. • Referrals for assist ASSESSMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: “eto nga at hianng hina siya, hindi naniya magalaw angright side niya” As stated by the significant other OBJECTIVE:-grade of 0 in the level of functioning-paraesthesia in the right side of thebody-0/5 muscle strength in theRUE-1/5 muscle strength in the RLE-impaired coordination-inability to purposefully move body part IMPAIREDPHYSICALMOBILITY r t neuromuscular involvement (right sided paraesthesia) abed inability to purposefully move body parts. HPN, age, alcohol, smoking ↓Thrombus formation in the blood vessel ↓Obstruction to the flow of blood↓ metabolic acidosis, an aerobic respiration ↓Destruction of neurons↓ DISCHARGEPLAN: After 2 week of Nursing Intervention the client will be able to move and do minimal task such as:-go to the toilet with minimal assistance- ambulate moderately-eat without assistance-do tooth brushing without assistance SHORT TERM: After 1 week of Nursing Intervention the Significant other will be able to verbalize understanding of *Observe movement when client is unaware of observation*schedule activities with adequate rest periods during the day* encourage energy conserving techniques for rising ADLs*encourage adequate intake of fluids and nutritious foods like: fruits and vegetables.*Plan for progressive increase of activity level/ participation in exercise, training as tolerated by the client, such as:-performing ROM*to note any in congruencies w/reports or abilities*to reduce fatigue and increase comfort.*limit fatigue and maximize participation*maximize energy production and aides in fast recovery.*Helps to minimize frustrations and rechanneled energy .DISCHARGE PLAN: After 2 week of Nursing Intervention the client had been able to move and do minimal task such as:-go to the toilet with minimal assistance-ambulate moderately-eat without assistance-do tooth brushing without assistance SHORT TERM: After 1 week of Nursing Intervention the Significant other had been able to verbalize understanding of the situation and /evaluation.
