Medical Diagnosis

Definition and Discussion

Management

Suggested Nursing Diagnoses

Kidney Failure 1. Acute Kidney Failure (ARF) A progressive, irreversible deterioration in the renal function in which the bodys ability to maintain metabolic and fluid and electrolyte balance fails, resulting to uremia or azotemia. The kidneys fail in an organized fashion following these stages: Stage 1: Diminished renal reserve with a gradual decrease of renal function of 30-50% but with no accumulation of metabolic wastes in the blood yet; Stage 2: Renal insufficiency wherein metabolic wastes begin to collect in the blood; and Stage 3: EndStage renal disease which occurs when kidney function is too poor to maintain homeostasis or sustain life. It is now more commonly described using 5 stages (CKD I-V) with the

2. Chronic Kidney Failure (End-Stage Renal Disease)

y y y y

Dietary control o protein restriction o sodium and fluid evaluation o potassium restriction o adequate caloric intake Erythropoietin Dialysis Supportive therapy Renal transplantation

1. Excess Fluid Volume 2. Decreased Cardiac Output 3. Fatigue 4. Anxiety 5. Imbalanced Nutrition: Less than Body Requirements 6. Activity Intolerance 7. Risk for Injury 8. Risk for Infection

following characteristics: IBeginning kidney damage with normal or increased GFR (90ml/min); II-Mild kidney damage with mild decrease in GFR by around 50% (6089ml/min); III-Moderate kidney damage and decrease in GFR (30-59 ml/min); IV- Severe kidney damage and decrease in GFR (15-29ml/min); and VKidney failu 3. Dialysis Excess Fluid Volume Definition of the Problem
Fluid volume excess (FVE), or hypervolemia, refers to an isotonic increase of the extracellular fluid (ECF) due to abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF. It is always secondary to an increase in the total body sodium content, which, in turn leads to an increase in total body water. The homeostatic mechanisms that regulate fluid balance might have been impaired with the existence of some disease process or conditions. This fluid excess usually results from compromised regulatory mechanisms for sodium and water and other electrolytes as seen in the following conditions: congestive heart failure (CHF), kidney failure, and liver failure. Other medical conditions that could contribute to excess fluid volume are as follows: hemodialysis, peritoneal dialysis and myocardial infarction. In addition, it may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Medical management lies on treating the cause of excess in fluid volume either through the administration of diuretics, restriction of sodium and fluid intake or even more intensive modalities such as hemodialysis. Nursing management includes preventing fluid volume excess through monitoring of input and output and sodium restriction in the diet. The restorative goal is to treat directly the cause. If the fluid excess is related to too much administration of sodium-containing fluids, discontinuing the infusion may be all that is required. When it comes with symptomatic treatments, administering diuretics and restricting fluids and sodium are required.

Goals and objectives

Patient will maintain sufficient fluid volume and electrolyte balance as manifested by vital signs within normal limits, balance of input and output, stable weight, clear lung sounds, pulmonary congestion not present on x-ray, and resolution of edema.

Subjective and Objective y y y y y y y y y y y y y y y y y y y y y y Adventitious breath sounds: crackles (rales) Altered electrolyte levels Azotemia Bounding pulses Change in mental status (lethargy or confusion) Change in respiratory pattern (shortness of breath, wheezing) Decreased hemoglobin or hematocrit Dyspnea Edema Increased blood pressure Increased central venous pressure (CVP) Increased pulmonary artery pressure (PAP) Intake exceeds output Jugular vein distension Oliguria Orthopnea Pulmonary congestion on x-ray Restlessness and anxiety Tachycardia Third heart sound (S3) Urine specific gravity changes Weight gain over short period of time

Related Factors
y y y y y Decreased cardiac output; chronic or acute heart disease Decreased plasma protein from organ failure, burns and draining fistulas Drug therapies (carbamazepine and chlorpropamide) Excessive fluid intake Excessive sodium intake

y y y y y y y y

Head injury Hormonal disturbances Impaired regulatory mechanism (Syndrome of Inappropriate Antidiuretic Hormone) Liver disease Low protein intake or malnutrition Renal insufficiency or failure Severe stress Steroid therapy

Assessment
y Assess urine output in reaction to diuretic therapy. Concentration is on checking the reaction to the diuretics, instead of the actual quantity voided. At home, it is unrealistic to expect patients to quantify each void. Thus, recording two voids versus six voids after a diuretic medication may give more helpful information. NOTE: Fluid volume excess in the abdomen may hinder with absorption of oral diuretic medications. Medications may require to be administered intravenously by a nurse in the home or outpatient setting. Assess weight in relation to nutritional status. In some heart failure patients, weight may be a poor gauge of fluid volume condition. Poor nutrition and diminished appetite over time lead to a reduction in weight, which may come with fluid retention even though the net weight stays unchanged. Significant weight gain in a short period of time, assessed by taking the patients daily weight, may indicate fluid retention. Auscultate for a third heart sound or other abnormal heart sounds, and check for bounding peripheral pulses. These are signs of fluid overload. Auscultate for crackles in lungs, alterations in respiratory pattern, shortness of breath, and orthopnea. These are initial signs of pulmonary congestion. Check and document vital signs. Sinus tachycardia and elevated blood pressure are seen in initial stages. Geriatric patients have diminished reaction to catecholamines; therefore their reaction to fluid overload may be blunted, with less increse in heart rate. BP may increase due to increase in circulating fluid although it can be within normal limits due to the fluid shift out of the vascular space. Check chest x-ray reports. As interstitial edema builds up, the x-rays show cloudy white lung fields. Evaluate necessity for an indwelling urinary catheter. Management concentrates on diuresis of excess fluid and accurate measurement with the aid of an indwelling catheter. Get patient history to determine the possible cause of the fluid disturbance. This can assist to direct management. May reveal data on the etiology of the problem such as elevated fluid or sodium intake, or compromised regulatory mechanisms.

y y y

y y

Monitor hemodynamic status including CVP, PAP, and PCWP (if available) if hospitalized. These direct measurements serve as accurate possible guides for therapy. Note for existence of edema by palpating over tibia, ankles, feet, and sacrum. Pitting edema is marked by a depression that sustains after ones finger is pressed over an edematous area and then removed. Grade edema from trace to 4. Measurement of an extremity with a measuring tape is one more technique of accurately grading edema. Observe for distended neck veins and ascites. Check abdominal girth to follow any ascites precisely. Reflects accumulation of fluids and shifting into the peritoneal space (ascites). The fluid shift causes excess fluid accumulation creating signs of decreased circulating blood volume or dehydration. Distention of neck veins is due to vascular congestion. Observe for excessive response to diuretics: 2-pound loss in 1 day, hypotension, hypovolemia, weakness, blood urea nitrogen (BUN) elevated out of proportion to serum creatinine level. Adverse effects of diuretics should be assessed to implement change in diuretic therapy and prevent occurrence of various side effects and complications that can pose greater risk to the patient. Observe input and output closely. Even though general fluid intake may be sufficient, shifting of fluid out of the intravascular to the interstitial spaces may lead to dehydration. The risk of this incident augments when diuretics are ordered. Input and output difference also reflects fluid status and response to therapy. Review daily log or chart for recorded intake if patient is on fluid restriction. Recording allows more accurate measurement of intake especially when the patient is on fluid restriction.

Therapeutic Interventions
y Give innovative methods for monitoring fluid allotment at home. This gives a visual guide for how much fluid is still allowed all through the day. Facilitates continuity of care and independence of patient at home. Give diuretics as ordered. Diuretic therapy may comprise several various types of agents for maximal therapy, depending on the acuteness or chronicity of the problem. Compliance is frequently hard for patients trying to sustain a normal lifestyle especially for chronic patients. Administer plasma expanders as ordered. Albumin pulls the fluid in the vascular compartment through colloid osmotic pressure, thus, decreasing the circulating fluid volume. For acute patients:  Apply/use saline lock on IV line. This keeps patency but reduces fluid delivered to patient in a 24-hour period.

 Give IV fluids via infusion pump, if possible. This guarantees precise delivery of IV fluids.  Help with repositioning every 2 hours if patient is not mobile. This avoids fluid buildup in dependent areas.  Work together with the pharmacist to maximally concentrate IVs and medications. This reduces unneeded fluids. y Institute or instruct patient regarding fluid restrictions as necessary. This assists to decrease extracellular volume. For some patients, fluids may require to be restricted to 1000 ml per day. Instruct necessity for use of antiembolic stockings or bandages as ordered. These help improve venous return and reduce fluid accumulation in the extremities. Instruct patient to avoid drugs that may cause fluid retention, such as over-the-counter non-steroidal anti-inflammatory agents (NSAIDs), certain vasodilators, and steroids. Imposes compliance to prescribed medications and avoidance of drug therapies that may precipitate hypervolemic states. Lessen constriction of vessels (wearing tight, restrictive clothing; crossing legs; stress; overly cold environment). This avoids venous pooling. Limit sodium intake as ordered. Sodium diets of 2 to 3 g are typically ordered. Sodium causes fluid retention in the interstitial space. Hyponatremia (dilutional) may occur when there is increase in fluid retention, thus sodium restriction should also be coupled with fluid restriction. Raise edematous extremities. This enhances venous return and, in turn, reduces edema. Provide occasional ice chips and frequent mouth care. Reduces thirst sensation that may cause intake of more fluids. Provide time for bed rest. Prevents sweating or perspiration that can stimulate thirst sensation and may promote recumbency (lying) - induced diuresis.

y y

y y y

Educative Interventions
y Educate causes of fluid volume excess and/or excess intake to patient or caregiver. Knowledge of risk factors enable the client with the help of significant others to avoid factors that may cause or aggravate disease condition for better compliance. Give details or strengthen rationale and anticipated effect of management program. Knowledge of the expected results enables planning for appropriate intervention to achieve desired results and promotes better compliance with the therapeutic regimen. Give explanation about the significance of keeping appropriate nutrition and hydration, and diet modifications. Encourages patients cooperation and helps in the maintenance of effective fluid management and preventing nutrition-related complications and adverse conditions.

Give information as required regarding the individuals medical diagnosis. Enables the client to specifically understand the nature of the disease condition in relation to the existence of hypervolemia, and the manner by which chosen therapeutic interventions address the problem. Educate on the signs and symptoms of fluid volume excess and those which are supposed to be reported. Helps allay anxiety when symptoms of hypervolemia are manifested and facilitates immediate action on possible adverse conditions should they manifest on the patient. Evaluate or teach patient to monitor weight daily with same scale, same amount of clothing, and if possible at the same time of day. This enables precise measurement and assists to follow trends accurately so that the approaches taken towards fluid management can also be evaluated accurately.

Decreased Cardiac Output

Definition of the Problem

Cardiac output refers to the volume of blood pumped by each ventricle for a given period. A number of factors affect the heart s pumping action and contractility. Common etiologies of decreased cardiac output include the following: angina, myocardial infarction, severe hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, chronic heart failure, cardiac surgery, acute and chronic renal failure, Grave s disease, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. These conditions can result in decreased contraction (systole), decreased filling (diastole), or both. Due to decreased blood volume ejected from the ventricles, epinephrine and norepinephrine are stimulated to increase heart rate and contractility and support the myocardium. This causes vasoconstriction, increases blood pressure and afterload. As the heart s work load increases, contractility of the myocardial muscle fibers decreases. This results in a decrease in cardiac output which affects various organs due to impairment of perfusion or blood supply. Geriatric patients are at high risk of developing this problem since their ventricles have reduced compliance due to aging process. Though advances in diagnostic procedures that allow prompt and more precise diagnoses, so that early management could be initiated before significant debilitation occurs are available, heart disease still remains a chronic condition. The overall goals of management are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.

Goals and objectives

y y y y Patient will demonstrate an improved or adequate cardiac output as evidenced by enhancement in activity tolerance or absence of palpitations, fatigue, dyspnea or shortness of breath with activity, or by relief of specific symptoms experienced by the patient associated with decreased cardiac output (refer to subjective and objective data). Patient will demonstrate unwavering cardiac rhythm and rate within own normal range. Patient will maintain BP within standard limits; have regular cardiac rhythms; maintain warm, dry skin; clear lung sounds, and strong bilateral, equal peripheral pulses. Patient will participate in activities that decrease BP or cardiac workload.

Subjective and Objective y

Abnormal heart sounds; extra heart sounds (S3, S4), murmurs

y y y y y y y y y y y y y y y y y y y

Angina Anxiety, restlessness Arrhythmias (tachycardia, bradycardia, electrocardiogram [ECG] changes. Chest pain Cold, clammy, pale or ashen (cyanotic) skin; diaphoresis Decreased urine output Edema Jugular vein distention (JVD) Liver engorgement Confusion, change in mental status Decreased peripheral pulses Ejection fraction less than 40% Prolonged capillary refill Pulsus alternans Rales, cough, tachypnea, dyspnea, shortness of breath, orthopnea, paroxysmal norturnal dyspnea (PND), abnormal arterial blood gases (ABGs), frothy sputum Syncope, dizziness Variations in hemodynamic parameters (blood pressure [BP], heart rate, central venous pressure [CVP], pulmonary artery pressures, venous oxygen saturation [SVO2], cardiac output) Weakness, fatigue Weight gain

Related Factors
y y y y y y y

Alteration in afterload Alterations in heart rate, rhythm, electrical conduction Structural changes (e.g., valvular defects, ventricular aneurysm, infarcted or dyskinetic muscle) Cardiac muscle disease Decreased oxygenation Impaired contractility/inotropic changes Increased or decreased ventricular filling (preload)

Assessment
y

Assess color and temperature of skin and time of capillary refill. Cold, clammy skin is due to compensatory increase in sympathetic nervous system stimulation, reduced cardiac output, and desaturation. Peripheral circulation is reduced due to a fail in the cardiac output and there could also be diminished peripheral pulses. Assess mentation status. In the early stages, restlessness is seen; in later stages, severe anxiety and confusion are being manifested. Auscultate apical pulse; monitor heart rate, rhythm (if telemetry is available record dysrrhythmia). To compensate for reduced ventricular contractility, tachycardia is usually present even at rest. Tachycardia results from the sympathetic response as a result of the release of catecholamines. Irregularities or dysrrhythmias develop with electrolyte shifts or imbalances. Note! Common dysrrythmias associated with heart failure are as follows: premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibrillation (AF). Monitor heart rate and blood pressure. In the early stages, sinus tachycardia and augmented arterial blood pressure are being manifested; blood pressure drops as the state deteriorates. Tachycardia can be due to anxiety, pain, hypoxemia and reduced cardiac output. Either hypertension or hypotension can occur depending on the response of the heart. Geriatric patients have diminished response to catecholamines, hence their response to decreased cardiac output may be blunted, with lower rise in heart rate. In heart failure patients, pulsus alternans (alternating strong-then-weak pulse) is often seen. Observe changes in sensorium (anxiety, confusion, depression, disorientation, and lethargy). This may indicate insufficient cerebral perfusion secondary to reduced cardiac output. Observe presence and quality of central and peripheral pulses. With reduced cardiac output, pulses are weak. In addition, bounding carotid, femoral, jugular, and radial pulses may be noted or palpated. Due to the effects of vasoconstriction and venous congestion, pulses in the legs or feet may be reduced.

PERIPHERAL VASCULAR ASSESSMENT Compare Right to Left Check for Symmetry Compare Upper Extremity to Lower Extremity

Palpable Pulses

Temporal Carotid Brachial BP, CPR in infant Radial pulse Ulnar Femoral arterial studies Popliteal Dorsalis Pedis Posterior Tibial blood clots edema of feet or legs intermittent claudication leg cramps leg ulcers pain on walking disappears with rest pallor of fingertips varicose veins

History

INSPECTION (Upper Extremities )

Compare Side to Side

y y y y

Size Symmetry Skin/color Nail Beds / Capillary Refill

Nails
y y

Hair Growth Venous Pattern

INSPECTION (Lower Extremities)

Compare Side to Side

y y y y y y

Size Symmetry Skin -color, lesions Nail Beds / Capillary Refill Nails Venous Pattern

PALPATION (Upper Extremities)

Hair Growth Compare Side to Side

y y y

Temperature Capillary refill Pulses o Radial o Brachial o Ulnar

CHARACTERISTICS OF PULSES

palpate along LENGTH of artery with finger pads

y y y y

Rate Rhythm Contour/elasticity Strength (Amplitude) o +4 = bounding o +3 = full, increased o +2 = normal o +1 = diminished, weak o 0 = absent

Rhythm/Pattern regular
y y

irregular (dysrhythmia) if irregular - take apical

PALPATION ( Lower Extremities)

apical/radial Compare Side to Side

y y y

Pulses Femoral Popliteal Pulses o Dorsalis Pedis o Posterior Tibial o Femoral o Popliteal Temperature Edema

y y

+1- +4 pitting
y

Sensation

Arterial Insufficiency of Lower Extremities Pulses Color Temperature Edema Skin Decreased/Absent Pale on elevation Dusky Rubor on dependency Cool/Cold None Shiny, thick nails, no hair Ulcers on Toes Pain, more with exercise Paresthesias

Sensation

Venous Insufficiency of Lower Extremities Pulses Present Pink to cyanotic Color Brown pigment at ankles Temperature Warm Edema Present Discolored, scaly Skin ulcers on ankles Pain, More with Sensation standing or

sitting. Relieved with elevation/support hose

Determine type of dysrrythmia. It is useful in determining type of intervention necessary.

Dysrrhythmia Sinus tachycardia

Evident In Stress, infection, fever, pain, hypovolemia, hypoxia. May not require medications but medications are necessary for shortened diastolic filling time and increased oxygen demand Sinus bradycardia Acute MI, loss of automaticity of the heart, increased parasympathetic activity. Atrial dysrrythmias (PACs, atrial flutter and PAC-Ischemia, Atrial flutter and fibrillation fibrillation, supraventricular tachycardia) (Coronary artery and valvular disease) Ventricular dysrrythmias (Premature PVCs or VPBS (MI, digitalis toxicity, ventricular contractions/ventricular coronary vasospasm. Polymorphic VT premature beats, ventricular tachycardia, (Torsades de pointes) is drug related ventricular flutter or ventricular fibrillation Heart blocks MI, coronary artery disease, drug toxicity and cardiac surgery
y

Auscultate lung sounds. Note any episode of paroxysmal nocturnal dyspnea (PND) or orthopnea. Orthopnea is difficulty of breathing when the patient is in supine position. Paroxysmal Nocturnal Dyspnea (PND) is difficulty of breathing that occurs during the night. Crackles echoes accumulation of fluid secondary to damaged left ventricular emptying. They are more apparent in the dependent areas of the lungs.

Monitor heart sounds, noting gallops, S3, S4. S3 indicates lowered left ventricular ejection and is a classic sign of left ventricular failure occurring with cardiac decompensation and some medications (especially blockers). S4 takes place with lowered compliance of the left ventricle, which impairs diastolic filling. Murmurs may be indicative of valvular damage or papillary muscle rupture. Review weight gain and fluid balance. Body weight is a more accurate indicator of fluid or sodium retention than intake and output. Fluid and sodium retention may be caused by compromised regulatory mechanisms. If hemodynamic monitoring is in place: Check central venous, pulmonary artery pressure, pulmonary capillary wedge pressure, and right arterial pressure. Hemodynamic parameters give information aiding in differentiation of reduced cardiac output due to fluid overload versus deficit in fluid. Watch SVO2 continuously. One of the initial indicators of decreased cardiac output is change in oxygen saturation of mixed venous blood. Do cardiac output determination. Gives objective number/value to guide therapy. Check ECG for rate; rhythm; ectopy; and change in PR, QRS, and QT intervals. Tachycardia, bradycardia, and ectopic beats can compromise cardiac output. ECG changes indicating ischemia or myocardial infarction or dysrrythmia indicates further therapeutic intervention or evaluation. Geriatric patients are particularly sensitive to the loss of atrial kick in atrial fibrillation.

y y

y y y

THE STANDARD 12 LEAD ECG The standard 12-lead electrocardiogram (ECG/EKG) represents the heart's electrical activity recorded from electrodes on the body surface. ECG Waves and Intervals P wave QRS complex ST-T wave U wave the sequential activation (depolarization) of the right and left atria right and left ventricular depolarization (normally the ventricles are activated simultaneously) ventricular repolarization origin for this wave is not clear - but probably represents "afterdepolarizations"

PR interval QRS duration QT interval RR interval PP interval

in the ventricles time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex) duration of ventricular muscle depolarization duration of ventricular depolarization and repolarization duration of ventricular cardiac cycle (an indicator of ventricular rate) duration of atrial cycle (an indicator of atrial rate

Orientation of the 12 Lead ECG It is significant to consider that the 12-lead ECG provides spatial information about the heart's electrical activity of the heart in 3 approximately orthogonal directions namely: Right Left, Superior Inferior, and Anterior Posterior. Further, each of the 12 leads represents a particular orientation in space. (RA = right arm; LA = left arm, LF = left foot) Bipolar limb leads (frontal plane): Lead I: RA (-) to LA (+) (Right Left, or lateral) Lead II: RA (-) to LF (+) (Superior Inferior) Lead III: LA (-) to LF (+) (Superior Inferior) Augmented unipolar limb leads (frontal plane): Lead aVR: RA (+) to [LA & LF] (-) (Rightward) Lead aVL: LA (+) to [RA & LF] (-) (Leftward)

Lead aVF: LF (+) to [RA & LA] (-) (Inferior) Unipolar (+) chest leads (horizontal plane): Leads V1, V2, V3: (Posterior Anterior) Leads V4, V5, V6:(Right Left, or lateral) Location of chest electrodes V1: right 4th intercostal space V2: left 4th intercostal space V3: halfway between V2 and V4 V4: left 5th intercostal space, mid-clavicular line V5: horizontal to V4, anterior axillary line V6: horizontal to V5, mid-axillary line
y

Check laboratory data (cardiac enzymes, ABGs, electrolytes, etc). Enzymes evaluate resolution/extension of infarction. Existence of hypoxia shows necessity for supplemental oxygen. Electrolyte imbalance such as in potassium, calcium and magnesium unfavorably affects cardiac rhythm/contractility and potentiates CNS excitability. ABG determines the adequacy of respiratory status and the sufficiency of supplemental oxygen. Look out for dependent or general edema. May signify heart failure, renal or vascular injury. Monitor response to increased activity. Physical activity augments the demands placed on the heart; fatigue and exertional dyspnea are frequent problems with reduced cardiac output conditions. Close monitoring of patients response to increased activity serves as a guide for most favorable succession of activity.

y y

Note for chest pain. This signifies an imbalance between oxygen supply and demand. Chest pain may be indicative of the underlying pathologic cause as in ischemia, decreased myocardial perfusion or increased oxygen demand and altered electrical conduction in the heart. Review urine output. Find out how often the patient urinates. Oliguria can echo decreased renal perfusion. Diuresis is anticipated with diuretic therapy. Monitor for adverse reactions to medications. Drugs with negative inotropic effect can decrease perfusion to an already ischemic myocardium. Also, combination of nitrates and blockers can gradually build up effects on the cardiac output. Assess for signs and symptoms of heart failure. Angina is a symptom of underlying pathology of myocardial ischemia or infarction. Disease may compromise tissue perfusion in vital organs to a point of cardiac decompensation.

Therapeutic Interventions
y

Give medication as prescribed, noting reaction and inspecting for side effects and toxicity. Make clear with the physician, the parameters for halting medication particularly the following: digitalis therapy, diuretics, vasodilator therapy, antidysrrhythmics, ACE inhibitors, and inotropic agents. Limit fluids and sodium as prescribed for patients with increased preload. This reduces extracellular fluid volume. Retain hemodynamic parameters at prescribed levels. Close monitoring of these parameters directs titration of fluids and medications for patients in the acute setting. Sustain optimal fluid balance. Giving of fluid increases extracellular fluid volume and consequently elevates cardiac output. Keep up adequate ventilation and perfusion, as in the following: o Put patient in semi- to high-Fowlers position. This lessens preload and ventricular filling. o Put patient in supine position. This promotes venous return, and increases diuresis. o Give humidified oxygen as ordered. The deteriorating heart may not be able to compensate with increased oxygen demands. Maintain physical and emotional rest, as in the following:

y y

y y

Limit activity. This decreases oxygen demand reducing myocardial decompensation and workload. Offer quiet, relaxed milieu. Emotional stress adds to cardiac demands. This also reduces stimulation and release of catecholamines which aggravates dysrrhythmias and vasoconstriction, and increases workload. o Systematize nursing and medical care. This permits rest periods. o Check progressive activity within restriction of cardiac function. o Use stress management activities (relaxation techniques, guided imagery, deep breathing exercise). Promotes relaxation from stressful situations which can cause stimulation and release of catecholamines.
o o y y

Check sleep patterns; administer sedative as prescribed. Rest is essential for conserving energy. Offer bedside commode. Have patient keep away from activities provoking a vasovagal response. Give stool softeners as considered necessary. Use of commode lowers demand for energy needed in getting to the bathroom and saves the patient from exerting a great effort to use the bedpan. Vasovagal or Valsalva maneuver especially when straining or bearing down during defecation, should be avoided as this leads to vagal stimulation which reduces the heart rate (bradycardia). Rebound tachycardia subsequently occurs, which compromises cardiac function or output. Offer little, easily digested meals. Restrict caffeine intake. Huge meals may augment myocardial workload and root vagal stimulation, leading to bradycardia or ectopic beats. Caffeine is a direct cardiac stimulant that can increase the heart rate. Note: New guidelines propose no need to limit caffeine in regular coffee drinkers. If arrhythmia takes place, verify patients response, document, and report if significant or symptomatic. o Have antiarrhythmic drugs readily accessible. o Care for arrhythmias according to medical orders or procedure and evaluate reaction. o Either tachyarrhythmias or bradyarrhythmias can lower cardiac output and myocardial tissue perfusion. Have emergency apparatus or medications accessible. Abrupt coronary occlusion, lethal dysrhythmias, infarct, and unremitting pain are conditions that may lead to cardiac arrest, requiring urgent life-saving management. Administer supplemental oxygen as needed. This increases oxygen available for the heart to compensate from decreased oxygenation due to perfusion problems. It reduces ischemia and lactic acid levels as well as it improves cardiac contractility. Prepare for cardiopulmonary resuscitation as necessary. CPR is necessary to prevent irreversible heart and brain damage brought about by myocardial ischemia and even death.

Administer antiarrythmics as indicated. Examples Mode of Action Disopyramide, procainamide, Increases action potential, quinidine duration and refractory period and decreases membrane responsiveness Lidocaine, phenytoin, Shortens QT interval tocainide (refractory period) Flecainide, Propafenone, Slows conduction by encainide depressing SA node automaticity and decreasing conduction velocity Blockers Have antiadrenergic properties and decreases automaticity Bretylol, amiodarone, sotalol, Prolongs refractory period ibutilide and action potential duration Verapamil, nifedipine, Slows conduction through the diltiazem AV node Atropine sulfate, cardiac Increases SA and AV node to glycoside, digoxin increase automaticity

Drug Class Class Ia

Class Ib Class Ic

Class II

Class III Class IV Class V

Educative Interventions
y Encourage to report immediately for initial pain felt. Timely interventions can reduce myocardial workload and oxygen depletion, which can also prevent further serious complications. Clarify progressive activity program and signs of overexertion. Activities should only be limited to that which will not make the patient overexert in order to conserve energy and reduce cardiac workload.

Explain diet restrictions especially regarding fluid and sodium. This reduces the extracellular fluid volume that will also decrease the cardiac workload and help improve cardiac contractility. Give details on symptoms and management for reduced cardiac output related to respective etiological factors. Gives the patient pertinent information for self-specific etiologic factors that may contribute to reduced cardiac output. May help the patient modify lifestyle or behavior contributory to reduced cardiac output. Give explanation about the drug regimen, purpose, dose, and possible side effects. Information gives the client more knowledge that promotes adherence and compliance to medications.

Fatigue Definition of the Problem

Fatigue is a covert complaint. It can be present in both acute and chronic illnesses. In an acute illness, it serves as a defensive function that keeps the person from sustaining injury resulting from too hard work in a destabilized condition. Fatigue is a distressing symptom that has the greatest impact in the quality of life and level of functioning of an individual. The distress in fatigue can be measured with the clients inability to assume responsibilities, to cope with the demands of life and the assistance that is received from others. It can be a barrier to various interests, relationship with significant others, hobbies and even sexual desires. Fatigue can either be acute or chronic. Acute fatigue as a protective mechanism is a sense of exhaustion immediately after an energy-demanding activity while chronic is an excessive or overwhelming sense of exhaustion not relieved by rest and could greatly affect the quality of life. Fatigue is associated with a variety of physical and psychological conditions. Patient who have the following medical conditions could experience fatigue: hepatitis, rheumatoid arthritis, fibromyalgia, systemic lupus erythematosus, myasthenia gravis, depression, AIDS, diabetes mellitus, diabetic ketoacidosis, thyrotoxicosis, and multiple sclerosis. The patient may be unable to work full-time and maintain acceptable performance of the job, when experiencing fatigue due to a chronic illness. Chronic fatigue syndrome, a condition characterized by prolonged, debilitating fatigue, neurological problems, general pain, gastrointestinal problems, and flu-like symptoms is not yet fully understood, but is believed to be an abnormal response of the immune system to highly stressful physiological or psychological events. Nursing interventions therefore are centered on balancing activity and rest for fatigue is a common and oppressive condition for many patients. The nurse should carefully assess various parameters including feelings of weakness, weariness, inability to carry out and assume responsibilities, lack of energy and motivation so appropriate interventions could be implemented. Both physiologic (dyspnea, pain, etc.) and psychological factors (fear and anxiety) that cause fatigue should be determined. There must be a careful consideration on rest because too much of it can also promote inactivity and deconditioning or disuse syndrome. Due to the sense of exhaustion from the underlying disease entity, patient may have impaired immune function and should be protected when performing the activities. Patients may also lack the motivation and energy so simple activities like sitting up in the chair instead of staying at bed could be initiated. If necessary, physical therapy could be initiated to promote further tolerance, endurance and functioning. The goals of management focuses on the following: conservation of energy, promotion of exercise, providing adequate nutrition, and enhancement of sleep.

Goals and objectives

y y Patient will demonstrate increased interest and motivation to assume roles and responsibilities. Patient will verbalize and demonstrate having sufficient energy to complete preferred activities and ADLs at ability level.

Subjective and Objective y y y y y y y y y y y y y y y y y y

Accident-prone Disinterest in surroundings/introspection Drowsy; decreased performance Pale looking Report of (overwhelming and unremitting) lack of energy Verbalizes no desire and/or lack of interest in activity Compromised concentration Decreased libido or no sexual desires Feelings of guilt for not keeping up with responsibilities Inability to maintain usual routines Inability to restore energy, even after sleep Increased physical complaints Increased rest requirements Less verbal communication Lethargic or listless Perceived need for additional energy to accomplish routine tasks Relaxed facial musculature Tired

Related Factors
y Environmental y Humidity y Light y Noise

y Temperature Physiological y Altered body chemistry: side effects of medication, chemotherapy, insufficient insulin, irritability of central nervous system (CNS) y Anemia y Bedrest or immobility y Decreased energy production, increased energy requirements to perform activities y Disease states y Generalized weakness y Hypermetabolic state/infection (decreased metabolic energy production, increased energy requirements) y Imbalance between oxygen supply and demand y Increased physical exertion y Malnutrition y Pain/discomfort y Poor physical condition y Pregnancy y Progressive disease state/debilitating condition y Sleep deprivation Psychological y Anxiety y Boring lifestyle y Cognitive deficits/emotional status, secondary to underlying disease process/depression y Depression y Emotional lability/irritability y Extreme stress y Impaired ability to concentrate y Jittery behavior y Nervousness, tension y Overwhelming psychological/emotional demands y Pain Situational y Negative life event y Occupation

Assessment
y Review characteristics of fatigue: y Severity

y y y

Changes in severity over time Aggravating factors Alleviating factors

Utilizing a quantitative scoring scale, 1 to 10 for example, can assist the patient express the amount of fatigue experienced. Further scoring scales can be developed by utilizing pictures or descriptive language. This technique allows the nurse to weigh against changes in the patients fatigue level over time. It is significant to conclude if the patients level of fatigue is unvarying or if it varies over time. This also helps determine whether fatigue is of acute or chronic condition. Acute fatigue is usually a protective mechanism immediately after an energy-demanding activity so the person can recognize the bodily response to rest or stop the activity for energy conservation. However, chronic fatigue can be debilitating since it greatly affects the quality of life and performance of both desired and necessary activities and it cannot be relieved by ample rest. y Check for possible origins of fatigue: y Latest physical illness y Emotional stress y Depression y Side effects of medication y Anemia y Sleep disorders y Imbalanced nutritional intake y Greater than before responsibilities and demands at home or work

Determining the related factors with fatigue can help in identifying possible causes and creating a collaborative plan of care for both cure and prevention. y Assess the patients emotional reaction to fatigue. The more common emotional responses associated with fatigue are anxiety and depression. These emotional conditions can increase the persons fatigue level and produces a vicious cycle. Assess the patients routine medications and over-the-counter drugs. Medication side effect can cause fatigue. Drug interaction can signal fatigue. The nurse must perform particular notice to the patients utilization of the following: -blockers, calcium channel blockers, tranquilizers, alcohol, muscle relaxants, and sedatives. Assess the patients sleep patterns for quality, quantity, time taken to fall asleep and feeling upon awakening and observe alteration in thought processes or behaviors. Alteration in the persons sleep pattern may be an aggravating factor in the development of fatigue. Numerous factors can intensify fatigue, together with sleep deprivation, emotional distress, side effects of drugs, and progressing CNS disease Check breath sounds. Observe for feelings of panic or air hunger. Hypoxemia augments sense of fatigue that weakens capability to function.

Evaluate the patients nutritional ingestion of the following: calories, protein, minerals, and vitamins. Protein-calorie malnutrition, vitamin deficiency, or iron deficiency may cause fatigue. Evaluate the patients typical level of exercise and physical movement. Both increased physical exertion and inadequate levels of exercise can add to fatigue. Review the patients capability to perform the following: activities of daily living, instrumental activities of daily living, and demands of daily living. Fatigue can bound the persons capability to partake in self-care and carry out his or her role and responsibilities in the family and society. Watch physiological reaction to activity such as the follwing: changes in BP, respiratory rate, or heart rate. Degree of endurance is affected by the phase of the disease progression, nutrition condition, fluid balance, and quantity or sort of opportunistic diseases that patient has been exposed with. Monitoring vital signs will also help determine the level of physiologic tolerance to activity and extent of fatigue. Assess results of laboratory or diagnostic test: y Blood glucose y Hemoglobin/hematocrit y BUN y Oxygen saturation, resting and with activity Alterations in these physiological measures can be contrasted with other measurement data to recognize possible sources of the patients fatigue.

Evaluate the patients outlook for fatigue relief, eagerness to partake in strategies to reduce fatigue, and level of family and social support. The patient has to be an active participant in planning, implementing, and evaluating therapeutic management to alleviate fatigue. Social support will be essential to assist the patient put into practice changes to decrease fatigue. Watch the patients nutritional ingestion for adequate energy sources and metabolic demands. The patient will necessitate sufficient ingestion of carbohydrates, protein, vitamins, and minerals to supply energy resources needed in the performance of desired and required activities.

Therapeutic Interventions
y Give comfort measures such as the following: judicious touch or massage, and cool showers. May reduce nervous energy and will help the patient to relax and rest. Help out the patient to make a schedule for daily activity and rest. A plan that equates periods of activity with periods of rest can assist the patient finish preferred activities without contributing to levels of fatigue.

Identify energy conservation methods. For example, sitting, dividing ADLs into convenient segments. Assist with movement or self-care demands as appropriate. Weakness may make activities of daily living almost not possible for patient to finish while energy conservation methods help improve role and activity assumption and performance.

y y

Institute practical activity goals with patient. Offers a sense of control and feelings of achievement; avoids discouragement from fatigue of overactivity. Keep away from topics that annoy or disturb patient. Communicate ways to react to these feelings. Heightened irritability of the CNS may make the patient to become easily excited, agitated, and prone to emotional outburst which also increases the energy expenditure of the patient. Offer calm milieu; cool room, lessened sensory stimuli, calming colors, calm music. Decreases stimuli that may intensify disturbance, hyperactivity, and insomnia. Offer diversional activities that are soothing. Permits for utilization of nervous energy in a positive manner and may lessen anxiety. Persuade the patient to utilize assistive devices for ADLs and IADLs: 1) Long-handled sponge for bathing 2) Long shoehorn 3) Sock-puller 4) Long-handled grabber Utilization of assistive devices can diminish energy outflow and avoid harm with activities.

y y

y y y

Assist the patient to classify tasks that can be assigned to others. Assigning tasks and responsibilities to others can help the patient to save energy. Assist the patient in putting priorities for preferred activities and role responsibilities. Setting priorities is an energy conservation method that permits the patient to utilize available energy to complete significant activities. Attaining desired goals can develop the patients mood and sense of emotional health. Give supplemental O2 as specified. Incidence of anemia or hypoxemia decreases oxygen available for cellular uptake and adds to fatigue.

y y y y

Lessen environmental stimuli, in particular during scheduled times for rest and sleep. Vivid lighting, noise, visitors, numerous distractions, and litter in the patients physical surroundings can restrain relaxation, disrupt rest or sleep, and adds to fatigue. Maintain bed in low position, pathways clear of furniture. Support patient with ambulation. Keeps patient from harm during activities. Refer the patient to an occupational therapist. The occupational therapist can offer the patient with assistive devices and educate the patient on energy conservation methods. Cluster nursing activities and interventions. Promotes rest and prevents excessive fatigue from therapeutic interventions that interrupt rest and energy charging.

Educative Interventions
y Assist the patient build up habits to encourage effective rest or sleep patterns. Encouraging relaxation before sleep and providing for some hours of continuous sleep can add to energy refurbishment. May help in the conservation of strength and improving stamina so various activities can be performed without undue fatigue. Counsel on scheduling activities when patient has the majority of energy. Plan care to permit for rest periods. Engage patient or significant other in schedule planning. Planning permits patient to be active during episodes when energy level is higher, which may refurbish a feeling of well-being and a sense of control. Numerous rest episodes are required to refurbish or save energy. Educate the patient and family on task organization and time organization methods. Organization and management of time can assist the patient to save energy and avoid fatigue Help the patient partake in escalating levels of physical activity and exercise. Appropriate exercise can lessen fatigue and assist the patient to build stamina for physical activity. Persuade the patient and family to express feelings about the impact of fatigue. Fatigue can have an intense unconstructive effect on family processes and social interaction. Encouraging verbalization may also help relieve the patient and family of emotional concerns that add to the fatigue while giving the nurse a chance to understand and address these feelings and concerns. Persuade the patient to maintain a 24-hour fatigue or activity log for at least 1 week. Being familiar with relationships between definite activities and levels of fatigue can assist the patient to recognize unnecessary energy outflow. The log may signify times of day when the person feels the least fatigued. This information can help the patient make choices about setting his or her activities to take advantage of episodes of high energy levels. Encourage participation to activity that can be done according to tolerance and level of ability. Promotes autonomy and self-confidence that will help increase interest and motivation as the patient begins to feel in control of desired and required activities in a tolerable situation.

Show correct performance of activities of daily living, ambulation or position changes. Recognize safety issues, such as the following: utilization of assistive devices, temperature of bath water, keeping travel-ways clear of furniture. Ensures safety and protects the patient against injuries during activities and minimizes straining and use of improper body mechanics that may cause feeling of overwhelming exhaustion. Explore ways with the client on how realistic goals for activity and effective role assumption of the client can be met. Allows the client to gain sense of control on the expectations that can be met when proper planning coupled with interest and right energy amount are made and carried out. Setting goals also gears the client to act on how to meet the expectations and earn a sense of accomplishment.

Anxiety Definition of the Problem

Anxiety is a common reaction to stress. It is experienced at a conscious, subconscious, or unconscious level. Anxiety is probably present at some point in every person, but its degree and frequency of its manifestation differs. Some people are capable of using the emotional rim that anxiety provokes to inspire creativity or problem-solving abilities, while others can become immobilized to a pathological degree. It is categorized in four levels namely: mild, moderate, severe, and panic. Medical and surgical conditions that could trigger anxiety are as follows: angina, myocardial infarction, lung cancer, ventilatory assistance, ruptured intervertebral disc, gastrectomy, peritonitis, thyrotoxicosis, renal dialysis, BPH, mastectomy, burns, transplantation, psychosocial conditions, surgical interventions, cancer, and disaster situations. The presence of the nurse may provide support to an anxious patient and offer some strategies for traversing anxious moments or panic attacks.

Goals and objectives

y y y y y y y y y

Patient will acknowledge and discuss fears or concerns Patient will appear calmed and relaxed Patient will be able to identify or recognize feelings and signs of anxiety Patient will demonstrate problem-solving skills and behaviors to cope with current situations Patient will describe a decrease in the level of anxiety experienced Patient will identify or use available resources appropriately and support systems effectively Patient will identify possible causes or contributing factors to the current situation Patient will report beginning the use of individually appropriate coping strategies Patient will verbalize or communicate awareness of feelings and healthy ways to deal with the

Subjective and Objective y Physiological

y y y y y y y y y y y y y y y y y y y y y y y

Anger and irritability Apprehension Dizziness, light-headedness Dry mouth Dyspnea Feelings of helplessness and discomfort Flushing Frequent urination Headaches Hypervigilance; overexcitement Impaired functioning; verbal expressions of having no control or influence over situation, outcome, or self-care Increase in blood pressure, pulse, and respirations Increased muscle/facial tension Insomnia, nightmares Nausea and/or diarrhea Pacing Palpitations Perspiration Pupil dilation Restlessness Somatic complaints/sympathetic stimulation; extraneous movements (restlessness, foot shuffling, hand/arm fidgeting, rocking movements) Trembling

Behavioral y Apprehension, uncertainty, restlessness, worry, sense of impending doom y Association of diagnosis with loss of healthy body image, loss of place/influence y Crying y Difficulty concentrating y Expressed concern regarding changes in life events y Expressions of denial, shock, guilt, insomnia y Expressions of helplessness y Fear of death as an imminent reality y Feelings of inadequacy y Fight (e.g., belligerent attitude) or flight behavior y Focus on self, expressions of concern about current and future events y Focus on self/negative self-talk y Inability to problem-solve y Lack of awareness of surroundings

y y y y y

Preoccupation Scanning and vigilance Uncertainty, feelings of inadequacy View of self as noncontributing member of family/society Withdrawal

Related Factors
y y y y y y y y y y y y y y y y y y y y y y y

Changes in environment and routines Changes in role function Concern about sexual ability Embarrassment/loss of dignity associated with experiences including genital exposure before, during, and after treatment Interpersonal conflicts Interpersonal transmission/contagion Intrusive diagnostic and surgical tests and procedures Negative self-talk Perceived threat of death/dependency on mechanical support Physiological factors, hypermetabolic state Sensory impairment; environmental stimuli Separation from support system (hospitalization, treatments); knowledge deficit Side effects of steroids and/or cyclosporine Situational (hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement) and maturational crises Stress Substance abuse Threat or perceived threat to physical and emotional integrity Threat or perceived threat to self-concept (altered image/abilities; [perceived or actual] organ rejection, threat of death) Threat to (or change in) socioeconomic status Threat to or change in health status (disease course that can lead to further compromise, debility, even death) Unconscious conflict about essential values, beliefs, and goals of life Underlying pathophysiological response Unmet needs

Assessment

Monitor and document patients level of anxiety. Patients awareness and ability to identify and solve problems are enhanced by mild anxiety. While moderate anxiety limits awareness of environmental stimuli and problem solving can occur but may be more difficult, and patient may need help. In severe anxiety, patients ability to integrate information and solve problems decreases. With panic, the final state of anxiety, the patient is unable to follow directions and may experience hyperactivity, agitation, and immobilization.

ANXIETY ASSESSMENT GUIDELINE Background Anxiety disorders are not negligible they cause as much distress and social interference as depressive disorders. It affects all ages. Thus, there is a real need for the following: early and precise identifications in all ages, differentiation from other clinical problems, and effective management. Screening Possible questions which can help with an initial evaluation of whether anxiety is present include the following:  Have you been feeling tense or anxious lately?  If so, please can you tell me more?  Have you been worrying a lot about things lately?  Have you been experiencing any unusual physical symptoms?  What situations make the symptoms worse?  What do you do when stressed or anxious?  What makes the symptoms better? Levels of anxiety Level 1 Level 2 Level 3 Mild Anxiety Moderate Anxiety Severe Anxiety increased alertness to inner feelings/environment; increased ability to learn concentration is focused to a specific thing; characterized by tremors and rapid speaking ability to perceive is narrowed: characterized by inability to communicate, decreased intellectual functioning and feeling of worthlessness

Level 4

Panic State

ability to perceive is completely disrupted: characterized by disintegration of personality and loss of control

Common signs and symptoms of anxiety disorders AFFECTIVE/ PHYSICAL appetite changes
 chest

y y

EMOTIONAL anger
anxiety

y y

COGNITIVE  catastrophising
 excessive, worrying thoughts

y y y

BEHAVIOURAL agitation
avoidance

y y y

pains y
depersonalisation

 checking

 cold

hands y
depression

 fear

of losing y
drinking alcohol/substance abuse

control y
impaired concentration

dizziness/light-

headedness y y y y
dry

y y y y y y

derealisation

mouth

 fear

y y
 jumping

 escape

to y y y y y
 fidgeting

 fatigue

guilt

negative conclusions y
memory

hyperventilation
muscular

irritability

hypervigilance

impairment
numbness

inhibition

aches/pains y y
palpitations

panic

negative anticipation

restlessness

 shortness

of

negative

breath y
 sleep

predictions y y
 self-blaming

 safety behaviour

tearfulness

problems

thoughts of impending doom/catastrophe

y y

 sweating

tension headache

tremor

Acknowledge positive behaviors indicative of beginning acceptance and/or use of effective strategies to deal with situation. Fear/anxiety will decrease as patient begins to accept/deal positively with reality. Establish how patient deals with anxiety and ways that are related to effective coping. Interviewing the patient may be done to determine the effectiveness of his coping strategies. Enables the nurse to provide additional information on other ways and methods of relieving anxiety. Effective coping involves recognition of the problem causing stress and anxiety through problem solving skills, development and implementation of effective strategy to cope with or solve the problem. This may include time management, assertiveness, solution-oriented therapy and development of support system. Note: A way of effective coping;  Identifying the problem. Helps the client differentiate the problem from anxiety response to the problem. Assess if:  The problem really exists or is just imagined? Problems worried upon by some clients do not really exist and are only imagined. This helps the client assess the validity of the problem before working on a solution.  The problem is really important or just nuisance? (Use of cognitive reappraisal techniques)  The problem has feasible solutions? Problems may be inevitable and beyond control so the best coping is acceptance as the nurse develops ongoing support system and provides assistance through the crisis.

Explore changes in mentation and occurrence of hypervigilance, hallucinations, sleep disturbances (e.g., nightmares), agitation/apathy, disorientation, and labile affect, all of which may vary from time to time. These are signs of extreme anxiety/delirium state in which the patient is literally struggling for life. Although it may be psychologically based, pathological life-threatening causes (e.g., shock, sepsis, hypoxia) must be ruled out. Sleep and rest are natural forms of relaxation that are essential for healing and repairing the physiologic consequences of anxiety related to stress. Inadequate rest worsens stress, especially due to impaired mental functioning, resulting to greater anxiety. Monitor and document mental status, including mood/affect, understanding of events, content of thoughts and judgment, e.g., false impressions or manifestations of terror/panic. Initially, patient may use defense mechanism or coping mechanism - e.g. denial and repression - to minimize and sort out information that might be overwhelming, while some patients exhibit calm behavior and alert mental status, representing dissociation from truth or reality, which is also a defense mechanism.

Observe behavioral cues and clues, e.g., restlessness, irritability, withdrawal, narrowed attention, lack of eye contact, demanding behavior. Indicators of level of anxiety/stress, e.g., patient may feel uncontrollable at home or work in managing personal problems. Stress may build up as a result of physical symptoms of condition and the reaction of others. Observe for presence of aggression, withdrawal, and or denial (inappropriate refusal or rejection to comply with medical regimen). Reinforce patients coping strategies/abilities. Recommend that the patient note episodes of anxiety. Instruct patient to describe what is experienced and the events leading up to and surrounding the event. Patient should note how the anxiety starts or what triggers it. Symptoms often provide the care provider with information regarding the degree of anxiety being experienced. Physiological symptoms and/or complaints intensify as the level of anxiety increases. Watch for physical responses, e.g., restlessness, changes in vital signs, repetitive movements and agitation. Note for conformity of verbal/nonverbal communication. This is helpful in evaluating extent/degree of concerns, especially when compared with verbal comments.

Therapeutic Interventions
y Acknowledge but do not reinforce use of denial. Avoid confrontations as much as possible. Denial can be beneficial in reducing anxiety but can delay dealing with the truth or reality of the current situation. Confrontation can promote anger and boost use of denial which eventually reduces cooperation and delays recovery. Acknowledge patients awareness of anxiety. Acknowledgment of the patients feelings confirms the feelings and shows acceptance of those feelings. Answer all questions truthfully. Provide information that is consistent; repeat as necessary. Factual information about the situation decreases fear, builds up nurse-patient relationship, and assists patient/significant others to deal realistically with the current situation. Attention span may be short, and repetition of information aids with retention. As patients level of anxiety subsides, encourage exploration of specific events prior to both the beginning and reduction of the anxious feelings. Recognition and exploration of causative factors leading to or reducing anxious feelings are essential steps in developing alternative solutions. Also, when the information is explored when the anxiety subsides, more accurate information essential to treatment can be derived. Assist the patient in developing anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). Using anxiety-reduction strategies enhances patients sense of personal mastery and confidence in anxiety reduction relief and management. Assist the patient to identify or recall positive coping behaviors used in the past. Successful behaviors in the past can be reinforced in dealing with current problems/stress, enhancing patients sense of self-control.

y y

Be empathic and nonjudgmental while working with patient and family. Showing empathy and nonjudgmental attitude enhances cooperation of the patient and family and reduces anxiety that can be a result of mistrust of the nurse-patient relationship. Familiarize patient to the environment, routine procedures, anticipated activities and new experiences or people as necessary. Encourage participation when possible. Expectedness of information can promote comfort and may lessen anxiety. Identify and discuss with patient and significant others the safety and standard precautions being taken, e.g., power supply backup and emergency equipment. Discuss the meanings and significant of alarm system. Provides reassurance to help allay anxiety, decrease concerns of the unknown, and preplan for response in emergency condition. Initiate other forms of mental and physical relaxation. Stress Resistance

Technique Progressive relaxation- a technique of slowly focusing on muscle groups tensing the muscles for 5 to 7 seconds and then relaxing them Meditation- focusing on breath awareness or a mantra, meditative movements such as yoga or Tai Chi, mindfulness and prayer

Rationale Promotes control on relaxation of the entire body and benefits people who might be anxious due to muscle tension, spasm, insomnia, neck or back pains Lowers blood pressure and decreases heart disease risk

Cognitive reappraisal Technique Thought stopping- clients identify the obsessive thought that may contribute to anxiety and the person interrupts with a loud STOP and substitutes a positive thought Refuting irrational ideas- Identifies irrational ideas and replace with facts. E.g., I must be perfect in everything I do with Nobody is perfect Guided imagery- done with a therapist who assists a patient to imagine a picture of a stressful situation and switched to imagining a more relaxing environment Rationale Disrupts anxiety provoking obsessive thoughts that are non productive and automatically replaces them with a positive message Substitutes more rational thought from previous irrational thought for better coping Guides the inner self to take control of stressful situations and to manage anxiety by shifting to a lesser stressful stimulus or situation

y y

Maintain a calm and confident behavior while interacting with patient (without false reassurance). A calm and nonthreatening atmosphere can enhance patients feeling of stability. Honest explanations can lessen fear and anxiety

Maintain matter-of-fact approach in dealing with patient. Protect patients privacy. Communicates acceptance and reduces patients embarrassment.

Minimize sensory stimuli by promoting a quiet environment; keep "threatening" equipment out of sight. Anxiety may be triggered by excessive conversation, noise, and equipment around the patient.

Observe for congruency of verbal/nonverbal signs of anxiety, and stay with patient. Intervene if patient displays destructive behavior. Patients may not express concerns directly through words, but actions may suggest sense of agitation, aggression, and hostility. Overt signs may provide cues on the level of anxiety and the corresponding interventions which have to be verified with the covert cues.

Provide adequate rest periods or uninterrupted time for sleep, quiet surroundings, with patient controlling the type, and amount of external stimuli. Promotes conservation of energy and enhances patients coping abilities. Lessening external stimuli may lessen factors that may contribute to the worsening of anxiety levels.

Provide Therapeutic Touch, massage, and other adjunctive therapies as indicated e.g., tapping of shoulders. Helps patient in meeting basic human need, reducing sense of isolation, and assisting patient to feel less anxious. Note: Functional Therapeutic Touch entails the nurse to have specific knowledge and experience with the use of touch in proper timing and manner in order to allay patients feeling of anxiety and not to aggravate it.

Reassure patient that he or she is safe. If necessary, stay with the patient. The existence of a trusted person may be helpful to reduce fear/ anxiety during an attack.

Set up a working relationship with the patient through continuity of care. A continuing relationship establishes a foundation for comfort in communicating anxious feelings.

Utilize simple language and brief statements when teaching patient about self-care measures or about diagnostic and surgical procedures. Keep it short and simple. Attention span may be reduced, concentration lessened, and capacity to understand information limited with high levels of anxiety.

Help patient in acknowledging problem-solving capabilities.

 Provide positive feedback when patient exhibits better ways to manage anxiety and is able to calmly and /or realistically evaluate own situation. Promotes acknowledgement and reinforcement, and enhances ability to deal with anxious feelings.  Provide support of normal grieving process, including time necessary for resolution. Can provide encouragement that feelings are normal responses to situations or perceived alterations.  Refer to spiritual counselor as needed. Facing ones mortality may aggravate feelings of anxiety and questions about ones spiritual beliefs and practices.  Stress the importance of logical strategies that the patient can use when experiencing anxiety. Learning to recognize a problem and evaluate alternatives to resolve it assists the patient to cope.

Educative Interventions
y Assist patient in guided imagery/relaxation techniques; e.g., imagining a pleasant place, use of music/tapes, deep-breathing, meditation, and mindfulness. Reduces anxiety by promoting the release of endorphins which assist in developing internal locus of control, enhancing coping skills, and allowing body to go about its work of healing. Note: Mindfulness is a technique of being in the here and now, concentrating on what is occurring at the moment.

Demonstrate how to utilize relaxation techniques, e.g., focused breathing, progressive relaxation, and guided imagery. Provide music therapy, biofeedback as needed. This promotes active management of situation to decrease feelings of anxiety and serves as a form of relaxation and distraction from the stressor or externally provoking stimulus. Discuss to patient the proper use of medications and educate him or her to identify adverse reactions. Medications that can help in the relief of anxiety may be used if patients anxiety continues to rise and the feeling of anxiety becomes disabling or becomes a hindrance to activities of daily living. Encourage autonomy, self-care, and decision making within accepted treatment plan. Empowers the patient to take the initiative for own healthcare, enhances decision making capabilities and promotes and advocates responsibility and accountability for own health care. Increased independence and autonomy from healthcare staff promotes self-confidence and reduces feelings of abandonment. Encourage patient to verbalize feelings of anxiety and assess anxiety-provoking situations if he/she is able to identify them. Avoid false reassurances. This helps the patient in evaluating the situation realistically and recognizing causative factors to the anxious feelings. Gradually, this also minimizes fear and helps the client develop a sense of control if confronted with the situation presenting similar known causes of anxiety. It prevents the patient from believing or relying on reassurances that would just cause frustrations and unnecessary expectations that are less likely to happen or take place in reality. This also establishes a therapeutic working relationship that will assist patient and significant others in identifying problems causing stressful situations. Help patient in identifying symptoms of increasing feeling of anxiety; identify other alternatives used to prevent the anxiety from immobilizing her or him. The ability to distinguish anxiety symptoms at lower-intensity levels allows the patient to intervene faster to manage his or her anxiety. Refer the patient for psychiatric assistance if anxiety becomes disabling to activities of daily living. May need additional support in regaining control and coping with acute and chronic episodes/exacerbations and consequences of the disease and therapeutic regimen. Reiterate to patient that mild anxiety level can encourage sense of confidence, empowerment, and motivation for growth and improvement. Helps the client develop a sense of control to manage moderate anxiety to a tolerable level using anxiety reduction techniques. Support patient to look for assistance from an understanding significant other or health care provider when difficulty arises from feelings of anxiety. The presence of significant others strengthens feelings of safety and security for the patient which decreases anxiety derived from people and the environment.

Imbalanced nutrition: less than body requirements Definition of the Problem

Adequate nutrition plays an important role in healing and recovery. Imbalanced nutrition: less than body requirements refers to an intake of nutrients insufficient to meet daily requirements because of inadequate food intake or improper digestion and absorption of food. An inadequate food intake may be caused by the inability to acquire or prepare food, inadequate knowledge about essential nutrients and a balanced diet, discomfort during or after eating, dysphagia, anorexia, nausea, or vomiting. Improper digestion and absorption of nutrients may be caused by an inadequate production of hormones or enzymes or by medical conditions resulting in inflammation or obstruction of the gastrointestinal tract. It can also be affected by the following: gastrointestinal [GI] malabsorption, cancer, burns, muscle weakness, poor dentition, activity intolerance, pain, substance abuse, lack of financial resources to obtain nutritious foods, depression, boredom, trauma, surgery, sepsis, burns. In addition, medical conditions that could alter nutrition are as follows: AIDS, anemias, cancer, COPD, asthma, cirrhosis of the liver, diabetes mellitus, diabetic ketoacidosis, anorexia nervosa, bulimia nervosa, inflammatory bowel disease, ulcerative colitis, Crohns disease, ileocolitis, pancreatitis, pulmonary tuberculosis, radical neck surgery, laryngectomy, renal dialysis, ventilatory assistance, and post-operative conditions. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complications associated with malnutrition, and regain specified normal weight.

Goals and objectives

y y y y y y y
Patient or significant other will express and show selection of foods or meals that will help in achieving optimal or ideal weight.

Patient will demonstrate behaviors, lifestyle changes to recover and/or keep appropriate weight. Patient will demonstrate nutritional ingestion sufficient to meet metabolic needs as manifested by stable weight or muscle-mass measurements, positive nitrogen balance, tissue regeneration and display of improved energy level. Patient will experience no signs of malnutrition.

Patient will indicate understanding of significance of nutrition to healing process and general health.
Patient will maintain weight or display weight gain on the way to preferred goal, with normalization of laboratory values. Patient will weigh within 10% of ideal body weight (IBW).

Subjective and Objective y y y y y y y y y y y

0% to 20% below ideal body weight or weight below normal for age, height, and body type (build) Abdominal cramping, hyperactive bowel sounds, diarrhea and/or steatorrhea Abnormal laboratory results: vitamin/mineral and protein deficiencies, electrolyte imbalances Changes in gastric motility and stool characteristics Changes in gums, oral mucous membranes (sore, inflamed buccal cavity) Decreased tolerance for activity Decreased triceps skin-fold measurement Lack of interest in food, aversion to eating, altered taste sensation Loss of muscle mass/subcutaneous fat (wasting), and development of negative nitrogen balance Amenorrhea Bradycardia, cardiac irregularities, hypotension

y y y y y y y y y y y y

Documented inadequate caloric or food intake less than recommended daily allowance (RDA) or recommended energy and nutritional intake (RENI) Excessive loss of hair; increased growth of hair on body (lanugo) Hypothermia Imbalances in nutritional studies (decreased albumin, total proteins, iron deficiency) Increased ketones (end product of fat metabolism) Increased urinary output, diluted urine Lack of information, misinformation, misconception (specify) Loss of weight with or without adequate caloric intake Pale conjunctiva Poor skin turgor Reported lack of food/evidence of lack of available food Weakness of muscles required for swallowing or mastication

Related Factors
y y y y y y y y y y y y y y

Abnormal bowel function Altered absorption and metabolism of ingested foods: reduced peristalsis (visceral reflexes), bile stasis Altered feedback mechanisms of desire to eat, taste, and smell because of surgical/structural changes, radiation, or chemotherapy Anorexia Dyspnea; sputum production Early satiety (ascites) Failure to absorb nutrients necessary for formation of normal RBCs Inability or altered ability to ingest, digest and/or metabolize nutrients: nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract infections, fatigue Increased metabolic rate/nutritional needs caused by disease process or therapy (fever/infection, can be as much as 50%60% higher than normal proportional to the severity of injury) Indigestion Medication side effects; anorexia, nausea/vomiting Protein catabolism Restricted oral intake

y y y y y y y y y y y

Chronic/excessive laxative use Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone) Inadequate diet Infectious process Insufficient financial resources to sustain nutritional needs Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism) Knowledge deficit Loss of digestive enzymes and insulin (related to pancreatic outflow obstruction or necrosis/autodigestion) Loss of peptides and amino acids (building blocks for proteins) during dialysis Medically restricted intake; fear that eating may cause diarrhea or temporary or permanent alteration in mode of food intake Sensation of feeling full (abdominal distension during continuous ambulatory peritoneal dialysis [CAPD])

Assessment
y Auscultate bowel sounds. Reduced or hypoactive bowel sounds may be a sign of reduced gastric motility and constipation due to low fluid intake, poor food choices, reduced activity, and hypoxemia. Evaluate capability to masticate, taste, and swallow. Lesions of the mouth, throat, and esophagus and metallic or other taste alterations produced by medications may cause dysphagia, impairing patients capacity to take food and lessening desire to eat. Evaluate nutritional condition frequently, throughout every day nursing care, taking note of energy level; state of skin, nails, hair, oral cavity; craving to eat or anorexia. Gives the chance to examine deviations from the patients baseline, for accurate evaluation and more appropriate choice of interventions Get nutritional history; incorporate family, significant others, or caregiver in evaluation. Patients awareness of actual intake may vary. Significant others may be assisting the patient on feeding and can provide more accurate description of what the patient has actually ingested. Observe muscle mass or subcutaneous fat as specified. If available, indirect calorimetry may be helpful in more precisely approximating body reserves or losses and efficiency of therapy. Record actual weight; do not approximate. Gives more accurate or precise measurement of actual weight or weight loss instead of mere weight approximation. Review abdomen, noting incidence or character of bowel sounds, abdominal distention, and reports of nausea. Gastric distention and intestinal atony are often present, leading to decrease or absent bowel sounds.

GORDONS FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL NUTRITIONAL-METABOLIC PATTERN ASSESSMENT SUBJECTIVE: 1. 2. 3. 4. Any weight gain in the last 6 months? No__ Yes__ Amount: ___________ Any weight loss in the last 6 months? No__ Yes__ Amount:____________ How would you describe your appetite? Good__ Fair__ Poor__ Do you have any food intolerance? No__ Yes__ Describe: ____________

5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that patient restricts voluntarily, for example, to prevent flatus) No__ Yes__ Describe: ___________________ 6. 7. 8. 9. 10. Describe an average days food intake for you (meals and snacks): _____ Describe an average days fluid intake for you. _____________________ Describe food likes and dislikes. _________________________________ Would you like to: Gain weight?__ Lose weight?__ Niether__ Any problems with: . . . . Nausea: No__ Yes__ Describe: _______________________________ Vomiting: No__ Yes__ Describe: ______________________________ Swallowing: No__ Yes__ Describe: ____________________________ Chewing: No__ Yes__ Describe: ______________________________

. 11.

Indigestion: No__ Yes__ Describe: ____________________________

Would you describe your usual lifestyle as: Active__ Sedate__

For breastfeeding mothers only: 12. 13. Do you have any concerns about breast feeding? No__ Yes__ Describe: Are you having any problems with breastfeeding? No__ Yes__ Describe:

OBJECTIVE 1. Skin examination a. b. c. d. Warm__ Cool__ Moist__ Dry__ Lesions: No__ Yes__ Describe: _______________________________ Rash: No__ Yes__ Describe: _________________________________ Turgor: Firm__ Supple__ Dehydrated__ Fragile__

e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__ Other____________________________________________________ 2. Mucous Membranes a. Mouth i. ii. iii. Moist__ Dry__ Lesions: No__ Yes__ Describe: __________________________ Color: Pale__ Pink__

iv. v. vi. vii. b. Eyes i. ii. iii. 3. Edema a.

Teeth: Normal__ Abnormal__ Describe:____________________ Dentures: No__ Yes__ Upper__ Lower__ Partial__ Gums: Normal__ Abnormal__ Describe:____________________ Tongue: Normal__ Abnormal__ Describe:___________________

Moist__ Dry__ Color of conjunctiva: Pale__ Pink__ Jaundiced__ Lesions: No__ Yes__ Describe:___________________________

General: No__ Yes__ Describe:_______________________________ Abdominal girth: ___inches

b. c.

Periorbital: No__ Yes__ Describe:_____________________________ Dependent: No__ Yes__ Describe:_____________________________ Ankle girth: Right:__ inches; Left__inches

4. 5. 6. 7.

Thyroid: Normal__ Abnormal__ Describe: _________________________ Jugular vein distention: No__ Yes__ Gag reflex: Present__ Absent__ Can patient move easily (turning, walking)? Yes__ No__

Describe limitations: __________________________________________ 8. Upon admission, was patient dressed appropriately for the weather? Yes__ No__ Describe: ________________________________________ For breastfeeding mothers only: 9. 10. No__ Breast exam: Normal__ Abnormal__ Describe:______________________ If mother is breastfeeding, have infant weighed. Is infants weight within normal limits? Yes__

Establish etiological factors for diminished nutritional intake. Correct assessment of etiologic factors guides intervention. For example, patients with dentition problems need referral to a dentist, while patients with memory losses may need other services such as Meals-on-Wheels. Observe or discover manners toward eating and food. Various psychological, psychosocial, and cultural factors conclude the type, quantity, and aptness of food consumed in preference to both quality and quantity of food intake. Persuade patient to partake in recording food intake utilizing a daily log. Establishing the type, quantity, and pattern of food or fluid ingestion is aided by precise recording by patient or caregiver as the intake happens; memory is inadequate. The food record may include assessment of the patients eating patterns through the 24-hour diet recall and 3-day dietary log in which the client records all foods and drinks for 3 days. It includes when, how and why the client ate to help recognize eating patterns and problematic eating behaviors. Watch environment in which eating takes place. Observing families on a general meal together may not always be applicable at the hospital setting. The patients satiety and interest on eating may be affected by how well he/she finds ease in eating with others, and by the presence of a more pleasing environment that is free from noise or stressors. A lot of adults find themselves "eating on the run" or relying heavily on fastfood with lower nutritional components. Review laboratory values that signifies nutritional health or worsening:  Serum albumin. This shows degree of protein reduction (2.5 g/dl signifies severe diminution; 3.8 to 4.5 g/dl is normal).  Transferrin. This is significant for iron transfer and typically diminishes as serum protein lowers.

 RBC and WBC counts. These are frequently lowered in malnutrition, showing anemia and reduced resistance to infection.  Serum electrolyte values. Potassium is classically elevated and sodium is classically lowered in malnutrition. These values show nutritional condition and organ function, and signifies replacement needs. Note: Nutritional tests can be changed because of disease processes and reaction to a number of medications or therapies. (Various medications are metabolized by the liver and have possibility for synergistic harm.) y Document ongoing caloric intake. Establishes necessity for supplements or alternative feeding techniques.

Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound per day.

Therapeutic Interventions
y Administer medications between meals (if tolerated) and minimize fluid intake with meals, except when fluid has nutritional value. Gastric fullness reduces appetite and food ingestion. Medications administered between meals can mask unpleasant sensation and minimize gastric distress with the presence of food. Advocate rest before meals. Prevent stressful measures close to mealtime. Calms down peristalsis and boosts available energy for eating. Helps out save energy, particularly when metabolic requirements are augmented by fever or disease condition. Arrange diet with patient or significant other, suggestive of foods from home if suitable. Offer small, frequent meals or snacks of nutritionally dense foods and non-acidic foods and beverages, with preference for foods appetizing to patient. Persuade high-calorie or nutritious foods, a number of which may be considered appetite stimulants. Note time of day when appetite is finest, and aim to serve bigger meal at that time. Counting patient in planning provides sense of control of surroundings and may improve intake. Satisfying cravings for noninstitutional food may also enhance intake. Note: In this population, foods with a higher fat content may be suggested as tolerated to improve taste and oral ingestion. Small frequent feedings may prevent sudden feeling of bloatedness or fullness which may stop further intake of foods and may be recommended for patients who have vomiting episodes or are nauseated. Ask dietitian for further evaluation and suggestions regarding food partialities and nutritional assistance. Dietitians have a broader knowledge of the nutritional value of foods and may be useful in evaluating specific ethnic or cultural foods. Avoid food(s) that provoke nausea or vomiting or are poorly tolerated by patient because of mouth sores or dysphagia. Limit serving very hot liquids or foods. Dish up foods that are easy to swallow. Pain in the mouth or fear of irritating oral lesions may lead the patient to be unwilling to eat. Some foods

especially those that can make the client nauseated or vomit may also lead to loss of appetite and aversion to ingestion of foods. Avoiding these may be helpful in escalating food intake. y Build up and persuade a pleasing milieu for meals. Dish up foods in well-ventilated, pleasing environment, with unhurried ambiance, and friendly company. Pleasing milieu helps in lowering stress and is more favorable for eating. Encourages socialization and maximizes patient comfort when eating difficulty cause discomfiture. Eliminate existing noxious environmental stimuli or situations that provoke gag reflex. Diminishes stimulus of the vomiting center in the medulla. Give enteral or parenteral feedings as indicated. Take into consideration some complications of parenteral nutrition for necessary action. Enteral feedings are ideal because they cost less and carry less risk of aggravating endocrine dysfunction than TPN. Nevertheless, TPN may be necessary when oral or enteral feedings are not endured. TPN is set aside for those whose gut cannot take in even an elemental formula (such as those with severe refractory diarrhea). Parenteral nutrition improves nutritional status by establishing a nitrogen balance, maintaining appropriate weight, and improving muscle mass.

y y

Complications of Parenteral Nutrition Complications Prevention or Treatment Air Embolism y Secure all tubing sites by taping them appropriately. y
Stop the infusion. Tape all tubing site connections. Avoid connecting other lines to the main line.

Catheter displacement and contamination

y y
Clotted

Administration of heparin and inspection of flow of the line

catheter line y
 Use of infusion pump, stop or decrease the flow rate

Fluid

overload

Insulin administration, monitoring of glucose levels and use of infusion pump

Fowlers

position and possible chest

 Hyperglycemia

tube insertion y
Gradual weaning from parenteral nutrition

y y
Pneumothorax

Sterile technique on dressing, changing the tubing and admixture bag

 Rebound

hypoglycemia

Sepsis

Give frequent mouth care, noting secretion precautions. Prevent use of alcohol-containing mouthwashes. Lowers discomfort related with nausea or vomiting, oral lesions, mucosal dryness, and halitosis. Clean mouth may improve appetite. Give multivitamins, together with ascorbic acid (vitamin C), folic acid, vitamins B6 and D, and iron supplements, as ordered. Restores vitamin or mineral insufficiencies resulting from malnutrition/anemia or loss during dialysis. Give nutritional solutions at ordered rate via infusion control device as required. Regulate rate to deliver ordered hourly intake. Do not raise rate to catch up if infusion slows. Nutrition support orders are based on individually estimated caloric and protein necessities. A regular rate of nutrient administration guarantees correct utilization with fewer side effects, such as hyperglycemia or dumping syndrome. Note: Constant and cyclic infusion of enteral formulas are usually better tolerated than bolus feedings and result in enhanced absorption. Give small, frequent feedings; include patients likes or dislikes in meal preparation as much as possible, and incorporate home foods, as fitting. May improve patients craving for food and increase quantity of intake. Institute fitting short- and long-range goals. Depending on the etiological factors of the problem, development in nutritional condition may take a long time. Without practical short-term goals to give tangible rewards, patients may be unable to find interest in addressing this problem. Maintain patient on NPO as indicated. Resting the bowel reduces peristalsis and diarrhea, preventing malabsorption or loss of nutrients.

Offer a balanced diet of complex carbohydrates and planned quantity of high-quality protein and essential amino acids. Supplies adequate nutrients to enhance energy and avoid muscle wasting (catabolism); upholds tissue regeneration or healing, and electrolyte balance. Note: Fifty percent of protein ingestion should be derivative of protein sources with high biological value, such as the following: red meat, poultry, fish, and eggs. Offer companionship during mealtime. Consideration to the social aspects of eating is significant in both the hospital and home settings. Creates a therapeutic and pleasing environment of enjoying meals with others company. Permit sufficient time for mastication, swallowing, savoring food; offer socialization and feeding assistance as necessary. Patients require support/help to overcome underlying problems such as the following: anorexia, fatigue, muscular weakness. Unhurried time for eating should be considered so the person can find more ease even in the presence of eating difficulties and disorders. Persuade use of seasoning for patients with alteration in sense of taste. Natural seasonings like onions, lemons and honey adds additional flavor to the food and serves as healthy additives that may increase appetite. Propose ways to help patient with meals as required. Guarantee a pleasant milieu, assist with correct eating position if possible, and offer good oral hygiene and dentition. Oral hygiene is necessary to maintain the pleasant taste sensation, and dentition to provide adequate mastication. Elevating the head of bed 30 degrees helps in swallowing and lessens risk of aspiration. Recommence or advance diet as ordered. For example, clear liquids succeeding to bland, low residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber as ordered. Permits the intestinal tract to readjust to the digestive process. Protein is essential for tissue healing and integrity. Low bulk reduces peristaltic reaction to meal. Note: Dietary procedures depend on patients state. In moderate disease, elemental enteral products may be administered to give nutrition without overstimulating the bowel. A patient with toxic colitis is on NPO and placed on parenteral nutrition. Refer to occupational therapist for adaptive devices for patients with physical impairments. Other patients may necessitate use of assistive devices or need assistance during feeding. Talk about potential need for enteral or parenteral nutritional assistance with patient, family, and caregiver as appropriate. Enteral tube feedings are ideal for patients with a working GI tract. Feedings may be unremitting or intermittent (bolus). Parenteral nutrition may be designated for patients who cannot bear enteral feedings. Either solution can be customized to give necessary glucose, protein, electrolytes, vitamins, minerals, and trace elements. Fat and fat-soluble vitamins can also be given two or three times per week. These feedings may be utilized with in-hospital, long-term care, and sub-acute care settings, as well as in the home. Assist patient or significant other build up nutritionally balanced home meal plans. Enhances awareness of individual requirement and importance of adequate nutrition and balanced diet in healing and recovery process.

Educative Interventions

Evaluate knowledge on and strengthen the following to patient and caregivers:  The basic four food groups, as well as necessity for particular minerals or vitamins. Patients may not be aware of what is included in a balanced diet.  Significance of maintaining sufficient caloric intake; a typical adult (70 kg) requires 1800 to 2200 kcal per day; patients with burns, severe infections, or draining wounds may need 3000 to 4000 kcal per day  Foods high in calories and protein that will enhance weight gain and nitrogen balance.

Avoid beverages that are caffeinated or carbonated. These may reduce appetite and result to early satiety. May cause gastric irritation since they activate production of hydrochloric acid. Offer referral to community nutritional resources such as Meals-on-Wheels or hot lunch programs for seniors as necessary. Available community sponsored eating programs can help promote nutrition and gathers people for nutritional education and awareness during seminars or symposiums. Persuade exercise or as much physical activity as feasible. Metabolism and utilization of nutrients are improved by activity. May enhance appetite and general feelings of health. Persuade patient to express feelings concerning recommencement of diet. Uncertainty to eat may be a result of fear that food will lead to worsening of symptoms. Persuade patient to sit up for meals. Aids swallowing and decreases risk of aspiration. Persuade small, frequent meals with foods high in protein and carbohydrates. Makes the most of nutrient intake without unnecessary fatigue or energy loss from eating large meals, and diminishes gastric irritation. Persuade utilization of herbs or spices, such as the following: garlic, onion, pepper, parsley, cilantro, and lemon. Builds up appetite for food and helps lower boredom with diet. Note: Some salt substitutes are high in K+, and regular soy sauce is high in Na+, and as a result, must be avoided. Persuade/help out with fine oral hygiene; before and after meals, use soft-bristled toothbrush for gentle brushing. Offer dilute, alcohol-free mouthwash if oral mucosa is ulcerated. Improves appetite and oral intake. Reduces bacterial growth, lessens potential for infection. Particular mouth-care methods may be required if tissue is sensitive/ulcerated/bleeding and pain is severe. Encourage family to take food from home as fitting for hospitalized patients. Patients with specific ethnic, religious partialities or restrictions may not be able to consume hospital foods.

y y

Activity Intolerance Definition of the Problem

Activity tolerance is the quantity and quality of exercise or daily living activities an individual is able to perform without experiencing adverse effects. Functional strength is the ability of the body to perform work. When activity tolerance and functional strength had been affected by a certain condition, it leads to activity intolerance. Activity intolerance is usually associated to generalized weakness (body malaise) and debilitation secondary to acute or chronic illness and disease. Medical conditions that could lead to activity intolerance are as follows: hypertension, heart failure, myocardial infarction, anemia and end of life conditions. Other factors that contribute to activity intolerance are as follows: obesity, malnourishment, side effects of medications, depression or lack of confidence to exert one's self. Activity intolerance is manifested by alterations in heart rate and BP with activity, development of dysrrhythmias, changes in skin color or moisture, exertional angina and generalized weakness. This problem is especially apparent in geriatric patients with certain medical conditions that hinder with their own performance and completion of the activities of daily living (ADL). In addition, the aging process causes reduction in muscle strength and function, which can impair the ability to maintain activity. Nursing goals are as follows: to reduce the effects of inactivity, promote optimal physical activity, assist the patient to maintain a satisfactory lifestyle and help the client demonstrate measurable or progressive increase in tolerance for activity. Goals and objectives
As to energy management, the patient will: y y y y Adjust lifestyle and activity to energy level Display normal hemoglobin and hematocrit values within normal range (anemia) Maintain activity level within capabilities, as evidenced by the following: normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue Take part in necessary or desired activities including self-care needs

As to endurance, the patient will: y y y Demonstrate a reduction in physiological signs of activity intolerance; e.g. pulse, respirations, and BP remain within patients normal range Report a measurable increase in activity tolerance, specifying activities of daily living and other activities the patient can perform with minimal to no assistance required and evidenced by acceptable level of fatigue/weakness based on the amount and quality of activity performed Report absence of chest pain, shortness of breath, palpitations, fatigue or generalized weakness with usual activity

As to education or teaching: Prescribed Activity/Exercise, patient will: y y y Compare physiologic changes with increasing activity level and performance Express understanding of potential loss of ability in relation to existing condition Identify negative factors and conditions affecting performance and ways to remove or minimize their effects when possible

Verbalize and utilize energy-conservation techniques.

Subjective and Objective y y y y y y y y y y y y y y y

Abnormal heart rate or blood pressure (BP) in response to activity Changes in skin color/moisture Disinterest in surroundings/introspection Generalized weakness, sleeps and rests frequently Lethargic; drowsy; decreased performance Pallor, diaphoresis Report of lack of energy, inability to maintain usual routines Requires partial to full assistance in performing activities of daily living Verbalizes no desire and/or lack of interest in activity Changes in vital signs Electrocardiogram (ECG) changes reflecting ischemia; dysrrhythmias Exertional angina Exertional discomfort or dyspnea Inability to begin or perform activity Verbal report of fatigue or weakness

Related Factors
y y y y y y y y y y y

Cognitive deficits/emotional status, secondary to underlying disease process/depression Presence of ischemia/necrotic myocardial tissues Deconditioned state Depression or lack of motivation Generalized weakness Imbalance between oxygen supply and demand Imposed activity restriction Insufficient sleep or rest periods Pain, vertigo, extreme stress Prolonged bed rest or immobility; progressive disease state/debilitating condition Sedentary lifestyle

Side effects of medications; cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics

Assessment
y

Determine patient's opinion of causes of fatigue or activity intolerance. The cause may be temporary or permanent, physical or psychological. Determination guides treatments and interventions that are specific to patients needs or condition. Assess level of mobility of the patient. Defining what the patient is capable of is necessary before setting realistic goals. It also determines the extent of care or assistance that should be given to the patient to promote independence, enhance functioning and improve endurance.

GORDONS FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL ACTIVITY-EXERCISE PATTERN ASSESSMENT SUBJECTIVE 1. Have patient rate each area of self-care on a scale of 0 to 4.

0 Completely independent 1 requires use of equipment or device 2 requires help from another person for assistance, supervision or teaching 3 requires help from another person and equipment device 4 dependent; does not participate in activity

Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; Ambulation__;

Care of

home__; Shopping__; Meal preparation__; Laundry__; Transportation__

2. Oxygen use at home? No__ Yes__ Describe: ______________________ 3. How many pillows do you use to sleep on?_____ 4. Do you frequently experience fatigue? No__ Yes__ Describe: _________ 5. How many stairs can you climb without experiencing any difficulty (can be individual number or number of flights)? ___________________________ 6. How far can you walk without experiencing any difficulty? _____________ 7. Has assistance at home for self-care and maintenance of home: No__ Yes__ Who? __________ If no, would you like to have or believes needs assistance: No__ Yes__ With what activities? _________________ 8.Occupation (if retired, former occupation): _________________________ 9.Describe you usual leisure time activities/hobbies: ___________________ 10. Any complaints of weakness or lack of energy? No__ Yes__ Describe: 11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe: 12. Any problems with concentration? No__ Yes__ Describe: ______

OBJECTIVE 1.Cardiovascular a. b. Cyanosis: No__ Yes__ Where? _______________________________ Pulses: Easily palpable? Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__ Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__; Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__ c. Extremities: i. ii. iii. iv. v. vi. vii. d. Temperature: Cold__ Cool__ Warm__ Hot__ Capillary refill: Normal__ Delayed__ Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________ Homans sign: No__ Yes__ Nails: Normal__ Abnormal__ Describe: _____________________ Hair distribution: Normal__ Abnormal__ Describe: ____________ Claudication: No__ Yes__ Describe: _______________________

Heart: PMI location: ________

i. ii.

Abnormal rhythm: No__ Yes__ Describe: ___________________ Abnormal sounds: No__ Yes__ Describe: ___________________

2.Respiratory a. b. c. d. e. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__ Have patient cough. Any sputum? No__ Yes__ Describe: ___________ Fremitus: No__ Yes__ Any chest excursion? No__ Yes__ Equal__ Unequal__ Auscultate chest: i. f. i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __

Have patient walk in place for 3 minutes (if permissible): Any shortness of breath after activity? No__ Yes__ ii. iii. iv. v. Any dypnea? No__ Yes__ BP after activity: ___/___ in (right/left) arm Respiratory rate after activity: _______ Pulse rate after activity: _______

3.Musculoskeletal a. b. c. d. Range of motion: Normal__ Limited__ Describe: __________________ Gait: Normal__ Abnormal__ Describe: __________________________ Balance: Normal__ Abnormal__ Describe: ______________________ Muscle mass/strength: Normal__ Increased__ Decreased__ Describe: ________________________________________________ e. Hand grasp: Right:: Normal__ Decreased__ Left: Normal__ Decreased__ f. Toe wiggle: Right: Normal__ Decreased__ Left: Normal__ Decreased__ g. h. i. j. k. Postural: Normal__ Kyphosis__ Lordosis__ Deformities: No__ Yes__ Describe: ____________________________ Missing limbs: No__ Yes__ Where? ____________________________ Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____ Tremors: No__ Yes__ Describe: ______________________________

4.Spinal cord injury: No__ Yes__ Level: ____________________________ 5. Paralysis present: No__ Yes__ Where? ___________________________ 6.Developmental Assessment: Normal__ Abnormal__ Describe: _________

Level 1 Level 2 Level 3 Level 4

FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987) Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally Walk one city block or 500 ft on level; climb one flight slowly without stopping Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping Dyspnea and fatigue at rest

Assess activity pattern and initiate plan to increase physical activity using the Activity pyramid. The activity pyramid is a pictorial representation of the principles of healthy activity and can be used during nurse-client interaction to provide basic information. Assess for possible physical injury with activity. Injury may be a result of falls or overexertion and may cause further decline in the patients tolerance to activity. To promote safety, risks for injury associated with the patient, the environment, and the activity have to be assessed to determine the precautions and considerations that are needed to be taken.

Review nutritional status or the use of food supplements. Adequate reserves of energy are necessary for activity. Food intake and nutritional status can greatly affect the strength of performance and the tolerance against debilitating ailments or conditions that can contribute to conservation of energy. Assess need for ambulation aids, such as bracing, cane, walker, equipment modification, for activities of daily living (ADLs). The use of aids can help disabled clients perform more activities or maximize their level of functioning for the activities. Some aids may necessitate more energy expenditure for patients who have diminished upper arm strength. Sufficient estimation of energy requirements is indicated so that this will coincide with the prescribed level of activities for the client.

AMBULATORY (GAIT) AIDS Purposes 1. To increase area of support 2. To decrease loading & demand on the lower extremities. & skeletal structures 3. To reduce lower limb pain 4. To assist with acceleration & deceleration during ambulation 5. To provide additional sensory information

Indications 1. For need of increase in balance 2. For pain reduction of the lower extremities

3. For decreased weight bearing on the injure/inflamed lower extremity 4. For compensation of weak muscles.

ENERGY USING IN GAIT TRAINING AMBULATION GAIT TRAINING % ENERGY INCREASE (FROM NORMAL AMBULATION) 61 36 18 41 9

Three point (NWB) Three point (PWB) Two point Swing through Wheelchair

Assess patient's cardiopulmonary status before activity using the following measures: 1. Chest pain or dyspnea; too much weakness and fatigue 2. Dizziness or fainting; excessive perspiration 3. Effect of Valsalva maneuver on heart rate. When patient moves in bed, the patient holds breath and bears down. This then causes bradycardia and decreased cardiac output. 4. Heart rate should not rise to more than 20 to 30 beats per minute over resting rate with routine activities. Depending on the intensity of exercise the patient is attempting, this range will change. 5. Oxygen demand with increased activity. Evaluation for oxygen desaturation can be done with the aid of portable pulse oximetry. Compensation for the increased oxygen demands can be aided by supplemental oxygen. 6. Postural hypotension. Geriatric patients are more prone to drops in blood pressure with changes in position.

Monitor sleep pattern of the patient and amount of sleep for the recent days. Amount and quality of sleep should be first determined since sleep contributes to energy reserves and restoration. Sleeping difficulties should be prioritized before activity progression can be achieved. Monitor and document response to activity. Report any of the following: 1. Body malaise, fatigue 2. Dizziness, excessive perspiration, lightheadedness, pallor 3. Increase or decrease of about 20 mm Hg in systolic BP 4. Labored breathing 5. Palpitations 6. Rapid pulse (120 beats per minute during resting rate )

A guide for optimal progression of activity is provided during close monitoring of these responses to activity. This serves as the basis for the improvement of functioning and tolerance in relation to meeting desired goals and patient outcomes.
y

Assess response of the patients emotions with change in physical status and activity performance. Inability to perform required activities can result to depression that could further worsen the activity intolerance. Emotional disturbance and lack of confidence can also affect the desire, interest and motivation in performing prescribed and necessary activities.

Therapeutic Interventions
y Anticipate patient's needs. Enables the health care provider to determine extent of care needed to promote independence, improve functioning, and enhance performance, and increase activity tolerance or endurance. Assist with ADLs as indicated. According to Dorothea Orems Self-care Deficit Theory, individuals can take responsibility for their health. Supporting the patient with ADLs allows for conservation of energy; however, assisting should only be done when it is needed by the patient so as to promote independence and restoration of function. This would avoid overdependence that would delay the patients improvement of functioning and hinder with the self- controlled performance. Avoid performing unnecessary procedures that may hinder patients work effectiveness or delay the performance. Patients with limited tolerance to activity need to prioritize tasks. Any time-consuming procedures can necessitate more energy requirements, cause disinterest and distress and consume the strength necessary in carrying out activities.

Alternate activity with ample rest periods, especially for the following: during ambulation, before meals, exercise sessions and other ADLs. Time for energy conservation and recovery is provided during rest between activities. Increasing quality and quantity of activity should be assessed after every rest periods and resumption of activities to determine level of tolerance improvement. Help out patient to plan activities in times when the patient has the most energy. To conserve energy, the client should plan the amount and extent of activity that he is capable of performing. The client can perform better and more efficiently if he has regained enough energy for the activity. Not all self-care and hygiene activities need to be completed at once. Likewise, not all house chores need to be done in a day. Offer bedside commode as indicated. This reduces expenditure of energy than the client ambulating to reach the comfort room. It must be noted that a bedpan would require more energy than a commode. Set up guidelines and goals of activity with the patient and caregiver. Goal setting involving participation of the patient enhances motivation. It also allows comparison of improvement or progress of treatment. Depending on the cause of the activity intolerance, some patients may be able to live independently and work outside the home, while others remain homebound. Progress activity slowly, as with the following: 1) Active range-of-motion (ROM) exercises in bed, progressing lying to sitting and standing 2) Dangling of feet 10 to 15 minutes three times a day. 3) Deep breathing exercises three times a day 4) Sitting up in chair 30 minutes three times a day 5) Walking in room 1 to 2 minutes three times a day This promotes achievement of short-range goals and avoids overexerting the heart.

Offer emotional support while the patient increases his/her activity. This upholds a positive attitude regarding the patients abilities and motivates him/her for further improvement or enhancement of function and performance.

Educative Interventions
y Encourage expression of feelings with regard to limitations. Expression of limitation prevents the clients tendency to exert or overdo activities just to meet the desired outcomes. Coping is enhanced, when it is acknowledged that living with activity intolerance is both physically and emotionally difficult.

Persuade performing of active ROM exercises three times a day. Exercises sustain muscle strength and joint ROM. The activity should be given frequency and interval that the patient is capable of doing. CLIENT TEACHING: ACTIVE ROM

Exercises

1. Execute each ROM exercise as trained to the point of slight resistance, but not beyond, and by no means to
the point of discomfort. 2. Execute the actions systematically, using the similar sequence during each session. 3. Execute each exercise thrice. 4. Execute each series of exercises twice a day.

Geriatric considerations   For geriatric patients, it is not necessary to attain full ROM in all joints. Emphasize instead on achieving an adequate ROM to carry out activities of daily living, such as the following: walking, dressing, combing hair, showering, and preparing a meal.

Educate patient and caregivers to be familiar with signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician. This promotes awareness of when to decrease or stop present activity. This also sets the boundaries to determine the extent of work that he/she is capable of doing before the appearance of any signs or symptoms of activity intolerance. Also, development of signs and symptoms such as syncope, angina, and dyspnea, point outs the need for changes in the prescribed exercise procedure or administration of needed medication. Educate on the importance of continued activity at home. Continuity of performing the activity aids in the improvement of strength, and enhances endurance and independence of patient at home. Continuation of activity also sustains strength, ROM, and endurance gain. Involve patient together with the caregivers in the setting of goals and planning of care. Setting little, achievable goals can augment self-confidence and self-esteem. The patients independence will further be promoted if he/she is directly involved in his own care. Persuade progressive activity and self-care as tolerated. Offer support as needed. Continuing activity progression avoids a sudden increase in workload of the heart. Increasing activity assesses patients readiness for a higher level of activity as well as his/her own limitations for further activity. Offering support as needed encourages independence in performing activities.

Help out in assigning priority to activities based on importance and resulting productivity, time needed and amount of energy required to perform the activity. Teach energy conservation techniques. Some examples include the following: 1) Changing positions frequently. This distributes work to different muscles to prevent fatigue. 2) Making a work-rest-work schedule 3) Pushing instead of pulling 4) Resting for at least an hour after meals before initiating a new activity. Energy is required to digest food. 5) Sitting to do everyday activities. Standing requires more work. 6) Sliding instead of lifting 7) Storing often used items within easy reach. This avoids bending and reaching. 8) Utilizing wheeled carts for laundry, shopping, and cleaning requirements 9) Working at an even pace. This allows sufficient time so not all work is done in a short period. These allow for longer periods of activity due to reduced oxygen consumption.

Teach appropriate use of environmental aids such as bed rails. These preserve energy and avoid injury from fall. It also enables the client to identify available resources in the environment that the client can readily make use of to minimize energy demands and prolong activity performance duration.

Risk for infection Definition of the Problem Individuals normally have defenses that protect the body from infection. These defenses can be categorized as nonspecific and specific. Nonspecific defenses protect the person against all microorganisms, regardless of prior exposure. Specific (immune) defenses, by contrast, are directed against identifiable bacteria, viruses, fungi, or other infectious agents. Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. An infection happens when there is an invasion of body tissue by microorganisms and when they

grow there. Such microorganism is called an infectious agent. If the microorganism produces no clinical evidence of disease, the infection is called asymptomatic or subclinical. Some subclinical infections can cause considerable damage. A detectable alteration in normal tissue function, however, is called disease. Infections can be transmitted, either by contact or through direct, indirect (vehicleborne or vector-borne), airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Patients who are at risk for infection are as follows: those who have break in the integument; those whose immune system cannot combat the invading organism adequately; those who have open, traumatic or surgical wounds; those who are malnourished, have inadequate resources for sanitary living conditions, lack knowledge about disease transmission; and those who have medical conditions such as AIDS, amputation, anemias, burns, COPD, cancer, asthma, craniocerebral trauma, diabetes mellitus, diabetic ketoacidosis, fractures, hepatitis, leukemias, pancreatitis, peritonitis, pneumonia, pulmonary tuberculosis, undergoing dialysis, sickle cell crisis, post-surgical interventions, total nutritional support (enteral feeding), transplantation, urinary diversions, and ventilatory assistance (mechanical), among the many other medical conditions that impair or alter the immune system. Antimicrobials are used to treat infections when susceptibility is present. Organisms may become resistant to antimicrobials, requiring multiple antimicrobial therapies. There are organisms for which no antimicrobial is effective, such as the human immunodeficiency virus (HIV). Health care workers must understand how to take precautions to prevent transmission, and to protect themselves and others from acquiring the disease. The aims of nursing management are to maintain or restore defenses, avoid the spread of infectious organisms, and reduce or alleviate problems associated with the infection.
Goals and objectives
y y y y y y y

Patient will attain timely healing of wounds or lesions. Patient will exhibit methods, lifestyle changes to uphold safe environment. Patient will keep a safe aseptic environment. Patient will recognize infection promptly to allow for early management. Patient will remain free of infection, as manifested by normal vital signs and nonexistence of purulent drainage from wounds, incisions, and tubes. Patient will take part in behaviors to decrease risk of infection. Patient will verbalize awareness of individual causative or risk factors.

Subjective and Objective

Data to support presence of causative/contributing factors may be included depending on the format of the care plan. Related Factors

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Altered integrity of closed system (CSF leak) Altered nutritional status Antibiotic therapy Chronic disease Depression of the immune system Failure to avoid pathogens (exposure) Failure to recognize/treat infection and/or exercise proper preventive measures Inadequate acquired immunity Inadequate primary defenses: broken skin, injured tissue, body fluid stasis, decreased ciliary action, change in pH secretions, altered peristalsis Inadequate secondary defenses: immunosuppression, leukopenia or decreased granulocytes (suppressed inflammatory response), decreased hemoglobin Indwelling catheters, drains Insufficient knowledge on how to avoid exposure to pathogens Intravenous (IV) devices Intubation Invasive procedures; environmental exposure Malnutrition Rupture of amniotic membranes Skeletal traction Use of antimicrobial and other pharmaceutical agents (corticosteroids, chemotherapeutic agents)

Assessment
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Check for existence, presence of, and history of risk factors for instance open wounds and abrasions; in-dwelling catheters, wound drainage tubes, endotracheal or tracheostomy tubes; venous or arterial access devices; and orthopedic fixator pins. All of these examples represent a break in the bodys normal first line of defense. Assess for classical signs of inflammation and infection. Monitor vital signs every 4 hours, noting minor temperature elevations, which may suggest early sepsis. The presence of these signs signifies infection, requiring additional interventions not only to prevent further progress of, but also to treat existing infection.

CLASSICAL SIGNS OF INFECTION Appearance of urine. Cloudy, foul-smelling urine with visible sediment signifies urinary tract or bladder infection. Character, odor of sputum. Foul smelling, yellow, or greenish secretions implies the existence of pulmonary infection. Elevated temperature Fever of up to 38 C (100.4 F) for 48 hours after surgery is associated to surgical stress; after 48 hours, fever above 37.7 C (99.8 F) signifies infection; fever spikes that take place and subside are manifestations of wound infection; very high fever together with sweating and chills may specify septicemia. Redness, swelling, increased pain, or Any suspicious drainage must be cultured; antibiotic purulent drainage at incisions, therapy is determined by pathogens recognized at injured sites, and exit sites of tubes, culture. drains, or catheters. Shaking chills and profuse diaphoresis. Chills usually go before temperature spikes in incidence of generalized infection.

Assess intactness of amniotic membranes in pregnant patients. Protracted rupture of amniotic membranes, which surrounds the fetus and protects it from external pressure, before delivery places the mother and infant at higher risk for infection by allowing microorganisms to easily enter the amniotic cavity. Check white blood count (WBC). Elevated WBC signifies bodys efforts to fight pathogens (normal value: 4000 to 11,000 mm3). Very low WBC (neutropenia <1000 mm3) suggests severe risk for infection because patient does not have adequate WBCs to fight infection. NOTE: In geriatric patients, infection may be existing without an elevated WBC. Evaluate nutritional status, together with weight, history of weight loss, and serum albumin. Patients with poor nutritional state may be anergic, or not capable to gather a cellular immune response to pathogens and are consequently more prone to infection.

Evaluate patient awareness and aptitude to keep opportunistic infection prophylactic regimen. Manifold medication regimen is not easy to continue over a long period of time. Patients may modify medication regimen based on side effects experienced, adding to insufficient prophylaxis, active disease, and resistance. Examine oral cavity for white plaques (oral thrush). Examine verbalization of vaginal or perineal itching or burning. Depression of immune system and use of antibiotics augments risk of secondary infections, especially yeast. Examine site of invasive devices, checking for signs of local inflammation/infection. Assess also dressings and wound; observe characteristics of drainage. Prompt recognition of developing infection gives chance for timely intervention and avoidance of more serious complications. Review for history of drug use or management modalities that may cause immunosuppression. Note the patients response to determine both effectiveness of therapy and presence of side effects. Antineoplastic agents and corticosteroids decrease immunocompetence. Review immunization status. Geriatric patients and those not raised in the urban areas may not have finished immunizations, and consequently not have adequate acquired immunocompetence.

Therapeutic Interventions
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Confirm sterility of all manufacturers items. Prepackaged items may come into view to be sterile; but, every item have to be examined for manufacturers statement of sterility, breaks in packaging, environmental effect on package, and delivery methods. Package sterilization and expiration dates, lot or serial numbers have to be documented on implant items for additional follow-up if needed. Get wound or drainage cultures and sensitivities as suitable. Determines existence of infection or specific organisms and proper therapy. Give antimicrobial/antibiotic drugs as ordered. Antimicrobial drugs comprise antibacterial, antifungal, antiparasitic, and antiviral agents. Each of these agents are either toxic to the pathogen or retard the pathogens growth. Give meticulous skin, oral, and perianal care. Lowers the risk of skin or tissue breakdown and infection.

Give perineal care. Preserve integrity of closed urinary drainage system if utilized. Lowers possibility for bacterial growth or ascending infection. Grant for infection precautions or isolation as necessary. Lowers the risk of cross-contamination to staff, visitors, and other patients. Help with medical procedures as indicated. Helps conclude causative factors for proper management and enhances recovery. Maintain asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access treatment. Reduces chance for introduction of bacteria. Keep patency of and regularly empty drainage device. Devices such as Hemovac and Jackson-Pratt drains make for possible removal of drainage, enhancing wound healing and decreasing risk of infection. Monitor visitors or staff for signs of infection. Manage visitor adherence to protocol as necessary. Limit visitors to healthy adults. Cluster nursing interventions to limit the number of visits to the clients room. This decreases the amount of organisms in patients surroundings and limits visitation by individuals with any kind of infection to decrease the transmission of pathogens to the patient at risk for infection. It also decreases potential of patient contracting a nosocomial infection. The most frequent modes of transmission are by means of direct contact and by droplet transmission. Offer tissue paper and trash bag in a suitable location for sputum and other secretions. Educate patient in correct handling of secretions. Reduces spread of infection. Put patient in defensive isolation if patient is at very high risk for infection. Protective isolation is instituted if white blood cell counts signify neutropenia (<500 to 1000 mm3). Situate in private room. Forbid use of live plants or cut flowers. Limit fresh fruits and vegetables or make certain they are washed or peeled. Guard patient from possible sources of pathogens or infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy situate patient at higher risk for infection. Stick to facility infection control, sterilization, and aseptic policies/measures. Standard mechanisms designed to avoid infection.

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Uphold sufficient dietary and fluid intake. Helps in liquefying respiratory secretions to make possible the expectoration and avoid stasis of body fluids. Uphold sufficient rest or exercise periods. Prevents fatigue, nevertheless promotes adequate movement to avoid stasis complications, for example, pneumonia, decubitus, and thrombus formation. Utilize gowns, gloves, masks, and strict aseptic technique during direct wound care and offer sterile or freshly laundered bed linens or gowns. Avoids exposure to infectious organisms. Observe standard precaution in dealing with all patients. Following institutional policies and depending on the patients condition, observe special infection precautions such as airborne precautions, reverse isolation precautions, and contact precautions as necessary. Wash hands and educate other caregivers to wash hands prior to contact with patient and between measures with patient. Friction and running water efficiently take away microorganisms from hands. Washing between procedures decreases the risk of transmitting pathogens from one area of the body to another. Utilization of disposable gloves does not lessen necessity for hand washing. It also lowers risk of cross-contamination.

Educative Interventions
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Educate patient or caregiver to wash hands regularly, particularly after toileting, prior to meals, and prior to and after administering self-care. Patients and significant others can spread infection from one part of the body to another; hand washing diminishes this risk. Educate patient to take antibiotics as ordered (dosage and length of therapy). The majority of antibiotics work best when a constant blood level is sustained; a constant blood level is sustained when medications are taken as ordered. Premature discontinuation of treatment may also result in rebound or return of infection. Also, the absorption of some antibiotics is delayed by certain foods; patient must be educated therefore. Persuade fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Fluids promote diluted urine and regular emptying of bladder; decreasing stasis of urine, in turn, lessens risk of bladder infection or urinary tract infection (UTI). Educate on the necessity for sufficient nutritional intake. Persuade increased intake of foods high in protein calorie-rich foods and fluids with ample fiber. Malnutrition can affect over all health and decrease resistance to infection. Protein calorie and

fiber rich-foods improve healing and avoids dehydration. Note: Constipation potentiates stasis of toxins and risk of rectalirritation or tissue injury.
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Encourage to avoid smoking, exposure to crowded places, and unclean environment. Discuss the roles of these on the patients immunocompromised state. Encourages participation by providing appropriate and comprehensive information. Educate patient on significant others on proper food handling and preparation in collaboration with the physician and the nutritionist. Advise to eat a low-bacteria diet, avoiding salads, raw fruits and vegetables, undercooked meat, pepper and paprika. Reduces the risk of gastrointestinal infection from unwanted microorganisms in food. Advise not to share personal toilet articles, such as toothbrushes, toothpastes, washcloths, or deodorant sticks with others. Prevents transfer of microorganisms from one person to another. Advise patient to bathe daily if possible, and to wash the armpits, groin, genitals and anal area at least twice a day with an antimicrobial soap. Maintains hygiene and prevents unwanted growth of microorganisms especially in areas where two skin surfaces touch, moisture is greater, and there is greater chance of skin breakdown and infection. Promote coughing and deep breathing; consider use of incentive spirometer. These measures decrease stasis of secretions in the lungs and bronchial tree. When stasis takes place, pathogens can root upper respiratory infections, together with pneumonia. Promote proper oral hygiene. Advocate the use of soft-bristled toothbrushes to guard mucous membranes. Lessens risk of oral or gum disease. Promote regular position changes and out of bed or ambulation as tolerated. Prevents stasis of body fluids, promotes maximal functioning of organ systems, GI tract. Show and allow return demonstration of all high-risk measures that patient or caregiver will do after discharge, such as dressing changes, peripheral or central IV site care, peritoneal dialysis; self-catheterization. Bladder infection is more associated with over distended bladder resulting from irregular catheterization than with the use of clean versus sterile technique.

Talk about extent and rationale for isolation precautions and continuation of personal hygiene. Upholds cooperation with treatment and may reduce feelings of isolation. Teach patient or Significant Other(s) on methods to avoid spread of infection, keep the integrity of skin, and care for wounds or lesions. Self-care activities that may give protection for patient or others.