.

Nursing Intervention: HF

4. Nursing Intervention:
Promoting activity tolerance / Promoting rest: Physical and mental rest Complete bed rest during acute phase, then encourage gradual activity to increase activity tolerance and induce diuresis. Changing position, deep breathing exercise, use elastic stoking, leg exercises in case of complete bed rest. Avoid long term bed rest to prevent occurrence of complications of immobility. Elevate the head of the bed 20-30 cm or position the patient in armchair. If the patient is orthopneic, position him/or her in orthopneic position. O2 administeration during acute phase to decrease work of breathing.

Reducing fatigue: Alternate periods of activity with periods of rest. Check vital signs before, during and after activity, so heart rate should return to normal within 3 minutes. Avoid two energy consuming activities occur on the same day or same sessions Small frequent meals.

Relieving anxiety:

Avoid situations that provoke anxiety

Speak in slow, calm and confident manner. Give correct information Raise the head of the bed Keep a night light and ensure sleepy

environment Presence of a family member may be helpful

Promoting normal perfusion: Moderate daily exercise Effective diuresis Adequate rest

tissue

Managing fluid volume: In case of severe HF IV diuretics In case less severe HF oral diuretics early in the morning Monitor patients fluid status:
Auscultate the lungs Daily weighing Intake and output Low Na diet Fluid restriction Assess skin breakdown

measures Use elastic pressure stocking and leg exercise to prevent skin injury

and use preventive

Patient education: Obtain adequate rest Take digitalis, diuretic, vasodilator as prescribed. Restrict sodium as directed Review activity program Be alert to the following symptoms: weight gain, loss of appetite, shortness of breath with activity, swelling of ankles and feet, persistent cough and frequent urination at night.

Nursing Interventions: For DM

Improving self-care: Patient teaching is the major strategy used to prepare the patient for self-care. Prevention of infection: Monitor temperature Maintain strict aseptic technique when changing dressings, performing invasive procedures, or manipulating indwelling catheter. Monitor for indicators of infection. Consult health care provider about obtaining culture specimens for blood, sputum, and urine during temperature spikes or for wounds that produce purulent drainage.

Proper insulin administration: Teach patient to check expiration date on insulin vial, the importance of avoiding temperature extremes and proper storage of insulin. Demonstrate the way of mixing insulin. Avoid vigorous shaking. Explain that insulin should be taken 30 minutes before mealtime Provide the patient with a chart that depicts rotation of injection sites. Explain that the injection sites should be at least I inch apart. Explain that the needle should be inserted perpendicular except for thin persons who need 45-degree angle. Ensure that the patient understands and demonstrates the technique correctly. . Maintaining fluid and electrolyte balance: Intake and output are measured. Oral fluid intake is encouraged. Monitor serum Na+ and K+. Monitor vital signs and signs of dehydration (Tachycardia, orthostatic hypotension, dryness of skin & m.m. and diminished skin turgor). IV fluids and electrolytes are administered as prescribed.

Maintain tissue perfusion: Compliance with the therapeutic regimen. Hypertension is common complication of DM, therefore, Check BP regularly, & administer anti-hypertensive agents as prescribed. Avoid crossing the legs and constricting garments on extremities to prevent venous stasis. Reducing anxiety: Provide emotional support. Let patient express his/her feelings. Assist both patient and family to focus on learning self-care behaviors. Positive reinforcement is given for self-care behaviors attempted e.g. Selfinjection, monitoring blood glucose. Improving nutritional intake: Consider patients life style, cultural background, activity level, food likes and dislikes. Appropriate caloric intake to achieve and maintain desired body weight. Encourage the patient to follow prescribed regimen. In case of increase activity arrange with dietitian for extra snakes. Ensure that insulin orders are altered

Maintain skin intact: Assess skin integrity and evaluate reflexes of the lower extremities by checking knee and ankle deep tendon reflexes and sensation, if sensations are impaired anticipate patients inability to respond appropriately to harmful stimuli. Monitor peripheral pulses bilaterally. Use foot cradle on bed to prevent pressure points. Discourage extended rest periods in the same position. Teach the patient the following steps for food care: Wash feet daily with mild soap and warm water; check water temperature with thermometer or elbow. Inspect feet daily with mirror. Use well fitted shoes. Alternate between two pairs of shoes to avoid potential for pressure points that can occur by wearing one pair only. Change socks daily and wear cotton socks. Use gentle moisturizers to soften dry skin, avoiding areas between the toes. Prevent ingrown toenails by cutting toenails straight after softening them during bath. Do not self-treat corns or calluses. Attend to any foot injury immediately, and seek medical attention to avoid any potential complication. Do not go barefoot indoors or outdoors.

Gallbladder Disease

Postoperative Nursing Interventions

After recovery from anesthesia (immediate care): Place patient in low Fowlers position. Start Intravenous fluids as needed, Nasogastric suction (a nasogastric tube was probably inserted immediately before surgery for a nonlaparoscopic procedure) may be instituted to relieve abdominal distention. Water & other fluids are given in about 24 hours, & a soft diet is started when bowel sounds return.

Postoperative Nursing Interventions Relieving Pain

Administer analgesic agents as prescribed to

relieve pain & to promote well-being Help patient turn, cough, breathe deeply, & ambulate as indicated. Instruct patient to use of a pillow or binder over incision to reduce pain during coughing, turning and breathing deeply.

Postoperative Nursing Interventions Improving Respiratory Status

Nurse reminds patients to take deep breaths &

cough every hour to expand lungs fully & prevent atelectasis. Early & consistent use of incentive spirometry also helps improve respiratory function. Early ambulation prevents pulmonary complications as well as other complications, such as thrombophlebitis. Pulmonary complications are more likely to occur in elderly & in obese patients.

Postoperative Nursing Interventions Improving Nutritional Status

Nurse encourages patient to eat a diet low in

fats & high in carbohydrates & proteins immediately after surgery. At time of hospital discharge, there are usually no special dietary instructions other than to maintain a nutritious diet & avoid excessive fats. Fat restriction usually is lifted in 4 to 6 weeks when biliary ducts dilate to accommodate volume of bile once held by gallbladder. After this, when patient eats fat, adequate bile will be released into digestive tract to emulsify fats & allow their digestion.

Postoperative Nursing Interventions Evaluation

Expected Patient Outcomes Reports decrease in pain Demonstrates appropriate respiratory function Exhibits normal skin integrity around biliary

drainage site (if applicable) Obtains relief of dietary intolerance Absence of complications

Hypertension

Nursing Intervention: The objective of nursing care focuses on lowering and controlling the blood pressure without adverse effects and without undue cost. To achieve these goals, the nurse must support and teach the patient to adhere to the treatment regimen by:

Increasing knowledge:
It is important for the patient to understand: disease process lifestyle changes and medications can control hypertension. Emphasize the concept of controlling hypertension rather than curing it through: Taking antihypertensive drug as prescribed. Consult a dietitian to: develop a plan for weight loss, restrict sodium (2.4-6 gm/day) and fat intake, increase intake of fruits and vegetables Implement regular physical exercise.

Explaining

that it will take 2-3 months for the taste buds to adapt to changes in salt intake, may help the patient adjust to reduce salt intake. Advising the patient to avoid alcohol and smoking. Using support group for weight control, smoking cessation and stress reduction. Emphasizing the importance of scheduling regular follow-up. Assisting the patient to practice self-

Patient education for self-care:

Administer anti-hypertensive drug as

prescribed Restrict sodium and fat Control weight Follow an Exercise program Regular follow up Control smoking Self-monitoring of blood pressure.

Evaluation:
Maintains adequate tissue perfusion:

* Maintains BP less than 140\90 mmHg or less than 130\80 mmHg for patients with DM. *Demonstrates no symptoms of angina, palpitations, or vision changes. Complies with the self-care program Has no complications

ANEMIA

Goal :MANAGING FATIGUE Nursing Interventions 1.Assisting the patient to prioritize activities

and to establish a balance between activity and rest 2.Help patient to maintain some physical activity and exercise to prevent the deconditioning

Goal : MAINTAINING ADEQUATE

NUTRITION Nursing Interventions

1.Encourage healthy diet intake 2.Advise the patient to avoid alcohol 3.Dietary teaching sessions 4.Dietary supplements (eg, vitamins B12 ,

iron, folate, protein) as prescribed

Goal : MAINTAINING ADEQUATE

PERFUSION Nursing Interventions

1.Monitor vital signs closely 2.Monitor effect of medications such as

antihypertensive agents

Goal : MONITORING & MANAGING

POTENTIAL COMPLICATIONS Nursing Interventions

1.Assess for signs and symptoms of heart

failure. 2.A serial record of body weights 3.Record dietary intake and Output 4.A neurologic assessment for patients with known or suspected megaloblastic anemia.

Nursing Management of IDA 1.Help the patient select a healthy diet rich in

iron include meats (organ meat as liver) , beans ,leafy green vegetables. 2.Taking iron-rich foods with a source of vitamin C enhances the absorption of iron. 3.Nutritional counseling can be provided for those whose usual diet is inadequate 4.Patients with strict vegetarian diets are counseled that such diets often contain inadequate amounts of absorbable iron

Encourage patients to continue iron therapy

as long as it is prescribed 6.Advise the patient to take the supplement an hour before meals because iron is best absorbed on an empty stomach. 7.If taking iron on an empty stomach causes gastric distress, the patient may need to take the iron supplement with meals 8.Managing IM iron injection.

Managing IM iron injection: 1.The intramuscular injection causes local

pain and stain the skin. 2.These side effects are minimized by using the Z-track technique for administering iron dextran deep into the gluteus maximus muscle . 3.Avoid vigorously rubbing the injection site after the injection. 4.Because of the problems with intramuscular administration, the intravenous route is

SCA

Goal : MANAGING PAIN

Nursing Interventions 1- Rating of pain on a pain scale 2- Administer analgesics 3- Support and elevate any swollen joint until

the swelling diminishes. 4- Physical therapy , breathing exercises,

AND MANAGING INFECTION

Nursing Interventions 1- Monitor the patient for signs and symptoms

of infection. 2- Assess for signs of dehydration 3- Prescribed antibiotics should be initiated promptly 4- Instruct the patient to complete the entire course of antibiotic at home

Nursing Care Plan for SCA Goal

:MINIMIZING DEFICIENT KNOWLEDGE Patient education: 1- Understanding what situations can precipitate a sickle cell crisis 2- The steps he can take to prevent or diminish such crises. 3- Keeping warm and maintaining adequate hydration can be very effective in diminishing the occurrence and severity of attacks. 4- Avoiding stressful situations

The Leukemias

MANAGING INFECTION

Hand hygiene before entering patients room 2.Allow no one with a cold or sore throat to

care for the patient or to enter room, or come in contact with patient at home. 3.Care for neutropenic patients before caring for others 4.Use private room for patient if ANC <1000. 5.Allow no fresh flowers (stagnant water). 6.Ensure room is cleaned daily.

MANAGING INFECTION

Eliminate fresh salads and unpeeled fresh

fruits or vegetables. 8.Maintain proper IV site care: Inspect IV sites every shift; monitor closely for any discomfort; or erythema. 9.Clean skin with antimicrobial solution before venipuncture 10.Administer antimicrobial agents on time.

Goal : PREVENTING OR MANAGING BLEEDING

Avoid aspirin (inhibit platelet function). 2.Do not give intramuscular injections. 3.Do not insert indwelling catheters. 4.Use smallest possible needles when

performing venipuncture. 5. Apply pressure to venipuncture sites for 5 min or until bleeding has stopped. 6. Pad side rails as needed. 7. Prevent falls by ambulating with patient

Goal : PREVENTING OR MANAGING BLEEDING

8- Control Bleeding if occur as: a)Apply direct pressure. b)For epistaxis, position patient in high

Fowlers position; apply ice pack to back of neck and direct pressure to nose. c)Notify physician for prolonged bleeding (eg, unable to stop within 10 min). d)Administer platelets, fresh frozen plasma, packed red blood cells, as prescribed.

Goal: IMPROVING NUTRITIONAL INTAKE Mouth care before and after meals and
2.Administer analgesics before eating can

help increase intake. 3.Antiemetic therapy after chemotherapy . 4.Small, frequent feedings of foods that are soft and moderate in temperature 5.Nutritional supplements & calorie counts 6.Daily body weight 7.Monitor fluid status. 8.Administer parenteral nutrition to maintain adequate nutrition.

Goal : DECREASING PAIN AND DISCOMFORT

Acetaminophen is given to decrease fever,

muscle and joint pain 2.Gentle back and shoulder massage provide comfort. 3.Apply oral hygiene and analgesia for controlling the pain of stomatitis 4.Implement creative strategies that permit uninterrupted sleep for at least a few hours while still administering necessary medications on time.

ELECTROLYTE BALANCE
Measure intake, output and daily weight 2.Assess for signs of dehydration and fluid

overload particularly pulmonary status and the development of dependent edema. 3.Monitor laboratory test results, particularly electrolytes, blood urea nitrogen, creatinine, and hematocrit and compared with previous results. 4.Replacement of electrolytes, particularly potassium and magnesium

CANCER

Nursing Diagnosis: Impaired tissue integrity: alopecia Goal : Maintenance of tissue integrity; coping with hair loss
Prevent or minimize hair loss through the following: a. Use scalp hypothermia b. Cut long hair before treatment. c. Use mild shampoo and conditioner, and avoid excessive

shampooing. d. Avoid electric curlers, curling irons,dryers, clips, and hair dyes e. Avoid excessive combing or brushing; use wide-toothed comb RATIONAL Retains hair as long as possible. a. Decreases hair follicle uptake of Chemotherapy be. Minimizes hair loss due to the weight and manipulation of hair.

Nursing Diagnosis: Impaired oral mucous membrane: stomatitis Goal: Maintenance of intact oral mucous membranes

Assess oral cavity daily. 2. Instruct patient to report

oral burning, pain, areas of redness, open lesions on the lips, pain associated with swallowing, or decreased tolerance to temperature extremes of food. 3. Encourage and assist in oral hygiene

RATIONAL Identification of initial stages of stomatitis will facilitate prompt interventions, including modification of treatment as prescribed by physician

Nursing Diagnosis: Impaired skin integrity as a reactions to therapy Goal: Maintenance of skin integrity
In erythematous areas: 1. Avoid the use of soaps, cosmetics, perfumes, powders,

lotions and ointments,deodorants. 2.Avoid rubbing or scratching the area. 3.Avoid applying hot-water bottles, heating pads, ice, and adhesive tape to thearea. 4.Avoid exposing the area to sunlight or cold weather.

RATIONal Care to the affected areas must focus on preventing further skin irritation, drying,

and damage

Nursing Diagnosis: Risk for infection related to altered immunologic response Goal: Prevention of infection
Assess patient for evidence of . 1infection: a. Check vital signs every 4 hours. b. Monitor WBC count daily. c. Inspect all sites of entry for pathogens (IV sites, wounds, skin

folds, bony prominences ,perineum, and oral cavity).

1. IV lines are sites of entry for pathogens 2. Prompt recognition of infection and subsequent

initiation of therapy will reduce morbidity and mortality associated with infection.

Goal: Prevention of infection

2. Report fever 38.3C (101F), chills
3.Obtain cultures and sensitivities as indicated before initiation of antimicrobial treatment 4. Assess intravenous sites every day for evidence of

infection
5. Change intravenous sites every other day.

Rational
2. Early detection of infection facilitates early intervention. 3. These tests identifynthe most appropriate antimicrobial

therapy. 4. Nosocomial staphylococcal septicemia is closely associated with intravenous catheters. 5. Incidence of infection is increased when catheter is in place >72 hr.

Nursing Diagnosis, Nursing Intervention and Expected outcomes:

1. Pain related to the effect of gastric acid secretion on damaged tissue. Nursing Intervention: Administer drug therapy as prescribed. Aspirin, foods and beverages that contain caffeine, and decaffeinated coffee are avoided. Why? Because they are irritating to gastric mucosa. Instruct the patient to increase water. Why? Because it is considered a good antacid.

Instruct patient to eat slowly and

chew food well. Why? Because the greater the size of the particles, the greater the secretion of HCL. Encourage the patient to eat regularly spaced meals in a relaxed atmosphere. Why? This will help keep food particles in the stomach, which helps to neutralize the acidity of gastric secretions. Advice patient to stop smoking. Why? Smoking increases the possibility of recurrence of ulcer.
Expected outcome:

2. Anxiety related to coping with an acute disease Nursing Intervention: Encourage the patient to express concerns and fears and ask questions as needed. Explain the reason for adhering to a planned treatment schedule. Why? Knowledge can have positive influence on behavior modification and reduces anxiety from unknown. Assist the patient to identify anxiety producing situations.

Encourage

patients family to participate in care and provide emotional support.

Expected outcome: Has less anxiety by avoiding stress.

3. Altered nutrition less than body requirements related to pain associated with eating / changes in diet. Nursing Intervention: Encourage the patient to eat regularly spaced meals in a relaxed atmosphere. Encourage the patient to avoid irritating foods and beverages. Suggest avoidance of snacks at bedtime. Why? Because snacks before bedtime increase acid secretion from stomach. Expected outcome: Maintains weight.

4. Knowledge deficit about prevention of symptoms and management of the condition. Nursing Intervention: Assess patients level of knowledge and readiness to learn. Teach necessary information. Reassure that the disease can be managed. Expected outcome: Complies with therapeutic regimen.:
Avoids irritating foods and beverages. Eats regularly schedule meals. Takes prescribed medication as scheduled.

5. High risk for complications (Hemorrhage). Nursing Intervention: Assess the patient for faintness or dizziness and nausea , which may precede or accompany bleeding. If hematemesis occur, identify quickly the amount of blood loss to replace it immediately. Insert a peripheral IV line for the infusion of saline and ringers solution. Monitor vital signs for tachycardia, tachypnea and hypotension.

Monitor HB and hematocrit. Insert an indewelling catheter and record

urinary output hourly. Insert a nasogastric tube. Why? To distinguish fresh blood from coffee grounds material, to aid in the removal of clots and acid, to prevent nausea and vomiting and to provide a mean of monitoring further bleeding. Monitor PH of gastric secretion hourly through NGT, and administer antacids, if prescribes for a PH less than 4.

Position the patient in recumbent position to

prevent hypotension or side-lying position to prevent aspiration. Treating hypovolemic shock. Test stool for the presence of occult blood. Expected outcome: Avoids complications.