NURSING CARE PLAN

Problem: anxiety
Nursing Diagnosis: anxiety r/t breathlessness and restlessness secondary to inadequate oxygenation tertiary to Congestive heart failure
Taxonomy: Self-Perception – Self-concept Pattern
Cause analysis: The result from impaired oxygenation of tissues, the stress associated with respiratory difficulty and the knowledge that the heart is
not functioning properly. ( medical surgical nursing 6th edition by: Brunner/Suddarth page. 582

Cues Objectives Nursing Intervention Rationale Evaluation

STO: Independent:
No subjective After 2 hrs. of giving health 1. Assesses client’s level of 1. Anxiety is highly individualize,
cues. teaching and nursing care, the anxiety. Validate normal, physical, and
patient will be able to enumerate observation by saying to psychological response to
different methods of relaxation client. “Are you feeling internal and external life events.
Objective cues: techniques such as destruction anxious now/” 2. Being supportive and
technique, deep breathing approachable encourages
• restless exercise, meditation and prayer. 2. Used presence, touch, communication.
• has difficulty verbalization or demeanor
in sleeping to remind client and to
• fatigue LTO: encourage expressions or
• changes in Within 3 days of implementing clarification of needs,
health effective nursing interventions, concerns, unknowns, and 3. If defenses are not threatened,
status with the patient will be able to express questions. the client may feel safe enough
physical decrease level of anxiety as to look at behavior
manifest evidence by the pt. appearing 4. Talking or otherwise expressing
tation rested and relax and having a 3. Accepted client’s feeling sometimes reduces
• non good eye contact during defenses, do not confront, anxiety.
productive communication. argue and debate.
cough
4. Allowed and reinforced 5. Gaining insight enables the client
• poor eye
clients personal reactions to reevaluate the threat and or identify
contact
to/or pain, discomfort or new ways to deal with the threat.
• hospital bills
threats to well being
• prolonged
social
isolation 5. Helped client identified
precipitants to
anxiety
Problem: decreased cardiac output
Nursing Diagnosis: : Cardiac Output, decreased r/t disruption of normal cardiac functioning and increase preload secondary to CHF
Taxonomy: Activity- Exercise Pattern
Cause analysis: Disruption of cardiac functioning result in problem associated with feeling ties of the atrium/ventricles. Compromise filling times or an
altered heart rate will dec.stroke volume thereby decreasing cardiac output. Increase preload usually increases contractility and stretch because of
filling pressure from venous return and previous volume. Stretch and filling pressure may raise beyond the capabilities of the normally compliant
heart. These increased preload lessens the force and efficiency of ventricular contraction. (med Surg by Keene & Hope page. 1530)
Cues Objectives Nursing Intervention Rationale Evaluation
Independent
No subjective STO:
A. Auscultate apical pulse; assess heart rate, rhythm (document
cues dysrhythmia if telemetry available).
-Tachycardia is usually present (even at rest) to
compensate for decreased ventricular contractility.
After 30 minutes of Premature atrial contractions (PACs), paroxysmal atrial
providing health tachycardia (PAT), PVCs, multifocal atrial tachycardia
Objective: teaching of the (MAT), and atrial fibrillation (AF) are common
importance of the dysrhythmias associated with HF, although others may
also occur. Note: Intractable ventricular dysrhythmias
-unstable BP lifestyle, activity and unresponsive to medication suggest ventricular aneurysm.
fluctuating diet modification on
ranging from compromised heart, B. NOTE HEART SOUNDS. -S1 AND S2 MAY BE WEAK BECAUSE OF
80/60- 110/80. pt.will manifest DIMINISHED PUMPING ACTION. GALLOP
RHYTHMS ARE COMMON (S3 AND S4), PRODUCED
-tachypnec RR understanding as AS BLOOD FLOWS INTO
26-35 evidence by active NONCOMPLIANT/DISTENDED CHAMBERS.
-PR- 40-50bpm participation in MURMURS MAY REFLECT VALVULAR
INCOMPETENCE/STENOSIS.
-dysrhythmic activities that reduce
-body malaise cardiac workload c. Palpate peripheral pulses.
Decreased cardiac output may be reflected in diminished
such as stress radial, popliteal, dorsalis pedis, and posttibial pulses. Pulses
avoidance and may be fleeting or irregular to palpation, and pulsus alternans
(strong beat alternating with weak beat) may be present.
getting enough rest
and eating the right d. Monitor BP.
In early, moderate, or chronic HF, BP may be elevated
kind of food(low salt because of increased SVR. In advanced HF, the body may
low fat diet). no longer be able to compensate, and profound/irreversible
hypotension may occur.
e. Inspect skin for pallor, cyanosis.
Pallor is indicative of diminished peripheral perfusion secondary
LTO: to inadequate cardiac output, vasoconstriction, and anemia.
Within 2 days of Cyanosis may develop in refractory HF. Dependent areas are
often blue or mottled as venous congestion increases.
providing nursing
intervention the f.Monitor urine output, noting decreasing output and
Kidneys respond to reduced cardiac output by retaining
dark/concentrated urine.
pt.will maintain water and sodium. Urine output is usually decreased during
cardiac output
adequate to perfuse
as evidence vital g.Note changes in sensorium, e.g., lethargy, confusion,
signs within normal disorientation, anxiety, and depression.
range and will have
h.Encourage rest, semirecumbent in bed or chair. Assist with
lessen episodes of physical care as indicated.
respiratory distress.
i.Provide quiet environment; explain medical/nursing
management; help patient avoid stressful situations;
listen/respond to expressions of feelings/fears.
j.Provide bedside commode. Have patient avoid activities
eliciting a vasovagal response, e.g., straining during defecation,
holding breath during position changes.
k.Elevate legs, avoiding pressure under knee. Encourage
active/passive exercises. Increase ambulation/activity as
tolerated.
l. Check for calf tenderness; diminished pedal pulse; swelling,
local redness, or pallor of extremity.
m. Withhold digitalis preparation as indicated, and notify
physician if marked changes occur in cardiac rate or rhythm or
signs of digitalis toxicity occur.
Collaborative:
Administer supplemental oxygen as indicated.
Administer medications as indicated:
Diuretics, e.g., furosemide (Lasix), ethacrynic acid
(Edecrin), bumetanide (Bumex), spironolactone
(Aldactone);
the day because of fluid shifts into tissues but may be
increased at night because fluid returns to circulation when
patient is recumbent.
May indicate inadequate cerebral perfusion secondary to
decreased cardiac output.
Physical rest should be maintained during acute or
refractory HF to improve efficiency of cardiac contraction
and to decrease myocardial oxygen demand/consumption
and workload.
Psychological rest helps reduce emotional stress, which
can produce vasoconstriction, elevating BP and increasing
heart rate/work.
Commode use decreases work of getting to bathroom or
struggling to use bedpan. Vasovagal maneuver causes
vagal stimulation followed by rebound tachycardia, which
further compromises cardiac function/output.
Decreases venous stasis, and may reduce incidence of
thrombus/embolus formation.
Reduced cardiac output, venous pooling/stasis, and
enforced bedrest increases risk of thrombophlebitis.
Incidence of toxicity is high (20%) because of narrow
margin between therapeutic and toxic ranges. Digoxin may
have to be discontinued in the presence of toxic drug
levels, a slow heart rate, or low potassium level. (Refer to
CP: Dysrhythmias, ND: Poisoning, risk for digitalis
toxicity.)
Increases available oxygen for myocardial uptake to
combat effects of hypoxia/ischemia.
A variety of medications may be used to increase stroke
volume, improve contractility, and reduce congestion.
Diuretics, in conjunction with restriction of dietary sodium
and fluids, often lead to clinical improvement in patients
with stages I and II HF. In general, type and dosage of
diuretic depend on cause and degree of HF and state of
renal function. Preload reduction is most useful in treating
patients with a relatively normal cardiac output
accompanied by congestive symptoms. Loop diuretics
block chloride reabsorption, thus interfering with the

Vasodilators, e.g., nitrates (Nitro-Dur, Isordil);
arteriodilators, e.g., hydralazine (Apresoline); combination
drugs, e.g., prazosin (Minipress);
ACE inhibitors, e.g., benazepril (Lotensin), captopril
(Capoten), lisinopril (Prinivil), enalapril (Vasotec),
quinapril (Accupril), ramipril (Altace), moexipril
(Univasc);
Angiotensin II receptor antagonists, e.g., eprosartan
(Teveten), ibesartan (Avopro), valsartan (Diovan);
Digoxin (Lanoxin);
Beta-adrenergic receptor antagonists, e.g., carvedilol
(Coreg), bisoprolol (Zebeta), metoprolol (Lopressor);
Monitor serial ECG and chest x-ray changes.
Reference: NCP 6th edition by: Doenges pp.97-98.
reabsorption of sodium and water.
Vasodilators are the mainstay of treatment in HF and are
used to increase cardiac output, reducing circulating
volume (venodilators) and decreasing SVR, thereby
reducing ventricular workload. Note: Parenteral
vasodilators (e.g., Nitropress) are reserved for patients with
severe HF or those unable to take oral medications.
ACE inhibitors represent first-line therapy to control heart
failure by decreasing venticular filling pressures and SVR
while increasing cardiac output with little or no change in
BP and heart rate.
Antihypertensive and cardioprotective effects are
attributable to selective blockade of AT1 (angiotensin II)
receptors and angiotensin II synthesis.
Increases force of myocardial contraction when diminished
contractility is the cause of HF, and slows heart rate by
decreasing conduction velocity and prolonging refractory
period of the atrioventricular (AV) junction to increase
cardiac efficiency/output.
Useful in the treatment of HF by blocking the cardiac
effects of chronic adrenergic stimulation. Many patients
experience improved activity tolerance and ejection
fraction.
ST segment depression and T wave flattening can develop
because of increased myocardial oxygen demand, even if
no coronary artery disease is present. Chest x-ray may
show enlarged heart and changes of pulmonary congestion
Problem: Activity intolerance
Nursing Diagnosis: Activity intolerance r/t Imbalance between oxygen supply/demand
Taxonomy: Activity-exercise pattern
Cause analysis: the reduction in tissue oxygen decreases the reduction of ATP, the immediate energy source for muscle contraction. In addition, the
impaired circulation causes a decrease in the removal of the metabolic waste product, the result of these is further decreased muscle function (Med-
Surg 3rd edition by Phillips p.678
Cues Objectives Nursing Intervention Rationale Evaluation
STO: Independent
SUBJECTIVE: Within 30 min. of
Check vital signs before and immediately after activity,
demonstrating the pt especially if patient is receiving vasodilators, diuretics, or beta- Orthostatic hypotension can occur with activity because of
medication effect (vasodilation), fluid shifts (diuresis), or
The pt. may passive ROM blockers. compromised cardiac pumping function.
verbalize “dali exercise & explaining
rako it’s importance, pt will Document cardiopulmonary response to activity. Note Compromised myocardium/inability to increase stroke
tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor.
makapuyan…” be able to participate volume during activity may cause an immediate increase in
heart rate and oxygen demands, thereby aggravating
in the exercise weakness and fatigue.

OBJECTIVE: Assess for other precipitators/causes of fatigue, e.g., treatments, Fatigue is a side effect of some medications (e.g., beta-
pain, medications. blockers, tranquilizers, and sedatives). Pain and stressful
regimens also extract energy and produce fatigue.
-confined in
bed Evaluate accelerating activity intolerance. May denote increasing cardiac decompensation rather than
-tachypneic overactivity.
(RR-25-36) Provide assistance with self-care activities as indicated. Meets patient’s personal care needs without undue
-bradycardic Intersperse activity periods with rest periods. myocardial stress/excessive oxygen demand.
(PR-40-50bpm)
Collaborative
IMPLEMENT GRADED CARDIAC REHABILITATION/ACTIVITY
PROGRAM. Strengthens and improves cardiac function under stress, if
cardiac dysfunction is not irreversible. Gradual increase in
activity avoids excessive myocardial workload and oxygen
consumption.
Problem: Edema
Nursing Diagnosis: Fluid Volume excess r/ t compromised cardiac functioning seconadry to CHF
Taxonomy: Nutrition-Metabolic pattern
Cause analysis: Ind. With cardiac problems frequently have difficulty with fluid balance. The greater the fluid volume, the greater the stress and
cardiac workload. Compromised cardiac functioning causes fluids to accumulate in various body tissues. These fluid overload stresses the circulatory
system and increases the workload of the heart. ( Mediacal and Health Encyclopedia page 242).

Cues Objectives Nursing Intervention Rationale Evaluation

Independent:
No subjective STO: Monitor urine output, noting amount and color, as well as time
Urine output may be scanty and concentrated (especially
cues After 6 hours of of day when diuresis occurs.
during the day) because of reduced renal perfusion.
duty the pt. will be Recumbency favors diuresis; therefore, urine output may
able to verbalize be increased at night/during bedrest.
understanding of
Objective: individual Monitor/calculate 24-hour intake and output (I&O) balance.
Diuretic therapy may result in sudden/excessive fluid loss
-Weakness, dietary/fluid (circulating hypovolemia), even though edema/ascites
restrictions as remains.
-fatigue evidence by Maintain chair or bedrest in semi-Fowler’s position during
drinkng only the acute phase.
Recumbency increases glomerular filtration and decreases
-Changes in prescribed amount production of ADH, thereby enhancing diuresis.
vital signs, of fluid. Establish fluid intake schedule if fluids are medically restricted, Involving patient in therapy regimen may enhance sense of
incorporating beverage preferences when possible. Give control and cooperation with restrictions.
-presence of frequent mouth care/ice chips as part of fluid allotment.
dysrhythmia LTO:
s Weigh daily.
After 3 days of duty the Documents changes in/resolution of edema in response to
-Pallor, patient will be able to therapy. A gain of 5 lb represents approximately 2 L of
Demonstrate stabilized fluid. Conversely, diuretics can result in rapid/excessive
-diaphoresis fluid volume with fluid shifts and weight loss.
balanced intake and
Assess for distended neck and peripheral vessels. Inspect Excessive fluid retention may be manifested by venous
-edema (+) output, breath sounds
dependent body areas for edema with/without pitting; note
clear/clearing, vital signs engorgement and edema formation. Peripheral edema
presence of generalized body edema (anasarca). begins in feet/ankles (or dependent areas) and ascends as
within acceptable range,
stable weight, and failure worsens. Pitting edema is generally obvious only
absence of edema. after retention of at least 10 lb of fluid. Increased vascular
congestion (associated with RHF) eventually results in
systemic tissue edema.

Change position frequently. Elevate feet when sitting. Inspect Edema formation, slowed circulation, altered nutritional
skin surface, keep dry, and provide padding as indicated. (Refer intake, and prolonged immobility/bedrest are cumulative
to ND: Skin Integrity, risk for impaired.) stressors that affect skin integrity and require close
supervision/preventive interventions.

Auscultate breath sounds, noting decreased and/or adventitious
sounds, e.g., crackles, wheezes. Note presence of increased
dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea,
persistent cough.
Excess fluid volume often leads to pulmonary congestion.
Symptoms of pulmonary edema may reflect acute left-
sided HF. RHF’s respiratory symptoms (dyspnea, cough,
orthopnea) may have slower onset but are more difficult to
reverse.
Investigate reports of sudden extreme dyspnea/air hunger, need May indicate development of complications (pulmonary
to sit straight up, sensation of suffocation, feelings of panic or edema/embolus) and differs from orthopnea paroxysmal
impending doom. nocturnal dyspnea in that it develops much more rapidly
and requires immediate intervention.

Assess bowel sounds. Note complaints of anorexia, nausea, Visceral congestion (occurring in progressive HF) can alter
abdominal distension, constipation. gastric/intestinal function.

Provide small, frequent, easily digestible meals. Reduced gastric motility can adversely affect digestion and
absorption. Small, frequent meals may enhance
digestion/prevent abdominal discomfort.

Measure abdominal girth, as indicated. In progressive RHF, fluid may shift into the peritoneal
space, causing increasing abdominal girth (ascites).

Encourage verbalization of feelings regarding limitations. Expression of feelings/concerns may decrease

stress/anxiety, which is an energy drain that can contribute
to feelings of fatigue.

Palpate abdomen. Note reports of right upper quadrant Advancing HF leads to venous congestion, resulting in
pain/tenderness. abdominal distension, liver engorgement (hepatomegaly),
and pain. This can alter liver function and impair/prolong
drug metabolism.

Collaborative:
Administer medications as indicated:

Diuretics, e.g., furosemide (Lasix), bumetanide (Bumex) Increases rate of urine flow and may inhibit reabsorption of
sodium/chloride in the renal tubules.
Thiazides with potassium-sparing agents, e.g.,
spironolactone (Aldactone) Promotes diuresis without excessive potassium losses.

Maintain fluid/sodium restrictions as indicated. Reduces total body water/prevents fluid reaccumulation.

Consult with dietitian. May be necessary to provide diet acceptable to patient that
meets caloric needs within sodium restriction.

Monitor chest x-ray. Reveals changes indicative of increase/resolution of

pulmonary congestion.
Problem: DOB
Nursing Diagnosis: impaired gas exchange r/t Alveolar-capillary membrane changes, e.g., fluid collection/shifts into interstitial space/alveoli
Taxonomy: activity-exercise pattern
Cause analysis: Pulmonary congestion predominates when the left ventricle fails, because the left ventricle is enable to adequately pump the blood
coming to it from the lungs. The inc.pressure in the pulmonary circulation causes fluid to be forced into the pulmonary tissues. Dyspnea result from
the accumulation of fluid in the alveoli, which impares gas exchange. ( medical surgical nursing 6th edition by: Brunner/Suddarth page. 582)

Cues Objectives Nursing Intervention Rationale Evaluation

The pt may Independent
verbalized STO:
Auscultate breath sounds, noting crackles, wheezes.
“Dyspnea”. After 8 hrs. of Reveals presence of pulmonary congestion/collection of
secretions, indicating need for further intervention.
effective nursing
intervention the Instruct patient in effective coughing, deep breathing. Clears airways and facilitates oxygen delivery.
Objective: pt.will be able to
Encourage frequent position changes.
Uncomforta have an increase O2 Helps prevent atelectasis and pneumonia.
ble behavior saturation within Maintain chair/bedrest, with head of bed elevated 20–30 Reduces oxygen consumption/demands and promotes
when in bed normal range ( 95- degrees, semi-Fowler’s position. Support arms with pillows. maximal lung inflation.
Holding 100 %).
breath
intermittentl
Collaborative
y Hypoxemia can be severe during pulmonary edema.
Appears Monitor/graph serial ABGs, pulse oximetry.
Compensatory changes are usually present in chronic HF.
weak and LTO: Note: In patients with abnormal cardiac index, research
pale suggests pulse oximeter measurements may exceed actual
Tachypnea After 3 days of duty oxygen saturation by up to 7%.
with shallow the pt. will be able to
Increases alveolar oxygen concentration, which may
breaths; RR maintain adequate Administer supplemental oxygen as indicated.
correct/reduce tissue hypoxemia.
25 – 36 O2 saturation as
Use of evidenced by Administer medications as indicated:
accessory minimal signs of
muscle Reduces alveolar congestion, enhancing gas exchange.
respiratory distress Diuretics, e.g., furosemide (Lasix)
Fatigue such as being free Increases oxygen delivery by dilating small airways, and
Cyanosis from cyanosis, BRONCHODILATORS, E.G., AMINOPHYLLIN
exerts mild diuretic effect to aid in reducing pulmonary
(peripheral) congestion.
normal O2 Sat,
Delayed
capillary normal RR (16-
refill time of 20bpm) & rhythm.
1 sec
O2
saturation
Below 90%
-(+) crackles
Problem: itching
Nursing Diagnosis: Skin Integrity, risk for impaired r/t pruritus secondary to hepatic engorgement
Taxonomy: Nutritional-Metabolic Pattern
Cause analysis: In a person with hepatomegaly, the normal flow of bile into the duodenum is blocked, allowing excessive bile salts to accumulate in the skin. This
accumulation of bile salts leads to pruritus (itching) or a burning sensation. This predisposes the individual to impaired skin integrity. (Medical-Surgical Nursing
by Ignativicius p. 1397

Cues Objectives Nursing Intervention Rationale Evaluation

The client may STO: • Health Teachings: -hot baths stimulates itching.
verbalized itching After 30 minutes of a) Advise the client not to take hot
both in upper and effective health teaching, baths.
lower extremities. the patient will be able to b) Advise the client against -it stimulates itching and increases risk for
verbalized understanding scratching. infection.
as evidenced scratching c) Explain the cause of itching. -for clients further understanding.
episodes and increased d) Avoid clothing that continuously -(this are guidelines to prevent dryness of the
comfort. rubs the skin such as tight belts, skin)
nylon stockings and panty hose. -to prevent dry skin
e) Do not apply rubbing alcohol,
astringents or other agents.
OBJECTIVES: LTO: f) Avoid caffeine and alcohol -to reduce skin damage
*yellowish, itchy Within 3 days of effective ingestion.
skin nursing intervention, the g) Encourage client to keep the -it can help to prevent inadvented scratching
*scratching patient will be able to fingernails trimmed short, with during sleep.
*restlessness maintain clean, moist rough edges filed.
*irritability skin, free from scratching h) Tell the clients to wear mitters or
and the patient verbalizes splints at night.
increased comfort.
• Keep bedclothes dry, use nonirritating -this may give temporary relief.
materials, and keep bed free from wrinkles,
crumbs, and so forth.
-to decrease irritable itching.
• Therapeutic baths (balneotherapy) with
colloidal oatmeal preparations or tar extracts.
• Suggest use of ice, colloidal bath, lotions. -May reduce itching.
COLOABORATIVE:
• 1) Give antihistamine as prescribed
and closely monitor the client’s
 response

References: Nurse’s Pocket Guide 10th edition by Doenges pp. 492-495

Nursing Diagnosis and Intervention by Campbell pp.922-923
Medical Surgical Nursing 5th edition by Ignativicius p. 1576

Problem: body weakness

Nursing Diagnosis: fatigue r/t decreased cardiac output
Taxonomy: activity-exercise Pattern
Cause analysis: results from the low cardiac output that deprives tissues of normal circulation and dercreases the removal of catabolic waste
products. It may also result of the inc.energy expended for breathing and the insomnia that results from respiratory distress and coughing. . ( medical
surgical nursing 6th edition by: Brunner/Suddarth page. 582)

Cues Objectives Nursing Intervention Rationale Evaluation

STO: INDEPENDENT
No subjective cues After 2-3 days in giving >Monitor the client for evidence of excess physical >Extended periods of inactivity may place the
nursing intervention, the and emotional fatigue. client at risk for excessive fatigue when carrying
Objective: patient will be able to out desired activities.
verbalize a measurable >Monitor nutritional intake. > Monitoring nutritional intake ensures that the
Objectives: increase in activity client has adequate energy resources.
• Decrease tolerance. > Reduce physical discomforts. > Physical discomforts could interfere with
performance cognitive function and self-monitoring/regulation
• Body of activity.
weakness or > Arrange Physical activities (e.g., avoid activity >Arranging physical activities reduces
malaise immediately after meals). competition for oxygen supply to vital body
• Irritable functions.
• restless LTO: > Encourage alternate rest and activity periods. >This avoids extended periods of either activity
• yawning After 10 days of giving or exercise.
nursing intervention, the >Assist the client to schedule rest periods and avoid > Rest periods should help restore client energy
• dark shadows
patient will be able to have care activities during scheduled rest periods. levels.
under the eye
responsibility to self and to > Instruct the client or significant other to recognize
• uncoordinated
demonstrate progressive the signs and symptoms of fatigue. > Symptoms of undue fatigue require a
movements
Activity as tolerated and reduction in activity.
• lethargic utilizes (activity) energy COLLABORATIVE
• inability to saving techniques. >Collaborate with the client/family and the
concentrate rehabilitation team. >Effective interdisciplinary interventions
facilitate the client’s ability to manage his or her
life.
References: NCP 6th edition by: Doenges
Medical-Surgical Nursing 5th edition by Ignativicius p.1387

Problem: loss of appetite

Nursing Diagnosis: risk for imbalance nutrition less body requirements r/t venous engorgement secondary to anorexia
Taxonomy: Nutritional-Metabolic Pattern
Cause analysis: venous engorgement of the liver leads to hepatomegaly & tenderness in the right upper abdominal quadrant. As this process
progresses, pressure w/in the portal vessels can become great enough to cause fluid to be forced into the abdominal cavity. Condition known as
ascites. Anorexia & nausea result from the venous engorgement & venous stasis w/in the abdominal organs.

Cues Objectives Nursing Intervention Rationale Evaluation

Independent Useful in promoting appetite/reducing nausea
 Provide a pleasant atmosphere at mealtime;
remove noxious stimuli
A clean mouth enhances appetite
 Assist in oral hygiene before meals if already
indicated
May lessen nausea and relieve gas but may be
 Offer effervescent drinks with meals, if contraindicated if beverage causes gas
tolerated formation/gastric discomfort

Nonverbal signs of discomfort associated with

 Assess for abdominal distention, frequent
belching, guarding, reluctance to move.
 Ambulate and increase activity as tolerated.
impaired digestion, gas pain.
Helpful in expulsion of flatus, reduction of abdominal
distention. Contributes to overall recovery and sense
of well-being and decreases possibility of secondary
problems r/t immobility (eg pneumonia)

Useful in establishing individual nutritional needs

Dependent and most appropriate route
 Consult with dietitian/physician as indicated
Meets nutritional requirements while minimizing
Advance diet as tolerated, usually low-fat, high- stimulation of the gallbladder.
fiber. Restrict gas-producing foods and foods/fluids
high in fats