Nursing Care Plans Wide

Nursing Care Plans
2015
By Linda Stanford, RN, MSN
CCS Publishing
Nursing Diagnosis Care Plans
Activity Intolerance
related to
Generalized weakness
Prolonged bed rest
Activity restriction
Imbalanced oxygen supply and demand
Pain
Adverse medication effects
Desired Outcomes:
Patient has tolerance to physical activity, as evidenced by an exertion rating of <3 (on a scale of 0 to 10), heart rate <120 bpm, RR
<20 bpm, and absence of chest pain or labored breathing.
Patient is able to perform activities of daily living.
Assessments and Interventions Rationales
Assess the patient’s level of physical activity and mobility. Activity level and mobility provides a basis for goal setting.
Assess the patient’s nutritional status. Adequate energy reserves are needed for activities.
Assess the patient’s sleep pattern and the over the last 2 Difficulties sleeping should be addressed and treated.
weeks.
Assess the patient’s medications. Fatigue is an adverse effect of beta-Blockers, calcium blockers, anti-
depressants, alcohol, muscle relaxants, and sedatives.
Assess the patient’s heart rate and check for orthostatic Heart rate should not increase by more than 20 bpm with activities.
blood pressure changes Elderly patients often have an orthostatic decrease in BP of 20
mmHg.
Assess the patient’s response to activity. Abnormal respons- Assessment helps to guide progression of activity.
es to activity include tachycardia of 20 bpm over the resting
heart rate, or >120 bpm; increase in systolic blood pressure
of more than 20 mmHg; labored breathing, weakness, light-
headedness.
Create activity goals. The motivation will be increased if he sets his own goals. The goal
may be able to live independently.
Gradually increase activity with active range-of-motion exer- Gradual progression prevents heart overexertion of the heart. The
cises in bed, increasing to sitting and standing. Dangling the duration and frequency of exercise should be increased before in-
legs from the beside for 10 to 15 minutes, tid. Sitting in a creasing the intensity of exercise.
chair for 30 minutes, tid. Walking in the room tid.
Teach range-of-motion exercises. Exercise improves muscle strength and joint ROM.
Assess for the need for a walker or cane. Assistive devices will help the patient prepare to function.
Teach energy-conservation techniques: Conservation of energy reduces the patient’s oxygen consumption.
Sitting to perform tasks.
Pushing rather than pulling.
Sliding rather than lifting.
Using wheeled carts.
Teach to use bed rails and head of bed elevation when get- Assistive aids conserve energy and reduce the risk of falls.
ting out of bed. Place a chair in bathroom and install hall rails.
Airway'Clearance' 4
Ineffective Airway Clearance
related to
Fatigue
Pneumonia or bronchitis
Foreign body airway obstruction
Excessive tracheobronchial secretions
Decreased respiratory muscle function
Desired Outcomes:
Patient will maintain an open airway, as evidenced by normal breath sounds, normal respiratory rate, and normal depth of respira-
tions.
Assess airway for patency. Auscultate for wheezing, rhonchi, Wheezing indicates partial airway obstruction.
or crackles Crackles indicate fluid in the alveoli.
Assess rate, rhythm, and depth of respirations, labored Abnormal respirations indicate respiratory compromise. Increased
breathing, use of accessory muscles, or tripod positioning. respiratory rate indicates airway obstruction.
Assess for decreased level of consciousness. Confusion and restlessness are early signs of cerebral hypoxia. Leth-
argy and somnolence are late signs of hypoxia.
Assess for temperature >38.6° C, heart rate >100/min, and a Fever may be a manifestation of pneumonia. Tachycardia and hypo-
systolic blood pressure <90 mm Hg. tension may result from hypoxia.
Assess color and volume of secretions. Pneumonia or bronchitis may cause yellow sputum.
Send a sputum specimen for culture and sensitivity testing. Respiratory infections and pneumonia require antibiotic treatment.
Monitor oxygen saturation and assess arterial blood gases. Pulse oximetry detects oxygen desaturation.
Oxygen saturation should be maintained between 94% and 99%.
Decreased partial pressure of oxygen and decreasing oxygen satura-
tion can result from excessive airway secretions.
Assess hydration status by checking skin turgor, mucous Dehydration and thick secretions reduce airway clearance.
membrane moisture, and tongue moisture.
If the patient is on a mechanical ventilator, monitor peak air- Increased airway pressure and resistance indicates excessive secre-
way pressures and airway resistance. tions and inadequate ventilation.
Encourage the patient to take deep breaths and cough three Coughing is the best method of removing secretions.
times to succession.
Instruct the patient to assume the sitting position Coughing expels secretions from the airways. The sitting position and
Use of pillow to splint when coughing splinting of the abdomen increases the effectiveness of coughing.
Use incentive spirometry Walking improves lung expansion.
Encourage walking
Place the patient in the upright position with head of bed at The upright position prevents the abdominal contents from pushing
45 degrees. up on the diaphragm.
If gurgling or increased ventilatory pressure is present, use Suctioning is indicated when secretions are obstructing the airways.
nasotracheal suctioning.
Administer humidified oxygen. Humidity in inspired air reduces the viscosity of secretions.
Encourage increased fluid intake. Hydration reduces the viscosity of secretions.
Administer antibiotics, inhaled steroids, bronchodilators, and These medications promote reduce airway resistance.
nebulized bronchodilators.
Airway'Clearance' 5
Anticipate the need for an artificial airway if secretions cannot Intubation may be needed if secretions prevent adequate oxygena-
be cleared. tion.
Allergy'Response' 6
Latex Allergy Response
related to
Hypersensitivity to latex rubber
Desired Outcomes:
Patient avoids exposure to latex rubber.
Patient seeks treatment when symptoms of latex allergy response develop.
Assess for a history of myelomeningocele or childhood uro- Childhood surgeries for neural tube defects or urinary tract abnormali-
genital abnormalities. ties are associated with latex allergy.
Assess for a history of allergy to bananas, avocados, toma- These foods contain antigens that are similar to latex rubber. Patients
toes, kiwi, mangos, and chestnuts. with these food allergies often have a sensitivity to latex.
Assess for a history of allergic reactions after contact with Symptoms of latex allergy may have previously occurred after blow-
balloons, condoms, diaphragms, or latex gloves. ing up a balloon or after medical or dental procedures.
Place an allergy band on the patient. Record the latex allergy Other health care providers should be apprised of the patient's latex
in the patient's medical record, and post a latex allergy sign allergy.
over the patient's bed.
Remove latex products from the patient’s environment. Latex products include blood pressure cuffs, gloves, adhesive tape,
tourniquets, injection ports, electrode pads, stethoscope tubing, and
vial stoppers.
Place latex-free equipment in the patient’s room. Latex-free equipment and a latex-free an emergency crash cart
should be available.
Latex-free gloves should be used for patient care. Non-latex gloves prevent the patient from inhaling latex or contact
with latex particles.
Administer preventive medications. Antihistamines, corticosteroids, and H2-histamine blockers are used
as pre-drugs if the patient is undergoing procedures in which latex
exposure may occur.
Initiate emergency care if the patient has Circulation, airway patency, and breathing are priorities. Drug therapy
an anaphylactic reaction. includes epinephrine and methyl prednisolone.
Educate the patient and family members about the symptoms Early recognition of latex allergy reaction allows for prompt initiation
of latex allergy reaction, such as hives, flushing, and itching. of treatment.
Educate the patient and family about the emergency Patients with latex sensitivity and their families should learn to use
treatment of latex allergy. injectable epinephrine.
Educate the patient and family about sources of latex in the Sources of latex include balloons, condoms and diaphragms, rubber
home and work place. bands, adhesive tape, toys, sports equipment, carpet backing, elastic
on clothing, computer mouse pads, and shoe soles.
Advise the patient to wear a medical alert tag and notify phy- Identification reduces the risk of exposure to latex.
sicians about the latex allergy.
Anxiety' 7
Anxiety
related to
Changes in Economic status
Interpersonal relationships
Role function or status
Environment
Health status
Desired Outcomes:
Patient uses effective stress coping mechanisms
Patient states a decrease in anxiety level
Assess the patient's level of anxiety. Patients with mild anxiety may report nervousness. Heart rate may be
increased.
Determine how the patient uses coping strategies to reduce Evaluation helps determine the effectiveness of coping strategies
anxiety. used by the patient. Coping strategies may include journaling or tak-
ing a walk.
Orient the patient to his environment. Orientation to surroundings decreases anxiety.
Use simple, brief statements when giving instructions. Anxiety reduces the patient’s ability to understand instructions.
Maintain a quiet environment. Excessive conversation or noise may cause increased anxiety.
Teach the patient to talk about anxiety-provoking situations. Talking about anxious feelings can help the patient recognize factors
that lead to anxious feelings.
Teach the patient anxiety-reducing skills, such as relaxation, Coping methods will provide the patient with techniques to manage
deep breathing, and reassuring self-statements. anxiety.
Instruct the patient in the use of an anxiolytic medication. Antianxiety drugs can enhance patient coping and reduce physiologi-
cal manifestations of anxiety.
Teach about benzodiazepines, such as lorazepam (Ativan) Benzodiazepines should be used for short-term treatment of anxiety.
and alprazolam (Xanax) Physical dependence and tolerance may develop.
Teach about Buspirone (BuSpar) BuSpar causes less dependence than benzodiazepines. BuSpar re-
quires 1 to 2 weeks to produce a therapeutic effect.
Selective serotonin reuptake inhibitors (SSRIs) SSRIs are used for panic disorder and generalized anxiety.
Teach the patient to avoid central nervous system Caffeine and methamphetamine can exacerbate anxiety.
stimulants.
Refer the patient for psychiatric care. Psychiatric care may be needed when
anxiety becomes severe and interferes with daily
functioning.
Aspiration' 8
Risk for Aspiration
related to
Reduced level of consciousness.
Impaired swallowing.
Tracheostomy or endotracheal tube.
Gastrointestinal tubes.
Tube feedings.
Drug or alcohol intoxication
Patient maintains a patent airway, as evidenced by normal breath sounds and absence of cough or labored breathing.
Assess level of consciousness Decreased level of consciousness is a risk factor for aspiration.
Assess gag reflex. Assess swallowing ability by having the pa- Loss of the gag reflex increases the risk of aspiration. Coughing,
tient swallow a sip of water. choking after swallowing indicates dysphagia. Dysphagia in-
creases the risk of aspiration.
Assess swallowing studies. A videofluoroscopic swallowing study assesses swallowing.
Assess for nausea or vomiting. Vomiting increases the risk for aspiration. Antiemetics prevent
aspiration.
Check nasogastric tube position by instilling and removing 5 mL A displaced tube may deliver tube feeding into the airway. Chest
of sterile water before feeding. x-ray verification is the most reliable method of checking tube
position.
Check residuals before feeding or every 4 hours if feeding is con- Residuals of more than 15 mL indicate delayed gastric emptying
tinuous. Hold feedings if residual volume is more than 15 mL. and can cause emesis.
If the patient has dysphagia, make the patient NPO, and notify Patients at high risk for aspiration should be kept NPO until a
the physician of difficulty swallowing. swallowing study has been completed.
Observe the patient during oral intake. Supervision of eating allows for detection of aspiration.
Offer thickened foods, such as pudding and oatmeal. Thickened foods, such as pudding and oatmeal, are less likely to
be aspirated. Liquids are most likely to be aspirated.
Encourage the patient to chew food thoroughly and eat slowly. Well-masticated food is easier to swallow. Food should be cut
into small pieces.
Remove distractions during mealtimes. Recommend that the Talking while eating or drinking causes the airway to be open
patient not talk while eating. while food is in the pharynx.
Place medications and food on the strong side of the patient’s Placement of the food on the strong side facilitates chewing and
mouth. swallowing.
Offer liquids after solid food has been eaten. Separation of food and liquids lessens dysphagia.
Position the patient at 90-degrees and keep the patient upright The upright position facilitates the flow of food through the gastro-
for 30 minutes after feedings. intestinal tract.
For patients with feeding tubes: Elevate the head of the head-of- Upright positioning reduces the risk of aspiration by reducing
bed to 30 degrees during feedings and for 30 minutes after feed- reflux of gastric contents.
ings.
Consult a speech pathologist. A speech pathologist can perform a dysphagia evaluation, video-
fluoroscopy, and can teach techniques to prevent aspiration.
Aspiration' 9
Demonstrate to the caregiver what Aspiration requires immediate action by the caregiver to maintain
should be done if the patient aspirates. Use the abdominal thrust the airway.
maneuver if the patient is unable to speak or breathe. If liquid
aspiration, turn the patient three-fourths prone with the head low-
er than the chest. If the patient has difficulty breathing, call the 9-
1-1.
Bleeding' 10
Risk for Bleeding
related to
Gastrointestinal disorders, impaired liver function, coagulopathies or trauma
Desired Outcomes:
Patient uses measures to prevent bleeding and identifies signs of bleeding that should be reported.
Patient does not experience bleeding, as evidenced by stable hemoglobin and hematocrit levels, normal coagulation profiles, normal
blood pressure and heart rate, and a pulse pressure 30-40 mmHg.
Assess the patient’s health history for bleeding risk factors, such Early identification of risks for bleeding allows for preventive
as liver disease, and peptic ulcer disease. measures.
Assess for use of salicylates, anticoagulants, NSAIDs, or cancer Drugs that delay clotting or impair platelet activity increase the
chemotherapy, which can cause bleeding. risk of bleeding. NSAIDs reduce platelet aggregation. Warfarin,
an oral anticoagulant, decreases blood clotting. Drugs used to
treat cancer may suppress bone marrow platelet production.
Assess for systolic BP <90 mm hg, heart rate >100/min, pulse Tachycardia, hypotension, narrowed pulse pressure and cold
pressure <35 mm Hg, and cold skin. skin are signs of shock due to hemorrhage. The patients with
blood loss may have lightheadedness after changing positions.
Assess skin and mucous membranes for petechiae, bruising, or Patients with thrombocytopenia or impaired clotting may have
bleeding. bleeding after minor injuries.
Assess international normalized ratio (INR), partial thromboplas- Decreased clotting factors can prolong clotting. These laboratory
tin time (PTT). tests provide information about the patient's bleeding risk.
Assess hematocrit and hemoglobin. Decreased Hgb and Hct levels decrease after bleeding.
Assess stool for occult blood. This test detects bleeding from the gastrointestinal tract.
Teach patients at risk for bleeding to take precautions to prevent Avoiding dangerous activities reduces the risk of bleeding.
trauma, such as avoiding activities where injury may occur.
Avoid rectal suppositories, rectal thermometers, enemas, vaginal These devices may cause mucosal trauma and blood loss.
douches, and tampons.
Avoid straining with bowel movements and avoid forceful nose These activities may cause trauma to the rectum and nasal pas-
blowing. Use caution with sharp objects. Use an electric razor for sages.
shaving.
For bleeding associated with dabigatran (Pradaxa) administer Prothrombin complex concentrate reverses dabigatran (Pradaxa).
prothrombin complex concentrate. For warfarin (Coumadin), ad- Fresh frozen plasma reverses warfarin.
minister fresh frozen plasma.
Encourage dietary fiber, fluids, and a stool softener to reduce Hard, dry feces may cause hemorrhoids. Fiber, fluids, and a stool
constipation. softener will soften the stools and prevent bleeding from hemor-
rhoids.
Teach the patient to monitor stools for black tar color. Black tarry stools are a sign of upper gastrointestinal bleeding.
Teach the patient to avoid aspirin and NSAIDs (ibuprofen and Medications that reduce platelet aggregation may increase gas-
naproxen). trointestinal bleeding.
Teach the patient to control bleeding with direct pressure. Application of direct pressure controls bleeding.
Breathing'Pattern' 11
Ineffective Breathing Pattern
related to
Spinal cord injury, muscle weakness, viral or bacterial infection, or tracheobronchial obstruction
Desired Outcomes:
The patient maintains an effective breathing pattern, as evidenced by breathing at a normal rate and depth and absence of labored
breathing.
Assess the patient’s respiratory rate and depth. Rapid breathing (>20/minute) or slow breathing (<12/min) is signs
of respiratory distress.
Assess for use of accessory muscles (scalene and sternocleido- Patients with COPD may use accessory muscles for breathing.
mastoid muscles).
Assess for paradoxical abdominal motion. Paradoxical movement of the abdomen (inward during inspira-
tion) indicates respiratory muscle fatigue.
Assess the patient’s breathing position. The tripod position (leaning forward and supporting the chest with
arms) is a sign of respiratory distress.
Assess for precipitating and alleviating factors. Knowing precipitating and relieving factors aids in planning pre-
ventive interventions.
Assess for cough and increased sputum. Cough and sputum may indicate pneumonia or bronchitis.
Send a sputum specimen for culture and sensitivity. Sputum culture may reveal the cause of the pneumonia.
Assess for decreased consciousness. Restlessness, confusion, or irritability are early
indicators of cerebral hypoxia. Lethargy and unconsciousness
are signs of severe hypoxia.
Assess pulse oximetry and an arterial blood gas. Pulse oximetry is useful for monitoring oxygen saturation. In-
creasing PaO2 and decreasing PaO2 are signs of respiratory
failure and decreased respiration will cause increased PaCO2.
Position the patient in the high-Fowler’s position. The sitting position increases diaphragmatic excursion.
Encourage the use of an incentive spirometer Incentive spirometry promotes deep inspiration, which increases
oxygenation and prevents atelectasis.
If upper airway secretions cannot be cleared, perform suctioning. Suctioning may be needed to maintain an open airway.
Administer oxygen to maintain an oxygen saturation of 94-99%. An oxygen saturation of <94% may cause hypoxia, acidosis, and
dysrhythmias.
Administer albuterol and prednisone. Beta-agonists, such as albuterol (Ventolin) cause bronchodila-
tion. Corticosteroids decrease bronchiolar inflammation.
Arrange for intubation and mechanical ventilation if the patient Early intubation and mechanical ventilation prevents respiratory
has inadequate breathing. failure.
Teach patient to use the metered-dose inhaler. Teaching provides safe and effective administration of beta an-
tagonist medication.
Instruct in the use of oxygen. Knowledge of home oxygen use, storage, and precautions allows
for effective and safe use.
Call the primary care physician. Respiratory distress usually requires treatment in the emergency
department.
Body'Image' 12
Disturbed Body Image
related to
Physical body changes due to disease.
Presence of a drain or tube or dressing.
Physical alterations and/or altered function due to surgery or removal of a body part.
Desired Outcomes:
Patient demonstrates enhanced body image, as evidenced by ability to look at, touch, discuss, and care for the actual or perceived
altered body part.
Assess the effect of the change on activities of daily living, social Changes in body image can reduce the patient’s engagement in
activities, relationships, and work. roles and responsibilities.
Assess the effect of changed body part on the patient’s behavior. Behavior changes may include ignoring the altered structure or
preoccupation with the altered structure.
Assess the patient’s feelings about the change in body part or Negative statements about the affected part indicate an inability
function. to integrate the change into the self-concept.
Acknowledge the normalcy of the patient’s emotional response to Grief over the loss of a body part or function is normal.
the change in body structure.
Help the patient to talk about positive or negative feelings about The patient should separate feelings about the changes in her
the body change. body from feelings about her self-worth.
Help the patient to incorporate body changes into Positive responses in social situations will promote adaptation to
activities of daily living, social activities, relationships, and work. the body change.
Teach the patient to use wigs, cosmetics, and clothing that con- Adaptive changes compensate for the changed body structure
ceals the altered body part. and function.
Refer the patient to support groups for patients with similar body Patients in similar situations will provide the patient with support.
alterations.
Bowel'Incontinence' 13
Bowel Incontinence
related to
Immobility
Fecal impaction
Medications
Multiple sclerosis
Myasthenia gravis
Lower motor nerve trauma
Spinal cord injury
Sphincter injury
Radiation to pelvis
Desired Outcomes:
Patient is continent of stool or reports decreased episodes of bowel incontinence.
Assess the patient's normal bowel elimination pattern. Some patients have two bowel movements per day. Other pa-
tients may normally have a bowel movement every fourth day.
Determine the cause of the incontinence. Knowledge of cause factors helps to plan interventions, which will
correct the cause.
Digitally check for fecal impaction. Liquid stool may leak past a fecal impaction, appearing as fecal
incontinence.
Assess for drugs or treatments that may cause bowel inconti- Hyperosmolar tube feedings, magnesium antacids, pelvic irradia-
nence. tion, chemotherapeutic agents, and antibiotics may cause diar-
rhea and fecal incontinence.
Arrange for diagnostic testing. Fecal incontinence testing may include sigmoidoscopy, colonos-
copy, and anal manometry.
Assess the effects of the fecal incontinence on the patient’s activ- Patients may restrict activities or become isolated
ities. from family and friends.
Assess the integrity of perineal skin. Stool and incontinence briefs may irritate the skin.
Assess the patient's ability ambulate to the bathroom. Soiling often results from the patient’s inability to walk to the bath-
room before defecation occurs. Planning trips to the bathroom or
a bedside commode may reduce soiling.
Assess the patient’s environment for an Inadequate access to a toilet, such as bathroom on an upper
accessible toilet. level, can contribute to incontinence.
Increase fluid and fiber intake. Increased fiber and fluid intake can result in formed stools, reduc-
ing incontinence.
Digitally remove impacted feces. Fecal impaction will interfere with the regular bowel routine.
Advise mobility or exercise. Mobility stimulates peristalsis and bowel evacuation.
Provide a bedside commode and a cane or walker. Easy access to a toilet reduces soiling accidents.
Teach a bowel program of A regular bowel evacuation schedule will prevent incontinence.
bowel elimination at the same time every day. Toileting after a meal (breakfast) promotes bowel elimination
because the gastrocolic reflex is stimulated by ingestion of food.
Wash the perineal area after each bowel evacuation with soap Feces on the skin may cause skin excoriation. Perianal pain may
and water. Thoroughly dry and apply a moisture barrier ointment. result in a fear of defecation.
Bowel'Incontinence' 14
Avoid the use of pads and diapers. A bowel-training program will eliminate the need for pads and
diapers.
Encourage increased fluid and fiber. Fluid and fiber will promote the formation of promote solid stool
and reduce incontinence.
Cardiac'Output' 15
Decreased Cardiac Output
related to
Impaired cardiac contractility
Bradycardia, arrhythmia, or conduction block
Desired Outcomes:
Patient has adequate cardiac output, as evidenced by systolic BP >90 mmHg; HR >60 bpm with regular rhythm; urine output >30
mL/hr; warm, skin; absence of crackles, and orientation to person, time, and place.
Actions and Interventions Rationales
Assess for change in consciousness Hypoxia and inadequate blood flow to the brain may cause rest-
lessness, irritability, or drowsiness.
Assess for HR >120/min and systolic blood pressure <90 mm Hg. Decreased cardiac output may cause tachycardia and hypoten-
sion.
Assess for cold skin. Cold, clammy skin results from vasoconstriction due to increased
sympathetic output caused by low cardiac output.
Assess daily weights. Monitor for pedal and sacral edema. Congestive heart failure results in fluid and sodium retention.
Body weight is a sensitive indicator of fluid retention.
Monitor for paroxysmal nocturnal dyspnea (PND), orthopnea, and Orthopnea is labored breathing when supine; PND is difficulty
crackles. breathing at night when supine. Crackles are a sign of pulmonary
edema.
Assess beta-type natriuretic peptide (BNP). BNP is elevated with left ventricular failure. BNP differentiates
cardiac from noncardiac causes of labored breathing.
Assess oxygen saturation with pulse oximetry. Decreased oxygen saturation is an indicator of reduced cardiac
output.
Assess electrocardiogram for sinus tachycardia or dysrhythmias. Cardiac dysrhythmias may be caused by low myocardial perfu-
sion, acidosis, and hypoxia.
Assess for chest pain or discomfort. Low cardiac output can reduce myocardial perfusion and cause
chest pain or discomfort. Chest pain or discomfort is a sign of an
acute coronary syndrome, requiring emergency assessment.
Position the patient in the semi-Fowler’s to high-Fowler’s position Upright positioning reduces preload and ventricular filling for fluid
overload and pulmonary edema.
Administer oxygen. Oxygen prevents hypoxia of the heart, brain, and other major
organs.
For patients with peripheral edema encourage a low sodium diet A low sodium diet decreases extracellular fluid and reduces car-
of <3g/d. Restrict fluids to 1.5-2 L/day if the patient has refractory diac workload.
HF with hyponatremia.
Administer furosemide (Lasix) 20-40 mg qAM, and monitor re- Drugs may include digoxin, diuretics, vasodilators, antidysrhyth-
sponse and adverse effects. mics, angiotensin-converting enzyme inhibitors, lisinopril (Zestril),
digoxin, metoprolol (Lopressor), or carvedilol (Coreg).
Administer an ACE inhibitor, such as lisinopril (Zestril) 5 mg PO ACE inhibitors improve survival in patients with left ventricular
qd. systolic dysfunction (LVEF ≤40 percent).
Administer metoprolol (Lopressor) extended release 12.5 mg Beta-blockers, particularly carvedilol, metoprolol succinate, and
once daily. Or carvedilol (Coreg) 3.125 mg twice daily. bisoprolol, improve survival in patients with NYHA class II to IV
heart failure.
Cardiac'Output' 16
Administer digoxin 0.125 mg qd. Digoxin therapy is associated with a significant reduction in hos-
pitalization for HF and may prolong survival.
Administer a docusate (Colace) 50 to 500 mg daily. Straining during bowel movements reduces cardiac output.
Maintain intra-aortic balloon pump or pacemakers within proto- Electrical or mechanical assist devices help to support cardiac
cols. output.
Explain the medication regimen, purpose, dose, and adverse Information provides the rationale for therapy and increases pa-
effects. tient compliance.
Explain sodium dietary restrictions. A low sodium diet reduces labored breathing and peripheral
edema.
Caregiver Role Strain' 17
Caregiver Role Strain
related to
Severe illness of care receiver
Caregiver with health problems
Disruption of the caregiver’s personal and social life
Economic hardship
Desired Outcomes:
Caregiver expresses satisfaction with the caregiver role.
Caregiver demonstrates competence in caring for recipient’s needs.
Caregiver reports that formal and informal support systems are helpful.
Assess the caregiver-care recipient relationship. A mutually rewarding relationship fosters a therapeutic experi-
ence. Dysfunctional relationships result in inadequate care, or
neglect.
Assess family communication. Family communication creates a positive environment.
Assess the resources and support of the family. Family and social support promote good coping. Aging parents,
and limited financial resources may impair coping.
Determine the caregiver's ability to provide bathing, skin care, Information provides a starting point for education.
nutrition, medications, and ambulation.
Assess the caregiver's willingness to assume caregiver role. The caregiver’s responses are mediated by the person’s motiva-
tions.
Assess for patient for neglect or abuse. The nurse must prevent injury to the care recipient.
Assess the caregiver's physical and mental health. The caregiver may have vision problems, musculoskeletal dis-
ease, upper body weakness, or cognitive impairment.
Encourage the caregiver to identify family and friends who can Respite care helps family members manage the burden of care.
help with caregiving.
Suggest community, respite care, home health care, adult day- Resources provide assistance and services.
care, geriatric care, and Meals-On-Wheels.
Teach the caregiver to allow time for rest. The caregiver will need time to attend to her own needs.
Encourage the caregiver to participate in a support group. Support groups can provide mutual support.
Demonstrate necessary caregiving skills and have the caregiver Increased knowledge and skills will decrease frustration.
give a return demonstration.
Communication, Impaired Verbal' 18
Impaired Verbal Communication
related to
Brain injury or tumor
Language differences
Laryngectomy, tracheostomy, or intubation
Labored breathing
Impaired hearing or vision
Desired Outcomes:
Patient uses an alternative form of communication to fulfill his needs and to interact with others.
Assess the patient’s preferred means of communication, such as Patients usually prefer one method of communication.
verbal, written, or gestures
Assess the patient’s ability to understand spoken English An interpreter may be required to communicate with patients.
Assess the patient’s preferred language for verbal and written Discharge and self-care follow-up information must be reinforced
communication with written materials in the patient’s language.
Asses for conditions that prevent the patient from understanding A tracheostomy, nasal intubation, or wired jaws may impair the
language. patient's ability to communicate. Alzheimer disease may impair
the patient’s understanding of instructions.
Assess for inability to communicate verbally and inability to un- Patients with expressive dysphasia have non-fluent speech. Re-
derstand language. ceptive dysphasia causes an inability to understand language.
Assess for labored breathing. Patients with breathing problems have difficulty communicating
verbally.
Provide an alternative means of communication. Flashcards, symbol boards, and electronic messaging devices
can help the patient communicate.
Minimize distractions, such as a television, when talking to the Removal of distractions keeps the patient focused and enhances
patient. communication.
Maintain eye contact and stand close to the patient when speak- Patients with visual field defects have better comprehension
ing to him. when they see the speaker’s lips.
Give the patient ample time to respond. This approach reduces frustration. Patients may need extra time
to respond.
Use short sentences and ask one question at a time. This technique allows the patient to stay focused on one thought.
Shifting between subjects will confuse the patient.
Give simple directions to the patient, such as "open your mouth”. Simple directions enhance comprehension.
Provide the patient with language practice with simple words, Practice with language increases communication.
such as "yes," "no," and "this is water".
Give the patient practice in naming images, such as "cup" or Visual cueing reinforces language comprehension.
"pen".
Provide a speech therapy referral. Speech therapy can improve language skills
Assess the patient’s home setting. This evaluation will determine the need for assistive computers
and telephone typing devices.
Refer deaf patients to community support, education, and sign Specialized services may be required to meet the patient’s
language training. needs.
Confusion' 19
Confusion
related to
Alzheimer’s disease
Multi-infarct neurodegenerative disorder
Ischemic stroke
Acquired immunodeficiency syndrome
Hepatic encephalopathy
Parkinson’s disease
Desired Outcomes:
Patient remains safe and free from injury.
Family states an understanding of the disease and prognosis, and the patient's needs and participates in interventions.
Assess the patient’s degree of impairment. The extent of confusion will determine the patient’s needs for
reorientation and intervention.
Assess memory, reality orientation, attention span, and calcula- Impaired memory can impair the patient’s response to environ-
tion with the Mini-Mental State Examination. mental stimuli.
Test the patient’s ability to communicate. The ability to respond to verbal direction decreases with disorien-
tation.
Note deterioration in personal hygiene or behavior. Poor grooming and hygiene are signs of severe confusion.
Assess onset or progression of the problem. Assessment identifies the patient’s needs for assistance with
nutrition, elimination, bathing, and dressing.
Determine the patient’s anxiety level and potential for violence. Confusion, disorientation, impaired judgment, and suspicious-
ness may result in inappropriate behaviors.
Provide a calm environment and reduce noise and stimuli. Visual and auditory stimulation can exacerbate confusion.
Communicate with simple positive terms. Simple communication reduces the patient’s anxiety and im-
proves understanding.
Maintain consistency in the patient’s environment and schedule. Consistency increases orientation and memory. A consistent
schedule reduces anxiety.
Provide a reality-oriented environment with display clocks, calen- Orientation decreases the patient’s anxiety. Familiar personal
dars, and personal items. items increase the patient’s comfort level.
Provide an identification bracelet, medication lockup, and re- These measures promote patient safety. The confused patient
duced hot water temperature. may not have insight and judgment.
Identify community resources, such as an Community resources provide support and assistance.
Alzheimer's support group, Meals-On-Wheels, and adult day
care.
Constipation' 20
Constipation
related to
Low-fiber diet
Inactivity
Medication use
Withholding of stool
Colon cancer or other obstructing mass
Neurogenic disorders
Desired Outcomes:
The patient passes soft, formed stool at a normal frequency.
Patient states constipation prevention measures.
Assess the patient’s usual pattern of elimination. The normal frequency of passing stools may vary from twice daily
to every three to four days.
Assess dietary fiber intake and fluid intake. Inadequate fiber from fresh fruits and vegetables can cause con-
stipation.
Assess the patient’s activity level. Bed rest and inactivity can worsen constipation.
Assess for use of drugs that may can constipation. Drugs that can cause constipation include opioids, antacids with
calcium (Tums), antidepressants, anticholinergics, antihyperten-
sives, and iron supplements.
Assess if the patient withholds stool after the urge to defecate. Stool withholding results in chronic constipation because the rec-
tum fails to respond to the presence of stool.
Recommend 20 g of dietary fiber per day, such as raw fruits, Fiber absorbs water in the intestine and increases the bulk to the
fresh vegetables, and whole grains. stool.
Increase bulk fiber with (Metamucil) 30 gm per day. Fiber increases the bulk of the intestinal contents.
Administer a stool softener, such as docusate (Colace) 50-500 Colace softens the stool and prevents constipation.
mg qd.
Recommend physical activity and regular exercise. Ambulation improves intestinal peristalsis and facilitates defeca-
tion.
Encourage the patient to defecate after dinner. Many patients defecate following the dinner because of the gas-
trocolic reflex may facilitate elimination.
Give glycerin rectal suppository or bisacodyl suppository to lique- For treatment of defecatory dysfunction, glycerin rectal supposito-
fy the stool. ry or bisacodyl suppository can be effective in liquefying stool and
overcoming obstructive defecation.
Digitally remove impacted stool. After disimpaction, give Stool that remains in the rectum for long periods may become dry
a mineral oil enema. and hard.
If disimpaction is unsuccessful, arrange for a water-soluble con- A Gastrografin contrast enema will assure absence of any ob-
trast enema (Gastrografin) under fluoroscopy. struction and to remove more proximal fecal impactions.
After disimpaction, give daily warm water enemas for three days. After disimpaction, daily warm water enemas should be given for
Or sorbitol 30 mL PO per day or lactulose 30-60 mL PO per day three days. Or give sorbitol 30 mL PO per day or lactulose 30-60
to produce one stool at least every other day. mL PO per day to produce one stool at least every other day.
Constipation' 21
In demented or bedridden patients with fecal impaction, disimpact In demented or bedridden patients with fecal impaction, a fiber
the rectum, and give tap water enemas for 3 days. Then start a restricted diet and twice weekly cleansing enemas will prevent
fiber-restricted diet and give cleansing enemas once or twice per the buildup of stool and will avoid fecal impaction.
week.
Give lubiprostone (Amitiza) 24 mcg taken twice daily with food. Lubiprostone (Amitiza) increases intestinal fluid secretion.
Coping' 22
Ineffective Coping
related to
Inadequate support system
Inadequate resources
Inadequate level of confidence
Situational crises
Desired Outcomes:
Patient describes and uses effective coping strategies
Patient describes positive results from new behaviors
Assess ability to cope and make decisions Behavioral responses to stress can affect the patient’s ability to
cope
Assess for stressors. Assessment of stressors facilitates development of coping strate-
gies.
Assess the patient’s decision-making and problem-solving abili- Successful adjustment is influenced by previous coping success-
ties. es.
Assess the patient’s resources and support systems. Coping resources include significant others, home health nurses,
community resources, and spiritual counselors.
Provide opportunities to express concerns, fears, and feelings. Verbalization of perceived threats can reduce anxiety.
Help patients to evaluate the situation. Evaluation can help the patient to use his skills and strengths to
manage the situation.
Teach the patient to set goals. Goal setting helps the patient to gain control over the situation by
viewing the situation in smaller, more manageable parts.
Assist the patient with problem solving. Constructive problem solving will promote independence.
Involve social services, psychiatric liaisons, and pastoral care. Specialized services may be required to meet support needs.
Dentition, Impaired' 23
Impaired Dentition
related to
Ineffective oral hygiene
Deficient knowledge of dental health maintenance
Dietary habits or nutritional deficits
Lack of access to care
Desired Outcomes:
Patient demonstrates ability to care for teeth and mouth independently, as evidenced by regular brushing and flossing.
Patient has a clean teeth and healthy gums.
Patient obtains regular dental checkups.
Assess the patient's oral hygiene practices. Oral hygiene information helps to determine the causes of im-
paired dentition.
Assess the teeth, gums, mucous membranes, and tongue for A tongue blade should be sued to expose areas of oral cavity for
color, moisture, and infection. inspection.
Assess the patient's nutritional status Poor food choices contribute to dentition problems.
Assess the fit of dental appliances. Evaluation may suggest possible causes and guide patient edu-
cation.
Assess the patient’s ability to complete daily oral care. Patients may need assistance in completing oral care.
Assess for financial problems that may prevent adequate dental Community services are available for assistance with paying for
hygiene. dental care.
Touch chest to brush teeth at regular intervals with a soft-bristle Cleaning of the teeth with a toothbrush prevents the build-up of
toothbrush and fluoride toothpaste twice a day. plaque.
Teach gentle flossing of the teeth with unwaxed dental floss. Flossing improves gum health and prevents plaque buildup.
Teach that dentures should be removed and cleaned every night. Regular cleaning of dentures will prevent mucosal irritation.
Instruct to avoid high-sugar foods. High sugar foods may cause tooth decay. promotes good oral
health and healing.
Instruct the patient to obtain regular dental checkups. Regular dental checkups identify dental problems early.
Diarrhea' 24
Diarrhea
related to
Viral, bacterial, or parasitic gastroenteritis
Adverse effects of medication use
Irritable bowel syndrome
Crohn disease or ulcerative colitis
Lactase deficiency
Tube feedings
Desired Outcomes:
Patient passes soft, formed stool no more than three times per day.
Assess for abdominal pain, frequency of bowel movements, and These symptoms are commonly associated with diarrhea.
loose or liquid stools.
Culture stool for enteric pathogens. Testing will identify the cause of the diarrhea.
Ask about tolerance to milk and other dairy products and medica- Diarrhea is common with lactose intolerance. Lactase is the en-
tions. zyme that digests lactose. Excessive lactose in the intestines
draws water into the intestinal lumen, resulting in diarrhea. Mag-
nesium-containing laxatives and antibiotics may cause diarrhea.
Magnesium and calcium supplements can cause diarrhea.
Food intolerances Fatty or high-carbohydrate foods; sugar-free foods with sorbitol
may cause diarrhea.
Assess for a history of previous gastrointestinal surgery After bowel resection, diarrhea is normal for 1-2 weeks.
Assess for gastrointestinal diseases Crohn disease and gastroenteritis can result in malabsorption
and chronic diarrhea.
Assess for fecal impaction. Liquid stool may seep past a fecal impaction, appearing as diar-
rhea.
Assess hydration status, including inputs and outputs, skin turgor, Diarrhea can cause dehydration.
and moisture of mucous membranes Dehydration may cause decreased skin turgor and skin tenting
and dry mucous membranes.
Assess the perianal skin. Diarrheal stools may irritate the skin.
Give loperamide (Imodium) antidiarrheal medication. Antidiarrheal medication suppresses gastrointestinal motility.
Encourage the intake of bulk fiber, such as unrefined cereal, Dietary fiber absorbs fluid from the stool and thickens the stool.
grains, and Metamucil
Encourage fluid intake of 1.5 to 2 L/24 hr unless contraindicated. Adequate fluid intake replaces fluid lost in the diarrhea.
Provide perianal care and apply barrier ointment after bowel Cleansing of the perianal skin after bowel movements prevents
movements. skin excoriation. Barrier ointment protects the skin from break-
down.
For patients on enteral tube feeding: Cold and hot temperatures can over-stimulate peristalsis.
administer tube feedings at room temperature.
Decrease the rate of the tube feeding if diarrhea develops. Decreasing the rate of infusion or prevents diarrhea.
For patients with infectious diarrhea, initiate contact precautions. Contact precautions are necessary to prevent transmission of
microorganisms to other patients.
Diarrhea' 25
Encourage the patient to avoid fatty foods. Dietary changes can slow the passage of stool through the colon
Avoid foods that worsen the diarrhea. and reduce or eliminate diarrhea.
Electrolyte Imbalance' 26
Risk for Electrolyte Imbalance
related to
Diarrhea
Endocrine dysfunction
Fluid imbalance
Renal failure
Drug adverse effects
Vomiting
Imbalanced dietary intake
Desired Outcomes:
Patient will maintain normal serum electrolytes as evidenced by a sodium of 136-145 mEq/L; potassium of 3.5-5.1 mEq/L; chloride of
98-107 mEq/L; ionized calcium of 4.6-5.1 mg/dL; and magnesium of 1.8-3 mg/dL
Assess medication therapy Thiazide and loop diuretics may cause hypokalemia. Potassium-
sparing diuretics, angiotensin converting enzyme inhibitors may
cause hyperkalemia.
Assess dietary intake Sodium imbalances can occur with excesses or deficits of fluid
intake. Inadequate nutrition may cause hypokalemia.
Assess for gastrointestinal fluid losses Vomiting, diarrhea, and gastrointestinal suctioning may cause
hyponatremia, and hypokalemia.
Assess for wound drainage and muscle injury Draining wounds or gastrointestinal fistulas may cause excessive
loss of sodium. Extensive tissue injury from trauma may cause
hyperkalemia.
Assess for endocrine dysfunction High or low secretion of antidiuretic hormone from the posterior
pituitary gland may place the patient at risk for sodium imbalanc-
es.
Asses for renal disease Impaired renal function places the patient at risk for imbalances
of sodium, potassium, and calcium. Hyperkalemia may result
from kidney disease.
Assess for cancer Hypercalcemia may result from tumor metastasis to bones. Acute
tumor lysis syndrome is a complication of cancer medication
therapy, which causes hyperkalemia and hypocalcemia.
Assess serum electrolyte levels: Detection of changes in serum electrolyte levels allows for initia-
Sodium 136-145 mEq/L tion of treatment.
Potassium 3.5-5.1 mEq/L
Chloride 98-105 mEq/L
Total calcium 9-10.5 mg/dL
Ionized calcium 4.6-5.0 mg/dL
Magnesium 1.8-3 mg/dL
Administer electrolyte solutions IV as Use of sodium free IV solutions, such as D5W may cause hypo-
prescribed. natremia.
Initiate measures to reduce electrolyte excesses. Hemodialysis may be indicated to treat patients with severe hy-
perkalemia.
Anticipate administration of electrolyte replacements. Oral or IV administration of electrolytes may be required to main-
tain electrolyte balance.
Electrolyte Imbalance' 27
Teach the patient about dietary electrolytes sources. A balanced diet provides electrolytes to prevent imbalances.
Whole grain, nuts, fruits, and vegetables are good sources for
magnesium and potassium. Dairy products, dark green, leafy
vegetables, and legumes are good sources of calcium.
Teach patients using diuretics, such as furosemide (Lasix) about Potassium replacement should include potassium chloride sup-
potassium replacements. plements.
Risk for Falls' 28
Risk for Falls
related to
Age 65 years or older
Use of assistive devices for mobility
Wheelchair use
Orthostatic hypotension
Visual impairment
Diminished mental status
Ataxic gait
Impaired balance
Neuropathy
Decreased lower extremity strength
Desired Outcomes:
Patient will not sustain a fall.
Patient implements strategies to prevent falls.
Assess for fall risk factors A person who has sustained a fall in the past 6 months is more
History of falls likely to fall again.
Assess for mental status changes Confusion and impaired judgment increase the risk for falls.
Assess for age-related physical changes The risk of falling is increased with impaired visual capacity, un-
steady gait, decreased muscle strength.
Assess for visual or hearing deficits Impaired vision and hearing prevent recognition of hazards.
Assess use of mobility assistive devices Use of canes, walkers, and wheelchairs increases the risk for
falls.
Assess for orthostatic hypotension Falls are more likely in patients with orthostatic hypotension,
edema,
dizziness, weakness, and confusion.
Assess the patient’s medications for drugs that may cause seda- Drugs that affect blood pressure and cause sedation have the
tion or orthostatic hypotension, resulting in falls. highest fall risk. Falls are associated with antihypertensives, sed-
atives, opioid analgesics, tricyclic antidepressants, and diuretics.
Assess the patient's environment for inadequate lighting, wet These factors increase the patient’s risk of falls
surfaces, slippery floors, and objects on floor.
Post signs to warn that the patient is at risk for falls. A nearby location provides for more frequent observation and
Move the patient to a room close to the nurses' station. faster response.
Place bed in the lowest position. Use side rails on beds. Keeping beds in the lowest position reduces the risk for falls and
injury.
Ensure sufficient room lighting. Older adults with reduced visual capacity will benefit from ade-
quate lighting. A night-light increases visibility.
Teach the patient to wear shoes or slippers with Non-skid footwear decreases the risk of slipping.
non-skid soles.
Use bed and chair alarms to alert staff when the patient gets up Audible alarms can remind the patient not to get up alone.
without assistance.
Provide a chair with a firm seat and arms on both sides. A chair with arms is easier to get out of, when a patient has
weakness and impaired balance.
Risk for Falls' 29
Assess for drugs that may contribute to falling, such as medica- Drugs may cause dizziness, orthostatic hypotension, drowsiness,
tions that cause sedation or orthostatic hypotension. and nocturia, which increase the risk of falls.
Teach the patient to wear his eyeglasses and hearing aid. Poor vision increases the risk of falls.
Arrange for physical therapy to assist with gait technique. Gait belts help transfer patient from the bed to the chair.
Arrange for occupational and therapy to provide assistive devices Raised toilet seats facilitate transfer to the toilet.
for transfers, walking, and home safety.
Provide high-risk patients with a hip pad. Hip pads reduce the risk of hip fracture during a fall.
Educate the patient and caregivers about risk factors for falls in Falls are the leading cause of accidental death in the home.
the home.
Place bright, nonskid strips on the edges of stair treads. Install Older have poor depth perception.
handrails on both sides of the stairs. Loose throw rugs increase the risk for slipping and falling.
Ensure that rugs are fastened to the floor or removed.
Install nonslip surfaces in tubs and showers. Place grab bars Wet surfaces in bathrooms increase the risk for falls. Grab bars
near the tub or shower and toilet. Use a shower chair. provide support in the bathroom.
Rearrange furniture to provide a clear pathway between the pa- People with decreased strength are less able to move around
tient's room and the bathroom. Keep pathways free of clutter and obstacles.
electrical cords.
Provide adequate lighting at the top and bottom of stairs. Use Older adults have poor vision at night and in dimly lit areas. Im-
night-lights in bathrooms, bedrooms and hallways. proved lighting reduces the risk of falls.
Educate the patient and family caregivers about mobility assistive Incorrect use of canes, walkers, and wheelchairs can increase
devices. the risk for falls.
Suggest that the patient wear an alarm device in case of a fall. Devices are available to alert providers if a patient falls.
Fatigue' 30
Fatigue
related to
Sleep deprivation
Poor physical condition
Disease state
Malnutrition
Anemia
Chemotherapy/radiation therapy
Desired Outcomes:
Patient states decreased fatigue, as evidenced by increased ability to perform activities.
Assess the patient’s fatigue, including timing, severity, relation- A rating scale of 0 to 10 can help the patient describe the amount
ship to activities, and aggravating and alleviating factors. of fatigue experienced.
Assess for recent physical changes, depression, medication ad- Identifying the cause of the fatigue can aid in determining treat-
verse effects, anemia, poor sleep, poor nutrition, increased de- ments.
mands
Assess the patient’s ability to perform activities of daily living. Fatigue can limit the patient’s ability to participate in self-care and
complete responsibilities.
Assess the patient’s prescription and over-the- Fatigue may be a medication adverse effect of beta-blockers,
counter drugs. calcium channel blockers, tricyclic antidepressants, alcohol, mus-
cle relaxants, and sedatives.
Assess the patient’s nutritional intake of calories and protein. Fatigue may be a symptom of protein-calorie malnutrition or iron
deficiency.
Assess the patient’s sleep quality, quantity, sleep latency, snor- An abnormal sleep pattern may contribute to fatigue.
ing, and feeling on awakening.
Help the patient to developing a schedule of daily activity and A plan that balances periods of activity with periods of rest can
rest. help the patient complete desired activities.
Implement a long-handled sponge for bathing, sock-puller, long- Assistive devices minimize energy expenditure with activities.
handled grabber
Encourage adequate nutrition. A balanced intake of fats, carbohydrates, and protein will provide
more energy.
Encourage an exercise-conditioning program. Fatigue caused by deconditioning and prolonged bed rest can be
reduced.
Help the patient develop an effective rest and sleep pattern. Relaxation before sleep and several hours of uninterrupted sleep
can restore energy.
Fluid Volume, Deficient' 31
Fluid Volume, Deficient
related to
Inadequate fluid intake
Diuresis, abnormal drainage or bleeding.
Diarrhea
Fever, infection
Edema
Desired Outcomes:
Patient is normovolemic, as evidenced by systolic blood pressure > 90 mmHg, pulse pressure of >30 mmHg, heart rate of 60 to 100
bpm, and urine output >30 mL/hr.
Determine the cause of the hypovolemia, such as bleeding, re- Assessment guides interventions.
duced fluid intake drainage after surgery, and diarrhea.
Monitor weight daily. Accurate measurement of weight provides data for following
trends.
Assess fluid status. Some elderly patients may intentionally restrict fluids to avoid
incontinence.
Assess blood pressure and heart rate. Loss of blood can cause hypotension, tachycardia, and a narrow
pulse pressure.
Assess BP for pulse pressure (systolic pressure minus diastolic Manifestation of
pressure) A pulse pressure of <35 mmHg indicates that blood volume is
decreased by 20%.
Assess skin turgor and oral mucous membranes for dehydration. Decreased fluid volume causes decreased skin turgor. Skin tur-
gor should be assessed over the sternum or the forehead.
Assess urine output. Report urine output <30 mL/hr for 2 hours. Decreased urine output indicates the presence of hypovolemia.
Assess temperature. Fever causes fluid loss through perspiration.
Assess fluid losses from wound drainage, drains, diarrhea, bleed- Fluid loss from wound drainage, diarrhea, bleeding, and vomiting
ing, and vomiting. Record input and output. can lead to dehydration.
Assess serum electrolytes and osmolality, and report abnormal An elevated blood urea nitrogen and osmolality suggests the
values. presence of a fluid deficit.
Assess for changes in mental status. Dehydration may cause lethargy and confusion.
During treatment, monitor for circulatory overload, such as ve- Monitoring during therapy reduces the risk of fluid overload.
nous distention, labored breathing, and tachypnea.
Monitor CVP, pulmonary artery diastolic pressure, and cardiac These direct measurements are the best guides for fluid therapy.
output.
Encourage the patient to drink the prescribed volume fluid. Oral fluid replacement is indicated for mild fluid deficits. Older
patients have a decreased sense of thirst.
Assist the patient if she is unable to eat or drink without assis- Dehydrated patients may be weak and unable to ingest food of
tance. fluids independently.
For more severe hypovolemia: Parenteral fluid replacement is indicated for significant
Insert an IV catheter. hypovolemia.
Administer an IV fluid challenge for patients with tachycardia or Fluids are needed to maintain hydration states. Isotonic fluids are
an increased pulse pressure. used to replace volume deficits.
Fluid Volume, Deficient' 32
Administer blood products as prescribed. Blood transfusion may be required to correct fluid loss caused by
bleeding.
If signs of fluid overload occur, stop the infusion and have the Upright positioning decreases venous return and decreases pul-
patient sit up and dangle her legs. monary edema.
Teach the patient or caregiver the importance of maintaining fluid Adequate fluid intake will prevent dehydration.
intake. Patients should understand the importance of drinking fluids dur-
ing diarrhea, fever, and hot weather.
If patients are to receive IV fluids at home, instruct the caregiver Maintenance of venous access sites and IV requires teaching
in using the IV equipment. and practice.
Fluid Volume, Excess' 33
Fluid Overload
related to
Excessive fluid intake
Excessive sodium intake
Heart failure
Liver disease
Renal failure
Desired Outcomes:
Patient is normovolemic as evidenced by urine output >30 mL/hr, balanced intake and output, stable weight, decreased edema,
heart rate of 60 to 100 bpm, and absence of lung crackles.
Determine the cause of the fluid disturbance. The history can help guide interventions. The history may reveal
increased fluid or sodium intake.
Instruct the patient to monitor her weight daily at the same time of Sudden weight gain indicates fluid retention.
day.
Assess for weight change of more than 2 pounds in 1 day. Body weight is a sensitive indicator of fluid or sodium retention. A
2- to 3-pound increase in weight indicates that diuretic therapy
should be increased.
Monitor input and output. Fluid shifts out of the intravascular to the extravascular space
may result in volume overload.
Assess blood pressure and heart rate. Sinus tachycardia and decreased pulse pressure are signs of
hypovolemia.
Assess for distended neck veins and ascites. Distended neck veins are caused by elevated CVP. Ascites is
fluid accumulation in the peritoneal cavity.
Assess for lung crackles, labored breathing, tachypnea and or- These signs are caused by pulmonary edema due to fluid over-
thopnea. load.
Assess for edema by pressing down on the skin over the tibia, Edema is fluid accumulation in the tissues. Edema accumulates
ankles, feet, and sacrum. in dependent areas and is graded from trace to 4 (severe).
Assess for overdiuresis, indicated by a >2-pound weight loss in 1 Excessive diuretic therapy can result in a hypovolemia, hypo-
day. natremia, and hypokalemia.
Assess serum electrolytes. The sodium level is an indicator of fluid status and guides thera-
py.
Educate the patient about CHF or renal failure. Patients are better able to seek assistance when they understand
their medical condition.
Teach symptoms of fluid volume excess. Patients must have information to assist in their treatments and
prevent excess fluid volume.
Instruct the patient to avoid NSAIDs. NSAIDs may cause fluid retention and renal failure.
Explain the importance of fluid restriction, and a low-salt diet. Knowledge will increase compliance with the treatment plan.
Unstable Glucose Level 34
Unstable Glucose Level
related to
Diabetes
Excessive glucose intake
Desired Outcome
Patient maintains blood glucose levels between 60 and 120 mg/dL
Assess for hyperglycemia. Hyperglycemia results when insulin levels are inadequate. High
blood glucose levels may cause polydipsia, polyphagia, and pol-
yuria.
Assess for hypoglycemia. Signs of hypoglycemia include diaphoresis, tremor, headache,
anxiety, and hunger.
Assess the patient’s medication regimen. Hyperglycemia is an adverse effect of beta-blockers, corticoster-
oids, and thiazide diuretics.
Measure fasting and postprandial glucose levels. Normal fasting blood glucose for adults is 70 to 105 mg/dl. The
critical value for hypoglycemia is <50 mg/dL. The critical value for
hyperglycemia is >200 mg/dL.
Assess eating patterns. Patients with diabetes may develop hyperglycemia or hypogly-
cemia when medication, exercise, and food intake are not bal-
anced.
Assess the patient’s physical activity. Exercise may cause hypoglycemia.
Consult a dietitian for diet instruction. An individualized meal plan is based on the patient’s body
weight, and clinical condition. Patients with diabetes should limit
refined carbohydrates. Whole grains, vegetables, and fresh fruits
should be increased.
Administer insulin or metformin. Insulin is required to lower blood glucose levels in type 1 diabetes
and in many patients with type 2 diabetes. Metformin is used for
type 2 diabetes.
Administer food, fruit juice, or crackers if the patient has symp- Glucose is indicated for hypoglycemia. Candy and fruit juice can
toms of be ingested to treat hypoglycemia. For hospitalized unconscious
hypoglycemia. patients, intravenous 25% dextrose is indicated.
Teach the patient about medications for hyperglycemia. The patient with diabetes mellitus should learn about taking insu-
lin or metformin (Glucophage) to lower blood glucose.
Instruct the patient about self-treatment of hypoglycemia. Food should not be used to raise blood glucose levels if the pa-
tient has symptoms of hypoglycemia.
Teach the patient eat a snack before exercise. A snack will prevent hypoglycemia because exercise decreases
glucose levels.
Teach the patient to measure her capillary blood glucose. Capillary blood glucose monitoring allows the patient to inject
insulin to return the blood glucose level to normal.
Instruct the patient to wear a medical alert bracelet. Medical personnel need to be able to identify the patient as hav-
ing diabetes.
Incontinence, Functional Urinary 35
Functional Urinary Incontinence
related to
Altered environment
Limited physical mobility
Desired Outcomes:
Patient receives toileting assistance in a timely manner, and patient has no episodes of incontinence.
Assess the patient's ability to recognize the need to urinate. Functional incontinence is caused by inability to ambulate to the
toilet to void.
Assess the patient's ability to ambulate to the toilet. The patient may need assistance with transfer to the toilet or
bedside commode.
Assess the patient’s pattern of urination and circumstances asso- Assessment is the basis for planning an individualized toileting
ciated with incontinence. program.
Create a toileting schedule. A toileting schedule reduces functional incontinence episodes.
Place a bedside commode near the patient's bed and ensure A bedside commode ensures that the patient can reach the toilet
privacy. before incontinence occurs.
Advise the patient to wear clothing that can be easily removed for Functional continence may occur if the patient has difficulty re-
toileting. moving clothing before voiding. Women may find skirts or dress-
es easier to remove. Men may find that pants with an elastic
waistband are easier to remove.
Teach the patient to limit fluid intake 2 to 3 hours Limiting fluid intake and voiding before bedtime reduces the need
before bedtime. to void at night.
Teach family members and other caregivers to respond immedi- Functional continence is less likely when caregivers quickly re-
ately to the patient’s requests for voiding assistance. spond to the patient’s requests for assistance with voiding.
Incontinence, Reflex Urinary 36
Reflex Urinary Incontinence
related to
Radiation cystitis
Radical pelvic surgery
Spinal cord lesions
Brain injury to the pontine micturition center
Desired Outcomes:
Patient establishes a regular voiding pattern.
Patient has no incontinence episodes.
Assess the patient's recognition of the need void. Patients with neurological disorders may not sense the need to
void.
Measure urine volume with each voiding. High urine volumes are diagnostic of reflex incontinence.
Assess the results of urodynamic studies. A cystometrogram measures bladder pressures and fluid vol-
umes during filling, storage and urination.
Encourage voiding at regular intervals. Voiding at regular intervals prevents uncontrolled incontinence
Teach the patient to void before bedtime. Voiding before bedtime eliminates the need to wake up at night to
void.
Discuss the use of absorbent pads. Changing the pads regularly prevents skin irritation.
Incontinence, Stress Urinary 37
Stress Urinary Incontinence
related to
Multiple vaginal deliveries
Pelvic surgery
Hypo-estrogenism (postmenopausal)
Pelvic trauma
Obesity
Desired Outcomes:
Patient has no episodes of incontinence.
Patient implements activities to increase pelvic floor muscle tone.
Ask about urine loss during coughing, laughing, sneezing, or lift- Sphincter or relaxed pelvic floor muscles allow urine to leak due
ing. to increased intraabdominal pressure.
Examine the perineal area for pelvic relaxation: Pelvic relaxation can cause incontinence because of poor muscle
Cystourethrocele (prolapsing bladder or urethra) control
Rectocele (prolapsing rectal mucosa)
Uterine prolapse (prolapsing uterus)
Determine the parity of the patient. Vaginal births weaken the pelvic muscles.
Determine the patient's menstrual status. Postmenopausal hypo-estrogenism increases urethral relaxation.
Ask about previous surgical procedures. Transurethral resection of the prostate in men can result in uri-
nary incontinence.
Administer pseudoephedrine and vaginal estrogen These drugs increase bladder sphincter and pelvic muscle tone.
Prepare the patient for surgery, such as the Marshall-Marchetti- Surgical procedures are used to correct stress incontinence.
Krantz, Burch’s colposuspension, and sling procedures. These procedures support the urinary sphincter.
Teach the patient to perform Kegel exercises. Kegel exercises strengthen the pelvic floor muscles. Tightening
and relaxation of the pelvic muscles (10 repetitions four times per
day) helps improve continence.
Encourage the patient about to use of absorptive Pads should be changed three times a day to prevent skin irrita-
pads. tion.
Teach patient to use a vaginal pessary. Pessaries elevate the bladder neck and increase urethral re-
sistance.
Incontinence, Urge Urinary 38
Urge Urinary Incontinence
related to
Hypoestrogenism
Stroke
Parkinson's
Multiple sclerosis
Infections
Desired Outcomes:
Patient has no periods of incontinence.
Ask the patient to describe the incontinence episodes. Urge incontinence occurs when the bladder suddenly contracts.
The patient suddenly feels the need to urinate, and the patient
may not be able to reach the bathroom before a large volume of
urine is expelled.
Obtain a urine specimen for culture. Bladder infection can result in strong urges to urinate at frequent
intervals.
Assess the cystometry test results. Urodynamic testing measures bladder pressures and volume
during bladder filling, storage, and urination. Testing will demon-
strate the cause of the incontinence.
Teach the patient to take Anticholinergics block detrusor contractions, reducing inconti-
Anticholinergics nence.
Help the patient create a bladder-training program with scheduled Scheduled voiding decreases detrusor overactivity and increases
voiding every 3 hours, gradually increasing the time between bladder volume.
voidings.
Teach Kegel exercises. Kegel exercises improve pelvic floor muscle tone and sphincter
tone.
Infection 39
Risk for Infection
related to
Broken skin, injured tissue, body fluid stasis, immunosuppression, leukopenia
Malnutrition
Intubation
Indwelling catheters or drains
Intravenous devices
Chronic disease
Desired Outcomes:
Patient remains free of infection, as evidenced by absence of fever or purulent drainage.
Infection is recognized and treated early.
Assess for open wounds and abrasions; indwelling catheters; These items result in a break in the body’s first line of defense.
wound drainage tubes; endotracheal tubes; venous or arterial
access devices.
Assess white blood cell count. An increasing WBC count indicates that the immune system is
combating an infection. The normal WBC is 4,000 to 11,000/mcL.
Assess nutritional status, including weight and serum albumin. Patients with poor nutritional status may be unable to produce an
immune response against infection.
Assess for medications or treatments that may cause immuno- Chemotherapy agents and corticosteroids may reduce immuno-
suppression. competence.
Assess immunization status Older patients and persons raised outside of the United States
may not be completely immunized.
Monitor for signs of infection: Signs of infection include redness, warmth, swelling, and pain.
Erythema, swelling, pain; purulent drainage from wounds, fever, Drainage should be cultured; antibiotic therapy is determined by
cough, yellow sputum the most likely pathogen.
Temperature greater than 37.7° C suggests infection. High fever
with chills indicates septicemia.
Teach aseptic dressing changes, wound care, catheter care, and Aseptic technique decreases the risk of transmitting pathogens.
IV management.
Teach caregivers to wash hands before contact with the patient. Hand washing reduces the risk for transmitting pathogens.
Encourage intake of high protein, high calorie foods. Optimal nutrition supports the immune system.
Teach a fluid intake of 2000 mL of water per day (unless contra- Fluids promote diluted urine and frequent emptying of the blad-
indicated). der, reducing stasis of urine and decreasing the risk for bladder
infection.
Encourage the use of an incentive spirometer. These measures reduce stasis of secretions in the lungs and
bronchial tree. Stasis of secretions causes pneumonia.
Place the patient in protective isolation if she is immunosup- Protective isolation is indicated when the WBC count is
pressed. <500/mm3 (neutropenia).
Administer antibiotics. Antibiotics include antibacterial, antifungal, antiparasitic, and an-
tiviral agents.
Teach the patient or caregiver to wash hands often. Patients and caregivers can spread infection.
Teach the patient to avoid contact with persons with infections. Family members can spread infections to a susceptible patient.
Infection 40
Demonstrate and receive return demonstration of dressing Patient and caregivers should learn skills to reduce transmission
changes, peripheral IV site care, and self-catheterization. of infection.
Teach the patient the signs and symptoms of infection, which Patients should recognize signs of infection to allow for early
should be reported. treatment.
Insomnia 41
Insomnia
related to
Pain or discomfort
Environmental changes
Anxiety or fear
Depression
Medications
Desired Outcome:
The patient obtains an adequate amount of sleep, as evidenced by a rested appearance. The patient states that she feels well rest-
ed in the morning.
Assess the patient’s patterns of sleep amount, depth, and length. Information about sleep patterns provides a baseline for planning
interventions.
Assess the cause of the sleep difficulty, and assess measures Patients may have insight into the cause of the insomnia, such as
used to facilitate sleep. anxiety about a disease, worry about family, or depression.
Assess for drugs that can disrupt sleep. Drugs that may cause insomnia include SSRI antidepressants
and medications containing caffeine. Changing the schedule of a
medication to morning dosing may prevent nighttime insomnia.
Instruct the patient to keep a consistent a schedule of retiring and A consistent sleep schedule regularizes the circadian rhythm.
awakening.
Instruct the patient to avoid heavy meals and caffeine before re- Meals close to bedtime may cause insomnia due to heartburn.
tiring. Caffeine in coffee, tea, colas, and chocolate may cause insom-
nia.
Instruct the patient to avoid fluid before bedtime. Restriction of evening fluids eliminates the need for the patient to
get up and go to the bathroom during the night.
Increase daytime physical activity; however, avoid strenuous Daytime activity improves sleep. However, overactivity before
activity before retiring. bedtime may cause insomnia.
Discourage daytime naps. Napping may disrupt normal sleep patterns.
Encourage a warm bath, calm music, or reading a book before These activities promote relaxation before sleep.
retiring
Teach about prescription sedative drugs. Sedative drugs are associated with dependence, reduced rapid
eye movement sleep, and daytime drowsiness.
Provide bedtime pain relief, comfortable positioning, and relaxa- These activities promote relaxation.
tion techniques.
Move the patient to a room far from the nursing The nursing station is noisy and the noise may disrupt sleep.
station.
Lifestyle, Sedentary 42
Deficient Knowledge
related to
Condition or procedure
Complexity of treatment
Cognitive impairment
Desired Outcomes:
Patient demonstrates a willingness to learn.
Patient states an understanding of the information and performs desired skill.
Assess the motivation and willingness of the patient to learn. Some patients are ready to learn after a diagnosis. Some pa-
tients may refuse instruction.
Assess the patient’s ability to learn, remember, and perform Cognitive impairments should be identified to allow an appropri-
treatments. ate teaching. The Mini-Mental State Examination (MMSE) can be
used to identify memory problems.
Assess the patient’s preferred learning method, such as written Patients may prefer written materials to verbal instruction.
or verbal.
Provide information as explanations, discussions, demonstra- The learning style of the patient should be matched with the pa-
tions, pictures, written instructions, computer-assisted programs, tient’s preferred educational approach.
and videos.
Pace the instruction and keep sessions short. Learning requires energy, and slow, paced sessions will reduce
fatigue.
Use the teach-back technique to determine the patient's under- The teach-back technique assesses the recipient’s knowledge of
standing of what was taught. the content discussed.
The nurse gives information. Then the nurse asks the patient to
explain what she learned.
Allow the learner to practice new skills and provide feedback. Practice enhances the patient’s retention of knowledge.
Include significant others in teaching. One person usually assumes a supportive role for treatments.
Memory, Impaired 43
Impaired Memory
related to
Alzheimer disease
Neurological lesion
Medications
Desired Outcomes:
Patient is able to recall immediate, recent, and remote information.
Patient is able to maintain attention.
Patient is oriented to time, person, place, and self.
Patient uses techniques to promote recall of information.
Perform a mental status examination. Assess orientation to time, Changes in memory may be detected by the mini-mental status
place. Assess recall of three words. exam, which assesses cognitive ability.
Assess serial subtraction of 7s.
Naming of familiar objects. Repetition of a phrase.
Ability to follow a 2-step command.
Reading, writing a sentence.
Copy a figure.
Assess the patient’s medications and use of alcohol. Benzodiazepines, opiate analgesics, and alcohol may impair
memory.
Assess nutritional status and diet. Nutritional deficiencies, such as thiamine deficiency, may cause
impair memory.
Administer cognitive medications as prescribed. Acetylcholinesterase inhibitors, such as donepezil (Aricept) and
rivastigmine (Exelon) increase cholinergic transmission and delay
cognitive decline.
Teach the patient memory techniques, such as calendars, Memory techniques improve recall of information and delay
alarms, timers, reminder notes, check lists, smart phones, and memory loss.
notebooks.
Mobility, Impaired Physical 44
Impaired Physical Mobility
related to
Cognitive impairment
Perceptual impairment
Musculoskeletal disorder
Decreased muscle strength, control
Prolonged bedrest
Pain and discomfort
Desired Outcomes:
Patient performs physical activities independently
Patient demonstrates use of adaptive techniques that improve ambulation and transferring
Patient is free of complications caused by immobility, as evidenced by intact skin and normal bowel pattern.
Assess for barriers to mobility, such as arthritis, weakness, or Assessment aids in treatment planning.
pain.
Assess the patient's ability to perform activities of daily living. Restricted movement reduces the patient’s ability to per-
form ADLs.
Assess the patient’s range of motion in all joints. This assessment guides the therapeutic plan.
Assess the patient’s need for assistive devices. Wheelchairs, canes, and transfer bars promote independence.
Assess the safety of the patient’s environment. Throw rugs, children's toys, and pets may cause falls.
Assess the need for home physical therapy. Assistance promotes gradual progression of activity.
Assess the skin for redness and skin abrasions. Examination of the skin will allow for recognition of pressure ul-
cers.
Assess bowel elimination status (e.g., usual pattern, constipa- Immobility can cause or worsen constipation.
tion).
Encourage early ambulation. Advance activity from dangling legs, Early mobility promotes independence and prevents debilitation.
sitting in chair, to ambulation.
Encourage the use of assistive devices, such as crutches, cane, Crutches, canes, or walkers help patients increase mobility.
or walker.
Facilitate transfer training by teaching and using techniques to Learning to transfer helps the patient maintain mobility.
transfer patients.
Administer analgesic medications. Analgesics reduce pain that impedes movement
Initiate measures to prevent skin breakdown and deep vein These measures reduce skin breakdown. Compression devices
thrombosis: increase venous return and prevent venous stasis and thrombo-
• Clean, dry, and moisturize the skin. phlebitis.
• Use sequential compression devices.
• Use a pressure-relieving gel mattress.
• Change the patient’s position every 2 hours. Position changes optimize circulation and relieve pressure.
Heavy linens can push the feet out of alignment.
• Keep the feet in a dorsiflexed position. Use a bed cradle.
Encourage adequate fluid, fiber, and stool softeners. Record Prolonged bed rest and physical inactivity can result in constipa-
bowel activity. tion.
Mobility, Impaired Physical 45
Instruct the patient or caregivers about the hazards of immobility. Information enables the patient or caregivers to take control of
Emphasize the importance of position changes, and ROM. the recovery.
Refer the patient to occupational and physical therapy. Physical and occupational therapy can provide instruction and
assistive aids.
Imbalanced Nutrition: Less Than Required 46
Imbalanced Nutrition: Less Than Body Requirements
related to
Inability to ingest foods
Refusal to eat
Inability to obtain food
Desired Outcomes:
The patient states and demonstrates selection of foods or meals that will maintain a stable weight.
Patient weighs within 10% of ideal body weight.
Measure the patient’s weight and height. Weight and height should be accurately measured.
Obtain a nutritional history. Family members may provide a more accurate estimate of the
patient's eating habits.
Determine the causes of the impaired nutrition. Proper assessment guides intervention. Patients with memory
losses may require a Meals-On-Wheels service.
Monitor laboratory indicators of nutrition. Laboratory tests monitor the degree of protein depletion (<2.5
g/dL indicates severe depletion; 3.8 to 4.5 g/dL is normal).
Transferrin Transferrin is an iron transfer protein, which declines with malnu-
trition.
Consult a dietitian for nutritional recommendations. A dietitian can measure nitrogen balance to assess the patient’s
nutritional status.
Establish nutritional goals. Improvement in nutritional status requires several months. Short-
term goals allow for provision of rewards early in the treatment.
Provide extra seasoning for patients with a decreased sense of Seasoning enhances the taste of food and promotes eating.
taste.
For patients with physical impairments, consult an occupational An occupational therapist can provide plate guards and strap-on
therapist for adaptive devices. utensils, which help the patient to feed himself.
Consult a speech therapist for patients with impaired swallowing. A speech therapist can assess dysphagia and make recommen-
dations about soft or ground foods.
For hospitalized patients, encourage the family to bring food from Patients with ethnic or religious preferences or restrictions may
home. not be able to eat hospital foods.
Suggest the use of nutritional supplements between meals. Supplements can increase calories and protein.
Assess the need for enteral or parenteral nutrition. Enteral tube feedings are indicated for patients who are unable to
maintain nutritional intake by the oral route. Parenteral nutrition is
indicated for patients who cannot tolerate enteral feedings.
Explain the four food groups and the MyPlate food guides Adequate caloric intake for an adult is 1800 to 2200 kcal/day.
High caloric content and high protein food promote weight gain
and nitrogen balance.
Encourage small frequent meals of high calories and high protein Small frequent melas are easier to digest.
foods.
Refer the patient to Meals-On-Wheels or a hot lunch programs Many seniors are not able to cook their own meals.
for seniors.
Imbalanced Nutrition: More Than Required 47
Imbalanced Nutrition: More than Requirements
related to
Excessive intake in relation to metabolic needs
Poor dietary habits
Lack of nutritional knowledge
Metabolic disorders
Sedentary lifestyle
Desired Outcomes:
Patient states accurate information about the benefits of weight loss.
Patient states measures necessary to achieve weight reduction.
Patient demonstrates appropriate selection of meals.
Measure the patient’s weight, waist circumference, and body BMI is weight in kilograms divided by the square of the height in
mass index. meters. A BMI between 20 and 24 is healthy. BMIs greater than
25 are associated with increased morbidity and mortality. A BMI
of ≥30 is obesity.
Assess for complications of obesity. Cardiovascular disease, sleep apnea, diabetes, and osteoarthritis
are associated with obesity.
Assess the patient’s readiness for a weight loss regimen: How do If the patient is unsure about starting a weight loss program, ef-
you feel about starting a weight loss program? forts may be directed toward emphasizing the health benefits of
healthy eating.
Perform a nutritional assessment: Record a daily food intake re- Assessment of the patient’s eating pattern provides a baseline for
call (type and amount of food). Calculate the daily caloric intake. change. Assessment includes a 24-hour recall of foods eaten and
a food diary.
Assess for behavioral factors that may contribute to overeating. Overeating may be related to environmental and behavioral fac-
tors.
Assess for barriers to weight loss, such as lack of motivation, An awareness of barriers to weight loss increases the likelihood
interpersonal support, or knowledge. of successful change.
Assess the patient’s ability to read food labels. Food labels contain nutritional information. "Low-fat” or "fat-free"
foods may still have many calories.
Assess the patient's ability to plan a menu. Menu planning may be learned during education.
Establish goals. Realistic short-term goals to provide attainable rewards
Consult a dietitian to formulate a weight loss program. A dietitian will assess the fat content of usual, cultural, and ethnic
foods.
Educate the patient about the benefits of weight loss. Information on the health benefits of weight loss and the health
risks of obesity will increase the patient’s motivation to lose
weight.
Oral Mucous Membrane, Impaired 48
Impaired Oral Mucous Membrane
related to
Dehydration
Medication side effects
Chemotherapy
Decreased salivation
Ineffective oral hygiene
Infection
Desired Outcomes:
Patient has a healthy oral cavity, as evidenced by intact, pink, moist mucous membranes.
Patient demonstrates oral hygiene practices.
Observe for infection: Early assessment facilitates early treatment.
Candidiasis causes cottage cheese-like, white patches on the
tongue, buccal mucosa, and palate
Assess the patient’s oral hygiene practices. Information will suggest possible causes of mucous membrane
lesions.
Assess the tongue, lips, mucous membranes, gums, and teeth Inspection of the oral mucosa facilitates treatment planning.
after removal of dental appliances.
Perform mouth care after each meal and every 4 hours while Mouth care prevents accumulation of plaque and bacteria.
awake.
If mild stomatitis: Oral hygiene promotes comfort. Sensitivity to pain may result
• Rinse mouth with a medicated mouthwash between brush- from thinning of the oral mucosa.
ings.
• Administer systemic or topical analgesics.
Teach that topical analgesics can be administered as a "swish Lidocaine viscous gel (2%) is a topical analgesic that reduces
and swallow" or a "swish and spit," 15 minutes before meals. pain.
Explain the use of topical protective agents: Topical protective agents coat lesions and promote healing.
• Zilactin or Zilactin-B Zilactin gel contains the benzocaine anesthetic and is painted on
the lesion to form a protective seal, which promotes healing.
For severe mucositis administer topical antimicrobial agents. Mycostatin, nystatin, and Mycelex troches are prescribed for fun-
gal infections.
Use a foam stick instead of a toothbrush and floss. Brushing may damage ulcerated tissues. A disposable foam stick
should be used to apply cleansing solutions.
Encourage a high protein diet. A high protein diet promotes healing. The patient should eat food
Soft, serve lukewarm or cold foods and fluids. and fluids that are less irritating. Soft, bland lukewarm or cool
Provide frequent small meals or snacks. foods will sooth the oral tissues.
Instruct the patient to brush with baking soda and then rinse with Baking soda improves cleaning of the teeth without abrading the
water. mucous membranes.
Encourage the use of artificial saliva. Artificial saliva products coat and lubricate the mouth.
Pain, Acute 49
Acute Pain
related to
Medical problems
Procedures or treatments
Trauma
Desired Outcomes:
Patient reports pain control to a level of less than 3, on a rating scale of 0 to 10.
Patient uses pain-relief strategies.
Patient has a pulse of <100 bpm, and blood pressure <130/90 mmHg.
Assess the characteristics of the pain: Assessment of the pain is the first step in pain management and
• Quality (e.g., sharp, burning) allows for treatment planning.
• Severity (scale of 0 to 10)
• Location
• Onset (gradual or sudden)
• Duration (intermittent or constant)
• Precipitating or relieving factors
Assess for signs associated with the pain. Acute pain may cause an elevated BP, HR, and temperature.
The patient's skin may be pale and cool.
Assess the patient's response to the pain management The patient’s response to pain relief measures guides the thera-
peutic plan.
Assess cultural, environmental, and intrapersonal effects on pain These variables may modify the patient's expression of pain.
relief. Some cultures openly express pain, whereas others suppress the
expression of pain.
Assess the patient’s expectations for pain relief. Some patients expect only decreased pain. Other patients expect
complete elimination of pain.
Determine if a patient-controlled analgesia device is needed. PCA is an IV infusion of morphine with an infusion pump, which is
controlled by the patient. The patient is able to manage her pain
relief within limits.
If the patient is on a PCA: If demands for medication are frequent, the dosage of morphine
• Assess the amount of pain medication the patient demands. should be increased.
• PCA complications include excessive sedation, respiratory Assessment for complications prevents adverse reactions to
distress, urinary retention, nausea and vomiting, constipation, morphine.
and IV site pain, redness, or swelling
If the patient is receiving an epidural: These symptoms may be indicators of an allergic response to the
Report numbness, tingling in the extremities, metallic taste in the anesthetic or improper catheter placement.
mouth
Assess for epidural analgesia complications, such as excessive Respiratory depression may result from catheter migration.
sedation, respiratory depression, or urinary retention
Anticipate the need for pain relief. Pain should be prevented before the pain actually occurs. Early
intervention decreases the total amount of analgesic required to
relieve pain.
Pain, Acute 50
Respond quickly to complaints of pain. Anxiety and fear about delayed pain relief can exacerbate the
pain. A prompt response to pain decreases anxiety.
Determine the appropriate pain medication, such as morphine, Patients with acute pain should receive an opiate analgesic, such
fentanyl, Percocet, Vicodin, and/or acetaminophen. as morphine, and acetaminophen around-the-clock.
Pharmacologic pain relief methods include: NSAIDs block the synthesis of prostaglandin. NSAIDs are effec-
• Acetaminophen, NSAIDs, and COX-2 inhibitors tive for relief of mild to moderate pain.
Opioids may be administered orally, intravenous-
• Opioid analgesics ly, by PCA, or epidurally for severe pain.
Nonpharmacological pain relief methods include relaxation Visualization of a mental picture or an event will distract the pa-
exercises, breathing exercises, and music therapy tient from the painful stimuli.
• After giving analgesics, assess the effectiveness, and ob- Pain medication efficacy must be assessed and adverse effects
serve for adverse effects. reported.
If the patient is on PCA: IV incompatibilities are possible with the PCA.

• Dedicate an IV line to the PCA.
If the patient is receiving epidural analgesia: Inappropriate use of an epidural catheter can cause neurological
Label all tubing to prevent inadvertent administration of fluids or injury.
drugs into the epidural space.
Teach the patient the medication purpose, benefits, and tech- Effective pain management requires patient knowledge.
niques of use.
Pain, Chronic 51
Chronic Pain
related to
Chronic physical disability
Physical injury
Desired Outcomes:
Patient reports pain at a level of 3-4 on a 0 to 10 scale.
Patient uses pharmacological and non-pharmacological pain relief strategies.
Patient engages in desired activities.
Assess pain characteristics: Assessment of chronic pain guides the pain management plan.
Quality (eg, sharp, burning).
Severity on a scale of 0 to 10.
Location.
Onset (gradual or sudden).
Precipitating factors.
Relieving factors.
Assess for insomnia, anxiety, or depression. Chronic pain can deplete the patient's energy, resulting in insom-
nia, anxiety, or depression.
Assess cultural, and religious factors that are influencing the pa- Culture and religion will influence the patient’s expressions of
tient’s pain experience. suffering associated with the pain.
Assess the patient’s expectations of pain relief. Patients with chronic pain may be content with only a decreased
severity of pain.
For patients taking opioid analgesics, assess for side effects, and Drug dependence and tolerance to opioid analgesics may occur
tolerance. with long-term use.
Assess the patient’s ability to complete activities of daily activity Fatigue, anxiety, and depression due to chronic pain and may
and demands of daily living. affect activities and reduce the patient’s ability to fulfill role re-
sponsibilities
Encourage the patient to keep a pain diary to identify factors that Understanding the factors that influence the pain can guide life-
aggravate and relieve the pain. style modifications.
Encourage the patient to follow a pain management strategy. Nonopioid medications are preferred because of a low side-effect
profile. Medications should be given around-the-clock to achieve
consistent pain relief. The oral route is preferred.
Teach the patient about: NSAIDs inhibit the synthesis of prostaglandins and reduce in-
Acetaminophen and NSAIDs flammation and edema. These drugs can be taken orally, are not
associated with dependency and addiction, and should be taken
around-the-clock.
Teach the patient about opioid analgesics, such as Vicodin and Opioid analgesics bind to CNS opiate receptors. The side effects
Percocet associated with opioids include respiratory depression, tolerance,
and dependency
Skin Integrity, Impaired 52
Risk for Impaired Skin Integrity
related to
Extremes of age
Immobility
Impaired circulation
Impaired sensation
Pressure, shear, and friction
Fecal or urinary incontinence
Edema
Desired Outcomes:
Patient's skin remains intact, as evidenced by an absence of redness over bony prominences.
Assess skin turgor, temperature, moisture, and integrity. Skin assessment provides a basis for interventions. Healthy skin
should have good turgor, be warm and dry, free of bruises, exco-
riation, and rashes.
Assess the skin over the sacrum, trochanters, scapulae, elbows, Areas where skin is stretched over bony prominences are at risk
heels, malleolus, knees, and back of head. for breakdown. Areas that are under pressure will initially appear
as red areas.
Assess the patient’s sensation to touch. Patients with decreased sensation are unaware of the pain
caused by pressure, which may result in skin ischemia.
Assess the patient’s ability to shift weight while sitting, turn over Immobility is the most significant risk factor for skin breakdown.
in bed, and move from bed to chair.
Assess nutritional status, including weight, and serum albumin. An albumin level of <2.5 mg/dL indicates protein depletion and
high risk for skin breakdown.
Assess for edema The skin over edematous tissue is at risk for breakdown.
Assess for fecal or urinary incontinence. Urine contains ammonia, which is caustic to the skin. Stool en-
zymes may cause skin breakdown. Diapers and incontinence
pads trap moisture and worsen skin breakdown.
Assess the patient’s mattress and wheelchair cushion. A pressure reduction or pressure relief device will distribute pres-
sure more evenly on the patient’s skin.
Assess the skin: Dermatitis and irritants can cause inflammation, resulting in red-
Dermatitis or exposure to chemical irritants ness and bullae.
If the patient is bedbound, post a turning schedule and turn the A written schedule should require turning of the patient every 2
patient every 2 hours. hours.
Use bed linen or a trapeze to lift and move the patient in bed. These measures reduce shearing forces and reduce pressure
Use pillows or foam wedges to prevent bony prominences from and reduce pressure on the skin.
coming into direct contact. Place pillows under heels.
Encourage walking. Walking reduces pressure on the skin.
For low-risk patients: use a foam mattress overlay to reduce skin Egg crate mattresses with a thickness of 5 inches help to relieve
pressure. pressure.
For moderate-risk patients, use a water mattress or an air mat- Dynamic mattresses alternate between inflation and deflation. A
tress. waterbed is acceptable for home use.
Skin Integrity, Impaired 53
For high-risk patients or patients with stage III or IV pressure ul- Low-air-loss beds allow the head of bed to be raised if the patient
cers, use a low-air-loss bed or an air-fluidized bed. has dyspnea due to heart failure. Air-fluidized beds support the
patient’s weight, but restrict the patient is restricted from getting
out of bed.
Clean, dry, and moisturize the skin twice daily. Use cornstarch to Smooth, supple skin resists mechanical injury. A mild cleansing
keep the skin dry. agent should be used. Moisturizers or emollients with lipids will
retain moisture and prevent skin drying. Talc can be inhaled and
cause lung injury.
Leave bullae intact by wrapping the bullae in gauze. Intact blisters maintain form a barrier to infection.
Teach the causes of pressure ulcers: This information will help the patient or caregiver to prevent skin
Pressure on skin, over bony prominences breakdown.
Incontinence
Shearing or friction.
Teach the patient or caregiver to use pressure-redistribution de- Pressure-redistribution devices help prevent pressure ulcers.
vices.
Teach patients and caregivers about skin care. Skin care prevents skin breakdown.
Suicide 54
Risk for Suicide
related to
Chronic illness
Death of a family member
Developmental crisis or situational crisis
Life changes
Desired Outcomes:
Patient does not have suicidal thoughts
Patient agrees to desist from suicidal behavior
Patient does not have impulses to harm himself.
Assess for self-harm potential: Suicidal ideation increases the risk of suicide. The suicide risk is
“Do you now feel like killing yourself?” “What is your plan?” “What higher if there was a suicide attempt. A plan and the ability to
means do you have to kill yourself?” carry out the plan increase the risk of suicide.
“Will you be able to maintain control over your impulses?”
Assess for the giving away of valued possessions Giving away possessions is a warning sign of suicide.
Assess for a history of depression, bipolar disorder, schizophre- Depression is common in patients who attempt suicide. Patients
nia, or other mental disorder. with hallucinations or delusions may feel compelled to commit
suicide.
Assess the patient’s support resources. Patients who are depressed may be unable to access support
resources.
Assess for specific stressors. Assessment of stressors facilitates development of coping strate-
gies.
Assess the need for hospitalization and safety precautions. Suicide precautions include removal of electrical appliances,
sharp instruments, belts and ties, glass items, and medications.
Provide suicide precautions. The suicidal patient should be directly supervised at all times.
Make a verbal or written contract with the patient stating that the A written or verbal agreement creates a commitment by the pa-
patient will not self-harm. tient to not attempt suicide.
Refer the patient to community support resources. Support sources include community-based mental health ser-
vices, crisis lines, spiritual support, financial aid, and housing.
Swallowing, Impaired 55
Impaired Swallowing
related to
Decreased or absent gag reflex
Decreased strength of muscles of mastication
Tumor
Oropharyngeal infection
Desired Outcomes:
Patient exhibits ability to safely swallow, as evidenced by absence of coughing or choking during eating/drinking, and no stasis of
food in oral cavity.
Patient uses correct positioning during eating.
Patient and caregiver state emergency measures for choking.
Assess the patient’s gag and cough reflexes. The lungs are protected against aspiration by the cough and gag
reflexes.
Assess the patient’s ability to swallow a sip of water. The ability to swallow is tested with a sip of water.
Check for residual food in the mouth after eating. Residual food may be easily aspirated.
Assess for coughing or choking during eating and drinking. These signs indicate a risk for aspiration.
Assess a swallowing study. A videofluoroscopic swallowing study will determine the extent of
oropharyngeal swallowing abnormalities.
Reduce environmental stimuli, such as a TV, during meals. The patient will be better able to concentrate on swallowing if
distractions are minimized.
Provide oral care and ensure that dentures are in place before Oral care improves the patient’s appetite. Dentures will improve
meals. the patient’s ability to chew food.
Consult with a speech pathologist to assess dysphagia and plan Minimal dysphagia requires thickened liquids. Mild-moderate
meals. dysphagia requires special swallowing techniques and a thick-
ened or ground diet. Severe dysphagia requires nothing by
mouth.
Place suction equipment at the bedside, and suction as needed Dysphagia causes secretions to accumulate in the mouth, in-
creasing the risk for aspiration.
If decreased salivation: Tart flavors will stimulate salivation, lubricate food, and increase
Give the patient a lemon wedge, pickle, or tart candy before ability to swallow.
meals.
Use artificial saliva.
Place the patient in high-Fowler's position with the head flexed The upright position promotes the flow of food and fluid through
forward during meals. the hypopharynx. Aspiration is less likely with the head tilted
slightly forward during swallowing.
Use thickening agents. Pudding, cooked cereal, and semi-solid foods are easier to swal-
low.
Instruct the patient: (1) hold food in the mouth, (2) close the Instruction on the steps of swallowing reduces aspiration.
lips, (3) think about swallowing, and then (4) swallow.
Instruct the patient to talk not while eating. Concentration must be focused on swallowing.
If the patient has had a stroke, place food on the unaffected side The unaffected side of the mouth is better able to completely
of her mouth. chew and swallow.
Swallowing, Impaired 56
If oral intake is not possible or is inadequate, initiate nasogastric Enteral feedings are often required for optimal nutrition.
feedings or gastrostomy feedings.
Teach the patient exercises to enhance the muscular strength of Muscle strengthening promotes the patient’s ability to chew and
the face and tongue. position food in the mouth.
Arrange for a home care aide or meal provision. Homebound patients may require assistance to maintain ade-
quate nutrition.
Demonstrate use of suction and the abdominal thrust maneuver. Aspiration requires immediate action to maintain the airway.
If a liquid aspiration occurs, turn place the patient on his side. If
the patient as difficulty breathing, call 911.
Urinary Retention 57
Urinary Retention
related to
General anesthesia
Urethral obstruction by a tumor
Urethral obstruction by a kidney stone
Desired Outcomes:
Patient empties bladder completely, as evidenced by urine voidings >300 mL and residual volume of <100 mL.
Assess the patient’s pattern of voiding. Urinary retention causes difficulty starting the stream of urine or
causes incomplete bladder emptying.
Palpate the lower abdomen for distention. The lower abdomen becomes distended if urine is retained in the
bladder.
Measure the interval between voidings, and record the voided A 48-hour log of voiding will reveal the voiding pattern.
volumes.
Use a bladder ultrasound to measure residual urine. Retention of urine in the bladder predisposes to urinary tract in-
fection.
Assess intakes and outputs. A total lack of urine output may indicate an obstruction. Medica-
tions and benign prostatic hyperplasia may cause urinary ob-
struction.
Assess urinalysis. Urinary tract infection can cause urinary retention.
If an indwelling catheter is in place, assess for patency and An occluded or kinked catheter may cause urinary obstruction.
kinking.
Assess blood urea nitrogen and creatinine. Increased BUN and creatinine are signs of renal failure.
Initiate the following: An upright position on a commode increases voiding success.
Position the patient upright in a commode to facilitate voiding.
Encourage the patient to void at least every 4 hours. Voiding at frequent intervals empties the bladder and prevents
urinary retention.
Teach the patient to perform Crede’s maneuver by pressing Crede’s maneuver will promote complete emptying of the blad-
down over a bladder during voiding. der.
Insert an indwelling catheter. Treatment of acute urinary retention begins with insertion of an
indwelling catheter to drain the bladder.
Begin an intermittent catheterization program. Intermittent catheterization is used to relieve chronic urinary re-
tention.
Encourage the patient to take bethanechol (Urecholine). Bethanechol stimulates the release of acetylcholine, which in-
creases contractions of the bladder.
Teach the symptoms of a urinary tract infection, such as fever, Knowing the symptoms of urinary tract infection allows the patient
frequent urination, and burning with urination. to seek treatment.
Teach the patient about surgical treatments. If prostate enlargement is the cause of urinary retention, surgery
is indicated. Women may need surgery to correct a prolapsed
bladder.
Cancer 58
Medical-Surgical Nursing
Cancer
Diagnosis: Pain caused by cancer

related to the disease process, surgery, or chemotherapy
Desired Outcome: Patient follows pain management plan and reports that her pain has decreased to a level of <4, based on 1-10
scale within 1 hr of treatment.
Assess the patient’s level of pain or paresthesias. Neuropathic pain is caused by damage to the nervous system
and is described as chronic, burning, tingling, or numbness.
Assess the characteristics of the pain, including the location and Characterizing the pain and assessing the location of the pain
radiation of the pain. will maximize the effect of analgesic therapy.
Determine the duration of pain. Evaluation of precipitating factors may decrease the severity of
the pain.
Assess the severity of the pain on a pain scale of 0 to 10. Severe pain is a sign of internal bleeding or intestinal perforation.
Relief of pain is a score of 4 or less on a 0-10 scale.
Assess aggravating and relieving factors for the pain. Removal of factors that worsen the pain may assist in pain re-
duction.
Assess the patient’s attitudes and knowledge about treatment of Inappropriate fear of addiction may result in inadequate pain
pain. management.
Give nonopioid and opioid analgesics on an around-the-clock Chronic cancer analgesia is more effective on an around-the-
schedule. clock schedule.
Report and treat adverse effects of opioid analgesia. Adverse effects of opioids include respiratory depression, nau-
sea and vomiting, constipation, sedation, and pruritus.
Assess the patient for signs of tolerance. Patients with chronic pain often require increasing doses of opi-
oids because of tolerance.
Opioids should not be abruptly discontinued in patients who Physical dependence occurs in patients who take opioids for
have been taking opioids for more than two weeks. prolonged periods. Opioids should be tapered gradually over
months.
Diagnosis: Lymphedema caused by cancer

related to disease process (interrupted blood flow occurring with lymphedema)
Desired Outcome: Intervention results in adequate peripheral perfusion, as evidenced by normal skin color, decreased edema,
and full range of motion.
Assess extremity for edema, color, sensation, and range of mo- This evaluation determines the degree of lymphedema and risk
tion. of limb ischemia.
Assess edematous limb for erythema. Signs of infection should be reported.
Elevate the involved extremity on a pillow. Elevating the extremity reduces edema.
Do not perform blood pressure readings, venipuncture, IV cathe- BP cuffs can impair lymphatic drainage. Injections and blood
ters, and vaccinations in the affected arm. draws will increase risk of infection.
Cancer 59
Encourage the patient to follow an exercise plan. Exercise increases lymphatic flow and reduces edema.
Encourage use of elastic bandages or sequential compression Elastic bandages and sequential compression devices reduce
devices. edema.
Diagnoses: Ineffective Peripheral Tissue Perfusion, Risk for Decreased Cardiac Tissue Perfusion
related to interrupted venous flow caused by deep venous thrombosis/venous thromboembolism
Desired Outcome: Before hospital discharge, patient correctly takes anticoagulant treatment.
Instruct patient to self-inject low-molecular-weight heparin. Individuals with brain, breast, colon, renal, pancreatic, and lung
cancer are at increased risk for DVT.
Instruct patient to report unilateral limb swelling, erythema, and DVT may recur.
tenderness.
Dyspnea and chest pain should be reported. DVT may progress to pulmonary embolism.
Diagnoses: Risk for Impaired Skin integrity

related to disease state or related treatments
Desired Outcome: Following instruction, patient states measures that preserve skin integrity and improve management of open
wounds.
Assess the patient’s risk for skin lesions. Patients with breast, lung, colon, renal cancers, lymphoma, and
melanoma are at risk for skin breakdown.
Assess common sites of cutaneous lesions. Cancer or chemotherapy may result in skin lesions on the anterior
chest, abdomen, scalp, and neck.
Assess skin for swelling, erythema and purulent drainage. These are signs of infection.
Inspect skin lesions for location, size, drainage Skin integrity reduces the risk of infection.
Wash affected area with tepid water and pat dry. Hot water will cause thermal damage to healing tissue.
Apply dry dressings to skin lesions. A dressing will protect the skin from exposure to irritants, and
scratching.
For ulcers, use 1/2-strength hydrogen peroxide, followed by a This solution will irrigate and debride the lesion. Rinsing removes
normal saline rinse. residual peroxide.
Use cotton swabs to cleanse ulcers. Pressure from swabs or sponges debrides the ulcerated area and
leaves granulation tissue intact.
Use wet dressings with normal saline or Burrow's solution Wet dressings will debride bacteria, and necrotic tissue from the
(aluminum acetate) on the involved skin. ulcer.
Thoroughly rinse away hydrogen peroxide or aluminum ace- Failure to rinse may exacerbate skin breakdown.
tate.
Use wet-to-dry dressings. Wet-to-dry dressings provide gentle debridement.
Cancer 60
Diagnosis: Risk for infection

related to inadequate secondary defenses, resulting from myelosuppression caused by cancer treatments
Desired Outcomes: Patient is free of infection, as evidenced by temperature <38° C and heart rate <100 bpm.
Assess temperature, and catheter sites Q4h. Temperature >38° C, tachycardia, tenderness, erythema, swell-
ing, and drainage are signs of infection.
Before administering chemotherapy, ensure that blood counts Chemotherapy causes low WBCs, RBCs, and platelet counts
are normal. because of bone marrow suppression.
Determine the patient’s risk for infection by calculating the abso- Neutropenia increases the risk of bacterial infections. A low ANC
lute neutrophil count. ANC = (% of segmented neutrophils + % is a contraindication to chemotherapy.
of bands) x WBC count
3
ANC of 1500-2000/mm -no significant risk of infection.
3
ANC of 1000-1500/mm -minimal risk.
3
ANC 500-1000/mm -moderate risk.
3
ANC <500/mm - severe risk.
3
Neutropenic precautions should be initiated for patients with an Patients with an ANC <1000/mm are at high-risk for infection.
3
ANC <1000/mm
3
If ANC is <1000/mm , place sign on the patient’s door indicating
neutropenic precautions.
Instruct all persons entering the patient’s room to wash hands. Hand hygiene is the most important aspect of infection preven-
tion.
Prevent individuals with transmissible illnesses from entering the Individuals with URIs, influenza, or herpes zoster can transmit
patient’s room. these illnesses to patients with neutropenia.
Restrict fresh flowers in the patient’s room. Flowers may transmit infection to neutropenic patients.
Notify the physician if temperature is >38° C. Fever is a sign of infection and requires evaluation and CBC.
Neutropenic patients with fever should receive antibiotic treat- Fever is a sign of infection; therefore, antibiotics should be start-
ment within one hr. ed urgently.
Advise patient to clean teeth with a soft-bristle toothbrush after Soft toothbrushes help prevent injury to the oral mucosa, which
meals and before bedtime. could result in infection.
Assess the oral cavity daily for erosions, erythema, or exudate Neutropenia increases the risk of fungal, bacterial, and viral in-
on the tongue or mucous membranes. fections of the oral cavity.
Avoid rectal suppositories, rectal thermometers, or enemas. Suppositories, rectal thermometers, and enemas may trauma-
tize the rectal mucosa and cause infection.
Recommend that the patient shave with an electric shaver and These measures help prevent lacerations of the skin and reduce
use an emery board for nail care. the risk of infection.
Teach the patient to avoid raw eggs, raw fruits and vegetables, These measures reduce the risk of bacterial infection.
houseplants and fresh flowers.
Diagnosis: Impaired Skin Integrity

related to radiation treatment
Desired Outcome: After teaching, patient states skin reactions and interventions that will maintain skin integrity.
Cancer 61
Assess for skin rashes caused by radiation therapy. Severe skin reactions may require a postponement of radiation
treatments.
Wash skin gently , using mild soap, tepid water, and a soft cloth. Mild reactions to radiation are treated with gentle skin care.
Rinse and pat the skin dry.
Apply cornstarch, MD ointment, lanolin, or mild corticosteroids. Patchy desquamation is treated with ointments.
Cleanse area with 1/4-strength hydrogen peroxide and normal Moist desquamation, blisters, and edema are treated with
saline. Rinse with saline and pat dry. cleansing and absorbent dressings. Adhesive dressings may
damage the skin.
Use moisture- and vapor-permeable dressings on noninfected These dressings enhance healing of damaged skin.
areas.
Debride wound of eschar. Debridement aids healing and prevents infections.
After removing eschar, wet-to-moist dressings are used. Wet-to-moist dressings prevent infection by removing necrotic
debris.
Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

related to nausea and vomiting or anorexia caused by chemotherapy.
Desired Outcome: At least 24 hr before hospital discharge, patient states an understanding of basic nutritional principles to pre-
vent loss of weight.
Weigh patient daily. Nausea, vomiting, anorexia, and dysgeusia may exacerbate
weight loss.
Explain that the cancer or adverse effects of chemotherapy and Taste and olfactory receptors are sensitive to chemotherapy
radiation may cause anorexia. and radiation treatment.
Advise patient to increase her caloric and protein intake. Increasing calories minimizes weight loss and improves tissue
repair.
Recommend that patient eat several small meals at frequent Smaller, more frequent meals are better tolerated than large
intervals. meals.
Encourage nutritional supplements. Protein and calories aid in healing and provide energy.
Administer megestrol and prednisone. Megestrol and prednisone stimulate appetite enhance weight
gain during chemotherapy.
Assess the amount and character of nausea and emesis. Knowledge about the pattern of nausea and vomiting enhances
use of antiemetics.
Teach patient to take antiemetic 1 hr before chemotherapy. Nausea is better controlled by prevention.
Advise patient to eat cold foods or room temperature foods. The odor of hot food may increase nausea.
Recommend intake of clear liquids and bland foods. Avoid foods Strong odors and tastes can stimulate nausea and reduce ap-
with strong odors. petite.
Recommend sour candy or mints during chemotherapy. These candies decrease the metallic taste associated with
chemotherapy.
Teach patient to take oral chemotherapy with an antiemetics at Bedtime timing minimizes nausea.
bedtime.
Teach the patient avoid eating or drinking 2 hr before and after Reducing eating before and after chemotherapy reduces nau-
chemotherapy. sea.
Cancer 62
Instruct patient to slowly sip clear liquids, such as broth, ginger These actions increase oral moisture and relieve dry mouth.
ale, cola, or tea.
Diagnosis: Impaired Oral Mucosa Membranes

related to adverse effects of chemotherapy; ineffective oral hygiene; gingival disease
Desired Outcomes: Patient's oral mucosal condition improves, as evidenced by intact mucous membranes and absence of oral
inflammation or erosions.
Assess oral mucosa for integrity, color, and signs of infection. Patients receiving cancer treatments are at risk for oral lesions,
such as dryness, inflammation, infection, and pain.
Teach the myelosuppressed patient not to floss teeth, use oral Brushing with a stiff toothbrush and flossing could damage the
irrigators, or a stiff toothbrush. oral mucosa and cause infection.
Encourage patients with xerostomia to chew sugarless gum or These products hydrate the mouth and enhance mucous mem-
suck on sugarless candy. brane integrity.
Pain
Diagnoses: Acute Pain, Chronic Pain

related to disease process, injury, or surgical procedure
Desired Outcome: Patient's report of pain using a pain scale is at an acceptable level within 2 hours.
Assess pain, quality, location, and intensity. A numerical rating scale of 0 to 10 (worst pain) is commonly
used to measure the severity of pain.
Administer as needed pain medications before pain becomes Prolonged stimulation of pain receptors causes sensitivity to
severe. painful stimuli to increase.
For relief of mild-moderate pain: Administer NSAIDs may be administered in conjunction with opioids. Ad-
nonsteroidal antiinflammatory drugs (ibuprofen, ketorolac) verse effects of NSAIDs include epigastric pain, nausea, dys-
pepsia, GI bleeding, and renal failure.
Administer acetaminophen Reduce acetaminophen dose for patients with impaired liv-
er/renal function.
Administer morphine. Morphine is an opioid analgesic.
Assess patients for level of pain relief and excessive sedation or Close monitoring of sedation level prevents respiratory depres-
respiratory depression (RR <10/min or SpO2 <92%). sion.
Wean patient as prescribed from opioid analgesics. When discontinuing an opioid analgesic, the dose should be
reduced by 20% per day.
Assess for and report adverse effects of analgesics. Adverse effects of analgesics include sedation, respiratory de-
pression, nausea, vomiting, and hypotension.
Perioperative'Care' 63
Perioperative Care
Diagnosis: Deficient Knowledge

related to unfamiliarity with surgical procedure, preoperative routine, and postoperative care
Desired Outcome: Patient states knowledge of the procedure, preoperative preparations, and postoperative care; and patient
demonstrates postoperative exercises.
Assess the patient’s concerns or fears related to surgery. Assessing the patient’s concerns will enable the nurse to provide
appropriate teaching.
Clarify and explain the diagnosis and surgical procedure. This information provides a knowledge base from which the pa-
tient can make informed consent.
Explain preoperative testing, medications, and the arrival time These measures increase the patient’s knowledge of the surgical
for the surgery. procedure.
Teach about preoperative medications and timing of surgery Explaining information and procedures improves patient out-
and explain the preoperative bowel preparation. comes.
Explain pain management. Have the patient give a return This information increases likelihood of adequate pain manage-
demonstration of the use of patient-controlled analgesia. ment.
Teach pain assessment tools, such as the numeric pain rating Pain assessment tools aid in the evaluation of pain.
scale.
Explain use of sequential compression devices. These devices prevent venous stasis and decrease risk of throm-
bosis.
Explain restrictions on activity and position. Patients undergoing hip arthroplasty will have positional limita-
tions.
Postoperatively: Adherence to treatment is enhanced when patients are informed
Explain postoperative activities, exercises, and precautions. about exercises and precautions.
Explain deep-breathing and coughing exercises These actions prevent atelectasis during the postoperative period.
Explain the use of incentive spirometry. Incentive spirometry expands the lungs and mobilizes secretions,
which prevents atelectasis.
Explain movement in and out of bed, such as log rolling. Logrolling, using a trapeze device, and gradual movement may be
required to prevent injury to the surgical repair.
Teach activity precautions, including avoiding lifting of more Activity restriction prevents excessive strain on the operative site.
than 10 lb, and avoiding driving.
Diagnosis: Risk for injury

related to exposure to pharmaceutical agents or the surgical procedure.
Desired Outcome: Patient does not experience injury from pharmacotherapy or the surgical procedure.
Assess the need for holding or adjusting the patient’s mainte- Anticonvulsants and cardiac medications, should be continued.
nance medications. Oral hypoglycemics, such as metformin, are discontinued before
surgery.
Explain the need for NPO status. NPO status reduces the risk of postoperative aspiration.
Verify the correct patient, correct procedure, and correct site of Verification should take place upon admission in the preoperative
operation. area, in the surgical room, and just prior to the start of the proce-
dure.
Verify that the surgeon has used a permanent marker to des- The mark should be at the incision site.
ignate the planned incision site.
Document allergies, skin breakdown, bruises, wounds, drains, Knowledge of preexisting wounds, dressings, and drains helps
or ostomy. determine appropriate intraoperative positioning.
Document the availability of care and transportation of the Surgery and analgesic medications will impede the patient’s self-
patient upon discharge. care ability.
Verify that the patient understands the procedure and that These interventions ensure that the correct documentation is pre-
consent has been signed and witnessed. sent.
Review the medical record to ensure that all documentation is Report recent, abnormal ECG, chest radiograph, or laboratory
present. findings to the surgeon.
Prepare the surgical site and perform presurgical preparation. Clipping of hair is associated with a decreased rate of infection
Clip hair to prepare the site. compared to shaving.
Administer preoperative analgesia, sedation, and antibiotics. This intervention provides adequate serum levels of the medica-
tion.
Place the bed in the lowest position with side rails up. Sedatives administered preoperatively increase the risk for injury.
Postoperative Care
Diagnosis: Ineffective Airway Clearance

related to alterations in pulmonary function caused by anesthetics, neuromuscular blockers, mechanical ventilation, and increased
secretions.
Desired Outcome: Patient's airway becomes clear, as evidenced by normal breath sounds, respiratory rate 12-20 breaths/min, and
oxygen saturation 94-99%.
Assess respiratory rate and breath sounds q1h during the Rhonchi, labored breathing, tachypnea, and decreased mental
postoperative period and q8h during recovery. status, are signs of airway obstruction by secretions.
Assess oxygen saturation and report oxygen saturation <94%. Arterial oxygen saturation. <94% indicates hypoxia and the need
for oxygen supplementation.
Administer humidified oxygen. Humidified oxygen prevents drying of the respiratory passage-
ways.
Encourage deep breathing and coughing q2h for the first 72 These actions expand the alveoli and mobilize secretions. Anes-
hours postoperatively. Demonstrate how to splint abdominal thesia and immobility cause atelectasis.
and thoracic incisions with hands or a pillow.
If the patient has a weak cough, teach the "step-cough" tech- Three coughs in a row stimulate a larger, productive cough to
nique of the three rapid coughs in succession. clear bronchial secretions.
Diagnosis: Ineffective Breathing Pattern (or risk of same)

related to hypoventilation caused by CNS depression, pain, muscle splinting, recumbent position, obesity, narcotics, and anesthe-
sia
Desired Outcome: Patient displays effective ventilation, as evidenced by RR 12-20 breaths/min, clear breath sounds, oxygen satu-
ration >94%, PaCO2 <35-45 mm Hg.
Perform preoperative assessment of respiratory rate, breath Baseline assessment enables rapid detection of postoperative
sounds, smoking, respiratory medications, and oxygen satura- deterioration.
tion.
Monitor oxygen saturation. Notify physician of oxygen saturation Pulse oximetry measures the percentage of hemoglobin saturat-
<94%. ed with oxygen. Oxygen saturation <94% indicates the need for
supplemental oxygen.
Assess ABG values, and notify physician of PaO2 <80 mm Hg Hypoxemia may require supplemental oxygen. Early signs of
and PaCO2 > 50 mm Hg. hypoxia include restlessness, dyspnea, and tachycardia.
Assist patient with turning, deep breathing, and coughing exer- These activities enhance expansion of the alveoli and prevent
cises every 2 hours for the first 72 hours after surgery. pooling of secretions.
If the patient has an incentive spirometer, encourage use q2h. Incentive spirometry expands the alveoli and mobilizes airway
secretions.
Diagnosis: Risk for Aspiration

related to decreased level of consciousness and depressed cough and gag reflexes.
Desired Outcome: Patient's upper airway remains unobstructed, as evidenced by clear breath sounds, RR 12-20 breaths/min, and
oxygen saturation >94%.
If patient has vomiting, place him in a side-lying position. The side-lying position minimizes the risk of aspiration.
Encourage patient to remain in an upright position after meals. The upright position after meals reduces risk of aspiration.
Suction oropharynx with Yankauer to remove secretions or vomi- Vomitus could be aspirated if not removed.
tus.
Administer antiemetics and omeprazole (Prilosec). These agents decrease vomiting, gastric acid.
Check placement of gastric tubes by instilling and removing 5 These actions prevent instillation of fluids into the patient’s air-
mL of water q8h and before instillation of feedings and medica- way.
tions.
Assess abdomen q4h for distention and decreased bowel A distended and rigid abdomen with absent bowel sounds indi-
sounds. cates ileus, which places patient at risk for vomiting.
Notify physician of abdominal distention or pain. Abdominal distention indicates intraabdominal hemorrhage or
compartment syndrome.
Encourage early ambulation. Ambulation improves gastric motility and reduces abdominal
distention.
Diagnosis: Risk for Infection

related to broken skin, traumatized tissue, or invasive procedures.
Desired Outcome: Patient is free of infection, as evidenced by temperature <38.5° C, heart rate <100 bpm; RR <20 breaths/min;
negative blood cultures; negative urinalysis; and absence of drainage.
Monitor for tachycardia, tachypnea, or fever. Fever may indicate pneumonia, urinary tract infection, wound
infection, or thrombophlebitis.
Assist with coughing, deep breathing, incentive spirometry, and These activities expand the alveoli and mobilize secretions,
turning q2h. which decreases the risk of pneumonia.
Assess IV catheter sites for erythema, swelling, or tenderness. These are signs of infection.
Change IV line and site if signs of infection are present. These actions prevent worsening of the infection. Initiate IV anti-
biotics.
Assess patency of tubes or drains. Irrigate, gently milk, or attach These actions prevent stasis and reflux of body fluids, which can
tube to low-pressure suction. cause infection.
Assess color and volume of drainage. Report significant find- Purulent or copious drainage is an indicator of infection.
ings.
Assess wounds for erythema, tenderness, induration, swelling, These are indicators of wound infection.
and purulent drainage.
Assess for sudden drainage of serous fluid or a bulge in the There are signs of wound dehiscence or evisceration.
dressing.
Diagnoses: Deficient Fluid Volume, Risk for Electrolyte Imbalance

related to loss caused by drainage tubes, wound drainage, or vomiting; inadequate intake of fluids, NPO status.
Desired Outcomes: Patient becomes normovolemic, as evidenced by blood pressure >90/60 mm Hg, HR 60-100 bpm, and urinary
output >30 mL/hr.
Monitor vital signs q4h. Hypotension and tachycardia are signs of dehydration.
Monitor urinary output q4h. Urine output of 30 mL/hr indicates deficient fluid volume.
Administer IV fluids with 5% dextrose until patient resumes oral Oral fluids are restricted until peristalsis returns and the NG tube
intake. is removed. Ice chips or small sips of clear liquids are permitted.
Glucose in IV fluids prevents hypoglycemia.
Measure output from drains, ostomies and wounds. Report ex- Sensible and insensible losses should be measured to assess
cessive losses. fluid volume status.
Replacement fluids should replace losses.
Monitor weight daily. Weight is an estimate of hydration and nutritional status.
Administer antiemetics, such as hydroxyzine, ondansetron, pro- Antiemetics decrease nausea and vomiting.
chlorperazine, or promethazine.
Monitor serum electrolytes. Fluid loss may result in electrolyte imbalances.
Assess for hypokalemia <3.5 mEq/L, which may result in weak- Signs of hypokalemia must be reported before cardiac
ness, paresthesias, and dysrhythmias. dysrhythmias develop.
Diagnoses: Risk for Bleeding

related to operative procedure
Risk for Shock
related to hypovolemia
Desired Outcomes: Patient is normovolemic, as evidenced by >BP 90/60 mm Hg, pulse pressure >30 mm Hg, HR 60-100 bpm,
RR 12-20 breaths/min, and urinary output >30 mL/hr.
Assess vital signs q1h during the postoperative period. Hypotension, tachycardia, and tachypnea are signs of internal
hemorrhage. Shock causes pallor, diaphoresis, cool extremities,
restlessness, and disorientation.
Inspect surgical dressings for saturation. Saturation of the dressing with bright red blood indicates active
bleeding.
If the initial postoperative dressing becomes saturated, reinforce The surgeon should perform the initial dressing change.
the dressing and notify the surgeon.
Monitor wound drainage and report significant drainage. Assess Drainage of >50 mL/hr should be reported.
the volume and character of drainage from tubes q8h. Blood is bright red, burgundy, or has an appearance of coffee
grounds.
Measure urinary output q2h. Report oliguria. Urine output <30 mL/hr indicates deficient fluid volume due to
hemorrhage.
Review for signs of bleeding. Bleeding is indicated by decreased hemoglobin (normal 14-18
gm/dl); and decreased hematocrit (normal 40-50%).
Maintain an IV catheter. An IV catheter will enable rapid infusions of blood products if
hemorrhagic shock develops.
Diagnosis: Excess Fluid Volume

related to excessive IV fluid infusion after surgery
Desired Outcome: Following intervention, patient becomes normovolemic, as evidenced by clear breath sounds, absence of pe-
ripheral edema, and jugular venous pressure <8 cm H2O.
Assess for jugular venous pressure >10 cm, dyspnea, crackles, An increase in jugular venous pressure >10 cm H2O may indi-
and pretibial or sacral edema. cate heart failure. Crackles and dyspnea indicate pulmonary
edema.
Record input and output every 8 hours. Report imbalances of Normal urine output is 60 mL/hr.
>20%.
Weigh patient daily. Report weight gain of >1.5 kg. Weight changes reflect changes in body fluid volume. One liter
of fluid retention equals 1 kg of weight gain.
Administer furosemide (Lasix). Diuretics remove interstitial fluid and decrease excessive fluid
volume.
Monitor patients on diuretics for hypokalemia and volume deple- Diuretic treatment may result in hypokalemia that could lead to
tion. dysrhythmias. Diuretics can cause hyponatremia.
Diagnosis: Risk for Trauma

related to weakness and ataxia due to anesthetics and opioid analgesics
Desired outcome: Patient does not fall and remains free of trauma, as evidenced by absence of bruises or fractures.
Orient patient to person, place, and time during the postoperative Orientation and explanations decrease the risk of falls.
period.
Keep side rails in upright and locked positions. Side rails prevent trauma due to falling out of bed.
Maintain the bed in the lowest position. The lowest position protects the patient from trauma due to
falls.
Place call button within the patient’s reach. This presents the patient from needing to get out of bed unas-
sisted.
Diagnosis: Impaired Physical Mobility

related to postoperative pain.
Desired Outcome: By hospital discharge, patient returns to preoperative mobility, as evidenced by ability to ambulate.
Assess the patient’s preoperative mobility. Preoperative assessments enable evaluation of postoperative
mobility.
Initiate movement from bed to chair, then progress activity to am- A graduated progression in activity will prevent muscle wast-
bulation. ing.
Assist patient with moving slowly to a sitting position in bed and Anesthetic agents can lead to hypotension with standing.
then standing at the bedside.
Encourage ambulation and provide assistance. These actions reduce postoperative atelectasis, pneumonia,
thrombophlebitis, and ileus.
Diagnoses: Risk for Constipation

related to immobility, opioids, anticholinergics, disruption of abdominal muscles, or surgical manipulation of intestines.
Desired Outcome: Patient returns to his normal bowel elimination pattern, as evidenced by active bowel sounds within 48 hr, ab-
sence of distention, and soft, formed stools.
Assess for and document flatus or stools. Flatus and stool are signs of the return of intestinal motility.
Assess for abdominal distention, tenderness, absent bowel Distention and tenderness are signs of ileus. High-pitched
sounds. Report severe distention and tenderness. bowel sounds indicate bowel obstruction.
Encourage position changes, exercises, and ambulation. Activities will stimulate peristalsis.
If an NG tube is in place, check placement of the tube after inser- Instillation of feeding into a malpositioned NG tube in the tra-
tion by instilling and removing 5 mL of water and q8h. chea may cause respiratory failure.
Measure and record volume and quality of nasogastric output. Gastric fluid will usually be green. After gastric surgery, output
may be brownish because of blood.
Verify low, intermittent suction of gastric sump tubes. When the port is open and air is entering the stomach, contin-
uous suction is safe.
Monitor response to diet advancement. Abdominal distention and vomiting indicates decreased GI
motility.
Administer stool softeners, bisacodyl laxatives, and enemas. These interventions increase the softness of stools.
Prolonged'Bedrest' 70
Prolonged Bedrest
Diagnosis: Risk for Activity intolerance

related to deconditioned status
Desired Outcomes: Within 48 hr of discontinuing bedrest, patient displays tolerance to activity, as evidenced by heart rate <100
bpm and respiratory rate <20 breaths/min during activity.
Assess for orthostatic hypotension. Orthostatic hypotension may be caused by decreased plasma
volume and delayed heart rate increase.
Assess exercise tolerance to range-of-motion exercises. Dyspnea may occur if pulmonary congestion occurs second-
ary to LV failure.
Perform range of motion exercises 4 times/day on each extremity. These exercises increase muscle strength and endurance and
prevent contractures.
Measure HR and BP at rest, during exercise, and 5 min after exer- These assessments determine tolerance to exercise. If HR or
cise. SBP increases more than 20 bpm or SBP increases >20 mm
Hg over resting level, repetitions should be decreased.
As the patient’s condition improves, increase activity to sitting in a Activity should be increased to the patient’s tolerance.
chair.
Diagnosis: Risk for Disuse Syndrome

related to paralysis, immobilization, pain, or decreased level of consciousness.
Desired Outcomes: When bedrest is discontinued, patient displays complete ROM of joints without pain.
Assess range of motion of the shoulder, wrist, hips, knees, and These joints are susceptible to joint contractures.
feet.
Assist the patient to change position at least q2h. Post a turning Position changes prevent contractures and reduce pressure
schedule at the bedside. on bony prominences.
Ensure that patient is side lying with hips extended 3 times/day for This position prevents hip flexion contractures
1 hr.
Assess the skin q8h. Assessing for alterations in skin integrity prevents skin break-
down.
Teach the patient the reasons and procedure for ROM exercises, These actions enhance adherence to the exercise regimen
and have patient give a return demonstration. and prevent contractures.
Encourage participation in self-care. Self-care helps maintain muscle strength and enhances a
sense of independence.
Teach the patient transfer techniques, crutch-walking techniques, These interventions maintain the patient’s mobility.
use of a walker, wheelchair, and/or a cane.
Prolonged'Bedrest' 71
Diagnosis: Constipation
related to inadequate fluid or dietary intake and bulk, immobility, and use of opioid analgesics
Desired Outcomes: Within 24 hr, patient states knowledge of measures that enhance bowel elimination, and has a return of his
normal bowel pattern within 3-5 days.
Assess the patient’s bowel history. This evaluation assesses the patient’s normal bowel habits and
his usual interventions for constipation.
Assess the patient’s bowel movements and diet. Constipation is decreased bowel movements with abdominal
distention, straining at stool, and rectal fullness.
Assess bowel sounds by auscultating all four abdominal quad- Bowel sounds are gurgles. Paralytic ileus causes loss of bowel
rants. sounds.
Use a gloved, lubricated finger to remove impacted stool. Digital stimulation stimulates bowel movement. Retention ene-
mas soften impacted stool.
Maximize the patient’s activity level. Activity promotes peristalsis, which prevents constipation.
Administer psyllium, bran, prune juice, stool softeners (docus- Fiber additives, psyllium, bran. Natural laxatives (prune juice).
ate), laxatives and suppositories (bisacodyl), and Fleet Stool softeners (docusate).
Enemas. Potent laxatives and suppositories (bisacodyl). Enemas can
relieve obstructive defecation.
Teach that overuse of opioids, antidepressants, and anticholin- Use of anticholinergics, opioids, antidepressants, and iron sup-
ergics may worsen constipation. plements can cause constipation.
Older Adult Care 72
Older Adult Care
Diagnosis: Acute Confusion

related to Alzheimer disease, renal failure, cardiac failure; or decreased sensory reception.
Desired Outcomes: Patient's mental status returns to normal within 3 days of treatment, and patient sustains no injury due to con-
fusion or disorientation.
Assess patient’s baseline level of consciousness and mental Baseline evaluation allows comparison of subsequent assess-
status. ments.
Test short-term memory by showing the patient how to use the Inability to remember beyond 5 min indicates impaired short-term
call light, and having the patient return the demonstration. memory.
Identify the cause of the patient’s acute confusion. Acute confusion is usually caused by a physical condition. Oxime-
try may demonstrate hypoxia. Fingerstick glucose may reveal glu-
cose <60 mg/dL.
Assess pulse and notify physician of an irregular pulse. Dysrhythmias may lead to decreased oxygenation and confusion.
Review medications. Toxic levels of digoxin and anticholinergics can result in confusion.
Assess intake and output q8h. Output should match intake. Dehydration can cause delirium.
Review the patient’s electrolytes and creatinine. Treat the un- Impaired renal function may cause fluid and electrolyte deficits and
derlying cause of the acute confusion. cause confusion.
Have patient wear his glasses and hearing aid. Glasses and hearing aids will reduce sensory confusion.
Keep a clock with large numerals and a large print calendar at Reorientation decreases confusion.
the patient’s bedside. Remind patient of the date daily.
Use Olanzapine (Zyprexa) to control behavior. Olanzapine (Zyprexa) will calm patients with dementia and para-
noia.

related to depressed cough and gag reflexes
Desired Outcomes: Patient swallows independently without aspirating, and the patient's lungs are clear to auscultation after
meals.
Assess the patient’s ability to swallow by asking the patient to Ability to swallow and an intact gag reflex are necessary to pre-
swallow while palpating the patient’s larynx. vent aspiration.
Place the patient in the upright position with chin down while This position reduces the risk of aspiration.
eating or drinking.
Monitor the patient for crackles, wheezes, rhonchi, and dyspnea. These are signs of aspiration.
Request an evaluation by a speech therapist A speech therapist will assess swallowing ability with video
fluoroscopy.
Give thickened fluids if swallowing ability is impaired. Thickening agents are added to the fluids to increase viscosity.
Mechanical soft, pureed, or liquid diets are prepared.
Ensure that the patient’s dentures fit correctly. Chewing well minimizes risk of aspiration.
Ensure that the patient is observed during meals or fluid intake. This provides safety in the event of choking or aspiration.
Older Adult Care 73
Be aware of the location of suction equipment to be used in the If the patient is at increased risk for aspiration, suction equip-
event of aspiration. ment should be available at the bedside.
For partial airway obstruction, encourage the patient to cough. This action will clear the airway.
For partial airway obstruction in unconscious patients, suction Suctioning clears the airway.
the airway with a large-bore catheter.
For complete airway obstruction in a conscious patient, adminis- Abdominal thrusts will remove the object and open the airway.
ter abdominal thrusts.
For complete airway obstruction in an unconscious patient, ad- Chest compressions will remove the object and open the airway.
minister chest compressions.
Diagnosis: Risk for Deficient Fluid Volume

related to inability to obtain fluids because of illness or poor access to fluids
Desired Outcomes: Patient's mental status, vital signs, and urine specific gravity are normal, and oral mucous membranes are
moist.
Assess fluid intake. Adequate fluid intake ensures good hydration.
Assess and document skin turgor over the forehead. Skin remains tented in the presence of dehydration.
Monitor the patient’s orientation and ability to follow commands. Inability to follow commands can lead to poor fluid intake and
subsequent dehydration.
Weigh the patient daily. Loss of weight >2 kg suggests dehydration.
Assess serum sodium, BUN, and creatinine. Hypernatremia and increased BUN and creatinine are signs of
dehydration.
Assess the patient’s ability to obtain and drink fluids. Place fluids These actions remove barriers to fluid intake.
within easy reach.
Diagnosis: Risk for Impaired Skin Integrity

related to decreased subcutaneous fat and decreased skin capillaries.
Desired Outcome: Patient's skin remains non-erythematous and intact while the patient is hospitalized.
Assess the patient’s skin for redness or abrasions. This evaluation provides a baseline for subsequent assessments.
Ensure that patient turns at least every 2 hours. Turning alternates sites of pressure.
Lift or roll patient when repositioning. Pulling or dragging across sheets can result in shear injury to skin.
Monitor skin over bony prominences for redness. Skin over the sacrum, scapulae, heels, spine, hips, pelvis, greater
trochanter, knees, ankles, and ischial tuberosities are at risk for
breakdown.
Place pillows or pads around bony prominences. Pads maintain alternative positions and protect skin.
Use lotions on dry skin. Lanolin-containing lotions retain moisture.
Use alternating-pressure mattress, air-fluidized mattress, or an These mattresses protect the skin from injury caused by pressure.
airbed.
Older Adult Care 74
Avoid placing tubes under the patient’s limbs or head. Place a Excess pressure from tubes can cause skin ulcerations.
pad between tube and the patient’s skin.
Get patient out of bed as often as possible. These actions enhance blood flow, which prevents skin break-
down.
Post a turning schedule at the bedside. A schedule will increase awareness of the turning schedule.
Place at least one layer of cloth between the patient and a These pads trap moisture, which can cause skin breakdown.
plastic pad. For incontinent patients check the pad q2h.
Document the percentage of food intake with each meal. High protein foods prevent skin breakdown.
related to changes in diet and decreased activity.
Desired Outcomes: Patient states that his regular bowel pattern has returned within 4 days, and stool appears soft.
Assess patient’s normal bowel frequency. This evaluation establishes a baseline pattern of bowel elimina-
tion.
Encourage the patient to increase fluid intake. A high fluid intake increases stool softness and reduces constipa-
tion.
Recommend a diet with fruits and vegetables, whole grains, Roughage consumption reduces potential for constipation by in-
and nuts. Encourage bran cereals, muffins, and breads. creasing bulk in the stool.
Teach the patient the relationship between constipation and Exercise can prevent or decrease constipation by increasing peri-
activity. stalsis.
Use the gastrocolic reflex to facilitate colonic emptying by hav- A bowel movement is more likely to occur after a meal.
ing the patient defecate 30 minutes after dinner.
Recommend psyllium or bran and ample fluids, Psyllium or bran and ample fluids may be helpful. Stool softeners
stool softeners (docusate), laxatives and suppositories with include docusate sodium. Laxatives and suppositories contain
bisacodyl. Recommend a tap water enema. bisacodyl. A tap water enema may be required.
Chronic Obstructive Pulmonary Disease 75
Respiratory Nursing
Chronic Obstructive Pulmonary Disease
Diagnosis: Ineffective Breathing Pattern

related to airflow restriction
Desired Outcome: Following intervention, the patient's breathing pattern improves, as evidenced by absence of dyspnea and oxy-
gen saturation >94%, pH >7.35, and PaCO2 <60 mm Hg.
Assess respiratory rate and depth q6h. Restlessness, dyspnea, tachypnea, use of accessory muscles of
respiration are signs of respiratory distress, which should be re-
ported.
Auscultate breath sounds q6h. A decrease in breath sounds or an increase in wheezes is a sign
of respiratory failure.
Administer bronchodilator therapy with albuterol metered dose Albuterol increase expiratory volume by decreasing airway
inhalers 2-4 puffs every 4 to 6 hours as needed. smooth muscle constriction.
Administer ipratropium (Atrovent) 80 mcg, three times per day. Inhaled anticholinergics improve lung function and decrease hy-
Formoterol (Foradil) 12 mcg every 12 hours. Or administer tio- perinflation, while also decreasing dyspnea and exacerbations.
tropium (Spiriva) 1 capsule (18 mcg) inhaled once daily by
HandiHaler device
Administer inhaled beclomethasone Steroids with decreased airway inflammation.
Administer inhaled budisonide (Pulmicort) 1-2 puffs bid. Or ad- Glucocorticoids combined with a long-acting beta-2 agonist are
minister fluticasone (Flovent) 1-2 puffs twice daily; maximum: more convenient.
200 mcg once daily
Monitor oximetry readings. Oxygen saturation <94% indicates the need for supplemental
oxygen.
Monitor ABG values as needed. PaO2 will continue to decrease as patient's disease progresses.
Diagnosis: Impaired Gas Exchange

related to decreased oxygenation of alveoli caused by airway inflammation and lung tissue destruction.
Desired Outcomes: Within 1 hr of intervention, patient has adequate gas exchange, as evidenced by RR 12-20 breaths/min. 24
hours before discharge, the patient has a PaO2 >80 mm Hg, PaCO2 35-50 mm Hg; and oxygen saturation 94-100%.
Assess for signs and symptoms of hypoxia, such as anxiety, Anxiety, somnolence, and restlessness indicate hypoxia.
somnolence, or restlessness
Decreased wheezes may indicate closure of airways due to
Auscultate breath sounds q2h for wheezes.
bronchoconstriction.
Monitor pulse oximetry, and report abnormal findings. Oxygen saturation <94% requires oxygen therapy.
Decreasing PaO2 and increasing PaCO2 are signs of respiratory
Monitor arterial blood gases.
failure.
Chronic Obstructive Pulmonary Disease 76
Position the patient in high Fowler's, leaning forward with his This position optimizes gas exchange by maximizing chest ex-
elbows on an over-the-bed table. pansion.
Titrate supplemental oxygen to keep saturation >90%. Oxygen therapy for COPD decreases hypoxia and reduces mor-
tality.
Administer noninvasive positive pressure ventilation. NIPPV increases blood pH, reduces PaCO2, and avoids the
need for mechanical ventilation.
Pneumonia' 77
Pneumonia

related to decreased alveolar oxygenation and alveolar-membrane changes caused by inflammation and exudate in the lungs
Desired Outcome: Before hospital discharge, the patient has a temperature <37.7° C, HR <100 bpm, RR <24 breaths/min, and
oxygen saturation >92%.
Assess for and report signs of respiratory distress. Signs of respiratory distress include anxiety, dyspnea, tachypnea,
and use of accessory muscles.
Auscultate breath sounds q2h. Report wheezes, rhonchi, or Decreased breath sounds and wheezes indicate respiratory dis-
crackles. tress.
Monitor vital signs q2-4h. Report temperature >38.5° C, RR A rising temperature, tachycardia, and tachypnea indicate worsen-
>20/min, or HR > 100/min. ing infection of the lungs, hypoxia and need for mechanical ventila-
tion.
Administer antibiotics. Early administration of antibiotics eradicates the bacterial infection.
Antibiotic therapy for community-acquired pneumonia is cefotax-
ime with erythromycin.
Monitor pulse oximetry; report oxygen saturation <94%. Oxygen saturation <94% is a sign of a hypoxia and need for oxy-
gen therapy.
Administer oxygen. Oxygen is administered when oxygen saturation is <94%.
Monitor arterial blood gasses. Hypoxemia (PaO2 <80 mm Hg) indicates the need for O2 therapy.
Hypocarbia (PaCO2 <35 mm Hg), with a respiratory alkalosis (pH
>7.45) indicates hyperventilation.
Position patient in semi-Fowler's position This position increases diaphragmatic descent, maximizes inhala-
tions, and decreases work of breathing.

related to tracheobronchial secretions caused by infection
Desired Outcomes: Patient demonstrates effective cough and the patient's airway is free of rhonchi.
Auscultate breath sounds q8h. Crackles and wheezes are signs of airway obstruction.
Encourage patient to perform deep breathing and coughing These exercises help clear airway secretions.
q2h while awake.
Place patient in semi-Fowler's position. Semi-Fowler’s position facilitates lung expansion.
Teach patient to splint his chest with a pillow or crossed arms. Splinting reduces pain when coughing, promoting a more effective
cough.
Suction as needed. Suctioning maintains a patent airway.
Encourage fluid intake. Increasing hydration reduces the viscosity of the sputum.
Pneumonia' 78
Diagnosis: Deficient Fluid Volume

related to increased insensible loss occurring with tachypnea and fever
Desired Outcome: At least 24 hr before hospital discharge, patient is normovolemic, as evidenced by urine output >30 mL/hr, HR
<90 bpm, and fluid intake equal to fluid output.
Weigh patient daily. Report weight changes of >2 lbs/day. Weight changes of >2 lbs per day can occur with fluid volume
excess or deficits.
Encourage fluid intake. Maintain intravenous fluid therapy. These actions ensure adequate hydration.
Pulmonary'Embolus' 79
Pulmonary Embolism
Diagnosis: Risk for Injury

related to venous stasis, hypercoagulable state, or vessel injury resulting in a venous thromboembolism
Desired Outcome: Following intervention, patient has no venous thromboembolic events.
Assess for thromboembolic risk factors, such as advanced age, Risk factors for VTE include advanced age, surgery, immobility,
surgery, immobility, or cancer. and cancer.
Begin treatment for thromboembolic disease with low molecular A fractionated heparin infusion is started immediately in patients
weight heparin, such as enoxaparin (Lovenox) 1 mg/kg/dose with suspected pulmonary embolus.
every 12 hours.

related to ventilation-perfusion mismatch.
Desired Outcomes: Following intervention, patient has adequate gas exchange, as evidenced by RR 12-20 /min; and normal men-
tal status. 24 hr before discharge, and the patient has O2 saturation >94%.
Assess patient for tachypnea, dyspnea, anxiety, restlessness, These signs indicate respiratory distress and are indicators of
confusion, and cyanosis. pulmonary embolism and right heart failure.
Monitor pulse oximetry; report oxygen saturation <94%. Decreased oxygen saturation indicates the need for supple-
mental oxygen. Oxygen saturation <92% should be reported.
Diagnosis: Risk for Bleeding

related to anticoagulation therapy
Desired Outcome: Patient is free of bleeding and has a HR <100 bpm, SBP >90 mm Hg, and RR <20 breaths/min.
Assess for tachycardia, systolic BP <90 mm Hg, or a pulse pres- Hypotension and tachycardia are signs of hemorrhage, result-
sure <35 mm Hg. Report abnormal findings. ing from anticoagulant therapy.
Inspect wounds, oral mucous membranes, and IV catheter sites This assessment helps determine if bleeding is present.
for bleeding q8h.
Inspect torso and extremities q8h. Petechiae or ecchymoses are signs of tissue bleeding.
Apply pressure to bleeding venipuncture or arterial puncture sites Prolonged pressure is applied to stop bleeding.
until bleeding stops.
If the patient has severe bleeding, give 1 mg protamine per 1 mg Protamine is required in cases of serious bleeding or to re-
of enoxaparin. store coagulation for surgery.
If patient is on intravenous heparin therapy, monitor PTT. Therapeutic PTT is 1.5-2.5 times control.
If patient is receiving warfarin therapy, monitor international nor- This will confirm that the INR is in the therapeutic range of
malized ratio. 2.0-3.0.
Discuss the effects of anticoagulant therapy and advise patient to Hematuria, melena, epistaxis, hemoptysis, and menometror-
report bleeding. rhagia are adverse effects of anticoagulant therapy.
Pulmonary'Embolus' 80

related to unfamiliarity with oral anticoagulant therapy.
Desired Outcome: Before hospital discharge, patient verbalizes knowledge of anticoagulant drug, side effects, and adverse drug
interactions of anticoagulant therapy.
Assessments and Interventions Rationales --
Discuss the medication; purpose; dose; schedule; precautions; Knowledgeable patients are more likely to comply with treat-
drug-drug interactions; and side effects. ment.
Discuss adverse effects of anticoagulant therapy, such as easy This information will keep the patient to report complications.
bruising, prolonged bleeding epistaxis, bleeding gums, black
stools, and hematuria.
Discuss importance of laboratory testing of patients taking warfa- Testing helps ensure that the patient's INR remains within the
rin (Coumadin). therapeutic range.
Instruct patient to consult health care provider before taking over- Aspirin, cimetidine, and macrolides may increase the effect of
the-counter or prescribed drugs. warfarin. Drugs that decrease the effect of warfarin include
antacids, diuretics, and oral contraceptives.
Pulmonary'Tuberculosis' 81
Pulmonary Tuberculosis

related to unfamiliarity with the spread of tuberculosis and procedure for airborne infection isolation
Desired Outcome: Following instruction, patient states how TB is spread and states measures necessary to prevent the spread of
TB.
Teach patient about TB and the mode of transmission by respir- A well-informed patient is more likely to adhere to precautions
atory droplets. that prevent transmission of TB.
Explain airborne precautions to the patient. Post an isolation If AFB smears are positive, airborne precautions require a pri-
precaution notice on the patient’s door. vate room with special ventilation that removes airborne organ-
isms. The patient should wear a surgical mask when he is out-
side of the room.
Keep the patient's door closed. A closed door enables effective function of the negative pres-
sure ventilation system.
Explain to visitors the importance of wearing N-95 respirator, N-95 respirators have a tight face seal and filter 1- to 5- micron
including proper fit. Provide respirators at doorway. particles.
Aneurysms' 82
Cardiovascular Nursing
Aneurysms
Diagnosis: Risk for Decreased Cardiac Tissue Perfusion, Risk for Ineffective Renal Perfusion, Risk for Ineffective GI Perfusion
related to interrupted arterial flow caused by rupture, bleeding, or embolization
Desired Outcome: Patient has adequate perfusion, as evidenced by extremity sensation, motor function, and normal color.
Assess vital signs and peripheral pulses and report changes in Loss of pulse indicates embolization.
VS or absent peripheral pulses by Doppler.
Assess peripheral sensation. Instruct patient to report impaired Impaired sensation indicates impaired perfusion caused by em-
sensation. bolization or bleeding.
Assess urine output frequently, and record intake and output. Hypotension or renal artery occlusion can decrease renal perfu-
sion. Maintain urine output >30 mL/hr.
Report extremity Coolness, pallor or mottling, decreased motor function, and

pallor, polar, motor paralysis, or paresthesias. pain, indicate embolization, and arterial occlusion.
Keep patient in the neutral position and on bedrest. Bedrest maintains BP and perfusion. The neutral position main-
tains integrity of the graft.
Report bloody diarrhea to the surgeon. Bloody diarrhea indicates bowel ischemia.
Administer beta-blockers, such as metoprolol (Lopressor), These agents slow the heart rate and decrease BP, which will
atenolol, to decrease myocardial contractility. reduce the risk of aortic rupture.
Peripheral'Arterial'Occlusive'Disease' 83
Peripheral Arterial Occlusive Disease
Diagnosis: Impaired Tissue integrity

related to altered arterial circulation caused by an atherosclerotic process
Desired Outcome: Over a period of days or weeks, the patient’s lower extremity tissue improves and perfusion is maximized, as
evidenced by palpable pulses and decreased leg pain.
Assess legs, feet, and between toes for ulcers. Ulcers can result from decreased arterial circulation. Arterial ob-
struction decreases oxygen delivery to the tissues.
Encourage the patient to ambulate in the hallway. Patients should walk until the pain starts. Walking improves the
collateral circulation.
Recommend daily foot inspections. Early treatment of breaks in skin integrity may prevent serious
ulcerations.
Encourage cessation of smoking with smoking cessation med- Stopping tobacco use helps prevents progression of atherosclero-
ication (Chantix). sis and circulatory obstruction. Varenicline (Chantix) reduces the
craving for nicotine.
Advise patient to wear socks and shoes when walking. Socks and shoes prevent trauma to the feet.
Caution patient about heating pads. The patient’s sensitivity to temperature is often decreased, and
burns can result.
Diagnosis: Ineffective Peripheral Tissue Perfusion (or risk for same)

related to decreased arterial flow caused by atherosclerosis or embolus
Desired Outcome: Following interventions, patient has adequate peripheral perfusion, as evidenced by BP within 15-20 mm Hg of
baseline BP and absence of extremity pain.
Assess extremity pulses, pain, pallor, pulselessness, paresthe- Sensory changes precede other symptoms of ischemia, such as
sia, polar (coolness), and paralysis. pain and paresthesias.
- Antiplatelet agents, such as aspirin, clopidogrel, or ticlopidine. These drugs help prevent platelet adherence and thromboembo-
Anticoagulants, such as heparin or warfarin lism.
Fibrinolytics, such as tissue plasminogen activator These drugs are used to lyse a clot if an embolus or thrombus is
present.
Blood viscosity-reducing and antiplatelet agent, such as pentoxi- These drugs increase flexibility of erythrocytes, preventing ag-
fylline or cilostazol gregation of red blood cells.
Lipid-lowering agents, such as lovastatin, atorvastatin, simvas- Statins reduce serum cholesterol levels and decrease the size of
tatin, and pravastatin cholesterol plaques in vessel walls.
Antihypertensive agents, such as angiotensin-converting en- Control of hypertension slows progression of peripheral arterial
zyme inhibitors, beta-blockers, diuretics, or calcium channel occlusive disease.
blockers.
Explain endarterectomy. Endarterectomy is removal of the atheromatous obstruction.
Use a Doppler probe to check pulses, holding probe at a 45- Doppler probes assess the amount of blood flow in arteries.
degree angle to the blood vessel.
Peripheral'Arterial'Occlusive'Disease' 84
Use a foot cradle or foam protectors to keep sheets and blan- A cradle will prevent pressure on the sensitive feet.
kets elevated over legs and feet.
Monitor BP. Report any increase or decrease >20 mm Hg. An increase in BP may cause intracranial bleeding. Hypotension
may promote graft occlusion.
For the first 72 hr after graft surgery, prevent acute joint flexion. Joint flexion can impede blood flow. Elevation of the foot may
decrease hyperemia.
Shock' 85
Shock
Diagnoses: Ineffective Tissue Perfusion Risk for Electrolyte imbalance

related to decreased circulating blood volume caused by shock
Desired Outcome: Within 2 hr of treatment, patient has adequate perfusion, as evidenced by SBP >90 mm Hg, SaO2 >92%; CVP
5-10 cm H2O; HR <100/min; and urine output >30 mL/hr.
Assess for systolic BP <90 mm Hg or pulse pressure <30 mm Hypotension requires prompt intervention to prevent irreversible
Hg q1h. Assess for cool skin, decreased mentation, or urine organ damage. Coolness and pallor of the extremities are signs of
output <30 mL/hr. decreased peripheral perfusion, which is a sign of shock. The BP
must be at least 80/60 mm Hg for adequate coronary and renal
artery perfusion.
Monitor CVP with a central line Adequate blood volume is a CVP of 5-10 cm H2O. A CVP of <5 cm
H2O indicates hypovolemia.
Monitor urinary output q1h. Weigh patient daily. Decreased urine output is a sign of decreased cardiac output and
decreased renal perfusion. Weight gain is a sign of fluid retention.
For cardiogenic shock, administer dopamine to support blood Maintains blood pressure
pressure.
Place a Intraaortic balloon counterpulsation pump or insert a Used to augment perfusion pressures to assist the ventricles and
ventricular assist device lower the myocardial oxygen requirement.
Hold diuretics if jugular venous pressure is <10 cm H2O. Fluids should be restricted if JVP is >10 cm H2O to prevent over-
load.
Administer vasodilators, such as nitroprusside and nitroglycer- Vasodilators are used to reduce afterload. Vasoconstriction pre-
in vents hypotension.
Administer oxygen by non-rebreather mask. Oxygen administration increases coronary tissue oxygenation.
Correct acidosis and electrolyte imbalances. Electrolyte imbalances and acidosis need correction with fluids or
electrolytes.
For anaphylactic shock give epinephrine (0.5 mL, 1:1000) Used to increase vasoconstriction.
For wheezes, give albuterol, nebulized Used to relieve bronchospasm.
For anaphylaxis, give an antihistamine, such as Benadryl. Used to relieve urticaria.
For anaphylaxis, give methylprednisolone IV Antiinflammatory effects.
For anaphylaxis, give normal saline 500 mL IV boluses (2-6 L) Isotonic solution is used to replace intravascular fluid losses.
For septic shock, administer an antibiotic. Initial antibiotic treatment is broad spectrum until the causative
organism is identified.
Vasoactive drugs, such as norepinephrine, dopamine Used to maintain perfusion blood pressure and cardiac output.
For hemorrhagic shock, control hemorrhage, then transfuse Control of bleeding with direct pressure will maintain the blood
packed RBCs. pressure. Blood transfusions will increase oxygen delivery to the
tissues. Isotonic solution should be used to replace fluids.
Shock' 86

related to decreased oxygen supply caused by decreased respiratory muscle function
Desired Outcome: Within 2 hr of intervention, patient has adequate gas exchange, as evidenced by SaO2 >94%: PaO2 >80 mm
Hg.
Monitor ABG. Report significant findings. Hypoxemia, hypercapnia (increased PaCO2), and acidosis (de-
creased pH) are signs of impaired gas exchange.
Monitor SaO2. SaO2 <94% indicates decreased oxygenation; provide supple-
mental oxygen or ventilation.
Assess respirations q30min; report tachypnea or dyspnea. Tachypnea is a sign of respiratory distress, which indicates the
need for oxygen or mechanical ventilation.
Assess for decreased mental status or restlessness. Decreased mental status and restlessness are signs of hypoxia.
Cardiac'Surgery' 87
Cardiac Surgery
Diagnosis: Deficient Knowledge (preoperative)

related to unfamiliarity with diagnosis, surgical procedure, and preoperative and postoperative course
Desired Outcome: Before surgery, patient states knowledge about the diagnosis, surgical procedure, and preoperative and post-
operative interventions.
Demonstrate deep breathing and coughing, and ask patient to Deep breathing and coughing prevent atelectasis after surgery.
give a return demonstration.
Advise patient that in the postoperative period, speaking will An endotracheal tube will assist with breathing and prevent
be impossible but writing will be possible. speech.
Review and demonstrate sternal precautions. Sternal precautions include getting in and out of bed without using
arms and not lifting more than 5 kg for 6 weeks.
Diagnosis: Activity intolerance

related to generalized weakness and bed rest following cardiac surgery
Desired Outcome: Before hospital discharge, patient displays cardiac tolerance to activity, as evidenced by heart rate <110 bpm
and RR < 20 breaths/min.
Assess vital signs q1h. Notify physician of blood pressure Hypotension, tachycardia, crackles, and tachypnea are signs of
<100/60 mm Hg. cardiac failure.
Monitor for activity intolerance. Dyspnea and cool skin indicate that the activity should be discon-
tinued.
Assist with exercises and initiate cardiac rehabilitation. Monitored exercise will increase the activity tolerance of the pa-
tient.
Acute'Coronary'Syndrome' 88
Acute Coronary Syndrome
Diagnosis: Acute Angina Pain

related to decreased oxygen supply to the myocardium
Desired Outcomes: Within 30 min of onset of pain, the patient is free of angina.
Assess the location, character, and severity of pain on a scale This evaluation monitors pain to determine if intervention is neces-
of 0 to 10 (worst pain). sary.
Assess HR and BP. Report significant findings. Tachycardia >100/min and systolic hypertension, >150 mm Hg
indicate excessive myocardial oxygen demands and require inter-
vention.
Administer humidified oxygen by nonrebreather mask. Oxygen increases the oxygenation to the myocardium and reduc-
es ischemia.
Have the patient chew and swallow aspirin, 325 mg. Aspirin reduces platelet aggregation, which prevents coronary
artery obstruction.
Administer sublingual nitroglycerine 0.4 mg as needed for an- NTG increases myocardial perfusion and causes venous dilation.
gina, then repeat q5min x 3 if needed. Venous dilation decreases preload to the heart.
Obtain 12 lead ECG. ECG may show dynamic ST- or T-wave changes or left bundle
branch block.
Administer morphine sulfate 2 to 3 mg every 5 minutes until For patients with pain due to myocardial ischemia, morphine may
pain is relieved. be given for the relief of refractory chest pain or anxiety.
Monitor for headache and hypotension caused by nitroglycer- Headache and hypotension are adverse effects of NTG, which
ine. result from vasodilation.
Administer metoprolol (Lopressor) 50 to 100 mg PO twice dai- These drugs block beta stimulation to the sinoatrial node, reducing
ly or metoprolol succinate (extended release) 50 or 100 mg myocardial oxygen demand.
daily
Administer an ACE inhibitor, such as enalapril, captopril, quin- ACE inhibitors reduce BP and improve survival.
april, or ramipril.
Administer atorvastatin. Statin drugs reduce hyperlipidemia and stabilize the coronary
plaque.
Administer stool softeners. Prolonged bedrest causes constipation. Straining at stool may
cause an arrhythmia.
Diagnosis: Activity Intolerance

related to generalized weakness caused by coronary ischemia.
Desired Outcome: During activity, patient displays tolerance to activity, as evidenced by respiratory rate <20 breaths/min, HR
<120, and absence of chest pain.
Assess frequency of angina. Determine if angina occurs with This evaluation detects imbalance between oxygen supply and
exercise. activity.
Assess patient’s response to activity. Chest pain, increase in HR >20 bpm, SBP >20 mm Hg, fatigue,
and dyspnea are signs of activity intolerance.
Have patient perform range-of-motion exercises. Cardiac tolerance to activity can be decreased by myocardial is-
chemia.
Diagnosis: Imbalanced Nutrition: More than Body Requirements

related to excessive intake of calories, sodium, or cholesterol
Desired Outcome: Before hospital discharge, patient demonstrates knowledge of the low cholesterol, low saturated fat diet.
Assess body mass index. Explain that weight loss decreases Excessive weight is a risk factor for coronary artery disease and
the risk of myocardial infarction. increases cardiac workload.
Teach ways to decrease dietary intake of saturated fats. Reducing dietary saturated fat lowers the risk of cardiovascular
disease.
Encourage patient to limit dietary cholesterol. Excessive cholesterol intake lowers the risk of vascular disease.
Teach patient to limit dietary intake of sodium chloride to <4 Excessive sodium increases blood pressure, which increases car-
g/day. diac workload.

related to unfamiliarity with purpose, precautions, and adverse effects of nitrates
Desired Outcome: 24-hr before hospital discharge, patient states understanding of the purpose, precautions, and adverse effects
of nitrates.
Teach patient the purpose of nitroglycerine. Nitrates increase venous dilation and blood flow to the heart,
which decreases angina.
Advise patient to report headache associated with nitrates. Vasodilation caused by nitrates can result in headaches. Aceta-
minophen (Tylenol) reduces headache.
Instruct the patient to rise slowly from the supine position and Vasodilation from nitrates may cause orthostatic hypotension and
to remain by bed for 1 min after standing because fainting may falls.
occur.

related to unfamiliarity with purpose, precautions, and adverse effects of beta-blockers
Desired outcome: Within the 24-hr before hospital discharge, patient states an understanding of the purpose, precautions, and
adverse effects of beta-blockers.
Teach patient the purpose of beta-blockers. beta-Blockers block beta-adrenergic stimulation to the SA node
and myocardium. HR and contractility are decreased, and the
workload of the heart is reduced. beta-blockers decrease myocar-
dial oxygen demand.
Teach patient that depression, fatigue, dizziness, respiratory Knowledge of adverse effects will enhance compliance with beta-
distress, and sexual dysfunction are side effects of beta- blockers.
blockers.
Explain that BP is assessed before administration of beta- beta-Blockers can result in hypotension and bradycardia.
blockers.
Caution patient not to abruptly discontinue beta-blockers. Abrupt discontinuation of beta-blockers may cause rebound hyper-
tension or myocardial infarction.

related to unfamiliarity with CAD and lifestyle implications of CAD.
Desired Outcome: Before hospital discharge, patient states knowledge of CAD and lifestyle implications.
Teach patient about CAD, angina, and infarction. Knowledge will enhance the patient’s adherence to treatment.
Teach the patient about CAD risk factor modification. Risk factor modification includes:
- Low cholesterol, low saturated fat diet
- Smoking cessation
- Exercise
- Weight loss
Teach symptoms that require medical attention. Angina at rest, angina unrelieved by NTG, increasing frequency of
angina, requires medical attention.
Teach guidelines for sexual activity. Phosphodiesterase inhibitors, such as Viagra cannot be taken with
NTG because severe hypotension may occur. Resting before in-
tercourse, the female-superior position, and taking prophylactic
NTG will reduce myocardial oxygen demand.
Teach the rationale for These agents inhibit the cholesterol enzyme, reducing LDL choles-
HMG-CoA reductase inhibitors, such as lovastatin, simvas- terol triglycerides, and increasing HDL
tatin, fluvastatin, pravastatin, atorvastatin
- Nicotinic acid Niacin decreases triglyceride and LDL levels and increases HDL
levels.
- Fibric acid derivatives, such as gemfibrozil and fenofibrate These agents lower triglycerides and raise HDL levels
Teach about cardiac catheterization, PCI, and CABG. PCl is a procedure that improves coronary blood flow by using a
small balloon to dilate a coronary artery. It is performed in the
catheterization laboratory under local anesthesia.
Cardiac Catheterization
Diagnosis: Risk for Decreased Cardiac Perfusion

related to interrupted arterial flow caused by the catheterization procedure
Desired Outcome: After the procedure, patient has adequate perfusion, as evidenced by HR <100/min; BP >100/60 mm Hg, leg
warmth, and pink extremities.
Assess BP q15min until stable, then q2h for the next 12 hr, These assessments monitor for hypotension caused by hemor-
and q4h for 24 hr. rhage.
If the femoral artery was the insertion site, maintain HOB at no Hip joint flexion may compromise femoral arterial flow.
more than a 33-degree elevation.
If SBP drops to <100 mm Hg, lower the HOB and notify the Hypotension is a sign of bleeding and shock. Lowering the HOB
physician. increases perfusion to the heart and brain.
Assess for dysrhythmias. Dysrhythmias are signs of cardiac ischemia.
Report cool extremities, loss of peripheral pulses, cyanosis, These are signs of perfusion.
decreased consciousness, and dyspnea.
Diagnoses: Risk for Bleeding and Deficient Fluid Volume

related to hemorrhage due to an arterial puncture.
Desired Outcomes: Patient remains normovolemic, as evidenced by HR <100 bpm, BP 90/60 mm Hg, pulse pressure of >35 mm
Hg, dry dressing, and absence of swelling at the arterial puncture site.
Assess vital signs and report hypotension, tachycardia, or These are indicators of hemorrhage.
decreased level of consciousness.
Assess dressing q15min. Assessment detects formation of bleeding or hematomas.
Assess for distal pulses, cold extremities, and pallor. Decreased peripheral perfusion indicates embolization or hemor-
rhagic shock.
Prevent patient from flexing hip more than 30 degrees for 8 hr. Restriction of flexion reduces the risk of bleeding from the femoral
puncture site.
If bleeding occurs, apply pressure 2 cm proximal to the punc- Pressure stabilizes bleeding. Pressure may be applied with a 5 lb
ture site. sandbag.
Diagnosis: Ineffective Peripheral Tissue Perfusion

related to interrupted arterial flow to the involved limb due to embolization
Desired Outcome: Within 2 hr of intervention, patient has adequate perfusion in the limb, as evidenced by peripheral pulses and
normal color, sensation, and temperature.
Assess peripheral perfusion by palpating pulses q15min for 30 Recognition of loss of pulse prevents ischemic limb loss.
min, then q30min for 1 hr, then q1h for 2 hr.
Assess extremity for loss of pulse, coldness, pallor, cyanosis, These are signs of embolization. Prompt recognition will lead to
numbness, tingling, or pain. prompt intervention.
Ensure that patient remains at bedrest for 6 hours. Immobility reduces the risk of bleeding.

related to unfamiliarity with catheterization procedure and post catheterization regimen
Desired Outcome: Before the procedure, patient states knowledge about cardiac catheterization and post catheterization care.
Before cardiac catheterization, have the patient practice exer- Valsalva’s maneuver, coughing, and deep breathing may be re-
cises that will be used during the procedure. quired during cardiac catheterization.
Explain that a "flushing" feeling may occur when the dye is Dye injection causes vasodilation, which is a flushing sensation.
injected.
Explain that after catheterization, flexing the insertion site will After the procedure, bedrest will be required and vital signs, circu-
be contraindicated for 6 hours. lation, and the insertion site will be checked every hour.
Stress importance of promptly reporting pain or dyspnea. Groin, leg, or back pain; dizziness, chest pain, and dyspnea are
signs of hemorrhage.
Dysrhythmias' 93
Dysrhythmias
Diagnosis: Decreased Cardiac Output

related to altered rate, rhythm, or conduction.
Desired Outcome: After intervention, patient has improved cardiac output, as evidenced by BP >90/60 mm Hg, HR 60-100 bpm.
Assess the patient’s heart rhythm continuously on a monitor. This evaluation will detect the occurrence of dysrhythmias.
Assess BP and symptoms associated with dysrhythmias. Decreased cardiac output may cause hypotension, palpitations,
chest pain, dyspnea, tachycardia (>150 bpm), dizziness, and syn-
cope.
If decreased cardiac output occurs, arrange transfer of patient Transfer to the CCU allows for ECG and invasive monitoring.
to the CCU.
Assess dysrhythmias with a 12-lead ECG. 12-lead ECG better characterize dysrhythmias.
Monitor electrolytes and digoxin levels. Potassium <3.5 mEq/L or >5.0 mEq/L can result in dysrhythmias.
Digoxin toxicity may result in heart block or dysrhythmias.
Class Ia: sodium channel blockers, such as quinidine, pro- Class Ia antiarrhythmics decrease depolarization and prolong re-
cainamide, and disopyramide polarization.
Class Ib: sodium channel blockers, such as phenytoin, mex- Decrease depolarization.
iletine, and tocainide
Class Ic: sodium channel blockers, such as encainide, Decrease depolarization
flecainide, and propafenone
Class II: beta-blockers; propranolol, metoprolol, atenolol Slow sinus automaticity, slow A-V node conduction, control ven-
tricular response.
Class IIIa: potassium channel blockers, such as bretylium, Increase the action potential and refractory period of Purkinje fi-
amiodarone, sotalol, ibutilide, or dofetilide bers, increase ventricular fibrillation threshold.
If dysrhythmias cause loss of consciousness, chest pain, This restores the heart to sinus rhythm.
dyspnea, or hypotension, initiate advanced cardiac life sup-
port.

related to unfamiliarity with dysrhythmias and treatments.
Desired Outcome: Before hospital discharge, patient states knowledge about dysrhythmias and treatment.
Teach mechanism of dysrhythmias A knowledgeable patient is more likely to adhere to the treat-
ment regimen.
Teach signs and symptoms of dysrhythmias. Palpitations, chest pain, dyspnea, tachycardia, dizziness, and
syncope should be reported.
Explain the purpose, dosage, schedule, precautions, and ad- An informed patient is more likely to adhere to treatment.
verse effects of medications.
Advise patient and significant other to take cardiopulmonary Emergency life-saving procedures may be necessary if cardiac
resuscitation classes. arrest occurs.
Dysrhythmias' 94
The ICD device delivers an electrical stimulus after assessing Implantable defibrillators are used for patients who have sur-
the ECG. ICDs provide defibrillation and pacing. vived sudden cardiac death.
The ICD will have a pulse generator, powered by a battery. The pulse generator is powered by lithium batteries, and the
device is surgically inserted into a pocket under the skin of the
chest. Leads are tunneled beneath the skin from the pocket to
the right ventricle.
Postoperative complications include pneumonia, seroma in the An informed patient will be able to report these complications.
pocket, pneumothorax, and lead movement.
Electrocautery and MRI interfere with and may change pro- ICDs should be deactivated before electrocautery and magnetic
gramming of the device. resonance imaging.
Patient should keep a pocket card with information about the This card ensures that information is available if a dysrhythmia
ICD. occurs.
Explain that home monitoring may be needed, and provide in- Monitoring the device ensures correct ICD function.
struction.
Heart'Failure' 95
Heart Failure

related to fluid accumulation in the alveoli.
Desired Outcome: After intervention, patient has adequate gas exchange, as evidenced by normal breath sounds, RR <20/min,
HR <100/min, PaO2 >80 mm Hg.
Assess breath sounds doe crackles. Crackles indicate alveolar fluid accumulation and systolic HF.
Monitor pulse oximetry and report an oxygen saturation of Oximetry <94% is hypoxemia.
<94%.
Assess respiratory rate, dyspnea, decreased mental status, These are signs of respiratory distress.
heart rate >100/min or systolic BP <90 mm Hg.
Place patient in high Fowler's position with head-of-bed at 90 Fowler’s position reduces work of breathing and increases gas
degrees. exchange.
Administer oxygen by non-rebreather mask. Hypoxia causes myocardial depression. High-flow oxygen may be
given by non-rebreathing mask or positive airway pressure to keep
saturation >94%.
Administer furosemide (Lasix) 40 mg IV bid. Diuretics reduce lung fluid and blood volume. Fluid in the lungs
may cause hypoxemia.
Monitor potassium levels. Hypokalemia <3.5 mEq/L may be caused by furosemide.
Administer an ACE inhibitor, such as lisinopril 5 mg once daily. ACE inhibitors suppress the renin-angiotensin-system.
Administer metoprolol (Lopressor) extended release 12.5 mg Beta-blockers, such as metoprolol and alpha/beta-adrenergic
once daily; double dosage every 2 weeks as tolerated (target blockers (carvedilol) decrease cardiac workload. Initiate only in
dose: 200 mg daily). Or carvedilol (Coreg) 3.125 mg twice stable patients or hospitalized patients after volume status has
daily for 2 weeks; if this dose is tolerated, may increase to been optimized and IV diuretics, vasodilators, and inotropic agents
6.25 mg twice daily. Double the dose every 2 weeks to the have all been successfully discontinued. Caution should be used
highest tolerated dose. when initiating in patients who required inotropes during their hos-
pital course. Increase dose gradually and monitor for congestive
signs and symptoms of HF making every effort to achieve target
dose shown to be effective
Administer nitroglycerine. Nitroglycerine causes vasodilation and decreased pulmonary con-
gestion, which improves gas exchange. Nitrates are coronary vas-
odilators.

related to decreased cardiac output.
Desired Outcomes: Within 1 hr of intervention, patient has decreased dyspnea. Within 1 day of intervention, edema is 1+ or less.
Assess I&O. Low urine output results from low cardiac output and inadequate
renal blood flow.
Assess daily weight and report gain >5 kg. This evaluation detects fluid retention.
Assess for ankle edema. Weight gain and edema are signs of fluid retention.
Heart'Failure' 96
Assess for crackles. Crackles are caused by fluid volume excess and systolic dysfunc-
tion.
Assess for jugular vein distention, peripheral edema, and asci- Hyponatremia is an indicator of fluid overload.
tes.
Monitor for hyponatremia. These are indicators of fluid retention.
Administer furosemide (Lasix) 40 mg qAM. Diuretics enhance normovolemia by reducing fluid accumulation.
Furosemide increases excretion of water and sodium.
Teach patients about the low-sodium diet. Excessive sodium can result in fluid retention. A 2-g per day sodi-
um diet is recommended.
Diagnosis: Decreased Cardiac Output

related to decreased cardiac contractility
Desired Outcomes: 24 hr before hospital discharge, patient has adequate cardiac output, as evidenced by SBP >90 mm Hg, HR
<100 bpm, urinary output >30 mL/hr.
Assess for jugular venous distention, S3 heart sounds, de- These are indicators of congestive heart failure.
creased mental status, hypotension, tachycardia, and tachyp-
nea.
Assess for crackles, wheezes, and dyspnea. Dyspnea, crackles, and wheezes indicate pulmonary edema,
and heart failure.
Monitor I&O. Decreased urine output suggests heart failure, which can result
in decreased renal perfusion.
Assess for peripheral edema. Edema can occur with diastolic HF and cardiogenic shock
caused by myocardial infarction.
Administer metoprolol (Lopressor) or carvedilol Beta-blockers, such as metoprolol and alpha/beta-adrenergic
blockers (carvedilol) decrease cardiac workload.
Explain the implantable cardioverter-defibrillator. Dysrhythmias may require an implantable cardioverter-
defibrillator because of episodes of ventricular tachycardia.
Place patient into semi-Fowler's position. This position reduces work of breathing and decreases cardiac
workload.
Diagnosis: Activity intolerance

related to imbalance between oxygen supply and demand caused by decreased cardiac contractility.
Desired Outcome: During activity, patient displays cardiac tolerance, as evidenced by RR 20 breaths/min, HR <100/min, and ab-
sence of chest pain.
Assess the patient’s response to activity and report abnormal Chest pain, dysrhythmias, dyspnea, HR >100 bpm are signs of
findings. congestive heart failure.
Assess for oliguria, hypotension, decreased mental status, These are signs of low cardiac output.
and dizziness.
Assess peripheral pulses, pale skin color, and urinary output. These signs of poor peripheral perfusion should be reported.
Heart'Failure' 97
Administer oxygen as prescribed. Increasing oxygen supply to the myocardium increases activity
tolerance.
Assist with range-of-motion exercises. Exercise prevents joint contractures and muscle atrophy.

related to unfamiliarity with purpose, precautions, and adverse effects of diuretic treatment
Desired Outcome: 24-hr before discharge, patient states knowledge of the precautions and adverse effects of diuretics.
Teach the purpose of the diuretic. Diuretics reduce fluid accumulation and reduce blood volume.
Teach patient to report irregular pulse and muscle cramps. Furosemide (Lasix) can cause hypokalemia, which can cause ar-
rhythmias and cramps.
Explain importance of follow-up monitoring of blood potassium Diuretics cause hypokalemia and hyponatremia.
and sodium.
For patients taking furosemide (Lasix), teach need to take a A potassium supplement and foods high in potassium content,
potassium supplement. such as bananas, oranges and raisins, will replenish the potassi-
um deficit.
Instruct patient to use care when rising from a supine position. Orthostatic hypotension can occur with diuretic treatment because
of hypovolemia.

related to unfamiliarity with purpose, precautions, and adverse effects of digoxin.
Desired Outcome: Within the 24-hr period before hospital discharge, patient states understanding of the purpose and adverse
effects of digoxin.
Teach the purpose of digoxin treatment. Digoxin increases myocardial contractility. Digoxin slows AV con-
duction and is used to control heart rate in atrial fibrillation.
Teach patient to not take digoxin dose if there is a 20 bpm Such a change may indicate that patient is receiving excessive
increase or decrease rate, and notify physician. digoxin.
Explain that serum potassium levels are monitored. Hypokalemia can potentiate digoxin toxicity.
Teach patient that nausea, vomiting, anorexia, headache, diar- These are signs of digoxin toxicity.
rhea, blurred vision, yellow-vision, and confusion should be
reported.
Heart'Failure' 98

related to unfamiliarity with precautions and adverse effects of vasodilators
Desired Outcome: Within 24-hr before hospital discharge, patient states knowledge of the purpose, precautions, and adverse ef-
fects of ACE-inhibitors.
Teach importance of assessment of peripheral edema. ACE-inhibitors may cause edema.
Explain importance of monitoring creatinine. ACE inhibitors may cause hyperkalemia in patients with renal in-
sufficiency.
Hypertension' 99
Hypertension

related to unfamiliarity with need for adherence to antihypertensive treatment and lifestyle changes.
Desired Outcome: Following teaching, patient states the importance of regular BP checks and adhering to antihypertensive treat-
ment and lifestyle changes.
Teach importance of regular BP checks and adhering to drug Frequent assessment provides feedback on the patient’s re-
treatment. sponse to treatment.
Stage 1 hypertension: systolic 140 to 159 mmHg or diastolic 90 to
99 mmHg. Stage 2 hypertension: systolic ≥160 mmHg or diastolic
≥100 mmHg
Encourage exercise, weight loss, decreased alcohol, and a 2- Treatment of hypertension should include lifestyle modification
g/day-sodium DASH diet, which is high in vegetables, fruits, low- and the DASH dietary program.
fat dairy products, whole grains, poultry, fish, and nuts; and low in
sweets and red meats.
Initiate antihypertensive medications if the systolic pressure is Treatment with antihypertensive medications reduces coro-
≥140 mmHg (<60 years) or ≥150 mmHg (60 years and older) nary events by 16 percent and reduces the incidence of stroke
and/or the diastolic pressure is ≥90 mmHg by 40 percent.
Goal blood pressure is <140/90 mmHg <60 years. Goal blood Treatment with antihypertensive medications reduces coro-
pressure is <150/90 mmHg 80 years and older. Goal blood pres- nary events by 16 percent and reduces the incidence of stroke
sure is <150/90 mmHg for persons aged 60 to 79 years. by 40 percent.
Administer chlorthalidone 12.5 to 25 mg per day, or amlodipine Classes of drugs that have been used for initial monotherapy:
(Norvasc) 5 mg per day. thiazide diuretics, long-acting calcium channel blockers, and
ACE inhibitors or ARBs. Each has been equally effective.
Venous'Thromboembolism' 100
Venous Thromboembolism
Diagnoses: Ineffective Peripheral Tissue Perfusion and Risk for Decreased Cardiac Perfusion
related to thrombus formation or embolization.
Desired Outcome: Following interventions, patient has adequate tissue perfusion, as evidenced by normal extremity color; RR 12-
20 breaths/min; HR <100 bpm; BP >100/60 mm Hg.
Assess for leg pain, erythema, calf swelling, warmth, and vein These are early indicators of peripheral thrombus formation, which
dilation. require bed rest and an anticoagulant.
Assess for pleuritic chest pain, dyspnea, tachypnea, tachycar- These are signs of PE, which require prompt anticoagulant thera-
dia, hypotension, hemoptysis, and oxygen saturation <94% py with heparin.
Administer low molecular weight heparin Anticoagulant prevents propagation of the clot. Low molecular
weight heparin is used during the first five days.
Administer oral Coumadin or dabigatran (Pradaxa) Coumadin or Pradaxa is used for long-term treatment after treat-
ment overlap with LMW heparin for 4-5 days. Three months of
anticoagulation is recommended for a first DVT.
Maintain the patient on bedrest. This measure decreases lower extremity edema.
Elevate the affected leg. This measure increases venous drainage.
Diagnosis: Acute Pain

related to inflammatory process due to thrombus formation
Desired Outcomes: Within 1 hr of intervention, the patient’s subjective perception of pain decreases.
Assess for presence of pain. Administer analgesics. This evaluation assesses the patient’s perception of pain and as-
sesses relief from analgesics.
Ensure that the patient maintains bedrest and limb elevation. These measures minimize pain, enhance venous drainage, and
decrease embolization.

related to unfamiliarity with the disease process of VTE and at-home treatment.
Desired Outcome: Before hospital discharge, patient states knowledge of the disease and treatment.
Teach the definition of VTE and ways to prevent thrombosis Avoiding prolonged periods of standing and elevate legs above the
and discomfort. Avoid long periods of inactivity. heart when sitting to enhance venous return. Walking enhances
venous return.
Teach the signs of venous stasis ulcers. Redness and skin breakdown are signs of venous stasis ulcers.
Acute'Renal'Failure' 101
Acute Renal Failure

related to presence of uremia.
Desired Outcome: Patient is free of infection, as evidenced by temperature <38.5° C and urinalysis being negative
Assess temperature. Fever is a sign of infection. Uremia causes immunodeficiency.
Avoid use of indwelling urinary catheters. Use intermittent Indwelling urinary catheters are a source of urinary infections.
catheterization.
Provide frequent oral hygiene and skin care. Intact skin and mucous membranes are barriers to infection.
Increased'Intracranial'Pressure' 102
Neurology Nursing
Increased Intracranial Pressure
Diagnosis: Increased Intracranial Pressure

related to obstruction of CSF outflow or herniation due to brain trauma, ischemic stroke, or intracranial hemorrhage.
Desired Outcome: Patient becomes free of symptoms of ICP, as evidenced by improved sensorimotor functioning; normal blood
pressure; HR 60-100 bpm; orientation, and normoreactive pupils.
Assess for and report indicators of increased ICP or impend- Intracranial pressure is the pressure within the skull. Normal ICP is
ing herniation: 0-10 mm Hg; IICP is >15 mm Hg. Cerebral perfusion pressure is
the difference between mean arterial pressure and ICP. Normal
CPP is 70-100 mm Hg.
Assess for early indicators of increased ICP, such as de- The most important indicator of early increased ICP is a de-
creased level of consciousness, irritability, confusion lethargy; creased level of consciousness.
headache; pupillary sluggishness; diplopia, weakness, and
nausea.
Assess for late indicators of increased ICP, such as stupor, Late signs of IICP are caused by brain herniation due to brain
coma; projectile vomiting; hemiplegia; posturing; wide pulse stem compression.
pressure, bradycardia, hypertension; Cheyne-Stokes breath-
ing; pupillary inequality, dilation, nonreactivity; papilledema.
Assess for signs of brain herniation include deep coma, fixed Brain herniation occurs when IICP causes displacement of the
and dilated pupils, posturing progressing to flaccidity, loss of brain from one cranial compartment to another.
brain stem reflexes, and bradypnea.
Transfer of patient to the intensive care unit. Insertion of ICP sensors for continuous ICP monitoring, continuous
cerebral blood flow monitoring by transcranial Doppler is neces-
sary.
Provide oxygen, intubation, and mechanical ventilation. As- Preventing hypoxia requires maintaining oxygen saturation >94%.
sess arterial blood gas or pulse oximetry.
Monitor cerebral blood flow, jugular venous oxygen saturation, Mechanical hyperventilation decreases cerebral PaCO2 to 30-35
and brain tissue oxygenation. mmHg, resulting in an alkalosis, cerebral vasoconstriction, and
decreased CBF and ICP.
Maintain head and neck in alignment to avoid hyperextension, These measures enhance venous blood return to the heart to re-
flexion, or rotation. Endotracheal tube ties should not com- duce cerebral congestion.
press the jugular vein.
Keep head of bed at 30 degrees to optimize CPP. Maintain CPP >70 mm Hg to prevent ischemia. HOB at 30 de-
grees facilitates venous drainage and decreases ICP.
Administer a stool softeners or a bisacodyl suppository (Dul- These measures prevent straining at stool, which increases in-
colax). traabdominal and intracranial pressures.
Monitor intake and output. Avoid fluid restriction because hypotension may reduce CPP.
Maintain body temperature between 36.5° and 38.5° with ac- Hypothalamic injury may result in hyperthermia. Fever exacer-
etaminophen or a hypothermia blanket. bates hypoxia.
Administer hypertonic saline or mannitol for increased ICP. Mannitol and furosemide reduce cerebral edema and blood vol-
ume, thereby lowering ICP.
Administer antihypertensives. BP control enhances CBF by decreasing cerebral edema. Hypo-

tension reduces CBF. Hypertension is treated with labetalol.
Administer analgesics for pain. Pain can increase ICP. Intubated, restless patients should be se-
dated with continuous propofol. Lidocaine is used to prevent hypo-
tension due to suctioning.
Administer antiepilepsy medication if a seizure occurs. AEDs control seizures.
Administer lorazepam, midazolam, and propofol for agitation. These measures decrease agitation, which increases ICP.

related to facial and throat muscle weakness, depressed gag or cough reflex, and impaired swallowing, or decreased LOC.
Desired Outcomes: Patient is free of signs of aspiration, as evidenced by RR 12-20 /min oxygen saturation >94%, and normal
breath sounds.
For patients with a neurologic deficit, perform dysphagia screen- Dysphagia screening identifies patients at risk for aspiration.
ing. Patients should be kept nothing by mouth until swallowing eval-
uation.
Assess lung sounds before and after the patient eats. Wheezing after a meal is a sign of aspiration.
Keep HOB elevated after meals. Elevation position increases flow of food and fluids by gravity
from the stomach to the pylorus.
Use a gastrointestinal stimulant, such as erythromycin, metoclo- Erythromycin and metoclopramide stimulate upper GI tract motil-
pramide. ity and gastric emptying, which prevents aspiration.
Provide oral hygiene after meals. Oral hygiene removes food particles that may be aspirated.
Inspect the mouth after meals and suction as needed. These actions assess for particles or secretions that could be
aspirated.

related to facial and throat muscle weakness, depressed gag or cough reflex, impaired swallowing, or decreased LOC.
Desired Outcome: Patient is normovolemic, as evidenced by balanced I&O, normal BP, HR <100 bpm, and urinary output >30
mL/hr.
Assess gag reflex, alertness, cough, and swallow before giving Intact swallowing and gag reflexes and an intact cough are re-
oral fluids. quired before drinking fluids.
Keep suction equipment at the bedside. This enables immediate suctioning of the airway as needed.
Assess I&O and measure weight daily. Patients with neurologic deficits have difficulty maintaining fluid
intake.
Alert physician to significant input and output imbalance. Imbalance suggests the need for enteral feedings to prevent
dehydration and malnutrition.
Assess for poor skin turgor, hypotension, tachycardia, and de- These are indicators of dehydration. Fever and diarrhea in-
creased urinary output crease fluid loss and may cause dehydration.
Offer fluids q1-2h. Drinking fluids at frequent intervals will prevent dehydration.
Feed weak or paralyzed patients. Feeding assistance ensures that fluid goals are obtained.
Instruct patient to flex head slightly forward. Flexing the head forward closes the airway and prevents aspira-
tion.
Provide special-handled, spill-proof cups or straws. These devices enhance independence, which increases fluid
intake.

related to chewing and swallowing deficits, weakness, paresis, paralysis, or decreased LOC.
Desired Outcome: Patient achieves adequate nutrition, as evidenced by maintenance of body weight before discharge.
Assess alertness, cough, and gag reflexes before meals. Deficits increase the risk for aspiration.
Assess type of diet that can be eaten. Soft, semisolid, or Pureed food should only be given if the patient has dysphagia.
chopped foods are indicated for difficulty swallowing. Pureed food is unappealing.
Offer small, frequent servings of palatable food. These measures will enhance eating.
Provide oral care before feeding. Insert clean dentures. Oral care and good dentition enhance the patient’s ability to taste
and chew.
Encourage liquid nutritional supplements. Supplement milkshakes will enhance intake.
Feed or assist weak or paralyzed patients. Elevate HOB. En- Raising the HOB prevents aspiration by promoting drainage into
sure that the patient’s head is flexed slightly forward. the stomach.
Provide built-up utensil handles, broad-handled spoons, spill- Assistive eating devices enhance independence.
proof cups, rocker knife, wrist or hand splints with clamps to
hold utensils, stabilized plates, and sectioned plates.
Assess the patient’s appetite. Weigh patient daily. Weight is an indicator of nutritional status.
Obtain dietitian consultation. The patient may require enteral or parenteral nutrition.
Refer to a speech pathologist. Speech pathologists teach exercises that improve swallowing abil-
ity.

related to spasms or headache, caused by neurologic dysfunction.
Desired Outcomes: Within 1 hr of intervention, the patient’s discomfort decreases, as documented by pain scale. Grimacing is
absent or decreased.
Assess quality, severity, location, onset, duration, and head- These assessments evaluate the degree and type of headache,
ache. Document pain on a scale of 1 to 10 (worst pain). and measure relief obtained from interventions.
Administer analgesics. Document effectiveness of the medica- Prolonged stimulation of pain receptors causes increased sensi-
tion. tivity to painful stimuli.
Diagnosis: Impaired Verbal Communication

related to throat muscle weakness or intubation.
Desired Outcome: Following intervention, patient communicates verbally or nonverbally.

Assess the patient’s ability to speak, read, write, and compre- This evaluation determines the patient’s ability to communicate.
hend language.
Obtain a referral to a speech pathologist These actions assist in strengthening the muscles of speech.
Provide a language board, alphabet cards, flash cards, pad These alternative methods will facilitate communication.
and pencil, or communication board.
Provide a voice amplifier. This measure projects the patient’s voice.
For patient with permanent tracheostomy, encourage use of Esophageal speech involves use of a fenestrated tube or covering
esophageal speech. the tracheostomy tube with a finger to produce speech.
Bacterial'Meningitis' 106
Bacterial Meningitis
Diagnosis: Bacterial Meningitis

related to unfamiliarity with transmission precautions: Droplet
Desired Outcome: Before visitation, patient and significant other verbalize knowledge about Transmission Precautions: Droplet,
and follow precautions.
Arrange for lumbar puncture Examination of the CSF is crucial for establishing the diagnosis of
bacterial meningitis, identifying the causative organism, and per-
forming in vitro susceptibility testing
Administer antibiotics, such as ceftriaxone or cefotaxime plus The empiric approach to antimicrobial selection in patients with
vancomycin plus ampicillin suspected bacterial meningitis is directed at the most likely bacte-
ria based on the patient's age and underlying disease status
For patients with meningitis due to H. Influenzae or N. menin- Transmission-Based Precautions for Droplets are required for 24
gitidis, explain disease transmission by respiratory droplets. hr after initiation of antibiotics. The patient should be placed in a
private room.
Teach patient to cover his mouth before coughing or sneezing. Respiratory droplets or oral secretions may spread infection.
Advise patients to stay in their room. If they must leave the Close contacts should wear a mask.
room, a mask must be worn. Contacts should wear a surgical
mask and practicing hand hygiene.

related to headache, photophobia, and neck stiffness
Desired Outcomes: Within 2 hr, the patient’s discomfort decreases, as documented by pain scale.
Assess patient for pain and discomfort using a pain scale. A pain scale measures the effectiveness of pain relief.
Provide passive range of motion exercises. These measures help relieve stiffness and decrease pain.
Administer analgesic medications for headache. Acetaminophen with codeine is given to relieve headache and
myalgias.
GuillainRBarre'Syndrome' 107
Guillain-Barre Syndrome

related to weakness or paralysis of the respiratory muscles
Desired Outcome: The patient’s respiratory weakness is treated effectively, as evidenced by PaO2 <80 mm Hg, vital capacity
<800-1000 mL, tidal volume >75% of predicted value, or oxygen saturation >92%.
Assess respiratory rate and depth. Dyspnea and shallow respirations are signs of respiratory weak-
ness, which should be reported.
Observe for decreased mental status and disorientation. These changes indicate brain hypoxia due to weakness of the
respiratory muscles.
Periodically assess for ascending loss of sensation by touching Decreased sensation develops before muscle weakness. Hypoes-
lightly with fingers from the iliac crest upward toward the thesia at the T8 signals impending intercostal muscle weakness.
shoulders. Note the level of decreased sensation.
Assess patient for arm drift and shoulder shrug. Arm drift is assessed by having the patient hold both arms out
with closed eyes. Shoulder weakness and arm drift occur before
respiratory dysfunction.
Assess patient q8h and before oral intake for cough reflexes, These assessments detect muscle weakness dysphagia.
gag reflexes, and dysphagia.
Keep patients with impaired swallowing NPO. Impaired swallowing, cough, and gag reflexes require enteral
feedings.
Ask patient to take a deep breath and count. A limited ability to count quantifies the patient’s ventilatory func-
tion.
Monitor effectiveness of breathing with serial vital capacity Vital capacity <800-1000 ml or tachycardia, increasing restless-
measurements. ness, mental dullness, decreased oxygen saturation should be
reported.
Assess arterial blood gases and pulse oximetry. These assessments detect hypoxia or hypercapnia (PaCO2 >45
mm Hg). Oxygen saturation <94% indicates a need for supple-
mental oxygen.
Raise head of bed. This position increases chest expansion by removing the pressure
of abdominal organs on the diaphragm.
Encourage coughing and deep breathing. These actions mobilize secretions.

related to unfamiliarity with therapeutic plasma exchange transfusion
Desired Outcome: Before the procedure, patient states accurate information about plasma exchange.
Discontinue angiotensin-converting enzyme inhibitors and noti- ACE inhibitors are associated with flushing, hypotension, and
fy the physician. abdominal cramping during plasmapheresis. ACEIs should be
held for 24 hr.
Explain the plasma exchange procedure. Blood is removed from the patient, and plasma is discarded.
RBCs, WBCs, and platelets are returned to the patient. Multiple
exchanges are done over weeks.
GuillainRBarre'Syndrome' 108
Exchange transfusion reduces GBS disease duration and se- Exchange transfusion removes antibodies to nerve tissue from the
verity. blood.
Explain the complications of exchange transfusion. Exchange transfusions may cause deficient fluid volume, fluid
overload, hypokalemia, hypocalcemia, dysrhythmias, and im-
paired clotting.
Explain that exchange transfusions are performed over a 2-4 The length of time of exchange transfusion depends on the condi-
hr period. tion of the patient’s veins and hematocrit.
Explain that weight and vital signs will be taken before, during, Hypotension and fluid volume shifts may occur during exchange
and after the procedure. transfusions.
Teach patient to monitor for bruising or bleeding. Warn patient Citrate is used as an anticoagulant in the extracorporeal machine
to avoid trauma and to apply pressure over any lacerations for to prevent clotting. Excessive bleeding may occur at the access
2 hours. site.
Intervertebral'Disk'Disease' 109
Intervertebral Disk Disease

related to unfamiliarity with pain control measures
Desired Outcome: Following instruction, patient understands pain control measures for low back pain.
Teach methods of controlling back pain. Pain control methods include counter-irritants, massage, and re-
laxation techniques. Heat reduces muscle spasm.
Recommend that the patient use a straight-back chair and a Higher seats enhance movement in and out of the chair.
raised toilet seat.
Encourage patient to use a firm mattress and pillows for posi- These measures support the lumbar spine.
tioning.
Caution patient to avoid sudden twisting or turning. Teach pa- These measures prevent movements that may injure the back.
tient to logroll. Splints, braces, cervical collars may be used to limit spine motion.
Recommend lying on the side with knees bent or lying supine These measures enhance spinal comfort
with knees supported on pillows. Avoid prolonged sitting.
Give acetaminophen, tramadol, and hydrocodone. Sufficient medication should be given to relieve pain.
Nonsteroidal antiinflammatory drugs NSAIDs reduce inflammation and pain. Adverse effects include
platelet dysfunction, gastric irritation, and renal injury.
Stomach protectants, such as omeprazole. These agents may reduce gastric irritation due to NSAIDs.
Muscle relaxants, such as cyclobenzaprine, carisoprodol, These medications decrease muscle spasms. Adverse effects
methocarbamol include drowsiness and dry mouth.
Local injection of lidocaine or bupivacaine and/or cortisone into These medications reduce pain and muscle spasms.
the epidural space, joints, or trigger points

related to unfamiliarity with correct body mechanics for prevention of back injury
Desired Outcome: After teaching, patient states knowledge of measures that prevent back injury and demonstrates correct body
mechanics.
Teach body mechanics: Using correct body mechanics prevents
Stand and sit with back straight. back injury.
Bend at knees and hips, keeping back straight.
Hold objects close to the body, avoiding twisting. Spread feet.
Lift with legs.
Turn using entire body.
Avoid lifting anything heavier than 10 pounds.
Teach patient to keep body in alignment Correct body alignment prevents back strain
Support feet on a book when sitting.
Use a firm mattress or bed board; sleep in a side-lying position
with knees supported; avoid the prone position. Avoid chairs
without back support.
Pelvic tilt: Tighten stomach and buttock, and tilt pelvis. Pelvic tilts strengthen the abdominal muscles.
Knee-to-chest raise: Raise each knee to the chest. Knee-to-chest raises increase spine flexibility.
Half sit-ups: Slowly raise chin to chest. Half sit-ups strengthen the abdomen muscles.
Instruct patient to wear shoes with a low heel. This helps maintain alignment of back and hips.
Teach to stand up by logrolling, then pushing up against mat- This technique prevents strain on the back.
tress.

related to unfamiliarity with diskectomy with laminectomy or spinal fusion
Desired Outcomes: Before surgery, patient states correct knowledge of the surgical procedure and the preoperative and postop-
erative regimen.
Instruct the patient to expect the surgeon to mark the spinal These measures ensure that the surgery will be performed on the
level and side of the surgical site. correct site.
Microdiskectomy The herniated area of the disk and lamina are microsurgically
excised.
Diskectomy with laminectomy An incision is made and a section of vertebra bone is removed
(laminectomy). The central part of the disk is then removed.
Percutaneous lumbar disk removal Ultrasonic nucleotome cannula or fiberoptic arthroscopic cannula
is inserted into the disk.
Spinal fusion Fusion is indicated for recurrent low back or neck pain, spondylo-
listhesis, vertebral subluxation, or multilevel disease. Bone chips
are harvested from the iliac crest and placed between two verte-
brae.
Intradiskal electrothermal treatment IDET uses an electric probe to heat and shrink collagen within the
annulus wall to seal tears.
Total intervertebral disk replacement with artificial disks. This procedure inserts an artificial disk in place of the disk.
Diskoplasty This procedure reduces a bulging disk with a probe, which re-
moves the center of the disk.
Teach deep breathing and incentive spirometry. Deep breathing and incentive spirometry are performed after sur-
gery to expand the alveoli.
Advise the patient to report paresthesias, weakness, and loss These are signs of cord compression due to bleeding or hemato-
of bowel or bladder function. ma.
Explain that the dressing will be inspected for drainage q2h A laminectomy causes minimal bleeding. A fusion may cause
and drainage device may be in place for 1-3 days. slight oozing.
Caution the patient to avoid straining at stool. Straining could result in increased intraspinal pressure. Stool sof-
teners help prevent constipation.
Inform the patient that pain may take days or weeks to resolve. Postoperative pain or tingling (paresthesia) often is due to nerve
root irritation and edema.
Teach patient to request medication for pain. Pain is easier to manage before it becomes severe.
Explain postoperative activity restrictions. Patients are required to lie supine for several hours to minimize
wound hematoma. After this period, the head of bead can be
raised to 20 degrees.
Teach patient to logroll with shoulders and pelvis straight The logroll method is used for turning. This method maintains
alignment. alignment and prevents bone graft dislodgement.
Explain that sequential compression devices will be applied This device increases venous return and prevents thrombus for-
after surgery. mation.
Advise patient about postoperative activity restrictions. Explain Sitting is restricted after surgery.
that sitting in a car, sexual activity, lifting, and tub bathing are
prohibited.
Multiple'Sclerosis' 112
Multiple Sclerosis
Diagnosis: Chronic Pain

related to motor and sensory nerve tract damage
Desired Outcomes: Within 2 hr of intervention, the patient’s pain improves, as documented by pain scale.
Advise the patient to avoid hot baths or showers. Heat aggravates the symptoms of multiple sclerosis.
Teach range of motion exercise q2h and stretching exercises. Range of motion exercise reduce muscle spasms, maintain joint
function, and prevent contractures.
Administer antispasmodics, such as baclofen or dantrolene. Antispasmodics reduce muscle spasm pain.
Administer acetaminophen and neuropathic pain medications. Neuropathic pain medications include carbamazepine, gabapen-
tin, topiramate, lamotrigine, and amitriptyline.

related to unfamiliarity with factors that exacerbate MS symptoms
Desired Outcome: By hospital discharge, patient states factors that exacerbate and relieve the symptoms of MS.
Teach patient to avoid heat, such as hot weather, hot baths, Heat aggravates the weakness and pain caused by MS.
and fever. Encourage use of acetaminophen to reduce fever.
Caution patient to avoid exposure to persons with infections. Infection exacerbate MS. Patients should be immunized against
influenza.
Instruct patient to check for urinary frequency and urgency. MS patients are susceptible to UTI because of urinary retention.
Patients may not be able to feel dysuria.
Recommend that the patient rest often and avoid fatigue. The patient can conserve energy by sitting while getting dressed
and getting help for tasks.

related to unfamiliarity with precautions and adverse effects of medications
Desired Outcome: Before discharge, patient states accurate information about medications.
Provide instructions about the name, purpose, dose, and schedule An informed patient is more likely to follow the medication
of medications. regimen.
Topical cortisone and rotating sites reduces inflammation from These measures reduce skin inflammation due to injections.
interferon injection.
Interferon causes post-injection fever, headache, muscle aches, Flu-like symptoms are common after interferon injection.
which is treated with acetaminophen.
Fatigue, diarrhea, abdominal pain, nausea, vomiting, joint aches, These are common adverse effects of interferon.
and dizziness can occur.
Depression or suicidal thoughts may be caused by infection. These adverse effects should be reported.
Multiple'Sclerosis' 113
Blood counts and liver function tests should be monitored. Anemia, thrombocytopenia, and elevated liver transaminase
levels may occur.
Explain the purpose of methylprednisolone. Methylprednisolone may be prescribed during an exacerba-
tion of MS and for optic neuritis to decrease inflammation.
Baclofen or dantrolene are taken with food. These drugs decrease spasticity. Dantrolene causes muscle
- Patient should avoid activities that require alertness. weakness. Food reduces gastric upset or nausea. Muscle
relaxants cause drowsiness.
Parkinson'Disease' 114
Parkinson Disease
Diagnosis: Risk for Falls

related to unsteady gait caused by bradykinesia, tremors, and rigidity
Desired Outcome: Following instruction, patient demonstrates safe ambulatory techniques and preventive measures for falls.
Assess ambulation and movement. This evaluation aids in planning of specific interventions.
Encourage the patient to swing arms and lift heals during am- These actions assist gait and prevent falls.
bulation
Teach patient to turn in wide arcs. These actions prevent the crossing of one leg over the other,
which could cause a fall.
Remind patient to maintain an upright posture and look up Stooped posture and looking down may cause the patient may
when walking. collide with objects.
Encourage a wide-based gait A wide-based gait improves balance.
Recommend range of motion and stretching exercises daily. Exercising increases flexibility, strength, and balance.

related to difficulty initiating movement
Desired Outcome: Following instruction, patient demonstrates measures that aid in initiation of movement.
Teach patient techniques that initiate movement. Rocking from side to side helps to start the leg movement.
Teach patient to get out of a chair by moving to edge of seat, Parkinson disease causes rigidity, tremors, bradykinesia, and
placing hands on arm supports, bending forward, and then difficulty getting out of a chair.
rocking to a standing position.
Recommend that patient sit in chairs with backs and arms and These interventions will help with rising from a sitting position and
to use elevated toilet seats or sidebars in the bathroom. Place prevent falls.
blocks under head of bed.
Recommend that sexual relations be planned for when the PD causes bradykinesia, which can impair intimacy.
medication is active. Sildenafil is beneficial.

related to unfamiliarity with adverse effects of and precautionary measures for taking anti-Parkinson medications
Desired Outcome: Following instruction, patient states knowledge about adverse effects of and precautions for anti-Parkinson
medications.
Advise the patient to take the anti-parkinsonism drugs on The patient can adjust the schedule to produce peak effect at
schedule. mealtime, when mobility is needed.
Encourage patient to raise head of bed and make position These measures reduce orthostatic hypotension. Fludrocortisone
changes slowly. Teach patient to dangle his legs a few minutes or midodrine may be prescribed for orthostatic hypotension.
before standing. Avoid dehydration and maintain adequate
dietary salt.
Encourage the patient to chew sugarless chewing gum or suck These measures ease dry mouth, a common side effect.
on hard candy to keep his mouth moist.
Teach patient that levodopa should be taken with a full glass of An empty stomach facilitates absorption. Timing of medication 20-
water on an empty stomach. 30 min before meals will promote movement during meals.
Explain that symptoms of motor fluctuations are abnormal body Immediate medical intervention is necessary because respiratory
movements, cramps, and postures. and cardiac support may be required.
Explain that signs of on-off response, in which the patient is On-off response is a rapid fluctuation or change in the patient’s
“on” with relative mobility, and then in the next moment, he condition. Dose reduction may reduce this effect.
may be “off,” in a state of immobility.
Explain the side effects of pramipexole, ropinirole, bromocripti- These dopamine agonist drugs are administered to reduce levo-
ne, and ropinirole, apomorphine dopa-induced dyskinesia.
Caution patients taking pramipexole against driving or using Pramipexole may cause somnolence without warning.
machinery.
Teach the patient that apomorphine does not contain mor- Apomorphine is a dopamine agonist given subcutaneously as a
phine. An antiemetic, such as trimethobenzamide, should be "rescue" drug for acute hypomobility. Dizziness or postural hypo-
taken before taking apomorphine. tension can occur.
Explain the adverse effects of anticholinergics (e.g., trihex- These drugs are used with dopamine replacement. Tremors and
yphenidyl, benztropine mesylate, ethopropazine, cycrimine, rigidity may improve.
procyclidine, biperiden).
Teach the patient to take his medications early in the day. Early administration may help prevent insomnia, a side effect of
selegiline.
Explain the side effects of the COMT inhibitors, tolcapone and COMT inhibitors reduce levodopa degradation in the GI tract, kid-
entacapone. neys, and liver.
Teach the patient that orange urine discoloration is common An informed patient is not likely to become anxious if orange
and benign with COMT inhibitors. urine.

related to unfamiliarity with facial/tongue exercises that enhance communication and prevent aspiration
Desired Outcome: Following demonstration, patient demonstrates facial and tongue exercises.
Explain that facial and tongue exercises improve Teach patient to hold a sound for 5 sec; sing the scale; recite
communication. the alphabet; read aloud, and extend the tongue.
Encourage the patient to practice increasing voice volume and These exercises will reduce monotone speech
read newspapers out loud. and increase understandability of speech.
Teach tongue exercises: stick out tongue as far as possible; move These exercises improve speech articulation.
tongue from corner to corner.
Teach patient to open and close mouth quickly; close lips tightly; Lip and jaw exercises improve speech articulation.
wide smile; then pucker lips.
Encourage practice of facial emotions, such as happiness and an- Practicing of facial expressions promotes nonverbal commu-
ger. nication.

related to unfamiliarity with deep brain stimulation
Desired Outcome: After instruction, the patient states understanding of the deep brain stimulation procedure.
Explain that the neurostimulator is implanted in the brain, and a Stimulation of the thalamus reduces tremors. Stimulation of
battery that is placed under the skin near the clavicle powers the the globus pallidus reduces rigidity and improves balance.
device.
Explain the adverse effects of deep brain stimulation, including Adverse effects of deep brain stimulation include paresthesi-
paresthesias, muscle contractions, and double vision. as, muscle contractions, double vision, and mood disturb-
ances.
Advise the patient not to turn off the neurostimulator at night. Rigidity responds only to continuous stimulation.
Teach that adverse effects are corrected by reducing the level of Tingling of the head or hand, depression, slurred speech, loss
stimulation. of balance or muscle tone, and double vision are reduced be
decreasing stimulation.
Caution patients that they cannot undergo MRI scans. MRI scans can heat the wires and leads, causing injury.
Seizures'and'Epilepsy' 117
Seizures and Epilepsy

related to oral or musculoskeletal injury caused by seizure activity
Desired Outcomes: Patient demonstrates no signs of injury or airway compromise after the seizure. Before hospital discharge, the
patient’s spouse states the correct actions to take during a seizure.
Initiate seizure precautions by padding side rails with blankets or Seizure precautions protect the patient from trauma if a sei-
pillows, keeping bedside rails up, and placing the bed in the lowest zure occurs.
position.
Keep suction, oxygen, and a bag-mask device available. Suction, oxygen, and a bag-mask device may be needed to
prevent hypoxia if a seizure occurs.
Place a saline lock for intravenous access. AEDs must be administered by the IV route to stop seizures.
Caution patients to lie down and push the call button if they expe- Aural warnings may precede seizures in many patients.
rience an aural warning of an oncoming seizure.
During a seizure, record the type, duration, and characteristics of Seizure activity should be documented to aid in classification
the seizure. and identification of triggering factors.
Ease the patient to floor if a seizure occurs while patient is out of These actions prevent physical injury.
bed.
Lower the head of bed to the flat position. The flat position reduces risk of falling out of bed during a sei-
zure.
Do not place any object in the patient’s mouth during a seizure. Placing objects in the patient’s mouth can damage the pa-
tient’s teeth.
Remove objects that may injure the patient. Do not restrain the Protect the patient from injury during the seizure.
patient.
Provide oxygen and suction if needed. These actions maintain a patent airway and prevent hypoxia.
Give lorazepam and fosphenytoin IV as prescribed. IV administration of AEDs can stop the seizure.
After the seizure, reassure and reorient the patient. Check neuro- During the postictal period, the patient should be reoriented
logic status and vital signs. because of memory loss.
Do not offer food or drink until the patient is fully awake. This prevents vomiting and aspiration.
Check the patient’s tongue for lacerations and examine his body These findings may be present after a seizure.
for injuries.
Assess urine for red or cola color. Rhabdomyolysis or myoglobinuria may result from muscle
trauma.
Obtain serum glucose, electrolytes, calcium, and myoglobin levels. Hyponatremia, hypocalcemia, and hypoglycemia may cause
seizures. Rhabdomyolysis may cause renal injury.
Seizures'and'Epilepsy' 118

related to unfamiliarity with preventive interventions for seizures
Desired Outcomes: Before hospital discharge, patient states measures that may prevent seizures and states precautions for sei-
zures.
Advise the patient of automobile operation laws. Three months to 2 seizure-free years are required before an
individual can operate motor vehicle.
Advise the patient to refrain from operating dangerous equipment, These restrictions prevent injury during a seizure.
swimming, climbing or tub bathing until he has been seizure free
for 3 months.
Teach that adequate rest, not fasting, and avoiding flashing lights Meals should be spaced throughout the day. Flashing lights
may prevent seizures. and video games may trigger seizures.
Avoid hard candy, chewing gum, or lozenges. Candy in the mouth may be aspirated during a seizure.
Encourage the patient to wear a medical alert bracelet. A bracelet will provide information to emergency responders if
the patient is unconscious.

related to unfamiliarity with purpose, precautions, and adverse effects of AEDs
Desired Outcome: 24 hours before hospital discharge, patient states knowledge of antiepileptic drug therapy.
Stress importance of taking AED on schedule. Missing a scheduled antiepilepsy drug dose can cause a seizure.
Teach the patient to report bruising, bleeding, jaundice, or Many AEDs can cause blood dyscrasias, liver damage, and rash-
rash. es.
Warn the patient to avoid activities that require alertness. AEDs may cause drowsiness. Splitting the dose or giving the dose
at bedtime may reduce drowsiness.
Teach patient to take the medication with food. Nausea and vomiting caused by AEDs may be reduced with food.
Advise the patient that visual changes or pain should be re- Valproic acid may cause ocular toxicity. Topiramate may cause
ported. blurred vision. Vigabatrin therapy requires periodic visual testing
because of retinal damage.
Instruct patient to report ataxia, diplopia, or nystagmus. These are adverse effects of AEDs that may require dosage re-
duction.
Teach patients who take carbamazepine (Tegretol), These are possible adverse effects that may require a medication
ethosuximide (Zarontin), or zonisamide (Zonegran) to report change.
fever, mouth ulcers, sore throat, bruising, or bleeding.
Advise patients taking phenytoin to gently floss and brush Phenytoin can cause gingival hypertrophy and a severe, exfolia-
teeth 3 times/day and to use a soft toothbrush. tive rash.
Diabetes'Insipidus' 119
Stroke

related to neuromuscular impairment of limbs
Desired Outcome: By hospital discharge, patient demonstrates ambulation and transfer techniques.
Keep the head-of-bed flat for the first 24 hours after an ischemic Cerebral blood perfusion will be maintained by keeping the head of
stroke if the patient is not at risk for increased intracranial pres- bed flat for the first 24 hours after a stroke if the patient is not at
sure, aspiration, or heart failure. risk for increased intracranial pressure, aspiration, or heart failure.
Establish the time of onset of ischemic stroke symptoms Establishing the time of onset of ischemic stroke symptoms de-
termines the patient’s eligibility for thrombolysis. For patients who
are unable to provide a time of onset, the onset is defined as the
time the patient was last free of stroke symptoms.
Assess for carotid bruits and palpate pulses in the neck, arms, Physical examination should evaluate for carotid bruits and pal-
and legs to assess absence. Auscultate for murmurs. Assess pate pulses in the neck, arms, and legs to assess absence,
the lungs for crackles. asymmetry, or irregularity. The heart should be auscultated for
murmurs. The lungs should be assessed for abnormal breath
sounds or crackles.
The National Institutes of Health Stroke Scale (NIHSS) should The NIH stroke scale is composed of 11 items, adding up to a
be assessed, including facial paresis, arm drift/weakness, and total score of 0 to 42. An NIHSS score of ≤20 indicates a severe
abnormal speech. stroke. The three most predictive examination findings for the
diagnosis of acute stroke are facial paresis, arm drift/weakness,
and abnormal speech.
Assess laboratory studies: CT scan or MRI is required to exclude hemorrhage as a cause of
Noncontrast brain CT or brain MRI the deficit. Do not delay administration of a thrombolytic to obtain
Serum glucose, electrocardiogram, CBC, troponin, electro- laboratory studies.
lytes, creatinine, INR, and PTT.
Control blood pressure for patients with acute ischemic stroke For patients with acute ischemic stroke who are eligible for throm-
who are eligible for thrombolytic therapy, systolic BP should be bolytic therapy, before lytic therapy is started, systolic BP should
decreased to ≤185 mmHg and diastolic BP to ≤110 mmHg. be decreased to ≤185 mmHg and diastolic BP to ≤110 mmHg.
After thrombolytic treatment, the BP should only be stabilized and
maintained ≤180/105 mmHg for at least 24 hours.
For patients with ischemic stroke who are not treated with For patients with ischemic stroke who are not treated with throm-
thrombolytic therapy, the BP should not be treated acutely un- bolytic therapy, the BP should not be treated acutely unless the
less the systolic is >220 mmHg. systolic is >220 mmHg or diastolic is >120 mmHg.
Administer labetalol (Normodyne) 10 mg over 1 to 2 minutes IV labetalol and nicardipine are first-line antihypertensive agents
followed by an infusion of 2 to 8 mg/minute. in the acute phase. Nicardipine dose is 5 mg/hour, which can be
increased to a maximum of 15 mg/hour. Intravenous nitroprusside
is often required; however, nitroprusside has a theoretical risk of
increasing intracranial pressure.
Determine if the patient is eligible for recombinant tissue plas- Eligibility criteria for the treatment of ischemic stroke with recom-
minogen activator. binant tissue plasminogen activator (alteplase) include an ischem-
ic stroke causing measurable neurologic deficit. Onset of symp-
toms <4.5 hours, and age ≥18 years
Determine if the patient has any contraindications to rtPA. Exclusion criteria for rtPA include a
significant stroke or head trauma in the previous three months;
previous intracranial hemorrhage; intracranial neoplasm, arterio-

venous malformation, or aneurysm; recent intracranial or in-
traspinal surgery; arterial puncture at a noncompressible site in
the previous seven days; active internal bleeding, bleeding diath-
esis; head CT showing hemorrhage, multilobar infarction
Tell patient that the risks and benefits of alteplase as follows: The patient should be advised of the risks and benefits of altep-
“Alteplase is a clot-buster drug, which is 10 times more likely to lase as follows: “Alteplase is a clot-buster drug, which is 10 times
help than to harm patients when given within 3 hours of stroke more likely to help than to harm patients when given within 3
onset. Treatment is still more likely to help than harm up to 4½ hours of stroke. Alteplase dose is 0.9 mg/kg, with a maximum of
hours. Alteplase can cause fatal bleeding in the brain in 1 of 90 mg. 10% of the dose is given as an IV bolus over one minute,
15 patients.” and the remainder is infused over 1 hour.
Give aspirin 325 mg qd or aspirin-dipyridamole tablet qd. Most patients with acute ischemic stroke or TIA should be given
early aspirin therapy (160 to 325 mg/day) within 48 hours of
stroke onset, but aspirin should not be administered in the first 24
hours after treatment with thrombolytic therapy. Long-term an-
tiplatelet therapy for secondary stroke prevention should be con-
tinued with aspirin-extended-release dipyridamole combination
tablet.
Give atorvastatin (Lipitor), 40 to 80 mg per day Statin therapy reduces the risk of recurrent stroke and cardiovas-
cular events and should be continued for patients receiving statin
therapy before an ischemic stroke. Atorvastatin should be started
within 72 hours of thrombolysis.
Use a lift sheet to reposition the patient in bed. Support the These measures help prevent subluxation.
arm when the patient is sitting.
Teach methods for turning and moving. Use the stronger arm Movement of the affected leg is achieved by sliding the unaffected
to move the weaker arm. foot under the affected ankle.
Support the paralyzed arm with a sling when the patient is out The sling will support the arm and shoulder when the patient is
of bed. out of bed.
Obtain physical therapy consults. Physical therapy retrains the patient to use of affected side for
mobility. The patient learns to bear weight on the affected side.
Diagnosis: Unilateral Neglect

related to brain injury affecting the right hemisphere
Desired Outcome: Following intervention, patient responds to stimuli on the affected side.
Assess the patient’s ability to recognize objects to the right or Neglect of and inattention to stimuli on the affected side occurs
left; perceive body parts; perceive pain, touch, and tempera- with right hemisphere strokes.
ture sensations.
Keep necessary objects on the patient’s unaffected side. This will facilitate performance of activities of daily living.
The nurse should perform activities while located on the unaf- Communication and activities should take place while standing on
fected side. the patient’s unaffected side.
If approaching from the affected side, the nurse should an- This announcement avoids startling patient.
nounce herself first.
Assess for visual neglect, such as eating from only one side of The patient does not turn his head to see all parts of an object. He
the plate or grooming only one side of the body. may eat from only one side of the plate.
Gradually add stimuli to the affected side. While communicating with the patient, physically move across the
patient’s visual boundary to shift the patient’s attention to neglect-
ed side.
Assess the patient for side-neglect Side-neglect occurs when the patient does not perceive one of his
arms or legs as being a part of his body. The patient will often
attend to only the unaffected side of his face and head.
Encourage the patient to monitor the affected side for position Monitoring prevents contractures, skin breakdown, and injury.
and exposure to sharp objects or cold.
When the patient is in bed, keep side rails up. The patient is unaware of his affected side, and he may attempt to
stand up.
Assess for auditory neglect The patient may ignore individuals speaking from the affected
side.
Diagnosis: Disturbed Sensory Perception

related to altered sensory reception, transmission, and integration
Desired Outcome: Following intervention, patient interacts with the environment.
Remind patients who have a dominant hemisphere injury to These patients may have decreased pain sensation and have a
scan their environment visual field deficit.
Mark the outside of the patient’s shoes with an “L” and an "R." The patient may have trouble judging distance,
size, position, rate of movement, and form. The patient may un-
derestimate distances.
Assist patients with eating. Monitor environment for safety The patient may not know the purpose of silverware and may not
hazards and sharp objects. recognize dangerous objects.

related to unfamiliarity with carotid endarterectomy, carotid angioplasty or stent procedure
Desired Outcome: Before surgery, patient states understanding of carotid endarterectomy, including the purpose, risks, benefits,
and postsurgical care.
Explain the carotid endarterectomy procedure. Carotid endarterectomy is removal of a plaque in an obstructed
artery, which increases the blood supply to the brain.
Ask the patient may be asked to swallow, move tongue, smile, Deficits are signs of cranial nerve impairment. Stretching of the
speak, and shrug shoulders. Assess for facial droop, tongue cranial nerves during surgery can cause temporary deficits.
weakness, speech difficulty, dysphagia, and shoulder weak-
ness.
Ask the patient to report numbness, tingling, or weakness. These signs may indicate occlusion of the carotid artery.
Palpate the temporal and facial pulses. The presence of pulses indicates patency of the external carotid
. artery.
Monitor for neck for edema, hematoma, bleeding, and tracheal Bleeding or excess edema at the surgical site can result in neck
deviation. edema, which can compromise the airway.
Monitor pulse oximetry and provide oxygen to keep the oxygen Surgery in the carotid sinus may cause hypoxia.
saturation between 94% to 99%.
Monitor for systolic BP <90 mm Hg, and administer norepi- Temporary carotid sinus dysfunction may result in hypertension.
nephrine for hypotension that does not respond to 1-2 L of Vasoactive drugs may be given to keep systolic BP >100 mm Hg
normal saline. to maintain cerebral perfusion.
Keep head of bed elevated and keep patient off of the opera- Head of bed should be elevated to facilitate wound drainage.
tive side.
Give heparin IV and aspirin 81-325 mg daily. Anticoagulant and antiplatelet treatment (aspirin, warfarin) is pre-
scribed for 3-6 months after the procedure.
Provide instructions for incision care (wash with soap and wa- Following these instructions will decrease risk of infection.
ter), signs of infection (redness, swollen, and painful; drainage,
fever >38.5° C); activity restrictions (no heavy lifting, no driv-
ing).
Diabetes Insipidus
Diagnosis: Deficient Fluid, Volume Risk for Shock

related to active loss caused by polyuria
Desired Outcome: Patient becomes normovolemic within 7 days, as evidenced by balanced I&O, BP 90-140/60-100 mm Hg, HR
60-100 bpm, CVP 8-12 cm H2O.
Assess for hypovolemia by monitoring I&O and vital signs. Signs of hypovolemia include weight loss, decreased urine
output, hypotension, and tachycardia.
Monitor CVP. CVP may be <2 mm Hg in hypovolemia.
Provide unrestricted fluids: keep a water pitcher within easy reach Oral rehydration will prevent dehydration may caused by ex-
of patient. cessive output of urine.
Provide a low solute diet (low in sodium and protein). Administer A low solute diet and hydrochlorothiazide will aid in elimina-
hydrochlorothiazide 12.5 to 100 mg once daily. tion of sodium and will promote retention of water.
Administer desmopressin. Desmopressin prevents excessive diuresis.
Adverse effects of exogenous desmopressin include HTN, MI,
and uterine cramps.
Administer IV fluids. For every milliliter of urine output, infuse 1 Lost water is replaced with IV 0.45% NaCI to provide rehydra-
milliliter of IV fluid. tion.
Diagnosis: Risk for Electrolyte Imbalance

related to adverse effects of vasopressin
Desired Outcomes: Patient demonstrates normal mental status and is free of adverse effects of vasopressin.
Assess vital signs and report significant changes. Systolic blood pressure elevated >20 mm Hg over baseline is
a sign of vasoconstriction.
Assess for confusion, weight gain and headache. Confusion, headache, and convulsions are signs of water
intoxication due to desmopressin-induced fluid retention.
If signs of hyponatremia develop, stop the desmopressin, restrict Water intoxication due to desmopressin may cause hypo-
fluids, obtain testing for electrolytes, and notify the physician. natremia and hypokalemia.
Diabetes'Mellitus' 124
Endocrine Nursing
Diabetes Mellitus
Diagnosis: Risk for Unstable Blood Glucose

related to inadequate blood glucose monitoring or insulin deficiency or excess.
Desired Outcomes: Patient has a blood glucose reading <180 mg/dL; fasting blood glucose readings <140 mg/dL; and a hemo-
globin A1C level <7%.
Assess blood glucose level before meals and at bedtime. Blood glucose should be between 140-180 mg/dL. Non-intensive
care patients should be maintained at pre-meal levels <140 mg/dL.
Assess for anxiety, tremors, and slurred speech. Treat hypo- These are signs of hypoglycemia. The treatment of hypoglycemia
glycemia with 50% dextrose. is
Assess feet for temperature, pulses, color, and sensation. These assessments monitor peripheral perfusion and neuropathy.
Administer basal and prandial insulin. Adherence to the therapeutic regimen promotes tissue perfusion.
Keeping glucose in the normal range slows progression of micro-
vascular disease.
Teach patient how to perform home glucose monitoring. Blood glucose is monitored before meals and at bedtime. Glucose
values are used to adjust insulin doses.
Report systolic BP >160 mm Hg. Administer antihypertensive. Hypertension is commonly associated with diabetes. Control of BP
prevents coronary artery disease, stroke, retinopathy, and
nephropathy.
Teach patients to avoid heating pads and to always wear Patients have decreased sensation in the extremities secondary to
shoes when walking. peripheral neuropathy.
Monitor urine albumin to serum creatinine ratio for renal fail- Renal failure causes creatinine >1.5 mg/dL. Microalbuminuria is
ure. the first sign of diabetic nephropathy.

related to chronic hyperglycemia, neurogenic bladder, or peripheral vascular disease.
3
Desired Outcome: Patient is free of infection, as evidenced by normothermia, negative cultures, and WBC <11,000/mm .
Assess temperature q4h. Notify physician of fever. Fever is a sign of an infection. Infection is the most common
cause of DKA.
Monitor for signs of infection, such as fever, rhonchi, dyspnea, These are indicators of pneumonia.
and cough.
Assess for dysuria, tachycardia, These are indicators of UTI. Neurogenic bladder predisposes to
diaphoresis, nausea, vomiting, and abdominal pain. UTI.
Assess for erythema, swelling, and purulent drainage at IV These are signs of IV catheter infection.
sites.
Diagnosis: Risk for Impaired Skin integrity

related to decreased circulation and sensation caused by peripheral neuropathy and arterial obstruction
Desired Outcomes: The skin on the patient’s legs and feet remains intact while the patient is hospitalized, and the patient demon-
strates foot care.
Assess integrity of the skin and assess knee and ankle deep These are assessments for neuropathy. Skin on lower extremity
tendon reflexes, proprioception, and two-point discrimination. pressure points is at risk for ulceration.
Use a foot cradle on the bed. Use space boots on ulcerated These measures prevent pressure points.
heels. Use elbow protectors and use a pressure-relief mat-
tress.
Wash feet daily with mild soap and warm water. Check water Decreased sensation increases the risk for burns.
temperature before immersing feet in water.
Inspect feet daily for erythema or trauma. These are signs that the skin needs preventive care.
Change socks or stockings daily. Encourage the patient to These measures prevent infection from moisture. White fabric
wear white cotton socks. enables visualization of blood or exudates.
Use gentle moisturizers on the feet. Moisturizers soften and lubricate dry skin, preventing skin crack-
ing.
Cut toenails straight across after softening toenails with a bath. This action prevents ingrown toenails, which could cause infec-
tion.
The patient should not walk barefoot. Walking barefoot is high risk for trauma, which may result in ul-
ceration and infection.

related to unfamiliarity with insulin injection, dietary modifications, and exercise for normoglycemia
Desired Outcome: Before discharge, patient demonstrates knowledge of insulin injection, symptoms, treatment of hypoglycemia,
and diet.
Explain that long-acting insulin, such as glargine (Lantus) only Long-acting insulin does not have a peak of action. Glargine is
need to be injected once or twice daily. effective over 24 hours.
Explain that regular prandial insulins, such as Humulin, should Dosage may be adjusted based on the actual amount of food in-
be injected 30 min before meals; rapid acting insulins (Novo- gested because rapid acting insulins can be given after a meal.
Log, Humalog) may be injected before or after eating.
Explain that insulin dosages may need to be adjusted. Insulin dosage should be reduced when fasting for surgery, when
not eating, or when hypoglycemia occurs. Illness or infection may
increase insulin requirements.
Teach the patient to rotate injection sites. Multiple injections in the same site may cause fat deposits.
Explain importance of inserting the needle perpendicular to the This ensures deep subcutaneous administration of insulin.
skin.
Verify that the patient understands and demonstrates the tech- Monitoring provides data on the degree of glucose control and
nique and timing of home monitoring of glucose. identifies the need for changes in the insulin dosage.
Teach the patient to follow a diet that is low in simple sugars, A diet low in fat and high in fiber helps to control cholesterol and
low in fat, and high in fiber and whole grains. triglycerides. Three daily meals and an evening snack are rec-
ommended. Refined and simple sugars should be reduced, and
complex carbohydrates, such as cereals, pasta, beans, should be
increased.
Teach patient that anxiety, tremors, and slurred speech are These are indicators of hypoglycemia, which can cause seizures,
signs of hypoglycemia. coma, and death.
Teach patient to treat hypoglycemia with crackers, a snack, or Symptoms of hypoglycemia should be treated with a carbohydrate
a glucagon injection. snack. If the patient is unconscious, glucagon should be given IM
by a caregiver.
Diabetic'Ketoacidosis' 127
Diabetic Ketoacidosis

Risk for Electrolyte Imbalance, Risk for Shock
related to inadequate insulin levels and hyperglycemia
Desired Outcomes: Patient becomes normovolemic within 10 hours, as evidenced by BP >90/60 mm Hg, HR 60-100 bpm, CVP 6-
8 cm H2O, urinary output >30 mL/hr, and normal electrolyte levels.
Assess vital signs for hypovolemic shock q15min until patient is Hyperglycemia causes severe fluid and electrolyte losses, which
stable. can result in hypovolemic shock. HR >120 bpm, BP <90/60 mm
Hg, and CVP <2 cm H2O are signs of hypovolemia.
Assess for poor skin turgor, dry mucous membranes, tachycar- These are physical signs of hypovolemia, which should be re-
dia, and hypotension. ported.
Measure inputs and outputs. Urine output <30 mL/hr should be Decreasing urinary output indicates low intravascular fluid vol-
reported. ume.
Administer intravenous fluids. Normal saline is administered until plasma glucose decreases to
between 200-300 mg/dL. Dextrose-containing solutions are then
given to prevent hypoglycemia. IV fluids are administered rapid-
ly at up to 4 L over the first hour, and then at 150-250 mL/hr
until hypotension resolves.
Assess for fluid overload. Fluid overload (jugular venous distention, dyspnea, crackles,
CVP >12 cm H2O) can occur with infusion of fluids.
Administer an insulin bolus of 0.1 U/kg, followed by an infusion Insulin is given by continuous IV infusion. The insulin dosage is
of 0.1 U/kg/hr (7 U/hr). adjusted based on serial glucose levels and until the serum ani-
on gap is <12 mEq/L.
Flush the tubing with 30 mL of the insulin solution before initiat- Insulin is absorbed by the plastic tubing.
ing the insulin infusion.
Report serum potassium levels <3.5 mEq/L. Hypokalemia must be monitored and corrected. Patients with
DKA usually are potassium depleted. If the phosphorus is low,
potassium phosphate should be added to the IV in place of KCl.

related to a suppressed inflammatory response caused by hyperglycemia.
Desired Outcome: Patient is free of infection, as evidenced by normothermia, HR <100 bpm, BP within the normal range, and
3
WBC count <11,000/mm .
Assess for signs of infection. Monitor for increased WBC Infection is a common cause of DKA. Signs of infection include
count. fever, dysuria, and increased WBC.
Inspect insertion sites for erythema, swelling, or induration. These are signs of local infection that should be reported.
Provide skin care. Intact skin protects against infection.
Diabetic'Ketoacidosis' 128

related to unfamiliarity with the causes, prevention, and treatment of diabetic ketoacidosis.
Desired Outcome: Within the 24-hr of hospital discharge, patient has an understanding of diabetic ketoacidosis.
Explain the signs of diabetic ketoacidosis. Symptoms of hyperglycemia include polyuria, polydipsia, polypha-
gia, flushed skin, and malaise.
Assess patient’s ability to measure glucose and give insulin. Blood glucose >250 mg/dL and high urine ketones should be re-
Teach sick day management, including not stopping insulin, ported to the physician. The insulin dose should be increased if
increasing frequency of glucose testing, and testing urine for glucose is >250 mg/dL.
ketones if ill.
Teach that anxiety, pallor, and tremors are signs of hypogly- These are signs of excessive insulin dosage, resulting in hypogly-
cemia. cemia.
Caution patient that polyuria, polydipsia, and polyphagia are These are signs of inadequate insulin dosage and hyperglycemia,
signs of hyperglycemia, which requires increased insulin. which may lead to coma and death if untreated.
Explain importance of eating three meals per day. Diet should consist of 60% carbohydrates, 20%-30% fats, and
12%-20% proteins. Increase whole grains, fruits, and vegetables.
Decrease intake of simple sugars.
Teach patient to monitor blood glucose during periods of exer- The insulin dose should be adjusted after increased or decreased
cise and to adjust insulin dose. food intake and before any exercise. Exercise may increase usage
of glucose.
Advise the patient that daily foot care is necessary to prevent Persons with diabetes are susceptible to infection because of de-
infection. Teach to avoid exposure to infection, and explain creased immune response.
that infections require prompt treatment.
Instruct patient that, when ill, he should perform blood glucose Hypoglycemia indicates that the insulin dose should be reduced.
checks q4h, and report glucose >250 mg/dL. Maintain ade- Hyperglycemia can develop when the patient becomes ill.
quate hydration.
Hyperglycemic'Hyperosmolar'Syndrome' 129
Hyperglycemic Hyperosmolar Syndrome

related to unfamiliarity with causes, prevention, and treatment of hyperglycemic hyperosmolar syndrome.
Desired Outcome: Within 24-hr before hospital discharge, patient states an understanding of hyperglycemic hyperosmolar syn-
drome.
Explain that the cause of HHS is inadequate insulin and inade- Discuss the early symptoms of HHS, such as polyuria, polydipsia,
quate water intake, and explain that the treatment of HHS is IV polyphagia, and dry skin.
fluids and insulin.
Teach the patient to test his blood glucose levels before meals Blood glucose monitoring is essential for adjusting insulin dosag-
and at bedtime. es.
Explain that a fasting morning blood glucose >250 mg/dL Reporting hyperglycemia allows for an increase in insulin dose.
should be reported.
Discuss the importance of taking metformin (Glucophage) Oral hypoglycemic agents prevent hyperglycemia.
and/or glipizide (Glucotrol) as prescribed.
Teach that increased insulin may be required and that blood Stress causes insulin resistance, which may result in hyperglyce-
glucose levels should be monitored during exercise or illness. mia.
Hyperthyroidism' 130
Hyperthyroidism
Diagnosis: Ineffective Protection

related to potential for thyroid storm.
Desired Outcomes: Patient has no symptoms of thyroid storm, as evidenced by normothermia; blood pressure <90/60 mm Hg;
heart rate <100 bpm.
Assess for hyperthermia and report temperature >38.5° C. Hyperpyrexia is the first sign of a thyroid storm.
Assess vital signs hourly. Vital signs may demonstrate hypertension, tachycardia, or fever.
Provide a cool environment. This measure minimizes heat stress, which can worsen a thyroid
storm.
Treat hyperthermia with acetaminophen. Acetaminophen will reduce fever caused by the thyroid storm.
Provide cool sponge baths and apply ice packs to the axilla These actions will reduce fever caused by a thyroid storm.
and groin. Use a hypothermia blanket
Administer propylthiouracil and methimazole. Thioamides prevent synthesis of thyroid hormone. The most se-
vere side effect of thioamides is leukopenia. Patients should dis-
continue thioamides at the first sign of infection, and a CBC
should be checked.
Administer propranolol. Propranolol blocks the sympathetic effects of thyroid hormone.

Propranolol reduces HR and blood pressure.
Administer intravenous fluids. IV fluids will prevent hypovolemia and hypotension.
Monitor intake and output hourly. Assessment of I&O may reveal fluid overload or inadequate fluid
replacement.

related to hypermetabolic state
Desired Outcomes: Before hospital discharge, patient has adequate nutrition, as evidenced by stable weight.
Weigh patient daily. Assess daily nutritional intake. Daily weight is an indicator of nutritional status.
Manage diarrhea with antidiarrheal medications. Antidiarrheals reduce fluid and electrolyte losses from diarrhea.
Provide foods high in calories, protein, and carbohydrates. This will help restore the normal nutritional state.
Diagnosis: Anxiety
related to sympathetic nervous system stimulation
Desired Outcomes: Within 24 hr of hospital admission, patient is free of anxiety, as evidenced by an HR <100 bpm and RR 12-20
breaths/min, and an absence of anxiety.
Hyperthyroidism' 131

Assess for signs of anxiety. Administer sedatives. Lorazepam reduces anxiety.
Administer propranolol. Propranolol reduces anxiety, tachycardia, and hypertension.
Provide a quiet environment. A quiet environment will help reduce anxiety.
Reassure patient that anxiety symptoms are caused by Grave Reassurance reduces emotional stress.
disease.
Diagnosis: Impaired Tissue integrity: Corneal

related to dryness caused by exophthalmos of Graves' disease
Desired Outcome: Within 24 hr of admission, the patient’s corneas are moist and intact.
Assess for dry eyes and administer lubricating eye drops. Sympathetic nervous system stimulation causes lid retraction. Eye
drops lubricate the eyes.
Apply eye shields before bedtime. Hyperthyroidism can prevent the eyelids from closing fully, result-
ing in conjunctival dryness and ulceration.
Administer thioamides as prescribed. Thioamides maintain the normal metabolic state and reduce ex-
ophthalmos.

related to unfamiliarity with potential for adverse effects from iodides and thioamides.
Desired Outcome: Within 24-hr before hospital discharge, patient states knowledge about adverse effects of thioamide medica-
tions.
Teach the patient to take antithyroid medications daily, in di- An educated patient is more likely to adhere to the treatment reg-
vided doses, at regular intervals. imen.
Teach adverse effects of thioamides and symptoms that re- Appearance of a rash, fever, or pharyngitis can be caused by
quire medical attention. agranulocytosis, which is a side effect of thioamides. If agranulo-
cytosis is present on the CBC, discontinue the antithyroid medica-
tion.
Hypothyroidism' 132
Hypothyroidism
Diagnosis: Ineffective Breathing Pattern (or risk for same)

related to decreased ventilatory drive due to decreased metabolism
Desired Outcomes: Patient has an effective breathing pattern, as evidenced by respiratory rate of 12-20 breaths/min, oxygen sat-
uration >95%.
Assess rate, depth, and quality of breath sounds. This enables detection of hypoventilation and pleural effusion.
Assess for inadequate ventilation. Decreased respiratory rate and shallow breathing are signs of
inadequate ventilation.
Assess for hypoxemia by measuring oxygen saturation. Oxygen saturation <92% requires oxygen supplementation.
Patients with respiratory distress need transfer to the ICU and Patients with hypoventilation will need emergency intensive care.
intubation of mechanical ventilation.
Diagnosis: Risk for Imbalanced Nutrition: More Than Body Requirements

related to slowed metabolism
Desired Outcomes: Patient has stable weight. Before hospital discharge, patient states understanding of dietary regimen.
Weigh patient daily. Increasing weight indicates fluid retention.
Provide a high protein, low calory diet. A high protein, low calory diet will prevent excessive weight
gain.
Foods high in protein and low in calories and sodium will pro-
mote weight control while patient is in a hypometabolic.
Recommend foods that are high in fiber, such as fruits, vegeta- Adding bulk to the diet improves elimination.
bles, whole grain breads, cereals, and nuts.
Diagnoses: Constipation
related to inadequate intake of roughage and fluids, prolonged bedrest, and/or decreased peristalsis caused by hypothyroidism
Desired Outcome: Within 48 hr, patient relates return of his normal pattern of bowel elimination.
Assess for abdominal distention. Distention is a sign of constipation related to hypothyroidism.
Recommend that the patient follow a diet with increased fiber Fruits, fruit juices, cooked fruits, vegetables, and whole grain
and fluids. breads will improve bowel elimination.
Administer stool softeners and a bisacodyl suppository (Dul- These medications reduce constipation by hydrating the stool and
colax). increasing peristalsis.
Encourage patient to increase exercise. Exercise increases regularity by increasing peristalsis.

SIADH' 133
Syndrome of Inappropriate Antidiuretic Hormone
Diagnosis: Fluid Volume Excess

related to hyponatremia
Desired Outcomes: Within 72 hr, patient states orientation to time, place, and person; has stable weight; BP is 90-140/60.85 mm
Hg; HR 60-100 bpm. Sodium 137-143 mEq/L.
Assess for signs of hyponatremia and hypervolemia. Promptly Hyponatremia can cause lethargy, coma, seizures, headache,
report significant findings. confusion, and weakness. Sodium <120 mEq/L can result in sei-
zures/coma. Elevated BP, increased central venous pressure, and
low urine output <30 mL/hr are signs of SIADH.
Monitor for hyponatremia. Report significant findings. Hyponatremia, low plasma osmolality, high urine osmolality, and
elevated urine sodium are associated with SIADH.
Initiate fluid restriction to reduce hypervolemia. Restricting fluids helps restore normal sodium levels.
Elevate the head-of-bed to 20 degrees. Elevated of the HOB increases venous return and reduces ADH
release.
Administer demeclocycline, conivaptan, tolvaptan, and furo- These drugs normalize hyponatremia if water restriction is not
semide (Lasix) as prescribed. effective.
Administer hypertonic saline as prescribed. Severe hyponatremia is treated with hypertonic saline. The serum
Na+ should not be raised by more than 10 mEq/L/24 hr because
of the risk of pontine demyelination.
Initiate seizure precautions, including padded side rails and Seizures can occur in hyponatremia with SIADH. Precautions in-
side rails up. clude padded side rails and side rails up.
Appendicitis' 134
Gastroenterology Nursing
Appendicitis

related to inadequate ruptured appendix, peritonitis, abscess formation) caused by bacterial infection
Desired Outcomes: Patient is free of infection, as evidenced by temperature <38.6C, HR <100 bpm, and a soft abdomen.
Assess quality, location, and duration of pain. Monitor for fever, Severe pain indicates worsening appendicitis. The side-lying posi-
tachycardia, and hypotension. Assess abdomen for rigidity, tion or supine position with flexed knees suggests appendicitis.
and distention. Pain that worsens and then disappears is a sign of rupture of the
appendix.
Assess for pain with hip flexion. A retrocecal abscess may irritate the psoas muscle and cause
pain with hip flexion.
Administer postoperative antibiotics. Antibiotics prevent systemic infection from appendicitis.

related to inflammatory process in the appendix
Desired Outcomes: Within 2 hr of interventions, the patient’s perception of pain decreases, as documented by a pain scale. Gri-
macing is absent.
Assess and document quality, location, and duration of pain on Early stage appendicitis: Abdominal pain may be diffuse with nau-
a scale from 0 to 10. sea, vomiting, and fever.
Acute stage: Pain that shifts from epigastrium to RLQ at McBur-
ney’s point (5 cm from anterior superior iliac spine on a line drawn
from umbilicus).
Administer antiemetics and analgesics; assess the patient’s Opioids may be given after appendicitis has been diagnosed. An-
response, using a pain scale. tiemetics reduce vomiting.
Keep patient NPO before surgery. NPO status prevents aspiration during anesthesia.
Insert a gastric tube. A gastric tube decompresses intestines in patients with severe
nausea and vomiting.
Position patient for optimal comfort. The side-lying position with knees bent is the most comfortable
position.
Cholelithiasis,'Cholecystitis,'and'Cholangitis'' 135
Cholecystitis, Cholelithiasis, and Cholangitis
Diagnoses: Acute Pain, Nausea

related to obstructive or inflammatory process in the gallbladder
Desired Outcomes: Patient's subjective perception of pain decreases within one hr of intervention, as documented by pain scale.
Monitor patient for pain with a pain scale of 0 to 10 (worst This evaluation enables objective measurement of pain relief.
pain).
Explain that a low Fowler's position will decrease pain This position decreases tension on abdominal wall.
Teach patient about diet. Nothing by mouth status with IV fluids is maintained before sur-
gery. A NG tube is inserted and attached to low, intermittent suc-
tion. After cholecystectomy, a low-fat diet is initiated.
Administer analgesics as prescribed. Epidural, continuous IV, and patient-controlled IV opioids are used
postoperatively. IV ketorolac controls postoperative pain.
Administer acid suppression. Acid suppression with ranitidine or rabeprazole reduces gastric
hyperacidity.
Administer antiemetics. Antiemetics, such as ondansetron, prochlorperazine, and pro-
methazine reduce vomiting.
Diagnosis: Risk for injury

related to potential for postsurgical perforation or biliary obstruction
Desired Outcomes: Patient is free of symptoms of postsurgical perforation, as evidenced by decreasing brown drainage <1000
mL/day and a soft abdomen.
Monitor color of the skin, sclera, urine, and stool. Biliary obstruction causes jaundice, dark urine, and clay-colored
stools.
Note color and volume of T-tube or wound drainage q2h for Initially, drainage will be dark brown with blood and volume of 500
24-h. mL/day.
Ensure that drainage collection device is lower than common Dependent positioning of collection container will prevent reflux of
bile duct. drainage.
Assess for abdominal distention, rigidity, and tenderness. These are indicators of a dislodged or clogged drainage tube
causing bile leakage into the abdomen.
Cirrhosis' 136
Cirrhosis

related to anorexia and nausea
Desired Outcome: Within 4 weeks, patient demonstrates adequate nutritional status, as evidenced by stable weight.
Assess and record intake and output; weigh patient daily. These measures assess nutritional intake and
effects of diuretic therapy on ascites.
Explain dietary restrictions. Sodium and fluids are restricted for edema or ascites. Protein
intake is restricted.
Recommend abstinence from alcohol. Abstinence is the primary intervention for alcoholic
cirrhosis.

related to portal hypertension and decreased clotting factors
Desired Outcomes: Patient is free of bleeding, as evidenced by blood pressure >90/60 mm Hg; heart rate <100 bpm; orientation
to person, place, and time, and absence of hematemesis.
Assess vital signs for hypotension. Upper GI hemorrhage is common with chronic liver disease be-
cause of esophageal varices, portal hypertensive gastropathy,
duodenal or gastric ulcers, or Mallory-Weiss tears.
Assess the patient for bleeding. Melena, hematemesis, hypotension, tachycardia, irritability, and
pallor are signs of bleeding.
Examine stools for blood; perform stool blood test. This is an assessment for bleeding within the GI tract.
Monitor INR. INR: Normal range is <2.0. A prolonged INR indicates risk for
bleeding.
Administer stool softeners. Stool softeners prevent constipation and straining during defeca-
tion.
Avoid injections and rectal temperatures. If the clotting is prolonged, invasive procedures could cause
bleeding.
Monitor patient undergoing band ligation of varices for tachy- Tachycardia indicates esophageal perforation caused by rupture
cardia. of the esophageal varix.
If signs of variceal bleeding occur, notify physician, keep pa- NPO status is necessary because the patient may require endos-
tient NPO, and begin gastric suction. Administer antibiotics to copy. Gastric suction is necessary to determine if bleeding is con-
prevent peritonitis. tinuing. Antibiotics prevent peritonitis in cirrhotic patients who
have ascites.
Cirrhosis' 137

related to compromised regulatory mechanism and sequestration of fluids caused by portal hypertension
Desired Outcome: By hospital discharge, patient is normovolemic, as evidenced by decreased abdominal girth, RR 12-20
breaths/min, and edema <1.
Measure abdominal girth daily. Abdominal girth measurements quantity the amount of ascitic fluid
in the abdomen.
Monitor and record daily weight and I&O. Output should be equal to intake. Weight loss should not exceed
0.25 kg/day. Rapid diuresis can result in hyponatremia and renal
failure.
Assess degree of edema from 1 to 4 (deep pitting). Edema indicates excess body water.
Monitor serum sodium and potassium and report sodium <135 Normal serum sodium is 135-147 mEq/L and normal potassium is
mEq/L or a potassium <3.5 mEq/L. 3.5-5 mEq/L. Sodium retention causes water retention and hypo-
natremia.
Assess for dyspnea, basilar crackles, orthopnea, and tachyp- Pulmonary edema is caused by excessive fluid volume.
nea.
Advise patient to avoid high-sodium foods. Sodium restriction reduces ascites and edema.
Elevate the patient’s legs. Leg elevation will decrease edema.
Monitor for variceal hemorrhage. Variceal hemorrhage can cause severe GI bleeding in cirrhosis.
Crohn'Disease' 138
Crohn Disease

related to fluid and electrolyte loss caused by diarrhea
Desired Outcomes: Patient is normovolemic within 24 hr of admission, as evidenced by urine output >30 mL/hr, BP >100/60 mm
Hg, RR 12-20 breaths/min, less diarrhea and normal potassium, sodium, and chloride.
Assess I&O, weigh patient daily, and monitor electrolytes. These assessments monitor fluid and electrolytes. Diarrhea can
result in hyponatremia, hypokalemia, and hypochloremia.
Assess for poor skin turgor and dry mucous membranes. These are signs of dehydration.
Administer IV normal saline to replace volume deficits, and Patients require iron, folate, and magnesium. Patients with mega-
correct electrolyte deficits. loblastic anemia require IM vitamin B12.
Provide low residue diet. Diet should be low in residue and fat but high in protein, calories,
and carbohydrates. A lactose-free diet may reduce cramping.
Administer mesalamine (Asacol) Extended-release mesalamine (Pentasa) and delayed-released
mesalamine (Asacol) are used for maintenance treatment of ile-
ocolonic and ileal Crohn disease.
Patients on prolonged 5-ASA must have annual creatinine test- 5-aminosalicylic acid preparations may cause kidney damage with
ing. high doses.
Budesonide 9 mg once daily in the morning. Budesonide reduces inflammation and controls exacerbations.
The oral route is most effective for disease of the small intestine.
Administer methylprednisolone 1 mg/kg per dose every 12 Corticosteroids reduce intestinal inflammation.
hours, up to a maximum of 30 mg every 12 hours or predni-
sone is 40 to 60 mg/day.
Diagnosis: Risk for injury, Risk for infection

related to potential complications due to an intestinal inflammatory disorder
Desired Outcomes: Patient is free from infection, as evidenced by normothermia; RR 12-20 breaths/min, and lack of abdominal
pain.
Assess for nausea and vomiting or abdominal distention. These are indicators of intestinal obstruction caused by opioids
and antidiarrheals.
Assess for fever and abdominal pain. Fever and pain are signs of intestinal perforation, abscess and
peritonitis.
Assess orientation and level of consciousness q4h. Confusion, lethargy, and restlessness are signs of peritonitis.
Obtain cultures of blood and urine if fever occurs. Monitor cul- Abscesses or fistulas to the abdominal wall, bladder, or vagina
ture reports. may cause bacteremia or bacteriuria.
Administer antibiotics. Antibiotics control bacterial infection and perianal fistulas.
Administer immunomodulators and biologic agents. Immunomodulators and modulators improve healing.

Crohn'Disease' 139
related to intestinal inflammatory process

Desired Outcomes: Patient's discomfort decreases within 1 hr of intervention, as documented by pain scale and absence of gri-
macing.
Assess and document characteristics of discomfort on a scale Pain, nausea, and abdominal cramping may be associated with
from 0 to 10 (worst pain). Avoid foods associated with cramp- legumes, dairy products, or cauliflower.
ing
Keep patient NPO and provide parenteral nutrition. These measures allow bowel rest.
Administer loperamide. Loperamide reduces diarrhea.
Diagnoses: Diarrhea
related to intestinal inflammation
Desired Outcome: Frequency of stools is decreased and stool consistency becomes normal within 3 days of hospital admission.
If the patient has frequent passage of loose stools, provide Easy access to a commode or bathroom will help the patient cope
covered commode. with diarrhea.
Administer loperamide (Imodium). Antidiarrheals decrease fluidity and number of stools, inhibit peri-
staltic activity, and increase stool consistency. Loperamide reduc-
es diarrhea.
Decrease fat in the diet Fat increases diarrhea in individuals with malabsorption.
Restrict raw vegetables, fruits, whole-grain cereals, legumes, These foods will exacerbate diarrhea and cramping.
carbonated beverages, milk, and milk products.

related to unfamiliarity with drugs used for Crohn disease
Desired Outcome: Following teaching, patient states accurate information about drugs used for CD.
Assess for fever, skin rash, joint pain. Adverse effects are caused by allergy to the sulfa component of
sulfasalazine.
5-Aminosalicylic acid (5-ASA) Preparations Extended-release mesalamine (Pentasa) and delayed-released
mesalamine (Asacol) are used for maintenance treatment of ile-
ocolonic and ileal Crohn disease.
Patients on prolonged 5-SAS must have annual creatinine test- 5-aminosalicylic acid preparations may cause kidney damage with
ing. high doses.
Administer budesonide 9 mg PO qd Budesonide reduces inflammation and controls exacerbations.
Controlled ileal release (CIR) budesonide is a glucocorticoid with
a high hepatic metabolism rate, used for right-sided colitis. Sys-
temic side effects minimal.
Use hydrocortisone enemas for proctosigmoidal Crohn dis- Topical hydrocortisone enemas control inflammation in proc-
ease. tosigmoiditis; suppositories are effective for Crohn's proctitis.
Crohn'Disease' 140
If taking azathioprine or 6-mercaptopurine, check CBC every Immunomodulators suppress the immune system and allow re-
other week for 6 mo. Monitor every month for 3 months, then duction in the steroid dosage and lowering the relapse rate. Leu-
once every 3 mo. kopenia, anemia, thrombocytopenia, and abnormal liver function
can occur.
When taking azathioprine or 6-mercaptopurine: assess for fe- These are possible adverse effects.
ver, rash, pancreatitis (abdominal pain).
Administer biologic agents: Biologic agents block inflammation or stimulate antiinflammatory
- Adalimumab mediators. Biologics are used IV (infliximab and natalizumab) or
- Certolizumab pegol SQ (adalimumab, certolizumab pegol).
- Infliximab
- natalizumab
The patient should report sore throat and fever. Risk of infection is increased with biologic agents.
Tuberculosis skin testing should be performed before inflixi- Treatment of latent tuberculosis infection is necessary before
mab. starting infliximab.
The patient should avoid live-virus vaccines. Live-virus vaccines should not be administered because biologics
cause immunosuppression.
Fecal'Diversions' 141
Colostomy, Ileostomy, and Ileal Pouch Anal Anastomoses
Diagnosis: Risk for Impaired Skin integrity: Peristomal

related to exposure to effluent or sensitivity to appliance material
Desired Outcomes: Patient's peristomal skin remains normal color and intact. Patient's stoma remains red, moist, and intact.
Assess colostomy or ileostomy stoma for viability q8h. The stoma should be red, moist, and shiny. A pale, dark purple, or
dull stoma is a sign of ischemia.
Apply a pectin or gelatin, methylcellulose-based skin barrier This barrier will protect peristomal skin from irritation.
around the stoma.
Cut an opening in the skin barrier to the circumference of the The skin barrier may be a one-piece pouch system.
stoma. Remove release paper, and apply the skin barrier to the
peristomal skin.
Remove the skin barrier and inspect skin q3-4 days. These signs indicate infection or sensitivity to the appliance.
Tell the patient to report burning or itching under skin barrier. Burning, itching, and odor are signs that stool or effluent has con-
tacted the skin.
Empty pouch when one-third to one-half full of stool. Large amounts of stool will cause loss of the seal.
Assess continent ileostomy (Kock pouch) site for redness or These are signs of infection or hypersensitivity to materials.
erosions.
Assess catheter q2h for patency and irrigate with 30 mL of These measures prevent catheter obstruction.
sterile saline.
Notify physician if solution cannot be instilled, if there is Instilling 30 mL of saline will flush the catheter and liquefy the
no return from the catheter, or if leakage occurs. effluent.
Attach the catheter to low, continuous suction or gravity drain- The catheter traverses through the stoma into the continent ileos-
age. tomy pouch.
Change 4 x 4 dressing around stoma q2h or when wet. This will help prevent peristomal skin irritation.
Assess the stoma for viability with each dressing change. The stoma should be red, moist, and shiny. A pale, dark purple
stoma indicates ischemia.
After the first stage of the ileal pouch anal anastomosis, per- Ileostomy should be red, moist, and shiny. An ostomy pouch
form care for the temporary diverting ileostomy. should be applied.
Maintain perineal/perianal skin integrity by cleansing with water After the first stage of the operation, patient may have inconti-
and cotton balls. Avoid soap. nence of mucus. Soap may cause irritation.
Use an absorbent anal pad at night. A pad will absorb oozing mucus from the anus.
Assess perineal/perianal skin for erythema and excoriation. Enzymes in the effluent can result in skin breakdown.
Clean the perianal area with warm water or cleansing solution. This will ensure skin integrity. Sitz baths will enhance comfort and
Apply protective skin sealants or ointments. cleanse the perianal area. Sealants maintain skin integrity.
Diagnosis: Fecal incontinence

related to disruption of normal bowel function with fecal diversion
Desired Outcomes: 2 days after surgery, patient eliminates gas and stool via the fecal diversion. After teaching, patient demon-
strates measures that will maintain normal elimination.
After colostomy and ileostomy, assess intake and output. Normal is serosanguineous to serous liquid drainage. Colostomy
Empty stool from pouch opening and assess quality and vol- output of clear brown, liquid stool begins within 4 days. Ileostomy
ume of stool. output of liquid, bilious effluent begins after 48 hours.
If colostomy is not eliminating stool after 3-4 days and bowel Palpation may reveal a stricture and stool. Irrigate the colostomy
sounds have returned, insert a gloved, lubricated finger into the to stimulate elimination.
stoma.
After a continent ileostomy (Kock pouch), monitor I&O, and Kock pouches drain serosanguineous fluid during the postopera-
record volume and color of output, which should be serosan- tive period. Drainage should change from blood-tinged to greenish
guineous for 3 days, then greenish brown. brown liquid. When ileal output begins, suction is discontinued
and the catheter is connected to a drain.
Teach catheter irrigation q2h, and demonstrate how to empty Irrigation maintains the patency of the catheter. Ileal output thick-
the pouch through the catheter into the toilet. ens when the diet progresses to solids.
Irrigation liquefies effluent for flow through the catheter. Frequent
irrigation prevents overdistention of the Kock pouch.
After an Ileal pouch anal anastomosis, assess for fever, These are signs of infection or leak.
perianal pain, or purulent or bloody discharge.
Irrigate the ileal pouch drains. Irrigation maintains patency, decrease stress on suture lines, and
prevents infection.
After the first stage of the operation, advise patient to wear a After the first stage, the patient may have anal mucus.
perianal pad.
Assist with perianal care, and apply protective ointment. Perianal care maintains the integrity of decrease row height skin.
Administer loperamide (Imodium). Antidiarrheals decrease stool frequency and fluidity.
Arrange for a diet consultation and advise the patient to avoid Avoid foods that cause liquid stools, such as spinach, prune and
spinach, prune and grape juices. Increase cheese, bananas, grape juices, alcohol. Increase foods that thicken stools, such as
and peanut butter. cheese, bananas, applesauce, creamy peanut butter, and pasta.
Diagnosis: Disturbed Body Image

related to presence of fecal diversion
Desired Outcome: One week after surgery, patient demonstrates acceptance of the fecal diversion, as evidenced by viewing the
stoma and participating in care.
Assess patient for fears about the fecal diversion. The patient may fear rejection and isolation, and he may have
feelings of uncleanliness and loss of self-control.
Help the patient to express fears and clarify misconceptions. Body image fears and anxieties may be reduced by talking.
Recommend that patient participate in care. Patient participation will enhance the patient’s acceptance of the
fecal diversion.
Assure patient that social and work activities will not be affect- Resumption of previous lifestyle gives the patient a sense of self-
ed. esteem.

related to unfamiliarity with colostomy irrigation procedure
Desired Outcome: Within 3 days after teaching, patient demonstrates proficiency with colostomy irrigation.
Teach patient the colostomy irrigation procedure, and have Colostomy irrigation is used for descending or sigmoid colosto-
patient return the irritation demonstration. mies. Colostomy irrigation is performed daily, allowing the patient
to avoid wearing a pouch.
Position the irrigating sleeve over the colostomy. Secure The irrigation sleeve directs the stool and solution into the toilet.
sleeve in place with the adhesive disk.
Fill the irrigation container with 500 ml of warm water. With The volume of water should be adjusted to cause colon distention
patient sitting on the toilet, position sleeve to empty into the without cramping.
toilet. Hang the irrigation container at shoulder level.
Open slide or roller clamp and flush tubing, then reclamp. Flushing removes air from the tubing.
Gently dilate stoma with a gloved finger with water-soluble Dilation enables patient to identify direction of intestinal lumen.
lubricant.
Lubricate the cone attached to the catheter, and insert the The catheter should be inserted 3 inches.
catheter into the stoma.
Allow the water to slowly enter stoma through the tubing. Slow the infusion of water to prevent cramping.
After water has entered the colon, hold the cone in place for a This ensures that the water is completely infused.
few seconds and then remove the cone.
Leave sleeve in place for 30-40 min. This enables water and stool to drain into the toilet.
Hepatitis' 144
Acute Hepatitis

related to unfamiliarity with causes of hepatitis and modes of transmission.
Desired Outcome: 24-hr period before hospital discharge, patient states knowledge about the causes and prevention of hepatitis.
Teach patient and Significant other to wear gloves and use These measures help prevent transmission of HBV infection.
hand hygiene before contact with body fluids.
Remind patients with HBV and HCV that they should modify Contact with blood is a mode of transmission. Blood contact can
sexual behavior. Advise patients not to donate blood. occur with sexual activity.
Advise patients with HBV that sexual partners should receive Sexual contact is a mode of transmission.
the HBV vaccine.

related to pruritus caused by hepatic dysfunction
Desired Outcome: Patient's skin remains intact while the patient is hospitalized.
Keep the patient’s skin hydrated with emollient baths. Apply Hot water and harsh soaps cause skin dryness and irritation.
emollient lotions. Emollients keep the patient’s skin moist.
Recommend the patient not to scratch skin and to keep nails These measures help prevent skin breakdown.
trimmed.
Administer antihistamines. Antihistamines are used for relief of pruritus.

related to decreased synthesis of clotting factors.
Desired Outcome: Patient is free of bleeding, as evidenced by absence of ecchymoses and bleeding gums.
Monitor hematocrit and hemoglobin daily. These assessments detect bleeding.
Minimize intramuscular injections. Use small-gauge needles. Bleeding may result from injection with large-bore needles.
Apply pressure after an injection. These measures minimize bleeding at injection sites.
Observe for ecchymotic areas. Inspect gums. These assessments detect early bleeding.
Encourage patient to use an electric razor and soft-bristle These measures reduce risk of bleeding from abrasions.
toothbrush.
Pancreatitis' 145
Pancreatitis

related to the inflammatory process of the pancreas
Desired Outcomes: Within 6 hr of intervention, pain decreases, and pain is controlled within 24 hr, as documented by pain scale.
Assess for degree of pain with a pain scale of 0 to 10 (worst Use of a pain scale measures the effectiveness of pain relief.
pain).
Maintain nothing by mouth status. NPO status decreases stimulation of pancreatic secretions by
food. After acute pain and ileus have resolved, clear liquids are
started, and the diet is advanced.
Administer morphine, H2 blockers, antiemetics, and antibiotics. Morphine reduces pain associated with pancreatitis. H2-receptor
blockers reduce gastric acid. Hydroxyzine, ondansetron, pro-
chlorperazine, and promethazine reduce vomiting.
Encourage patient to request analgesic before pain becomes Pain is more easily managed when treated before the pain be-
severe. comes severe.
Assist patient in finding a position of comfort. The sitting or supine position with knees flexed relieve abdominal
pain.

related to potential for tissue destruction caused by release of pancreatic enzymes.
Desired Outcome: Patient remains free of infection, as evidenced by temperature <37.7° C, negative culture results.
Assess temperature q4h. Fever indicates infection of the pancreatic phlegmon.
If fever occurs, obtain cultures of blood, sputum, and urine. Cultures enable detection of infection.
Assess BP, HR, and RR q4h. Tachycardia of 100-140 bpm and tachypnea are associated with
infection of the pancreatic phlegmon. Hypotension may be caused
by pancreatic hemorrhage.
Assess mental status, orientation, and LOC q4h. Decreased mental status may be caused by alcohol withdrawal,
hypotension, hypoxia, and sepsis.
Administer parenteral antibiotics. Bacteriocidal serum levels of antibiotics result in eradication of
infection.
Diagnosis: Risk for Imbalanced Fluid Volume and Risk for Electrolyte Imbalance
related to active losses caused by NG suctioning.
Desired Outcomes: Patient is normovolemic within 8 hr, as evidenced by HR 60-100 bpm, central venous pressure 5-12 cm H2O,
urinary output >30 mL/hr.
Assess vital signs q2-4h. This evaluation enables detection of hypotension and tachycardia,
caused by fluid loss.
Pancreatitis' 146
Assess intake and output and monitor CVP q2-4h. CVP <2 mm Hg can occur with hypovolemia. Output greater than
intake indicates fluid loss.
Administer IV normal saline. Volume infusion maintains adequate circulating blood volume.
Monitor closely for adventitious breath sounds, and decreased These are signs of fluid overload and pulmonary edema.
hematocrit.
Assess for Chvostek’s sign (facial muscle spasm) and Trous- These are signs of hypocalcemia caused by blood transfusions.
seau's sign (carpopedal spasm).
Monitor hematocrit, hemoglobin, WBC, calcium, glucose, BUN, Infection, inflammation, and bleeding may cause abnormal values.
creatinine, and potassium.

related to anorexia and dietary restrictions.
Desired Outcome: Patient attains baseline body weight by 24 hr before hospital discharge.
Monitor blood glucose for hyperglycemia. Give insulin if blood Monitoring of blood glucose may reveal hyperglycemia because of
glucose levels are increased. pancreatic insufficiency.
Assess for steatorrhea. Steatorrhea is an indicator of fat malabsorption.
Administer enteral or parenteral nutrition. Enteral feedings should be infused past the ligament of Treitz to
avoid stimulation of the pancreas. Parenteral nutrition is started if
enteral feedings cause diarrhea.
Advance diet as prescribed. Small, high-carbohydrate, low-fat meals at six meals per day may
be tolerated.
Administer pancreatic enzyme supplements and medium-chain Enzyme supplements digest fat. Medium-chain triglycerides do
triglycerides. not require
pancreatic enzymes for absorption.
Provide small meals throughout the day. Smaller, more frequent meals reduce bloating and nausea.
Peptic'Ulcer'Disease' 147
Peptic Ulcer Disease
Diagnosis: Ineffective Protection Risk for Bleeding

related to potential for obstruction and perforation caused by the duodenal or gastric ulcer
Desired Outcome: Patient is free of bleeding, obstruction, perforation, as evidenced by absence of blood in the nasogastric aspi-
rate, and a nondistended abdomen.
Monitor for a systolic blood pressure <90 mm Hg, pulse pressure Hypotension, a narrow pulse pressure, tachycardia, and cool
<35 mm Hg, heart rate >100/min, and cool extremities. skin are signs of hypovolemia and shock. The pulse pressure
is the systolic minus the diastolic pressure.
Assess for hematemesis and melena. Check stools for occult Bleeding can be caused by the ulcerative process.
blood.
Monitor the CBC A hematocrit less than 40% and a hemoglobin less than 14
g/dL indicates bleeding. However, the hematocrit and hemo-
globin may be normal for several hours after the onset of
acute bleeding.
Insert a gastric tube. A gastric tube will monitor bleeding.
Do not use gastric tubes in patients who have esophageal varices. Trauma from the tube could cause hemorrhage from the
esophageal varices.
If the patient is actively bleeding or if Hct is low, administer oxygen. Low Hct or Hb indicates anemia, which reduces oxygen
transport by the blood.
Administer pantoprazole, esomeprazole, or omeprazole (where A proton-pump inhibitor will decrease gastric acid production
available) at a dose of 40 mg IV twice daily. and promote healing of the ulcer.
Assess for abdominal pain, "rushes," or "tinkles", distention, vomit- These are signs of obstruction.
ing, constipation, or obstipation.
Monitor for severe abdominal pain, distention, fever, nausea, and These are indicators of perforation and peritonitis.
vomiting.
Diagnosis: Impaired Tissue integrity

related to exposure to gastric acid and pepsin
Desired Outcomes: Healing of duodenal mucosal tissues occurs, as evidenced by absence of pain and bleeding.
Recommend that the patient avoid NSAIDs, alcohol, and aspi- NSAIDs, aspirin, and alcohol are associated with increased acidity
rin. and peptic ulcer disease of the duodenum or stomach.
Obtaining stool testing, blood testing, or breath testing for Heli-
cobacter pylori infection.
Administer H. pylori treatment. Triple therapy with omeprazole (Prilosec), amoxicillin, clarithromy-
cin (Biaxin) is effective for eradication of H. pylori.
Suppression treatment with omeprazole, esomeprazole, lanso- PPIs are given for acute episodes of ulceration.
prazole, pantoprazole, or rabeprazole. PPIs deactivate the hydrogen ion pump in the parietal cells, and
inhibit gastric acid secretion.
Histamine H2-receptor blockers (eg, cimetidine, ranitidine, niza- H2-blockers suppress secretion of gastric acid and enhance ulcer
tidine, famotidine) healing.
Peritonitis' 148
Peritonitis
Diagnosis: Risk for infection Risk for Shock

related to potential for peritonitis or development of inflammatory process
Desired Outcome: Patient is free of peritonitis, as evidenced by normothermia, BP >90/65 mm Hg, heart rate <100 bpm.
Palpate abdomen for rigidity or tenderness. Increased rigidity and tenderness indicate worsening of peritonitis.
Assess for septic shock, characterized by temperature >38.6° In early shock, the skin is warm, pink, and dry. In the late shock,
C, systolic BP <90 mm Hg, pulse pressure <30 mm Hg, HR > extremities become pale and cold.
120/min.
Administer antibiotics, such as cefotaxime, as prescribed. Begin antibiotics against gram-negative bacilli and anaerobics.
Cefotaxime, cefepime, gentamicin, ampicillin, ofloxacin, and met-
ronidazole are used.
Measure peak and trough antibiotic levels. Peak and trough levels are drawn before and after the third dose
of antibiotic.
3
Monitor complete blood count for leukocytosis, which indicates WBC >11,000/mm is a sign of infection.
infection.

related to inflammatory process, fever, and tissue damage
Desired Outcomes: Patient's subjective perception of pain decreases within 1 hr of intervention, as evidenced by a pain scale and
absence of grimacing.
Assess and document character and severity of discomfort on This evaluation will quantify the pain and demonstrate relief of
a scale of 0 to 10 (worst pain) q2h. pain.
Administer morphine for pain. Morphine relieves severe pain.
Recommend that the patient request the analgesic before the Pain management is more effective when given before the pain
pain becomes severe. becomes severe.
Keep patient in semi-Fowlers position with knees bent. This position shifts fluid to the lower abdomen, which will reduce
pressure on the diaphragm. Bending the knees relaxes the ab-
dominal wall muscles.
Administer antiemetics, such as hydroxyzine, ondansetron, Antiemetics reduce nausea and vomiting.
prochlorperazine or promethazine.

related to alveolar hypoventilation
Ineffective Breathing Pattern
related to decreased depth of respirations caused by guarding
Desired Outcomes: Patient has optimal gas exchange, as evidenced by PaO2 >80 mm Hg; oxygen saturation >92%; HR <100
bpm.
Monitor VS, ABG, and oximetry. Indications for supplemental oxygen include PaO2 <80 mm Hg
and oxygen saturation <92%.
Peritonitis' 149
Auscultate lungs for adventitious breath sounds. This evaluation monitors ventilation and detects pleural effusions
or pneumonia.
Keep patient in semi-Fowlers and encourage deep breathing This position reduces respiratory effort and enhances deep
and coughing. breathing.
Administer oxygen as prescribed. Oxygen reduces hypoxia.

related to vomiting and intestinal suctioning
Desired Outcome: By discharge, patient demonstrates adequate nutritional status, as evidenced by stable weight.
Keep patient NPO during the acute phase of peritonitis. Start oral fluids after flatus has been passed and the gastric tube
has been removed.
Restart oral fluids gradually after bowel sounds return, disten- Gradual reintroduction of oral fluids increases the patient is toler-
tion decreases, and flatus has been passed. ance for fluids.
Administer total parenteral nutrition (TPN) if GI tract is not func- TPN usually is started after the patient has been NPO for 5 days.
tional after 5 days.
Administer IV fluids and electrolytes. Hydration and electrolytes restore losses from the gas-
tric/intestinal tube and fluid shifts. Serum electrolytes should be
measured daily.
Ulcerative'Colitis' 150
Ulcerative Colitis
Diagnosis: Deficient Fluid Volume, Risk for Bleeding, Risk for Electrolyte Imbalance
related to fluid and electrolyte losses caused by diarrhea
Desired Outcomes: Patient is normovolemic within 24 hr of admission, as evidenced by urine output >30 mL/hr, moist mucous
membranes, and BP >90/60 mm Hg.
Assess for pulse pressure <35 mm Hg, heart rate >100/min, Hypotension, tachycardia, narrow pulse pressure, and cold skin
and cold skin. are signs of hemorrhagic shock.
Assess for thirst, dry mucous membranes, fever, and de- These are indicators of dehydration.
creased urinary output.
Assess electrolytes and CBC. The normal serum potassium is 3.5 mEq/L. The normal hemato-
crit is 40-54%. The normal hemoglobin is 14-18 g/dL.
Assess frequency and consistency of stools. Assess for blood Ulcerative colitis can cause watery stools with blood and mucus.
in the stools.
Provide IV replacement of fluids with 500 mL IV boluses of These measures maintain fluid and electrolyte balance.
normal saline. Correct hypokalemia of <3.0 mEq/dL with 40
mEq of KCL in 1 L of normal saline.
Transfuse packed red blood cells to maintain the hemoglobin Transfusion will correct anemia caused by colonic hemorrhage.
>10 gm/dL.
Provide a high-protein, high-calorie, low-residue diet when the For less severely ill patients, a low-residue elemental diet will re-
patient is taking food by mouth. duce diarrhea.
Assess tolerance to diet. Cramping, diarrhea, and flatulence are signs of dietary intoler-
ance.
Diagnosis: Risk for Injury Risk for infection

related to potential for perforation caused by inflamed colonic mucosa
Desired Outcome: Patient is free of signs of perforation, as evidenced by normothermia; HR 60-100 bpm; absence of abdominal
distention or tenderness.
Assess for fever, chills, tachypnea, tachycardia, and abdominal These signs can occur with perforation of the colon.
pain.
Report abdominal distention and severe pain. These are signs of a toxic megacolon. Surgery is indicated for
toxic megacolon.
If the patient has fever, culture blood and urine. Fever indicates septicemia. Culture will identify causative organ-
ism.
Administer antibiotics as prescribed. Control infection in acute ulcerative colitis and toxic megacolon.
Diagnosis: Acute Pain related to the intestinal inflammatory process

Desired Outcomes: Within 1 hr of intervention, the patient’s pain decreases by pain scale, and grimacing is absent.
Assess discomfort on a scale of 0 to 10 (worst pain). These assessments quantify the degree of pain reduction by in-
terventions.
Maintain patient NPO. Initiate TPN to provide bowel rest. These measures provide bowel rest and reduce diarrhea and ab-
dominal pain.
Administer loperamide (Imodium) Imodium is an anticholinergic, which r diarrhea. Anticholinergics
should not be used in severe ulcerative colitis.
Diagnoses: Diarrhea, Risk for Electrolyte Imbalance related to inflammatory process of the colon
Desired Outcome: Patient's stools become normal in consistency, and frequency is decreased within 3 days.
Assess amount, frequency, and character of stools. Bloody diarrhea is the most common symptom of ulcerative colitis.
Assess electrolytes. Notify physician if potassium is <3.5 Hypokalemia may result from diarrhea.
mEq/L.
Administer loperamide (Imodium) for diarrhea. Imodium is an anticholinergic, which decreases diarrhea output
and inhibit GI peristasis. Anticholinergics should not be adminis-
tered in severe ulcerative colitis.
Administer prednisone 40-60 mg per day, mesalamine (Asac- These agents reduce mucosal inflammation.
ol), ciprofloxacin, and metoclopramide (Flagyl).
Diagnosis: Risk for Impaired Perineal/Perianal Skin integrity

related to persistent diarrhea
Desired Outcome: Patient's perineal and perianal skin remains intact with no erythema.
Assist patient with cleansing and drying perineal area after These measures keep the skin clean and intact.
bowel movements.
Apply protective skin preparations, gels, or barrier films. Protective preparations prevent irritation caused by liquid stools
and maintain perianal skin integrity.
Administer hydrophilic colloids and anticholinergics. These agents decrease stool output and inhibit GI peristasis. An-
ticholinergics should be administered with caution.
Diagnosis: Deficient knowledge

related to unfamiliarity with purpose and side effects of medications used to treat UC
Desired Outcome: Following teaching, patient states accurate information about drugs used for UC.
Teach the patient about corticosteroids Corticosteroids reduce mucosal inflammation by suppressing the
immune system.
Teach patient that the corticosteroid dosage and routes of ad- Disease limited to the sigmoid colon and rectum is treated with
ministration vary with the extent of disease. steroid enemas. Pan-colonic disease is treated with oral
budesonide.
5-Aminosalicytic acid (5-ASA) preparations are effective in 5-ASA preparations are used if patient is unable to tolerate sul-
treating mild to moderate UC. fasalazine. Mesalamine is available in delayed-release tablets
(Asacol) and extended-release capsules (Pentasa). Aminosalicy-
lates decrease intestinal inflammation.
Give topical mesalamine for proctitis or proctosigmoiditis. Mesalamine suppositories (Canasa) are used for proctitis. Mesal-
amine retention enema (Rowasa) is used for proctosigmoiditis.
Administer immunomodulators to Immunomodulators reduce inflammation in patients who do not
decrease inflammation. respond to steroids and sulfasalazine; or as an alternative to ster-
oid dependency.
Administer infliximab (Remicade) for severe ulcerative colitis. This biologic agent blocks inflammation. Remicade is used IV for
severe ulcerative colitis.
Amputation 201
Orthopedic Nursing
Amputation
Diagnoses: Acute Pain Chronic Pain related to phantom limb sensation

Desired Outcome: Within 24 hr of intervention, the patient’s subjective perception of pain decreases, as evidenced by pain rating
scale.
Assess the patient’s pain using a pain rating scale of 0 to 10 = The rating scale enables the nurse to effectively assess changes
worst pain. in the degree of pain.
Administer naproxen 250-500 mg bid and opioid analgesics, NSAIDS and opioids are effective for phantom limb sensation.
such as Percocet or Vicodin, and administer gabapentin (Neu- Anticonvulsants, such as gabapentin and topiramate, and amitrip-
rontin). tyline may be effective for neuropathic pain.
Explain that continued pain sensations may come from the Teaching prepares the patient for phantom limb sensations.
amputated part after surgery.
Teach the patient to use capsaicin cream (0.075%) qid prn to Counterirritation may reduce painful sensations by providing a
reduce pain. new stimulus.
Administer prednisone 60 mg PO qd. An oral glucocorticoid may provide symptomatic relief of complex
regional pain syndrome (CRPS).
Use transcutaneous electrical nerve stimulation on the contra- TENS may provide short-term relief from phantom limb sensation.
lateral limb.
Instruct patient to massage the residual limb daily. Massage will desensitize the area in preparation for the prosthe-
sis.
Encourage the use of sympathetic blocking agents, acupunc- These modalities may decrease phantom limb sensation.
ture, ultrasound, and injection with anesthetics.
Refer patient to a pain clinic. Pain clinics provide comprehensive programs.

related to severe pain and immobility caused by lower extremity amputation.
Desired Outcomes: Within 24 hr of instruction, patient states understanding of the exercise regimen and performs exercises.
Patient is free of contractures, as evidenced by full joint range of motion.
Assess ROM of the affected extremity and the patient’s ability Assessment allows for creation of an exercise program.
to perform exercises.
Establish a goal for pain management. Effective pain management enhances early ambulation, which
prevents contractures.
Elevate the affected extremity for the first 24 hr after amputa- Elevation decreases swelling, reduces pain, and promotes mobili-
tion. ty.
On the second postoperative day, ensure that patient keeps The flat position decreases risk for hip flexion contracture.
the residual lower limb flat when at rest.
Amputation' 154
Diagnoses: Disturbed Body Image

related to loss of limb
Desired Outcome: Within 72 hr of surgery, patient begins to show adaptation to limb loss.
Assess the patient’s acceptance of the amputation. The patient's response to the residual limb will allow formulation of
a care plan.
Assist patient with adapting to the loss of the limb. Books, pamphlets, audiovisuals, and videotapes can be used.
Encourage the patient to look at and touch the residual limb, The patient may have a negative image of disability and he may
and verbalize his feelings about the amputation. feel unattractive after the amputation.
Teach the patient new methods of task performance. Assistive devices may be needed for continued functioning.
Encourage the use of a prosthesis. After a period of grieving, the patient will accept the need for a
prosthesis.

related to unfamiliarity with care of the residual limb and prosthesis and signs of skin irritation.
Desired Outcomes: Within 24 hr of discharge, patient states knowledge about the care of the residual limb and returns a demon-
stration of wrapping the residual limb.
Elevate the residual limb for the first 24 hours after the ampu- Elevation reduces edema and pain in the residual limb.
tation.
After 24 hours, keep the residual lower limb flat when at rest in The flat position reduces the risk of hip flexion contracture.
bed.
Apply an elastic wrap or elastic sock to the residual limb. A shrinkage device molds the residual limb for prosthesis fitting.
Teach patient to monitor residual limb for skin abrasions and Abrasions and blisters indicate skin irritations or pressure necro-
bullae. sis.
Explain that if erythema persists, the patient should notify the Persistent erythema is a sign of a pressure ulcer.
physician.
Teach the patient to clean the skin of the residual limb with Soap and water have antibacterial effects. Patient should not ap-
soap and water daily. ply lotions, or oils to the residual limb.
Instruct the patient to massage the residual limb 3 weeks after Massage will break up scar tissue and prepare skin for contact
surgery. with the prosthesis.
Ensure that the patient receives prosthesis care instructions The patient should become complement at self-care.
by a prosthetist-orthotist.
Fractures' 155
Fractures

related to injury or surgical repair
Desired Outcomes: Within 1 hr of intervention, the patient’s pain decreases as indicated by a lower pain rating.
Assess the patient’s pain using a pain rating scale of 0 to 10. The patient’s baseline pain assessment, enables the nurse to
assess changes in pain.
If patient-controlled analgesia is used, assess effectiveness of the Excessive respiratory depression may require reversal with
pain management. naloxone.
If a patient-controlled analgesia pump is used, verify that the PCA Verification of pump settings ensures safe delivery of the an-
contains the correct medication and concentration. algesia.
Time the analgesic effect with exercise or ambulation. Timing should achieve optimal pain control before exercise or
ambulation.
Administer NSAIDs, and assess the effectiveness of the manage- NSAIDs reduce pain and reduce the need for opioids.
ment.
Teach patient to use the patient-controlled analgesia device. Understanding the use of the PCA will help patient obtain
effective pain management.
Diagnosis: Risk for Peripheral Neurovascular Dysfunction

related to interruption of capillary blood flow caused by increased myofascial compartment pressure (compartment syndrome).
Desired Outcomes: Patient has peripheral neurovascular function in the involved extremity, as evidenced by normal muscle tone,
Doppler pressures <15 mm Hg, minimal skin tautness, and decreasing pain.
Assess the patient’s pain at regular intervals. Notify the physi- Pain out of proportion to the physical findings is the first sign of
cian of increased pain. compartment syndrome.
Assess tissue pressures in all compartments. Notify physician If pressures exceed 10 mm Hg, perfusion will be impaired by
to pressures >10 mm Hg. compartment syndrome.
Assess temperature, movement, and sensation q1h. Paresthesia, pallor, and polar are signs of compartment syn-
drome. Paralysis is a late sign of compartment syndrome.
Elevate the fractured extremity unless acute compartment syn- A fractured limb is typically elevated for the first 24 hr to decrease
drome is suspected. edema. Elevation will compromise vascular supply if compartment
syndrome has developed.
If neurovascular status is impaired, bivalve the cast and wrap a When compartment syndrome develops, the constricting cast or
dressing around the split cast. splint must be loosened to reduce vascular compromise.
Teach patient and spouse other the symptoms of neurovascu- Awareness of compartment syndrome will enable the patient to
lar compromise that should be reported. report symptoms promptly.
Fractures' 156

related to musculoskeletal pain and unfamiliarity with a cast.
Desired Outcomes: 24 hours before hospital discharge, the patient uses mobility aids.
Teach patient to perform active and passive ROM exercises ROM exercises preserve joint mobility and prevent contractures.
q8h.
Instruct the patient in care of the casted extremity. Teach signs The patient should demonstrate cast care, describe neurovascular
of complications, such as skin maceration and impaired neuro- assessment, describe pressure necrosis, and perform exercises.
vascular function.
Instruct patient in use of crutches or walker. Crutches or walkers encourage mobilization and prevent venous
thromboembolism.
Diagnoses: Risk for Impaired Skin integrity and Impaired Tissue integrity
related to irritation and pressure caused by a cast.
Desired Outcomes: Within 2 hr of application of the cast, patient states knowledge of signs of pressure necrosis, and has no dis-
comfort under the cast.
Ensure adequate padding between bony prominences and the Padding decreases pressure over bony prominences and pre-
cast. vents skin breakdown.
Instruct patient not to insert any object between the cast and Inserting a stick or other object under the cast can result in skin
the skin. infection.
Teach the patient the signs of pressure necrosis, such as pain An informed patient is more likely to report these findings.
or drainage.
related to decreased mobility and opioid analgesics
Desired Outcomes: After application of the immobilization device, patient states an understanding of bowel elimination methods,
and the patient maintains normal bowel elimination.
Encourage a high fiber diet to normalize bowel elimination. Bran, whole grains, nuts, raw vegetables, and fruits add bulk to
stool, which will enhance bowel elimination.
Encourage ample fluid intake. Fluid intake softens the stool and improves elimination.
Administer a stool softener, such as docusate (Colace) A stool softener will enhance bowel elimination. A laxative or ene-
ma may be needed for refractory constipation.
Encourage mobility Mobility increases intestinal peristalsis and bowel elimination.
Joint'Replacement'Surgery' 157
Joint Replacement Surgery
Diagnosis: Risk for Peripheral Neurovascular Dysfunction

related to interrupted arterial blood flow caused by compression from abduction wedge.
Desired Outcomes: Patient maintains adequate peripheral neurovascular function distal to operative site, as evidenced by
warmth, normal color, foot movement and sensations.
Assess neurovascular function of the operative leg q2h. Com- Pressure from the abductor wedge can impair arterial blood flow
pare to nonoperative leg. and compress the peroneal and tibial nerves.
Apply cold packs to the operative site. Edema increases intra-compartmental pressure in the lower leg,
reducing arterial flow and compressing the nerves. Cold packs
decrease swelling.
Warn patient of the risk of neurovascular impairment. Advise These findings indicate impaired circulation and nerve function.
patient to report pain, decreased sensation, decreased Nerve damage can result in footdrop and paresthesias.
strength, decreased movement, coldness, and paleness.
Instruct patient to perform ankle pumps at regular intervals. Exercise stimulates circulation to the distal extremity.
Diagnosis: Ineffective Peripheral Tissue Perfusion (or risk for same)

related to development of venous thromboembolism
Desired Outcome: Patient exhibits adequate tissue, as evidenced by normal skin temperature and absence of calf pain or swell-
ing.
Assess for swelling, warmth, pain, or tenderness. Monitoring for signs of venous thrombosis ensures prompt treat-
ment.
Teach the patient to perform ankle pumps q6h. Muscle contraction decreases the risk of venous thrombosis.
Encourage the patient to participate in physical therapy. Early mobilization decreases the risk of venous thrombosis.
Advise the patient to wear intermittent pneumatic compression This device compresses the leg muscles, decreasing the risk of
devices. venous thrombosis.
Teach patient about anticoagulant therapy. Anticoagulant treatment prevents venous thromboembolism.
Administer anticoagulants and review INR and PTT. A low molecular-weight heparin (enoxaparin) or heparin derivative
(fondaparinux) is administered SQ. Inform the patient about risk of
bleeding.

related to joint replacement surgery
Desired Outcome: Within 24 hr of surgery, patient is free of symptoms of bleeding, as evidenced by normal heart rate, and blood
pressure; and output from wound drain <10 ml/hr.
Assess drainage from the wound q4h. Report output from Bleeding from the wound may occur during the patient’s recovery.
drainage system >50 mL/hr.
Assess vital signs and neurovascular function. Warmth beneath dressing, pain, or paleness is a sign of hemor-
rhage.
Reassess vital signs for hypotension and tachycardia q4h. These are signs of hemorrhage or hematoma formation.
Reassess for pallor, pulselessness, or coolness of distal ex-
tremity q4h.
If hemorrhage or hematoma formation is suspected, notify the Interventions may include limb elevation or elastic wrap.
physician promptly.
If hypotension and tachycardia develop, the dressing should This allows direct inspection of the wound. Apply pressure to con-
be removed and the wound should be assessed. trol hemorrhage.

related to postoperative musculoskeletal pain and immobilization device
Desired Outcomes: By hospital discharge, patient demonstrates use of ambulatory aids, and the patient understands the use of
analgesics.
Teach patient to use walker or crutches. Safe use of walker or crutches prevents injury.
Teach exercises that improve muscle strength and joint flexibil- Improved muscle strength and joint flexibility facilitates early mobi-
ity. lization and use of ambulatory aids.
Instruct patient and in use of analgesics. Pain management enables the patient to become mobile and de-
crease the risk of venous thromboembolism.
Total Hip Arthroplasty

related to unfamiliarity with activity precautions
Desired Outcome: 24 hr before hospital discharge, patient states knowledge of the risk of dislocation of the repaired hip and activi-
ty precautions.
Advise the patient of the potential for postoperative hip dislocation. Risk of dislocation remains high until the periarticular tissues
heal. Dislocation is treated with closed reduction.
Demonstrate the use of ambulatory aids and assistive devices. Preoperative introduction to ambulatory aids and assistive
devices will enable the patient to become familiar with devic-
es.
After surgery, teach position restrictions, such as not pivoting on After total hip arthroplasty, the patient should use an abduc-
the operative leg, siting on a toilet seat of regular height, bending tion wedge to prevent internal rotation and should avoid flex-
over to tie shoelaces, or crossing legs. ion past 90°.
Advise the patient to get out of bed on the affected side. Getting out of bed on the affected side decreases the risk of
hip dislocation after arthroplasty.
Advise the patient of the need for assistive devices for use at home Dressing, bathing, and toileting require use of long-handled
after discharge. reachers sock donners and elevated toilet seats.
Nursing diagnosis for patients following TKA

related to unfamiliarity with continuous passive motion machine and other exercises.
Desired Outcome: After instruction, patient states understanding of CPM machine and returns a demonstration of exercises.
Provide instructions for muscle-strengthening and joint range-of- Exercises and CPM will facilitate return of normal joint func-
motion exercises. tion.
Teach use of continuous passive motion machine for the pre- The CPM machine supplements PT in rehabilitation.
scribed amount of time each day.
Osteoarthritis' 160
Osteoarthritis
Diagnoses: Chronic Pain Acute Pain

related to degenerative joint changes
Desired Outcomes: Within 2 hr of intervention, the patient’s pain decreases as documented by pain intensity scale. Patient is able
to perform activities of daily living.
Assess the patient’s discomfort with a pain scale of 0 to 10. The baseline evaluation of pain severity allows the nurse to
measure improvement in the patient’s pain.
Administer acetaminophen, naproxen 250-500 mg tid. Observe Acetaminophen is the initial treatment for pain caused by osteoar-
for adverse effects of naproxyn, such as GI bleeding. thritis. If acetaminophen is ineffective, NSAIDs are recommended
for patients with normal renal function.
Recommend that the patient time the peak effectiveness of the Timing of analgesics enables the patient to achieve optimal pain
analgesic with periods of exercise. relief during exercise.
Apply topical analgesics, such as capsaicin cream. Topical analgesics improve pain management for OA. Capsaicin
cream reduces pain.
Encourage the use of assistive devices, dressing aids, and Sock donners and long-handled reachers and brushes minimize
grooming aids. joint stress. Clothing can be fitted with zipper pulls and Velcro
closures.

related to musculoskeletal impairment
Desired Outcomes: Within 1 wk of instruction, patient demonstrates upper body strength for use an assistive device. Patient
demonstrates use of assistive device.
Ensure that patient has sufficient upper extremity strength to Upper extremities must have sufficient strength to support the pa-
use the assistive device. tient’s body before crutches or walker can be used.
Teach armchair push-ups to increase triceps muscle strength. Armchair push-ups strengthen the triceps muscles, which are im-
portant for ambulation with crutches or walker.
Ensure that height of walker or crutches allows for 15 degrees The assistive device must be the correct size for the patient.
of elbow flexion.
Ensure crutch tops rest 1-1.5 inches below the patient’s axil- This position avoids upper extremity nerve injury due to pressure
lae. of the crutches on the brachial plexus.
Demonstrate use of assistive device and have the patient re- Return demonstration, and ensure that the patient will be able to
turn the demonstration. use the device on different surfaces.
Osteoporosis' 161
Osteoporosis

related to unfamiliarity with prevention and treatment of osteoporosis.
Desired Outcome: Within 48 hr of instruction, patient states knowledge of osteoporosis, treatments, and adequate calcium intake.
Assess the patient’s understanding of osteoporosis. Most individuals with osteoporosis are not diagnosed until an
acute fracture occurs.
Teach patient about nutrition and calcium intake. Adequate calcium intake helps to prevent osteoporosis in women
with a small frame, increased age, Caucasians, and Asians.
Teach the patient that calcium carbonate is the most effective Calcium carbonate (e.g., OsCal) is best absorbed in an acidic
form of calcium. stomach. Adults 19-50 yr of age should take 1000 mg of ele-
mental calcium daily and individuals 51 yr and older should take
1200 mg daily.
Instruct patient that vitamin D supplementation is indicated for Supplements are needed by institutionalized, living in extreme
patients with limited sun exposure. northern or southern latitudes, and limited sun exposure. Recom-
mended vitamin D is 200 IU through age 50 yr, 400 IU for 51-70
yr, and 600 IU for >70 yr.
Teach patient about medications for osteoporosis, adverse An informed patient is likely to adhere to the medication regimen
effects, administration, and need for follow-up tests. and report adverse effects.
Administer alendronate (Fosamax), risedronate (Actonel), Bisphosphonates inhibit the activity of osteoclasts. Medronate and
ibandronate (Boniva), or zoledronate (Reclast) risedronate may be taken once daily or weekly. Ibandronate re-
quires only monthly administration. Zoledronate is given IV once
yearly. Oral bisphosphonates must be taken on first rising, without
eating or drinking for 30 min.
Or administer raloxifene (Evista) Evista is a selective estrogen receptor modulator. Raloxifene has
positive effects on bone mineral density and can be taken at any
time of day.
Teach patient about weight-bearing exercise. Weight-bearing exercise contributes to increased bone density
and prevents bone loss.

related to inadequate calcium and vitamin D
Desired Outcomes: After instruction, patient demonstrates adequate intake of calcium and vitamin D.
Teach recommended daily intake for calcium. Premenopausal women (19-50 yr of age) need 1000 mg of
calcium daily. After menopause, the requirement is 1200 mg
daily.
Teach importance of adequate exposure to sunlight to prevent The patient should be outside 15 minutes daily.
vitamin D deficiency.
If the patient has limited exposure to sunlight, such as resident of Supplementation will ensure adequate vitamin D intake.
a long-term care facility, encourage vitamin D supplementation.
Rheumatoid'Arthritis' 162
Rheumatoid Arthritis

related to unfamiliarity with rheumatoid arthritis therapy.
Desired Outcome: Following teaching, patient states accurate information about RA drugs.
Teach about disease-Modifying Antirheumatic Drugs DMARDs control synovitis and prevent joint erosions and dam-
(DMARDs) age. Early use of DMARDs slows the erosive course of RA.
NSAIDs are often prescribed along with DMARDs.
Administer methotrexate The dose of methotrexate is of 7.5-25 mg weekly by mouth.
Teach the patient about other DMARDs Sulfasalazine, hydroxychloroquine, cyclosporin, cyclophospha-
mide, and leflunomide.
Teach the patient that laboratory monitoring of renal and liver Patient should be instructed to complete follow-up tests because
function is required with DMARDs. of renal and hepatic toxicity.
Teach the patient about Biologic Response Modifiers BRMs modulate cytokines in moderate to severe RA, which has
not responded to DMARDs. Adalimumab, etanercept, infliximab,
and golimumab block TNF-alpha.
Teach that most BRMs are given subcutaneously by self- Self-administration by RA patients may be difficult because of
injection. muscle weakness and joint deformity.
Teach the patient to minimize exposure to ill individuals and DMARDs and BRMs result in immunosuppression.
report illness.
Teach that NSAIDs may cause GI bleeding and ulcers, and the The patient should report bleeding or gastric ulceration.
patient should report black stools or abdominal pain.
Teach about corticosteroids Injection of corticosteroids into joints can temporarily relieve pain
and inflammation.
Diagnosis: Dressing/Bathing/Toileting Self-Care Deficit

related to pain and decreased joint ROM.
Desired Outcome: Within 1 wk of instruction, patient exhibits independence in dressing and grooming.
Assess effect of pain and decreased joint ROM on dressing Evaluation of the severity of impairment enables creation of a care
and bathing. plan.
Assess pain and ROM in joints. Independence in dressing and grooming is lost as small joints
become inflamed and deformed.
Refer patient to an occupational therapist. The occupational therapist is able to provide dressing/bathing/
toileting aids.
Teach patient to coordinate time of peak effectiveness of anal- Timing of analgesics enables the patient to achieve pain man-
gesics with activities. agement during activities.
HIV' 163
Human Immunodeficiency Virus Infection

related to altered oxygen supply caused by pulmonary infiltrates
Desired Outcomes: After intervention, patient has adequate gas exchange, as evidenced by RR 12-20 breaths/min. By hospital
discharge, patient’s oximetry demonstrates an oxygen saturation >94%.
Assess the rate and quality of respirations, cough, and sputum Accessory muscle use, rhonchi, cough, and cyanosis are signs of
production. respiratory dysfunction.
Continuously monitor oxygen saturation. Report findings of Oxygen saturation <94% indicates the need for supplementary
<94%. oxygen and should be reported.
Assess ABG results. Report abnormal findings. Decreased PaCO2 <35 mm kg and increased pH >7.40 indicates
compensatory hyperventilation.
Cough and dyspnea are signs of an opportunistic respiratory in-
Instruct patient to report increased cough or dyspnea.
fection.
Assess for increased sputum. Obtain sputum for culture and Increased sputum may indicate an infection. Culture will deter-
sensitivity. mine the bacterial cause of the pneumonia.
When administering Trimethoprim + Sulfamethoxazole for These are adverse effects of TMP-SMX.
PCP, monitor for rash, fever, or neutropenia.
If administering pentamidine for PJP, assess for hypotension, These adverse effects require BP checks, glucose testing, and
hypoglycemia, hyperglycemia, or increased creatinine. creatinine measurement.
If administering corticosteroids, assess for thrush. Adverse effects of corticosteroids include increased susceptibility
to infection. Corticosteroids are given for PCP when PaO2 is <70
mm Hg.

related to inadequate immune system function.
Desired Outcome: Patient is free of opportunistic infections, as evidenced by absence of fever and negative blood cultures.
Assess for fever, persistent cough, diarrhea, and headache. These are signs of opportunistic infections.
Monitor CBC, differential, and cultures. Abnormal values indicate the presence of infection.
Assess temperature and vital signs at q6h. These assessments detect fever and sepsis. Fever, confusion,
decreased level of consciousness, tachycardia, and hypotension
are signs of infection.
Assess for rhonchi or crackles. Adventitious breath sounds may indicate the presence an oppor-
tunistic disease. PCP occurs in severe immunocompromise
(CD4+ counts <200).
When providing care to patients with active tuberculosis or Respiratory protection prevents the spread of tuberculosis.
unknown TB status, wear respiratory protection.

related to diarrhea and nausea associated with malabsorption, anorexia, and dysphagia.
HIV' 164
Desired Outcomes: By hospital discharge, patient has adequate nutrition, as evidenced by stable weight, and patient states that
nausea is controlled.
Assess weight and caloric intake daily Weight loss can cause increased susceptibility to infection.
Provide small, frequent, high-calorie, high-protein meals. Pro- Smaller, more frequent meals may be more easily tolerated.
vide supplements between feedings.
Provide antiemetics if the patient is nauseated. Antiemetics reduce nausea and vomiting.
If the patient has dysphagia, advise intake of fluids that are Fluids may be better tolerated than solids because fluids cause
high in calories and protein. less esophageal irritation.

related to unfamiliarity with disease process and treatment plan
Desired Outcome: Before discharge, patient states accurate information about HIV disease, behaviors that increase risk of trans-
mitting the virus, and the treatment plan.
Assess the patient’s knowledge about HARRT and viral re- This enables the nurse to formulate teaching plans.
sistance.
Advise patient to inform sexual partners of HIV status and re- These measures reduce the risk of transmitting the HIV virus.
duce high-risk behaviors.
Anemia'of'Chronic'Disease' 165
Hematology Nursing
Anemia of Chronic Disease
Diagnosis: Activity Intolerance

related to anemia and decreased oxygen-carrying capacity of the blood due to decreased RBCs
Desired Outcome: Hgb and Hct levels are normal and the patient perceives exertion at <3 on a 0-10 scale and tolerates activity,
as evidenced by RR 12-20 breaths/min, HR <100 bpm, and absence of dizziness.
Assess for signs of activity intolerance. Ask the patient to rate Dyspnea an exertion, dizziness, palpitations, headaches, and fa-
his perceived exertion. tigue are signs of decreased tissue oxygenation.
Assess patient for risk of falling and implement fall prevention Anemia may cause weaknesses and loss of balance.
measures.
Monitor oximetry and report O2 saturation <92%. O2 saturation <92% indicates a need for supplementary oxygen.
Administer oxygen and encourage deep breathing. Oxygen enhances the delivery of oxygen to the tissues.
Gradually increase activities as exercise tolerance improves. Exercise promotes endurance and prevents deconditioning caused
by prolonged bedrest.
Transfuse packed RBCs through an intravenous catheter. Transfusions increase the blood oxygen-carrying capacity of the
blood.
Double-check type and crossmatching and patient identifiers Verification of blood type reduces the risk of the transfusion reac-
with another RN. Monitor for signs of a transfusion reaction. tions.
Teach the patient that tolerance to activity is increased with Therapy includes erythropoietin replacement (recombinant EPO
erythropenia. [epoetin-alta]), 150 units/kg IV 3 times each week, or 600 units/kg
subcutaneously once each week, or darbepoetin alfa 200 mcg eve-
ry 2 weeks. Iron, cobalamin, and folate, may be given to replenish
Hb.
Disseminated'Intravascular'Coagulation' 166
Disseminated Intravascular Coagulation

Risk for Ineffective Cerebral Tissue Perfusion
Risk for Ineffective Renal Tissue Perfusion
Risk for Decreased Cardiac Tissue Perfusion
related to coagulation and fibrinolysis
Desired Outcome: Following treatment, patient has adequate tissue perfusion, as evidenced by BP >90/60 mm Hg, HR <100
bpm, and urinary output >30 mL/hr.
Monitor BP and HR. Hypotension, tachycardia, and decreased amplitude of peripheral
pulses indicate that a thrombus has formed, which can lead to digi-
tal ischemia.
Monitor orientation, mental status, pupillary reaction to light, Deficits indicate that cerebral perfusion is impaired. Increased con-
level of consciousness (LOC), and motor response. fusion, agitation, or seizures, a unilaterally dilated pupil are signs of
cerebral ischemia.
Monitor intake and output. Urine output <30 mL/hr may indicate renal vessel thrombosis.
Monitor for hemorrhage from wounds GI and genitourinary Hemorrhage is a risk after fibrinolysis.
tracts, and mucous membranes.
Monitor oxygen saturation by pulse oximetry every 4 hours or Oxygen perfusion may be compromised by pulmonary emboli
as indicated; report oxygen saturation <92%. and/or pulmonary hemorrhage. Oxygen saturation <92% often
signals the need for supplemental oxygen.
Monitor laboratory values for signs of DIC. Increased D-dimer serum fibrinogen <200 mg/dL, platelet count
3
<250,000/mm , increased FSPs >9 mcg/ mL, possible increased
INR >2, and PTT >40-100 sec are common with DIC.
Prepare for emergent blood product transfusion and transfer to Careful monitoring and aggressive therapy is indicated for DIC.
the ICU.
Administer antithrombin agents. Antithrombin III and drotrecogin alfa have anticoagulant and anti-
inflammatory effects.

related to disseminated intravascular coagulation with hemorrhage
Desired Outcome: Patient is free of bleeding as evidenced by SBP >90 mm Hg; HR <100 bpm; urinary output >30 mL/hr; secre-
tions and excretions negative for blood.
Monitor vital signs and level of consciousness at frequent inter- Hypotension, tachycardia, dyspnea, disorientation, and decreased
vals. mental status are signs of hemorrhage.
Assess for abdominal pain and distention. Pain and distension are signs of gastric bleeding.
Assess IV puncture sites every 8 hours. Assessment of IV sites will detect bleeding due to DIC.
Apply thrombin-soaked gauze (Gelfoam), or topical thrombin pow-
Treat bleeding sites with pressure, elevation, and Gelfoam.
der.
Assess for visual changes, headache, and joint pain. Visual changes, joint pain, and headache are signs of bleeding.
Monitor coagulation studies and complete blood count. INR >2 is a sign of clotting factor depletion and risk for hemor-
rhage.
Disseminated'Intravascular'Coagulation' 167
Avoid IM injections and venipunctures. Avoiding IM injections and vein punctures minimize the risk for
bleeding.
Place a "Bleeding Precautions" sign on the patient’s bed. This will notify phlebotomists that venipuncture sites require more
prolonged manual pressure to stop bleeding.
Administer packed RBCs, platelets, fresh frozen plasma, and IV These products restore blood volume. Cryoprecipitate or FFP may
fluids. be used to restore low fibrinogen levels. Platelets may be given if
3
the platelet count is <10,000/mm or if bleeding develops.
Recommend an electric shaver, soft-bristle toothbrush, avoid- These precautions reduce the risk of bleeding.
ance of forceful nose blowing, and enemas.
Prepare for blood product transfusion and transfer to ICU. Patients with DIC require aggressive therapy and monitoring.
Polycythemia' 168
Polycythemia

related to headache, angina, pruritus, abdominal and joint discomfort due to altered circulation caused by blood hyperviscosity.
Desired Outcome: The patient's subjective perception of pain decreases within one hr, as documented by pain scale.
Assess for headache, angina, abdominal pain, and joint pain. A baseline pain assessment helps monitor subsequent increases
Use a pain scale from 0 to 10 (worst pain). or decreases in pain.
Assess for calf pain and tenderness. Calf pain and tenderness are indicators of peripheral thrombosis,
which should be reported.
Use range-of-motion exercises as tolerated. Elevation prevents pooling of blood in the joints. ROM improves
circulation.
Administer analgesics. Analgesics reduce pain from joints and muscles.
Avoid aspirin or nonsteroidal antiinflammatory drugs. Aspirin and NSAIDs may exacerbate bleeding associated with
thrombocytosis.
Instruct patient to request analgesic before pain becomes se- Pain is easier to control before it becomes severe. Prolonged
vere. stimulation of pain receptors results in increased sensitivity to pain.

Risk for Ineffective Cerebral Tissue Perfusion
Risk for Ineffective Renal Perfusion
related to hyperviscosity of the blood
Desired Outcome: Patient has adequate renal, peripheral and cerebral perfusion, as evidenced by urinary output >30 mL/hr; dis-
tal extremity warmth; and orientation to person, place, and time.
Monitor intake and output. Urine output <30 mL/hr is a sign of decreased renal perfusion.
Assess for muscle weakness, decreased sensation, and de- Weakness, decreased sensation, and decreased LOC are indica-
creased level of consciousness. tors of thrombosis.
In the absence of cardiac and renal failure, provide prescribed Dehydration increases blood viscosity and contributes to polycy-
IV hydration and encourage fluid intake to decrease viscosity themia.
Perform phlebotomy.
Phlebotomy reduces the hematocrit to 45 g/dL.
Administer antiplatelet and myelosuppressive agents. Low-dose aspirin or anagrelide and chemotherapy agents inhibit
overproduction of blood cells and prevent thrombosis.
Thrombocytopenia' 169
Thrombocytopenia

related to low platelet count
Desired Outcome: Patient does not have signs of bleeding, as evidenced by absence of blood seepage, BP >90/60 mm Hg, HR
<100 bpm, RR 12-20 breaths/min, and absence of bruising or active bleeding.
Assess for hematuria, melena, epistaxis, hematemesis, hemop- These are signs of bleeding due to thrombocytopenia.
tysis, menometrorrhagia, gingival bleeding, and ecchymoses.
3
Monitor platelet count daily, and monitor INR and PTT weekly. The normal platelet count is 150,000-400,000/mm . Platelets
3
<20,000/mm is a risk for bleeding.
Type and screen for red blood cells. RBC transfusions may be necessary to maintain intravascular vol-
ume in the event of bleeding.
After venipuncture, apply pressure on site for 5-10 min. Avoid Patient is at risk for prolonged bleeding because of thrombocyto-
intramuscular injections. penia.
Give docusate (Colace) to prevent constipation. Prevention of constipation reduces straining at stool and decreas-
es the risk for bleeding.
Administer IV methylprednisolone Corticosteroids reduce platelet destruction.
Recommend that the patient use an electric razor and a soft- These practices decrease the risk of injury and bleeding.
bristle toothbrush.
Tell the patient to avoid aspirin and NSAIDs because of the risk Alcohol, aspirin, and NSAIDs may cause gastrointestinal bleeding.
of bleeding.
Administer platelet-stimulating agents. Intravenous immunoglobulin increases the platelet count, reducing
antibody production by the patient. Romiplostim stimulates throm-
bopoiesis in ITP.
Recombinant interleukin II stimulates megakaryocyte differentiation
and platelet production.
IV anti-D immune globulin increases platelet count.
Transfuse platelets. Platelet transfusion is used if deficient platelet formation is the pri-
mary cause of the thrombocytopenia. ITP will cause destruction of
platelets in minutes. Platelet transfusions are only used for life
threatening bleeding in ITP.
Pneumothorax'and'Hemothorax' 170
Trauma Nursing
Pneumothorax and Hemothorax

related to decreased lung expansion occurring with pneumothorax/hemothorax.
Desired Outcome: Following intervention, patient becomes eupneic and lung expansion is noted on chest x-ray.
Assess the patient's respiratory, and cardiac status q1-2h. This assessment monitors the patient’s status while the chest
drainage system is in place. The chest drainage system drains
air or fluid from the pleural space and reexpands the lung.
Tape all chest drainage connections and secure the chest tube These actions facilitate drainage of the pleural space.
to patient’s thorax with tape.
Avoid tubing kinks, and ensure that the bed is not compressing These actions ensure drainage of the chest drainage system.
any component of the drainage system.
Maintain the tube with an underwater seal. The amount of suction is determined by the water level in the
suction control chamber.
Monitor bubbling in the underwater-seal chamber. Intermittent bubbling in this chamber indicates that air is leaving
the pleural space. Absence of bubbling indicates that suction is
not being maintained.
Seal any leak in the system if bubbling is present. Bubbling in the underwater-seal chamber is a sign that air is
leaking into the drainage system.
Set the level of dry suction to 20 cm. Suction aids in lung reexpansion, but removing suction for short
periods for transporting will not be detrimental.
Monitor the fluctuations in the underwater-seal chamber. Fluctuations indicate that the chest tube is patent. Fluctuations
stop
when either the lung has reexpanded or there is an obstruction
in the tube.
If fluid is present in the tube, squeeze hand-over-hand along the Chest tube milking moves fluid along the tube.
drainage tube.
If the chest tube becomes dislodged, place a petrolatum im- This gauze pad is applied over the insertion site if the chest tube
pregnated gauze pad over the insertion site. becomes dislodged.
If the chest tubing is disconnected, submerge the tube in a bottle Submerge the chest tube in a bottle of sterile water if it becomes
of sterile water. disconnected
from the drainage system.
Do not clamp a chest tube unless ordered to do so by the physi- Clamping may cause a tension pneumothorax because air in the
cian. pleural space will accumulate.
Pneumothorax'and'Hemothorax' 171

related to ventilation-perfusion mismatch
Desired Outcomes: Following intervention, patient displays adequate gas exchange, as evidenced by RR <20 breaths/min; and no
mental status changes. 24 hr before hospital discharge, patient's oxygen saturation is >92%.
Monitor oximetry. Report significant findings to physician. These assessments detect decreasing oxygen saturation and
increasing PaCO2,which are signs of respiratory failure.
Assess for indicators of hypoxia. Report significant findings. Restlessness, anxiety, tachycardia, and decreased mental sta-
tus are indicators of hypoxia and impending respiratory failure.
Assess vital signs and breath sounds q2h. Report significant Significant changes, such as tachycardia, tachypnea, and uni-
findings. lateral decreased breath sounds, indicate worsening status.
Following tube thoracotomy, assess patient q15min. Assessments enable detection of respiratory distress, including
tachypnea, decreased or absent chest wall movement, and in-
creased work of breathing.
Assess HR and blood pressure for tachycardia and hypotension. Tachycardia and tachypnea are signs of hypoxia and shock.
Place patient in semi-Fowler position This position enables full expansion of the lungs.
Encourage patient to take deep breaths. Deep breathing decreases risk of atelectasis. Analgesia and
splinting decrease discomfort.
Provide oxygen and humidity for oxygen saturation <92%. This intervention ensures adequate oxygen levels.

related to impaired pleural integrity, inflammation, or chest tube
Desired Outcomes: Within 1 hr of intervention, the patient's pain decreases by pain scale.
Assess the patient's degree of discomfort on a pain scale from 0 These assessments monitor the effect of pain interventions.
to 10 (worst pain). Chest tube placement causes pain.
Administer analgesics as prescribed. This action provides pain relief.
Give analgesia 30 min before exercising or repositioning. This intervention provides comfort during painful activities.
Stabilize the chest tube by taping the tube to the chest. These actions reduce pull on the tubing and facilitate drainage.
Abdominal'Trauma' 172
Abdominal Trauma

related to pain from injury and diaphragmatic elevation caused by abdominal distention
Desired Outcome: Within 24 hr of admission, patient is eupneic with RR of 12-20 breaths/min and clear breath sounds.
Assess breath sounds, RR, cough, and sputum. Abdominal trauma causes tachypnea and poor ventilatory effort,
which may cause atelectasis and pneumonia.
Monitor oximetry q2-4h and report O2 saturations <92% O2 saturation <92% indicates the need for supplemental oxygen.
Administer supplemental oxygen. Supplemental O2 should be delivered if the oximetry is >92%
Assist patient with coughing, deep breathing, incentive spi- These measures prevent pneumonia and atelectasis.
rometry, and turning q2-4h.
Administer analgesics to relieve pain. Alleviation of pain enables full excursion of the chest.
Instruct patient in abdominal splinting. Splinting helps to reduce pain on coughing and deep breathing,
which improves respiratory effort.

Risk for Shock
related to decreased blood volume due to trauma
Desired Outcome: Within 2 hr of admission, patient is normovolemic, as evidenced by systolic BP >90 mm Hg, pulse pressure
>30 mm Hg, HR 60-100 bpm, urinary output >30 mL/hr, warm extremities.
Assess for systolic BP <90 mm Hg, pulse pressure <30 mm Hg, Decreased SBP is a sign of hemorrhage.
HR >110/min every 10 minutes.
Assess extremities for coldness, and decreased pulses. Pallor, coolness, and decreased or absent peripheral pulses are
signs of bleeding, hemorrhage, or shock.
Monitor for decreasing BP; HR >100 bpm, RR >20 breaths/min, These are clinical indicators of bleeding or hemorrhage or shock. If
confusion, lethargy, or coma. signs should be reported Immediately.
Normal saline 2 L boluses should be given. Packed red blood Massive blood loss frequently occurs with abdominal injuries.
cells are given if systolic is <90 mm Hg after 4 L of NS. Place
two large-bore IV lines.
Measure urinary output hourly. Low urine output is a sign of inadequate intravascular volume and
renal hypoperfusion.
Measure output from wounds, drainage tubes and catheters. These measurements estimate ongoing blood loss.

related to irritation caused by intraperitoneal blood or secretions, trauma or surgical incision
Desired Outcome: Within 4 hours of admission, patient's perception of pain decreases on a pain scale. Patient's pain is controlled
with opioid analgesia.
Assess for pain. Devise a pain scale from 0 (no pain) to Incisional and some visceral pain can be intense or prolonged pain
10 (severe pain). and can signal bleeding, bowel infarction, infection.
Administer opioid analgesics. Administer analgesics on a continual or regular schedule with ad-
ditional analgesia as needed, or provide patient-controlled analge-
sia. Relieving pain promotes ventilatory excursion.
Encourage patient to request analgesic before pain becomes Prolonged stimulation of pain receptors increases the patient’s
severe. sensitivity to pain.
Assess for alcohol and opioid involvement in traumatic events. Patients may be drug or alcohol users with a high tolerance for
opioids. Drug and alcohol users require increased dosages of an-
algesics. Alcohol withdrawal may cause tremors, tachycardia, hy-
pertension, agitation, and hallucinations. Narcotic withdrawal may
cause lacrimation, rhinorrhea, anxiety, tremors, muscle twitching,
mydriasis, nausea, abdominal cramps, and vomiting.

related to inadequate defenses against infection due to open wounds, multiple indwelling catheters and drainage tubes, and de-
creased immunity
Desired Outcome: Patient is free of infection as evidenced by temperature <37.5° C; HR <100 bpm; and absence of erythema,
edema, or drainage at wounds.
Assess temperature, heart and respiratory rates. Increased temperature, heart rate, and respiratory rate are signs of
infection.
Assess mental status and level of consciousness q8h. Mental status changes, confusion, or decreases LOC can signal
infection.
Assess incisions and wound sites for erythema, tenderness, These signs of localized infection.
edema, and purulent drainage.
Assess amount, color, character, and odor of drainage. Malodorous or abnormal drainage can result from infection.
Ensure patency of all surgically placed tubes or drains. Irrigate Blocked drainage systems may promote Infection and abscess
or attach to low-intermittent suction. Maintain continuity of formation. Maintaining sterility decreases infection.
closed drainage systems and use sterile technique when emp-
tying drainage containers.
Administer antibiotics on schedule. Reschedule parenteral anti- Failure to administer antibiotics on schedule may result in treat-
biotics if a dose is delayed more than 1 hr. Check blood levels ment failure.
of vancomycin or gentamicin.
Administer pneumococcal vaccine to patients with total sple- Vaccination minimizes the risk of postsplenectomy sepsis due to
nectomy. encapsulated bacteria.
Administer tetanus immune globulin and tetanus toxoid. Risk for tetanus following trauma increases if the patient has not
been immunized or has not received a tetanus booster within the
past 10 years.
Change dressings using sterile technique. Sterile technique prevents infection and cross-contamination.
If evisceration occurs, do not reinsert the intestines. Covering evisceration prevents infection and maintains moisture
Place sterile, saline-soaked gauze over eviscerations, and cov- until surgical intervention can be accomplished.
er with sterile plastic wrap.
Keep patient on bedrest in Fowler's position with knees bent Fowler’s position reduces strain on eviscerated organs.
Maintain nothing by mouth (NPO) status for the patient Emergency surgery will be required.
Diagnoses: Risk for Impaired Skin Integrity

related to exposure to irritating GI drainage
Impaired Tissue Integrity
related to trauma, surgery, and catabolic state
Desired Outcome: Patient exhibits wound healing and skin remains nonerythemic and intact.
Assess wounds, fistulas, and drain sites at regular intervals. Assessments identify signs of irritation, infection, and ischemia.
Remove infected and devitalized tissue by irrigation, Removal of devitalized tissue promotes wound healing.
wound packing, or debridement.
Promptly change all dressings that have become soiled with Drainage irritates the skin and can cause excoriation.
drainage or blood.
Apply ointments, skin barriers, or drainage bags to skin around These measures prevent excessive injury to surrounding skin.
draining wounds.

related to decreased intake caused by disruption of GI tract integrity and increased needs due to the post trauma state
Desired Outcome: By 24 hr before discharge, patient has adequate nutrition as evidenced by maintenance of baseline body
weight.
Provide increased nutrition based on the type of injury. Patients with abdominal trauma have a hypermetabolic state. En-
teric feedings provide calories, proteins, vitamins, and minerals.
Parenteral feedings are given if enteral feedings cannot be used.
Monitor prealbumin, albumin, total protein, and glucose. Prealbumin, albumin, and total protein are indicators of nutritional
status and guide nutritional replacement.
Assess patency of gastric or intestinal tubes. Gastric decompression requires a patent gastrointestinal tube to
prevent accumulation of gas or fluid in the stomach and promote
healing and return of bowel function. The tube remains in place
until bowel function returns with flatus and decreased gastric tube
output.
Confirm correct placement of feeding tube before each tube Instill 5 mL of water and withdraw the water to verify correct tube
feeding. After initial insertion, check x-ray film for feeding tube placement in the stomach.
location. Mark to tube, secure tubing, and check placement q6h
and before feedings.
Avoid opioid analgesics if possible; administer IV ketorolac in- Opioid analgesics decrease GI motility and may cause ileus. Ke-
stead. torolac is an IV NSAID.
Diagnosis: Post-trauma Syndrome

related to a life-threatening traumatic accident or event
Desired Outcome: By 24 hr before hospital discharge, patient verbalizes the psychosocial affect of the event and does not exhibit
inappropriate affect, suicidal behavior, agitation or depression.
Assess the patient's mental status at regular intervals. Assess Victims of major abdominal trauma may have a prolonged or se-
affect, suicidal ideation, agitation, depression, and failure to vere reaction to the trauma
cooperate.
Assess for organic causes of behavior change. Severe pain, alcohol intoxication or withdrawal, electrolyte imbal-
ance, metabolic encephalopathy, and impaired cerebral perfusion
may cause a posttraumatic stress reaction.
Spinal'Cord'Injury' 176
Spinal Cord Injury
Diagnosis: Risk for Autonomic Dysreflexia

related to unopposed autonomic response to noxious stimuli due to a SCI at or above T6.
Desired Outcomes: Patient is free of AD symptoms, as evidenced by BP <150/110 mmHg and HR 60-100 bpm. Patient states
factors that result in AD, treatment, and prevention.
Assess for signs of AD, including BP >150/110 mm Hg, pound- AD is a medical emergency that can occur after spinal shock
ing headache, bradycardia, blurred vision, nasal congestion, resolution in patients with spinal cord injuries at or above the T6
flushing and diaphoresis above the level of injury, and piloerec- level.
tion or pallor below the level of injury.
If AD is suspected, raise head of bed to 90 degrees. HOB elevation decreases BP. Seizures, subarachnoid hemor-
rhage, myocardial infarction, stroke, and retinal hemorrhage can
occur.
Remove any noxious stimulus. The noxious stimulus that is causing AD, such as distended
bladder, must be removed.
Assess for distention of the bladder, UTI, obstructions, bladder Bladder problems are the most common causes of AD.
spasms, and catheterization status.
Suprapubic pressure should not be used to relieve a distended Increased bladder pressure will exacerbate autonomic dysreflex-
bladder. ia.
Catheterize patient using anesthetic jelly if there is bladder dis- Bladder distention is a common cause of autonomic dysreflexia.
tention. Anesthetic jelly prevents exacerbation of AD.
If a catheter is in place, check tubing for kinks and lower the These interventions ensure catheter patency. Obstruction is a
drainage bag. If obstructed, irrigate the catheter with 30 mL of common cause of AD.
normal saline.
Check urinalysis. UTI and urinary calculi are causes of autonomic dysreflexia.
Loosen clothing, remove leg bandages or abdominal binder. For Pressure on the skin or genitalia may exacerbate AD.
male patients, remove pressure on the penis, scrotum, or testi-
cles.
Check skin below the level of injury for pressure ulcers, infec- Skin infection, pain, pressure and injury are common causes of
tion, laceration, rash, ingrown toenails, or skin contact with a AD.
hard object.
Give an antihypertensive agent, such as nifedipine, nitroglycerin, Antihypertensives will reduce blood pressure and prevent hyper-
or phenoxybenzamine. tensive encephalopathy.
Diagnoses: Risk for Ineffective Cerebral Tissue Perfusion, Risk for Decreased Cardiac Tissue Perfusion
related to relative hypovolemia caused by decreased vasomotor tone
Desired Outcomes: 24 hr before hospital discharge, patient has adequate cardiac and cerebral tissue perfusion, as evidenced by
SBP >90 mm Hg.
Assess for systolic BP <90 mm Hg, lightheadedness, dizziness, Hypotension can result from loss of vasomotor tone.
and confusion.
Assess oxygen saturation and administer oxygen. Oxygen should maintain oxygen saturation >94%.
Assess heart rate and rhythm. Document dysrhythmias. Sinus tachycardia or bradycardia may be caused by sympathet-
ic stimulation or vagal stimulation. Symptomatic bradycardia is
treated with atropine.
Assess intake and output Hydration will maintain stable hemodynamics.
Give intravenous fluids and dopamine for hypotension. Impaired vascular tone can cause increased sensitive to in-
creases in circulating volume. Dopamine will correct hypoten-
sion.
Perform range-of-motion exercises q2h. This prevents venous pooling in the leg veins and prevents con-
tractures.
Patients with SCI above T6 should wear an abdominal binder in This helps prevent venous pooling. These patients may have
addition to sequential compression devices. severe hypotensive reactions.
Diagnoses: Urinary Retention or Reflex Urinary incontinence

related to neurologic impairment caused by spasticity or flaccidity.
Desired Outcomes: 24 hours before discharge, patient has urinary output without incontinence and residual volumes <50 mL. Pa-
tient demonstrates control over voiding.
Assess for bladder dysfunction by cystometric testing. Cystometric testing assesses the type of incontinence.
If intermittent catheterization produces >500 mL of urine, in- During acute spinal shock, an indwelling urinary catheter or
crease the frequency of catheterization. scheduled intermittent catheterization is initiated.
Teach patient procedure for intermittent catheterization. This teaching prepares the patient for self-care.
Teach patient bladder scheduling by gradually increasing time Bladder volume should be gradually increased to 300-400 mL of
between catheterizations. urine. Bladder ultrasound is used to measure bladder volume.
Restrict fluids before bedtime. This measure prevents nighttime incontinence.
Patients using bladder-emptying techniques should void q3h. A regular schedule of voiding prevents bladder distention.
Diagnoses: Constipation
related to immobility, atonic bowel, and loss of voluntary sphincter control
Desired Outcome: Patient has soft bowel movements every 1-3 days.
Assess bowel sounds and abdominal distention. Constipation is common for 1-4 weeks after spinal shock.
Manage flaccid bowel by manual disimpaction and enemas. Lesions below the conus medullaris (T12) may injure S3, S4,
and S5 nerves, causing flaccid bowel and loss of anal tone.
For patients with injuries at T8 or above, encourage fluid intake, These measures add bulk and moisture to the stool.
stool softeners and a high-fiber diet

related to paralysis and spasticity
Desired Outcomes: Before discharge, patient exhibits complete ROM of all joints and demonstrates measures that enhance mobil-
ity, and prevent contractures.
Once injury is stabilized, assist patient with changes in position. Position changes relieve pressure sites and lowers risk of con-
tractures.
For spasticity, use hand splints to maintain fingers in extension. This device maintains the hands in a functional grasp position.
If the patient has spasticity, fit him with splints. Splints prevent foot contractures.
Teach patients range-of-motion and daily stretching exercises. Steady, continuous, directional stretching several times daily
decreases spasticity.
Give muscle relaxants, such as lorazepam, and antispasmodics, Severe spasticity may be treated with botulinum toxin injections.
such as baclofen, tizanidine, or dantrolene. Dantrolene causes muscle weakness.
Encourage participation in physical therapy. Passive ROM is started on all joints. After the injury is stabi-
lized, rehabilitation includes muscle strengthening and condi-
tioning.
Explain options for surgery. Tenotomy, myotomy, peripheral neurectomy, and rhizotomy are
surgical methods of relieving spasticity.
Assess for pain, swelling, and decreased ROM in joints, espe- These are indicators of heterotopic ossification, which is the
cially the hips. abnormal formation of bone within the joint cartilage.
Traumatic'Brain'Injury' 179
Traumatic Brain Injury
Diagnosis: Deficient Knowledge (for patients going home with a concussion)

related to unfamiliarity with caretaker's responsibilities for observing patient who is sent home with a concussion
Desired Outcomes: Following instruction, caretaker states knowledge of the observation regimen.
Give acetaminophen for relief of headache. Opioids should be avoided because masking of neurologic indica-
tors of IICP may occur.
Assess patient q1-2h for first 24 hr. Ask the patient’s name, his Caretaker should return patient to the hospital immediately if the
location, and caretaker's name. patient becomes difficult to awaken; cannot answer questions;
becomes confused or agitated; or develops slurred speech.
Ensure that the patient rests and eats lightly for the first day Nausea and vomiting occur with IICP.
after a concussion.
Over the next 2-3 days, caution patient to avoid alcohol, driv- Activity restrictions ensure the patient’s safety in the event of neu-
ing, and swimming. rologic deterioration.
Inform patient that postconcussion syndrome may occur. Headaches, dizziness, or lethargy may occur for several weeks or
months after a concussion.
Traumatic Brain Injury - Hospitalized

related to inadequate primary defenses caused by skull fractures or surgical wounds
Desired Outcomes: Patient is free of symptoms of infection, as evidenced by normothermia, improving LOC, and absence of
headache or neck stiffness. Patient states knowledge about symptoms of infection.
Clean and cover scalp wounds with sterile dressings. Docu- Clear or bloody drainage from the nose, throat, or ears may result
ment drainage, amount, and color. from a dural tear with CSF leakage. The physician should be noti-
fied.
Inspect dressing and pillowcases for a halo ring (blood encir- A halo ring indicates CSF drainage.
cled by a yellow stain).
Test clear drainage for beta-2 transferrin. The presence of beta-2 transferrin in non-sanguineous drainage
indicates that the drainage is CSF.
If CSF leakage occurs, do not clean ears or nose. These measure prevent introduction of bacteria into the CNS.
Place a sterile pad over the affected ear or under the nose to ab-
sorb drainage.
Place patient in semi-Fowler's position. This position reduces cerebral edema and increases venous
drainage.
Nasal suction is contraindicated with CSF leakage or basilar Nasal suction may cause bacteria to enter the nervous system.
fracture.
Instruct patient not to Valsalva, strain with bowel movements, These actions may tear the dura and increase CSF leakage.
or cough vigorously. Caution patient not to blow his nose,
sneeze, or sniff.
If the gastric tube must be placed nasally, the physician should Nasogastric tubes may enter the cranial vault. The tube for gastric
perform the intubation. decompression should be placed through the mouth if a basilar
skull fracture is possible.
Check tube placement by x-ray. These measures confirm the correct placement of the tube.
Keep individuals with basilar skull fractures flat in bed. This position decreases CSF pressure and reduces CSF leakage.
Give antibiotics. Antibiotics to prevent infection.
Assess injury site or wound for infection. Erythema, pain, and purulent drainage are signs of infection.
Diagnoses: Excess Fluid Volume, Risk for Electrolyte Imbalance

related to increased antidiuretic hormone, and increased renal sodium resorption caused by SIADH.
Desired Outcome: Within 3 days of injury, patient is normovolemic, as evidenced by balanced intake and output, urine output >30
mL/hr, BP systolic >100 mmHg, and absence of ankle edema.
Differentiate between SIADH and cerebral salt wasting syn- SIADH and CSW involve hyponatremia and a sodium <137
drome. mEq/L. SIADH causes hypervolemia and CSW results in dehydra-
tion.
Monitor serum Na+, I&O, and weight. SIADH may result from TBI due to excessive water retention and
dilutional hyponatremia. Seizures may occur if sodium is 118
mEq/L.
In SIADH, fluids may be restricted to 500-1000 mL/24 hr. Fluid overload can increase ICP.

related to headaches caused by Traumatic Brain Injury
Desired Outcome: Within 1 hr of intervention, the patient’s pain decreases on a pain scale of 1-10.
Assess character of the patient’s pain on a scale of 0 to 10 (worst This evaluation quantifies the degree of pain and pain relief
pain). Assess for grimacing or irritability. obtained by treatment with analgesics.
Administer analgesics as prescribed. Patients with TBI do not have severe pain. Pain is relieved by
analgesics, such as acetaminophen and codeine.
Nursing diagnosis for patients undergoing craniotomy

related to unfamiliarity with the craniotomy procedure.
Desired Outcome: Following the explanation, patient states accurate understanding of the craniotomy procedure and postsurgical
care.
Assess the patient’s level of understanding of purpose, risks, A craniotomy is a surgical opening in the skull to remove a hema-
and benefits. Provide and review printed material. toma, tumor, or repair a ruptured aneurysm, control hemorrhage,
remove bone fragments or foreign objects, or decompress the
brain.
Explain that the bone flap may be left open postoperatively. This enables accommodation of cerebral edema and prevents
compression.
Explain that before surgery, antiseptic shampoos may be given Hair is a source of bacterial infection. Dexamethasone reduces
and patient may be started on dexamethasone, and phenytoin. cerebral edema; antiepilepsy drugs prevent seizures.
Explain that neurologic assessments will be performed. These provide a basis for assessment of neurologic status.
Assess vital signs and neurologic status will be assessed q1h. Patient will be asked to squeeze the nurse's hand, move extremi-
ties, extend tongue, and answer questions.
A sequential compression device should be placed on the pa- This equipment will be used to prevent thrombophlebitis or pul-
tient’s legs and ICP monitoring ventriculostomy. monary emboli; continuous BP, and ICP monitoring.
Administer oxygen, intubate, and ventilate. Respirations will be supported.
Patient should be given nothing by mouth for the first 24-48 hr. NPO status reduces the risk of aspiration.
Interventions for periorbital swelling include cold compresses Periorbital swelling occurs within 24 hr of supratentorial surgery.
around the eyes, and raising the HOB. Relief is obtained with cold compresses around the eyes, and
raising the HOB.
Insert an indwelling urinary catheter. A catheter enables accurate measurement of I&O and monitors
for diabetes insipidus.
Teach patient wound care and indicators of infection: fever, A surgical cap is worn after removal of head dressing. Patient
redness, drainage, and headache. must keep incision dry.
Traumatic Brain Injury - Ventricular Shunt Procedure

related to unfamiliarity with ventricular shunt procedure
Desired Outcome: Following explanation, patient states accurate information about ventricular shunt procedure, and presurgical
and postsurgical care.
Purpose, risks, and benefits of ventriculostomy. A ventriculostomy is a temporary procedure used to remove ex-
cess CSF. A ventricular shunt allows permanent drainage of CSF.
Explain that patient may have a chest or abdomen dressing. Shunts can extend from the lateral ventricle of the brain to the
subarachnoid space of the spinal canal, or the peritoneal cavity.
Explain that the patient should avoid lying on the insertion site This restriction prevents pressure on the shunt, which could de-
after the procedure. crease CSF drainage.
Advise patient to keep head and neck in alignment. This prevents kinking and compression of the shunt catheter.
Explain that there is a shunt valve for controlling CSF drainage Most shunts have a valve that permits CSF flow.
or reflux.
Explain that the valve, behind the ear is the size of a pencil. Malfunction may be noted by either deterioration in neurologic
status or failure of the reservoir to refill when pumped.
Specific instructions will be given about shunt care, recognition Kinked tubing, obstructed tubing or valve, and movement of the
of infection and malfunction. Teach symptoms of IICP, such as cannula can lead to blocked drainage of the ventricles.
headache, drowsiness, and lethargy.
If the patient is to have an endoscopic third ventriculostomy, Endoscopic ventriculostomy an alternative to a standard shunt in
explain the procedure and its purpose. order to provide drainage of CSF in cases of obstructive hydro-
cephalus. A small hole or holes are made in the third ventricle to
facilitate CSF drainage.
Nutritional'Support' 183
Nutritional Support

related to inability to ingest, digest, or absorb carbohydrates, protein, and/or fat
Desired Outcome: Patient maintains adequate nutrition, as evidenced by stabilization of weight or steady weight gain of 1 lb/wk;
presence of wound granulation.
Assess for nutritional deficiencies with a nutritional screening Hospitalized patients are at risk for protein-236 malnutrition.
tool, and repeat weekly.
Assess for food allergies and intolerances. Celiac disease may cause bloating, cramping and diarrhea after
ingestion of wheat and gluten.
Measure weight once a week. Maintenance of weight or weight gain of 1 lb/wk is an appropriate
goal.
Position the patient in high Fowler's position for eating. An upright eating position reduces the risk of aspiration.
Provide cold, liquid nutritional supplements. Cold supplements increase the quantity of calories consumed and
provide vitamins and minerals.
Monitor electrolytes, BUN, creatinine, phosphorus and magne- Abnormal values indicate metabolic deficits, decreasing renal func-
sium weekly. tion, or refeeding syndrome. Refeeding syndrome may occur after
a large carbohydrate infusion in a patient with previous inadequate
food intake, resulting in hypokalemia, diarrhea, and cardiac
dysrhythmias.
Monitor albumin, alkaline phosphatase, and total bilirubin week- These laboratory values assess tolerance, clearance, and metabo-
ly. lism.
Administer continuous enteral feedings with a pump. Infusion of feedings decreases feelings of fullness and avoids
peaks in blood glucose. Postoperative patients may have ileus and
benefit from feedings delivered into the small bowel.
Administer intermittent feedings over 30 min by gravity drip. Intermittent feeding emulates the natural pattern of eating.
Administer TPN with a volumetric pump. Excessively rapid infusion may cause hyperglycemia and hyper-
kalemia. A continuous infusion rate is better tolerated.
Monitor the infused volume and rate of TPN every 4 hours. Monitoring the volume and rate of the infusion prevents volume
overload.

related to GI feeding or delayed gastric emptying
Desired Outcome: The patient is free of aspiration, as evidenced by auscultation of clear lung sounds, normal vital signs, and no
signs of respiratory distress.
Assess placement of NG tube. Mark NG tube at the time of The NG tube can easily slide out of the nose because of nasal
placement. Check this mark to prevent tube migration. Secure discharge, sweat, and loosening of the tape. The tube may migrate
the tubing. beyond the pylorus.
Check tube position q4h and before each feeding. If tube migration is suspected before infusing feedings, obtain x-ray
to confirm placement.
Assess respiratory rate and breath sounds q8h. Clear lung sounds and absence of respiratory distress should be
verified before infusion of a feeding solution.
Auscultate bowel sounds q8h. High-pitched or absent bowel sounds, abdominal distention, or
nausea can occur with ileus and small bowel obstruction.
Raise head of bed to 30 degrees or place the patient in a right The upright or right lateral position promotes gravity flow from the
side-lying position during and for 1 hr after a bolus feeding. greater curvature of the stomach and through the pylorus and re-
duces risk for aspiration.
Stop the tube feeding for one hour before placing the patient Holding of feeding for one hour allows the stomach to empty and
supine. decreases the risk of aspiration.
Check residuals after each feeding or q8h if continuous feeding. Hold the feeding if residuals are >200 mL from an NG or >100 mL
from a gastrostomy. High residual volume is a sign of intolerance
due to ileus or small bowel obstruction.
Diagnosis: Diarrhea
related to related to medications, dumping syndrome or formula intolerance
Desired Outcome: Patient has formed stools within 2-3 days of intervention.
Assess bowel sounds, distention, cramping, nausea, and fre- These assessments establish a baseline from which trends can be
quency of bowel movements. compared. Hyperactive bowel sounds may occur with increased
stooling, along with signs and symptoms of distention, cramping,
and nausea.
Assess hydration status by evaluating I&O and weight daily. Dehydration would cause decreased urinary output to <30 ml/hr for
4hr. Daily weight measurement is used to assess fluid status.
Diagnosis: Nausea
related to a medical condition, excessively rapid infusion of enteral feedings, or a medication
Desired Outcome: Following interventions, patient does not have nausea or vomiting after intake of food.
Assess for abdominal distention and auscultate bowel sounds. Absence of bowel sounds is a sign of ileus. Distention may appear
with ileus or with decreased motility.
Record bowel movements. Decreased bowel movements and flatus may indicate ileus or par-
tial obstruction.
Assess electrolyte values, especially potassium. Low potassium is associated with ileus and nausea.
Administer an ondansetron (Zofran). Antiemetics, such as Zofran, decrease nausea and vomiting.
Provide food in small portions, 6 times per day. Smaller, more frequent meals are better tolerated than fewer, larg-
er meals.
Give chewing gum or hard candies as needed. Sugar may stimulate the GI tract and reduce nausea.
Assess for medication-related diarrhea. Diarrhea may be caused by metoclopramide, erythromycin (proki-
netic agents), stool softeners, and antacids.
Collect a stool sample for bacterial pathogen culture, ova and Diarrhea may be caused by bacteria or parasites. C. difficile caus-
parasites, or Clostridium difficile toxin. es a secretory diarrhea.
Do not give an antidiarrheal medication if the patient has signifi- Antidiarrheals may cause toxic megacolon and bowel perforation.
cant abdominal pain.
Enteral solutions may be kept at room temperature for up to 12 Storage of solutions at room temperature will allow growth of bac-
hours. teria. Closed systems prevent touch contamination.
Reduce the rate of enteral formula infusion. Nausea and distention may result from rapid infusion.
Change bolus infusions to intermittent or continuous infusions. Bolus infusion may cause overdistention and nausea. Slow inter-
mittent or continuous infusion may be better tolerated.
Give a stimulant laxative suppository, such as Dulcolax. A laxative suppository will stimulate the intestinal tract and prevent
constipation.
related to insufficient dietary fluid and fiber
Desired Outcome: Patient states that he has had a soft bowel movement within 3 days.
Assess the patient’s abdomen for distention and auscultate for A distended abdomen is a sign of excessive stool and gas in the
bowel sounds. large intestine.
If the patient is receiving a formula that contains fiber, ensure Fiber pulls fluid into the intestines. Constipation will occur if the
adequate intake of water. patient is dehydrated.
Encourage oral fluid intake. Free water helps maintain fluid balance and softens stools.
Discontinue opioid analgesics. Opioid medications often cause constipation.
Administer a stool softener, such as docusate (Colace). A stool softener will prevent constipation.
Diagnosis: Impaired Swallowing

related to decreased or absent gag reflex, facial paralysis, obstruction, fatigue, or deceased strength of masticatory muscles
Desired Outcome: Patient demonstrates adequate cough and gag reflexes and the ability to ingest foods by swallowing.
Assess oral motor function and cough and gag reflexes before If the patient has adequate oral motor function, oral intake can be
the first feeding. advanced.
Patients with gastric reflux or vomiting can aspirate.
Begin with semisolid foods and progress to thicker liquids as Liquids are difficult to swallow and are most likely to be aspirated.
tolerated.
Teach the patient the phases of food ingestion: open mouth, Swallowing muscles may be weak and uncoordinated, and having
insert food, close lips, chew, transfer food from side to side in the patient swallow in a series of steps will decrease the risk of
the mouth and then to the back of the oral cavity, elevate aspiration.
tongue, and swallow between breaths.
Keep patient in high Fowler's position for 30 min after eating. The upright position minimizes the risk of aspiration by promoting
gravity flow through the stomach.
Provide smaller and more frequent meals. Six smaller feedings per day may allow for better swallowing and
be less likely to result in aspiration.
Obtain a speech therapy consult. A speech therapist can assist in swallowing retraining.

related to invasive procedures, nasogastric tube, decreased nutritional intake, and immunosuppression
Desired Outcome: Patient is free of infection, as evidenced by normal temperature and absence of erythema at the catheter inser-
tion sites.
Assess for increased WBC and temperature >38.9° C. Fever and leukocytosis are signs of infection. Fever increases fluid
requirements.
Assess bedside glucose values. If the premeal glucose levels Glucose intolerance is a sign of sepsis. Hyperglycemia increases
are >140 mg/dL, increase the patient’s basal NPH insulin dos- the risk for infection. Insulin is given to maintain the premeal glu-
age. cose levels between 70 and 144 mg/dL
Assess the catheter insertion site q12h for erythema or dis- Erythema, swelling, and discharge are signs of local infection.
charge.
Change transparent semipermeable membrane dressings eve- TSM dressings allow visualization of the insertion site.
ry 7 days.
Use sterile technique when changing central line dressings, Sterile technique helps prevent infection.
containers, or administration lines.
Obtain blood cultures at two sites if the patient has a tempera- A positive culture may indicate a bloodstream infection.
ture >38.6° C.
Change TPN administration sets every 24 hours. Changing the TPN administration sets helps prevent infection.
Diagnosis: Risk for Imbalanced Fluid Volume

related to medications, fever, infection, or fluid administration
Desired Outcome: Patient has adequate hydration status, as evidenced by normal vital signs, glucose less than 200 mg/dL, bal-
anced I&O, 1 lb weight gain per wk, and normal electrolytes.
Assess infusion rate and volume of nutritional support q4h. This assessment verifies the rate and volume of infusion, and pre-
vents volume overload.
Assess the patient's weight daily. Assessments of weight will weight gain goals.
Assess I&O q8h. Measurement of I&Os assess fluid imbalances and overhydratlon
or dehydration.
Assess electrolytes daily. Changes in sodium, chloride, and BUN may result from deficits in
fluid status.
Assess for signs of circulatory overload, such as crackles, jugu- Circulatory overload may occur during fluid replacement, manifest-
lar venous distention, and pretibial edema. ing as edema, jugular distention, and crackles. Circulatory over-
load is more likely to occur in older adults with heart failurĀ or re-
nal insufficiency.
Asthma' 187
Pediatric Nursing
Asthma

related to bronchospasm and airway edema
Desired Outcomes: Within 48 hr of interventions, wheezing, cough, and work of breathing are reduced. Within 24 hr, RR <20/min,
and retractions are absent.
Assess respiratory status and vital signs q10min. Baseline assessments and reassessments enable detection of
clinical deterioration.
Assess RR, HR, O2 saturation, and breath sounds before and These evaluations assess the effectiveness of treatment.
after each nebulizer treatment.
Administer albuterol nebulized or MDI. Albuterol reduces bronchospasm or mucosal edema.
Use a spacer when giving albuterol by metered dose inhaler. Spacers maximize medication delivery to the lower airways.
Position child in high Fowler's position. High Fowler’s ensures maximum lung expansion and disperses
more medication into the lower airways.
Check PEFR before and after each albuterol treatment. A peak flow meter assesses bronchodilator efficacy in increasing
airflow.
Administer prednisolone by mouth Corticosteroids reduce inflammation and improve airway clear-
ance. Antibiotics are given if a bacterial infection is present.
Assess intake and output q4h. Assessing I&O detects inadequate intake or output. Dehydration
may cause thick secretions.
Encourage oral fluids. Fluids reduce the viscosity of mucus and improve airway clear-
ance.

related to unfamiliarity with purpose, precautions, and adverse effects of medications
Desired Outcome: Following instructions, child and parents state accurate knowledge about the medication.
Advise Parents and Child of the corticosteroids (purpose of in- Corticosteroids are taken daily to maintain control of inflammation
haled or Systemic Forms) in persistent asthma.
For inhaled corticosteroids, such as fluticasone (Flovent), be- Rinsing prevents oral candidiasis.
clomethasone (Vanceril), and flunisolide (AeroBid), gargle with
water after oral inhalation.
Recommend use of a spacer. Spacers enhance medication delivery to the lower airways.
Teach the purpose of cromolyn and Nedocromil Antiallergic agents, which prevent release of histamine from mast
cells.
Assess for rash, cough, and bronchospasm. These are adverse effects of cromolyn and nedocromil.
Long-Acting Beta-Agonists (LABAs), such as salmeterol LABAs relax bronchial smooth musses and reduce bron-
(Serevent) chospasm.
Asthma' 188
Assess for tachycardia, tremors, palpitations, dizziness, head- These are adverse effects of salmeterol.
ache, and nausea.
Short-acting inhaled beta-agonists (SABAs), such as albuterol SABAs are bronchodilators used to treat acute symptoms.
(Ventolin)
Assess for tachycardia, palpitations, tremor, insomnia, anxiety, These are adverse effects of beta-agonists.
nausea, and headache.
If using an MDI, use with a spacer. Spacers increase medication delivery to the small airways.
Oral corticosteroids, such as methylprednisolone or prednisolone Corticosteroids reduce airway inflammation.
ADHD' 189
Attention Deficit/Hyperactivity Disorder
Diagnosis: Disturbed Sensory Perception

related to excessive distractibility impulsivity and inability to organize thoughts.
Desired Outcomes: Within 1 month, the child carries out activities of daily living and shows behavioral improvement at school.
Within one semester, child shows improvement in grades.
Advise parents to provide a structured environment and con- Structure and consistency help the child to focus on behavior
sistency. improvement
Encourage communication between parents and teachers. Consistency in reinforcing good behavior among family and
teachers improves the child's ability to focus on tasks.
Recommend that parents work with the school in determining if Classroom placement helps children with ADHD reach their full
the child is eligible for care under individuals with Disabilities potential.
Education Act (IDEA).

related to hyperactivity, limited judgment, and impulsivity
Desired Outcome: Child remains free of signs of trauma.
Encourage parents to have the child use safety equipment, such Protective equipment lowers the risk of injury.
as seat belts and a bicycle helmet.
Encourage participation in active play, such as playing soccer Active play helps the child with ADHD to redirect energy.
rather than playing video games.
Teach the parents to monitor the child's activities. Supervision reduces the risk of trauma.
Advise parents to frequently reinforce good behavior with posi- Positive reinforcement encourages good behavior.
tive feedback and rewards.

related to unfamiliarity with purpose, precautions, and adverse effects of ADHD medications
Desired Outcome: Within 1 wk of starting medication, child and parents state accurate information about the purpose and adverse
effects of medications.
Shorty, intermediate, and long-acting methylphenidate (Ritalin); Stimulants promote attentiveness and reduce restlessness by
short, intermediate, and long-acting dextroamphetamine (Dexe- increasing dopamine and norepinephrine in the CNS.
drine); mixed dextroamphetamine salts; and methylphenidate
Assess for loss of appetite, weight loss, abdominal pain, insom- These are common adverse effects of stimulants, which may re-
nia, inertness, irritability, and withdrawal. quire dosage reduction.
Assess the child for aggression or hostility. These are adverse effects that may require a change in dosage.
Assess for facial tics. Tics occur in 15-30% of children treated with stimulants and are
usually transient.
Monitor height, weight, and BP. Growth delay and hypertension may occur with long-term stimu-
lant use
ADHD' 190
Assess for impulsiveness, decreased social interaction, and im- These behaviors should improve with medication.
paired academic function.
Take stimulants on an empty stomach, 30-45 min before meals. Absorption of methylphenidate is increased when taken with
meals. Concerta, a long-acting form, is not affected by meals.
Do not crush, chew, or break sustained-release forms. The duration of action will be reduced, and the medication will be
less effective.
Take the last daily dose of methylphenidate several hours before Not taking methylphenidate before bedtime decreases insomnia.
bedtime.
Norepinephrine reuptake inhibitor, atomoxetine (Strattera) Strattera improves attentiveness, ability to complete tasks. Strat-
tera reduces forgetfulness and hyperactivity.
Assess for headache, insomnia, abdominal pain, vomiting, or These adverse effects may require dosage reduction.
anorexia.
Assess for chest pain, palpitations, urinary retention, anorexia, These are adverse effects, which require a decrease in dosage.
weight loss, or insomnia.
Assess weight regularly. Adjust the dosage of medications as An accurate weight is needed for optimal medications effects
weight increases. dosed by the child’s weight.
Monitor HR and BP while on therapy. Atomoxetine may cause tachycardia, hypertension, and palpita-
tions.
Report aggression, hostility, and suicidal ideation. There is increased risk of suicidal ideation in children taking Strat-
tera.
Administer clonidine when stimulants and atomoxetine have Clonidine is used when children respond poorly to a trial of stimu-
failed. lants or atomoxetine, have unacceptable side effects, or have
significant coexisting conditions.
Burns' 191
Bronchiolitis

related to increased mucosal edema and secretions caused by respiratory infection
Desired Outcomes: Within 24 hr of intervention, child exhibits reduced RR and reduced work of breathing. By discharge, child has
decreased respiratory secretions, as evidenced by RR <20/min.
Assessments and interventions Rationales
Assess level of consciousness, RR, breath sounds, work of Early identification of reduced consciousness, increased RR,
breathing, and skin color q1-2h. wheezing, and cyanosis, and increased WOB ensures prompt
intervention.
Assess HR, RR, O2 saturation, and breath sounds before and Tachycardia is an adverse effect of racemic epinephrine.
after nebulizer treatment.
Administer racemic epinephrine or albuterol with handheld Racemic epinephrine will open the airway and reduce work of
nebulizer. breathing.
Instill saline nose drops, wait 1-2 min, and suction nares before Saline drops before suctioning loosens secretions.
feedings.

related to edema of the bronchial mucosa and increased mucus
Desired Outcomes: Following interventions, child attains O2 saturation >94%. By discharge, child maintains O2 saturation >94% on
room air.
Assess for signs of hypoxia, such as restlessness, decreased Close observation allows for early detection of hypoxia.
consciousness, dyspnea, or cyanosis.
Assess level of consciousness, RR, breath sounds, increased Assessment of Respiratory status ensures early identification of
work of breathing, such as nasal flaring, retractions, use of ac- hypoxia.
cessory muscles.
Assess vital signs q2-4h. Hypoxia causes tachypnea and tachycardia. Bradycardia and
bradypnea are signs of respiratory arrest.
Maintain continuous oximetry and document at least q2h. Oximetry monitors O2 saturation and alerts the nurse to hypoxia.
Provide humidified O2 via nasal cannula to maintain O2 satura- Humidity helps to liquefy mucus.
tion >90%.
Report O2 saturation <90%. O2 saturation <90% indicates deteriorating respiratory condition.
Position child with head elevated. Children are diaphragmatic breathers until 7 years of age.
Use cardiorespiratory monitor for infants with a history of apnea. This monitor ensures rapid detection of apneic episodes.

related to increased insensible loss caused by increased RR, fever, increased metabolic rate, and reduced intake
Burns' 192
Desired Outcome: Within 4 hr treatment, child has adequate fluid volume, as evidenced by alertness and responsiveness, moist
oral mucous membranes, good skin turgor, and urine output >2-3 mL/kg/hr.
Assess hydration status: level of consciousness, oral mucous The child may become dehydrated because of increased insen-
membranes, and urine output q4h. sible losses.
Assess intake and output q2h. Weigh diapers. These assessments detect volume deficit.
Administer daily maintenance fluids based on weight Daily maintenance fluids:
Up to 10 kg: 100 ml/kg/24 hr. 10-20 kg: 50 ml/kg/24 hr. More than
20 kg: 20 ml/kg/24 hr.
Offer frozen juices, Popsicles, Pedialyte, Rice-Lyte, breast milk, Fluids help to liquefy secretions.
formula.
Burns' 193
Burns
Diagnosis: Deficient Fluid Volume related to fluid shift from the intravascular to interstitial compartment, increased metabolic de-
mands, and reduced intake
Desired Outcomes: Within 4 hr intervention, child has adequate fluid volume, as evidenced by urine output >2-3 mL/kg/hr.
Assess hydration status q4h: Assess level of consciousness, oral Signs of dehydration include decreased LOC, sunken fontanel,
mucous membranes, and urine output. dry mucous membranes, and reduced urine output.
Assess intake and output q2h. Maintain urine output >1 ml/kg/hr This assessment maintains adequate fluid intake and output.
Assess vital signs q4h. Hypovolemia may result from decreased blood volume second-
ary to plasma loss through burns. Tachycardia and decreased
LOC are early signs of shock.
Assess daily weights. Weight changes are indicators of fluid loss or gain.
Administer IV fluids. Fluid resuscitation is required in children with burns >10% of
body surface. Fluids maintain circulation to vital organs.

related to thermal injuries
Desired Outcome: Within 1 hr after intervention, the child's pain level is reduced to <3 on a 0-10 scale.
Assess the child's developmental level and pain on a 10-point A pain scale measures changes in pain and the degree of relief
scale. Assess level of pain q2-4h. provided by treatment.
Provide pain medications Scheduled, rather than prn, pain relief provides better pain control.
on a schedule.
Teach the patient to operate the patient-controlled analgesia A child is capable of pushing the button on the
(PCA) pump. pump by 5-6 yrs of age.
Premedicate the child before painful procedures. Use topical An analgesic before painful procedures will reduce pain.
anesthetic before blood draws or IV insertion.
Diagnosis: Impaired Skin Integrity

related to burn injury
Desired Outcomes: The burn injury site heals without infection, as evidenced by lack of drainage, erythema, or pain. Superficial
burns heal within 7 days; deep burns heal within 30 days.
Assess child and wound q4h for signs of infection. These assessments ensure prompt recognition of signs of infec-
tion, such as drainage, erythema, and pain.
Clean wound as prescribed. Cleansing of the wound removes necrotic skin and bacteria, and
decreases the risk of infection.
Debride wound as prescribed. Debridement promotes healing by removing dead tissue, which
enhances healing.
Apply ointment and dressings as prescribed using sterile tech- These measures protect the wound and decrease risk of infection.
nique.
Burns' 194
Perform range-of-motion exercises on the affected joints. Range-of-motion exercises promote reabsorption of edema, pre-
vent contractures, and enhance healing.
Position for minimal pressure on wound. Position to protect wound/graft and keep sheets/blankets away
from the graft site.
Administer high-calorie, high-protein meals and snacks. Burn injury increases the requirements for calories and protein.

related to loss of skin barrier, altered nutritional status, and invasive procedures or lines.
Desired Outcome: Child exhibits wound healing without signs of wound infection, such as drainage, erythema, pain, or systemic
infection.
Assess vital signs q4h for temp >38.5° C, HR >100 bpm, or >RR Signs of infection include tachycardia, tachypnea, and fever.
30 breaths/min.
Monitor for signs of pneumonia q4h. Pneumonia presents with fever, cough, chest pain, and tachyp-
nea.
Screen visitors for upper respiratory infections. The child is at greater risk for infection because of open wounds.

related to hypermetabolic state and reduced appetite
Desired Outcome: Within 1 wk of intervention, child exhibits adequate nutrition, as evidenced by stable weight.
Weigh the patient daily. Weight is a reliable indicator of nutritional status.
Provide high-calorie, high-protein meals and snacks. Children are at risk for protein and calorie deficiency. Nutrients are
needed for wound healing.
Offer small, frequent meals. 5 small meals/day will be better tolerated than 3 large meals/day.
Assess for constipation or diarrhea. Constipation is caused by reduced activity and intake.
Diagnosis: Disturbed Body image

related to altered appearance
Desired Outcomes: Child discusses feelings related to change in appearance. Within 3 days, the child expresses realistic expecta-
tions for physical appearance.
Point out positive aspects of the child's appearance. Positive comments will improve the child’s self-esteem.
Point out evidence of healing. Sings of healing will increase the child’s sense of hope.
Encourage the child to provide for self-care. Self-care will increase the child’s positive self-image.
Arrange for continued schooling. Schooling reduces isolation and improves self-image.
Promote peer contact if possible. Prepare peers for the child's These measures will facilitate acceptance and support of the child.
appearance.
Assist the child in devising a plan to cope with the negative reac- This will increase sense of control. Role-playing may prepare the
tions of others. child for negative reactions.
Discuss ways that the child can conceal disfigurement. Clothing, wigs, and makeup will facilitate coping.
Burns' 195
Cerebral'Palsy' 196
Cerebral Palsy

related to chewing and/or swallowing difficulty
Desired Outcome: Within 1 wk of intervention, the child exhibits increased food intake and gains weight.
Assess intake and output q6h. Balanced I&O indicate that the child is receiving adequate fluids.
Weigh the child weekly Maintaining or gaining weight indicates that the child is receiving
adequate nutrition. If weight is decreasing, liquid nutritional sup-
plements should be given.
Provide high-calorie meals and snacks. The child will need increased calories because of muscle spastici-
ty.
Teach child to self-feed. Self-feeding may increase intake by enhancing the child’s control.
Place child upright for feeding. Upright positioning reduces aspiration and gastroesophageal re-
flux.
Place the feeding spoon in the middle of child's mouth and apply This measure prevents tonic bite reflex and tongue thrust. .
pressure on the tongue.
Hold the child’s jaw with your hand. This promotes jaw control and facilitates chewing and swallowing.
Ensure that child is receiving adequate nutrients. Some children are unable to take sufficient nutrients orally be-
cause of difficulty swallowing.

related to physical disability, perceptual or cognitive impairment, or seizures
Desired Outcomes: Child remains free from trauma and parents understand safety precautions.
Teach the family about childproofing the home. Childproofing decreases child's risk for trauma.
Remove furniture with sharp edges.
Remove throw rugs.
Remove small or sharp objects.
Use a protective helmet for the child.
Advise family of seizure precautions. This will protect the child from falling out of bed and will prevent
Keep side rails up when child is sleeping. the child from being injured during a seizure.
Keep side rails padded.
Advise family to secure child when he is in a wheelchair or mo- This information prevents injury caused by spasticity, posturing, or
tor vehicle. lack of muscular control.
Encourage safe toys for developmental age. Sharp, small, or easily shattered toys should not be allowed.

related to neuromuscular impairment
Desired Outcome: Within 1 month after intervention, child demonstrates improved mobility; and parents demonstrate use of orthotic
devices, walker, or wheelchair.
Encourage sitting, crawling, and walking. These tasks help to strengthen muscles.
Cerebral'Palsy' 197
Instruct child and parents in correct use of splints and braces. Orthotic devices prevent contractures, protect skin, and improve
joint function.
Encourage correct use of mechanical aids, such as rolling walk- Mechanical aids improve mobility.
er or wheelchair.
Diagnosis: Bathing, Dressing, Feeding, Toileting Self-Care Deficit

related to neuromuscular impairment
Desired Outcome: Within 1 month of intervention, child begins to perform activities of daily living.
Teach child to assist with care. This facilitates independence in self-care.
Use toys and activities that encourage motor and sensory activi- Improved fine motor control will promote self-care tasks.
ty.
Encourage use of adapted clothing and utensils and consump- Clothing that opens up in front with Velcro closures, shoes with
tion of finger foods. Velcro large spoons with padded handles, and finger foods, facili-
tate self-care.
Encourage good oral hygiene and regular dental care. Teeth should be brushed after every meal with a soft toothbrush,
and the child should see dentist q6mo. Cleaning should begin at 2
yrs.
Diagnosis: Impaired Verbal Communication

related to hearing loss, neuromuscular impairment, and impaired articulation
Desired Outcome: Within 1 month of intervention, the child's communication ability improves.
Consult with speech therapist if the child has difficulty with artic- Interventions maximize speech and feeding skills in children with
ulation or feeding. poor control of oral musculature.
Encourage jaw control exercise and feeding techniques. Increased control of oral musculature improves ability to chew,
swallow, and speak.
Encourage use of communication aids for child. Communication aids, such as computers, communication boards,
and voice synthesizers facilitate communication.

Desired Outcome: Following teaching, child and parents state accurate information about medications.
- Benzodiazepines (diazepam) Diazepam relieves muscle spasticity.
- Baclofen Baclofen is a centrally acting skeletal muscle relaxant.
- OnabotulinumtoxinA (Boto24)-administered IM or intradermally OnabotulinumtoxinA treats muscle contractures.
Child'Abuse'and'Neglect' 198
Child Abuse and Neglect
Diagnoses: Risk for Trauma

related to neglect or physical, emotional, or sexual abuse
Desired Outcome: Following intervention, child exhibits no signs of abuse or neglect.
Assess the bruises, scars, or unusual emotional responses. A thorough evaluation should be done.
Observe the interactions between child and family. A child who is neglected may not want to be held or may avoid
eye contact.
Obtain a detailed history. Lack of correlation between the history and the severity of trauma
suggests abuse.
Keep factual, detailed, objective documentation. Records should include:
Physical description of lesions
Pictures should be dated and placed in the child’s chart.
Child's behavioral response to parents
Comments by the child or parents.
Report all cases of suspected child abuse or neglect. Health care workers are required by law to report child abuse or
neglect
Keep the child in a safe environment in the hospital. The suspected abuser should usually be restricted from visiting.
Refer families to social agencies for assistance with finances, These measures help relieve the financial and social causes of
food, clothing, and health care. neglect
Diagnosis: Risk for Impaired Parenting

related to the caregiver's unrealistic expectations of the child. Temperament
Desired Outcome: Within 1 wk following interventions, parents demonstrate more positive interactions with the child and under-
stand normal child expectations.
Identify families at risk for abuse or neglect. Abuse and neglect is associated with young, single parents; par-
ents who were abused as children; premature infants; parental
substance abuse; and limited social support.
Assess the parents' strengths and weaknesses, coping behav- This assessment facilitates creation of a parenting plan and refer-
iors, and support systems. rals.
Demonstrate age-correct communication and discipline. Parents may have unrealistic child-rearing expectations.
Teach behavior modification techniques, such as rewards, Parents should learn non-violent methods of discipline.
time-outs, consequences, and verbal disapproval.
Teach family about physical, psychosocial, and cognitive de- This reinforces accurate expectations of what is normal for the
velopment. child.
Refer family for financial support, housing, and employment This helps to reduce the risk factors for abuse and neglect.
assistance.
Cystic'Fibrosis' 199
Cystic Fibrosis

related to thick mucus in the airways
Desired Outcome: Following interventions, child expectorates mucus and has improved airway clearance, as evidenced by de-
creased rhonchi and RR <20/min.
Assess HR, RR, and breath sounds. Ineffective airway clearance will cause tachycardia and tachypnea.
Decreased breath sounds and rhonchi may be detected.
Assess HR, RR, breath sounds, and O2 saturation before nebu- Assessment before and after treatments evaluates the effective-
lization and after chest physiotherapy. ness of the treatments.
Position child in an upright sitting position. The upright position facilitates inhalation of medication and in-
creases cough effectiveness.
Administer nebulized albuterol 1 hr before or This treatment opens bronchi and improves nutrient ingestion.
2 hr after meals.
Perform chest physiotherapy after nebulizer treatment. Physiotherapy loosens secretions and facilitates expectoration.
Physiotherapy is performed 2-4 times/day.
Chest percussion and postural drainage for 20-30 min Chest percussion loosens secretions for postural drainage.
Mucus clearance device, such as a flutter valve, should be used This handheld, pipe-like device has a plastic mouthpiece on one
for 5-15 min end. Exhaling into the device vibrates the airways, loosening pul-
monary mucus.
Airway clearance system (the Vest) This inflatable vest provides high frequency chest wall vibrations
to loosen secretions and increase mucus expectoration.
Suction as necessary. Infants and young children with large volumes of mucus may need
suction to remove secretions.
Administer maintenance fluids. Hydration thins and loosens secretions.
Administer dornase (Pulmozyme). Pulmozyme thins mucus and facilitates expectoration.

related to airway obstruction caused by air trapping in the alveoli and excessive airway mucus
Desired Outcome: Within 2 hr of intervention, the child has adequate gas exchange, as evidenced by O2 saturation >94%.
Along with vital signs, assess respiratory status q4h. Tachycardia, tachypnea, chest retractions, increased work of
breathing, and use of accessory muscles are signs of respiratory
distress.
Continuously monitor pulse oximetry and report saturations Decreased O2 saturation indicates the need for oxygen supple-
<94%. mentation.
Position the child in high Fowler's position, leaning forward. This position promotes optimal gas exchange by enabling maxi-
mum chest expansion.
Deliver humidified O2. Humidity replaces convective moisture losses.

related to reduced appetite or increased metabolic requirements and malabsorption.
Desired Outcome: By discharge, patient maintains or gains weight and has <3 stools per day.
Assess daily and weekly weight. This assesses the effectiveness of nutritional interventions.
Administer pancreatic enzymes with meals for pancreatic insuf- Replacement of enzymes facilitates digestion and absorption of
ficiency. nutrients.
Mix powdered pancreatic enzymes with a carbohydrate food if Protein foods break down pancreatic enzyme. 2 tsp of applesauce
the child is unable to swallow capsule. help the child ingest the enzyme.
Do not administer pancreatic enzymes with formula or milk. Pancreatic enzymes curdle milk and formula. The child may not
receive all the medication and may refuse milk/formula.
Monitor frequency and appearance of stools. Reduce the dosage of pancreatic enzymes for constipation. In-
creased pancreatic enzymes are given for frequent, bulky, stools.
Provide a well-balanced, high-calorie, high-protein, high fat diet. Impaired intestinal absorption necessitates increased dietary sup-
plementation.
Provide adequate salt, especially with fever or hot weather. The patient is at risk for hyponatremia because of high sodium
concentration in sweat.
Administer supplemental tube feedings or total parenteral nutri- Supplemental feedings or TPN provide increased calories.
tion.
Position child in the upright position during and for 1 hr after The upright position decreases gastroesophageal reflux.
eating.

Desired Outcome: Within one week, patient and parent state accurate information about medications.
Aerosolized Bronchodilators: Albuterol Albuterol opens the bronchioles and promotes expectoration of
mucus.
Assess for palpitations, tachycardia, tremors, dizziness, and These are adverse effects, which may require dosage adjustment.
headache.
Assess for nervousness, hyperactivity, and insomnia. These are adverse effects that are more common in younger chil-
dren.
Aerosolized Mucolytic Enzymes: Dornase Alfa (Pulmozyme) Dornase reduces the viscosity of pulmonary mucus and prevents
infections. A special nebulizer unit is used.
Assess for hoarseness, laryngitis, rash, and chest pain. Do not Adverse effects of dornase usually subside within a few weeks.
mix Pulmozyme with other drugs in the nebulizer. Mixing with other drugs may deactivate the enzyme.
Aerosolized Antibiotics: Tobramycin Tobramycin prevents pulmonary infection.
Give bronchodilator first, then chest physiotherapy, then give Absorption of Tobi is enhanced by clearance of the airways of
other inhaled medications, and give tobramycin last mucus.
Monitor the serum aminoglycoside level. Some patients are significant absorbers of tobramycin and are at
risk for ototoxicity and nephrotoxicity.
Pancreatic enzymes: Take oral pancreatic enzymes 30 minutes Pancreatic enzymes break down food for absorption.
before eating.
Open capsule and give enzymes in a small amount of nonfat, Pancreatic enzymes will be deactivated if premixed with protein
nonprotein food, such as 1-2 tsp applesauce. food.
Do not mix enzymes with milk or formula. Pancreatic enzymes will curdle milk or formula.
Monitor stools. Constipation or increased frequency of stools (>3 stools/day) indi-
cates the need to reduce or increase the dosage of pancreatic
enzymes.
Assess for nausea, abdominal cramps, These are adverse effects that may indicate the need for dosage
constipation, or diarrhea. adjustment.
Take fat-soluble vitamins in water-miscible form. The water-miscible form is better absorbed.
Intravenous Ticarcillin and Tobramycin are administered for 10 Antibiotics are used to treat lung infections. Children with CF have
days. frequent respiratory infections and often develop drug resistance.
Administer ibuprofen Ibuprofen slows the rate of pulmonary decline improves growth
and reduces hospitalizations.
Administer azithromycin Azithromycin improves lung function, increases weight gain, and
reduces hospitalizations.
Diabetes Mellitus

related to unfamiliarity with blood glucose monitoring
Desired Outcome: Within 48 hr, child and family demonstrate and state accurate understanding of blood glucose monitoring.
Explain reasons for blood glucose testing. Blood glucose testing allows for adjustment of the insulin dosage
and diet
If blood glucose is >250 mg/dL or if child is ill, check urine for Stored body fats are used for energy because blood glucose can-
ketones. not be used for energy. Ketone bodies are by-products of fat
breakdown and cause DKA.
Teach use of log to record blood glucose levels, insulin dose, The log assists the physician in making adjustments based on the
and diet. glucose pattern.
Instruct family about when to call physician about glucose levels Parents should call if the blood glucose is >250 mg/dL or if blood
or ketones. glucose is <70 mg/dL or ketones are moderate or large.

related to unfamiliarity with causes, symptoms, and treatment of hypoglycemia and hyperglycemia
Desired Outcome: After teaching, child and family state an understanding of the causes, symptoms, and treatment of hypoglycemia
and hyperglycemia.
Explain the definition of hypoglycemia. Hypoglycemia is a low blood glucose <60 mg/dL. Hypoglycemia
should be treated promptly.
Explain the causes of hypoglycemia. Causes of hypoglycemia include inadequate food or not eating as
scheduled; increased exercise with no increased intake; excessive
insulin dosage.
Teach the child and family to recognize the symptoms of hypo- Symptoms of hypoglycemia should cause the family to check the
glycemia. blood glucose level.
Early signs of hypoglycemia include tremors, sweating, anxiety,
and hunger.
Later signs of hypoglycemia are dizziness, irritability, slurred
speech, loss of coordination, and decreased consciousness.
Teach child and family to assess and treat hypoglycemia. Treatment of hypoglycemia includes:
Checking blood sugar to determine if child is hypoglycemic.
If glucose is <60 mg/dL, give 15 g of carbohydrates, such as 4 oz
orange juice, 6 oz regular soda, 4 glucose tablets.
Teach the definition of hyperglycemia. Hyperglycemia is defined as blood glucose levels >250 mg/dL.
Teach the child and family the causes of hyperglycemia. Hyperglycemia can result from increased food intake, inadequate
insulin, reduced exercise, infection, or illness.
Teach the symptoms of hyperglycemia. Symptoms include polydipsia, polyuria, polyphagia, fatigue, fruity-
smelling breath, and weight loss.
Explain the treatment for hyperglycemia. If blood glucose level is >250 mg/dL, urine should be checked for
ketones.
If ketones are large, the physician should be contacted.
Advise child or family to call physician if blood glucose is >250 The physician may need to increase the insulin dosage.
mg/dL.
Fractures'R'Pediatric' 204
Fractures - Pediatric

related to fracture and other injury
Desired Outcome: Following intervention, child's pain level is <4 on a 10-point scale.
Assess pain before and after analgesia and q4h. This assessment helps determine degree of pain.
Administer pain medication around the clock for first 24-48 hr Scheduled administration of pain medication reduces pain more
after a fracture. effectively than as needed dosing.
Position, align, and support the fractured extremity. Appropriate positioning reduces tension on the injury and de-
creases pain.
Apply ice and elevate the fractured extremity for the first 48 hr. Ice packs and elevation reduce edema and pain.
Notify physician if relief is not obtained 15 min after IV pain med- Analgesic dosage may need to be increased. Compartment syn-
ication or 1 hr after PO. drome may be developing.
Diagnoses: Risk for Peripheral Neurovascular Dysfunction and Ineffective Tissue Perfusion
related to edema following a fracture
Desired Outcome: Child's neurovascular checks are normal within 24 hr of fracture, as evidenced by digits that are warm and sen-
sitive to touch, good peripheral pulses, and minimal swelling.
Assess neurovascular status (color, sensation, pulses, warmth, These checks assess peripheral neurovascular function in the
swelling) q1h for first 24 hr. Verify that one or two fingers can be injured limb. Paleness, reduced sensation, loss of pulse, coldness,
inserted under the cast opening. or increased swelling is a sign of impaired neurovascular impair-
ment.
Assess for symptoms of peripheral neurovascular dysfunction. Increasing pain on passive movement of the digits and numbness
or tingling is a sign of peripheral neurovascular dysfunction.
Elevate the involved extremity. Elevation reduces edema and increases tissue perfusion.
Apply an ice pack to the injury for the first 48 hrs. Swelling is most severe during the first 48 hr. Ice reduces edema
and promotes tissue perfusion.
Notify the physician if tissue perfusion declines from baseline. Compartment syndrome may be developing.
Check that the child is able to move his digits. Moving toes or fingers in the affected limb promotes circulation by
decreasing edema. Inability to move digits is a sign of compart-
ment syndrome.
Diagnosis: Risk for Impaired Skin Integrity

related to presence of immobilization device (splint, cast)
Desired Outcome: Child's skin remains intact while wearing the immobilization device.
Assess for redness or irritation caused by the immobilization de- Assessment allows for early detection of impaired skin integrity.
vice every 2 hours.
Check edges of immobilization device for roughness.
Fractures'R'Pediatric' 205
Palpate the space under the edges of the immobilization device A tight cast will cause pressure, reduced tissue perfusion, and
for tightness q4h. skin breakdown.
Instruct patient not to put powder under the cast. Powders may cake and cause skin irritation and breakdown.
Encourage the family to use cool air from fan to relieve itching. Cool air may prevent the child from scratching and causing skin
breakdown.
Warn child and family not to put anything inside the cast to Scratching can cause skin breakdown or the object may be-
scratch the skin. come lodged inside cast.
Teach position changes q2-4h. Position changes promote circulation and prevent prolonged
pressure.
Gastroenteritis' 206
Gastroenteritis

related to fluid loss caused by fever, vomiting, diarrhea
Desired Outcome: Within 4 hr of intervention, the child exhibits adequate hydration, as evidenced by responsiveness, moist oral
mucous membranes, and urine output >2 mL/kg/hr.
Weigh the child daily. Weight loss indicates inadequate fluid replacement.
Assess vital signs q4h. Report abnormalities to physician. Tachycardia and normal BP occurs in compensated shock. Hypo-
tension is a sign of decompensated shock. Dehydration can
quickly progress to shock in infants and young children.

related to irritation caused by frequent stooling
Desired Outcome: Child's perineal and perianal skin remains intact.
Assess perineal and perianal areas for inflammation or excoria- Early detection of skin breakdown will facilitate appropriate inter-
tion from diaper changes. ventions.
Cleanse buttocks gently with water. Soap will dry the skin by removing normal moisturizing skin oils.
Do not use baby wipes with alcohol or perfume or baby powder These products are painful to irritated skin.
on irritated skin.
Apply protective Vaseline, A&D, or zinc oxide to diaper area. Protective ointments protect the skin from irritation.
Leave the diaper area open to air. This practice facilitates drying and healing.

related to gastroenteritis and lack of knowledge about prevention of transmission
Desired Outcome: Following intervention, family members are free of symptoms of gastroenteritis.
Implement Standard Precautions and Transmission-Based Pre- Standard precautions decrease the risk of transmission of infec-
cautions. tion and include hand hygiene and wearing gloves when changing
diapers.
Properly dispose of linen and other soiled items. This will prevent spread of infection.
Instruct family members and visitors in protective measures and These instructions decrease the risk of spreading infection.
handwashing.

related to inadequate intake and fluid loss caused by vomiting, diarrhea, and fever
Desired Outcome: Within 24-48 hr of intervention, child maintains or gains weight.
Assess weight on admission and daily. These evaluations ensure adequate nutrition.
Encourage continued breastfeeding. This practice maintains adequate nutrition.
Gastroenteritis' 207
Resume regular diet after the child is rehydrated. Enteral nutrition stimulates regrowth of intestinal cells. Fasting
causes gut atrophy.
Instruct the family to provide diet of well-cooked meats, vegeta- A nutritious diet promotes regrowth of intestinal cells.
bles, rice, potatoes, and breads.
Otitis'Media' 208
Otitis Media

related to middle ear infection and middle ear pressure
Desired Outcome: Child is free from pain or has significantly reduced pain (<2 on a numeric scale 0-10) within 1 hr after interven-
tion.
Assess pain level q4h using pain scale. A pain scale enables accurate assessment of relief of pain.
Administer antipyretics and analgesics, such as acetaminophen Scheduled dosing provides control of fever and pain. Overdosage
on a schedule q4-6h or ibuprofen q6-8h. of acetaminophen may cause hepatic necrosis.
Administer antibiotics AOM improves with antibiotic therapy.
Administer analgesic otic drops if prescribed. Analgesic drops relieve severe ear pain.
Position for comfort Positioning reduces pressure on the TM.

with affected ear in a dependent position.

related to losses caused by fever and reduced intake
Desired Outcome: Within 24 hr of intervention, child is alert and responsive, oral mucous membranes are moist, and urine output is
>2 mL/kg/hr.
Assess hydration status q4h. Assessment of dehydration facilitates rapid treatment of dehydra-
tion.
Advise parents when to call physician regarding dehydration. Parent should call physician if:
Child is not as alert as usual
Anterior fontanel sunken
inside of mouth is dry
Offer child small amounts of fluid and soft food. Chewing can increase ear pain.

related to unfamiliarity with otitis media and prevention
Desired Outcome: Immediately following teaching, parents state understanding of otitis media and prevention of OM.
Describe the different types of OM Acute otitis media is infection of middle ear with fever and pain.
Otitis media with effusion is an infection of middle ear with fluid
behind the TM.
Discuss preventive feeding practices. Feeding practices that prevent OM in infants include feeding in an
upright position to facilitate drainage and not putting the infant to
bed with a bottle.
Poisoning' 209
Poisoning
Diagnosis: Risk for Poisoning

related to lack of parental knowledge about prevention of poisoning
Desired Outcome: Child does not ingest, inhale, or touch toxic substances, and parents state understanding of home childproofing.
Discuss areas in need of childproofing, such as the kitchen, Knowledge of childproofing reduces the risk of toxic exposures.
storage areas, and bathroom.
Teach about poisonous materials in the home. Poisons include cleansers, disinfectants, cosmetics, insecticides,
mouthwashes with alcohol, rubbing alcohol, liquid dishwasher de-
tergent, foreign bodies and toys, toxic plants, hydrocarbons, and
medications
Describe home childproofing. Put childproof locks on kitchen, and bathroom cabinets.
Make sure all poisons are out of reach in locked cabinets.
Buy medications with child-resistant caps
Do not store poisonous substances in food containers.
Install a carbon monoxide detector.
Do not refer to medicine as "candy." The child may think that the medicine is harmless and tastes good.

related to unfamiliarity with first aid for toxic exposures and poisonings
Desired Outcome: Following teaching, parents state accurate knowledge of steps to take after accidental poisoning.
Post the phone number for the Poison Control Center on A poison control center should be called for ingestion of a toxic
phones. substance if the child is conscious. If the child is unconscious, 911
should be called.
Remove any remaining poison from the child’s mouth and call This knowledge reduces absorption of poisons.
PCC.
If poison is on the skin, remove contaminated clothing and rinse
the skin with water. Call PCC.
If poison is in the eye, flush the eye with lukewarm water for 15
min.
Sickle'Acute'Painful'Crisis' 210
Sickle Acute Painful Crisis

related to tissue anoxia caused by vasoocclusion
Desired Outcomes: Child states that pain has decreased within 1 hr of oral medication. Pain is <2 on a 5-point scale.
Assess pain level q2h. A pain scale monitors the degree of pain relief.
Assess hydration status q4h. Assess the oral mucous mem- This evaluation detects dehydration.
branes and urine output
Give scheduled pain medication. Scheduled pain medication lowers the total amount of medication
used.
Diagnoses: Risk for ineffective Cerebral Tissue Perfusion

related to vasoocclusion and anemia
Desired Outcomes: Within 2 hr of intervention, the child's oxygen saturation is >94%.
Assess respiratory and mental status q2h. Frequent assessment detects changes in respiratory status.
Monitor pulse oximetry. Oximetry is a noninvasive method of measuring oxygen satura-
tion.
Administer oxygen to keep saturation >94%. Oxygen reduces work of breathing.
Elevate the head of bed Elevation of the HOB facilitates chest expansion.

related to unfamiliarity with sickle cell disease and measures used to prevent vasoocclusive crises
Desired Outcome: After teaching, child and family state an understanding of sickle cell disease, painful crises, treatment, and the
genetics of transmission.
Teach the child and family about SCD and measures to mini- Penicillin and folic acid should be taken. Immunizations should be
mize sickling. given, and dehydration should be avoided. Exposure to ill individ-
uals and high altitudes should be avoided.
Explain symptoms of pain crisis and the treatment. Knowledge about acute painful crises prevents severe crises. An
infant or toddler may display inconsolability, when he is in pain.
Discuss treatments for pain crises. The severity of pain crises may be reduced by increasing fluid.
Explain the transmission of sickle cell disease and refer for ge- This information enables the family to make reproductive deci-
netic counseling. sions.

related to unfamiliarity with precautions and adverse effects of medications
Desired Outcome: After teaching, child and family state accurate information about medications, and adverse effects.
Teach the child and parent about morphine sulfate Morphine is an IV opioid analgesic administered in hospital.
Sickle'Acute'Painful'Crisis' 211
Assess child for level of sedation, pain relief, oxygen saturation, This assesses the effect of medications and need for adjustment.
and respiratory and cardiac status. Morphine can cause respiratory depression, resulting in de-
creased O2 saturation.
Assess for drowsiness, itching, vomiting, constipation, and hypo- Adverse effects suggest that a change may require a decrease in
tension. dosage.
Acetaminophen with Codeine This medication is an opioid analgesic and antipyretic.
Assess for palpitations, drowsiness, itching, vomiting, hypoten- These adverse effects may require a reduction in dosage.
sion, and respiratory depression.
Assess if pain has reduced within 1 h hr. If no relief occurs after This assesses the effectiveness of medication.
the physician should be notified.
Ibuprofen Ibuprofen reduces pain when administered with morphine or co-
deine.
Folic acid Folic acid helps the bone marrow to regenerate blood cells.
Penicillin Prophylactic penicillin prevents infection and sepsis.
Teach that daily administration of penicillin is necessary until the Penicillin lowers the risk of pneumococcal septicemia.
child is 5-6 yr old.
Administer docusate when giving opioids. Docusate prevents constipation caused by opioids.
Ensure that the child is receiving maintenance fluids. Fluids reduce constipation and prevent recurrence of acute painful
crises.
Acetaminophen is administered for mild pain. This analgesic reduces pain.
Hydroxyurea Hydroxyurea increases production of Hgb F, which prevents sick-
ling of RBCs and prevents vasoocclusive crises.
Bleeding'in'Pregnancy' 212
Maternity Nursing
Bleeding in Pregnancy
Diagnoses: Risk for Bleeding

related to spontaneous abortion, ectopic pregnancy, placenta previa, or abruptio placenta
Risk for Shock
related to hypovolemia
Desired Outcome: Within 2-3 hr of intervention, patient has a urinary output >30 mL/hr BP 90-130/60-80 mm Hg, HR 60-100 bpm,
and a reactive FHR.
Assess volume of blood loss, including color and the source. One gram of peripad blood represents 1 ml of blood lost.
Weigh peripads and count the number of soaked pad.
Assess for pain and fever. Uterine cramping with hemorrhage is a sign of spontaneous abor-
tion. Painless vaginal bleeding in the third trimester indicates pla-
centa previa. Severe abdominal pain may indicate abruption (with
or without dark red bleeding).
Assess for reduced pulse pressure, tachycardia, cool clammy Abnormal vital signs reflect the degree of hemorrhage and the
skin, decreased mentation, and hypotension. need for fluid replacement.
Assess vital signs q5-15min. Secure IV access with a large-bore IV access is necessary for IV fluids and blood.
catheter.
Obtain a blood sample for CBC and type and crossmatch. Packed red blood cell transfusion will often be needed.
Administer and monitor transfusion of packed red blood cells. Excessive infusion of fluids causes fluid overload and pulmonary
Monitor for fluid overload (dyspnea). edema.
Insert a Foley catheter and monitor urine output. Maintain urine output at >30mL/hr.
Monitor CBC, INR, PTT, and hemoglobin levels. Transfusion of packed RBCs raises the Hb by 1 g/dL and raises
the Hct by 3%. Platelet transfusions increase platelets by
3
5000/mm /unit. Hct should be maintained >30%.
Administer oxygen by face mask at 8 L/min. Oxygen increases oxygen tension in the blood.
Avoid the supine position. Use a hip wedge or place in the side- The lateral position prevents compression of the aorta by the uter-
lying position. Change position q30min while the patient is us.
awake.
Save the expelled placenta, membranes, or fetus for pathologic Tissue remaining in the uterus may cause prolonged bleeding.
examination.
Prepare for dilation and curettage for missed or incomplete Dilation and curettage is necessary for missed or incomplete abor-
abortion. tion; laparotomy may be necessary for ectopic pregnancy. Cesar-
ean delivery may be necessary for placental abruption or previa.

related to decreased maternal circulation to the utero-placental unit
Desired Outcomes: Oxygenation and perfusion to the fetus is adequate, as evidenced by FHR accelerations and reassuring FHR
pattern of 110-160 bpm, and no late decelerations.
Bleeding'in'Pregnancy' 213

Monitor for fetal distress monitoring after 20 weeks gestation. Reactive FHR tracing indicates good fetal oxygenation. Nonreac-
tive FHR is a sign of fetal hypoxia. The early fetal response to
hypoxia is tachycardia. Bradycardia is a sign of severe hypoxia.
Administer oxygen by face mask at 8-10 L/min. Oxygen supplementation increases oxygen delivery to the fetus.
Avoid the supine position. Use a hip wedge or the side-lying These positions ensure adequate fetal circulation. A hip wedge
position. prevents compression to the aorta by the uterus.
After 20 wk gestation, assist with amniocentesis and tocolysis. Assessment of fetal lung maturity will aid in determining the best
management.
When the fetus is at 20 wks or later gestation, the neonatal re- Delivery of a compromised newborn may require resuscitation.
suscitation team should be called before delivery. The fetus is unable to sustain life before 20 wks.

related to uterine contractions, cervical enlargement, or ectopic pregnancy
Desired Outcomes: Within 1 hr of intervention, the patient's pain is reduced to <3 on a 0-10 scale.
Assess location, type of pain, and severity. The characteristics and location of pain will suggest a cause.
Cramping pain occurs with spontaneous abortion.
Assess pain q1h. Increased pain indicates rupture of an ectopic pregnancy or uter-
us.
Position for comfort in the left lateral position. Positioning in labor improves cardiac output and enhances effec-
tiveness of uterine contractions.
Facilitate analgesia by an anesthesiologist. Ensure adequate pain relief by epidural analgesia.

related to unfamiliarity with effects of bleeding on the fetus and patient and the treatment regimen
Desired Outcomes: Following instruction, patient states an understanding of her condition, therapeutic procedures, and complica-
tions.
Explain diagnosis to patient and spouse. Explain the maternal Explanations will decrease apprehension.
and fetal condition.
Address the patient’s concerns and questions. Encourage the Patient and family preferences should be included in the decision
patient and partner to participate in the decision-making. making process.
Diabetes'in'Pregnancy' 214
Diabetes in Pregnancy
Diagnosis: Risk for Unstable Glucose Level

related to hormonal changes during pregnancy
Desired Outcome: Euglycemia is maintained, as evidenced by blood glucose and hemoglobin A1c measurements.
Prenatal: Assess the patient's hemoglobin A1c and blood glu- Hemoglobin A1c >8% cause congenital anomalies. Target fasting
cose. glucose is <95 mg/dL and 2-hr postprandial <120 mg/dL.
Assess daily diet compliance with the American Diabetic Associ- GDM may be controlled by diet low in simple sugars and high in
ation diet. whole grains and vegetables.
Explain to the patient that insulin administration may be neces- Insulin requirements double in the third trimester. Diet often fails
sary. to keep fasting glucose <100 mg/dL.
Assess administration of insulin by the patient. The nurse should ensure that the patient's technique is correct.
Assess fundal height and gestational age. Hyperglycemia increases the risk of macrosomia.
Intrapartum: Assess blood glucose levels hourly. Maintenance of euglycemia (75-126 mg/dL) in labor decreases
the risk for neonatal hypoglycemia.
If blood glucose is >126 mg/dL, begin insulin infusion at 2 Blood glucose requirements need to be careful during labor.
units/hr.
Postpartum: Assess fasting blood glucose level. After the placenta is expelled, human placental lactogen (hPL)
declines, and the insulin resistance resolves. Supplemental insulin
usually is no longer needed.

related to unfamiliarity with the effects of diabetes the fetus and the patient.
Desired Outcome: Following teaching, the patient states accurate knowledge about the effects of diabetes on the fetus and follows
the treatment regimen.
Explain to the patient how diabetes affects the pregnancy. An informed patient is more likely to perform frequent blood glu-
cose checks and insulin injections.
Teach adherence to daily glucose testing, diabetic diet, and ex- Prenatal visits enable timely modification in the therapeutic regi-
ercise. men.
Teach patients with diabetes about the increased need for insulin Insulin therapy should be started when diet modification fails to
during the pregnancy. keep FBG <100 mg/dL.
Arrange for teaching by a diabetes educator. Diabetes education increases understanding of diabetes.
Teach patient and her spouse the signs and symptoms of hypo- The patient is more likely to experience hyperglycemia and hypo-
glycemia, and diabetic ketoacidosis. glycemia.
Advise the patient to have a snack before exercising. Moderate exercise lowers glucose levels and may cause hypogly-
cemia.
Advise daily fetal movement counts. Fetal movement counts are an indicator of fetal well being from 28
wk. 10 movements within a 2-hr period is reassuring.
Diagnosis: Imbalanced Nutrition: Less Than Body Requirements/More Than Body Requirements
related to inability to follow prescribed dietary regimen for glycemic control
Diabetes'in'Pregnancy' 215
Desired Outcome: Patient follows the diabetic diet plan.

Arrange for a meeting with a dietitian. Nutritional modifications should achieve normal glucose levels.
Teach patient to keep a daily glucose log. A log facilitates adjustment of insulin dosage.
Educate patient about the risks of poor glycemic control. Dietary non-adherence can result in fetal anomalies, fetal macro-
somia, and shoulder dystocia.
Teach the patient to test blood glucose, draw up, and inject insu- This teaching ensures correct compliance with treatments.
lin.

related to unfamiliarity with benefits and adverse effects of insulin used to treat GDM
Desired Outcome: Following teaching, patient and significant other verbalize accurate understanding of the risks and benefits of
insulin.
Advise patient to report tremors, nervousness, headache, and These are signs of hypoglycemia.
glucose <60 mg/dL.
Teach monitoring of blood glucose levels. Test fasting blood glucose fasting (in morning), 2 hr after eating,
and at bedtime.
Lispro (rapid acting), insulin, and NPH (intermediate) Lispro has a rapid onset of action. Insulin does not cross the pla-
centa. Administration of insulin is by SQ injection.
Advise patient to report tremors, nervousness, and low blood These are symptoms of hypoglycemia.
glucose.
Hyperemesis'Gravidarum' 216
Hyperemesis Gravidarum
Diagnoses: Deficient Fluid Volume

Risk for Electrolyte imbalance
related to excessive gastric losses and decreased intravascular volume caused by vomiting
Desired Outcome: 24 hr after interventions, patient has adequate hydration, as evidenced by reduced emesis, balanced intake and
output, and normalize electrolyte status.
Assess the vomiting frequency, duration amount, color, and ab- Assessment allows the nurse to evaluate the effectiveness of
dominal pain. treatments.
Assess for dry mucous membranes, hypotension, tachycardia, With fluid losses, blood and urine become concentrated, circulat-
and increased BUN. ing blood volume declines, BP falls, and tachycardia develops.
Monitor serum electrolytes. Potassium is lost with prolonged vomiting. Muscle weakness is
associated with hypokalemia.
Initiate IV hydration and keep the patient NPO. Add potassium IV fluids correct dehydration and electrolyte deficits.
to IV fluids.
Administer parenteral nutrition if the patient is NPO for >3 days. Parenteral nutrition maintains fetal growth and prevents maternal
malnutrition.
Teach patient to drink liquids between meals and avoid fluids This measure prevents distension of the stomach during meals.
with meals.
Diagnosis: Imbalanced Nutrition: Less than Body Requirements

related to inability to ingest nutrients and calories because of prolonged vomiting
Desired Outcome: Within 1 wk of diagnosis, patient demonstrates improvement in electrolyte and nutritional status.
Initiate enteral feeding or parenteral nutrition. These are methods of providing nutrients and hydration when the
patient cannot ingest oral nutrition.
After nausea resolves, start clear liquids and advance gradually Gradually introduce foods and gradually increases nutrition.
to solid foods.
Suggest frequent, small, dry meals, six per day, with clear liq- Small, frequent, dry meals may decreases vomiting caused by
uids between meals. gastric distention.
Encourage foods with high protein/calorie content 30 min after The patient will be able to absorb protein and calories after reduc-
an antiemetic. tion of nausea.
Advise the patient to avoid food odors, greasy foods, spicy, rich, These measures prevent stimulating the gag reflex.
or sweet foods.
Teach patient to remain in the upright position for 2 hr after eat- The upright position reduces reflux of acid into the esophagus.
ing.
Administer antiemetics, such as pyridoxine (vitamin B6), meto- These therapies reduce nausea.
clopramide (Reglan), or promethazine (Phenergan).
Assess weight daily. Weight changes indicate effective nutritional intake.

related to unfamiliarity with purpose, adverse effects and safety of medications used to treat hyperemesis gravidarum
Hyperemesis'Gravidarum' 217
Desired Outcome: Following teaching, patient states accurate understanding of the risks, benefits, and precautions of antiemetics.
Metoclopramide (Reglan) Metoclopramide stimulates gastrointestinal motility.
Assess for periorbital twitching or muscle contractions of the These are extrapyramidal reactions associated with metoclo-
face, hands, or legs. pramide (Reglan).
Assess for drowsiness, agitation, and diarrhea. These are common adverse effects of metoclopramide.
Promethazine (Phenergan) Antiemetic. PO/IV/IM/rectal.
Assess for blurred vision and drowsiness. These are common adverse effects.
Assess for involuntary movements and hypotension Extrapyramidal reactions appear as involuntary movements of the
face or limbs.
Assess for dry mouth and blurred vision. These are anticholinergic adverse effects of promethazine.
Prochlorperazine (Compazine) Antiemetic.
Assess for blurred vision and drowsiness. These are common CNS adverse effects of Compazine.
Assess for involuntary movements and hypotension Extrapyramidal reactions and hypotension may occur.
Assess for palpitations, dry mouth, constipation, and urinary These are less common adverse effects.
retention.
Ondansetron (Zofran) Ondansetron is an antiemetic. Administration: PO/IM/IV.
Doxylamine (Unisom) Unisom is an oral antiemetic combination with pyridoxine.
Assess for sedation. Sedation is a common adverse effect of Unisom. The patient
should avoid activities that require alertness.
Pyridoxine This vitamin may be used as an antiemetic is combination with
doxylamine (Unisom).
Postpartum'Wound'Infection' 218
Postpartum Wound Infection
Diagnoses: Impaired Skin and Tissue Integrity

related to wound infection and dehiscence
Desired Outcome: After initiation of therapy, the patient describes characteristics of an infected wound that would necessitate inter-
vention.
Assess pain q2h and provide analgesics, warm compresses, Pain relief encourages patient movement. Warmth increases cir-
and sitz baths. culation.
Assess the cesarean wound or episiotomy q4h. Early identification of infection decreases maternal morbidity.
Cesarean site infection causes redness surrounding the incision,
drainage, and dehiscence.
Episiotomy infection causes extreme pain, drainage, and dehis-
cence.
Assess temperature, pulse, respirations, and pain q2h. Temperature >38° C indicates infection. Tachypnea is a sign of
sepsis.
Teach the patient hand hygiene and cleansing of the wound with Regularly changing a dressing removes bacteria.
aseptic techniques.
Teach the patient to eat a balanced diet with protein, carbohy- An adequate diet provides nutrients and promotes wound healing.
drates, fruits, vegetables, and fluids.

related to unfamiliarity with antibiotics used for treating wound infections
Desired Outcome: Following teaching, patient states an understanding of the antibiotics used to treat postpartum wound infections.
Cephalosporins: cefazolin (Ancef), cefoxitin (Mefoxin), cefotetan These agents may be used to treat wound infection. Administra-
(Cefotan), cefoperazone (Cefobid). tion: IV.
Explain that caution is necessary for patients with sensitivity to Cross-sensitivity with penicillins is possible. Serious and possible
penicillins. fatal reactions may occur.
Advise patient to assess for diarrhea and vomiting. These are possible adverse effects.
Caution patient to watch for a rash and pruritus. These are signs of an allergic reaction.
Gentamicin (Garamycin) Gentamicin is contraindicated in pregnancy because it may cause
congenital deafness.
Reduce gentamicin dose in patients with impaired renal function. Gentamicin may cause nephrotoxicity.
Linezolid (Zyvox) Linezolid is used to treat resistant skin structure infections caused
by MRSA.
Oxycodone with acetaminophen (Percocet) and hydrocodone These are opioid analgesics used to treat moderate to severe
with acetaminophen (Vicodin) pain.
PO.
Teach patient to breastfeed before taking the medication. Breastfeeding just before taking the medication decreases effects
on the newborn.
Advise patient to report itching and rash. These are signs of an allergic reaction.
Caution patient to avoid activities that require alertness. Drowsiness is a common effect of opioids
Postpartum'Wound'Infection' 219

related to unfamiliarity with postpartum wound infection the treatment of
Desired Outcome: Following teaching, patient states accurate knowledge about postpartum wound infections and treatment.
Advise patient about the effects of postpartum wound infection. Infection may cause pain, fever, dehiscence, and sepsis. Treat-
Teach about treatments. ments include IV antibiotics and wound packing.
Teach the patient the symptoms of wound infection that should Signs of infection include fever, severe pain, drainage, and dehis-
be reported. cence.
Explain daily wound packing or secondary wound closure and After hospital treatment of acute infection with IV antibiotics,
antibiotics. wound care consists of irrigation, packing, and dressing changes.
Advise to patient and partner that intercourse is not recommend- Intercourse may impair wound healing.
ed until 6 wk postpartum.
Preeclampsia' 220
Preeclampsia
Diagnosis: Risk for Imbalanced Fluid Volume

related to vasospasm, endothelial cell damage, and fluid shifts
Desired Outcome: Imbalanced fluid volume diminishes within 8-12 hr, as evidenced by BP <150/100 mmHg, urine output >30
ml/hr, and absence of pitting edema.
Assess BP, heart rate, and RR q1-4h. Hypertension is a sign of vasoconstriction. Pulmonary edema may
result in dyspnea.
Assess amount of edema q1-8h. Edema is caused by extravascular fluid accumulation.
Assess deep tendon reflexes q1-4h. Hyperreflexia signals worsening of preeclampsia.
Assess for headaches: q1-4h. Headaches are a sign of increased intracranial pressure.
Monitor fluid intake and output q1-4h. Fluid retention could cause pulmonary edema. Oliguria indicates
renal compromise.
Collect a 24-hr urine specimen for protein and creatinine. Severe preeclampsia causes glomerular endothelial damage.
Monitor hematologic tests: Hematocrit, hemoglobin, platelets, Increased Hct is caused by hemoconcentration. A low platelet
AST and ALT, reatinine and uric acid count indicates HELLP syndrome. Increased liver function tests
indicate hepatitis. Creatinine and uric acid increase with renal fail-
ure.
For patients with worsening preeclampsia, explain need for be- Bedrest and left lateral position lower BP and increase perfusion
drest and left lateral position. of the kidneys and uteroplacental unit.
Administer labetalol (Normodyne) or methyldopa (Aldomet). Antihypertensives lower BP by decreasing systemic vascular re-
sistance.
Prepare for cesarean delivery for severe preeclampsia. Delivery is the definitive treatment of preeclampsia. Cesarean is
indicated when vaginal delivery is not imminent.
Diagnosis: Risk for Injury: Maternal

related to vasoconstriction, tissue hypoxia, and disseminated intravascular coagulation
Desired Outcome: Patient remains free of injury from the effects of preeclampsia, as evidenced by BP <130/90 mmHg, urine >30
mL/h after delivery
Assess for headache, visual changes, urinary output, pro- Organ system damage results from vasoconstriction, vasospasm,
teinuria, FHR pattern, and vital signs q1-4h. and endothelial damage.
Administer IV magnesium sulfate. Assess DTRs, BP, respira- Magnesium sulfate depresses the CNS, and reduces BP. Respira-
tions, urine output, and FHR. tions <12/min indicates magnesium toxicity.
Administer IV magnesium sulfate IVPB by infusion pump. Overdose and overhydration are prevented with an infusion pump.
Loading dose is 4 g over 20 min, followed by 2 g/hr. At 8-12 mg/dl, DTRs become absent. At 14 mg/dl, respiratory ar-
rest occurs. At 30 mg/dL, cardiac arrest occurs.
Keep an ampule of calcium gluconate at the bedside. Admin- Calcium gluconate is the antidote for magnesium toxicity.
ister 1 g
(10 ml of a 10% solution) over a period of 3 min if RR <12/min.
Monitor intake and output q1h. Magnesium is excreted via the kidneys. Oliguria indicates renal
failure.
Preeclampsia' 221
Administer cervical ripening agents, such as Cervical ripening agents soften the cervix before induction of labor
dinoprostone (Cervidil insert or Prepidil Gel), followed by oxy- with oxytocin.
tocin for labor induction.
Assess baseline FHR, vital signs, and uterine activity prior to Abnormal baseline findings are contraindications to oxytocin. Infu-
administration of oxytocin. sion pump decrease the risk of fluid overload.
Maintain seizure precautions with padded rails and suctioning Precautions enable an immediate response if a seizure occurs.
equipment.
Diagnosis: Risk for injury: Fetal

related to vasospasm and decreased perfusion of the uteroplacental unit and reduced fetal oxygenation
Desired Outcome: Interventions stop the progression of preeclampsia.
Assess for adverse effects of magnesium sulfate and labetalol Eclamptic convulsion block oxygen delivery to the fetus. Labetalol
(Trandate). may cause bronchospasm and hypotension. Magnesium sulfate
may cause loss of DTRs and hypoventilation.
Infuse oxytocin by pump 1 mU/min to maintain one uterine con- Uterine hyperstimulation by oxytocin may result in fetal hypoxia and
traction occur every 2-3 minutes. precipitous delivery.
Prepare to assist in amniocentesis for lecithin and sphingomye- Respiratory distress syndrome develops in the preterm is born be-
lin levels for fetal lung maturity if preterm birth at <32 weeks. fore lung surfactant is mature (lecithin to sphingomyelin [ratio
>2.0]).
Administer maternal betamethasone 12 mg IM x 2 doses, 24 hr Corticosteroids stimulate fetal lung maturity by increasing produc-
apart. tion of lung surfactants.
Monitor FHR in labor with documentation q30min. May cause fetal distress, decreased FHR variability, and late de-
celerations.
Arrange for neonatologist and resuscitation team in the birth Preeclampsia and early gestational age may cause newborn hy-
room. poxia.

related to unfamiliarity with the effects of preeclampsia and treatments on the mother and fetus
Desired Outcome: After teaching, the patient monitors BP, edema, and fetal activity.
Teach the patient about the effects of preeclampsia on the An informed patient is more likely to adhere to treatment plans.
pregnancy, and fetus.
Encourage a balanced diet, adequate fluids, and left side-lying A balanced diet and adequate fluids promote fetal growth. Patients
position. with hypertension may be treated with labetalol.
Assess for magnesium sulfate adverse effects or toxicity. Adverse effects of magnesium sulfate therapy are lethargy, weak-
ness, vomiting. Loss of DTRs and respiratory depression (RR
<12/min).
Preterm'Labor' 222
Preterm Labor
Diagnosis: Risk for Maternal or Fetal Injury

related to adverse effects of tocolytics
Desired Outcome: After 4 hr of tocolytic therapy, uterine contractions decrease without toxic adverse effects.
Assess blood pressure, heart rate, RR. Tocolytics may cause hypertension and tachycardia.
Administer magnesium sulfate, IV. Magnesium sulfate protects the fetus from cerebral palsy.
Indomethacin Indomethacin prevents preterm labor when given between 24 to
32 weeks labor.
Administer Nifedipine Nifedipine prevents preterm labor and is used between 32 to 34
weeks.

related to unfamiliarity with the effects of PTL on the fetus
Desired Outcome: The patient states knowledge about the effects of PTL on her fetus.
Teach the effects of preterm labor on the newborn. Preterm labor and delivery can result in neonatal respiratory dis-
tress syndrome, hypoglycemia, IVH, and necrotizing enterocolitis.
Teach the symptoms of PTL. Diagnosis of PTL prolongs the pregnancy and decreases fetal
morbidity and mortality.
Teach patient about the need for decreased activity, bedrest, Uterine perfusion is increased by adherence to left lateral position-
and use of the left lateral position. ing.
Encourage daily fetal movement counts. Fetal movement counts are an indicator of fetal well being and are
started at 28 wks; 10 movements within 2-hr is reassuring.
Preterm'Premature'Rupture'of'Membranes' 223
Preterm Premature Rupture of Membranes

related to bacterial infection of the amniotic membranes
Desired Outcome: Maternal temperature remains <38.5°C
Assist physician with sterile speculum examination, collection of These assessments confirm the diagnosis of PPROM.
amniotic fluid, placental alpha microglobulin-1 (AmniSure), and
evaluation of ferning.
Assist with collecting specimens from amniocentesis for bacteri- Group B streptococcus, Chlamydia trachomatis and gonorrhea are
al culture. common causes of chorioamnionitis.
Monitor maternal vital signs q2-4h. Fever and uterine tenderness are signs of chorioamnionitis.
Perform a nonstress test q8h. Fetal tachycardia and nonreactive NST are signs of fetal distress.
Arrange for BPP and amniocentesis for AmniSure test. BPP assesses fetal status. The AmniSure test assesses lung ma-
turity.
Collect maternal blood for complete blood count and urine for White blood cell count increases with infection. Bacteriuria is a
urinalysis. sign of UTI.

related to unfamiliarity with signs and symptoms of PPROM, and its effects on the fetus
Desired Outcome: Following teaching, patient states knowledge about the effects of PPROM.
Advise patient of the signs of PPROM and chorioamnionitis. Signs of chorioamnionitis include abdominal pain, uterine pain,
fever, and chills.
Teach patient about the effects PPROM on the patient and fe- PPROM increases maternal risks of chorioamnionitis, abruptio
tus. placentae, and postpartum endometritis.
Encourage daily fetal movement counts beginning at 28 wk Fetal movement is an indicator of fetal well being. 10 movements
gestation. in a 2-hr period are reassuring.
Advise patient to report fever or decreased fetal movement. These are common signs of an intraamniotic infection.
Explain purpose of the antenatal betamethasone. Corticosteroids accelerate the development of fetal lungs and
prevent neonatal respiratory distress syndrome when delivery is
anticipated to be preterm and after 20 wk.
Betamethasone: two doses of 12 mg given 24 hr apart.
Maximum benefit occurs 48 hr after administration.
Explain purpose of Rh-immune globulin RhoGAM if prescribed. This agent prevents formation of antibodies to the Rh-positive
antigen in the mother’s blood and prevents hemolytic disease in
future pregnancies. Given IM only to nonsensitized Rh-negative
women after spontaneous abortion or after delivery.
Anxiety'and'Panic'Attacks' 224
Psychiatric Nursing
Anxiety and Panic Attacks
Diagnosis: Anxiety (Recurring Panic Attacks)

related to lack of knowledge regarding symptoms of anxiety and treatment of anxiety
Desired Outcome: Within 24 hr of intervention, patient states understanding of panic attacks.
Inform patient and significant other that anxiety disorders are Medications are effective for treatment of anxiety disorders and
treatable. may include antidepressants and anxiolytics.
Administer SSRI antidepressants for panic attacks. Panic attacks are caused by a neuropsychiatric disorder that re-
sponds to SSRI antidepressants.
Stay with patient during panic attacks. Use short, simple direc- During a panic attack, the patient needs reassurance that he is not
tions. Teach patient to use relaxation. dying and that the symptoms will resolve spontaneously.
Teach the patient to administer anxiolytic medication when the This information provides a strategy for control of the panic at-
first symptoms of a panic attack start. tacks.

related to unfamiliarity with medications and potential adverse effects
Desired Outcome: By discharge or after 4 wk of outpatient treatment, the patient states correct information about medications and
adverse effects.
Explain the physiologic action of SSRI antidepressants in reliev- Anxiety disorders are caused by a neuropsychiatric disorder that
ing anxiety. responds to medication.
SSRIs: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline SSRIs are effective for obsessive-compulsive symptoms, panic,
(Zoloft), paroxetine (Paxil), citalopram (Celexa), and escital- and anxiety.
opram (Lexapro)
Assess for nausea, headache, nervousness, insomnia, agitation, These are adverse effects of SSRIs. Treatment should be started
sexual dysfunction, diarrhea, and anorexia. at very low doses and increased gradually.
Other Antidepressant Drugs: mirtazapine (Remeron); nefazo- Antidepressants are frequently prescribed for anxiety disorders
done (Serzone); venlafaxine (Effexor); and desvenlafaxine because of better efficacy and low adverse effect profile.
(Pristiq)
Benzodiazepines: diazepam (Valium), lorazepam (Ativan), oxa- Benzodiazepines, such as lorazepam, are used for generalized
zepam (Serax), and clonazepam (Klonopin) anxiety disorder and panic disorder.
Explain that benzodiazepines may cause drowsiness, impaired These are common adverse effects that subside as tolerance to
intellectual function, impaired memory, and ataxia. the drug develops.
Assess for fatigue, drowsiness, and cognitive impairments. These are common adverse effects.
A gradual tapering is necessary when a benzodiazepine is dis- Abrupt discontinuation of a benzodiazepine can cause recurrence
continued. of anxiety.
Bipolar'Disorder' 225
Bipolar Disorder
Diagnosis: Risk for Other-Directed Violence

related to impulsivity and agitation caused by manic excitement
Desired Outcome: By discharge, patient demonstrates self-control and reduced hyperactivity.
Remove objects that could be dangerous. Hyperactive behavior and grandiose thinking can cause the pa-
tient to harm self or others.
Decrease environmental stimuli and remove patient if he be- Bipolar patients are unable to focus attention.
comes agitated.
If the patient becomes agitated, intervene with direct verbal Early intervention assists the patient in regaining control, and pre-
prompts of appropriate behavior, establish a voluntary time-out vents violence.
or place the patient in a quiet room.
Do not argue with patient who has grandiose ideas. Arguing increases agitation and reinforces undesirable behavior.
Teach alternative problem-solving strategies. When calm, the patient should be helped to understand and solve
problems.
When the patient is calm, help him examine the precipitants to This promotes early recognition of the problem.
agitation.
Lithium (Lithobid), divalproex sodium (Depakote), valproic acid Lithium is the drug of choice for mania and is indicated for relief of
(Depakene), valproate (Depacon), carbamazepine (Tegretol), manic symptoms. Some patients may need divalproex, carbam-
topiramate (Topamax), oxcarbazepine (Trileptal), topiramate azepine, topiramate, valproic acid, valproate, tiagabine or
(Topamax), tiagabine (Gabitril), and lamotrigine (Lamictal). lamotrigine.
Atypical antipsychotics: Olanzapine (Zyprexa), quetiapine Olanzapine is better tolerated and prevents relapse more effec-
(Seroquel), aripiprazole (Ability), clozapine (Clozaril), paliperi- tively than lithium. Quetiapine is effective for the anxiety symp-
done (Invega), risperidone (Risperdal Consta, M-tabs), ziprasi- toms of bipolar depression. Atypical antipsychotics are effective
done (Geodon) for mania.

related to inadequate intake in relation to increased rate of metabolism
Desired Outcome: following interventions, patient displays increased eating.
Establish baseline nutritional and fluid intake. This assessment quantifies nutritional deficits.
Weigh patient daily. Weight maintenance indicates that diet interventions are effective.
Serve meals in a room with minimal distractions. This encourages the patient to focus on eating.
Stay with patient during mealtime. This provides support and encouragement for the patient to eat.
Provide finger foods, snacks, and juice drinks. Patient may prefer to eat small frequent meals.

related to unfamiliarity with medications and adverse effects
Desired Outcome: Following teaching, patient states correct information about the medications.
Bipolar'Disorder' 226
Teach the patient about the purpose mood stabilizers. Bipolar mania is treated with lithium carbonate and other mood
stabilizers.
Teach the patient about the need for follow-up blood tests to Lithium requires blood levels.
monitor serum levels.
Lithium carbonate (Lithobid) or lithium citrate (Cibalith) Lithium provides mood stability and prevents affective highs and
lows.
Teach the patient to report swelling of feet or hands, fine hand These are common adverse effects of lithium.
tremor, diarrhea, weakness, metallic taste, nausea, polydipsia,
and polyuria.
Regular laboratory testing of blood levels. This verifies that the serum drug level is between 0.6 and 1.2
mEq/L.
Notify prescriber before taking any other medications. Many drugs interact with lithium to increase or reduce the serum
lithium level.
Antiepileptic drugs: divalproex or valproic acid (Depakote or These medications are used when lithium is not effective or when
Depakene), carbamazepine (Tegretol), topiramate (Topamax), adverse effects from lithium are not tolerated.
lamotrigine (Lamictal) oxcarbazepine (Trileptal), and tiagabine
(Gabitril).
Atypical antipsychotics: olanzapine (Zyprexa), quetiapine Olanzapine is better tolerated and prevents relapse more effective-
(Seroquel), aripiprazole (Ability), clozapine (Clozaril), risperi- ly than lithium. Second generation antipsychotics are effective for
done (Risperdal Consta, M-tabs), ziprasidone (Geodon) mania.
Advise patient to report vomiting, drowsiness or tremor. These are common adverse effects of second-generation antipsy-
chotics.
Alzheimer'Disease' 227
Alzheimer Disease

related to unfamiliarity with disease progression and treatment
Desired Outcome: After teaching, significant other and family state accurate information about Alzheimer neurodegenerative disor-
der.
Provide significant other and family with information about the The significant other and family will be the primary caregivers.
disease.
Teach about safety issues. Alzheimer patients may slip on scat- The Alzheimer patient is at risk for falls, memory deficits, and
ter rugs. Wandering, forgetting the stove is turned on, and inges- wandering.
tion of toxic substances are also dangers.
Provide information about health care resources. Family members often need to place the patient in adult day care
centers or use respite care.
Teach strategies to prevent wandering, incontinence, difficulty These strategies help the family manage the behavior problems
following directions, and memory loss. associated with Alzheimer neurodegenerative disorder.

related to impaired judgment and inability to recognize danger
Desired Outcome: Patient remains free of injury.
Assess the degree of the patient’s impairment and environment Patients have impulsive behaviors, and patients have visual or
hazards. Teach interventions that will ensure safety. perceptual deficits that increase the risk of falls.
Advise the caregiver to remove knobs from the stove, remove
scatter rugs, place a safety gate at the top and bottom of stairs,
and make sure exit doors are locked.
Ensure that the patient wears an ID bracelet with his name, These patients may not be able to provide this information be-
phone number, and diagnosis. cause of memory deficits.
Ensure that patient is dressed appropriately for the type of The patient is not able to make appropriate dressing choices.
weather.
Inspect the patient's skin regularly. Identification of rashes, lacerations, and ecchymoses enables
necessary treatment.
Monitor for medication adverse effects, such as gastrointestinal The patient may not be able to report signs of drug toxicity.
upset; extrapyramidal symptoms; and orthostatic hypotension.
Diagnoses: Chronic Confusion

Impaired Environmental interpretation Syndrome
related to physiologic changes/dementia caused by Alzheimer neurodegenerative disorder
Desired Outcome: Patient remains calm and does not display unsafe behaviors.
Assess the degree of confusion and assess short-term memory. Patients with moderate AD have only 5 min of short-term memory.
Provide a simple environment with orientation cues. Scheduled activities, low noise levels, calendars, clocks, and fre-
quent verbal orientations help calm the patient.
Alzheimer'Disease' 228
Give simple step-by-step directions using simple words. As the disease progresses, the patient's ability to comprehend
complex directions diminishes. Simplicity is necessary for effective
communication.
Observe patient for verbal and nonverbal signs of hallucinations. Validate that the patient is hearing voices and assurance the pa-
tient that the hallucination is caused by Alzheimer neurodegenera-
tive disorder.

related to unfamiliarity with rationale, and adverse effects
Desired Outcome: following teaching, caregiver states accurate information about the use of medications and adverse effects.
Describe the cognitive effect of cholinesterase inhibitors. Cholinesterase inhibitors, such as donepezil (Aricept), rivastigmine
tartrate (Exelon), and galantine (Razadyne), slow cognitive decline
by inhibiting breakdown of acetylcholine by brain neurons.
Describe the effect of memantine. Memantine (Namenda) blocks glutamate, the excitatory neu-
rotransmitter of the brain. Memantine blocks the N-methyl-O-
aspartate receptors involved in memory.
Teach patient, caregiver, and family that these drugs will only This improvement may briefly delay nursing home placement.
return patient's function to the level that was present 6 months
earlier.
Explain the adverse effects of the medications. Knowledge of adverse effects promotes adherence to treatment.
Assess for headache and fatigue, dizziness, nausea, vomiting, These common adverse effects should be reported.
diarrhea, GI stomach, anorexia, abdominal pain, rhinitis, and
rash.
If GI upset occurs, administer memantine with meals. A full stomach may reduce gastric upset.
Monitor liver function tests. Patient with preexisting renal, liver, or cardiac disease require
close monitoring.
Major'Depression' 229
Major Depression

related to unfamiliarity with symptoms and treatment of depression
Desired Outcome: By discharge or after one wk of treatment, patient and significant other state correct information about the symp-
toms of depression and treatment.
Teach the patient the symptoms of depression. Symptoms include sadness and loss of interest in activities: de-
creased appetite or weight loss, sleep disturbance, and decreased
psychomotor activity; worthlessness and guilt; difficulty concentrat-
ing suicidal ideation.
Teach the patient and significant other that depression is treata- Antidepressants usually relieve the symptoms of depression in a
ble. few weeks.
Teach the patient and significant other about ECT. ECT is used to achieve a more rapid response and may be nec-
essary for suicidal patients or for patients who want to avoid the
adverse effects of antidepressants.
Diagnosis: Risk for Suicide

related to depressed mood and feelings of hopelessness
Desired Outcome: By discharge or by the end of 2 weeks, patient states that he does not have suicidal thinking.
Complete a suicide assessment. Risk for suicide is increased if the patient has a history of a previ-
ous attempt or there is a family history of suicide. Patients who
display impulsive behaviors are more likely to attempt suicide. Pa-
tients with psychotic thinking are at highest risk. High suicide risk
should prompt hospitalization.
Administer antidepressant medication. Suicidal thinking is a symptom of depression.
If the patient is hospitalized: Monitor at least q15 minutes or Close observation will prevent suicidal attempts.
constant one-on-one observation for serious risk.
Remove belts, scarves, razor blades, shoelaces, and scissors. This provides environmental safety.
Check all items brought into the unit.
Provide supervision when patient is in bathroom. Prevent all opportunities for self-harmful behaviors.
Make sure that the patient swallows his medications. This prevents saving up of medications for an overdose or discard-
ing and not taking the medication.
Major'Depression' 230
Recheck environment for hazards. Minimize opportunities for self-harm by locking doors, windows,
and stairways.

related to unfamiliarity with medication use to treat depression and adverse effects
Desired Outcome: By discharge or after 2 wks of outpatient treatment, patient states correct information about medications and
adverse effects.
Discuss the positive effects of antidepressants. SSRI antidepressants reduce the symptoms of depression by
blocking the reuptake of serotonin.
SSRIs: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline SSRIs are effective for depression and have a good side effect
(Zoloft), paroxetine (Paxil), citalopram (Celexa), and escital- profile. These agents inhibit serotonin uptake.
opram (Lexapro)
Assess for nausea, headache, insomnia, anxiety, sexual dys- These are adverse effects of SSRIs.
function, dizziness, fatigue, diarrhea, excessive sweating, and
anorexia.
Assess for drug interactions. Interaction of SSRIs with MAO inhibitors can cause fatal serotonin
syndrome.
Serotonin-norepinephrine reuptake inhibitors: venlafaxine SSRIs inhibit reuptake of norepinephrine and serotonin.
(Effexor, nefazodone (Serzone), mirtazapine (Remeron), duloxe-
tine (Cymbalta), and desvenlafaxine (Pristiq)
Assess for nausea, somnolence, dizziness, dry mouth, and These are adverse effects of SNRIs.
sweating.
Monitor BP in patients taking venlafaxine. Venlafaxine causes an increased blood pressure
Schizophrenia' 231
Schizophrenia
Diagnosis: Disturbed Sensory Perception: Auditory

related to biochemical imbalance, caused by schizophrenia
Desired Outcome: Before discharge or after 4 wk of outpatient treatment, patient recognizes that hallucinations are not real.
Assess for hallucinations. Redirect the patient back to reality. Assessment enables evaluation of the patient's responses to hal-
lucinations.
Ask what the voices are telling the patient Assess for command hallucinations that tell the patient to harm
self or others.
Administer antipsychotic medications. Antipsychotic medications decrease hallucinations.

related to unfamiliarity with medications used for schizophrenia and adverse effects
Desired Outcome: Before discharge or after 2 weeks of outpatient treatment, patient states accurate information about medica-
tions.
Teach the patient about the effects of antipsychotic medications. Antipsychotics block dopamine receptors, reducing hallucina-
tions, delusions, and confusion.
First generation antipsychotics: chlorpromazine (Thorazine), First generation antipsychotics block dopamine receptors in the
thioridazine (Mellaril,) perphenazine (Trilafon), trifluoperazine (Ste- CNS and can cause extrapyramidal movement abnormalities.
lazine), thiothixene (Navane), fluphenazine (Prolixin), and
haloperidol (Haldol).
Explain that sedation, orthostatic hypotension, and anticholinergic These are common adverse effects of first generation antipsy-
effects can occur. chotic drugs.
Advise the patient to report dystonia, parkinsonism, akathisia (rest- These are extrapyramidal symptoms of first generation antipsy-
lessness). chotic drugs.
Explain the potential for neuroleptic malignant syndrome (muscle This is an idiosyncratic reduction to antipsychotics.
rigidity, fever, hypertension, and delirium)
Caution patient that there is a risk for seizures. Antipsychotics can decrease the seizure threshold.
Advise the patient to avoid antihistamines and over-the-counter Drugs with anticholinergic properties increase the anticholiner-
sleeping aids. gic effects of antipsychotic drugs, such as dry mouth, constipa-
tion, blurred vision, urinary obstruction, and tachycardia.
Second-generation antipsychotic agents: clozapine (Clozaril), Second generation antipsychotics are less likely to cause ex-
risperidone (Risperdal Consta, M-tabs), olanzapine (Zyprexa), trapyramidal symptoms.
quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole
(Abilify).
Patients taking clozapine should report drowsiness, tachycardia, These are common adverse effects of clozapine.
constipation, and postural hypotension.
Patients taking clozapine need weekly complete blood count moni- Agranulocytosis occurs in 1% of patients taking clozapine in the
toring for the first 6 months of treatment, and then after 6 months. first 6 mo.
Substance'Abuse'Disorders' 232
Alcohol Use Disorder

related to ataxia and disorientation caused by alcohol withdrawal
Desired Outcome: Patient does not exhibit injuries caused by alcohol withdrawal.
Assess the stage of alcohol withdrawal and severity of symptoms. Severe tremors, disorientation and confusion are associated
Monitor vital signs, tremors, mental status, and electrolytes. with delirium tremens.
Institute seizure precautions with bed in lowest position with pad- Withdrawal seizures usually occur within 48 hr after the last
ded side rails, and oral airway at the bedside. drink.
Orient patient to surroundings. Disorientation can last several days.
Administer IV or oral fluids. Fluid replacement prevents dehydration.
Administer lorazepam (Ativan) Lorazepam (Ativan) is used to control neuronal hyperactivity by
the IV route. Lorazepam controls trembling and is tapered and
discontinued over 96 hr.
Diagnosis: Ineffective Denial

related to lack of control of alcoholism
Desired Outcome: Before discharge or after 4 wk if patient is outpatient, patient acknowledges that his drinking is out of control.
Assess patient's level of acceptance that his alcohol use is a Denial interferes with the patient's ability to participate in treat-
problem. ment.
Teach patient that alcoholism is a physiologic problem. The patient will be more likely to accept treatment for alcohol-
ism if he understands that alcoholism is an illness.
Ask patient to write a list of the negative consequences of exces- These interventions help decrease the process of denial
sive alcohol.

related to unfamiliarity with medications and adverse effects
Desired Outcome: Patient states accurate information about medication and adverse effects.
Disulfiram (Antabuse) Disulfiram is a deterrent to impulsive drinking.
Advise patient of the risks of drinking while taking Antabuse. Ingestion of alcohol while on Antabuse will result in severe nau-
sea, vomiting, headache, palpitations, seizures, and death.
Adverse effects may occur when ingesting cough syrups con- Adverse effects may occur because many medications may con-
taining alcohol. tain alcohol.
The metallic aftertaste is temporary. Antabuse will remain active for 2 weeks. Drinking before the drug
Avoid drinking for 14 days after discontinuing disulfiram (Anta- is metabolized.
buse).
Naltrexone (Re-Via) and the long-acting injectable, Vivitrol, may Naltrexone is a narcotic antagonist approved for treatment of al-
improve adherence to alcohol dependency treatment. coholism. Naltrexone and Vivitrol decrease the cravings for alco-
hol.
Advise the patient to report insomnia, anxiety, nervousness, These are common adverse effects of naltrexone.
headache, fatigue, abdominal pain, cramps, nausea, vomiting.
Substance'Abuse'Disorders' 233
Nalmefene (Revex) Revex is an opioid antagonist that is similar to naltrexone. Revex

prevents relapse to heavy drinking.
Acamprosate (Campral) Acamprosate increases abstinence by reducing the craving for
alcohol.

Nursing Care Plans Wide

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nursing Care Plans Wide

Uploaded by

Copyright:

Available Formats

Nursing Care Plans

Ineffective Airway Clearance

Latex Allergy Response

Risk for Aspiration

Risk for Bleeding

Ineffective Breathing Pattern

Disturbed Body Image

Decreased Cardiac Output

Caregiver Role Strain

Impaired Verbal Communication

Risk for Electrolyte Imbalance

Risk for Falls

Fluid Volume, Deficient

Unstable Glucose Level

Functional Urinary Incontinence

Reflex Urinary Incontinence

Stress Urinary Incontinence

Urge Urinary Incontinence

Risk for Infection

Impaired Physical Mobility

Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: More than Requirements

Impaired Oral Mucous Membrane

If the patient is on PCA: IV incompatibilities are possible with the PCA.

Risk for Impaired Skin Integrity

Risk for Suicide

Diagnosis: Pain caused by cancer

Diagnosis: Lymphedema caused by cancer

Diagnoses: Risk for Impaired Skin integrity

Diagnosis: Risk for infection

Diagnosis: Impaired Skin Integrity

Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Diagnosis: Impaired Oral Mucosa Membranes

Diagnoses: Acute Pain, Chronic Pain

Diagnosis: Deficient Knowledge

Diagnosis: Risk for injury

Diagnosis: Ineffective Airway Clearance

Diagnosis: Ineffective Breathing Pattern (or risk of same)

Diagnosis: Risk for Aspiration

Diagnosis: Risk for Infection

Diagnoses: Deficient Fluid Volume, Risk for Electrolyte Imbalance

Diagnoses: Risk for Bleeding

Diagnosis: Excess Fluid Volume

Diagnosis: Risk for Trauma

Diagnosis: Impaired Physical Mobility

Diagnoses: Risk for Constipation

Diagnosis: Risk for Activity intolerance

Assessments and Interventions Rationales

Diagnosis: Risk for Disuse Syndrome

Older Adult Care

Diagnosis: Acute Confusion

Diagnosis: Risk for Aspiration

Diagnosis: Risk for Deficient Fluid Volume

Diagnosis: Risk for Impaired Skin Integrity

Chronic Obstructive Pulmonary Disease

Diagnosis: Ineffective Breathing Pattern

Diagnosis: Impaired Gas Exchange

Diagnosis: Impaired Gas Exchange

Diagnosis: Ineffective Airway Clearance

Diagnosis: Deficient Fluid Volume

Assessments and Interventions Rationales

Diagnosis: Risk for Injury

Diagnosis: Impaired Gas Exchange

Diagnosis: Risk for Bleeding