Vous êtes sur la page 1sur 115

Decreased Cardiac Output

Dec Defcient Fluid Volume


Decreased Intracranial Adaptive Capacity
Defcient Knowledge
Disturbed Body Image
Disturbed Sleep attern
!"cess Fluid Volume
#ypert$ermia
#ypot$ermia
Imbalanced %utrition& 'ess ($an Body )e*uirements
Impaired +as !"c$ange
Impaired Spontaneous Ventilation
Impaired Swallowing
Impaired Verbal Communication
Ine,ective Airway Clearance
Ine,ective Breat$ing attern
Ine,ective Cardiopulmonary (issue er-usion
Ine,ective Coping
Ine,ective +astrointestinal (issue er-usion
Ine,ective erip$eral (issue er-usion
Ine,ective )enal (issue er-usion
owerlessness
)is. -or Aspiration
)is. -or In-ection
Situational 'ow Sel-/!steem
0nilateral %eglect
Nursing Management Plan
Decreased Cardiac Output
Defnition: Inadequate blood pumped by the heart to meet the metabolic
demands of the
Body
Decreased Cardiac Output Related to Alterations in Preload
Defning Characteristics
Cardiac output <4. !"min
Cardiac inde# <$.% !"min"m$
&eart rate '( beats"min
)rine output <* ml"hr or .% ml"+,"hr
Decreased mentation- restlessness- a,itation- confusion
Diminished peripheral pulses
Blue- ,ray- or dar+ purple tint to ton,ue and sublin,ual area
.ystolic blood pressure </ mm &,
.ub0ecti1e complaints of fati,ue
Reduced Preload:
Ri,ht atrial pressure <$ mm &,
Pulmonary artery occlusion pressure <% mm &,
Excessive Preload:
Ri,ht atrial pressure '2 mm &,
Pulmonary artery occlusion pressure '($ mm &,
Outcome Criteria
Cardiac output 434 !"min
Cardiac inde# $.%34 !"min"m$
Ri,ht atrial pressure $34 mm &,
Pulmonary artery occlusion pressure %3($ m, &,
(%5(
Nursing Interventions and Rationale
1. Collaborate 6ith physician re,ardin, the administration of o#y,en to
maintain an .po$
'/$7 to prevent tissue $ypo"ia1
2. 8aintain sur1eillance for si,ns of decreased tissue perfusion and acidosis
to -acilitate
t$e early identifcation and treatment o- complications1
3. 8onitor 9uid balance and daily 6ei,hts to -acilitate regulation o- t$e
patient2s 3uid
balance1
For Reduced Preload econdar! to "olume #oss:
1. Collaborate 6ith physician re,ardin, the administration of crystalloids-
colloids- blood-
and blood products to increase circulating volume1
2. !imit blood samplin,- obser1e intra1enous lines for accidental
disconnection- apply
direct pressure to bleedin, sites- and maintain normal body temperature to
minimi4e
3uid loss1
3. Position patient 6ith le,s ele1ated- trun+ 9at- and head and shoulders
abo1e the chest
to en$ance venous return1
$. :ncoura,e oral 9uids ;as appropriate<- administer free 6ater 6ith tube
feedin,s- and
replace 9uids that are lost throu,h 6ound or tube draina,e to promote
ade*uate 3uid
inta.e1
%. 8aintain sur1eillance for si,ns of 9uid 1olume e#cess and ad1erse e=ects
of blood and
blood product administration to -acilitate t$e early identifcation and
treatment o-
complications1
For Reduced Preload econdar! to "enous Dilation:
1. Collaborate 6ith physician re,ardin, the administration of 1asocontrictors
to increase
venous return1
2. 8aintain sur1eillance for ad1erse e=ects of 1asoconstrictor therapy to
-acilitate t$e
early identifcation and treatment o- complications1
3. If patient is hyperthermic- administer tepid bath- hypothermia blan+et-
and"or ice ba,s
to a#illa and ,roin to decrease temperature and promote
vasoconstriction1
For Excessive Preload econdar! to "olume &verload:
1. Collaborate 6ith physician re,ardin, the administration of the follo6in,>
Diuretics to remo1e e#cessi1e 9uid.
?asodilators to decrease 1enous return.
Inotropes to increase myocardial contractility.
2. Restrict 9uid inta+e and double concentrate intra1enous drips to
minimi4e 3uid inta.e1
3. Position patient in semi@Ao6lerBs or hi,h@Ao6lerBs position to reduce
venous return1
$. 8aintain sur1eillance for si,ns of 9uid 1olume deCcit and ad1erse e=ects
of diuretic-
1asodilator- and inotropic therapies to -acilitate t$e early identifcation
and
treatment o- complications1
For Excessive Preload econdar! to "enous 'onstriction:
1. Collaborate 6ith physician re,ardin, the administration of 1asodilators to
promote
venous dilation1
2. 8aintain sur1eillance for ad1erse e=ects of 1asodilator therapy to
-acilitate t$e early
identifcation and treatment o- complications1
3. If patient is hypothermic- 6rap patient in 6arm blan+ets or administer
hyperthermia
blan+et to increase temperature and promote vasodilation1
Decreased Cardiac Output Related to Alterations in Afterload
Defning Characteristics
Cardiac output <4 !"min
Cardiac inde# <$.% !"min"m$
&eart rate '( beats"min
)rine output <* ml"hr
Decreased mentation- restlessness- a,itation- confusion
Diminished peripheral pulses
Blue- ,ray- or dar+ purple tint to ton,ue and sublin,ual area
.ystolic blood pressure </ mm &,
.ub0ecti1e complaints of fati,ue
Reduced ()terload:
Pulmonary 1ascular resistance <( dynes"sec"cm@%
.ystemic 1ascular resistance <4 dynes"sec"cm@%
Excessive ()terload:
(%5*
Pulmonary 1ascular resistance '$% dynes"sec"cm@%
.ystemic 1ascular resistance '($ dynes"sec"cm@%
Outcome Criteria
Cardiac output 434 !"min
Cardiac inde# $.%34 !"min"m$
Pulmonary 1ascular resistance 43$% dynes"sec"cm@%
.ystemic 1ascular resistance 43($ dynes"sec"cm@%
Nursing Interventions and Rationale
1. Collaborate 6ith physician re,ardin, the administration of o#y,en to
maintain an .po$
'/$7 to prevent tissue $ypo"ia1
2. 8aintain sur1eillance for si,ns of decreased tissue perfusion and acidosis
to -acilitate
t$e early identifcation and treatment o- complications1
For Reduced ()terload:
1. Collaborate 6ith physician re,ardin, the administration of 1asocontrictors
to promote
arterial vasoconstriction and prevent relative $ypovolemia1 If
decreased preload is
present- implement nursin, mana,ement plan of care- Decreased Cardiac
Output
Related to Alterations in Preload.
2. 8aintain sur1eillance for ad1erse e=ects of 1asoconstrictor therapy to
-acilitate t$e
early identifcation and treatment o- complications1
3. If patient is hyperthermic- administer tepid bath- hypothermia blan+et-
and"or ice ba,s
to a#illa and ,roin to decrease temperature and promote
vasoconstriction1
For Excessive ()terload:
1. Collaborate 6ith physician re,ardin, the administration of 1asodilators to
promote
arterial vasodilation1
2. Collaborate 6ith physician re,ardin, initiation of intraaortic balloon pump
to -acilitate
a-terload reduction1
(%54
3. Promote rest and rela#ation and decrease en1ironmental stimulation to
minimi4e
sympat$etic stimulation1
$. 8aintain sur1eillance for ad1erse e=ects of 1asodilator therapy to
-acilitate t$e early
identifcation and treatment o- complications1
%. If patient is hypothermic- 6rap patient in 6arm blan+ets or administer
hyperthermia
blan+et to increase temperature and promote vasodilation1
*. If patient is in pain- treat pain to reduce sympat$etic stimulation1
Implement nursin,
mana,ement plan of care- Acute Pain Related to Dransmission and Perception
of
Cutaneous- ?isceral- 8uscular- or Ischemic Impulses.
Decreased Cardiac Output Related to Alterations in Contractility
Defning Characteristics
Cardiac output <4 !"min
Cardiac inde# <$.% !"min"m$
&eart rate '( beats"min
)rine output <* ml"hr
Decreased mentation- restlessness- a,itation- confusion
Diminished peripheral pulses
Blue- ,ray- or dar+ purple tint to ton,ue and sublin,ual area
.ystolic blood pressure </ mm &,
.ub0ecti1e complaints of fati,ue
Ri,ht 1entricular stro+e 6or+ inde# <5 ,"m$"beat
!eft 1entricular stro+e 6or+ inde# <*% ,"m$"beat
Outcome Criteria
Cardiac output 434 !"min
Cardiac inde# $.%34 !"min"m$
Ri,ht 1entricular stro+e 6or+ inde# 53($ ,"m$"beat
!eft 1entricular stro+e 6or+ inde# *%34% ,"m$"beat
Nursing Interventions and Rationale
1. Collaborate 6ith physician re,ardin, the administration of o#y,en to
maintain an .po$
'/$7 to prevent tissue $ypo"ia1
2. 8aintain sur1eillance for si,ns of decreased tissue perfusion and acidosis
to -acilitate
t$e early identifcation and treatment o- complications1
3. :nsure preload is optimiEed. If preload is reduced or e#cessi1e- implement
nursin,
(%5%
mana,ement plan of care- Decreased Cardiac Output Related to Alterations in
Preload.
$. :nsure afterload is optimiEed. If afterload is reduced or e#cessi1e-
implement nursin,
mana,ement plan of care- Decreased Cardiac Output Related to Alterations in
Afterload.
%. :nsure electrolytes are optimiEed. Collaborate 6ith physician re,ardin, the
administration of electrolyte replacement therapy to en$ance cellular
ionic
environment1
*. Collaborate 6ith physician re,ardin, the administration of inotropes to
en$ance
myocardial contractility1
+. If myocardial ischemia present- implement nursin, mana,ement plan of
care- Altered
Cardiopulmonary Dissue Perfusion.
Decreased Cardiac Output Related to Alterations in &eart Rate or Rhythm
Defning Characteristics
Cardiac output <4 !"min
Cardiac inde# <$.% !"min"m$
&eart rate '( beats"min
)rine output <* ml"hr or .% ml"+,"hr
Decreased mentation- restlessness- a,itation- confusion
Diminished peripheral pulses
Blue- ,ray- or dar+ purple tint to ton,ue and sublin,ual area
.ystolic blood pressure </ mm &,
.ub0ecti1e complaints of fati,ue
&eart rate <2 beats"min
Dysrhythmias
Outcome Criteria
Cardiac output 434 !"min
Cardiac inde# $.%34 !"min"m$
Absence of dysrhythmias or return to baseline
&eart rate '2 beats"min
Nursing Interventions and Rationale
1. Collaborate 6ith physician re,ardin, the administration of o#y,en to
maintain an .po$
'/$7 to prevent tissue $ypo"ia1
2. :nsure electrolytes are optimiEed. Collaborate 6ith physician re,ardin, the
(%52
administration of electrolyte therapy to en$ance cellular ionic
environment and
avoid precipitation o- dysr$yt$mias1
3. Collaborate 6ith physician and pharmacist re,ardin, patientBs current
medications and
their e=ect on heart rate and rhythm to identi-y any prodysr$yt$mic or
bradycardic
side e,ects1
$. 8aintain sur1eillance for si,ns of decreased tissue perfusion and acidosis
to -acilitate
t$e early identifcation and treatment o- complications1
%. 8onitor .D se,ment continuously to determine c$anges in myocardial
tissue
per-usion1 If myocardial ischemia is present- implement nursin,
mana,ement plan of
care- Altered Cardiopulmonary Dissue Perfusion.
For #et,al D!sr,!t,mias or (s!stole
1. Initiate Ad1anced Cardiac !ife .upport inter1entions and notify physician
immediately.
For Nonlet,al D!sr,!t,mias
1. Collaborate 6ith physician re,ardin, administration of antidysrhythmic
therapy-
synchroniEed cardio1ersion- and"or o1erdri1e pacin, to control
dysr$yt$mias1
2. 8aintain sur1eillance for ad1erse e=ects of antidysrhythmic therapy to
-acilitate t$e
early identifcation and treatment o- complications1
For -eart Rate .*/ 0eats1Min
1. Collaborate 6ith physician re,ardin, the initiation of temporary pacin, to
increase
$eart rate1
Decreased Cardiac Output Related to .ympathetic Bloc+ade
Defning Characteristics
Decreased cardiac output ;CO< and cardiac inde# ;CI<
.ystolic blood pressure ;.BP< </ mm &, or belo6 patientBs baseline
Decreased ri,ht atrial pressure ;RAP< and pulmonary artery occlusion
pressure ;PAOP<
Decreased systemic 1ascular resistance ;.?R<
Bradycardia
Cardiac dysrhythmias
(%55
Postural hypotension
Outcome Criteria
CO and CI are 6ithin normal limits.
.BP is '/ mm &, or returns to baseline.
RAP and PAOP are 6ithin normal limits.
.?R is 6ithin normal limits.
.inus rhythm is present.
Dysrhythmias are absent.
Aaintin, or diEEiness 6ith position chan,e is absent.
Nursing Interventions and Rationale
1. Implement measures to pre1ent episodes of postural hypertension>
Chan,e patientBs position slo6ly to allo6 the cardio1ascular system time to
compensate.
Apply antiembolic stoc+in,s to promote 1enous return.
Perform ran,e of motion e#ercises e1ery $ hours to pre1ent 1enous poolin,.
Collaborate 6ith the physician and physical therapist re,ardin, the use of a
tilt
table to pro,ress the patient from supine to upri,ht position.
2. Collaborate 6ith the physician re,ardin, the administration of the
follo6in,>
Crystalloids and"or colloids to increase the patientBs circulatin, 1olume-
6hich
increases stro+e 1olume and subsequently cardiac output.
?asopressors if 9uids are ine=ecti1e to constrict the patientBs 1ascular
system-
6hich increases resistance and subsequently blood pressure.
3. 8onitor cardiac rhythm for bradycardia and"or dysrhythmias- w$ic$ can
-urt$er
decrease cardiac output1
$. A1oid any acti1ity that can stimulate the 1a,al response because
bradycardia can
result1
%. Dreat symptomatic bradycardia and symptomatic dysrhythmias accordin,
to unitBs
emer,ency protocol or Ad1anced Cardiac !ife .upport ;AC!.< ,uidelines.
Nursing Management Plan
Decreased Intracranial Adaptive Capacity
Defnition: Intracranial 9uid dynamic mechanisms that normally compensate
for increases in
intracranial 1olumes are compromised- resultin, in repeated disproportionate
increases in
intracranial pressure ;ICP< in response to a 1ariety of no#ious and non@no#ious
stimuli
Decreased Intracranial Adapti1e Capacity Related to Aailure of Formal
Intracranial Compensatory 8echanisms
(%54
Defning Characteristics
ICP '(% mm &,- sustained for (%3* minutes
&eadache
?omitin,- 6ith or 6ithout nausea
.eiEures
Decrease in Glas,o6 Coma .cale score of $ or more points from baseline
Alteration in le1el of consciousness- ran,in, from restlessness to coma
Chan,e in orientation> disoriented to time and"or place and"or person
DiHculty or inability to follo6 simple commands
Increasin, systolic blood pressure of more than $ mm &, 6ith 6idenin,
pulse
pressure
Bradycardia
Irre,ular respiratory pattern ;e.,.- Cheyne@.to+es- central neuro,enic
hyper1entilation-
ata#ic- apneustic<
Chan,e in response to painful stimuli ;e.,.- purposeful to inappropriate or
absent
response<
.i,ns of impendin, brain herniation>
&emiparesis or hemiple,ia
&emisensory chan,es
)nequal pupil siEe ;( mm or more di=erence<
Aailure of pupil to react to li,ht
Dyscon0u,ate ,aEe and inability to mo1e one eye beyond midline if third-
fourth-
or si#th cranial ner1es in1ol1ed
!oss of oculocephalic or oculo1estibular re9e#es
Possible decorticate or decerebrate posturin,
Outcome Criteria
ICP is I(% mm &,.
Cerebral perfusion pressure ;CPP< is '2 mm &,.
Clinical si,ns of increased ICP as pre1iously described are absent.
Nursing Interventions and Rationale
(%5/
1. 8aintain adequate CPP.
a. Collaborate 6ith physician re,ardin, the administration of 1olume
e#panders-
1asopressors- or antihypertensi1es to maintain t$e patient2s blood
pressure
wit$in normal range1
2. Implement measures to reduce ICP.
:le1ate head of bed * to 4% de,rees to -acilitate venous return1
8aintain head and nec+ in neutral plan ;a1oid 9e#ion- e#tension- or
lateral rotation< to en$ance venous drainage -rom t$e $ead1
A1oid e#treme hip 9e#ion.
Collaborate 6ith the physician re,ardin, the administration of steroids-
osmotic a,ents- and diuretics and need for draina,e of cerebrospinal
9uid ;C.A< if a 1entriculostomy is in place.
Assist patient to turn and mo1e self in bed ;instruct patient to e#hale
6hile turnin, or pushin, up in bed< to avoid isometric contractions and
Valsalva maneuver1
2. 8aintain patent air6ay and adequate 1entilation and supply o#y,en to
prevent
$ypo"emia and $ypercarbia1
3. 8onitor arterial blood ,as ;ABG< 1alues and maintain Pao$ '4 mm &,-
Paco$ at $%3
*% mm &,- and p& at 5.*%35.4% to prevent cerebral vasodilation1
$. A1oid suctionin, beyond ( seconds at a timeJ hypero#y,enate and
hyper1entilate
before and after suctionin,.
%. Plan patient care acti1ities and nursin, inter1entions around patientBs ICP
response.
A1oid unnecessary additional disturbances- and allo6 patient up to ( hour of
rest
bet6een acti1ities as frequently as possible. Studies $ave s$own t$e
direct
correlation between nursing care activities and increases in IC1
*. 8aintain normothermia 6ith e#ternal coolin, or heatin, measures as
necessary. Krap
hands- feet- and male ,enitalia in soft to6els before coolin, measures to
prevent
s$ivering and -rostbite1
+. Kith physicianBs collaboration- control seiEures 6ith prophylactic and as@
necessary
;PRF< anticon1ulsants. Sei4ures can greatly increase t$e cerebral
metabolic rate1
3. Collaborate 6ith the physician re,ardin, the administration of sedati1es-
barbiturates-
or paralyEin, a,ents to reduce cerebral metabolic rate1
4. Counsel family members to maintain calm atmosphere and a1oid
disturbin, topics of
con1ersation ;e.,.- patient condition- pain- pro,nosis- family crisis- Cnancial
diHculties<.
1/. If si,ns of impendin, brain herniation are present- implement the
follo6in,>
a. Fotify the physician at once.
2. Be sure head of bed is ele1ated 4% de,rees and patientBs head is in neutral
plane.
c. Administer mainline intra1enous ;I?< infusion slo6ly to +eep@open rate.
d. Drain C.A as ordered if a 1entriculostomy is in place.
e. Prepare to administer osmotic a,ents and"or diuretics.
). Prepare patient for emer,ency computed tomo,raphy ;CD< head scan
and"or
emer,ency sur,ery.
Nursing Management Plan
Defcient Fluid Volume
Defnition: Decreased intra1ascular- interstitial- and"or intracellular 9uid.
Dhis refers to
dehydration- 6ater loss alone 6ithout chan,e in sodium
(%4
DeCcient Aluid ?olume Related to Absolute !oss
Defning Characteristics
Cardiac output ;CO< <4 ! "min
Cardiac inde# ;CI< <$.$ ! "min
Pulmonary artery occlusion pressure ;PAOP<- pulmonary artery diastolic
;PAD<
pressure less than normal or less than baseline- central 1enous pressure
;C?P< less
than normal or less than baseline ;PAOP <2 mm &,<
Dachycardia
Farro6ed pulse pressure
.ystolic blood pressure ;.BP< <( mm &,
)rinary output <* ml"hr
Pale- cool- moist s+in
Apprehensi1eness
Outcome Criteria
CO is '4 ! "min- and CI is '$.$ ! "min.
PAOP- PAD- and C?P are normal or bac+ to baseline le1el.
Pulse is normal or bac+ to baseline.
.BP is '/.
)rinary output is '* ml"hr.
Nursing Interventions and Rationale
1. .ecure air6ay- and administer hi,h@9o6 o#y,en.
2. Place patient in supine position 6ith le,s ele1ated to increase preload1
Aor patient
6ith head in0ury- consider usin, lo6@Ao6lerBs position 6ith le,s ele1ated.
3. Aor 9uid repletion- use the *>( rule- replacin, three parts of 9uid for e1ery
unit of blood
lost.
$. Administer crystalloid solutions usin, the 9uid challen,e technique> infuse
precise
aliquots of 9uid ;usually % to $ ml"min< o1er (3minute periodsJ monitor
cardiac
loadin, pressure serially to determine success-ul c$allenging1 If the
pulmonary
PAOP or PAD ele1ates more than 5 mm &, abo1e be,innin, le1el- the infusion
should
be stopped. If the PAOP or PAD rises only to * mm &, abo1e baseline or falls-
another
9uid challen,e should be administered.
%. Replete 9uids Crst before considerin, use of 1asopressors- since
vasopressors
increase myocardial o"ygen consumption out o- proportion to t$e
reestablis$ment o- coronary per-usion in t$e early p$ases o-
treatment1
*. Khen blood replacement is indicated- replace it 6ith fresh pac+ed red cells
and fresh
froEen plasma to .eep clotting -actors intact1
(%4(
+. 8o1e or reposition patient minimally to decrease or limit tissue
o"ygen demands1
3. :1aluate patientBs an#iety le1el- and inter1ene throu,h patient education
or sedation to
decrease tissue o"ygen demands1
4. 8aintain sur1eillance for si,ns and symptoms of 9uid o1erload.
DeCcient Aluid ?olume Related to Decreased .ecretion of Antidiuretic
&ormone ;AD&<
Defning Characteristics
Confusion and lethar,y
Decreased s+in tur,or
Dhirst
Kei,ht loss o1er short period
Decreased PAOP
Decreased C?P
)rinary output '2 !"day
.erum sodium '(44 m:q"!
.erum osmolality '$/% mOsm"+,
)rine osmolality <( mOsm"+,
)rine speciCc ,ra1ity <(.%
Outcome Criteria
Kei,ht returns to baseline.
)rinary output is '* ml"hr and <$ ml"hr.
.erum osmolality is $43$/% mOsm"+,.
)rine speciCc ,ra1ity is (.(3(.*.
Nursing Interventions and Rationale
1. Record inta+e and output e1ery hour- notin, color and clarity of urine
because color
and clarity are an indication o- urine concentration1
2. 8onitor :CG rhythm continuously for dysrhythmias caused by
electrolyte imbalance1
3. Collaborate 6ith physician re,ardin, administration of 1asopressin or
desmopressin to
replace AD#1
a. 8onitor patient for ad1erse e=ects of medications ;i.e.- headache- chest
pain-
abdominal pain< caused by vasoconstriction1
2. Report ad1erse e=ects to physician immediately.
(%4$
$. Collaborate 6ith physician re,ardin, intra1enous 9uid and electrolyte
replacement
therapy to restore 3uid balance5 correct de$ydration5 and maintain
electrolyte
balance1
a. Administer hypotonic saline to replace -ree water defcit1
%. Pro1ide oral 9uids lo6 in sodium such as 6ater- co=ee- tea- or oran,e 0uice
to
decrease sodium inta.e1
*. Kei,h patient daily ;at same time- in same amount of clothin,- and
preferably 6ith
same scale< to ensure accuracy o- readings1
+. Reposition patient e1ery $ hours to prevent s.in integrity issues
caused by
de$ydration1
3. Pro1ide mouth care e1ery 4 hours to prevent brea.down o- oral
mucous
membranes1
4. Collaborate 6ith physician re,ardin, administration of medications to
pre1ent
constipation caused by de$ydration1
1/. 8aintain sur1eillance for symptoms of hypernatremia ;muscle t6itchin,-
irritability-
seiEures<- hypo1olemic shoc+ ;hypotension- tachycardia- decreased C?P and
PAOP<-
and deep 1ein thrombosis ;calf pain- tenderness- s6ellin,<.
DeCcient Aluid ?olume Related to Relati1e !oss
Defning Characteristics
PAOP- PAD pressure- C?P less than normal or less than baseline
Dachycardia
Farro6ed pulse pressure
.BP <( mm &,
)rinary output <* ml"hr
Increased hematocrit le1el
Outcome Criteria
PAOP- PAD- and C?P are normal or bac+ to baseline.
.BP is '/ mm &,.
)rinary output is '* ml"hr.
&ematocrit le1el is normal.
Nursing Interventions and Rationale
1. Collaborate 6ith the physician re,ardin, the administration of intra1enous
;I?< 9uid
replacements ;usually normal saline solution or lactated Rin,erBs solution< at
a rate
(%4*
suHcient to maintain urinary output '* ml"hr. Colloid solutions are a1oided
in the initial
phases ;but can be used later< because of the possibility of increased edema
formation
as a result o- t$e increased capillary permeability1
Nursing Management Plan
Defcient Knowledge
Defnition: Absence or deCciency of co,niti1e information related to a
speciCc topic
DeCcient Lno6led,e Related to Co,niti1e"Perceptual !earnin, !imitations
;e.,.- sensory o1erload- sleep depri1ation- medications- an#iety- sensory
deCcits- lan,ua,e barrier<
Defning Characteristics
?erbaliEed statement of inadequate +no6led,e of s+ills
?erbaliEation of inadequate recall of information
?erbaliEation of inadequate understandin, of information
:1idence of inaccurate follo6@throu,h of instructions
Inadequate demonstration of a s+ill
!ac+ of compliance 6ith prescribed beha1ior
Outcome Criteria
Patient participates acti1ely in necessary and prescribed health beha1iors.
Patient 1erbaliEes adequate +no6led,e or demonstrates adequate s+ills.
Nursing Interventions and Rationale
1. Determine speciCc cause of patientBs co,niti1e or perceptual limitation.
2. Pro1ide uninterrupted rest period before teachin, session to decrease
-atigue and
encourage optimal state -or learning and retention1
3. 8anipulate en1ironment as much as possible to provide *uiet and
uninterrupted
learning sessions1
:nsure that li,hts are bri,ht enou,h to see teachin, aids but not too bri,ht.
.chedule care and medications to allo6 uninterrupted teachin, periods.
8o1e patient to quiet- pri1ate room for teachin, if possible.
$. Adapt teachin, sessions and materials to patientBs and familyBs le1els of
education and
(%44
ability to understand.
Pro1ide printed material appropriate to readin, le1el.
)se terminolo,y understood by the patient.
Pro1ide printed materials in patientBs primary lan,ua,e if possible.
)se interpreters durin, teachin, sessions when necessary.
%. Deach only present@tense focus durin, periods of sensory o1erload.
*. Determine potential e=ects of medications on ability to retain or recall
information.
A1oid teachin, critical content 6hile patient is ta+in, sedati1es- anal,esics-
or
other medications that a=ect memory.
+. Reinforce ne6 s+ills and information in se1eral teachin, sessions. )se
se1eral senses
6hen possible in teachin, session ;e.,.- see a Clm- hear a discussion- read
printed
information- and demonstrate s+ills related to self@in0ection of insulin<.
3. Reduce patientBs an#iety.
!isten attenti1ely- and encoura,e 1erbaliEation of feelin,s.
Ans6er questions as they arise in a clear and succinct manner.
:licit patientBs concerns- and address those issues Crst.
Gi1e only correct and rele1ant information.
Continually assess response to teachin, session- and discontinue if an#iety
increases or physical condition becomes unstable.
Pro1ide nonthreatenin, information before more an#iety@producin,
information is
presented.
Plan for se1eral teachin, sessions so information can be di1ided into small-
mana,eable pac+a,es.
DeCcient Lno6led,e Related to !ac+ of Pre1ious :#posure to Information
Defning Characteristics
?erbaliEed statement of inadequate +no6led,e or s+ills
Fe6 dia,nosis or health problem requirin, self@mana,ement or care
!ac+ of prior formal or informal education about the speciCc health problem
Demonstration of inappropriate beha1iors related to mana,ement of health
problem
Outcome Criteria
Patient 1erbaliEes adequate +no6led,e about or performs s+ills related to
disease
process- its causes- factors related to onset of symptoms- and self@
mana,ement of
disease or health problem.
Patient acti1ely participates in health beha1iors required for performance of
a procedure
or in those beha1iors enhancin, reco1ery from illness and pre1entin,
recurrence or
complications.
(%4%
Nursing Interventions and Rationale
1. Determine e#istin, le1el of +no6led,e or s+ill.
2. Assess factors that a=ect the +no6led,e deCcit
!earnin, needs- includin, patientBs priorities and the necessary +no6led,e
and
s+ills for safety.
!earnin, ability of client- includin, lan,ua,e s+ills- le1el of education-
ability to
read- preferred learnin, style.
Physical ability to perform prescribed s+ills or proceduresJ consider e=ect of
limitations imposed by treatment such as bedrest- restriction of mo1ement by
intra1enous or other equipment- or e=ect of sedati1es or anal,esics.
Psycholo,ic e=ect of sta,e of adaptation to disease.
Acti1ity tolerance and ability to concentrate.
8oti1ation to learn ne6 s+ills or ,ain ne6 +no6led,e.
3. Reduce or limit barriers to learnin,>
Pro1ide consistent nurse"patient contact to encoura,e de1elopment of
trustin,
and therapeutic relationship.
.tructure en1ironment to enhance learnin,J control unnecessary noise-
interruptions.
Indi1idualiEe teachin, plan to Ct patientBs current physical and psycholo,ic
status.
Delay teachin, until patient is ready to learn.
Conduct teachin, sessions durin, period of day 6hen patient is most alert
and
recepti1e.
8eet patientBs immediate learnin, needs as they arise ;e.,.- ,i1e brief
e#planation of procedures 6hen they are performed<.
$. Promote acti1e participation in the teachin, plan by the patient and family>
.olicit input durin, de1elopment of plan.
De1elop mutually acceptable ,oals and outcomes.
.olicit e#pression of feelin,s and emotions related to ne6 responsibilities.
:ncoura,e questions.
%. Conduct teachin, sessions- usin, the most appropriate teachin, methods.
*. Repeat +ey principles- and pro1ide them in printed form -or re-erence at
a later time1
+. Gi1e frequent feedbac+ to patient 6hen practicin, ne6 s+ills.
3. )se se1eral teachin, sessions 6hen appropriate. %ew in-ormation and
s.ills s$ould
be rein-orced several times a-ter initial learning1
4. Initiate referrals for follo6@up if necessary>
&ealth educators.
&ome health care.
Rehabilitation pro,rams.
.ocial ser1ices.
1/. :1aluate e=ecti1eness of teachin, plan- based on patientBs ability to
meet preset ,oals
and ob0ecti1es to determine need -or -urt$er teac$ing1
Nursing Management Plan
Disturbed Body Image
Defnition: Confusion in mental picture of oneBs physical self
Disturbed Body Ima,e Related to Actual Chan,e in Body .tructure- Aunction-
or Appearance
Defning Characteristics
Actual chan,e in appearance- structure- or function
A1oidance of loo+in, at body part
A1oidance of touchin, body part
&idin, or o1ere#posin, body part ;intentional or unintentional<
Drauma to nonfunctionin, part
Chan,e in ability to estimate spatial relationship of body to en1ironment
?erbaliEation of the follo6in,>
5
Aear of re0ection or reaction by others
5
Fe,ati1e feelin, about body
5
Preoccupation 6ith chan,e or loss
5
Refusal to participate in or to accept responsibility for self@care of altered
body
part
PersonaliEation of part or loss 6ith a name
DepersonaliEation of part or loss by use of impersonal pronouns
Refusal to 1erify actual chan,e
Outcome Criteria
Patient 1erbaliEes the speciCc meanin, of the chan,e to him or her.
Patient requests appropriate information about self@care.
Patient completes personal hy,iene and ,roomin, daily 6ith or 6ithout
help.
Patient interacts freely 6ith family or other 1isitors.
Patient participates in the discussions and conferences related to plannin,
his or her
medical and nursin, mana,ement in the critical care unit and transfer from
the unit.
Patient tal+s 6ith trained 1isitors ;support@,roup representati1es< at least
t6ice about
his or her loss.
Nursing Interventions and Rationale
(%45
1. :1aluate patientBs mental- physical- and emotional stateJ reco,niEe assets-
stren,ths-
response to illness- copin, mechanisms- past e#perience 6ith stress- and
support
system.
2. Appraise the response of family and si,niCcant others. Body image is
derived -rom
t$e 6re3ected appraisals7 o- -amily and signifcant ot$ers1
3. Determine the patientBs ,oals and readiness for learnin,.
$. Pro1ide the necessary information to help the patient and family adapt to
the chan,e.
Clarify misconceptions about future limitations.
%. Permit and encoura,e the patient to e#press the si,niCcance of the loss or
chan,eJ
note non1erbal beha1ior responses.
*. Allo6 and encoura,e the patientBs e#pression of an#iety. An"iety is t$e
most
predominant emotional response to a body image disturbance1
+. Reco,niEe and accept the use of denial as an adapti1e defense mechanism
6hen used
early and temporarily.
3. Reco,niEe maladapti1e denial as that 6hich interferes 6ith the patientBs
pro,ress
and"or alienates support systems. )se confrontation.
4. Pro1ide an opportunity for the patient to discuss se#ual concerns.
1/. Douch the a=ected body part to provide t$e patient wit$ sensory
in-ormation about
altered body structure and8or -unction1
11. :ncoura,e and pro1ide mo1ement of altered body part to establis$
.inest$etic
-eedbac.1 ($is enables t$e person to .now $is or $er body as it now
e"ists1
12. Prepare the patient to loo+ at the body part. Call the body part by its
anatomic name
;e.,.- stump- stoma- limb< as opposed to MitN or Mshe.N ($e use o-
impersonal
pronouns increases a sense o- -antasy and depersonali4ation o- t$e
body part1
13. Allo6 the patient to e#perience e#cellence in some aspect of physical
functionin,O
6al+in,- turnin,- deep breathin,- healin,- self@careOand point out pro,ress
and
accomplishment. ($is $elps to balance t$e patient2s sense o-
dys-unction wit$
-unction1
1$. A1oid false reassurance. Ac+no6led,e the diHculty of incorporatin, the
altered body
part or function into oneBs body ima,e. ($is evidences t$e nurse2s
sensitivity and
promotes trust1
1%. Dal+ 6ith the patient about his or her life- ,enerati1ity- and
accomplishments. atients
wit$ disturbances in body image -re*uently see t$emselves in a
distortedly
6narrow7 sense1 !ncouraging a wider -ocus o- t$emselves and t$eir
li-e reduces
t$is distortion1
1*. &elp the patient e#plore realistic alternati1es.
1+. Reco,niEe that incorporatin, a body chan,e into oneBs body ima,e ta+es
time. A1oid
settin, unrealistic e#pectations and t$ereby inadvertently rein-orcing a
low sel-esteem1
13. .u,,est the use of additional resources such as trained 1isitors 6ho ha1e
mastered
situations similar to those of the patient. Refer the patient to a psychiatric
liaison nurse
or psychiatrist if needed.
Disturbed Body Ima,e Related to Aunctional Dependence on !ife@.ustainin,
Dechnolo,y ;e.,.- 1entilator- dialysis- IABP- halo traction<
Defning Characteristics
Actual chan,e in function requirin, permanent or temporary replacement
Refusal to 1erify actual loss
(%44
?erbaliEation of the follo6in,> feelin,s of helplessness- hopelessness-
po6erlessness-
fear of failure to 6ean from technolo,y
Outcome Criteria
Patient 1eriCes actual chan,e in function.
Patient does not refuse or C,ht technolo,ic inter1ention.
Patient 1erbaliEes acceptance of e#pected chan,e in lifestyle.
Nursing Interventions and Rationale
1. :1aluate patientBs response to the technolo,ic inter1ention.
2. Assess responses of family and si,niCcant others. Body image is
derived -rom t$e
6re3ected appraisals7 o- -amily and signifcant ot$ers1
3. Pro1ide information needed by patient and family.
$. Promote trust- security- comfort- and pri1acy.
%. Reco,niEe an#iety. Allo6 and encoura,e its e#pression. An"iety is t$e
most
predominant emotion accompanying body image alterations1
Implement nursin,
mana,ement plan of care- An#iety.
*. Assist patient to reco,niEe his or her o6n functionin, and performance in
the face of
technolo,y. Aor e#ample- assist patient to distin,uish spontaneous breaths
from
mechanically deli1ered breaths. ($e activity will assist in weaning
patient -rom t$e
ventilator w$en -easible1 (o establis$ realistic5 accurate body
boundaries5 a
patient needs $elp to separate $imsel- or $ersel- -rom t$e
tec$nology t$at is
supporting $is or $er -unctioning1 Any participation or -unction on
t$e part o- t$e
patient during periods o- dependency is $elp-ul in preventing and8or
resolving an
alteration in body image1
+. Plan for discontinuation of the treatment ;e.,.- 6eanin, from 1entilator<.
:#plain
procedure that 6ill be follo6ed- and be present durin, its initiation.
3. Plan for transfer from the critical care en1ironment.
4. Document care- ensurin, an up@to@date mana,ement plan is a1ailable to
all in1ol1ed
care,i1ers.
Nursing Management Plan
Disturbed Sleep attern
Defnition: Dime@limited disruption of sleep ;natural- periodic suspension of
consciousness<
amount and quality
Disturbed .leep Pattern Related to Ara,mented .leep
Defning Characteristics
(%4/
Decreased sleep durin, one bloc+ of sleep time
Daytime sleepiness
Decreased sleep
!ess than one half of normal total sleep time
Decreased slo6@6a1e- or rapid@eye@mo1ement ;R:8<- sleep
An#iety
Aati,ue
Restlessness
Disorientation and hallucinations
Combati1eness
Arequent a6a+enin,s
Outcome Criteria
PatientBs total sleep time appro#imates patientBs normal.
Patient can complete sleep cycles of / minutes 6ithout interruption.
Patient has no delusions or hallucinations.
Patient has reality@based thou,ht content.
Nursing Interventions and Rationale
1. Assess normal sleep pattern on admission and any history of sleep
disturbance or
chronic illness that may a=ect sleep or sedati1e"hypnotic use. Promote
normal sleep
acti1ity 6hile patient is in critical care unit. Assess sleep e=ecti1eness by
as+in, patient
ho6 his or her sleep in the hospital compares 6ith sleep at home. ($e best
treatment
-or sleep pattern disturbance is prevention1
2. Promote comfort- rela#ation- and a sense of 6ell@bein,. Dreat painJ chan,e-
smooth- or
refresh bed linens at bedtimeJ and pro1ide oral hy,iene. :liminate stressful
situations
before bedtime. )se rela#ation techniques- ima,ery- music- massa,e- or
6arm
blan+ets. Other inter1entions may include ha1in, a close family member sit
beside the
bed and pro1idin, the patient 6ith his or her o6n ,arments or co1erin,s.
Indi1idual
patients may prefer quiet or may prefer the bac+,round noise of the
tele1ision or music
to best promote sleep. Pro1ide a comfortable room temperature.
3. 8inimiEe noise- particularly that of the sta= and noisy equipment. Reduce
the le1el of
en1ironmental stimuli. Dim li,hts at ni,ht.
$. Aoods containin, tryptophan ;e.,.- mil+- tur+ey< may be appropriate
because t$ese
promote sleep1
%. Plan nap times to assist in appro#imatin, the patientBs normal $43hour
sleep time.
*. 8inimiEe a6a+enin,s to allow -or at least 9:;minute sleep cycles1
Continually
assess the need to a6a+en the patient- particularly at ni,ht. Distin,uish
bet6een
(%/
essential and nonessential nursin, tas+s. Or,aniEe nursin, mana,ement to
allo6 for
ma#imal amount of uninterrupted sleep 6hile ensurin, close monitorin, of
the patientBs
condition. Khene1er possible- monitor physiolo,ic parameters 6ithout
6a+in, the
patient. Coordinate a6a+enin,s 6ith other departments- such as respiratory
therapy-
laboratory- and #@ray- to minimi4e sleep interruptions1
+. Be a6are of the e=ects of commonly used medications on sleep. <any
sedative and
$ypnotic medications decrease )!< sleep1 .edati1e and anal,esic
medications
should not be 6ithheld- but rather- dru,s that minimally disrupt sleep are to
be used to
complement comfort measures- 6ith dosa,es reduced ,radually as the
medication is
no lon,er necessary. Do not abruptly 6ithdra6 R:8@suppressin, medications
because
t$is can result in 6)!< rebound17
3. Document amount of uninterrupted sleep per shift- especially sleep
episodes lastin,
lon,er than $ hours. Dhis can be e=ecti1ely documented as part of the $43
hour 9o6
sheet and reported routinely- shift to shift. Sleep pattern disturbance is
diagnosed5
treated5 and resolved more e=ciently w$en -ormally documented in
t$is manner1
Nursing Management Plan
Dys-unctional Ventilatory >eaning )esponse
Defnition: Inability to ad0ust to lo6ered le1els of mechanical 1entilator
support that interrupts
and prolon,s the 6eanin, process
Dysfunctional ?entilatory Keanin, Response ;D?KR< Related to Physical-
Psycholo,ic- or .ituational Aactors
Defning Characteristics
Mild D"6R
Responds to lo6ered le1els of mechanical 1entilator support 6ith>
5
Restlessness
5
.li,htly increased respiratory rate from baseline
5
:#pressed feelin,s of increased need for o#y,enJ breathin, discomfortJ
fati,ueJ
6armth
Pueries about possible machine malfunction
Increased concentration on breathin,
Moderate D"6R
Responds to lo6ered le1els of mechanical 1entilator support 6ith>
.li,ht baseline increase in blood pressure <$ mm &,
.li,ht baseline increase in heart rate <$ beats per minute ;beats"min<
Baseline increase in respiratory rate <% breaths"min
&yper1i,ilance to acti1ities
5
Inability to respond to coachin,
5
Inability to cooperate
5
Apprehension
5
Diaphoresis
5
:ye@6idenin, ;M6ide@eyed loo+N<
5
Decreased air entry on auscultation
5
Color chan,es> pale- sli,ht cyanosis
5
.li,ht respiratory accessory muscle use
evere D"6R
Responds to lo6ered le1els of mechanical 1entilator support 6ith>
5
A,itation
5
Deterioration in arterial blood ,ases from current baseline
5
Baseline increase in blood pressure '$ mm &,
5
Baseline increase in heart rate '$ beats"min
5
Respiratory rate increases si,niCcantly from baseline
5
Profuse diaphoresis
5
Aull respiratory accessory muscle use
5
.hallo6- ,aspin, breaths
5
Parado#ic abdominal breathin,
5
Discoordinated breathin, 6ith the 1entilator
(%/$
5
Decreased le1el of consciousness
5
Ad1entitious breath sounds- audible air6ay secretions
5
Cyanosis
Outcome Criteria
Air6ay is clear.
)nderlyin, disorder is resol1in,.
Patient is rested- and pain is controlled.
Futritional status is adequate.
Patient has feelin,s of percei1ed control- situational security- and trust in
the nurses.
Patient is able to adapt to selected le1els of 1entilator support 6ithout
undue fati,ue.
Nursing Interventions and Rationale
1. Communicate interest and concern for the patientBs 6ell@bein,- and
demonstrate
conCdence in ability to mana,e 6eanin, process to instill trust in t$e
patient1
2. )se normaliEin, strate,ies ;e.,.- ,roomin,- dressin,- mobiliEin,- social
con1ersation<
to rein-orce t$e patient2s sel-/esteem and -eeling o- identity1
3. Identify parameters of the patientBs usual functionin, before the 6eanin,
process
be,ins to -acilitate early identifcation o- problems1
$. Identify the patientBs stren,ths and resources that can be mobiliEed to
en$ance t$e
patient2s coping and ma"imi4e weaning e,ort1
%. Fote concerns that ad1ersely a=ect the patientBs comfort and conCdence-
and mana,e
them discretely to -acilitate t$e patient2s ease1
*. Praise successful acti1ities- encoura,e a positi1e outloo+- and re1ie6 the
patientBs
positi1e pro,ress to date to increase t$e patient2s perceived sel-/
e=cacy1
+. Inform the patient of his or her situation and 6eanin, pro,ress to permit
t$e patient
as muc$ control as possible1
3. Deach the patient about the 6eanin, process and ho6 he or she can
participate in the
process.
4. Fe,otiate daily 6eanin, ,oals 6ith the patient to gain cooperation1
1/. Position the patient 6ith the head of the bed ele1ated to optimi4e
respiratory e,orts1
11. Coach the patient in breath control by re,ular demonstrations of slo6-
deep- rhythmic
patterns of breathin, to assist wit$ dyspnea1
12. Remain 1isible in the room and reassure the patient that help is
immediately a1ailable if
needed to reduce t$e patient2s an"iety and -ear-ulness1
13. :ncoura,e the patient to 1ie6 6eanin, trials as a form of trainin,-
re,ardless of
6hether the 6eanin, ,oal is achie1ed to avoid discouragement1
1$. :ncoura,e the patient to maintain emotional calmness by reassurin,-
bein, present-
(%/*
comfortin,- tal+in, do6n if emotionally aroused- and reinforcin, the idea that
he or she
can and 6ill succeed.
1%. 8onitor the patientBs status frequently to avoid undue -atigue and
an"iety1
1*. Pro1ide re,ular periods of rest by reducin, acti1ities- maintainin, or
increasin,
1entilator support- and pro1idin, o#y,en as needed before fati,ue ad1ances.
1+. Pro1ide distraction ;e.,.- 1isitors- radio- tele1ision- con1ersation< 6hen
the patientBs
concentration starts to create tension and increases an#iety.
13. :nsure adequate nutritional support- suHcient rest and sleep time- and
sedation or pain
control to promote t$e patient2s optimal p$ysical and emotional
com-ort1
14. .tart 6eanin, early in the day w$en t$e patient is most rested1
2/. Restrict unnecessary acti1ities and 1isitors 6ho do not cooperate 6ith
6eanin,
strate,ies to minimi4e energy demands on t$e patient during t$e
weaning
process1
21. Coordinate necessary acti1ities to promote ade*uate time -or rest
and rela"ation1
22. 8onitor the patientBs underlyin, disease process to ensure it is
stabili4ed and under
control1
23. Ad1ocate for additional resources ;e.,.- sedation- anal,esia- rest< needed
by the
patient to ma"imi4e com-ort status1
2$. De1elop and adhere to an indi1idualiEed plan of care to promote t$e
patient2s
-eelings o- control1
Nursing Management Plan
!"cess Fluid Volume
Defnition: Increased isotonic 9uid retention
:#cess Aluid ?olume Related to Increased .ecretion of Antidiuretic &ormone
;AD&<
Defning Characteristics
&eadache
Decreased sensorium
Kei,ht ,ain o1er short period
Inta+e ,reater than output
Increased pulmonary artery occlusion pressure ;PAOP<
Increased central 1enous pressure ;C?P<
)rine output <* ml"hr
.erum sodium <($ m:q"!
.erum osmolality <$5% mOsm"+,
)rine osmolality ,reater than serum osmolality
(%/4
)rine sodium '$ m:q"!
)rine speciCc ,ra1ity '(.*
Outcome Criteria
Kei,ht returns to baseline.
)rine output is '* ml"hr.
.erum sodium is (*%3(4% m:q"!.
)rine speciCc ,ra1ity is (.%3(*.
Nursing Interventions and Rationale
1. 8onitor electrocardio,ram ;:CG< rhythm continuously for dysrhythmias
caused by
electrolyte imbalance1
2. Restrict patientBs 9uids to % ml less than output per day to decrease
3uid retention1
3. Pro1ide patient chilled be1era,es hi,h in sodium content such as tomato
0uice or broth
to increase sodium inta.e1
$. Collaborate 6ith physician re,ardin, administration of demeclocycline-
lithium- and"or
narcotic a,onists to in$ibit renal response to AD#1
%. Collaborate 6ith physician re,ardin, administration of hypertonic saline
and furosemide
-or rapid correction o- severe sodium defcit and diuresis o- -ree
water1
a. Administer hypertonic saline at a rate of ( to $ ml"+,"hr until the patientBs
serum
sodium is increased no ,reater than ( to $ m:q"! "hr.
*. Kei,h patient daily ;at same time- in same amount of clothin,- and
preferably 6ith
same scale< to ensure accuracy o- readings1
+. Pro1ide frequent mouth care to prevent brea.down o- oral mucous
membranes1
3. Initiate seiEure precautions because patient is at $ig$ ris. as a result
o-
$yponatremia1
a. Pad side rails of bed to protect patient from in0ury.
2. Remo1e any ob0ects from immediate en1ironment that could in0ure patient
in the
e1ent of a seiEure.
c. Leep appropriate@siEe oral air6ay at bedside to assist 6ith air6ay
mana,ement
postseiEure.
4. Collaborate 6ith physician re,ardin, administration of medications to
pre1ent
constipation caused by decreased 3uid inta.e and immobility1
1/. 8aintain sur1eillance for symptoms of hyponatremia ;head@ache-
abdominal cramps-
6ea+ness< and con,esti1e heart failure ;dyspnea- rales- increased C?P and
PAOP<.
:#cess Aluid ?olume Related to Renal Dysfunction
Defning Characteristics
(%/%
Kei,ht ,ain that occurs durin, a $43 to 443hour period
Dependent pittin, edema
Ascites in se1ere cases
Aluid crac+les on lun, auscultation
:#ertional dyspnea
Oli,uria or anuria
&ypertension
:n,or,ed nec+ 1eins
Decrease in urinary osmolality as renal failure pro,resses
C?P '(% cm of &$O
PAOP $3$% mm &,
Outcome Criteria
Kei,ht returns to baseline.
:dema or ascites is absent or reduced to baseline.
!un,s are clear to auscultation.
:#ertional dyspnea is absent.
Blood pressure returns to baseline.
&eart rate returns to baseline.
Fec+ 1eins are 9at.
8ucous membranes are moist.
Nursing Interventions and Rationale
1. Promote s+in inte,rity of edematous areas by frequent repositionin, and
ele1ation of
areas 6here possible. A1oid massa,in, pressure points or reddened areas of
s+in
because t$is results in -urt$er tissue trauma1
2. Plan patient care to pro1ide rest periods to not $eig$ten e"ertional
dyspnea1
3. Kei,h patient daily ;at same time- in same amount of clothin,- and
preferably 6ith
same scale<.
$. Instruct the patient about the correlation bet6een 9uid inta+e and 6ei,ht
,ain- usin,
commonly understood 9uid measurementsJ for e#ample- in,estin, 4 cups
;( ml< of
9uid results in an appro#imate $3pound 6ei,ht ,ain in the anuric patient.
(%/2
Nursing Management Plan
#ypert$ermia
Defnition: Body temperature ele1ated abo1e normal ran,e
&yperthermia Related to Increased 8etabolic Rate
Defning Characteristics
Increased body temperature abo1e normal ran,e
.eiEures
Alushed s+in
Increased respiratory rate
Dachycardia
.+in 6arm to touch
Diaphoresis
Outcome Criteria
Demperature is 6ithin normal ran,e.
Respiratory rate and heart rate are 6ithin patientBs baseline ran,e.
.+in is 6arm and dry.
Nursing Interventions and Rationale
1. 8onitor temperature e1ery (% minutes to ( hour until 6ithin normal ran,e
and stable
and then e1ery 4 hours to maintain close surveillance -or temperature
3uctuations
and evaluate e,ectiveness o- interventions1
a. )se temperature ta+en from pulmonary artery catheter or bladder catheter
if
a1ailable because t$ese met$ods closely re3ect core body
temperature1
2. )se tympanic membrane temperature i- core body temperature
devices are
unavailable1
c. )se rectal temperature if none of the methods listed abo1e are a1ailable.
2. Collaborate 6ith physician re,ardin, administration of antithyroid
medications to bloc.
t$e synt$esis and release o- t$yroid $ormone1
3. Collaborate 6ith physician re,ardin, the use of coolin, blan+et to
-acilitate $eat loss
via conduction1
a. Krap hands- feet- and ,enitalia to protect them from maceration durin,
coolin,
and decrease chance of shi1erin,.
2. A1oid rapidly coolin, the patient and o1ercoolin, the patient because this
initiates the heat@conser1in, response ;i.e.- shi1erin,<.
$. Place ice pac+s in patientBs ,roin and a#illa to -acilitate $eat loss via
conduction1
%. 8aintain patient on bedrest to decrease t$e e,ects o- activity on t$e
patient2s
metabolic rate1
*. Pro1ide tepid spon,e baths to -acilitate $eat loss via evaporation1
+. Decrease the patientBs room temperature to -acilitate radiant $eat
loss1
3. Place fan near patient to circulate cool air to -acilitate $eat loss via
convection1
4. Pro1ide patient 6ith nonrestricti1e ,o6n and li,ht6ei,ht bed co1erin,s to
allow $eat to
escape -rom t$e patient2s trun.1
1/. Collaborate 6ith physician and respiratory therapist on the
administration of o#y,en to
maintain .po$ '/7 because patient $as increased o"ygen
consumption
secondary to increased metabolic rate1
11. Collaborate 6ith physician re,ardin, use of antipyretic medications to
-acilitate patient
com-ort1
12. Collaborate 6ith physician re,ardin, use of intra1enous and oral 9uids to
maintain
ade*uate $ydration o- t$e patient1
&yperthermia Related to Pharmaco,enic &ypermetabolism ;8ali,nant
&yperthermia<
Defning Characteristics
Earl! igns
Blood pressure ;BP< '(4"/ mm &,
Profuse diaphoresis
Pulse rate '( beats"min
8asseter and ,eneral s+eletal muscle ri,idity and fasciculations
Dachypnea
Decreased le1el of consciousness
#ate igns
Increasin, core body temperature up to 4$Q to 4*Q C ;(5.2Q to (/.4Q A<
&ot s+in
&i,h@output left 1entricular failure
.ystemic BP </ mm &,
Pulse rate '( beats"min and 1entricular dysrhythmias
Cardiac inde# ;CI< '4. ! "min"m$
Pulmonary artery occlusion pressure ;PAOP< and pulmonary artery diastolic
;PAD< pressure '(% mm &,J possible pulmonary edema
Continued s+eletal muscle ri,idity and fasciculations
Pao$ <4 mm &,
(%/4
Respiratory and metabolic acidosis
Ai#ed- dilated pupils
.eiEures"coma"decerebrate posturin,
)rinary output <* ml"hrJ urine color reddish bro6n ;myo,lobinuria<
Prolon,ed bleedin, ;disseminated intra1ascular coa,ulation RDICS<
Outcome Criteria
Core body temperature is belo6 *4.*Q C ;((Q A<.
8uscle ri,idity and fasciculations are absent.
Patient is alert and oriented.
Pupils are normoreacti1e.
Nursing Interventions and Rationale
1. Obtain the emer,ency +it for mali,nant hyperthermia. It is recommended
that health
care institutions ha1e an emer,ency mali,nant hyperthermia +it a1ailable
that contains
the items mentioned in the follo6in, plan.
2. Collaborate 6ith the physician to implement measure to rapidly decrease
metabolism>
a. Administer dantrolene ;Dantrium<- w$ic$ rela"es s.eletal muscles by
reducing t$e release o- calcium -rom t$e sarcoplasmic reticulum1
2. Obser1e for inCltration of dantrolene into surroundin, tissues. Dantrolene
is
very al.aline and irritating to tissues1
3. Collaborate 6ith the physician to initiate coolin, measures>
a. Administer cold intra1enous ;I?< solutions ;I? ba, has been submer,ed in
ice
bath before solution is administered<.
2. Pro1ide cool@6ater spon,e bath.
c. Apply coolin, blan+et until temperature is 6ithin (Q to *Q A of desired le1el
to
avoid 6overs$oot57 in w$ic$ e"cessive cooling lowers t$e body
temperature below t$e desired range1
d. Institute iced saline la1a,es of stomach- rectum- and bladder.
e. 8onitor core temperature continuously to avoid overcooling1
$. Collaborate 6ith physician to implement inter1entions to re1erse
metabolic and
respiratory acidosis>
a. Administer sodium bicarbonate as necessary to treat metabolic
acidosis1
2. &yper1entilate patient 6ith (7 o#y,enJ then 1entilate 6ith (%3$ ml"+,
tidal
1olume at (%3$ breaths" min.
c. Assess arterial blood ,as ;ABG< 1alues frequently- and ma+e 1entilatory
ad0ustments as necessary to remedy $ypo"emia and $ypercarbia1
%. Collaborate 6ith physician to pro1ide adequate nutrients to the tissues-
and correct
electrolyte imbalances>
a. Administer %7 de#trose and re,ular insulin to increase glucose
upta.e into
liver to meet $ypermetabolic needs o- body and en$ance t$e
movement o-
(%//
potassium -rom e"tracellular 3uid bac. into t$e cells1
2. 8onitor serum electrolytes to assess e=cacy o- previously
mentioned
action1
c. 8onitor blood urea nitro,en ;B)F< and creatinine le1els to evaluate -or
renal
-ailure1
d. 8onitor serum enEyme le1els- particularly creatine phospho+inase ;CPL<
ele1ations -or indication o- degree o- muscle $yperactivity1
*. Collaborate 6ith physician to correct cardio1ascular instability and
dysrhythmias>
a. Ditrate 1asoacti1e and inotropic drips per protocol to desired systemic BP-
PAOP- and"or PAD.
2. Aollo6 critical care emer,ency standin, orders about the administration of
antidysrhythmic a,ents.
+. Collaborate 6ith physician to maintain a hi,h urinary output ;'% ml"hr<>
a. Administer osmotic a,ents ;mannitol< -or e"cretion o- e"cess 3uid
load and
to increase urinary output to prevent renal -ailure1
2. Administer diuretics ;furosemide< to en$ance secretion o- myoglobin5
potassium5 sodium5 and magnesium1
c. Administer supplemental potassium chloride as indicated by serum
potassium
le1els.
d. Administer steroids ;e.,.- .olu@Cortef< -or its mineralocorticoid e,ect
o-
potassium e"cretion5 to increase glomerular fltration rate5 and to
reduce
cerebral edema1
3. 8aintain sur1eillance for hematolo,ic abnormalities>
a. 8onitor coa,ulation studies -or indications o- DIC and -or e=cacy o-
$eparin
t$erapy1
2. Assess stool"urinary"naso,astric ;FG< draina,e for occult blood.
4. Kei,h patient daily ;at same time- in same amount of clothin,- and
preferably 6ith
same scale< to assist in assessment o- $ydration status1
Nursing Management Plan
#ypot$ermia
Defnition: Body temperature belo6 normal ran,e
&ypothermia Related to Decreased 8etabolic Rate
Defning Characteristics
Reduction in body temperature belo6 normal ran,e
.hi1erin,
Pallor
Piloerection
&ypertension
.+in cool to touch
Dachycardia
Decreased capillary reCll
(2
Outcome Criteria
Demperature is 6ithin normal ran,e.
&eart rate is 6ithin patientBs baseline ran,e.
.+in is 6arm and dry.
Capillary reCll is normal.
Nursing Interventions and Rationale
1. 8onitor temperature e1ery (% minutes to ( hour until 6ithin normal ran,e
and stable
and then e1ery 4 hours to maintain close surveillance -or temperature
3uctuations
and evaluate e,ectiveness o- interventions1
a. )se temperature ta+en from pulmonary artery catheter or bladder catheter
if
a1ailable because t$ese met$ods closely re3ect core body
temperature1
2. )se tympanic membrane temperature i- core body temperature
devices are
unavailable1
c. )se rectal temperature if none of the methods listed abo1e are a1ailable.
2. Collaborate 6ith physician re,ardin, administration of thyroid medications
to replace
lac.ing t$yroid $ormone1
3. Collaborate 6ith physician re,ardin, the use of 9uid@Clled heatin, blan+et
to -acilitate
rewarming via conduction1
$. Initiate forced air@6armin, therapy to -acilitate convective $eat gain1
%. Pro1ide patient 6ith 6arm blan+ets to -acilitate $eat trans-er to t$e
patient1
*. Increase the patientBs room temperature to decrease radiant $eat loss1
+. Replace 6et patient ,o6n and bed linen promptly to decrease
evaporative $eat loss1
3. Karm intra1enous 9uids and blood products to -acilitate rewarming via
conduction1
&ypothermia Related to :#posure to Cold :n1ironment- Drauma- or Dama,e
to the &ypothalamus
Defning Characteristics
Core body temperature belo6 *%Q C ;/%Q A<
.+in cold to touch
.lurred speech- incoordination
At temperature belo6 **Q C ;/(.4Q A<>
5
Cardiac dysrhythmias ;atrial Cbrillation- bradycardia<
5
Cyanosis
(2(
5
Respiratory al+alosis
At temperatures belo6 *$Q C ;4/.2Q A<>
5
.hi1erin, replaced by muscle ri,idity
5
&ypotension
5
Dilated pupils
At temperatures belo6 $4Q to $/Q C ;4$.4Q to 44.$Q A<>
5
Absent deep tendon re9e#es
5
;* to 4 breaths"min to apnea<
5
?entricular Cbrillation possible
At temperatures belo6 $2Q to $5Q C ;54.4Q to 4.2Q A<>
5
Coma
5
Alaccid muscles
5
Ai#ed- dilated pupils
5
?entricular Cbrillation to cardiac standstill
5
Apnea
Outcome Criteria
Core body temperature is ,reater than *%Q C ;/%Q A<.
Patient is alert and oriented.
Cardiac dysrhythmias are absent.
Acid@base balance is normal.
Pupils are normoreacti1e.
Nursing Interventions and Rationale
1. 8onitor core body temperature continuously.
2. Collaborate 6ith the physician re,ardin, the need for intubation and
mechanical
1entilation.
a. &eated air or o#y,en can be added to $elp rewarm t$e body core1
(2$
2. Do not hyper1entilate the hypothermic patient because carbon dio#ide
production is lo6 and this action may induce se1ere al+alosis and precipitate
1entricular Cbrillation.
3. 8aintain cardiopulmonary resuscitation ;CPR< and ad1anced cardiac life
support
;AC!.< until core body temperature is up to at least $/.%Q C ;4%.(Q A< before
determinin, that patients cannot be resuscitated. !lectrical defbrillation
is usually
success-ul in terminating ventricular fbrillation i- t$e temperature is
greater t$an
?@AC B@?1CA FD1
$. Administer cardiac resuscitation dru,s sparin,ly because as t$e body
warms5
perip$eral vasodilation occurs1 Drugs t$at remain in t$e perip$ery
are suddenly
released5 leading to a 6bolus e,ect7 t$at may cause -atal
dysr$yt$mias1
%. 8onitor arterial blood ,as ;ABG< 1alues to direct -urt$er t$erapy5 and
ensure that the
p&- Pao$- and Paco$ are corrected for temperature.
*. Re6arm patient rapidly because t$e pat$op$ysiologic c$anges
associated wit$
c$ronic $ypot$ermia $ave not $ad time to evolve1
a. Institute rapid- acti1e re6armin, by immersion in 6arm 6ater ;*4Q to 4*Q
C<
;(.4Q to (/.4Q A<.
2. Apply thermal blan+et at *2.2Q to *5.5Q C ;/5./Q to //./Q A<. .ome
researchers
su,,est re6armin, only the torso or trun+ Crst- lea1in, the e#tremities
e#posed
to room temperature. ($is is to prevent early perip$eral vasodilation
wit$
abrupt redistribution o- intravascular volume1 ($is also prevents
colder
blood trapped in t$e e"tremities -rom returning to t$e body core
be-ore
t$e $eart is rewarmed1
c. Perform rapid core re6armin, 6ith heated ;*5Q to 4*Q CJ /4.2Q to (/.4Q A<
intra1enous ;I?< infusion- hemodialysis- peritoneal dialysis- and colonic or
,astric irri,ation 9uids.
+. 8onitor peripheral circulation because ,an,rene of the Cn,ers and toes is
a common
complication of accidental hypothermia.
Nursing Management Plan
Imbalanced %utrition& 'ess ($an Body
)e*uirements
Defnition: Inta+e of nutrients insuHcient to meet metabolic needs
Imbalanced Futrition> !ess than Body Requirements Related to !ac+ of
:#o,enous Futrients and Increased 8etabolic Demand
Defning Characteristics
)nplanned 6ei,ht loss of $7 of body 6ei,ht 6ithin the past 2 months
.erum albumin <*.% ,"dl
Dotal lymphocytes <(%"mm*
Aner,y
Fe,ati1e nitro,en balance
(2*
Aati,ueJ lac+ of ener,y and endurance
Fonhealin, 6ounds
Daily caloric inta+e less than estimated nutritional requirements
Presence of factors +no6n to increase nutritional requirements ;e.,.- sepsis-
trauma-
multiple or,an dysfunction syndrome R8OD.S<
8aintenance of nothin, by mouth ;FPO< status for '53( days
!on,@term use of %7 de#trose intra1enously
Documentation of suboptimal calorie counts
Dru, or nutrient interaction that mi,ht decrease oral inta+e ;e.,. chronic
use of
bronchodilators- la#ati1es- anticon1ulsi1es- diuretics- antacids- narcotics<
Physical problems 6ith che6in,- s6allo6in,- cho+in,- and sali1ation and
presence of
altered taste- anore#ia- nausea- 1omitin,- diarrhea- or constipation
Outcome Criteria
Patient e#hibits stabiliEation of 6ei,ht loss or 6ei,ht ,ain of Tlb. daily.
.erum albumin is '*.% ,"dl.
Dotal lymphocytes are <(%"mm*.
Patient has positi1e response to cutaneous s+in anti,en testin,.
Patient is in positi1e nitro,en balance.
Kound healin, is e1ident.
Daily caloric inta+e equals estimated nutritional requirements.
Increased ambulation and endurance are e1ident.
Nursing Interventions and Rationale
1. Inquire if patient has any food aller,ies and food preferences to ensure the
food
pro1ided to the patient is not contraindicated.
2. 8onitor patientBs caloric inta+e and 6ei,ht daily to ensure adequacy of
nutritional
inter1entions.
3. Collaborate 6ith dietitian re,ardin, patientBs nutritional and caloric needs
to determine
the appropriateness of the patientBs diet to meet those needs.
$. 8onitor patient for si,ns of nutritional deCciencies to facilitate e1aluation
of e#tent of
nutritional deCcient.
%. Pro1ide patient 6ith oral care prior to eatin, to ensure optimal
consumption of diet.
*. Assist patient to eat as appropriate to ensure optimal consumption of diet.
+. Collaborate 6ith physician re,ardin, the administration of parenteral and
enteral
nutrition as needed.
(24
Nursing Management Plan
Impaired +as !"c$ange
Defnition: :#cess or deCcit in o#y,enation and"or carbon dio#ide
elimination at the al1eolarcapillary
membrane
Impaired Gas :#chan,e Related to Al1eolar &ypo1entilation
Defning Characteristics
Abnormal arterial blood ,as ;ABG< 1alues ;decreased Pao$- increased
Paco$-
decreased p&- decreased .ao$<
.omnolence
Feurobeha1ioral chan,es ;restlessness- irritability- confusion<
Dachycardia or dysrhythmias
Central cyanosis
Outcome Criteria
ABG 1alues are 6ithin patientBs baseline.
Central cyanosis is absent.
Nursing Interventions and Rationale
1. Initiate continuous pulse o#imetry or monitor .po$ e1ery hour.
2. Collaborate 6ith physician on the administration of o#y,en to maintain an
.po$ '/7.
a. Administer supplemental o#y,en 1ia appropriate o#y,en@deli1ery de1ice
to
increase driving pressure o- o"ygen in t$e alveoli1
2. If supplemental o#y,en alone is not e=ecti1e- administer continuous
positi1e
air6ay pressure ;CPAP< or mechanical 1entilation 6ith positi1e end@e#piratory
pressure ;P::P< to open collapsed alveoli and increase t$e sur-ace
area
-or gas e"c$ange1
3. Pre1ent hypo1entilation.
a. Position patient in hi,h@Ao6lerBs position or semi@Ao6lerBs position to
promote
(2%
diap$ragmatic descent and ma"imal in$alation1
2. Assist 6ith deep@breathin, e#ercises and"or incenti1e spirometry 6ith
sustained
ma#imal inspiration % to ( times"hr to $elp rein3ate collapsed portions
o-
t$e lung1 .ee the nursin, mana,ement plan for Ine=ecti1e Breathin, Pattern
Related to Decreased !un, :#pansion for further instructions.
c. Dreat pain- if present- to prevent $ypoventilation and atelectasis1
Implement
the nursin, mana,ement plan of care- Acute Pain Related to Dransmission
and
Perception of Cutaneous- ?isceral- 8uscular- or Ischemic Impulses.
$. Assist physician 6ith intubation and initiation of mechanical 1entilation as
indicated.
Impaired Gas :#chan,e Related to ?entilation"Perfusion 8ismatchin, or
Intrapulmonary .huntin,
Defning Characteristics
Abnormal ABG 1alues ;decreased Pao$- decreased .ao$<
.omnolence
Feurobeha1ioral chan,es ;restlessness- irritability- confusion<
Central cyanosis
Outcome Criteria
ABG 1alues are 6ithin patientBs baseline.
Central cyanosis is absent.
Nursing Interventions and Rationale
1. Initiate continuous pulse o#imetry- or monitor .po$ e1ery hour.
2. Collaborate 6ith physician on the administration of o#y,en to maintain an
.po$ '/7.
a. Administer supplemental o#y,en 1ia appropriate o#y,en@deli1ery de1ice
to
increase driving pressure o- o"ygen in t$e alveoli1
2. If supplemental o#y,en alone is not e=ecti1e- administer CPAP or
mechanical
1entilation 6ith P::P to open collapsed alveoli and increase t$e
sur-ace
area -or gas e"c$ange1
3. Position patient to optimiEe 1entilation"perfusion matchin,.
a. Aor patient 6ith unilateral lun, disease- position 6ith the ,ood lun, do6n
because gravity will improve per-usion to t$is area5 and t$is will
best
matc$ ventilation wit$ per-usion1
(22
2. Aor patient 6ith bilateral lun, disease- position 6ith the ri,ht lun, do6n
because t$is lung is larger t$an t$e le-t and a,ords a greater area
-or
ventilation and per-usion5 or chan,e position e1ery $ hours- fa1orin,
positions
that impro1e o#y,enation.
c. A1oid any position that seriously compromises o#y,enation status.
$. Perform procedures only as needed and pro1ide adequate rest and
reco1ery time in
bet6een to prevent desaturation1
%. Collaborate 6ith the physician re,ardin, the administration of the
follo6in,>
a. .edati1es to decrease ventilator async$rony and -acilitate patient2s
sense
o- control1
2. Feuromuscular bloc+in, a,ents to prevent ventilator async$rony and
decrease o"ygen demand1
c. Anal,esics to treat pain i- present1 Implement the nursin, mana,ement
plan
of care- Acute Pain Related to Dransmission and Perception of Cutaneous-
?isceral- 8uscular- or Ischemic Impulses.
*. If secretions are present- implement the nursin, mana,ement plan of care-
Ine=ecti1e
Air6ay Clearance Related to :#cessi1e .ecretions or Abnormal ?iscosity of
8ucus.
Nursing Management Plan
Impaired Spontaneous Ventilation
Defnition: Decreased ener,y reser1es results in an indi1idualBs inability to
maintain
breathin, adequate to support life
Impaired .pontaneous ?entilation Related to Respiratory 8uscle Aati,ue or
8etabolic Aactors
Defning Characteristics
Dyspnea and apprehension
Increased metabolic rate
Increased restlessness
Increased use of accessory muscles
Decreased tidal 1olume
Increased heart rate
Abnormal arterial blood ,as ;ABG< 1alues ;decreased Pao$- increased
Paco$-
decreased p&- decreased .ao$<
Decreased cooperation
Outcome Criteria
8etabolic rate and heart rate are 6ithin patientBs baseline.
Patient e#periences eupnea.
(25
ABG 1alues are 6ithin patientBs baseline.
Nursing Interventions and Rationale
1. Collaborate 6ith the physician re,ardin, the application of pressure
support to the
1entilator to assist patient in overcoming t$e wor. o- breat$ing
imposed by t$e
ventilator and endotrac$eal tube1
2. Carefully snip e#cess len,th from the pro#imal end of the endotracheal
tube to
decrease dead space and t$ereby decrease t$e wor. o- breat$ing1
3. Collaborate 6ith the physician and dietitian to ensure that at least %7 of
the dietBs
nonprotein caloric source is in the form of fat 1ersus carbohydrates to
prevent e"cess
carbon dio"ide production1
$. Collaborate 6ith the physician and respiratory therapist re,ardin, the best
method of
6eanin, for indi1idual patients because eac$ situation is di,erent and
a variety o-
weaning options are available1
%. Collaborate 6ith the physician and physical therapist re,ardin, a
pro,ressi1e
ambulation and conditionin, plan to promote overall muscle
conditioning and
respiratory muscle -unctioning1
*. Determine the most e=ecti1e means of communication for the patient to
promote
independence and reduce an"iety1
+. De1elop a daily schedule and post it in patientBs room to coordinate care
and
-acilitate patient2s involvement in t$e plan1
3. Dreat pain- if present- to prevent respiratory splinting and
$ypoventilation1
Implement the nursin, mana,ement plan of care- Acute Pain Related to
Dransmission
and Perception of Cutaneous- ?isceral- 8uscular- or Ischemic Impulses.
4. :nsure that patient recei1es at least $3 to 43hr inter1als of uninterrupted
sleep in a
quiet- dar+ room. Collaborate 6ith the physician and respiratory therapist
re,ardin, the
use of full 1entilatory support at ni,ht to provide respiratory muscle rest1
1/. Place patient in semi@Ao6lerBs position or in a chair at the bedside -or
best use o-
ventilatory muscles and to -acilitate diap$ragmatic descent1
11. :#plain the 6eanin, procedure to the patient before the trial so t$at
patient will
understand w$at to e"pect and $ow to participate1
12. 8onitor patient durin, the 6eanin, trial for e1idence of respiratory
muscle fati,ue to
avoid overtiring t$e patient1
13. Pro1ide di1ersional acti1ity durin, the 6eanin, trial to reduce t$e
patient2s an"iety1
1$. Collaborate 6ith physician and respiratory therapist re,ardin, the
remo1al of the
1entilator and artiCcial air6ay 6hen patient has been successfully 6eaned.
Nursing Management Plan
Impaired Swallowing
(24
Defnition: Abnormal functionin, of the s6allo6in, mechanism associated
6ith deCcits in
oral- pharyn,eal- or esopha,eal structure or function
Impaired .6allo6in, Related to Feuromuscular Impairment- Aati,ue- and
!imited A6areness
Defning Characteristics
:1idence of diHculty s6allo6in,
5
Droolin,
5
DiHculty handlin, oral secretions
5
Absence of ,a,- cou,h- and"or s6allo6 re9e#
5
8oist- 6et- ,ur,lin, 1oice quality
5
Decreased ton,ue and mouth mo1ements
5
Presence of dysarthria
5
DiHculty handlin, solid foods> )ncoordinated che6in, or s6allo6in, .tasis of
food in the oral ca1ity Ket@soundin, 1oice or chan,e in 1oice quality
.neeEin,-
cou,hin,- or cho+in, 6ith eatin, Delay in s6allo6in, of more than % seconds
Chan,e in respiratory patterns
5
DiHculty handlin, liquids> 8omentary loss of 1oice or chan,e in 1oice quality
Fasal re,ur,itation of liquids Cou,hin, 6ith drin+in,
:1idence of aspiration>
5
&ypo#emia
5
Producti1e cou,h
5
Arothy sputum
5
KheeEin,- crac+les- or rhonchi
5
Demperature ele1ation
Outcome Criteria
:1idence of s6allo6in, diHculties is absent.
:1idence of aspiration is absent.
Nursing Interventions and Rationale
(2/
1. Collaborate 6ith physician and speech therapist re,ardin, s6allo6in,
e1aluation and
rehabilitation pro,ram to decrease t$e incidence o- aspiration1
2. Collaborate 6ith physician and dietitian re,ardin, a nutritional assessment
and
nutritional plan to ensure t$at t$e patient is receiving enoug$
nutrition1
3. Place the patient in an upri,ht position 6ith the head midline and the chin
sli,htly do6n
to .eep -ood in t$e anterior portion o- t$e mout$ and to prevent it
-rom -alling
over t$e base o- t$e tongue into t$e open airway1
$. Pro1ide patient 6ith sin,le@te#tured soft foods ;e.,.- cream cereals< that
maintain their
shape because t$ese -oods re*uire minimal oral manipulation1
%. A1oid particulate foods ;e.,.- hambur,er< and foods containin, more than
one te#ture
;e.,.- ste6< because t$ese -oods re*uire more c$ewing and oral
manipulation1
*. A1oid dry foods ;e.,.- popcorn- rice- crac+ers< and stic+y foods ;e.,.-
peanut butter-
bananas< because t$ese -oods are di=cult to manipulate orally1
+. Pro1ide patient 6ith thic+ liquids ;e.,.- fruit nectar- yo,urt< because t$ic.
li*uids are
more easily controlled in t$e mout$1
3. Dhic+en thin liquids ;e.,.- 6ater- 0uice< 6ith a thic+enin, preparation or
a1oid them
because t$in li*uids are easily aspirated1
4. Place foods in the unin1ol1ed side of the mouth because oral sensitivity
and
-unction are greatest in t$is area1
1/. A1oid the use of stra6s because t$ey can deposit t$e li*uid too -ar
bac. in t$e
mout$ -or t$e patient to $andle1
11. .er1e foods and liquids at room temperature because t$e patient may
be overly
sensitive to $eat or cold1
12. O=er solids and liquids at di=erent times to avoid swallowing solids
be-ore being
properly c$ewed1
13. Pro1ide oral hy,iene after meals to clear -ood particles -rom t$e
mout$ t$at could
be aspirated1
1$. Collaborate 6ith physician and pharmacist re,ardin, oral medication
administration to
adEust medication regimen to prevent aspiration and c$o.ing and to
ensure all
prescribed medications are swallowed1
1%. Crush tablets ;if appropriate< and mi# 6ith food that is easily formed into
a bolus- use
thic+ened liquid medications ;if a1ailable<- and"or embed small capsules into
food to
-acilitate oral medication administration1
1*. Inspect mouth for residue after all medication administration to ensure
medication
$as been swallowed1
1+. :ducate patient and family on the s6allo6in, problem- rehabilitation
pro,ram- and
emer,ency measures for cho+in,.
Nursing Management Plan
Impaired Verbal Communication
Defnition: Decreased- delayed- or absent ability to recei1e- process-
transmit- and use a
system of symbols
(2(
Impaired ?erbal Communication Related to Cerebral .peech Center In0ury
Defning Characteristics
Inappropriate or absent speech or responses to questions
Inability to spea+ spontaneously
Inability to understand spo+en 6ords
Inability to follo6 commands appropriately throu,h ,estures
DiHculty or inability to understand 6ritten lan,ua,e
DiHculty or inability to e#press ideas in 6ritin,
DiHculty or inability to name ob0ects
Outcome Criterion
Patient is able to ma+e basic needs +no6n.
Nursing Interventions and Rationale
1. Consult 6ith physician and speech patholo,ist to determine t$e e"tent
o- t$e
patient2s communication defcit Be1g15 w$et$er 3uent5 non3uent5 or
global ap$asia
is involvedD1
2. &a1e the speech therapist post a list of appropriate 6ays to communicate
6ith the
patient in the patientBs room so t$at all nursing personnel can be
consistent in t$eir
e,orts1
3. Assess the patientBs ability to comprehend- spea+- read- and 6rite.
As+ questions that can be ans6ered 6ith a MyesN or a Mno.N If a patient
ans6ers
MyesN to a question- as+ the opposite ;e.,.- MAre you hotUN MVes.N MAre you
coldUN
MVes.N<. ($is may $elp determine w$et$er in -act t$e patient
understands
w$at is being said1
As+ simple- short questions- and use ,estures- pantomime- and facial
e#pressions to ,i1e the patient additional clues.
.tand in the patientBs line of 1ision- ,i1in, a ,ood 1ie6 of your face and
hands.
&a1e the patient try to 6rite 6ith a pad and pencil. O=er pictures and
alphabet
letters at 6hich to point.
8a+e 9ash cards 6ith pictures or 6ords depictin, frequently used phrases
;e.,.-
,lass of 6ater- bedpan<.
$. 8aintain an uncluttered en1ironment- and decrease e#ternal distractions
t$at could
$inder communication1
%. 8aintain a rela#ed and calm manner- and e#plain all dia,nostic-
therapeutic- and
comfort measures before initiatin, them.
*. Do not shout or spea+ in a loud 1oice. #earing loss is not a -actor in
ap$asia5 and
s$outing will not $elp1
(2((
+. &a1e only one person tal+ at a time. It is more di=cult -or t$e patient
to -ollow a
multisided conversation1
3. )se direct eye contact- and spea+ directly to the patient in unhurried-
short phrases.
4. Gi1e one@step commands and directions- and pro1ide cues throu,h
pictures and
,estures.
1/. Dry to as+ questions that can be ans6ered 6ith a MyesN or a Mno-N and
a1oid topics that
are contro1ersial- emotional- abstract- or len,thy.
11. !isten to the patient in an unhurried manner- and 6ait for his or her
attempt to
communicate.
:#pect a time la, from 6hen you as+ the patient somethin, until the
patient
responds.
Accept the patientBs statement of essential 6ords 6ithout e#pectin,
complete
sentences.
A1oid Cnishin, the sentence for the patient if possible.
Kait appro#imately * seconds before pro1idin, the 6ord the patient may
be
attemptin, to Cnd ;e#cept 6hen the patient is 1ery frustrated and needs
somethin, quic+ly- such as a bedpan<.
Rephrase the patientBs messa,e aloud to validate it1
Do not pretend to understand the patientBs messa,e if you do not.
12. :ncoura,e the patient to spea+ slo6ly in short phrases and to say each
6ord clearly.
13. As+ the patient to 6rite the messa,e- if able- or dra6 pictures if only
1erbal
communication is a=ected.
1$. Obser1e the patientBs non1erbal clues for 1alidation ;e.,.- ans6ers MyesN
but sha+es
head MnoN<.
1%. Khen handin, an ob0ect to the patient- state 6hat it is because
$earing language
spo.en is necessary to stimulate language development1
1*. :#plain 6hat has happened to the patient- and o=er reassurance about
the plan of
care.
1+. ?erbally address the problem of frustration o1er inability to
communicate- and e#plain
that both the nurse and the patient need patience.
13. 8aintain a calm- positi1e manner- and o=er reassurance ;e.,.- MI +no6
this is 1ery hard
for you- but it 6ill ,et better if 6e 6or+ on it to,etherN<.
14. Dal+ to the patient as an adult. Be respectful- and a1oid tal+in, do6n to
the patient.
2/. Do not discuss the patientBs condition or hold con1ersations in the
patientBs presence
6ithout includin, him or her in the discussion. ($is may be t$e reason
some ap$asic
patients develop paranoid t$oug$ts1
21. Do not e#hibit disappro1al of emotional utterances or spontaneous use of
profanityJ
instead- o=er calm- quiet reassurance.
22. If the patient ma+es an error in speech- do not reprimand or scold but try
to compliment
the patient by sayin,- MDhat 6as a ,ood try.N
23. Delay con1ersation if the patient is tired. ($e symptoms o- ap$asia
worsen i- t$e
patient is -atigued5 an"ious5 or upset1
2$. Be prepared for emotional outbursts and tears from patients 6ho ha1e
more diHculty in
e#pressin, themsel1es than 6ith understandin,. Dhe patient may become
depressed-
refuse treatment and food- i,nore relati1es- and push ob0ects a6ay. Comfort
the patient
6ith statements such as- MI +no6 itBs frustratin, and you feel sad- but you are
not alone.
Other people 6ho ha1e had stro+es ha1e felt the 6ay you do. Ke 6ill be here
to help
you ,et throu,h this.N
Nursing Management Plan
Ine,ective Airway Clearance
Defnition: Inability to clear secretions or obstructions from the respiratory
tract to maintain a
clear air6ay
Ine=ecti1e Air6ay Clearance Related to :#cessi1e .ecretions or Abnormal
?iscosity of 8ucus
Defning Characteristics
Abnormal breath sounds ;displaced normal sounds- ad1entitious sounds-
diminished or
absent sounds<
Ine=ecti1e cou,h 6ith or 6ithout sputum
Dachypnea- dyspnea
?erbal reports of inability to clear air6ay
Outcome Criteria
Cou,h produces thin mucus.
!un,s are clear to auscultation.
Respiratory rate- depth- and rhythm return to baseline.
Nursing Interventions and Rationale
1. Assess sputum for color- consistency- and amount.
2. Assess for clinical manifestations of pneumonia.
3. Pro1ide for ma#imal thoracic e#pansion by repositionin,- deep breathin,-
splintin,- and
pain mana,ement to avoid $ypoventilation and atelectasis1 If
hypo1entilation is
present- implement the nursin, mana,ement plan of care- Ine=ecti1e
Breathin, Pattern
Related to Decreased !un, :#pansion.
$. 8aintain adequate hydration by administerin, oral and intra1enous 9uids
;as ordered<
to t$in secretions and -acilitate airway clearance1
%. Pro1ide humidiCcation to air6ays 1ia o#y,en@deli1ery de1ice or artiCcial
air6ay to t$in
secretions and -acilitate airway clearance1
*. Administer bland aerosol e1ery 4 hours to -acilitate e"pectoration o-
sputum1
+. Collaborate 6ith the physician re,ardin, the administration of the
follo6in,>
a. Bronchodilators to treat or prevent bronc$ospasms and -acilitate
e"pectoration o- mucus1
2. 8ucolytics and e#pectorants to en$ance mobili4ation and removal o-
secretions1
c. Antibiotics to treat in-ection1
3. Assist 6ith directed cou,hin, e#ercises to -acilitate e"pectoration o-
secretions1 If
(2(*
patient is unable to perform cascade cou,h- consider usin, hu= cou,h
;patients 6ith
hyperacti1e air6ays<- end@e#piratory cou,h ;patient 6ith secretions in distal
air6ay<- or
au,mented cou,h ;patient 6ith 6ea+ened abdominal muscle<.
a. Cascade cou,hOinstruct patient to do the follo6in,>
718 Da+e a deep breath- and hold it for ( to * seconds.
728 Cou,h out forcefully se1eral times until all air is e#haled.
738 Inhale slo6ly throu,h the nose.
7$8 Repeat once.
7%8 Rest- and then repeat as necessary.
2. &u= cou,hOinstruct patient to do the follo6in,>
718 Da+e a deep breath- and hold it for ( to * seconds
728 .ay the 6ord Mhu=N 6hile cou,hin, out se1eral times until air is e#haled
738 Inhale slo6ly throu,h the nose
7$8 Repeat as necessary
c. :nd@e#piratory cou,hOinstruct patient to do the follo6in,>
718 Da+e a deep breath- and hold it for ( to * seconds.
728 :#hale slo6ly.
738 At the end of e#halation- cou,h once.
7$8 Inhale slo6ly throu,h the nose.
7%8 Repeat as necessary- or follo6 6ith cascade cou,h.
d. Au,mented cou,hOinstruct patient to do the follo6in,>
718 Da+e a deep breath- and hold it for ( to * seconds.
728 Perform one or more of the follo6in, maneu1ers to increase
intraabdominal pressure>
7a8 Di,hten +nees and buttoc+s.
728 Bend for6ard at the 6aist.
7c8 Place a hand 9at on the upper abdomen 0ust under the #iphoid
process and press in and up abruptly durin, cou,hin,.
7d8 Leep hands on the chest 6all and press in6ard 6ith each cou,h.
738 Inhale slo6ly throu,h the nose.
7$8 Rest and repeat as necessary.
4. .uction nasotracheally or endotracheally as necessary to assist wit$
secretion
removal1
1/. Reposition patient at least e1ery $ hours or use continuous lateral
rotation therapy to
mobili4e and prevent stasis o- secretions1
11. Allo6 rest periods bet6een cou,hin, sessions- suctionin,- or any other
demandin,
acti1ities to promote energy conservation1
Nursing Management Plan
Ine,ective Breat$ing attern
Defnition: Inspiration and"or e#piration that does not pro1ide adequate
1entilation
Ine=ecti1e Breathin, Pattern Related to Decreased !un, :#pansion
Defning Characteristics
(2(4
Abnormal respiratory patterns ;hypo1entilation- hyper1entilation-
tachypnea- bradypnea-
obstructi1e breathin,<
Abnormal arterial blood ,as ;ABG< 1alues ;increased Paco$- decreased p&<
)nequal chest mo1ement
.hortness of breath- dyspnea
Outcome Criteria
Respiratory rate- rhythm- and depth return to baseline.
8inimal or absent use of accessory muscles.
Chest e#pands symmetrically.
ABG 1alues return to baseline.
Nursing Interventions and Rationale
1. Dreat pain- if present- to prevent $ypoventilation and atelectasis1
Implement the
nursin, mana,ement plan of care- Acute Pain Related to Dransmission and
Perception
of Cutaneous- ?isceral- 8uscular- or Ischemic Impulses.
2. Position patient in hi,h@Ao6lerBs or semi@Ao6lerBs position to promote
diap$ragmatic
descent and ma"imal in$alation1
3. Assist 6ith deep@breathin, e#ercises and incenti1e spirometry 6ith
sustained ma#imal
inspiration % to ( times"hr to $elp rein3ate collapsed portions o- t$e
lung1
Deep breathin,Oinstruct patient to>
a. .it up strai,ht or lean for6ard sli,htly 6hile sittin, on ed,e of bed or
chair ;if possible<.
2. Da+e in a slo6- deep breath.
c. Pause sli,htly- or hold breath for at least * seconds.
d. :#hale slo6ly.
e. Rest- and repeat.
Incenti1e spirometryOinstruct patient to>
a. :#hale normally.
2. Place lips around the mouthpiece- and close mouth ti,htly around it.
c. Inhale slo6ly and as deeply as possible- notin, the ma#imal 1olume of
air inspired.
d. &old ma#imal inhalation for * seconds.
e. Da+e the mouthpiece out of mouth- and slo6ly e#hale.
). Rest- and repeat.
$. Assist physician 6ith intubation and initiation of mechanical 1entilation as
indicated.
(2(%
Ine=ecti1e Breathin, Pattern Related to 8usculos+eletal Aati,ue or
Feuromuscular Impairment
Defning Characteristics
)nequal chest mo1ement
.hortness of breath- dyspnea
)se of accessory muscles
Dachypnea
Dhoracoabdominal asynchrony
Abnormal ABG 1alues ;increased Paco$- decreased p&<
Fasal 9arin,
Assumption of *3point position
Outcome Criteria
Respiratory rate- rhythm- and depth return to baseline.
)se of accessory muscles is minimal or absent.
Chest e#pands symmetrically.
ABG 1alues return to baseline.
Nursing Interventions and Rationale
1. Pre1ent unnecessary e#ertion to limit drain on patient2s ventilatory
reserve1
2. Instruct patient in ener,y@sa1in, techniques to conserve patient2s
ventilatory
reserve1
3. Assist 6ith pursed@lip and diaphra,matic breathin, techniques to
-acilitate
diap$ragmatic descent and improved ventilation1
Diaphra,matic breathin,Oinstruct the patient to>
a. .it in the upri,ht position.
2. Place one hand on the abdomen 0ust abo1e the 6aist and the other on
the upper chest.
c. Breathe in throu,h the nose- and feel the lo6er hand push outJ the upper
hand should not mo1e.
d. Breathe out throu,h pursed lips- and feel the lo6er hand mo1e in.
$. Position patient in hi,h@Ao6lerBs or semi@Ao6lerBs position to promote
diap$ragmatic
descent and ma"imal in$alation1
%. Assist physician 6ith intubation and initiation of mechanical 1entilation as
indicated.
(2(2
Nursing Management Plan
Ine,ective Cardiopulmonary (issue er-usion
Defnition: Decrease in o#y,en resultin, in the failure to nourish the tissues
at the capillary
le1el
Ine=ecti1e Cardiopulmonary Dissue Perfusion Related to Decreased Coronary
Blood Alo6
Defning Characteristics
An,ina for more than * min
.D@se,ment ele1ation on ($3lead electrocardio,ram ;:CG<
:le1ated troponin I
:le1ated CL@8B enEymes
Apprehension
.hortness of breath
Outcome Criteria
.ystolic blood pressure ;.BP< is '/ mm &,.
8ean arterial pressure ;8AP< is '2 mm &,.
&eart rate is <( beats"min.
Pulmonary artery ;PA< pressures are 6ithin normal limits or bac+ to
baseline.
Cardiac inde# ;CI< is '$.$ ! "min"m$.
)rine output is '.% ml"+,"hr or '* ml"hr.
($3lead :CG is normaliEed 6ithout ne6 P 6a1es.
An,ina is absent.
CL@8B enEymes and troponin I le1els are 6ithin normal ran,e.
Nursing Interventions and Rationale
1. Collaborate 6ith the physician re,ardin, the administration of thrombolytic
therapy or
percutaneous transluminal coronary an,ioplasty ;PDCA< to restore
myocardial blood
3ow1
2. Collaborate 6ith the physician re,ardin, the administration of aspirin- anti@
platelet
therapy and heparin to prevent recurrent t$rombosis and in$ibit
platelet -unction1
3. Collaborate 6ith the physician re,ardin, the administration of beta@
bloc+ers to
decrease myocardial o"ygen demand and prevent recurrent
isc$emia1
$. Collaborate 6ith the physician re,ardin, the administration of an,iotensin@
con1ertin,
(2(5
enEyme ;AC:< inhibitors to bloc. t$e conversion o- angiotensin I to
angiotensin II5
a potent vasoconstrictor1
%. Collaborate 6ith physician re,ardin, the administration of sublin,ual
nitro,lycerin
;FDG< and"or intra1enous ;I?< FDG infusion to augment coronary blood
3ow and
reduce cardiac wor. by decreasing preload and a-terload1
*. Collaborate 6ith physician re,ardin, the administration of morphine to
control pain1
+. Collaborate 6ith physician re,ardin, the administration of o#y,en at $
!"min to achie1e
.po$ '/7 to ma"imi4e myocardial o"ygen supply1
3. 8aintain the patient on bed rest 6ith bedside commode pri1ile,es to
minimi4e
myocardial o"ygen demand1
4. 8onitor patientBs hemodynamic and cardiac rhythm status>
a. .elect electrocardio,raphic ;:CG< monitorin, leads based on infarct
location
and rhythm to obtain the best rhythm for monitorin,.
2. :1aluate cardiac rhythm for presence of dysrhythmias 6hich are common
complications of myocardial ischemia.
c. Collaborate 6ith physician re,ardin, the administration of antidysrhythmic
medications.
d. Assess serum electrolytes ;potassium and ma,nesium< and arterial blood
,ases ;ABGs<.
e. Collaborate 6ith physician re,ardin, the administration of electrolytes to
correct
any imbalances.
). 8onitor .D se,ment continuously to determine chan,es in myocardial
tissue
perfusion.
g. 8onitor patientBs BP at least e1ery hour as many conditions ;dru,s-
dysrhythmias- myocardial ischemia< may cause hypotension ;.BP </ mm
&,<.
,. Dreat symptomatic dysrhythmias accordin, to unitBs emer,ency protocol or
Ad1anced Cardiac !ife .upport ;AC!.< ,uidelines.
1/. Instruct patient to a1oid the ?alsal1a maneu1er as forced e#piration
a,ainst a closed
,lottis causes sudden and intense chan,es in systolic blood pressure and
heart rate.
Nursing Management Plan
Ine,ective Cerebral (issue er-usion
Defnition: Decrease in o#y,en resultin, in the failure to nourish the tissues
at the capillary
le1el
Ine=ecti1e Cerebral Dissue Perfusion Related to Decreased Blood Alo6
Defning Characteristics
Decreased le1el of consciousness
&emiparesis or hemiple,ia
?isual chan,es
Aphasia
Dyspha,ia
Aacial droop
Co,niti1e deCcits
(2(4
Ata#ia
Outcome Criteria
Absence of neurolo,ic deCcits
Blood pressure 6ithin ordered parameters
Nursing Interventions and Rationale
1. Collaborate 6ith physician re,ardin, the administration of thrombolytic
therapy to
-acilitate lysis o- t$e clot and restoration o- blood 3ow to a,ected
area1
2. 8onitor the patient for alterations in blood pressure- o#y,enation-
temperature- rhythm
and ,lucose le1els.
3. Collaborate 6ith physician re,ardin, the administration 1asodilators for
hypertension to
maintain t$e patient2s blood pressure wit$in desired range1 )se
caution in lo6erin,
blood pressure as $ypotension decreases cerebral blood 3ow1
a. Patients recei1in, thrombolytic therapyO+eep systolic blood pressure
;.BP<
<(4% mm &, and diastolic blood pressure ;DPB< <(( mm &,.
2. Patients not recei1in, thrombolytic therapyO+eep .BP <$$ mm &, and
DBP
<(4 mm &,
$. Collaborate 6ith physician re,ardin, the administration of intra1enous
9uids and
1asocontrictors for hypotension as $ypotension decreases cerebral
blood 3ow1
%. Collaborate 6ith physician re,ardin, the administration of o#y,en to
maintain .po$
'/%7 to prevent $ypo"emia and potential worsening o- t$e
neurologic inEury1
*. Collaborate 6ith physician re,ardin, administration of acetaminophen for
ele1ated
temperature as $ypert$ermia is associated increase morbidity in t$e
stro.e
patient1
+. Collaborate 6ith the physician re,ardin, the treatment of dysrhythmias
due to
increased sympat$etic nervous system stimulation1
3. Collaborate 6ith the physician re,ardin, the administration of insulin for
hyper,lycemia
as elevated blood glucose as been lin.ed to an increase t$e area o-
in-arct1
4. Collaborate 6ith the speech therapist re,ardin, the patientBs ability to
s6allo6 before
initiatin, oral feedin,s to ensure patient is not at ris. -or aspirating1
1/. Collaborate 6ith the physical therapist to assess the patientBs ability to
ambulate safely
to ensure t$e patient is not at ris. -or -alling and ability to perform
acti1ities of daily
li1in, to -acilitate disc$arge $ome1
11. 8aintain sur1eillance for complications such as increased intracranial
pressure-
seiEures- and acute respiratory failure.
Ine=ecti1e Cerebral Dissue Perfusion Related to &emorrha,e
Defning Characteristics
9ntracere2ral -emorr,age
(2(/
Alteration in le1el of consciousness
Fausea and 1omitin,
&eadache
.eiEures
&ypertension
Aocal neurolo,ic deCcits
u2arac,noid -emorr,age
.udden onset of se1ere headache- nausea- and"or 1omitin,
.ymptoms of menin,eal irritation>
Fuchal ri,idity and pain
Bac+ pain
Bilateral le, pain
Lerni,Bs si,n> resistance to full e#tension of the le, at the +nee 6hen the
hip is
9e#ed
BrudEins+iBs si,n> 9e#ion of the hip and +nee durin, passi1e nec+ 9e#ion
Photophobia and 1isual chan,es
.udden loss of consciousness
Altered le1el of consciousness
.eiEures
Aocal neurolo,ic deCcits
Outcome Criteria
Patient is oriented to time- place- person- and situation.
Pupils are equal and normoreacti1e.
BP is 6ithin patientBs norm.
8otor function is bilaterally equal.
&eadache- nausea- and 1omitin, are absent.
Patient 1erbaliEes importance of and displays compliance 6ith reduced
acti1ity.
Nursing Interventions and Rationale
1. Assess for indicators of increased intracranial pressure ;ICP< and brain
herniation ;see
the nursin, mana,ement plan Decreased Intracranial Adapti1e Capacity
Related to
(2$
Aailure of Formal Intracranial Compensatory 8echanism<.
2. Collaborate 6ith the physician re,ardin, the administration of
anticon1ulsant
medications to prevent t$e onset o- sei4ures or to control sei4ures1
3. Collaborate 6ith physician re,ardin, the administration 1asodilators for
hypertension to
avoid -urt$er bleeding1 )se caution in lo6erin, blood pressure as
$ypotension
decreases cerebral blood 3ow1
$. Initiate precautions to prevent rebleeding1
a. :nsure bed rest in a quiet en1ironment to lessen e"ternal stimuli1
2. 8aintain a dar+ened room to lessen symptoms o- p$otop$obia1
c. Restrict 1isitors- and instruct them to +eep con1ersation as nonstressful as
possible.
d. Administer prescribed sedati1es as prescribed to reduce an"iety to
promote
rest1
e. Administer anal,esics as prescribed to relieve or lessen $eadac$e1
). Pro1ide a soft- hi,h@Cber diet and stool softeners to prevent
constipation5
w$ic$ can lead to straining and increased ris. o- rebleeding1
g. Assist 6ith acti1ities of daily li1in, ;feedin,- bathin,- dressin,- toiletin,<.
,. A1oid any acti1ity that could lead to increased ICPJ ensure that patient
does not
9e# hips beyond / de,rees and a1oids nec+ hyper9e#ion- hypere#tension- or
lateral hyperrotation t$at could impede Eugular venous return1
Nursing Management Plan
Ine,ective Coping
Defnition: Inability to form a 1alid appraisal of the stressors- inadequate
choices of practiced
responses- and"or inability to use a1ailable resources
Ine=ecti1e Copin, Related to .ituational Crisis and Personal ?ulnerability
Defning Characteristics
?erbaliEation of inability to cope. Sample statements MI canBt ta+e this
anymore.N MI donBt
+no6 ho6 to deal 6ith this.N
Ine=ecti1e problem sol1in, ;problem lumpin,<. Sample statements MI ha1e
to eliminate
salt from my diet. Dhey tell me I can no lon,er mo6 the la6n. Dhis
hospitaliEation is
costin, a mint. Khat about my +idsB futureU KhoBs ,oin, to chan,e the oil in
the carU
Dhis is an incredible amount of time a6ay from 6or+.N
Ine=ecti1e use of copin, mechanisms
5
Pro0ection> blames others for illness or pain
5
Displacement> directs an,er and"or a,,ression to6ard family. Sample
statements MGet out of here. !ea1e me alone.N Cursin,- shoutin,- or
demandin,
attentionJ stri+in, out or thro6in, ob0ects
5
Denial> of se1erity of illness and need for treatment
Foncompliance. !"amples acti1ity restrictionJ refusal to allo6 treatment or
to ta+e
medications
.uicidal thou,hts ;1erbaliEes desire to end life<
.elf@directed a,,ression. !"amples disconnects or attempts to disconnect
lifesustainin,
equipmentJ deliberately tries to harm self
(2$(
Aailure to pro,ress from dependent to more independent state ;refusal or
resistance to
care for self<
Outcome Criteria
Patient 1erbaliEes be,innin, ability to cope 6ith illness- pain- and
hospitaliEation.
Sample statements MIBm tryin, to do the best I can.N MI 6ant to help myself
,et better.N
Patient demonstrates e=ecti1e problem sol1in, ;lists and prioritiEes
problems from most
to least ur,ent<.
Patient uses e=ecti1e beha1ioral strate,ies to mana,e the stress of illness
and care.
Patient demonstrates interest or in1ol1ement in illness or en1ironment.
!"amples
patient does the follo6in,>
5
Requests medications 6hen anticipatin, pain.
5
Puestions course of treatment- pro,ress- and pro,nosis.
5
As+s for clariCcation of en1ironmental stimuli and e1ents.
5
.ee+s out supporti1e indi1iduals in his or her en1ironment.
5
)ses copin, mechanisms and strate,ies more e=ecti1ely to mana,e
situational
crisis.
5
Demonstrates si,niCcant reduction in impulsi1e- an,ry- or a,,ressi1e
outbursts
;pro0ection- shoutin,- cursin,< directed to6ard family.
5
?erbaliEes future@based plans- 6ith cessation of self@directed a,,ressi1e acts
and suicidal thou,hts.
5
Killin,ly complies 6ith treatment re,imen.
5
Be,ins to participate in self@care.
Nursing Interventions and Rationale
1. Acti1ely listen and respond to patientBs 1erbal and beha1ioral e#pressions.
Active
listening signifes unconditional respect and acceptance -or t$e
patient as a
wort$w$ile individual1 It builds trust and rapport5 guides t$e nurse
toward
problem areas5 encourages t$e patient to e"press concerns5 and
promotes
compliance1
2. O=er e=ecti1e copin, strate,ies to help the patient better tolerate the
stressors related
to his or her illness and care. Gi1e permission to 1ent feelin,s in a safe
settin,. Sample
statements> MI donBt blame you for feelin, an,ry or frustrated.N MOthers 6ho
are ill li+e
you ha1e e#pressed similar feelin,s.N MI 6ill listen to anythin, you 6ant to
share 6ith
me.N MKe donBt ha1e to tal+J IBd li+e to sit here 6ith you.N MItBs perfectly OL to
cry.N
Individuals w$o are provided wit$ opportunities to e"press t$eir
-eelings will be
better able to release pent/up emotions and derive a greater sense
o- relie- and
(2$$
com-ort1 ($us t$ey are less li.ely to resort to overly impulsive5
aggressive acts5
w$ic$ may $arm sel- or ot$ers1
3. Inform the family of the patientBs need to displace an,er occasionally but
that you 6ill
be 6or+in, 6ith the patient to help him or her release his or her feelin,s in a
more
constructi1e- e=ecti1e 6ay. Family members w$o are well/in-ormed are
better
e*uipped to cope wit$ t$eir loved one2s emotional anguis$ and
outbursts1 ($ey
are less li.ely to waste energy on -eelings o- guilt5 -ear5 anger5 or
despair and can
use t$eir strengt$ to $elp t$e patient in more constructive ways1
($e .nowledge
t$at t$eir loved one is being cared -or emotionally5 as well as
p$ysically5 will o,er
-amily members a greater sense o- com-ort and understanding1 ($ey
will -eel
nurtured and respected by t$e nurse2s attempt to include t$em in
t$e process1
$. Kith the patient- list and number problems from the most to least ur,ent.
Assist him or
her in Cndin, immediate solutions for most ur,ent problemsJ postpone those
that can
6aitJ dele,ate some to family membersJ and help him or her to ac+no6led,e
problems
that are beyond his or her control. 'isting and numbering problems in an
organi4ed
-as$ion $elp to brea. t$em down into more manageable 6pieces7 so
t$at t$e
patient is better able to identi-y solutions -or t$ose t$at are solvable
and to
suppress t$ose t$at are less relevant or not amenable to
interventions1
%. Identify indi1iduals in the patientBs en1ironment 6ho best help him or her
to cope- as
6ell as those 6ho do not. ?alidate your obser1ations 6ith the patient. Sample
statements> MI notice you seemed more rela#ed durin, your dau,hterBs 1isit.N
MAfter the
cler,y left- you 6ere able to sleep a bit lon,er than usualJ 6ould you li+e to
see him
more oftenUN MVour ,randson 6as a bit upset todayJ IBll be ,lad to tal+ to him
if you li+e.N
Supportive persons can invo.e a calming e,ect on t$e patient2s
p$ysiologic and
psyc$ologic states1 Conversely5 well/meaning but nonsupportive
individuals can
$ave a deleterious e,ect on t$e patient2s ability to cope and must
be care-ully
screened and counseled by t$e nurse1
*. Deach the patient e=ecti1e co,niti1e strate,ies to help him or her better
mana,e the
stress of critical illness and care. &elp him or her construct pleasant thou,hts-
situations- or ima,es that can simultaneously inhibit unpleasant realities.
!"amples> a
day at the beach- a 6al+ in the par+- drin+in, a ,lass of 6ine- or bein, 6ith a
lo1ed one.
leasant t$oug$ts and images constructed during critical illness and
care tend
to in$ibit or reduce t$e intensity o- t$e unpleasant5 stress-ul e,ects
o- t$e
e"perience1
+. Assist the patient in usin, copin, mechanisms more e=ecti1ely so he or
she can better
mana,e his or her situational crisis.
.uppression of problems beyond his or her control
Compensation for illness and its e=ectsJ focusin, on his or her stren,ths-
interests- family- and spiritual beliefs
Adapti1e displacement of an,er- fear- or frustration throu,h healthy- 1erbal
e#pressions to sta=. !,ective use o- coping mec$anisms $elps to
assuage
t$e patient2s pain-ul -eelings in a sa-e setting1 ($us t$e patient is
strengt$ened and need not resort to t$e use o- more ine,ective
de-enses
to eliminate an"iety1
3. Initiate a suicidal assessment if the patient 1erbaliEes the desire to die-
states that life is
not 6orth li1in,- or e#hibits self@directed a,,ression. Sample statement MKe
+no6 that
this is a bad time for you. VouBre sayin, repeatedly that you 6ant to die. Are
you
plannin, to harm yourselfUN If the response is Myes-N remain 6ith the patient-
alert sta=
members- and pro1ide for psychiatric consultation as soon as possible.
Continue to
e#press concern to the patient and protect him or her from harm. Suicidal
t$oug$ts as
a result o- ine,ective coping or e"$austion o- coping devices are not
an
uncommon occurrence in critically ill patients1 I- t$e mood state is
distressing
enoug$5 a patient may see. relie- by attempting a sel-/ destructive
act1 Alt$oug$
t$e patient may not imminently $ave t$e energy to succeed in $is or
$er attempt5
voicing a specifc plan signifes a depressed mood state and
depletion o- coping
strategies1 ($us immediate intervention is needed5 since t$e
attempt may be
(2$*
success-ul w$en t$e patient2s energy is restored1
4. :ncoura,e the patient to participate in self@care acti1ities and treatment
re,imen in
accordance 6ith his or her le1el of pro,ress. O=er praise for his or her e=orts
to6ard
self@care. atients w$o ta.e an active role in t$eir own treatment and
progress are
less apt to -eel li.e $elpless or powerless victims1 ($is greater sense
o- control
over t$eir illness and environment will guide t$em more swi-tly
toward becoming
as independent as possible.
Nursing Management Plan
Ine,ective +astrointestinal (issue er-usion
Defnition: Decrease in o#y,en resultin, in the failure to nourish the tissues
at the capillary
le1el
Ine=ecti1e Gastrointestinal Dissue Perfusion Related to Decreased
Gastrointestinal Blood Alo6
Defning Characteristics
Abdominal pain
8elena
Abdominal distention
&yperacti1e to absent bo6el sounds ran,e from hyperacti1e to absent
Guardin,
Ae1er
&ypotension
Dachycardia
Altered mental status
)rine output <* ml"hr
Outcome Criteria
Formal bo6el sounds
Absence of abdominal pain- distention- and ,uardin,
)rinary output is '* ml"hr.
?ital si,ns at baseline
Formal mentation
Nursing Interventions and Rationales
(2$4
1. Collaborate 6ith physician re,ardin, the administration of crystalloids-
colloids- blood-
and blood products to maintain ade*uate circulating volume1 Implement
the nursin,
mana,ement plan- DeCcit Aluid ?olume Related to Absolute !oss.
2. Collaborate 6ith physician re,ardin, pain mana,ement. Implement the
nursin,
mana,ement plan- Acute Pain Related to Dransmission and Perception of
Cutaneous-
?isceral- 8uscular- or Ischemic Impulses.
3. Collaborate 6ith physician re,ardin, the administration of o#y,en to
maintain .po$
'/$7 to prevent $ypo"emia and potential worsening o- t$e
gastrointestinal
inEury1
$. Collaborate 6ith physician re,ardin, the administration of electrolyte
replacement
therapy to maintain ade*uate electrolyte balance1
%. Collaborate 6ith dietitian re,ardin, administration of nutrition as patient
will be unable
to eat1 Implement the nursin, mana,ement plan- Imbalanced Futrition> !ess
Dhan
Body Requirements.
*. 8aintain sur1eillance for complications such as ,astrointestinal
hemorrha,e-
hypo1olemic shoc+- and septic shoc+.
+. Collaborate 6ith physician re,ardin, preparation for sur,ery to remove
in-arcted
bowel1
Nursing Management Plan
Ine,ective erip$eral (issue er-usion
Defnition: Decrease in o#y,en resultin, in the failure to nourish the tissues
at the capillary
le1el
Ine=ecti1e Cerebral Dissue Perfusion Related to Decreased Peripheral Blood
Alo6
Defning Characteristics
Kea+ and"or unequal peripheral pulses
Delayed capillary reCll
Ischemic pain from e#tremity
Cool s+in on e#tremity
Pale e#tremity
Paresthesias from e#tremity
Outcome Criteria
Peripheral pulses are full and equal bilaterally.
Capillary reCll is equal bilaterally.
Ischemic pain is absent.
.+in temperature is equal in both e#tremities.
(2$%
.+in is pin+ and 6arm in both e#tremities.
Paresthesias are absent.
Nursing Interventions and Rationale
1. Collaborate 6ith physician re,ardin, the administration of antiplatelet-
anticoa,ulant-
and"or thrombolytic therapy.
2. Collaborate 6ith physician re,ardin, pain mana,ement. Implement the
nursin,
mana,ement plan of care- Acute Pain Related to Dransmission and Perception
of
Cutaneous- ?isceral- 8uscular- or Ischemic Impulses.
3. :nsure patient is adequately hydrated to decrease blood viscosity1
$. 8aintain a=ected e#tremity in dependent position if possible to en$ance
blood 3ow1
%. Leep a=ected e#tremity 6arm and protect it from in0ury. Do not apply
$eat directly to
t$e a,ected e"tremity as t$is can result in inEury1
*. 8aintain sur1eillance for pain- pallor- pulselessness- paresthesia- paralysis-
and
poi+ilothermia as indicators o- abrupt c$ange in blood 3ow1
+. 8aintain sur1eillance for tissue brea+do6n and arterial ulcers as
indicators o- inEury1
3. Prepare patient for possible sur,ery or inter1entional procedure to restore
blood 9o6.
Nursing Management Plan
Ine,ective )enal (issue er-usion
Defnition: Decrease in o#y,en resultin, in the failure to nourish the tissues
at the capillary
le1el
Ine=ecti1e Renal Dissue Perfusion Related to Decreased Renal Blood Alo6
Defning Characteristics
Anuria or oli,uria
Decreased urinary creatinine clearance
Increased serum creatinine
Increased blood urea nitro,en ;B)F<
:lectrolyte abnormalities> potassium- sodium
Increased 8AP- pulmonary artery occlusion pressure ;PAOP<- pulmonary
artery
diastolic ;PAD< pressure- central 1enous pressure ;C?P< secondary to 9uid
o1erload
.inus tachycardia
8etabolic acidosis
Crac+les on lun, auscultation
:n,or,ed nec+ 1eins
Aluid 6ei,ht ,ain
Pittin, edema
8ental status chan,es
Anemia
(2$2
Outcome Criteria
CO is '4. ! "min.
CI is '$.$ ! "min"m$.
8AP- PAOP- PAD- and C?P are 6ithin normal limits for patient.
:lectrolytes are 6ithin normal ran,e.
.erum creatinine and B)F are 6ithin normal ran,e.
Formal acid@base balance.
!e1el of consciousness is normal.
!un,s are clear on auscultation.
)rinary output is 6ithin normal limits- or patient is stable on dialysis.
&emo,lobin and hematocrit 1alues are stable.
Nursing Interventions and Rationale
1. 8onitor inta+e and output- urine output- and patient 6ei,ht.
2. Collaborate 6ith physician re,ardin, the administration of crystalloids-
colloids- blood-
and blood products to increase circulating volume and maintain <A
FG: mm #g1
3. Collaborate 6ith physician re,ardin, the administration of inotropes to
en$ance
myocardial contractility and increase CI to F?1H ' 8min1
$. Collaborate 6ith physician re,ardin, the administration of diuretics to the
oli,uric
patient to 3us$ out cellular debris and increase urine output1
%. 8inimiEe the patientBs e#posure to nephroto#ic dru,s to decrease
damage to
.idneys1
*. 8onitor blood le1els of dru,s cleared by +idneys to avoid accumulation1
+. 8onitor patient for si,ns of electrolyte imbalance due to impaired
electrolyte
regulation1
3. 8aintain sur1eillance for si,ns and symptoms of 9uid o1erload.
4. 8onitor patientBs clinical status and response to dialysis therapy to
ensure t$e patient
is receiving sa-e and e,ective dialytic t$erapy1
Nursing Management Plan
owerlessness
Defnition: Perception that oneBs o6n action 6ill not si,niCcantly a=ect an
outcomeJ a
percei1ed lac+ of control o1er a current situation or immediate happenin,
Po6erlessness Related to !ac+ of Control O1er Current .ituation and"or
Disease Pro,ression
Defning Characteristics
(2$5
evere
?erbal e#pressions of ha1in, no control or in9uence o1er situation
?erbal e#pressions of ha1in, no control or in9uence o1er outcome
?erbal e#pressions of ha1in, no control o1er self@care
Depression o1er physical deterioration that occurs despite patientBs
compliance 6ith
re,iments
Apathy
Moderate
Fonparticipation in care or decision ma+in, 6hen opportunities are
pro1ided
:#pressions of dissatisfaction and frustration about inability to perform
pre1ious tas+s
and"or acti1ities
!ac+ of pro,ress monitorin,
:#pressions of doubt about role performance
Reluctance to e#press true feelin,s- fearin, alienation from care,i1ers
Passi1ity
Inability to see+ information about care
Dependence on others that may result in irritability- resentment- an,er- and
,uilt
Fo defense of self@care practices 6hen challen,ed
#o:
Passi1ity
Outcome Criteria
Patient 1erbaliEes increased control o1er situation by 6antin, to do thin,s
his or her
6ay.
Patient acti1ely participates in plannin, care.
Patient requests needed information.
Patient chooses to participate in self@care acti1ities.
Patient monitors pro,ress.
(2$4
Nursing Interventions and Rationale
1. :1aluate the patientBs feelin,s and perception of the reasons for lac+ of
po6er and
sense of helplessness.
2. Determine as far as possible the patientBs usual response to limited control
situations.
Determine throu,h on,oin, assessment the patientBs usual locus of control
;i.e.-
belie1es that in9uence o1er his or her life is e#erted by luc+- fate- po6erful
persons
Re#ternal locus of controlS or that in9uence is e#erted throu,h personal
choices- selfe=ort-
self@determination Rinternal locus of controlS<.
3. .upport patientBs physical control of the en1ironment by in1ol1in, him or
her in care
acti1itiesJ +noc+ before enterin, room if appropriateJ as+ permission before
mo1in,
personal belon,in,s. Inform the patient that- althou,h an acti1ity may not be
to his or
her li+in,- it is necessary. ($is gives t$e patient permission to e"press
dissatis-action wit$ t$e environment and t$e regimen1
$. PersonaliEe the patientBs care usin, his or her preferred name. ($is
supports t$e
patient2s psyc$ologic control1
%. Pro1ide therapeutic rationale for all the patient is as+ed to do for himself or
herself and
for all that is bein, done for and 6ith him or her. Reinforce the physicianBs
e#planationsJ
clarify misconceptions about the illness situation and treatment plans. ($is
supports
t$e patient2s cognitive control1
*. Include the patient in care plannin, by encoura,in, participation and
allo6in, choices
6here1er possible ;e.,.- timin, of personal care acti1itiesJ decidin, 6hen pain
medicines are needed<. Point out situations in 6hich no choices e#ist.
+. Pro1ide opportunities for the patient to e#ert in9uence o1er himself or
herself and his or
her body- thereby a=ectin, an outcome. Aor e#ample- share 6ith the patient
the nurseBs
assessment of his or her breath sounds and e#plain that they can be
impro1ed by selCnitiated
deep@breathin, e#ercises. Feedbac. t$at t$e patient $as been
success-ul
in $elping clear $is or $er lungs rein-orces t$e in3uence $e or s$e
does retain1
3. :ncoura,e family to permit patient to do as much independently as
possible to -oster
perception o- personal power1
4. Assist the patient to establish realistic short@term and lon,@term ,oals.
Setting
unrealistic or unattainable goals inadvertently rein-orces t$e
patient2s perception
o- powerlessness1
1/. Document care to pro1ide for continuity so t$at t$e patient can
maintain appropriate
control over t$e environment1
11. Assist the patient to re,ain stren,th and acti1ity tolerance as
appropriate- t$us
increasing a sense o- control and sel-/reliance1
12. Increase the sensiti1ity of the health team members and si,niCcant
others to the
patientBs sense of po6erlessness. )se po6er o1er the patient carefully. )se
the 6ords
Mmust-N Mshould-N and Mha1e toN 6ith caution because t$ey communicate
coercive
powers and imply t$at t$e obEects o- 6musts7 and 6s$oulds7 are o-
beneft to t$e
nurse versus t$e patient1
13. Plan 6ith the patient for transfer from the critical care unit to the
intermediate unit and
e1entually to home.
(2$/
Nursing Management Plan
)is. -or Aspiration
Defnition: At ris+ for entry of ,astrointestinal secretions- oropharyn,eal
secretions- solids- or
9uids into tracheobronchial passa,es
Ris+ Aactors
Impaired laryn,eal sensation or re9e#
Reduced le1el of consciousness
:#tubation
Impaired pharyn,eal peristalsis or ton,ue function
5
Feuromuscular dysfunction
5
Central ner1ous system dysfunction
5
&ead or nec+ in0ury
Impaired laryn,eal closure or ele1ation
5
!aryn,eal ner1e dysfunction
5
ArtiCcial air6ays
5
Gastrointestinal tubes
Increased ,astric 1olume
5
Delayed ,astric emptyin,
5
:nteral feedin,s
5
8edication administration
Increased intra,astric pressure
5
)pper abdominal sur,ery
5
Obesity
5
Pre,nancy
5
Ascites
Decreased lo6er esopha,eal sphincter pressure
5
Increased ,astric acidity
5
Gastrointestinal tubes
Decreased ante,rade esopha,eal propulsion
5 Drendelenbur, or supine position
(2*
5
:sopha,eal dysmotility
5
:sopha,eal structural defects or lesions
Outcome Criteria
Breath sounds are normal- or there is no chan,e in patientBs baseline breath
sounds.
Arterial blood ,as ;ABG< 1alues remain 6ithin patientBs baseline.
Dhere is no e1idence of ,astric contents in lun, secretions.
Fursin, Inter1entions and Rationale
1. Assess ,astrointestinal function to rule out $ypoactive peristalsis and
abdominal
distention1
2. Position patient 6ith head of bed ele1ated * de,rees to prevent gastric
re3u"
t$roug$ gravity1 If head ele1ation is contraindicated- position patient in
ri,ht lateral
decubitus position to -acilitate passage o- gastric contents across t$e
pylorus1
3. 8aintain patency and functionin, of naso,astric suction apparatus to
prevent
accumulation o- gastric contents1
$. Pro1ide frequent and scrupulous mouth care to prevent coloni4ation o-
t$e
orop$aryn" wit$ bacteria and inoculation o- t$e lower airways1
%. :nsure that endotracheal"tracheostomy cu= is properly in9ated to limit
aspiration o-
orop$aryngeal secretions1
*. Dreat nausea promptlyJ collaborate 6ith physician on an order for
antiemetic to
prevent vomiting and resultant aspiration1
(dditional 9nterventions )or Patient Receiving 'ontinuous or
9ntermittent Enteral
;u2e Feedings
+. Position patient 6ith head of bed ele1ated 4% de,rees to prevent gastric
re3u"1 If a
head@do6n position becomes necessary at any time- interrupt the feedin, *
minutes
before the position chan,e.
3. Chec+ placement of feedin, tube either by auscultation or radio,raphically
at re,ular
inter1als ;e.,.- before administerin, intermittent feedin,s and after position
chan,es-
suctionin,- cou,hin, episodes- or 1omitin,< to ensure proper placement
o- t$e tube1
4. 8onitor patient for si,ns of delayed ,astric emptyin, to decrease
potential -or
vomiting and aspiration1
a. Aor lar,e@bore tubes- chec+ residuals of tube feedin,s before intermittent
feedin,s and e1ery 4 hours durin, continuous feedin,s. Consider 6ithholdin,
feedin,s for residuals ,reater than (%7 of the hourly rate ;continuous
feedin,<
or ,reater than %7 of the pre1ious feedin, ;intermittent feedin,<.
2. Aor small@bore tubes- obser1e abdomen for distention- palpate abdomen
for
hardness or tautness- and auscultate abdomen for bo6el sounds.
(2*(
Nursing Management Plan
)is. -or In-ection
Defnition: At increased ris+ for bein, in1aded by patho,enic or,anisms
Ris+ Aactors
Inadequate primary defenses ;bro+en s+in- traumatiEed tissue- decreased
ciliary action-
stasis of body 9uids- chan,e in p& secretions- altered peristalsis<
Inadequate secondary defenses ;decreased hemo,lobin- leu+openia-
suppressed
in9ammatory"immune response<
Immunocompromise
Inadequate acquired immunity
Dissue destruction and increased en1ironmental e#posure
Chronic disease
In1asi1e procedures
8alnutrition
Pharmacolo,ic a,ents ;antibiotics- steroids<
Outcome Criteria
Dotal lymphocyte count is '("mm*.
Khite blood cell count is 6ithin normal limits.
Demperature is 6ithin normal limits.
Blood- urine- 6ound- and sputum cultures are ne,ati1e.
Fursin, Inter1entions and Rationale
1. Perform proper hand hy,iene before and after patient care to reduce t$e
transmission o- microorganisms1
2. )se aseptic technique for insertion and manipulation of in1asi1e
monitorin, de1ices-
intra1enous ;I?< lines- and urinary draina,e catheters to maintain sterility
o-
environment1
3. .tabiliEe all in1asi1e lines and catheters to avoid unintentional
manipulation and
contamination1
$. )se aseptic technique for dressin, chan,es to prevent contamination
o- wounds or
insertion sites1
%. Chan,e any line placed under emer,ent conditions 6ithin $4 hours
because aseptic
tec$ni*ue is usually breac$ed during an emergency1
*. Collaborate 6ith the physician to chan,e any dressin, that is saturated
6ith blood or
(2*$
draina,e because t$ese are mediums -or microorganism growt$1
+. 8inimiEe use of stopcoc+s and maintain caps on all stopcoc+ ports to
reduce t$e
ports o- entry -or microorganisms1
3. A1oid the use of naso,astric tubes- nasoendotracheal tubes- and
nasopharyn,eal
suctionin, in the patient 6ith a suspected cerebrospinal 9uid lea+ to
decrease t$e
incidence o- central nervous system in-ection1
4. Chan,e 1entilator circuits 6ith humidiCers no more often than e1ery 44
hours to avoid
introducing microorganisms into t$e system1
1/. Pro1ide the patient 6ith a clean manual resuscitation ba, to avoid
crosscontamination
between patients1
11. Pro1ide meticulous mouth care at least e1ery 4 hours and suction
oropharyn,eal
sub,lottic secretions ;in patients 6ith artiCcial air6ays< to avoid
accumulation1
12. Cleanse in@line suction catheters 6ith sterile saline accordin, to the
manufacturerBs
instructions to avoid accumulation o- secretions wit$in t$e cat$eter1
13. 8aintain the head of the bed ele1ated at * to 4% de,rees in patient
artiCcial air6ays to
decrease t$e incidence o- aspiration1
1$. )se disposable sterile scissors- forceps- and hemostats to reduce t$e
transmission
o- microorganisms1
1%. 8aintain a closed urinary draina,e system to decrease incidence o-
urinary
in-ections1
1*. Leep the urinary draina,e tubin, and ba, belo6 the le1el of the patientBs
bladder to
prevent t$e bac.3ow o- urine1
1+. Assess the urinary draina,e tubin, for +in+s to prevent stasis o-
urine1
13. Protect all access de1ice sites from potential sources of contamination
;naso,astric
re9u#- drainin, 6ounds- ostomies- sputum<.
14. Refri,erate parenteral nutrition solutions and opened enteral nutrition
formulas to
in$ibit bacterial growt$1
2/. 8aintain daily sur1eillance of in1asi1e de1ices for si,ns and symptoms of
infection.
21. Fotify physician of ele1ated temperature or if any si,ns or symptoms of
infection are
present.
(dditional 9nterventions )or Patient Receiving 9mmunosu<<ressive
Drugs
22. Obtain blood- urine- and sputum cultures for temperature ele1ations
'*4Q C ;(.4Q A<
inasmuc$ as elevation li.ely is caused by bacteremia or bladder or
pulmonary
in-ection1
23. Auscultate breath sounds at least e1ery 2 hours. ulmonary in-ection
is t$e most
common type o- in-ection5 and c$anges in breat$ sounds mig$t be
an early
indication1
2$. Inspect 6ounds at least e1ery 4 hours for redness- s6ellin,- and"or
draina,e- w$ic$
may indicate in-ection1
2%. Inspect o1erall s+in inte,rity and oral mucosa for si,ns of brea+do6n-
w$ic$ place t$e
patient at ris. -or in-ection1
2*. Fotify physician of ne6@onset cou,h. !ven a nonproductive coug$
may indicate
pulmonary in-ection1
2+. 8onitor 6hite blood cell count daily- and report leu+ocytosis or sudden
de1elopment of
leu+openia- w$ic$ may indicate an in-ectious process1
23. Protect patient from e#posure to any sta= or family member 6ith
conta,ious lesion
;e.,.- herpes simple#< or respiratory infections.
24. Collaborate 6ith dietitian re,ardin, the patientBs nutritional status and
need for
au,mentation of nutritional inta+e as necessary to prevent debilitation
and increased
susceptibility to in-ection1
3/. Collaborate 6ith physician to remo1e in1asi1e lines and catheters as
soon as possible
to decrease potential portals o- entry1
31. Deach patient the clinical manifestations of infection. A .nowledgeable
patient will
(2**
see. medical attention promptly5 w$ic$ will result in earlier
treatment and a
decreased ris. t$at in-ection will become li-e/t$reatening1
Nursing Management Plan
Situational 'ow Sel-/!steem
Defnition: De1elopment of a ne,ati1e perception of self@6orth in response
to a current
situation
.ituational !o6 .elf@:steem Related to Aeelin,s of Guilt About Physical
Deterioration
Defning Characteristics
Inability to accept positi1e reinforcement
!ac+ of follo6@throu,h
Fonparticipation in therapy
Fot ta+in, responsibility for self@care ;i.e.- self@ne,lect<
.elf@destructi1e beha1ior
!ac+ of eye contact
Outcome Criteria
Patient 1erbaliEes feelin,s of self@6orth.
Patient maintains positi1e relationships 6ith si,niCcant others.
Patient manifests acti1e interest in appearance by completin, personal
,roomin, daily.
Nursing Interventions and Rationale
1. :1aluate the meanin, of health@related situation. &o6 does the patient
feel about
himself or herself- the dia,nosis- and the treatmentU &o6 does the present Ct
into the
lar,er conte#t of his or her lifeU
2. Assess the patientBs emotional le1el- interpersonal relationships- and
feelin, about
himself or herself. Reco,niEe the patientBs uniqueness ;ho6 the hair is 6orn-
preference for name used<.
3. &elp the patient disco1er and 1erbaliEe feelin,s and understand the crisis
by listenin,
and pro1idin, information.
$. Assist the patient to identify stren,ths and positi1e qualities that increase
the sense of
self@6orth. Aocus on past e#periences of accomplishment and competency.
&elp the
(2*4
patient 6ith positi1e self@reinforcement. Reinforce the ob1ious lo1e and
a=ection of
family and si,niCcant others.
%. Assess copin, techniques that ha1e been helpful in the past. &elp the
patient decide
ho6 to handle ne,ati1e or incon,ruent feedbac+ about the situation.
*. :ncoura,e 1isits from family and si,niCcant others. Aacilitate interactions-
and ensure
pri1acy. &elp family members enterin, the critical care unit by e#plainin,
6hat they 6ill
see. Increase 1isitorsB comfort 6ith equipmentJ o=er chairs and other
courtesies.
+. :ncoura,e the patient to pursue interest in indi1idual or social acti1ities-
e1en thou,h
diHcult in the critical care unit.
3. Re9ect carin,- concern- empathy- respect- and unconditional acceptance
in
nurse"patient relationships.
4. Remember that for the patient the nurse is a si,niCcant other 6ho
pro1ides important
appraisals of the patient and 6ho can facilitate the chan,e process.
1/. &elp the family support the patientBs self@esteem.
11. Pro1ide for continuity of nurse assi,nment to ensure consistent contacts
that can
-acilitate support o- t$e patient2s sel-/esteem1
Nursing Management Plan
0nilateral %eglect
Defnition: !ac+ of a6areness and attention to one side of the body
)nilateral Fe,lect Related to Perceptual Disruption
Defning Characteristics
Fe,lect of in1ol1ed body parts and"or e#trapersonal space
Denial of e#istence of the a=ected limb or side of body
Denial of hemiple,ia or other motor and sensory deCcits
!eft homonymous hemianopia
DiHculty 6ith spatial@perceptual tas+s
!eft hemiple,ia
Outcome Criteria
Patient is safe and free from in0ury.
Patient is able to identify safety haEards in the en1ironment.
Patient reco,niEes disability and describes physical deCcits present ;e.,.-
paralysis-
6ea+ness- numbness<.
(2*%
Patient demonstrates ability to scan the 1isual Celd to compensate for loss
of function or
sensation in a=ected limb;s<.
Nursing Interventions and Rationale
1. Adapt en1ironment to patientBs deCcits to maintain patient sa-ety1
Position the patientBs bed 6ith the una=ected side facin, the door.
Approach and spea+ to the patient from the una=ected side. If the patient
must
be approached from the a=ected side- announce your presence as soon as
enterin, the room to avoid startling t$e patient1
Position the call li,ht- bedside stand- and personal items on the patientBs
una=ected side.
If the patient 6ill be assisted out of bed- simplify the en1ironment to
eliminate
$a4ards by remo1in, unnecessary furniture and equipment.
Pro1ide frequent reorientation of the patient to the en1ironment.
Obser1e the patient closely- and anticipate his or her needs. In spite of
repeated
e#planation- the patient may ha1e diHculty retainin, information about the
deCcits.
Khen patient is in bed- ele1ate his or her a=ected arm on a pillo6 to
prevent
dependent edema and support t$e $and in a position o- -unction1
2. Assist the patient to reco,niEe the perceptual defect.
:ncoura,e the patient to 6ear any prescripti1e correcti1e ,lasses or
hearin,
aids to -acilitate communication1
Instruct the patient to turn the head past midline to view t$e
environment on
t$e a,ected side1
:ncoura,e patient to loo+ at the a=ected side and to stro+e the limbs 6ith
the
una=ected hand. :ncoura,e handlin, of the a=ected limbs to rein-orce
awareness o- t$e a,ected side1
Instruct the patient to loo+ for the a=ected e#tremity 6hen performin,
simple
tas+s to .now w$ere it is at all times1
After pointin, to them- ha1e the patient name the a=ected parts.
:ncoura,e the patient to use self@e#ercises ;e.,.- liftin, the a=ected arm
6ith the
una=ected hand<.
If the patient is unable to discriminate bet6een the concepts of Mri,htN and
Mleft-N
use descripti1e ad0ecti1es such as Mthe 6ea+ arm-N Mthe a=ected le,-N or Mthe
,ood armN to refer to the body. )se ,estures- not 0ust 6ords- to indicate ri,ht
and
left.
3. Collaborate 6ith the patient- physician- and rehabilitation team to design
and
implement a beginning re$abilitation program -or use during t$e
critical care unit
stay1
)se adapti1e equipment ;braces- splints- slin,s< as appropriate.
Deach the patient the indi1idual components of any acti1ity separately- and
then
proceed to inte,rate the component parts into a completed acti1ity.
Instruct the patient to attend to the a=ected side- if able- and to assist 6ith
the
bath or other tas+s.
)se tactile stimulation to reintroduce t$e arm or leg to t$e patient1
Rub the
a=ected parts 6ith di=erent te#tured materials to stimulate sensations
Bwarm5
cold5 roug$5 so-tD1
(2*2
:ncoura,e acti1ities that require the patient to turn the head to6ard the
a=ected
side- and retrain the patient to scan the a=ected side and en1ironment
1isually.
If the patient is allo6ed out of bed- cue him or her 6ith reminders to scan
1isually
6hen ambulatin,. Assist and remain in constant attendance because t$e
patient may $ave di=culty maintaining correct posture5 balance5
and
locomotion1 Dhere may be 1ertical@horiEontal perceptual problems- 6ith the
patient leanin, to the a=ected side to ali,n 6ith the percei1ed 1ertical.
Pro1ide
sittin,- standin,- and balancin, e#ercises before ,ettin, the patient out of
bed.
Assist patient 6ith oral feedin,s.
a. A1oid ,i1in, patient any 1ery hot food items that could cause in0ury.
2. Place the patient in an upri,ht sittin, position if possible.
c. :ncoura,e the patient to feed himself or herselfJ if necessary- ,uide the
patientBs hand to the mouth.
d. If the patient is able to feed himself or herself- place one dish at a time in
front of the patient. Khen the patient is Cnished 6ith the Crst- add
another dish. Dell the patient 6hat he or she is eatin,.
e. Initially place food in patientBs 1isual CeldJ then ,radually mo1e the food
out of the Celd of 1ision and teach the patient to scan the entire 1isual
Celd.
). Khen the patient has learned to 1isually scan the en1ironment- o=er a
tray of food 6ith 1arious dishes.
g. Instruct the patient to ta+e small bites of food and to place the food in the
una=ected side of the mouth.
,. Deach the patient to s6eep out poc+ets of food 6ith the ton,ue after
e1ery bite to eliminate retained -ood in t$e a,ected side o- t$e
mout$1
i. After meals or oral medications- chec+ the patientBs oral ca1ity for
poc+ets of retained material.
$. Initiate patient and family health teachin,.
Assess to ensure that both the patient and the family understand the
nature of
the neurolo,ic deCcits and the purpose of the rehabilitation plan.
Deach the proper application and use of any adapti1e equipment.
Deach the importance of maintainin, a safe en1ironment- and point out
potential
en1ironmental haEards.
Instruct family members ho6 to facilitate relearnin, techniques ;e.,.-
cuein,-
scannin, 1isual Celds<.