Intervention Rationale Evaluationdocshare01.docshare.tips/files/12359/123592887.pdfNursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction Long Term Goal: Patient
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Nursing Diagnosis
Ineffective Airway Clearance r/t tracheobronchial obstruction
Long Term Goal:
Patient will maintain a patent
airway
Short Term Goals / Outcomes:
Patients lungs sounds will be clear to auscultate
Patient will be free of dyspnea
Patient will demonstrate correct coughing and deep breathing techniques
Intervention Rationale Evaluation
Assess airway for
patency by asking the
patient to state his
name.
Maintaining an airway is always top priority
especially in patients who may have experienced
trauma to the airway. If a patient can articulate
an answer, their airway is patent.
Patient is able to state their name
without difficulty.
Inspect the mouth,
neck and position of
trachea for potential
obstruction.
Foreign materials or blood in the mouth,
hematoma of the neck or tracheal deviation can
all mean airway obstruction.
No foreign objects, blood in mouth
noted. Neck is free of
hematoma. Trachea is midline.
Auscultate lungs for
presence of normal
or adventitious lung
sounds.
Decreased or absent sounds may indicate the
presence of a mucous plug or airway
obstruction. Wheezing indicates airway
resistance. Stridor indicates emergent airway
obstruction.
Patient’s lungs sounds are clear to
auscultation throughout all lobes.
Assess respiratory
quality, rate, depth,
effort and pattern.
Flaring of the nostrils, dyspnea, use of accessory
muscles, tachypnea and /or apnea are all signs
of severe distress that require immediate
intervention.
Patient is free of signs of distress.
Assess for mental
status changes.
Increasing lethargy, confusion, restlessness and /
or irritability can be early signs of cerebral
hypoxia.
Patient is awake, alert and oriented
X3.
Assess changes in Tachycardia and hypertension occur with Patient is normotensive with heart
vital signs. increased work of breathing. rate 60 – 100 bpm.
Monitor arterial
blood gases (ABGs).
Increasing PaCO2 and decreasing PaO2 are signs
of respiratory failure.
ABGs show PaCO2 between 35-45
and PaO2 between 80 – 100.
Administer
supplemental
oxygen.
Early supplemental oxygen is essential in all
trauma patients since early mortality is
associated with inadequate delivery of
oxygenated blood to the brain and vital organs.
Patient is receiving oxygen. SaO2 via
pulse oximetry is 90 – 100%.
Position Patient with
head of bed 45
degrees (if tolerated).
Promotes better lung expansion and improved
gas exchange.
Patient’s rate and pattern are of
normal depth and rate at 45 degree
angle.
Assist Patient with
coughing and deep
breathing techniques
(positioning,
incentive spirometry,
frequent position
changes).
Assist patient to improve lung expansion, the
productivity of the cough and mobilize
secretions.
Patient is able to cough and deep
breathe effectively.
Prepare for
placement of
endotracheal or
surgical airway (i.e.
cricothyroidectomy,
tracheostomy).
If a patient is unable to maintain an adequate
airway, an artificial airway will be required to
promote oxygenation and ventilation; and
prevent aspiration.
Artificial airway is placed and
maintained without complications.
Confirm placement of
the artificial airway.
Complications such as esophageal and right
main stem intubations can occur during
insertion. Artificial airway placement should be
confirmed by CO2 detector, equal bilateral
breath sounds and a chest x-ray.
CO2 detector changes color, bilateral
breath sounds are audible equally
and artificial airway is at the tip of
the carina on x-ray.
If maxillofacial
trauma is present:
1. position the
patient for
The patient with maxillofacial trauma is usually
more comfortable sitting up. Any time there is
trauma to the maxillofacial area there is the
possibility of a compromised airway.
Patient exhibits normal respiratory
rate and depth in sitting
position. Patient is free of
wheezing, stridor and facial edema.
optimal
airway
clearance and
constant
assessment
of airway
patency
2. note the
degree of
swelling to
the face and
amount of
blood loss
3. prepare the
patient for
definitive
treatment
Noting swelling is important as a baseline for
comparison later.
If neck trauma is
present:
1. assess for
potential
hemorrhage
and
disruption of
the larynx or
trachea
2. prepare the
patient for CT
scan
Hemorrhage or disruption of the larynx and
trachea can be seen as hoarseness in speech,
palpable crepitus, pain with swallowing or
coughing, or hemoptysis. The neck should be
also assessed for ecchymosis, abrasions, or loss
of thyroid prominence.
Laryngeal injuries are most definitely diagnosed
by CT scans as soft tissue neck films are not
sensitive to these injuries.
Patient is free of signs of
hemorrhage or disruption. CT scan
reveals no injury to the larynx.
Teach patient correct coughing and Deep breathing techniques.
Weak, shallow breathing and coughing is ineffective in removing secretions.
Patient is able to demonstrate correct coughing and breathing techniques.
Nursing Diagnosis Long Term Goal
Patient will maintain optimal gas
Impaired Gas Exchange r/t altered oxygen supply exchange
Short Term Goals / Outcomes:
Patient will maintain normal arterial blood gas (ABGs).
Patient will be awake and alert.
Patient will demonstrate a normal depth, rate and pattern of respirations.
Interventions Rationale Evaluation
Assess respirations:
quality, rate, pattern,
depth and breathing
effort.
Rapid, shallow breathing and hypoventilation
affect gas exchange by affecting
CO2 levels. Flaring of the nostrils, dyspnea, use of
accessory muscles, tachypnea and /or apnea are
all signs of severe distress that require immediate
intervention.
Patient is free of signs of distress.
ABGs show PaCO2 between 35-45
Pts respirations are of a normal
rate and depth.
Assess for life-
threatening
problems. (i.e. resp
arrest, flail chest,
sucking chest
wound).
Absence of ventilation, asymmetric breath
sounds, dyspnea with accessory muscle use,
dullness on chest percussion and gross chest wall
instability (i.e. flail chest or sucking chest wound)
all require immediate attention.
Patient exhibits spontaneous
breathing, no dyspnea, use of
accessory muscles, resonance on
percussion and no chest wall
abnormalities.
Auscultate lung
sounds. Also assess
for the presence of
jugular vein
distention (JVD) or
tracheal deviation.
Absence of lung sounds, JVD and / or tracheal
deviation could signify a Pneumothorax or
Hemothorax.
Patient’s lungs sounds are clear to
auscultate throughout all lobes.
Assess for signs of
hypoxemia.
Tachycardia, restlessness, diaphoresis, headache,
lethargy and confusion are all signs of hypoxemia.
Patient is free of signs of hypoxia.
Monitor vital signs. Initially with hypoxia and hypercapnia blood
pressure (BP), heart rate and respiratory rate all
increase. As the condition becomes more severe
BP may drop, heart rate continues to be rapid
with arrhythmias and respiratory failure may
ensue.
Patient is normotensive with heart
rate 60 – 100 bpm and respiratory
rate 10-20.
Assess for changes in
orientation and
behavior.
Restlessness is an early sign of
hypoxia. Mentation gets worse as hypoxia
increases due to lack of blood supply to the brain.
Patient is awake, alert and
oriented X3.
Monitor ABGs. Increasing PaCO2 and decreasing PaO2 are signs of
respiratory failure.
ABGs show PaCO2 between 35-45
and PaO2 between 80 – 100.
Place the patient on
continuous pulse
oximetry.
Pulse oximetry is useful in detecting changes in
oxygenation. Oxygen saturation should be
maintained at 90% or greater.
SaO2 via pulse oximetry remains at
90 – 100%.
Assess skin color for
development of
cyanosis, especially
circumoral cyanosis.
Lack of oxygen delivery to the tissues will result in
cyanosis. Cyanosis needs treated immediately as
it is a late development in hypoxia.
Patient is free of cyanosis.
Provide supplemental
oxygen, via 100%
O2 non-rebreather
mask.
Early supplemental oxygen is essential in all
trauma patients since early mortality is associated
with inadequate delivery of oxygenated blood to
the brain and vital organs.
Patient is receiving 100%
oxygen. SaO2 via pulse oximetry is
90 – 100%.
Prepare the patient
for intubation.
Early intubation and mechanical ventilation are
necessary to maintain adequate oxygenation and
ventilation, prior to full decompensation of the
patient.
Artificial airway is placed and
maintained without complications.
Treat the underlying
injuries with
appropriate
interventions.
Treatment needs to focus on the underlying
problem that leads to the respiratory failure.
Appropriate injury specific
treatment has been started.
If rib fractures exist:
1. Assess for
paradoxical
chest
movements.
2. Provide
adequate
Paradoxical movements accompanied by dyspnea
and pain in the chest wall indicate flail chest. Flail
chest is a life-threatening complication of rib
fractures that requires mechanical ventilation and
aggressive pulmonary care.
Pain relief is essential to enhance coughing and
deep breathing.
No paradoxical movements are
noted.
Patient reports pain as <3 on 0-10
scale.
Bilateral breath sounds present in
all lobes.
pain
3. relief.
Assess breath
sounds.
Absence of bilateral breath sounds in the
presence of a flail chest, indicates a
pneumo/hemo thorax.
If Pneumothorax or
Hemothorax exist:
1. obtain chest
x-ray
2. prepare for
insertion of a
chest tube
If open
Pneumothorax exists
place a dressing that
is taped on three
sides for temporary
management.
A chest x-ray confirms the presence of a
Pneumothorax and / or Hemothorax.
A chest tube decreases the thoracic pressure and
re-inflates the lung tissue.
A three sided dressing gives the accumulated air a
way to escape, thereby decreasing thoracic
pressure and preventing a tension
Pneumothorax. A chest tube must then be
inserted.
Chest tube is placed and connected
to 20cm wall suction with good
tidaling and no air leak or SQ
emphysema noted.
Three-sided dressing
maintained. No further
cardiopulmonary decompensation
noted in patient.
Position patient with
head of bed 45
degrees (if tolerated).
Promotes better lung expansion and improved
gas exchange.
Patient’s rate and pattern are of
normal depth and rate at 45
degree angle.
Assist patient with
coughing and deep
breathing techniques
(positioning,
incentive spirometry,
frequent position
changes, splinting of
the chest).
Promotes alveolar expansion and prevents
alveolar collapse.
Splinting helps reduce pain and optimizes deep
breathing and coughing efforts.
Patient is able to cough and deep
breathe effectively.
Suction patient as
needed.
Suctioning aides to remove secretions from the
airway and optimizes gas exchange.
Patient suctioned for moderate
amount of thin yellow
secretion. Lung sounds clear after
suctioning.
Hyperoxygenate
patient with 100%
before and after
suctioning. Keep
suctioning to 10-15
seconds.
Prevents alteration in oxygenation during
suctioning.
Patient’s SaO2 remained >90%
during suctioning.
Pace activities and
provide rest periods
to prevent fatigue.
Even simple activities, such as bathing, can
increase oxygen consumption and cause fatigue.
No changes to cardiopulmonary
status noted during activity.
Patients SaO2 remains >90% during
activities.
Nursing Diagnosis
Deficient Fluid Volume r/t active fluid loss due to bleeding
Long Term Goal
Patient will maintain adequate
fluid and electrolyte balance.
Short Term Goals / Outcomes:
Patient will maintain urine output >30cc/hr.
Patient will be normotensive with heart rate 60 -100bpm.
Patient will demonstrate normal skin turgor.
Interventions Rationale Evaluation
Palpate pulses: carotid,
brachial, radial, femoral,
popliteal and pedal. Note
quality and rate.
If carotid and femoral pulses are palpable,
then the blood pressure is usually at least
60 – 80 mmHg systolic. If peripheral pulses
are present, the blood pressure is usually
higher than 80 mmHg systolic. Pulses may
be weak and irregular.
All pulses palpable, strong and
regular.
Assess skin color and
temperature.
Cool, pale, diaphoretic skin suggests
ineffective circulation due to hypovolemia.
Skin pink, warm and dry.
Monitor patient for active
blood loss from wounds,
tubes, etc. Control any
external bleeding.
Active fluid and/or blood loss adds to
Hypovolemic state and must be accounted
for when replacing fluids.
All external bleeding controlled.
Monitor vital signs.
(T,P,R,B/P)
Sinus tachycardia may occur with
hypovolemia to maintain cardiac
output. Hypotension is a hallmark of
hypovolemia. Febrile states decrease body
fluids through perspiration and increase
respiratory rate.
Vital signs within normal limits.
Monitor blood pressure for
orthostatic changes.
Greater than 10 mmHg drop signifies that
circulating volume is reduced by
20%. Greater that 20 – 30 mmHg drop
signifies blood volume is decreased by 40%.
No orthostatic changes noted
when patient placed from supine
to Fowlers position.
Auscultate heart tones and
inspect jugular veins.
Abnormally flattened jugular veins and
distant heart tones are signs of ineffective
circulation.
S1, S2 audible. No flattening or
distention of jugular vein noted.
Assess mental status. Loss of consciousness accompanies
ineffective circulating blood volume to the
brain.
Awake, alert and oriented X3.
Assess skin turgor over the
sternum or inner thigh; and
assess moisture and
condition of mucous
membranes.
Dry mucous membranes and tenting of the
skin are signs of hypovolemia. The sternum
and inner thigh should be used for skin
turgor due to loss of elasticity with aging.
Normal skin turgor. Mucous
membranes pink and moist.
Assess color and amount of
urine.
Concentrated urine and output <30cc for
two consecutive hours indicate insufficient
circulating volume.
Urine clear, yellow. Output at
least 30cc/hr.
Monitor serum electrolytes
and urine osmolality.
Elevated hemoglobin, Hematocrit and blood
urea nitrogen (BUN) accompany a fluid
deficit. Urine specific-gravity is also
increased.
All lab values within normal
ranges.
Monitor hemodynamic
pressures: central venous
pressure (CVP), pulmonary
artery pressure (PAP),
pulmonary capillary wedge
All values decrease with inadequate
circulating volume. Hemodynamic stability
is the goal of fluid
replacements. Monitoring of hemodynamic
All pressures within normal
ranges.
pressure (PCWP), if
available.
pressures can guide fluid replacements.
Initiate two large bore
intravenous catheters (IVs)
and start intravenous fluid
replacements as ordered.
14 -16 gauge catheters are preferred in case
fluids need to be given rapidly. Parenteral
fluids are necessary to restore
volume. Lactated Ringers is usually the fluid
of choice due to its isotonic properties and
close resemblance to the electrolyte
composition of plasma.
Two large bore IVs started,
lactated ringers infusing as per
physician orders without
complications.
Obtain a serum specimen
for type and cross
matCh Administer blood
and blood products as
ordered.
Blood and blood products will be necessary
for active blood loss. If there is no time to
wait for cross matching, Type O blood may
be transfused.
Type and cross sent. Type specific
blood infusing as per physician
orders.
During treatment monitor
for signs of fluid overload.
Due to large amounts of fluids administered
rapidly, circulatory overload can occur.
Headache, flushed skin, tachycardia, venous
distention, elevated hemodynamic
pressures (CVP, PCWP), increased blood
pressure, dyspnea, crackles, tachypnea and
cough are all signs of overload.
No signs of overload noted with
fluid replacements.
Assist the physician with
insertion of a central venous
line and arterial line if
indicated.
Provides for more effective fluid
replacements and accurate monitoring of
hemodynamic picture.
Central venous line and arterial
line inserted without difficulty.
Nursing Diagnosis
Acute Pain r/t trauma
Long Term Goal
Patient will be free of
pain
Short Term Goals / Outcomes:
Patient will report pain less than 3 on 0-10 scale.
Patient’s vital signs will be within normal limits.
Interventions Rationale Evaluation
Assess pain
characteristics: quality
(sharp, burning);
severity (0 -10 scale);
location; onset
(gradual, sudden);
duration (how long);
precipitating or
relieving factors.
A good assessment of pain will help in the treatment
and ongoing management of pain.
Patient reports pain as
3 or less on 0-10 scale;
intermittent and sharp
in incision area.
Monitor vital signs. Tachycardia, elevated blood pressure, tachypnea and
fever may accompany pain.
Vital signs within
normal limits.
Assess for non-verbal
signs of pain.
Some patients may verbally deny pain when it is still
present. Restlessness, inability to focus, frowning,
grimacing and guarding of the area may be non-
verbal signs of acute pain.
No non-verbal signs of
pain noted.
Give analgesics as
ordered and evaluate
the effectiveness.
Narcotics are indicated for severe pain. Pain
medications are absorbed and metabolized
differently in each patient, so their effectiveness
must be assessed after administration.
Analgesics given as
ordered. Patient
reports satisfactory
pain relief after
administration.
Assess the patient’s
expectations of pain
relief.
Some patients are content with reduction in pain,
others may expect complete elimination. This effects
the patient’s perception of the effectiveness of
treatment.
Patient states “I want
some relief. I know
some pain will still
exist.”
Assess for
complications to
analgesics, especially
respiratory depression.
Excessive sedation and respiratory depression are
severe side effects that need reported immediately
and may require discontinuation of
medication. Urinary retention, nausea/vomiting and
constipation can also occur with narcotic use and
need reported and treated.
No complications of
analgesia noted.
Anticipate the need for
pain relief and respond
The most effective way to deal with pain is to
prevent it. Early intervention can decrease the total
Patient reports pain as
immediately to
complaints of pain.
amount of analgesic required. Quick response
decreases the patient’s anxiety regarding having
their needs met and demonstrates caring.
soon as it starts.
Eliminate additional
stressors when
possible. Provide rest
periods, sleep and
relaxation.
Outside sources of stress, anxiety and lack of sleep all
may exaggerate the patient’s perception of pain.
Patient appears
relaxed, is sleeping
throughout the night.
Institute non-
pharmacological
approached to pain
(detraction, relaxation
exercises, music
therapy, etc.).
Non-pharmacological approaches help distract the
patient from the pain. The goal is to reduce tension
and thereby reduce pain.
Patient is relaxing by
use of non-
pharmacological
technique of choice.
If patient is on patient
controlled analgesia
(PCA):
1. Dedicate an IV
line for PCA
only.
2. Assess pain
relief and the
amount of pain
the patient is
requesting.
3. Educate
patient and
significant
others on
correct use of
PCA.
Drug interaction may occur, if dedicated line is not
possible consult pharmacist before mixing drugs.
If demands for the drug are frequent the basal or
lock-out dose may need to be increased to cover the
patient’s pain.
If demands for the drug are very low, the patient may
need further education of use of the PCA.
The patient and significant others must understand
that the patient is the only one who should control
the PCA.
PCA infusing without
complications. Patient
and family understand
purpose and use of
PCA. Patient is getting
adequate pain relief
with current dose.
If the patient is
receiving epidural
analgesia:
These symptoms indicate an allergic response, or
improper catheter placement.
Labeling of tubing is necessary to prevent
All tubing labeled. No
signs of allergic
reaction or catheter
1. Assess for
numbness,
tingling in
extremities;
and a metallic
taste in the
mouth.
2. Label all tubing
clearly.
inadvertent administration of fluids or drugs in the
epidural space.
Catheter migration or improper administration
through the catheter can result in life-threatening
complications.
migration noted.
For PCA and epidural
analgesia:
1. Keep Narcan
readily
available.
2. Place “No
additional
analgesia” sign
over head of
bed.
In event of respiratory depression reversal agent
must be available.
This prevents inadvertent analgesia overdosing.
Narcan on unit if
needed. Sign placed in
room for safety.
Nursing Diagnosis
Risk For Infection r/t inadequate primary defenses
Long Term Goal
Patient will be free of
infection
Short Term Goals / Outcomes:
Patient will maintain normal vital signs.
Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes.
Interventions Rationale Evaluation
Assess for presence of risk
factors: open wounds,
abrasions; indwelling catheters;
drains; artificial airways; and
venous access devices.
Represent a break in body’s first line of
defense.
Patient has midline
thoracic incision, Foley,
chest tube and
peripheral IV access.
Monitor white blood count Normal WBC is 4-11 mm3. Rising WBC Patient’s WBC are within
(WBC). indicates the body’s attempt to combat
pathogens.
the normal range.
Monitor incisions, injured sites
and exit sites of tubes, drains
and catheters for signs of
infection.
Redness, swelling, increased pain, or
purulent drainage is suspicious of infection
and should be cultured.
All areas are without
signs of infection.
Monitor temperature and the
presence of sweating and chills.
In the first 24-48 hours fever up to 38
degrees C (100.4F) is related to the stress of
surgery. After 48 hours fever above 37.7C
(99.8F) suggests infection. High fever with
sweating and chills suggests septicemia.
Temperature is less than
37.7C. No sweating or
chills present.
Monitor the color of respiratory
secretions.
Yellow or yellow-green sputum indicates a
respiratory infection.
Patient coughs up only
thin clear secretions.
Monitor the appearance of
urine.
Cloudy, foul-smelling urine, with sediments
indicates a urinary tract or bladder
infection.
Urine is clear yellow
with no sediments.
Maintain strict aseptic
technique with all dressing
changes; tubes, drains and
catheter care; and venous
access devices.
Strict asepsis is necessary to prevent cross-
contamination and nosocomial infections.
No further infections are
noted.
Wash hands and teach others to
wash hands before and after
patient care.
Hand washing reduces the risk of
transmitting pathogens from one area of
the body to another as well as from one
patient to another.
No further infections are
noted.
Encourage fluid intake of
2000ml – 3000ml of water per
day (unless contraindicated).
Fluids promote frequent emptying of the
bladder, reducing stasis of urine and risk of
urinary tract and bladder infections.
Patient drinks 2000 -
3000 ml of fluid. No
presence of urinary tract
or bladder infections.
Encourage intake of protein and
calorie rich foods. Provide
enteral feeding in patients who
Optimal nutritional status promotes wound
healing.
Wounds are well
approximated.
are NPO.
Encourage coughing and deep
breathing.
Reduces stasis of pulmonary secretions,
reducing the risk of pneumonia.
Patient coughs up thin
clear secretions.
Administer and teach the use of
antimicrobial drugs as ordered.
All agents are either toxic to the pathogens
or retard the pathogen’s growth. Ideally
medications should be selected based on a
culture from the infected area. A broad-
spectrum agent may be started until culture
reports are available.
WBC within normal
limits. No further
infections noted.
Nursing Diagnosis
Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary,
or central r/t hypovolemia, decreased arterial flow & cerebral edema
Long Term Goal
Patient will maintain
optimal tissue
perfusion to vital
organs
Short Term Goals / Outcomes:
Patient will maintain strong peripheral pulses.
Patient will report absence of chest pain.
Patient will be awake, alert and oriented.
Patient will maintain normal arterial blood gases (ABGs).
Patient will maintain normal urine output.
Patient will maintain normal bowel sounds.
Interventions Rationale Evaluation
Assess each area for
signs of decreased
tissue perfusion.
Early detection facilitates prompt, effective
treatment.
Signs may be:
Peripheral: weak, absent pulses; edema; numbness,
pain, aches; cool to touch; mottling; prolonged
capillary refill
Cardiopulmonary: tachycardia, arrhythmias,
hypotension, tachypnea, abnormal ABGs, angina
Renal: decreased output, hematuria, elevated
BUN/creatinine ratio
No signs of decreased
perfusion noted.
GI: decreased or absent bowel sounds; nausea;
abdominal pain / distention
Cerebral: restless, change in mentation seizure
activity, papillary changes and decrease reaction to
light
Monitor vital signs for
optimal cardiac output.
Adequate perfusion to vital organs is essential. A
mean arterial blood pressure of at least 60 mmHg is
essential to maintain perfusion.
All vital signs within
normal limits.
Administer fluids and
blood products as
ordered.
Aids in maintaining adequate circulating volume to
prevent irreversible ischemic damage.
Fluids infusing. Vital
signs, urine output and
mentation all within
normal limits.
Anticipate the need for
possible
antithrombolytic
therapy.
If an obstruction to the area has developed an
embolectomy, heparinzation, or thrombolytic
therapy may be necessary to restore flow and
prevent ischemia
Heparin infusing. PTT
within therapeutic
range.
Assess for
compartment
syndrome if peripheral
circulation is impaired
(pain, palor,
pulselessness,
paralysis, parathesia).
Compartment syndrome develops as the tissue
swells and the fascial covering over the muscles can
not yield to the pressure. Blood flow to the
extremity is drastically reduced. An emergent
fasciotomy may need to be performed to restore
flow.
No signs of
compartment
syndrome noted.
Administer oxygen as
prescribed. Titrate
oxygen based on
continuous pulse
oximetry levels.
Oxygen saturates circulating hemoglobin and
increases the effectiveness of blood that reached the
ischemic tissues. Thus improving tissue perfusion.
Patient receiving
oxygen. Pulse
Oximetry 90 – 100%.
Monitor ABGs,
especially for metabolic
acidosis and hypoxia.
Metabolic acidosis and hypoxia indicate that tissues
are not adequately being perfused.
ABGs within normal
limits.
If Patient complains of NTG causes vasodilation, decreases preload and
afterload and thus improves perfusion to the
NTG
administer. Patient
angina;
1. administer
nitroglycerin
(NTG)
sublingually.
myocardium. reports relief of angina.
If cerebral perfusion is
compromised:
1. Ensure proper
functioning of
intracranial
pressure (ICP)
catheter if
present.
2. Elevate head of
bed 30 -45
degrees.
3. Avoid
measures that
may trigger
increased ICP
4. Administer
anticonvulsants
as needed.
Promotes venous outflow from brain and helps
reduce pressure.
Straining, coughing, neck or hip flexion and lying
supine may increase ICP and further reduce blood
flow.
Reduces the risk of seizures, which may result from
cerebral edema or ischemia.
Patient awake and alert
with no change in
mentation.
No seizures noted
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTI
ON
RATIONALE EVALUATIO
N
SUBJECTIVE:
“Namamanas
ang paa
ko”(My feet
are swelling)
as verbalized
by the
patient.
OBJECTIVE:
Restlessn
ess
Fatigue
Edema on
lower
extremitie
s
V/S taken
as follows
T: 36.9˚C
Excess fluid
volume
related to
compromis
ed
regulatory
mechanism
Excessive
fluid
volume in
the blood.
This fluid
excess
usually
results
from
compromis
ed
regulatory
mechanism
s for
sodium and
water as
seen in
congestive
heart
failure
(CHF),
kidney
failure, and
liver failure.
It can also
be caused
by too
much
intake of
sodium
from foods,
intravenous
(IV)
solutions,
medication
s, or
After 4
hours of
nursing
interventio
ns, the
Patient will
demonstrat
e stabilized
fluid
volume as
evidenced
by balanced
intake and
output
(I&O) and
vital signs
within
client’s
normal
range.
INDEPENDEN
T
Monitor
vital
signs as
well as
central
venous
pressure.
Auscultat
e lung
and
heart
sounds.
Maintain
adequat
e I&O.
Note
decrease
d urinary
output
Tachycar
dia and
hyperten
sion are
common
manifest
ations.
Crackle
sounds
and extra
heart
sounds
are
indicative
of fluid
excess,
possibly
resulting
in rapid
develop
ment of
pulmonar
y edema.
Decrease
d renal
perfusion
, cardiac
insufficie
ncy, and
fluid
shifts
may
cause
After 4
hours of
nursing
interventio
ns, the
Patient was
able to
demonstrat
e stabilized
fluid
volume as
evidenced
by balanced
intake and
output
(I&O) and
vital signs
within
client’s
normal
range.
P: 102
R: 20
BP: 110/ 80
diagnostic
contrast
dyes. The
excess
fluid,
mainly salt
and water,
builds up in
different
body
locations
and can
lead to
swelling in
the legs
and arms
(peripheral
edema),
and/or fluid
in the
abdomen
(ascites).
and
positive
fluid
balance
on 24-
hour
calculati
ons.
Weigh as
indicated
. Be alert
for
sudden
weight
gain.
Encourag
e
coughing
and deep
breathin
g
exercises
.
Maintain
semi-
fowler’s
position.
decrease
urinary
output
and
edema
formatio
n.
One liter
of fluid
retention
equals a
weight
gain of 1
kilogram.
Pulmonar
y fluid
shifts
potentat
e
respirato
ry
complicat
ions.
Gravity
improves
lung
expansio
n.
Reduce
pressure
and
friction
on
edemato
us tissue.
Turn or
repositio
n, and
provide
skin care
at
regular
intervals.
Encourag
e bed
rest.
Limited
cardiac
reserves
results in
fatigue
and
activity
intoleran
ce.
Caregiver Role Strain - Evaluation, Interventions, Documentation
9:23 PM Posted by Pak Mantri
Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify resources within self to deal with situation.
• Provide opportunity for care receiver to deal with situation in own way.
• Express more realistic understanding and expectations of the care receiver.
• Demonstrate behavior/lifestyle changes to cope with and/or resolve problematic factors.
• Report improved general well-being, ability to deal with situation.
Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impaired function:
• Inquire about/observe physical condition of care receiver and surroundings as appropriate.
• Assess caregiver’s current state of functioning (e.g., hours of sleep, nutritional intake, personal
appearance, demeanor).
• Determine use of prescription/over-the-counter (OTC) drugs, alcohol to deal with situation.
• Identify safety issues concerning caregiver and receiver.
• Assess current actions of caregiver and how they are received by care receiver (e.g., caregiver may be
trying to be helpful but is not perceived as helpful; may be too protective or may have unrealistic
expectations of care receiver). May lead to misunderstanding and conflict.
• Note choice/frequency of social involvement and recreational activities.
• Determine use/effectiveness of resources and support systems.
NURSING PRIORITY NO. 2. To identify the causative/contributing factors relating to the impairment:
• Note presence of high-risk situations (e.g., elderly client with total self-care dependence, or family
with several small children with one child requiring extensive assistance due to physical
condition/developmental delays). May necessitate role reversal resulting in added stress or place
excessive demands on parenting skills.
• Determine current knowledge of the situation, noting misconceptions, lack of information.May
interfere with caregiver/ care receiver response to illness/condition.
• Identify relationship of caregiver to care receiver (e.g., spouse/lover, parent/child, sibling, friend).
• Ascertain proximity of caregiver to care receiver.
• Note physical/mental condition, complexity of therapeutic regimen of care receiver.
• Determine caregiver’s level of responsibility, involvement in and anticipated length of care.
• Ascertain developmental level/abilities and additional responsibilities of caregiver.
• Use assessment tool, such as Burden Interview, when appropriate, to further determine caregiver’s
abilities.
• Identify individual cultural factors and impact on caregiver. Helps clarify expectations of
caregiver/receiver, family, and community.
• Note co-dependency needs/enabling behaviors of caregiver.
• Determine availability/use of support systems and resources.
• Identify presence/degree of conflict between caregiver/care receiver/family.
• Determine preillness/current behaviors that may be interfering with the care/recovery of the care
receiver.
NURSING PRIORITY NO. 3. To assist caregiver in identifying feelings and in beginning to deal with
problems:
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard.
• Acknowledge difficulty of the situation for the caregiver/ family.
• Discuss caregiver’s view of and concerns about situation.
• Encourage caregiver to acknowledge and express feelings. Discuss normalcy of the reactions without
using false reassurance.
• Discuss caregiver’s/family members’ life goals, perceptions and expectations of self to clarify
unrealistic thinking and identify potential areas of flexibility or compromise.
• Discuss impact of and ability to handle role changes necessitated by situation.
NURSING PRIORITY NO. 4. To enhance caregiver’s ability to deal with current situation:
• Identify strengths of caregiver and care receiver.
• Discuss strategies to coordinate caregiving tasks and other responsibilities (e.g., employment, care of
children/dependents, housekeeping activities).
• Facilitate family conference to share information and develop plan for involvement in care activities as
appropriate.
• Identify classes and/or needed specialists (e.g., first aid/CPR classes, enterostomal/physical therapist).
• Determine need for/sources of additional resources (e.g., financial, legal, respite care).
• Provide information and/or demonstrate techniques for dealing with acting out/violent or disoriented
behavior. Enhances safety of caregiver and receiver.
• Identify equipment needs/resources, adaptive aids to enhance the independence and safety of the
care receiver.
• Provide contact person/case manager to coordinate care, provide support, assist with problem-
solving.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Assist caregiver to plan for changes that may be necessary (e.g., home care providers, eventual
placement in long-term care facility).
• Discuss/demonstrate stress management techniques and importance of self-nurturing (e.g., pursuing
self-development interests, personal needs, hobbies, and social activities).
• Encourage involvement in support group.
• Refer to classes/other therapies as indicated.
• Identify available 12-step program when indicated to provide tools to deal with enabling/co-
dependent behaviors that impair level of function.
• Refer to counseling or psychotherapy as needed.
• Provide bibliotherapy of appropriate references for self-paced learning and encourage discussion of
information.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, functional level/degree of impairment, caregiver’s understanding/perception of
situation.
• Identified risk factors.
PLANNING
• Plan of care and individual responsibility for specific activities.
• Needed resources, including type and source of assistive devices/durable equipment.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Caregiver/receiver response to interventions/teaching and actions performed.
• Identification of inner resources, behavior/lifestyle changes to be made.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Plan for continuation/follow-through of needed changes.
• Referrals for assist
ASSESSMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“eto nga at hianng hina siya, hindi naniya magalaw angright side niya”
As stated by the significant other
OBJECTIVE:-grade of 0 in the level of functioning-paraesthesia in the right side of thebody-0/5 muscle
strength in theRUE-1/5 muscle strength in the RLE-impaired coordination-inability to purposefully move
body part IMPAIREDPHYSICALMOBILITY r t neuromuscular involvement (right sided paraesthesia) abed
inability to purposefully move body parts. HPN, age, alcohol, smoking ↓Thrombus formation in the
blood vessel ↓Obstruction to the flow of blood↓ metabolic acidosis, an aerobic respiration
↓Destruction of neurons↓
DISCHARGEPLAN:
After 2 week of Nursing Intervention the client will be able to move and do minimal task such as:-go to
the toilet with minimal assistance- ambulate moderately-eat without assistance-do tooth brushing
without assistance
SHORT TERM: After 1 week of Nursing Intervention the Significant other will be able to verbalize
understanding of *Observe movement when client is unaware of observation*schedule activities with
adequate rest periods during the day* encourage energy conserving techniques for rising
ADLs*encourage adequate intake of fluids and nutritious foods like: fruits and vegetables.*Plan for
progressive increase of activity level/ participation in exercise, training as tolerated by the client, such
as:-performing ROM*to note any in congruencies w/reports or abilities*to reduce fatigue and increase
comfort.*limit fatigue and maximize participation*maximize energy production and aides in fast
recovery.*Helps to minimize frustrations and rechanneled energy .DISCHARGE PLAN: After 2 week of
Nursing Intervention the client had been able to move and do minimal task such as:-go to the toilet with
minimal assistance-ambulate moderately-eat without assistance-do tooth brushing without assistance
SHORT TERM: After 1 week of Nursing Intervention the Significant other had been able to verbalize
understanding of the situation and /evaluation.
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