Ulrich & Cz oa

Carotid Endarterectomy, 238

Nursing Diagnosis Care Plans Cerebrovascular Accident, 346
Chemotherapy, 753nee
Activity Intolerance, 25
Airway Clearance, Ineffective, 27 Cholecystectomy,
Obstructive Pulmonary y Disease, 123
Chronicic Obstructi
Anxiety, 29
Cirrhosis, 578 : ernie
Aspiration, Risk for, 31
Blood Glucose Level, Risk for Unstable, 53 Cystectomy With pamela OP)
Breathing Pattern, Ineffective, 33 a eae Biae 2
Cardiac Output, Decreased, 35 labetes ,
Comfort, Readiness for Enhanced, 38 (©) End-of-Life Nursing Care, 845
-of-Li i
P Enteral Nutrition, 500
Confusion, Acute, 38
Constipation, 40 External Radiation Therapy (Teletherapy), Online* (©)
aati
Contamination, 43 Femoropopliteal Bypass, 255 way ;
Coping, Ineffective, 45 ©p) i With Internal Fixation
Fractured Hip t Prosthesi
or Prosthesis
Decision Making, Readiness for Enhanced, 45 (©) Insertion, 685
i
Diarrhea, 45 Gastrectomy, 506 (©P)
Falls 5, 9 Gastrointestinal Bleed, Acute, 519
i Deficient, 47 Heart Failure, 265
TS
Fluid anacre
Volume, Excess, 49 Heart
BakeSurgery: Coronary
Pah Artery Bypass Grafting or Valve
Gas Exchange, Impaired, 51 i Saeeneeeane
Grievi Hepatitis, 601
be
Health Behavior, Risk Prone, 57 Human
yy Immunodeficiency Virus (HIV) Infection and
- De18
Health Care—Associated Infections, Acquired Immune Deficiency Syndrome (AIDS), 412
Hospital-Acquired Pressure Ulcers/Injury, 12 Hypertension, 301
Infection, Risk for, 57 Hyperthyroidism/Thyroidectomy, 465
Mobility, Impaired Physical, 60 Hypothyroidism/Myxedema, 465
Nutrition: Less Than Body Requirements, Imbalanced, 62 Hysterectomy, 713
Oral Mucous Membrane Integrity, Impaired, 64 Implantable Cardiac Devices, 312 _ x
Pain, Acute, 66 Inflammatory Bowel Disease: Ulcerative Colitis and Crohn
Self-Care, Readiness for Enhanced, 68 Disease, 527
Self-Concept, Readiness for Enhanced, 69 (p>) Internal Radiation Therapy (Brachytherapy), 779 (©)
Skin Integrity, Impaired, Risk for, 69 Intestinal Obstruction and Bowel Resection, 544
Sleep Pattern, Disturbed, 72 Laminectomy/Diskectomy With or Without Fusion, 701
Swallowing, Impaired, 74 Mastectomy, 720
Urinary Elimination, Impaired, 76 Mechanical Ventilation, 141
Urinary Retention, 78 Myocardial Infarction, 323
Nephrectomy, 640
(All nursing diagnoses care plans can be found in the Nursing Care of the Elderly Client, 806
Online Care Planner at Pancreatitis, Acute, 613
http://evolve.elsevier.com/Haugen/careplanning/.) Parenteral Nutrition, 566
Parkinson Disease, 398
Peptic Ulcer, 571 (©p)
Pneumonia, 151
Disorder Care Plans I) neumothorax,
> " r
166
™
.
Nursing Care of a Client Having Surgery, 81
Abdominal Trauma, 466 Pulmonary Embolism, 177
Acute Kidney Injury and Chronic Kidney Disease, 649 Radical Prostatectomy, 733
Alzheimer Disease/Dementia, 340 Sepsis, 434
Amputation, 670 Spinal Cord Injury, 375 j
Abdominal Aortic Aneurysm, 217 Splenectomy, 446 (@}>)
Angina Pectoris, 227 Thoracic Surgery, 191
Appendicitis/Appendectomy, 478 (©) Total Joint Arthroplasty (Hip/Knee), 689
Asthma, 116 Transurethral Resection of the Prostate, 742
Bariatric Surgery, 507 Traumatic Brain Injury/Craniotomy, 359
Bowel Diversion: [leostomy, 478 Tuberculosis, 203
Cardiac Dysrhythmias, 237 Urolithiasis (Renal Stones), 631

©P Find these care plans online at

http://evolve.elsevier.com/Haugen/careplanning/
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 - oe

Ulrich & Canale's Sih

elhiteya

NURSING CARE
PLANNING GUIDES
Prioritization, Delegation. and Clinical Reasoning

Nancy Haugen, PhD, RN

Associate Professor and Associate Dean
Prelicensure and Undergraduate Programs
School of Nursing
Samuel Merritt University
Oakland, California

Sandra J. Galura, PhD, RN, CCRP

Assistant Professor
College of Nursing
University of Central Florida
Orlando, Florida
ULRICH AND CANALE’S NURSING CARE PLANNING GUIDES: ISBN: 978-0-323-59542-1
PRIORITIZATION, DELEGATION, AND CLINICAL REASONING,
EIGHTH EDITION

Copyright © 2020, by Elsevier Inc. All rights reserved.

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and Classification 2018-2020, Eleventh Edition © 2017 NANDA International, ISBN 978-1-62623-929-6. Used
by arrangement with the Thieme Group, Stuttgart/New York.

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 To my husband David and my children Jeffery and Sara
Thank you for your love and support. You are my pride and joy!
—Nancy Haugen

To my son Jacob, husband Mike, and all of my past and current students who
continue to challenge me to be the very best at whatever role I assume!
—Sandra J. Galura
 About the Authors

Nancy Haugen, PhD, RN, has more than 35 years of experi- Sandra J. Galura, PhD, RN, CCRP, has more than 30 years
ence in nursing and nursing education. She has clinical experi- of clinical and leadership experience in critical care, post
ence in medical-surgical nursing, obstetrics, critical care, and anesthesia nursing practice, and nursing research. She is cur-
post anesthesia care and nursing research. She has also worked rently an Assistant Professor in the College of Nursing at the
in health care facilities as the Director of Education, Infection University of Central Florida in Orlando, Florida. Dr. Galura’s
Control, and Employee Health. Dr. Haugen’s academic experi- academic experience includes teaching in associate degree,
ence includes teaching in associate degree, generic baccalaure- baccalaureate, and master’s degree nursing programs. Her
ate degree, and accelerated baccalaureate degree programs. Her current areas of teaching include nursing leadership and
areas of teaching include medical-surgical nursing, health management. She received her BSN from Troy University in
assessment, pharmacology, and pathophysiology. Dr. Haugen Troy, Alabama, and her MSN and PhD from the University of
is currently an Associate Professor and Associate Dean, Prelicen- Central Florida in Orlando, Florida. She is active both locally
sure and Undergraduate Programs in the School of Nursing at and nationally in professional organizations including the
Samuel Merritt University, in Oakland, California. She received American Society of PeriAnesthesia Nurses (ASPAN) where she
her ASN and BSN from Southern Adventist University, her has served as a member of multiple committees at the local,
MN from Louisiana State University, and her PhD from the state, and national level. She is a member of Sigma Theta Tau
University of Florida. She is a member of Sigma Theta Tau International, Theta Epsilon chapter.
International, Nu XI chapter.
 Mary Pinto Englert, DNP, NP-C, CNE Rosemary Macy, PhD, RN, CNE, CHSE
Nursing Faculty Associate Professor
College of Health Professions Nursing
Western Governors University Boise State University
Salt Lake City, Utah Boise, Idaho

Michelle L. Finch, PhD, RN, CPN Nancy Noble, MSN, RN, CNE
Assistant Professor Associate Professor
Nursing Nursing
Middle Tennessee State University Marian University
Murfreesboro, Tennessee Fond Du Lac, Wisconsin

Christina D. Keller, MSN, RN, CHSE Charles D. “Chad” Rogers, MSN, APRN, FNP-C
Instructor, Clinical Simulation Center Associate Professor of Nursing
School of Nursing Nursing
Radford University Morehead State University
Radford, Virginia Morehead, Kentucky

Melissa A. Layne, MSN, RN

Capito Department of Nursing
Bert Bradford Department of Health Sciences
University of Charleston
Charleston, West Virginia

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 Preface

Ulrich and Canale’s Nursing Care Planning Guides provide a com- with a strong understanding of how each intervention helps
prehensive guide for the planning of nursing care for adults to achieve a positive, client-centered outcome. Information
with common and chronic medical-surgical conditions. The accompanying each nursing diagnosis in this unit includes:
care plans provided include information that is applicable to NANDA-I-definition, related factors or risk factors, defining
‘clients receiving nursing care in acute care, community, ex- characteristics, desired outcomes, documentation criteria,
tended care, and home care settings. The book includes the and suggested NIC interventions and NOC outcomes. Infor-
most recent NANDA International (NANDA-I)-approved nurs- mation provided in this chapter can facilitate the planning
ing diagnoses, Nursing Outcomes Classification (NOC), and of care for a client with a medical-surgical condition not
Nursing Interventions Classification (NIC) labels. addressed in this text.
Each of the care plans in the book provide a description of Chapter 4 focuses on care of the client having surgery.
the medical condition or surgery and identifies the relevant The chapter includes standardized care plans on procedural
nursing diagnoses and collaborative diagnoses. For each diag- sedation and preoperative and postoperative nursing care.
nosis there is a specific etiology statement, a desired outcome, Chapters 5 through 15 include care plans that provide
NIC and NOC, and a comprehensive list of nursing actions. information regarding conditions and/or treatment modali-
This edition provides comprehensive etiology statements, com- ties. These chapters are divided according to body systems.
prehensive coverage of potential complications (collaborative Care plans within each chapter deal with conditions often
diagnoses), and thorough client teaching. The content repre- seen in health care settings. The care plans in Chapter 15
sents standards of nursing care and can be used as a guide for cover treatment modalities for specific neoplastic disorders.
students and practitioners in planning individualized client- Chapter 16 focuses on care of the elderly client. It in-
centered care. cludes the nursing diagnoses that reflect the biopsychosocial
Chapter 1 discusses prioritization, management, and changes that commonly occur with the aging process and can
delegation of nursing care. It can be used as a guide on how be intensified with the stress of illness. The information is
to prioritize, manage, and delegate nursing care and how to applicable to care of the elderly in all health care settings and
modify and individualize nursing care plans. Included in the can be used independently or in combination with care plans
chapter is a step-by-step approach to delegating nursing ac- appropriate to the client’s concurrent medical condition(s)
tions to both patient care assistants and licensed practical or and/or surgical situation.
vocational nurses. Guidelines are provided for modifying and Chapter 17 focuses on care at the end of life. The infor-
individualizing nursing care using a case-study approach to mation applies clients in acute and community care settings.
demonstrate the components of the nursing process used to Nursing diagnoses included in the care plans are those com-
provide individualized client-centered care. mon to all persons facing death and should be used in con-
Chapter 2 focuses on nurse-sensitive indicators that reflect junction with care plans pertinent to the client’s specific
the structure (supply and skill level of nursing staff), processes medical diagnoses.
(assessment, intervention), and outcomes (patient outcomes) of Each of the standardized care plans in this book can be
nursing care. Nurse-sensitive indicators provide a reliable means used to plan care for a client with a medical condition not
to support and evaluate nursing care quality in the hospital set- covered in this text. The content in each care plan is organized
ting. Hospitals use data provided by measures of nurse-sensitive in a traditional nursing care plan format that can readily be
indicators to evaluate, improve, and demonstrate nursing care adapted to other plan-of-care formats used by health care pro-
quality. Improving nursing care quality improves patient out- viders (e.g., critical pathways, clinical practice guidelines,
comes while reducing costs associated with patient care. The nursing protocols). Each care plan is organized as follows:
nurse-sensitive indicators examined in this chapter include falls,
hospital-acquired pressure ulcers (HAPU), and hospital acquired
conditions (HACs) including catheter-associated urinary tract INTRODUCTION
infections (CAUTI), central-line associated bloodstream infec-
tions (CLABSI), and ventilator acquired pneumonia (VAP). The reader is provided with an overview of the condition in-
Chapter 3 presents frequently used nursing diagnoses. cluding a basic definition and pathophysiological mecha-
Importantly, this unit includes the rationale for nursing nisms involved and/or a description of the surgical procedure
actions that provides the nursing student and practitioner and/or selected treatment modality. This overview is not a

1x
xX Preface

substitute for the information provided in medical-surgical

nursing texts or other references, but rather provides a quick DESIRED OUTCOMES
review or a beginning point for additional research.
The desired outcomes for all diagnoses include evaluation
criteria to evaluate effectiveness of care provided. The
OUTCOME/DISCHARGE CRITERIA student and practitioner should modify goals and specific
outcome criteria as needed to reflect what is realistic to
When client care is provided, the nurse should focus on the maintain client-centered care. Target dates for the desired
outcomes required to support return to optimal health. This outcomes are not included as these are determined in
section includes outcome criteria that serve as a guide for collaboration with the patient and based on the client’s
determining the client’s readiness for discharge from the spe- current status.
cific health care setting. Recognizing that client education is
a vital aspect of health care, the authors use client outcomes
as the basis for detailed teaching included at the end of each SUGGESTED NIC AND NOC LABELS
care plan.
Suggested Nursing Interventions Classification (NIC) and the
Nursing Outcomes Classification (NOC) are listed for the
NURSING AND COLLABORATIVE nursing diagnoses in each care plan. These classification
DIAGNOSES systems are included to demonstrate how they are linked
to nursing diagnoses and to increase awareness and use of
The nursing and collaborative diagnoses for each plan of care standardized outcome criteria and for determining nursing
describe actual or potential health problems a client with a interventions in the care planning process.
particular condition may experience. Nursing diagnoses were
selected from those approved by NANDA-I through 2020 and
are indicated with the NDx symbol. Nursing diagnoses that NURSING ASSESSMENT, NURSING
are not unique to a particular condition but may be relevant ACTIONS, AND SELECTED PURPOSES/
for a client (e.g., spiritual distress) have not consistently been RATIONALES
included but should be considered when individualizing each
care plan. Collaborative diagnoses have been included to in- These columns contain nursing actions/interventions that
corporate potential client alterations for which there are no can assist the client to achieve desired outcomes. The actions
established nursing diagnostic labels. Pathophysiological and include detailed assessments based on clinical manifestations
psychosocial factors are provided for the majority of nursing associated with each diagnostic label as identified in the lit-
and collaborative diagnoses. As with other portions of the erature and/or as defined by NANDA-I. These assessments can
standardized care plans, these etiologies are to be individual- be used to determine if the nursing or collaborative diagnosis
ized for each client. In most instances, the authors did not is an actual problem or if the client is at risk for developing it.
include etiologies for the nursing diagnosis labels that deal The nursing interventions are specific and realistic yet broad
directly with client teaching (i.e., deficient knowledge, inef- enough to allow for regional and multidisciplinary variations
fective health maintenance, ineffective health management) in standards of care. Rationales have been included to clarify
because of the numerous individual variables that may affect actions that may not be fundamental nursing knowledge.
a Client’s ability to learn, maintain health, and manage his/
her treatment regimen.
In order to provide consistency in the care plans, the CLIENT TEACHING/CONTINUED CARE
nursing and collaborative diagnoses statements have usu-
ally been listed in the same order. Within each care plan, an Although client teaching is included throughout the care plans,
effort has been made to prioritize the diagnoses; however, the majority of the teaching is found in the actions for the nurs-
individual patient circumstances may necessitate reprioriti- ing diagnoses of deficient knowledge, ineffective health mainte-
zation. Priorities will need to be established by the student nance, ineffective health management, and/or ineffective family
and practitioner based on the individual client’s current health management. Included client teaching uses terminology
needs. that most clients can understand. :

CLINICAL MANIFESTATIONS ONLINE RESOURCES

The clinical manifestations for the nursing and collaborative The eighth edition’s companion @volve website provides even
diagnosis provide assessment criteria for the client. Clinical more planning and study resources. The Online Care Planner
manifestations are differentiated between subjective and offers access to all of the nursing diagnoses care plans printed
objective manifestations and supporting data is provided in the edition in electronic format, allowing users to build care
for selection and prioritization of the appropriate nursing plans for specific conditions by selecting and customizing
diagnosis. nursing diagnoses. All care plans can then be saved to another
 Preface xi

location and printed. Additional in-depth care plans are pro- The authors hope that the eighth edition of this book
vided on the @volve website. A comprehensive list of all care will assist with the integration of the numerous aspects of
plans, both print and electronic, is located inside the front client-centered care, facilitate critical thinking and imple-
cover of this book. In addition, the companion website now mentation of the nursing process, and provide both the stu-
also features more than 100 narrated, 3-D, pathophysiology- dent and the practitioner with a guide for planning and im-
based animations that correspond to disorders content in plementing high-quality client care.
the text.
The value of a systematic approach to individualized client-
centered care is measured by its effect on the quality of care ACKNOWLEDGMENTS
provided to the client. While overall care of a client is coordi-
nated, and planned by registered nurses, many interventions are The authors of the eighth edition of Ulrich & Canale’s
delegated to licensed and unlicensed members of the health care Nursing Care Planning Guides would like to acknowledge
delivery team. Within each care plan, actions that can be dele- the work by reviewers of this text. Updating and revising
gated to licensed practical nurse/licensed vocational nurse (LPN/ a book of this scope is no small undertaking; however, it
LVN) or nursing assistive personnel are indicated with a(*) at the cannot be done without external feedback. We would also
bottom of each page. Although actions may be indicated as del- like to acknowledge all the nurses who continue to develop
egatable, students and practitioners should consult their indi- and revise, the NANDA-I diagnoses. Their work provides
vidual state’s Nurse Practice Act as well as organizational policies all nurses with tools by which they can improve client-
-when deciding whether to delegate nursing interventions. centered care.
 Contents

Acute Pain, 66
1 Prioritization, Delegation, and Critical
Readiness for Enhanced Self-Care, 68
ing
Thinkin Client Management, 1 Readiness for Ehnanced Self-Concept, 69*
Prioritization, 1
Risk for Impaired Skin Integrity, 69
Disturbed Sleep Pattern, 72
Delegation, 1
Critical Thinking, 3 Impaired Swallowing, 74
Creating an Individualized, Prioritized Plan of Impaired Urinary Elimination, 76
Care, 4 Urinary Retention, 78

2 Nurse-Sensitive Indicators, 9 Nursing Care of the Client Having

Surgery, 1
Falls, 10
Hospital Acquired Pressure Ulcers, 13 Procedural Sedation, 81
Health Care Associated Infections, 19 Preoperative Care, 87
Postoperative Care, 91
3 Selected Nursing Diagnoses,
Interventions, Rationales, and The Client With Alterations in
Documentation, 25 Respiratory Function, 116

Activity Intolerance, 25 Asthma, 116

Ineffective Airway Clearance, 27 Chronic Obstructive Pulmonary Disease, 123
Anxiety, 29 Mechanical Ventilation, 141
Risk for Aspiration, 31 Pneumonia, 151
Ineffective Breathing Pattern, 33 Pneumothorax, 166
Decreased Cardiac Output, 35 Pulmonary Embolism, 177
Readiness for Enhanced Comfort, 38* Thoracic Surgery, 191
Acute Confusion, 38 Tuberculosis, 203
Constipation, 40
Contamination, 43 The Client With Alterations in
Ineffective Coping, 45* Cardiovascular Function, 217
Readiness for Enhanced Decision-Making, 45*
Diarrhea, 45 Abdominal Aortic Aneurysm, 217
Deficient Fluid Volume, 47 Angina Pectoris, 227
Excess Fluid Volume, 49 Carotid Endarterectomy, 238
Impaired Gas Exchange, 51 Deep Vein Thrombosis, 246 '
Risk for Unstable Blood Glucose Level, 53 Femoropopliteal Bypass, 255
Grieving, 55 Heart Failure, 265
Risk-Prone Health Behavior, 57* Heart Surgery: Coronary Artery Bypass Grafting
Risk for Infection, 57 or Valve Replacement, 282
Impaired Physical Mobility, 60 Hypertension, 301
Imbalanced Nutrition: Less than Body Implantable Cardiac Devices, 312
Requirements, 62 Myocardial Infarction, 323
Impaired Oral Mucous Membrane Integrity, 64

*For a full, detailed care plan on this topic, go to http://evolve/

elsevier.com/Haugen/careplanning/
 Contents Xili

‘The Client With Alterations in

Neurological Function, 340 1 The Client With Alterations in
Musculoskeletal Function, 670

Alzheimer’s Disease/Dementia, 340 Amputation, 670

Cerebrovascular Accident, 346 Fracture (Hip) With Internal Fixation or Prosthesis
Traumatic Brain Injury/Craniotomy, 359 Insertion, 685
Spinal Cord Injury, 375 Total Joint Replacement/Arthroscopy—
Parkinson Disease, 398 (Hip/Knee), 689
Laminectomy/Discectomy With or Without
The Client With Alterations in Fusion, 701
Hematologic and Immune Function, 412

Human Immunodeficiency Virus Infection

and Acquired Immune Deficiency Syndrome, 412
14 The Client With Alterations in the Breast
and Reproductive System, 713
Sepsis, 434 Hysterectomy, 713
Splenectomy, 446* Mastectomy, 720
Radical Prostatectomy, 733
The Client With Alterations in Transurethral Resection of the Prostate, 742
Metabolic Function, 447

Diabetes Mellitus, 447

Hyperthyroidism/Thyroidectomy, e1
15 The Client Receiving Treatment for
Neoplastic Disorders, 753
Hypothyroidism/Myxedema, e16 Chemotherapy, 753
External Radiation Therapy (Teletherapy), e1

10 The Client With Alterations in the Internal radiation therapy (Brachytherapy), e1

Gastrointestinal Tract, 466

Abdominal Trauma, 466

Appendicitis/Appendectomy, 478*
16 Nursing Care of the Elderly Client, 806

Bowel Diversion: Ileostomy, 478

Enteral Nutrition, 500
Gastrectomy, 506*
Bariatric Surgery, 507
17 End-of-Life Nursing Care, 845

Gastrointestinal Bleed, Acute, 519

Inflammatory Bowel Disease: Ulcerative Colitis and Bibliography, 861
Crohn Disease, 527
Intestinal Obstruction and Bowel Resection, 544
Index, 871
Parenteral Nutrition, 566
Peptic Ulcer, 571*

11 Nursing Care of the Client With

Disturbances of the Liver, Biliary Tract,
and Pancreas, 572

Cholecystectomy, 572
Cirrhosis, 578
Hepatitis, 601
Pancreatitis, Acute, 613

12 The Client With Alterations in the

Kidney and Urinary Tract, 631

Urolithiasis (Renal Stones), 631

Cystectomy With Urinary Diversion, 639*
Nephrectomy, 640*
Acute Kidney Injury and Chronic Kidney
Disease, 649*
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 CHAPTER

| Prioritization, Delegation, and

Critical Thinking in Client
Management

he management and provision of nursing care is an excit- be considered a high priority as long as the client’s physiologic
ing, challenging, and rewarding experience. Nurses prac- needs have been stabilized.
tice in a variety of care settings as critical members of an
interdisciplinary health care team. The delivery of nursing
care is accomplished with registered nurses (RNs), licensed DELEGATION
vocational nurses (LVNs)/licensed practical nurses (LPNs),
and unlicensed assistive personnel. The RN is responsible for Both the National Council of State Boards of Nursing (NCSBN)
management of client care and includes clinical decision and the American Nurses Association (ANA) define delegation
making and proper delegation of client care to other mem- as “the process for a nurse to direct another person to perform
bers of the care delivery team. While each member of the nursing tasks and activities” (ANA and NCSBN, 2017, p. 1).
team plays an important role in the care of the client, it is the Nurses responsible for delegation must be aware of many vari-
RN’s responsibility to determine which nursing interventions ables aside from the client’s condition. To safely and appropri-
are to be safely assigned and/or delegated to specific team ately delegate nursing care, the nurse must have an understand-
members. ing of the appropriate state’s Nurse Practice Act, which identifies
which tasks may be delegated, when the tasks may be dele-
gated, and to whom the tasks may be delegated.
PRIORITIZATION The first step in the delegation process is assessment of
the client. In addition, to delegate safely, the nurse must as-
The nurse is responsible for prioritizing and individualizing a sess the qualifications of each member of the health care
client’s plan of care. Prioritization is defined as “ deciding delivery team. Once the nurse determines the client’s condi-
which needs or problems require immediate action and tion and the tasks to be delegated, he or she then identifies
which ones could tolerate a delay in response until a later time the team member to whom the task will be delegated based
because they are not urgent”. (L Silvestri and A Silvestri, 2017, on an understanding of the member’s qualifications and
p- 67). The RN must use all steps in the nursing process and skills. Once the tasks to be delegated have been determined,
collaborate with the client to individualize care. Interven- the nurse must communicate the actions to the team mem-
tions should be client-centered and prioritized to achieve ber, including what to do, when to do it, and to whom it
optimum client outcomes. However, planning care that is should be done. These individuals should also be informed
prioritized, client-centered, and comprehensive can be chal- of the circumstances under which they should ask for assis-
lenging owing to lack of time and adequate resources. tance. Clear communication in the transfer of information is
Alfaro-LeFevre (2017, p. 170) provides steps for setting critical, so that each person has a complete understanding of
nursing priorities. All priority setting should be determined the delegated task as well as of the conditions that require
through the lens of maintaining patient and care giver safety. the assistance of an RN. The Five Rights of Delegation (ANA
The first level priority setting is to maintain airway, breathing, and NCSBN, 2017) summarize the process and include the
and circulation. Additional priority setting includes identifi- following:
cation and treatment of abnormal vital signs and _ life- . The right task
threatening lab values. Second level client priorities include . Under the right circumstance
issues related to mental health changes, untreated medical . To the right person
problems, pain, and urinary elimination problems. Lastly, the . With the right directions and communication
nurse should address any health challenges that do not fall nN
Fe. Under the right supervision and evaluation
®wWN

into the other categories. Although the RN is responsible for the safe delegation of
An additional level of priority setting includes Maslow’s nursing tasks to the appropriate team members, responsibility
hierarchy of needs, which spans the continuum from the most and accountability for the safe completion of interventions
crucial needs necessary for survival to self-actualization. Physi- are not delegated and remain the ultimate responsibility of
ologic needs necessary for the continued function of the hu- the RN. The nurse must monitor the implementation of the
man body often require the greatest attention when client care task and determine whether the task was completed appropri-
is being prioritized. However, attention to safety needs, such as ately and in a timely manner. After the completion of dele-
the prevention of accidents and adverse client outcomes, must gated tasks, the nurse must evaluate both the delegation

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation 1
ce SEU age
2 Chapter1 * Prioritization, Delegation, and Critical Thinking in Client Management

process and the client outcomes. Questions that should be Was the communication between the nurse and the team
answered in evaluating this process include the following: member appropriate to accomplish the required inter-
Was the task delegated to the appropriate individual? vention?
Did that individual perform the task correctly and in a timely What if anything did not go as planned, and what could have
manner? prevented this from occurring?
Was the expected client outcome achieved? The algorithm in Fig. 1.1 may serve to assist the nurse in
Was the client satisfied with the care received? the delegation process.

Decision Tree for Delegation to Nursing Assistive Personnel

Step One — Assessment and Planning

If not in the licensed nurse’s scope of
practice, then cannot delegate to the
nursing assistive personnel (NAP).
Are there laws and rules in place that Authority to delegate varies, so
support the delegation? licensed nurses must check the
jurisdiction’s statutes and regulations.

Is the task within the scope of the

>| Do not delegate.
delegating nurse?

Has there been assessment of the Assess client needs, and then proceed
client needs? to a consideration of delegation.

Do not delegate until can provide and

Is the delegating nurse competent to document additional education, then
make delegation decisions? reconsider delegation; otherwise do not
delegate.

Is the task consistent with the recommended criteria

for delegation to nursing assistive personnel (NAP)?
Must meet all the following criteria:
8 /s within the NAP range of functions
= Frequently recurs in the daily care of a client or
| NO > Do not delegate.
group of clients
= /s performed according to an established
sequence of steps
= /nvolves little or no modification from one
client-care situation to another
= May be performed with a predictable outcome
® Does not inherently involve ongoing assessment,
interpretation, or decision-making, which cannot
be logically separated from the procedure(s) itself
=" Does not endanger a client's life or well-being
wees
WES

Does the NAP have the appropriate knowledge,

Do not delegate until evidence of education
skills, and abilities (KSA) to accept the delegation?
and validation of competency available,
NO ;
then reconsider delegation; otherwise
Does the ability of the NAP match the case needs
of the client? do not delegate.

| WES

Are there agency policies, procedures, and/or Do not proceed without evaluation of need
protocols in place for this task/activity? for policy, procedures, and/or protocol i
determination that it is in the best interest
YES of the client to proceed to delegation.

Is appropriate supervision available? }

AO] > Do not delegate.

[ve
Proceed with delegation. |

Figure 1-1 National Council of State Boards of Nursing Decision Tree for Delegation to Nursing Assistive Personnel. From the
American Nurses Association and the National Council of State Boards of Nursing: Joint statement on delegation [2005]. https://
www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/joint-statement-on-delegation-by-ANA-
and-NCSBN/. Accessed March 16, 2017.
 Chapter 1 = Prioritization, Delegation, and Critical Thinking in Client Management 3

Step Two — Communication

Communication must be a two-way process.
The nurse: The NAP: Documentation:
= Assesses the assistant’s understanding = Asks questions regarding the Timely, complete, and
© How the task is to be accomplished delegation and seeks clarification of accurate documentation of
© When and what information is to be reported, expectations if needed provided care:
including: # Informs the nurse if the assistant has = Facilitates communication
Y Expected observations to report and record not done a task/function/activity before, with other members of the
Y Specific client concerns that would require or has only done infrequently health care team
prompt reporting a Asks for additional training or supervision = Records the nursing care
= Individualizes for the NAP and client situation a Affirms understanding of expectations provided
» Addresses any unique client requirements and = Determines the communication method
characteristics, and clear expectations of: between the nurse and the NAP
© Assesses the assistant’s understanding of = Determines the communication and plan of
expectations, providing clarification if needed action in emergency situations
© Communicates his or her willingness and
availability to guide and support assistant
o Assures appropriate accountability by
verifying that the receiving person accepts
the delegation and accompanying responsibility

Step Three — Surveillance and Supervision

The purpose of surveillance and monitoring is related to nurse’s responsibility for client care within the context of a client population. The
nurse supervises the delegation by monitoring the performance of the task or function and assures compliance with standards of practice,
policies, and procedures. Frequency, level, and nature of monitoring vary with needs of client and experience of assistant.

The nurse considers the: The nurse determines: The nurse is responsible for:
= Client’s health care status = The frequency of onsite = Timely intervening and follow-up on problems and
and stability of condition supervision and assessment concerns. Examples of the need for intervening include:
= Predictability of responses based on: oO Alertness to subtle signs and symptoms (which allows
and risks © Needs of the client nurse and assistant to be proactive before a client's
= Setting where care occurs © Complexity of the delegated condition deteriorates significantly)
= Availability of resources function/task/activity o Awareness of assistant’s difficulties in completing
and support infrastructure © Proximity of nurse’s location delegated activities
= Complexity of the task © Providing adequate follow-up to problems and/or
being performed changing situations is critical aspect of delegation

Step Four — Evaluation and Feedback

Evaluation is often the forgotten step in delegation.
In considering the effectiveness of delegation, the nurse addresses the following question:
a Was the delegation successful?
© Was the task/function/activity performed correctly?
© Was the client’s desired and/or expected outcome achieved?
© Was the outcome optimal, satisfactory, or unsatisfactory?
© Was communication timely and effective?
© What went well? What was challenging?
o Were there any problems or concerns? If so, how were they addressed?
= Is there a better way to meet the client need?
= Is there a need to adjust the overall plan of care, or should this approach be continued?
= Were there any “learning moment’ for the assistant and/or the nurse?
= Was appropriate feedback provided to the assistant regarding the performance of the delegation?
|
|:Was the assistant acknowledged for accomplishing the task/activity/function?

Figure 1-1, cont'd

CRITICAL THINKING physiologic needs. Critical thinking is composed of attitudes,

knowledge, and skills.
To deliver client-centered, prioritized, individualized, and The attitude of inquiry enables the professional nurse to
safe nursing care, the professional nurse must be able to think recognize the existence of a client problem and to seek out
critically by analyzing information. This information is ob- both assessment and collaborative data that describe the en-
tained from multiple sources to determine the best plan of countered problem. Knowledge enables the professional
action that will safely and effectively meet the client’s basic nurse to weigh the accuracy of different kinds of evidence as

D = Delegatable Action @ = UAP + =LVN/LPN ©) = Go to ©volve for animation

NDx = NANDA Diagnosis
4+ Chapter 1 = Prioritization, Delegation, and Critical Thinking in Client Management

the client’s plan of care is altered to address prioritized prob- 10. Communicate delegable actions to the appropriately
lems. Finally, skill enables the professional nurse to apply qualified individual.
both inquiry and knowledge in the delivery of safe client- 11. Evaluate the delegation process, the quality of the dele-
centered care. gated task, and client outcomes.
The nursing process (assess, diagnose, plan, implement, The following situation serves to illustrate how these stan-
evaluate) provides a framework by which the professional dardized nursing care plans can be used by the student and
nurse can connect clinical events and data obtained from a the practitioner in planning individualized client care.
variety of sources with the appropriate interventions to safely Mary G. is a 30-year-old woman hospitalized following
manage and evaluate client care. a spinal cord injury suffered in a motor vehicle colli-
This book is intended to facilitate the care planning pro- sion (MVC). She has been bedridden for the past
cess with adults with common and recurring medical-surgical 3 weeks due to a thoracic spine injury at the T-10 level.
conditions. Within each care plan specific interventions are It resulted in paraplegia. The client has improving up-
identified that may be delegated to members of the nursing per body strength, movement of the upper extremities,
care team. Within each care plan are nursing and collabora- and diminished respiratory capacity and endurance.
tive diagnoses with etiologic factors, desired outcomes with She has two children between the ages of 3 and
measurable behavioral criteria, and independent and depen- 6 years. Both Mary and her husband have been trying
dent nursing actions and delegable actions with selected to prepare the children for Mary’s physical disability.
purposes or rationales. Safe, comprehensive care can be They have no other family members living nearby.
planned in a minimal amount of time using this book. 1. Read the nurse’s admission assessment/history infor-
mation and the medication administration record of
the assigned client.
CREATING AN INDIVIDUALIZED, PRIORITIZED
It is determined that Mary is a 30-year-old married
PLAN OF CARE woman. Her religious preference is Protestant. Her diagno-
To be most effective, the standardized nursing care plan must sis is spinal cord transection at T-10. She is receiving
be adapted in collaboration with the client to meet his or her morphine sulfate, 15 mg every 8 hrs (q 8 h); Dialose,
individual needs. A process for planning individualized, pri- 100 mg/day; and milk of magnesia, 30 mL orally (PO)
oritized client care follows: every evening.
1. Read the nurse’s admission assessment/history informa- 2. Review the history, current diagnostic test results,
tion and the medication administration record of the as- nurses’ notes for the last 48 hrs, progress notes of
signed client. health care providers (e.g., physician, dietitian, physi-
2. Review the history, current lab, and diagnostic test results; cal and occupational therapists, pain management
nurses’ notes for the last 48 hrs; progress notes of health specialist, social worker, discharge planner), and con-
care providers (e.g., physician, dietitian, physical and oc- sultation reports.
cupational therapists, pain management specialist, social From the history it is determined that Mary had an
worker, discharge planner), and current consultation MVC 3 weeks ago. She is experiencing back pain related to
reports. nerve root irritation at the site of her spinal cord injury.
3. Interview the client and complete an assessment using the She has been bedridden since the time of her accident. The
tool provided by your nursing school or health care facil- physician’s progress notes indicate that Mary’s paraplegia
ity. Discuss with clients what they would like to be the is permanent, and the goal of care is to optimize her cur-
focused outcome of their care. rent physiologic state and keep her comfortable.
4. Read about the client’s medical diagnosis and appropriate Diagnostic test results reveal that Mary’s red blood cell
nursing Care in a current medical-surgical nursing text. (RBC) count, hemoglobin (Hgb), hematocrit (Hct), and
5. Select the appropriate standardized care plan or plans from serum protein levels are decreased.
this text and read the introductory information at the be- The nurses’ notes reveal that Mary needs assistance
ginning of each care plan. with all activities. She is able to feed herself but is consum-
6. Select the nursing and collaborative diagnoses that are ap- ing only 10% of her meals. She had a bowel movement
propriate for your client and supported by assessment this morning following digital stimulation. Mary has an
findings; choose the etiologic factors that are relevant and indwelling urinary catheter, and her intake and output are
modify them as appropriate. balanced. She has been crying frequently and states that
7. Modify the collaboratively identified and desired out- neither she nor her husband are coping well with her dis-
comes so that they are measurable and realistic for your ability.
client; establish appropriate target dates. 3. Interview the client and complete an assessment using
8. Select and prioritize the nursing actions that are relevant the tool provided by your nursing school or health care
to the client’s immediate care needs; add to or modify the facility.
actions required to meet these needs; include specific The interview and physical assessment reveal that Mary
medications and treatments as well as client preferences has persistent reddened areas on her left hip and coccyx;
and other actions that will facilitate achievement of the diminished breath sounds in both lung bases, shallow
desired client outcomes. respirations of 24 breaths per minute; crackles (rales) in
9. Determine whether the client is stable and to which team both lungs; and a cough that is productive of yellow, foul-
member nursing interventions may be delegated. smelling sputum. She has normal bowel sounds and states
 Chapter1 = Prioritization, Delegation, and Critical Thinking in Client Management 5

that she usually has a bowel movement every other day Examples of some of the nursing diagnoses within this care
following digital stimulation. Mary is alert, oriented, and able plan are as follows (the etiologic factors have been modi-
to move her upper extremities. She has no movement in her fied to reflect Mary’s situation):
lower extremities but is able to transfer herself with assistance a. Ineffective Breathing Pattern NDx related to
to a wheelchair. She complains of pain in her back. 1. The depressant effect of narcotic (opioid) analgesics
4. Read about the client’s diagnosis and nursing care in a loss of abdominal and intercostal muscle function
current medical-surgical nursing text. (innervation of these muscles at the thoracic level)
Review Spinal Cord Injury and Impaired Physical b. Ineffective Airway Clearance NDx related to:
Mobility. NDx 1. Decreased mobility, decreased effectiveness of cough
5. Select the appropriate standardized care plan or plans resulting from diminished lung/chest wall expan-
from this text and read the introductory information at sion, depressant effect of narcotic (opioid) analgesics
the beginning of the care plans. c. Acute/Chronic Pain NDx: back-, rib-, and _ pelvic-
The physician has sstated that Mary’s primary treat- related nerve root irritation at the site of spinal cord
ment plan is focused on optimizing her current physical injury metastases
condition and controlling her pain, and Mary agrees with d. Ineffective Coping NDx related to ongoing grieving
that plan. The appropriate care plans for Mary are Spinal associated with spinal cord injury and its effect on body
Cord Injury and Impaired Physical Mobility. function
6. Select and prioritize the nursing and collaborative di- 7. Determine which nursing interventions may be dele-
agnoses that are appropriate for your client. Choose the gated to the appropriately qualified individual within
etiologic factors that are relevant and modify them as the nursing care team.
appropriate. The process for individualization of etiologies and dele-
It is determined that there are numerous diagnoses and gation of nursing actions is demonstrated using the nurs-
etiologic factors from the care plan on Spinal Cord Injury. ing diagnosis of Risk for Constipation NDx as a prototype.

STANDARDIZED INDIVIDUALIZED

Risk for chronic functional constipation NDx related to: Risk for chronic functional constipation NDx related to:
(Etiologies from the care plan on Impaired Physical Mobility
NDx)
a. Diminished defecation reflex associated with: a. Diminished defecation reflex associated with:
1. Suppression of urge to defecate because of lack of privacy 1. Lack of awareness of stool in rectum associated with sen-
and reluctance to use bedpan sory loss below the level of injury
2. Decreased gravity filling of lower rectum resulting from 2. Decreased gravity filling of lower rectum resulting from
horizontal positioning horizontal positioning
3. Loss of central nervous system control over defecation
reflex
b. Weakened abdominal muscles associated with generalized b. Loss of autonomic nervous system function below the level
loss of muscle tone resulting from prolonged immobility and of injury (T-10) during a period of spinal shock
lack of innervation
c. Decreased gastrointestinal motility associated with decreased c. Decreased activity
activity and the increased sympathetic nervous system activ-
ity that occurs with anxiety
POSSESS SHSHHESHHHSSHESSHSHSESHEHEHSHEHEHHHHEHESHSHHSHHEHEHEHEHHEHHSHEHEOHS SOOSHSHSSSESESHEHSEHEEHSESHHSHEHHEHHHEHSHEHHHHSHSESH
HEHEHE HEHEHE SHEE ESEEEE

8. Modify the desired outcomes so that they are measur- The process for individualization of a desired outcome
able and realistic for your client. Establish appropriate is demonstrated using the nursing diagnosis of Risk for
target dates. chronic functional constipation NDx as a prototype.

STANDARDIZED INDIVIDUALIZED

(Outcome from the care plan on Immobility)

The client will not experience constipation as evidenced by: Mary will not experience constipation as evidenced by:
a. Usual frequency of bowel movements a. Passing soft, formed stool at least every other day
b. Passage of soft, formed stool b. Absence of abdominal distention and abdominal pain
c. Absence of abdominal distention and pain, feeling of rectal
fullness or pressure, and straining during defecation
Coe eoeeoeaeeseeeeeeeeeseseeeeeseeeeeeeeeeeeeee CROSSES HSS HSH HSEHEHHEEEHEEHSHHHESESHSHHESOSHEHOHHHEHOHSHSHH
SHH EHH EHHHHSHHHEHO HEHEHE HEEEHEEE

NDx = NANDA Diagnosis D = Delegatable Action @=UAP =LVN/LPN ©} = Go to ©volve for animation
 Chapter1 = Prioritization, Delegation, and Critical Thinking in Client Management

2). Select the nursing actions that are relevant to the cli- The process for individualization of nursing actions is
ent’s care. Add to or modify the actions to meet the demonstrated below using the nursing diagnosis of risk for
needs of your client. Include specific medications and chronic functional constipation NDx as a prototype.
treatments as well as client preferences and other ac-
tions that will facilitate the achievement of the desired
client outcomes.

STANDARDIZED INDIVIDUALIZED

(Actions from impaired physical mobility NDx)

a. Assess for signs and symptoms of constipation (e.g., decrease Assess Mary every shift for signs and symptoms of constipa-
in frequency of bowel movements; passage of hard, formed tion (e.g., no bowel movement for 3 days; passage of hard,
stools; anorexia; abdominal distention and pain; feeling of formed stools; increased anorexia; abdominal distention).
fullness or pressure in rectum; straining during defecation).
b. Assess bowel sounds. Report a pattern of decreasing bowel Assess bowel sounds. Report a pattern of decreasing bowel
sounds. sounds.
©. Implement measures to prevent constipation: Implement measures to prevent Mary’s constipation:
1. Encourage client to defecate whenever the urge is felt. 1. Encourage Mary to use regular rectal stimulation to have
a regular bowel movement.
2. Place client in high Fowler’s position for bowel move- 2. Place Mary on bedpan in high Fowler’s position for
ments unless contraindicated. bowel movements.
3. Encourage client to relax, provide privacy, and have call 3. Turn on soft music, provide privacy, and have call signal
signal within reach during attempts to defecate. (Mea- within reach during attempts to defecate.
sures to promote relaxation enable client to relax the
levator ani muscle and external anal sphincter, which
facilitates evacuation of stool.)
4. Encourage client to establish a regular time for defeca- 4. Encourage Mary to attempt digital rectal stimulation
tion, preferably within an hour after a meal. about 30 minutes after breakfast.
5. Instruct client to increase intake of foods high in fiber 5. Offer bran cereal and fresh fruit for breakfast; encourage
(e.g., bran, whole-grain breads and cereals, fresh fruits Mary to select foods high in fiber for lunch and dinnet.
and vegetables) unless contraindicated.
6. Instruct client to maintain a minimum fluid intake of 6. Encourage Mary to increase her fluid intake; offer
2500 mL/day unless contraindicated. 200 mL of apple juice, orange juice, or water every hour
while she is awake.
7. Encourage client to drink hot liquids upon arising in the 7. Offer hot tea or hot water with lemon with breakfast.
morning in order to stimulate peristalsis.
8. Encourage client to perform isometric abdominal 8. Omit; not appropriate for a client with spinal cord
strengthening exercises unless contraindicated. injury.
9. If client is taking analgesics for pain management, 9. Omit; Mary currently requires the narcotic analgesic for
encourage the use of nonnarcotic rather than narcotic effective pain management.
(opioid) analgesics when appropriate.
10. Increase activity as allowed. 10. Increase passive and active range-of-motion (ROM) exer-
cises as indicated.
11. Administer laxatives or cathartics and/or enemas if 11. Administer milk of magnesia, 30 mL PO, each evening,
ordered. and Dialose, 100 mg PO, each morning.
Consult physician about checking for an impaction and digi- Gal. Consult physician about checking for an impaction and digi-
tally removing stool if client has not had a bowel movement tally removing stool if Mary has not had a bowel movement
in 3 days, if client is passing liquid stool, or if other signs for 4 days and other signs and symptoms of constipation are
and symptoms of constipation are present. present.
Consult appropriate health care provider if signs and e Consult appropriate health care provider if signs and
symptoms of constipation persist and appear to be an symptoms of constipation occur and this appears to be an
ongoing problem. ongoing problem.
'
SOSH SHHHHSHHHHHHOHEHEHEEHESEHSHEHOHE SHOE EHEHHEHEE HH HHEHHEESEHHEH HEHE EEHHES OSES EE SEEEEEEEESEEES OHO EE EEE HEHE EEE EEL EEE SEES LOCC
 Chapter1 = Prioritization, Delegation, and Critical Thinking in Client Management 7

MPLE INDIVIDUALIZE D CARE PLAN

ERS

DATA NURSING DIAGNOSIS DESIRED OUTCOME NURSING ACTIONS

Mary states had a Risk for chronic func- Mary will not experi- a. Assess Mary every shift for signs and symptoms of
bowel move- tional constipation ence constipation as constipation (e.g., no bowel movement for 3 days;
ment this NDx related to: evidenced by: passage of hard, formed stool; increased anorexia;
morning. a. Diminished defeca- a. Passing a soft, abdominal distention; abdominal pain.
Normal bowel tion reflex associated formed stool at b. Assess bowel sounds. Report a pattern of
sounds. with decreased ner- least QOD decreasing bowel sounds.
Physician’s or- vous system responses b. Absence of abdomi- Cc. Implement measures to prevent Mary’s
ders: milk of in spinal cord injury nal distention constipation. D@® @
magnesia, state and decreased 1. Place Mary on bedpan in high Fowler’s position
30 mL PO each gravity filling of lower for bowel movements. D @ $
evening; Di- rectum resulting from 2. Turn on soft music, provide privacy, and have
alose, 100 mg horizontal positioning call signal within reach during attempts to defe-
PO, every b. Decreased ability to cate. D@
morning. respond to urge to 3. Encourage Mary to attempt to digital rectal stim-
Bedridden for defecate associated ulation about 30 minutes after breakfast. D
+ 3 weeks. with weakened ab- 4. Offer bran cereal and fresh fruit for breakfast;
Consuming only dominal muscles and encourage Mary to select foods high in fiber for
10% of meals. impaired physical lunch and dinner. D
Mary states she mobility 5. Encourage Mary to increase her fluid intake;
usually has a c. Decreased gastrointes- offer 200 mL of apple juice, orange juice, or
bowel move- tinal motility associ- water every hour while she is awake. D
ment every ated with decreased 6. Offer hot tea with breakfast. D
other day activity, use of mor- 7. Administer milk of magnesia, 30 mL PO, each eve-
(QOD) about phine sulfate, and in- ning; give Dialose, 100 mg PO, each morning. D coy
30 minutes af- creased sympathetic Consult physician about checking for an impaction
ter breakfast. nervous system activ- and digitally removing stool if Mary has not had a
Activity: bed rest. ity that occurs with bowel movement for 4 days and other signs and
Mary requires anxiety and pain symptoms of constipation are present.
assistance with d. Decreased intake of Consult appropriate health care provider if signs
all activities. fluids and foods high and symptoms of constipation occur and given the
Receiving mor- in fiber clients condition, constipation could be an ongoing
phine sulfate problem.
every 2 hrs.

See spinal cord injury care plan for additional nursing diagnosis.

NDx = NANDA Diagnosis D = Delegatable Action @ =UAP @ =LVN/LPN © = Goto ©volve for animation
_ le PiGees (tas Gre

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a) ae ey ’
S Ptegie = @ 4%

ii a Manu + @
 CHAPTER

Nurse-Sensitive Indicators

Patient falls and falls with injury are nurse-sensitive indica- but occur due to an event, the timing of which could
tors that represent both the processes and outcomes associ- not be predicted, such as a stroke, syncopal episode, or
ated with quality nursing care. The National Quality Forum seizure. Accidental falls occur in otherwise low-risk clients,
(NQF) defines a fall as an unplanned descent to the floor (or due to an environmental hazard. Some researchers have
extension of the floor, e.g., trash can or other equipment) further suggested categorizing falls as either preventable or
with or without injury to the patient. The Agency for Health- nonpreventable.
care Research and Quality (2017) estimates that in the United Given the patient safety challenges presented by falls,
States, up to 1 million hospitalized patients and approxi- hospitals are charged with treating not only the problem
mately half of the 1.6 million nursing home residents fall that prompted admission to the hospital but keeping the pa-
each year. In addition, more than one-third of falls occurring tient safe, which requires balancing fall prevention with
in hospitals result in injury, including serious injury (e.g., other care priorities. Successful fall prevention requires an
head trauma, fractures). Falls are associated with increased interdisciplinary approach with some standardized interven-
length of stay, higher rates of discharge to extended care fa- tions that include both environmental measures and clinical
cilities, and greater health care utilization. The Centers for interventions that are individualized to each client’s specific
Medicare and Medicaid services (CMS) have identified falls as risk profile. Many health care facilities adopt standardized fall
an event that is preventable and one that should never occur. intervention “bundles” which represent the latest available
As a result, falls are listed as a hospital-acquired condition evidence related to fall prevention interventions. Nurses and
(HAC) for which reimbursement is limited. In addition, the nurse leaders within health care organizations are tasked with
CMS does not reimburse hospitals for additional costs associ- and accountable for monitoring the outcome of nursing
ated with patient falls. interventions aimed at fall prevention, which includes the
There are multiple categories of risk factors associated with number of falls and the number of falls with various levels
falls including age, gender, alterations in mobility or the use of injury.
of assistive devices, medications (e.g., polypharmacy, medica- This care plan focuses on care of the adult client at risk
tions for sedation, pain), alternations in mental status, medi- for falls and hospitalized in an acute care setting. Given the
cal diagnoses, and alterations in continence. Different clients need to balance patient safety with other care priorities, this
may have different combinations of risk factors that change care plan should be used in conjunction with the plan of
over time during hospitalization. Although client risk for falls care developed for the primary admitting diagnosis of the
may vary, with some being at higher risk, by virtue of illness, client. Much of this information is applicable to clients receiv-
all patients should be considered at risk for falls. ing follow-up care in an extended care facility or home setting.
To better understand falls in terms of contributing
tisk factors, researchers have classified falls into three key
categories—anticipated physiologic falls, unanticipated phys- OUTCOME/DISCHARGE CRITERIA
iologic falls, and accidental falls. Most in-hospital falls are
classified as anticipated physiologic, occurring in clients The client will:
identified as having risk factors for falls that can be identi- 1. Remain free from injury
fied in advance such as altered mental status, abnormal gait, 2. Return to baseline mobility
frequent toileting, or high-risk medications. Unanticipated 3. Demonstrate understanding of risk factors for falls and risk
physiologic falls occur in clients normally of low fall risk reduction strategies.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation 9
(% RY
Rc
10 Chapter 2. = Nurse-Sensitive Indicators

Nursing Diagnosis RISK FOR FALLS nox

Definition: Susceptible to increased susceptibility to falling, which may cause physical harm and compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Expressed concern for safety during ambulation; stated Unsteadiness when ambulating; use of ambulation aids; visual
history of previous falls field deficits; confusion; orthostatic hypotension; medication
therapy (e.g., antihypertensives, diuretics, hypnotics, antianxi-
ety agents, narcotics, antidepressants); anemias, arthritis

RISK FACTORS
e Age 265 yr e Gait difficulty e Impaired vision
e History of falls e Impaired mobility e Lower limb prosthetics
e Environmental e Incontinence/urinary urgency e Neuropathy
e Cluttered environment e Sleeplessness e Orthostatic hypotension
e Insufficient lighting e Associated conditions e Pharmaceutic agents
e Unfamiliar setting e Acute illness e Postoperative recovery period
e Use of restraints e Alterations in cognitive function e Use of assistive devices
e Physiologic e Anemia e Vascular disease
e Alterations in blood glucose levels e Arthritis
e Decrease in lower extremity e Hearing impairment
strength (deconditioning) e Impaired balance

DESIRED OUTCOMES DOCUMENTATION

The client will remain free from falls and injury associated e Standardized fall risk assessment score
with falls. e Universal fall precaution interventions
e Mobility/ambulation; use of assistive devices
e Restraints

NURSING OUTCOMES CLASSIFICATION (NOC) NURSING INTERVENTIONS CLASSIFICATION (NIC)

Falls prevention behavior; falls occurrence; risk detection; Environmental management: safety; fall prevention
knowledge: personal safety

NURSING ASSESSMENT RATIONALE

Assess Client’s risk for falls using standardized assessment tool Determining the client’s risk for falls allows implementation of
(e.g., Morse Falls Scale, on admission, transfer from one care standardized and individualized preventive measures. Risk fac-
unit to another, and/or following a significant change in tors and a client’s overall risk may vary during hospitalization
patient condition). Assessment should include evaluation of: and should be assessed at the appropriate intervals, as defined
e History of falls by organizational policy and/or standard operating procedures.
e Mobility problems/use of assistive devices
e Mental status
e Continence
Consult organizational policy and/or standard operating pro-
cedures for assessment frequency.
Assess Client’s gait, balance, and mobility skills. Determining the client’s baseline status allows for the Hage lop
tion of the appropriate preventive measures.
Evaluate client’s medications to determine whether they Some medications may cause excessive drowsiness, altered mental
place the client at increased risk for falls. states, or physiologic changes, such as orthostatic hypotension,
that can increase the risk of falls in clients. Early identification
of such medications allows for implementation of appropriate
preventive measures.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement scheduled rounding protocols (e.g., 5 P’s - pain, Hourly rounding is an excellent proactive strategy to ensure client’s
personal needs, position, placement, prevent falls) accord- needs are met, potentially reducing the risk for falls.
ing to organizational policy and/or standard operating
procedure D @ +.
 Chapter 2. = Nurse-Sensitive Indicators 11

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to prevent falls: D @+ Physical hazards in the client’s immediate environment increase
° Orient client to surroundings (e.g., room; nurse call system).
the risk for accidental injury. Falls are usually a result of both
° Instruct client to call for assistance with movement as intrinsic (e.g., illness, drug therapy) and extrinsic, or environ-
appropriate. mental, factors. Extrinsic factors are much easier to modify and
e Place articles within easy reach of the client. eliminate. Many organizations implement fall prevention “bun-
° Reduce clutter in client’s immediate environment. dles” that are based on the most recent scientific evidence and
e Assist unsteady client with ambulation. are independent nursing actions. Consult organizational policy
° Have client wear safe footwear when ambulating (crag and standard operating procedures for fall prevention bundles.
nonskid shoes/slippers).
° Have client wear prescription glasses as appropriate.
e Ensure adequate lighting in client’s room.
° Encourage client to use ambulation aids and glasses.
° Keep bed in lowest position.
° Keep bed wheels in locked position
° Use side rails of appropriate height and length.
° Keep floor surfaces clean and dry.
« Implement appropriate alerts identifying clients at high risk
for falls (e.g., room signage; wrist identification bands [ID])
e Apply bed sensor pad/bed alarms.
° Apply wheelchair lap belt/safety belt as appropriate.
¢ Monitor client’s ability to transfer to and from a bed, Older adults are more likely to fall in the bedroom and the bath-
wheelchair, and toilet. D@ + room, with most falls occurring when transferring from beds,
e Use proper technique when transferring a patient to and chairs, and toilets.
from a bed, wheelchair, and toilet.
e Involve family to aid with activities of daily living and In the acute care environment, frequent observation of clients at
prevention of falls. D@ + risk for falls is necessary to reduce the risk for falls.

Dependent/Collaborative Actions
Collaborate with multidisciplinary team members to monitor Intrinsic factors increasing the risk of falls may be modified or
and minimize side effects of medications that increase the eliminated if identified and discussed with the appropriate
risk of falls. health care provider.
Implement the use of restraints as ordered. Avoid the use of restraints ifat all possible. If restraints must be used,
choose the least restrictive device and follow institutional policy for
the monitoring and documentation of the client’s condition.
Consult physical therapy for strengthening, exercises, gait Collaboration with other disciplines is an important part of a client’s
training, and help with balance to increase mobility. plan of care. Additional resources provided during the hospital stay,
as well as in preparation for discharge, can assist the client in gain-
ing the strength, mobility, and endurance to reduce the risk for falls.
Notify physician of client falls. Notifying the appropriate health care provider allows for modification
of the treatment plan.

|Nursing ss
Diagnosis DEFICIENT KNOWLEDGE nox

Definition: Absence of cognitive information related to a specific topic, or its acquisition.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report acknowledging lack of understanding of Inaccurate follow-through of instructions; insufficient
fall risk. knowledge

RISK FACTORS DESIRED OUTCOMES

e Alteration in cognitive function The client will:
e Insufficient interest in learning e Identify ways to reduce the risk for falls
e Insufficient information e Remain free of falls and/or injury from falls

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
 2, Chapter 2 = Nurse-Sensitive Indicators

NOC OUTCOMES NIC INTERVENTIONS

‘ss
SSS esses Ss

Knowledge: personal safety Teaching: individual; learning: readiness enhancement;

learning: facilitation

NURSING ASSESSMENT RATIONALE

Assess for client’s understanding of fall risk upon admission Client engagement in his or her health care could lead to safe
to the hospital. hospital stays. Many clients may not be aware of their risk for
falls and prevention interventions.
Assess Client’s ability and readiness to learn. Learning is more effective when the client is motivated and understands
the importance of what is to be learned. Readiness to learn changes
based on situations and physical and emotional challenges.
Assess client’s understanding of teaching. It is important for the nurse to ensure client’s understanding
of teaching. Further education using different instructional
modalities may be necessary.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
e Instruct client, family, and visitors regarding factors that Clients without alterations in mobility may not be aware of factors
contribute to the risk for falls in the hospital setting. that may increase their risk for fall while hospitalized. Family
e Effects of medications and visitors should be included.
e Changes in mobility
e Deconditioning—weakness resulting from prolonged
periods of bed rest
e Age
e Comorbid conditions
e Instruct and reinforce institutional fall prevention Instructing clients, including visitors and family members, regard-
interventions that will be implemented during hospital ing fall prevention interventions can potentially increase client
stay—including standard interventions and interventions engagement and adherence. Instructions may need to be rein-
tailored to client’s clinical condition. forced frequently

ADDITIONAL NURSING DIAGNOSES

IMPAIRED PHYSICAL MOBILITY NDx RISK FOR INJURY NDx

Related to: Related to:
e Physical deconditioning e Physical deconditioning
e Disuse e Extremes of age
e Reluctance to initiate movement e Impaired primary defense mechanisms
e Alterations in cognitive/psychomotor functioning

HOSPTAL ACQUIRED PRESSURE ULCERS/INJURIES

Another nurse-sensitive indicator associated with processes In 2016, national definitions for pressure ulcers where rede-
and outcomes related to quality nursing care is pressure ulcers fined by the National Pressure Ulcer Advisory Panel. The up-
(e.g., bed sores, decubitus ulcers, pressure sores). Pressure ulcers dated definition changes terminology from pressure, ulcer to
are one of the biggest challenges health care organizations face on pressure injury defined as localized damage to the skin and
a day-to-day basis. Pressure ulcers interfere with a client’s func- underlying soft tissue usually over a bony prominence or re-
tional recovery and may be complicated by pain and infection, lated to a medical or other device. The injury can present as
contributing to longer hospital stays. Each year, more than 2.5 intact skin, or an open ulcer and may be painful. The injury
million people in the United States develop pressure ulcers, occurs as a result of intense and/or prolonged pressure or pres-
which bring pain, increased risk for serious infection, and in- sure in combination with shear and/or friction. The tolerance
creased health care utilization and costs. Approximately 60,000 of soft tissue for pressure and shear may also be affected by the
patients die each year as a direct result of a pressure ulcer. In microclimate, which is defined as the climate between the sup-
the United States, pressure ulcers costs $9.1 to $11.6 billion per port surface and the client and influenced by temperature,
year, with individual patient costs ranging from $20,900 to humidity, airflow, nutrition, comorbidities, and the condition
$151,700 per pressure ulcer. As of 2008, the CMS no longer of the soft tissue. Pressure injuries are classified based on stages.
pays for additional costs associated with hospital-acquired The current classification includes: stage 1: nonblanchable ery-
pressure ulcers, a potentially preventable condition. thema of intact skin; stage 2: partial-thickness skin loss with
 Chapter 2. = Nurse-Sensitive Indicators 13

exposed dermis; stage 3: Full-thickness skin loss; stage 4: full- care planning and implementation to address areas of risk.
thickness skin loss and tissue loss; unstageable: obscured full- Detailed strategies outlined by the National Pressure Ulcer Ad-
thickness skin and tissue loss; and deep tissue: persistent non- visory Panel include risk assessment (starting point), skin care
blanchable deep red, maroon, or purple discoloration. (protection and monitoring), nutrition (prevention of under-
Additional pressure injury definitions include pressure injuries nutrition), position and mobilization (immobility significantly
related to medical devices and mucosal membrane pressure contributes to pressure injuries), and monitoring training and
injuries. Clients at high risk for the development of pressure leadership support related to process improvement initiatives.
injuries include the elderly and the critically ill. Critically ill Nurses and nurse leaders within health care organizations are
patients are at higher risk due to the use of mechanical/medical tasked with and accountable for monitoring the outcome of
devices (e.g., nasal cannula tubing, braces, splints, respiratory nursing interventions aimed at the prevention of pressure in-
masks), hemodynamic instability, and the use of vasoactive jury, which includes the prevalence of stage 3 or stage 4 pres-
drugs which may compromise blood flow to the tissues. sure injury acquired after admission to a health care facility.
Prevention of pressure injuries is a patient safety priority This care plan focuses on care of the adult client at
and requires an interdisciplinary approach to care involving risk for hospital-acquired pressure ulcers/injury and hos-
physicians, dieticians, physical therapists, nurses (often includ- pitalized in an acute care setting. Given the need to
ing wound ostomy certified nurses), patients, and their family balance patient safety with other care priorities, this
members. As with falls, prevention and treatment of pressure care plan should be used in conjunction with the plan of
injury involve implementation of evidence-based intervention care developed for the primary admitting diagnosis of
using a “bundle” of standardized interventions. Key elements the client. Much of this information is applicable to
of a pressure injury prevention bundle include comprehensive clients receiving follow-up care in an extended care
assessment, standardized pressure ulcer risk assessment, and facility or home setting.

|Nursing *Diagnosis
. |RISK FOR PRESSURE ULCER nox ,
Definition: Susceptible to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of
pressure, Or pressure in combination with shear (NPUAP), 2007.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of localized pain in affected skin/ Localized damage to the skin and soft underlying tissue
tissue area. usually over a bony prominence; stage 1: intact skin with
localized area of nonblanchable erythema, changes in sen-
sation, temperature, or firmness; stage 2: partial-thickness
loss of skin with exposed dermis; stage 3: full-thickness
loss of skin with visible exposed adipose (fat); stage 4: full-
thickness loss of skin and tissue loss with exposed fascia,
muscle, or bone; deep tissue pressure injury: persistent
nonblanchable deep red, maroon, or purple discoloration;
unstageable pressure injury: obscured full-thickness skin
and tissue loss; mucosal membrane injury.

RISK FACTORS
e Decrease in mobility/immobility ° Shearing/friction forces (e.g., e Microclimate with high humidity
e Extended period of immobility on a client rubbing feet across sheets); (e.g., linen with insufficient mois-
hard surface (e.g., surgery) force of gravity added to friction ture wicking property)
e Inadequate nutrition (e.g., same agitate client with head ° Diabetes
e Incontinence of bed elevated) e Circulatory impairment
e Smoking

DESIRED OUTCOMES DOCUMENTATION

The client will remain free from pressure injury as e Standardized risk assessment score (e.g., Braden Scale)
evidenced by intact skin and mucous membranes. e Skin care
e Nutrition
¢ Positioning/mobilization
e Skin/mucous membrane changes
e Photo documentation of wounds

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14 Chapter 2. = Nurse-Sensitive Indicators

NOC OUTCOMES NIC INTERVENTIONS

Risk control: pressure injury; immobility consequences: Positioning; intraoperative; pressure ulcer prevention;
physiologic pressure ulcer care; skin surveillance; skin care: topical
treatment

NURSING ASSESSMENT RATIONALE

Assess client’s risk for using standardized/structured risk Determining the client’s risk for pressure injury allows implementa-
assessment tool (e.g., Braden Scale) on admission (at mini- tion of standardized and individualized preventive measures
mum within 8 hours from admission). Risk assessment based upon areas of risk. Risk factors and a client’s overall risk
should be repeated at regular intervals and with change may vary during hospitalization and should be assessed at the
in condition. Frequency of assessments based on acuity appropriate intervals as defined by organizational policy and/or
levels: standard operating procedures.
e Acute care: every shift
e Long-term care: weekly for 4 weeks, then quarterly
e Home care: at every nurse visit.
Assess client for additional risk factors: Preexisting skin wounds/prior pressure injuries must be docu-
e Fragile skin mented accordingly on admission so as to not adversely impact
Existing pressure injury of any stage, including those hospital reimbursement. Additional risk factors should be
ulcers that are healed or closed considered in addition to standardized risk score when develop-
e Impaired blood flow (poor perfusion) to the extremities. ing the plan ofcare.
e Pain in areas exposed to pressure
Poor nutritional status
Evaluate the client’s ability to eat independently
e Increased skin moisture.
e Inspect skin upon admission and at least daily. Inspection of skin upon admission and identification ofpreexisting
Inspect skin at least daily for signs of pressure injury wounds is critical to the classification of a wound as hospital
(e.g., nonblanchable erythema, ulcerations, color, acquired, which impacts reimbursement of associated costs.
firmness) Early identification of signs of pressure injury and/or signs of
Inspect skin for excessive moisture/dryness microclimate (e.g. dryness/excessive moisture) that can contrib-
Inspect mucous membranes for areas of discoloration or ute to injury allows for prompt modification of the treatment
breakdown plan.
e Inspect skin for rashes and abrasions
In dark pigmented clients, look for changes in skin tone,
skin temperature, and tissue consistency compared with
adjacent skin.
Assess bony prominences (e.g., sacrum, coccyx, buttocks, Pressure exerted over bony prominences reduces blood flow to the
heels, ischium, trochanters, elbows, and beneath medical tissues, resulting in hypoxia, increasing risk for the development
devices (e.g., NG tubes, nasal cannula/oxygen masks). ofa@pressure injury.
Assess for sources of pressure and friction (e.g., prolonged Identification of sources of pressure, shear, and friction allows for
pressure of objects against skin, rubbing of sheets against modification of the treatment plan.
skin).
Assess for presence of pain using standardized pain assess- Pain is associated with pressure injury. Assessment of pain
ment scale. provides for modification of the treatment plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement pressure injury prevention measures:
Skin care D@ +
e Keep skin clean and dry, removing excessive moisture Presence of skin damage from moisture may increase the risk
from perspiration, wound drainage, and/or incontinence. for pressure ulceration/injury. Use of a breathable incontinence
e Cleanse skin promptly following episodes of inconti- pad may be helpful when using microclimate management
nence, use pH-balanced skin cleanser, and avoid use of surfaces.
hot water.
e Consider use of a breathable incontinence pad.
 Chapter 2. = Nurse-Sensitive Indicators 15

Continued... p

THERAPEUTIC INTERVENTIONS RATIONALE

¢ Moisturize dry, unbroken skin. Use a skin moisturizer to hydrate dry skin to reduce the risk of
damage. Consult organizational policies and standard operat-
ing procedures and/or skin care bundles for evidence-based in-
terventions.
e Apply protective barriers, such as creams or moisture Presence of skin damage from moisture may increase the risk for
absorbing pads, to remove excess moisture as appropriate. pressure ulceration/injury. Consult organizational policies and
standard operating procedures and/or skin care bundles for
evidence-based interventions.
e Do not massage or vigorously rub skin at risk of pressure ulcers. Friction massage can cause mild destruction or provoke inflamma-
tory reactions, particularly in frail older adults.
° Do not apply heating devices (e.g., hot water bottles, heat- Heat increases the metabolic rate, induces sweating, and decreases
ing pads) directly on skin. the tolerance of skin/tissue for pressure.
Repositioning D@ +
e Reposition all individuals at risk for development of pres- Repositioning serves to reduce the duration and magnitude of
sure injuries. pressure over vulnerable areas of the body and contribute to
e Avoid positioning on an area of erythema whenever comfort, hygiene, dignity, and functional ability.
- possible. Erythema indicates the body/skin area has not recovered from pre-
e Frequency of repositioning based upon: vious pressure loading and requires further rest.
e Support surface Regular repositioning may not be possible for all clients based upon
e Tolerance of skin for pressure medical condition—alternate strategies may need to be consid-
e Individual preferences ered (e.g., high-specification mattress).
e Reposition the client in a manner that relieves pressure or When repositioning, it is important to assess whether pressure is
redistributes pressure avoiding shear/friction forces. actually relieved or redistributed. Lift—do not drag—the client
when repositioning. Use a hand to determine if sacrum is off
the bed.
e Avoid repositioning on bony prominences with preexist- Erythema is an indication of the early signs of pressure injury.
ing areas of erythema. Further compromise to blood supply may occur, thereby worsen-
ing damage.
¢ Repositioning individuals in bed:
e Use the 30-degree, tilted side-lying position (alternate right Elevating HOB greater than 30 degrees has potential to increase pres-
side, back, left side) or the prone position if tolerated sure, shear, and friction, increasing the risk for tissue damage.
e Avoid head of bed elevation that places pressure and Individuals should be positioned and supported to prevent sliding
shear on the coccyx and sacrum down in bed and creating shearing forces.
e Ensure heels are free of the surfaces of the bed—use heel Heels should be free of all pressure. Suspension devices should be
suspension devices (e.g., pillow elevating heels off bed) removed frequently to assess for skin breakdown.
¢ Maintain knee in slight flexion (e.g. 5-10 degrees) Hyperextension of the knee may cause obstruction of the popliteal
vein.
¢ Repositioning seated individuals (e.g., wheelchair) The ischia bear intense pressure when a client is seated in a wheel-
e Adjust footrests and armrests to maintain proper chair. Positioning should minimize pressure and shear exerted
posture and pressure distribution on soft tissues.
e Provide adequate sit tilt to prevent sliding forward.
Positioning Devices D@ +
e Apply elbow and heel protectors as appropriate. Protection of bony prominence areas prone to shear friction may
prevent tissue injury.
e Use devices on bed that protect individual (e.g., natural Natural sheep skin, not synthetic sheep skin, may assist in prevent-
sheepskin). ing pressure ulcers.
e Do not use ring- or donut-shaped devices. Edges of ring- or donut-shaped devices crease areas ofhigh pressure
that may damage skin/tissue.
Keep bed linens clean and wrinkle free D © +
e Consider using silk-like fabrics to reduce friction/shear.
Mobilization D ® +
e Increase activity as tolerated developing a plan for progres- Clients on bed rest should progress to sitting and ambulation as
sive sitting. rapidly as tolerated to help offset deconditioning seen in clients
on bed rest.

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 16 Chapter 2 = Nurse-Sensitive Indicators

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Medical Devices
e Remove medical devices as soon as feasibly possible. Adults with medical devices should be considered at risk for pres-
e Keep skin clean and dry under medical devices. sure injury and appropriate prevention measures should be im-
e Do not reposition client directly on the medical device plemented.
unless it is unavoidable.
e Rotate or reposition medical device when possible (e.g.,
ET tube).
Nutrition
e Provide and encourage adequate daily fluid intake as Adequate hydration is essential to transport of essential nutrients
appropriate to client’s underlying condition. critical to sustain the health state of the client.
Implement measures to decrease pain associated with Pain is often associated with pressure injury and should be ad-
pressure injury. dressed accordingly with multimodal interventions.
e Organize care to ensure coordination with pain medica-
tion administration.
e Encourage client to request a “time-out” during any treat-
ment procedures that may cause pain.
e Reduce pressure ulcer pain by keeping wound bed covered,
moist, and using a nonadherent dressing.
e Use a lift or transfer sheet to minimize friction and/or
shear when repositioning.
e Ifan ulcer is present, reposition off ulcer whenever possible.

Dependent/Collaborative Actions
Implement measures to prevent pressure injury:
Consult Dietician/Nutrition
e Screen nutritional status for the client at risk or with a A qualified member of the health care team should perform a com-
pressure ulcer. prehensive nutrition assessment in patients at risk for pressure
e In collaboration with interprofessional team, develop and injury. An appropriate diet is necessary to sustain normal body
individualized nutritional plan based on the individual’s functions and promote tissue healing. The focus of the assess-
nutritional needs. The following needs should be ment should be on energy intake, unintended weight change,
addressed in the plan: and the impact of stress. In addition, the client’s individual
e Energy/caloric intake appropriate to client’s condition caloric, protein, and/or fluid requirements.
using appropriate fortified foods and/or high-calorie,
high-protein oral nutritional supplements.
e For inadequate oral intake, consideration of enteral or
parenteral nutritional strategies.
e Hydration/daily fluid intake
e Vitamins and minerals.
Consult wound care advanced practice nurse (APN)/
physician for appropriate support surface
e Collaborate with members of the health care team to select Support surfaces are specialized devices for pressure redistribution
the support surface that best meets the needs of the client designed for managing tissue load, microclimate, and/or other
and is based on: therapeutic functions. The type of support surface selected
e Level of immobility should be compatible to the care setting, be used according to
e Need for microclimate control manufacturer's recommendations, and be used with compatible
e Size and weight of individual bed lines and other positioning devices. Note: organizations
e Risk for development of new pressure injuries may have decision algorithms to drive selection of support sur-
e Number, severity, and location of pressure injuries. faces. Review organizational policies and/or standard operating
procedures for evidence-based practices.
e Use a high-specification reactive foam mattress for all indi- Support surfaces/mattresses are designed to either reduce pressure
viduals assessed for being at risk. or sequentially alter the parts of the body that bear load to re-
duce the time of pressure on any given part of the body.

e For seated support surfaces, select cushion with consider- Pressure redistribution surfaces should be used in clients sitting in
ation for body size, effects of posture and deformity on a chair whose mobility is reduced.
pressure distribution, and mobility and lifestyle needs.
e Cushion cover should be breathable and fit loosely on the A tight cover will adversely impact cushion performance.
top surface of the cushion.
 Chapter 2 = Nurse-Sensitive Indicators 17

Continued... _

THERAPEUTIC INTERVENTIONS RATIONALE

Consult wound care APN/physician for the use of
Prophylactic dressings placed in anatomic areas prone to friction
prophylactic dressings. and shear (e.g., heels, elbows, sacrum) can reduce the risk of
° Consider application of a polyurethane foam dressing to a
injury. Prophylactic dressings differ in qualities, therefore the
bony prominence (e.g., heels/elbows/sacrum). selected dressings must be appropriate to clinical use and the
e Selection of dressing for prophylactic or existing wounds
individual. Note, application of a prophylactic dressing may be
should be based on ability of dressing to manage micro- considered an independent nursing action—consult organiza-
climate (e.g., moisture), ease of application/removal; ability tional policies and/or standard operating procedures.
to regularly assess skin; anatomic location to be applied;
and the correct size.
° Consider type of medical device in use as applicable.
Implement measures to manage existing pressure injuries
Consult wound care APN/physician for wound
management Cleansing of the wound is the first step in preparing the pressure
e Wound care cleansing as ordered by physician or APN. injury to heal by removing surface debris. Wound cleansing is
most often completed by APNs using evidence-based treatment
protocols developed collaboratively by members of the health
care team. Cleansing allows for better visualization and assess-
ment of a wound.
Debridement is performed only when there is evidence of adequate
e Wound care debridement as ordered by a physician or APN. perfusion to the tissue. Debridement of devitalized tissue within
the wound bed and/or edges of pressure ulcer when appropriate
to the client’s condition. Wound debridement is completed by a
physician or APN.
Listed adjunct therapies promote healing by providing a form of
e Biophysical agents for use in wound healing as ordered by biophysical energy. Indications for therapy vary depending upon
physician or APN: status of the pressure injury.
e Negative pressure wound therapy
e Whirlpool
e Pulsatile lavage
e Hyperbaric oxygen therapy. Acute pain associated with pressure injury should be evaluated and
e Administer pain medications (opioids/nonopioids) as or- treated according to client’s pain goals.
dered for acute pain associated with pressure injury and/or
cleansing/débriding procedures.
e Consult appropriate pain resources for management of
chronic pain associated with pressure injury.

|Nursing oo)
Diagnosis DEFICIENT KNOWLEDGE nox
Definition: Absence of cognitive information related to a specific topic, or its acquisition.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report acknowledging lack of understanding of Inaccurate follow-through of instructions; insufficient
strategies to reduce risk for pressure injury. knowledge

RISK FACTORS DESIRED OUTCOMES

e Alteration in cognitive function
The client will:
e Insufficient interest in learning
e Identify ways to reduce the risk for pressure injury
e Insufficient information
e Remain free of pressure injury

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen Teaching: individual; learning: readiness enhancement;

learning: facilitation

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to @volve for animation
18 Chapter 2. = Nurse-Sensitive Indicators

NURSING ASSESSMENT RATIONALE

Assess for client’s understanding of pressure injury preven- Client engagement in his or her health care could lead to safe hos-
tion upon admission to the hospital. pital stays. Many clients may not be aware of their risk for
pressure injury and prevention interventions.
Assess client’s ability and readiness to learn. Learning is more effective when the client is motivated and under-
stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges.
Assess client’s understanding of teaching. It is important for the nurse to ensure client’s understanding
of teaching. Further education using different instructional
modalities may be necessary.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client and family on individual risk for pressure Clients, including family members, should be instructed on the
injury, including signs and symptoms of skin breakdown. client’s individual risk factors for pressure injury and signs and
symptoms of skin breakdown that should be promptly reported
to a health care provider.
Instruct client and family on preventative skin care: Clients, including family members, should be instructed on the
* Keep skin clean and dry. appropriate interventions to keep skin dry and intact, reducing
e Cleanse skin promptly following incontinent episode. the risk for breakdown.
e Do not massage or vigorously rub skin prone to breakdown.
e Protect skin from excessive moisture using prescribed bar-
rier products.
e Apply skin moisturizer to hydrate skin.
e Application of prophylactic dressings to bony prominence
areas.
Instruct client and family on repositioning techniques: Clients and family should be instructed on appropriate reposition-
e Reposition at least every 2 hours. ing techniques, with special attention on how to reduce friction
e Avoid shearing/friction (e.g., do not drag) during reposi- and shear when moving. Instruction should also include ensur-
tioning (e.g., use assist devices such as overhead trapeze, ing that pressure is truly alleviated with change in position.
mechanical lift).
e Avoid postures that increase pressure (e.g., 90 degrees
side-lying; semi-recumbent position).
e Avoid repositioning on areas or erythema.
e Avoid repositioning on medical devices.
e “Pressure relief lifts” (e.g. alleviating pressure/lifting off
areas of pressure at intervals).
e Elevate/pad heels/bony prominences.
Instruct client and family on the proper use of support sur- Support surface and positioning devices must be used in accordance
faces and positioning devices. with manufacturers recommendations to prevent unintended injury.
Encourage caloric and fluid intake conducive to client’s clini- Appropriate caloric and fluid intake is necessary to ensure mainte-
cal condition/comorbid conditions. nance of skin integrity and/or appropriate healing.
Instruct client and family on the importance of increasing Increasing activity as quickly as tolerated reduces the risk of pres-
activity as rapidly as tolerated conducive to the client’s sure injury by reducing pressure load on areas at risk for skin
clinical condition/comorbid conditions. breakdown.
t

ADDITIONAL NURSING DIAGNOSES

RISK FOR INFECTION NDx
ACUTE PAIN NDx Related to
Related to * Bacteria present on skin surfaces that invade wounds
e Alterations in skin integrity when primary defense provided by intact skin is lost.
e Pressure load on erythematic areas of the skin * Unfavorable microclimate (temperature of skin combined
with humidity or skin surface moisture) that promotes
bacterial growth.
 Chapter 2. = Nurse-Sensitive Indicators 19

HEALTH CARE-ASSOCIATED INFECTIONS

Health care-associated infections (HAIs), or infections ac- concerns related to patient safety. HAIs, identified as nursing
quired while receiving health care for another condition, can sensitive and associated with the quality of nursing care,
occur in a variety of health care settings, including hospitals, include catheter-associated urinary tract infections (CAUTIs),
ambulatory surgery centers, and long-term care facilities. CLABSIs, and ventilator-associated pneumonia (VAP).
It is estimated that on any given day, approximately 1 in As with other nurse-sensitive indicators, the approach to
25 hospitalized patients has at least one HAI. HAIs are often con- prevention of these HAIs rests on implementation of evidence-
sidered preventable and present a major threat to patient safety. based “bundles” based on the most current evidence support-
HAIs, caused by bacteria, fungi, viruses, and other patho- ing interventions. Nurses and nurse leaders within health care
gens, are a significant cause of death and emotional, financial, organizations are tasked with and accountable for monitoring
and additional medical consequences. Factors known to in- the outcome of nursing interventions aimed at the prevention
crease the risk of HAIs include the presence of catheters, surgi- of HAIs which include rates of each type of HAIs (CAUTI,
cal procedures, injections, improper cleaning and disinfecting CLABSI, VAP). Effective in 2015, hospitals risked a reduction in
of hospital settings/equipment, communicable diseases passed reimbursement from Medicare and Medicaid for how they
between patients and health care workers, and overuse/im- performed in meeting HAI outcome measures.
proper use of antibiotics. Common infections acquired in This care plan focuses on care of the adult client at risk
hospital settings include urinary tract infections, central line- for HAIs (including CAUTI, CLABSI, and VAP), identified
associated bloodstream infections (CLASBIs), pneumonia, sur- as nurse sensitive, and in an acute care setting. Given the
gical site infections, methicillin-resistant Staphylococcus aureus need to balance patient safety with other care priorities,
(MRSA) infections, and Clostridium difficile infections. this care plan should be used in conjunction with the plan
At the national level the 2018 National Patient Safety Goals of care developed for the primary admitting diagnosis of
as issued by the Joint Commission on Accreditation of Health- the client. Much of this information is applicable to clients
care Organizations include “reducing the risk of health care- receiving follow-up care in an extended care facility or
associated infections” as one of 15 goals addressing current home setting.

Nursing Diagnosis RISK FOR INFECTION nox

Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
CAUTI CAUTI
Verbal self-report of pain in the bladder, groin, lower abdo- Fever and/or chills not related to infection at another site;
men, or pelvic area; verbal self-report of fatigue foul-smelling urine; cloudy, dark, and/or blood urine; laboratory
evidence of elevated WBCs, RBCs, and/or bacteria in urinalysis
CLABSI
CLABSI Fever and/or chills not related to infection at another site;
Verbal self-report of pain or tenderness along path of cath- redness at or near the catheter insertion site; drainage
eter or insertion site from skin around the catheter; laboratory evidence of a
recognized pathogen from one or more blood cultures
drawn on separate occasions and catheter tip cultures and
catheter site exudate if present.
VAP
Fever; purulent, increased, or change in pulmonary secre-
tions; positive tracheal cultures; abnormal breath sounds
(e.g., rales/rhonchi, crackles); tachypnea/dyspnea; hypoxia

RISK FACTORS
CAUTI e Contamination of the urine collec- CLABSI
¢ Meatal, rectal, or vaginal organism tion system. e¢ Contaminated hands of health care
° Prolonged/inappropriate personnel during insertion, manipu-
colonization
hands of health care catheterization lation during changing of the line
e Contaminated
° Older age dressing, or during administration of
personnel during insertion or manip-
e Impaired immunity medication through the line.
ulation of the collection system.
e Break in the urine closed drainage * Comorbid conditions (e.g., diabetes, |* Prolonged time in place.
system renal dysfunction)

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20 Chapter 2. = Nurse-Sensitive Indicators

VAP ° Contaminated hands of health care e Presence of a nasogastric or orogastric

e Mechanical ventilation/presence of personnel tube (increased risk for reflux and as-
an endotracheal tube >48 hours e Loss of gag reflex/cough reflex associ- piration)
(aspiration/leakage of secretions ated with decreased level of con- ° Comorbid conditions (e.g., immuno-
above the cuff of an endotracheal tube sciousness and/or sedation. suppression, chronic obstructive
e Ventilator circuit (e.g., collection of Patient positioning (e.g., higher in pulmonary disease [COPD], adult re-
condensation in circuitry) supine patients) spiratory distress syndrome [ARDS])

DESIRED OUTCOMES DOCUMENTATION

The client will remain free from infection as evidenced CAUTI
by: ¢ Catheter insertion date/time
CAUTI e Perineal/catheter maintenance care
e Absence of WBCs, RBCs, and/or bacteria in urine CLABSI
e Normal or baseline urine color ¢ Central line insertion date/time
CLABSI e Dressing change date/time
e Absence of cultured pathogens from blood, catheter tip, VAP
or site samples e Intubation date/time
VAP e Oral care
e Normal or baseline chest x-ray ¢ Insertion depth of ET tube (ET cm marking at lip)*
e Normal or baseline respiratory rate e ET cuff pressure”
e Normal or baseline oxygen saturation (arterial blood
gases as indicated)
e Absence of purulent, excessive secretions

NOC OUTCOMES NIC INTERVENTIONS

Risk control: infectious process; infection severity CAUTI—Infection control; infection protection; urinary
catheterization; tube care: urinary
CLABSI—Infection control; infection protection; central
venous access device management
VAP—Infection control; infection protection; aspiration
prevention; mechanical ventilation management—pneumo-
nia prevention

NURSING ASSESSMENT RATIONALE

Assess for systemic and localized signs and symptoms of Identification of signs and symptoms of infection, both systemic
infection. and localized to the site, allows for prompt intervention.
Systemic
See bevien
e Fatigue
e Headache
e Nausea
Localized
CAUTI
e Foul-smelling urine
e Cloudy, dark, and/or blood urine
CLABSI
e Pain at insertion site
e Exudate at insertion site
e Redness/swelling at insertion site.
VAP
e Purulent, increased, or change in pulmonary secretions
e Abnormal breath sounds
e Dyspnea, tachypnea

*Documentation may be responsibility of respiratory therapy ri

 Chapter 2. = Nurse-Sensitive Indicators 21

Continued...

NURSING ASSESSMENT RATIONALE

Assess laboratory values/cultures for values indicating Serum lab results indicative of infection include abnormal values
infection: in WBC and differential cell counts. National guidelines define
e Absolute granulocyte count collection methods and interpretation of findings specific to in-
e WBC fection sites to be classified as hospital acquired/associated.
e Differential Refer to organizational policies and standard operating proce-
e Cultures (e.g., blood, sputum, urine, site, catheter tip as dures for processes to follow when collecting site specific culture
applicable) for infection determination. Collection of cultures from devices
such as catheter tips requires following detailed steps to prevent
untoward contamination.
Assess applicable radiographic results for evidence of infec- Supporting evidence for diagnosis of VAP is presence of a new infil-
tion (e.g., chest x-ray) trate on chest radiograph.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Follow appropriate hand hygiene practices Hand hygiene must be followed by all health care professionals
e Before touching a client when providing care and should be based upon CDC/World
e Before a procedure Health Organization guidelines.
e After a procedure or exposure to body fluid
e After touching a client
e After touching a client’s surroundings
Implement infection prevention measures during insertion, Organizations implement written guidelines and care bundles that
maintenance care, and removal of devices as appropriate are evidence based and based on national clinical practice rec-
CAUTI ommendations by leading infection prevention organizations
Insertion: (e.g., Society for Healthcare Epidemiology of America [SHEA];
e Adhere to aseptic technique during insertion using sterile Association for Professionals in Infection Control and Epidemi-
equipment—performing hand hygiene prior to insertion. ology [APIC]), as best practices to reduce the risk of infections.
e Cleanse meatus with appropriate antiseptic solution. To ensure quality care, nurses must be aware of and adhere to
organizational policy and standard operating procedures spe-
cific to devices with increased risk for infection.
e Use smallest catheter as possible consistent with proper Use of the smallest appropriate catheter reduces the risk of urethral
drainage. trauma, which may provide an avenue for infection.
Maintenance:
e Properly secure indwelling catheters after insertion. Prevents movement and urethral traction/trauma, which may pro-
vide an avenue for infection.
e Maintain sterile, continuously closed drainage system. Prevents contamination and reduces the risk for infection. If leaks
or breaks in the drainage system occur, replace catheter and
collection system using aseptic technique.
e Maintain unobstructed urine flow, keeping the drainage Allows for free drainage of urine, preventing backflow ofurine into
bag below the level of the bladder and tubing free from the bladder which increases the risk for infection.
kinks.
e Perform routine hygiene, cleaning the metal area with Current guidelines state cleansing with antiseptic solutions is un-
soap and water. necessary. Refer to organizational policy and standard operating
CLABSI procedures for frequency of routine hygiene.
Insertion: Central line insertions, often done at the bedside, are often accom-
e Ensure adherence to aseptic technique performing hand plished with the use of a procedural checklist to ensure adher-
hygiene prior to procedure. ence to aseptic technique and safety procedures. Although inser-
e Maximum sterile barrier precautions should be observed at tion is a function of the physician, all providers assisting should
bedside (e.g., sterile gown, gloves, caps, client drapes). be empowered to stop the procedure if aseptic technique is not
maintained or safety procedures are not being followed.
e Skin preparation with alcoholic chlorhexidine Reduces skin microbes. Skin prep must be allowed to dry before
Maintenance: puncture.
e [CU clients should be bathed with a broad-spectrum topi- Daily bathing with a broad-spectrum topical antimicrobial agent
cal antimicrobial agent (e.g., chlorhexidine) daily. (e.g., chlorhexidine) may reduce HAIs.
e Disinfect catheter hubs, needless connectors, and injec- Before accessing central venous access catheters for infusions, ports
tion ports before accessing catheters. should be vigorously scrubbed with an alcoholic chlorhexidine
° Vigorously scrub with friction for no less than 5 seconds. preparation. Refer to organizational policy and/or standard op-
erating procedures.

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22, Chapter 2. * Nurse-Sensitive Indicators

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Change central venous access catheter dressings, perform- Refer to organizational policy/standard operating procedures for
ing site care with a chlorhexidine- based antiseptic every dressing change frequency. Chlorhexidine, an antimicrobial
5-7 days or immediately if dressing is soiled, loose, or topical solution, has been effective in preventing CLABSIs-
damp. many commercial dressing change kits include a chlorhexidine-
VAP impregnated dressing.
Maintenance: The majority of interventions focused on the prevention of VAP are
e Minimize pooling of secretions above the endotracheal implemented during maintenance while the client is intubated
tube cuff and mechanically ventilated. Keeping the oropharynx free of
e Suctioning the oropharynx as needed subglottic secretions reduces the risk of aspiration of secretions
and the development of pneumonia. Some endotracheal tubes
may have subglottic drainage ports and be used in clients
expected to be ventilated for more than 48-72 hours.
e Perform oral care with chlorhexidine Oral care with chlorhexidine had demonstrated a decrease in VAP
e Consider brushing teeth rates in clinical research studies. Refer to organizational policies
and standard operating procedures for frequency of oral care.
e Endotracheal suctioning should be performed only when Endotracheal suctioning should be performed only as needed,
assessment findings indicate (e.g., rhonchi) using aseptic using sterile technique to avoid cross-contamination. Instilling
technique. of saline prior to suctioning is no longer a recommended
practice.
e Maintain and improve physical conditioning by providing Interventions that promote early mobility in ventilated patients
early exercise and mobilization. increase the rate of return to independent function/extubation
and reduce the risk of VAP.
Ensure appropriately trained personnel are involved in the Delegation practices vary by institution. Nurses must be aware of
insertion, maintenance, and removal of indwelling devices unlicensed assistive personnel who are appropriately trained in
(e.g., urinary catheters, central venous access catheters). the insertion (e.g., urinary catheters) and/or maintenance (e.g.,
perineal care, chlorhexidine bathing, central line dressing
changes) of indwelling devices prone to infection. Review orga-
nizational policy and standard operating procedures before
delegating care.

Dependent/Collaborative Actions
Collaborate with other health care providers in implementing To reduce the risk for hospital-acquired infections, many organiza-
evidence-based care bundles for the appropriate use, inser- tions have established evidence-based written guidelines/care
tion, and maintenance of indwelling devices: bundles for the appropriate use, insertion, and maintenance of
e Urinary catheters urinary catheters, central venous access devices, and endotra-
e Central venous access catheters. cheal tubes/intubation. In addition, many organizations have
e Endotracheal tubes/intubation. implemented nurse driven protocols for the removal of these
same devices. Nurses must be aware of these guidelines and
collaborate with other members of the health care team to en-
sure adherence.
Collaborative with other members of the health care team to Indwelling devices (e.g., urinary catheters/central venous access
ensure indwelling devices (e.g., urinary catheters, central catheters) should be removed as soon as no longer necessary, to
venous access catheters, endotracheal tubes) are removed reduce the risk for infection. Many organizations implement
as soon as no longer necessary. electronic reminders and/or continued use documentation
requirements in the electronic health record to ensure continued
use of these devices is justified.
Collaborate with other members of the health care team for Goal of interventions is to reduce intubation time ana progress
specific interventions to reduce VAP: client towards extubation, reducing the risk for infection.
e Minimize sedation in intubated/mechanically ventilated
clients
e Interrupt sedation (sedation vacation) once a day in clients
without contraindications)
e Conduct spontaneous breathing trials
e Administer prophylactic probiotics as ordered by physi- Some research evidence has reported reduction of VAP rates with
cian or advance practice provider (ARNP, PA). use of probiotics.
 Chapter 2. = Nurse-Sensitive Indicators 23

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Lene
eee ee
If signs and symptoms of infection are observed, consult Allows for modification of the treatment plan.
physician or advanced practice provider (e.g. ARNP; PA).
Obtain blood, urine, site, and/or device-specific cultures as Organizational policies and/or standard operating procedures must
ordered in accordance with hospital policy/standard oper- be followed when obtaining cultures, specimens with potential
ating procedures for collection methods. to confirm an infection, classify the infection as hospital
Administered ordered antibiotics and antifungals as acquired, and guide medical treatment. Not following appropri-
ordered and guided by results of cultures and serum lab ate collection methods may result in cross-contamination, pre-
values. scribing of inappropriate antibiotic therapy, and inappropriate
classification of the infection as hospital acquired.

|Nursing ~Diagnosis |DEFICIENT KNOWLEDGE npx

Definition: Absence of cognitive information related to a specific topic, or its acquisition.
+

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report acknowledging lack of understanding of Inaccurate follow-through of instructions; insufficient
strategies to reduce risk for pressure injury. knowledge

RISK FACTORS DESIRED OUTCOMES

e Alteration in cognitive function
The client will:
e Insufficient interest in learning
e Identify ways to reduce the risk for infection
e Insufficient information
e Remain free of hospital associated infection

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen Teaching: disease process; learning readiness enhancement;
learning facilitation

NURSING ASSESSMENT RATIONALE

Assess for client’s understanding of the risk for acquiring Client engagement in his or her health care could lead to safe
infections upon admission to the hospital. hospital stays. Many clients may not be aware of their risk
for acquiring infections in the hospital and prevention inter-
ventions.
Assess client’s ability and readiness to learn. Learning is more effective when the client is motivated and under-
stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges.
Assess client’s understanding of teaching. It is important for the nurse to ensure client’s understanding
of teaching. Further education using different instructional
modalities may be necessary.

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24 Chapter 2. * Nurse-Sensitive Indicators

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client and family on proper handwashing/use of Hand hygiene is the first line of defense against infection. Clients
alcohol-based foam. and family members can contribute to reducing the risk for
e Instruct client and family to monitor health care provider infection by participating in hand hygiene.
adherence to handwashing when entering the client’s
room.
e Instruct client and family members on when and how best
to perform handwashing.
e Hand hygiene should be performed before preparing or Best practices for hand hygiene include the use of either soap and
eating food; before touching eyes, nose, or mouth; after water or alcohol-based hand sanitizer. Sanitizing with alcohol-
using the restroom; after blowing nose, coughing, or based sanitizers involves covering hands with alcohol-based
sneezing; after touching hospital surfaces (e.g., bed rails, hand sanitizer, rubbing hands together for approximately
bedside tables, phone). 20 seconds, covering all surfaces until hands feel dry. Soap and
e Hand hygiene can be performed using alcohol-based hand water hand hygiene involves application of soap, rubbing hands
sanitizer or with soap and water. together for approximately 15 seconds, rinsing under warm
water, and drying with a paper towel.
Encourage client and family to “speak up” about hand hy- Engaging clients in their care helps to hold all members of the
giene practices, instructing them it is OK to ask health care health care team accountable for preventing infection.
providers if they have cleaned their hands.
Instruct client and family on individual risk for acquiring an Clients and family members should be instructed on the client’s
infection, including signs and symptoms of infection. individual risk factors for infection and signs and symptoms
that should be promptly reported to a health care provider.
 CHAPTER

Selected Nursing Diagnoses,

Interventions, Rationales,
and Documentation

IVT
gsTave BIE Tetatexy is ACTIVITY INTOLERANCE nox
Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

“CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue or weakness Abnormal heart rate or blood pressure response to activity;
exertional discomfort or dyspnea; electrocardiographic
changes reflecting dysrhythmias or ischemia; unable to
speak with physical activity

RISK FACTORS
e Bedrest or immobility e Sedentary lifestyle
e Physical deconditioning e Imbalance between oxygen supply/demand

DESIRED OUTCOMES DOCUMENTATION

The client will demonstrate an increased tolerance for e Activity level
activity as evidenced by: e Statements of weakness and fatigue
a. Verbalization of feeling less fatigued and weak e Exertional dyspnea, chest pain, diaphoresis, or dizziness
b. Ability to perform activities of daily living without e Vital signs before, during, and after activity
exertional dyspnea, chest pain, diaphoresis, dizziness, e Therapeutic interventions
and significant changes in vital signs e Client teaching

NURSING OUTCOMES CLASSIFICATION (NOC) NURSING INTERVENTION CLASSIFICATION (NIC)

OUTCOMES INTERVENTIONS

Activity tolerance; discomfort level; endurance; fatigue level; Activity therapy; energy management; oxygen therapy; nu-
psychomotor energy; self-care status; self-care: activities of trition management; sleep enhancement; cardiac care; car-
daily living; vital signs; energy conservation diac rehabilitation; teaching regarding prescribed activity

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention.
e Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping activ-
ity, change from regular to irregular rate)
° A significant change (e.g. 15-20 mmHg) in blood pressure
with activity.
Assess complete blood cell count (CBC) and report abnormal Anemia results in decreased oxygen-carrying capacity of the blood.
values.

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26 Chapter 3 "Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote rest and/or conserve energy Cells use oxygen and fat, protein, and carbohydrate to produce the
(e.g., maintain prescribed activity restrictions, minimize energy needed for all body activities. Rest and activities that
environmental activity and noise, provide uninterrupted conserve energy result in a lower metabolic rate, which preserves
rest periods, assist with care, and limit the number of nutrients and oxygen for necessary activities.
visitors). D@ >
Discourage smoking and excessive intake of beverages high in Both nicotine and excessive caffeine intake can increase cardiac
caffeine such as coffee, tea, and colas. workload and myocardial oxygen utilization, thereby decreasing
the amount of oxygen necessary for energy production.
Implement measures to improve respiratory status (e.g., en- Altered respiratory function can lead to inadequate tissue oxygen-
courage use of incentive spirometer; elevate head of bed; ation, which results in less efficient energy production and a
assist with turning, coughing, and deep breathing) if inef- reduced ability to tolerate activity. Improving respiratory status
fective breathing pattern, ineffective airway clearance, or increases the amount of oxygen available for energy production.
impaired gas exchange is contributing to client’s activity It also eases the work of breathing, which reduces energy expen-
intolerance. D+ diture.
Instruct client to report a decreased tolerance for activity and These symptoms indicate that insufficient oxygen is reaching the
to stop any activity that causes chest pain, shortness of tissues and that activity has been increased beyond a therapeu-
breath, dizziness, or extreme fatigue or weakness. tic level.

Dependent/Collaborative Actions
Implement measures to increase cardiac output (e.g., admin- Sufficient cardiac output is necessary to maintain an adequate
ister positive inotropic agents, vasodilators, or antidys- blood flow and oxygen supply to the tissues. Adequate tissue
thythmics as ordered; elevate the head of the bed) if de- oxygenation promotes more efficient energy production, which
creased cardiac output is contributing to the client’s subsequently improves client’s activity tolerance.
activity intolerance.
Implement measures to reduce fever if present (e.g., adminis- An elevated temperature increases the metabolic rate with subse-
ter tepid sponge bath, administer antipyretics as ordered). quent depletion of available energy and a decrease in the ability
D+ to tolerate activity.
Maintain oxygen therapy as ordered. An oxygen deficiency results in anaerobic metabolism, which is less
efficient than the aerobic mechanism of energy supply. Supple-
mental oxygen helps to alleviate hypoxia and restore the more
efficient aerobic metabolism, thereby improving energy levels
and activity tolerance.
Implement measures to maintain an adequate nutritional Metabolism is the process by which nutrients are transformed into
status (e.g., provide a diet high in essential nutrients, energy. If nutrition is inadequate, energy production is de-
provide dietary supplements as indicated, and administer creased, which subsequently reduces one’s ability to tolerate
vitamins and minerals as ordered). activity.
Implement measures to treat anemia if present (e.g., adminis- Anemia reduces the oxygen-carrying capacity of the blood. Resolu-
ter prescribed iron, folic acid, and/or vitamin B12; admin- tion of anemia increases oxygen availability to the cells, which
ister packed red blood cells as ordered). increases the efficiency of energy production and subsequently
improves activity tolerance.
Increase client’s activity gradually as allowed and tolerated. A gradual increase in activity helps prevent a sudden increase in
De+ cardiac workload and myocardial oxygen consumption and
the subsequent imbalance between oxygen supply and de-
mand. Progressive activity also helps strengthen the myocar-
dium, which enhances cardiac output and improves activity
tolerance. '
Consult physician if signs and symptoms of activity intoler- Notifying the physician allows for modification of the treatment
ance persist. plan.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 27.

Nursing Diagnosis INEFFECTIVE AIRWAY CLEARANCE no.

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Dyspnea, orthopnea; diminished breath sounds; adventi-
tious breath sounds (e.g., crackles, rhonchi, wheezes);
cough, ineffective or absent sputum production; difficulty
vocalizing; wide-eyed; restlessness; changes in respiratory
rate and rhythm; cyanosis

RISK FACTORS
e Environmental: Smoking; smoke in- presence of artificial airway; foreign walls; chronic obstructive pulmo-
halation; second-hand smoke; air body in airway; secretions in the nary disease; infection; asthma;
quality/pollutants bronchi; exudates in the alveoli allergic/reactive airways
“e Obstructed airway: Airway spasm; e Physiologic: Neuromuscular dysfunc-
retained secretions; excessive mucus; tion; hyperplasia of the bronchial

DESIRED OUTCOMES DOCUMENTATION

The client will maintain clear, open airways as evidenced e Breath sounds
by: e Rate, depth, and ease of respirations
a. Normal breath sounds e Characteristics of cough
b. Normal rate and depth of respirations e Description of sputum
c. Absence of dyspnea e Therapeutic interventions
e Client teaching

NOC OUTCOMES NIC INTERVENTIONS

Risk control: aspiration; mechanical ventilation response: Respiratory monitoring; airway management; airway
respiratory status: airway patency; respiratory status: suctioning; chest physiotherapy; cough enhancement
ventilation

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of ineffective airway clearance: Early recognition of signs and symptoms of ineffective airway
e Abnormal breath sounds clearance allows for prompt intervention.
e Rapid, shallow respirations
e Dyspnea
e Nonproductive cough

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to decrease pain if present: Pain often interferes with a client’s willingness to move, cough, and
e Splint chest or abdominal incisions with pillow when deep breathe. Pain reduction enables the client to increase activ-
coughing and deep breathing. D+ ity and cough and deep breathe more effectively, all of which
promote effective airway clearance.
Instruct and assist client to change position, deep breathe, Repositioning helps mobilize secretions. Deep breathing helps clear
and cough or “huff” every 1 to 2 hrs. D + the airways by loosening secretions and promoting a more effec-
tive cough. Coughing or “huffing” (i.e., a forced expiration
technique) accelerates airflow through the airways, which helps
mobilize and clear mucus and foreign matter from the respira-
tory tract.

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Discourage smoking. Irritants present in smoke increase mucus production, impair cili-
ary function, and can cause inflammation and damage to the
bronchial walls. This results in narrowed airways and stasis of
pulmonary secretions.
Perform oral suctioning if needed. D + Suctioning removes secretions from the large airways. It also
stimulates coughing, which helps clear airways of mucus and
foreign matter.

Dependent/Collaborative Actions
Implement measures to decrease pain: Pain often interferes with a client’s willingness to move, cough, and
e Administer prescribed analgesics before planned activity. deep breathe. Pain reduction enables the client to increase activ-
D+ ity and cough and deep breathe more effectively, all of which
promote effective airway clearance.
Increase activity as allowed and tolerated. D@ + Activity helps to mobilize secretions and promotes deeper breath-
ing. Deep breathing can help loosen secretions and enhance the
effectiveness of coughing.
Implement measures to thin secretions and maintain ade- Adequate hydration and humidified inspired air help thin secre-
quate moisture of the respiratory mucous membranes: tions, which facilitates the mobilization and expectoration
e Maintain a fluid intake of 2500 mL/day, if tolerated of secretions. These actions also reduce dryness of the respi-
° Humidify inspired air D + ratory mucous membrane, which helps enhance mucociliary
Assist with the administration of mucolytics (e.g., acetylcyste- clearance.
ine) and diluting or hydrating agents (e.g., water, saline) Mucolytics and diluents or hydrating agents are mucokinetic
via nebulizer as ordered. substances that reduce the viscosity of mucus, thus making it
easier for the client to mobilize and clear secretions from the
respiratory tract.
Administer expectorants if ordered (e.g., guaifenesin, dornase Expectorants reduce the viscosity of sputum, making it easier to be
alfa). D+ removed by coughing or suctioning.
Administer the following medications if ordered: These medications increase the patency of the airways and en-
e Bronchodilators hance bronchial airflow. Methylxanthines and sympathomi-
e Methylxanthines (e.g., theophylline, aminophylline, metics produce bronchodilation by relaxing the bronchial
oxtriphylline) smooth muscle. Anticholinergic agents block cholinergic reflex
e Sympathomimetic (adrenergic) agents (e.g., albuterol, constriction of the bronchioles and decrease mucus production.
terbutaline, metaproterenol, salmeterol) Corticosteroids and leukotriene modifiers reduce inflammation
° Anticholinergic agents (e.g., ipratropium) in the airways, which results in decreased bronchial hyperactiv-
° Corticosteroids ity and constriction and mucus production.
e Prednisone
e Methylprednisolone
e Beclomethasone
e Flunisolide
e Triamcinolone
e Budesonide
e Leukotriene modifiers
° Montelukast
° Zafirlukast +
Administer central nervous system depressants judiciously. Central nervous system depressants depress the cough reflex, which
can result in stasis ofsecretions.
Assist with or perform postural drainage therapy if ordered. Postural drainage therapy techniques (e.g., vibration, pertussion,
postural drainage) use the forces of motion and gravity to
mobilize secretions from the periphery of the lungs to the larger
central airways where they can be removed by coughing or
suctioning.
Consult the appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
respiratory therapist) if signs and symptoms of ineffective tion of the treatment plan.
airway clearance persist.
 Chapter 3 " Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 29

ae mec e ANXIETY nox

Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspe-
cific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting
sign that warns of impending danger and enables the individual to take measures to deal with that threat.

CLINICAL MANIFESTATIONS

Subjective Objective
Behavioral: Verbal self-report of concerns due to change Behavioral: Diminished productivity; scanning and
in life events vigilance; poor eye contact; restlessness; glancing about;
extraneous movement (e.g., foot shuffling, hand/arm
movements); insomnia; fidgeting
Affective: Verbal self-report of painful and persistent Affective: Regretful; irritability, anguish; scared; jittery;
increased helplessness; uncertainty; increased wariness; overexcited; rattled; focus on self; fearful; distressed;
feelings of inadequacy worried, apprehensive; anxious
Physiologic: Verbal self-report of dry mouth; nausea, Physiologic: Voice quivering; trembling/hand tremors;
fatigue shakiness; urinary urgency; increased pulse; pupil dilation;
increased reflexes; abdominal pain; sleep disturbance; tin-
gling in extremities; cardiovascular excitation; increased
perspiration; facial tension; anorexia; heart pounding;
diarrhea; weakness; facial flushing; superficial vasoconstric-
tion; twitching; faintness; respiratory difficulties; increased
blood pressure
Cognitive: Verbal self-report of fear of unspecified Cognitive: Blocking of thought; confusion; preoccupation;
consequences; awareness of physiological symptoms forgetfulness; rumination; impaired attention; decreased
perceptual field; tendency to blame others; difficulty con-
centrating; diminished ability to problem solve; dimin-
ished ability to learn

RISK FACTORS
Exposure to toxins Situational/maturational crises Threat to or change in environment
Threat to or change in role status Threat of death Stress
Unconscious conflict about essential Threat to or change in health status Threat to or change in economic
values/goals of life Threat to or change in interaction status
Familial association/hereditary patterns Substance abuse
Unmet needs Threat to or change in role function
Interpersonal transmission/contagion Threat to self-concept

DESIRED OUTCOMES DOCUMENTATION

The client will experience a reduction in anxiety as evi- e Verbalization of feeling anxious
denced by: e Sleep pattern
a. Verbalization of feeling less anxious e Facial expression and body movement
b. Usual sleep pattern e Vital signs
c. Relaxed facial expression and body movements e Focus on self
d. Stable vital signs e Client’s perception of precipitating factors
e. Usual perceptual ability and interaction with others e Therapeutic interventions
e Client/family teaching

NOC OUTCOMES NIC INTERVENTIONS

Anxiety level; anxiety self-control; concentration; coping; Anxiety reduction; calming technique; emotional support;
hyperactivity level presence

NDx = NANDA Diagnosis D = Delegatable Action @=UAP > =LVN/LPN © = Go to ©volve for animation
 30 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of anxiety: Early recognition of signs and symptoms of anxiety allows for
e Verbalization of feeling anxious prompt intervention.
e Insomnia
e Tenseness
e Shakiness
e Restlessness
e Diaphoresis
e Tachycardia
e Elevated blood pressure
e Self-focused behaviors

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage verbalization of feelings and concerns and assist Verbalization of feelings and concerns helps the client identify fac-
client to identify specific stressors that may be causing tors that are causing anxiety. Providing feedback helps the client
anxiety. Provide feedback. clarify and validate feelings and concerns, and identify tech-
niques that can reduce anxiety.
Orient client to environment, equipment, and routines. Familiarity with the environment and usual routines reduces the
D+e client’s anxiety about the unknown, provides a sense of secu-
rity, and increases his/her sense of control, all of which help
decrease anxiety.
All care providers should properly introduce themselves and Introduction to staff familiarizes the client with those individuals
identify their role. If possible, maintain consistency in who will be working with him/her, which provides the client
staff assigned to his/her care. with a feeling of stability, which reduces the anxiety that typi-
cally occurs with change.
Assure client that staff members are nearby. Respond to call Close contact and a prompt response to requests provide a sense of
signal as soon as possible. security and facilitates the development of trust, thus reducing
the client’s anxiety.
All care providers should maintain a calm, supportive, confi- A sense of calmness and confidence conveys to the client that some-
dent manner when interacting with the client. D ¢ @ one is in control of the situation, which helps reduce anxiety.
Reinforce physician’s explanations and clarify misconcep- Factual information and an awareness of what to expect help
tions the client has about the diagnostic tests, disease decrease the anxiety that arises from uncertainty.
condition, treatment plan, surgical procedure, and/or
prognosis.
Implement measures to reduce respiratory distress if present: Improvement of respiratory status helps relieve anxiety associated
e Elevate the head of the bed with the feeling of not being able to breathe.
e Encourage the client to breathe deeply and more slowly
Implement measures to reduce pain if present: Pain can create or increase anxiety because it is often perceived as
e Instruct and assist with relaxation techniques. a threat to well-being. Pain also causes sympathetic nervous
system stimulation with subsequent feelings of tenseness and
increased anxiety.
Provide a calm, restful environment. D+ @ A calm, restful environment facilitates relaxation and promotes a
sense of security, which reduces anxiety.
When appropriate, assist the client to meet spiritual needs Spiritual support is a source of comfort and security for many
(e.g., arrange for a visit from the clergy). people and can help reduce the client’s anxiety.
Encourage significant others to project a caring, concerned Anxiety is easily transferable from one person to anothe. Ifsig-
attitude without obvious anxiousness. nificant others convey empathy, provide reassurance, and do not
appear anxious, they can help reduce the client’s anxiety.
Include significant others in orientation and teaching ses- Significant others can help reduce the client’s anxiety by reinforcing
sions and encourage their continued support of the client. information that he/she has difficulty understanding or recall-
ing. In addition, the presence of significant others often provides
the client with a sense of support and security, which helps to
reduce anxiety.
Provide information based on current needs of client at a Providing the client with information that he/she is not ready to
level he/she can understand. Encourage the client to process or cannot understand tends to increase anxiety. Making
ask questions and to seek clarification of information the client feel comfortable enough to ask questions or clarify
provided. information helps to reduce anxiety.
 Chaptencm Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 31

THERAPEUTIC INTERVENTIONS RATIONALE

Include significant others in orientation and teaching ses- Significant others can help reduce the client’s anxiety by reinforcing
sions and encourage their continued support of the client. information that he/she has difficulty understanding or recall-
ing. In addition, the presence of significant others often provides
the client with a sense of support and security, which helps
reduce anxiety.

Dependent/Collaborative Actions
Administer oxygen therapy as ordered. D> Improvement of respiratory status helps relieve anxiety associated
with the feeling of not being able to breathe.
Administer prescribed analgesics if pain is present. D+ Pain can create or increase anxiety because it is often perceived as
a threat to well-being. Pain also causes sympathetic nervous
system stimulation with subsequent feelings of tenseness and
increased anxiety.
Administer prescribed antianxiety agents if indicated. D+ Medications are sometimes prescribed to help reduce the client’s
anxiety. Benzodiazepines (e.g., lorazepam, diazepam, alpra-
zolam, chlordiazepoxide) are the drugs of choice for manage-
ment of short-term anxiety. These drugs augment the inhibitory
effect of gamma-aminobutyric acid (GABA) on cell membrane
responses to excitatory neurotransmitters.
Initiate a social service referral and/or assist client to identify Concerns about factors such as finances, follow-up medical care,
and contact appropriate community resources if indicated. and home maintenance can be a source of great anxiety. Facili-
tating contact with the appropriate resources can help reduce
the client’s anxiety and provide ongoing support.
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse practitioner, psychologist, psychiatrist, physician) if tion of the treatment plan.
above actions fail to control anxiety.

Nursing Diagnosis

Definition: Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheobron-
chial passages, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath, difficulty Rhonchi; dull percussion note over affected lung area;
swallowing cough; tachypnea; tachycardia; presence of tube feeding
in tracheal aspirate; dyspnea, cough, excessive drooling

RISK FACTORS
e Reduced level of consciousness ° Gastrointestinal tubes ° Increased gastric residual
e Depressed cough and gag reflexes e Tube feedings e Decreased gastrointestinal motility
e Presence of tracheostomy or ° Medication administration ° Delayed gastric emptying
endotracheal tube ° Situations hindering elevation of ° Impaired swallowing
upper body e Facial, oral, neck surgery or trauma
e Incompetent lower esophageal
sphincter ° Increased intragastric pressure ° Wired jaws

DESIRED OUTCOMES DOCUMENTATION

The client will not aspirate secretions or foods/fluids as e Breath sounds

evidenced by: e Percussion note over lungs
a. Clear breath sounds ¢ Respiratory rate and effort
b. Resonant percussion note over lungs e Presence of cough
c. Absence of cough, tachypnea, and dyspnea e Pulse rate
e¢ Color of tracheal aspirate
e Therapeutic interventions
¢ Client/family teaching

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 32 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

NOC OUTCOMES NIC INTERVENTIONS

Risk control: aspiration; body positioning; gastrointestinal Aspiration precautions; respiratory monitoring; swallowing
function; nausea and vomiting control; respiratory status; therapy; airway suctioning
swallowing status

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of aspiration of Early recognition of signs and symptoms of aspiration allows for
secretions or foods/fluids: prompt intervention.
e Rhonchi
Dull percussion note over affected lung area
¢ Cough
e Tachypnea
Dyspnea
Tachycardia
e Presence of tube feeding in tracheal aspirate
Assist with diagnostic studies to determine if aspiration is Aspiration of foods/fluids during swallowing process is evident on
occurring during swallowing (e.g., videofluoroscopy). studies such as video fluoroscopy. Knowing when aspiration
occurs during the swallowing process aids in the development of
an individualized plan of care to prevent further aspiration.
Monitor chest radiograph results. Report findings of pulmo- Evidence of pulmonary infiltrate on chest radiograph results can
nary infiltrate. indicate that aspiration has occurred.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent aspiration if client has a The risk for aspiration is high when mechanisms to protect the cli-
depressed or absent gag reflex, severe dysphagia, and/or ent’s airway (e.g., gag reflex, swallowing reflex) are impaired or
decreased level of consciousness: the client has a decreased level ofconsciousness.
e Withhold oral foods/fluids. D+ Withholding oral foods/fluids eliminates the possibility of aspira-
tion of same.
Place client in a side-lying position unless contraindicated. Placing the client in a side-lying position allows oral secretions to
De+ accumulate in the mouth where they can be expectorated or
removed by suctioning rather than flow into the pharynx where
they can enter the larynx and be aspirated.
Perform oral hygiene and/or oropharyngeal suctioning as Removing excess secretions from the mouth and pharynx prevents
often as needed to remove excess secretions. D + them from entering the larynx and being aspirated.
Implement measures to prevent vomiting (e.g., eliminate When the client vomits, gastric contents move up the esophagus,
noxious sights and odors). D + through the pharynx, and into the mouth. While vomitus is in
the pharynx, it can spill into the larynx resulting in aspiration.
If client is receiving tube feedings, check tube placement be- Verification of feeding tube placement ensures that the tube feeding
fore each feeding or on a routine basis if tube feeding is solution goes into the alimentary tract rather than the lungs.
continuous. D +
Implement measures to prevent aspiration when client is eat- When the client is eating and drinking, there is a high risk for as-
ing and drinking: piration before the swallowing reflex is triggered (i.e., the larynx
and pharynx are at rest and the airway is open at this time),
during swallowing if the larynx does not close completely, and
after swallowing when the larynx opens again.
e Place client in high Fowler’s position unless contra- This position uses gravity to facilitate movement of foods/fluids
indicated. D@ + through the pharynx into the esophagus where the risk for aspi-
ration is greatly reduced.
e Instruct client to avoid laughing or talking when swallowing. Normally, when the swallowing reflex is triggered, the folds of the
larynx that form its three valves contract so that aspiration does
not occur as foods/fluids pass from the back of the mouth
through the pharynx. When the client talks and laughs, air is
forced through the trachea and the larynx opens. Instructing the
client to avoid talking and laughing when swallowing reduces
the risk of the airway being open when food/fluid is in the
pharynx.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 33

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to concentrate on eating and drinking If the client becomes distracted and/or is rushed during meals or
and allow ample time for meals and snacks. snacks, swallowing and breathing attempts can become uncoor-
dinated. This results in the larynx being open when the food/
fluid is in the pharynx, which greatly increases the risk for
aspiration.
e Instruct client to dry swallow, cough twice, or clear his or If the client has a swallowing impairment such as decreased pha-
her throat after swallowing if indicated. ryngeal peristalsis, food/fluid can remain in the pharyngeal re-
cesses after the swallowing reflex has occurred. Dry swallowing,
coughing, or clearing the throat helps ensure that the pharynx
is clear after swallowing, which reduces the risk for aspiration.
e Instruct and assist the client to perform oral hygiene after Good oral hygiene after meals results in removal of remaining
meals. food particles that could enter the larynx and be aspirated
into the lungs.

Dependent/Collaborative Actions
Administer antiemetics as ordered. D > When the client vomits, gastric contents move up the esophagus,
+ through the pharynx, and into the mouth. While vomitus is in
the pharynx, it can spill into the larynx resulting in aspiration.
Implement measures to reduce the risk of regurgitation (i.e., As gastric secretions or foods/fluids accumulate in the stomach,
maintain gastric decompression as ordered, provide small upward pressure is placed on the lower esophageal sphincter
meals rather than large ones, evaluate patient clinical tol- (LES). If the pressure increases significantly and/or the client
erance of tube feedings if gastric residual >200-250 mL), has an incompetent LES, regurgitation can occur. Contents that
maintain client in high Fowler’s position for at least 30 move up through the esophagus into the pharynx can spill into
minutes after meals and tube feedings, administer upper the larynx, resulting in aspiration.
gastrointestinal stimulants as ordered. D +
Perform actions to improve swallowing if indicated (e.g., se- Improving the ability to swallow helps ensure that foods/fluids do
lect foods/fluids appropriate to client’s swallowing ability, not enter the larynx when the client is eating or drinking.
reinforce exercises to strengthen and develop muscles used
in swallowing).

Nursing Diagnosis INEFFECTIVE BREATHING PATTERN nox

Definition: Inspiration and/or expiration that does not provide adequate ventilation.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Dyspnea; orthopnea; respiratory rate (adults [ages =14 years],
<11 or >24 breaths/min; infants, <25 or >60 breaths/
min; ages 1-4 years, <20 or >30 breaths/min; ages
5-14 years, <14 or >25 breaths/min); depth of breathing
(tidal volume: adults, 500 mL at rest; infants, 6-8 mL/kg);
decreased inspiratory/expiratory pressure; decreased min-
ute ventilation; decreased vital capacity; nasal flaring; use
of accessory muscles to breathe; assumption of three-point
position; altered chest excursion; pursed-lip breathing;
prolonged expiration phases; increased anterior-posterior
chest diameter; decreased pulse oximetry readings

RISK FACTORS
e Hyperventilation e Decreased energy/fatigue e Spinal cord injury
e Respiratory muscle fatigue e Neuromuscular dysfunction e Body position that inhibits lung
e Pain e Musculoskeletal impairment expansion
e Perception/cognitive impairment e Chest wall deformity e Neurologic immaturity
e Anxiety ° Obesity

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to @volve for animation
 34 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

DESIRED OUTCOMES DOCUMENTATION

The client will maintain an effective breathing pattern as ¢ Rate, depth, and ease of respirations
evidenced by: e Chest excursion
a. Normal rate and depth of respirations ¢ Oximetry results
b. Symmetric chest excursion e Therapeutic interventions
c. Absence of dyspnea ¢ Client teaching

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: airway patency; respiratory status: venti- Respiratory monitoring; ventilation assistance; anxiety
lation; respiratory status: gas exchange; vital signs reduction

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern (e.g., shallow respirations, tachypnea, limited pattern allows for prompt intervention.
chest excursion, dyspnea, use of accessory muscles when
breathing).
Monitor for and report a significant decrease in oximetry Oximetry is a noninvasive method of measuring arterial oxygen
results. saturation. The results assist in evaluating respiratory status.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce chest or abdominal pain if A client with chest or upper abdominal pain often guards respira-
present (e.g., splint incision with pillow during coughing tory efforts and breathes shallowly in an attempt to prevent
and deep breathing). D+ additional discomfort.
Implement measures to decrease fear and anxiety (e.g., assure Fear and anxiety may cause a client to breathe shallowly or to
client that breathing deeply will not dislodge tubes or hyperventilate. Decreasing fear and anxiety allows the client to
cause incision to break open, interact with client in a con- focus on breathing more slowly and taking deeper breaths.
fident manner).
Implement measures to increase strength and activity toler- An increase in strength and activity tolerance enables the client to
ance if client is weak and fatigued (e.g., provide uninter- breathe more deeply and participate in activities to improve
rupted rest periods, maintain optimal nutrition). D + breathing pattern.
Place client in a semi- to high-Fowler’s position unless contra- A semi- to high-Fowler’s position allows for maximal diaphrag-
indicated. Position with pillows to prevent slumping. matic excursion and lung expansion. Prevention of slumping
De+ is essential because slumping causes the abdominal contents
to be pushed up against the diaphragm and restricts lung
expansion.
If client must remain flat in bed, assist with position change Compression of the thorax and subsequent limited chest wall and
at least every 2 hrs. D@® lung expansion occur when the client lies in one position. Fre-
quent repositioning promotes maximal chest wall and lung
expansion.
Instruct client to deep breathe or use incentive spirometer Deep breathing and use of an incentive spirometer promote maxi-
every 1 to 2 hrs. D$ mal inhalation and lung expansion. Deep inhalation also
stimulates surfactant production, which lowers alveolar surface
tension and subsequently increases lung compliance and ease of
inflation.
Instruct client in and assist with diaphragmatic and pursed- Diaphragmatic breathing promotes greater movement of the dia-
lip breathing techniques if appropriate. NOTE: Diaphrag- phragm and decreases the use of accessory muscles for inspira-
matic breathing is most often indicated for clients who tion. Use of this technique eases the work of breathing and ul-
have had thoracic surgery or clients who have chronic timately promotes an increased efficiency of alveolar ventilation.
airflow limitation (e.g., emphysema) or neuromuscular Pursed-lip breathing causes a mild resistance to exhalation,
conditions that cause fixation or weakening of the which creates positive pressure in the airways. This pressure
diaphragm. helps prevent airway collapse and subsequently promotes more
complete alveolar emptying.
Instruct client to breathe slowly if hyperventilating. Hyperventilation is an ineffective breathing pattern that can even-
tually lead to respiratory alkalosis. The client can often slow
breathing rate ifhe/she concentrates on doing so.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 35

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Administer prescribed analgesics before planned activity. D + Pain reduction enables the client to breathe more deeply.
Assist with positive airway pressure techniques (e.g., continu- Positive airway pressure techniques increase intrapulmonary (i.e.,
ous positive airway pressure [CPAP], bilevel positive airway alveolar) pressure, which helps reexpand collapsed alveoli and
pressure [BiPAP], flutter/positive expiratory pressure [PEP] prevent further alveolar collapse.
device) if ordered.
Instruct client in and assist with segmental or localized Segmental or localized breathing exercises improve expansion of
breathing exercises if appropriate (may be indicated for apical and/or basal areas of the lung by having the client focus
clients with painful respiratory conditions or clients who on selectively expanding these areas of the chest.
have had thoracic or abdominal surgery).
Increase activity as allowed and tolerated. D + During activity, especially ambulation, the client usually takes
deeper breaths, thus increasing Tung expansion.
Administer central nervous system depressants judiciously. Central nervous system depressants cause depression of the respira-
Hold medication and consult physician if respiratory rate tory center in the brainstem, which can result in a decreased
is less than 12/min. rate and depth of respiration.
Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
~ respiratory therapist) if ineffective breathing pattern tion of treatment plan.
continues.

Nursing Diagnosis DECREASED CARDIAC OUTPUT nox

Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body.

CLINICAL MANIFESTATIONS

Subjective Objective
Behavioral/Emotional: Verbal self-report of anxiety; Altered Heart Rate/Rhythm: Dysrhythmias; palpitations;
restlessness electrocardiogram (ECG) changes
Altered Preload: Jugular vein distention (JVD); fatigue;
edema; murmurs; increased/decreased central venous pres-
sure (CVP); increased/decreased pulmonary artery wedge
pressure (PAWP); weight gain
Altered Afterload: Cold/clammy skin; shortness of breath/
dyspnea; oliguria; prolonged capillary refill; decreased pe-
ripheral pulses; variations in blood pressure (BP) readings;
increased/decreased systemic vascular resistance (SVR);
increased/decreased pulmonary vascular resistance (PVR);
skin color changes
Altered Contractility: Crackles; cough; orthopnea/parox-
ysmal nocturnal dyspnea; cardiac output (CO) <4, L/min;
cardiac index <2.5 L/min; decreased ejection fraction,
stroke volume index (SVJ), left ventricular stroke work
index (LVSWI); S3 or Sy sounds

RISK FACTORS
e Altered heart rate/rhythm e Altered afterload
e Altered stroke volume e Altered contractility
e Altered preload

D = Delegatable Action @ = UAP @ =LVN/LPN ©) = Go to ©volve for animation

NDx = NANDA Diagnosis
 36 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

DESIRED OUTCOMES DOCUMENTATION

The client will maintain adequate CO as evidenced by: e Vital signs
. BP within normal range for client ¢ Heart sounds
. Apical pulse regular and 60 to 100 beats/min e Activity tolerance
. Absence of gallop rhythms e Breath sounds
. Absence of fatigue and weakness e Ease of respirations
. Unlabored respirations at 12 to 20 breaths/min ¢ Mental status
. Clear, audible breath sounds e Peripheral pulses
op
AmoUsual mental status e Capillary refill time
e Skin color and temperature
e Urine output
e Presence of edema
e Presence of JVD
¢ Hemodynamic measurements (e.g., CO, pulmonary
artery pressure [PAP], pulmonary capillary wedge pres-
sure [PCWP], CVP)
e Therapeutic interventions
¢ Client teaching
e¢ Dysrhythmias

NOC OUTCOMES NIC INTERVENTIONS

———_—__
S err __—____—_———————————
S ————————— S

Cardiac pump effectiveness; cardiopulmonary status; circula- Cardiac care: acute; invasive hemodynamic monitoring;
tion status; fluid overload severity; tissue perfusion: abdomi- hemodynamic regulation; cardiac precautions; dysrhythmia
nal organs, cardiac, cellular, cerebral, and peripheral; vital management; oxygen therapy; hypovolemia management;
signs hypervolemia management; electrolyte management: hypo-
magnesemia; electrolyte management: hyperkalemia; cardiac
care: rehabilitative

NURSING ASSESSMENT
RATIONALE
eee

Assess for and report signs and symptoms of decreased CO: Early recognition of signs and symptoms of decreased CO allows
e Variations in BP (may be increased because of compensa- for prompt intervention.
tory vasoconstriction; may be decreased when compensa-
tory mechanisms and pump fail)
e Tachycardia
e Presence of gallop rhythm
e Fatigue and weakness
e Dyspnea, tachypnea
e Crackles (rales)
° Restlessness, change in mental status
e Dizziness, syncope
e Diminished or absent peripheral pulses
° Cool extremities
e Pallor or cyanosis of skin
° Capillary refill time greater than 2 to 3 seconds
e Oliguria
e Edema
¢ JVD
e Hemodynamic abnormalities such as decreased CO and
increased PAP, PCWP, and CVP
Monitor ECG readings and report significant abnormalities. ECG readings provide data regarding functioning of the heart’s
electrical conduction system. Altered generation or transmission
of electrical impulses often causes an abnormal heart rate or
rhythm that can lead to decreased CO.
Monitor chest radiograph results. Report findings of cardio- Chest radiograph films provide data regarding the size of the heart,
megaly, pulmonary vascular congestion, pleural effusion, volume of blood in the pulmonary vessels, and fluid accumula-
or pulmonary edema. tion in the pleural space, pulmonary interstitium, and alveoli.
Cardiomegaly often results in decreased CO, whereas pulmo-
nary vascular congestion, pleural effusion, and pulmonary
edema are often a result of decreased CO.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 37

NURSING ASSESSMENT RATIONALE

crceee ee ee eee

Monitor serum electrolytes, cardiac enzymes, troponin, and Alterations in serum electrolytes such as potassium and magne-
brain natriuretic peptide (BNP) levels. sium can precipitate cardiac dysrhythmias that may. signifi-
cantly alter CO/tissue perfusion. Serum troponin level altera-
tions can indicate myocardial tissue damage, while serum BNP
levels can indicate congestive heart failure. The presence of
either situation can influence optimum CO.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce cardiac workload: Cardiac workload is the effort the heart expends to pump blood. The
work of the heart is determined largely by the volume of blood
distending the ventricles at the end of diastole (preload) and the
amount of tension the ventricle must pump against to eject blood
(afterload). Decreasing cardiac workload reduces the work that
the compromised heart must perform in order to pump an ade-
+
quate amount of blood. This results in increased CO.
e Place client in a semi- to high-Fowler’s position. D @+ Elevation of client’s upper body reduces cardiac workload by
decreasing venous return from the periphery and subsequently
reducing preload.
e Instruct client to avoid activities that create a Valsalva re- When a client exhales after the Valsalva maneuver, the intra-
sponse (e.g., straining to have a bowel movement, holding thoracic pressure falls, causing a sudden increase in venous return
breath while moving up in bed). and a subsequent increase in preload and cardiac workload. The
rebound increase in heart rate and BP that occurs after the Val-
salva maneuver also causes an increase in cardiac workload.
e Perform actions to promote physical and emotional rest Physical rest reduces cardiac workload by lowering the body’s en-
(e.g., maintain a calm, quiet environment; limit the num- ergy requirements and subsequent need for oxygen. Promoting
ber of visitors; maintain activity restrictions). D+ emotional rest reduces cardiac workload by preventing the in-
crease in heart rate and BP that accompanies stress-induced
sympathetic nervous system stimulation.
e Perform actions to promote adequate tissue oxygenation When tissue oxygenation is adequate, the heart does not need to
(e.g., encourage deep breathing exercises and use of incen- work as hard to supply oxygen to the tissues; thus more oxygen
tive spirometer). D+ is available for myocardial use.
e Discourage smoking. Nicotine stimulates catecholamine output, which increases heart
rate and causes vasoconstriction and subsequently increases car-
diac workload. Smoking also reduces oxygen availability because
hemoglobin has a greater affinity for the carbon monoxide in
smoke than for oxygen. This increases cardiac workload as the
heart tries to compensate for the reduced oxygen levels.
e Discourage excessive intake of beverages high in caffeine Excessive caffeine can increase cardiac workload because caffeine
such as coffee, tea, and colas is a myocardial stimulant and can increase the rate and force of
myocardial contractions.
e Provide small meals rather than large ones. Large meals can increase cardiac workload because they require a
greater increase in blood supply to the gastrointestinal tract to
aid digestion.

Dependent/Collaborative Actions
Implement measures to prevent hypovolemia (e.g., maintain Hypovolemia reduces venous return to the heart, which subse-
a minimal fluid intake of 1000 mL/day unless ordered quently decreases the amount of blood in the ventricles at the
otherwise, consult physician before giving diuretics if ex- end of diastole (preload). This results in a decrease in stroke
cessive weight loss has occurred or client develops postural volume and CO.
hypotension, administer blood and/or colloid or crystal-
loid solutions as ordered).
Maintain oxygen therapy as ordered. D + When tissue oxygenation is adequate, the heart does not need to
work as hard to supply oxygen to the tissues; thus more oxygen
is available for myocardial use.
Perform actions to prevent or treat fluid volume excess (e.g, Preventing or treating excess fluid volume reduces vascular volume,
maintain prescribed fluid and dietary sodium restrictions, which decreases preload and afterload and subsequently reduces
administer diuretics as ordered). cardiac workload.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Goto ©volve for animation
 38 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Increase activity gradually as allowed and tolerated. D@ A gradual increase in activity prevents a sudden increase in cardiac
workload. A graded activity program also helps strengthen and
tone the myocardium, which ultimately increases CO.
Administer the following medications if ordered:
e Positive inotropic agents (e.g., digitalis preparations, Positive inotropic agents increase CO by improving myocardial
dobutamine, dopamine, inamrinone, milrinone) contractility.
e Nitrates (e.g., nitroglycerin, isosorbide dinitrate) Nitrates decrease cardiac workload and myocardial oxygen de-
mands by relaxing peripheral veins and, to a lesser extent, arte-
rioles. This reduces venous return to the heart (preload) and
peripheral vascular resistance (afterload). Nitrates also dilate
nonsclerosed coronary arteries, which improves coronary blood
flow and myocardial oxygen supply.
e Direct-acting vasodilators (e.g., sodium nitroprusside, hy- Vasodilators reduce cardiac workload by dilating the arterioles and
dralazine) or centrally acting or alpha-adrenergic inhibi- subsequently decreasing peripheral vascular resistance (after-
tors (e.g., clonidine, prazosin, doxazosin) load). Certain vasodilators also dilate the veins, which de-
creases venous return and lowers diastolic ventricular filling
pressure (preload).
e Angiotensin-converting enzyme (ACE) inhibitors (e.g., capto- ACE inhibitors/angiotensin II receptor antagonists block the forma-
pril, enalapril, lisinopril, benazepril, fosinopril, quinapril) or tion/effect of angiotensin II (a potent vasoconstrictor), which
angiotensin II receptor antagonists (e.g., losartan, valsartan) subsequently also causes a decrease in aldosterone output. The
reduction in angiotensin II and aldosterone results in a decrease
in total peripheral vascular resistance and reduced sodium and
water retention, which leads to decreased cardiac workload.
e Beta-adrenergic blocking agents (e.g., propranolol, meto- Beta-adrenergic blockers reduce cardiac workload by blocking sym-
prolol, atenolol, nadolol, sotalol) pathetic nervous system stimulation of beta-receptors in the
heart.
e Anticholinergic agents (e.g., atropine) CO is dependent on stroke volume and heart rate. Anticholinergics
increase the heart rate (i.e., have a positive chronotropic effect)
and are used to increase CO in clients with bradydysrhythmias.
e Antidysrhythmics (e.g., flecainide, lidocaine, disopyra- Antidysrhythmics improve CO by correcting automaticity and/or
mide, procainamide, amiodarone, esmolol, — sotalol, conduction abnormalities in the heart. By slowing the heart rate
adenosine) and/or decreasing irregularity of the heart rate, the diastolic fill-
ing time is prolonged, resulting in an increased preload and
stroke volume.
e Calcium channel blocking agents (e.g., nifedipine, Calcium channel blockers dilate the coronary arteries, thus improv-
verapamil, diltiazem, nicardipine, amlodipine) ing coronary blood flow and myocardial oxygen supply.
They also reduce cardiac workload by dilating peripheral
arteries and subsequently reducing afterload. Certain calcium
channel blockers (e.g., diltiazem, verapamil) also have an anti-
dysrhythmic effect, which subsequently increases CO by helping
restore normal heart rate and rhythm.
Consult physician if signs and symptoms of decreased CO Notifying the physician allows for modification of treatment plan.
persist Or worsen.

_Nursing Diagnosis READINESS FOR ENHANCED COMFORT nox ;

For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

ACUTE CONFUSION no»

Definition: Reversible disturbances of consciousness, attention, cognition, and perception that develop
over a short period of
time, and which lasts less than 3 months.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 39

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of visual, auditory hallucinations Exaggerated emotional responses; fluctuations in level of
consciousness/cognition; alterations in normal sleep/wake
cycle; increased agitation/restlessness; altered perceptive
ability (inappropriate responses); lack of ability to initiate or
follow through with goal-directed or purposeful behavior

RISK FACTORS
° Medication reaction/drug-to-drug e Chronic illness exacerbation e Sleep deprivation
interaction e Elderly e Infection
e Substance abuse e Dementia
e Delirium e Hypoxemia
e Metabolic imbalances e Pain

DESIRED OUTCOMES DOCUMENTATION

“The client will regain usual reality orientation and level of Level of consciousness/orientation
consciousness as evidenced by: e Electrolyte values
a. Ability to participate independently in activities of e Oxygenation
daily living e Vital signs
b. Decrease in agitation/restlessness e Safety risk
c. Improvement in sleep/wake cycles e Restraint use
d. Appropriate responses to environmental stimuli

NOC OUTCOMES NIC INTERVENTIONS

Cognitive orientation; neurologic status: consciousness; Delirium management; electrolyte monitoring; electrolyte
fatigue level; anxiety level; agitation level; sleep; electrolyte management; acid-base management; oxygen therapy;
and acid-base balance; respiratory status: gas exchange; peripheral sensation management
blood glucose level

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of acute confusion (¢.g., Early recognition of signs and symptoms of acute confusion allows
changes in level of consciousness, changes in baseline for prompt intervention.
behavior, increased agitation, hallucinations, and impaired
perceptive ability).
Assess vital signs for evidence of poor perfusion (e.g., hypo- Poor perfusion to vital organs such as the brain, which can be
tension, tachycardia, tachypnea). exacerbated by hypotension or extreme tachycardia, can alter
normal cognitive states, leading to confusion.
Monitor serum glucose levels, drug levels for abnormalities. Altered metabolic parameters (e.g., hypoglycemia and hypoxia) can
Monitor pulse oximetry for hypoxemia. contribute to confusion and as a priority must be ruled out as
potential causes of confusion. Failure to rule out possible meta-
bolic causes of confusion can lead to serious adverse patient
outcomes.
Assess for contributing factors (e.g., substance abuse/withdrawal, Because of the reversible nature of acute confusion, contributing
episodes of high fever, exposure to toxic substances, drug- factors should be identified and corrected to return the patient
to-drug interactions, chronic illness exacerbations, sleep to his/her normal state of cognition.
alterations, diet/nutritional alterations, infection).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain a safe patient care environ- A confused patient is at risk for injury. Measures must be imple-
ment (e.g., supervision/sitter, family member assistance, mented that protect the patient from injury. Restraints must be
side rails). D > used with extreme caution (e.g., behavior that is indicative of
violence) because use may increase the risk of patient injury.
Note: the use of restraints should be limited because this may
worsen the situation by increasing agitation.

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40 Chapter3 " Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures that assist with client orientation (e.g., The use of orientation aids will assist the patient in establishing an
clock/calendar within visual field of the client). D @ + awareness of self and the environment.
Establish routines as much as possible when providing care A consistent routine aids in task completion and helps reduce con-
and be as consistent as possible in following the routine. fusion. A consistent, stable environment reduces confusion and
De+ frustration.
Implement measures that reduce sensory overload to the Reducing sensory overload by limiting environmental noise and
patient: D@ + stimulation will help prevent the patient from becoming more
e Cluster nursing care to provide adequate rest periods. confused.
e Maintain a calm environment, eliminating any unneces-
sary noise.
e Provide undisturbed periods of rest.
Implement measures that foster an awareness of self and Fostering a sense of self and environment will aid in regaining/
environment: D @ + maintaining usual reality orientation.
e Address patient by name.
¢ Mention the date, time, and place frequently during the
day.
Provide simple instructions allowing patient adequate time to These actions help to decrease confusion, reduce frustration, and
respond, communicate, and make decisions. D@ promote task completion.
Encourage family members to share stories, discuss familiar Sharing familiar events promotes a sense of continuity and creates
people and events, and assist with orientation. D + a sense of overall security and comfort in a confused patient.

Dependent/Collaborative Actions
Administer short-acting sleep aids as ordered to facilitate Undisturbed rest periods will help restore cognitive orientation in
undisturbed periods of rest. D acutely confused patients without metabolic alterations.
Administer psychotropics cautiously to control restlessness, Medication to reduce restlessness, hallucinations, and agitation
hallucinations, and agitation. D+ can help calm a confused patient. It is most important that
metabolic alterations are ruled out as the cause of the
confusion/agitation and restlessness before medication admin-
istration.
Notify physician of continued or intensifying confusion, con- Notifying the appropriate health care provider allows for modifica-
cerning drug-to-drug interactions, signs and symptoms of tion of the treatment plan.
infection, and abnormal laboratory results.

| CONSTIPATION nox
Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or
passage of excessively hard, dry stool.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of straining with defecation; pain with Change in bowel pattern; bright red blood with stool;
defecation; increased abdominal pressure; feeling of rectal presence of soft, pastelike stool in rectum; distended abdo-
fullness or pressure; inability to pass stool; headache; indi- men; dark, black, or tarry stool; percussed abdomina} dull-
gestion; verbalization of abdominal pain and tenderness, ness; decreased volume of stool; decreased frequency; dry,
and nausea hard, formed stool; palpable rectal mass; abdominal pain;
anorexia; Change in abdominal growling (borborygmi);
atypical presentation in older adults (e.g., change in men-
tal status, urinary incontinence; unexplained falls, elevated
body temperature); severe flatus; hypoactive or hyperactive
bowel sounds; palpable abdominal mass; abdominal ten-
derness with or palpable muscle resistance; nausea and/or
vomiting; oozing liquid stool
 Chapter 3" Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 41

RISK FACTORS
e Functional: Recent environmental calcium carbonate; aluminum- neurologic impairment; rectal anal
changes; habitual denying/ignoring containing antacids; nonsteroidal stricture; rectocele; postsurgical
of urge to defecate; insufficient antiinflammatory agents; opiates; obstruction; hemorrhoids; obesity
physical activity; irregular defecation anticholinergics; diuretics; iron e Physiologic: Poor eating habits;
habits; inadequate toileting (e.g., salts; phenothiazines; sedatives; decreased motility of gastrointestinal
timeliness, positioning for defeca- sympathomimetics; bismuth salts; tract; inadequate dentition or oral
tion, privacy); abdominal muscle antidepressants; calcium channel hygiene; insufficient fiber intake;
weakness blockers insufficient fluid intake; change in
e Psychologic: Depression; emotional ¢ Mechanical: Rectal abscess or ulcer; usual foods and eating pattern;
stress; mental confusion; decreased pregnancy; rectal anal fissures; dehydration
mobility/immobility tumors; megacolon (Hirschsprung’s
e Pharmacologic: Anticonvulsants; disease); electrolyte imbalance; rectal
antilipemic agents; laxative overdose; prolapse; prostate enlargement;

DESIRED OUTCOMES DOCUMENTATION

The client will maintain usual bowel elimination pattern e¢ Occurrence of last bowel movement
as evidenced by: e Characteristics of stool
‘a. Usual frequency of bowel movements e Abdominal distention or report of pain
b. Passage of soft, formed stool e Reports of fullness or pressure in rectum
c. Absence of abdominal distention and pain, feeling e Reports of straining at stool
of rectal fullness or pressure, and straining during e Bowel sounds
defecation e Therapeutic interventions
e Client teaching

NOC OUTCOMES NIC INTERVENTIONS

Bowel elimination; gastrointestinal function; hydration; Constipation/impaction management

nausea and vomiting severity; symptom control

NURSING ASSESSMENT RATIONALE

Ascertain client’s usual bowel elimination habits. Knowledge of the client’s usual bowel elimination habits is essen-
tial in determining whether constipation is present, because the
frequency of defecation varies among individuals.
Assess for signs and symptoms of constipation: Early recognition of signs and symptoms of constipation allows for
e Decrease in frequency of bowel movements prompt intervention.
e Passage of hard, formed stools
e Anorexia
e Abdominal distention and pain
e Feeling of fullness or pressure in rectum
e Straining during defecation
Assess bowel sounds. Report a pattern of decreasing bowel Bowel sounds are produced by peristaltic activity. A pattern ofde-
sounds. creasing bowel sounds indicates a decrease in bowel motility,
which can lead to and be present with constipation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage client to defecate whenever the urge is felt. D @ + If the client feels the urge to defecate but suppresses it by contract-
ing the external anal sphincter, the defecation reflex will sub-
side after a few minutes and not recur for several hours or until
additional feces enter the rectum. Repeated inhibition of the
defecation reflex results in progressive weakening of the reflex.
In addition, when the defecation reflex is inhibited, feces re-
main in the colon longer and water continues to be absorbed
from the feces, making the stool drier, harder, and subsequently
more difficult to evacuate.

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42 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Assist client to toilet or bedside commode or place in high- A sitting position aids in the expulsion of stool by taking advantage
Fowler’s position on bedpan for bowel movements unless of gravity. This position also enhances the client’s ability
contraindicated. D@ to perform the Valsalva maneuver, which increases intra-
abdominal pressure and forces the fecal contents downward
and into the rectum where the defecation reflex is then elicited.
Encourage client to relax, provide privacy, and have call If the client is able to relax during attempts to defecate, he/she will
signal within reach during attempts to defecate. D + be able to relax the levator ani muscle and external anal
sphincter, thus facilitating the passage of stool.
Encourage client to establish a regular time for defecation, Attempting to have a bowel movement within an hour after a
preferably within an hour after a meal. D + meal, particularly breakfast, takes advantage of mass peristal-
sis, which occurs only a few times a day and is strongest after
meals. Mass peristalsis is stimulated by the gastrocolic reflex,
which is initiated by the presence of foods/fluids in the stomach
and duodenum.
Instruct client to increase intake of foods high in fiber (e.g., Foods high in fiber provide bulk to the fecal mass and keep the
bran, whole grain breads and cereals, fresh fruits and veg- stool soft because of the ability of fiber to absorb water. The
etables) unless contraindicated. increased bulkiness (i.e., mass) of the stools stimulates peristal-
sis, which promotes more rapid movement of stool through the
colon. Also, the shorter the time that feces remain in the intes-
tine, the less water is absorbed from it, which helps prevent the
formation of hard, dry stools that are difficult to expel.
Encourage client to drink hot liquids (e.g., coffee, tea) upon Ingestion of hot fluids can stimulate peristalsis.
arising in the morning. D
Encourage client to increase activity as tolerated/as condition Increase in activity increases bowel motility, decreasing risk for
allows. D+ constipation.

Dependent/Collaborative Actions
Instruct client to maintain a minimal fluid intake of 2500 Inadequate fluid intake reduces the water content of feces, which
mL/day unless contraindicated. results in hard, dry stool that is difficult to evacuate.
Increase activity as allowed and tolerated. D @ Ambulation stimulates peristalsis, which promotes the passage of
stool through the intestines.
When appropriate, encourage the use of nonnarcotic rather Narcotic analgesics slow peristalsis, which delays transit of intes-
than opioid analgesics for pain management. tinal contents. This delay also results in increased absorption of
fluid from the fecal mass with the subsequent formation of
hard, dry stool.
Administer laxatives or cathartics (e.g., stool softeners, bulk- Laxatives/cathartics act in a variety of ways to soften the stool,
forming agents, irritants/stimulants, lubricants, saline/ increase stool bulk, stimulate bowel motility, and/or lubricate
osmotic agents) as ordered. D+ the fecal mass and thereby promote the evacuation of stool.
Administer cleansing and/or oil retention enemas if ordered. A cleansing enema stimulates peristalsis and evacuation of stool
De+ by distending the colon with a large volume of solution and/or
by irritating the colonic mucosa. An oil retention enema facili-
tates the passage of stool by softening the fecal mass and lubri-
cating the rectum and anal canal.
Consult physician about checking for an impaction and digi- An impaction prohibits the normal passage of feces. Digital re-
tally removing stool if the client has not had a bowel moval of an impacted fecal mass may be necessary before nor-
movement in 3 days, if he/she is passing liquid stool, or if mal passage of stool can occur.
other signs and symptoms of constipation are present. t
Consult appropriate health care provider if diarrhea persists. Notifying the appropriate health care provider allows for modifica-
tion of the treatment plan.
 Chapter 3 " Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 43

Nursing Diagnosis CONTAMINATION nox,

Definition:
° Exposure to environmental contaminants in doses sufficient to cause adverse health effects.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal report of exposure to potentially toxic agents Note: Health effects will depend upon the type of contami-
nant and may include all body systems. Principal routes
of exposure include inhalation, absorption, ingestion, and
injection.
Types of contaminants include incapacitating agents,
chemical agents (organophosphates), nerve agents (sarin),
cyanide agents, vesicant/blister agents (nitrogen mustards),
pulmonary/choking agents (chlorine), riot control agents
(pepper spray/tear gas). Objective assessment data will
reflect the offending agent and route of absorption.
Pesticides/Chemicals/Biologicals: Verbal self-report of a Cardiac dysrhythmias; hypertension/hypotension;
“stomachache”; cramping; blurred vision; joint and mus- diarrhea; nausea; muscle weakness; confusion; seizures;
cle aches; difficulty breathing; flu symptoms; verbalization decreased level of consciousness; cough; labored breathing;
of nausea; hallucinations cyanosis; skin lesions (e.g., rash, pustules, scabs)
Radiation: Verbal self-report of nausea; visual changes; Symptoms of radiation sickness (i.e., weakness, hair loss,
difficulty breathing; verbalization of weakness; fatigue; changes in blood chemistries, hemorrhage, diminished
skin irritation; abdominal pain organ function); paresthesias; confusion; lethargy; changes
in level of consciousness; skin irritation; itching; blistering;
burns; erythema; ulcerations
Waste: Verbal self-report of nausea; abdominal cramps Anorexia; diarrhea; weight loss; jaundice; weakness; fever
Pollution: Verbal self-report of difficulty breathing; chest Reddened conjunctiva; tearing; wheezing; pulmonary
pain; headaches; shortness of breath congestion; nasal congestion

RISK FACTORS
e External: Chemical contamination inappropriate or no use of protec- e Internal: Gestational age during ex-
of food and/or water; bioterrorism; tive clothing; living in poverty; posure; developmental stage; gender;
disasters; insufficient or absent poor sanitation; climate nutritional factors; the presence of
use of decontamination protocol; conditions preexisting disease

DESIRED OUTCOMES DOCUMENTATION

The client will experience minimal health alterations. e Therapeutic interventions
e Decontamination protocol
e Jsolation precautions

NOC OUTCOMES NIC INTERVENTIONS

S$ ————$————

Respiratory status: gas exchange; physical injury severity; Triage: disaster; infection control; anxiety reduction; crisis
anxiety level; fear level; community disaster readiness intervention; environmental risk protection; bioterrorism
preparedness

NURSING ASSESSMENT RATIONALE

Assess vital signs, including temperature, noting signs and Early recognition of signs and symptoms of contamination allows
symptoms of inhalation, absorption, ingestion, or injec- for prompt intervention.
tion of environmental contaminants by performing
frequent, prioritized multisystem assessment.
* Monitor airway and respiratory status (e.g., rate and depth Effects of contaminants can be delayed 2 to 24 hrs. Rapid onset
of breathing, adventitious breath sounds, pulse oximetry). of pulmonary symptoms indicates a poor prognosis. Early
detection allows for aggressive treatment of symptoms.

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44 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

NURSING ASSESSMENT RATIONALE

e Monitor cardiac rhythm. Cardiac monitoring should be implemented for any patients exhib-
iting irregularity (i.e., symptomatic bradycardia, symptomatic
tachycardia) to allow for prompt intervention.
e Assess neuromuscular status. Variable routes of exposure to nerve agents may result in symptoms
that may not appear for 30 minutes to 18 hrs. Vaporized
nerve agents are most toxic, with symptoms appearing within
seconds. Diagnosis and treatment are based on observations of
signs and symptoms.
e Assess integumentary system. Contaminants absorbed through the skin or eyes produce immedi-
ate symptoms. Prompt assessment allows for early implementa-
tion of interventions.
e Monitor serum chemistry and complete blood cell count Monitoring lab values allows for the assessment of hematologic
(CBC) results, reporting abnormalities. and multisystem consequences of exposure to contaminants.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Actual exposure:
Provide protective clothing for all health care providers car- Health care providers must protect themselves from contamination
ing for the exposed client (e.g., disposable scrubs, water- and control further spread.
proof shoe covers, gowns with seams taped, hat, mask,
goggles, double gloves taped at the wrist). D @ +
Institute decontamination protocols:
e Remove and isolate clothing for decontamination. Cloth- Prompt removal of contaminated clothing prevents further expo-
ing exposed to radiation must be sealed in an airtight sure of skin to contaminants, prevents further absorption
container and labeled appropriately. of contaminants, and facilitates effective decontamination.
Removing clothing can reduce contamination 80% to 90%.
e Wash intact skin or damaged skin with soap and water. Washing exposed skin reduces the amount of contaminants
De+ absorbed. .
e Irrigate exposed/injured eyes copiously with water. D + Irrigation of eyes reduces the amount of contaminants absorbed.
e Implement appropriate isolation precautions (e.g., universal, Appropriate isolation precautions will assist in reducing the further
airborne, droplet, and contact isolation). D+ spread of contaminants and protect health care providers caring
for the exposed client.
Explain decontamination protocols and the need for isolation Providing factual information to the patient and family concerning
to patient and family to help alleviate anxiety. treatment will help in reducing anxiety associated with fear.
Encourage patient to verbalize feelings, perceptions, and Verbalization of fears or concerns can assist the health care practi-
fears. D+ tioner in identifying knowledge deficits amenable to education
while alleviating apprehension on the part of the client.

Dependent/Collaborative Actions
Establish intravenous access for the administration of medica- Many of the drugs used to treat environmental contamination
tions. D> are administered intravenously requiring establishment of
access.

Administer oxygen, bronchodilators, corticosteroids for pul- The use of supplemental oxygen will improve the client’s arterial
monary symptoms. D + oxygen level, which may become compromised with the
development of pulmonary edema. Bronchodilators and cortico-
steroids will assist with treating inflammatory changes occur-
ring with pulmonary pathology, improving oxygenation and
ventilation.
Wash exposed skin with 0.5% sodium hypochlorite solution Use of this solution is helpful with gross contamination of the skin,
for 10 minutes. D + rendering offending contaminants harmless.
Administer activated charcoal as quickly as possible for Activated charcoal should be administered as soon as possible be-
gastrointestinal decontamination. D + cause it absorbs almost all commonly ingested drugs and
chemicals except iron, lithium, ethanol, and potassium. Emesis
and gastric lavage should be avoided.
 Chapter 3)" Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 45

THERAPEUTIC INTERVENTIONS RATIONALE

Administer drugs for treatment of nerve agent poisoning Atropine administration is indicated for clients exhibiting musca-
(e.g., atropine, pralidoxime, and diazepam). D+ rinic cholinergic excess (e.g., drying of bronchial secretions and
decreasing adverse effects including salivation, lacrimation,
urination, defecation, and emesis). Pralidoxime administration
is indicated for all patients requiring atropine and in those with
or at risk for nicotinic cholinergic (e.g., decreased atropine
requirements) and treatment of muscle fasciculations and
weakness (e.g., nicotinic signs of poisoning). Diazepam or other
benzodiazepines are indicated in patients with signs of severe
toxicity or seizures.
Administer drugs for the treatment of cyanide poisoning (e.g., Amyl nitrite is administered as an inhalant, followed by sodium
intranasal amyl nitrate, sodium nitrite, sodium thiosul- nitrite and sodium thiosulfate, which are given intravenously.
fate). D> The nitrites are given to convert hemoglobin in the red blood cell
to methemoglobin, which attracts the cyanide away from the
cytochrome oxidase and allows the cell to continue the process
of aerobic metabolism. Thiosulfate is given to facilitate detoxi-
fication of cyanide by the body’s own cyanide clearance system.
Administer antibiotics for secondary bacterial infections. Clients exhibiting signs and symptoms of infection (e.g., fever,
D+ chills, sweating, increased white blood cell count, pus in open
wounds) require the administration of antibiotics to help the
body and normal defenses overcome infections.

Risk for Exposure

Conduct surveillance for environmental contamination. Assessment of the client’s community and immediate environment
Notify agencies authorized to protect the environment of can assist with the identification of contaminants that could
contaminants in the area. threaten individual and community health status.
Assist individuals to modify the environment to minimize Nurses can assist individuals and communities in incorporating
risk or assist in relocating to a safer environment. environmentally responsible ways in dealing with activities of
daily living.
Collaborate with other agencies to schedule mass casualty In the event a disaster that predisposes a community to contami-
and disaster readiness drills. nants becomes a reality, local health care providers and the
community at large must be prepared to respond appropriately.

|Nursing oo
Diagnosis |INEFFECTIVE COPING nox ,
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|Nursing »Diagnosis
---* |READINESS FOR ENHANCED DECISION-MAKING nox
For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

|Nursing o>)
Diagnosis |DIARRHEA nox

Definition: Passage of loose, unformed stools.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of urgency, abdominal pain and cramping Hyperactive bowel sounds; at least three loose liquid stools
per day

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to @volve for animation
46 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

RISK FACTORS
e Situational: Alcohol abuse; toxins; e Psychosocial: High stress levels and e Physiologic: Inflammation; malab-
laxative abuse; radiation; tube feed- anxiety sorption; infectious processes; irrita-
ings; adverse effects of medications; tion; parasites
contaminants; travel

DESIRED OUTCOMES DOCUMENTATION

The client will have fewer bowel movements and more e Frequency of defecation
formed stool. ¢ Characteristics of stool
¢ Complaints of abdominal cramping
¢ Bowel sounds
e Therapeutic interventions
¢ Client teaching

NOC OUTCOMES NIC INTERVENTIONS

Bowel continence; bowel elimination; fluid balance; symp- Diarrhea management

tom severity; gastrointestinal function

NURSING ASSESSMENT RATIONALE

Ascertain client’s usual bowel elimination habits. Knowledge of the client’s usual bowel elimination habits helps
determine the severity of the diarrhea.
Assess for and report signs and symptoms of diarrhea (e.g., Early recognition of signs and symptoms of diarrhea allows for
frequent loose stools; urgency; abdominal cramping; prompt intervention.
hyperactive bowel sounds).
Assess for factors that may be causing diarrhea (e.g., anti- Knowing the cause of the diarrhea is a critical component in
microbial agents, laxative use, tube feedings, gastrointesti- identifying the appropriate treatment.
nal disorder, change in dietary intake, intestinal infection).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
As diet advances, gradually progress from fluids to small Gradual introduction of small amounts of fluid and then food
meals. D @+ helps prevent a sudden increase in peristalsis and diarrhea.
Instruct the client to avoid the following foods/fluids:
e Those known to aggravate diarrhea such as spicy foods, These substances are thought to increase intestinal motility and
alcohol, coffee, and fatty foods may also cause excessive mucus secretion, which increases the
liquidity of the intestinal contents.
e Those that are extremely hot or cold Extremes in temperature of ingested foods/fluids often stimulate
peristalsis.
e Those high in lactose such as milk and milk products Diarrhea may temporarily deplete the gastrointestinal enzyme lac-
tase, which is essential for the hydrolysis and subsequent ab-
sorption of lactose. The nonabsorbed lactose has an osmotic
effect and draws water into the colon, which results in more
liquid stool. The lactose also serves as a base for bacterial fer-
mentation in the colon. The lactic and fatty acids produced by
this fermentation process irritate the colon, with a shbsequent
increase in bowel motility and diarrhea.
e Those foods high in fiber such as whole-grain cereals, raw Fiber increases bulk of the stool because of its ability to absorb water.
fruits, and vegetables The increased mass (i.e., bulk) of the stools stimulates peristalsis.
Limiting fiber intake decreases the water content of the stool,
which results in drier, firmer, and less bulky stools. The decrease
in bulk (i.e., mass) results in less stimulation of peristalsis, and
the dryness of the stools slows intestinal transit time.
e Those foods made with synthetic, nonabsorbable sugars Synthetic, nonabsorbable sugars are not well absorbed from the
(e.g., sorbitol) that are found in many dietetic foods gastrointestinal tract and tend to draw water into the intestine
by osmosis. This excess water in the intestine increases fluidity
and volume of stool.
 Chapter 3." Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 47

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to reduce fear and anxiety: Parasympathetic activity may dominate in some stressful
e Provide client teaching. situations and cause increased gastrointestinal motility and
e All care providers are to interact with the client in a calm diarrhea.
mannet.
Encourage the client to rest. D Physical activity stimulates peristalsis.

Dependent/Collaborative Actions
Limit oral intake to clear liquids and replacement solutions as Peristalsis is stimulated by the presence of foods/fluids in the stom-
ordered. D+ ach and duodenum. Restricting oral intake to clear liquids and/
e Pedialyte or replacement solutions during the acute phase of diarrhea not
e Resol only allows the bowel to rest but also helps prevent malnutri-
e Rehydrate tion and fluid and electrolyte imbalances.
e Administer prescribed antianxiety agents. D +
If the client is receiving tube feeding, administer the solution Tube feeding can increase peristalsis if the solution is given while
at room temperature. Consult physician about reducing cold or if large amounts are given too quickly. Full-strength tube
the rate of administration and/or the concentration of the feeding solution has relatively high osmolality, which subse-
. tube feeding solution if diarrhea occurs. D + quently draws water into the intestine and causes an osmotic
diarrhea. Reducing the concentration of the feeding solution
lessens the risk for osmotic diarrhea.
Consult physician regarding measures to remove fecal impac- When a fecal impaction is present, the secretory activity of the
tion if present (e.g., digital removal of stool, oil retention bowel increases in an attempt to lubricate and promote evalua-
enema). tion of the impacted feces. The liquid portion of the feces above
the mass then leaks around the impaction, resulting in a con-
tinuous oozing of diarrheal stool.
Administer the following antidiarrheal agents if ordered:
D+
e Opioids (e.g., paregoric) or synthetic opioids (e.g., loper- Opioids and synthetic opioids decrease gastrointestinal motility,
amide, diphenoxylate hydrochloride) which delays the passage of intestinal contents and subse-
quently allows more time for water to be reabsorbed from the
feces. This results in fewer bowel movements and more formed
stool.
e Bulk-forming agents (e.g., methylcellulose, psyllium Bulk-forming agents absorb water in the bowel, resulting in a more
hydrophilic mucilloid, polycarbophil) formed stool.
e Adsorbents/protectants (e.g., attapulgite [Kaopectate], Adsorbents/protectants act locally to coat the walls of the gastroin-
bismuth subsalicylate [Pepto-Bismol]) testinal tract and absorb toxins that are stimulating gut motil-
ity and/or secretions.
Consult appropriate health care provider if diarrhea persists. Notifving the appropriate health care provider allows for modifica-
tion of the treatment plan.

|Nursing >)
Diagnosis |DEFICIENT FLUID VOLUME nox
Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without
change in sodium.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of thirst; weakness Decreased urine output; increased urine concentration;
sudden weight loss (except in third spacing); decreased
venous filling; increased body temperature; decreased
pulse volume/pressure; change in mental status; elevated
hematocrit (Hct); decreased skin/tongue turgor; dry skin/
mucous membranes; increased pulse rate; decreased blood
pressure (BP)

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48 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

RISK FACTORS
e Active fluid volume loss
e Failure of regulatory mechanisms

DESIRED OUTCOMES DOCUMENTATION

The client will not experience a deficient fluid volume as e Vital signs
evidenced by: e Condition of skin and mucous membranes
a. Normal skin turgor e Weight
b. Moist mucous membrane e Capillary refill time
c . Stable weight e Appearance of neck veins when client is supine
d . BP and pulse within normal range for client and stable e Mental status
with position change e Intake and output
e. Capillary refill time less than 2 to 3 seconds e Presence of nausea, vomiting, or other contributing
f. Usual mental status factors
g. Blood urea nitrogen (BUN) and Hct within normal e Intravenous fluid therapy
range e Client teaching
h. Balanced intake and output

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; hydration; kidney function; vital signs; risk Fluid management; fluid monitoring; fluid resuscitation;
control hypovolemia management; intravenous therapy

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of deficient fluid volume: Early recognition of signs and symptoms of deficient fluid volume
e Decreased skin turgor allow for prompt intervention.
e Dry mucous membranes, thirst
e Weight loss of 2% or greater over a short period
e Postural hypotension and/or low BP
e Weak, rapid pulse
e Capillary refill time greater than 2 to 3 seconds
e Neck veins flat when client is supine
e Change in mental status
e Decreased urine output
Assess BUN/Hct for abnormal elevations. Net fluid volume deficits result in decreased renal blood flow,
decreased glomerular filtration, acute tubular necrosis, and re-
sulting elevated blood urea nitrogen (BUN) levels. Hypovolemia
results in hemoconcentration resulting in elevated hematocrit
(Hct) levels.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce nausea and vomiting if present: Nausea often causes the client to have decreased fluid volume
e Instruct client to ingest food/fluid slowly. intake. Persistent vomiting results in excessive loss of fluid.
e Eliminate noxious sights and odors.
Implement measures to control diarrhea if present: Persistent or severe diarrhea results in excessive loss @f gastro-
e Discourage intake of spicy foods and foods high in fiber or intestinal fluid.
lactose.
Implement measures to reduce fever if present: D @ + Fever may be accompanied by diaphoresis, which can result in
e Sponge bath client with tepid water. excessive loss of fluid.
e Remove excessive clothing or bedcovers.
Carefully measure drainage: D+ Accurate intake/output records must be maintained to ensure fluid
e Nasogastric loss is replaced appropriately.
e Wound
e Urine
Maintain a fluid intake of at least 2500 mL/day unless contra- Adequate fluid intake needs to be provided in order to ensure
indicated. D + adequate hydration.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 49

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Administer antiemetics as ordered. D + Nausea often causes the client to have decreased fluid volume
intake. Persistent vomiting results in excessive loss of fluid.
Administer antidiarrheal agents as ordered. D+ Persistent or severe diarrhea results in excessive loss of gastrointes-
tinal fluid.
Administer antipyretics as ordered. D> Fever may be accompanied by diaphoresis, which can result in
excessive loss of fluid
Administer and maintain intravenous replacement fluids as Replacing fluid volume that is lost helps prevent/treat deficient
ordered. D + fluid volume.
Consult physician if signs and symptoms of deficient fluid Notifying the physician allows for modification of the treatment
volume persist or worsen. plan.

|Nursing poorest
Diagnosis |EXCESS FLUID VOLUME nox
Definition: Surplus intake and/or retention of fluid.

CLINICAL MANIFESTATIONS
Subjective Objective
Verbal self-report of shortness of breath Jugular venous distention; decreased hemoglobin and
hematocrit (Hct); weight gain over short period; dyspnea;
intake exceeds output; pleural effusion; orthopnea; S;
heart sound; pulmonary congestion; change in respiratory
pattern; change in mental status; blood pressure (BP)
changes; pulmonary artery pressure changes; oliguria;
specific gravity changes; azotemia; altered electrolytes;
restlessness; anxiety; abnormal breath sounds (crackles);
edema, may progress to anasarca; increased central venous
pressure (CVP); positive hepatojugular reflex

RISK FACTORS
e Compromised regulatory mechanism
e Excess fluid intake
e Excess sodium intake

DESIRED OUTCOMES DOCUMENTATION

The client will not experience excess fluid volume as e BP
evidenced by: e Weight
. Stable weight e Heart sounds
. BP within normal range e Pulse volume
. Absence of S3 heart sound e Intake and output
Normal pulse volume ¢ Mental status
Balanced intake and output e Breath sounds, ease of respirations
. Usual mental status e Presence of edema and neck vein distention
. Normal breath sounds e CVP readings
. Blood urea nitrogen (BUN) and Hct within normal limits e Therapeutic interventions
=. Absence of dyspnea, orthopnea, peripheral edema,
TMmoan
sw e Client teaching
and distended neck veins
j. CVP within normal range

NOC OUTCOMES NIC INTERVENTIONS

Cardiopulmonary status; fluid balance; fluid overload sever- Fluid management; fluid monitoring; hypervolemia
ity; kidney function; respiratory status; vital signs; weight: management
body mass

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50 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of excess fluid volume: Early recognition of signs and symptoms of excess fluid volume
° Weight gain of 2% or greater in a short period allows for prompt intervention.
e Elevated BP (Note: BP may not be elevated if fluid has
shifted out of the vascular space)
e Presence of an S3 heart sound
e Bounding pulse
e Intake greater than output
e Change in mental status
e Crackles (rales), diminished or absent breath sounds
e Dyspnea, orthopnea
e Peripheral edema
e Distended neck veins
e Elevated CVP
Monitor chest radiograph results. Report findings of pulmo- Chest radiograph films provide data about pulmonary vascular
nary vascular congestion, pleural effusion, or pulmonary status and fluid accumulation in the pleural space, pulmonary
edema. interstitium, and alveoli.
Monitor BUN, Het, and electrolytes for abnormalities. Fluid volume excess results in a decreased Hct because of hemodi-
lution and a decreased BUN. Electrolyte values will be altered
in the presence of excess fluid volume.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage client to rest periodically in a recumbent position Lying flat promotes venous return, which leads to increased cardiac
if tolerated. D> output and renal blood flow. This increases the glomerular
filtration rate and promotes diuresis.

Dependent/Collaborative Actions
Maintain fluid restrictions as ordered. D > Fluid restriction helps to reduce total body water and prevent the
accumulation of excess fluid.
Restrict sodium intake as ordered. D + Excess fluid volume is an isotonic retention of both sodium
and water. Restricting sodium intake will result in less so-
dium and subsequently less water being reabsorbed by the
kidneys.
If client is receiving intravenous fluids that contain a sizeable Excess fluid volume can result from overzealous or prolonged intra-
amount of sodium (e.g., 0.9% normal saline, lactated Ringer’s), venous administration of sodium-containing fluids, particularly
consult physician about a change in the solution or rate of ones that contain sizable amounts of sodium.
infusion.
If client is receiving numerous and/or large-volume intra- Limiting the amount of intravenous solution infused at any one
venous medications, consult pharmacist about ways to time and maximizing the concentration of intravenous medica-
prevent excessive fluid administration. Stop primary tions help prevent an additional fluid burden in the person who
infusion during administration of intravenous medica- has or is at risk for fluid volume overload.
tions, dilute medications in the minimum amount of
solution.
Administer diuretics as ordered. D + Most diuretics inhibit sodium reabsorption in the renal tubules.
This results in decreased water reabsorption and subsequent
excretion of excess fluid. '
Consult physician if signs and symptoms of excess fluid vol- Notifying the physician allows for modification of the treatment
ume persist Or worsen. plan.
 Chaptersmas Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 51

|Nursing yeu)
Diagnosis |IMPAIRED GAS EXCHANGE nox

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of visual disturbances; headache upon Decreased CO); tachycardia; hypercapnia; restlessness;
awakening somnolence; irritability; hypoxia; confusion; dyspnea; ab-
normal arterial blood gases; cyanosis (in neonates only);
abnormal skin color (pale, dusky); hypoxemia; abnormal
rate, rhythm, depth of breathing; diaphoresis; nasal flar-
ing; low partial pressure of oxygen (O2) in arterial blood
(PaO); low pulse oximetry

RISK FACTORS
e Ventilation/perfusion imbalance
e. Alveolar-capillary membrane changes

DESIRED OUTCOMES DOCUMENTATION

The client will experience adequate gas (O2/CO2) exchange e Respiratory rate
as evidenced by: e Difficulty breathing
. Usual mental status e Mental status
. Unlabored respirations at 12 to 20 breaths/min e Oximetry results
. Oximetry results within normal range e Route and rate of O2 administration
. Arterial blood gas (ABG) values within normal range e Therapeutic interventions
Normal breath sounds e Client teaching
. Normal rate and depth of respirations
. Absence of dyspnea
mMroandnase

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation; gas exchange; activity tolerance; Respiratory monitoring; oxygen therapy; airway manage-
airway patency; tissue perfusion: pulmonary; vital signs ment; chest physiotherapy; cough enhancement; acid-base
management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired gas Early recognition of signs and symptoms of impaired gas exchange
(O2/COz) exchange: allows for prompt intervention.
e Restlessness, irritability
e Confusion, somnolence
e Tachypnea, dyspnea
e Decreased PaO, and/or increased partial pressure of CO; in
arterial blood (PaCOz)
Monitor for and report a significant decrease in oximetry Oximetry is a noninvasive method of measuring arterial Oz satura-
results. tion. The results assist in evaluating respiratory status.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Place client in a semi- to high-Fowler’s position unless contra- These positions allow for increased diaphragmatic excursion and
indicated. Position with pillows to prevent slumping. If maximum lung expansion, which promotes optimal alveolar
client is experiencing dyspnea or orthopnea, position ventilation and O2/CO>2 exchange.
overbed table so he/she can lean on it if desired. D @

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52 Chapter 3 "Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Instruct client to change position, deep breathe, and cough or Frequent repositioning helps mobilize secretions and aids lung ex-
“huff” every 1 to 2 hrs. pansion. Deep breathing helps loosen secretions and promotes a
more effective cough. It also promotes maximum lung expan-
sion and stimulates surfactant production. Coughing or “huff-
ing” (a forced expiration technique) mobilizes secretions and
facilitates removal of these secretions from the respiratory tract.
These actions promote optimal alveolar ventilation and O2/COz
exchange.
Reinforce correct use of incentive spirometer every 1 to Incentive spirometer use promotes slow, deep inhalation, which
2 hrs. D improves lung expansion and helps clear airways by loosening
secretions and promoting a more effective cough. These actions
enhance alveolar ventilation and the exchange of O2/COb.
Implement measures to reduce chest or abdominal pain if A client with chest or abdominal pain often guards respiratory ef-
present (e.g., splint incision with pillow during coughing forts and breathes shallowly in an attempt to prevent additional
and deep breathing). D@ + discomfort. Pain reduction enables the client to breathe more
deeply, which enhances alveolar ventilation and O2/COz
exchange.
Implement measures to decrease fear and anxiety (e.g., assure Fear and anxiety may cause a client to breathe shallowly or to
client that breathing deeply will not dislodge tubes or hyperventilate. Decreasing fear and anxiety allows the client to
cause incision to break open, interact with client in a con- focus on breathing more slowly and taking deeper breaths,
fident manner). D@ which subsequently enhances alveolar ventilation and the
exchange of O2/CO>.
Instruct client in, and assist with, diaphragmatic breathing Diaphragmatic breathing promotes greater movement of the
and pursed-lip breathing techniques if appropriate. NOTE: diaphragm and decreases the use of the accessory muscles for
Diaphragmatic breathing is most often indicated for cli- inspiration. Use of this technique eases the work of breathing
ents who have had thoracic surgery or clients who have and ultimately promotes an increased efficiency of alveolar
chronic airflow limitation (e.g., emphysema) or neuro- ventilation. Pursed-lip breathing causes a mild resistance to
muscular conditions that cause fixation or weakening of exhalation, which creates positive pressure in the airways. This
the diaphragm. pressure helps prevent airway collapse and subsequently
promotes more complete alveolar emptying.
Discourage smoking. D+ Smoking impairs gas exchange because it:
e Reduces effective airway clearance by increasing mucus produc-
tion and impairing ciliary function.
e Decreases Oz availability as hemoglobin binds with the carbon
monoxide in smoke rather than with Oo.
e Causes damage to the bronchial and alveolar walls.
* Causes vasoconstriction and subsequently reduces pulmonary
blood flow.

Dependent/Collaborative Actions
Implement measures to facilitate removal of pulmonary Excessive secretions and/or client’s inability to clear secretions from
secretions (e.g., suction, postural drainage, percussion, the respiratory tract lead to stasis of secretions, which can im-
vibration) if ordered. pair O2/COz exchange. Suction and chest physiotherapy tech-
niques may be necessary to facilitate removal of pulmonary
secretions and thereby promote adequate gas exchange.
Assist with positive airway pressure techniques (e.g., continu- Positive airway pressure techniques increase intrapulmonary (al-
Ous positive airway pressure [CPAP], bilevel positive airway veolar) pressure, which helps reexpand collapsed alyeoli and
pressure [BiPAP], flutter/positive expiratory pressure [PEP] prevent further alveolar collapse so that gas exchange can take
device) if ordered. place.
Maintain O, therapy as ordered. D@ + Supplemental Oz increases the concentration of Oz in the alveoli,
which increases the diffusion of O> across the alveolar-capillary
membrane.
Maintain activity restrictions as ordered. Increase activity Restricting activity lowers the body’s O2 requirements and thus in-
gradually as allowed and tolerated. D@ + creases the amount of O2 available for gas exchange. A gradual
increase in activity conserves energy and thereby lessens O>
utilization, yet promotes mobilization.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 53

THERAPEUTIC INTERVENTIONS RATIONALE

Administer medications that may be ordered to improve cli- Medication therapy is an integral part of treating many respiratory
ent’s respiratory status (e.g., bronchodilators, analgesics, conditions that impair alveolar gas exchange (e.g., bronchodila-
antibiotics, corticosteroids, anticoagulants, diuretics). D + tors improve bronchial airflow and subsequently increase O./
COz exchange; analgesics can reduce pain and promote deeper
breathing and increased activity; antibiotics help resolve certain
respiratory infections; corticosteroids reduce inflammation in
the lungs and improve bronchial airflow; anticoagulants treat
thromboemboli of the pulmonary vessels and subsequently im-
prove pulmonary perfusion; diuretics reduce fluid accumulation
in the pulmonary interstitium and alveoli, which subsequently
improves gas exchange).
Administer central nervous system depressants judiciously. Central nervous system depressants cause depression of the respira-
Hold medication and consult physician if respiratory rate tory center and cough reflex. This can result in hypoventilation
is less than 12 breaths/min. and stasis of secretions with subsequent impaired gas exchange.
Consult appropriate health care provider (e.g., physician, re- Notifying the appropriate health care provider allows for modifica-
spiratory therapist) if signs and symptoms of impaired gas tion of treatment plan.
- exchange persist or worsen.

|Nursing =.
Diagnosis |RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL nox
Definition: Susceptible to variation in serum levels of glucose from the normal range, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Hypoglycemia: Verbal self-report of hunger; lightheaded- Hypoglycemia: Confusion; difficulty speaking; shakiness;
ness and weakness sweating; below-normal blood glucose levels
Hyperglycemia: Verbal self-report of frequent hunger; Hyperglycemia: Frequent urination; elevated blood
blurred vision; weight loss; dry mouth glucose levels

RISK FACTORS
e Type I and II diabetes, prediabetes, e High-density lipoprotein (HDL) e Ethnic background of Hispanic,
poor diet and nutrition cholesterol <35 mg/dL black, Native American, and Asian
e Obesity e High triglyceride levels e Metabolic syndrome
e Sedentary lifestyle e High blood pressure e Deficient knowledge of diabetes
e Family history of diabetes e Age >45 years management
e Giving birth to a baby weighing >9 Ib * History of gestational diabetes

DESIRED OUTCOMES DOCUMENTATION

The client will not experience unstable glucose levels as ¢ Blood glucose levels
evidenced by: e Diet and nutrition
a. Serum fasting serum glucose levels of 70 to 110 mg/dL e Therapeutic interventions
b. 2-hrs postprandial serum glucose readings of: ¢ Client and family teaching
e (to 50 years <140 mg/dL
e 50 to 60 years <150 mg/dL
e 260 years <160 mg/dL
c. Glycosylated hemoglobin levels (hemoglobin Aj.)
<7%
d. Demonstrated ability to accurately monitor blood
glucose
e. Demonstrated ability to accurately administer insulin
f. Identification of self-care measures if blood glucose is
too high or too low

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 54 Chapter 3 " Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

NOC OUTCOMES NIC INTERVENTIONS

panes aa en a ee EE a —————

Healthy diet; stable blood glucose levels; diabetes self- Hyperglycemia management; hypoglycemia management
management; medication adherence; health-promoting
behaviors

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of variations in Early recognition of signs and symptoms of abnormal blood glu-
blood glucose levels: cose levels allows for prompt intervention.
e Anxiety
e Confusion
e Irritability
e Lethargy or behavior changes
e Drowsiness or fatigue
e Polydipsia
e Nausea
e Vomiting
e Dry mouth
e Blurred vision
e Cold, clammy skin
e Shakiness
e Nervousness
e Fainting
Obtain blood glucose levels and hemoglobin A,. levels and Blood glucose levels and hemoglobin A,- levels indicate the effec-
report abnormalities. tiveness of monitoring and treatment.
Assess self-management skills related to blood glucose levels. Assessment determines need for education and support in self-
management of blood glucose levels.
Monitor hemoglobin A,, levels. Provides the health care team with a 2- to 3-month overview of
how well the client has controlled glucose levels. These data are
helpful in discharge planning.
Evaluate client’s medication regimen for medications that can Some medication can cause hyperglycemia or hypoglycemia.
alter blood glucose levels.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor intake and output. D@ + Individuals at risk for blood glucose alterations are at a significant
risk for dehydration.
Client and family teaching and discharge planning on Education has been shown to improve control of blood glucose
control of blood glucose level through: levels and client self-monitoring, and client sense of control over
disease.
e Diet Adherence to a diabetic diet can be used to help regulate blood
glucose levels.
e Exercise A regular exercise routine has been shown to control blood glucose
levels and decrease the amount of adipose tissue.
e Medication administration Improves client’s sense of control over the disease process and
maintenance of blood glucose levels
e Self-monitoring of blood glucose Reduces incidences of hyperglycemia or hypoglycemic episodes and
reduces complications of disease
e Recognition and treatment of signs and symptoms of Allows for prompt intervention and decreases large variations in
hyperglycemia and hypoglycemia blood glucose levels
e Smoking cessation Smoking has been associated with worsening glucose control and
insulin resistance.

Dependent/Collaborative Actions
Monitor blood glucose levels at meals and at bedtime. More Frequent blood glucose testing is important for maintenance of
frequent monitoring of blood glucose levels (e.g., every appropriate blood glucose levels. When the client is NPO, this
4-6 hrs) is required when client is to have nothing by is important to prevent significant declines in blood glucose
mouth (NPO). Refer to facility policy for frequency. D @ + levels.
 Chapter 37" Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 55

THERAPEUTIC INTERVENTIONS RATIONALE

Monitor blood glucose levels every hour in a client who is Blood glucose levels change quickly and may require immediate
receiving continuous intravenous insulin. D + intervention.
Administer oral hypoglycemics and insulin as needed. NOTE: Timely administration of insulin assists in maintaining appropri-
Always check blood glucose levels before insulin adminis- ate blood glucose levels and prevents progression to diabetes
tration. D> ketoacidosis.
Administer 1/2 cup of fruit juice for hypoglycemia if client is Early treatment of hypoglycemia can prevent more severe hypogly-
able to take fluids. Administer 50% dextrose in water cemia. DSOW is an alternative to oral carbohydrates when the
(DSOW) or intramuscular glucagon if client is unable to patient is unable to take fluids.
take oral carbohydrates. NOTE: Review hospital policy for
variations.
Refer client for dietary counseling and diabetic education. Dietary counseling and diabetic education are interventions that
can increase client knowledge of the disease process. Knowledge
of disease process can facilitate adherence to treatment plans.
Refer client and family to community resources. Provides for continuum of care.

|Nursing eee)
Diagnosis |GRIEVING nox <
Definition: A normal, complex process that includes emotional, physical, spiritual, social, and intellectual responses and be-
haviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into
their daily lives.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sorrow, guilt, pain; changes in dream Changes inactivity level; anger; blame, detachment; disor-
patterns ganization; difficulty in expressing the loss; denial of loss;
changes in sleep patterns

RISK FACTORS
e Loss of an object (e.g., people, possessions, job status,
home, ideals, parts and processes of the body)

DESIRED OUTCOMES DOCUMENTATION

The client will demonstrate beginning progression through e Verbalization of feelings about the loss
the grieving process as evidenced by: e Participation in activities
a. Verbalization of feelings about the loss e Eating pattern
b. Usual sleep pattern e Sleep pattern
c. Participation in treatment plan and self-care activities e Interaction with others
d. Use of available support systems ¢ Measures used to adapt to loss
e Client/family teaching

NOC OUTCOMES NIC INTERVENTIONS

ee EEUU UyIEEEEE SEIESSSEnEESEEEESEE EERE

Grief resolution Grief work facilitation; emotional support; support system

enhancement

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 56 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of grieving: Assessment of signs and symptoms of grieving helps the nurse de-
e Expression of distress about the loss termine the phase of grieving the client is experiencing. This
e Change in eating habits knowledge aids in the development of effective strategies that
e Inability to concentrate can assist the client to progress through the phases of grieving.
e Insomnia
e Anger
e Sadness
e Withdrawal from significant others
e Denial of loss
Assess for factors that may hinder and facilitate client’s In order for grief work to begin, the client needs to acknowledge the
acknowledgment of the loss. loss. An awareness of factors that may hinder and facilitate
this acknowledgment assists in the development of effective
strategies to accomplish this goal.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Assist client to acknowledge the loss (e.g., encourage conver- The client needs to acknowledge the loss in order for grief work to
sation about the loss including how or why it occurred begin.
and its impact on his/her future).
Discuss the grieving process and assist client to accept the An awareness of the feelings and behaviors commonly associated
phases of grieving as an expected response to an actual with each phase of the grieving process assists the client to
and/or anticipated loss. accept his/her responses to the loss.
Allow time for client to progress through the phases of griev- Grieving is a process that occurs in phases or stages that progress
ing phases vary among theorists but progress from shock over time. Some phases may not be experienced by the client,
and alarm to acceptance. and some may overlap or recur. The amount of time necessary
to reach resolution of grief is very individual, may take months
to years, and must be allowed to occur in order to reduce the risk
for dysfunctional grieving.
Provide an atmosphere of care and concern (e.g., provide A supportive, nonthreatening environment provides the basis for a
privacy, be available and nonjudgmental, display empathy constructive, therapeutic relationship between the client and
and respect). D@ + nurse. This allows the client to express feelings of grief and
work toward its resolution.
Implement measures to promote trust (e.g., answer questions A feeling of trust in the caregiver promotes the development
honestly, provide requested information). D@ + of a therapeutic relationship in which the client can feel free
to verbalize feelings. This facilitates the progression of grief
work.
Encourage the verbal expression of anger and sadness about The verbal expression of feelings of anger and sadness facilitates
the loss experienced. Recognize displacement of anger and movement toward resolution of grief. Displacement of angry
assist client to see the actual cause of angry feelings and feelings needs to be acknowledged so that grieving can progress
resentment. Establish limits on abusive behavior if demon- but should not be allowed to interfere with the therapeutic pro-
strated. D@ + cess.
Encourage client to express feelings in whatever ways are Expression of feelings helps the client integrate both positive
comfortable (e.g., writing, drawing, conversation). D@ and negative aspects of the loss and move toward _ its
acceptance.
Assist client to use techniques that have helped him/her cope Techniques that have previously facilitated the client’s adjustment
in previous situations of loss. to situations of loss are often effective when used to help him/
her cope with the current loss.
Support behaviors suggesting successful grief work (e.g., ver- Positive feedback about behaviors that suggest successful grief work
balizing feelings about loss, focusing on ways to adapt to reinforces those behaviors and promotes positive adaptation to
loss, learning needed skills, developing or renewing rela- loss.
tionships).
Explain the phases of the grieving process to significant When significant others are knowledgeable about the phases of the
others. Encourage their support and understanding. Srieving process, they are more likely to understand and accept
the client’s behavior and assist him/her to move toward resolu-
tion of grief.
 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 57

THERAPEUTIC INTERVENTIONS RATIONALE

Facilitate communication between the client and significant Effective communication between the client and significant others
others. Be aware that they may be in different phases of enhances the client’s ability to express feelings and successfully
the grieving process. move through the phases of grieving.

Dependent/Collaborative Actions
Provide information about counseling services and support Counseling and support groups can assist the client in working
groups that might assist client in working through grief. through grief by:
e Providing insight into his/her responses to the loss
e Decreasing the feelings of aloneness and isolation that fre-
quently accompany a loss
e Helping identify methods or skills that can be used to help cope
with the loss
When appropriate, assist client to meet spiritual needs (e.g., Spiritual support can be a source of strength and solace to the client
arrange for a visit from clergy). and can facilitate resolution of grief.
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse practitioner, grief counselor, physician) if signs of tion of the treatment plan.
- dysfunctional grieving (e.g., persistent denial of losses,
excessive anger or sadness, emotional lability) occur.

|Nursing o--~
Diagnosis |RISK-PRONE HEALTH BEHAVIOR nox
For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

-Nursing “7
Diagnosis RISK FOR INFECTION nox |
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

CLINICAL MANIFESTATIONS*

Subjective Objective
Verbal self-report of chills; loss of energy; loss of appetite; Elevated temperature; increased heart rate; abnormal
reports of pain, frequency, urgency, or burning with breath sounds; productive cough of purulent, green, or
urination rust-colored sputum
Cloudy urine
Increase WBC count in urinalysis; presence of bacteria
Heat, swelling, and/or unusual drainage in an area
Increase WBC count for significant change in differential

RISK FACTORS
e Inadequate primary defenses (broken ° Immunosuppression ° Pharmaceutic agents (e.g., immuno-
skin, traumatized tissue, decrease in e Inadequate acquired immunity suppressants)
ciliary action, stasis of body fluids, e Trauma e Rupture of amniotic membranes
change in pH of secretions, altered e Tissue destruction and increased e Insufficient knowledge to avoid
peristalsis) environmental exposure exposure to pathogens
e Inadequate secondary defenses (e.g., e Chronic disease
decreased hemoglobin, leukopenia, e Malnutrition
suppressed inflammatory response) ° Invasive medical procedures

*Clinical manifestations vary depending on the site of infection.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN © = Goto ©volve for animation
 58 Chapter 3. * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

DESIRED OUTCOMES DOCUMENTATION

The client will remain free of infection as evidenced by: e Temperature
a. Absence of fever and chills e Pulse rate
b. Pulse rate within normal limits e Presence of chills
c. Usual mental status ¢ Mental status
d. Normal breath sounds e Breath sounds
e. Cough productive of clear mucus only ¢ Characteristics of urine, sputum, and wound drainage
f. Voiding clear urine without reports of frequency, e Evidence of inflammation in any area
urgency, and burning e Evidence of unusual drainage from any area
g. Absence of heat, pain, redness, swelling, and unusual e Therapeutic interventions
drainage in any area ¢ Client/family teaching
h. White blood cell (WBC) and differential counts within
normal range for client
i. Negative results of cultured specimens

NOC OUTCOMES NIC INTERVENTIONS

Infection severity Infection control; infection protection; incision site care;
tube care; wound care; nutrition management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of infection NOTE: Early recognition of signs and symptoms of infection allows for
Be aware that some signs and symptoms vary depending prompt intervention.
on the site of infection, the causative agent, and the age
and immune status of the client:
e Elevated temperature
© Chills
e Increased pulse rate
e Malaise, lethargy, acute confusion
° Loss of appetite
e Abnormal breath sounds
e Productive cough of purulent, green, or rust-colored sputum
e Cloudy urine
e Reports of frequency, urgency, or burning when urinating
° Urinalysis showing a WBC count greater than 5, positive
leukocyte esterase or nitrites, or presence of bacteria
° Heat, pain, redness, swelling, or unusual drainage in any area
e Elevated WBC count and/or significant change in differential
Obtain specimens (e.g., urine, wound drainage, vaginal drain- Cultures are done to identify the specific organism(s) causing the
age, sputum, blood) for culture as ordered. Report positive infection. Culture results provide information that helps deter-
results. mine the most effective treatment.

THERAPEUTIC INTERVENTIONS RATIONALE

n n ae
n
Independent Actions
Maintain a fluid intake of at least 2500 mL/day unless contra- Adequate hydration helps prevent infection by:
indicated. D ¢ Helping maintain adequate blood flow and nutrient supply to
the tissues. '
° Promoting urine formation and subsequent voiding, which
flushes pathogens from the bladder and urethra.
° Thinning respiratory secretions so that they can more easily be
removed by coughing or suctioning (respiratory secretions provide
a good medium for growth and colonization of microorganisms).
Use good hand hygiene and encourage client to do the same. Good hand hygiene removes transient flora, which reduces the risk
De+ of transmission of pathogens. Use ofproducts such as an anti-
bacterial soap, a chlorhexidine solution, or an alcohol-based
hand rub agent can actually inhibit the growth of or kill micro-
organisms, which further reduces infection risk.
 Chapter3 ° Selected Nursing Diagnoses, Interventions, Rationales, and Documentation oy)

THERAPEUTIC INTERVENTIONS RATIONALE

Adhere to the appropriate precautions established to prevent Adhering to the appropriate precautions that have been established
transmission of infection to the client (e.g., standard pre- to help prevent the transmission of microorganisms reduces the
cautions, transmission-based precautions on other clients, client’s risk of infection.
neutropenic precautions). D@ +
Use sterile technique during invasive procedures (e.g., urinary Use of sterile technique reduces the possibility of introducing patho-
catheterizations, venous and arterial punctures, injections, gens into the body.
tracheal suctioning, wound care and dressing changes).
D+
Anchor catheters/tubings (e.g., urinary, intravenous, wound Catheters/tubings that are not securely anchored have some degree
drainage) securely. D+ of in-and-out movement. This movement increases the risk of
infection because it allows for the introduction of pathogens
into the body. It can also cause tissue trauma, which can result
in colonization of microorganisms.
Change equipment, tubings, and solutions used for treat- The longer that equipment, tubings, and solutions are in use, the
ments, such as intravenous infusions, respiratory care, greater the chance of colonization of microorganisms, which
irrigations, and enteral feedings according to hospital can then be introduced into the body.
- policy.
Maintain a closed system for drains (e.g., wounds, chest Each time a drainage or infusion system is opened, pathogens from
tubes, urinary catheters) and intravenous infusions when- the environment have an opportunity to enter the body. Main-
ever possible. taining a closed system decreases this risk, which reduces the
possibility of infection.
Change peripheral intravenous line sites according to hospi- Peripheral intravenous line sites are changed routinely to reduce
tal policy. D+ persistent irritation of one area of a vein wall and the resultant
colonization of microorganisms at that site.
Protect client from others with infections. D @ + Protecting the client from others with infections reduces his/her risk
of exposure to pathogens.
Implement measures to maintain healthy, intact skin (e.g., Healthy, intact skin reduces the risk for infection by:
keep skin lubricated, clean, and dry; instruct or assist e Providing a physical barrier against the introduction of patho-
client to turn every 2 hrs; keep bed linens dry and gens into the body.
wrinkle-free). D @ + e Removing many of the microorganisms on the surface of the
skin by means of the constant shedding of the epidermis.
e Inhibiting the growth of some bacteria on the surface of the skin
sebum contains fatty acids, which create a slightly acidic envi-
ronment that inhibits the growth of some bacteria.
Implement measures to reduce stress (e.g., reduce fear, anxi- Stress causes an increased secretion of cortisol. Cortisol interferes
ety, and pain; help client identify and use effective coping with some immune responses, which subsequently increases the
mechanisms). D + client’s susceptibility to infection.
Maintain an optimal nutritional status. Adequate nutrition is needed to maintain normal function of the
immune system.
Instruct and assist client to perform good perineal care rou- The perineal area contains a large number of organisms. Routine
tinely and after each bowel movement. D + cleansing of the area reduces the risk of colonization of organ-
isms and subsequent perineal, urinary tract, and/or vaginal
infection.
Instruct and assist client to perform good oral hygiene as Frequent oral hygiene helps prevent infection by removing most of the
often as needed. D> food, debris, and many of the microorganisms that are present in
the mouth. It also helps maintain the integrity ofthe oral mucosa,
which provides a physical and chemical barrier to pathogens.
Implement measures to prevent urinary retention (¢.g., A client experiencing urinary retention is at increased risk for uri-
instruct client to urinate when the urge is felt, promote nary tract infection because:
relaxation during voiding attempts). e The urine that accumulates in the bladder creates an environment
conducive to the growth and colonization of microorganisms.
¢ Voiding does not occur so microorganisms are not flushed from
the mucous lining of the urethra; these microorganisms can
colonize and ascend into the bladder.
Implement measures to prevent stasis of respiratory secre- Respiratory secretions provide a good medium for growth of micro-
organisms. By preventing stasis, there is less chance of coloniza-
tions (e.g., assist client to turn, cough, and deep breathe;
increase activity as allowed and tolerated; perform tracheal tion of the microorganisms and a decreased risk for develop-
suctioning if indicated). D+ ment of respiratory tract infection.

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THERAPEUTIC INTERVENTIONS RATIONALE

Instruct client to receive immunizations (e.g., influenza vac- Immunizations are often recommended to reduce the possibility of
cine, pneumococcal vaccine) if appropriate. some infections in high-risk clients (e.g., those clients who are
immunosuppressed, elderly, or have a chronic disease).

Dependent/Collaborative Actions
Administer vitamins and minerals as ordered. D> Adequate nutrition is needed to maintain normal function of the
immune system.
Provide appropriate wound care (e.g., use dressing materials Proper wound care facilitates wound healing and reduces the num-
that maintain a moist wound surface, assist with debride- ber of pathogens that enter or are present in the wound, which
ment of necrotic tissue, use dressing materials that absorb reduces the risk of the wound becoming infected.
excess exudate, protect granulating tissue from trauma
and contamination, maintain patency of wound drains).
D+
Administer bethanechol as ordered. D+ Relaxes the bladder sphincter muscles and stimulates urination.
Consult appropriate health care provider regarding initiation Most antimicrobials disrupt cell wall synthesis, which halts the
of antimicrobial therapy if indicated. Question orders growth of, or kills, microorganisms. This can effectively reduce
that do not seem appropriate (e.g., prolonged use of anti- the client’s risk for infection. Antimicrobial orders that seem
microbials, excessively high dose of an antimicrobial, inappropriate should be questioned because they can result in
unnecessary use of broad-spectrum or multiple anti- the elimination of normal flora and/or the development of drug-
microbials). resistant microorganisms, which actually increase the client’s
risk for infection.

|Nursing poo
Diagnosis IMPAIRED PHYSICAL MOBILITY nox
Definition: Limitation in independent, purposeful movement of the body or of one or more extremities.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; discomfort; fatigue Decreased reaction time; difficulty moving; engages in
substitution for movement; supporting the affected limb;
exceptional dyspnea; contractures; limited ability to per-
form gross and fine motor skills; limited range of motion
(ROM); intentional movement-induced tremor; postural
instability; uncoordinated movements

RISK FACTORS
e Sedentary lifestyle e Neuromuscular impairment ¢ Cognitive impairment
e Limited cardiovascular endurance ¢ Prescribed movement restrictions * Lack of knowledge regarding the
e Joint stiffness or contracture e Decreased muscle strength and/or value of physical activity
e Pain and/or discomfort mass e Loss of bone mass
e Depression and/or anxiety e Activity intolerance * Sensoriperceptual impairments

DESIRED OUTCOMES DOCUMENTATION i

The client will improve mobility as evidenced by:
. . . “a: .

e ADLs
Peal) OE SS Se eae Se Se

a. Increased physical activity ¢ Muscle strength

b. Movement of affected limb or limbs ¢ Distance ambulated
c. Participation in activities of daily living (ADLs) ¢ Passive or active ROM
d. Demonstration of appropriate use of assistive devices ¢ Therapeutic interventions
to improve movement ¢ Client/family teaching
 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 61

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance; cardiovascular status; fall prevention Positioning; ambulation; pain relief; active and/or passive
behavior; endurance; joint movement ROM

NURSING ASSESSMENT RATIONALE

Assess client’s movement ability and activity tolerance. Use a Assessment of mobility is used to best determine how to facilitate
tool such as the Assessment Tool for Safe Patient Handling movement. Assessment of activity tolerance provides a baseline
and Movement or the Functional Independence Measures for patient strength and endurance with movement.
(FIM).
Assess for cause of immobility. It is important to determine if the cause of immobility is physical
or psychologic, and to plan interventions to improve mobility.
Assess circulation, motion, and feeling in digits. Circulation may be compromised by edema of extremities, which
can lead to tissue necrosis and/or contractures.
Assess skin integrity. Routine examination of the skin provides for early detection and
intervention of pressure sores. Pressure sores develop quickly in
patients who are immobile.
Assess emotional response to immobility. Determine client’s acceptance of temporary or permanent limita-
tions. This impacts implementation of therapeutic interventions.
Assess need for assistive devices. Determine client’s needs for assistive devices as well as proper use
of wheelchairs, walkers, canes, etc., to reduce incidence of falls.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage and implement strength training activities: Inactivity contributes to muscle weakening. Contractures can de-
e Active and/or passive ROM velop as early as 8 hrs of immobility. These activities maintain
e Ambulation and increase the client’s strength and ability to move.
e Use of trapeze for pull-ups
¢ ADIsD® +
Use assistive devices to help client with movement: Assistive devices help the caregivers decrease the potential for falls
e Crutches and/or injuries.
° Gait belt
e Walker D@ +
Cluster treatments and care activities to allow for uninter- Increases client’s tolerance and strength for activities.
rupted periods of rest. D@ +
Encourage patient with positive reinforcement during A positive approach to activities supports the client’s accomplish-
activities. D@ + ment, engagement in new activities, and improves self-esteem.
Implement falls protocol. Client safety is a priority.
Maintain the bed in low position and keep side rails up. Reduces prolonged pressure on tissues, decreasing potential for
De+ tissue ischemia and pressure sores.
For bedridden patients, turn and reposition every 2 hrs. Turning clients allows for appropriate circulation to tissues.
De+
Position client with appropriate devices (e.g., wedges, pillows, Reduces prolonged pressure on tissues, decreasing potential for
kinetic bed, air bed, gel mattress). D @ + tissue ischemia and pressure sores.
Use sequential compression devices or antiembolic stockings. Improves venous circulation and helps to prevent thrombophlebitis
De+ in lower extremities.
Implement measures to maintain healthy, intact skin (e.g., Healthy, intact skin reduces the risk ofpressure sores and infection.
keep skin lubricated, clean, and dry; instruct or assist
client to turn every 2 hrs; keep bed linens dry and
wrinkle-free). D @ +
Maintain an optimal nutritional status. Increase protein Adequate nutrition is needed to maintain adequate energy level.
intake.
Increase fluid intake to 2000 to 3000 mL/day unless contra- Increased fluid maintains adequate hydration and helps prevent
indicated. constipation and hardening of the stool.
Encourage coughing and deep breathing exercises and use of Prevents buildup of secretions and promotes lung expansion.
incentive spirometry.
Initiate bowel program. Prolonged immobility can lead to constipation.
Assist client with acceptance of immobility. Helps patient accept limitations and focus on a new quality of life.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Consult appropriate health care provider: dietitian, physi- These individuals provide specific activities and exercise programs
cian, and occupational therapist. to improve strength and mobility.
Administer pain medications before activities. D + Reduces muscle stiffness and tension, allowing the client to par-
ticipate in activities.

|Nursing 2)
Diagnosis IMBALANCED NUTRITION: LESS THAN BODY
: REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal of lack of appetite; fatigue; irritability; poor self- Loss of weight with adequate food intake; body weight
esteem; verbalization of sore mucous membranes 20% or more under ideal weight; sore, inflamed buccal
cavity; capillary fragility; pale conjunctiva and mucous
membranes; poor muscle tone; excessive hair loss; amenor-
thea; decreased blood urea nitrogen (BUN) and elevated
creatinine levels; decreased albumin and prealbumin lev-
els; decreased hematocrit (Hct), decreased hemoglobin
(Hgb), and decreased white blood cells

RISK FACTORS
e Inability to ingest or digest food or absorb nutrients
because of biologic, psychologic, or economic factors

DESIRED OUTCOMES DOCUMENTATION

The client will maintain an adequate nutritional status as e Weight
evidenced by: e Activity tolerance
a. Weight within normal range for the client ¢ Condition of oral mucous membrane
b. Normal BUN and serum albumin, prealbumin, Hct, ¢ Type of diet and amount consumed
Hgb, and lymphocyte levels ¢ Therapeutic interventions
c. Usual strength and activity tolerance ¢ Client/family teaching
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

Appetite; body image; bowel elimination; compliance behav- Nutritional monitoring; nutritional counseling; nutritional
ior: prescribed diet; hydration; weight maintenance behavior management; nutrition therapy; weight gain assistance;
weight management

NURSING ASSESSMENT
RATIONALE
——$———
eee t
Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
° Weight significantly below client’s usual weight or below prompt intervention.
normal for client’s age, height, and body frame
e Increased BUN and low serum albumin, prealbumin, Hct,
Hgb, and lymphocyte levels
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Monitor percentage of meals and snacks client consumes. An awareness of the amount of foods/fluids the client consumes
Report a pattern or inadequate intake. alerts the nurse to deficits in nutritional intake. Reporting an
inadequate intake allows for prompt intervention.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 63

NURSING ASSESSMENT RATIONALE

Perform or assist with anthropometric measurements such as Anthropometric measurements provide information about the
skinfold thickness, body circumferences (e.g., hip, waist, amount of muscle mass, body fat, and protein reserves the
mid-upper arm), and bioelectrical impedance analysis if client has. These assessments assist in evaluating the client’s
indicated. Report results that are lower than normal. nutritional status.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent vomiting if indicated (e.g., Vomiting results in actual loss of nutrients.
eliminate noxious sites and odors). D @ +
Implement measures to control diarrhea if present (e.g., dis- Increased intestinal motility that occurs with or causes diarrhea
courage intake of spicy foods and foods high in fiber or results in a decreased absorption of nutrients in the bowel. In
lactose). D@ + addition, diarrhea causes an actual loss of nutrients.
Implement measures to improve oral intake: Decreases client’s appetite and oral intake.
e Perform actions to reduce nausea, pain, fear, and anxiety if
present. D® +
e Perform actions to relieve gastrointestinal distention if Distention of the gastrointestinal tract, especially the stomach and
present (e.g., encourage and assist client with frequent duodenum, can result in stimulation of the satiety center and
ambulation) unless contraindicated. D@ + subsequent inhibition of the feeding center in the hypothala-
mus. This effect, along with the discomfort that occurs with
distention, decreases appetite.
e Increase activity as allowed and tolerated. D® + Activity usually promotes a general feeling of well-being, which
can result in improved appetite.
e Maintain a clean environment and a relaxed, pleasant Noxious sites and odors can inhibit the feeding center in the hypo-
atmosphere. D@ + thalamus. Maintaining a clean environment helps prevent this
from occurring. In addition, maintaining a relaxed, pleasant at-
mosphere can help reduce the client’s stress and promote a feeling
of well-being which tends to improve appetite and oral intake.
e Encourage a rest period before meals if indicated. D@ + The physical activity of eating requires some expenditure of energy.
Fatigue can reduce the client’s desire and ability to eat.
e Provide oral hygiene before meals. D@ Oral hygiene moistens the oral mucous membrane, which may
make it easier to chew and swallow. It also freshens the mouth
and removes unpleasant tastes. This can improve the taste of
foods/fluids, which helps stimulate appetite and increase oral
intake.
e Serve foods/fluids that are appealing to the client and ad- Foods/fluids that appeal to the client’s senses, especially sight and
here to personal and cultural (e.g., religious, ethnic) prefer- smell, and are in accordance with personal and cultural prefer-
ences whenever possible. D@ + ences are most likely to stimulate appetite and promote interest
in eating.
e Serve frequent, small meals rather than large ones if client Providing small rather than large meals can enable a client who is
is weak, fatigues easily, and/or has a poor appetite. D @ + weak or fatigues easily to finish a meal. Also, a client who has
a poor appetite is often more willing to attempt to eat smaller
meals because they seem less overwhelming than larger ones. If
smaller meals are served, the number of meals per day should
be increased to help ensure adequate nutrition.
° Encourage significant others to bring in client’s favorite A client’s favorite foods/fluids tend to stimulate his/her appetite
foods unless contraindicated and eat with him/her if client more than institutional foods/fluids. The presence of significant
desires. others during meals helps create a familiar social environment
that can stimulate appetite and improve oral intake.
e If client is experiencing dyspnea, place him/her in a high- Because a person cannot swallow and breathe at the same time,
Fowler’s position and provide supplemental oxygen ther- relief of dyspnea increases the likelihood of maintaining a good
apy during meals if indicated. oral intake. In addition, relieving dyspnea decreases the client's
anxiety about and preoccupation with breathing efforts and
increases the ability to focus on eating and drinking.
e Perform actions to compensate for taste alterations if pres- Enhancing the taste of foods/fluids and providing nutritious alter-
ent (e.g., add extra sweeteners to foods unless contraindi-
natives to those that taste unpleasant to the client help to
cated, encourage client to experiment with different fla- stimulate appetite and improve oral intake.
vorings and seasonings, provide alternative sources of
protein if meats such as beef or pork taste bitter or rancid).

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64 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

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THERAPEUTIC INTERVENTIONS RATIONALE

e Allow adequate time for meals; reheat foods/fluids if neces- A client who feels rushed during meals tends to become anxious,
sary. D@ + loses his/her appetite, and stops eating. Appetite is also sup-
pressed iffoods/fluids normally served hot or warm become cold
and do not appeal to the client.
e Limit fluid intake with meals unless the fluid has a high When the stomach becomes distended, its volume receptors stimu-
nutritional value. D® + late the satiety center in the hypothalamus, and the client re-
duces his/her oral intake. Drinking liquids with meals distends
the stomach and may cause satiety before an adequate amount
of food is consumed.
Ensure that meals are well balanced and high in essential The client must consume a diet that is well balanced and high in
nutrients. essential nutrients in order to meet his/her nutritional needs.
Dietary supplements are often needed to help accomplish this.
Allow the client to assist in the selection of foods/fluids that The client who is actively involved in menu planning is more likely
meet nutritional needs. D @+ to adhere to the diet plan. In addition, the involvement in-
creases his/her sense of control, which promotes a feeling of
well-being and can lead to an increased oral intake.
Dependent/Collaborative Actions
Administer medications that may be ordered to improve cli- Medications may relieve vomiting, diarrhea, and distention of the
ent’s nutritional status (e.g., antiemetics, antidiarrheals, gastric tract, which decreases the discomfort that occurs with
gastrointestinal stimulants, and vitamins and minerals). each of these signs and symptoms. Vitamins and minerals are
D+ needed to maintain metabolic functioning. If the client’s dietary
intake does not provide adequate amounts of them, oral and/or
parenteral supplements may be necessary.
Obtain a dietary consult if necessary. A dietitian is best able to evaluate whether the foods/fluids selected
will meet the client’s nutritional needs.
Perform a calorie count if ordered. Report information to the A calorie count provides information about the caloric and nutri-
dietitian and physician. tional value of the foods/fluids the client consumes. The infor-
mation obtained helps the dietitian and physician determine
whether an alternative method ofnutritional support is needed.
Consult the physician about an alternative method of provid- If the client’s oral intake is inadequate, an alternative method of
ing nutrition (e.g., parenteral nutrition, tube feeding) if providing nutrients needs to be implemented.
the client does not consume enough food or fluids to meet
nutritional needs.

| Nursing »—---
Diagnosis |IMPAIRED ORAL MUCOUS MEMBRANE INTEGRITY nox
Definition: Injury to the lips, soft tissue, buccal cavity, and/or oropharynx.

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of sensitive tongue; bad taste in the mouth; oral Purulent drainage or exudates; gingival recession, pockets
pain/discomfort; self-report of difficulty eating or swallow- deeper than 4 mm; enlarged tonsils beyond what is devel-
ing; self-report of diminished or absent taste opmentally appropriate; smooth, atrophic geographic
tongue; mucosal denudation; presence of pathogens; diffi-
cult speech; gingival or mucosal pallor; xerostomia (dry
mouth); vesicles, nodules, or papules; white patches/
plaques, spongy patches, or white curdlike exudate; oral
lesions or ulcers; halitosis; edema; hyperemia; desquama-
tion; coated tongue; stomatitis; bleeding; macroplasia;
gingival hyperplasia; fissures, cheilitis; red or bluish masses
(e.g., hemangiomas)
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 65

RISK FACTORS
e Chemotherapy Lack of or decreased salivation Mechanical (e.g., ill-fitting dentures,
e Chemical (e.g., alcohol, tobacco, Trauma braces, tubes [endotracheal/
acidic foods, drugs, regular use of Pathologic conditions: oral cavity nasogastric], surgery in oral cavity)
inhalers or other noxious agents) (e.g., radiation to head or neck) Decreased platelets
e Depression Nothing by mouth (NPO) for more Immunocompromised
e Immunosuppression than 24 hrs Radiation therapy
e Aging-related loss of connective, Mouth breathing Barriers to oral self-care
adipose, or bone tissue Malnutrition or vitamin deficiency Diminished hormone levels
e Barriers to professional care Dehydration (women)
° Cleft lip or palate Infection Stress
e¢ Medication side effects Ineffective oral hygiene Loss of supportive structures

DESIRED OUTCOMES DOCUMENTATION

The client will maintain a healthy oral cavity as evidenced ¢ Client reports of oral dryness and/or discomfort
by: e¢ Condition of oral mucous membranes
a. Absence of inflammation and discomfort e Therapeutic interventions
b. Pink, moist, intact mucosa e Client teaching
+

NOC OUTCOMES NIC INTERVENTIONS

Oral health; tissue integrity: skin and mucous membranes; Oral health maintenance; oral health restoration; oral health
hydration; nutritional status promotion

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired oral mu- Early recognition of signs and symptoms of impaired oral mucous
cous membrane (e.g., reports of oral dryness and discomfort, membrane allows for prompt intervention.
coated tongue, inflamed and/or ulcerated oral mucosa).
Culture oral lesions as ordered. Report positive results. A positive culture reveals the organisms present in a lesion, which
provides direction for the treatment plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Assist client to perform oral hygiene as often as needed (e.g., Good oral hygiene helps maintain health of the oral mucous mem-
after meals and at bedtime, at least every 2 hrs if NPO). brane by removing food particles and debris that harbor or
De+ promote the growth of pathogenic organisms that can cause
inflammation and infection. Brushing the teeth also stimulates
circulation to the gums.
Assist client to perform oral hygiene using a soft bristle Use of appropriate oral hygiene devices and techniques helps to
toothbrush or sponge-tipped swab and to floss teeth effectively remove food particles and debris from client’s mouth
gently. D@® + without causing trauma to the oral mucous membrane.
Avoid use of mouthwashes containing alcohol and oral care Mouthwashes containing alcohol and oral care products containing
products that contain lemon and glycerin. D @ + lemon and glycerin have a drying and irritating effect on the
oral mucous membrane. Excessive use of the lemon-glycerin
products also increases acidity in the mouth, which results in
further irritation of the oral mucosa.
Encourage client to rinse mouth frequently with water. Frequent rinsing of the mouth helps alleviate dryness, which re-
bpe+ duces the risk for cracking and breakdown of the oral mucosa.
Rinsing also helps prevent inflammation and infection in the
mouth by removing food particles and debris that can harbor or
promote the growth of pathogenic organisms.
D@ + Lubricating the client’s lips helps keep them moist, which helps
Lubricate client’s lips frequently.
prevent drying and cracking of the lips.
Air inspired through the nose is humidified by the layer of mucus
Encourage client to breathe through nose rather than mouth.
D+ that coats the lining ofthe nasal cavity. Air inspired through the
mouth lacks this moisture and is drying to the oral mucous
membrane.

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THERAPEUTIC INTERVENTIONS RATIONALE

Encourage client not to smoke or chew tobacco. Smoking dries the oral mucous membrane. Irritation and subse-
quent inflammation can occur when tobacco is in contact with
the oral mucosa.
Encourage a fluid intake of at least 2500 mL/day unless Adequate hydration helps keep the oral mucosa moist, which
contraindicated. D@ + reduces the risk of cracking and breakdown.
Encourage client to suck on hard candy if allowed. D+ Sucking on hard candy stimulates salivation, which helps alleviate
dryness of the oral mucosa and the subsequent risk of cracking
and breakdown. Saliva also helps maintain oral mucosal health
by washing away food particles and debris that harbor or
promote the growth of pathogenic organisms and by directly
destroying some of the bacteria present in the mouth.
Assist client to select foods of moderate temperature and Foods that are extremely hot or cold; hard, crusty, or rough; spicy;
those that are soft and bland. D@ + and/or acidic may cause thermal, mechanical, or chemical
trauma to the oral mucosa.
Encourage client to maintain an optimal nutritional status. Adequate nutrition is needed to maintain the high cellular turnover
of the oral mucous membrane. Good nutrition also promotes
optimal function of the immune system, which reduces the
client’s risk of oral cavity infection.
Inspect client’s dentures. Note if they are rough, cracked, or Rough, cracked, or ill-fitting dentures can cause mechanical trauma
ill-fitting. and subsequent inflammation and breakdown of the oral
mucosa. The discomfort in the affected area(s) can result in a
decreased oral intake, which further compromises the health of
the oral mucosa.

Dependent/Collaborative Actions
Administer topical anesthetics, oral protective agents, analge- Topical anesthetics, oral protective agents, and analgesics promote
sics, and antimicrobials if ordered. D > comfort if the oral mucous membrane is inflamed or if break-
down is present. The increased comfort can result in an im-
proved oral intake, which helps maintain health of the oral
mucosa. Antimicrobials prevent or treat infection of the oral
mucosa.
Consult appropriate health care provider if dryness, irritation, Notifying the appropriate health care provider allows for modifica-
discomfort, and/or breakdown of the oral cavity persist or tion of the treatment plan.
worsen. Consult the physician about an alternative treat-
ment plan
Consult a dentist if dentures are rough, cracked, or ill-fitting. Notifying a dentist to improve fit and condition of dentures will
help improve the health of the oral mucosa.

| yee
Nursing Diagnosis
ere es |ACUTE PAIN nox
Definition: Unpleasant sensory and emotional experience associated with actual or potential
tissue damage. or described in
terms of such damage (International Association for the Study of Pain); sudden or slow
onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than
3 months.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; self-sleep disturbance; self-focus; Autonomic responses (e.g., facial mask diaphoresis;
narrowed focus (altered time perception, impaired thought changes in blood pressure [BP], respiration, pulse rate; pu-
processes) pillary dilatation); expressive behavior (e.g., restlessness,
moaning, crying, vigilance, irritability, sighing); changes in
appetite and eating; protective gestures; guarding behavior;
eyes lack luster, fixed or scattered movement, beaten
look,
grimace; reduced interaction with people and environ-
ment; autonomic change in muscle tone may span from
listless to rigid; distraction behavior (e.g., pacing, seeking
out other people and/or activities, repetitive activities)
 Chaptersies Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 67

RISK FACTORS
e Injury agents (e.g., biologic, chemical, physical, psychologic)

DESIRED OUTCOMES DOCUMENTATION

The client will experience diminished pain as evidenced e Verbal description of pain
by: e Rating of pain intensity
a. Verbalization of decrease in or absence of pain e Facial expression
b. Relaxed facial expression and body positioning ¢ Body movement and position
c. Increased participation in activities e Vital signs
d. Stable vital signs e Participation in activities
e Factors that precipitate, aggravate, and alleviate pain
e Therapeutic interventions
e Client/family teaching

NOC OUTCOMES NIC INTERVENTIONS

Pain control; comfort status: physical discomfort level; pain Pain management; environmental management: comfort;
level; stress level analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (e.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
pain, grimacing, reluctance to move, restlessness, diapho- intervention and improved pain control.
resis, increased BP, tachycardia).
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps deter-
intensity rating scale. mine the most appropriate intervention(s) for pain manage-
ment. Use of a pain intensity rating scale gives the nurse a
clearer understanding of the pain being experienced and pro-
motes consistency when communicating with others about the
client’s pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identification
duration, precipitating factors, aggravating factors, allevi- of effective pain management interventions.
ating factors).
Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex, Cop-
methods used to manage pain effectively. ing style, previous experience with pain, culture, cause of pain).
Knowledge of the client’s usual response to pain and methods
previously used to manage pain effectively enables the nurse to
evaluate the client’s pain more accurately and facilitates the
identification of effective strategies for pain management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that his/her need for pain relief is understood, plan for pain and thereby heighten the perception of pain. In addi-
methods for achieving pain control with client, provide a tion, pain management methods are not as effective if the client
calm environment). is tense and unable to relax.
Implement measures to promote rest (e.g., minimize environ- Fatigue can decrease the client’s threshold and tolerance for pain
mental activity and noise). D@® + and thereby heighten the perception of pain. If the client is well
rested, he/she often experiences decreased pain and increased
effectiveness of pain management measures.
Provide or assist with nonpharmacologic methods for pain Nonpharmacologic pain management includes a variety of inter-
relief. Examples include: ventions. It is believed that most of these are effective because
e Relaxation techniques (e.g., progressive relaxation exer- they stimulate closure of the gating mechanism in the spinal
cises, meditation, guided imagery) cord and subsequently block the transmission of pain impulses.
e Distraction measures (e.g., listening to music, conversing, In addition, some interventions are thought to stimulate the
watching television, playing cards, reading) release of endogenous analgesics (e.g., endorphins) that inhibit
e Position change the transmission of pain impulses and/or alter the client’s per-
ception of pain. Many of the nonpharmacologic interventions
also help decrease pain by promoting relaxation.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing event
can cause pain and before pain becomes severe. D + helps minimize the pain that will be experienced. Analgesics are
also more effective if given before pain becomes severe because
mild to moderate pain is controlled more quickly and effectively
than severe pain.
Administer the following medications as ordered: D+ Pharmacologic therapy is an effective method of reducing or reliev-
e Opioid (narcotic) analgesics ing pain.
° Nonopioid (nonnarcotic) analgesics such as acetamino- Opioid analgesics act mainly by altering the client’s perception of
phen and salicylates and other nonsteroidal antiinflammatory pain and emotional response to the pain experience.
agents (e.g., ketorolac, ibuprofen, naproxen) Nonopioid analgesics are thought to interfere with the transmission
of pain impulses by inhibiting prostaglandin synthesis.
e Anesthetic agents (e.g., bupivacaine, etidocaine). Anesthetics help control pain by inhibiting the initiation and con-
duction of pain impulses along the sensory pathways at and
near the infusion site.
Provide or assist with nonpharmacologic methods for pain It is believed that most of these are effective because they stimulate
relief such as cutaneous stimulation measures (e.g., pres- closure of the gating mechanism in the spinal cord and subse-
sure, Massage, heat and cold applications, transcutaneous quently block the transmission of pain impulses.
electrical nerve stimulation [TENS], acupuncture).
Consult physician about an order for patient-controlled anal- The use of PCA allows the client to self-administer analgesics
gesia (PCA) if indicated. within parameters established by the physician. This method
facilitates pain management by ensuring prompt administra-
tion of the drug when needed, providing more continuous pain
relief, and increasing the client’s control over the pain.
Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
pharmacist, pain management specialist) if above mea- tion of the treatment plan.
sures fail to provide adequate pain relief.

:Nursing Diagnosis READINESS FOR ENHANCED SELF-CARE nox

Definition: A pattern of performing activities for oneself to meet health-related goals, which can be strengthened.

Related to:

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-expressed desire to advance independence in Not applicable
maintaining life; enhance independence in maintaining
health; enhance independence in maintaining personal
development; enhance independence in maintaining
well-being; enhance knowledge of strategies for self-care

DESIRED OUTCOMES DOCUMENTATION '

The client will have enhanced self-care as evidenced by: * Client/family teaching
a. Identification and performance of desired self-care
activities
b. Expressed desire to improve self-care habits
c. Ability to evaluate effectiveness of self-care habits
 Chapter375 Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 69

NOC OUTCOMES NIC INTERVENTIONS

Adherence behavior; health-seeking behavior; health promo- Active listening; family integrity promotion; self-care
tion behavior; information processing; decision-making; assistance; self-responsibility facilitation; support system
health promoting behavior; patient engagement behavior; enhancement; spiritual growth facilitation; self-care
self-care status teaching

NURSING ASSESSMENT RATIONALE

Assess client’s current self-care habits. Assessment of the client’s current self-care activities provides the
basis for planning further self-care activities.
Assess Client’s confidence in ability to perform more self-care It is important to determine whether the client has the confidence
habits. to perform new self-care activities. Confidence in one’s ability to
change behaviors impacts the success in maintaining change.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage client in pursuit of enhanced self-care activities. Encouragement will support the client to begin and maintain self-
+
care activities.
Collaborate with the client to set realistic goals. Developed goals should include short- and long-term goals. Short-
term goals are more achievable and provide the client confi-
dence to reach the long-term goals. Goals should be specific and
realistic, with consideration for the patient’s ability.
Provide positive reinforcement when behaviors are met. Positive reinforcement promotes a sense of self-efficacy in the
client.
Promote family involvement in developing self-care activities. Self-care activities help improve a client’s health and decrease the
incidence of repeated hospitalizations. The client’s family plays
a significant role in promoting success of self-care behaviors.
Implement culturally sensitive interventions. Recognize the impact of culture on self-care. A client’s cultural
background influences self-care activities and adherence to
them.
Provide client with information to enhance self-care behaviors. Specific self-care needs are based on the type of disease process and/
or symptoms experienced by the client.
Inform client of community resources available to support and Client should know what community resources are available to
enhance self-care. enhance self-care behaviors.
Use a variety of teaching strategies to enhance self-care behaviors. Learning is enhanced when a variety of teaching methods are used.
Evaluate effectiveness of self-care behaviors. This helps the client realize the progress made and verifies the cli-
ent’s ability to maintain self-care behaviors and/or identify new
behaviors.
Educate client and family to evaluate the effectiveness of self- This helps the client determine when and/or if progress is being
care activities. made and improves the client’s confidence in his/her ability to
improve well-being.

|Nursing >»...
Diagnosis |READINESS FOR ENHANCED SELF-CONCEPT nox

For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

Diagnosis |RISK FOR IMPAIRED SKIN INTEGRITY nox

|Nursing >»...
Definition: Susceptible to alteration in epidermis and/or dermis, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Pallor, redness, and breakdown of skin covering bony
Verbal self-report of areas of decreased sensation
prominences, dependent areas, pruritic areas, perineum,
and areas of decreased sensation

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RISK FACTORS
e External: Radiation; physical immo- excretions and/or secretions; mois- altered pigmentation; altered metabolic
bilization; hypothermia or hyper- ture; extremes of age state; altered circulation; alterations
thermia; chemical substance; me- ° Internal: Medication; skeletal promi- in skin turgor (changes in elasticity);
chanical factors (e.g., shearing nence; immunologic factors; develop- alterations in nutritional state (e.g.,
forces, pressure, restraint); humidity; mental factors; altered sensation; obesity, emaciation); psychogenetic

DESIRED OUTCOMES DOCUMENTATION

The client will maintain skin integrity as evidenced by: e Appearance of skin
a. Absence of redness and irritation e Therapeutic interventions
b. No skin breakdown ¢ Client/family teaching

NOC OUTCOMES NIC INTERVENTIONS

——_—_—_—n—Xnr”_ gkx+ —XxsK—X—eeeeOC OO

Tissue integrity: skin and mucous membranes Pressure ulcer prevention; skin surveillance; bathing; pres-
sure management; skin care: topical treatments; positioning;
bedrest care

NURSING ASSESSMENT RATIONALE

SNS
eee

Determine client’s risk for skin breakdown using a risk assess- Prompt identification of the client’s risk for skin breakdown leads
ment tool (e.g., Norton Scale, Braden Scale, Gosnell Scale). to earlier implementation of actions to maintain skin integrity.
Use of a risk assessment tool aids in the identification of factors
that could cause skin breakdown.
Inspect the skin especially bony prominences, dependent ar- Early recognition of signs of impaired skin integrity allows for
eas, pruritic areas, perineum, and areas of decreased sensa- prompt intervention.
tion and/or edema for pallor, redness, and breakdown.

THERAPEUTIC INTERVENTIONS RATIONALE

Se
Independent Actions
Implement measures to prevent prolonged and/or excessive Prolonged and/or excessive pressure on the skin obstructs capillary
pressure on any area of the skin: D@ + blood flow to that area. The resultant hypoxia, impaired flow
e Assist client to turn at least every 2 hrs unless contra- of nutrients, and accumulation of waste products in the area of
indicated. obstructed blood flow make that tissue more susceptible to
e Instruct or assist client to shift weight at least every breakdown. Measures that prevent the excessive pressure or en-
30 minutes. sure that pressure is relieved often enough to avoid obstruction
° Position client properly using supportive devices such as ofcapillary blood flow help maintain skin integrity.
pillows and pads as needed.
e Keep bed linens wrinkle-free.
e Ensure that external devices such as braces, casts, and
restraints are applied properly.
e Ensure that client is not lying on tubings.
° Use pressure-reducing or pressure-relieving devices (e.g.,
gel or foam cushions, alternating pressure mattress, air-
fluidized bed) if indicated.
Gently massage around reddened areas at least every 2 hrs. Massage stimulates circulation to the skin and underlying tissues.
De+ The improved blood flow helps maintain skin integrity by in-
creasing the supply of oxygen and nutrients availablt to the
cells and by removing waste products of metabolism. To avoid
damaging the capillaries, massage should be gentle rather than
deep, and massage over reddened areas should be avoided.
Implement measures to prevent shearing (e.g., keep head of When one tissue layer slides past another in an opposite direction
bed as flat as possible, gatch knees slightly when head of (i.e., Shearing), the capillaries in the affected area are kinked,
bed is elevated 30 degrees or higher, limit length of time stretched, or severed. This compromises the area’s blood supply
client is in semi-Fowler’s position to 30-minute intervals). and increases the risk of tissue breakdown. A client in a semi-
De+ Fowler’s position is likely to slide down in the bed. When this
occurs, his/her skin tends to remain stationary while the under-
lying tissues and skeletal structures shift position, resulting in
shearing.
 Chapter sr Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 71

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to reduce friction between the skin and The outermost layers of skin can be damaged when dragged along
another surface (e.g., apply a protective covering such as a or rubbed against another surface. Reducing friction helps pre-
hydrocolloid or transparent membrane dressing to suscep- vent skin surface irritation and abrasion.
tible areas of the skin, apply thin layer of a dry lubricant
such as powder or cornstarch to bottom sheet or client’s
skin, lift and move client carefully using turn sheet and
adequate assistance, adequately secure restraints and tub-
ings, pat skin dry rather than rub). D@
Keep client’s skin clean. D@ + Keeping the skin clean removes many of the surface micro-
organisms, which, if allowed to accumulate, increase the risk
of irritation or infection and subsequent skin breakdown.
Use a mild soap when bathing client. D@ Sebum, which is secreted by the skin, helps maintain skin integrity
by preventing excess evaporation of moisture, keeping the skin
soft and pliable, and destroying some of the bacteria on
the skin’s surface. Using a mild rather than a harsh, alkaline
soap helps ensure that some sebum remains on the skin after
bathing.
Implement measures to keep skin free of excessive moisture: Excessive moisture on the skin or prolonged exposure of the skin to
e Thoroughly dry skin after bathing and as often as needed, moisture softens the epidermal cells and makes them less resis-
paying special attention to skinfolds and opposing skin tant to damage. Moisture also harbors microorganisms that can
surfaces (e.g., axillae, perineum, beneath breasts). D® + cause irritation or infection, and it increases the possibility of
e Keep bed linens dry. D+ friction between the skin and the surface it is against. Removing
e Protect skin surrounding wound from drainage (e.g., excessive moisture and protecting the skin from prolonged con-
change dressing when damp, apply a drainage collection tact with moisture reduces the risk of skin irritation and subse-
device if needed). D+ quent breakdown.
e If use of absorbent products such as pads or undergarments
is necessary, select those that effectively absorb moisture
and keep it away from the skin.
Increase activity as allowed and tolerated. D@ Activity stimulates circulation, which helps maintain skin integrity
by increasing the flow of oxygen and nutrients to the skin and
underlying tissues. In addition, increasing activity reduces the
risk of prolonged pressure occurring on any area as a result of
decreased mobility.
Maintain an optimal nutritional status. An inadequate nutritional status results in muscle atrophy, a de-
crease in the amount of subcutaneous tissue, and skin that is
thin and less elastic. Subsequently, the skin and tissue are more
vulnerable to injury because they are less able to withstand
minor trauma. In addition, a malnourished client is more sus-
ceptible to the effects of pressure because there is less padding
between the skin and underlying bone.
Implement measures to prevent drying of the skin: Dry skin is more prone to cracking and has decreased elasticity,
which makes it susceptible to damage.
e Encourage a fluid intake of 2500 mL/day unless contra- e An adequate fluid intake helps ensure that the skin remains
indicated. well hydrated.
e Apply a moisturizing lotion and/or emollient to the skin at ¢ Moisturizing lotion and some emollients provide a source of
least once a day. D@® + moisture to the skin. Emollients also form a protective barrier
on the epidermis, which reduces the evaporation ofmoisture.
Protect skin from contact with urine and feces (e.g., perform Urine and feces are irritants that can cause inflammation and
actions to prevent incontinence and/or diarrhea, keep breakdown of the skin. In addition, the moisture in urine and
perineal area clean and dry, apply a protective ointment or feces softens epidermal cells and increases friction between op-
cream to perineal area). D@ + posing skin surfaces and between the skin and bed linen.
If edema is present, handle edematous areas carefully and Edematous areas have an increased risk for skin breakdown be-
implement measures to reduce fluid accumulation in de- cause the oxygen and nutrient supply to the skin is compro-
pendent areas (e.g., instruct client in and assist with range mised by the increased distance that exists between the capillar-
of motion exercises, elevate affected extremities whenever ies and the cells. Handling edematous areas carefully and
possible). implementing measures to reduce edema decrease the risk for
skin breakdown.

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THERAPEUTIC INTERVENTIONS RATIONALE

If the client is experiencing pruritus, implement measures to The client experiencing pruritus is likely to scratch the affected ar-
reduce the itching sensation (e.g., apply cool compress to eas, which irritates the skin and can cause excoriation. Imple-
pruritic area), keep his/her nails trimmed, and apply mit- menting measures to reduce the itching sensation helps prevent
tens if necessary. D@ + scratching. Trimming the client’s nails and applying mittens if
necessary reduce the risk of trauma to the skin if he/she does
scratch the pruritic areas.

Dependent/Collaborative Actions
Administer antihistamines as prescribed. D + Administering antihistamines can decrease itching.
Notify appropriate health care provider (e.g., physician, en- Notifying the appropriate health care provider allows for modifica-
terostomal therapist, wound care specialist) if skin break- tion of treatment plan.
down occurs.

. Nursing Diagnosis DISTURBED SLEEP PATTERN nox

Definition: Time-limited awakenings due to external factors.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty falling asleep, not feeling well Awakening earlier than desired; prolonged awakenings;
rested, and/or dissatisfaction with sleep sleep maintenance insomnia; self-induced impairment of
normal pattern; sleep onset greater than 30 minutes; early
morning insomnia; increased proportion of stage 1 sleep;
less than age-normed total sleep time; three or more night-
time awakenings; decreased proportion of stages 3 and
4 sleep (e.g., hyporesponsiveness, excess sleepiness,
decreased motivation); decreased proportion of rapid eye
movement (REM) sleep (e.g., REM rebound, hyperactivity,
emotional lability, agitation and impulsivity, atypical
polysomnographic features); decreased ability to function

RISK FACTORS
° Psychologic: Ruminative pre-sleep of sleep partner, life change; pre- other-generated awakening; exces-
thoughts; daytime activity pattern; occupation with trying to sleep; sive stimulation; physical restraint;
thinking about home; body temper- periodic gender-related hormonal lack of sleep privacy/control; inter-
ature; temperament; dietary; child- shifts; biochemical agents; fear; sepa- ruptions for therapeutics, monitor-
hood onset; inadequate sleep hy- ration from significant others; social ing, lab tests; sleep partner; noxious
giene; sustained use of anti-sleep schedule inconsistent with chrono- odors
agents; circadian asynchrony; fre- type; aging-related sleep shifts; anxi- Parental: Mother's sleep-wake
quently changing sleep-wake sched- ety; medications; fear of insomnia; pattern; parent-infant interaction;
ule; depression; loneliness; frequent maladaptive conditioned wakeful- mother’s emotional support
travel across time zones; daylight/ ness; fatigue; boredom Physiologic: Urinary urgency,
darkness exposure; grief; anticipa- Environmental: Noise; unfamiliar incontinence; fever; nausea; stasis
tion; shift work; delayed or ad- sleep furnishings; ambient of secretions; shortness of breath;
vanced sleep phase syndrome; loss temperature, humidity; lighting; position; gastroesophageal reflux

DESIRED OUTCOMES DOCUMENTATION

The client will attain optimal amounts of sleep as evi-
. . . . . OT

* Statements of difficulty falling asleep, interruptions in

denced by: sleep, and/or not feeling well rested
a. Statements of feeling well rested e Therapeutic interventions
b. Ability to perform normal daily activities * Client teaching
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 73

NOC OUTCOMES NIC INTERVENTIONS

EEE
EE ee eee ee eee eee

Rest; sleep; personal well-being Sleep enhancement; energy management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of a disturbed sleep pattern Early recognition of signs and symptoms of a disturbed sleep pat-
(e.g., statements of difficulty falling asleep, sleep inter- tern allows for prompt intervention.
ruptions, or not feeling well rested).
Determine client’s usual sleep habits. Knowledge of the client’s usual sleep-wake cycle and routines that
help induce and maintain sleep helps the nurse plan inter-
ventions aimed at preventing a sleep pattern disturbance.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Discourage long periods of sleep during the day unless signs Long periods of sleep during the day are often a change in the cli-
and symptoms of sleep deprivation exist or daytime sleep ent’s usual sleep-wake cycle and cause desynchronization of his/
is usual for client. D@ + her circadian rhythm. This can result in a poorer quality of
sleep.
Implement measures to reduce fear and anxiety (e.g., main- Fear and anxiety stimulate the sympathetic nervous system, which
tain a calm, confident manner when working with client; increases alertness and makes it difficult for the client to fall
assist client to identify specific stressors and ways to cope asleep. Sympathetic nervous system stimulation is also believed
with them). to shorten the duration of nonrapid eye movement (NREM) and
REM sleep, which results in a poorer quality of sleep.
Encourage participation in relaxing diversional activities dur- Involvement in relaxing activities in the evening helps the client
ing the evening. D@ + fall asleep more easily.
Discourage intake of foods/fluids high in caffeine (e.g., choc- Caffeine acts as a central nervous system stimulant and can inter-
olate, coffee, tea, colas) in the evening. D@ + fere with relaxation and subsequent sleep induction. Caffeine
also acts as a diuretic, which can cause an interruption in sleep
if the client awakens in response to the urge to urinate.
Offer client an evening snack that includes milk unless contra- Milk contains the amino acid I-tryptophan, which is believed to
indicated. D@® + help induce and maintain sleep.
Allow client to continue usual sleep practices (e.g., position; Adherence to usual sleep practices promotes mental and physical
time; presleep routines such as reading, watching televi- relaxation that assists the client to maintain his/her usual
sion, listening to music, and meditating) whenever possible. sleep-wake cycle.
De+
Reduce environmental distractions (e.g., close door to client’s Environmental activity, noise, and light can interfere with the cli-
room; use night light rather than overhead light whenever ent’s ability to fall asleep and stay asleep. Reducing stimuli
possible; lower volume of paging system; keep staff con- helps prevent a sleep pattern disturbance.
versations at a low level and away from client’s room;
close curtains between clients in a semi-private room or
ward; keep beepers and alarms on low volume; provide
client with “white noise” such as a fan, soft music, or tape-
recorded sounds of the ocean or rain; have sleep mask and
earplugs available for client if needed). D @ +
Encourage client to avoid drinking alcohol in the evening. Although alcohol can induce drowsiness, which promotes sleep
induction, it is known to interfere with REM sleep. Alcohol also
inhibits the release of antidiuretic hormone (ADH), which can
cause an interruption in sleep if the client awakens in response
to the urge to urinate.
Encourage client to avoid smoking before bedtime. D @ + Nicotine is a stimulant that can interfere with sleep by making it
difficult for the client to relax and fall asleep and to stay asleep.
Implement measures to reduce interruptions during sleep One sleep cycle takes about 70 to 100 minutes to complete. Each
(e.g., restrict visitors, group care whenever possible) so time the cycle is interrupted, it begins again with NREM stage
that client is able to sleep undisturbed for 70- to 100- 1 sleep so the client loses portions of NREM and/or REM sleep.
minute intervals. D+ When the client is deprived of NREM sleep, lethargy and depres-
sion occur. Loss of REM sleep results in irritability and anxiety.
Reducing the frequency of sleep interruptions helps ensure that
the client progresses through all the sleep stages and does not
experience a sleep pattern disturbance.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If possible, administer medications that can interfere with Administering these medications as early as possible during
sleep (e.g., steroids, diuretics) early in the day rather than the day helps prevent nighttime insomnia and/or frequent
late afternoon or evening. D + awakenings.
Administer prescribed sedative-hypnotics if indicated. D Sedative-hypnotics are central nervous system depressants that
promote sleep by reducing anxiety, shortening sleep induction,
and/or reducing arousal level (wakefulness). These medications
should be used for only a short time because they interfere with
the length of REM sleep and can actually create a disturbance
in the client’s sleep-wake cycle.
Consult appropriate health care provider if signs and symp- Notifying the appropriate health care provider allows for modifica-
toms of sleep deprivation (e.g., irritability, lethargy, agita- tion of treatment plan.
tion, inability to concentrate) occur and persist or worsen.

IMPAIRED SWALLOWING np
Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal
structure or function.

CLINICAL MANIFESTATIONS

Subjective Objective
Esophageal phase impairment: Verbal self-report of Pharyngeal phase impairment: Altered head positions;
heartburn or epigastric pain; unexplained irritability sur- inadequate laryngeal elevation; food refusal; unexplained
rounding mealtime; complaints of “something stuck” fevers; delayed swallow; recurrent pulmonary infections;
gurgly voice quality; nasal reflux; choking, coughing, or
gagging; multiple swallows; abnormality in pharyngeal
phase by swallow study
Oral phase impairment: Lack of tongue action to form
bolus; weak suck resulting in inefficient nippling; incom-
plete lip closure; food pushed out of mouth; slow bolus
formation; premature entry of bolus; piecemeal degluti-
tion; lack of chewing; food falls from mouth; nasal reflux;
inability to clear oral cavity; long meals with little con-
sumption; coughing, choking, gagging before a swallow;
abnormality in oral phase of swallow study; pooling in
lateral sulci; sialorrhea or drooling
Esophageal phase impairment: Acidic-smelling breath;
vomitus on pillow; repetitive swallowing or ruminating;
regurgitation of gastric contents or wet burps; bruxism;
nighttime coughing or awakening; observed evidence of
difficulty in swallowing (e.g., stasis of food in oral cavity,
coughing or choking); hyperextension of head, arching
during or after meals; abnormality in esophageal phase by
swallow study; odynophagia; hematemesis; vomiting

RISK FACTORS
e Congenital deficits: Upper airway or excursion of muscles involved in disease; acquired anatomic defects;
anomalies; failure to thrive or protein- mastication, perceptual impairment, cerebral palsy; internal traumas; tra-
energy malnutrition; conditions facial paralysis); mechanical obstruc- cheal, laryngeal, esophageal defects;
with significant hypotonia; respira- tion (e.g., edema, tracheostomy traumatic head injury; developmen-
tory disorders; history of tube feed- tube, tumor); congenital heart dis- tal delay; external traumas; nasal or
ing; behavioral feeding problems; ease; cranial nerve involvement nasopharyngeal cavity defects; oral
self-injurious behavior; neuro- Neurologic problems: Upper airway cavity or oropharynx abnormalities;
muscular impairment (e.g., decreased anomalies; laryngeal abnormalities; premature infants
or absent gag reflex, decreased strength achalasia; gastroesophageal reflux
 Chapter3 “ Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 75

DESIRED OUTCOMES DOCUMENTATION

—_eee—
OO eee
eoe— eee
The client will experience an improvement in swallowing ¢ Verbalization of difficulty swallowing
as evidenced by: ¢ Stasis of food in oral cavity
a. Verbalization of same ¢ Coughing or choking when eating or drinking
b. Absence of food in oral cavity after swallowing ¢ Consistency of foods/fluids client is able to swallow
c. Absence of coughing and choking when eating and without difficulty
drinking ¢ Therapeutic interventions
¢ Client/family teaching

NOC OUTCOMES NIC INTERVENTIONS

Swallowing status; swallowing status: oral phase; swallowing Swallowing therapy; aspiration precautions; positioning; risk
status: pharyngeal phase identification

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired swallowing (e.g., Early recognition of signs and symptoms of impaired swallowing
_ Statements of difficulty swallowing, stasis of food in oral allows for prompt intervention.
cavity, coughing or choking when eating or drinking).
Assist with studies to evaluate client’s swallowing (e.g., video- Swallowing is a complex act that consists of voluntary and invol-
fluoroscopy) if ordered. untary neuromotor components. Studies that evaluate the cli-
ent’s ability to swallow help identify the specific physiologic
dysfunction, which aids in planning effective interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If client has viscous oral secretions, implement measures to Thick oral secretions interfere with movement of food in the
liquefy these secretions (e.g., encourage a fluid intake of mouth. Liquefying these secretions makes it easier for a bolus of
2500 mL/day unless contraindicated, administer a papain food to be formed and moved to the back of the mouth. Liquefy-
product before meals as ordered). D @ + ing the secretions also helps ensure that the bolus formed is
moist so that it stays intact and triggers an effective swallowing
reflex.
If client’s mouth is dry, implement measures to moisten A moist mouth helps lubricate food, which makes it easier to chew,
mouth before meals and snacks (e.g., provide good oral form into a bolus, and manipulate toward the back of the
care, stimulate salivation by having client suck on hard mouth. A formed, moist bolus more effectively triggers the swal-
candy unless contraindicated, encourage use of a saliva lowing reflex and moves more easily through the esophagus.
substitute such as Salivart). D @ +
Instruct and assist client to select foods/fluids that are appro- Impaired swallowing can result from structural or neurologic prob-
priate for his/her swallowing ability. Some general guide- lems. The types of foods/fluids a client can swallow effectively
lines include: vary depending on the particular swallowing difficulty.
e Avoiding foods that tend to fall apart in the mouth (e.g., Clients with impaired tongue movement have difficulty keeping
applesauce, cake, muffins) and those that consist of small foods that tend to fall apart in the mouth or consist of small
food particles (e.g., rice, peas, corn, nuts) if client has im- pieces in a bolus that can be transferred to the back of the
paired tongue control mouth. Some small pieces of food may fall to the back of the
mouth, but because the food is not in a bolus, it will not trigger
a strong swallowing reflex.
Avoiding foods that are sticky (e.g., peanut butter, soft Sticky foods are difficult to move through the mouth because they
bread, honey) tend to adhere to various structures, especially the hard palate.
It is also difficult to form these foods into the distinct bolus
needed to trigger the swallowing reflex.
Moistening dry foods with gravy or sauces (e.g., catsup, Moist foods are more easily formed into a bolus and moved through
sour cream, salad dressing) the mouth and esophagus.
Selecting thick rather than thin fluids or adding a thicken- Thin fluids pass rapidly through the mouth and can pour over the
ing agent (e.g.,. “Thick-It,” gelatin, baby cereal) if client has back of the tongue without triggering an effective swallow.
a delayed swallowing reflex and/or poor tongue control Thick fluids remain more cohesive and are able to stimulate the
swallowing reflex more effectively.
Place client in a high-Fowler’s position for meals and snacks A high-Fowler’s position uses gravity to aid in the flow of foods/
unless contraindicated. D@ + fluids through the esophagus.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 76 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

If client has difficulty chewing and maneuvering a bolus of Tilting the head down allows client more time to chew and form a
food to the back of the mouth, instruct him/her to tilt bolus because the food is in the front of the mouth where it does
head down when chewing and forming a bolus, then raise not trigger the swallowing reflex. Raising the chin facilitates
chin slightly when ready to swallow. movement of the bolus to the back of the mouth so that the
swallowing reflex can be triggered. NOTE: Caution client to
avoid tilting head back when swallowing since this position
increases the risk for aspiration.
Serve foods/fluids that are hot or cold instead of room tem- Foods/fluids that are hot or cold trigger a more effective swallowing
perature. D@ + reflex because they have a greater stimulatory effect on the
sensory receptors in the mouth.
If client has motor and sensory dysfunction of one side of the When foods/fluids are directed toward the unaffected side of the
mouth or face, instruct and assist him/her to tilt head to- mouth, the client is able to more effectively chew and use his/her
ward the unaffected side when eating and drinking and to tongue to form a bolus and move it to the back of the mouth. The
place food in the unaffected side of the mouth. unaffected side of the mouth also has more tension in the buccal
musculature so foods/fluids are more likely to get to the back of
the mouth rather than collect between the cheek and the man-
dible. Sensory receptors on the unaffected side also trigger a
stronger swallowing reflex than those on the affected side.
Encourage client to concentrate on the act of swallowing. The client can achieve a more effective swallow by focusing on
Provide verbal cueing as needed. chewing and moving foods/fluids to the back of the mouth
where the swallowing reflex is triggered.
Instruct client to avoid putting too much food/fluid in mouth Overfilling the mouth makes it difficult for the client to form a
at one time. D @ distinct bolus and effectively move it to the back of the mouth
where it triggers the swallowing reflex.
Encourage client to perform exercises to strengthen tongue and Strong tongue and facial muscles increase the client’s ability to
facial muscles if indicated (e.g., drinking through a straw; chew food, form a bolus, and direct the bolus to the back of the
opening mouth and moving tongue anteriorly, posteriorly, mouth where it triggers the swallowing reflex.
and laterally; pushing tongue upward against resistance us-
ing an object such as a tongue blade, Popsicle, or sucker).

Dependent/Collaborative Actions
Consult speech pathologist about methods for dealing with Consulting with persons who are knowledgeable about the manage-
client’s specific swallowing impairment. ment of swallowing difficulties aids in the development of an
individualized plan ofcare to improve the client’s swallowing.
Implement measures to reduce oral and pharyngeal discom- Oral and pharyngeal discomfort can interfere with the client’s
fort if indicated (e.g., administer topical and/or systemic ability and willingness to adequately chew food and swallow
analgesics as ordered). D effectively.
Consult appropriate health care provider (e.g., physician, speech Notifying the appropriate health care provider allows for modifica-
pathologist) if swallowing difficulties persist or worsen. tion of treatment plan.

IMPAIRED URINARY ELIMINATION* nox

Definition: Dysfunction in urine elimination
e Functional urinary incontinence: Inability of a usually continent person to reach the toilet in time to avoid unintentional
loss of urine.
e Overflow urinary incontinence: Involuntary loss of urine associated with overdistention of the bladder. '
e Reflex urinary incontinence: Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached.
° Stress urinary incontinence: Sudden leakage of urine with activities that increase intra-abdominal pressure.
e Urge urinary incontinence: Involuntary passage of urine occurring soon after a strong sensation or urgency to void.

*NANDA International identifies five types of urinary incontinence: functional, overflow, teflex, urge, and stress.
A client can
experience a combination of types of incontinence, and the actions for various types often are similar. The information
presented
here focuses on incontinence in general rather than a specific type.
 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 77

CLINICAL MANIFESTATIONS

Subjective Objective
Functional: Verbal self-report of need to void Functional: Loss of urine before reaching toilet; may be
Overflow: Verbal self-report of voluntary leakage of small incontinent only in early morning
volumes of urine; nocturia Overflow: Bladder distention; high post void residual vol-
Reflex: Verbal self-report of no sensation to void; sensa- ume; observed involuntary leakage of small volumes of
tion of urgency without voluntary inhibition of bladder urine
contraction; sensations associated with full bladder (Cty Reflex: Inability to voluntarily inhibit voiding; incomplete
restlessness, abdominal discomfort); inability to volun- emptying of bladder with lesions above sacral and pontine
tarily inhibit voiding; loss of urine with activities that micturition center
place pressure on the bladder Stress: Loss of urine with activities that place pressure on
Stress: Verbal self-report of involuntary leakage of small the bladder (i.e., coughing, sneezing, laughing, running)
amounts of urine. Urge: Observed involuntary loss of urine
Urge: Verbal self-report of urinary urgency; involuntary
loss of urine with bladder contractions and spasms; inabil-
ity to reach toilet in time to avoid urine loss

RISK FACTORS
e Functional: Changes in environ- severe pelvic prolapse; side effects of bladder capacity; fecal impaction;
mental factors; impaired cognition/ medications—anticholinergics, cal- use of diuretics; detrusor hyperactivity
vision; neuromuscular limitations; cium channel blockers, decongestants with impaired bladder contractility
psychological factors; weakened Reflex: Tissue damage; neurologic Stress: Degenerative changes in
supporting pelvic structures impairment above level of sacral or pelvic muscles; weak pelvic muscles;
e Overflow: Bladder outlet obstruction; pontine micturition center high intra-abdominal pressure;
fecal impaction; urethral obstruc- Urge: Alcohol intake; atrophic intrinsic urethral sphincter
tion; detrusor external sphincter dys- urethritis/vaginitis; bladder infec- deficiency
synergia; detrusor hypocontractility; tions; caffeine intake; decreased

DESIRED OUTCOMES DOCUMENTATION

The client will experience urinary continence. e Episodes of urinary incontinence
e Statements of being unable to control urinary elimination
e Therapeutic interventions
e Client teaching

NOC OUTCOMES NIC INTERVENTIONS

Symptom control; urinary continence; urinary elimination; Urinary incontinence care; prompted voiding; self-care assis-
knowledge: disease process tance: toileting; urinary habit training; urinary bladder train-
ing; pelvic muscle exercise

NURSING ASSESSMENT RATIONALE

Assess for and report urinary incontinence. Early recognition ofsigns and symptoms of urinary incontinence
allows for prompt intervention.
Monitor client’s pattern of fluid intake and urination (e.g., times Knowledge of the client’s fluid intake and urination pattern assists
and amounts of fluid intake, types of fluids consumed, times in the identification of factors that may be causing urinary in-
and amounts of voluntary and involuntary voiding, reports of continence. This information helps the nurse plan individual-
sensation of need to void, activities preceding incontinence). ized interventions that promote urinary continence.
Assist with urodynamic studies (e.g., urethral pressure profile, uro- Urodynamic studies may be done to determine the cause(s)
flowmetry, cystometrogram) if ordered. of urinary incontinence. The studies provide information
about the motor and sensory function of the bladder and
urethra.

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78 Chapter 3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Offer bedpan or urinal, or assist client to bedside commode or Urinary incontinence occurs when the pressure in the bladder be-
bathroom every 2 to 4 hrs if indicated. D@ + comes greater than the pressure exerted by the urinary sphinc-
ters. Emptying the bladder before the pressure becomes too great
reduces the risk of incontinence.
Allow client to assume a normal position for voiding (usually A sitting or standing position uses gravity to facilitate bladder
sitting for females and standing for males) unless contra- emptying. The more completely the bladder is emptied, the less
indicated. D ®> risk there is of incontinence.
Implement measures to reduce delays in toileting (e.g., have If client is having difficulty controlling urination, any delay in
call signal within client’s reach and respond promptly to toileting increases the risk of incontinence. Measures that en-
requests for assistance; have bedpan, urinal, or bedside able the client to use a bedpan, urinal, bedside commode, or
commode readily available to client; provide easy access toilet in a timely manner help reduce the risk of incontinence.
to bathroom; provide client with easy-to-remove clothing
such as pajamas with Velcro closures or an elastic
waistband). D@ +
Instruct client to perform pelvic floor muscle exercises (e.g., Pelvic floor muscle exercises help strengthen the pelvic floor mus-
stopping and starting stream during voiding; squeezing cles and improve the tone of the external urinary sphincter. As
buttocks together, then relaxing the muscles) if appropriate. this is achieved, the risk for incontinence decreases.
Instruct client to space fluids evenly throughout the day Drinking a large amount offluid at one time results in rapid filling
rather than drinking a large quantity at one time. of the bladder, which increases pressure in the bladder and the
subsequent risk of incontinence.
Limit oral fluid intake in the evening. D@ + As the client’s bladder fills and pressure in the bladder increases
during sleep, he/she is less likely to be aware of and/or able to
respond to the urge to urinate. By limiting fluid intake in the
evening, bladder filling during the night is decreased, which
reduces the risk of incontinence.
Instruct client to avoid drinking alcohol and _ beverages Alcohol and caffeinated beverages increase urine formation be-
containing caffeine such as colas, coffee, and tea. cause of their mild diuretic effect. With increased urine forma-
tion, bladder filling increases, causing a rise in pressure in the
bladder, which subsequently increases the risk of incontinence.
Alcohol and caffeine also act as chemical irritants to the blad-
der and contribute to urge incontinence.

Dependent/Collaborative Actions
Administer the following medications if ordered:
e Cholinergic (parasympathomimetic) agents (e.g., bethan- If incontinence results from incomplete bladder emptying, cholinergic
echol) D + (parasympathomimetic) drugs may be prescribed to stimulate con-
traction of the detrusor muscle (smooth muscle of the bladder). This
enhances bladder emptying and reduces the risk ofincontinence.
e Anticholinergics (e.g., tolterodine, oxybutynin) D + Hyperactivity of the bladder detrusor muscle can cause a sudden
increase in pressure in the bladder and result in incontinence,
especially if there is decreased bladder outlet resistance. Anti-
cholinergics may be prescribed to reduce bladder detrusor mus-
cle activity and thereby reduce the risk of incontinence.
Consult appropriate health care provider if urinary inconti- Notifying the appropriate health care provider allows for modifica-
nence persists. tion of treatment plan.
‘

|Nursing 5
Diagnosis |URINARY RETENTION nox
Definition: Inability to empty bladder completely.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sensation of bladder fullness or Bladder distention; small, frequent voiding or absence of
difficulty urinating urine output; dribbling of urine; residual urine; overflow
incontinence
 Chapter 3" Selected Nursing Diagnoses, Interventions, Rationales, and Documentation 79

RISK FACTORS
e High urethral pressure caused by weak detrusor ¢ Strong urinary sphincter
e Inhibition of reflex arc ¢ Blockage of urine

DESIRED OUTCOMES DOCUMENTATION

The client will not experience urinary retention as evi- e Frequency of urination and amount voided each time
denced by: ¢ Reports of bladder fullness and/or suprapubic discom-
a. Voiding at normal intervals fort
b. No reports of bladder fullness and suprapubic discom- e Bladder distention
fort e Evidence or statements of dribbling of urine
c. Absence of bladder distention and dribbling of urine e Patency of urinary catheter if present
d. Balanced intake and output e Intake and output
e Therapeutic interventions
e Client teaching

NOC OUTCOMES NIC INTERVENTIONS

Urinary elimination Urinary retention care; fluid management; bladder training;
intermittent catheterization

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of urinary retention: Early recognition of signs and symptoms of urinary retention
e Frequent voiding of small amounts (25-60 mL) of urine allows for prompt intervention.
e Reports of bladder fullness or suprapubic discomfort
¢ Bladder distention
e Dribbling of urine
e Output less than intake
Assist with urodynamic studies (e.g., urethral pressure profile, Urodynamic studies may be indicated when neurogenic dysfunction
uroflowmetry, cystometry) if ordered. is the suspected cause of urinary retention. The studies provide
information about the motor and sensory function of the bladder
and urethra.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client to urinate when the urge is first felt. D@ > If the client feels the urge to urinate but suppresses it by contracting
the external urinary sphincter, the urge will subside and not
recur until the bladder fills more. If the client repeatedly sup-
presses the urge to urinate and the bladder fills too much or
is chronically distended, the micturition reflex becomes less
sensitive and does not effectively stimulate urination when the
bladder fills.
Implement measures to promote relaxation during voiding If the client is relaxed when trying to urinate, he/she is better able
attempts (e.g., provide privacy, hold a warm blanket to relax the pelvic floor muscles and external urinary sphincter
against abdomen, encourage client to read). D @ + and allow voiding to occur.
If client is having difficulty voiding, run water, place his/her These measures have been found to trigger the micturition reflex
hands in warm water, and/or pour warm water over and thereby promote voiding. They also promote a sense of
perineum unless contraindicated. D + @ relaxation, which facilitates voiding.
Allow client to assume a normal position for voiding (usually A sitting or standing position uses gravity to facilitate bladder
sitting for females and standing for males) unless contra- emptying. Allowing the client to assume a normal voiding posi-
indicated. D @+ tion also promotes relaxation, which facilitates voiding.
Instruct and assist client to lean upper body forward and/or Leaning forward or gently pressing downward on the lower abdo-
gently press downward on the lower abdomen when at- men increases pressure on the bladder. This pressure helps
tempting to void unless contraindicated. D @ +> create a sensation of bladder fullness, which stimulates the
micturition reflex.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
80 Chapter3 * Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Administer cholinergic (parasympathomimetic) drugs (e.g., Cholinergic (parasympathomimetic) drugs promote urination by
bethanechol) if ordered. D + stimulating contraction of the bladder detrusor muscle.
Administer prescribed analgesic if client has pain. Pain blocks the client’s ability to relax and subsequently relax the
pelvic floor muscles and external urinary sphincter and allow
voiding to occur.
If an indwelling urinary catheter is present, implement mea- Maintaining patency of the indwelling catheter prevents urinary
sures to ensure its patency (e.g., keep tubing free of kinks, retention.
keep collection bag below bladder level, irrigate catheter if
indicated). D ® +
Consult appropriate health care provider if signs and symp- Notifying the appropriate health care provider allows for modifica-
toms of urinary retention persist. tion of treatment plan.
 CHAPTER

Nursing Care of the Client

Having Surgery

PROCEDURAL SEDATION
In the acute care setting, many clients undergo invasive pro- midazolam [Valium], lorazepam [Versed]). Opioids (e.g.,
cedures using sedation. The depth of sedation required for a morphine, meperidine [Demerol], fentanyl [Sublimaze]) are
client to tolerate an invasive procedure exists along a con- commonly used in procedural sedation along with sedatives
tinuum that allows for balancing the client’s ability to toler- to reduce the incidence and severity of pain associated with
ate a procedure without compromising optimum respiratory procedures.
and circulatory function. The American Society of Anesthesi- Currently, acute care settings are charged with ensuring
ologists (2014) defines four levels of sedation: policies and procedures are in place that specify the minimum
1. Minimal Sedation (Anxiolysis)—a drug-induced state dur- qualifications for each type of licensed provider (anesthesia/
ing which clients responds to verbal commands. Although nonanesthesia) permitted to provide procedural sedation.
cognitive function and physical coordination may be im- Although deep sedation/analgesia and general anesthesia are
paired, airway reflexes and ventilatory and cardiovascular routinely provided by licensed anesthesia providers (anesthe-
function are unaffected. siologist, certified registered nurse anesthetist [CRNA]), many
2. Moderate Sedation/Analgesia (“Conscious Sedation”)—a state boards of nursing have position statements, declaratory
drug-induced depression of consciousness during which rules, or guidelines allowing the administration of sedation
clients respond purposefully to verbal commands, either medications by a professional registered nurse with demon-
alone or accompanied by light tactile stimulation. No in- strated competency in both the administration of sedation
terventions are required to maintain a patent airway, and medications and physiologic monitoring of the client’s
spontaneous ventilation is adequate. Cardiovascular func- response.
tion is usually maintained. This care plan focuses on the care of the adult client who
3. Deep Sedation/Analgesia—a drug-induced depression of is receiving or has received sedation for an invasive proce-
consciousness during which clients cannot be easily aroused dure. Because of the nature of ongoing assessment, interven-
but respond purposefully following repeated or painful tion, and evaluation of the client’s tolerance to medications
stimulation. The ability to maintain independent ventila- and the invasive procedure, delegation rarely occurs. Much of
tory function may be impaired. Clients may require assis- the information is applicable to clients undergoing conscious
tance in maintaining a patent airway, and spontaneous sedation in an outpatient setting (e.g., physician’s office,
ventilation may be inadequate. Cardiovascular function is surgical care center).
usually maintained.
4. General Anesthesia—a drug-induced loss of conscious-
ness during which clients are not arousable, even by OUTCOME/DISCHARGE CRITERIA
painful stimulation. The ability to maintain independent
ventilatory function is often impaired. Clients often re- The client will:
quire assistance in maintaining a patent airway, and Maintain optimum respiratory function
positive pressure ventilation may be required because of Maintain optimum circulatory function
depressed spontaneous ventilation or drug-induced de- Return of protective reflexes (e.g., gag reflex, cough reflex)
pression of neuromuscular function. Cardiovascular Return to baseline cognition
function may be impaired. Gat
ge
SD
eo Remain free from injury
Sedatives routinely used to improve the client’s tolerance os Obtain adequate pain control
of an invasive procedure include benzodiazepines (e.g.,

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to @volve for animation 81
82 Chapter 4 * Nursing Care of the Client Having Surgery

|Nursing 2s
Diagnosis |ACTUAL/RISK FOR IMPAIRED RESPIRATORY FUNCTION*
Ineffective breating pattern NDx
Definition: Inspiration and/or expiration that does not provide adequate ventilation.
Impaired gas exchange NDx
Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
Related to: Impaired gas exchange:
Ineffective breathing pattern: ¢ Depressed ventilation associated with administration of
e Procedure-related anxiety sedatives and/or opioids
e Procedure-related pain
e Body position that inhibits lung expansion

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficuity breathing Abnormal breathing pattern (e.g., bradypnea, dyspnea,
tachypnea); use of accessory muscles to breathe; abnormal
pulse oximetry/capnography/arterial blood gas (ABG)
values; diaphoresis; irritability; restlessness; tachycardia;
cyanosis

RISK FACTORS DESIRED OUTCOMES

e Administration of pharmacologic agents with potential to
The client will maintain effective respiratory function, as
depress normal respiratory function (opioids, benzodiaze- evidenced by:
J ae Seas a ee a. Self-report of ability to breathe comfortably
: : b. Rate, depth, and of respirations within client’s base-
e Airway obstruction gheed line range
; Canaan ees c. Pulse oximetry, capnography, and/or ABG values
within client’s baseline range
d. Baseline mental status

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: airway patency; gas exchange; Airway management; aspiration precautions;
ventilation; postprocedure recovery oxygen therapy; respiratory monitoring

NURSING ASSESSMENT RATIONALE

a ee ee
Assess for anxiety. Early identification ofanxiety, which may alter normal breathing
patterns and indicate early respiratory distress, allows for
appropriate intervention.
Assess rate, depth, and effort of respirations every 5-15 minutes Early recognition of signs and symptoms of ineffective respiratory
or more frequently as client condition warrants during function allows for prompt intervention.
and after the administration of sedation. Report signs and
symptoms of ineffective respiratory function: i
e Tachypnea
e Bradypnea
e Apnea
e Dyspnea
e Restlessness
e Diaphoresis
e Irritability
Assess for signs of airway obstruction. Occlusion of the airway by the tongue can occur in an unconscious
client. Loss of consciousness in a patient undergoing sedation is
an untoward side effect and report to the physician immediately.

*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern and impaired gas exchange.
 Chapter 4 = Nursing Care of the Client Having Surgery 83

NURSING ASSESSMENT RATIONALE

Assess continuous pulse oximetry during the procedure and Early recognition of low arterial oxygen saturation (SaO2) values
post procedure until client has returned to baseline status. allows for prompt intervention. Pulse oximetry provides an
Consider monitoring continuous capnography for deeper indirect measure of oxygen saturation.
levels of sedation. An early marker of sedation-induced respiratory depression can be
obtained using capnography, which measures exhaled carbon
dioxide. Capnography monitoring is currently recommended for
use during moderate and deep sedation.
Assess ABG values as indicated. Allows for a more direct assessment of a client’s oxygenation status,
including carbon dioxide level, ifwarranted by clinical condition.
Assess level of consciousness. To ensure the administered level of sedation does not compromise
the client’s level of consciousness, risking aspiration.

THERAPEUTIC INTERVENTIONS RATIONALE

SS

Independent Actions
Implement measures to decrease fear and anxiety: Fear and anxiety associated with the procedure may cause the
e Assure client during the procedure. client to breathe shallowly or hyperventilate. Decreasing anxiety
may allow client to focus on breathing more slowly and regularly.
If the procedure allows, position the client to maximize A side-lying position will prevent the tongue from falling back and
optimum ventilation: occluding the client’s posterior pharynx.
e Side-lying position
If the procedure allows, encourage the client to deep breathe Periodic deep breathing allows for ventilation of carbon dioxide that
periodically during the procedure. may accumulate if the client’s ventilations become too shallow.
Post procedure, encourage the client to deep breathe at After the conclusion of the procedure and conscious sedation,
intervals to assist with recovery: stimulating the patient to deep breathe at intervals assists in
Stir-up regimen” which consists of five post-procedure activities: returning the patient to a more conscious state and enhances
1. Deep breathing the elimination of carbon dioxide.
2. Coughing
3. Positioning
4. Mobilization
5. Pain management
Monitor for the recurrence of respiratory depression if Extended monitoring of the client’s respiratory status is necessary if
narcotic/sedative reversal agents were administered. reversal agents were administered, because the half-life of admin-
istered sedatives/opioids may outlast the effects of reversal agents.
Monitor the effectiveness of ventilation. Ongoing monitoring of continuous pulse oximetry, capnography,
e Pulse oximetry and/or ABGs allows for early identification of respiratory
e Capnography (as indicated) depression and prompt intervention to prevent hypoxemia.
e ABGs (as indicated)
Implement appropriate safety measures Suction should be readily available to clear airway of accumulated
e Keep suction setup available secretions, thereby preventing aspiration should the client not
be able to do so independently.

Dependent/Collaborative Actions
Administer supplemental oxygen as ordered. Administer supplemental oxygen as needed to keep SaOz >95% or
e Monitor the oxygen liter flow within client’s normal range. Administer oxygen with caution
e Monitor position of oxygen delivery device to clients with chronic obstructive pulmonary disease (COPD),
e Periodically check oxygen delivery device to ensure pre- because this action may take away their hypoxic stimulus to
scribed concentration is being delivered. breathe.
Implement measures to reverse apnea: Apnea is an adverse effect of sedative/narcotic administration.
e Ventilate the apneic client with an Ambu bag that delivers While preparing to administer the appropriate reversal agents,
a fraction of inspired oxygen (FIO2) of 100%. the nurse should assist with proper ventilation of the
e Administer opioid/sedative reversal agents as ordered. client until spontaneous respiratory effort returns or the client is
e Naloxone (Narcan) intubated.
e Flumazenil (Romazicon)
e Prepare to assist with intubation/mechanical ventilation if
apnea is not corrected.
Notify the appropriate health care provider of continued Notifying the appropriate health care provider allows for modifica-
signs and symptoms of ineffective respiratory function. tion of the treatment plan.

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 84 Chapter 4 * Nursing Care of the Client Having Surgery

|Nursing eecuecs
Diagnosis |RISK FOR INJURY nox
Definition: Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and
defensive resources, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of auditory, visual, or sensory Changes in vital signs (e.g. blood pressure (BP), heart rate
hallucinations (HR), and/or respiratory rate (RR)

RISK FACTORS DESIRED OUTCOMES

e Procedural sedation
The client will
e Age
e Maintain vital signs within normal range
e Remain free of injury

NOC OUTCOMES NIC INTERVENTIONS

Safe health care environment; vital signs Interventions: vital sign monitoring; environmental
management: safety

NURSING ASSESSMENT RATIONALE

Assess Client’s baseline vital signs before start of procedure: Assessment of client’s baseline status provides comparison values
Vital signs: blood pressure, heart rate, respiratory rate, tempera- by which to evaluate response to procedural sedation.
ture, pulse oximetry
Cardiac rhythm
Pain level
Cognitive orientation
Assess safety needs of patient based on level of cognitive and Early identification of environmental factors that may contribute
physical functions. to injury in the sedated client allows for implementation of the
appropriate safety precautions. Ensure appropriate emergency
equipment is functioning properly and readily available in
procedural area (e.g., oxygen, suction, defibrillator).

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Independent Actions
Before procedure, ensure the availability of essential equip- In the event of an adverse reaction to pharmacologic agents used
ment for resuscitation: for conscious sedation or an adverse reaction to a procedure, the
e Oxygen and delivery sources appropriate emergency equipment must be available and in
e Suction apparatus proper working order.
e Noninvasive blood pressure device
e Electrocardiograph
e Pulse oximeter
e Opioid and sedative reversal agents
e Naloxone (Narcan)
e Flumazenil (Romazicon)
Modify environment to minimize hazards and risk of client Ifthe procedure is done at the bedside, ensure the client’s bed is in
injury. the locked and lowest possible position that does not interfere
e Ensure proper positioning of the client during the proce- with the procedure. Side rails and safety straps may be neces-
dure, to prevent injury: Maintain proper body alignment. sary to secure the client, preventing injury.
Avoid pressure on bony prominences During a procedure requiring conscious sedation, a client’s mobility
e Ensure the bed is locked and in the lowest possible may be limited.
position and appropriate protective devices are present to Maintaining proper body alignment and padding bony promi-
secure patient during the procedure: nences will help to protect the client from injury.
Side rails
Safety straps
 Chapter 4 = Nursing Care of the Client Having Surgery 85

THERAPEUTIC INTERVENTIONS RATIONALE

During and following the procedure, monitor client’s Evaluation of client’s response to procedural sedation by compari-
response to procedural sedation: son with baseline values allows for early identification of
° Vital signs (i-e., BP, HR, RR) monitored every 5-15 minutes, abnormal responses, and intervention and prevention of injury.
or more frequency as condition warrants, for deviation
from normal values for client
° Cognitive orientation agents (sedatives/opioids;
intravenous (IV) fluids)

Dependent/Collaborative Actions
Monitor the environment for changes in safety status.
e Alterations in cognition (obtunded level of consciousness; Ongoing collaborative monitoring during and immediately
increased confusion/disorientation). following procedural sedation will allow for prompt interven-
tion preventing client harm.

|Nursing eee”
Diagnosis |ACUTE PAIN nox
+

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain/discomfort Crying; wincing; muscle tension or rigidity; diaphoresis;
elevated blood pressure; increased heart rate; increased
respiratory rate

RISK FACTORS DESIRED OUTCOMES

e Physical injury agents (e.g. medical/surgical procedure)
The client will report pain to be relieved or controlled at a
satisfactory level.

NOC OUTCOMES NIC INTERVENTIONS

Pain level Pain management: acute

NURSING ASSESSMENT RATIONALE

Using standardized pain assessment scale, assess the client for Early recognition of signs and symptoms of pain allows for prompt
signs and symptoms of pain frequently during the course intervention.
of the procedure:
Verbalization of pain
Grimacing
Restlessness
Increased blood pressure
Tachycardia

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety: Fear and anxiety can decrease the client’s threshold and tolerance
e Assure client that a nurse will be present during the entire for pain and thereby heighten the perception of pain.
procedure to assess and ensure that adequate sedation and
pain relief are provided.

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 86 Chapter 4 * Nursing Care of the Client Having Surgery

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Incorporate nonpharmacologic interventions as appropriate: Proper positioning of limbs and support of bony prominences may
e Position the patient for comfort as the procedure allows: assist in alleviating pain associated with lying prolonged in one
e Pad bony prominences. D + position during a procedure.
e Provide joint support as needed. D+
Monitor sedation and respiratory status before administrating Cautiously administer opioids when administered in combination
opioids. with sedatives to avoid respiratory depression.

Dependent/Collaborative Actions
Administer opioids as ordered. Opioids act mainly by altering the client’s perception of pain and
emotional response to the pain experience. It is important for
the nurse to address pain needs because sedation alone will not
relieve pain.
Consult appropriate health care provider if aforementioned Notifying the appropriate health care provider allows for modifica-
measures fail to provide adequate pain relief. tion of the treatment plan.

|Nursing voces
Diagnosis=|RISK FOR ACUTE CONFUSION nox
Definition: Susceptible to reversible disturbances of consciousness, attention, cognition, and perception that develop over a
short period of time, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of hallucinations Fluctuation in consciousness; level of consciousness;
increased agitation; increased restlessness; exaggerated
emotional responses

RISK FACTORS DESIRED OUTCOMES

e Pain
e Pharmaceutic agent The client will not exhibit signs and symptoms of acute
confusion, as evidenced by:
e Invasive procedure
a. Orientation to person, place, and time
b. Return to baseline cognition

NOC OUTCOMES NIC INTERVENTIONS

—_—_
Cognitive orientation Delirium management

NURSING ASSESSMENT RATIONALE

ee
SSS

Assess the client for signs and symptoms of acute confusion: Early recognition of signs and symptoms of acute confusion allows
e Fluctuations in consciousness for prompt intervention.
e Hallucinations
e Increased agitation
e Increased restlessness ‘
Assess for and report possible physiologic alterations: Acute confusion is a clinical manifestation of a variety of physio-
e Hypoglycemia logic alterations. To reduce the risk of injury/untoward out-
e Hypoxia comes, it is critical that any physiologic alteration is ruled out
e Hypotension as a contributing factor. Prompt attention to these physiologic
e Adverse effects of medications factors may shorten the duration of the confusion.

THERAPEUTIC INTERVENTIONS RATIONALE

_— eSSSSSSSSSSSSSSessSese
Independent Actions
Reorient the patient as indicated: Use of reality orientation can help to improve the cognition of a
e Address the client by a familiar name. D client.
 Chapter 4 = Nursing Care of the Client Having Surgery 87

THERAPEUTIC INTERVENTIONS RATIONALE

Communicate clearly and provide simple explanations to the Simple explanations are more readily understood by a confused
client. D+ client.
Provide the patient with ongoing information and reassur- Actions may help to reduce the frustration/anxiety that may
ance as needed. D> accompany confusion.
Maintain a hazard-free environment: A confused client is at risk for injury.
° Keep side rails up. D+ Protective measures help to ensure risk reduction. These measures
e Provide constant surveillance. D > should be continued until return of the client’s baseline
cognition.

Dependent/Collaborative Actions
Administer medications for anxiety/agitation as ordered. Confusion may be treated with medications.
The client must be monitored for side effects of these medications.
Use soft physical restraints as needed only if client is at an A confused client is at risk for injury.
increased risk for injury and if all other interventions fail Protective measures help to ensure risk reduction. These measures
to correct confusion. should be continued until return of the client’s baseline cognition.

ADDITIONAL CARE PLANS

RISK FOR ASPIRATION ANXIETY

Related to medication administration altering normal level of Related to stressors (unfamiliar environment; procedure)
consciousness

> i ie
The preoperative phase begins when the client decides to have
PREOPERATIVE GOALS
surgery and ends when the client enters the operating room
area. Although surgical procedures are performed in a variety
The client will:
of settings (e.g., hospitals, day surgery centers, physicians’ of-
e Share thoughts and feelings about the impending surgery
fices), basic preoperative client care is similar. The goals of
and its anticipated effects
preoperative care are to prepare the client physically and psy-
e Verbalize an understanding of the surgical procedure, pre-
chologically for the surgery and the postoperative period.
operative care, and postoperative sensations and care
Thorough preoperative preparation reduces the client’s post-
e Demonstrate the ability to perform activities designed to
operative fear and anxiety and the risk of postoperative complica-
prevent postoperative complications
tions. To individualize this care plan, the client’s psychological e Adhere to preoperative instructions as validated in the
and physiologic status, the surgical setting, the length of time preoperative care area on the day of surgery.
before the surgical procedure, the type of anesthesia to be used,
and the planned surgical procedure must be considered.
This care plan focuses on the adult client who is scheduled
for a surgical procedure. It should be used in conjunction
with each surgical care plan.

|Nursing ooo)
Diagnosis |FEAR npx/ANXIETY nox

Definition: Fear: Response to perceived threat that is consciously recognized as a danger; Anxiety: Vague, uneasy feeling of
discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the
individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of
impending danger and enables the individual to take measures to deal with that threat.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report expressing concern due to surgical proce- Preoccupation; impaired attention; difficulty concentrat-
dure; scared, rattled, distressed; apprehensive; fearful; ing; forgetfulness; increased pulse; increased blood
sense of impending doom; fear of consequences pressure; increased respiratory rate, trembling hands/facial
tension

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 88 Chapter 4 * Nursing Care of the Client Having Surgery

RISK FACTORS DESIRED OUTCOMES

e Unfamiliar setting The client will experience a reduction in fear and anxiety,
e Separation from support system
as evidenced by:
e Learned response to threat
a. Verbalization of feeling less anxious
e Stressors related to surgical procedure and findings
Usual sleep pattern
e Threat of death
Relaxed facial expression and body movements
Stable vital signs
paoUsual perceptual ability and interactions with others

NOC OUTCOMES NIC INTERVENTIONS

Anxiety level; anxiety self-control; fear level; fear self-control Anxiety reduction; calming technique; relaxation therapy

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms of fear and anxiety: Early recognition of signs and symptoms of anxiety allows for
e Verbalization of feeling anxious prompt intervention.
e Insomnia
e Tenseness
e Shakiness
° Restlessness
e Diaphoresis
e Tachycardia
e Elevated blood pressure
e Self-focused behaviors
Gather the following assessment data from the client during Assessment of the client’s baseline knowledge and understanding
the preoperative period: of the procedure allows for the nurse to formulate individual-
e Level of understanding of planned surgical procedure ized preoperative teaching.
e Perceptions about the surgery and its anticipated results Identification of available support systems assists with the
e Significance of the surgical procedure and hospitalization discharge planning process.
e Previous surgical and hospital experiences
e Availability of adequate support systems
e Arrangements made for responsibilities such as job, child
care, meal preparation, and home maintenance if needed
during the recovery period

THERAPEUTIC INTERVENTIONS RATIONALE

-_-_--———ooo———————————————————————————
ee SSSSSSSSSSSSSSSSSSSMSsSMSses

Independent Actions
Implement measures to reduce fear and anxiety:
* Orient client to environment, equipment, and routines. Familiarity with the environment and routines reduces the client’s
De¢+ anxiety about the unknown, provides a sense of security, and
increases the client’s sense of control, all of which help to reduce
anxiety.
e Introduce client to staff who will be participating in care; Introduction of staff familiarizes the client with those individuals
if possible, maintain consistency in staff assigned to who will be working with him/her, which provides a sense of
client’s care. comfort with the environment. Consistency in staff assignment
provides the client with a feeling of stability, which reduces
anxiety associated with change. '
e Assure client that staff members are nearby; respond to call Close contact and a prompt response to requests provide a sense of
signal as soon as possible. D @ + security and facilitate the development of trust, reducing the
client’s anxiety.
¢ Maintain a calm, supportive, confident manner when A sense of calmness and confidence conveys to the client that some-
interacting with client: one is in control of the situation, which helps reduce anxiety.
e Provide a calm, restful environment.
e Instruct client in relaxation techniques and encourage
participation in diversional activities.
e Encourage verbalization of fear and anxiety; provide feedback: Verbalization of fears, feelings, and concerns helps the client
e Assist client to identify specific stressors and ways to identify factors that are causing anxiety.
cope with them.
 Chapter 4 = Nursing Care of the Client Having Surgery 89

THERAPEUTIC INTERVENTIONS RATIONALE

e Reinforce physician’s explanations and clarify misconcep- Factual information and an awareness of what to expect help to
tions the client has about the surgical procedure, includ- decrease the anxiety that arises from uncertainty.
ing purpose, size and location of incision, and anticipated
outcome:
e Explain all pre-surgical diagnostic tests.
e Provide information about preoperative routines and
anticipated postoperative care.
e Provide information based on current needs of the
client at a level that the client can understand; encour-
age questions and clarification of information provided.
e Assure client that blood is screened carefully and that
the risk for contracting blood-borne disease is minimal.
e Perform actions to help client maintain a sense of dignity: Increasing a client’s sense of control regarding his/her body can
e Provide privacy when appropriate. help the client to maintain a sense of dignity, which can reduce
e Avoid unnecessary body exposure during preoperative anxiety.
procedures.
e Allow client to wear dentures, glasses, wig, etc. into the
operating room suite if possible.
e Orient client to measures implemented to ensure safety in National patient safety goal requirements issued by The Joint Com-
the surgical setting: mission require the implementation of safety measures designed
e Instruct client that they will be involved in marking the to reduce surgical errors.
surgical site—at minimum when there is more than one The “Speak Up” Universal Protocol for Preventing Wrong Site,
possible location for the procedure and when performing Wrong Procedure, and Wrong Person Surgery published by The
the procedure in a different location could harm the pa- Joint Commission outlines processes including preprocedure
tient (e.g., aterality [left/right]; spinal procedures) verification, marking of the surgical and performance of a
e Instruct client that before the start of any invasive medi- “time-out” to help prevent errors and patient harm.
cal procedure, a time-out is taken by the operating room
staff to confirm the correct client, procedure, and site
e Instruct client that it is OK to ask questions if there is
reason for concern
e Assure client that pain relief needs will be met Fear and anxiety can decrease the client’s threshold for pain and
postoperatively. heighten a client’s perception of pain. Anxiety can be reduced if
the client is assured that pain needs will be met after surgery.
e Encourage significant others to project a caring, con- Anxiety is easily transferable from one person to another. If sig-
cerned attitude without obvious anxiousness. nificant others covey empathy, provide reassurance, and do not
e Include significant others in orientation and teaching appear anxious, they can help reduce a client’s anxiety. In
sessions and encourage their continued support of addition, significant others can help to reduce anxiety by rein-
client. forcing information that the client has difficulty understanding
or recalling.
e Enable client to maintain a sense of control by: Enabling the client to make health care decisions can enhance feel-
e Including client in planning of preoperative care and ings of autonomy and decrease anxiety.
allowing choices whenever possible
° Explaining that the purpose of the written consent
form is to indicate voluntary and informed consent and
to protect against unsanctioned surgery
e Discussing the purpose and benefits of an advanced
directive for health care and providing assistance as
needed to complete the necessary documents
e When appropriate, assist client to meet spiritual needs Spiritual support is a source of comfort and security for many
e Arrange for a visit from clergy. people and can help reduce a client’s anxiety.

Dependent/Collaborative Actions
Implement measures to reduce fear and anxiety:
e Initiate a social service referral if indicated Concerns about factors such as finances, follow-up medical care,
and home maintenance can be a source of great anxiety.
Facilitating contact with the appropriate resources can help reduce
the client’s anxiety and provide ongoing support.

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 90 Chapter 4 = Nursing Care of the Client Having Surgery

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Administer prescribed antianxiety agents if indicated. Medications are sometimes prescribed to help reduce the client's
anxiety. Benzodiazepines (e.g., lorazepam, diazepam, alpra-
zolam, chlordiazepoxide) are the drugs of choice for managing
short-term anxiety.
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider can allow for modi-
nurse clinician, physician) if aforementioned actions fail fication of the treatment plan.
to control fear and anxiety.

|Nursing ©...
Diagnosis |DEFICIENT KNOWLEDGE npx
Definition: Absence of cognitive information related to a specific topic, or its acquisition.

CLINICAL MANIFESTATIONS

Subjective Objective
e Verbal self-report of lack of knowledge related to surgical e Inaccurate follow-through of instruction; inaccurate per-
process/procedures. formance of test; inappropriate behaviors (e.g., hysteri-
cal, hostile, agitated, apathetic); insufficient knowledge

RISK FACTORS
° Alteration in cognitive functioning
e Alteration in memory
e Lack of understanding regarding the surgical procedure

NOC OUTCOMES NIC INTERVENTIONS

———??"[?}.
R . "— Q

Knowledge: diagnostic and therapeutic procedures; Health literacy enhancement; teaching: individual; teaching
treatment procedures; treatment regimen preoperative

NURSING ASSESSMENT RATIONALE

—————————
SSESSSESESESESSFSFSSSS
eee SSSSSSSSSSSSSSSSSSS

Assess client’s cognitive, psychomotor, and affective abilities Identification of client limitations will allow for modification of
or disabilities. the teaching plan and determine the need for family caregiver
presence during education sessions.
Assess Client’s previous experiences with surgery, background, Identifying the client’s baseline knowledge level will allow for the
culture, and current level of knowledge related to surgical development of the appropriate, patient-centered teaching plan.
procedure.
Assess the client’s baseline literacy level through formal or A client's health literacy level should be assessed before providing
informal assessments. instruction so the appropriate teaching plan can be developed.
Unless the nurse considers the client’s intellectual abilities when
developing the teaching plan, teaching will be unsuccessful.
Assess client’s learning needs and preferred learning style. Identification of specific client learning needs and preferred learn-
ing styles allows for development of an individualized teaching
plan using methods appropriate for the identified learning Style.

THERAPEUTIC INTERVENTIONS RATIONALE

ar erie a
Desired Outcomes: The client will demonstrate:
a. An understanding of the surgical procedure, preoperative
care, and postoperative sensations and care
b. The ability to perform activities designed to prevent post-
operative complications
 Chapter 4 = Nursing Care of the Client Having Surgery 91

THERAPEUTIC INTERVENTIONS RATIONALE ee

nS

Independent Actions
Provide information about usual preoperative routines for the Providing information about procedures enhances knowledge and
surgery to be performed, such as preoperative testing, includ- decreases anxiety because clients have a better understanding of
ing but not limited to blood work, electrocardiogram [ECG], what to expect during a procedure.
urinalysis, chest radiograph, insertion of urinary catheter
and/or nasogastric tube, bowel and skin preparation, and re-
moval of prosthetic devices.
Provide information about: Provides client a sense of control and time to ask questions
e Scheduled time and estimated length of surgery concerning procedure or postoperative experience.
e Food and fluid restrictions before surgery
e Preoperative medications and planned anesthesia
e Body position during surgical procedure
e Purpose for and estimated length of stay in preoperative
holding area and postanesthesia care unit (PACU)
e Sensations that can occur after surgery such as dryness of
mouth, sore throat after endotracheal intubation, and
- pain at surgical site
Inform client of the anticipated postoperative care: Allows client time to ask questions and to identify areas of concern.
e Equipment such as dressings, intravenous lines, drainage
tubes, traction devices, antiembolism stockings, and inter-
mittent pneumatic compression device
e Activity limitations and expectations
e Dietary modifications
e Treatments, such as respiratory care, circulatory manage-
ment, and wound care, and the expected frequency
e Assessments, such as intake and output, lung sounds, vital
signs, neurologic checks, and bowel sounds, and the ex-
pected frequency
e Medications such as antiemetics, analgesics, and antimicrobials
e Pain management measures such as oral, parenteral, and/or
intravenous medications; epidural analgesia; patient controlled
analgesia [(PCA)]; positioning; and relaxation techniques
Provide instructions about activities the client will be Return demonstration provides the nurse a better understanding of
expected to perform postoperatively, allowing time for clients’ skills and where more teaching is necessary.
return demonstration. These may include:
e Techniques for splinting incision, coughing, and deep
breathing techniques
e Correct use of incentive spirometer (IS)
e Active foot and leg exercises
* Correct methods for moving in bed, getting out of bed,
early ambulation
Allow time for questions and clarification. Allowing time for questions and clarification allows the nurse to
evaluate the effectiveness of teaching and make the appropriate
adjustments to the teaching plan.

Reinforce information provided by the anesthesiologist and Reinforcing important information allows the nurse to both sum-
surgeon about the surgery. marize key concepts and further assess the client's understand-
ing of instructions.

cs POSTOPERATIVE CARE
The postoperative phase begins when the client is transferred This care plan focuses on postoperative care of an adult
from surgery to a postanesthesia care unit (PACU). and ends client who has received general anesthesia and has been
with discharge from the hospital. The length of the post- transferred from the recovery area to the clinical care
operative phase varies depending on factors such as the unit. Much of the information is applicable to clients
client’s age and preoperative health status, the type of having surgery in an outpatient setting (e.g., physician’s
anesthesia used, the length and type of surgery, and the client’s
office, surgical care center) and to those receiving follow-
physiologic and psychological responses postoperatively. up care in an extended care facility or home setting.

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 92 Chapter 4 * Nursing Care of the Client Having Surgery

This care plan should be used in conjunction with all 6. Have no signs and symptoms of infection or post-
surgical care plans. operative complications.
7. Identify ways to prevent postoperative infection.
ee). Demonstrate ability to perform wound care.
OUTCOME/DISCHARGE CRITERIA 9. State signs and symptoms to report to health care
provider.
The client will: 10. Share thoughts and feelings about the surgery, diagnosis,
. Tolerate prescribed diet prognosis, and treatment plan.
. Tolerate expected level of activity 11. Develop a plan for adhering to the recommended follow-
. Have adequate surgical pain controlled up care including future appointments with health care
. Have clear, audible breath sounds throughout lungs provider, dietary modifications, activity level, treatments,
nA
FR. Have evidence of normal wound healing.
PWN and medications prescribed.

|Nursing pec)
Diagnosis INEFFECTIVE BREATHING PATTERN nox
Definition: Inspiration and/or expiration that does not provide adequate ventilation.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dyspnea/difficulty breathing Alterations in depth of breathing; altered chest excursion;
bradypnea; decreased minute ventilation; use of accessory
muscles to breathe, nasal flaring, orthopnea, tachypnea

RISK FACTORS DESIRED OUTCOMES

e Increased rate of respirations associated with fear and
anxiety The client will maintain an effective breathing pattern, as
e Decreased rate and depth of respirations associated with evidenced by:
the depressant effect of anesthesia and some medications a. A normal rate and depth of respirations
(e.g., opioid, analgesics, some antiemetics) b. Absence of dyspnea
° Reluctance to breathe deeply because of pain, fear, anxi-
ety, weakness, and fatigue
e Restricted chest expansion resulting from positioning and
elevation of the diaphragm if abdominal distention is
present

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status Ventilation assistance

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern: pattern allows for prompt intervention.
e Auscultate breath sounds, noting decreased or absent
ventilation/presence of adventitious breath sounds
° Tachypnea, dyspnea, bradypnea
e Limited chest excursion
° Use of accessory muscles when breathing
© Assess/monitor pulse oximetry (SaO,) and ABGs as indicated. Monitoring continuous SaO, readings allows for the early detection
of hypoxia. Assessment of ABGs allows for a more direct mea-
surement of both the partial pressure of oxygen in arterial blood
(PaQ2) and the partial pressure of carbon dioxide in arterial
blood (PaCO3), which reflect the adequacy of ventilation.
 Chapter 4 * Nursing Care of the Client Having Surgery 93

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve breathing pattern: D@ +
e Perform actions to reduce fear and anxiety: Reducing fear and anxiety helps to prevent shallow and/or rapid
e Promote a calm, restful environment. breathing.
e Perform actions to reduce pain: D+ Reducing pain helps to increase the client’s willingness to move and
e Reposition client for comfort breathe more deeply.
e Instruct client to support incision when moving or
coughing.
e Perform actions to reduce the accumulation of gas and Reducing the accumulation of gas in the gastrointestinal tract de-
fluid in the gastrointestinal tract: D+ creases pressure on the diaphragm, facilitating more effective
e Maintain patency of nasogastric, gastric, or intestinal ventilation.
tubes if present.
e Perform actions to increase strength and improve activity Increasing activity tolerance enables the client to breathe more
tolerance: deeply and participate in activities to improve breathing
e Implement measures to conserve energy (e.g., organize pattern.
care to allow for periods of rest; decrease noise).
e. Have client deep breathe using incentive spirometry (IS) Use of an incentive spirometry (IS) promotes maximal inhalation
every 1-2 hrs. D and lung expansion.
e Instruct client to breathe slowly if hyperventilating. Hyperventilation is an ineffective breathing pattern that can lead
to respiratory alkalosis. A client can often slow breathing rate
by concentrating on doing so.
e Place client in a semi- to high-Fowler’s position unless A semi- to high-Fowler’s position allows for maximal diaphrag-
contraindicated. D @ matic excursion and lung expansion.
e If client must remain flat in bed, assist with position Compression of the thorax and subsequent limited chest wall
change at least every 2 hrs. D @ expansion occur when the client lies in one position. Frequent
repositioning promotes maximal chest wall and lung
expansion.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
e Increase activity as allowed and tolerated, ambulating During activity, especially ambulation, the client usually takes
three to four times per day as appropriate. D @ + deeper breaths, thus increasing lung expansion.
e Assist with positive airway pressure techniques if ordered. Positive airway pressure techniques increase intrapulmonary alveo-
¢ Continuous positive airway pressure (CPAP) lar pressure, which helps to reexpand collapsed alveoli and
e Bilevel positive airway pressure (BiPAP) prevent further alveoli collapse.
e Flutter/positive expiratory pressure ([PEP] device)
e Administer central nervous system depressants judiciously. Central nervous system depressants cause depression ofthe respira-
¢ Hold medication and consult physician if respiratory rate tory center in the brainstem, which can result in a decreased
is less than 12/min. rate and depth of respiration.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
e Administer analgesics before activities and procedures breathe more deeply.
that can cause pain and before pain becomes severe. D +
e Consider nonpharmacologic interventions as appropri-
ate to client condition (e.g., guided imagery, music
therapy).
Consult appropriate health care provider if: Notifying the appropriate health care provider allows for modifica-
e Ineffective breathing pattern continues. tion of treatment plan.
° Client develops signs and symptoms of impaired gas ex-
change such as restlessness, irritability, confusion, signifi-
cant decrease in oximetry results, decreased PaO , and
increased PaCO, levels.

NDx = NANDA Diagnosis _D = Delegatable Action @=UAP =LVN/LPN ©) = Goto ©volve for animation
 94 Chapter 4 * Nursing Care of the Client Having Surgery

|Nursing ooo)
Diagnosis INEFFECTIVE AIRWAY CLEARANCE nox
Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dyspnea/difficulty breathing Dyspnea, orthopnea; diminished breath sounds; adventi-
tious breath sounds (e.g. crackles, rhonchi, wheezes); cough,
ineffective or absent sputum production; difficulty vocaliz-
ing; wide eyed; restlessness; changes in respiratory rate and
rhythm; cyanosis

RISK FACTORS DESIRED OUTCOMES

° Occlusion of the pharynx in the immediate postoperative
period associated with relaxation of the tongue, resulting The client will maintain clear, open airways, as evidenced
by:
from the effects of anesthesia and some medications (e.g.,
narcotic [opioid] analgesics) a. Normal breath sounds
e Stasis of secretions associated with (1) decreased activity,
b. Normal rate and depth of respirations
c. Absence of dyspnea
(2) depressed ciliary function resulting from the effects
of anesthesia, and (3) difficulty coughing up secretions
resulting from the depressant effects of anesthesia and
some medications (e.g., [opioid] analgesics, some anti-
emetics), pain, weakness, fatigue, and the presence
of tenacious secretions can occur as a result of deficient
fluid volume
° Increased secretions associated with irritation of the
respiratory tract (can result from inhalation anesthetics
and endotracheal intubation)

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: airway patency Airway management; cough enhancement; respiratory mon-
itoring;

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of ineffective airway clearance: Early recognition of signs and symptoms of an ineffective airway
e Abnormal breath sounds clearance allows for prompt intervention.
° Rapid, shallow respirations
e Dyspnea
¢ Cough
Assess/monitor pulse oximetry (SaOz) and ABGs as indicated. Monitoring continuous SaO, readings allows for the early detection
of hypoxia. Assessment of ABGs allows for a more direct mea-
surement of both PaO, and PaCOz, which reflect the adequacy
of ventilation.

THERAPEUTIC INTERVENTIONS RATIONALE i

Independent Actions
Implement measures to promote effective airway clearance:
OP - Position client on side and/or insert an artificial airway An artificial airway helps prevent obstruction of airway by tongue.
if necessary.
¢ Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
° Reposition client for comfort. D + @ breathe more deeply.
e Instruct client to support incision when moving or
coughing. D>
 Chapter 4 * Nursing Care of the Client Having Surgery 95

sa
THERAPEUTIC INTERVENTIONS RATIONALE
e Instruct and assist client to change position at least every Repositioning helps mobilize secretions.
2 hrs while in bed. D@ +
e Perform actions to promote the removal of secretions: Deep breathing can help loosen secretions and enhance the
e Instruct and assist client to deep breathe and cough effectiveness of coughing.
every 1-2 hrs D +
e Assist client in using a pillow or rolled blanket as a
splint against incision when coughing. D+
e Assist with IS. D >
e Discourage smoking. Irritants in smoke increase mucus production, impair ciliary func-
tion, and can cause inflammation and damage to the bronchial
walls.
e Perform suctioning if needed. D> Suctioning removes secretions from the large airways. It also
stimulates coughing, which helps to clear airways of mucus and
foreign matter.

Dependent/Collaborative Actions
Implement measures to promote effective airway clearance:
® Implement measures to thin tenacious secretions and Adequate hydration and humidified inspired air help thin secretions,
reduce drying of the respiratory mucous membrane: which facilitates the mobilization and expectoration of secretions.
e Maintain a fluid intake of at least 2500 mL/day unless These actions also reduce dryness of the respiratory mucous mem-
contraindicated brane, which helps enhance mucociliary clearance.
e Humidify inspired air as ordered. D +
e Assist with administration of mucolytics and diluent or Mucolytics and diluents or hydrating agents are mucokinetic sub-
hydrating agents via nebulizer if ordered: stances that reduce the viscosity of mucus, thus making it easier
e Acetylcysteine for the client to mobilize and clear secretions from the respira-
e Water, saline tory tract.
e Assist with administration of bronchodilators as appropriate. Bronchodilators are substances that dilate airways facilitating air
exchange.
e Increase activity as allowed and tolerated. D@ + Activity helps to mobilize secretions and promotes deeper
breathing.
e Administer central nervous system depressants judiciously. Central nervous system depressants depress the cough reflex, which
can result in stasis of secretions.
Consult appropriate health care provider such as a physician Notifying the appropriate health care provider allows for modifica-
or respiratory therapist if: tion of the treatment plan.
e Signs and symptoms of ineffective airway clearance persist
e Signs and symptoms of impaired gas exchange are present:
e Restlessness
e Irritability
e Confusion
e Significant decrease in oximetry results
e Decreased PaO, and increased PaCOz

|Nursing eee)
Diagnosis |ACUTE PAIN nox

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain in the cognitively aware patient Facial expression of pain; guarding behavior; inability to
take a deep breath (e.g., splinting), guarding, elevated
can be rated using a standardized pain intensity scale
(e.g., O-10) blood pressure, elevated pulse rate, diaphoresis, increase
in the rate and depth of breathing

NDx = NANDA Diagnosis D = Delegatable Action @ =UAP @ =LVN/LPN ©) = Go to ©volve for animation
 96 Chapter 4 = Nursing Care of the Client Having Surgery

RISK FACTORS DESIRED OUTCOMES

© TNGATG TR ISDE Ne GS RSS Soe RUUSENOS EMS Hit The client will experience diminished pain, as evidenced
the surgery by:
ee oeOrn drainage tube 3 , : a. Verbalization of a decrease or absence of pain
e Stress on surgical area associated with deep breathing, b. Relaxed facial expression and body positioning
Be Sais uo vencnt c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

es ee a ee ee ee ee eee
Pain control; pain: disruptive effects; pain level Pain management: acute; analgesic administration

NURSING ASSESSMENT RATIONALE

a a A at a a
Assess for signs and symptoms of acute pain, including non- Early recognition of signs and symptoms of pain allows for prompt
verbal cues in clients unable to communicate: intervention.
e Verbalization of pain
e Grimacing
e Reluctance to move
e Restlessness
e Diaphoresis
e Increased B/P
° Tachycardia
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps to
intensity rating scale. Assessment to include: determine the most appropriate interventions for pain manage-
e Location ment. Use of a pain intensity rating scale gives the nurse
© Quality a clearer understanding of the pain being experienced and
e Onset promotes consistency with others about the client’s pain
e Duration experience.
e Precipitation factors
e Aggravating factors
e Alleviating factors

S THERAPEUTIC INTERVENTION
RATIONALE
e e ee a
Independent Actions
Implement measures to reduce pain:
° Perform actions to reduce fear and anxiety about the pain Fear and anxiety can decrease the client’s threshold and tolerance
experience: for pain and thereby heighten the perception of pain. In addi-
¢ Assure client that the need for pain relief is understood tion, pain management methods are not as effective ifthe client
e Plan methods for achieving pain control with client. is tense and unable to relax.
e Perform actions to promote rest: Promoting rest helps to reduce fatigue and subsequently increase
e Minimize environmental activity and noise. D @ the client’s threshold and tolerance for pain.
° Provide or assist with nonpharmacologic methods for pain Nonpharmacologic pain management includes a variety of inter-
relief: D @ ventions. It is believed that most of these are effective because
° Massage they stimulate closure of the gating mechanism in the spinal
e Position change cord and subsequently block the transmission of pain impulses.
e Progressive relaxation exercises In addition, some interventions are thought to stimulate the
e Restful environment release of endorphins that inhibit the transmission gf nerve
e Diversional activities such as watching television, read- impulses and/or alter the client’s perception of pain. Many of
ing, or conversing the nonpharmacologic interventions also help to decrease pain
by promoting relaxation.
e Instruct and assist client to support abdominal or chest The action of “splinting” an incision or providing support to the
incision with a pillow or hands when turning, coughing, incision when turning, coughing, and deep breathing helps to
and deep breathing. D + provide support and reduce tension on the incision.
e If an abdominal incision is present, instruct the client to Bending the knees while coughing and deep breathing helps to
bend knees while coughing and deep breathing. D + reduce tension on abdominal muscles and incisions.
Monitor pain using a valid and reliable rating tool appropri- Quantifies pain level for evaluating response to therapy.
ate for age and ability to communicate. Ensures client safety
 Chapter 4 = Nursing Care of the Client Having Surgery 97

THERAPEUTIC INTERVENTIONS RATIONALE

Monitor sedation and respiratory status before administration of
opioids and at regular intervals when opioids are administered.

Dependent/Collaborative Actions
Implement measures to reduce pain:
e Use combination/multimodal analgesics for severe pain D + Pharmacologic therapy is an effective method of reducing or reliev-
e Opioid analgesics ing pain. All medications reduce pain by a variety of pharma-
¢ Nonopioid analgesics such as acetaminophen and salicy- cologic effects.
lates and other nonsteroidal antiinflammatory agents
(NSAIDs)
e Local anesthetics (e.g., bupivacaine, etidocaine)
e Muscle relaxants
e Encourage client to use PCA device as instructed Better understanding of the pain management treatment approach
can help to improve control of pain.
e Maintain integrity of analgesia delivery system: Maintaining integrity of the delivery system ensures client receives
e Epidural full benefit of the prescribed medication.
e Intravenous
e Subcutaneous
e Transdermal
e Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing event
can cause pain and before pain becomes severe. D > helps to minimize the pain that will be experienced. Analgesics
are also more effective if given before pain becomes severe
because mild to moderate pain is controlled more quickly and
effectively than severe pain.
Consult appropriate health care provider if aforementioned Notifying the appropriate health care provider allows for modifica-
measures fail to provide adequate pain relief: tion of the treatment plan.
e Physician
e Pharmacist
e Pain management specialist

Ce
>»© RISK FOR VENOUS THROMBOEMBOLISM nox
Definition: Susceptible to the development of a blood clot in a deep vein, commonly in the thigh, calf, or upper extremity,
which can break off and lodge in another vessel, which may compromise health.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain or tenderness in an extremity Increase in circumference of extremity; distention of super-
ficial vessels in extremity; unusual warmth of extremity;
positive Homans sign (Note: not always a reliable indicator)

RISK FACTORS DESIRED OUTCOMES

e Venous stasis associated with decreased activity, position-
The client will not develop a deep vein thrombus, as
ing during and after surgery, increased blood viscosity
evidenced by:
¢ Hypercoagulability associated with increased release of
a. Absence of pain, tenderness, swelling, and distended
tissue thromboplastin into the blood
superficial vessels in extremities
e Obesity
b. Usual temperature of extremities
¢ Impaired mobility
e Trauma to vein walls during surgery

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Goto ©volve for animation
 98 Chapter 4 = Nursing Care of the Client Having Surgery

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: peripheral Embolus precautions; embolus care: peripheral

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of a deep vein Early recognition of signs and symptoms of venous thromboembo-
thrombus: lism allows for prompt intervention.
e Pain or tenderness in extremity
e Increase in circumference of extremity
e Distention of superficial vessels in extremity
e Unusual warmth of extremity

—
S
THERAPEUTIC INTERVENTIONS RATIONALE
ee s sss se sss

Independent Actions
Implement measures to prevent embolus formation: D + Leg and ankle exercises help promote venous return and reduce the
° Perform actions to prevent peripheral pooling of blood risk of venous thromboembolism.
such as leg exercises:
e Ankle rotation
e Alternate dorsiflexion and plantar extension of feet and
legs at least 10 times every hour
e Passive or active range of motion
e Change position every 2 hrs
e Encourage early mobilization/ambulate as tolerated
If signs and symptoms of a deep vein thromboembolism Avoid putting pressure on the posterior knees because this action
occur: D> will compress leg veins, increasing turbulent blood flow, and
e Maintain client on bed rest until activity orders received. increase the risk of venous thromboembolism formation. If a
° Elevate foot of bed 20 degrees or greater above heart level. thrombus is suspected, elevate the affected extremity and do
e Discourage positions that compromise blood flow (e.g., not massage the area because of the danger of dislodging the
pillows under knees, crossing legs, sitting for long periods). thrombus.
Dependent/Collaborative Actions
Implement measures to prevent thrombus formation:
e Apply mechanical devices designed to increase venous These devices decrease venous stasis in the lower extremities and
return in the immobile patient: D+ increase venous return through the deep leg veins, which are
° Intermittent pneumatic compression device stockings prone to the formation of a venous thromboembolism. These
e Graduated elastic compression stockings or sleeves devices should remain in place until the patient is ambulatory.
e Maintain a minimum fluid intake of 2500 mL/day (unless Adequate hydration helps to reduce blood viscosity, which may
contraindicated). D + contribute to the formation ofa thromboembolism.
e Administer prophylactic low dose anticoagulants or anti- Anticoagulants, if indicated, help to suppress the formation
platelet medications: of clots.
e Low- or adjusted-dose heparin
e Fondaparinux
e Warfarin
e Dextran
e Low-molecular-weight heparin D +
If signs and symptoms of a venous thromboembolism occur: Additional studies may be indicated to confirm the presence of
° Prepare client for diagnostic studies (e.g., venography, du- a thromboembolism so the appropriate interventions can be
plex ultrasound, impedance plethysmography, D dimer implemented.
for pulmonary embolism [PE]). uy

|Nursing ».
Diagnosis |RISK FOR IMBALANCED FLUID VOLUME nox AND RISK FOR
ELECTROLYTE IMBALANCE nox
Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease,
increase, or rapid shift from one to the other of intra-
vascular, interstitial, and/or intracellular fluid, which may compromise health.
This refers to body fluid loss, gain, or both.
Risk for Electrolye Imbalance NDx: Susceptible to changes in serum electrolyte
levels, which may compromise health.
 Chapter 4 = Nursing Care of the Client Having Surgery 99

CLINICAL MANIFESTATIONS

Subjective Objective
Decreased fluid volume: verbal self-report of increased Decreased fluid volume: restlessness; weakness; postural
thirst; headaches; muscle cramps hypotension; inability to concentrate; tachycardia;
Increased fluid volume: verbal self-report of swelling; decreased urine output
nausea, shortness of breath Increased fluid volume: adventitious breath sounds,
Electrolyte loss: verbal self-report of muscle cramps; blood pressure changes, oliguria, S; heart sound, changes
nausea; palpitations; paresthesia; dizziness in mental status, distended neck veins
Electrolyte loss: confusion, altered mental status, muscle
twitching/spasms, EKG changes, arrhythmias

RISK FACTORS
Decreased fluid volume: restricted oral fluid intake of antidiuretic hormone (ADH). Note: ADH is stimulated
before, during, and after surgery; blood loss; and loss of by trauma, pain, and anesthetic agents.
fluid associated with vomiting, nasogastric tube drainage, e Electrolyte imbalance: hypokalemia, hypochloremia,
and/or profuse wound drainage and metabolic alkalosis: loss of electrolytes and
Increased fluid volume: vigorous fluid therapy during hydrochloric acid associated with vomiting and
and immediately after surgery and an increased secretion nasogastric tube drainage

DESIRED OUTCOMES
1. The client will not experience deficient fluid volume, 1. Normal skin turgor
hypokalemia, hypochloremia, or metabolic alkalosis, as m. Moist mucous membranes
evidenced by: n. Stable weight
a. Clear lung sounds and being free of dyspnea 2. The client will not experience excess fluid volume, as
b. Absence of an S3 heart sound evidenced by:
c. B/P and pulse within normal range for client and a. Stable weight
stable with position change b. Stable B/P
d. Capillary refill time less than 2-3 secs c. Absence of an S3 heart sound
e. Normal pulse volume d. Normal pulse volume
f. Urine output greater than 30 mL/h e. Balanced intake and output within 48 hrs after surgery
g. Usual mental status f. Usual mental status
h. Balanced intake and output within 48 hrs after surgery g. Blood urea nitrogen (BUN)/hematocrit (Hct) and
i. Return of peristalsis within expected time serum sodium and osmolality levels within normal
j. Absence of cardiac dysrhythmias, muscle weakness, range
paresthesias, twitching, spasms, and dizziness h. Absence of dyspnea, orthopnea, edema, and
k. Serum electrolyte and ABGs (as indicated) values distended neck veins
within normal range

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; electrolyte balance Electrolyte management; electrolyte monitoring; fluid/

electrolyte management; fluid monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of imbalanced fluid and
volume: electrolytes allows for prompt intervention.
Decreased skin turgor, dry mucous membranes, thirst The specific gravity will usually increase with an actual fluid
Weight loss of 2% or greater over a short period volume deficit but may be decreased depending on the cause of
Postural hypotension and/or low B/P the deficit
Weak, rapid pulse
Capillary refill time greater than 2-3 secs
Neck veins flat when client is supine
Change in mental status
Continued low urine output 48 hrs after surgery with a
change in specific gravity
Elevated BUN

D = Delegatable Action @ = UAP + =LVN/LPN ©P = Go to ®volve for animation

NDx = NANDA Diagnosis
 100 Chapter 4 = Nursing Care of the Client Having Surgery

Continued...

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of electrolyte Identification of physical assessment findings indicative of electro-
imbalance (hypochloremia, hypokalemia, hyponatremia): lyte imbalances allows for prompt intervention preventing
e Cardiac dysrhythmias potential patient harm and delaying recovery.
e Postural hypotension
e Muscle weakness/twitching
e Nausea/vomiting
e Abdominal cramping/pain
Assess for and report signs and symptoms of excess fluid Assessment findings indicative of fluid volume overload allows
volume: for prompt intervention preventing potential patient harm and
° Weight gain of 2% or greater over a short period delaying recovery.
e Elevated BP Note: BP may not be elevated if fluid has
shifted out of vascular space
e Presence of an S3 heart sound
O TCE:
e Bounding pulse
e Intake that continues to be greater than output 48 hrs
postoperatively
e Change in mental status
e Crackles (rales), diminished or absent breath sounds
e Low serum sodium level and low osmolality indicate
hypoosmolar overhydration.
e Decreased BUN and Het Note: Low HCT could also indicate
blood loss
e Dyspnea, orthopnea
e Edema
e Distended neck veins
° Chest radiograph results showing pulmonary vascular
congestion, pleural effusion, or pulmonary edema
Assess serum electrolyte levels, hemogram, serum osmolality, Assessing serum electrolyte levels, hemogram, and serum
and ABG values as indicated. osmolality allows for the early detection of fluid/electrolyte
imbalances.
Assessment of ABG values allows for a more direct measurement
of both pH and PaCOz, which may influence electrolyte
imbalances.
Assess results of chest radiograph as indicated. Chest radiograph films provide data about pulmonary vascular
status and fluid accumulation in the pleural space, pulmonary
interstitium, and alveoli.

THERAPEUTIC
oS eSSS INTERVENTIONS RATIONALE
—— FSFSSMSmmmSS SSssssssSeses
Independent Actions
Implement measures to prevent or treat deficient fluid vol-
ume, hypokalemia, hyponatremia, and/hypochloremia,
and/or acid/base imbalances:
° Perform actions to prevent nausea and vomiting: Nausea often causes the client to have decreased fluid volume
° Encourage client to take deep, slow breaths when nau- intake. Persistent vomiting results in excess loss of fluid and
seated. D> electrolytes.
° If a nasogastric tube is present and needs to be irrigated Irrigation ofanasogastric tube with normal saline insteadtof water
frequently and/or with large volumes of solution, irrigate helps to prevent excess loss of gastric electrolytes.
it with normal saline rather than water. D+
° Perform actions to reduce fever if present: Fever may be accompanied by diaphoresis, which can result in
° Sponge client with tepid water. D @ excessive loss of fluid.
e Remove excessive clothing or bedcovers. D @
° Carefully measure drainage: D + Accurate intake/output records must be maintained to ensure fluid
e Wound loss is replaced appropriately.
° Nasogastric
 Chapter 4 * Nursing Care of the Client Having Surgery 101

THERAPEUTIC INTERVENTIONS RATIONALE

e When oral intake is allowed and tolerated, assist client to Intake of foods/fluids high in potassium helps correct hypokalemia.
select foods/fluids high in potassium: D +
e Bananas
e Orange juice
e Potatoes
e Raisins
e Cantaloupe
e Tomato juice
Implement measures to prevent or treat excess fluid volume:
e Maintain fluid restrictions if ordered. D+

Dependent/Collaborative Nursing Actions

Implement measures to prevent or treat deficient fluid
volume, hypokalemia, hypochloremia, and metabolic
alkalosis:
e Perform actions to prevent nausea and vomiting: Nausea often causes the client to have decreased fluid volume
e Administer antiemetics and gastrointestinal stimulants intake. Persistent vomiting results in excess loss of fluid.
as ordered. D+
e Perform actions to reduce fever if present: Fever may be accompanied by diaphoresis, which can result in
e Administer antipyretics as ordered. D + excessive loss of fluid
e Administer fluid and electrolyte replacements if ordered. Replacing lost fluid/electrolyte volume helps prevent/treat deficient
fluid volume.
e Maintain a fluid intake of at least 2500 mL/day unless Provide adequate fluid intake needs to ensure adequate hydration.
contraindicated. D+
Implement measures to prevent or treat excess fluid volume: The stress of surgery along with anesthesia can trigger the secretion
e Administer fluid replacement therapy judiciously, espe- of ADH, which can lead to fluid retention/positive fluid bal-
cially within first 48 hrs after surgery. ance. The client must be monitored for fluid volume excess
until perioperative fluids are mobilized.
e If client is receiving intravenous fluids that contain sizable Excess fluid volume can result from overzealous or prolonged intra-
amounts of sodium such as 0.9% sodium chloride (NaCl) venous administration of sodium-containing fluids, particularly
or lactated Ringer solution, consult physician about a ones that contain sizable amounts of sodium.
change in the solution or a decrease in the rate of infusion.
e If client is receiving numerous and/or large-volume intra- Limiting the amount of intravenous solution infused at any one
venous medications, consult pharmacist about ways to time and maximizing the concentration of intravenous medica-
prevent excessive fluid administration: tions help prevent an additional fluid burden in the person who
e Stop primary infusion during administration of intra- has or is at risk for fluid volume overload.
venous medications, dilute medication in the minimum
amount of solution.
e Administer diuretics, if ordered, to increase excretion of Most diuretics inhibit sodium reabsorption in the renal tubules.
water. D> This results in decreased water reabsorption and subsequent
excretion of excess fluid.
Consult physician if signs and symptoms of deficient fluid Notifying the physician allows for modification of the treatment
volume, excess fluid volume, and electrolyte imbalances plan.
persist or worsen.

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal cramping or pain; aversion Inadequate food intake; inability to ingest food; diarrhea;

toward eating; lack of interest in food; altered taste sensa- hypoactive or absent bowel sounds; weakness of muscles
tion; weakness/fatigue; sore, painful mucous membranes of mastication; weight significantly below client’s usual
weight; pale conjunctiva; inflamed mucous membranes

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©} = Goto ©volve for animation
 102 Chapter 4 = Nursing Care of the Client Having Surgery

RISK FACTORS DESIRED OUTCOMES

e Inability to ingest food and/or absorb nutrients, de-
The client will maintain an adequate nutritional status, as
creased oral intake associated with prescribed dietary
evidenced by:
modifications, pain, weakness, fatigue, nausea, dislike of
a. Weight within normal range for client
prescribed diet, and feeling of fullness. This can occur as
b. Normal BUN, serum albumin, Hct, and hemoglobin
a result of abdominal distention
(Hgb) levels and lymphocyte count
e Inadequate nutritional replacement therapy
c. Usual strength and activity tolerance
¢ Loss of nutrients associated with vomiting
d. Healthy oral mucous membrane
e Increased nutritional needs associated with the increased
metabolic rate that occurs during wound healing

NOC OUTCOMES NIC INTERVENTIONS

ee
e ee ee

Nutritional status: biochemical measures; food and Nutritional monitoring; nutrition management; nutrition
fluid intake; nutrient intake therapy; diet staging

NURSING ASSESSMENT
RATIONALE
eee

Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
° Weight significantly below client’s usual weight or below prompt intervention.
normal for client’s age, height, and body frame
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
° Pale conjunctiva
Assess for return of bowel function every 2-4 hrs. Once the client begins to expel flatus, notify the health care
provider so oral intake can be resumed as soon as possible.
Monitor serum albumin, prealbumin, serum total protein, Serum albumin level less than 3.5 g/100 mL is considered an indi-
serum ferritin, transferrin, Hgb, Hct, and electrolyte levels cator of poor nutritional status. Early recognition of abnormal
as indicated. lab values reflective of the client’s overall nutritional state
allows for prompt intervention.
When oral intake is allowed, monitor percentage of meals An awareness of the amount of foods/fluids a client consumes
and snacks client consumes. Report pattern of inadequate alerts the nurse to deficits in nutritional intake. Reporting inad-
intake. equate intake allows for prompt intervention.

ee
THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
When food or oral fluids are allowed, implement measures to
maintain an adequate nutritional status:
e Implement measures to prevent nausea and vomiting: D @ + The presence of nausea can decrease the appetite. Preventing nau-
e Eliminate noxious sights and odors from the environ- sea and vomiting can improve the client’s appetite.
ment
e Encourage the client to take deep, slow breaths when
nauseated
e Instruct client to change positions slowly
° Apply a cold washcloth to the client’s forehead
* Consider alternative therapies (e.g., aromatherapy;
acupressure bands).
¢ Implement measures to reduce pain: The presence of pain decreases the appetite.
¢ Instruct client to support incision with movement. D
i
e Implement measures to reduce the accumulation of The subsequent feeling of fullness that accompanies gas accumula-
gas and fluid in the gastrointestinal tract and prevent tion leads to an early feeling of satiety.
constipation:
e Encourage frequent position changes D +
e Encourage ambulation. D+
e Encourage a rest period before meals. D > To conserve energy for consuming meals, rest periods before eating
e Provide nursing assistance during meals. D @ should be encouraged.
° Maintain a clean environment and a relaxed, pleasant A pleasant environment helps to promote adequate intake.
atmosphere. D @
e Provide oral hygiene before meals. D@ Good oral hygiene enhances appetite. A moist oral mucosa
makes
chewing and swallowing easier. Oral hygiene can also
remove
unpleasant tastes, improving the taste of foods/fluids.
 Chapter 4 * Nursing Care of the Client Having Surgery 103

THERAPEUTIC INTERVENTIONS RATIONALE

e Serve frequent, small meals rather than large ones if client Small, frequent meals are better tolerated in clients with a poor
is weak, fatigues easily, and/or has a poor appetite. D > appetite.
e Encourage significant others to bring in client’s favorite Food preferences enhance a client’s appetite.
foods unless contraindicated. D>
e Allow adequate time for meals; reheat foods/fluids if Research has demonstrated that it takes 35 minutes to feed the
necessary. D @ client who is willing to eat.
e Limit fluid intake with meals unless the fluid has high A high fluid intake with meals promotes a feeling of fullness and
nutritional value. D+ early satiety that may decrease actual food intake.

Dependent/Collaborative Nursing Actions

When food or oral fluids are allowed, implement measures to
Maintain an adequate nutritional status:
e Administer antiemetics as ordered. D+ The presence of nausea can decrease the appetite. Preventing nau-
sea and vomiting can improve the client’s appetite.
e Administer pain medications as ordered. D > The presence of pain decreases the appetite.
e Increase activity as tolerated and allowed. D @ Activity promotes gastric emptying, which reduces feeling of gastric
fullness; it also usually promotes a sense of well-being, which
can improve appetite.
e Obtain a dietary consult if necessary, to assist client in A dietician or nutritional support team can help clients individual-
selecting foods/fluids that meet nutritional needs, are ize their diet within prescribed dietary restrictions. Providing
appealing, and adhere to personal and cultural prefer- food in line with client preferences can enhance adherence to
ences, as well as the prescribed dietary modifications. prescribed diet.
e Ensure that meals are well balanced and high in essential Dietary supplements have shown a _positive relationship with
nutrients; offer dietary supplements if indicated. weight gain, reduced mortality, and reduced length of hospital-
ization.
e Administer vitamins and minerals if ordered. D Vitamins and minerals are essential to many metabolic processes
in the body.
e Perform a calorie count if ordered. Report information to Information gathered from an accurate calorie count is used to
dietitian and physician. D+ determine the adequacy of a client’s daily diet or the need for
nutritional support.
Consult physician about an alternative method of providing Notifying the physician allows for modification of the treatment
nutrition if client does not consume enough food or fluids plan.
to meet nutritional needs:
e Enteral tube feedings
e Parenteral nutrition.

|Nursing eee)
Diagnosis |NAUSEA npx |

Definition: A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which may or may not
result in vomiting.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea/aversion toward food; sour Gagging; increased salivation; increase in swallowing
taste in the mouth

RISK FACTORS DESIRED OUTCOMES

e Stimulation of visceral afferent pathways resulting from The client will experience relief of nausea and vomiting, as
abdominal distention and/or the irritating effect of some evidenced by:
medications on the gastric mucosa a. Verbalization of relief of nausea
e Stimulation of the cerebral cortex resulting from pain, b. Absence of vomiting
stress, and/or noxious environmental stimuli
e Stimulation of the chemoreceptor trigger zone resulting
from rapid movement and the effect of some medications
(e.g., morphine)

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 104 Chapter 4 = Nursing Care of the Client Having Surgery

NOC OUTCOMES NIC INTERVENTIONS

Nausea and vomiting control; nausea and vomiting severity; Nausea management; vomiting management; environmen-
nausea and vomiting disruptive effects tal management: comfort

NURSING ASSESSMENT RATIONALE

Assess for nausea and vomiting. Early recognition of signs and symptoms of nausea and vomiting
allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent nausea and vomiting:
° Perform actions to reduce the accumulation of gas and As gas accumulates in the intestines, the bowel wall stretches caus-
fluid in the gastrointestinal tract: D+ ing feelings of fullness, pain, and cramping that can contribute
e Frequent position changes to nausea.
e Early ambulation
e Expel flatus when urge felt
Consider alternative therapies for the treatment of nausea: Inhalation of isopropyl alcohol for clients who have undergone
e Inhalation of isopropyl alcohol general anesthesia has been shown to be somewhat effective for
e Continuous acupressure with bands or buttons on the postoperative nausea and vomiting (PONV). Acupressure was
wrist demonstrated to be a noninvasive, inexpensive, safe treatment
for PONV.
e Perform nonpharmacologic actions to reduce pain: Pain is known to contribute to PONV.
e Proper positioning
e Splinting of incisions
e Eliminate noxious sights and odors from the environment. Noxious stimuli can cause stimulation of the vomiting center.
Implement distraction techniques when client experiences Distraction techniques can help to draw attention away from nau-
nausea: sea. Slow, deep breaths in the immediate postanesthesia period
e Slow, deep breaths can help to rid the body of inhaled anesthetic agents.
e Guided imagery
° Instruct client to change positions slowly. Rapid movement can result in chemoreceptor trigger zone stimula-
tion and subsequent excitation of the vomiting center.
e Provide oral hygiene after each emesis. D @ Oral care can help remove foul tastes associated with vomiting.
e When oral intake is allowed: Slow advances in diet allow for gradual adjustment of the digestive
e Advance diet slowly usually beginning with clear tract to the presence of food.
liquids and progressing to solid food.
° Avoid serving foods with an overpowering aroma; remove Sudden, concentrated food odors can stimulate nausea.
lids from hot foods before entering room.
e Provide small, frequent meals rather than three (3) large Nausea can be prevented by ingesting small meals.
ones.
° Instruct client to ingest foods and fluids slowly. Eating slowly can reduce the incidence of nausea.
° Instruct client to avoid foods/fluids that irritate the gastric Foods that irritate the gastric mucosa may lead to the development
mucosa (e.g., spicy foods; caffeine-containing beverages of nausea.
such as coffee, tea, and colas).
° Encourage client to consume foods that prevent nausea Foods that are bland and dry are better tolerated by a nauseated
(e.g., dry, bland foods such as toast/crackers and liquids client. Ginger root has been demonstrated to be an effective
such as ginger ale). treatment for nausea and vomiting.
e Instruct client to avoid foods high in fat. Fat delays gastric emptying and may contribute to naus@g.
e Instruct client to rest after eating with head of bed Resting in a sitting position after eating may help prevent nausea.
elevated.

Dependent/Collaborative Nursing Actions

Implement measures to prevent nausea and vomiting:
e Administer antiemetics and gastrointestinal stimulants Antiemetic medications can reduce the incidence of nausea.
(e.g., metoclopramide) if ordered. D+ Gastrointestinal stimulants promote peristalsis.
e Administer medications known to cause gastric irritation Administering medications known to irritate the stomach with
(e.g., aspirin and aspirin-containing products, corticoste- foods helps to reduce the potential for nausea and enhance
roids, ibuprofen) with or immediately after meals unless absorption of the medications.
contraindicated.
Consult physician if aforementioned measures fail to control Notifying the appropriate health care provider allows for modifica
-
nausea and vomiting. tion of the treatment plan.
 Chapter 4 * Nursing Care of the Client Having Surgery 105

|Nursing =/-.---
Diagnosis RISK FOR DELAYED SURGICAL RECOVERY nox |
Definition: Susceptible to an extension of the number of postoperative days required to initiate and perform activities that
maintain life, health, and well-being, which may compromise health.
Related to:
¢ Type of procedure performed
e Prolonged or extensive surgery
° Persistent nausea/vomiting
e Surgical site infection
e Impaired mobility

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain exceeding agreed upon pain goal; Interrupted healing of surgical area; impaired mobility;
loss of appetite; nausea required self-care assistance; vomiting

RISK FACTORS DESIRED OUTCOMES

e Extremes of age
The client will meet length of stay goal for admitting
e Obesity
diagnosis/procedure.
e Malnutrition
e Pain
¢ Comorbidities (e.g., diabetes mellitus)

NOC OUTCOMES NIC INTERVENTIONS

Surgical recovery: immediate postoperative; convalescence Nutrition management; pain management: acute; nausea
Management; vomiting management; exercise therapy: am-
bulation; wound care

NURSING ASSESSMENT RATIONALE

Assess pain to include location, onset, duration, frequency, Persistent, uncontrolled pain can delay surgical recovery and inter-
and location. fere with the ability to achieve discharge criteria
e Identify client’s knowledge and beliefs about pain, includ-
ing cultural influences.
e Identify client’s pain goal that allows a state of comfort
and appropriate function.
Assess for the presence of persistent nausea/vomiting includ- Persistent, unrelieved nausea and vomiting can be indicative of
ing frequency, duration, severity, and precipitating factors. surgical complications (e.g., paralytic ileus) which can delay
e Assess for the presence of bowel sounds, abdominal surgical recovery.
distention/pain.
e Identify factors that contribute to nausea/vomiting
e Identify treatment past treatment options successful in the
management of nausea/vomiting
Assess client’s nutritional status and ability to meet nutri- Inadequate nutrition can delay wound healing, resulting in delayed
tional needs. surgical recover and discharge.
e Identify food preferences
Assess surgical site for presence of drainage, color, odor, and Routine assessment ofsurgical wound integrity allows for the iden-
approximation of wound edges. tification of inadequate wound healing and allows for prompt
intervention.
Assess client’s ability to ambulate including level of assistance The ability to independently and safely ambulate will determine cli-
and the need for ambulation aids. ent’s discharge potential and the need for further rehabilitation.

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 106 Chapter 4 = Nursing Care of the Client Having Surgery

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to achieve client’s pain goals: Ongoing monitoring of pain level allows for evaluation of response
Monitor pain using a valid and reliable rating tool appro- to therapy and adjustment of the treatment plan if unable to
priate for age and ability to communicate. achieve client’s pain goals.
Ensure client receives prompt analgesic care before pain-
inducing activities and/or before the pain becomes severe. Nonpharmacologic pain relief practices may reduce the need for
Incorporate nonpharmaceutic interventions to pain man- opioid narcotics and contribute to progressive recovery.
agement incorporating patient preference as appropriate
(e.g., application of ice; guided imagery; meditation). D @
Implement measures to relieve persistent nausea/vomiting Persistent, unrelieved nausea and/or vomiting interferes with ade-
Control environmental factors that may contribute to quate nutritional intake, which can impair wound healing and
nausea/vomiting (e.g., aversive smells, sound, unpleasant overall recovery.
visual stimulation). D ®
Reduce client factors that may precipitate nausea/vomiting
(e.g., anxiety, fear, fatigue).
Incorporate frequent oral hygiene into care to promote
comfort. D ®
Consider alternative therapies (e.g., acupressure; aroma-
therapy).
Implement measures to improve appetite. Adequate nutritional intake is necessary for optimum wound healing.
Provide optimum environment for meal consumption Enhances client’s desire to eat.
(e.g., clean, well ventilated). D @
Ensure food is prepared in a manner optimum for con-
sumption.
Assist patient with eating if needed. D @
Monitor caloric and dietary intake.
Implement measures to ensure progressive wound healing. Assures that client intake is appropriate to support healing.
D® Healthy diet is necessary to promote wound healing.
Ensure client and provider observe hand _ hygiene
practices.
Position patient to prevent tension on wound as
appropriate.
Ensure healthy diet to promote would healing.
Ensure client does not smoke during postoperative
period.
Implement measures to progress independent mobility. Smoking causes vasoconstriction and can interfere with wound
healing.
Provide low-height bed as appropriate. D@ Early ambulation is necessary to prevent muscle atrophy, reduce
the risk for falls, improve circulation, reduce edema, and pre-
vent additional surgical complications.
Provide footwear that promotes safe ambulation. D @ Improves ability for independence and prevents potential for falls
Encourage client to sit on side of bed (dangle) as tolerated. or other injury.
Assist patient with initial ambulation as necessary. D @
Assist patient to stand and ambulate specified distances. D @
Encourage patient to be up “ad lib” as appropriate to
condition. D ®
‘
Dependent/Collaborative Actions
Implement measures to achieve client’s pain goals: D @ Administration of pain medication around the clock during the
Consider administration of analgesics around the clock first 24-48 hrs after surgery when pain is most intense will
for the first 24-48 hrs after surgery unless contraindicated enhance recovery by facilitating client’s ability to comply with
by level of sedation or respiratory status. postoperative activities (e.g., ambulation, coughing).
Use combination analgesics if pain is severe (e.g., opioids/
nonopioids).
Consider alternative therapies (e.g., guided imagery;
meditation).
 Chapter 4 = Nursing Care of the Client Having Surgery 107

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to relieve persistent nausea/vomiting Unrelieved, persistent nausea/vomiting delays surgical recovery by
D® interfering with adequate nutritional intake and increasing
° Monitor fluid and electrolyte intake, gradually increasing tension on wound (e.g., abdominal), risking dehiscence.
fluids if no vomiting occurs.
e Administer appropriate antiemetic medications.
Implement measures to improve appetite. Identification of weight loss/inadequate nutritional intake can
e Monitor trends in weight loss/weight gain. delay wound healing/discharge. Consultation with dietician
e Offer nutrient-dense snacks allows for appropriate modification of the treatment plan.
e Obtain referral for dietician for supplemental nutrition as
indicated
Implement measures to ensure progressive wound healing. Surgical dressings, if applied, should be kept dry and intact—either
D® reinforcing or changing in accordance with physician’s orders to
e Maintain sterile dressing technique when changing ensure an optimum environment for wound healing. Sterile
dressings/performing wound care as appropriate. technique, when necessary, must be adhered to in order to
e Change dressings according to the amount of exudate prevent infection.
and drainage.
e .Reinforce dressings as needed.
Implement measures to progress independent mobility. Early, progressive ambulation is an independent function of the
e Consult physical therapy about ambulation plan as nurse. Any barriers to achieving ambulation should be
needed. discussed with physical therapy in a timely manner to prevent
delayed recovery and/or discharge.
Consult physician if signs and symptoms of any of the Notifying the appropriate health care provider allows for modifica-
following occur: tion of the treatment plan.
e Self-reported, unrelieved pain that exceeds identified
goals for comfort and optimum functioning.
e Self-reported, persistent, unrelieved nausea and vomiting.
e Inadequate nutritional/caloric intake.
e Signs/symptoms of wound infection or delayed healing
(e.g., swelling, odor, foul discharge/drainage, wound
edges that are not approximated).
e Inability to safety ambulate independently.

+ IMPAIRED ORAL MUCOUS MEMBRANE INTEGRITY nox

Definition: Injury to the lips, soft tissue, buccal cavity, and/or oropharynx.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty swallowing, oral discomfort, Difficult speech; decreased salivation; halitosis; impaired
or bad taste in the mouth ability to swallow; white patches in mouth; coated tongue

RISK FACTORS DESIRED OUTCOMES

e Deficient fluid volume associated with restricted oral
The client will maintain a moist, intact oral mucous
intake and fluid loss membrane.
e Decreased salivation associated with food and fluid
restrictions and the effect of anesthesia and some
medications (e.g., narcotic [opioid] analgesics)
e Inability to perform self-oral care
e Malnutrition

NOC OUTCOMES NIC INTERVENTIONS

Oral health Oral health maintenance; oral health promotion; oral health
restoration

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 108 Chapter 4 * Nursing Care of the Client Having Surgery

NURSING ASSESSMENT RATIONALE

Assess for dryness of the oral mucosa. Early recognition of signs and symptoms of a dry oral mucosa
allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to relieve dryness of the oral mucous
membrane: D +
e Instruct and assist client to perform oral hygiene as often
as needed.
e Avoid use of products that contain lemon and glycerin These products have a drying and irritating effect on the oral mu-
and use of mouthwashes containing alcohol. cous membrane.
e Encourage client to rinse mouth frequently with water. Prevents oral dryness and flushes out unwanted substances and
D® bacteria.
e Lubricate client’s lips frequently. D @ Frequent lubrication of the lips helps prevent drying and cracking.
e Encourage client to breathe through nose rather than Breathing through the nose allows for the proper warming and
mouth. humidification of air, which is bypassed with mouth breathing.
e Encourage client not to smoke. Smoking dries the oral mucosa and has been linked to mucous
membrane breakdown and oral cancer.
e Encourage client to suck on hard candy unless contraindicated. Action helps to stimulate salivation, moistening the oral mucosa.

Dependent/Collaborative Actions
Implement measures to relieve dryness of the oral mucous
membrane:
e Maintain intravenous fluid therapy as ordered. Intravenous fluid therapy enhances hydration and helps to improve
the condition of dry mucous membranes.
e Increase oral fluid intake as ordered. D@ > Increasing oral fluid intake promotes hydration and stimulates
salivation.
Consult physician if signs and symptoms of parotitis (e.g., pain, Notifying the appropriate health care provider allows for modifica-
tenderness, and swelling at the angle of the jaw; fever) occur. tion of the treatment plan.

Nursing Diagnosis BATHING, DRESSING, FEEDING, AND TOILETING

SELF-CARE DEFICIT
Definition: Bathing Self-Care Deficit NDx: Inability to independently complete cleansing activities; Dressing Self-Care
Deficit NDx: Inability to independently put on or remove clothing; Feeding Self-Care Deficit NDx: Inability
to eat independently; Toileting Self-Care Deficit NDx: Inability to independently perform tasks associated with
bowel and bladder elimination.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to perform basic personal Inability to access bathroom; inability to wash body;
care activities inability to maintain appearance at acceptable level;
inability to put on necessary items of clothing

RISK FACTORS DESIRED OUTCOMES

ee ee
e Impaired physical mobility associated with weakness,
The client will perform self-care activities within physical
fatigue, pain, nausea, depressant effect of some medica-
limitations and postoperative activity restrictions.
tions, fear of dislodging tubes and compromising surgical
wound, and activity restrictions
 Chapter 4 = Nursing Care of the Client Having Surgery 109

NOC OUTCOMES NIC INTERVENTIONS

a a
Self-care assistance: bathing/hygiene; dressing/grooming; Self-care assistance: bathing/hygiene; dressing/grooming;
feeding; toileting feeding; toileting

NURSING ASSESSMENT RATIONALE

Assess for physical limitations or postoperative restrictions that Early recognition of signs and symptoms of physical limitations
may interfere with a client’s ability to perform self-care: allows for prompt intervention.
bathing/hygiene; dressing/grooming; feeding; toileting.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
With client, develop a realistic plan for meeting daily basic Including the client in developing a plan of care promotes auton-
personal care activities. omy and helps to establish a sense of control.
Assist the client with activities he/she is unable to perform
independently. D@ +
Implement measures to facilitate the client’s ability to
“ perform self-care activities: D @ +
e Schedule care at a time when client is most likely to be able to Pain relief facilitates range of motion, which may increase the
participate (e.g., when analgesics are at peak effect, after rest client’s ability to perform self-care.
periods, not immediately after meals or treatments).
e Keep needed objects within easy reach.
e Allow adequate time for accomplishment of self-care activities.
e Perform actions to increase physical mobility.
Obtain assistive devices as necessary. Environmental and/or physical factors may interfere with the
e Toileting: bedside commode/urinal client’s ability to perform self-care activities. The ability to
e Feeding: adaptive devices (e.g., utensils with small straps; perform self-care activities may be enhanced with adaptation of
long-handled utensils; large-handled cups) the client’s care environment.
e Dressing: extension equipment for pulling on clothing as
appropriate
Encourage maximum independence within physical limita-
tions and postoperative activity restrictions. D @ +
Inform significant others of client’s abilities to perform own The ability to perform self-care is essential for optimum self-
care. Explain the importance of encouraging and allowing esteem.
client to maintain an optimal level of independence.

Dependent Collaborative Actions

Consult with physician and/or case management to evaluate Inability of client to perform activities of daily living, including
client for needed support services to assist with activities feeding, may hamper postoperative recovery. If family is unable
of daily living bathing, dressing, feeding, toileting. to support, home care services or rehabilitation services may be
required to ensure appropriate recovery.

|Nursing oo)
Diagnosis |URINARY RETENTION nox
Definition: Inability to empty bladder completely.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to urinate; feelings of the Palpable distended bladder; urinary dribbling; absence of
need to strain to empty the bladder urinary output; frequent voiding

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 110 Chapter 4 * Nursing Care of the Client Having Surgery

RISK FACTORS DESIRED OUTCOMES

e Increased tone of the urinary sphincters associated with
The client will not experience urinary retention, as evi-
sympathetic nervous system stimulation resulting from
denced by:
pain, fear, and anxiety
a. Voiding at normal intervals
e Decreased perception of bladder fullness associated with
b. No reports of bladder fullness and suprapubic
depressant effect of anesthesia and some medications
discomfort
(e.g., opioid analgesics)
i) Absence of bladder distention and dribbling of urine
Relaxation of the bladder muscle associated with depressant
d. Balanced intake and output within 48 hrs after surgery
effect of anesthesia and some medications (e.g., opioid
analgesics) and stimulation of the sympathetic nervous
system (can result from pain, fear, and anxiety)

NOC OUTCOMES NIC INTERVENTIONS

Urinary continence; urinary elimination Urinary catheterization; urinary elimination management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of urinary retention: Early recognition of signs and symptoms of urinary retention
e Frequent voiding of small amounts (25-60 mL) of urine allows for prompt intervention.
e Reports of bladder fullness or suprapubic discomfort
e Bladder distention
e Dribbling of urine
Monitor intake and output. Administration of anesthetic agents impairs normal bladder
emptying. Adequate volume replacement is necessary to fill
bladder and stimulate micturition.
Any continued oliguria or anuria should be reported to the
physician to allow for modification of the treatment plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Eee

Independent Actions
Implement measures to prevent urinary retention:
e Instruct client to urinate when the urge is first felt. If the client feels the urge to urinate but suppresses it by contracting
the external urinary sphincter, the urge will subside and not
recur until the bladder fills more.
Perform actions to promote relaxation during voiding at- If the client is relaxed when trying to urinate, he/she is better able
tempts: to relax the pelvic floor muscles and external urinary sphincter,
e Provide privacy, hold a warm blanket against abdomen, allowing voiding to occur.
encourage client to read. D @
e Perform actions that may help to trigger the micturition
reflex and promote a sense of relaxation during voiding
attempts:
e Run water, place client’s hands in warm water, pour
warm water over perineum. D
Allow client to assume a normal position for voiding A sitting or standing position, if possible, uses gravity to facilitate
unless contraindicated. D @ bladder emptying.
Instruct client to lean upper body forward and/or gently Proper positioning is necessary to put pressure on thé bladder
press downward on lower abdomen during voiding pressure helps create a sensation of bladder fullness, which
attempts unless contraindicated. stimulates the micturition reflex
 Chapter 4 = Nursing Care of the Client Having Surgery 111

ns

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent urinary retention:
e Perform actions to reduce postoperative pain. Narcotic analgesics may decrease the perception of a full bladder
e Encourage use of nonnarcotic rather than opioid analge- and promote urinary retention. The use of nonnarcotic analge-
sics once period of severe pain has subsided. D sics may reduce this effect.
Consult physician regarding intermittent catheterization or
insertion of an indwelling catheter if aforementioned
actions fail to alleviate urinary retention.
If urinary catheter is present, D + Prevents urinary retention by maintaining patency of the catheter.
¢ Keep tubing free of kinks, and irrigate as ordered.
Consult physician if there is no urine output within 6-8 hrs For the first 48 hrs postoperatively, urine output is expected to be
after surgery or if output continues to be less than intake less than intake because of factors such as blood loss and in-
48 hrs after surgery. creased secretion of ADH. Consulting the appropriate health
care provider allows for modification of treatment plan.
e Administer cholinergic (parasympathomimetic) drugs to Cholinergic (parasympathomimetic) drugs promote urination by
- Stimulate bladder contraction. D+ stimulating contraction of the bladder detrusor muscle.

|Collaborative »eeees’)
Diagnosis RISK FOR PARALYTIC ILEUS

Definition: Paralysis of the peristaltic activity resulting in blockage of the intestines.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of persistent abdominal pain and Firm, distended abdomen; absent bowel sounds; failure to
cramping pass flatus; abdominal x-ray showing distended bowel

RISK FACTORS DESIRED OUTCOMES

e Manipulation of intestines during abdominal surgery,
The client will not develop a paralytic ileus, as evidenced
depressant effect of anesthesia and some medications
by:
(e.g., opioid analgesics, some antiemetics) on bowel
a. Absence or resolution of abdominal pain and cramping
motility, hypokalemia, and hypovolemia (can cause
b. Soft, nondistended abdomen
decreased blood supply to the intestine)
c. Gradual return of bowel sounds
d. Passage of flatus

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of paralytic ileus: Early recognition of signs and symptoms of a paralytic ileus allows
e Development of or persistent abdominal pain and for prompt intervention.
cramping
e Firm, distended abdomen
e Absent bowel sounds
e Failure to pass flatus
Monitor results of abdominal x-ray. An abdominal x-ray that demonstrates distended bowel may be
indicative ofa paralytic ileus.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent paralytic ileus: Early ambulation in a postoperative client promotes the return of
e Increase activity as soon as allowed and tolerated. D@ + peristalsis.

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 112 Chapter 4 = Nursing Care of the Client Having Surgery

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent paralytic ileus:
e Perform actions to maintain adequate tissue perfusion: Gastrointestinal stimulants help to maintain adequate blood
e Administer gastrointestinal stimulants (e.g., metoclo- supply to the bowel.
pramide) if ordered. D+
e Perform actions to prevent hypokalemia. Hypokalemia promotes atony of the intestinal wall, which results
e Administer potassium supplements. in a decrease in peristalsis.
If signs and symptoms of paralytic ileus occur: D > Paralytic ileus results in cessation of normal peristalsis. The client
e Withhold all oral intake. should have nothing by mouth (NPO) with a nasogastric tube
¢ Insert nasogastric tube and maintain suction as ordered. in place to facilitate gastric decompression until the ileus is
resolved.

DISCHARGE TEACHING/CONTINUED CARE

|Nursing oo)
Diagnosis |DEFICIENT KNOWLEDGE nox

Definition: Absence of cognitive information related to specific topic, or its acquisition.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of not understanding postoperative Alteration in cognitive function; alteration in memory;
instructions inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS DESIRED OUTCOMES

° Cognitive deficiency
e Misinterpretation of information The client will demonstrate an understanding of post-
operative instructions as evidenced by:
° Lack of interest in learning
e lLanguage/cultural barriers a. Confirmation of understanding of postoperative
instructions provided during the teach-back method of
patient education

NOC OUTCOMES NIC INTERVENTIONS

ee EESSSSSFSFSFSFSSMSSSmsmmmmsmsFeFeFeFeFeFsefeseseseF
Knowledge: treatment regimen Teaching: individual; teaching: prescribed exercise; teaching:
prescribed medication; health system guidance

NURSING ASSESSMENT RATIONALE

eee
Assess Client’s ability and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges. '

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Desired Outcomes: The client will identify ways to pre-

vent postoperative infection.

Independent Actions
° Instruct client in ways to prevent postoperative respiratory Coughing and deep breathing exercises, as well as incentive
infection: spirometry, help to reduce atelectasis, reexpand alveoli, and
e Continue with coughing (unless contraindicated) and decrease the risk of a postoperative pulmonary infection. Deep
deep breathing every 2 hrs while awake. breathing helps to clear airways by loosening secretions and
° Continue to use IS if activity is limited. promoting a more effective cough.
 Chapter 4 = Nursing Care of the Client Having Surgery 113

THERAPEUTIC INTERVENTIONS RATIONALE

e Increase activity as ordered. Activity helps to mobilize secretions and promotes deeper breathing.
e Avoid contact with persons who have infections. During the healing process, while an individual’s resistance to in-
e Avoid crowds during flu and cold seasons. fection may be lowered, the client should avoid situations that
increase the risk for infection. Protecting the client from others
with infections reduces the risk of exposure to pathogens.
Decrease or stop smoking. Irritants in smoke increase mucus production and impair ciliary
function, which can increase the risk for postoperative pulmo-
nary infection.
Drink at least 10 glasses of liquid per day unless contra- Proper hydration helps to thin pulmonary secretions, which
indicated. facilitates mobilization and expectoration, reducing the risk of
pulmonary infection. Proper hydration also helps maintain
adequate blood flow and nutrient supply to healing tissues.
e Maintain a balanced nutritional intake. Adequate nutrition is necessary for proper wound healing and
maintenance of normal immune system function.
e Maintain a proper balance of rest and activity. Rest helps the body to better use nutrients and oxygen for healing.
Activity helps to reduce the risk of complications of prolonged
immobility.
¢ Maintain good personal hygiene, especially with oral care, Good personal hygiene helps to maintain the integrity of protective
hand washing, and perineal care. mucosal linings (oral), reduce the amount of harmful organ-
isms (perineal, oral, hand), and reduce the risk of colonization
of organisms and subsequent infection.
e Avoid touching any wound unless it is completely healed. Touching the wound may increase the transmission of pathogens,
increasing the risk for infection.
° Maintain sterile or clean technique as ordered during The use of sterile technique reduces the risk of introduction of
wound care. pathogens into the body.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will demonstrate the abil-

ity to perform wound care.

Independent Actions
Discuss the rationale for, frequency of, and equipment neces-
sary for the prescribed wound care.
Provide client with the necessary supplies (e.g., dressings, irrigat- Assures client has what is needed at discharge.
ing solution, tape) for wound care and with names and ad-
dresses of places where additional supplies can be obtained.
Demonstrate wound care and proper cleansing of any reus- Return demonstration allows for the nurse to determine the client’s
able equipment. Allow time for questions, clarification, comprehension of the task. Any deficiencies in performance can
and return demonstration. be addressed with further instruction.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct the client to report the following signs and symptoms: Signs and symptoms are indicative of potential infection and
e Persistent low-grade or significantly elevated (38.3°C should be reported to the appropriate health care provider in a
[101°F]) temperature timely manner to avoid complications.
e Difficulty breathing Recognition of signs and symptoms of infection allows for prompt
e Chest pain intervention.
e Cough productive of purulent, green, or rust-colored sputum
e Increasing weakness or inability to tolerate prescribed
activity level
e Increasing discomfort or discomfort not controlled by
prescribed medications and treatments
e Continued nausea or vomiting

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 114 Chapter 4 = Nursing Care of the Client Having Surgery

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THERAPEUTIC INTERVENTIONS RATIONALE

e Increasing abdominal distention and/or discomfort
e Separation of wound edges Possible paralytic ileus, bowel obstruction, or constipation.
e Increasing redness, warmth, pain, or swelling around Poor tissue healing.
wound
e Unusual or excessive drainage from any wound site
e Pain or swelling in calf of one or both legs
e Urine retention Possible thrombus development.
Frequency, urgency, or burning on urination
Cloudy or foul-smelling urine Possible urinary tract infection.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will develop a plan for A written plan assures that client has considered all aspects of
adhering to recommended follow-up care including future follow-up care and what support may be required to adhere to
appointments with health care provider, dietary modifica- therapeutic regimen.
tions, activity level, treatments, and medications prescribed.

Independent Actions
Reinforce importance of keeping scheduled follow-up A follow-up appointment with the health care provider is impor-
appointments with the health care provider. tant to monitor continued recovery.
Reinforce physician’s instructions about dietary modifica- A proper diet helps to enhance proper wound healing. Reinforcing
tions. Obtain a dietary consult for client if needed. instructions helps the nurse to both assess the client’s level of
understanding and determine the need for further instruction.
Reinforce physician’s instructions on suggested activity level Activity levels must be maintained to ensure the proper balance
and treatment plan. between rest that aids in healing and activity that prevents
complications.
Explain the rationale for, side effects of, and importance of The client should be educated on how to take medications that are
taking medications prescribed. Inform client of pertinent prescribed to be used as needed. It should be emphasized that
food and drug interactions. the client should not increase the frequency or dosage of these
medications without permission from the health care provider.
Implement measures to improve client compliance:
° Include significant others in teaching sessions if possible. Involvement of significant others in patient teaching improves
adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Information is presented with time for questions to allow for
clarification of information provided. clarification of information.
Provide written instructions on scheduled appointments Written instructions allow the client to refer to instructions as
with health care provider, dietary modifications, activity needed.
level, treatment plan, medications prescribed, and signs
and symptoms to report.

ADDITIONAL CARE PLANS diminished tissue perfusion of wound area and inadequate
nutritional status
RISK FOR CONSTIPATION NDx Urinary tract infection related to increased growth and
Related to decreased gastrointestinal motility associated with colonization of microorganisms associated with urinary sta-
sis; introduction of pathogens associated with an indwelling
manipulation of bowel during abdominal surgery, depressant
catheter if present ,
effect of anesthesia and opioid analgesics, and decreased activity

RISK FOR FALLS NDx

DISTURBED SLEEP PATTERN NDx Related to weakness and fatigue; dizziness or syncope associated
Related to fear, anxiety, discomfort, inability to assume usual with postural hypotension resulting from peripheral pooling of
sleeping position, and frequent assessments and treatments blood and blood loss during surgery; central nervous system
depressant effect of some medications opioid analgesics, some
RISK FOR INFECTION NDx antiemetics; presence of tubing or equipment
Pneumonia related to stasis of pulmonary secretions and
aspiration, if it occurs. IMPAIRED PHYSICAL MOBILITY NDx
Wound infection related to contamination associated with Related to weakness and fatigue associated with inadequate
introduction of pathogens during or after surgery; decreased nutritional status, disturbed sleep pattern, pain, nausea, activ-
resistance to infection associated with factors such as ity restrictions imposed by treatment plan
 Chapter 4 = Nursing Care of the Client Having Surgery 115

ACTIVITY INTOLERANCE NDx increased gastric pressure resulting from decreased gastroin-
Related to bed rest, immobility, and generalized weakness testinal motility

RISK FOR ASPIRATION NDx FEAR NDx/ANXIETY NDx

Related to decreased level of consciousness and absent or di- Related to unfamiliar environment; pain; lack of understand-
minished gag reflex associated with depressant effect of ing of surgical procedure performed; diagnosis and post-
anesthesia and narcotic (opioid) analgesics; supine position- operative treatment plan; possible change to body image and
ing; increased risk for gastroesophageal reflux associated with roles; and financial concerns

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 CHAPTER

The Client With Alterations

in Respiratory Function

ASTHMA
©P Asthma is a chronic disorder characterized by intermittent and factors. Triggers for an asthma attack also vary from client to
reversible obstruction of the airways. This airflow obstruction client and may include airborne allergens and air pollutants,
is caused by bronchial hyperresponsiveness and inflammation viral respiratory infections, cold air, stress, medications
of the airway mucous membganes. Allergens enter the airway (i.e., nonsteroidal anti-inflammatory drugs [NSAIDs]), exer-
and initiate the inflammatory cascade. Mast cells found in the cise, gastroesophageal reflex disease, smoke, and occupational
basement membranes of the bronchial walls degranulate and factors.
release inflammation response mediators, which cause Treatment of asthma is focused on prevention of symptoms.
increased capillary permeability and vasodilation, and recruit- Treatment consists of two types of medications: quick-relief or
ment of eosinophils, lymphocytes, and neutrophils. The rescue medications (betaz-agonists, anticholinergics) and long-
response leads to the production of thick, tenacious mucus term control medications (inhaled corticosteroids, immuno-
that blocks the airways, Combined with the bronchial hyper- modulators, antileukotrienes, long-acting inhaled beta»-
responsiveness and capillary vasodilation and permeability, agonists). Immunotherapy (allergy shots) may also be beneficial.
intake of air significantly decreases, and air is trapped in the This care plan focuses on care of the adult client
lungs below the obstruction. Chronic inflammation leads to with asthma who is hospitalized during an exacerba-
remodeling of the bronchial walls. The bronchial walls show tion of the illness. Much of the information is appli-
hypertrophy, and mucus-producing cells undergo hyperplasia. cable to clients receiving follow-up care in an extended
There are two types of asthma: allergic (caused by exposure care facility or home setting.
to an allergen) and nonallergic (caused by stress, exercise,
illnesses, or exposure to extreme weather). Asthma attacks are
variable and unpredictable, range from mild to severe, and OUTCOME/DISCHARGE CRITERIA
differ from client to client. Clinical manifestations of an
asthma attack include dyspnea, wheezing, chest tightness, The client will:
tachycardia, sweating, cough, tightening of neck muscles, 1. Have improved respiratory function
and the use of accessory muscles to breathe. The client may 2. Have vital signs within client's normal range
also have an audible wheezing or whistling on exhalation. 3. Tolerate expected level of activity
Indications that asthma is becoming worse include an 4. Develop an education plan for ordered medications
increase in the frequency and severity of asthma attacks and including rationale, food and drug interactions, side ef-
an increased need to use bronchodilators. fects, methods of administering, and importance of taking
There is no clear indication why some people get asthma as prescribed
and others, exposed to the same conditions, do not. It is 5. Demonstrate appropriate use of inhalers
possibly due to a combination of environmental and genetic

IMPAIRED RESPIRATORY FUNCTION*

SO ome

Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.

*This diagnostic label contains the following nursing diagnoses: Inneffective breathing pattern; ineffective airway clearance; and impaired
gas exchange.

116
 Chapter S « The Client With Alterations in Respiratory Function 117,

Ineffective breathing pattern NDx

Related to:
e Increased rate of respirations associated with fear and anxiety, and feeling of “air hunger”
e Decreased depth of respirations associated with weakness, fatigue, fear, and anxiety

Ineffective airway clearance NDx

Related to:
e Narrowing of the airways associated with:
e Excessive mucus production, inflammation, and bronchospasm
° Bronchial wall remodeling with bronchial hypertrophy and hyperplasia of mucus-secreting cells
e Stasis of secretions associated with:
° Difficulty in coughing up secretions resulting from fatigue, weakness, and presence of tenacious secretions if fluid intake
is inadequate
e Impaired ciliary function resulting from loss of ciliated epithelium (occurs with inflammation, destruction, and fibrosis
of bronchial walls)

Impaired gas exchange NDx

Related to;
e Narrowing or obstruction of the small airways

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of restlessness; irritability; somnolence; Rapid, shallow respirations; abnormal breath sounds—
chronic cough; chest tightness wheezing; cough; use of accessory muscles when breath-
ing; significant decrease in oximetry results; abnormal
arterial blood gas values; reduced activity tolerance;
tachycardia

RISK FACTORS DESIRED OUTCOMES

e Genetics
The client will maintain adequate respiratory function as
e Smoking
evidenced by:
e Allergies
a. Usual rate and depth of respiration
e Environmental factors
. Usual or improved breath sounds
. Usual mental status
. Oximetry results within normal range for client
. Arterial blood gas values within normal range for client
ou.

NURSING OUTCOME CLASSIFICATIONS (NOC) NURSING INTERVENTIONS CLASSIFICATIONS (NIC)

Respiratory status; airway patency; respiratory status: Respiratory monitoring; airway management; chest
ventilation; respiratory status: gas exchange physiotherapy; cough enhancement; oxygen therapy;
medication administration; ventilation assistance; fear and
anxiety reduction

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired respiratory Early recognition of signs and symptoms of ineffective breathing
function: patterns allows for prompt intervention.
e Rapid, shallow respirations
e Dyspnea, orthopnea
e Use of accessory muscles when breathing
e Abnormal breath sounds (e.g., wheezes, crackles)
e Cough effectiveness
e Restlessness, irritability
e Confusion, somnolence
e Central cyanosis (a late sign)
Assess arterial blood gas and pulse oximetry values and report Oximetry is a noninvasive method of measuring arterial oxygen
abnormal findings. saturation. Allows for evaluation of client’s current oxygenation
status, so that appropriate supplemental oxygen therapy can be
implemented.

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118 @hapter ous The Client With Alterations in Respiratory Function

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve respiratory status.
Place client in a semi-Fowler’s position. D@ + Positioning in semi-Fowler’s position promotes optimal gas ex-
change by enabling chest expansion and diaphragm excursion.
Instruct client in breathing exercises focusing on hypoventi- These techniques help clients decrease the need for betaz-agonists
lation, breath holding after exhalation, and breathing and inhaled corticosteroids.
through the nose.
Instruct client in exercises involving shoulder rotations and This technique helps expand the lungs.
arm lifts performed in sync with breathing.
Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause inflammation and damage to the
bronchial and alveolar walls; the carbon monoxide decreases
oxygen availability.
Maintain activity restrictions and increase activity as allowed Conservation of energy through activity restrictions allows energy
and tolerated. to be focused on breathing. Increasing activity as tolerated helps
to mobilize secretions and promotes deeper breathing.
Perform actions to reduce fear and anxiety (e.g., assure client The experience of anxiety during an asthma attack can exacerbate
that staff members are nearby; respond to call signal as the attack.
soon as possible; provide calm, restful environment;
instruct in relaxation techniques). D @ +
Maintain client fluid intake of at least 2500 mL/day unless Maintaining adequate hydration decreases the viscosity of
contraindicated. D+ secretions and improves ciliary action in removing secretions.

Dependent/Collaborative Actions
Implement measures to improve respiratory status.
Administer betaz-adrenergic agonists inhaled during an acute Betaz-agonists are the treatment of choice for an asthma attack
attack and oral for ongoing therapy. D + because they relax airway smooth muscles and decrease
bronchoconstriction.
Administer and monitor oxygen as ordered. Provides support for the respiratory system until it is able to
Administer Heliox (a helium/oxygen mixture). function appropriately.
The combination of helium and oxygen is lighter than air
and easier to breathe when gas flow is compromised by
bronchospasms.
Administer corticosteroids both inhaled and oral. Corticosteroids decrease airway inflammation and thereby improve
bronchial airflow.
Consult appropriate health care providers (respiratory therapist Notifying the appropriate health care professionals allows for a
and physician) if signs and symptoms of impaired respiratory multifaceted approach to treatment.
function persist or worsen.

|Nursing Soo)
Diagnosis ACTIVITY INTOLERANCE nox
Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Related to:
e Tissue hypoxia associated with impaired gas exchange
e Inadequate nutrition status
° Difficulty resting and sleeping associated with dyspnea, excessive coughing, fear, anxiety, frequent assessnfent and
treatments, and side effects of medication therapy (e.g., some bronchodilators, corticosteroids)
° Increased energy expenditure associated with strenuous breathing efforts and persistent coughing

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue or weakness Abnormal heart rate or blood pressure (B/P) response to
activity; exertional discomfort or dyspnea; electrocardio-
graphic changes reflecting dysrhythmias or ischemia;
unable to speak with physical activity
 Chapter 5 = The Client With Alterations in Respiratory Function 119

RISK FACTORS DESIRED OUTCOMES

e Smoking
e Malnutrition The client will demonstrate an increased tolerance for
Allergens activity as evidenced by:
Insomnia
a. Verbalization of feeling less fatigued and weak
b. Ability to perform ADL without exertional dyspnea,
chest pain, diaphoresis, dizziness, and significant
changes in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance; endurance, fatigue level; vital signs Activity therapy; energy management; oxygen therapy;
nutrition management; sleep enhancement; teaching:
prescribed medication; teaching: prescribed treatment

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention.
° “Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping
activity, change from regular to irregular rate)
Significant change of 15 to 20 mm Hg in B/P with activity.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote rest and/or conserve energy Cells use oxygen and fat, protein, and carbohydrates to produce the
(e.g., Maintain prescribed activity restrictions, minimize energy needed for all body activities. Rest and activities that
environmental activity and noise, provide uninterrupted conserve energy result in a lower metabolic rate, which preserves
rest periods, assist with care, keep supplies and personal nutrients and oxygen for necessary activities. Performing daily
articles within easy reach, keep daily log of periods of tasks during high energy periods allows for effectiveness and
high and low energy; limit the number of visitors, use productivity while allowing for periods of needed rest.
shower chair when showering, sit to brush teeth or comb
hair). D@ +
Implement measures to promote sleep (e.g., elevate head of Sleep replenishes a client’s energy and feelings of well-being.
bed and support arms on pillows to facilitate breathing,
maintain oxygen therapy during sleep, discourage
intake of fluids high in caffeine in the evening, reduce
environmental stimuli). D+
Implement measures to decrease excessive coughing and Altered respiratory function such as excessive coughing can lead to
frequency of asthma attacks (e.g., protect client from inadequate tissue oxygenation, which results in less efficient
exposure to irritants such as smoke, flowers, and powder; energy production and a reduced ability to tolerate activity.
avoid extremely hot or cold foods/fluids). D @ + Improving respiratory status increases the amount of oxygen
available for energy production.
Discourage smoking and excessive intake of beverages high in Excessive intake of nicotine and caffeine can increase cardiac
caffeine such as coffee, tea, and colas. workload and myocardial oxygen utilization, thereby decreasing
oxygen availability.
Perform actions to improve respiratory status (e.g., place Improvement of respiratory status is done to relieve dyspnea,
client in semi- to high-Fowler’s position; instruct client decrease frequency of asthma attacks, and improve tissue
to deep breathe or use incentive spirometry every | to oxygenation.
2 hrs; maintain bedrest as ordered; and use oxygen as
needed). D
Perform actions to maintain adequate nutritional status Adequate nutritional status is important in order to maintain ADL.
(e.g., increase activity as tolerated potentially improving
appetite; encourage a rest period before meals to reduce
fatigue; assist with oral hygiene before meals; maintain
a clean environment and a relaxed, pleasant atmosphere).
De

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 120 Chapter5 = The Client With Alterations in Respiratory Function

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THERAPEUTIC INTERVENTIONS RATIONALE

Instruct a client to: Changes in a client’s activity tolerance should be reported
e Report a change in the frequency and consistency of immediately. Assessment of the change will allow for timely
asthma attacks. diagnosis of the cause and subsequent treatment.
e Report a decreased tolerance for activity.
e Stop any activity that causes increased chest pain,
increased shortness of breath, dizziness, or extreme fatigue
or weakness.

Dependent/Collaborative Actions
Consult appropriate health care providers (e.g., respiratory Notifying the appropriate health care provider allows for modifica-
therapist, physician, dietitian) if signs and symptoms of tion of the treatment plan.
activity intolerance persist or worsen.

DISCHARGE TEACHING/CONTINUED CARE

| Nursing Diagnosis DEFICIENT KNOWLEDGE np; INEFFECTIVE HEALTH

MAINTENANCE nox; OR INEFFECTIVE HEALTH
MANAGEMENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain well-being;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; verbalizes Increased frequency and intensity of asthma attacks
inability to follow prescribed regimen

RISK FACTORS DESIRED OUTCOMES

e Cognitive deficit
e Financial concerns
The client will demonstrate an appropriate level of
e Smoking knowledge to maintain well-being as evidenced by:
a. Correctly stating the signs and symptoms to report to
e Inability to care for oneself
e Difficulty in modifying personal habits and integrating the health care provider
b. Ability to perform activities of daily living (ADL)
treatments into lifestyle
without exertional dyspnea, chest pain, diaphoresis,
dizziness, and significant changes in vital signs

NURSING ASSESSMENT RATIONALE

Assess client readiness and ability to learn Early recognition of client’s readiness to learn and meaning of their
Assess meaning of illness to client illness allows for implementation of the appropriate teaching
interventions.

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; energy conservation; Health system guidance; teaching: individual; teaching:
treatment procedure(s); health resources; adherence disease process; teaching: prescribed activity/exercise;
behavior; health beliefs teaching: prescribed medication; self-modification assistance;
values Clarification; medication management; smoking
cessation assistance
 Chapter 5 = The Client With Alterations in Respiratory Function 121

THERAPEUTIC INTERVENTIONS RATIONALE

a eee eee eee

Independent Actions
Instruct client in ways to maintain respiratory health:
e Maintain overall general good health (e.g., reduce stress, Good general health supports the individual’s ability to fight off
eat a well-balanced diet, obtain adequate rest). infection.
e Stop smoking. The irritants in smoke and respiratory irritants increase mucus
e Avoid exposure to respiratory irritants such as smoke, dust, production, impair ciliary function, and can cause inflamma-
aerosol sprays, paint fumes, and solvents; wear a mask or tion and damage to the bronchial and alveolar walls.
scarf over nose and mouth if exposure to high levels of
these irritants is unavoidable.
e Remain indoors as much as possible when air pollution Air pollution in high levels is harmful to persons with existing lung
levels are high. disease.
e Avoid extremes in hot and cold weather. Exposure to extreme hot and cold air may cause bronchoconstric-
tion, allowing less air into and out of the lungs.
e Avoid prolonged close contact with persons who have Increases a client’s potential for a respiratory infection
respiratory infection.
e Receive immunizations against influenza and pneumococcal Immunizations help prevent further respiratory disease.
~pneumonia.
Have client keep a log/diary of the frequency, duration, and Changes in the incidence of asthma attacks should be reported
intensity of asthma attacks, and morning peak flow rates. to the client’s health care provider because they may indicate
a change in the disease process, effectiveness of medications,
and/or a concurrent illness.
Include significant others in explanations and teaching Involvement of the client’s significant others contributes to
sessions and encourage their support. adherence to the treatment regimen.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Educate the patient about the disease process and treatment
of asthma:
e Explain asthma in terms the client can understand; stress Understanding of the disease and its treatment plan provides
that adherence to the treatment plan is necessary in order patients with a sense of control, and they will be more likely to
to prevent complications and reactivation of the disease. comply with the treatment regimen.
e Explain that asthma can be treated, but only if the client
adheres to the prescribed medication regimen.
e Provide written instructions about and encourage client to Written instructions allow the client to refer to them as needed.
participate in the treatment plan. The instructions should include all information needed to
e Provide client with written instructions about disease pro- understand disease processes and treatment.
cess, signs and symptoms to report, medication therapy,
and follow-up appointments.
Explain the rationale for side effects of drugs, food and drug Knowledge of medications and how they impact the system
interactions, the importance of taking medications as improves client adherence and helps enhance the client’s under-
prescribed, and drugs to manage side effects. standing of the importance of adhering to the prescribed medi-
cation regimen. The client must be able to recognize alterations
in functioning related to medication administration.
Examples of asthma medications: Corticosteroids suppress inflammation and the normal immune pro-
e Corticosteroids cess. Mast cell stabilizers decrease the frequency and intensity of
e Mast cell stabilizers allergic reactions. Anticholinergics provide adjunctive management
e Anticholinergics of bronchospasms caused by asthma. IgE antagonists prevent the
e IgE antagonists release ofmediators of the allergic response. Leukotriene modifiers
e Leukotriene modifiers decrease the inflammatory process.
e Betaz-Adrenergic agonists Beta blockers can promote bronchodilation and reduce airway inflam-
e Methylxanthines mation that improves asthma control and improve symptoms.
Methylxanthines promote bronchodilation through relaxing the
airways.
Assist client to develop a method to promote adherence to Knowledge of the medication regimen and the impact of these
the medication schedule. medications on the body, as well as how the medication
e Assist client to identify ways the medication regimen can regimen can be incorporated into the client’s lifestyle, allows the
be incorporated into the client's lifestyle. client some mechanism of control of his/her disease and the
ability to have an active part in treatment and care.

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 122 ChapterS * The Client With Alterations in Respiratory Function

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THERAPEUTIC INTERVENTIONS RATIONALE

Instruct client to take all medications as often as prescribed Consistent use of medication(s) is important in preventing asthma
and avoid skipping doses or altering the prescribed dose; attacks.
if a dose is missed, instruct client to take it as soon as
remembered unless it is almost time for the next dose of
the same medication.
Teach the client how to use the different types of inhalers. Medication is not delivered to the lungs and remains in the
oral pharynx when inhalers are used incorrectly, leading to
infections in the oral pharynx.
Reinforce the need to consult physician before discontinuing This is important to prevent exacerbations in asthma attacks.
any medication or taking additional prescription and
nonprescription medications.
Provide information about and encourage utilization of Provides for continuum of care and can help improve client
community resources and social services that can assist adherence with the medication regimen and possibly financial
client to comply with the medication regimen or to assistance for medications.
provide financial support if needed (e.g., local Department
of Health and Human Services, local chapter of the
American Lung Association, support groups).

THERAPEUTIC INTERVENTIONS RATIONALE

Nr

Independent Actions
Instruct client to report the following to the health care provider: These clinical manifestations indicate an infection or super
° Persistent or recurrent loss of appetite, nausea, weakness, infection and should be reported to the health care provider.
fatigue, or weight loss
° Fever, chills, continued or increased night sweats
° Difficulty in breathing, continued or increased cough, or
chest pain
e Unusual color, amount, and odor of vaginal secretions;
white patches or ulcerated areas in mouth; stiff neck and
headache; hoarseness; persistent sore throat; bone pain;
swollen, red, painful joints; swollen lymph nodes
e Signs and symptoms of adverse effects of medications

THERAPEUTIC INTERVENTIONS RATIONALE

The client in collaboration with the nurse will develop a plan
for adhering to recommended follow-up care, including
future appointments with health care providers and graded
exercise programs.

Independent Actions
Reinforce the importance of keeping appointments for Regular health care appointments are important to determine
follow-up tests (e.g., blood work, chest radiographs) and effectiveness of the medication regimen and assess for side
physical examinations to determine effectiveness of the effects.
medication regimen and assess for side effects.

ADDITIONAL NURSING DIAGNOSES

DISTURBED SLEEP PATTERN NDx
Related to fear, anxiety, unfamiliar environment, excessive cough- to meet self-care needs; and alterations in roles, lifestyle, and
ing, frequent assessments and treatments, side effects of medica- future plans
tions (e.g., some bronchodilators, corticosteroids), and inability to
assume usual sleep position associated with orthopnea FEAR NDx AND ANXIETY NDx
Related to fear associated with difficulty breathing, fear
RISK FOR POWERLESSNESS NDx of death during an asthma attack, potential changes in
Related to physical limitations; disease progression despite lifestyle
efforts to comply with treatment plan; dependence on others
 Chapters" The Client With Alterations in Respiratory Function 123

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is an inflam- clients receiving follow-up care in an extended care
matory lung disease characterized by the presence of airflow facility or home setting.
obstruction in the lungs. The airflow obstruction is chronic,
usually progressive, and may be accompanied by airway
OUTCOME/DISCHARGE CRITERIA
hyperactivity. Other terms sometimes used to describe this
condition are chronic obstructive lung disease (COLD) and The client will:
chronic airflow limitation (CAL). Signs and symptoms usually 1. Have improved respiratory function
include dyspnea, cough, and sputum production that worsen 2. Tolerate expected level of activity
over time and during periodic exacerbations. 3. Have no signs and symptoms of complications
The two most common conditions that contribute to COPD 4. Identify ways to prevent or minimize further respiratory
are chronic bronchitis and emphysema. Chronic bronchitis is problems
characterized by a cough that persists at least 3 months of the . Verbalize ways to maintain an optimal nutritional status
year for 2 consecutive years and an excessive production of NN. Identify ways to conserve energy and/or reduce dyspnea
mucus in the bronchi due to inflammation of the bronchioles and fatigue
and hypertrophy and hyperplasia of the mucous glands. In 7. Demonstrate proper chest physiotherapy and use of
contrast, emphysema is characterized by dyspnea and a mild respiratory equipment
cough. The impaired airflow that occurs with emphysema is 8. Verbalize an understanding of medications ordered, includ-
related to loss of lung elasticity, narrowing of the terminal non- ing rationale, food and drug interactions, side effects, meth-
respiratory bronchioles, and destructive changes in the walls of ods of administering, and importance of taking as prescribed
the alveolar and/or respiratory bronchioles. Both chronic bron- 9. Identify precautions that should be adhered to when
chitis and emphysema are usually present in the person with using oxygen
COPD, although one of the two usually predominates. 10. State signs and symptoms to report to the health care
Causative factors of COPD include chronic irritation of the provider
lungs by cigarette smoke, exposure to air pollution and 11. Share feelings and thoughts about the effects of COPD on
chemical irritants, and recurrent respiratory tract infections. lifestyle and roles
In a small percentage of cases of emphysema, the destruction 12. Identify resources that can assist with financial needs,
of lung tissue by proteolytic enzymes is a result of a genetic home management, and adjustment to changes resulting
deficiency of alphal-antitrypsin. from COPD
This care plan focuses on care of the adult client 13. Develop a plan for adhering to recommended follow-up
with COPD who is hospitalized during an acute exac- care, including future appointments with health care
erbation. Much of the information is applicable to provider and graded exercise program.

Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION* —

Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation,
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.

Related to:
Ineffective breathing pattern NDx
Related to:
e Increased rate of respirations associated with fear and anxiety
diaphragm
e Decreased depth of respirations associated with weakness, fatigue, fear, anxiety, and presence of a flattened
(a result of prolonged hyperinflation of the lungs)

Ineffective airway clearance NDx

Related to:
e Narrowing of the airways associated with:
chronic bronchitis)
e Excessive mucus production and inflammation and hyperplasia of the bronchial walls (especially with
° Destruction of the elastic fibers in the walls of the small airways (with emphysema)
e Stasis of secretions associated with:
of tenacious secretions if fluid intake is
e Difficulty coughing up secretions resulting from fatigue, weakness, and presence
inadequate
(occurs with inflammation, destruction, and fibrosis
e Impaired ciliary function resulting from loss of ciliated epithelium
of bronchial walls)
e Decreased mobility

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NDx = NANDA Diagnosis
 124 ChapterS = The Client With Alterations in Respiratory Function

Impaired gas exchange NDx

Related to:
e Narrowing or obstruction of the small airways
° A decrease in effective lung surface (occurs as a result of collapse or destruction of alveolar walls)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of confusion; disorientation; restlessness; Rapid, shallow respirations; abnormal breath sounds;
irritability; somnolence; chest tightness chronic cough; use of accessory muscles when breathing;
increased anterior-posterior diameter; dyspnea; nasal
flaring; central cyanosis (late sign); decreased expiratory
and inspiratory pressure; decreased minute ventilation
and vital capacity; significant decrease in oximetry results;
abnormal arterial blood gas values; reduced activity
tolerance

RISK FACTORS DESIRED OUTCOMES

e Smoking
The client will maintain adequate respiratory function as
e Obstruction of airways
evidenced by:
° Excessive mucous production
Usual rate and depth of respiration
e Impaired ciliary function
Decreased dyspnea
e Occupational dust and chemicals
Usual or improved breath sounds
° Alpha,-Antitrypsin deficiency
Usual mental status
Oximetry results within normal range for client
moands
Arterial blood gas values within the normal range for
client

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: airway patency; ventilation; Respiratory monitoring; airway management; chest
gas exchange physiotherapy; cough enhancement; oxygen therapy;
medication administration; ventilation assistance; fear and
anxiety reduction

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired respiratory Early recognition of signs and symptoms of ineffective breathing
function: patterns allows for prompt intervention.
° Rapid, shallow respirations Rapid, shallow respirations do not provide adequate ventilatory
e Dyspnea, orthopnea support. Difficulty with breathing and the need to sit up to
° Use of accessory muscles when breathing breathe, as well as use of accessory muscles, lead to client
fatigue and further decline in respiratory status.
e Abnormal breath sounds (e.g., diminished or absent, Changes in the characteristics of breath sounds may be due to
rhonchi, wheezes) airway obstruction, mucus plugs, or retained secretions in larger
airways.
e Cough effectiveness Muscle fatigue/weakness may impair effective clearance of secretions.
° Restlessness, irritability Restlessness, irritability, and change in mental status of level
e Confusion, somnolence of consciousness indicate an oxygen deficiency and require
immediate treatment.
° Central cyanosis (a late sign) The bluish discoloration ofthe skin and mucous membranes occurs
in the presence deoxygenated hemoglobin (Hgb). This occurs
when arterial oxygen saturation falls below 85% to 90%.
Assess arterial blood gas and pulse oximetry values and report Oximetry is a noninvasive method of measuring arterial oxygen
abnormal findings. saturation. The results assist in evaluating respiratory status.
Decreasing PaO and increasing CO> are indicators of respira-
tory problems.
 ChapterS * The Client With Alterations in Respiratory Function 125

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve respiratory status:
° Reduce fear and anxiety. Fear and anxiety can lead to shallow, rapid breathing.
° Maintain supportive environment. The client’s anxiety may increase if left alone during periods of
° Don’t leave client during periods of acute respiratory respiratory distress.
distress. Decreases client’s feelings of being in an enclosed area, which can
e Open curtains and doors. increase anxiety.
Place client in a semi-Fowler’s position, and position overbed Positioning in semi-Fowler’s position promotes optimal gas
table so client can lean on it if desired. D@ + exchange by enabling chest expansion. Leaning on the overbed
table decreases dyspnea through pressure on the gastric contents
and diaphragmatic contraction.
e Instruct client in and assist with diaphragmatic and These techniques help clients slow their pace of breathing, which
pursed-lip breathing techniques. makes each breath more effective.
e Instruct client to deep breathe or use incentive spirometer Forced deep breathing and use of incentive spirometry will increase
every 1 to 2 hrs. D + expansion of the lungs and improve the client’s ability to clear
mucus from the lungs. The technique may also improve
the amount of oxygen that is able to penetrate deep into the
lungs.
e Maintain client’s fluid intake of at least 2500 mL/day Increased fluid intake promotes thinning of secretions and reduces
unless contraindicated. D+ dryness of the respiratory mucous membranes.
e Perform suctioning if needed. D+ Suctioning removes secretions from the large airways. It also
stimulates coughing, which helps clear airways of mucus and
foreign matter.
e Instruct client to avoid intake of large meals, gas-forming Gas-forming foods and carbonated beverages can cause abdominal
foods (i.e., cauliflower, beans, cabbage, onions, etc.), and bloating, which places pressure on the diaphragm and reduces
carbonated beverages. lung expansion.
e Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause inflammation and damage to the
bronchial and alveolar walls; carbon monoxide decreases
oxygen availability.
Maintain activity restrictions and increase activity as allowed Conservation of energy through activity restrictions allows energy
and tolerated. D@ + to be focused on breathing. Increasing activity as tolerated helps
to mobilize secretions and promotes deeper breathing.

Dependent/Collaborative Actions
Implement measures to improve respiratory status:
e Assist with administration of mucolytics and diluent or ° Mucolytics and diluent or hydrating agents help liquefy
hydrating agents via nebulizer if ordered. D + secretions for more effective removal.
e Avoid use of central nervous system (CNS) depressants. ° CNS depressants further depress respiratory status, exacerbating
D+ the client’s condition.
° Administer and monitor oxygen as ordered. D+ ° Oxygen should be administered at low doses. Question orders
for high concentration, since many persons with COPD are
depending on hypoxemia as a stimulus to breathe.
e Administer the following medications if ordered: Bronchodilators relax smooth muscles of the airway, thus
e Bronchodilators improving air exchange in the lungs. Corticosteroids decrease
e Corticosteroids airway inflammation and thereby improve bronchial airflow.
e Antimicrobials Antimicrobials may be given to prevent or treat pneumonia.
e Alpha,-Proteinase inhibitor Administration of alpha,-proteinase inhibitor may be required
if the cause of emphysema is a genetic deficiency of alpha,-
antitrypsin.
Consult appropriate health care providers (respiratory thera- Notifying the appropriate health care professionals allows for a
pist and physician) if signs and symptoms of impaired multidisciplinary approach to treatment.
respiratory function persist or worsen.

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 126 Chapter5 = The Client With Alterations in Respiratory Function

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with:
e Dyspnea, weakness, and fatigue
e Nausea (can occur in response to noxious stimuli such as the sight of expectorated sputum and as a side effect of some
medications)
° Early satiety resulting from compression of the stomach by flattened diaphragm
e Increased metabolic needs associated with increased energy expenditure resulting from strenuous breathing efforts and
persistent coughing

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of aversion to food; alteration in taste Weight loss; weight less than normal for client’s age,
sensation height, and body frame; abnormal blood urea nitrogen
(BUN) and low serum prealbumin levels; inflamed mucous
membranes; pale conjunctiva; excessive hair loss; poor
muscle tone

RISK FACTORS DESIRED OUTCOMES

e Lack of appetite
The client will maintain adequate nutrition status as
e Shortness of breath causing difficulty with eating
evidenced by:
e Poor diet
a. Weight within normal range for client
e Lack of resources
b. Normal BUN and serum prealbumin and albumin levels
c. Usual strength and activity tolerance
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

eo
ESSE
Nutritional status Nutritional monitoring; nutrition management; nutrition
therapy

NURSING ASSESSMENT RATIONALE

Eee
Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
°¢ Weight significantly below a client’s usual weight or less prompt intervention.
than normal for client’s age, height, and body frame Inadequate nutritional intake may be exhibited by significant
e Abnormal BUN and low serum prealbumin and albumin weight loss or a weight that is less than normal for a client’s
levels age, height, and body frame. If a significant amount of weight
e Increased weakness and fatigue loss occurs in a short period of time, this may be an indication
e Sore, inflamed oral mucous membranes of another disease process occurring.
e Pale conjunctiva

‘
THERAPEUTIC INTERVENTIONS
RATIONALE
SS
eee
Independent Actions
Monitor percentage of meals and snacks client consumes. Monitoring a client's intake helps to identify when a patient is at
Report a pattern of inadequate intake. D + risk for inadequate nutrition.
Implement measures to maintain an adequate nutritional status:
e Perform actions to improve oral intake.
e Implement measures to improve respiratory status. Interventions that relieve dyspnea allow the patient to eat a meal
without interruption or need to rest.
e Schedule treatments that assist in mobilizing mucus Appropriate scheduling of treatments assists in decreasing nausea.
(e.g., aerosol treatments, postural drainage therapy) at
least 1 hr before or after meals.
 Chapter on The Client With Alterations in Respiratory Function 127

»
-

THERAPEUTIC INTERVENTIONS RATIONALE

e Increase activity as allowed and tolerated. D> Activity usually promotes a sense of well-being and can help
improve an individual’s appetite.
e Encourage a rest period before meals. D @ > Rest before a meal helps to minimize fatigue during a meal.
e Eliminate noxious sights and odors from the environ- Noxious sites and odors can inhibit the feeding center in the
ment; provide client with an opaque, covered container hypothalamus. By eliminating them, the client’s intake may
for expectorated sputum. D @ + improve.
e Maintain a clean environment and a relaxed, pleasant An aesthetic pleasing and relaxed environment may help improve
atmosphere. D@ + clients’ intake.
e Provide oral hygiene before meals. D@ + Oral hygiene moistens the mouth, which makes it easier to chew
and swallow; it also removes unpleasant tastes, which often
improves the taste of foods and fluids.
e Assist the client who is dyspneic in selecting foods that Because a person cannot swallow and breathe at the same time,
require little or no chewing. relief of dyspnea increases the likelihood of maintaining a good
oral intake. Foods that require little or no chewing are easier to
eat and help maintain a client’s nutritional status.
e Serve frequent, small meals rather than large ones if Providing small rather than large meals can enable a client who is
. Client is weak, fatigues easily, or has a poor appetite. weak or fatigues easily to finish a meal. Also, a client who has
D+ a poor appetite is often more willing to attempt to eat smaller
meals because they seem less overwhelming than larger ones. If
smaller meals are served, the number of meals per day should
be increased to help ensure adequate nutrition.
e Place client in a high-Fowler’s position for meals. D@ + Because a person cannot swallow and breathe at the same time,
relief of dyspnea increases the likelihood of maintaining a good
oral intake.
e Allow adequate time for meals; reheat foods/fluids if Clients who feel rushed during meals tend to become anxious, lose
necessary. D@® their appetite, and stop eating. Appetite is also suppressed if
foods/fluids normally served hot or warm become cold and
do not appeal to the client.
e Limit fluid intake with meals (unless the fluid has high When the stomach becomes distended, its volume receptors
nutritional value). D+ stimulate the satiety center in the hypothalamus and clients
reduce their oral intake. Drinking liquids with meals distends
the stomach and may cause satiety before an adequate amount
of food is consumed.
e Ensure that meals are well balanced and high in essential Clients must consume a diet that is well balanced and high in
nutrients; offer dietary supplements if indicated. essential nutrients in order to meet their nutritional needs.
Dietary supplements are often needed to help accomplish this.

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional
status:
e Perform actions to improve oral intake:
e Provide supplemental oxygen during meals. D + Supplemental oxygen therapy relieves dyspnea and the client's
anxiety about and preoccupation with breathing efforts and
increases the ability to focus on eating and drinking.
e Obtain a dietary consult to assist the client in selecting Notifying the appropriate health care professionals allows for a
foods/fluids that meet nutritional needs, are appealing, multidisciplinary approach to treatment.
and adhere to personal and cultural preferences.
e Administer vitamins and minerals if ordered. D + Administration of vitamins and minerals helps maintain
nutritional status.
Perform a calorie count if ordered. Report information to A calorie count provides information about the caloric and
dietitian and physician. nutritional value of the foods/fluids the client consumes. The
information obtained helps the dietitian and_ physician
determine whether an alternative method of nutritional support
is needed.
Consult physician about an alternative method of providing If the client’s oral intake is inadequate, an alternative method of
providing nutrients needs to be implemented.
nutrition (e.g., parenteral nutrition, tube feedings) if
client does not consume enough food or fluids to meet
nutritional needs.

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 128 ChapterS = The Client With Alterations in Respiratory Function

|Nursing ~Diagnosis ACTIVITY INTOLERANCE nox

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Related to:
° Tissue hypoxia associated with impaired gas exchange
° Inadequate nutrition status
° Difficulty resting and sleeping associated with dyspnea, excessive coughing, fear, anxiety, frequent assessment and treat-
ments, and side effects of medication therapy (e.g., some bronchodilators, corticosteroids)
° Increased energy expenditure associated with strenuous breathing efforts and persistent coughing

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue or weakness Abnormal heart rate or B/P response to activity; exertional
discomfort or dyspnea; electrocardiographic changes
reflecting dysrhythmias or ischemia; unable to speak
with physical activity

RISK FACTORS DESIRED OUTCOMES

° Exertional dyspnea
° Dyspnea during rest and sleep The client will demonstrate an increased tolerance for
e Anxiety and fear activity as evidenced by:
° Increased energy expenditure—coughing and breathing
a. Verbalization of feeling less fatigued and weak
efforts b. Ability to perform activities of daily living without
exertional dyspnea, chest pain, diaphoresis, dizziness,
and significant changes in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance; endurance; fatigue level; vital signs; Activity therapy; energy management; oxygen therapy;
self-care: activities of daily living; energy conservation nutrition management; sleep enhancement; cardiac care;
cardiac rehabilitation; teaching prescribed exercise

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention and treatment.
° Exertional dyspnea, chest pain, diaphoresis, or dizziness
° Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping activ-
ity, change from regular to irregular rate)
° Significant change of 15 to 20 mm Hg in B/P with activity.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote rest and/or conserve energy Cells use oxygen and fat, protein, and carbohydrates to produce the
(e.g., maintain prescribed activity restrictions, minimize energy needed for all body activities. Rest and activities that
environmental activity and noise, provide uninterrupted conserve energy result in a lower metabolic rate, which preserves
rest periods, assist with care, keep supplies and personal nutrients and oxygen for necessary activities.
articles within easy reach, limit the number of visitors, use
shower chair when showering, sit to brush teeth or comb
hair). D @ +
Implement measures to promote sleep (e.g., elevated head of Sleep replenishes a client’s energy and feeling of well-being.
bed and support arms on pillows to facilitate breathing,
discourage intake of fluids high in caffeine in the evening,
and reduce environmental stimuli). D
 Chapter 5 = The Client With Alterations in Respiratory Function 129

wn

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to decrease excessive coughing (e.g., Altered respiratory function such as excessive coughing can lead to
protect client from exposure to irritants such as smoke, inadequate tissue oxygenation, which results in less efficient
flowers, and powder; avoid extremely hot or cold foods/ energy production and a reduced ability to tolerate activity.
fluids). D@ > Improving respiratory status increases the amount of oxygen
available for energy production.
Discourage smoking and excessive intake of beverages high in Excessive intake of nicotine and caffeine can increase cardiac
caffeine such as coffee, tea, and colas. workload and myocardial oxygen utilization, thereby decreasing
oxygen availability.
Perform actions to improve respiratory status (e.g., place Improvement of respiratory status through increased lung expansion.
client in semi- to high-Fowler’s position; assist client to
deep breathe or use incentive spirometry every 1 to
2 hrs; maintain bedrest as ordered; and use oxygen as
needed). D @ >
Perform actions to maintain adequate nutritional status (e.g., Adequate nutritional status is important in order to maintain ADL.
increase activity as tolerated, potentially improving
appetite; encourage a rest period before meals to reduce
_ fatigue; assist with oral hygiene before meals; maintain a
clean environment and a relaxed pleasant atmosphere).
D+
Increase client’s activity gradually as allowed and tolerated. Gradual increase will slowly improve strength and ability in
D+ performance of activities.
Instruct a client to:
e Report a decreased tolerance for activity. Changes in a client’s activity tolerance should be reported immedi-
e Stop any activity that causes increased chest pain, ately. Assessment of the change will allow for timely diagnosis
increased shortness of breath, dizziness, or extreme fatigue of the cause and subsequent treatment.
or weakness.

Dependent/Collaborative Actions
Consult appropriate health care providers (e.g., respiratory Notifying the appropriate health care provider allows for modifica-
therapist, physician, dietitian) if signs and symptoms of tion of the treatment plan.
activity intolerance persist or worsen,

Nursing Diagnosis RISK FOR INFECTION nox (PNEUMONIA)

Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
e Stasis of secretions in the lungs (secretions provide a good medium for bacterial growth)
° Inhalation of pathogens (especially if client is using respiratory equipment or medication delivery devices that are not being
cleaned adequately or routinely)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pleuritic pain Increased respiratory rate; dyspnea; abnormal breath
sounds (crackles, rales); productive cough with purulent
green or rust-colored sputum; chills and diaphoresis;
fever; elevated white blood cell (WBC) count; significant
decrease in pulse oximetry values; worsening arterial
blood gas values

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 130 Chapter 5 = The Client With Alterations in Respiratory Function

RISK FACTORS DESIRED OUTCOMES

e Stasis of secretions
The client will not develop pneumonia as evidenced by:
e Inhalation of pathogens
Usual breath sounds and percussion note over lungs
e Debilitated state
e Smoking
Absence of tachypnea
Cough productive of clear mucus only
Afebrile status
WBC count within normal range
Arterial blood gas values within normal range for client
Negative sputum culture
2
Bee
Pore
. Ability to perform ADL without increased dyspnea,
chest pain, diaphoresis, dizziness, and a significant
change in vital signs

NOC OUTCOMES NIC INTERVENTIONS

oS
Infection severity; immune status Infection protection; infection control; cough enhancement;
airway management

NURSING ASSESSMENT
RATIONALE
———
eee
Assess for and report signs and symptoms of pneumonia: Early recognition of signs and symptoms of pneumonia allows for
e Abnormal breath sounds (e.g., crackles [rales], pleural friction prompt intervention.
rub, bronchial breath sounds, diminished or absent breath
sounds)
e Dull percussion note over the affected lung area
e Increase in respiratory rate
° Cough productive of purulent, green, or rust-colored sputum
e Chills and fever
e Pleuritic pain
e Elevated WBC count
° Significant decrease in oximetry results
e Worsening of arterial blood gas values
e Positive sputum culture results
° Chest radiograph results indicative of pneumonia

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent pneumonia: Positioning the client in semi- to high-Fowler’s position promotes
e Perform actions to improve respiratory status (e.g., place optimal gas exchange by enabling chest expansion. Forced
client in semi- to high-Fowler’s position; assist client to deep deep breathing and use of incentive spirometry will increase
breathe or use incentive spirometer every 1 to 2 hrs; im- expansion of the lungs and improve the client’s ability to clear
prove activity tolerance; maintain fluid intake of at least mucus from the lungs. Maintaining fluid intake will help
2500 mL/day unless contraindicated). D liquefy secretions for expectoration.
° Protect client from persons with respiratory tract infections. The potential for illness is decreased through avoidance of persons with
D+ respiratory infections and crowds during the cold and flu season.
° Encourage and assist client to perform frequent oral Frequent oral hygiene helps to decrease the rate of infection through
hygiene. D® + removal of pathogens and secretions that could be aspirated.
° Replace or cleanse equipment used for respiratory care as Equipment that is inadequately or incompletely cleaned tfter use
often as needed. harbors bacteria may lead to a respiratory infection.
e Instruct and assist client to rinse and clean medication Inhaled medication devices only deliver a certain percentage of
delivery the
devices (e.g., dry powder inhaler, metered-dose medication to the lungs. The rest of the medication is deposited
inhaler, spacer) according to manufacturer’s instructions. in the oropharynx, which with some medications, increases the
risk for infection, dysphonia, and/or candidiasis.

Dependent/Collaborative Actions
If signs and symptoms of pneumonia occur, administer Early administration of antibiotics at the first sign of infectio
n can
antimicrobials as ordered. D+ decrease the impact and duration of the infection.
Consult other health care providers at the first signs and Notifying the appropriate health care provider allows for
modifica-
symptoms of an infection. tion of the treatment plan.
 Chapter s= The Client With Alterations in Respiratory Function 131

Collaborative Diagnosis
Diagnosis |RISK FOR RIGHT-SIDED HEART FAILURE
Definition: A condition where the right side of the heart is unable to pump blood efficiently to meet the body’s requirements.

Related to:
e Increased cardiac workload associated with:
e Pulmonary hypertension (can result from pulmonary vasoconstriction that occurs in response to hypoxia and the release
of vasoactive substances)
° Compensatory response to decreased pulmonary blood flow that results from compression of the pulmonary capillaries
by hyperinflated alveoli (with emphysema) and loss of large portions of the pulmonary vascular bed (occurs in emphy-
sema as a result of destruction of the alveolar walls)

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of weakness and fatigue Tachypnea; tachycardia; dyspnea; restlessness; confusion;
irritability; peripheral edema; decreased urine output;
distended neck veins

RISK FACTORS DESIRED OUTCOMES

e Hypertension The client will not develop right-sided heart failure as
e Chronic respiratory disease evidenced by:
e Smoking . Pulse rate of 60 to 100 beats/min
e Obesity . Usual mental status
. Usual strength and activity tolerance
. Adequate urine output
. Stable weight
® . Absence of edema and distended neck veins
dd
moan

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of right-sided heart Early recognition of signs and symptoms of right-sided heart failure
failure: allows for prompt intervention.
e Further increase in pulse rate
e Restlessness, confusion
e Weakness and fatigue
e Decreased urine output
e Weight gain
e Dependent peripheral edema
e Distended neck veins
° Chest radiograph results showing cardiomegaly

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve respiratory status (e.g., These interventions will reduce cardiac workload and the subse-
cough and deep breathe every 2-3 hrs, ambulate as tolerated, quent risk of right-sided heart failure by decreasing the pressure
maintain fluid restriction). against which the heart must pump.
If signs and symptoms of right-sided heart failure occur
e Maintain oxygen therapy as ordered. Supplemental O helps relieve dyspnea and improves gas exchange.
Maintain client on strict bedrest in a semi-Fowler’s to Placing the client on strict bedrest will help conserve energy during
high-Fowler’s position. periods of acute respiratory distress. Positioning the client in a
semi- to high-Fowler’s position promotes optimal gas exchange
by enabling chest expansion.
e Maintain fluid and sodium restrictions if ordered Restricting a client’s sodium and fluid intake will help reduce fluid
volume overload.

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 132 Chapter 5 = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

* Administer medications that may reduce vascular conges- Diuretics decrease fluid volume through inhibiting reabsorption
tion and/or cardiac workload (e.g., diuretics, cardiotonics, of water, which decreases fluid volume.
vasodilators). Cardiotonics increase the contractile force of the heart, which
increases cardiac output.
Vasodilators dilate the arterioles, which decreases B/P and
decreases the work of the heart.

|Nursing Diagnosis
Diagnosis FEAR nDx/ANXIETY nox
Definition: Fear NDx: Response to perceived threat that is consciously recognized as a danger.
Anxiety NDx: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response
(the source is
often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation
of danger. It is
an alerting sign that warns of impending danger and enables the individual to take measures to deal
with that threat.
Related to:
° Exacerbation of symptoms (e.g., increased dyspnea, feeling of suffocation), need for
hospitalization, and concern about
prognosis
° Lack of understahding of the diagnosis, diagnostic tests, treatments, and prognosis
° Financial concerns about hospitalization and lifelong treatment
° Feeling of lack of control over the progression of COPD and its effects on lifestyle and
roles
CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of anxiety and fear Unusual sleep patterns; relaxed facial expressions and
body movements; stable vital signs; restlessness; shakiness;
diaphoresis; self-focused behavior

RISK FACTORS DESIRED OUTCOMES

° Shortness of breath
° Feelings of suffocation The client will experience a reduction in fear and anxiety
e Fear of dying as evidenced by:
a. Verbalization of feeling less anxious
. Usual sleep pattern
. Relaxed facial expression and body movements
. Stable vital signs
Ss . Usual perceptual ability and interactions with others
Cain

NOC OUTCOMES NIC INTERVENTIONS

Anxiety level; fear level; anxiety self-control; fear self-control Anxiety reduction; calming technique; emotional support
;
presence; pain management

NURSING ASSESSMENT RATIONALE

Assess client for signs dnd symptoms of fear and anxiety (e.g., Moderate anxiety enhances the client’s ability to solve problem
verbalization of feeling anxious, insomnia, tenseness, shak- s.
With severe anxiety or panic, the client is not able to
iness, restlessness, diaphoresis, elevated B/P, tachycardia, follow directions and may become hyperactive and extreme
self-focused behaviors). ly
agitated.
Validate perceptions carefully, remembering that some behav- Assessment of the client’s fear helps determine whether
ior may result from hypoxia and/or hypercapnia. the coping
mechanisms are effective and which need to be strengt
hened.
 Chapteriomer The Client With Alterations in Respiratory Function 133

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety:
e Orient client to hospital environment, equipment, and Familiarity with the environment and usual routines reduces the
routines. D® + client’s anxiety about the unknown, provides a sense of security,
and increases the client’s sense of control, all of which help
decrease anxiety.
° Introduce staff who will be participating in client’s care. Introduction to staff familiarizes clients with those individuals
If possible, maintain consistency in staff assigned to who will be working with them, which provides clients with a
client’s care. feeling of stability, which reduces the anxiety that typically
occurs with change.
e Assure client that staff members are nearby; respond to call Close contact and a prompt response to requests provide a sense of
signal as soon as possible. D@ + security and facilitate the development of trust, thus reducing
the client’s anxiety.
e Maintain a calm, supportive, confident manner when A sense of calmness and confidence conveys to the client that
interacting with client; encourage verbalization of fear and someone is in control of the situation, which helps reduce
anxiety. anxiety.
e- Reinforce physician’s explanations and clarify misconcep- Factual information and an awareness of what to expect help
tions the client has about the disease process, treatment decrease the anxiety that arises from uncertainty.
plan, and possible recurrence; encourage questions.
Implement measures to reduce respiratory distress if present: Improvement of respiratory status helps relieve anxiety associated
e Elevate the head of the bed. with the feeling of not being able to breathe.
e Encourage the client to breathe deeply and more slowly.
De+
e Implement measures to reduce pain: Pain can create or increase anxiety because it is often perceived as
e Instruct client in relaxation techniques and encourage a threat to well-being.
participation in diversional activities once the period of Pain also causes sympathetic nervous system stimulation with
acute pain and respiratory distress has subsided. subsequent feelings of tenseness and increased anxiety.
e When appropriate, assist the client to meet spiritual needs Spiritual support is a source of comfort and security for many
(e.g., arrange for a visit from the clergy). people and can help reduce the client’s fear and anxiety.
e Provide information based on current needs of client at a Providing information that the client is not ready to process or
level that can be understood. cannot understand tends to increase anxiety.
e Encourage the client to ask questions and to seek clari- Making the client feel comfortable enough to ask questions or
fication of information provided. clarify information helps reduce anxiety.
e Provide a calm, restful environment. D ® + A calm, restful environment facilitates relaxation and promotes
a sense of security, which reduces fear and anxiety.
e Encourage significant others to project a caring, concerned Anxiety is easily transferable from one person to another.
attitude without obvious fear and anxiousness. If significant others convey empathy, provide reassurance, and
do not appear anxious, they can help reduce the client’s fear and
anxiety.

Dependent/Collaborative Actions
Implement measures to reduce fear and anxiety:
e Administer oxygen via nasal cannula rather than mask if The use of a mask for some clients seems restrictive and suffocat-
possible. D+ ing. The use of a nasal cannula is more comfortable and
less constraining. Improvement of respiratory status helps
relieve anxiety associated with the feeling of not being able
to breathe.
e Administer prescribed antianxiety agents if indicated. Decreases anxiety.
D+
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse clinician, physician) if the previously listed actions tion of the treatment plan.
fail to control fear and anxiety.

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 134 Chapter 5 = The Client With Alterations in Respiratory Function

|Nursing =.
Diagnosis |INEFFECTIVE HEALTH MANAGEMENT nox
Definition: Pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its
sequelae of illness that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness and/or Inaccurate follow-through with instructions; inappropriate
follow prescribed regimen behaviors; experience of preventable complications of
COPD; frequent exacerbation of illness

RISK FACTORS DESIRED OUTCOMES

e Cognitive impairment
e Insufficient resources
The client will demonstrate the probability of effective self-
health management as evidenced by:
° Feeling of lack of control over disease progression
a. Willingness to learn about and participate in treat-
e Difficulty modifying personal habits (e.g., smoking) and
ments and care
integrating necessary treatments into lifestyle b
. Statements reflecting ways to modify personal habits
and integrate treatments into lifestyle
c. Statements reflecting an understanding of the implica-
tions of not following the prescribed treatment plan

NOC OUTCOMES NIC INTERVENTIONS

eee ee
Adherence behavior; health beliefs; knowledge: treatment Self-modification assistance; values clarification; teaching:
regimen disease process; health system guidance; financial resource
assistance; medication management; smoking cessation
assistance

NURSING ASSESSMENT RATIONALE

ee
Assess Client’s knowledge base related to the disease process. The client’s knowledge base provides the basis for education.
Assess for indications that the client may be unable to Early recognition of inability to understand disease process or
effectively manage the therapeutic regimen: self-care allows for change in teaching modality.
° Statements reflecting inability to manage care at home
e Failure to adhere to treatment plan (e.g., refusing to use
proper breathing techniques, refusing medications)
e Statements reflecting a lack of understanding of factors
that may cause further progression of COPD
e Statements reflecting an unwillingness or inability to
modify personal habits and integrate necessary treatments
into lifestyle
e Statements reflecting view that the COPD is incurable or
that the situation is hopeless, and efforts to comply with
the treatment plan are useless

THERAPEUTIC INTERVENTIONS RATIONALE '

Eee
Independent Actions
Implement measures to promote effective therapeutic The client should understand that COPD is a chronic illness, and
regimen management: adherence to the treatment program is necessary in order to
e Explain COPD in terms the client can understand; stress delay and/or prevent complications; however, caution client
that COPD is a chronic condition, and adherence to the that some complications may occur despite strict adherence to
treatment program is necessary. treatment plan.
e Encourage questions and clarify misconceptions client has Everyone does not understand the information as presented.
about COPD and its effects. Questioning allows for clarification and for clients to put the
information within a context they understand.
 ChapterS * The Client With Alterations in Respiratory Function 135

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to participate in treatment plan (e.g., Client involvement in care helps reinforce the individual’s
postural drainage therapy, breathing exercises). understanding of lifestyle changes necessary to maintain health
status.
Consult occupational and/or physical therapist if indi- Involvement of a variety of individuals on the health care team
cated about a home evaluation to identify assistive devices allows for a multifaceted plan of care and discharge planning
and necessary environmental modifications. that assists clients to be more independent in their living
situation.
e Assist client to develop a system for recording frequency of Adherence to the medication regimen is required to improve and/or
use of medications and respiratory treatments in order to maintain the client’s health status. Working with the client
avoid omission of those that should be used routinely and to develop a system for monitoring the medication regimen
to avoid excessive use of those that should be used on improves the potential for adherence.
an “as needed” basis (in times of respiratory distress, the
client may tend to overuse medications because of fear,
anxiety, and impaired cognition).
e Provide client with written instructions about chest phys- Written instructions provide the client with information as a
iotherapy, ways to prevent further respiratory problems, reference to use as needed.
- prescribed medications, signs and symptoms to report,
where to obtain needed equipment and supplies, and
future appointments with health care provider.
e Assist client to identify ways treatments can be incorpo- To improve the potential for adherence to the treatment/medication
rated into lifestyle; focus on modifications of lifestyle rather regimen, the client must be actively involved in how/when and
than complete change (e.g., statements reflecting plans for what lifestyle modifications are implemented. An individual's
integrating treatments into lifestyle, active participation in chance of success is decreased if one has to make a total lifestyle
treatment plan, changes in personal habits). change.
e Encourage client to discuss concerns regarding cost of Financial concerns play a large part in an individual’s ability to
hospitalization, medications, oxygen equipment, and follow- adhere to a treatment regimen. Involvement of social services
up care; obtain a social service consult to assist with may be required to obtain financial assistance needed by the
financial planning and to obtain financial aid if indicated. patient.
e Provide information about and encourage utilization of Knowledge of community resources provides ongoing support and
community resources that can assist the client to make access to resources outside the acute care facility.
necessary lifestyle changes (e.g., American Lung Associa-
tion; pulmonary rehabilitation groups; counseling, voca-
tional, and social services; smoking cessation programs).
e Include significant others in explanations and teaching Involvement of significant others in client teaching improves
sessions, and encourage their support; reinforce the need adherence to discharge instructions and lifestyle changes.
for the client to assume responsibility for managing as
much of care as possible.

Dependent/Collaborative Actions
Consult appropriate health care provider about referrals Consult health care providers in the community for a continuum of
to community health agencies if continued instruction, care postdischarge.
support, or supervision is needed.

Nursing »Diagnosis |DEFICIENT KNOWLEDGE nox OR INEFFECTIVE HEALTH

MAINTENANCE?*® nox
or its acquisition.
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic,
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

teaching needs.
*The nurse should set the diagnostic label that is most appropriate for the client’s discharge

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 136 Chapter 5S = The Client With Alterations in Respiratory Function

RISK FACTORS
° Denial of disease process
° Cognitive deficiency
° Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; energy conservation; Health system guidance; teaching: individual; teaching:
treatment procedure(s); health resources disease process; teaching: prescribed activity/exercise;
teaching: prescribed medication

NURSING ASSESSMENT RATIONALE

Assess client understanding of illness and treatment plan. Learning is more effective when client is motivated and understands
Assess client’s ability and readiness to learn. the importance of what is to be learned.
Assess Client’s understanding of teaching. Readiness to learn changes based on situations and physical and
emotional challenges.

Se
THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

or minimize further respiratory problems.

Independent Actions
e Instruct client in ways to prevent or minimize further There are a variety of ways a client can maintain general good
respiratory problems. health and support interventions focusing on the respiratory
° Maintain overall general good health (e.g., reduce stress, system.
eat a well-balanced diet, obtain adequate rest, adhere to
prescribed graded exercise program).
° Stop smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause inflammation and damage to the
bronchial and alveolar walls; the carbon monoxide decreases
oxygen availability.
e Avoid exposure to respiratory irritants such as smoke, dust, Exposure to respiratory irritants increases the risk of infection and
some perfumes, aerosol sprays, paint fumes, and solvents; impacts ciliary function.
wear a mask or scarf over nose and mouth if exposure to
high levels of irritants, such as smoke, fumes, and dust, is
unavoidable.
e Remain indoors when air pollution levels and/or pollen Air pollution in high levels is harmful to persons with existing lung
counts are high and/or outdoor temperatures are extremely disease.
hot or cold.
° Exposure to extreme hot and cold air may cause broncho-
constriction, allowing less air into and out of the lungs.
° Avoid high altitudes; if air travel is required, consult physi- The oxygen content at high altitudes is decreased, which may
cian about the need for supplemental oxygen. cause significant dyspnea if supplemental oxygen is not
available.
e Adhere to chest physiotherapy (e.g., breathing exercises, Chest physiotherapy is important to handle secretions and main-
postural drainage therapy) as ordered. tain positive respiratory status.
° Take medications such as bronchodilators and mucolytics Adherence to medication regimen is important to maintain and
as prescribed. improve respiratory status. '
° Avoid contact with persons who have respiratory tract These actions decrease the client's risk of infection.
infections; avoid crowds and poorly ventilated areas;
receive immunizations against influenza and pneumococ-
cal pneumonia.
° Drink at least 10 glasses of liquid per day unless contra- Adequate fluid intake is necessary to liquefy secretions.
indicated.
° Take antimicrobials as prescribed (some physicians instruct Early treatment of infections may decrease the severity of the
clients to begin antimicrobial therapy if sputum color impact on the client with COPD.
becomes yellow or green).
 Chapter 5 = The Client With Alterations in Respiratory Function 137

THERAPEUTIC INTERVENTIONS RATIONALE

° Clean medication administration devices (e.g., metered-dose Equipment that is inadequately cleaned after use harbors bacteria,
inhaler, dry powder inhaler, spacer, table-top nebulizer), oxy- which may lead to an infection. Inhaled medication devices
gen delivery devices (e.g., mask, nasal cannula), humidifier, only deliver a certain percentage of the medication to the lungs.
and air filters as instructed by health care provider and The rest of the medication is deposited in the oropharynx,
manufacturer. which with some medications, increases the risk for infection,
dysphonia, and/or candidiasis.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to main-

tain an optimal nutritional status.

Independent Actions
Provide instructions regarding ways to maintain an optimal
nutritional status:
e Rest before meals; do the majority of food preparation in Preparing food in advance of eating and adequate rest before meals
- advance rather than just before eating. decrease fatigue that may occur when eating.
e Perform good oral hygiene before meals. Good oral hygiene reduces unpleasant tastes in the mouth and
moistens the mouth, making it easier to chew and swallow.
e Eat sitting down in a pleasant environment. Eating in a pleasant environment helps increase a client’s appetite.
e Eat foods that require little or no chewing when energy is Because a person cannot swallow and breathe at the same time,
low and/or dyspnea is increased. relief of dyspnea increases the likelihood of maintaining a good
oral intake. Foods that require little or no chewing will be easier
to eat and help maintain a client’s nutritional status.
e Eat meals that are well balanced; drink nutritional supple- Clients must consume a diet that is well balanced and high in
ments if needed to maintain an adequate caloric intake. essential nutrients in order to meet their nutritional needs.
Dietary supplements are often needed to help accomplish this.

Dependent/Collaborative Actions
Provide instructions regarding ways to maintain an optimal
nutritional status:
e Use supplemental oxygen via nasal cannula during meals Relief of dyspnea through the use of oxygen therapy decreases the
if needed. client’s anxiety about and preoccupation with breathing efforts
and increases the ability to focus on eating and drinking.
e Take vitamins and minerals as prescribed. Administration of vitamins and minerals helps maintain nutri-
tional status.
e Consult a dietician. To develop a nutritional plan that meets client’s caloric needs.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to con-

serve energy and/or reduce dyspnea and fatigue.

Independent Actions
Instruct client in ways to conserve energy and/or reduce
dyspnea and fatigue:
e Sit rather than stand during activities such as preparing Each of these actions is a method of conserving energy during a
food, rinsing dishes, ironing, showering, shaving, and variety of activities.
talking on the phone.
e Have most frequently used food items, dishes, cleaning
supplies, and clothing at waist level whenever possible
rather than on high or low shelves.
e Pace yourself during any activity; stop, relax your muscles,
and take a few deep breaths as often as needed.
e Simplify your life whenever possible; spread large projects
over several days or weeks.
e Allow others to assist you with or actually do strenuous or
lengthy tasks.

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 138 Chapter 57 s The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

¢ Modify activities to avoid bending, reaching, and raising
arms whenever possible (e.g., use long-handled assistive
devices, simplify hair style so that it does not need to be
blow-dried or curled, sit with elbows resting on table while
shaving).
¢ Do not try to carry on a conversation during activities
that also require energy (e.g., walking, eating, cleaning,
gardening).
e Use bronchodilators before activity as needed and
prescribed.
e Use oxygen during activity as needed and prescribed; have
portable oxygen system readily available.
e Use positions that minimize energy expenditure during
sexual activity (e.g., side-lying).

THERAPEUTIC INTERVENTIONS RATIONALE

SS
_

Desired Outcome: The client will demonstrate proper

chest physiotherapy and use of respiratory equipment.

Independent Actions
Reinforce instructions about proper breathing techniques A variety of techniques and therapy are required for clients with
(e.g., pursed-lip breathing, diaphragmatic breathing), COPD to maintain their health status.
postural drainage therapy (may be indicated if large
amounts of mucus continue to be produced), and use of
respiratory equipment (e.g., oxygen, incentive spirometer).
Allow time for questions, clarification, and return demonstration. Making the client feel comfortable enough to ask questions or
clarify information and to provide a return demonstration will
help improve adherence to treatment regimens.

THERAPEUTIC INTERVENTIONS
RATIONALE
eee

Desired Outcome: The client will verbalize an under-

standing of medications ordered including rationale, food
and drug interactions, side effects, methods of administra-
tion, and importance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, and importance of A client’s understanding of why medications are required, their side
taking medications prescribed. effects, and the importance of taking them as prescribed will
promote adherence.
Inform client of pertinent food and drug interactions. Clients need to understand what type of foods and other medica-
tions may impact their respiratory medications.
Have blood levels evaluated periodically, if indicated. There are many medications where a blood level is required. The client
needs to be aware of the importance ofhaving these levels moni-
tored to ensure appropriate dosing and to prevent toxic levels,
If client is discharged on medications via inhalation: ‘
¢ Provide information about the proper use, cleaning, and Equipment that is inadequately cleaned after use harbors bacteria,
replacement of the medication delivery devices (e.g., neb- which may lead to an infection.
ulizer, dry powder inhaler, metered-dose inhaler, spacer).
e Instruct to rinse mouth with water after using inhalers Inhaled medication devices only deliver a certain percentage of
the
(removing remaining drug particles from the mouth helps medication to the lungs. The rest ofthe medication is deposited
reduce unpleasant tastes, dryness or irritation of the oral in the oropharynx. Rinsing the mouth after medication admin-
mucosa, and systemic absorption of the drug). istration will remove remaining particles from the mouth.
¢ Instruct to observe for and report side effects such as per- Some inhaled medications increase the risk for infection, dyspho-
sistent sore throat, increased cough, hoarseness, and/or nia, and/or candidiasis.
white patches in mouth (could indicate candidiasis that
can occur with corticosteroid use).
 ChapterS = The Client With Alterations in Respiratory Function 139

THERAPEUTIC INTERVENTIONS
—————__eee
RATIONALE
QQ ————— —

e Instruct to use the prescribed bronchodilator before inhal- Separation of inhaled medications by 5 minutes is important in
ing the corticosteroid and to wait 5 minutes between these maximizing the effectiveness of the medications, particularly
two medications. (This maximizes the effectiveness of the corticosteroids.
corticosteroid.)
If client is discharged on a corticosteroid, instruct to:
e Take oral preparations with food to reduce gastric irrita-
tion.
e Expect that certain effects such as facial rounding, slight The client should be taught the correct method of administration
weight gain and swelling, increased appetite, and slight to decrease the incidence of side effects and adverse reactions.
mood changes may occur.
e Report undesirable effects such as marked swelling in Clients should be educated about the physical changes that
extremities, significant weight gain, extreme emotional can occur while taking corticosteroids, and the importance
and behavioral changes, extreme weakness, tarry stools, of notifying their health care professional for treatment and
bloody or coffee-ground vomitus, frequent or persistent potential readjustment of medication dosage.
headaches, insomnia, lack of menses, and _ persistent
gastric irritation.
e Avoid contact with persons who have an infection. Corticosteroids reduce the ability of the body to fight off infection;
therefore, it is important for the client to avoid contact with
persons who have an infection
e Follow recommendations about ways to reduce the risk Long-term use of corticosteroids increases the client’s risk of
for developing osteoporosis if long-term corticosteroid developing osteoporosis. It is important to provide the client
use is expected (e.g., take calcium and vitamin D supple- with methods of decreasing this risk.
ments, stop smoking, do 30-60 minutes of weight-bearing
exercise each day if able).
If client is discharged on a beta-adrenergic agonist (e.g.,
albuterol, metaproterenol, terbutaline, salmeterol),
instruct to:
e Take oral preparations with meals to reduce gastric
irritation.
e Expect that certain effects such as nervousness, restless- Clients need to be educated on the form of administration, side
ness, and slight tremor can occur. effects, and adverse reactions. Clients must also be informed
e Report undesirable effects such as persistent or excessive that if undesirable effects occur, they should notify their health
nervousness, restlessness, tremors, headache, and gastric care provider.
irritation; chest pain; vomiting; irregular heart beat; and
wheezing.
Instruct client to take regularly scheduled medications as of- Many medications require a blood level to be obtained in order for
ten as prescribed and to avoid skipping doses, altering the an appropriate client response. The client must be made aware
prescribed dose, making up for missed doses, and discon- of what to do when doses are missed, generic medications are
tinuing medication without permission of the health care used if they were not used initially when the medication
provider. was prescribed, and the importance of not discontinuing the
medication without the permission of the health care provider.
Reinforce instructions about the frequency and dosage of The client should be educated on how to take medications that
medications prescribed on an “as needed” basis. are prescribed to be used as needed. It should be emphasized
that the client should not increase the frequency or dosage of
these medications without permission from the health care
provider.
Instruct client to inform all health care providers of medica- Many clients have more than one physician and should be
tions and herbal supplements being taken. educated to inform all health care providers ofall medications
and herbal supplements being taken. This is important so that
the health care provider is aware of all medications and herbal
supplements taken by the client so if new medications are
ordered, the health care provider can determine the impact of
drug-to-drug interactions.
Reinforce the need to consult physician before taking Many over-the-counter (OTC) medications can cause significant
nonprescription medications. drug-to-drug interactions.

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 140 Chapter 5 = The Client With Alterations in Respiratory Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify precautions

that should be adhered to when using oxygen.

Independent Actions
Instruct client about precautions that should be adhered to A client using oxygen outside the health care facility should
when using oxygen: be educated on its use and safety issues. Oxygen is not a
Do not smoke. combustible gas by itself, but when exposed to an open flame
Do not set oxygen flow rate at a level higher than or a spark, it can exacerbate a fire.
prescribed by physician.
Do not allow the oxygen system to be within 10 feet of an Oxygen is highly flammable and should be placed at a safe
open flame (e.g., gas stove, kerosene heater or lamp, fire- distance from anything with an open flame. In the event of
place, candle) or a source of sparks (e.g., electric razor, fire, the oxygen system should be shut off and removed from
portable radio, wool blanket, hair dryer). the area.
Post “No Smoking” signs in and around areas of oxygen use. Prevents accidental smoking around oxygen
Ensure that all electrical equipment in the area of the Decreases risk of oxygen-related fire
oxygen source is grounded.
Always have a battery-operated oxygen delivery system A backup battery-operated system is necessary for power failures
readily available. and when away from a hardwired power source.
Demonstrate to the client how to recognize when the The client needs to be aware of how to assess the level of oxygen
oxygen supply is low, and how to get the oxygen source on hand and at what level to have it replenished to ensure it is
refilled or replaced. available when it is required.
Instruct client to have the oxygen delivery system checked This check helps ensure it is working properly.
regularly by the supplier.
Always wear a medical alert identification bracelet or tag. Wearing a medical alert identification bracelet provides informa-
tion important to ensure that the appropriate oxygen flow rate
for diagnosis is administered in emergency situations and to the
client’s history of COPD.
Instruct client on ways to prevent skin and mucous mem- A client who continuously uses oxygen should be taught methods
brane irritation and breakdown resulting from the use of to prevent skin and mucous membrane irritation. Oxygen is
oxygen and/or oxygen delivery devices: a dry gas and can cause dryness of the skin and mucous
Assess areas of skin and mucous membranes that are in membranes that may lead to skin breakdown.
contact with the oxygen mask or nasal cannula (e.g.,
nares, bridge of nose, tops of ears) a few times each day
for redness and irritation.
Pad areas of pressure and ensure that straps are not too tight. Pressure areas not padded and/or straps that are too tight may lead
Keep skin areas under straps and mask clean and dry. to skin breakdown.
Refill oxygen humidification reservoir as needed, perform Helps reduce dryness and cracking of the mucous membranes.
frequent oral hygiene, and apply water-based gel to nares
and lips to reduce dryness of the mucous membranes.

THERAPEUTIC INTERVENTIONS RATIONALE

eS ee ee ee eee
Desired Outcome: The client will state signs and symp-
toms to report to the health care provider.

Independent Actions
Instruct the client to report: '
Changes in sputum characteristics (e.g., increase in A respiratory infection increases dyspnea and may precipitate
volume or consistency, yellow or green color) respiratory failure.
Sputum that does not return to usual color after 3 days of Instruct the client on signs and symptoms of an infection. When
antimicrobial therapy these appear, the client is to contact the health care provider
Cough that becomes worse immediately. Prompt treatment may prevent the infection from
Increased fatigue, weakness, and shortness of breath becoming severe and precipitating respiratory infection.
Increased need for medications and/or oxygen therapy May indicate cardiac complications of COPD and require medical
Elevated temperature treatment.
Drowsiness, confusion, new or increased irritability
Chest pain
Persistent weight loss or sudden weight gain
Swelling in ankles and/or feet
 Chapter5 = The Client With Alterations in Respiratory Function 141

THERAPEUTIC
Doaneee ee
INTERVENTIONS
ee ee RATIONALE

Desired Outcome: The client will identify resources that

can assist with financial needs, home Management, and
adjustment to changes resulting from COPD.

Independent Actions
Provide information regarding resources that can assist client COPD is a chronic illness and can _ significantly impact an
and significant others with financial needs, home manage- individual’s and family’s financial status. Providing informa-
ment, and adjustment to changes resulting from COPD tion specific to community resources is important to provide a
(e.g., American Lung Association; respiratory equipment continuum of care and may impact the client’s health status.
suppliers; pulmonary rehabilitation programs; counseling,
vocational, and social services; Meals on Wheels; transpor-
tation services; home health agencies).
Initiate a referral to community and home health agencies if Provides for continuum of care postdischarge.
indicated.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider and graded exercise program.

Independent Actions
Implement measures to promote effective therapeutic regimen A chronic illness requires lifestyle changes. Client involvement in a
management (adhere to an appropriate diet and an exercise comprehensive program of lifestyle changes (i.e., diet, exercise,
plan; stop smoking and maintain medication regimen). stop smoking, etc.) has been shown to provide improved health
Reinforce importance of lifelong follow-up care. status and slows the progression of the disease.
Reinforce physician’s instructions about a graded exercise
program (e.g., walking for 20 minutes 3 times a week, sta-
tionary bicycling).

ADDITIONAL NURSING DIAGNOSES e Dependence on others to meet self-care needs

e Possible alteration in sexual functioning (may result from
SELF-CARE DEFICIT (BATHING, DRESSING, dyspnea, weakness, fatigue, and persistent cough)
FEEDING, TOILETING) NDx e Stigma associated with chronic illness
Related to weakness, fatigue, and dyspnea e Possible changes in lifestyle and roles

DISTURBED SLEEP PATTERN NDx RISK FOR POWERLESSNESS NDx

Related to fear, anxiety, unfamiliar environment, excessive cough- Related to physical limitations; disease progression despite
ing, frequent assessments and treatments, side effects of medica- efforts to comply with treatment plan; dependence on others
tions (e.g., some bronchodilators, corticosteroids), and inability to to meet self-care needs; and alterations in roles, lifestyle, and
assume usual sleep position associated with orthopnea future plans.

DISTURBED BODY IMAGE NDx

Related to:
e Change in appearance (e.g., “barrel” chest, clubbing of fin-
gers, retraction of tissues around the neck and shoulders)

MECHANICAL VENTILATION
Mechanical ventilation, in an intervention intended for of underlying disease process and the need for an artificial
use as a temporary, life-saving therapy, is indicated for clients airway.
with acute respiratory failure who are unable to maintain Acute respiratory failure can be a result of either the failure
normal gas exchange. Implemented using a variety of modes to oxygenate, the failure to ventilate, or a combination of
and techniques, methods of mechanical ventilation used in both. Two categories of respiratory failure influence the
acute and long-term care settings are influenced by the type method of mechanical ventilation selected for ventilatory

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 142 Chapter5 = The Client With Alterations in Respiratory Function

support. Type I, or hypoxemic respiratory failure, is defined as ventilator settings. The degree of mechanical support and the
the inability to maintain a PaO, greater than 60 mm Hg with duration of therapy are determined by the client’s underlying
the client at rest and breathing room air. A variety of disease disease process and current state of health. As duration of me-
processes interfere with the normal exchange of oxygen and chanical support increases, the client is at increased risk for the
carbon dioxide across the alveolar membrane, leading to development of complications associated with mechanical
disturbances in diffusion. These processes include pulmonary ventilation: tracheal damage, acid-base imbalances, aspiration
fibrosis, pulmonary edema, acute respiratory distress syn- pneumonia, nutritional imbalances, deep vein thrombosis
drome (ARDS), and loss of functional lung tissue (pneumo- (DVT), stress ulcers, immobility, and ventilator dependence.
nectomy). Effective gas exchange is influenced by even distri- To ensure the safe and effective care of a client requiring
bution of gas (ventilation) and blood (perfusion) in all mechanical ventilation, a miultidisciplinary approach is
portions of the lung. Disturbances in the relationship required. Collaboration among the physician provider, respi-
between ventilation and perfusion also contribute to type I or ratory therapist, dietician, physical therapist, and nurse is
hypoxemic respiratory failure and include pulmonary em- essential in order to resolve the underlying disease process,
boli, atelectasis, pneumonia, emphysema, and bronchitis, as prevent complications, and return the client to baseline
well as ARDS. Type II failure, or the failure to ventilate, results pulmonary function. In addition, as with any artificial lifesav-
from disease processes that interfere with a client’s ability to ing or life-extending therapy, client and family choice must
effectively ventilate the waste products of respiration (COz). be respected if end-of-life issues arise.
Characterized by a PaCQ, greater than 50 mm Hg or a pH This care plan focuses on the adult client hospital-
less than 7.35, type II respiratory failure, or hypercarbic respi- ized in an acute care setting with acute respiratory
ratory failure, can occur as a result of disease processes that failure requiring support with mechanical ventilation.
impair normal alveolar minute ventilation. These disease
processes include COPD, restrictive pulmonary diseases
(obesity, pneumothorax, diaphragmatic paralysis), neuromus- OUTCOME/DISCHARGE CRITERIA
cular defects (Guillain-Barré syndrome, myasthenia gravis,
multiple sclerosis, muscular dystrophy, spinal cord injury), The client will:
and chest trauma. Return to independent respiratory function
Invasive positive pressure ventilation is the most common Tolerate an expected level of activity
method of mechanical ventilation used in the acute care Maintain a balanced nutritional state
setting. Invasive ventilation techniques require the use of Have no signs or symptoms of infection
an artificial airway (tracheostomy, endotracheal tube [ETT]). SH
tes
SS
ge Identify ways to maintain respiratory health
With this method of ventilation, the client’s respiratory 6 State signs and symptoms to report to health care provider
function is supported as positive pressure delivers the appro- 7. Develop a plan for adherence to the treatment regimen
priate volume of air and concentration using the appropriate including prescribed medications, diet, and follow-up care

- Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*

Definition: Impaired Spontaneous Ventilation NDx: Inability to initiate and/or maintain independent breathing that is
adequate to support life; Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide
adequate ventilation; Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the
respiratory tract to maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or
carbon dioxide elimination at the alveolar-capillary membrane.

Impaired spontaneous ventilation NDx

Related to:
° Metabolic factors, respiratory muscle fatigue

Ineffective breathing pattern NDx

Related to:
° Cognitive impairment, neuromuscular dysfunction, respiratory muscle fatigue, spinal cord injury, obesity,
hypervehtilation/
hypoventilation

Ineffective airway clearance NDx

Related to:
e Presence of an artificial airway, retained secretions, secretions in the bronchi, excessive mucus, infection

Impaired gas exchange NDx

Related to:
e Alveolar-capillary membrane changes, ventilation-perfusion imbalance

*This diagnostic label includes the following nursing diagnoses: impaired spontaneous ventilation,
ineffective breathing pattern,
ineffective airway clearance, and impaired gas exchange.
 Chapter 55s The Client With Alterations in Respiratory Function 143

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue; confusion; restlessness; Dyspnea; orthopnea; use of accessory muscles; abnormal
somnolence; shortness of breath breath sounds; limited chest excursion; abnormal skin
color; diaphoresis; decreased pulse oximetry values;
abnormal arterial blood gas values

RISK FACTORS DESIRED OUTCOMES

e Apnea, or impending inability to breathe
The client will experience adequate respiratory function as
e Acute respiratory failure
evidenced by:
e Severe hypoxia
Normal rate and depth of breathing
e Respiratory muscle fatigue
Decrease or absence of dyspnea
Normal breath sounds
Usual mental status
Oximetry results within baseline range
» Arterial blood gas values within baseline range
moans

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: airway patency; gas exchange; Respiratory monitoring; ventilation assistance; artificial
ventilation; mechanical ventilation response: adult; airway management; mechanical ventilation management:
vital signs invasive; mechanical ventilatory weaning; acid-base
management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired respira- Early recognition of signs and symptoms of impaired respiratory
tory function: function allows for prompt intervention.
e Rapid, shallow, respirations
e Dyspnea, orthopnea
e Use of accessory muscles
e Abnormal breath sounds
e Limited chest excursion
e Restlessness, irritability
e Confusion
e Somnolence
Monitor arterial blood gas values/oximetry values. Allows for evaluation of therapy effectiveness.
Monitor vital signs. Allows for assessment ofclient tolerance to ventilator settings. Changes
in vital signs can indicate a decline in respiratory function.
Assess proper functioning of equipment: Any equipment malfunction can compromise safe and effective
e Ventilator connections mechanical ventilation.
e Artificial airway (presence of cuff leak)
Monitor chest radiograph results. Chest radiograph confirms proper position of ETT. Potential
complications such as pneumothorax, right mainstem
intubation, and infection can be assessed by assessing chest
radiograph results.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
)> Implement measures to ensure airway patency:
° Maintain position and patency of ETT or tracheostomy. Actions that ensure airway patency contribute to adequate
e ETT-Provide oral airway or bite block to prevent biting oxygenation and acid-base balance. An artificial airway must
on the ETT tube as appropriate. be maintained in proper position to ensure ventilation of both
e Document centimeter reference marking for ETT tube lung fields.
to monitor for potential displacement.
e Provide trach care every 4 to 8 hrs; cleaning the inner
cannula while maintaining sterile technique.

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 144 Chapter5 = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Or e Perform endotracheal suctioning as appropriate. Suctioning should occur as needed to clear the large airways of
e Perform hand hygiene. accumulated secretions observing appropriate hand hygiene
e Use universal precautions. precautions and sterile suctioning technique helps reduce the
e Use personal protective equipment (e.g. gloves, goggles, risk for ventilator-acquired pneumonia.
mask) as appropriate.
e Suction oropharynx before deflating cuff. Helps prevent aspiration/ventilator-acquired pneumonia.
Reposition client every 1 to 2 hrs. D@ Frequent repositioning helps loosen and mobilize secretions.
Position client in a semi- to high-Fowler’s position. D @ A semi- to high-Fowler’s position allows for maximal diaphrag-
matic excursion and lung expansion.
Implement measures to reduce the risk for impaired skin The presence of an artificial airway increases the risk for develop-
integrity/pressure injuries around mouth (ETT), neck (trach), ment of pressure injuries/impaired skin integrity to the mouth,
and oral mucosa. neck, and oral mucosa. Assessment of the skin around the
e Change endotracheal tapes/ties every 24 hrs, inspecting affected areas along with routine skin care is necessary to
the skin and oral mucosa. prevent the development of a pressure-related injury.
e Reposition the ETT tube to other side of mouth.
e Loosen commercial ETT holders at least once per day and
provide skin care.
e Inspect skin around tracheal stoma for drainage, redness/
irritation,
e Clean and dry area around stoma.
Maintain appropriate emergency equipment at bedside— An appropriate bag-valve device (Ambu) must be at the bedside
Ambu bag. of a client receiving mechanical ventilation in the event of
equipment failure.

Dependent/Collaborative Actions
Maintain appropriate ventilator settings: Adjustment of ventilator settings is accomplished collaboratively
Oxygen concentration (fraction of inspired oxygen [FiO,]) between the physician provider and the respiratory therapist.
Tidal volume (Vt) Settings are adjusted to reduce the work of breathing and facilitate
Ventilator rate (f) adequate ventilation and oxygenation. The nurse should
Positive end-expiratory pressure (PEEP) always reassess the client’s physiological response to ventilator
changes through physical assessment and examination of
arterial blood gas values.
Implement measures to ensure airway patency:
e Monitor cuff pressure of ETT/tracheostomy tube. Inflating the cuff with the minimal amount of air needed to
e Maintain cuff pressure at 15 to 25 mm Hg. prevent leakage of air around the cuff ensures delivery of
adequate Vt and prevents aspiration of oral secretions.
Implement measures to thin secretions and maintain Adequate hydration and humidified inspired air help thin secretions,
adequate moisture of the respiratory mucous membranes: which facilitates the mobilization and expectoration of secre-
e Humidify inspired air. tions, These actions also reduce dryness of the respiratory mucous
e Regulate fluid intake to optimize fluid balance. membrane, which helps enhance mucociliary clearance.
Maintain integrity of ventilator circuit: These actions help maximize the effectiveness of mechanical
e Keep ventilator circuit free of excess moisture. ventilation, ensure a patent airway, and promote patient safety.
e Respond to ventilator alarms.
e Monitor ventilator connections.
Assist with the administration of mucolytics as ordered: Mucolytics and diluent or hydrating agents are mucokinetic
e Acetylcysteine substances that reduce the viscosity of mucus, thus making it
e Water, saline easier for the client to mobilize and clear secretions, from the
respiratory tract.
Administer the following medications if ordered: These medications increase the patency of the airways and
e Bronchodilators enhance bronchial airflow. Bronchodilators produce bronchodi-
e Corticosteroids lation by relaxing the bronchial smooth muscle. Corticosteroids
e Leukotriene modifiers and leukotriene modifiers reduce inflammation in the airways,
which results in decreased bronchial hyperactivity and constric-
tion, and decreased mucus production.
Collaborate with physician to develop a sedation plan: These strategies will help facilitate optimum ventilation and gas
e Administer sedatives as ordered* (e.g., propofol [Diprivan]). exchange, reducing ventilator asynchrony.
e Administer neuromuscular blocking agents as ordered:
e Cisatracurium besylate (Nimbex)
 Chapter 5 «= The Client With Alterations in Respiratory Function 145

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to prevent spontaneous decannulation
(e.g., Secure airway with tapes/ties, administer sedatives,
consider use of restraints).
Consult appropriate health care provider if signs and symp- Notifying the appropriate health care provider allows for modifica-
toms of impaired respiratory function persist or worsen. tion of the treatment plan.

|Nursing =
Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to: Inability to absorb nutrients and ingest food

CLINICAL MANIFESTATIONS

Subjective Objective
Not evident in an intubated client Evidence of lack of food; poor muscle tone; hyperactive
+
bowel sounds; decreased subcutaneous fat; weight loss;
sore, inflamed buccal cavity; low serum albumin and total
protein levels, iron deficiency; electrolyte imbalances

RISK FACTORS DESIRED OUTCOMES

e Inadequate nutritional therapy
The client will maintain adequate nutrition status as
e Increased caloric requirements
evidenced by:
e Altered gastrointestinal motility
a. Consume adequate nourishment
b. Be free of signs of malnutrition
c. Weigh within normal range for height and age

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status Nutritional monitoring; nutritional management;

nutritional therapy

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
e Weight significantly below client’s usual weight or below prompt intervention.
normal for client’s age, height, and body frame
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Assess for return of bowel function every 2 to 4 hrs. Without bowel sounds, support for nutritional status must be
accomplished with parenteral nutrition, When BS are te-
established, recommend changing to tube feedings to support
bowel health.
Monitor serum albumin, prealbumin, total protein, ferritin, Serum albumin levels less than 3.5 g/100 dL are considered a risk
transferrin, Hgb, hematocrit (Hct), and serum ele¢trolyte for poor nutritional status. Early recognition of abnormal lab
levels as indicated. values reflective of the client’s overall nutritional state allows
for prompt intervention,

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Consult physician about an alternative method of providing Enteral feeding is the preferred method to meet the hypermetabolic
nutrition: nutritional needs pf the ventilated client. If the client is unable
e Enteral nutrition to be fed enterally, nutritional support in the form of parenteral
e Parenteral nutrition nutrition must be provided.

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 146 Chapter 5 = The Client With Alterations in Respiratory Function

|Nursing >>
Diagnosis |RISK FOR INFECTION nox (VENTILATOR-ACQUIRED
PNEUMONIA [VAP])
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
e Inadequate primary defenses
e Decrease in mucociliary action
e Stasis of pulmonary secretions
e Malnutrition
e Presence of invasive artificial airway
e Increased environmental exposure to pathogens

CLINICAL MANIFESTATIONS

Subjective Objective
Not applicable Increased temperature, tachypnea; increased or purulent
secretions/hemoptysis, rhonchi, crackles, decreased breath
sounds, bronchospasm; leukocytosis

RISK FACTORS DESIRED OUTCOMES

° Pooling of oropharyngeal secretions
¢ Immobility The client will remain free of infection as evidenced by:
a. No increase in temperature
e Malnutrition
b. Absence of purulent sputum
c. Normal breath sounds
d. Normal chest radiograph findings
e. WBC and differential counts returning to normal or
within normal limits

NOC OUTCOMES NIC INTERVENTIONS

SSS
Se SS SS SS
Immune status; infection severity Infection protection; infection control

a NURSING ASSESSMENT RATIONALE

Eanes ee
Assess for signs and symptoms of ventilator-acquired pneu- Early recognition of signs and symptoms of VAP allows for prompt
monia (VAP): intervention.
e Elevated temperature
e Purulent sputum
e Odorous sputum
e Abnormal breath sounds (crackles, rhonchi)
Assess WBC and differential cell counts for abnormalities. An increase in the WBC count above previous levels and/or a
significant change in the differential may indicate the presence
of an infection. Monitoring results allows for modification of
treatment plan.
Monitor chest radiograph results. The presence of pulmonary infiltrates on chest radiograph indicates
the presence of pneumonia. '
Monitor results of sputum cultures. Monitoring results allows for modification of treatment plan.

THERAPEUTIC INTERVENTIONS RATIONALE

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Independent Actions
Implement measures to reduce the risk for VAP:
e Elevate head of the bed a minimum of 30 to 45 degrees. Head of the bed elevation reduces the risk of aspiration of gastric
secretions.
¢ Perform hand hygiene: Prevents the transmission of bacteria to the patient
e Frequent hand washing before and after suctioning
° Wear gloves when in contact with the patient and change
gloves between activities.
 Chapter5 * The Client With Alterations in Respiratory Function 147

THERAPEUTIC INTERVENTIONS RATIONALE

e Drain excess condensation in ventilator circuit.
e Perform oral care every 2 to 4 hrs and prn.
e Suction oropharyngeal secretions. Removes bacteria from the oropharynx, protects integrity of oral
e Brush teeth and surface of the tongue using suction mucosal membranes, and prevents aspiration of bacteria-laden
toothbrush and small amounts of water and/or secretions.
chlorhexidine solution.
e Apply mouth moisturizer/lip balm if needed.
e Maintain integrity of ETT/tracheostomy cuff. Prevents silent aspiration of oral/gastric secretions.

Dependent/Collaborative Actions
Monitor cuff pressures every 4 to 8 hrs using manometer.
e Inflate cuff using minimal occlusive volume (MOV) Adequate cuff pressure is necessary to prevent silent aspiration
technique. of oropharyngeal secretions, which may increase the risk of
e Maintain cuff pressure at 15 to 25 mm Hg. ventilator-acquired pneumonia.
Notify the appropriate health care provider if signs and Notifying the appropriate health care provider allows for modifica-
symptoms of VAP develop. tion of the treatment plan.
Obtain cultures as ordered.

| “=
Nursing |
Diagnosis |DYSFUNCTIONAL VENTILATORY WEANING RESPONSE nox
Definition: Inability to adjust to lowered levels of mechanical ventilator support that interrupts and prolongs the weaning
Process.

Related to:
e Physiological factors: ineffective airway clearance; sleep disturbance; inadequate nutrition; uncontrolled pain or discomfort
e Psychological factors: knowledge deficient of the weaning process; moderate amount of anxiety or fear; hopelessness;
powerlessness; insufficient trust in health care team
e Situational factors: uncontrolled energy demands; inappropriate pacing of diminished ventilator support; inadequate social
support; adverse environment; low nurse-to-client ratio; history of ventilator dependence greater than 4; history of multiple
unsuccessful weaning attempts

CLINICAL MANIFESTATIONS

Subjective Objective
Not evident in an intubated client Apprehension; agitation; baseline increase in respiratory
rate (<5 breaths/min); diaphoresis; adventitious breath
sounds; asynchronized breathing with the ventilator;
cyanosis; decreased level of consciousness; use of
respiratory accessory muscles; gasping breaths; increase
from baseline blood pressure; inability to cooperate;
inability to respond to coaching

RISK FACTORS DESIRED OUTCOMES

e Prolonged mechanical ventilation The client will wean from mechanical ventilation as
e Muscle weakness evidenced by:
e Activity intolerance . Arterial blood gas values within client’s normal baseline
e Debilitated state . Absence of dyspnea
. Absence of restlessness
Ability to effectively clear secretions
. Tolerating and maintaining airway after extubation
©+. Vital signs within normal limits
2
aT
a0

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 148 Chapter S = The Client With Alterations in Respiratory Function

NOC OUTCOMES NIC INTERVENTIONS

Anxiety self-control; mechanical ventilation weaning Mechanical ventilatory weaning; mechanical ventilation
response: adult; respiratory status: gas exchange; management: invasive
ventilation; vital signs

NURSING ASSESSMENT RATIONALE

Assess client’s readiness for weaning: Early recognition of readiness to wean allows for prompt intervention.
° Resolution of underlying disease process
° Hemodynamic stability
e Absence of fever
e Normal state of consciousness
e Metabolic fluid balance
e Adequate nutritional status
e Adequate sleep
Assess Client’s psychological readiness to wean.
Assess Client’s tolerance of weaning process;
e Work of breathing
e Vital signs
e Pulse oximetry values
e Arterial blood gas values
Monitor Hgb/Hct; serum electrolyte levels; serum albumin/
prealbumin levels; chest radiograph for improvements.

THERAPEUTIC INTERVENTIONS
RATIONALE
eee
Independent Actions
Implement measures to facilitate the weaning process:
° Provide a safe, comfortable environment. Comfort will facilitate the weaning process,
° Coordinate pain and sedation medications to minimize Fatigued respiratory muscles require 12 to 24 hrs to recover.
sedative effects,
Schedule weaning periods for the time of the day when
the client is most rested,
Promote a normal sleep-wake cycle,
° Limit visitors to supportive persons.
e Coach client through periods of anxiety.
° Cluster care activities to promote successful weaning.
° Educate patient and family about the weaning process. Educating the client and family allows for the appropriate level of
psychological support.
Evaluate patient tolerance of the weaning process. Allows for modification of the weaning plan.

Dependent/Collaborative Actions
Assist respiratory therapist in assessing readiness to wean by Assessment of the mechanics of weaning allows for determination
assessing; of the client’s ability to support normal ventilation.
° Minute ventilation
° Negative inspiratory force
e Vital capacity
Use evidence-based protocols for weaning. Protocol-driven weaning provides a standardized approach to
the weaning process. ‘
Recommend a spontaneous breathing trial: Tolerance of a weaning trial helps demonstrate readiness for
° 30 to 120 minutes with PEEP/continuous positive airway extubation.
pressure (CPAP) or t-piece
Notify appropriate health care provider of signs and symp- Notifying the appropriate health care provider allows for modification
toms of dysfunctional weaning: of the treatment plan.
° Respiration rate less than 8 or greater than 30 breaths/min
e B/P changes greater than 20% of baseline
e Heart rate changes greater than 20% of baseline
e Pulse oximetry less than 90%
e Decrease in spontaneous tidal volume
 ChapterS = The Client With Alterations in Respiratory Function 149

THERAPEUTIC INTERVENTIONS RATIONALE

e Labored respirations
e Diaphoresis
e Restlessness
e Anxiety

|Collaborative/Nursing Diagnosis
»-)--* |RISK FOR DECREASED CARDIAC OUTPUT nox

Definition: Susceptible to inadequate blood pumped by the heart to meet metabolic demands of the body, which may
compromise health.
Related to:
Altered hemodynamics related to increased intrathoracic pressure associated with positive pressure mechanical ventilation

CLINICAL MANIFESTATIONS

Subjective Objective
Not evident in an intubated client Hypotension; tachycardia; decreased level of consciousness

RISK FACTORS DESIRED OUTCOMES

e Large tidal volumes
The client will maintain normal cardiac output as
= PEEP
evidenced by:
a. B/P within baseline range
b. Heart rate within baseline range
c. Measured cardiac output/index within client’s normal
range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of decreased cardiac Early recognition of signs and symptoms of decreased cardiac
output. output allows for prompt intervention.
Monitor vital signs frequently.
Measure cardiac output/index if ordered.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor client’s response to ventilator changes: PEEP increases intrathoracic pressure, which may further decrease
e Adding of PEEP venous return, compromising cardiac output.

Dependent/Collaborative Actions
Administer intravenous fluids as ordered. Helps restore circulating volume, which helps minimize cardiovas-
cular effects.
Administer vasoactive infusions to restore normal cardiac Helps maintain normal cardiac output.
output: Inotropes increase the force of cardiac contractions, which increases
e Inotropes cardiac output.
e Vasopressors Vasopressors should only be used if circulating volume has been
restored.
Notify physician provider if signs and symptoms of decreased Notifying the appropriate health care provider allows for modifica-
cardiac output persist or worsen. tion of the treatment plan.

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 150 ChapterS5 = The Client With Alterations in Respiratory Function

Ce eos RISK FOR GASTROINTESTINAL BLEEDING

Definition: Bleeding within the gastrointestinal tract

Related to:
e Positive pressure ventilation
e Stress of critical illness/stress ulcers
e Atrophy of mucosal lining of stomach due to lack of enteral feeding

CLINICAL MANIFESTATIONS

Subjective Objective
Not evident in an intubated client Bleeding in stools; hematemesis

RISK FACTORS DESIRED OUTCOMES

e Stress of acute illness
The client will not experience gastrointestinal bleeding.

NURSING ASSESSMENT RATIONALE

——e————————————— OC eee ——

Assess for and report signs and symptoms. Early recognition of signs and symptoms of gastrointestinal bleed-
ing allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Administer histamine (Hz) receptor blockers; proton pump Medications act to decrease gastric acidity and diminish the risk
inhibitors. ofstress ulcers.
Administer enteral feedings as ordered. Stimulates the intestinal mucosa, preventing atrophy and
disruption
Notify physician provider if signs and symptoms persist or Notifying the appropriate health care provider allows for modifica-
worsen. tion of the treatment plan.

|Collaborative 2
Diagnosis RISK FOR BAROTRAUMA

Related to:
e Increased lung inflation pressures
e Noncompliant lungs

ADDITIONAL NURSING DIAGNOSES

FEAR NDx /ANXIETY NDx IMPAIRED VERBAL COMMUNICATION NDx
Related to the perceived need for mechanical ventilation; in- Related to artificial airway and mechanical ventilation
ability to communicate effectively; psychological ventilator
dependence IMPAIRED ORAL MUCOUS MEMBRANE NDx
Related to the presence of an_ artificial airway; Dypass of
RISK FOR ASPIRATION NDx normal physiological humidification process
Related to presence of an artificial airway that bypasses nor-
mal upper airway defenses POWERLESSNESS NDx
Related to illness-related regimen; lifestyle of helplessness
IMPAIRED PHYSICAL MOBILITY NDx
Related to mechanical ventilation
 Chapter5 = The Client With Alterations in Respiratory Function 151

RISK FOR INJURY NDx ~ RISK FOR IMBALANCED FLUID VOLUME NDx
Related to: Related to:
External factors: Use of restraints during mechanical ventila- e Ventilator humidification
tion; presence of artificial airway; malfunction of equipment. e Stimulation of the renin-angiotensin-aldosterone mecha-
Internal factors: Agitation/confusion nism leading to retention of sodium and water

Pneumonia, or pneumonitis, is an acute inflammation of purulent or blood-tinged sputum, and pleuritic chest pain
lung tissue that can cause mild to severe illness of people in (in some cases). Elderly persons, who often have impaired
all ages and that can be caused by a variety of viruses, bacte- immune mechanisms, may present with a change in mental
ria, fungi, chemical irritants, or radiation therapy. Infectious status and a recent history of weakness, fatigue, and a decline
organisms that cause pneumonia reach the lungs by inhala- in appetite rather than the symptoms of typical pneumonia.
tion, aspiration of nasopharyngeal or oropharyngeal con- This care plan focuses on the adult client hospital-
tents, or by hematogenous spread of infection from another ized with bacterial pneumonia. Much of the informa-
site in the body. Smoking or the presence of underlying tion is applicable to clients receiving follow-up care in
medical conditions like diabetes or heart disease increases the an extended care facility or home setting.
risk of developing pneumonia.
Pneumonia may be classified according to the causative
organism (e.g., pneumococcal pneumonia, staphylococcal OUTCOME/DISCHARGE CRITERIA
pneumonia, viral pneumonia), the area of involvement (e.g.,
lobar pneumonia), or the etiological factor (e.g., aspiration The client will:
pneumonia, radiation pneumonitis). Pneumonia may also . Have improved respiratory function
be classified as community-acquired pneumonia (CAP) or . Tolerate expected level of activity
hospital-acquired pneumonia (HAP), the latter often referred . Have no signs and symptoms of complications
to as nosocomial. . State signs and symptoms to report to the health care provider
Most persons hospitalized with pneumonia have bacterial nA
FR. Develop
PWN a plan for adhering to recommended follow-
pneumonia. The onset of bacterial pneumonia is often up care, including future appointments with health care
abrupt and manifested by chills, fever, a cough productive of provider, medications prescribed, and activity limitations

Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*

Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.

Ineffective breathing pattern NDx

Related to:
e Decreased depth of respirations associated with:
e Weakness, fatigue, and reluctance to breathe deeply because of chest pain
e Decreased lung compliance (distensibility) if pleural effusion is present
e Increased rate of respirations associated with:
e Compensation for hypoxia that results from impaired gas exchange
e The increase in metabolic rate that occurs with an infectious process
Ineffective airway clearance NDx
Related to:
© Tracheobronchial inflammation and increased production of mucus associated with the infectious process
© Stasis of secretions associated with decreased activity, poor cough effort resulting from fatigue and chest pain, impaired
ciliary function (results from increased viscosity and volume of mucus that occurs with the infectious process)

Impaired gas exchange NDx

Related to:
A decrease in effective lung surface associated with the accumulation of mucus and consolidation of lung tissue

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 152 ChapterS « The Client With Alterations in Respiratory Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath and chest tightness Tachypnea; pharyngitis; dullness on percussion over
consolidated areas; abnormal breath sounds; productive
cough; fever; irritability; confusion; disorientation;
restlessness; somnolence; use of accessory muscles when
breathing; pink, rusty, purulent, green, yellow, or white
sputum; significant decrease in oximetry results; abnormal
arterial blood gas values; abnormal chest radiograph
results; declining results in pulmonary function tests;
reduced activity tolerance; asymmetrical chest excursion

DESIRED OUTCOMES
RISK FACTORS
The client will maintain adequate respiratory function as
e Smoking evidenced by:
e Outdoor/indoor pollutants Normal rate and depth of respirations
e Exposure to second-hand cigarette smoke Decreased dyspnea
e Allergies Usual or improved breath sounds
e Low birth weight Symmetrical chest excursion
e Periodontal disease Usual mental status
e Individuals older than 60 years Oximetry results within normal range for client
e White male p Arterial blood gas values within normal range for client
RMWmoadnd

NOC OUTCOMES NIC INTERVENTIONS

Soo
—————————EEeEeEeEeEeEeEeEeEeEEEEEEe
ee EeEeEeN
eC eN
Respiratory status: airway patency; ventilation; Respiratory monitoring; airway management; tube care:
gas exchange chest; cough enhancement; oxygen therapy; ventilation
assistance; anxiety reduction

NURSING ASSESSMENT
RATIONALE
SSeS
ee ss ree
Assess for signs and symptoms of impaired respiratory Early recognition ofsigns and symptoms of ineffective breathing
function: patterns allows for prompt intervention.
e Dyspnea, orthopnea
e Use of accessory muscles when breathing
e Abnormal breath sounds (e.g., diminished, bronchial, Changes in the characteristics of breath sounds may be due to
crackles, wheezes) airway obstruction, mucous plugs, or retained secretions in
e Asymmetrical or limited chest excursion larger airways.
° Cough (usually a productive cough of rust-colored, puru-
lent, or blood-tinged sputum)
e Restlessness, irritability Restlessness, irritability, and changes in mental status or level of
e Confusion, somnolence consciousness indicate an oxygen deficiency and require imme-
e Central cyanosis (a late sign) diate treatment.
e Significant decrease in oximetry results Oximetry is a noninvasive method of measuring arterial oxygen
saturation. The results assist in evaluating respiratory status.
e Abnormal arterial blood gas values Decreasing PaOz and increasing PaCO> are indicators of respira-
tory problems. '
e Changes in vital signs Increased work of breathing or hypoxia may cause tachycardia
and/or hypertension.
Assess arterial blood gas values, oximetry values, and chest Changes in infiltrates noted in the lungs require prompt treatment.
radiograph results. Report abnormal findings.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve respiratory status:
Place client in a semi-Fowler’s position and position overbed Positioning in semi-Fowler’s position promotes optimal gas
table so client can lean on it if desired. D@ + exchange by enabling chest expansion. Leaning on the overbed
table decreases dyspnea through pressure on the Sastric contents
and diaphragmatic contraction.
 Chapter 5 = The Client With Alterations in Respiratory Function 153

THERAPEUTIC INTERVENTIONS RATIONALE

° Instruct client to breathe slowly if hyperventilating. Slowing the pace of breathing makes each breath more effective.
° If client must remain flat in bed, assist with position Prevents consolidation of secretions.
change at least every 2 hrs. D+ @
e Assist client to deep breathe or use incentive spirometer Forced deep breathing and use of incentive spirometry will increase
every 1 to 2 hrs. D> expansion of the lungs and improve the client’s ability to clear
mucus from the lungs. The technique may also improve the
amount of oxygen that is able to penetrate deep into the lungs.
e Maintain client fluid intake of at least 2500 mL/day unless Increased fluid intake promotes thinning of secretions and reduces
contraindicated. D+ dryness of the respiratory mucous membranes.
e Instruct client to avoid intake of large meals, gas-forming Gas-forming foods and carbonated beverages can cause abdominal
foods (i.e., cauliflower, beans, cabbage, onions, etc.), and bloating, which places pressure on the diaphragm and reduces
carbonated beverages. lung expansion.
e Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause inflammation and damage to the bron-
chial and alveolar walls; the carbon monoxide decreases oxygen
availability.
e Maintain activity restrictions and increase activity as Conservation of energy through activity restrictions allows energy
allowed and tolerated. D@ + to be focused on breathing. Increasing activity as tolerated helps
mobilize secretions and promotes deeper breathing.

Dependent/Collaborative Actions
Implement measures to improve respiratory status:
e Assist with or perform postural drainage therapy if Prevents consolidation of secretions.
ordered.
e Perform suctioning if ordered. D+ Removes secretions from the large airways. It also stimulates
coughing, which helps clear airways of mucus and foreign mat-
ter.
e Humidify inspired air as ordered. D> Liquefies secretions, improving client’s ability to eliminate them
through expectoration
e Assist with administration of mucolytics and diluent or Mucolytics and diluent or hydrating agents help liquefy secretions
hydrating agents via nebulizer if ordered. D > for more effective removal.
e Avoid use of CNS depressants. CNS depressants further depress respiratory status, exacerbating
the client’s condition.
e Administer and monitor oxygen as ordered. D + Provides supplemental oxygen if required by client.
e Administer bronchodilators, antimicrobials, expectorants. Bronchodilators relax smooth muscles of the airway, thus improv-
D+ ing air exchange in the lungs. Antimicrobials may be given to
prevent or treat pneumonia. Expectorants help the client remove
secretions from the lungs.
Consult appropriate health care providers—(respiratory ther- Notifving the appropriate health care professionals allows for a
apist and physician) if signs and symptoms of impaired multidisciplinary approach to treatment.
respiratory function persist or worsen.

|Nursing >
Diagnosis -RISK FOR DEFICIENT FLUID VOLUME nox
Definition: Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may
compromise health.

Related to: Decreased oral intake and excessive fluid loss (occurs with profuse diaphoresis and hyperventilation if present)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of thirst Decreased B/P; decreased pulse pressure; decreased pulse
volume; decreased skin turgor; decreased urine output; dry
skin; elevated Hct; increased temperature; increased pulse
rate; weakness

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 154 Chapter5 * The Client With Alterations in Respiratory Function

RISK FACTORS DESIRED OUTCOMES

e Active fluid volume loss
The client will not experience a deficient fluid volume as
e Failure of regulatory mechanisms
evidenced by:
e Decreased fluid volume intake
a. Normal skin turgor
e Increased insensible loss of fluid
Moist mucous membrane
Stable weight
ie B/P and pulse rate within normal range for client and
stable with position change
Capillary refill time less than 2 to 3 seconds
Usual mental status
BUN and Het within normal range
Balanced intake and output
= Urine specific gravity within normal range
Oo
FI
ey

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; hydration; kidney function; vital signs Fluid management; fluid monitoring; fluid resuscitation;
hypovolemia management; intravenous therapy

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of deficient fluid volume: Early recognition of signs and symptoms of deficient fluid volume
e Decreased skin turgor allows for prompt intervention.
e Dry mucous membranes, thirst
e Weight loss of 2% or greater over a short period
e Postural hypotension and/or low B/P
e Weak, rapid pulse
e Capillary refill time greater than 2 to 3 seconds
e Neck veins flat when client is supine
e Change in mental status
e Elevated BUN and Hct
e Decreased urine output with increased specific gravity (re-
flects an actual rather than potential fluid volume deficit)

THERAPEUTIC INTERVENTIONS
RATIONALE
SSS
eee
Independent Actions
Implement measures to reduce nausea and vomiting if present: Nausea often causes the client to have decreased fluid volume
e Instruct client to ingest food/fluid slowly. intake. Persistent vomiting results in excessive loss of fluid.
e Eliminate noxious sights and odors. D @ +
Implement measures to control diarrhea if present: Persistent or severe diarrhea results in excessive loss of gastrointes-
° Discourage intake of spicy foods and foods high in fiber or tinal fluid.
lactose.
Implement measures to reduce fever if present: Fever may be accompanied by diaphoresis, which can result in
e Sponge bath client with tepid water. D@ + excessive loss of fluid.
e Remove excessive clothing or bedcovers. D@ +
Carefully measure drainage: Accurate intake/output records must be maintained to ensure fluid
e Nasogastric D+ loss is replaced appropriately.
e Wound D
° Urine D +

Dependent/Collaborative Actions
Maintain a fluid intake of at least 2500 mlL/day unless Adequate fluid intake needs to be provided in order to ensure
contraindicated. D+ adequate hydration.
Implement measures to reduce nausea and vomiting if Nausea often causes the client to have decreased fluid volume
present: intake. Persistent vomiting results in excessive loss of fluid.
e Administer antiemetics as ordered. D
Implement measures to control diarrhea if present: Persistent or severe diarrhea results in excessive loss of gastroint
es-
e Administer antidiarrheal agents as ordered. D tinal fluid.
Implement measures to reduce fever if present: Fever may be accompanied by diaphoresis, which can result
in
e Administer antipyretics as ordered. D + excessive loss of fluid.
 Chapters The Client With Alterations in Respiratory Function 155

THERAPEUTIC INTERVENTIONS RATIONALE

Administer and maintain intravenous replacement fluids as Replacing fluid volume that is lost helps prevent/treat deficient
ordered. fluid volume.
Consult physician if signs and symptoms of deficient fluid Notifying the physician allows for modification of the treatment
volume persist or worsen. plan.

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to: Increased expenditure of energy to support the work of breathing

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sore oral mucous membrane; altered Weight loss; weight less than normal for client’s age,
taste sensations height, and body frame; abnormal BUN and low serum
prealbumin and albumin levels; inflamed mucous
membranes; pale conjunctiva; dyspnea on exertion

RISK FACTORS DESIRED OUTCOMES

e Smoking The client will maintain adequate nutrition status as
e Aerosol treatments evidenced by:
e Productive cough a. Weight within normal range for client
e Dyspnea . Normal BUN and serum prealbumin and albumin levels
e Excessive coughing . Usual strength and activity tolerance
(SF. Healthy oral mucous membrane
(9)
(ak

NOC OUTCOMES NIC INTERVENTIONS

a ————

Nutritional status Nutritional monitoring; nutrition management; nutrition

therapy

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition of
signs and symptoms of malnutrition allows for
° Weight significantly below client’s usual weight or less prompt intervention.
than normal for client’s age, height, and body frame
e Abnormal BUN and low serum prealbumin and albumin
levels
e Increased weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
percentage of meals and snacks client consumes. Monitoring a client’s intake helps identify when a patient is at risk
Monitor
D@ + for inadequate nutrition and allows for prompt intervention.
Report inadequate intake.
Implement measures to maintain an adequate nutritional The foul odor and taste of sputum and some aerosols are likely to
decrease appetite. Appropriate scheduling of treatments also
status:
Schedule treatments that assist in mobilizing mucus (e.g., assists in decreasing nausea.
e
aerosol treatments, postural drainage therapy) at least
1 hr before or after meals. D +

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THERAPEUTIC INTERVENTIONS RATIONALE

° Increase activity as tolerated. D@ + Activity usually promotes a sense of well-being and can help
improve an individual’s appetite.
e Encourage a rest period before meals. Rest before a meal helps minimize the fatigue that may occur when
eating.
° Eliminate noxious sights and odors from the environ- Noxious sights and odors can decrease one’s appetite. By eliminat-
ment; provide client with an opaque, covered container ing them, the patient’s intake may improve.
for expectorated sputum. D @
° Maintain a clean environment and a relaxed, pleasant A clean environment and a relaxed atmosphere may increase
atmosphere. D@ intake.
° Provide oral hygiene before meals. D@ + Oral hygiene moistens the mouth, which makes it easier to chew
and swallow. It also removes unpleasant tastes, which often
improves the taste of foods/fluids.
° Assist the client who is quite dyspneic in selecting foods Dyspnea decreases the ability of an individual to eat complete
that require little or no chewing. meals.
° Serve frequent, small meals rather than large ones if Small, frequent meals decrease fatigue and help maintain an
the client is weak, fatigues easily, or has a poor appetite. individual’s nutritional status.
De+
° Limit fluid intake with meals unless the fluid has high Decreasing fluid intake during meals helps reduce early satiety and
nutritional value. D + subsequent decreased food intake.
° Allow for adequate time for meals. D @+ Clients who feel rushed during meals tend to become anxious, lose
their appetite, and stop eating.
° Ensure that meals are well balanced and high in essential A diet that is well balanced and high in essential nutrients meets
nutrients. the client’s nutritional needs.

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional
status:
° Place client in a high-Fowler’s position for meals and Supplemental oxygen helps relieve dyspnea.
provide supplemental oxygen therapy during meals if
indicated. D+
* Obtain a dietary consult to assist client in selecting foods/ Notifying the appropriate health care professionals allows for a
fluids that meet nutritional needs, are appealing, and multifaceted approach to treatment.
adhere to personal and cultural preferences.
° Perform a calorie count if ordered and report information A calorie count provides information about the caloric and
to dietitian and physician. nutritional value of the foods/fluids consumed. The informa-
tion helps the dietitian and physician determine whether an
alternative method of nutritional support is needed.
e Administer vitamins and minerals if ordered. D Administration of vitamins and minerals helps partially maintain
nutritional status ifdietary intake is not adequate.
Consult a physician about an alternative method of provid- Ifa client is unable to eat, collaboration with the physician is
ing nutrition (e.g., parenteral nutrition, tube feedings) if required to determine alternative methods of maintaining
client does not consume enough food or fluids to meet nutritional status.
nutritional needs.

"Nursing Diagnosis ACUTE PAIN nox (CHEST)

ty
Definition: Unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of
Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration
of less than 3 months.
Related to:
° Extension of the inflammatory/infection process to the pleura
° Muscle strain associated with excessive coughing
 Chapter 5 = The Client With Alterations in Respiratory Function 157

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain in chest with breathing and Increased blood pressure; increased heart rate; changes in
coughing respiratory rate; diaphoresis

RISK FACTORS DESIRED OUTCOMES

e Excessive coughing
The client will experience diminished chest pain as
e Increased sputum production
evidenced by:
¢ Smoking and exposure to second-hand smoke
a. Verbalization of a decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. increased participation in activities

NOC OUTCOMES NIC INTERVENTIONS

Comfort level; pain control Pain management; environmental management; analgesic

+ administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (e.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
pain, grimacing, reluctance to move, guarding of affected intervention and improved pain control.
side of chest).
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps
intensity rating scale. determine the most appropriate interventions for pain manage-
ment. Use of a pain intensity scale gives the nurse a clearer
understanding of the pain being experienced and promotes
consistency when communicating with others about the client’s
pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identification
duration, precipitating factors, aggravating factors, allevi- of effective pain management interventions.
ating factors).
Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex,
methods used to manage pain effectively. coping style, previous experience with pain, culture, cause of
pain). Knowledge of the client’s usual response to pain and
methods previously used to manage pain effectively enables
the nurse to evaluate the client’s pain more accurately and
facilitates the identification of effective strategies for pain
management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that chest pain is common with pneumonia and for pain and thereby heighten the perception of pain. In addi-
should subside with treatment of the pneumonia; assure tion, pain management methods are not as effective if the client
the client that the need for pain relief is understood). D + is tense and unable to relax.
Implement measures to promote rest (e.g., minimize environ- Fatigue can decrease the client’s threshold and tolerance for pain
mental activity and noise). D@ + and thereby heighten the perception ofpain. A client who is well
rested often experiences decreased pain and increased effective-
ness of pain management measures.
Instruct and assist the client to splint the chest with hands Splinting the chest with deep breathing, coughing, or changing
or pillows when deep breathing, coughing, or changing position reduces pain and promotes a more effective cough.
position. D+

Dependent/Collaborative Actions
Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing event
can cause pain and before pain becomes severe. D + helps minimize the pain that may be experienced during a
procedure.

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THERAPEUTIC INTERVENTIONS RATIONALE

Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
pharmacist, pain management specialist) if the provided tion of the treatment plan.
measures fail to provide adequate pain relief.

|Nursing ~..
Diagnosis HYPERTHERMIA npx
Definition: Core body temperature above the normal diurnal range due to failure of thermoregulation.
Related to: Stimulation of the thermoregulatory center in the hypothalamus by endogenous pyrogens that are related to an
infectious process

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chills Increased temperature; elevated heart rate; diaphoresis;
elevated respiratory rate; flushed skin; skin warm to touch

RISK FACTORS DESIRED OUTCOMES

e Infection
The client will experience resolution of hyperthermia as
e Smoking
e Smog evidenced by:
e Inadequate primary defenses a. Skin usual temperature and color
e Dehydration b. Pulse rate between 60 and 100 beats/min
c. Respiratory rate 12 to 20 breaths/min
d. Normal body temperature

NOC OUTCOMES NIC INTERVENTIONS

Thermoregulation Fever treatment

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of hyperthermia (e.g., warm, Early recognition of signs and symptoms of a fever allows for
flushed skin; tachycardia; tachypnea; elevated tempera- prompt intervention.
ture; chills; and excessive diaphoresis).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to resolve the infectious process:
° Assist client to cough and deep breathe frequently. D@ + Deep breathing and coughing will help remove secretions.
e Minimize environmental noise and activity. D@ + These actions promote rest and help conserve energy.
* Organize nursing care to allow for periods of uninter-
rupted rest. D@ +
e Provide adequate caloric and protein intake. Adequate nutrition is needed to support functioning of the immune
Implement measures to reduce elevated temperature. system. ‘
Administer tepid sponge bath and/or apply cold cloths to These interventions will work to decrease the client's temperature.
groin and axillae. D@
Use a room fan to provide cool circulating air. D@ + Maintains air circulation and may decrease environmental
temperature.

Dependent/Collaborative Actions
Implement measure to reduce elevated temperature. Helps decrease elevated temperature.
Apply a cooling blanket if ordered. D@ +
Administer antipyretics and antimicrobials if ordered. D Antipyretics will help reduce elevated temperature. Appropr
iately
prescribed anti-infectives can effectively treat the client’s infection
Consult physician if temperature remains elevated. .
Notify the physician if a client’s temperature does not
respond to
treatment.
 Chapterom The Client With Alterations in Respiratory Function 159

tiles fare meBIE Larexyns ACTIVITY INTOLERANCE nox

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Related to:
e Tissue hypoxia associated with impaired gas exchange
e Difficulty resting and sleeping associated with excessive coughing, dyspnea, discomfort, unfamiliar environment, anxiety,
and frequent assessments and treatments
e Inadequate nutritional status
e Increased energy expenditure associated with persistent coughing and the increased metabolic rate that is present in an
infectious process

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue or weakness Abnormal heart rate or B/P response to activity; exertional
discomfort or dyspnea; electrocardiographic changes
reflecting dysrhythmias or ischemia; unable to speak
with physical activity

RISK FACTORS DESIRED OUTCOMES

e Bedrest or immobility The client will demonstrate an increased tolerance for
e Generalized weakness
activity as evidenced by:
e Sedentary lifestyle a. Verbalization of feeling less fatigued and weak
e Imbalance between oxygen supply and demand b. Ability to perform ADL without dizziness, increased
dyspnea, chest pain, diaphoresis, and a significant
change in vital signs

NOC OUTCOMES NIC INTERVENTIONS

i

Energy conservation; rest; activity tolerance Energy management; oxygen therapy; sleep enhancement;
nutrition management; infection control

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention.
e Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping activ-
ity, change from regular to irregular rate)
° Significant change of 15 to 20 mm Hg in B/P with activity.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote rest and/or conserve energy Rest and activities that conserve energy result in a lower metabolic
(e.g., maintain prescribed activity restrictions, minimize rate, which preserves nutrients and oxygen for necessary
environmental activity and noise, provide uninterrupted activities.
rest periods, assist with care, keep supplies and personal
articles within easy reach, limit the number of visitors, use
shower chair when showering, sit to brush teeth or comb
hair). D@ +
Sleep replenishes a client’s energy and feeling of well-being.
Implement measures to promote sleep (¢.§., elevated head of
bed and support arms on pillows to facilitate breathing,
maintain oxygen therapy during sleep, discourage intake
of fluids high in caffeine in the evening, reduce environ-
-mental stimuli). D +

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THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to decrease excessive coughing (e.g., Excessive coughing can lead to inadequate tissue oxygenation,
protect client from exposure to irritants such as smoke, which results in less efficient energy production and a reduced
flowers, and powder; avoid extremely hot or cold foods/ ability to tolerate activity. Improving respiratory status
fluids). D @ increases the amount of oxygen available for energy production.
Discourage smoking and excessive intake of beverages high in Excessive intake of nicotine and caffeine can increase cardiac
caffeine such as coffee, tea, and colas. D workload and myocardial oxygen utilization, thereby decreasing
oxygen availability.
Perform actions to improve respiratory status (e.g., place Improvement of respiratory status is done to relieve dyspnea and
client in semi- to high-Fowler’s position; assist client to improve tissue oxygenation.
deep breathe or use incentive spirometry every 1 to
2 hrs; maintain bedrest as ordered; and use oxygen as
needed). D
Perform actions to maintain adequate nutritional status (e.g., Adequate nutritional status is important in order to maintain
increase activity as tolerated potentially improving ADL.
appetite; encourage a rest period before meals to reduce
fatigue; assist with oral hygiene before meals; maintain
a clean environment and a relaxed, pleasant atmosphere).
De+
Increase client’s activity gradually as allowed and tolerated. A gradual increase in activity will slowly improve strength and
De+ ability in performance of activities.
Instruct a client to: Changes in a client's activity tolerance should be reported immediately.
° Report a decreased tolerance for activity. Assessment of the change will allow for timely diagnosis of the
* Stop any activity that causes increased chest pain, in- cause and subsequent treatment.
creased shortness of breath, dizziness, or extreme fatigue
or weakness.

Dependent/Collaborative Actions
Consult appropriate health care providers (e.g., respiratory Notifying the appropriate health care provider allows for modifica-
therapist, physician, dietitian) if signs and symptoms of tion of the treatment plan.
activity intolerance persist or worsen.

|Nursing ~Diagnosis RISK FOR INFECTION nox: (EXTRAPULMONARY

(E.G., BACTEREMIA, PERICARDITIS, ENDOCARDITIS,
MENINGITIS, SEPTIC ARTHRITIS) AND/OR SUPERINFECTION
(E.G., CANDIDIASIS)
Definition: Susceptible to invasion and multiplication of pathogenic organisms,
which may compromise health.
Related to:
° Spread of infecting organisms into the blood and to other sites associated with
inadequate host defenses and resistance to
antimicrobial agents
* Interruption in the balance of usual endogenous microbial flora associated
with the administration of antimicrobial agents

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest pain, joint pain, fatigue, stiff Abnormal vital signs; unusual drainage from a body cavity;
neck, headache abnormal WBC and differential counts; white patches
and/or ulcerations in the mouth; yeast infecti
ons
 Chapter5 = The Ctient With Alterations in Respiratory Function 161

RISK FACTORS DESIRED OUTCOMES

e Smoking
The client will not develop an extrapulmonary infection
e Hospitalization
or a superinfection as evidenced by:
e Exposure to infectious agents
a. Gradual return of vital signs to the client’s normal
e Overuse of antimicrobial agents
range
b. Usual mental status
c. Absence of a pericardial friction rub, precordial pain,
and a pathological murmur
Absence of joint pain and swelling
Absence of unusual drainage from any body cavity
Absence of white patches and ulcerations in the mouth
Absence of stiff neck and headache
eh
mealies
WBC and differential counts returning toward normal
range for the client

NOC OUTCOMES NIC INTERVENTIONS

Immune status; infection severity Infection protection; infection control

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of an extrapulmo- Early recognition of signs and symptoms of an extrapulmonary or
nary infection or a superinfection: superinfection allows for prompt intervention.
Increase in temperature and pulse rate above previous
levels
e Change in mental status
e Pericardial friction rub, precordial pain, or development of
a pathological murmur
e Swollen, red, painful joints
e Unusual color, amount, and odor of vaginal drainage
(fungal infections are common. superinfections with
antimicrobial therapy); perineal itching; white patches or
ulcerated areas in the mouth
e Stiff neck, headache, increase in WBC count above previ-
ous levels and/or significant change in differential

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent an extrapulmonary infection
and/or a superinfection:
e Use good hand hygiene and encourage client to do the Good hand hygiene removes transient flora, which reduces the risk
same. D@ + of transmission of pathogens. Use of products such as an
antibacterial soap, a chlorhexidine solution, or an alcohol-
based hand rub agent can actually inhibit the growth of or kill
microorganisms, which further reduces infection risks.
° Maintain sterile technique during all invasive procedures Use of sterile technique reduces the possibility of introducing
(e.g., urinary catheterizations, venous and arterial punc- pathogens into the body.
tures, injections). D +
° Change peripheral intravenous tine sites according to Peripheral intravenous line sites are changed routinely to reduce
hospital policy. persistent irritation of one area of a vein wall and the resultant
colonization of microorganisms at that site.
° Protect client from others with infection. D@ + Protecting the client from others with infections reduces the client’s
risk of exposure to pathogens.
e Anchor catheters/tubings (e.g., urinary, intravenous) Trauma to the tissues and the risk for introduction of pathogens
securely. D + | associated with in-and-out movement of the tubing are reduced.
° Change equipment, tubings, and solutions used for treat- The longer equipment, tubings, and solutions are in use, the greater
ments such as intravenous infusions and respiratory care the chance of colonization of microorganisms, which can then
be introduced into the body.
according to hospital policy.

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THERAPEUTIC INTERVENTIONS RATIONALE

° Maintain a closed system for drains (e.g., urinary catheter) Each time a drainage or infusion system is opened, pathogens
and intravenous infusions whenever possible. D + from the environment have an opportunity to enter the body.
Maintaining a closed system decreases this risk, which reduces
the possibility of infection.
e Instruct and assist client to perform good perineal care Routine cleansing of the perineal area reduces the risk of coloniza-
routinely and after each bowel movement. D + tion of organisms and subsequent perineal, urinary tract, and/or
vaginal infection.
° Reinforce importance of frequent oral hygiene. D+ Frequent oral hygiene helps prevent infection by removing most
of the food, debris, and many of the microorganisms that are
present in the mouth. It also helps maintain the integrity of
the oral mucous membranes, which provides a physical and
chemical barrier to pathogens.

Dependent/Collaborative Actions
If signs and symptoms of an extrapulmonary infection or a An extrapulmonary and/or a superinfection should be addressed
superinfection occur: immediately. Preparation of the client for procedures that may
° Prepare client for and/or assist with diagnostic tests (e.g., be involved in the diagnostic process is important to alleviate
lumbar puncture, cultures, joint aspiration) if planned. associated fears and anxiety.
e Administer antimicrobials as ordered. Antimicrobials should be administered as soon as a culture and
sensitivity has been obtained.

Collaborative Diagnosis RISK FOR PLEURAL EFFUSION

Definition: An abnormal accumulation of fluid in the pleural cavity that may compromise lung expansion.

Related to: Pulmonary infection; increased permeability of capillary beds

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest pain (pleural); dyspnea Dull percussion note and diminished or absent breath
sounds; chest radiograph showing pleural effusion;
respiratory rate greater than 20 breaths/min; fever; night
sweats; cough; weight loss

RISK FACTORS DESIRED OUTCOMES

e Pulmonary infection
e Increased permeability of capillary beds The client will not develop pleural effusion as evi-
denced by:
a. No increase in dyspnea
b. Symmetrical chest excursion
c. Improved breath sounds and percussion note through-
out lung fields

NURSING ASSESSMENT RATIONALE ;

Assess for and report signs and symptoms of pleural effusion Early recognition of signs and symptoms of pleural effusion
allows
(e.g., dyspnea, chest pain, decreased chest excursion on for prompt intervention.
affected side, dull percussion note, decreased or absent
breath sounds over the affected area, chest radiograph
showing pleural effusion).
 Chapter5 = The Client With Alterations in Respiratory Function 163

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to resolve the infectious process: Resolution of an infectious process reduces the risk for development
of pleural effusion and/or atelectasis.
e Encourage coughing and deep breathing. Helps expand lungs and mobilize secretions.
e Administer antimicrobials as ordered. Treats infection.
If signs and symptoms of pleural effusion occur:
Continue with actions to improve respiratory status (e.g., in- Maintenance/improvement of the client’s respiratory status and
crease activity tolerance; instruct client in and assist with dia- removal of secretions decrease the potential of infection or the
phragmatic and pursed-lip breathing techniques; instruct occurrence of a pleural effusion.
client to deep breathe or use incentive spirometer every 1
to 2 hrs; encourage coughing and deep breathing; place
client in high semi-Fowler’s position).
e Prepare client for a thoracentesis if planned. Removal of fluid from the lungs will help improve the client’s
ability to maintain adequate gas exchange.

|Collaborative >
Diagnosis |RISK FOR ATELECTASIS

Definition: Collapse of lung tissue caused by hypoventilated alveoli.

Related to: Shallow respirations; stasis of secretion

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dyspnea Decreased breath sounds and/or crackles; cough; sputum
production; low-grade fever; heart rate greater than
60 to 100 beats/min; increased respiratory rate above
20 breaths/min/effort
Chest radiograph, ultrasound, or computed tomography
results showing patchy infiltrates

RISK FACTORS DESIRED OUTCOMES

e Ineffective cough effort The client will not develop atelectasis as evidenced by:
e Immobility a. Clear, audible breath sounds
e Smoking b. Resonant percussion note over lungs
c. Unlabored respirations at 12 to 20 breaths/min
. Pulse rate within normal range for client
o.
oa Afebrile status

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of atelectasis: Early recognition of signs and symptoms of atelectasis allows for
e Diminished or absent breath sounds implementation of the appropriate interventions.
e Dull percussion note over affected area
e Increased respiratory rate
e Dyspnea
e Tachycardia
e Elevated temperature
Monitor pulse oximetry results as indicated. Pulse oximetry is an indirect measure of arterial oxygen saturation.
Monitoring pulse oximetry (SaO2) allows for early detection of
hypoxia and implementation of the appropriate interventions.
Monitor chest radiograph results. Chest radiograph provides radiographic confirmation of atelectasis.

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 164 Chapter 5 * The Client With Alterations in Respiratory Function

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent atelectasis:
° Perform actions to improve breathing pattern: Lack of movement places a client at risk for atelectasis. Changing
° Encourage client to deep breathe. positions frequently, coughing, and deep breathing help expand
° Incentive spirometry the lungs, enhancing alveolar expansion.
° Perform actions to promote effective airway clearance. Helps mobilize secretions.
° Turn, cough, and breathe deeply.
Administer antibiotics as ordered. Treats infection.
If signs and symptoms of atelectasis occur:
° Increase frequency of position change, coughing or Improves lung expansion and mobilization of secretions.
“huffing,” deep breathing, and use of incentive spirometer.
Consult physician if signs and symptoms of atelectasis persist Allows for prompt alterations in interventions.
or worsen.

~
7) DEFICIENT KNOWLEDGE no», INEFFECTIVE HEALTH
MAINTENANCE nox, OR INEFFECTIVE HEALTH
MANAGEMENT?* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related
to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out
help to
maintain well-being; Ineffective Health Management NDx: Pattern of regulating and integrating
into daily living
a therapeutic regimen for the treatment of illness and its sequelae that is unsatisfact
ory for meeting
specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
° Denial of disease process
° Cognitive deficiency
° Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen; Health system guidance; teaching: individual; teaching:
infection control disease process; teaching: prescribed medications

NURSING ASSESSMENT RATIONALE

Assess client’s ability and readiness to learn. Learning is more effective when the client is motivated
and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness
to
learn changes based on situations and physical and
emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

_ee eee
Desired Outcome: The client will identify ways to maintain
respiratory health.
 Chaptertoum The Client With Alterations in Respiratory Function 165

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client in ways to maintain respiratory health:
e Consume a well-balanced diet. A well-balanced diet is important for the proper functioning of the
immune system.
Drink at least 10 glasses of liquid per day unless contra- Adequate fluid intake is necessary to liquefy secretions.
indicated.
e Maintain a balanced program of rest and exercise. Rest and exercise are important to maintain psychological and
physical well-being.
e Avoid crowds during flu and cold season. The potential for illness is decreased through avoidance of persons
e Avoid contact with persons who have respiratory infections. with respiratory infections and of crowds during the cold and
flu season.
e Consult physician about vaccinations available if at high Immunizations augment the client’s immune system in fighting off
risk for recurrent pneumonia. infection.
e Continue coughing and deep breathing exercises for at Deep breathing and coughing will help remove secretions.
least a few weeks after discharge and during any period of
decreased physical activity or respiratory infection.
e ~Maintain good oral hygiene. Good oral hygiene reduces the number of organisms in the
oropharynx.
e Avoid excessive alcohol intake and stop smoking to Avoidance of alcohol and smoking prevents depression of the
prevent depression of pulmonary antimicrobial defenses. pulmonary antimicrobial defenses.
e Avoid exposure to respiratory irritants (e.g., smoke and Respiratory irritation caused by smoke and other environmental
other environmental pollutants). pollutants can cause changes in respiratory status in susceptible
persons.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report the following signs and symptoms: The patient’s understanding of the signs and symptoms associated
e Persistent or recurrent temperature elevation with infection, superinfection, extension of infection to another
e Chills site, pleural effusion, and atelectasis is important for prompt
e Difficulty breathing identification, reporting, and treatment.
e Restlessness, irritability, drowsiness, or confusion
e Persistent or increased chest pain
e Persistent weight loss
e Persistent fatigue
e Persistent cough
e Unusual color, amount, and odor of vaginal secretions;
white patches or ulcerated areas in the mouth; stiff neck
and headache; or swollen, red, painful joints.
Reinforce the importance of keeping follow-up appointments A follow-up appointment with the health care provider is important
with health care provider. to monitor continued recovery.

THERAPEUTIC INTERVENTIONS RATIONALE

een

Desired Outcome: The client in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointment with health care
provider, medications prescribed, and activity limitations.

Independent Actions
Explain the rationale for, side effects of, and importance An informed client is more likely to adhere to medication regimens.
of taking medications prescribed (e.g., antimicrobials).
Inform client of pertinent food and drug interactions.

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 166 Chapter5 = The Client With Alterations in Respiratory Function

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eeTHERAPEUTIC INTERVENTIONS RATIONALE

ee
Implement measures to improve client compliance:
e Include significant others in all discharge teaching Involvement of significant others in patient teaching improves
sessions if possible. adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Everyone does not understand information as presented, so set aside
clarification of information provided. time for questions to allow for clarification of information.
Provide written instructions regarding scheduled appoint- Written instructions allow the client to refer to instructions as
ments with health care provider, medications prescribed, needed.
fluid requirements, respiratory care, and signs and symp-
toms to report.

ADDITIONAL NURSING DIAGNOSES

NAUSEA NDx FEAR NDx/ANXIETY NDx

Related to stimulation of the vomiting center associated with Related to severity of symptoms (e.g., cough, chest pain,
noxious stimuli (e.g., foul taste of sputum and some aerosol shortness of breath) and need for hospitalization, unfamiliar
treatments, sight of sputum) environment, and separation from significant others

DISTURBED SLEEP PATTERN NDx

Related to unfamiliar environment, discomfort, excessive
coughing, anxiety, inability to assume usual sleep position
because of dyspnea, and frequent assessments and treatments

PNEUMOTHORAX
Pneumothorax occurs when air accumulates in the pleural common type of closed pneumothorax occurs in the absence
space and causes complete or partial collapse of a lung. of obvious respiratory disease and is often referred to as a
Clinical manifestations vary with the degree of lung collapse primary spontaneous pneumothorax. Persons at greatest risk
but usually include sudden onset of unilateral sharp chest for this are men who are tall, 20 to 40 years of age, smokers,
pain, tachypnea, dyspnea, anxiety, agitation, absent or and have a family history of spontaneous pneumothorax.
diminished breath sounds, and tachycardia. When the pneu- Other causes of a closed pneumothorax include damage
mothorax is symptomatic and involves greater than 15% of to lung tissue as a result of a complication of pulmonary dis-
the lung tissue, it is usually treated with placement of a chest ease (e.g., COPD, cystic fibrosis, lung cancer, tuberculosis),
tube into the intrapleural space. The tube is then connected mechanical ventilation, a fractured rib, and migration of a
to suction through a closed water-seal drainage system or, subclavian catheter or pacemaker lead.
less frequently, to a flutter (Heimlich) valve to evacuate the This care plan focuses on the adult client hospital-
intrapleural air, reestablish negative intrapleural pressure, and ized for diagnosis and treatment of a pneumothorax.
reexpand the lung. After lung reexpansion, obliteration of
the pleural space may be necessary in some situations to
minimize the risk of a recurrent pneumothorax. Methods OUTCOME/DISCHARGE CRITERIA
for accomplishing this include chemical or mechanical
pleurodesis, partial pleurectomy, or pleural stapling. The client will:
A pneumothorax can be classified in a variety of ways (e.g., 1. Experience reexpansion of affected lung
open, Closed, iatrogenic, spontaneous [primary, secondary], 2. Have adequate respiratory function
traumatic [penetrating, blunt]). An open pneumothorax 3. Identify safety measures related to care of chest tupe
occurs when air enters the pleural space through an opening inser-
tion site and flutter valve (if present)
in the chest wall. This opening can result from a penetrating 4. Identify ways to reduce the risk of another pneumothorax
injury (e.g., gunshot wound, stab wound), surgery involving S. State signs and symptoms to report to the health
the chest or diaphragm, or a complication of a diagnostic care
provider
or therapeutic procedure (e.g., thoracentesis, lung biopsy, 6. Develop a plan for adhering to recommended follow-
insertion of a pacemaker, subclavian venipuncture),
up
care, including future appointments with a health
A closed pneumothorax occurs when air enters the pleural care
provider and activity restrictions
space without evidence of an external wound. The most
 Chapters = The Client With Alterations in Respiratory Function 167

Nursing Diagnosis INEFFECTIVE BREATHING PATTERN nox

Definition: Inspiration and/or expiration that does not provide adequate ventilation.
Related to:
e Increased rate of respirations associated with fear and anxiety
e Decreased rate of respirations associated with the depressant effect of some medications (e.g., narcotic [opioid] analgesics)
e Decreased depth of respirations associated with:
e Reluctance to breathe deeply resulting from chest pain and fear of dislodging chest tube or experiencing another
pneumothorax
e Complete or partial collapse of the lung
e Anxiety and the depressant effect of some medications (e.g., opioid analgesics)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain, anxiety, fear/agitation, shortness Tachypnea; dyspnea; hypotension; impaired chest wall
of breath expansion; cough and/or hemoptysis; diaphoresis;
. diminished breath sounds; tachycardia; use of accessory
muscles when breathing; significant decrease in oximetry
results; abnormal arterial blood gas values; chest
radiograph—collapsed lung

RISK FACTORS DESIRED OUTCOMES

e Fear The client will experience an effective breathing pattern as
e Anxiety evidenced by:
e Pain a. Normal rate and depth of respirations
b. Decreased dyspnea
c. Symmetrical chest excursion

NOC OUTCOMES NIC INTERVENTIONS

em

Respiratory status: ventilation Respiratory monitoring; ventilation assistance; anxiety

Management; pain management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms ofinfective breathing
pattern (e.g., shallow respirations, tachypnea, dyspnea, patterns allows for prompt intervention.
asymmetrical chest excursion, use of accessory muscles
when breathing).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve breathing pattern:
e Perform actions to reduce chest pain (e.g., orient client to Reduction of chest pain increases the client’s willingness to move
the hospital environment, equipment; maintain a calm, and breathe more deeply.
supportive, environment; instruct and assist client to
splint chest when coughing or deep breathing). De+
e Perform actions to reduce fear and anxiety (e.g., assure Reduction of fear and anxiety assists in preventing the shallow
client that staff members are nearby; respond to call signal and/or rapid breathing associated with these emotions.
as soon as possible; provide calm, restful environment;
instruct in relaxation techniques; encourage family to project
a supportive attitude without obvious anxiousness). D+
Place the client in semi- to high-Fowler’s position unless Positioning the client in semi- to high-Fowler’s position promotes
optimal gas exchange by enabling chest expansion.
contraindicated; position with pillows to prevent slumping.
Positioning with pillows prevents slumping.
De+

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 168 Chapter5 * The Client With Alterations in Respiratory Function

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THERAPEUTIC INTERVENTIONS RATIONALE

° Instruct client to breathe deeply or use incentive spirom- Forced deep breathing and use of incentive spirometry will increase
eter every 1 to2 hrs. D > expansion of the lungs and improve the client’s ability to clear
mucus from the lungs. The technique may also increase the
amount of oxygen that is able to penetrate deep into the lungs.
° Assure the client that deep breathing and turning should This assurance will decrease the client’s anxiety and fear associ-
not dislodge the chest tube or increase the risk of another ated with the chest tube and the original pneumothorax.
pneumothorax.
° Instruct the client to breathe slowly, if hyperventilating. Hyperventilation is an ineffective breathing pattern that can even-
tually lead to respiratory alkalosis. Clients can often slow their
breathing rate if they concentrate on doing so.
e Increase activity as allowed and tolerated. D@ + During activity, especially ambulation, the client usually takes
deeper breaths, thus increasing lung expansion.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
° Medicate with analgesics as needed. D+ Pain relief increases client’s willingness to take deep breaths and
improve lung expansion.
° Administer CNS depressants judiciously; hold medications CNS depressants cause depression of the respiratory center in the
and consult physician if respiratory rate is less than brainstem, which can result in a decreased rate and depth
12 breaths/min. D + of respiration.
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care provider allows for modifica-
therapist, physician) if ineffective breathing pattern tions of treatment.
continues.

“Nursing Diagnosis IMPAIRED GAS EXCHANGE nox

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-cap
illary membrane.
Related to: Loss of effective lung surface, associated with partial or complete lung collapse

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of restlessness, irritability, confusion, and Tachypnea; dyspnea; significant decrease in oximetry
somnolence results; decreased PaO, and/or increased PaCQ,; chest
radiograph—presence of air or blood in the pleural space
on the affected side and any mediastinal shift; abnormal
arterial blood gases-oxygen saturation less than 90%;
hypoxemia; hypercarbia; decreased Hgb and Het
associated with blood loss in a hemothorax; hypoxemia;
hypocarbia; nasal flaring; tachycardia

RISK FACTORS
DESIRED OUTCOMES
° Decreased lung expansion
° Pain The client will experience adequate O2/CO, exchange as
° Muscle fatigue evidenced by:
‘
° Obesity a. Usual mental status
b. Unlabored respirations of 12 to 20 breaths/min
c. Oximetry results within normal range
d. Arterial blood gas values within normal range

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: gas exchange Respiratory monitoring; oxygen therapy; chest
tube care;
acid-base management
 Chapter5 = The Client With Alterations in Respiratory Function 169

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired gas Early recognition of signs and symptoms of ineffective gas
exchange: exchange allows for prompt intervention.
° Restlessness, irritability
e Confusion, somnolence
e Tachypnea, dyspnea
e Significant decrease in oximetry results
e Decreased PaO, and/or increased PaCO,

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve gas exchange:
e Perform actions to promote lung reexpansion:
e Prepare client for and assist with insertion of chest Provide client with information related to the procedure to decrease
tube (the tube is then connected to a drainage system the experience of fear and anxiety.
[with or without suction] or, less commonly, to a flutter
- valve).
e After chest tube insertion, implement measures to main- These actions help ensure maintenance of the chest tube drainage
tain patency and integrity of chest drainage system: system and facilitate drainage.
e Maintain fluid level in water seal and suction chambers Fluid level determines the level of suction in a closed drainage
as ordered. system.
e Maintain occlusive dressing over chest tube insertion Maintains a seal around the chest tube insertion site, preventing
site. air leaks and loss of negative pressure
e Tape all connections securely. Supports maintenance of a closed system and reduces the risk of air
leaks
e Tape the tubing to the chest wall close to insertion site. Taping the tubing to the chest wall close to the insertion site
reduces the risk of inadvertent removal of the tube.
e Position tubing to avoid kinks; coil excess tubing on Excess tubing hanging over the bed in a dependent loop allows
the bed rather than allowing it to hang down below the drainage to collect in the loop and could occlude the drainage
collection device. D + system. Kinked tubing blocks drainage and may promote fluid
or blood accumulation in the pleural cavity.
° Keep drainage collection device below level of client’s The system must be lower than the level of the client’s chest to
chest at all times. promote chest tube drainage.
e Maintain suction as ordered; ensure that the air vent is These actions facilitate the escape of air from the pleural space.
open on the drainage collection device if the system is to
water seal only; if a flutter valve is present, ensure that there
is no fluid in the valve and that the distal end is open.
e Avoid stripping or clamping a chest tube. Stripping a chest tube may cause high negative pressure in the
pleural space and can potentially damage the lung tissue.
Clamping a chest tube can block air from escaping the pleural
space, which may lead to a tension pneumothorax.
° Keep a petrolatum gauze dressing at the bedside. This dressing is applied to the insertion site if the chest tube
becomes dislodged. This will maintain an airtight seal, prevent-
ing a recurrence ofapneumothorax.
° Keep a bottle of sterile water at the bedside. If the chest tube becomes disconnected, submerging it in a bottle of
sterile water will provide a temporary closed drainage system.
Perform actions to improve breathing patterns (e.g., place Positioning the client in semi- to high-Fowler’s position promotes
client in semi- to high-Fowler’s position to improve optimal gas exchange by enabling chest expansion.
air exchange; instruct client to breathe deeply or use Forced deep breathing and use of incentive spirometry will increase
incentive spirometer every 1 to 2 hrs). expansion of the lungs and improve the client’s ability to clear
mucus from the lungs. The technique may also increase the
amount of oxygen that is able to penetrate deep into the lungs.
e Discourage smoking. Smoking impairs gas exchange because it (1) reduces effective airway
clearance by increasing mucus production and impairing ciliary
function; (2) decreases oxygen availability (Hgb binds with the
carbon monoxide in smoke rather than with oxygen); (3) causes
damage to the bronchial and alveolar walls; and (4) causes
vasoconstriction and subsequently reduces pulmonary blood flow.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve gas exchange:
¢ Maintain activity restrictions as ordered; increase activity Conservation of energy through activity restrictions allows energy
gradually as allowed and tolerated. D ®+ to be focused on breathing. Increasing activity as tolerated helps
mobilize excretions and promotes deeper breathing and lung
expansion.
e Maintain oxygen therapy as ordered. D + Supplemental oxygen helps relieve dyspnea.
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care professionals allows for a
therapist, physician) if signs and symptoms of impaired prompt and multifaceted approach to treatment.
gas exchange persist or worsen.

Nursing Diagnosis” ACUTE PAIN nox (CHEST)

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and a duration of less than 3 months.

Related to: Irritation of the parietal pleura and associated with:

e Stretching of the pleura resulting from air in the pleural space
¢ ‘Tissue irritation associated with insertion and presence of a chest tube

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest pain with breathing and Grimacing; rubbing chest; reluctance to move; shallow
coughing respirations; restlessness; increased B/P; tachycardia

RISK FACTORS DESIRED OUTCOMES

e Excessive coughing Sa ee eat eet
e Increased sputum production The client will experience diminished chest pain as
° Chest tubes evidenced by:
a. Verbalization of a decrease in or absence of pain
Relaxed facial expression and body positioning
Improve breathing pattern
Increased participation in activities
oe
oF
ao Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

ese
Pain control; comfort level Pain management; environmental management; analgesic
administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of chest pain (e.g., verbalization Early recognition of signs and symptoms of pain allows for prompt
of pain, grimacing, rubbing chest, guarding of affected side intervention and improved pain control.
of chest, reluctance to move, shallow respirations, restless-
ness, increased B/P, tachycardia).
Assess Client's perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps
intensity rating scale. determine the most appropriate interventions for pain manage-
ment. Use of a pain intensity rating scale gives the nurse
a
clearer understanding of the pain being experienced and
promotes consistency when communicating with others
about
the client’s pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identific
ation
duration, precipitating factors, aggravating factors, allevi- ofeffective pain management interventions.
ating factors).
 ChapterS = The Client With Alterations in Respiratory Function 171

NURSING ASSESSMENT RATIONALE

Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex,
methods used to manage pain effectively. coping style, previous experience with pain, culture, cause of
pain). Knowledge of the client’s usual response to pain and
methods previously used to manage pain effectively enables the
nurse to evaluate the client’s pain more accurately and facilitates
the identification of effective strategies for pain management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that chest pain is common with pneumothorax and for pain and thereby heighten the perception of pain. In
should subside with treatment; assure client that the need addition, pain management methods are not as effective if the
for pain relief is understood). client is tense and unable to relax.
Implement measures to promote rest (e.g., minimize environ- Fatigue can decrease the client’s threshold and tolerance for pain
mental activity and noise). D@ + and thereby heighten the perception of pain. A client who is
well rested often experiences decreased pain and increased
+
effectiveness of pain management measures.
Perform actions to facilitate the escape of air from the pleural These actions promote the removal of air from the pleural space
space (e.g., maintain suction as ordered; ensure the air and work to expand lung tissue.
vent is open on the drainage collective device if system is
to water seal only; if flutter valve is present, ensure that
there is not fluid in the valve and that the distal end is
open).
Instruct and assist the client to splint the chest with hands Splinting the chest with deep breathing, coughing, or changing
or pillows when deep breathing, coughing, or changing position reduces pain and promotes a more effective cough.
position.
Provide or assist with nonpharmacological methods for Nonpharmacological pain management includes a variety of
pain relief (e.g., position change; progressive relaxation interventions. It is believed that most of these are effective
exercises; restful environment; diversional activities such because they stimulate closure of the gating mechanism in the
as watching television, reading, or conversing). spinal cord and subsequently block the transmission of pain
impulses. In addition, some interventions are thought to stimu-
late the release of endogenous analgesics (e.g., endorphins) that
inhibit the transmission of pain impulses and/or alter the
client’s perception of pain. Many of the nonpharmacological
interventions also help decrease pain by promoting relaxation.
Securely anchor the chest tube. Limiting movement of the chest tube prevents resulting tissue irri-
tation from the chest tube.

Collaborative/Dependent Interventions
Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing event
can cause pain and before pain becomes severe; and as helps minimize the pain that will be experienced. When given
ordered. D+ prior to a procedure, analgesics improve the client’s ability to
tolerate activities.
Consult appropriate health care provider (e.g., pharmacist, Notifying the appropriate health care professionals allows for a
pain management specialist, physician) if the provided prompt and multifaceted approach to treatment.
measures fail to provide adequate pain relief.

Diagnosis RISK FOR TENSION PNEUMOTHORAX

|Collaborative ~~ WITH
MEDIASTINAL SHIFT
Definition: Rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant
increased tension on the heart and great vessels; related to a significant increase in intrapleural pressure associated
with inability of air to leave pleural space during expiration (can occur as a result of chest tube or flutter valve
malfunction).

Related to: High intrapleural pressures, chest tube malfunction

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 WAZ Chapter5 = The Client With Alterations in Respiratory Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; fear; anxiety Lack of fluctuations in water seal chamber; dyspnea;
subcutaneous emphysema; expanding area of absent
breath sounds with hyperresonant percussion note; heart
rate irregular and greater than 100 beats/min; low B/P;
neck vein distention; hypoxemia (PaO, < 80 mm Hg);
hypercarbia (PaCO2 > 45 mm Hg); respiratory acidosis
(pH < 7.35); chest radiograph—expanding size of the
pneumothorax and mediastinal shift

RISK FACTORS DESIRED OUTCOMES

e Ineffective lung expansion
e Immobility The client will not develop tension pneumothorax with
° Stasis of secretions mediastinal shift as evidenced by:
. No sudden increase in dyspnea
. Vital signs within normal range for client
. Usual mental status
. Absence of neck vein distention
. Trachea in midline position
. Usual skin color
pp
& . Arterial blood gas values returning toward normal
amemoaan

NURSING ASSESSMENT
RATIONALE
eee
Assess for and immediately report signs and symptoms of: Early recognition of signs and symptoms of a malfunction in the
° Malfunction of chest drainage system (e.g., respiratory chest tube drainage system allows for prompt intervention
distress, lack of fluctuation in the water seal chamber and decreases the potential prevention of an extension of the
without evidence of lung reexpansion, excessive bubbling pneumothorax.
in water seal chamber, significant increase in subcutaneous
emphysema)
° Malfunction of the flutter valve if present (e.g., respiratory
distress, abrupt cessation of air flow from the distal end of
the valve during exhalation)
e Extended pneumothorax (e.g., extended area of absent
breath sounds with hyperresonant percussion note,
increased dyspnea, chest radiograph showing an increase
in size of pneumothorax)
° Tension pneumothorax (e.g., severe dyspnea, rapid and/or
irregular heart rate, hypotension, restlessness, agitation,
confusion, neck vein distention, shift in trachea from
midline, arterial blood gas values that have worsened,
chest radiograph showing a mediastinal shift).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to promote lung reexpansion (4a, Proper functioning of a closed chest drainage system réduces the
maintain proper functioning of the closed chest drainage risk of tension pneumothorax with mediastinal shift.
system).
If signs and symptoms of tension pneumothorax with
mediastinal shift occur:
Maintain client on bedrest in a semi- to high-Fowler’s Positioning the client in semi- to high-Fowler’s position promotes
position. optimal gas exchange by enabling chest expansion.
e Maintain oxygen therapy as ordered. Supplemental oxygen helps relieve dyspnea and improves gas exchange.
° Assist with clearing existing chest tube or flutter valve, By clearing existing chest tube/flutter valve, inserting
a new tube,
insertion of new tube, and/or needle aspiration of air from and/or performing needle aspiration, intrapleural pressure
is
the pleural space. reduced and lung expansion is promoted.
 Chapter5 = The Client With Alterations in Respiratory Function 3

|Nursing =
Diagnosis |FEAR nox/ANXIETY nox
|
Definition: Fear NDx: Response to perceived threat that is consciously recognized as a danger.
Anxiety NDx: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source
is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger.
It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with
the threat.

Related to:
e Exacerbation of symptoms (e.g., increased dyspnea, feeling of suffocation), need for hospitalization, and concern about
prognosis
_° Lack of understanding of the diagnosis, diagnostic tests, treatments, and prognosis
e Financial concerns about hospitalization

CLINICAL MANIFESTATIONS

Subjective. Objective
Verbal self-report of anxiety; usual perceptual ability and Unusual sleep patterns; unstable vital signs; restlessness;
interactions with others shakiness; diaphoresis; self-focused behavior

RISK FACTORS DESIRED OUTCOMES

e Pain
The client will experience a reduction in fear and anxiety
e Fear of unknown
as evidenced by:
e Fear of environment
. Verbalization of feeling less anxious
. Usual sleep pattern
. Relaxed facial expression and body movements
. Stable vital signs
Oe
oO
Oe . Usual perceptual ability and interactions with others

NOC OUTCOMES NIC INTERVENTIONS

Anxiety level; fear level; anxiety self-control; fear self-control Anxiety reduction; calming technique; emotional support;
presence; pain management

NURSING ASSESSMENT RATIONALE

Assess Client for signs and symptoms of fear and anxiety (e.g., Moderate anxiety enhances the client’s ability to solve problems,
verbalization of feeling anxious, insomnia, tenseness, shak- With severe anxiety or panic, the client is not able to follow
iness, restlessness, diaphoresis, elevated B/P, tachycardia, directions and may become hyperactive and extremely agitated.
self-focused behaviors).
Validate perceptions carefully, remembering that some behav- Assessment of the client’s fear helps determine whether the coping
ior may result from hypoxia and/or hypercapnia. mechanisms are effective and which need to be strengthened.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety:
e Orient client to hospital environment, equipment, and Familiarity with the environment and usual routines reduces the
routines. D@ client’s anxiety about the unknown, provides a sense of security,
and increases the client’s sense of control, all of which help
decrease anxiety.
e Introduce staff who will be participating in the client’s Introduction to staff familiarizes clients with those individuals
care. If possible, maintain consistency in staff assigned to who will be working with them, which provides clients with a
client’s care. feeling of stability, which reduces the anxiety that typically
occurs with change.
e Assure client that staff members are nearby; respond to call Close contact and a prompt response to requests provide a sense of
signal as soon as possible. D@ + security and facilitate the development of trust, thus reducing
the client’s anxiety.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to @volve for animation
174 Chapters The Client With Alterations in Respiratory Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Maintain a calm, supportive, confident manner when A sense of calmness and confidence conveys to the client that
interacting with client; encourage verbalization of fear and someone is in control of the situation, which helps reduce
anxiety. D@ + anxiety.
e Reinforce physician's explanations and clarify misconcep- Factual information and an awareness of what to expect help
tions the client has about the pneumothorax, treatment decrease the anxiety that arises from uncertainty.
plan, and possible recurrence; encourage questions.
e Implement measures to reduce respiratory distress if Improvement of respiratory status helps relieve the anxiety
present: associated with the feeling of not being able to breathe.
e Elevate the head of the bed.
e Encourage the client to breathe deeply and more slowly.
De+
e Implement measures to reduce pain: Pain can create or increase anxiety because it is often perceived as
e Instruct client in relaxation techniques and encourage a threat to well-being.
participation in diversional activities once the period of Pain also causes sympathetic nervous system stimulation with
acute pain and respiratory distress has subsided. subsequent feelings of tenseness and increased anxiety.
e When appropriate, assist the client to meet spiritual needs Spiritual support is a source of comfort and security for many
(e.g., arrange for a visit from the clergy). people and can help reduce the client’s fear and anxiety.
e Provide information based on current needs of client at a Providing information that the client is not ready to process or
level that can be understood. cannot understand tends to increase anxiety.
e Encourage the client to ask questions and to seek clarifica- Making the client feel comfortable enough to ask questions or
tion of information provided. clarify information helps reduce anxiety.
e Provide a calm, restful environment. D@ + A calm, restful environment facilitates relaxation and promotes a
sense of security, which reduces fear and anxiety.
e Encourage significant others to project a caring, concerned Anxiety is easily transferable from one person to another. If
attitude without obvious fear and anxiousness. D significant others convey empathy, provide reassurance, and do
not appear anxious, they can help reduce the client’s fear and
anxiety.

Dependent/Collaborative Actions
e Implement measures to reduce fear and anxiety:
e Administer oxygen via nasal cannula rather than mask if The use of a mask for some clients seems restrictive and suffocat-
possible. D+ ing. The use of a nasal cannula is more comfortable and less
constraining. Improvement of respiratory status helps relieve
anxiety associated with the feeling ofnot being able to breathe.
e Administer prescribed antianxiety agents if indicated. Reduces client’s fear and anxiety.
D+
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse clinician, physician) if the provided actions fail to tion of the treatment plan.
control fear and anxiety.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE Npx, INEFFECTIVE HEALTH

MAINTENANCE nox, OR INEFFECTIVE HEALTH
MANAGEMENT™ nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain
well-being; Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a
therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific
health goals.
 Chapter5 = The Client With Alterations in Respiratory Function 1S

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
e Denial of disease process
e Fear and anxiety that blocks ability to understand

_ NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; health promotion Health system guidance; teaching: individual; teaching:
procedure/treatment

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
client allows for implementation of the appropriate teaching
+
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify safety measures

related to care of chest tube insertion site and flutter valve
(if present).

Independent Actions
If the chest tube is removed before discharge, explain the The occlusive dressing over the insertion site maintains a seal to
importance of keeping a dressing over the insertion site the area where the chest tube was removed, preventing potential
until instructed by physician to remove it. air leaks and loss of negative pressure during healing. Removal
of this by someone other than a physician may cause a
recurrence of the pneumothorax.
If client is discharged with a flutter valve in place, reinforce
the following safety measures:
e Maintain an occlusive dressing around the insertion site. The occlusive dressing around the insertion site prevents potential
air leaks and loss of negative pressure.
e Ensure that the connection between the chest tube and Supports maintenance of a closed system and reduces the risk of air
flutter valve is taped securely and anchored to the chest leaks. Anchoring tubing to the chest wall close to the insertion
wall using tape. site reduces the risk of inadvertent removal of the tube.
e Maintain patency of the flutter valve (e.g., avoid occluding A decrease in patency of the flutter valve causes a loss ofnegative
the distal end of the flutter valve, contact physician if fluid pressure and may cause a recurrence of the pneumothorax.
collects in the valve, avoid activities such as swimming and
bathing [the valve should not be submerged in water)).
Allow time for questions and clarification of information Everyone does not understand information as presented, so set aside
provided. time for questions to allow for clarification of information.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of another pneumothorax.

Independent Actions
Caution client to avoid activities that involve experiencing Changes in atmospheric pressure may cause a recurrence in an
marked changes in atmospheric pressure (e.g., scuba diving, individual recovering from a pneumothorax.
flying in an unpressurized aircraft, mountain climbing).

NDx = NANDA Diagnosis D = Delegatable Action @=UAP > =LVN/LPN © = Goto ©volve for animation
 176 ChapterS = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Encourage client to stop smoking. Smoking impairs gas exchange because it (1) reduces effective air-
way clearance by increasing mucus production and impairing
ciliary function; (2) decreases oxygen availability (Hgb binds
with the carbon monoxide in smoke rather than with oxygen);
(3) causes damage to the bronchial and alveolar walls; and
(4) causes vasoconstriction and subsequently reduces pulmo-
nary blood flow.
Instruct client to continue treatment of any underlying lung Treatment of underlying lung disease helps prevent recurrence of a
disease (e.g,, COPD, tuberculosis) pneumothorax.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report the following signs and symptoms: Recognition of signs and symptoms of infection leads to early
e Difficulty breathing treatment of respiratory infections.
Chest pain
e Elevated temperature
e Chills
e Increased redness and warmth at chest tube insertion site
e Purulent drainage from chest tube insertion site or flutter
valve

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care, including future appointments with the
health care provider and activity restrictions.

Independent Actions
Reinforce importance of keeping follow-up appointments A follow-up appointment with the health care provider is impor-
with health care provider. tant to monitor continued recovery.
Instruct client to avoid excessive physical exertion and lifting Lifting an object over 10 Ib and physical exertion may place the
objects over 10 Ib until permitted by physician. client at risk for recurrence of a pneumothorax.
Reinforce physician’s explanation about the possibility of Clients need to be aware that they are at risk for a recurrence ofa
another pneumothorax. pneumothorax.
Assist client to develop a plan for obtaining emergency assis- An informed client is more likely to adhere to medication regimens.
tance if pneumothorax recurs.
Encourage client to continue with deep breathing exercises Forced deep breathing and use of incentive spirometry will increase
and use of incentive spirometer for the length of time rec- expansion of the lungs and improve the client’s ability to clear
ommended by physician. mucus from the lungs. The technique may also improve the
amount of oxygen that is able to penetrate deep into the lungs,
Implement measures to improve client compliance:
° Include significant others in teaching sessions if possible, Involvement of significant others in patient teaching improves
adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Information is presented with time for questions to allow for
clarification of information provided. clarification of information.
e Provide written instructions about precautions related to Written instructions allow the client to refer to instructions as
chest tube insertion site and flutter valve (if present), signs needed.
and symptoms to report, future appointments with health
care provider, and activity restrictions.
 ChapterS = The Client With Alterations in Respiratory Function 177

ADDITIONAL NURSING DIAGNOSES

NAUSEA NDx DISTURBED SLEEP PATTERN NDx

Related to stimulation of the vomiting center associated with Related to unfamiliar environment, discomfort, excessive
noxious stimuli (e.g., foul taste of sputum and some aerosol coughing, anxiety, inability to assume usual sleep position be-
treatments, sight of sputum) cause of dyspnea, and frequent assessments and treatments.

PULMONARY EMBOLISM
Pulmonary embolism is the partial or complete obstruction of to 6 months after discharge. If thrombolytic agents and anti-
one of the pulmonary arterial vessels by an embolus. The coagulant therapy are contraindicated or unsuccessful, or the
most common source of the embolus is a thrombus that source of the embolus is nonthrombotic, surgical removal of
originates in a deep vein of the lower extremities. The the embolus may be indicated.
embolus can also originate in the right side of the heart, the This care plan focuses on the adult client hospital-
upper extremities, and vessels that have sustained endothelial ized for treatment of a pulmonary embolism resulting
injury caused by factors such as trauma, surgery, or the from a deep vein thrombus. Much of the information
presence of an indwelling central venous catheter. Non- is also applicable to clients receiving follow-up care at
thrombotic sources of pulmonary embolism include air, fat, home.
amniotic fluid, tumor cells, and foreign material (e.g., broken
intravenous catheter, talc [often used to “cut” drugs injected
by intravenous drug abusers]). OUTCOME/DISCHARGE CRITERIA
The clinical manifestations of pulmonary embolism are
varied and nonspecific. The extensiveness of the signs and The client will:
symptoms depends on the size and number of emboli, size of 1. Have adequate respiratory function
the vessel that is occluded, extent of vessel occlusion, and 2. Have no signs and symptoms of complications
presence of preexisting cardiac or pulmonary disease. The 3. Identify ways to reduce the risk of recurrent thrombus
classic signs and symptoms of a moderate-size pulmonary formation and pulmonary embolism
embolism are sudden onset of dyspnea, tachypnea, tachycar- 4. Verbalize an understanding of medications ordered
dia, hypoxia, and a feeling of apprehension or impending including rationale, food and drug interactions, side
doom. The person may also experience pleuritic chest pain, effects, schedule for taking, and importance of taking as
cough, and low-grade fever. prescribed
Medical treatment varies depending on the source of the 5. Demonstrate the ability to correctly draw up and adminis-
embolus and its effect on cardiopulmonary function. When ter anticoagulant medication subcutaneously if prescribed
the source is a thrombus, treatment usually consists of bedrest 6. Identify ways to prevent bleeding associated with anti-
and immediate initiation of intravenous anticoagulant ther- coagulant therapy
apy. A thrombolytic agent might be administered if the 7. State signs and symptoms to report to the health care provider
thromboembolus is occluding a large vessel, cardiopulmo- ioe). Develop a plan for adhering to recommended follow-
nary status is severely compromised, or both. Anticoagulant up care, including future appointments with health care
therapy (subcutaneous and/or oral) often continues for 3 provider and activity level

|Nursing >
Diagnosis |oINEFFECTIVE BREATHING PATTERN nox
Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
e Increased rate of respirations associated with fear, anxiety, and stimulant effects of hypoxia
e Decreased rate of respirations associated with the depressant effect of some medications (e.g., narcotic [opioid] analgesics)
e Decreased depth of respirations associated with:
e Fear, anxiety, and reluctance to breathe deeply because of chest pain, if present
e Depressant effect of some medications (e.g., narcotic [opioid] analgesics)
e Decreased mobility

_NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto @volve for animation
 178 ChapterS * The Client With Alterations in Respiratory Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of restlessness, anxiety, nausea, chest Dyspnea; tachypnea; tachycardia; hypotension; impaired
pain, shortness of breath chest wall expansion; cough and/or hemoptysis; transient
pleural rub; jugular vein distention; diaphoresis; cyanosis;
abnormal breath sounds—crackles; $1 and S4 gallop
rhythms; transient pleural friction rub; fever; use of
accessory muscles when breathing; significant decrease in
oximetry results; abnormal arterial blood gas values; chest
radiograph—normal or elevated hemidiaphragm; after
24 hrs—small infiltrates

RISK FACTORS DESIRED OUTCOMES

¢ DVT
The client will experience an effective breathing pattern as
e Pain
evidenced by:
e Muscle fatigue
a. Normal rate and depth of respirations
e Obesity
b. Absence of dyspnea
e Immobility

NOC OUTCOMES NIC INTERVENTIONS

—.-_aeKkkt
eee

Respiratory status; ventilation Respiratory monitoring; ventilation assistance; anxiety man-

agement; pain management

NURSING ASSESSMENT RATIONALE

eee

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of ineffective breathing
pattern: patterns allows for prompt intervention.
e Rapid, shallow respirations
e Restlessness
e Significant decrease in oximetry results
e Abnormal arterial blood gas values
e Assess for significant abnormalities in chest radiograph
reports.

THERAPEUTIC INTERVENTIONS
RATIONALE
eee
Independent Actions
Implement measures to improve breathing pattern:
e Perform actions to reduce chest pain:
° Splint chest with pillow or hands when deep breathing, Splinting the chest with deep breathing, coughing, or changing posi-
coughing, and changing position. D @ tion reduces pain and promotes a more effective respiratory effort.
e Provide or assist with nonpharmacological methods Relaxation and diversional activities help alleviate pain, fear, and
for pain relief (e.g., relaxation techniques, restful anxiety. Pain causes sympathetic nervous system stimulation
environment, diversional activities). with subsequent feelings of tenseness and increased anxiety,
and can increase respiratory distress.
e Perform actions to reduce fear and anxiety: Reduction in fear and anxiety prevents the shallow and/or rapid
e Remain with client during periods of respiratory breathing that can occur with fear and anxiety. ’
distress.
e Provide a calm, restful environment. D @ A calm, restful environment facilitates relaxation and promotes a
sense of security, and reduces the rapid breathing associated
with fear and anxiety.
e Elevate the head of the bed. Provides for improved expansion of the lungs.
° Encourage the client to breathe deeply and more slowly. Helps calm the client while improving ventilation.
De+¢+
e Perform actions to improve gas exchange: Placing the client in a semi- to high-Fowler’s position promotes
Place client in a semi- to high-Fowler’s position unless optimal gas exchange by enabling chest expansion.
contraindicated. D @ +
¢ Position with pillows. D @ + Positioning with pillows helps prevent slumping.
 Chaptersue The Client With Alterations in Respiratory Function 179

_ THERAPEUTIC INTERVENTIONS RATIONALE

e Instruct client to breathe slowly; if hyperventilating, Deep breathing and use of incentive spirometry help reduce
instruct client to breathe deeply or use incentive spirom- dyspnea and improve tissue oxygenation.
eter every 1 to 2 hrs.
e Increase activity when allowed. D@ + Conservation of energy through activity restrictions allows energy
to be focused on breathing. Increasing activity as tolerated helps
mobilize excretions and promotes deeper breathing and lung
expansion.

Dependent/Collaborative Actions
- Implement measures to improve breathing pattern:
e Perform actions to reduce chest pain: Pain relief increases client’s willingness to take deep breaths and
e Administer analgesics as needed. improves lung expansion.
e Administer CNS depressants judiciously; hold medication CNS depressants cause depression of the respiratory center in the
and consult physician if respiratory rate is less than brainstem, which can result in a decreased rate and depth of
12 breaths/min. respiration.
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care professionals allows for a
therapist, physician) if ineffective breathing pattern persists prompt and multidisciplinary approach to treatment.
or worsens.

|Nursing oo"
Diagnosis |IMPAIRED GAS EXCHANGE nox
Definition: Deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Related to:
e Decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus and vasocon-
striction resulting from the release of vasoactive substances (e.g., serotonin, endothelin, some prostaglandins)
e Decreased bronchial airflow associated with bronchoconstriction resulting from:
e The release of substances such as serotonin and some prostaglandins
e A compensatory response to an increase in the amount of dead space in the underperfused lung area (the compensatory
bronchoconstriction also affects airways in perfused lung areas)
¢ Loss of effective lung surface associated with atelectasis if it occurs

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of restlessness; confusion; irritability; Tachypnea; dyspnea; diaphoresis; hypotension; decreased
somnolence; shortness of breath chest wall expansion; use of accessory muscles when
breathing; significant decrease in oximetry results;
abnormal arterial blood gas values; hypoxemia; hypocarbia;
nasal flaring; tachycardia

RISK FACTORS DESIRED OUTCOMES

Se Vall The client will experience adequate O2/CO, exchange as
e Pain
evidenced by:
° Muscle fatigue a. Usual mental status
e Obesity b. Unlabored respirations at 12 to 20 breaths/min
e Decreased lung expansion c. Oximetry results within normal range
d. Arterial blood gas values within normal range

NOC OUTCOMES NIC INTERVENTIONS

a ee EEUU UEEEE EEE NEEEE SSEEEESEE

Respiratory status: gas exchange Respiratory monitoring; oxygen therapy; airway

management; ventilation assistance; acid-base
management

_ NDx ='NANDA Diagnosis D = Delegatable Action @ = UAP @ =LVN/LPN ©P = Go to @volve for animation
 180 Chapter 5 = The Client With Alterations in Respiratory Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired gas Early recognition of signs and symptoms of impaired gas exchange
exchange: allows for prompt intervention.
e Restlessness, irritability
e Confusion, somnolence
e Tachypnea, dyspnea
e Abnormal arterial blood gas values
e Significant decrease in oximetry results
e Decreased PaO, and/or increased PaCO,

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve gas exchange:
e Maintain client on bedrest; increase activity gradually as Placing the client on strict bedrest will help conserve energy during
allowed and tolerated, D @ + periods of acute respiratory distress. Increasing activity gradu-
ally will improve strength and ability to perform activities.
e Discourage smoking, The carbon monoxide in smoke decreases oxygen availability,
and the nicotine can cause vasoconstriction and further reduce
pulmonary blood flow.

Dependent/Collaborative Actions
Implement measures to improve gas exchange:
e Maintain oxygen therapy as ordered. D > Supplemental oxygen helps relieve dyspnea and improves gas
exchange.
e Administer anticoagulants (e,g., continuous intravenous Anticoagulants will prevent blood clotting, which will help improve
heparin, low-molecular-weight heparin, warfarin) as ordered. pulmonary blood flow.
° Prepare client for the following if planned:
° Injection of a thrombolytic agent (e.g., streptokinase, Thrombolytics convert plasminogen to plasmin, which then
urokinase, alteplase) degrades the fibrin in clots. The loss of the fibrin results in the
lysis of a clot.
e Embolectomy An embolectomy is the surgical removal of a blood clot. The
patient should be educated about the procedure and _post-
operative care.
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care provider allows for a multi-
therapist, physician) if signs and symptoms of impaired faceted treatment plan.
gas exchange persist or worsen.

|Nursing 2-0")
Diagnosis ACUTE PAIN nox (CHEST)
Definition: Unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain);
sudden or slow onset of any intensity
from mild to severe with an anticipated or predictable end, and a duration
of less than 3 months.
Related to:
e Decreased pulmonary tissue perfusion associated with obstructed pulmonary blood
flow
e Inflammation of the parietal pleura associated with tissue damage if infarction occurs
i

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest pain with breathing and Grimacing; rubbing chest; reluctance to move; shallow
coughing respiration; tachycardia; increased B/P
 Chapter5 = The Client With Alterations in Respiratory Function 181

RISK FACTORS DESIRED OUTCOMES

DVT
e Excessive coughing The client will experience diminished chest pain as
e Increased sputum production evidenced by:
a. Verbalization of a decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. Increased participation in activities when allowed
d. Pulse and B/P within normal range for client

NOC OUTCOMES NIC INTERVENTIONS

i

- Pain control; pain level Analgesic administration; pain management; environmental

management: comfort; analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (e.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
pain, grimacing, reluctance to move, rubbing chest, guard- intervention and improved pain control.
ing of affected side of chest, shallow respirations, increased
B/P, tachycardia).
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps
intensity rating scale. determine the most appropriate interventions for pain manage-
ment. Use of a pain intensity scale gives the nurse a clearer
understanding of the pain being experienced and promotes
consistency when communicating with others about the client’s
pain experience.
Assess the client’s pain pattern (e.g., location, quality, Knowledge of the client’s pain pattern assists in the identification
onset, duration, precipitating factors, aggravating factors, of effective pain management interventions.
alleviating factors).
Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex,
methods used to manage pain effectively. coping style, previous experience with pain, culture, cause of
pain). Knowledge of the client’s usual response to pain and
methods previously used to manage pain effectively enables
the nurse to evaluate the client’s pain more accurately and
facilitates the identification of effective strategies for pain
management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that chest pain is common with embolism and for pain and thereby heighten the perception of pain. In addi-
should subside with treatment; assure the client that the tion, pain management methods are not as effective if the client
need for pain relief is understood). is tense and unable to relax.
Implement measures to improve gas exchange:
e Maintain client on bedrest and increase activity gradually Placing the client on strict bedrest will help conserve energy during
as allowed and tolerated. D@ + periods of acute respiratory distress. Increasing activity gradu-
ally will improve strength and ability to perform activities.
Place client in a semi- to high-Fowler’s position unless contra- Positioning the client in semi- to high-Fowler’s position promotes
indicated. D @® + optimal gas exchange by enabling chest expansion.
° Position with pillows. D@ + Positioning with pillows helps prevent slumping.
e Instruct and assist the client to splint the chest with hands Splinting the chest with deep breathing, coughing, or changing
or pillows when deep breathing, coughing, or changing position reduces pain and promotes a more effective cough.
position. D@® +
e Instruct client to breathe slowly if hyperventilating.
e Instruct client to breathe deeply or use incentive spirom- Deep breathing and use of incentive spirometry help expand the
eter every 1 to 2 hrs. D> lungs and improve oxygenation.
e Provide or assist with nonpharmacological methods for Relaxation and diversional activities help alleviate pain, fear, and
pain relief (e.g., relaxation techniques, restful environ- anxiety, which in turn will decrease dyspnea.
ment, diversional activities).

. NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN © = Goto @volve for animation
182 @hapterioms The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Implement measures to promote rest (e.g., minimize envi- A calm, restful environment facilitates relaxation and promotes a
ronmental activity and noise). D@ + sense of security, and reduces rapid breathing associated with
fear and anxiety.

Dependent/Collaborative Actions
Implement measures to improve gas exchange:
e Maintain oxygen therapy as ordered. D + Supplemental oxygen helps relieve dyspnea and improves gas
exchange.
Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing event
can cause pain and before pain becomes severe. D + helps minimize the pain that will be experienced. Analgesics are
also more effective ifgiven before a procedure and will improve
the client’s ability to tolerate the procedure.
Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for a
pharmacist, pain management specialist) if the provided multifaceted treatment plan.
measures fail to provide adequate pain relief.

|Nursing =
Diagnosis: RISK FOR BLEEDING nox |
Definition: Susceptible to a decrease in blood volume, which may compromise health.

Related to: Excessive use of thrombolytics and anticoagulants

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of excessive or unusual bruising Petechiae; bruises easily; prolonged bleeding from
puncture sites; unusual joint pain; hypotension;
tachycardia; decreases in Hgb and Hct

RISK FACTORS DESIRED OUTCOMES

e Treatment regimen
The client will not experience unusual bleeding as
evidenced by:
a. Skin and mucous membranes free of petechiae, purpura,
ecchymoses, and active bleeding
b. Absence of unusual joint pain
(ey) . No increase in abdominal girth
d. Absence of frank and occult blood in stool, urine, and
vomitus
e. Usual menstrual flow
f. Vital signs within normal range for client
g. Stable Hct and Hgb

NOC OUTCOMES NIC INTERVENTIONS

Blood coagulation; blood loss severity Bleeding precautions; bleeding reduction; blood product
administration

NURSING ASSESSMENT RATIONALE

a

Assess client for and report signs and symptoms of unusual Early recognition of signs and symptoms of unusual bleeding,
bleeding: which may occur as part of the infarction process and from
e Petechiae, purpura, ecchymoses medications (i.e., thrombolytics and anticoagulants) during
e Gingival bleeding treatment of a thrombus or pulmonary embolism, allows for
e Prolonged bleeding from puncture sites implementation of the appropriate interventions.
e Epistaxis, hemoptysis
e Unusual joint pain
e Increase in abdominal girth
 Chapters: The Client With Alterations in Respiratory Function 183

NURSING ASSESSMENT RATIONALE

e Frank or occult blood in stool, urine, or vomitus
¢ Menorrhagia
e Restlessness, confusion
e Decreasing B/P and increased pulse rate
e Decrease in Hct and Hgb levels

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
~ Monitor platelet count and coagulation test results (e.g., pro- Monitoring effectiveness and dosage requirements of heparin and
thrombin time or international normalized ratio [INR], warfarin is done via prothrombin time/INR/activated partial
activated partial thromboplastin time). Report a low plate- thromboplastin time. Platelet counts should be monitored every
let count and coagulation test results that exceed the 2 to 3 days because these medications may cause mild throm-
therapeutic range. bocytopenia.
If platelet count is low, coagulation test results are abnormal, Increased bleeding may occur when a patient is receiving anti-
or Hct and Hgb levels decrease, test all stools, urine, and coagulant therapy. Reporting any signs of bleeding, including a
yomitus for occult blood. Report positive results. positive result for occult blood, allows for timely treatment and
changes in medication dosage as needed.
Implement measures to prevent bleeding:
e Avoid giving injections whenever possible; consult a physi- It is important to prevent bleeding while the patient is receiving
cian about prescribing an alternative route for medications anticoagulants. Injections may cause increased bleeding and
ordered to be given intramuscularly or subcutaneously. oozing from the injection sites.
e When giving injections or performing venous or arte- Use of the smallest needle possible and application of gentle,
rial punctures, use the smallest gauge needle possible prolonged pressure at the puncture site will help prevent
and apply gentle, prolonged pressure to the site after excessive bleeding.
the needle is removed. D+
e Caution client to avoid activities that increase the risk for These activities increase the risk of trauma and associated bleeding.
trauma (e.g., shaving with a straight-edge razor, using stiff
bristle toothbrush or dental floss).
e Whenever possible, avoid intubations (e.g., nasogastric) Procedures that may cause injury to the mucous membranes may
and procedures that can cause injury to the rectal mucosa cause excessive bleeding. If the client must undergo one of
(e.g., taking temperature rectally, inserting a _ rectal these procedures, the nurse must monitor the client closely for
suppository, administering an enema). bleeding.
e Perform actions to reduce the risk for falls (e.g., keep bed in Falls are another way that a client who is receiving anticoagulants
low position with side rails up when client is in bed, avoid may experience increased bleeding. Mechanisms should be put
unnecessary clutter in room, instruct client to wear slippers/ in place to decrease the risk of falls.
shoes with nonslip soles when ambulating). D @ +
¢ Pad side rails if client is confused or restless.
e Instruct client to avoid blowing nose forcefully or Forcefully blowing one’s nose or straining with a bowel movement
straining to have a bowel movement; consult physician should be avoided during anticoagulant therapy because these
about an order for a decongestant and/or laxative if actions may increase bleeding.
indicated.
If bleeding occurs and does not subside spontaneously:
e Apply firm, prolonged pressure to bleeding areas if possible. Pressure at the site helps promote clotting.
If epistaxis occurs, place client in a high-Fowler’s position and Placing the client in high-Fowler’s and applying pressure and ice to
apply pressure and ice pack to nasal area. the nasal area helps promote clotting.
° Maintain oxygen therapy as ordered. D + Oxygen therapy will assist in maintaining oxygen saturation if
bleeding occurs.
e Administer protamine sulfate (antidote for heparin), vita- Administration of the antidotes for heparin and warfarin will
min K (e.g., phytonadione), and/or whole blood or blood reverse the effects of these medications and decrease bleeding.
products (e.g., fresh frozen plasma, platelets) as ordered.

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 184 Chapter5 * The Client With Alterations in Respiratory Function

Collaborative Diagnoses RISK FOR RIGHT-SIDED HEART FAILURE

Definition: A condition where the right side of the heart is unable to pump blood efficiently.

Related to:
Increased cardiac workload associated with:
e Pulmonary hypertension (can result from pulmonary vasoconstriction that occurs in response to hypoxia and the release of
vasoactive substances)
* Compensatory response to decreased pulmonary blood flow that results from obstruction of multiple and/or large pulmo-
nary vessels

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness and fatigue Tachypnea; tachycardia; dyspnea; restlessness; confusion;
irritability; peripheral edema; decreased urine output;
distended neck veins

RISK FACTORS DESIRED OUTCOMES

e Smoking
The client will not develop right-sided heart failure as
e Chronic respiratory disease
evidenced by:
e Obesity
. Pulse rate of 60 to 100 beats/min
e Hypertension
. Usual mental status
. Usual strength and activity tolerance
. Adequate urine output
. Stable weight
sD. Absence of edema and distended neck veins
moand

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of right-sided heart Early recognition of signs and symptoms of right-sided heart failure
failure: allows for prompt intervention.
e Further increase in pulse rate
e Restlessness, confusion
e Weakness and fatigue
e Decreased urine output
e Weight gain
e Dependent peripheral edema
e Distended neck veins
e Chest radiograph results showing cardiomegaly

THERAPEUTIC INTERVENTIONS RATIONALE

SSS
Dependent/Collaborative Actions
Implement measures to improve pulmonary blood flow: These interventions will reduce cardiac workload and the subse-
quent risk of right-sided heart failure by decreasing the pressure
against which the heart must pump.
e Administer anticoagulants (e.g., continuous intravenous hepa- Anticoagulants will prevent blood clotting, which will help improve
rin, low-molecular-weight heparin, warfarin [as ordered]). pulmonary blood flow and decrease the potential of an exten-
sion or recurrence of apulmonary embolism.
e Prepare client for the following if planned:
e Injection of a thrombolytic agent (e.g., streptokinase, Thrombolytics convert plasminogen to plasmin, which then degrades
urokinase, alteplase) the fibrin in clots. The loss of the fibrin results in the lysis of a clot.
e Embolectomy An embolectomy is the surgical removal of a blood clot. The patient
should be educated about the procedure and postoperative care.
If signs and symptoms of right-sided heart failure occur:
e Maintain oxygen therapy as ordered. Supplemental oxygen helps relieve dyspnea and improves gas exchange.
Maintain client on strict bedrest in a semi- to high-Fowler’s Placing the client on strict bedrest will help conserve energy during
position periods ofacute respiratory distress. Positioning the client in a
semi- to high-Fowler’s position promotes optimal gas exchange
by enabling chest expansion.
 Chapter5 = The Client With Alterations in Respiratory Function 185

THERAPEUTIC INTERVENTIONS RATIONALE

e Maintain fluid and sodium restrictions if ordered. Restricting a client’s sodium and fluid will help reduce fluid volume
overload.
e Administer medications that may reduce vascular conges- Diuretics decrease fluid volume through inhibiting reabsorption of
tion and/or cardiac workload (e.g., diuretics, cardiotonics, water, which decreases fluid volume.
vasodilators) Cardiotonics increase the contractile force of the heart, which
increases cardiac output.
Vasodilators dilate the arterioles, which decreases B/P and
decreases the work of the heart.

| |Collaborative Diagnosis
Diagnosis. RISK FOR ATELECTASIS

Definition: Collapse of lung tissue caused by hypoventilated alveoli.

Related to:
e Shallow respirations
e Stasis of secretions in alveoli and bronchioles
e Decreased surfactant production (results from inadequate deep breathing and changes in regional blood flow in the lungs)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty breathing Diminished or absent breath sounds; dull percussion
over affected area; increased respiratory rate; dyspnea;
tachycardia; elevated temperature

RISK FACTORS DESIRED OUTCOMES

e Immobility
The client will not develop atelectasis as evidenced by:
e Ineffective airway clearance
a. Clear, audible breath sounds
e Smoking
b. Resonant percussion note over lungs
e Obesity
fo). Unlabored respirations at 12 to 20 breaths/min
d. Pulse rate within normal range for client
fo). Afebrile status

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of atelectasis: Early recognition of signs and symptoms of atelectasis allows for
e Diminished or absent breath sounds implementation of the appropriate interventions.
e Dull percussion noted over affected area
e Increased respiratory rate
e Dyspnea
e Tachycardia
e Elevated temperature
Monitor pulse oximetry results as indicated. Pulse oximetry is an indirect measure of arterial oxygen saturation.
Monitoring pulse oximetry (SaO2) allows for early detection of
hypoxia and implementation of the appropriate interventions.
Monitor chest radiograph results. Chest radiograph provides radiographic confirmation of atelectasis.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent atelectasis: D + Improves client ability to expand lung tissue and improve oxygen-
e Perform actions to improve breathing pattern: ation and clearance of mucous
e Encourage client to breathe deeply.
e Incentive spirometry
e Perform actions to promote effective airway clearance.
e Turn, cough, and breathe deeply.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN ©) = Go to ©volve for animation
 186 ChapterS = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of atelectasis occur: Lack of movement places a client at risk for atelectasis. Changing
e Increase frequency of position change, coughing or “huff- positions frequently, coughing, and deep breathing help expand
ing,” deep breathing, and use of incentive spirometer. the lungs, enhancing alveolar expansion.
Consult physician if signs and symptoms of atelectasis persist Notifying the appropriate health care provider will allow for
or worsen. modification of the treatment plan.

|Nursing s
Diagnosis |6FEAR nox/ANXIETY nox
Definition: Fear NDx: Response to perceived threat that is consciously recognized as a danger.
Anxiety NDx: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source
often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an
alerting signal that warns of impending danger and enables the individual to take measures to deal with a threat.
Related to:
e Exacerbation of symptoms (e.g., increased dyspnea, feeling of suffocation)
e Lack of understanding of the diagnosis, diagnostic tests, treatments, and prognosis
e Unfamiliar environment
e Possibility of recurrent embolism; threat of death

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fear and/or anxiety Unusual sleep patterns; unstable vital signs; restlessness;
shakiness; diaphoresis; self-focused behavior

RISK FACTORS DESIRED OUTCOMES

e Fear of the unknown
e Fear of death The client will experience a reduction in fear and anxiety
e Pain as evidenced by:
e Unknown environment a. Verbalization of feeling less anxious
e Fear of recurrence of embolism
b. Usual sleep pattern
Qa . Relaxed facial expression and body movements

d. Stable vital signs

oO . Usual perceptual ability and interactions with others

NOC OUTCOMES NIC INTERVENTIONS

Anxiety level; fear level; anxiety self-control; fear self-control Anxiety reduction; calming technique; emotional support;
presence; pain management

NURSING ASSESSMENT
RATIONALE
eee
Assess Client for signs and symptoms of fear and anxiety (e.g., Moderate anxiety enhances the client’s ability to solve problems.
verbalization of feeling anxious, insomnia, tenseness, With severe anxiety or panic, the client is not able to follow
shakiness, restlessness, diaphoresis, elevated B/P, tachycar- directions and may become hyperactive and extremely agitated.
{%
dia, self-focused behaviors).
Validate perceptions carefully, remembering that some behav- Assessment of the client’s fear helps determine whether the coping
ior may result from hypoxia and/or hypercapnia. mechanisms are effective and which need to be strengthened.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety:
e Orient client to hospital environment, equipment, and Familiarity with the environment and usual routines reduces the
routines. D@ + client’s anxiety about the unknown, provides a sense of security,
and increases the client’s sense of control, all of which help
decrease anxiety.
 Chapter sw The Client With Alterations in Respiratory Function 187

THERAPEUTIC INTERVENTIONS RATIONALE

e Introduce staff who will be participating in the client’s Introduction to staff familiarizes clients with those individuals
care. If possible, maintain consistency in staff assigned to who will be working with them, which provides clients with
client’s care. a feeling of stability, which reduces the anxiety that typically
occurs with change.
e Assure client that staff members are nearby; respond to call Close contact and a prompt response to requests provide a sense of
signal as soon as possible. D @+ security and facilitate the development of trust, thus reducing
the client’s anxiety.
e Maintain a calm, supportive, confident manner when A sense of calmness and confidence conveys to the client that
interacting with client; encourage verbalization of fear and someone is in control of the situation, which helps reduce
anxiety. D@ + anxiety.
e Reinforce physician’s explanations and clarify misconcep- Factual information and an awareness of what to expect help
tions the client has about the pulmonary embolus, treat- decrease the anxiety that arises from uncertainty.
ment plan, and possible recurrence; encourage questions.
e Implement measures to reduce respiratory distress if Improvement of respiratory status helps relieve anxiety associated
present: with the feeling of not being able to breathe.
e Elevate the head of the bed.
2 Encourage the client to breathe deeply and more slowly.
De+
e Implement measures to reduce pain: Pain can create or increase anxiety because it is often perceived as
e Instruct the client in relaxation techniques and encour- a threat to well-being.
age participation in diversional activities once the period Pain also causes sympathetic nervous system stimulation with
of acute pain and respiratory distress has subsided. subsequent feelings of tenseness and increased anxiety.
e When appropriate, assist the client to meet spiritual needs Spiritual support is a source of comfort and security for many
(e.g., arrange for a visit from the clergy). people and can help reduce the client’s fear and anxiety.
e Provide information based on current needs of the client Providing information that the client is not ready to process or
at a level that can be understood. cannot understand tends to increase anxiety.
e Encourage the client to ask questions and to seek Making the client feel comfortable enough to ask questions or
clarification of information provided. clarify information helps reduce anxiety.
e Provide a calm, restful environment. D @ + A calm, restful environment facilitates relaxation and promotes a
sense of security, which reduces fear and anxiety.
e Encourage significant others to project a caring, concerned Anxiety is easily transferable from one person to another. If
attitude without obvious fear and anxiousness. significant others convey empathy, provide reassurance, and do
not appear anxious, they can help reduce the client’s fear and
anxiety.

Dependent/Collaborative Actions
Implement measures to reduce fear and anxiety:
e Administer oxygen via nasal cannula rather than mask if The use of a mask for some clients seems restrictive and suffocat-
possible. D+ ing. The use of a nasal cannula is more comfortable and less
constraining. Improvement of respiratory status helps relieve
anxiety associated with the feeling ofnot being able to breathe.
e Administer prescribed antianxiety agents if indicated. Decreasing anxiety may improve respiratory status.
D+
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse clinician, physician) if the provided actions fail to tion of the treatment plan.
control fear and anxiety.

Diagnosis DEFICIENT
|Nursing >». KNOWLEDGE nox, INEFFECTIVE HEALTH
MAINTENANCE nox, OR INEFFECTIVE HEALTH MANAGEMENT® nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition,
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain well-
being; Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation
 188 Chapter5 * The Client With Alterations in Respiratory Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
e Denial of disease process
° Fear and anxiety that blocks ability to understand

NOC OUTCOMES NIC INTERVENTIONS

——————
eee

Knowledge: disease process; treatment regimen Health system guidance; teaching: individual; teaching:
prescribed medication; teaching: prescribed activity/exercise;
teaching: psychomotor skill

NURSING ASSESSMENT RATIONALE

Assess client readiness to learn Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client client allows for appropriate teaching interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of recurrent thrombus formation and pulmonary
embolism.

Independent Actions
Provide the following instructions on ways to promote
venous blood flow and reduce the risk of thrombus
recurrence:
e Avoid wearing constrictive clothing (e.g., garters, girdles, Wearing constrictive clothing decreases blood flow from the lower
narrow-banded knee-high hose). extremities, increasing the risk of a thrombus.
e Avoid sitting and standing in one position for long Decreases the ability of veins to prevent stasis of blood.
periods.
° Avoid crossing legs and lying or sitting with pillows under Decreases blood flow and increases the risk of developing a
knees. thrombus.
e Wear graduated compression stockings or support hose Compression stockings and support hose prevent venous dilation
during the day. and increase blood flow to the heart.
° Engage in regular aerobic exercise (e.g., swimming, Each of these activities stimulates venous blood return to the heart,
walking, cycling) decreasing the incidence ofa thrombus.
° Elevate legs periodically, especially when sitting.
e Dorsiflex feet regularly.
° Maintain recommended weight for age, height, and body Overweight individuals are at a higher risk for development
frame. of a thrombus because of increased endothelial fibrinolytic
dysfunction and an increased risk for atherothrombotic
events.
e Inform client that smoking and the use of estrogen or oral Smoking and the use of estrogens or oral contraceptives have
contraceptives can increase the risk for recurrent thrombus been associated with thrombus formation and peelmonary
formation. embolism.
° Instruct client to avoid trauma to or massage of any area Trauma or massage to an area of suspected thrombus may dislodge
of suspected thrombus formation in order to decrease the the thrombus into the vascular system and place the patient at
risk of pulmonary embolism. risk for a pulmonary embolism.
° Provide information regarding exercise programs and sup- Providing information on community resources provides a contin-
port groups that can assist the client to stop smoking and/ uum ofcare.
or lose weight.
 Chapter5 = The Client With Alterations in Respiratory Function 189

~a

THERAPEUTIC INTERVENTIONS RATIONALEsss

a Ss Ss SS SSS se Ur sss ns rh

Desired Outcome: The client will verbalize an under-

standing of medications ordered, including rationale, food
and drug interactions, side effects, schedule for taking, and
importance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, and importance of Understanding of the impact of medications improves adherence.
taking medications prescribed.
If client is discharged on warfarin (e.g., Coumadin),
instruct to:
e Keep scheduled appointments for periodic blood studies to Appropriate dosing of warfarin is based on monitoring of lab
monitor coagulation time. values (INR) and bleeding time. If these values are not moni-
tored, the client’s dosage may become too high, increasing the
risk of bleeding, or too low, increasing the risk of thrombus.
e Take medication at the same time each day, do not stop Appropriate medication administration is important to obtain the
taking medication abruptly, and do not attempt to make most beneficial effects.
up for missed doses.
e Avoid regular and/or excessive intake of alcohol (may alter Alcohol intake beyond 1 to 2 drinks per day decreases the effects of
responsiveness to warfarin). warfarin; in clients with liver disease, alcohol will increase the
effects of warfarin.
e Avoid significantly increasing or decreasing consumption Increasing the amount of foods high in vitamin K will antagonize
of foods high in vitamin K (e.g., green leafy vegetables). warfarin’s anticoagulant effects.
e Report prolonged or excessive bleeding from skin, nose, or Increased incidence of bleeding must be reported to the client’s
mouth; red, rust-colored, or smoky urine; bloody or tarry health care provider for appropriate intervention.
stools; blood in vomitus or sputum; prolonged or excessive
menses; excessive bruising; severe or persistent headache;
or sudden abdominal or back pain.
e Inform physician immediately if pregnancy is suspected or Warfarin is contraindicated in pregnancy because it crosses the
if breastfeeding (warfarin crosses the placental barrier and placenta and is found in breast milk.
enters the breast milk).
e Wear a medical alert identification bracelet or tag identify- This allows health care providers to be aware of health conditions
ing self as being on anticoagulant therapy. and prescribed medications if the client is unable to provide this
information.
e Inform physician of any other medications being taken There are some medications that affect the anticoagulant activity
because there are some that affect the anticoagulant of warfarin (e.g., NSAIDs, various antimicrobials, phenytoin).
activity of warfarin (e.g., NSAIDs, various antimicrobials,
phenytoin).
e Notify health care provider immediately of any sudden Warfarin can cause necrosis of the skin.
changes in the skin, such as bruised, darkened, or painful
areas.
e Instruct client to inform all health care providers of Health care providers must be aware ofall medications and herbal
medications and herbal supplements being taken. supplements taken because they can interact with prescribed
medications.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to correctly draw up and administer heparin subcutaneously
if prescribed.

Independent Actions
If client is to be discharged on subcutaneous heparin, provide The client should be instructed on the proper method ofmedication
instructions about subcutaneous injection technique. administration.
Allow time for questions, practice, and return demonstration. Allowing for questioning, practice, and return demonstration of
proper medication administration helps clients feel confident
that they can perform this once they are at home.

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 190 Chapter 5 = The Client With Alterations in Respiratory Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

bleeding associated with anticoagulant therapy.

Independent Actions
Instruct client about ways to minimize the risk of bleeding
while receiving anticoagulant therapy:
e Use an electric rather than a straight-edge razor. All of these mechanisms will help minimize the risk of bleeding.
e Floss and brush teeth; use waxed floss and a soft bristle
toothbrush.
e Avoid putting sharp objects (e.g., toothpicks) in mouth.
¢ Do not walk barefoot.
e Cut nails carefully.
e Avoid situations that could result in injury (e.g., contact
sports).
e Do not blow nose forcefully.
e Avoid straining to have a bowel movement.
Instruct client to control any bleeding by applying firm, Application of firm, prolonged pressure will promote clotting.
prolonged pressure to the area if possible.

i THERAPEUTIC INTERVENTIONS RATIONALE

ee ee ee
Desired Outcome: The client will state signs and symp-
toms to report to the health care provider.

Independent Actions
Stress the importance of reporting the following: These symptoms are indicative of an embolism or increased
e Tenderness, swelling, or pain in extremity bleeding from the use ofanticoagulants. Immediate reporting
e Sudden chest pain allows for prompt treatment.
e New or increased shortness of breath
e Extreme anxiousness or restlessness
° Cough productive of blood-tinged sputum
e Unusual bleeding
See hevet

THERAPEUTIC INTERVENTIONS RATIONALE

= en a
Desired Outcome: The client will, in collaboration with
the nurse, develop a plan for adhering to recommended
follow-up care, including future appointments with the
health care provider and activity level.

Independent Actions
Reinforce the importance of keeping follow-up appointments Follow-up appointments are important to monitor the client’s
with the health care provider. recovery and medication regimen.
Reinforce the physician’s instructions regarding activity Clients may not fully understand the instructions regarding
limitations. activity limitations, as they are feeling better and may increase
activities prematurely. '
Implement measures to improve client compliance:
° Include significant others in teaching sessions if possible. Involvement of significant others in patient teaching improves
adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Everyone does not understand information as presented, so
clarification of information provided. set aside time for questions to allow for clarification
of
information.
° Provide written instructions regarding future appoint- Written instructions allow the client to refer to instructions
ments with health care provider, medications prescribed, as
needed.
activity restrictions, signs and symptoms to report, and
future laboratory studies.
 Chapter 5 = The Client With Alterations in Respiratory Function 191

THORACIC SURGERY
Thoracic surgery is a term used to refer to surgical procedures OUTCOME/DISCHARGE CRITERIA
that involve entry into the thoracic cavity to gain access to
the lungs, heart, aorta, or esophagus. Types of thoracic The client will:
surgery performed to treat pulmonary disorders include 1. Have optimal respiratory function
Boo De Ctomy, lobectomy, segmental resection, and wedge —. 2. Have evidence of normal healing of surgical wound
resection. The surgery may be performed to repair lung dam- 3. Have surgical pain controlled
age resulting from trauma and to tes benign or malig- 4. Have no signs and symptoms of postoperative complications
nant tumors; areas of bronchiectasis, fungal infection, or 5. Identify ways to promote optimal respiratory health
tuberculosis; abscesses; blebs; and bullae. Although some — 6, Demonstrate the ability to perform prescribed arm and
thoracic surgery can be accomplished using an intercostally shoulder exercises
inserted endoscope, an open thoracic approach is needed to —_7._ State signs and symptoms to report to the health care provider
treat conditions requiring surgery deep in the lung, extensive —_—g,_ Identify community resources that can assist with home
seme! of lung tissue, or both. . management and adjustment to the diagnosis, effects of
, This care (AD focuses on the adult client hospital- surgery, and subsequent treatment if planned
ized for thoracic Seer to remove a portion or all 9. Develop a plan for adhering to recommended follow-up
ee ace adeautormation 3s applicable.to care, including future appointments with health care
SUARS recetving OS care in an extended care providers, medications prescribed, activity level, pain
facility or home setting. management, wound care, and subsequent treatment of
the underlying disorder

POSTOPERATIVE CARE PLAN TO USE IN CONJUNCTION

WITH THE PREOPERATIVE CARE PLAN
—) IMPAIRED RESPIRATORY FUNCTION*
Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.
Ineffective breathing pattern NDx
Related to:
e Increased rate of respirations associated with fear and anxiety
e Decreased rate of respirations associated with the depressant effect of anesthesia and some medications (e.g., narcotic [opioid]
analgesics, some antiemetics)
e Decreased depth of respirations associated with:
e Reluctance to breathe deeply resulting from incisional pain and fear of dislodging chest tube(s) if in place
e Weakness, fatigue, fear, and anxiety
e Depressant effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics, some antiemetics)
e Limited chest expansion resulting from positioning and elevation of the diaphragm (can occur if abdominal distention is
present or if the phrenic nerve was injured during surgery)
Ineffective airway clearance NDx
Related to:
from the
* Occlusion of the pharynx in the immediate postoperative period associated with relaxation of the tongue resulting
effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics)
e Stasis of secretions associated with:
e Decreased activity
e Depressed ciliary function resulting from effects of anesthesia
(e.g., narcotic
° Difficulty coughing up secretions resulting from the depressant effect of anesthesia and some medications
fatigue, and presence of tenacious secretions (can occur as a result of
[opioid] analgesics, some antiemetics), pain, weakness,
deficient fluid volume)
inhalation anesthetics, endotracheal
e Increased secretions associated with irritation of the respiratory tract (can result from
intubation, and surgically induced lung tissue injury and inflammation)
ineffective airway clearance, and
*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern,
impaired gas exchange.

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NDx = NANDA Diagnosis
 192 Chapter 5 = The Client With Alterations in Respiratory Function

Impaired gas exchange NDx

Related to:
A decrease in alveolar surface area and pulmonary vasculature associated with the extensive removal of lung tissues

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; anxiety; fear/agitation; Tachypnea; orthopnea; dyspnea; diminished breath
restlessness; irritability; confusion sounds; tachycardia; productive cough; significant decrease
in oximetry values; abnormal arterial blood gas values;
chest radiograph changes

RISK FACTORS DESIRED OUTCOMES

e Increased secretions
e Postoperative incision pain The client will experience adequate respiratory function as
e Anxiety evidenced by:
e Analgesics Normal rate and depth of respirations
e Potential immobility Absence of dyspnea
e Anesthesia Normal breath sounds over remaining lung tissue
Usual mental status
Usual skin color
Oximetry results within normal range
|
>
Ce Arterial blood gas values within normal range
Sabb
Com

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: gas exchange; ventilation; Respiratory monitoring; airway management; chest
airway patency physiotherapy; cough enhancement; oxygen therapy;
medication administration; ventilation assistance; fear
and anxiety reduction

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired respiratory function: Early recognition of signs and symptoms of infective breathing
patterns allows for prompt intervention.
e Rapid, shallow respirations Changes in the characteristics of breath sounds may be due to
e Dyspnea, orthopnea airway obstruction, mucous plugs, or retained secretions in
e Use of accessory muscles when breathing larger airways.
e Abnormal breath sounds (e.g., diminished or absent over Muscle fatigue/weakness_ may impair effective clearance of
remaining lung tissue) secretions.
° Development of or increase in cough
e Restlessness, irritability Restlessness, irritability, and changes in mental status or level
e Confusion, somnolence of consciousness indicate an oxygen deficiency and require
immediate treatment.
° Significant decrease in oximetry results Oximetry is a noninvasive method of measuring arterial oxygen
saturation. The results assist in evaluating respiratory status.
e Abnormal arterial blood gas values Decreasing PaO» and increasing PaCQp are indicators of respira-
tory problems.
e Changes in vital signs Increased work of breathing or hypoxia may cause tathycar
dia
and/or hypertension.
° Significant abnormalities in chest radiograph reports Changes in infiltrates noted in the lungs require prompt treatmen
t.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate respiratory function:
° Perform actions to reduce chest pain (e.g., orient client to Reduction of chest pain increases the client’s willingness
the hospital environment, equipment; maintain a calm, to move
and breathe more deeply.
supportive environment; instruct and assist client to splint
chest when coughing or deep breathing). D+
 Chapter5 = The Client With Alterations in Respiratory Function 193

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to reduce fear and anxiety (e.g., assure Reduction of fear and anxiety assists in preventing the shallow
client that staff members are nearby; respond to call signal and/or rapid breathing associated with these emotions.
as soon as possible; provide calm, restful environment;
instruct in relaxation techniques; encourage family
to project a supportive attitude without obvious
anxiousness). D
e Perform actions to reduce the accumulation of gas and This helps decrease the pressure on the diaphragm, allowing the
fluid in the gastrointestinal tract (e.g., ambulate as early as individual to have greater lung expansion.
possible, progress to Solid foods slowly).
¢ Position client as ordered (e.g., usually on back or Proper positioning after surgery allows for full expansion of the
Operative side after pneumonectomy, on back or either remaining lung tissue.
side after removal of a portion of the lung).
e When positioning clients on their side, use a 30 to This position helps minimize lateral compression of lung tissue.
45 degrees “tip” position (rather than complete lateral
positioning).
e Instruct client to breathe deeply or use incentive spirom- Forced deep breathing and use of incentive spirometry will increase
eter every 1 to 2 hrs. De+ expansion of the lungs and improve the client’s ability to clear
mucus from the remaining lung tissue. The technique may also
improve the amount of oxygen that is able to penetrate deep
into the lungs.
e Assure the client that deep breathing and turning should This assurance will decrease the client’s anxiety and fear associ-
not dislodge the chest tube. ated with the chest tube.
e Maintain activity restrictions as ordered; increase activity During activity, especially ambulation, the client usually takes
gradually as allowed and tolerated. D @ + deeper breaths, thus increasing expansion of remaining lung
tissue.

Dependent/Collaborative Actions
Implement measures to maintain adequate respiratory function:
e Administer bronchodilators (e.g., methylxanthines, sym- These medications will dilate the bronchioles, improve the volume
pathomimetics) if ordered. of air reaching the lungs, and improve arterial blood gas values.
e Administer pain medications as ordered. Reduction of chest pain increases the client’s willingness to move
and breathe more deeply.
e Maintain oxygen therapy as ordered. D + Improves oxygenation of body tissues.
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care provider allows for modifica-
therapist, physician) if signs and symptoms of impaired tions of treatment.
respiratory function persist or worsen.

|Nursing >Diagnosis
>... |ACUTE PAIN nox (CHEST) |
Definition: Unpleasant sensory and emotional experierice associated with actual poterttial tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity
from mild to severe with An anticipated or predictable end, and a duration of less than 3 months.

Related to:
° Tissue trauma, reflex muscle spasm, and disruption of intercostal nerves associated with the surgery
e Irritation of the patietal pleura associated with surgical trauma and stretching of the pleura (occurs if there is an accumula-
tion of blood or air in the pleural space)
° Tissue irritation associated with the presence of chest tubes
e Stress on surgical area associated with deep breathing

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain in chest with breathing and Increased B/P; tachycardia; shallow respirations; grimacing
coughing and pain around the chest tube insertion site with movement

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NDx = NANDA Diagnosis
 194 Chapter5 = The Client With Alterations in Respiratory Function

RISK FACTORS DESIRED OUTCOMES

e Frequent coughing
e Suture line pain
The client will experience diminished chest pain as
evidenced by:
e Chest tubes
© . Verbalization of a decrease in or absence of pain
e Anxiety
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES
NIC INTERVENTIONS
re
ee ee ee eee
Pain control; comfort level Pain management; analgesic administration; environmental
management: comfort

NURSING ASSESSMENT
S RATIONALE
SS
Assess for signs and symptoms of pain (e.g., verbalization Early recognition of signs and symptoms ofpain allows for prompt
of pain, grimacing, reluctance to move, guarding of intervention and improved pain control.
affected side of chest, shallow respirations, increased B/P,
tachycardia).
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps
intensity rating scale. determine the most appropriate interventions for pain manage-
ment. Use of a pain intensity scale gives the nurse a clearer
understanding of the pain being experienced and promotes
consistency when communicating with others about the client’s
pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identification
duration, precipitating factors, aggravating factors, allevi- of effective pain management interventions.
ating factors).
Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex,
methods used to manage pain effectively. coping style, previous experience with pain, culture, cause of
pain). Knowledge of the client’s usual response to pain and
methods previously used to manage pain effectively enables
the nurse to evaluate the client’s pain more accurately and
facilitates the identification of effective strategies for pain
management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that chest pain is expected postoperatively, and as- for pain and thereby heighten the perception of pain. In
sure the client that the need for pain relief is understood). addition, pain management methods are not as effective if the
client is tense and unable to relax.
Perform actions to promote rest (e.g., minimize environmen- A restful environment reduces fatigue and subsequently increases
tal activity and noise). D@ the client’s threshold and tolerance for pain.
Provide or assist with nonpharmacologic methods for pain Relaxation and diversional activities help alleviate pain, fear,
and
relief (e.g., relaxation techniques, restful environment, anxiety, which may increase tolerance for pain.
watching television, reading).
Instruct and assist client to support chest incision with a Supporting the chest incision with a pillow or hands whey turning,
pillow or hands when turning, coughing, and deep coughing, and deep breathing supports the incision and makes
breathing. D @+ the activity less painful.
Securely anchor chest tubes. Anchoring of chest tubes decreases irritation from the movement of
the tubes.

Dependent/Collaborative Actions
Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing
can cause pain and before pain becomes severe. D event
helps minimize the pain that will be experienced. Analges
ics
given before procedures will improve the client’s ability
to
tolerate the procedures before the pain becomes severe.
 Chapter 5 * The Client With Alterations in Respiratory Function 195

THERAPEUTIC INTERVENTIONS RATIONALE

Encourage client to use the patient-controlled analgesia Patient-controlled analgesia allows the client to control pain
device as instructed. medication administration. Clients using patient-controlled
analgesia have been shown to use less medication and
ambulate more quickly after surgery than patients receiving
nurse-controlled analgesia.
Maintain integrity of analgesia delivery system (epidural,
intravenous, subcutaneous, transdermal).
Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for a multi-
pharmacist, pain management specialist) if the provided faceted treatment plan.
measures fail to provide adequate pain relief.

Collaborative 2)
Diagnosis |RISK FOR INEFFECTIVE LUNG EXPANSION
Definition: Inability to expand the lung to provide adequate oxygenation to the body.

Extended pneumothorax
Related to:
An increase in intrapleural pressure associated with accumulation of air in pleural space (can occur if the chest drainage system
malfunctions and/or air leaks into the pleural space through the incision)

Hemothorax
Related to:
Intraoperative or postoperative bleeding and/or malfunction of the chest drainage system

Mediastinal shift
Related to:
e A significant increase in intrapleural pressure on the operative side after a lobectomy associated with an accumulation of
fluid and air in the pleural space
e Excessive negative pressure on the operative side after pneumonectomy associated with inadequate serous fluid accumula-
tion in the empty thoracic space (the position of the mediastinum is maintained by accumulation of serous fluid in the
empty thoracic space)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Absent breath sounds; hyperresonant percussion with
pneumothorax; dull percussion with hemothorax; rapid,
shallow, and/or labored respirations; restlessness; agitation;
confusion; arterial blood gas values that have worsened;
chest radiograph results showing a lung collapse; further
decrease in Hct and Hgb

RISK FACTORS DESIRED OUTCOMES

tated The client will experience normal lung reexpansion as

ee evidence by:
e Pain a. Audible breath sounds and resonant percussion note
e Anesthetics over remaining lung tissue by third or fourth postop-
erative day
b. Unlabored respirations at 12 to 20 breaths/min
c. Arterial blood gas values within normal range
d. Absence of or no sudden increase in dyspnea
e . Vital signs within normal limits
f. Usual mental status
g. Trachea in midline position
h. Absence of neck vein distention
i. Chest radiograph showing lung reexpansion

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 196 Chapter 5 = The Client With Alterations in Respiratory Function

NURSING ASSESSMENT RATIONALE

Assess for and immediately report signs and symptoms of: Early recognition of signs and symptoms of respiratory problems
¢ Malfunction of chest drainage system (e.g., respiratory dis- after thoracic surgery allows for prompt ititervention.
tress, lack of fluctuation in water seal chamber without evi-
dence of lung reexpansion, excessive bubbling in water seal
chamber, significant increase in subcutaneous emphysema)
e Extended pneumothorax (e.g., é¢xtended area of absent
breath sounds with hyperresonant percussion note; rapid,
shallow, and/or labored respirations; restlessness; agitation;
confusion; arterial blood gas values that haVe worsened;
chest radiograph results showing delayed lung reexpansion
or further lung collapse).
° Mediastinal shift (e.g., severe dyspnea, rapid and/or irregular
pulse rate, hypotension, restlessness, agitation, confusion,
shift in trachea from midline, neck vein distention, arterial
blood gas values that have worsened, chest radiograph results
showing a deviation of trachea from midline)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote lung reexpansion and
prevent further lung collapse:
° Perform actions to maintain patency and integrity of chest
drainage system:
e Maintain fluid levels in the water seal and suction Maintains negative pressure within the lungs
chambers as ordered.
e Maintain occlusive dressing over chest tube insertion site. Maintains negative pressure seal
° Tape all connections securely. Prevents tubing from being disconnected and maintains a closed
drainage system
° Tape the tubing to the chest wall close to insertion site, Reduces the risk of inadvertent removal of the chest tube
° Position tubing to promote optimum drainage (e.g., coil Promotes drainage
excess tubing on bed rather than allowing it to hang
down below the collection device, keep tubing free of
kinks). D
e Drain fluid that accumulates in tubing into the collec- Maintains patency of the drainage system
tion chamber.
e Avoid stripping of chest tubes. If ordered, milk tubing Chest tube stripping increases high negative pressures in the pleural
using a hand over hand method while moving along space and may damage lung tissues.
the drainage tube.
° Keep drainage collection device below level of client’s Prevents backflow of drainage into the lungs
chest at all times. D +
° Perform actions to facilitate the escape of air from the Improves tung expansion and removal of secretions
pleural space (e.g., maintain suction as ordered, ensure
that the air vent is open on the drainage collection device
if system is to water seal only).
e Perform actions to improve breathing pattern and facilitate
airway clearance (e.g., encourage client to cough and
breathe deeply every 1 to 2 hrs; use incentive spirometry
every 2 hrs; ambulate as otdered and as tolerated), D +

Dependent/Collaborative Actions
If signs and symptoms of further lung collapse or a hemotho-
tax or mediastinal shift occur:
° Maintain client on bedrest in a semi- to high-Fowler’s position. Improves client's ability to expand the lungs
e Maintain oxygen therapy as ordered. D + Helps maintain tissue oxygenation
° Assess for and immediately report signs and symptoms of ten- Emergency treatment is required to prevent further respirato
sion pneumothorax (e.g., severe dyspnea, increased restless- ry
difficulty,
ness and agitation, rapid and/or irregular pulse rate, hypoten-
sion, neck vein distention, shift in trachea from midline).
 Chapter 5 = The Client With Alterations in Respiratory Function 197

THERAPEUTIC INTERVENTIONS RATIONALE

e Assist with clearing of existing chest tube and/or insertion Reestablishes a closed drainage system
of a new tube.
e Assist with autotransfusion of blood from chest tube and/ Addresses decreased Hct and Hgb
or administer blood products and/or volume expanders if
ordered.
e Assist with clearing of existing chest tubes, thoracentesis, Prevents drainage from accumulating in the lungs
or insertion of chest tube if not already present.
e Prepare client for surgical intervention to ligate bleeding Decreases anxiety
vessels if indicated.

|Collaborative oo
Diagnosis RISK FOR CARDIAC DYSRHYTHMIAS
Definition: A disturbance of the heart’s normal rhythm. Dysrhythmias can range from missed or rapid beats to serious
disturbances that impair the pumping ability of the heart.
+

Related to: Altered nodal function and myocardial conductivity associated primarily with myocardial hypoxia (may
result from impaired gas exchange and diminished myocardial blood flow that can occur with hypovolemia and
sympathetic nervous system—medicated vasoconstriction in the immediate postoperative period)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of palpitations or “skipped beats” Irregular apical pulse; heart rate less than 60 or greater
than 100 beats/min; apical-radial pulse deficit; syncope;
palpitations; abnormal rate, rhythm, or configuration on
electrocardiogram (ECG)

RISK FACTORS DESIRED OUTCOMES

e Electrolyte imbalance The client will maintain normal sinus rhythm as evidenced
e Activity intolerance by:
e Myocardial hypoxia a. Regular apical pulse rate at SO to 100 beats/min
e Hypovolemia b. Equal apical and radial pulse rates
c. Absence of syncope and palpitations
d. ECG showing normal sinus rhythm

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac dysrhyth- Early recognition of signs and symptoms of cardiac dysrhythmias
mias (e.g., irregular apical pulse; pulse rate less than 60 and after thoracic surgery allows for prompt intervention.
greater than 100 beats/min; apical-radial pulse deficit; syn-
cope; palpitations; abnormal rate, rhythm, or configurations
on ECG).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent cardiac dysrhythmias: Pain, anxiety, and fear cause stimulation of the sympathetic
nervous system, which increases the heart rate and causes
e Reduce pain, fear, and anxiety (e.g., assure client need for
vasoconstriction, both of which increase cardiac workload and
pain relief is understood, and plan methods for achieving
pain control with client; orient client to environment, decrease oxygen availability to the myocardium.
equipment, and routines; maintain a calm, supportive envi-
ronment; encourage/instruct client in use of relaxation
techniques; allow client to discuss anxiety and fears). D ca

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 198 Chapter5 = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If cardiac dysrhythmias occur:
e Administer antidysrhythmics (e.g., digoxin) as ordered. Prevention of dysrhythmias
e Restrict client’s activity based on client’s tolerance and Reduces client’s potential for injury
severity of the dysrhythmia.
e Maintain oxygen therapy as ordered. Provides supplemental oxygenation, which may decrease dysrhythmias
e Assess cardiovascular status frequently and report signs Provides for prompt treatment of dysrhythmias
and symptoms of inadequate tissue perfusion (e.g., Indications of decreased cardiac output
decrease in B/P, cool skin, cyanosis, diminished peripheral
pulses, urine output less than 30 mL/h, restlessness and
agitation, increased shortness of breath).

Collaborative see.)
Diagnosis RISK FOR ACUTE PULMONARY EDEMA
Definition: Accumulation of fluid in the lungs that leads to impaired O,/CO, exchange.

Related to:
e Increased pulmonary capillary permeability associated with hypoxia
e Increased hydrostatic pressure in the remaining pulmonary vessels associated with reduced size of the pulmonary vascular
bed and decreased effectiveness of lymphatic drainage resulting from extensive removal of pulmonary tissue (especially if
pneumonectomy was performed).

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath and difficulty Adventitious breath sounds (e.g., rales), productive cough
breathing (e.g. blood tinged, frothy sputum; increased work of
breathing, increased respiratory rate; decreased oxygen
saturation; diaphoresis; dyspnea; tachypnea; auscultated;
wheezes; decreasing pulse oximetry; abnormal arterial
blood gases

RISK FACTORS DESIRED OUTCOMES

e Increased pulmonary hydrostatic pressure
The client will not develop pulmonary edema as evi-
e Decreased effectiveness of the lymph drainage
e Smoking denced by:
a. Unlabored respirations at 12 to 20 breaths/min
b. Clear breath sounds and resonant percussion note over
nonoperated lung tissue
c. Absence of productive, persistent cough
d. Usual skin color
e. Oximetry results within normal range
f. Arterial blood gas values within normal range

NURSING ASSESSMENT RATIONALE

Pulmonary edema (e.g., severe dyspnea, tachycardia, develop- Early recognition of signs and symptoms of pulmonary edema
ment of or increase in crackles [rales] or wheezes, dull allows for prompt intervention.
percussion note over remaining lung tissue, persistent
cough productive of frothy and/or blood-tinged sputum,
cyanosis, significant decrease in oximetry results, decrease
in PaO, and/or increase in PaCO,, chest radiograph results
showing pulmonary edema)
 Chapter5 = The Client With Alterations in Respiratory Function 199

etl

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate respiratory function Improves lung expansion and mobilization of secretions
(e.g., encourage use of incentive spirometry every 2 to
3 hrs; ambulate as tolerated; provide supplemental oxygen as
needed; maintain patency of chest tube).

Dependent/Collaborative Actions
If signs and symptoms of pulmonary edema occur, administer Improves bronchial airflow and decreases pulmonary congestion
bronchodilators and agents to reduce pulmonary vascular
congestion (e.g., diuretics and morphine sulfate).

|Collaborative ==...
Diagnosis RISK FOR BRONCHOPLEURAL FISTULA |
Definition: A fistula between the lungs and the pleural space.

Related to: Inadequate bronchial closure and healing after a partial or complete resection of the lungs (most often associated
with preoperative radiation to the lungs and/or residual cancer of the bronchial stump).

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; shortness of breath, difficulty Hyperthermia; cough with purulent sputum; continuous
breathing bubbling of chest drainage system; increasing subcutane-
ous emphysema around neck and incision; elevated WBC
count; chest radiograph with presence of bronchopleural
fistula

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will experience resolution of a bronchopleural
e Radiation fistula if it occurs as evidenced by:
a. Afebrile status
b. Absence of cough
c. Absence of continuous bubbling in water seal chamber
of chest drainage system
d. Unlabored respirations at 12 to 20 breaths/min
e. WBC and differential counts returning toward normal

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of bronchopleural Early recognition of the signs and symptoms of bronchopleural
fistula (e.g., fever, cough, purulent sputum, continuous fistula allows for prompt intervention.
bubbling in water seal chamber of chest drainage system,
increasing subcutaneous emphysema around incision and
neck, respiratory distress, persistent elevation of WBC
count and significant change in differential, chest radio-
graph results showing presence of bronchopleural fistula).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If signs and symptoms of a bronchial fistula occur:
e Turn client to operative side unless contraindicated. Reduces risk for aspiration of pleural fluid
Severe subcutaneous emphysema in the neck can compress trachea
e Have tracheostomy tray readily available.
and obstruct the airway.
e Prepare client for chest tube insertion, thoracentesis, and Decreases client anxiety
surgical repair of bronchial stump if planned.

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 200 Chapter5 = The Client With Alterations in Respiratory Function

|Collaborative =>
Diagnosis |6RESTRICTED ARM AND SHOULDER MOVEMENT
Definition: Decreased movement of the upper limbs.

Related to: Decreased activity of the arm and shoulder on the operative side associated with weakness, fatigue, pain, and
adhesion formation between incised muscles

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty/inability in moving arm and Limited range of motion of arm and shoulder
shoulder, pain with movement

RISK FACTORS DESIRED OUTCOMES

e Limited movement
e Fatigue The client will maintain normal arm and shoulder func-
om Pain tion as evidenced by the ability to move the arm and
e Weakness shoulder on the operative side through the usual range of
motion.

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of restricted arm Early recognition of signs and symptoms of reduced arm and shoul-
and shoulder movement on operative side (e.g., inability der movement allows for prompt intervention.
to move arm and shoulder through usual range of motion,
inability to use arm in ADL).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent restriction of arm and shoul-
der movement on operative side:
e Instruct client in and assist with arm and shoulder exer- Early intervention and movement of the arms and shoulders
cises ordered (usually passive range of motion is started are important in preventing restricted movement.
the evening of surgery, and active range of motion exer-
cises are started by the second postoperative day).
e Perform actions to reduce pain (e.g., administer analgesics). Reduction ofpain will increase client’s ability and willingness to
D+ move arm and shoulder.
* Encourage client to use arm on operative side to perform Use of the arm on the operative side by the client helps maintain
self-care activities. D @ + movement.
° Place frequently used articles and bed stand on operative Place articles on the operative side of the bed so that client will be
side. D@ + more likely to use that arm.
e Anchor pull rope at foot of bed. D@ +

|4
Nursing «DEF
Diagnosis ICIENT KNOWLEDGE, nox INEFFECTIVE HEALTH
MAINTENANCE nox, OR INEFFECTIVE HEALTH
MANAGEMENT™* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related
to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage,
and/or seek out help to maintain
well-being; Ineffective Health Management NDx: Pattern of regulating
and integrating into daily living a
therapeutic regimen for the treatment of illness and its sequelae that is
unsatisfactory for meeting specific
health goals.
 Chapter5 = The Client With Alterations in Respiratory Function 201

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
e Denial of disease process
° Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: health promotion; health resources; Health system guidance; teaching: individual; teaching:
treatment regimen prescribed activity/exercise; teaching: disease process

NURSING ASSESSMENT RATIONALE

Assess client readiness to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for appropriate teaching interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to pro-

mote optimal respiratory health.

Independent Actions
Instruct client in ways to promote optimal respiratory health:
e Maintain overall general good health (e.g., reduce stress, Maintenance of good general health helps fight off respiratory
eat a well-balanced diet, obtain adequate rest, obtain ade- infections and maintain adequate respiratory status.
quate exercise).
e Stop smoking. The irritants in smoke and other respiratory irritants increase
e Avoid exposure to respiratory irritants such as smoke, dust, mucus production, impair ciliary function, and can cause
aerosol sprays, paint fumes, and solvents. inflammation and damage to the bronchial and alveolar walls;
the carbon monoxide decreases oxygen availability.
e Remain indoors as much as possible when air pollution High levels of air pollution are lung irritants and impair ciliary
levels are high. function.
e Wear a mask or scarf over nose and mouth if exposure to Wearing a mask or scarf decreases the level of exposure to irritants
high levels of irritants such as smoke, fumes, and dust is in the air.
unavoidable.
e Take medications as prescribed to treat any underlying Helps maintain adequate lung functioning and oxygenation of
respiratory disease such as COPD, cancer of the lung, or body tissues.
tuberculosis.
e Decrease the risk of respiratory tract infections: Each of these actions helps decrease the incidence of infections and
e Avoid contact with persons who have respiratory tract maintain good lung health.
infections.
e Avoid crowds and poorly ventilated areas.
° Drink at least 10 glasses of liquid/day unless contraindicated. Maintains adequate circulatory volume.
e Receive immunizations against influenza and pneumococ- Improves client’s resistance to influenza and pneumococcal
cal pneumonia. pneumonia.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to perform prescribed arm and shoulder exercises.
Instruct client regarding the importance of exercising the arm Exercise of the arm and shoulder on the operative side prevents
and shoulder on the operative side. Emphasize that the restriction of arm and shoulder movement.
exercises should be performed at least 5 times per day for
several weeks.
Demonstrate appropriate arm and shoulder exercises (e.g., The client’s ability to perform the exercises should be evaluated
shoulder shrugs, arm circles). before leaving the health care facility.

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THERAPEUTIC INTERVENTIONS RATIONALE

Allow time for questions, clarification, and return demonstration. Everyone does not understand information as presented; allowing
time for questioning helps clients assimilate the information in
terms they can understand. Return demonstration allows the
nurse to verify client’s ability to perform exercises.
THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.
Instruct the client to report these signs and symptoms: Clients need to be aware of the signs and symptoms that should
e Increased discomfort in or decreased ability to move arm be reported to their health care provider to allow for prompt
and shoulder on operative side treatment of complications.
e Increased shortness of breath
° Persistent cough
e Persistent low-grade fever
° Difficulty breathing
e Chest pain
e Increasing weakness or inability to tolerate prescribed
activity level
e Separation of wound edges
° Increased redness, warmth, pain, or swelling around the wound
° Unusual or excessive drainage from any wound site

THERAPEUTIC INTERVENTIONS
RATIONALE
SSS
eee

Desired Outcome: The client will identify community

resources that can assist with home management and adjust-
ment to the diagnosis, effects of surgery, and subsequent
treatment if planned.
Provide information about community resources that can Information on how to access community resources and informa-
assist the client and significant others with home manage- tion related to home management is important to maintain
ment and adjustment to the diagnosis, effects of surgery, client’s recovery.
and subsequent treatment if planned (e.g., American Lung
Association, American Cancer Society, smoking cessation
program, Meals on Wheels, counselors, support groups,
home health agencies).

THERAPEUTIC INTERVENTIONS RATIONALE

eee
eee

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care, including future appointments with health
care provider, medications prescribed, activity level, pain
management, wound care, and subsequent treatment of the
underlying disorder.
Reinforce physician’s instructions about activity level: Reinforcement of instructions and providing written instructions
° Gauge activity according to tolerance and ensure adequate for the client provide a reference for questions once tht client is
rest periods. home.
° Stop any activity that causes excessive fatigue, dyspnea, or
chest pain.
° Avoid lifting heavy objects and doing strenuous upper
body exercises until complete healing of chest muscles has
occurred (usually 3-6 months).
Inform client that numbness and discomfort in the operative The client should be aware of when numbness and discomfort in
area can persist for several weeks but are usually temporary. the operative area will resolve, so they won't become anxious if
pain and numbness persist.
Clarify plans for subsequent treatment of underlying disorder Client should be aware that the surgery may not completely remove
(e.g., chemotherapy, radiation therapy) if appropriate. the necessity of treatment of the underlying condition.
 ChapterS * The Client With Alterations in Respiratory Function 203

TUBERCULOSIS
Tuberculosis (TB) is an infectious disease caused by Mycobacte- started on a regimen of multiple antitubercular/antimicrobial
rium tuberculosis, a gram-positive, acid-fast bacillus. It is spread medications while awaiting results of sputum cultures. If
by airborne droplets released when a person with active TB the diagnosis is confirmed, a major health care focus becomes
disease coughs, sneezes, or speaks. These droplets can cause one of promoting compliance with the lengthy (usually
infection in others if contact with the infected person is close 6-18 months), multiple-drug treatment regimen.
and repeated or prolonged. The inhaled tubercle bacilli im- This care plan focuses on the adult client hospital-
plant themselves in the lung, multiply, and can spread to other ized with signs and symptoms of active pulmonary
areas of the body through the lymphatic channels (lymphatic tuberculosis. Much of the information presented here
dissemination) and blood (hematogenous dissemination). is applicable to clients receiving follow-up care in an
Most people who are infected with tubercle bacilli do not extended care facility or home setting.
develop an active form of TB. Those who do are usually part
of high-risk populations that include persons who are immu-
nosuppressed, persons in continued close contact with people OUTCOME/DISCHARGE CRITERIA
with active untreated TB, and those who have been exposed
to virulent strains of multidrug-resistant tuberculosis (MDR-TB). The client will:
In addition, TB that has previously been inactive (latent, . Have an adequate respiratory status
dormant) in a person with an effective immune system can . Tolerate expected level of activity
become active if that person experiences situations that sup- Have no signs and symptoms of complications
press the immune response (e.g., chemotherapy treatment, . Identify ways to maintain respiratory health
long-term corticosteroid use, malnutrition, human immuno- . Identify ways to prevent the spread of TB to others
deficiency virus [HIV] infection, advanced age). . Verbalize an understanding of medications ordered includ-
Signs and symptoms of active TB can include fatigue, an- ing rationale, food and drug interactions, side effects, and
orexia, weight loss, night sweats, fever (usually low grade), importance of taking as prescribed
cough (usually progresses from a dry cough to one that 7. State signs and symptoms to report to the health care
is productive of mucopurulent or blood-tinged sputum), provider
dyspnea, and/or pleuritic pain (in some Cases). 8. Develop a plan for adhering to recommended follow-
A person with suspected active TB is placed on precautions up care, including future appointments with health care
to prevent airborne transmission of the tubercle bacilli and providers.

ate

|Nursing ~~
Diagnosis |IMPAIRED RESPIRATORY FUNCTION*
Definition: Ineffective Breathing Pattern NDx : Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to maintain a
clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or carbon dioxide elimination at the
alveolar-capillary membrane.

Ineffective breathing pattern NDx

Related to:
e Decreased depth of respirations associated with weakness, fatigue, and reluctance to breathe deeply if chest pain is present
e Increased rate of respirations associated with the increase in metabolic rate that occurs with an infectious process

Ineffective airway clearance NDx

Related to:
e Tracheobronchial inflammation
e Increase in secretions associated with the infectious process and the necrosis and subsequent liquefaction of tubercle nodules
(the nodules, or caseations, are lesions that consist of tubercle bacilli surrounded by a fibrous capsule)
e Stasis of secretions associated with decreased activity; poor cough effort resulting from weakness, fatigue, and chest pain
(if present); and impaired ciliary function (results from the increased viscosity and volume of mucus that occurs with the
infectious process)

Impaired gas exchange NDx

Related to:
e A decrease in effective lung surface associated with the accumulation of secretions
° Destruction of normal lung tissue that occurs with the presence of the tubercle nodules

clearance, and
*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern, ineffective airway
impaired gas exchange.

NDx = NANDA Diagnosis D = Delegatable Action @ =UAP @ =LVN/LPN ©P = Go to ©volve for animation
 204 Chapter S = The Client With Alterations in Respiratory Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue, pleuritic pain, confusion, Dyspnea; orthopnea; use of accessory muscles; fever
restlessness, and somnolence (usually low grade); cough—progressive from a dry cough
to one that is productive of mucopurulent or blood-tinged
sputum; decreased expiratory and inspiratory pressures;
abnormal! breath sounds; limited chest excursion; signifi-
cantly decreased oximetry results; abnormal arterial
blood gas values; sputum positive for acid-fast stain; chest
radiograph—nodular calcification, enlargement of hilar
lymph nodes, parenchymal infiltrate, pleural effusion,
and cavitation

RISK FACTORS DESIRED OUTCOMES

e Exposure to someone who has TB
e Increased secretions The client will experience adequate respiratory function as
evidenced by:
e Smoking and exposure to second-hand smoke
e Ineffective medication regimen . Normal rate and depth of respirations
. Absence of dyspnea
. Normal breath sounds over remaining lung tissue
Usual mental status
. Usual skin color
. Oximetry results within normal range
. Arterial blood gas values within normal range
eameands

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: gas exchange; ventilation; Respiratory monitoring; airway management; chest
airway patency physiotherapy; cough enhancement; oxygen therapy;
medication administration; ventilation assistance

NURSING ASSESSMENT
RATIONALE
————————
eee
Assess for and report signs and symptoms of impaired respira- Early recognition ofsigns and symptoms of impaired respiratory
tory function: function allows for prompt intervention.
e Rapid, shallow respirations
e Dyspnea, orthopnea
e Use of accessory muscles when breathing
e Abnormal breath sounds (e.g., diminished, crackles [rales],
rhonchi)
e Cough (usually a productive cough of mucopurulent or
blood-tinged sputum)
e Limited chest excursion
e Restlessness, irritability
e Confusion, somnolence
Assess arterial blood gas values, oximetry values, and chest
radiograph results. Report abnormal findings.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve respiratory status:
e Perform actions to reduce chest pain if present (e.g., splint These actions increase the client’s willingness to move, cough, and
chest with pillow when coughing and deep breathing). breathe deeply.
D+
Place client in a semi- to high-Fowler’s position unless contra- Positioning in semi- to high-Fowler’s position promotes optimal
gas
indicated; position with pillows. D@ + exchange by enabling chest expansion. Positioning with pillows
prevents slumping.
 Chapter sis The Client With Alterations in Respiratory Function 205

THERAPEUTIC INTERVENTIONS RATIONALE

e If client must remain flat in bed, assist with position Changing positions every 2 hrs helps mobilize secretions for
change at least every 2 hrs. D@ > expectoration.
e Instruct client to breathe deeply or use inspiratory exer- Forced deep breathing and use of incentive spirometry will increase
cises every 1 to 2 hrs. D@® expansion of the lungs and improve the client’s ability to clear
mucus from the lungs. The technique may also improve the
amount of oxygen that is able to penetrate deep into the lungs.
¢ Perform actions to promote removal of pulmonary secretions: Coughing or “huffing” every 1 to 2 hrs will help remove
e Assist client to cough or “huff” every 1 to 2 hrs. D@ + secretions.
e Implement measures to thin tenacious secretions and Increasing fluid intake will help liquefy secretions.
reduce dryness of the respiratory mucous membrane:
e Maintain a fluid intake of at least 2500 mL/day unless
contraindicated. D@ +
e Increase activity as allowed and tolerated. D@ Conservation of energy through activity restrictions allows energy
to be focused on breathing. Increasing activity as tolerated helps
mobilize secretions and promotes deeper breathing.
e Discourage smoking. Irritants in smoke increase mucus production, impair ciliary func-
+ tion, and can cause inflammation and damage to the bronchial
and alveolar walls; the carbon monoxide decreases oxygen
availability.

Dependent/Collaborative Actions
Implement measures to improve respiratory status:
e Assist with positive airway pressure techniques (e.g., CPAP, Improves volume of air that is breathed into the lungs.
bilevel positive airway pressure [BiPAP], flutter/positive
expiratory pressure [PEP] device) if ordered.
e Maintain oxygen as ordered. D > Supplemental oxygen helps relieve dyspne.
e Humidify air as ordered. D+ Humidity will help liquefy secretions.
e Administer CNS depressants judiciously; hold medication CNS depressants may significantly decrease respiratory rate, lead-
and consult physician if respiratory rate is less than ing to respiratory acidosis and hypoxemia.
12 breaths/min. D+
e Administer the following medications as ordered: Bronchodilators open bronchioles and allow for improved ventila-
e Bronchodilators (e.g., methylxanthines, sympathomi- tion of the lungs.
metic [adrenergic] agents). Antitubercular agents impact the active infection.
e Antitubercular/antimicrobial agents

Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care professionals allows for a
therapist, physician) if signs and symptoms of impaired prompt and multifaceted approach to treatment.
respiratory function persist or worsen.

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with dyspnea, weakness, fatigue, excessive coughing, and the foul order and taste of sputum
and some aerosol treatments
e Nausea (can occur in response to noxious stimuli such as the sight of expectorated sputum and as a side effect of some
medications)
° Increased nutritional needs associated with the increase in metabolic rate that occurs with an infectious process

NDx = NANDA Diagnosis D = Delegatable Action @=UAP 4 =LVN/LPN © = Goto ©volve for animation
 206 Ghapter sais The Client With Alterations in Respiratory Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sore buccal membranes; report of Weight loss; weight less than normal for client’s age,
altered taste sensation height, and body frame; abnormal BUN and low serum
prealbumin and albumin levels; inflamed mucous
membranes; pale conjunctiva; poor muscle tone; excessive
hair loss

RISK FACTORS DESIRED OUTCOMES

e Shortness of breath
The client will maintain adequate nutrition status as
e Lack of appetite
evidenced by:
e Inappropriate diet
a. Weight within normal range for clients
e Nausea
b. Normal BUN and serum prealbumin and albumin levels
° Respiratory treatments
c. Usual strength and activity tolerance
e Productive cough
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

——_—_—_-_—_—_——————
C ————— —O eee
Nutritional status Nutritional monitoring; nutrition management; nutrition
therapy

a
ee
NURSING ASSESSMENT
RATIONALE
Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
° Weight significantly below client’s usual weight or less prompt intervention.
than normal for client’s age, height, and body frame
e Abnormal BUN and low serum prealbumin and albumin
levels
e Increased weakness and fatigue
e Sore, inflamed oral mucous membrane
° Pale conjunctiva
e Sore buccal membranes
° Excessive hair loss
¢ Poor muscle tone

THERAPEUTIC INTERVENTIONS
RATIONALE
eee
Independent Actions
Monitor percentage of meals and snacks client consumes. Monitoring a client’s intake helps identify when a patient is at risk
Report inadequate intake. D+ for inadequate nutrition and allows for prompt intervention.
Implement measures to maintain an adequate nutritional
Status:
° Schedule treatments that assist in mobilizing mucus (e.g. The foul odor and taste of sputum and some aerosols are likely
aerosol treatments, postural drainage therapy) at least to decrease appetite. Appropriate scheduling of treatments also
1 hr before or after meals. assists in decreasing nausea.
e Increase activity as tolerated. D @ Activity usually promotes a sense of well-being and can help
improve an individual’s appetite.
e Encourage a rest period before meals. D@ Rest before a meal helps minimize fatigue that may occur when
eating.
° Eliminate noxious sights and odors from the environ- Noxious sights and odors can decrease one’s appetite. By eliminat-
ment; provide client with an opaque, covered container ing them, the patient’s intake may improve.
for expectorated sputum. D@ +
° Maintain a clean environment and a relaxed, pleasant A clean environment and a relaxed atmosphere may increase
atmosphere. D® + intake.
e Provide oral hygiene before meals. D@ Oral hygiene moistens the mouth, which makes it easier to chew
and swallow. It also removes unpleasant tastes, which often
improves the taste of foods/fluids.
 Chapters. The Client With Alterations in Respiratory Function 207

THERAPEUTIC INTERVENTIONS RATIONALE

° Assist the client who is quite dyspneic in selecting foods Dyspnea decreases the ability of an individual to eat complete
that require little or no chewing. meals.
e Serve frequent, small meals rather than large ones if Small, frequent meals decrease fatigue and help maintain an
the client is weak, fatigues easily, or has a poor appetite. individual’s nutritional status.
De+
Place client in a high-Fowler’s position for meals. D+ The high-Fowler’s position improves lung expansion and helps
relieve dyspnea.
e Limit fluid intake with meals unless the fluid has high Decreasing fluid intake during meals helps reduce early satiety and
nutritional value. D @ + subsequent decreased food intake.
e Allow for adequate time for meals. D @+ Clients who feel rushed during meals tend to become anxious, lose
their appetite, and stop eating.
e Ensure that meals are well balanced and high in essential A diet that is well balanced and high in essential nutrients meets
nutrients. the client’s nutritional needs.

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional
Status:
e Administer dietary supplements as needed. D + If dietary intake does not provide the recommended daily allow-
ances of vitamins and minerals, supplements may be necessary.
Dietary supplements are often needed to accomplish appropriate
nutritional status.
e Administer supplemental oxygen while eating. D> Maintains appropriate oxygenation while client is eating, which
may improve intake
e Obtain a dietary consult to assist client in selecting foods/ Provides client an additional resource in determining which
fluids that meet nutritional needs, are appealing, and preferred fluids and foods that are best for meeting the client’s
adhere to personal and cultural preferences. nutritional needs.
e Perform a calorie count if ordered and report information A calorie count provides information about the caloric and
to dietitian and physician. nutritional value of the foods/fluids consumed. The informa-
tion helps the dietitian and physician determine whether an
alternative method of nutritional support is needed.
Consult a physician about an alternative method of provid- If a client is unable to eat, collaboration with the physician is
ing nutrition (e.g., parenteral nutrition, tube feedings) if required to determine alternative methods of maintaining
client does not consume enough food or fluids to meet nutritional status.
nutritional needs.

|Nursing oo)
Diagnosis ACTIVITY INTOLERANCE nox
Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Related to:
e Tissue hypoxia associated with impaired gas exchange
° Difficulty resting and sleeping associated with frequent coughing, dyspnea, and frequent assessments and treatment
e Inadequate nutritional status
e Increased energy expenditure associated with persistent coughing and the increased metabolic rate that is present in an
infectious process

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue, weakness, and/or dizziness Abnormal heart rate or B/P response to activity; exertional
discomfort or dyspnea; electrocardiographic changes
reflecting dysrhythmias or ischemia; unable to speak
during physical activity

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Goto @volve for animation
 208 ChapterS = The Client With Alterations in Respiratory Function

RISK FACTORS DESIRED OUTCOMES

e Generalized weakness
The client will demonstrate an increased tolerance for
e Imbalance between oxygen supply/demand
activity as evidenced by:
e Debilitated condition
a. Verbalization of feeling less fatigued and weak
e Immobility
b. Ability to perform ADL without exertional dyspnea,
e Sedentary lifestyle
chest pain, diaphoresis, dizziness, and significant
changes in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance, endurance: fatigue level; vital signs; Activity therapy; energy management; oxygen therapy;
energy conservation; symptom severity nutrition management; sleep enhancement; cardiac care;
cardiac rehabilitation; teaching regarding prescribed activity

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention.
e Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping
activity, change from regular to irregular rate)
° Significant change of 15 to 20 mm Hg in B/P with activity.

THERAPEUTIC INTERVENTIONS RATIONALE

S88
eee

Independent Actions
Implement measures to improve activity tolerance:
e Conserve energy. Cells use oxygen and fat, protein, and carbohydrates to produce the
¢ Maintain prescribed activity restrictions. energy needed for all body activities. Rest and activities that
e Minimize environmental activity and noise. conserve energy result in a lower metabolic rate, which preserves
e Provide uninterrupted rest periods. nutrients and oxygen for necessary activities.
e Assist with care,
e Keep supplies and personal articles within easy reach.
e Limit the number of visitors.
° Assist client in energy-saving techniques (e.g., using a
shower chair when showering, sitting to brush teeth or
comb hair).
e Implement measures to promote sleep (e.g., maintain a
quiet, restful environment; discourage client from nap-
ping during the day, participating in group care activities
to allow for periods of rest).
e Increase client’s activity gradually as allowed and toler- Progressive increase in activity helps strengthen the myocardium,
ated. D@ + which enhances cardiac output and improves activity tolerance.
e Discourage smoking and excessive intake of beverages Both nicotine and excessive caffeine intake can increase cardiac
high in caffeine such as coffee, tea, and colas. workload and myocardial oxygen utilization, thereby decreasing
the amount of oxygen necessary for energy production.
e Implement measures to improve respiratory status (Gro, Improving respiratory status increases the amount of oxygen avail-
encourage use of incentive spirometer; elevate head of able for energy production. It also eases the work of breathing,
bed; assist with turning, coughing, and deep breathing) if which reduces energy expenditure.
ineffective breathing pattern, ineffective airway clearance,
or impaired gas exchange is contributing to client’s activ-
ity intolerance. D +
Instruct client to report a decreased tolerance for activity and These symptoms indicate that insufficient oxygen is reaching the
to stop any activity that causes chest pain, shortness of tissues and that activity has been increased beyond a therapeu-
breath, dizziness, or extreme fatigue or weakness. tic level.
 ChapterS = The Client With Alterations in Respiratory Function 209

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve activity tolerance:
e Implement measures to increase cardiac Output (e.g, Sufficient cardiac output is necessary to maintain an adequate
administer positive inotropic agents, vasodilators, or anti- blood flow and oxygen supply to the tissues. Adequate tissue
dysrhythmics as ordered; elevate the head of the bed) if oxygenation promotes more efficient energy production, which
decreased cardiac output is contributing to the client’s subsequently improves client’s activity tolerance.
activity intolerance.
e Implement measures to reduce fever if present (e.g., An elevated temperature increases the metabolic rate with subse-
administer tepid sponge bath, administer antipyretics as quent depletion of available energy and a decrease in the ability
ordered). D > to tolerate activity.
e Maintain oxygen therapy as ordered. D > Supplemental oxygen helps alleviate hypoxia and restore the more
efficient aerobic metabolism, thereby improving energy levels
and activity tolerance.
e Implement measures to maintain an adequate nutritional Metabolism is the process by which nutrients are transformed into
Status (e.g., provide a diet high in essential nutrients, energy, If nutrition is inadequate, energy production is
provide dietary supplements as indicated, administer decreased, which subsequently reduces one’s ability to tolerate
vitamins and minerals as ordered). activity,
e Implement measures to treat anemia if present (e.g., Anemia reduces the blood’s oxygen-carrying capacity, Resolution of
administer prescribed iron, folic acid, and/or vitamin B12; anemia increases oxygen availability to the cells, which
administer packed red blood cells as ordered). increases the efficiency of energy production and subsequently
improves activity tolerance.
Consult physician if signs and symptoms of activity intoler- Notifying the physician allows for modification of the treatment
ance persist. plan.

|Nursing os)
Diagnosis RISK FOR INFECTION nox (EXTRAPULMONARY
(E.G., PERICARDIAL, LARYNGEAL, SKELETAL, JOINT, RENAL,
BRAIN, ADRENAL, LYMPHATIC) AND/OR SUPERINFECTION
(E.G., CANDIDIASIS)
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
e Spread of the tubercle bacilli into the lymph nodes (lymphatic dissemination) and blood (hematogenous dissemination)
e Decreased resistance to infection associated with inadequate nutritional status and/or presence of other disease (e.g., HIV
infection, COPD) and side effects of the treatment of those diseases
e Interruption in the balance of usual endogenous microbial flora associated with the administration of antitubercular/
antimicrobial agents

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of precordial pain; bone pain; painful Increase in temperature; increased pulse rate; pericardial
joints; headache friction rub and/or precordial pain; swollen lymph nodes;
swollen, reddened joints; unusual color, amount, and
odor of vaginal drainage; perineal itching; white patches
or ulcerated areas in the mouth; increased weakness or
fatigue; hoarseness, sore throat; increase in WBC count
above previous levels and/or significant change in
differential

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 210 Chapter ss) = The Client With Alterations in Respiratory Function

RISK FACTORS DESIRED OUTCOMES

e Inadequate primary defenses
The client will not develop extrapulmonary infection or
e Inadequate secondary defenses (decreased Hgb level, leu-
superinfection as evidenced by:
kopenia, suppressed inflammatory response)
No increase in temperature
e Inadequate acquired immunity
e Malnutrition Pulse rate within client’s normal range
Absence of a pericardial friction rub and precordial pain
e Ineffective pharmaceutical agents
=o
Ss Absence of heat, pain, redness, swelling, and unusual
e Insufficient knowledge to avoid exposure to pathogens
drainage in any area
Absence of white patches and ulcerations in mouth
No reports of increased weakness and fatigue
Normal voice quality
. Absence of headache
©enWBC and differential counts returning toward normal
rm
OQ

NOC OUTCOMES
NIC INTERVENTIONS
eee
Immune status; infection severity Infection protection; infection control

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of extrapulmonary Early recognition of signs and symptoms of infection allows for
infection or superinfection: prompt treatment.
° Further increase in temperature Fungal infections are common superinfections with antimicrobial
e Increased pulse rate therapy.
° Pericardial friction rub and/or precordial pain
e Bone pain
¢ Swollen, red, painful joints
¢ Swollen lymph nodes
e Unusual color, amount, and odor of vaginal drainage;
perineal itching
° White patches or ulcerated areas in the mouth
e Increased weakness or fatigue
e Hoarseness, sore throat
e Headache
e Increase in WBC count above previous levels and/or sig-
nificant change in differential

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for extrapulmonary
infection and/or superinfection:
° Use good hand hygiene and encourage client to do the Good hand washing prevents the spread of infection.
same. D® +
° Perform actions to maintain an adequate nutritional status Adequate nutritional status is important to prevent infections.
(provide frequent meals, provide oral hygiene before
meals, decrease fluid intake with meals).
° Maintain sterile technique during all invasive procedures Sterile technique during invasive procedures is important to prevent
(e.g., venous and arterial punctures, injections, urinary exposure to infectious agents.
catheterization).
e Change peripheral intravenous line sites, and change Changing intravenous line sites, equipment, tubings, etc. helps
equipment, tubing, and solutions used for treatments such prevent infection.
as intravenous infusions and respiratory care according to
hospital policy.
Protect client from others with an infection. D @ + Exposure to others with infection increases the client’s risk.
° Anchor catheters/tubings (e.g., urinary, intravenous) Securing catheters/tubing reduces trauma to the tissues and
the risk
securely. for introduction of pathogens associated with the in-and-
out
movement of the tubing.
* Maintain a closed system for drains (e.g., urinary catheter) Closed drainage systems prevent the introduction of
infectious
and intravenous infusions whenever possible. agents into the system.
 Chapter5 = The Client With Alterations in Respiratory Function 211

THERAPEUTIC INTERVENTIONS RATIONALE

e Assist client to perform good perineal care routinely and Good perineal care and hygiene prevent skin breakdown and
after each bowel movement. D @ exposure to potential infectious agents.
e Reinforce importance of frequent oral hygiene. D+ Good oral hygiene prevents accumulation of infectious agents.

Dependent/Collaborative Actions
If signs and symptoms of an extrapulmonary infection or
superinfection occur:
e Prepare client for and/or assist with diagnostic tests (e.g., If an infection occurs, a culture and sensitivity of the infected area
blood, vaginal, pleural fluid, and urine cultures; lumbar allow for prescription of appropriate antibiotics.
puncture; aspiration of joint fluid; bone marrow aspiration).
e Administer additional or alternative antitubercular/ Antitubercular and antimicrobial agents help resolve the infectious
antimicrobial medications as ordered. process.

|Collaborative =Diagnosis
-. |RISK FOR PLEURAL EFFUSION
Definition: An abnormal accumulation of fluid in the pleural cavity.

Related to: An increase in capillary permeability of the pulmonary and pleural vessels associated with the inflammatory
response to the presence of tubercle bacilli in the lung and pleural space

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dyspnea; chest pain (pleural) Dull percussion note and diminished or absent breath
sounds; chest radiograph showing pleural effusion;
respiratory rate greater than 20 breaths/min; fever; night
sweats; cough; weight loss

RISK FACTORS DESIRED OUTCOMES

e Pulmonary infection
The client will not develop pleural effusion as evi-
e Increased permeability of capillary beds
denced by:
a. No increase in dyspnea
b. Symmetrical chest excursion
c. Improved breath sounds and percussion note through-
out lung fields

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of pleural effusion Early recognition ofsigns and symptoms ofpleural effusion allows
(e.g., dyspnea, chest pain, decreased chest excursion on for prompt intervention.
affected side, dull percussion note, decreased or absent
breath sounds over the affected area, chest radiograph
showing pleural effusion)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to resolve the infectious process: Resolution of an infectious process reduces the risk for development
e Encourage coughing and deep breathing. of pleural effusion and/or atelectasis.
e Administer antimicrobials as ordered. Treats infection

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Go to ©volve for animation
 212 Chapter5 = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of pleural effusion occur:
Continue with actions to improve respiratory status (e.g., in- Maintenance/improvement of the client’s respiratory status and
crease activity tolerance; instruct client in and assist with removal of secretions decrease the potential of infection or the
diaphragmatic and pursed-lip breathing techniques; in- occurrence of a pleural effusion.
struct client to breathe deeply or use incentive spirometer
every 1-2 hrs; encourage coughing and deep breathing;
place client in semi- to high-Fowler’s position),
° Prepare client for a thoracentesis if planned. Removal of fluid from the lungs will help improve the client’s abil-
ity to maintain adequate gas exchange.

Collaborative “ce
Diagnosis RISK FOR ATELECTASIS
Definition: Collapse of lung tissue caused by hypoventilated alveoli.

Related to:
e Consolidation of lung tissue
e Proliferation of the infection
e Stasis of secretions

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dyspnea Decreased breath sounds and/or crackles; cough; sputum
production; low-grade fever; heart rate greater than 60 to
100 beats/min; increased respiratory rate >20 breaths/min;
increased work of breathing; chest radiograph, ultrasound,
or computed tomography results showing patchy
infiltrates

RISK FACTORS DESIRED OUTCOMES

° Ineffective treatment regimen
° Smoking The client will not develop atelectasis as evidenced by:
¢ Immobility a. Clear, audible breath sounds
b. Resonant percussion note over lungs
c. Unlabored respirations at 12 to 20 breaths/min
d, Pulse rate within normal range for client
e. Afebrile status

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of atelectasis: Early recognition of signs and symptoms of atelectasis allows
e Diminished or absent breath sounds for
implementation of the appropriate interventions.
e Dull percussion note over affected area
° Increased respiratory rate
e Dyspnea
e Tachycardia
e Elevated temperature '
Monitor pulse oximetry results as indicated. Pulse oximetry is an indirect measure of oxygen
saturation.
Monitoring pulse oximetry (SaQ2) allows for early detectio
n
of hypoxia and implementation of the appropriate interven
-
tions,
Monitor chest radiograph results, Chest radiograph provides radiographic confirmation of
atelectasis,
 Chapter5 = The Client With Alterations in Respiratory Function 213

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent atelectasis:
e Perform actions to improve breathing pattern: Lack of movement places a client at risk for atelectasis. Changing
e Encourage client to breathe deeply. positions frequently, coughing, and deep breathing help expand
e Use of incentive spirometry. the lungs, enhancing alveolar expansion.
e Perform actions to promote effective airway clearance:
e Turn, cough, and breathe deeply.
Administer antibiotics as ordered. Treats infection
If signs and symptoms of atelectasis occur: Improves lung expansion and mobilization of secretions
e Increase frequency of position change, coughing or “huff-
ing,” deep breathing, and use of incentive spirometer.
Consult physician if signs and symptoms of atelectasis persist Allows for prompt alterations in interventions
or worsen.

PATIENT AND DISCHARGE TEACHING/CONTINUED CARE

=

|Nursing 2)
Diagnosis |DEFICIENT KNOWLEDGE, nox INEFFECTIVE HEALTH
MAINTENANCE nox, OR INEFFECTIVE HEALTH
MANAGEMENT™ nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain
well-being; Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a
therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific
health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
¢ Denial of disease process
¢ Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: medication; health promotion; disease process;

infection control; treatment behavior: illness or injury;
compliance behavior; health beliefs: perceived resources;
health beliefs: perceived ability to perform; health beliefs:
perceived control

NURSING ASSESSMENT RATIONALE

Assess client readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

D = Delegatable Action @ = UAP + =LVN/LPN ©P = Goto ©volve for animation

NDx = NANDA Diagnosis
 214 Chapter5 = The Client With Alterations in Respiratory Function

THERAPEUTIC INTERVENTIONS
nnn
RATIONALE
nn. ,
ess ss SSS

Desired Outcome: The client will identify ways to main-

tain respiratory health and ways to prevent the spread of TB
to others.

Dependent/Collaborative Actions
Instruct client in ways to maintain respiratory health:
e Maintain overall general good health (e.g., reduce stress, Good general health supports the individual’s ability to fight off
eat a well-balanced diet, obtain adequate rest). infection.
e Stop smoking. The irritants in smoke and respiratory irritants increase mucus
e Avoid exposure to respiratory irritants such as smoke, dust, production, impair ciliary function, and can cause inflamma-
aerosol sprays, paint fumes, and solvents; wear a mask or tion and damage to the bronchial and alveolar walls; the
scarf over nose and mouth if exposure to high levels of carbon monoxide decreases oxygen availability
these irritants is unavoidable.
e Remain indoors as much as possible when air pollution Air pollution in high levels is harmful to persons with existing lung
levels are high. disease.
Exposure to extreme hot and cold air may cause bronchoconstric-
tion, allowing less air into and out of the lungs and decreasing
oxygen/CO 2 exchange.
e Avoid prolonged close contact with persons who have Leads to increased potential for an infection and the spread of TB
active TB or any other respiratory infection.
e Avoid crowds and poorly ventilated areas.
° Drink at least 10 glasses of liquid per day unless contrain- Increased fluid intake is necessary with many of the medications
dicated. used in the treatment of TB to maintain adequate hydration.
Increased fluid intake is important to thin or liquefy secretions
making them easier to expectorate.
° Receive immunizations against influenza and pneumococ- Immunizations help prevent further respiratory disease.
cal pneumonia.
Educate the patient on the disease process and treatment of TB:
e Explain TB in terms the client can understand; stress that Understanding of the disease and its treatment plan provides the
TB is an infectious disease and that adherence to the treat- patient with a sense of control and makes it more likely that the
ment plan is necessary in order to prevent transmission to patient will be adherent to the treatment regimen.
others, complications, and reactivation of the disease.
°
Explain that active TB can be treated successfully but only The client must understand that TB can be successfully treated
if the client adheres to the prescribed multiple drug therapy. only with a multiple drug regimen.
* Provide written instructions about and encourage the cli- Written instructions allow the client to refer to them as needed.
ent to participate in the treatment plan (e.g., protecting The instructions should include all information needed to
others from the infection, adhering to medication regi- understand disease processes and treatment.
men, participating in respiratory care treatments).
° Provide client with written instructions about disease
transmission, signs and symptoms to report, medication
therapy, and follow-up appointments.
Educate the patient on ways to prevent the spread of TB to These actions are important to prevent the spread of TB. TB is an
others: airborne bacteria and is spread through close contact with
* Cover nose and mouth with a tissue when coughing, someone who is infected.
sneezing, and laughing.
° Refrain from spitting or do so into a tissue.
° Practice good hand hygiene (e.g., wash hands using Appropriate hand washing and care of soiled tissues helps prevent
an antimicrobial soap, use an alcohol-base hand rub), spread of infection. '
especially after placing hands over mouth or nose and Individuals who are at high risk for infection are at high risk for
handling soiled tissues. contracting TB.
¢ Dispose of soiled tissues properly (e.g., place in paper or Medications require an adequate blood level to be effective
plastic bag, flush down toilet).
e Avoid close contact with people who are at high risk for
infection (e.g., those who are very young or elderly, those
with HIV infection); wear a mask if close contact is
unavoidable.
° Adhere strictly to the prescribed medication regimen for
the treatment of TB.
 Chapter5 * The Client With Alterations in Respiratory Function 215

THERAPEUTIC INTERVENTIONS RATIONALE

e Inform clients that they will continue to be infectious Clients need to know that they will be infectious for an extended
until three consecutive sputum cultures show absence of period even though they continue taking medications. The
the tubercle bacilli (this usually occurs after a couple of longer the medication regimen, the greater the incidence of
weeks of taking the antitubercular/antimicrobial agents) nonadherence.
and that in order to not become infectious again, they
must continue with the medication regimen for the pre-
scribed length of time (usually 6-18 months).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an under-

standing of medications ordered including rationale, food
and drug interactions, side effects, and importance of taking
as prescribed.

Dependent/Collaborative Actions
Explain the rationale for, side effects of, and importance of Knowledge of the medication regimen and the impact of these
taking medications prescribed, as well as food and drug medications on the body, as well as how the medication
interactions, and drugs to manage side effects. regimen can be incorporated into the client’s lifestyle, allows the
client some mechanism of control of his/her disease and the
ability to have an active part in treatment and care.
Examples of TB drugs: isoniazid, rifampin, ethambutol, pyra- Treatment failures often result from clients not taking their
zinamide, and streptomycin medications correctly or prematurely stopping their medica-
Assist client to identify ways the medication regimen can be tions. Clients must understand that they increase their chance
incorporated into the client’s lifestyle. of developing a “drug-resistant” strain of TB if the medications
Assist client to develop a method to promote adherence to are not taken as prescribed.
the medication schedule (e.g., filling a pill box or empty
egg carton with the medications that need to be taken that
day/week, setting a timer or alarm as a reminder of when
to take medications, using a checklist to document when
each medication is due and taken).
Remind client of the consequences of not adhering to the Nonadherence to the multiple drug regimen may cause spread of
multiple drug regimen. TB from lungs to other parts of the body, development of a
strain of TB that will be very difficult to treat, and transmission
of TB to others.
Reinforce the need to consult a physician before discontinu- There may be drug-drug interactions that occur when taking TB
ing any medication or taking additional prescription and prescriptions. A physician should approve of any medications
nonprescription medications. taken to alleviate potential negative effects.
Instruct client to take all medications as often as prescribed Proper treatment occurs when medications are taken as prescribed.
and avoid skipping doses or altering the prescribed dose, if If the clients are unable to take medications as prescribed, it
a dose is missed, instruct client to take it as soon as re- may prolong treatment time and lead to exacerbation of the
membered unless it is almost time for the next dose of the disease.
same medication.
Instruct client to consult health care provider if considering be- Some of the medications used to treat TB are contraindicated in
coming pregnant, if pregnancy occurs, and if breastfeeding. pregnancy and if breastfeeding.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN ©P = Go to ©volve for animation
216 Chapter5 = The Client With Alterations in Respiratory Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Instruct client to report the following: These signs and symptoms may indicate a superinfection or spread
e Persistent or recurrent loss of appetite, nausea, weakness, of infection to another site, ineffectiveness of medications, inad-
fatigue, or weight loss equate nutrition, and/or adverse effects of medication regimen.
e Fever, chills, continued or increased night sweats
e Difficulty breathing, continued or increased cough, or
chest pain
e Unusual color, amount, and odor of vaginal secretions;
white patches or ulcerated areas in mouth
e Stiff neck and headache
e Hoarseness; persistent sore throat
e Bone pain; swollen, red, painful joints
¢ Swollen lymph nodes

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care, including future appointments with health
care providers.

Dependent/Collaborative Actions
Reinforce the importance of keeping appointments for Monitoring of TB is critical in maintaining client’s health and the
follow-up tests (e.g., blood work, hearing tests, sputum effectiveness of the medication regimen.
cultures, chest radiographs) and physical examinations to
determine the effectiveness of the medication regimen
and assess for side effects such as liver and kidney damage.
Provide information about and encourage utilization of Provide for continuum of care and can help client’s adherence with
community resources and social services that can assist the the medication regimen and possibly financial assistance for
client to comply with the medication regimen or to medications
provide financial support if needed (e.g., home health
agencies, local Department of Health and Human Services,
directly observed therapy [DOT] programs, local chapter of
the American Lung Association, support groups).
Include significant others in explanations and teaching ses- Involvement of the client’s significant others contributes to
sions and encourage their support. treatment regimen adherence and may help with medication
administration, if needed.

ADDITIONAL NURSING DIAGNOSES

FEAR NDx/ANXIETY NDx ACUTE PAIN: CHEST NDx
Related to unfamiliar environment, separation from signifi- Related to extension of the inflammatory/infectious process
cant others, financial concerns, and fear of transmitting to the pleura and muscle strain (can result from excessive
disease to others coughing)

RISK FOR DEFICIENT FLUID VOLUME NDx DISTURBED SLEEP PATTERN NDx
Related to decreased oral fluid intake and excessive fluid loss Related to an unfamiliar environment, night sweats,
(can occur with night sweats and profuse diaphoresis) persistent coughing, anxiety, and frequent assessthents and
treatments
 CHAPTER

ahe Client With Alterations

in Cardiovascular Function

ABDOMINAL AORTIC ANEURYSM

An abdominal aortic aneurysm (AAA) is an abnormal dilation through a large incision in the abdomen followed by inser-
of the wall of the abdominal aorta. The aneurysm usually tion of a synthetic graft to replace or support the weakened
develops in the segment of the vessel that is between the vessel, or by endovascular repair, a minimally invasive option
renal arteries and the iliac branches of the aorta. The most through a small incision in the groin threading a stent and
common cause of an AAA is atherosclerosis. The plaque that graft up to the aneurysm for support.
forms on the wall of the artery causes degenerative changes This care plan focuses on the adult client hospital-
in the medial layer of the vessel. These changes lead to loss of ized for open surgical repair of an AAA. Much of the
elasticity, weakening, and eventual dilation of the affected postoperative information is applicable to clients
segment. Additional factors that may play a role in the devel- receiving follow-up care in an extended care facility or
opment of an AAA include inflammation (arteritis), trauma, home setting.
infection, congenital abnormalities of the vessel, connective
tissue disorders that cause vessel wall weakness, tobacco use,
and high blood pressure. AAAs also may be hereditary with OUTCOME DISCHARGE CRITERIA
the likelihood of developing a AAA 12 times greater in
individuals with a first-degree relative with the condition. The client will:
Most AAAs are asymptomatic and are discovered during a rou- . Tolerate prescribed diet
tine physical examination (signs include palpation of a pulsatile . Tolerate expected level of activity
mass in the abdomen and/or auscultation of a bruit over the ab- . Have surgical pain controlled
. Have clear, audible breath sounds throughout lungs
dominal aorta) or during a review of x-ray results of the abdomen
. Have evidence of normal healing of surgical wounds
or lower spine. The presence of symptoms such as mild to severe
Have no signs and symptoms of postoperative complications
abdominal, lumbar, or flank pain and/or lower extremity arterial
. Identify ways to prevent or slow the progression of athero-
insufficiency is usually indicative of a large aneurysm that is exert-
sclerosis
ing pressure on surrounding tissues or an aneurysm that is leaking.
. State signs and symptoms to report to the health care provider
Surgical repair of an aneurysm is usually performed if the
© . Develop a plan for adhering to recommended follow-up care
‘oO
aneurysm is growing rapidly and/or reaches a size of 5 to 6cm
including future appointments with health care provider,
or larger, or if the client experiences symptoms. Repair of an
medications prescribed, activity level, and wound care
AAA can be accomplished in one of two ways: open repair

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

Related Preoperative Nursing/Collaborative Diagnoses ANXIETY nox /FEAR nox

by an autonomic response (the source

Definition: Anxiety NDx: Vague, uneasy feeling of discomfort or dread accompanied
anticipation of danger.
is often nonspecific or unknown to the individual); a feeling of apprehension caused by
enables the individual to take measures to deal with that
It is an alerting sign that warns of impending danger and
threat that is consciously recognized as a danger.
threat. Fear NDx: Response to perceived

Related to:
e Unfamiliar environment and separation from significant others
postoperative care
° Lack of understanding of diagnostic tests, surgical procedure, and
¢ Anticipated loss of control associated with effects of anesthesia risk of disease if blood transfusions are necessary
sexual functioning
° Anticipated postoperative discomfort and potential change in
e Possibility of death

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NDx = NANDA Diagnosis
 218 Chapter 6 * The Client With Alterations in Cardiovascular Function

POSTOPERATIVE NURSING/COLLABORATIVE DIAGNOSIS*

Nursing/Collaborative Diagnosis RISK FOR IMBALANCED FLUID VOLUME nox AND RISK
FOR ELECTROLYTE IMBALANCE nox
Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease, increase, or rapid shift from one to the other
of intravascular, interstitial and/or intracellular fluid, which may compromise health. This refers to body fluid loss,
gain, or both; Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte levels, which may
compromise health.
Related to:
e Third-spacing of fluid related to:
e Increased capillary permeability in surgical area associated with the inflammation that occurs after extensive dissection
of tissue during major abdominal surgery
e Increased vascular hydrostatic pressure associated with excess fluid volume if present
¢ Hypoalbuminemia associated with the escape of proteins from the vascular space into the peritoneum (a result of
increased capillary permeability in the surgical area)
e Excess fluid volume NDx related to:
e Vigorous fluid replacement
e Fluid retention associated with increased secretion of antidiuretic hormone (ADH; output of ADH is stimulated by trauma,
pain, and anesthetic agents) and/or renal insufficiency (can occur if there is inadequate blood flow to the kidneys during
or after surgery)
¢ Reabsorption of third-space fluid (occurs about the third postoperative day)
° Deficient fluid volume NDx related to restricted oral fluid intake before, during, and after surgery; blood loss; and loss of
fluid associated with nasogastric tube drainage
° Hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with
nasogastric tube drainage

CLINICAL MANIFESTATIONS

Subjective Objective
Excessive fluid volume: Not applicable Excessive fluid volume: Weight gain of 2% or greater in a
short period; elevated B/P (B/P may not be elevated if
cardiac output is poor or fluid has shifted out of the
vascular space); presence of an S; heart sound; intake
greater than output; change in mental status; crackles
(rales); dyspnea, orthopnea; edema, distended neck veins;
elevated central venous pressure (CVP) (use internal jugu-
lar vein pulsation method to estimate CVP if monitoring
device is not present)
Deficient fluid volume: Verbal self-report of thirst Deficient fluid volume: Hypotension; tachycardia; de-
creased urine output; tenting skin turgor; dry mucous
membranes; thick, tenacious pulmonary secretions
Hypokalemia: Verbal self-report of muscular weakness, Hypokalemia: Decreased or absent deep tendon reflexes;
leg cramps; paresthesia; palpitations anorexia; Nausea; vomiting; rhabdomyolysis; orthostatic
hypotension; ventricular arrhythmias; cardiac arrest
Hypochloremia: Verbal self-report of muscle cramps, Hypochloremia: Tetany; hyperactive deep tendon reflexes;
weakness, and/or twitching; irritability arrhythmias; seizures, coma
Metabolic alkalosis: Verbal self-report of muscle cramps, Metabolic alkalosis: Apathy; confusion; slow, shallow
weakness, and/or twitching; irritability; complaints of respirations; hyperactive reflexes; seizures; stupor; an-
numbness and tingling of fingers, nose, and/or mouth orexia; nausea; vomiting

*Use in conjunction with the Standardized Postoperative Care Plan.

 Chapter 6 * The Client With Alterations in Cardiovascular Function 219

RISK FACTORS DESIRED OUTCOMES

e Aneurysm rupture resulting in hypovolemic shock
The client will experience resolution of third-spacing as
e Excessive volume replacement during resuscitation
evidenced by:
e Excessive electrolyte loss through nasogastric drainage
a. Absence of ascites
b. B/P and pulse rate within normal range for client and
stable with position changes
The client will not experience excess fluid volume as
evidenced by:
a. Stable B/P
b. Absence of an S3 heart sound
c. Balanced intake and output
d. Normal breath sounds
The client will experience fluid and electrolyte balance as
evidenced by:
a. B/P and pulse rate within normal range for client and
stable with position change
b. Balanced intake and output within 48 hrs after
surgery
c. Absence of cardiac dysrhythmias, muscle weakness,
paresthesias, twitching, spasms, and dizziness
d. Blood urea nitrogen (BUN), serum electrolytes, and
arterial blood gas values within normal range

NURSING OUTCOMES INTERVENTIONS (NOC) NURSING INTERVENTIONS CLASSIFICATIONS (NIC)

es
Se
Fluid balance; fluid overload severity; electrolyte and acid- Fluid monitoring; fluid/electrolyte management; electrolyte
base balance monitoring; acid-base management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of third-spacing: Early recognition of signs and symptoms of third-spacing allows for
e Ascites (e.g., increase in abdominal girth, dull percussion prompt intervention.
note over abdomen with finding of shifting dullness)
e Evidence of vascular depletion (e.g., postural hypotension;
weak, rapid pulse).
Monitor serum albumin levels. Report below-normal levels. Low serum albumin levels result in fluid shifting out of vascular
space because albumin normally maintains plasma colloid
osmotic pressure.
Monitor serum electrolyte values. Report abnormal values. Early recognition of signs of electrolyte imbalances allows for
prompt intervention.
Assess quantity of nasogastric tube drainage. Excessive nasogastric tube drainage can lead to hypokalemia,
hypochloremia, and metabolic alkalosis.

THERAPEUTIC UNIS INTERVEN TIONS RATIONALE ee EEE

ATS SD bt) en
Dependent/Collaborative Actions
Implement measures to prevent further third-spacing of fluid/ Actions help to reduce the risk of fluid volume overload.
fluid volume overload:
e Administer fluid replacement judiciously.
° Maintain fluid restrictions as ordered.
e [f client is receiving intravenous fluids that contain sizeable Actions help to reduce the risk of third-spacing and electrolyte
(e.g., 0.9% sodium chloride [NaCl] or imbalances.
amounts of sodium
lactated Ringer’s), consult the physician about a change in
solution or a decrease in the rate of infusion.
e Administer albumin infusions if ordered. Administration of albumin helps to increase colloid osmotic
pressure, promoting mobilization of fluid back into the vascular
Space.

Administer diuretics if ordered. D + Diuretics help to increase excretion of water.

°
Diuretics should only be administered ifsigns and symptoms of
fluid volume overload are evident.

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NDx = NANDA Diagnosis D = Delegatable Action
 220 Chapter 6 * The Client With Alterations in Cardiovascular Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to prevent or treat deficient fluid
volume, hypokalemia, hypochloremia, and metabolic
alkalosis:
e Administer fluid and electrolytes as ordered.
° Carefully measure all drainage (e.g., wound, nasogastric)
and administer fluid replacement as ordered. D +
Consult physician if signs and symptoms of third-spacing, Consulting the appropriate health care provider allows for modifi-
fluid volume deficit, fluid volume overload, or electrolyte cation of the treatment plan.
imbalances persist or worsen.

|Nursing ~Diagnosis |RISK FOR SHOCK nox

Definition: Susceptible to an inadequate blood flow to the body’s tissues that may lead to life-threatening cellular
dysfunction, which may compromise health.
Related to:
° Hypovolemia associated with blood loss during surgery
¢ Third-space fluid shift
e Hemorrhage (can occur as a result of inadequate wound closure and/or stress on and subsequent leakage or rupture of
anastomotic sites)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of anxiety; confusion; agitation Tachypnea; hypotension; tachycardia; decreased urine
output; pallor; cool, clammy skin, observable bleeding

RISK FACTOR
DESIRED OUTCOMES
e Aneurysm rupture
° Coagulopathy The client will not develop hypovolemic shock as
° Inadequate volume replacement during surgical procedure evidenced by:
. Usual mental status
. Stable vital signs
Skin warm and usual color
. Palpable peripheral pulses
. Urine output at least 30 mL/h
. Absence of bleeding
moan
tp

NOC OUTCOMES NIC INTERVENTIONS

Shock severity: hypovolemic; fluid balance; fluid overload Shock prevention; shock management: volume; electrolyte
severity; electrolyte and acid-base balance; vital signs management; fluid/electrolyte management; fluid monitor-
ing; acid-base management; vital sign monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of leakage at Early recognition of signs and symptoms of hypovolenic shock
anastomotic sites: allows for prompt intervention.
e New or expanding hematoma at incision site and/or
ecchymosis of flank or perineal area
° Increased abdominal girth (can also occur with third-spacing)
e New or increased reports of lumbar, flank, abdominal,
pelvic, or groin pain
° Increasing feeling of abdominal and/or gastric fullness
unrelated to oral intake
° Diminishing or absent peripheral pulses
° Decreased motor or sensory function in lower extremities
° Decreasing B/P, increasing pulse rate.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 221

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of hypovolemic
shock:
e Restlessness, agitation, changes in mental status
e Significant decrease in B/P
e Postural hypotension
e Rapid, weak pulse
e Rapid respirations
e Cool skin
e Pallor, cyanosis
e Diminished or absent peripheral pulses
e Urine output less than 30 mL/h
’ Monitor red blood cell (RBC) count, hematocrit (Hct), and While decreasing values may be indicative of hemorrhage, lab
hemoglobin (Hgb) values for abnormal trends. value trends should be evaluated in light of overall fluid status
because fluid volume overload may dilute actual Hgb values.
Monitor serum electrolyte values for abnormal trends. Decreased perfusion that occurs with shock can contribute to
abnormal serum electrolyte values which may further compro-
mise the health status of the client.

“THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
e Maintain accurate intake and output (I/O) record: Accurate I/O records are necessary to direct appropriate fluid man-
e Oral intake agement.
e Enteral intake
e IV intake (e.g., fluids/antibiotics)
e Urine output
e Drain output (e.g., NG tube)
e Maintain large bore IV access—consider more than one Appropriate IV access is necessary in clients at risk for shock in the
site as available. event that rapid fluid resuscitation becomes necessary.
e Perform actions to reduce stress on and separation of Stress on anastomotic sites increases the risk for disruption of
anastomotic sites: D+ suture lines, which may lead to hemorrhage and/or hypo-
e Instruct client to avoid positions that compromise volemic shock due to blood loss.
peripheral blood flow (use of knee gatch, crossing legs).
e Instruct client to avoid activities that create a Valsalva
response (e.g., straining to have a bowel movement,
holding breath while moving up in bed).
e Instruct client to avoid vigorous coughing.

THERAPEUTIC INTERVENTIONS RATIONALE

ea
Dependent/Collaborative Actions
Implement measures to prevent hypovolemic shock: Blood replaces loss of cells, volume expanders maintain vascular
e Perform actions to prevent or treat hypovolemia:
fluid volume.
° If bleeding occurs, apply firm pressure to area if possible.
e Administer blood and/or volume expanders (colloids/
crystalloids) as ordered.
e Provide maximum fluid intake allowed.
e Implement measures to reduce the accumulation of Interstitial fluid accumulation in the gastrointestinal tract along
with excessive gas accumulation can result in excessive stress
gas and fluid in the gastrointestinal tract (e.g., insert
nasogastric tube). on anastomotic sites, increasing the risk of disruption ofsuture
lines and subsequent hemorrhage.
Interstitial fluid accumulation in the gastrointestinal tract can lead
e Administer fluid replacement therapy judiciously.
to excessive stress on anastomotic sites, increasing the risk of
e Maintain fluid restrictions if ordered.
disruption of suture lines and subsequent hemorrhage.
e Administer antihypertensives if ordered. D +
Elevated B/P must be reduced to a level that does not stress vascu-
lar anastomotic sites. Medications must be administered to
keep a client’s B/P within an acceptable range, especially within
the immediate postoperative period.

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 222, Chapter6 = The Client With Alterations in Cardiovascular Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of hypovolemic shock occur:
e Place client flat in bed unless contraindicated.
e Monitor vital signs frequently.
e Administer oxygen as ordered.
Prepare client for surgery if signs and symptoms of hypo- Surgical exploration will aid in identifying and controlling
volemic shock occur, persist, or worsen. suspected sources of hemorrhage.

_(
= RISK FOR VENOUS THROMBOEMBOLIZATION nox
Definition: Susceptible to the development of a blood clot in a deep vein, commonly in the thigh, calf, or upper extremity,
which can break off and lodge in another vessel, which may compromise health.

Related to: Dislodgment of necrotic debris or clot from surgical site

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sudden, severe pain in affected limb; Diminished or absent pulses in affected limb; pale, cool,
numbness in affected limb mottled extremity
Six P’s of acute arterial ischemia: pain, pallor, pulselessness,
paresthesia, paralysis, poikilothermia

RISK FACTORS DESIRED OUTCOMES

e Virchow’s triad: venous stasis, hypercoagulability of blood,
The client will not experience venous thromboembolism
endothelial damage at surgical site
as evidenced by:
e History of previous thromboembolism
a. No reports of pain or diminished sensation in lower
e Surgery and total anesthesia time > 90 minutes
extremities
b. Palpable peripheral pulses
c. Usual temperature and color of extremities

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of lower extremity Early recognition of signs and symptoms of arterial embolization
arterial embolization: allows for prompt intervention.
e Sudden, severe onset of pain in extremity
e Diminishing or absent peripheral pulses (pulses may
be absent for a few hours after surgery as a result of
vasospasm)
e Cool, pale, or mottled extremities.

NOC OUTCOMES NIC INTERVENTIONS

ee ees
Tissue perfusion: peripheral Embolus precautions; embolus care: peripheral

THERAPEUTIC INTERVENTIONS RATIONALE

‘

Independent Actions
e Implement measures to prevent venous thromboembo-
lism.
e Assist patient with passive or active range of motion as Range of motion exercises, including flexion and extension of the
appropriate. feet and legs, promote reduced venous stasis by promoting
e Encourage flexion and extension of feet and legs at least venous return to the heart.
10 times per hour.
e Change client position every 2 hrs.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 225

THERAPEUTIC INTERVENTIONS RATIONALE

e Instruct patient on strategies to prevent venous thrombo-
embolism:
e Refrain from crossing legs and to avoid sitting for long Crossing legs and sitting for long periods of time increases venous
periods with legs dependent. stasis/pooling of blood in the extremities.
e Avoid activities that result in the Valsalva maneuver (e.g., Valsalva maneuver will change pressures in the body and affect
straining during bowel movement). venous blood flow in the system.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent venous thromboembolism:
e Apply intermittent pneumatic compression device stockings/ Application of intermittent pneumatic compression stockings and/or
graduated elastic compression stockings per organizational graduated elastic stockings promotes the return of blood to
policy and protocol. the heart and prevents the pooling of blood in the legs which
e Remove stockings for 15 to 20 minutes every 8 hrs or increases the risk of clot formation.
per organizational policy and protocol.
Encourage early mobilization or ambulate as tolerated as Early mobilization improves venous return from the lower extremi-
ordered by physician. ties, reducing the risk of thromboembolism.
If signs and symptoms of lower extremity arterial embolization
occur:
e Maintain client on bed rest. D+ In order to prevent dislodgment of existing thrombi.
e Prepare client for the following if planned: To restore blood flow, an embolus should be removed as soon as
e Diagnostic studies (e.g., Doppler ultrasound, arteriography) possible after identification/location of the obstruction.
e Embolectomy

Diagnosis «RISK FOR DECREASED

|Nursing ooo) CARDIAC OUTPUT nox
demands of the body, which may
Definition: Susceptible to inadequate blood pumped by the heart to meet metabolic
compromise health.

Related to: Altered nodal function and myocardial conductivity associated with:
e Alteration in heart rate
e Alteration in heart rhythm
flow/damage
Alteration in myocardial contractility due to diminished myocardial blood

CLINICAL MANIFESTATIONS

Objective
Subjective
Irregular apical pulse; pulse rate less than 60 or greater than
Verbal self-report of chest pain and/or shortness of breath;
100 beats/min; electrocardiogram (ECG) tracing abnormali-
verbalization of syncope, dizziness, palpitations; and/or
abdominal pain ties; ischemic changes on ECG tracing (e.g., dysrhythmias,
elevated or depressed T-wave); hypotension/hypertension,
decreased or absent urine output; diminished peripheral
pulses, cool clammy skin; auscultated rales/crackles in lung
fields; decreased oxygen saturation; distended neck veins

DESIRED OUTCOMES
RISK FACTORS nn
e Stress associated with general anesthesia The client will maintain normal cardiac output as evidenced by:
e Preexisting cardiovascular disease a. Regular apical pulse at 60 to 100 beats/min
e Electrolyte imbalances b. Normal sinus rhythm or return to client's baseline rhythm
c. Blood pressure within client’s normal range
d. Normal respiratory rate/clear breath sounds
e. Oxygen saturation within client's baseline
f. Balanced fluid intake/output
g. Presence of bowel sounds/bowel movements

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 224 Chapter 6 = The Client With Alterations in Cardiovascular Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of decreased cardiac Early recognition of signs and symptoms of decreased cardiac
perfusion: output allows for prompt intervention.
e Alterations in heart rate/rhythm
e Irregular apical pulse
e Pulse rate less than 60 or greater than 100 beats/min
e Abnormal rhythms, or configurations on ECG
e Verbalization of chest pain
Assess for signs and symptoms of decreased cardiac output
e Decrxeased blood pressure below client’s baseline
e Verbalization of shortness of breath
e Auscultation of crackles in lungs
e Decreased oxygen saturation
e Decreased urine output
e Abdominal pain/absence of bowel sounds
e Decreased strength and quality of peripheral pulses
e Cool, clammy skin
Assess baseline vital signs for symptoms of decreased cardiac
output:
e Increased or decreased heart rate
e Decreased blood pressure
e Decreased oxygen saturation
Assess baseline serum electrolytes, BUN, creatinine, brain natri-
uretic peptide (BNP), cardiac enzymes for abnormalities that
may contribute to alterations in normal cardiac rhythm and
cardiac output.
Assess baseline radiographic studies (e.g., CXR) for abnor-
malities indicating alterations in normal cardiac output.

NOC OUTCOMES NIC INTERVENTIONS

eee
Cardiac pump effectiveness; cardiopulmonary status; Cardiac care acute; dysrhythmia management; fluid/
gastrointestinal function; tissue perfusion abdominal electrolyte management; hypotension management;
organs; tissue perfusion cardiac; tissue perfusion cellular hypovolemia management

THERAPEUTIC INTERVENTIONS
ene
F RATIONALE
eeee r
Independent Actions
e Perform actions to maintain an adequate respiratory status. Actions help to maintain adequate myocardial tissue oxygenation.
e Assist client in performing incentive spirometry Q2h.
e Assist client in turning, coughing, and deep breathing Q2h
until ambulating.
e Perform actions to decrease stimulation of the sympathetic Sympathetic stimulation increases the heart rate and causes
nervous system: vasoconstriction, both of which increase cardiac workload and
e Implement measures to reduce pain and anxiety. decrease oxygen availability to the myocardium.
e Perform relaxation therapy if appropriate (e.g., music
therapy, meditation).
e Implement measures to keep client from getting cold.
e Ensure activity level does not compromise cardiac output Ensures myocardial oxygen demand does not exceed supply.
or provoke cardiac events.
e Provide frequent rest periods/avoid fatigue.

THERAPEUTIC INTERVENTIONS RATIONALE

SS aa aa

Dependent/Collaborative Actions
e Perform actions to prevent or treat hypokalemia: Electrolyte imbalances, particularly hypokalemia and hypo-
° Prevent nausea and vomiting. calcemia, can contribute to cardiac dysrhythmias.
e Administer fluid and_ electrolyte replacements as
ordered.
 Chapter 6 « The Client With Alterations in Cardiovascular Function 225

THERAPEUTIC INTERVENTIONS RATIONALE |

e Perform actions to prevent or treat hypotension: Actions help to ensure adequate vascular volume, tissue perfusion,
e Consult physician before giving negative inotropic and delivery of oxygen to the myocardial tissue.
agents, diuretics, and vasoditating agents if systolic B/P
is below 90 to 100 mm Hg.
e Administer opioid analgesics judiciously, being alert to
the synergistic effect of the narcotic ordered and the
anesthetic that was used during surgery.
e Gradually bring client’s body temperature to normal if Rapid warming results in vasodilation, which may reduce B/P and
hypothermic. tissue perfusion.
e Administer sympathomimetics (e.g., dopamine) if ordered. Sympathomimetics mimic the action of the sympathetic nervous
system, causing vasoconstriction, which elevates B/P.
If cardiac dysrhythmias occur: Cardiac dysrhythmias may deteriorate and become life-threatening.
e Administer antidysrhythmics as ordered. Life-threatening dysrhythmias or those that render the client
e Restrict client’s activity based on his/her tolerance and unstable are treated with electrical therapy.
severity of the dysrhythmia.
e Maintain oxygen therapy as ordered. Allows for modification of the treatment plan.
e Assess cardiovascular status frequently and report signs and
symptoms of inadequate tissue perfusion (e.g., decrease in
B/P, cool skin, cyanosis, diminished peripheral pulses, urine
output less than 30 mL/h, restlessness and agitation, short-
ness of breath).
e Have emergency cart readily available for cardiovetsion,
defibrillation, or cardiopulmonary resuscitation (CPR).
e Consult physician if signs and symptoms of decreased
cardiac output persist.

>.
Cece DEFICIENT KNOWLEDGE Npxt INEFFECTIVE HEALTH
AINTENANCE nox; OR INEFFECTIVE HEALTH
Ate MENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain well-being;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Inaccurate follow-through of instructions; inappropriate
Verbal self-report of the problem
behaviors

RISK FACTORS
e Denial of disease process
e Cognitive deficiency
e failure to take action to reduce risk factors

NIC INTERVENTIONS
NOC OUTCOMES
ment Health system guidance; teaching: individual; teaching:
Knowledge: treatment regimen; cardiac disease manage
disease process; teaching: prescribed diet

appropriate for the client’s discharge teaching needs.

*The nurse should select the diagnosis that is most

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 226 Chapter 6 = The Client With Alterations in Cardiovascular Function

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

or slow the progression of atherosclerosis.

Independent Actions
Inform the client that certain modifiable factors such as After vascular surgery, clients should be educated as to health
elevated serum lipid levels, a sedentary lifestyle, smoking, promotion activities that slow the progression of atherosclerosis.
and hypertension have been shown to increase the risk of Clients should be encouraged to control B/P, increase physical
atherosclerosis. activity, stop smoking, and maintain normal body weight and
serum lipid levels.
Assist client to identify changes in lifestyle that could reduce Appropriate modifications of diet, exercise, and smoking cessation
the risk for atherosclerosis: can modify the progression of coronary artery disease (CAD).
e Dietary modifications
e Smoking cessation
e Physical exercise on a regular basis
Provide instructions on ways the client can reduce intake of Decreasing intake of saturated fat and cholesterol and increasing
saturated fat and cholesterol: complex carbohydrates can reduce the risk of CAD by lowering
e Reduce intake of meat fat (e.g., trim visible fat off meat; low-density lipoprotein (LDL) cholesterol.
replace fatty meats such as fatty cuts of steak, hamburger,
and processed meats with leaner products).
e Reduce intake of milk fat (e.g., avoid dairy products
containing more than 1% fat).
e Reduce intake of trans fats (e.g., avoid stick margarine and
shortening and foods such as commercial baked goods
that are prepared with these products).
e Use vegetable oil rather than coconut or palm oil in cooking
and food preparation.
e Use cooking methods such as steaming, baking, broiling,
poaching, microwaving, and grilling rather than frying.
e Restrict intake of eggs (recommendations about the num-
ber of whole eggs allowed per week vary depending on the
client’s lipid levels).
Instruct client to take lipid-lowering agents (e.g., HMG-CoA Lipid-lowering agents inhibit the synthesis of cholesterol in the
[3-hydroxy-3-methylglutaryl-coenzyme A] reductase inhibi- liver. The result of this inhibition is an increase in hepatic LDL
tors [“statins”], ezetimibe, gemfibrozil, niacin) as prescribed. receptors. This results in the liver being able to remove more
LDLs from the blood.

THERAPEUTIC INTERVENTIONS RATIONALE

——
SSSSSSSSsSSSSSSSssssssssssssssSss
— ——

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions ‘
Instruct client to report these additional signs and symptoms: Additional signs and symptoms indicate internal bleeding. Prompt
e Sudden or gradual increase in lower back, flank, groin, or treatment for the client exhibiting signs and symptoms of
abdominal pain internal bleeding from graft site reduces the risk of life-
e Chest pain threatening complications.
e Coolness, pallor, or blueness of lower extremities
e Increased weakness and fatigue
e Decreased urine output
e Bloody or persistent diarrhea
e Increased bruising of incision site, flank area, or perineum
e Impotence
 Chapter 6 » The Client With Alterations in Cardiovascular Function 227

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, activity level, and
wound care.

Independent Actions
Reinforce the physician’s instructions regarding: The nurse should reinforce the need to follow up with the physician/
e Importance of scheduling adequate rest periods surgeon provider as instructed to ensure adherence to all aspects
e Ways to prevent constipation and subsequent straining to of the treatment plan.
have a bowel movement (e.g., drink at least 10 glasses of
liquid per day unless contraindicated, increase intake of
foods high in fiber, take stool softeners if necessary)
e The need to avoid sexual intercourse, isometric exercise/
activity (e.g., lifting objects over 10 lb, pushing heavy
objects), and strenuous exercise for specified length of
time (usually 4-12 weeks depending on the activity)
e The need to take prophylactic antimicrobials before any Some physicians recommend this for the first 6-12 months after
dental work or invasive procedure surgical placement of a synthetic graft.
e Collaborate with the client to develop a plan for success
following discharge from the acute care facility.

as a result of prolonged aortic clamp time during surgery,

ADDITIONAL NURSING DIAGNOSIS persistent hypovolemia, embolization, or graft occlusion)
and/or nerve damage (can occur during surgery)
SEXUAL DYSFUNCTION
Related to:
e Decreased libido associated with operative site discomfort RELATED CARE PLANS
and fear of surgical site bleeding
Impotence associated with prolonged reduction in blood Standardized Preoperative Care Plan
flow in the mesenteric or internal iliac arteries (can occur
Standardized Postoperative Care Plan

PNCel 3S
Angina pectoris is transient chest pain or discomfort that is very hot or very cold temperatures, heavy meals, or smoking.
caused by an imbalance between myocardial oxygen supply and Stable angina typically lasts a short time (S minutes or less), may
demand. The discomfort typically occurs in the retrosternal area; feel like gas or indigestion, may spread to arms, back or other
may or may not radiate; and is described as a tight, heavy, areas, and is relieved by rest and nitroglycerin. Unstable angina is
squeezing, burning, or choking sensation. The most common characterized by an increasing frequency and/or severity of
attacks that occur with less provocation or at rest. It is considered
cause of angina pectoris is decreased coronary blood supply due with
coronary syndrome, which is associated
to atherosclerosis of a major coronary artery. The atherosclerosis
to be an acute
thrombus formation in a coronary artery. Persons with unstable
causes narrowing of the vessel lumen and an inability of the ves-
angina are usually hospitalized and treated with heparin and
sel to dilate and supply sufficient blood to the myocardium at
antiplatelet agents while decisions regarding medical versus
times when myocardial oxygen needs are increased. Other condi-
surgical treatment are made. A third type of angina is Prinzmetal
tions that can compromise coronary blood flow (e.g., spasm
condi- variant angina. It is less common than stable or unstable angina,
and/or thrombosis of a coronary artery, hypovolemia) and
ty and/or increase myocardia l almost always occurs at rest usually between midnight and early
tions that reduce oxygen availabili
demands (e.g., anemia, smoking, exercise, morning, and is due to severe focal spasm of a coronary artery.
workload and oxygen
stress) may Angina symptoms can differ by gender. Angina symptoms
heavy meals, increased altitude, exposure to cold,
widen- in men are often to due blockages in the coronary arteries
precipitate or increase the frequency of angina attacks by
and availabilit y. referred to as CAD. In women, symptoms are more frequently
ing the gap between oxygen needs
pec- associated with disease within the very small arteries that
The two major types of angina are stable angina (angina
e angina (acute coronar y syndro me). Stable an- branch out from the coronary arteries referred to as microvas-
toris) and unstabl
commo n type, is usually precipi tated by physical cular disease (MVD). While angina is most often associated
gina, the most
exposure to with a heart attack, women are warned that they may
exertion or emotional stress, but can be triggered by

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 228 Chapter6 * The Client With Alterations in Cardiovascular Function

experience symptoms not related to angina at all and include 6. Identify modifiable cardiovascular risk factors and ways
unusual fatigue, sweating, and/or shortness of breath, and to alter these factors
neck, jaw, or back pain 7. Verbalize an tinderstanding of the rationale for and
This care plan focuses on the adult client hospital- components of a diet designed to lower serum cholesterol
ized during an episode of chest pain/discomfort sus- and triglyceride levels
pected to be unstable angina. 8. Demonstrate accuracy in counting pulse
9. Verbalize an understanding of medications ordered
including rationale, food and drug interactions, side
OUTCOME/DISCHARGE CRITERIA effects, schedule for taking, and importance of taking as
prescribed
The client will: 10. State signs and symptoms to report to the health care
1. Perform activities of daily living and ambulate without provider
angina 11. Identify community resources that can assist in making
. Have angina controlled by oral medication necessary lifestyle changes and adjusting to the effects of
. Have no signs and symptoms of complications angina pectoris
. Verbalize a basic understanding of angina pectoris 12. Develop a plan for adhering to recommended follow-up
me
On
WN . Identify factors that may precipitate angina attacks and care including future appointments with health care
ways to control these factors provider.

|Nursing >
Diagnosis RISK FOR DECREASED CARDIAC OUTPUT nox
Definition: Susceptible to inadequate blood pumped by the heart to meet metabolic demands of the body, which may
compromise health.

Related to: Mechanical and/or electrical dysfunction of the heart associated with severe or prolonged myocardial ischemia

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of palpitations; fatigue; shortness of Dysrhythmias; ECG changes; altered preload (jugular
breath/dyspnea; orthopnea; anxiety venous distention [JVD], edema, weight gain, increased
CVP, murmurs); altered afterload (cold, clammy skin;
cyanosis; prolonged capillary refill time; decreased
peripheral pulses); altered contractility (crackles, cough,
decreased cardiac output); restlessness

RISK FACTORS DESIRED OUTCOMES

e Altered heart rate ae eet |
The client will maintain adequate cardiac output as
e Altered heart rhythm
evidented by:
e Altered stroke volume
a. B/P within client’s normal range
b. Apical pulse regular and between 60 and 100 beats/min
c. Absence of $3, Sy heart sounds (gallop)
d. Absence of fatigue and weakness
e. Unlabored respirations at 12 to 20 breaths/min
f. Clear, audible breath sounds
g. Usual mental status
h. Absence of dizziness and syncope
i. Palpable peripheral pulses i
j. Capillary refill time less than 2 to 3 seconds
k. Urine output of at least 30 mL/h
1. Absence of edema and JVD

NOC OUTCOMES NIC INTERVENTIONS

Circulation status; cardiac pump effectiveness; tissue Cardiac care: acute; hemodynamic regulation; cardiac risk
perfusion: cardiac; peripheral management; cardiac tare: rehabilitative
 Chapter 6 * The Client With Alterations in Cardiovascular Function 229

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of decreased cardiac Early recognition of signs and symptoms of decreased cardiac
output: output allows for prompt intervention.
e Variations in B/P
e Tachycardia
e Presence of extra heart sounds (gallop)
e Fatigue and weakness
e Dyspnea, tachypnea
e Crackles (rales)
e Restlessness, change in mental status
e Dizziness, syncope
e Diminished or absent peripheral pulses
e Cool extremities
e Capillary refill time greater than 2 to 3 seconds
e Oliguria
e Edema
e JVD
Monitor and report abnormal chest radiograph, arterial blood Diagnostic tests may demonstrate vascular congestion (pulmonary
gas, or pulse oximetry values. edema) indicative of decreased cardiac output. Arterial blood
gas/pulse oximetry values may indicate hypoxia as cardiac
output decreases and pulmonary congestion worsens.
Monitor and report abnormal ECG readings. May demonstrate findings associated with ischemia such as
dysrhythmias, ST-segment depression/elevation, or inverted
T waves.
Monitor and report elevated cardiac enzymes (i.e., creatine Elevated values may indicate myocardial ischemia/damage. Exten-
kinase—-MB [CK-MB]; troponin). sive damage may further decrease cardiac output. .

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve cardiac output:
e Maintain a calm, quiet environment, limit the number of Actions promote emotional and physical rest and help to reduce
visitors, and maintain activity restrictions. D > cardiac workload.
Instruct client to avoid activities that create a Valsalva
response:
e Straining to have a bowel movement Excessive straining can increase cardiac workload.
e Holding breath while moving up in bed
Discourage excessive intake of beverages high in caffeine such Caffeine is a myocardial stimulant and can increase myocardial
as coffee, tea, and colas. oxygen consumption.
Discourage smoking. Nicotine has a cardiostimulatory effect and causes vasoconstric-
tion; the carbon monoxide in smoke reduces oxygen availability.

Dependent/Collaborative Actions
Maintain oxygen therapy as ordered. D + Oxygen helps to improve oxygenation and reduce damage to the
myocardium.
Medications act to improve blood flow to the coronary arteries
Administer the following medications if ordered:
helping to maintain adequate cardiac output.
e Nitrates
Nitrates dilate the coronary and peripheral (primarily venous) blood
vessels, thereby improving myocardial blood flow and reducing
cardiac workload and myocardial oxygen consumption.
e Beta-adrenergic blockers Beta blockers reduce myocardial oxygen requirements by decreasing
the heart rate and force of myocardial contractility.
CCBs dilate the coronary arteries and also reduce cardiac workload
e Calcium channel blockers (CCBs)
by dilating peripheral vessels.
Anticoagulants prevent obstruction of the coronary arteries by
e Anticoagulants
thrombosis.

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 230 Chapter6 = The Client With Alterations in Cardiovascular Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Prepare client for percutaneous coronary intervention if Providing information to a client about what will occur during a
planned: procedure may increase client’s participation in the procedure
e Balloon angioplasty and decrease anxiety.
e Atherectomy
e Intracoronary stenting
e Coronary artery bypass grafting (CABG)
Increase activity as allowed and tolerated. D +

Nursing Diagnosis ACUTE PAIN nox (RADIATING OR NONRADIATING

CHEST PAIN/DISCOMFORT)
Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Related to: Decreased myocardial oxygenation (an insufficient oxygen supply forces the myocardium to convert to anaerobic
metabolism; the end products of anaerobic metabolism act as irritants to myocardial neural receptors)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest discomfort or pain over the ECG changes (ST-segment depression/elevation);
sternal border, radiating to the neck, jaw, left arm; dysrhythmias
indigestion

RISK FACTORS DESIRED OUTCOMES

e Arteriosclerosis
The client will experience relief of chest pain/discomfort
e Increased oxygen demand
as evidenced by:
e Decreased oxygen supply
a. Verbalization of the same
e Hypertension
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

Comfort status; pain control Pain management acute; medication administration;
analgesic administration

NURSING ASSESSMENT RATIONALE

ee
SSSSSSSSSSSSSSSSsesesesesesSSSSSSSSSSSSsSS

Assess for signs and symptoms of pain/discomfort: Early recognition and reporting of signs and symptoms of ischemic
e Verbalization of pain chest pain allow for prompt intervention.
e Grimacing
e Rubbing neck, jaw, or arm
e Reluctance to move
e Clutching chest
e Restlessness
e Diaphoresis
e Increased B/P
e Tachycardia
Assess Client’s perception of the severity of the pain/discomfort
using an intensity rating scale.
Assess the client’s pattern of pain/discomfort (location,
quality, onset, duration, precipitating factors, aggravating
factors, alleviating factors).
 Chapter 6 * The Client With Alterations in Cardiovascular Function 231

NURSING ASSESSMENT RATIONALE

Monitor and report abnormal ECG readings. May demonstrate findings associated with ischemia such as
dysrhythmias, ST-segment depression/elevation, or inverted
T waves.
Monitor and report elevated cardiac enzymes (CK-MB; troponin). Elevated values may indicate myocardial ischemia.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Provide or assist with nonpharmacological measures for relief Activities that promote rest help to reduce myocardial oxygen
of discomfort: D + consumption.
e Position change
e Relaxation techniques
e Restful environment

Dependent/Collaborative Actions
Administer nitroglycerin as ordered. Nitrates dilate the coronary and peripheral (primarily venous) blood
Maintain oxygen therapy as ordered. D+ vessels, thereby improving myocardial blood flow and reducing
cardiac workload and myocardial oxygen consumption.
Administer a opioid analgesic (e.g., morphine sulfate) as ordered Narcotic analgesics help to alleviate pain and anxiety, lower B/P,
if pain/discomfort is unrelieved by rest and nitroglycerin and decrease myocardial oxygen consumption.
within 15 to 20 minutes (narcotic analgesics are usually
administered intravenously).
Consult physician if pain/discomfort persists or worsens. Consulting the appropriate health care provider allows for modifi-
Prepare client for percutaneous coronary intervention if cation of the treatment plan.
planned:
e Balloon angioplasty
e Atherectomy
e Intracoronary stenting
e CABG

Diagnosis |
|Collaborative "RISK FOR CARDIAC DYSRHYTHMIAS
missed or rapid beats to
Definition: A disturbance of the heart’s normal rhythm. Dysrhythmias can range in severity from
serious disturbances that impair the pumping ability of the heart.

Related to: Myocardial irritability associated with myocardial hypoxia

CLINICAL MANIFESTATIONS

Subjective Objective
ECG rate or rhythm abnormalities
Verbal self-report of palpitations or skipped beats; syncope

DESIRED OUTCOMES
RISK FACTORS
e Myocardial ischemia The client will maintain normal sinus rhythm as evi-
e Electrolyte disturbances denced by:
e Coronary artery disease a. Regular apical pulse at 60 to 100 beats/min
b. Equal apical and radial pulse rates
c. Absence of syncope and palpitations
d. ECG showing normal sinus rhythm

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232 Chapter6 = The Client With Alterations in Cardiovascular Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac Early recognition of signs and symptoms of dysrhythmias allows
dysrhythmias: for prompt intervention.
e Irregular apical pulse
e Pulse rate less than 60 or greater than 100 beats/min
e Apical-radial pulse deficit
e Syncope
e Palpitations
e Abnormal rate, rhythm, or configurations on ECG
Assess cardiovascular status frequently and report signs and
symptoms of inadequate cardiac output.
Assess ECG tracing.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Restrict client’s activity based on his/her tolerance and Decreases myocardial workload thus improving cardiac oxygenation.
severity of the dysrhythmia. D +
Have emergency cart readily available for cardioversion, Many dysrhythmias can be lethal and may only respond to electrical
defibrillation, or CPR. therapy.

Dependent/Collaborative Actions
Maintain oxygen therapy as ordered. D+ Oxygen helps to improve oxygenation and reduce myocardial
ischemia.
Implement measures to help maintain an adequate cardiac Classes of medications are administered in order to improve
output: myocardial blood flow and oxygenation, reducing the risk for
e Antidysrhythmics dysrhythmias. Antidysrhythmics help to reduce myocardial
e Add the following categories of medications: nitrates, beta- irritability.
adrenergic blocking agents; CCBs, anticoagulants

& Collaborative Diagnosis. FOR MYOCARDIAL INFARCTION

Definition: Irreversible myocardial damage.

Related to: Persistent ischemia or complete occlusion of a coronary artery

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sudden, severe chest pain; nausea Q-wave tracing on ECG; diaphoresis; variations in B/P;
increased heart rate; abnormal or extra heart sounds;
pericardial friction rub; increased CK-MB level; elevated
tropin level

RISK FACTORS DESIRED OUTCOMES }

e Coronary artery disease
The client will not experience a myocardial infarction (MI)
e Hypertension
e Hyperlipidemia as evidenced by:
a. Resolution of chest pain within 15 to 20 minutes
e Smoking
e Diabetes b. Stable vital signs
c. Cardiac enzyme levels within normal range
d. Absence of ST-segment depression or elevation, T-wave
inversion, and abnormal Q waves on ECG
 Chapter 6 = The Client With Alterations in Cardiovascular Function 233

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of an MI: Early recognition of signs and symptoms of an MI allows for
e Chest pain that lasts longer than 20 minutes prompt intervention.
e Increase in pulse rate
e Significant change in B/P
e Labored respirations
Assess for elevation of cardiac enzymes:
°¢ CK-MB
e Troponin
Assess ECG tracing for abnormalities:
e ST-segment depression or elevation
e T-wave inversion
e Abnormal Q waves on ECG

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Maintain client on strict bed rest in a semi- to high-Fowler’s Reduces myocardial oxygen consumption.
position. D +

Dependent/Collaborative Actions
Maintain oxygen therapy as ordered. D+ Oxygen helps to improve oxygenation and reduce myocardial
Administer the following medications if ordered: ischemia.
¢ Morphine sulfate Reduces pain and anxiety and decreases cardiac workload.
e Nitrates Improve myocardial blood flow and reduce myocardial oxygen
requirements.
Beta-adrenergic blockers Reduce myocardial oxygen requirements by decreasing heart rate
and force of myocardial contraction.
Prepare client for the following procedures that may be Procedures may be performed to improve myocardial blood flow.
performed:
e Injection of a thrombolytic agent (e.g., streptokinase,
alteplase [tissue-type plasminogen activator; tPA], anistre-
plase [APSAC, Eminase], reteplase, tenecteplase [TNK-tPA])
e Percutaneous coronary intervention
e Insertion of an intra-aortic balloon pump (IABP)

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY

HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE nox*
topic, or its acquisition;
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific
A pattern of regulating and integrating into family processes a
Ineffective Family Health Management NDx:
of illness and its sequelae that is unsatisfacto ry for meeting specific health goals of
program for the treatment
manage, and/or seek out help to
the family unit; Ineffective Health Maintenance NDx: Inability to identify,
maintain well-being.

CLINICAL MANIFESTATIONS

Objective
Subjective
Inaccurate follow-through of instructions; inaccurate
Verbal self-report of unfamiliarity with information
performance of a test; lack of recall
resources; collateral report of exaggerated behaviors

appropriate for the client’s discharge teaching needs.

*The nurse should select the diagnostic label that is most

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234 Chapter6 * The Client With Alterations in Cardiovascular Function

RISK FACTORS
e Denial of disease process
© Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

ee
Knowledge: treatment regimen; cardiac disease management Teaching: individual; teaching: disease process; teaching:
prescribed activity/exercise; teaching: prescribed medication;
health system guidance

NURSING ASSESSMENT RATIONALE

Assess Client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize a basic under-

standing of angina pectoris.

Independent Actions
Explain angina pectoris in terms that client can understand: Clients vary in physical and cognitive ability to learn. When
e Use teaching aids (e.g., pamphlets, diagrams) whenever educating clients, nurses need to determine their ability to read
possible. and understand written materials. If literacy barriers are
present, alternative educational materials should be provided.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify factors that may

precipitate an angina attack and ways to control these factors.

Independent Actions
Provide the following instructions regarding ways to reduce Clients with diagnosed cardiovascular disease should be educated
risk of precipitating an angina attack: to learn what may precipitate angina and ways to decrease
e Take nitroglycerin before strenuous activity or sexual the risk for angina. In addition, clients should be taught to
intercourse and during times of high emotional stress. recognize that changes in their individual pattern of angina
e Gradually increase activity by engaging in a regular aero- may indicate advancing disease, and if changes occur, prompt
bic exercise program (e.g., walking, biking, swimming). treatment should occur.
e Avoid strenuous exercise and activities that involve push-
ing or lifting heavy objects (e.g., weightlifting).
e Avoid exercising for at least an hour after eating, and
exercise with caution at higher altitude and when the
environmental temperature is extremely hot or cold.
e Avoid tobacco use before exercise.
e Rest between activities.
e Stop any activity that causes shortness of breath, palpita- Activities eliciting these responses may lead to angina and should
tions, dizziness, or extreme fatigue or weakness. be discontinued. '
e Begin a cardiovascular fitness program if recommended by Physical activity, if recommended, should be regular, rhythmic,
physician. and repetitive. .
e Adhere to the following precautions regarding sexual activity: Resumption of sexual activity should be based on the physiological
e Avoid intercourse for at least 1 to 2 hrs after a heavy meal or status of the patient.
alcohol consumption and when fatigued or stressed.
e Engage in sexual activity in a familiar environment and
in a position that minimizes exertion (e.g., side-lying,
partner on top).
e Recognize that a new sexual relationship can be started
but may result in greater energy expenditure initially.
e Avoid hot or cold showers just before and after intercourse.
 Chapter 6 «The Client With Alterations in Cardiovascular Function 235

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify modifiable

cardiovascular risk factors and ways to alter these factors.

Independent Actions
Inform client that certain modifiable factors such as elevated A person with modifiable risk factors should be encouraged to
serum lipid levels, a sedentary lifestyle, hypertension, and make lifestyle changes to reduce the risk for CAD. For the
smoking have been shown to increase the risk for CAD. motivated client, knowing how to reduce the risk may be all the
information that is needed.
Assist client to identify changes in lifestyle that can help
to eliminate or reduce the above risk factors and help to
manage angina:
e Dietary modification
e Physical exercise on a regular basis
e Moderation of alcohol intake
e Smoking cessation
Encourage client to limit daily alcohol consumption. Current Daily alcohol intake exceeding 1 oz of ethanol may contribute
recommendations: to the development of hypertension and some forms of heart
e No more than two drinks per day for men disease.
e No more than one drink per day for women and lighter- A “drink” is considered to be % oz of ethanol [e.g., 1% oz of
weight persons. 80-proof whiskey, 12 oz of beer, 5 0z of wine].

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of the rationale for and components of a diet designed to
lower serum cholesterol and triglyceride levels.

Independent Actions
Explain the rationale for a diet low in saturated fat and Fat intake should be approximately 30% of calories with most
cholesterol. coming from monosaturated fats found in nuts and oils such as
olive oil or canola oil.
Provide instructions on ways the client can reduce intake of Dietary modifications that reduce LDLs help reduce the risk of
saturated fat and cholesterol: CAD.
e Reduce intake of meat fat (e.g., trim visible fat off meat;
replace fatty meats such as fatty cuts of steak, hamburger,
and processed meats with leaner products).
e Reduce intake of milk fat (e.g., avoid dairy products
containing more than 1% fat).
* Reduce intake of trans fats (e.g., avoid stick margarine and
shortening and foods such as commercial baked goods
that are prepared with these products).
° Use vegetable oil rather than coconut or palm oil in cook-
ing and food preparation.
* Use cooking methods such as steaming, baking, broiling,
poaching, microwaving, and grilling rather than frying.
e Restrict intake of eggs Recommendations about the number of whole eggs allowed per
week vary depending on the client’s lipid levels.
Encourage client to increase intake of omega-3 fatty acids Omega-3 fatty acids have been shown to reduce the risk for CAD
fish such as salmon and if consumed regularly.
(e.g., flaxseed, cold water ocean
halibut) to help lower triglyceride levels and increase
high-density lipoprotein (HDL) levels.

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236 Chapter 6 * The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate accuracy in

counting pulse.

Independent Actions
Teach clients how to count their pulse, being alert to the Educating clients to their baseline rhythm allows for early detection
regularity of the rhythm. of irregularities warranting immediate attention from a health
Allow time for return demonstration and accuracy check. care provider. Early detection may reduce the incidence of
sudden death.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, and importance Taking medications as prescribed ensures that therapeutic drug
of taking the medications prescribed. Inform client of levels will be maintained.
pertinent food and drug interactions. Clients should be instructed not to discontinue taking medications
e Nitrates if they feel better. Clients without financial resources should be
e Nitroglycerin skin patches assisted in accessing appropriate resources to obtain needed
e Beta-adrenergic blockers medications (e.g., pharmacy assistance programs).
e CCBs
e Lipid-lowering agents
Instruct client to consult physician before taking other Drug-drug interactions may render medications inactive or result in
prescription and nonprescription medications. life-threatening side effects.
Instruct client to inform all health care providers of medica- Continuity of health care information is critical to reduce the
tions being taken. incidence of prescribing medications with potential adverse
drug-drug interactions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Stress the importance of reporting the following signs and Early identification of signs and symptoms of advancing coronary
symptoms: disease allows for prompt intervention by the appropriate health
e Chest, arm, neck, or jaw discomfort unrelieved by rest care provider.
and/or nitroglycerin taken every 5 minutes for 15 minutes
e Shortness of breath
e Irregular pulse or a resting pulse less than 56 or greater
than 100 beats/min (the rate the client should report may
vary depending on the medications prescribed, the client’s
baseline pulse rate, and physician’s preference)
e Fainting spells
e Diminished activity tolerance
e Swelling of feet or ankles
e Increase in severity or frequency of angina attacks
 Chapter 6 * The Client With Alterations in Cardiovascular Function 237

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community

resources that can assist in making necessary lifestyle changes
and adjusting to the effects of angina pectoris.

Independent Actions
Provide information about community resources that can Cardiac disease can significantly impact an individual’s and
assist client in making lifestyle changes and adjusting to family’s socioeconomic status. Providing information specific to
effects of angina pectoris (e.g., weight loss, smoking cessa- community resources is important to provide a necessary
tion, and stress management programs; American Heart continuum of care and may impact the client’s health status
Association; counseling services). preventing future hospitalizations.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended fol-
low-up care including future appointments with health care
provider.

Independent Actions
Collaborate with the client to develop a plan specific to treat- Regular health care appointments are important to determine the
ment regimen. effectiveness of the prescribed treatment plan.
Reinforce the importance of keeping follow-up appointments
with health care provider.
Implement measures to improve client compliance: Involvement of significant others in patient teaching improves
e Include significant others in teaching sessions if possible. adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Everyone does not understand information as presented, so
clarification of information provided. set aside time for questions to allow for clarification of
information.
e Provide written instructions regarding future appoint- Written instructions allow the client to refer to instructions as
ments with health care provider, dietary modifications, needed.
activity level, medications prescribed, and signs and symp-
toms to report.

ADDITIONAL NURSING DIAGNOSES

FEAR/ANXIETY NDx e Lack of understanding of diagnostic tests, diagnosis, and

Related to: treatment plan
° Discomfort during angina attack and threat of recurrent e Unfamiliar environment
attacks e Effect of angina pectoris on future lifestyle and roles

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238 Chapter 6 * The Client With Alterations in Cardiovascular Function

CAROTID ENDARTERECTOMY
Carotid endarterectomy is the surgical removal of athero- OUTCOME/DISCHARGE CRITERIA
sclerotic plaque from the intima of the carotid artery. The
most common site of plaque formation in the carotid artery The client will:
is the bifurcation. Access to this extracranial area is gained 1. Have adequate cerebral blood flow
through an incision along the anterior sternocleidomastoid 2. Have surgical pain controlled
muscle. Surgery is performed to improve carotid artery 3. Have evidence of normal wound healing
blood flow and to reduce the risk of cerebral embolization 4. Identify ways to prevent or slow the progression of athero-
and stroke. sclerosis
This care plan focuses on the adult client hospital- 5. Identify ways to manage signs and symptoms resulting
ized for a carotid endarterectomy. Much of the from cranial nerve damage if it has occurred
postoperative information is applicable to clients 6. State signs and symptoms to report to the health care provider
receiving follow-up care in an extended care facility 7. Develop a plan for adhering to recommended follow-up care
or home setting. including future appointments with health care provider,
medications prescribed, activity level, and wound care

| Nursing/Collaborative Diagnosis PRE OPERATIVE

Use in conjunction with the Standardized Preoperative Care Plan.

:Nursing Diagnosis RISK FOR INEFFECTIVE CEREBRAL TISSUE PERFUSION nox

Definition: Susceptible to a decrease in cerebral tissue circulation, which may compromise health.

Related to:
e Partial or complete occlusion of the carotid artery by atherosclerotic plaque and/or a thrombus
e A cerebral embolus associated with dislodgment of atherosclerotic plaque or a thrombus from the carotid artery

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of behavioral changes; changes in motor Altered mental status; changes in pupillary reactions;
response difficulty swallowing; extremity weakness; paralysis;
speech abnormalities

RISK FACTORS DESIRED OUTCOMES

e Arterial fibrillation
The client will maintain adequate cerebral tissue perfusion
° Carotid stenosis
as evidenced by:
e Hypertension
a. Mentally alert and oriented
e Hypercholesterolemia
b. Absence of dizziness, visual disturbances, and speech
e Embolism
impairments
c. Normal motor and sensory function

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: cerebral; neurological status; cognition Cerebral perfusion promotion; neurological monitoting

NURSING ASSESSMENT RATIONALE

eee
——

Assess for and report signs and symptoms of carotid artery Early recognition and reporting of signs and symptoms of ineffec-
occlusion and/or cerebral embolization: tive cerebral tissue perfusion allow for prompt intervention.
e Agitation
e Lethargy
e Confusion
e Dizziness
e Diplopia
e Ipsilateral blindness
e Homonymous hemianopsia
° Slurred speech
 Chapter 6 * The Client With Alterations in Cardiovascular Function 239

NURSING ASSESSMENT RATIONALE

e Expressive aphasia
e Paresthesias
e Hemiparesis
e Hemiplegia

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate cerebral tissue Actions help to prevent dislodgment of existing thrombi.
perfusion:
e Caution client to avoid activities that create a Valsalva
response.
e Straining to have a bowel movement
e Holding breath while moving up in bed
Perform actions to prevent hypertension in order to reduce
the risk of cerebral embolism:
e¢ Implement measures to reduce stress (e.g., explain proce-
dures, maintain calm environment).
If signs and symptoms of decreased cerebral tissue perfusion
persist or worsen:
e Provide emotional support to client and significant others;
be aware that the development of signs and symptoms
usually necessitates postponement or cancellation of
planned surgery.

Dependent/Collaborative Actions
Implement measures to maintain adequate cerebral tissue
perfusion:
e Administer anticoagulants if ordered: Anticoagulants act to prevent new or extended thrombus formation
e Heparin and further occlusion of the carotid artery. NoTE: These medica-
e Warfarin tions might be discontinued before surgery to reduce the risk of
e Antiplatelet agents intraoperative and postoperative hemorrhage.
Perform actions to prevent hypertension in order to reduce These medications are sometimes discontinued before surgery to
the risk of cerebral embolism: reduce the risk of a critical drop in B/P during and immediately
e Administer antihypertensives as ordered. after surgery.
If signs and symptoms of decreased cerebral tissue perfusion
persist or worsen:
e Administer anticoagulants if ordered. Notification of the appropriate health care provider allows for
e Maintain client on bed rest with head of bed flat unless modification of the treatment plan.
contraindicated.
e Notify the appropriate health care provider.

POSTOPERATIVE

Use in conjunction with the Standardized Postoperative

Care Plan.

es RISK FOR INNEFFECTIVE CEREBRAL TISSUE PERFUSION

e health.
Definition: Susceptible to a decrease in cerebral tissue circulation, which may compromis
Related to:
with clamping and manipulation of cerebral
° Prolonged carotid artery clamp time during surgery and/or vasospasm associated
vessels
development of a hematoma in the operative area
e Compression of carotid vessels associated with inflammation, edema, and/or
e Hypotension associated with:
blood loss
e Hypovolemia resulting from intraoperative and/or postoperative

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240 Chapter6 * The Client With Alterations in Cardiovascular Function

improved blood flow in the

° Stimulation of the carotid sinus baroreceptors resulting from surgica | manipulation and/or
carotid artery after surgery
system to adjust to increased
° Increased cerebral vascular dilation and pressure associated with inability of the autoregulatory
occur in the initial postoperative
blood flow in cerebral vessels distal to the surgical site (this hyperperfusion syndrom e can
that has resulted in chronic cerebral vessel
period in clients who have had a high-grade, long-term carotid artery blockage
dilation)
e Embolization during or after surgery and/or formation of a thrombus at surgical site

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dizziness Agitation; lethargy; confusion; visual disturbances (e.g.,
blurred or dimmed vision, diplopia, ipsilateral blindness,
homonymous hemianopsia); speech impairments (e.g.,
slurred speech, expressive aphasia); paresthesias, paresis,
paralysis

RISK FACTORS DESIRED OUTCOMES

e Arteriosclerosis The client will maintain adequate cerebral blood flow as
e Hypertension evidenced by:
a. Mentally alert and oriented
b. Absence of dizziness, visual disturbances, and speech
impairments
c. Normal sensory and motor function

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: cerebral; neurological status; cognition Cerebral perfusion promotion; neurological monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of: Early recognition and reporting of signs and symptoms of cerebral
e Cerebral ischemia ischemia allow for prompt intervention.
e Excessive operative site bleeding
e New or expanding hematoma
e Continued bright red bleeding from incision or wound
drain
¢ Hypovolemic shock
Assess RBC count, Hct and Hgb levels for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent cerebral ischemia: Interventions that focus on maintaining adequate cerebral blood
e Perform actions to reduce pressure on carotid vessels: flow and vessel patency help to prevent cerebral ischemia.
e Implement measures to reduce operative site inflamma- Corticosteroids help reduce operative site inflammation and/or
tion and/or edema: edema reducing pressure on carotid vessels.
¢ Keep head of bed elevated 30 degrees unless contrain-
dicated.
e Maintain patency of wound drain (e.g., keep tubing
free of kinks, empty collection device as often as neces-
sary) if present.
e Instruct client to support head and neck with hands Action helps to reduce stress on the suture line and prevent
during position changes and to avoid turning head subsequent bleeding and hematoma formation.
abruptly or hyperextending neck.
e Caution client to avoid activities that create a Valsalva Action helps to prevent dislodgment of existing thrombi and reduce
response (e.g., straining to have a bowel movement, hold- stress on and subsequent bleeding from the suture line.
ing breath while moving up in bed)
 Chapter 6 * The Client With Alterations in Cardiovascular Function 241

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent cerebral ischemia: Interventions that focus on maintaining adequate cerebral blood
° Perform actions to prevent or treat hypovolemic shock. flow and vessel patency help to prevent cerebral ischemia,
e Apply cooling pad or ice pack to incisional area as ordered. Corticosteroids help reduce operative site inflammation and/or
e Administer corticosteroids if ordered. edema reducing pressure on carotid vessels,
e Administer the following meflications if ordered: Medications help to maintain B/P within a safe range, preventing
e Antihypertensives either hypotension, which can teduce cerebral blood flow, or
e Sympathomimetics hypertension, which can stress and disrupt the operative vessel
leading to hemorrhage.

|Collaborative »evuess
Diagnosis |RISK FOR RESPIRATORY DISTRESS
Definition: Inability of a client to get enough oxygen to support respiration; can result from upper airway obstruction or lung
disease.

Related to: Airway obstruction associated with tracheal compression (can occur as a result of inflammation, edema, and/or
hematoma formation in the surgical area)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty getting “air” or breathing Agitation; restlessness; rapid/labored respirations; stridor;
sternocleidomastoid muscle retraction

RISK FACTOR DESIRED OUTCOMES

e Surgicat manipulation in close proximity to atrway The client will not experience respiratory distress as
evidenced by:
a. Usual mental status
b, Unlabored respirations at 12 to 20 breaths/min
c. Absence of stridor and sternocleidomastoid muscle
retraction
d. Oximetry results within normal range
e. Arterial blood gas values within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report: Early recognition of signs and symptoms of respiratory distress
e Increased edema or expanding hematoma in surgical area allows for prompt intervention,
e Deviation of trachea from midline
e New or increased difficulty swallowing
e Signs and symptoms of respiratory distress:
e Restlessness
e Agitation
e Rapid and/or labored respirations
e Stridor
e Sternacteidomastoid muscle retraction
Monitor arterial blood gas values and pulse oximetry values
for abnormalities.

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242 Chapter 6 = The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Have tracheostomy and suction equipment readily available. An emergency tracheostomy may be necessary if a client’s airway
becomes compromised.
Implement measures to prevent compression of the trachea: Compression of the trachea can result in respiratory distress.
e Perform actions to prevent inflammation, edema, and he- During the postoperative period, frequent assessment of the
matoma formation in the operative area (e.g., maintain position of the trachea (midline, shifted to the left or right) is
head and neck in alignment, place client in semi- to high- critical.
Fowler’s, apply ice to operative area as ordered).
e Perform actions to prevent excessive pressure: Interventions and medications help to prevent excessive pressure in
e Caution client to avoid activities that create a Valsalva the operative vessel and subsequent bleeding and hematoma
response (e.g., straining to have a bowel movement, formation.
holding breath while moving up in bed)
e Administer antihypertensives if ordered.
If signs and symptoms of respiratory distress occur: Identification of signs and symptoms of respiratory distress
e Place client in a high-Fowler’s position unless contraindicated. allows for modification of the treatment plan and initiation of
e Loosen neck dressing if it appears tight. emergency measures if indicated.
e Administer oxygen as ordered.
e Assist with intubation or tracheostomy if performed.
e Prepare client for evacuation of hematoma or surgical
repair of the bleeding vessel if planned.

Collaborative Diagnosis RISK FOR CRANIAL NERVE DAMAGE (FACIAL,

HYPOGLOSSAL, GLOSSOPHARYNGEAL, VAGUS,
AND/OR ACCESSORY NERVES)
Definition: Damage to cranial nerve(s).

Related to: Surgical trauma and/or compression of the nerves (can occur as a result of inflammation, edema, and/or
hematoma formation)

CLINICAL MANIFESTATIONS

Subjective Objective
Facial: Verbal self-report of altered taste sensations Facial: Difficulty raising eyebrows, closing eyes tightly,
pursing lips, and/or smiling.
Hypoglossal: Not applicable Hypoglossal: Inability to protrude tongue or move tongue
side to side
Glossopharyngeal/vagus: Not applicable Glossopharyngeal/vagus: Absence of gag reflex; difficulty
in swallowing
Accessory nerves: Not applicable Accessory nerves: Inability to shrug shoulders against
resistance.

RISK FACTOR DESIRED OUTCOMES

e Surgical retraction ae i Me em
The client will experience beginning resolution of cranial
nerve damage if it occurs as evidenced by:
a. Gradual return of facial symmetry and usual taste
sensation
b. Increased ability to chew and swallow
c. Improved speech
d. Return of usual shoulder movements
 Chapter 6 * The Client With Alterations in Cardiovascular Function 243

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of the following: Early recognition and reporting of signs and symptoms of nerve
e Facial nerve damage (e.g., facial ptosis on affected side, damage allow for prompt intervention.
impaired sense of taste)
e Vagus and glossopharyngeal nerve damage (e.g., loss of
gag reflex, difficulty swallowing, hoarseness, inability to
speak clearly)
¢ Hypoglossal nerve damage (e.g., tongue biting when
chewing, tongue deviation toward affected side, difficulty
swallowing and speaking).
e Accessory nerve damage (e.g., unilateral shoulder sag,
difficulty raising shoulder against resistance)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent compression of the cranial These actions decrease edema at the surgical site.
nerves at the operative site:
e Keep head of bed elevated 30 degrees unless contraindi-
cated.
e Apply ice pack to incisional area.
e Maintain patency of wound drain.
¢ Avoid Valsalva maneuvers. D+
If signs and symptoms of cranial nerve damage occur: Actions help to reduce the risk of aspiration.
e If the facial, hypoglossal, vagus, and/or glossopharyn-
geal nerves are affected:
e Withhold oral foods/fluids until gag reflex returns
and client is better able to chew and swallow; provide
parenteral nutrition or tube feeding if indicated.
e When oral intake is allowed and tolerated:
e Implement measures to improve client’s ability to chew
and/or swallow:
e Place client in high-Fowler’s position for meals and
snacks.
e Assist client to select foods that require little or no
chewing and are easily swallowed (e.g., custard,
eggs, canned fruits, mashed potatoes).
e Avoid serving foods that are sticky (e.g., peanut
butter, soft bread, honey).
e Serve thick rather than thin fluids or add a thicken-
ing agent (e.g., “Thick-It,” gelatin, baby cereal) to
thin fluids.
e Instruct client to add extra sweeteners or seasonings to Action helps to compensate for impaired sense of taste.
foods/fluids if desired.
e Implement measures to facilitate communication (¢.g.,
maintain quiet environment; provide pad and pencil,
Magic Slate, or word cards; listen carefully when client
speaks).
* Consult speech pathologist about additional ways to
facilitate swallowing and communication.
° If the accessory nerve is affected, instruct client in and Exercises help to prevent atrophy of trapezius and sternocleidomas-
assist with exercises (e.g., range of motion of affected toid muscles.
shoulder, wall climbing with fingers, shoulder shrugs).
e Provide emotional support to client and significant others;
assure them that the nerve damage is usually not perma-
nent, but caution them that the symptoms may take
months to resolve.

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DISCHARGE TEACHING/CONTINUED CARE

Diagnosis |DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

|Nursing >).
MAINTENANCE nox; OR INEFFECTIVE HEALTH
MANAGEMENT nox*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain well-being;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inaccurate follow-through of instructions
resources

RISK FACTORS
e Denial of disease process
e Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; cardiac disease management Health system guidance; teaching: disease process; teaching:
individual; teaching: prescribed diet

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

or slow the progression of atherosclerosis.

Independent Actions
Inform the client that certain modifiable factors such as A person with modifiable risk factors should be encouraged to
elevated serum lipid levels, a sedentary lifestyle, cigarette make lifestyle changes to reduce the risk for atherosclerosis in
smoking, and hypertension have been shown to increase order to prevent progression of the disease.
the risk of atherosclerosis.
Assist client to identify changes in lifestyle that could reduce
the risk for atherosclerosis (e.g., smoking cessation, dietary
modifications, physical exercise on a regular basis).
Provide instructions on ways the client can reduce intake of
saturated fat and cholesterol:
e Reduce intake of meat fat (e.g., trim visible fat off meat;
replace fatty meats such as fatty cuts of steak, hamburger,
and processed meats with leaner products).
e Reduce intake of milk fat (e.g., avoid dairy products con-
taining more than 1% fat).
e Reduce intake of trans fats (e.g., avoid stick margarine and
shortening and foods such as commercial baked goods
that are prepared with these products).

*The nurse should select the diagnostic label thatismost appropriate for the client's discharge teaching needs,
 Chapter 6 * The Client With Alterations in Cardiovascular Function 245

THERAPEUTIC INTERVENTIONS RATIONALE

e Use vegetable oil rather than coconut or palm oil in
cooking and food preparation.
e Use cooking methods such as steaming, baking, broiling,
poaching, microwaving, and grilling rather than frying.
e Restrict intake of eggs. Recommendations about the number of whole eggs allowed per
week vary depending on the client’s lipid levels
Instruct client to take lipid-lowering agents (e.g., HMG-CoA re-
ductase inhibitors [“statins”], ezetimibe, gemfibrozil, niacin)
and antiplatelet agents (e.g., low-dose aspirin) as prescribed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

signs and symptoms resulting from cranial nerve damage if it
has occurred.

Independent Actions
If signs and symptoms of hypoglossal, facial, vagus, and/or Educating the client as to normal nerve function allows for early
glossopharyngeal nerve damage are present: detection of irregularities warranting immediate attention from
e Reinforce techniques to improve swallowing and speaking. a health care provider. Early detection may reduce the incidence
e Assist client in identifying foods that are nutritious and of permanent nerve damage.
easy to chew and swallow; obtain a dietary consult if
needed.
e Instruct client to increase the amount of sweeteners and
seasonings usually used and/or to try different seasonings
in foods and beverages if sense of taste is altered.
If signs and symptoms of accessory nerve damage are present,
reinforce exercises that should be performed to maintain
shoulder muscle tone and prevent contractures.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to also report any of the following signs and Early identification of signs and symptoms of complications
symptoms to the health care provider: associated with surgery allows for prompt intervention.
e Increased swelling or purple discoloration at wound site
e New or increased difficulty chewing, swallowing, or
speaking
e Any loss of or change in vision
e Dizziness
¢ Numbness, tingling, or weakness of arms or legs
e Increasing irritability
e Lethargy, confusion
e Failure of signs and symptoms of cranial nerve damage to
resolve as expected; remind client that it can take months
for reversible signs and symptoms to resolve.

THERAPEUTIC INTERVENTIONS RATIONALE

Se ee eee
Desired Outcome: The client, in collaboration with the
nurse, will develop a plan for adhering to recommended follow-
up care including future appointments with health care
provider, medications prescribed, activity level, and wound care.

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246 Chapter6 * The Client With Alterations in Cardiovascular Function

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THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Collaborate with the client to develop a plan to adhere to the Actions help to prevent increased straining, which may lead to
treatment regimen including: wound or vascular graft dehiscence.
Reinforce the physician’s instructions regarding:
e Ways to prevent constipation and subsequent straining to
have a bowel movement (e.g., drink at least 10 glasses of
liquid per day unless contraindicated, increase intake
of foods high in fiber, take stool softeners if necessary)
¢ The need to avoid isometric exercise/activity (e.g., lifting
objects over 10 lb, pushing heavy objects) and strenuous
exercise for specified length of time (usually 4-12 weeks
depending on the activity)

RELATED CARE PLANS

Standardized Preoperative Care Plan
Standardized Postoperative Care Plan

DEEP VEIN THROMBOSIS

Venous thrombosis occurs when a thrombus forms in a superficial pulmonary embolism is low if there is no proximal vein in-
or deep vein. This condition is often called thrombophlebitis be- volvement. However, there is a risk of extension of calf vein
cause of the associated inflammation in the involved vessel wall. thrombi into a proximal venous segment if untreated, and
The predisposing factors for venous thrombus formation are ve- because of this risk, many persons with calf vein thrombosis
nous stasis, damage to the endothelium of the vein wall, and/or are treated with anticoagulants. There is also some variation in
hypercoagulability. Conditions/factors associated with a high risk the anticoagulant regimen in relation to the time that oral
for venous thrombosis include surgery (especially orthopedic and anticoagulants are initiated and the route and type of heparin
abdominal surgery), immobility, advanced age, heart failure, cer- ordered (e.g., continuous intravenous heparin, intermittent
tain malignancies, fractures or other injuries of the pelvis or lower intravenous heparin, adjusted-dose subcutaneous heparin,
extremities, varicose veins, pregnancy, obesity, estrogen and oral low-molecular-weight heparin [LMWH)]).
contraceptive use, sepsis, venous cannulation, administration of This care plan focuses on the adult client hospital-
vessel irritants (e.g., hypertonic solutions, chemotherapeutic ized for treatment of DVT in a lower extremity. The
agents, high-dose antibiotics), history of deep vein thrombosis information is also applicable to clients receiving
(DVT), and inherited coagulation abnormalities. follow-up care at home.
DVT usually develops in a lower extremity; however, the
incidence of subclavian venous thrombosis is rising because
of the increased use of central venous catheters. Clinical OUTCOME DISCHARGE CRITERIA
manifestations of DVT are often not distinctive and, in many
cases, the client is asymptomatic. Signs and symptoms that The client will:
may be present include pain, tenderness, swelling, unusual Have adequate tissue perfusion in affected extremity
warmth, and/or increase in calf circumference comparison Have no evidence of tissue irritation or breakdown
(with unaffected extremity). The greatest danger associated Have no signs and symptoms of complications
with DVT is that the clot, or parts of it, will detach and cause Ae
gee
ee
I Identify ways to promote venous blood flow and reduce
embolic occlusion of a pulmonary vessel. the risk of chronic venous insufficiency and recurrent
Diagnosis of a DVT is accomplished through physical exam, thrombus formation
including symptom and medical history. A D-dimer blood test S. Verbalize an understanding of medications ordered includ-
along with an ultrasound may be performed. Persons with ing rationale, food and drug interactions, side effects,
DVT are usually treated medically rather than surgically unless schedule for taking, and importance of taking as prescribed
there is massive occlusion of a vessel and anticoagulation and 6. Demonstrate the ability to correctly draw up and adminis-
thrombolytic therapy are contraindicated. With the increasing ter heparin subcutaneously if prescribed
use of thrombolytic therapy, thrombectomies and embolecto- 7. Identify precautions necessary to prevent bleeding associ-
mies are rarely performed. Medical treatment varies depending ated with anticoagulant therapy
on the location of the thrombus, the person’s risk for bleeding 8. State signs and symptoms to report to the health care provider
and history of previous thrombus, and whether a coagulation 9. Develop a plan for adhering to recommended follow-up
abnormality exists. Anticoagulant therapy is not universally care including future appointments with health care
used to treat calf vein thrombosis because the incidence of provider and activity level
 Chapter 6 * The Client With Alterations in Cardiovascular Function 247

|Nursing *Diagnosis
=. INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox Ta es
Definition: Decrease in blood circulation to the periphery, which may compromise health.

Related to:
° Obstructed venous blood flow in affected extremity associated with the presence of a thrombus and inflammation of the vessel
e Venous stasis associated with decreased mobility

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of tenderness/pressure over involved Edema; brawny hemosideric skin discoloration; dependent
vein; extremity pain blue or purple skin color; positive Homans’ sign; slow
healing of lesions; skin temperature changes; altered
sensations; weak or absent pulses

RISK FACTORS DESIRED OUTCOME

e Virchow’s triad: venous stasis, endothelial damage due to
trauma or inflammation, blood hypercoagulability The client will have improved venous blood flow in the
affected extremity as evidenced by diminished pain,
tenderness, swelling, and distention of superficial blood
vessels in extremity.

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: peripheral Embolus care: peripheral; circulatory care: venous

insufficiency; lower extremity monitoring

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired venous blood Early recognition of signs and symptoms of altered peripheral tissue
flow in the affected extremity: perfusion allows for prompt intervention.
e Pain or tenderness in extremity
e Increase in circumference of extremity
e Distention of superficial blood vessels in extremity
Assess activated clotting time (ACT), activated partial throm- Alterations in lab values may indicate risk factors for the formation
boplastin time (aPTT), bleeding time, Hgb level, Hct, of DVT. D-dimer elevation is suggestive of DVT.
international normalized ratio (INR), platelet count, and
D-dimer for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Elevate affected extremity 10 to 20 degrees above the level of Actions help to reduce venous stasis.
the heart. D +
Maintain the client on bed rest. Bed rest until the thrombus is considered stable helps to reduce the
risk ofdislodgment.
Discourage positions that compromise blood flow (e.g., pil-
lows under knees, crossing legs, sitting or standing for long
periods). D+

Dependent/Collaborative Actions
Administration of identified medications helps to improve venous
Perform actions to treat the thrombosis:
e Administer medications as ordered. blood flow.
e Indirect thrombin inhibitors Indirect thrombin inhibitors are divided into two classes: unfrac-
e Direct thrombin inhibitors tionated heparin, which acts upon both intrinsic and extrinsic
pathways, and LMWH, which acts as an antithrombin.
e Factor Xa inhibitors
e Anticoagulants Direct thrombin inhibitors bind with thrombin, inhibiting its function.
e Vitamin K antagonists Factor Xa inhibitors inhibit factor Xa directly or indirectly.

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THERAPEUTIC INTERVENTIONS RATIONALE

° Prepare client for intravenous injection of a thrombolytic Anticoagulants act by inhibiting clotting factors.
agent or catheter-directed fibrinolysis. Vitamin K antagonists inhibit vitamin K-dependent clotting
factors II, VII, IX, and X.
Maintain a minimum fluid intake of 2500 mL (unless contra- Ensuring adequate fluid intake helps to prevent increased blood
indicated). D+ viscosity.
Apply antiembolism stockings or intermittent compression Actions help to reduce venous stasis.
devices if ordered. D@ +
Consult physician if signs and symptoms of impaired venous Notification of the appropriate health care provider allows for
blood flow in affected extremity persist or worsen. modification of the treatment plan. Clients may require surgical
intervention to remove an embolus (embolectomy) or prevent a
pulmonary embolus (vena caval interruption device—Greenfield
filter).

2 ACUTE PAIN nox (AFFECTED EXTREMITY)

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Related to:
e Decreased tissue perfusion and swelling associated with obstructed venous blood flow
e Inflammation of vein

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain in the affected extremity Diaphoresis, B/P and heart rate changes; increased
respiratory rate

RISK FACTORS DESIRED OUTCOMES

e Arteriosclerosis
e Venous stasis
The client will experience diminished pain in the affected
extremity as evidenced by:
e Immobility
a. Verbalization of a decrease in pain
b. Relaxed facial expression and body positioning
c. Increased participation in activities when allowed

NOC OUTCOMES NIC INTERVENTIONS

SSS

Comfort level; pain control Pain management; analgesic administration; heat/cold

application

NURSING ASSESSMENT RATIONALE

eee

Assess for signs and symptoms of pain (e.g., verbalization Early recognition of signs and symptoms of pain allows for prompt
of pain, grimacing, rubbing affected area, restlessness, intervention. i
reluctance to move).
Assess client’s perception of the severity of pain using a pain
intensity rating scale.
Assess client’s pain pattern (e.g., location, quality, onset,
duration, precipitating factors, aggravating factors, allevi-
ating factors).
 Chapter 6 * The Client With Alterations in Cardiovascular Function 249

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce pain:
e Perform actions to protect the affected extremity from Bed cradles help to relieve pressure from bed linens.
trauma, pressure, or excessive movement: D +
e Avoid jarring the bed.
e Use a bed cradle or footboard.
e Support extremity during position changes.
e Maintain activity restrictions as ordered.
e Instruct client to move affected extremity slowly and
cautiously.
e Provide or assist with nonpharmacological methods for
pain relief: D@ +
e Position change
e Relaxation techniques
e Restful environment
e Diversional activities
e Instruct client and significant others that the painful Rubbing the affected extremity could dislodge the thrombus, result-
extremity should not be rubbed to relieve pain. ing in a thromboembolism.

Independent Actions
Implement measures to reduce pain:
e Administer analgesics and anti-inflammatory agents if
ordered. D >
Consult physician if above measures fail to provide adequate Notification of the appropriate health care provider allows for
pain relief. modification of the treatment plan.

Nursing Diagnosis RISK FOR IMPAIRED TISSUE INTEGRITY nox

Definition: Susceptible to damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon,
bone, cartilage, joint capsule, and/or ligament, which may compromise health.

Related to:
e Accumulation of waste products and decreased oxygen and nutrient supply to the skin and subcutaneous tissue associated
with prolonged pressure on tissues as a result of decreased mobility
° Damage to the skin and/or subcutaneous tissue associated with friction or shearing that can occur with movement while on
bed rest
e Increased skin fragility in affected extremity associated with insufficient blood flow and edema

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain or altered sensation at site of Color changes; redness; swelling; warmth of skin areas
tissue impairment demonstrating impairment

RISK FACTORS DESIRED OUTCOMES

e Altered circulation The client will maintain tissue integrity as evidenced by:
e Impaired mobility a. Absence of redness and irritation
e Mechanical factors: shear b. No skin breakdown

NOC OUTCOMES NIC INTERVENTIONS

Skin surveillance; pressure management; pressure ulcer
Tissue integrity: skin and mucous membranes
prevention

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250 Chapter6 * The Client With Alterations in Cardiovascular Function

NURSING ASSESSMENT RATIONALE

Inspect the skin (especially bony prominences, dependent Early recognition of impaired skin integrity allows for prompt
areas, and affected extremity) for pallor, redness, and intervention.
breakdown.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent tissue breakdown: D @ Prolonged pressure on the skin obstructs capillary blood flow.
e Assist client with turning every 2 hrs.
e Use pressure-relieving devices to position client properly:
e Pillows, gel or foam cushions
e Keep client’s skin dry. Excessive moisture on the skin softens epidermal cells and makes
¢ Keep bed linens dry and wrinkle free. them less resistant to damage.
Implement measures to prevent tissue breakdown in involved
extremity:
e Perform actions to protect affected extremity from trauma
and/or excessive pressure: D
e Use a bed cradle or footboard to relieve pressure from
bed linens.
° Keep heel off bed by elevating extremity on foam block
or pillows or using heel protector.
e Instruct and assist client to move affected extremity
cautiously.
e Remove antiembolism stockings for 30 to 60 minutes at
least twice daily.
e Use caution when applying heat to extremity.

Dependent/Collaborative Actions
If tissue breakdown occurs: Notification of the appropriate health care provider allows for
e Notify appropriate health care provider (e.g., wound care modification of the treatment plan.
specialist, physician).
e Perform care of involved areas as ordered or per standard
hospital procedure.

| _ RISK FOR PULMONARY EMBOLISM

Definition: Occlusion of a portion of the pulmonary vascular bed by an embolus, which can be a thrombus (blood clot).

Related to: Dislodgment of thrombus

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest or pleural pain Pleural friction rub; pleural effusion; tachycardia;
tachypnea; dyspnea; unexplained anxiety

RISK FACTORS DESIRED OUTCOMES

e Virchow’s triad: venous stasis, endothelial trauma or
The client will not experience a pulmonary embolism as
inflammation, blood hypercoagulability
evidenced by:
a. Absence of sudden chest pain
b. Unlabored respirations at 12 to 20 breaths/min
c. Pulse rate 60 to 100 beats/min
d. Arterial blood gas values within normal range
 Chapter 6 * The Client With Alterations in Cardiovascular Function 251

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of a pulmonary Early recognition of signs and symptoms of a pulmonary embolism
embolism: allows for prompt intervention.
e Sudden chest pain
e Dyspnea
e Tachypnea
e Tachycardia
e Apprehension
Assess pulse oximetry and arterial blood gas values for abnor-
malities.
Assess vital signs for signs of shock associated with massive Clinical stability of the client is dependent upon the degree of
pulmonary embolism. obstruction associated with the embolism (e.g., massive
occlusion, embolus with infarction, embolus without infarction,
or chronic/recurrent pulmonary embolism).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent a pulmonary embolism: D + Actions help to prevent dislodgment of thrombus.
e Maintain client on bed rest as ordered.
e Do not exercise or check for Homans’ sign in affected
extremity during acute phase of DVT.
e Never massage affected extremity, and caution client not
to allow significant others to massage extremity.
e Caution client to avoid activities that create a Valsalva
response (e.g., straining to have a bowel movement,
blowing nose forcefully, holding breath while moving up
in bed).
° Administer anticoagulants as ordered. D+ While anticoagulants will not dissolve clots, they will prevent
development of new thrombi.
e Prepare client for a vena caval interruption (e.g., insertion These devices allow for filtration of clots without interruption of
of an intracaval filtering device) if planned. blood flow, reducing the risk of an embolus.
If signs and symptoms of a pulmonary embolism occur:
e Maintain client on bed rest in a semi- to high-Fowler’s position. Semi- to high-Fowler’s position facilitates adequate lung expansion.
e Maintain oxygen therapy as ordered.
° Prepare client for diagnostic tests (e.g., arterial blood gases,
D-dimer level, ventilation-perfusion lung scan, pulmonary
angiography).
e Administer anticoagulants as ordered.
e Prepare client for the following if planned:
e Injection of a thrombolytic agent (e.g., streptokinase, Anticoagulants (e.g., heparin) prevent the formation ofnew clots,
urokinase, tissue plasminogen activator [tPA]) while thrombolytic agents dissolve pulmonary embolism.
° Vena caval interruption (e.g., insertion of an intracaval Vena caval interruption techniques assist in preventing further
filtering device) pulmonary embolization.
e Embolectomy Primary indication for surgery is to prevent the recurrence of a
pulmonary embolism.

|Nursing >
Diagnosis RISK FOR BLEEDING nox

Definition: Susceptible to a decrease in blood volume, which may compromise health.

and possible heparin-induced
Related to: Prolonged coagulation time associated with anticoagulant therapy
thrombocytopenia

NOC OUTCOMES NIC INTENTIONS

Bleeding precautions
Bleeding status

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252 Chapter 6 * The Client With Alterations in Cardiovascular Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of bleeding Petechiae, purpura, ecchymoses; gingival bleeding;
prolonged bleeding from puncture sites; epistaxis,
hemoptysis; unusual joint pain; increase in abdominal
girth; frank or occult blood in stool, urine, or vomitus;
menorrhagia; restlessness, confusion; decreasing B/P and
increased pulse rate; decrease in Hct and Hgb levels

RISK FACTORS DESIRED OUTCOMES

e Anticoagulant therapy The client will not experience unusual bleeding as evi-
e Prolonged clotting times
denced by:
e Heparin-induced thrombocytopenia
a. Skin and mucous membranes free of petechiae, purpura,
ecchymoses, and active bleeding
b. Absence of unusual joint pain
(2). No increase in abdominal girth

d. Absence of frank and occult blood in stool, urine, and

vomitus
e. Usual menstrual flow
hh. Vital signs within normal range for client
g. Stable Hct and Hgb

NURSING ASSESSMENT RATIONALE

Assess client for and report signs and symptoms of unusual Early recognition of signs and symptoms of bleeding allows for
bleeding: prompt intervention.
e Petechiae, purpura, ecchymoses
° Gingival bleeding
e Prolonged bleeding from puncture sites
e Epistaxis, hemoptysis
e Unusual joint pain
e Increase in abdominal girth
e Frank or occult blood in stool, urine, or vomitus
e Menorrhagia
e Restlessness, confusion
e Decreasing B/P and increased pulse rate
e Decrease in Hct and Hgb levels
Monitor Het, platelet count, and coagulation test results (e.g.,
prothrombin time [PT], INR, aPTT, partial thromboplastin
time [PTT]), and report abnormal values.
Assess stool, urine, and vomitus for blood.
Monitor and assess vital signs.

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Dependent/Collaborative Actions
Implement measures to prevent bleeding: Nursing activities should be adjusted to reduce the risk of bleeding
e Avoid giving injections whenever possible; consult physi- while a client is undergoing anticoagulation therapy.
cian for alternative routes.
e When giving injections or performing venous or arterial
punctures, use the smallest gauge needle possible and
apply gentle, prolonged pressure to the site after the
needle is removed. D +
e Caution client to avoid activities that increase the risk for
trauma (e.g., shaving with a straight-edge razor, using a
stiff bristle toothbrush or dental floss).
° Pad side rails if client is confused or restless.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 253

THERAPEUTIC INTERVENTIONS RATIONALE

e Whenever possible, avoid intubations (e.g., nasogastric)
and procedures that can cause injury to rectal mucosa
(e.g., inserting a rectal suppository or tube, administering
an enema).
e Perform actions to reduce the risk for falls (e.g., keep bed
in low position with side rails up when client is in bed,
avoid unnecessary clutter in room, instruct client to wear
shoes with nonslip soles when ambulating). D +
e Instruct client to avoid blowing nose forcefully or strain-
ing to have a bowel movement; consult physician about
an order for a decongestant and/or laxative if indicated.
If bleeding occurs and does not subside spontaneously: If bleeding occurs, efforts must be directed at controlling active
e Apply firm, prolonged pressure to bleeding areas if possible. bleeding, replacing blood products as needed, and reversing
e If epistaxis occurs, place client in a high-Fowler’s position anticoagulant therapy effects.
and apply pressure and ice pack to nasal area.
e Maintain oxygen therapy as ordered.
e Administer protamine sulfate (antidote for heparin), vitamin
K (e.g., phytonadione), and/or whole blood or blood prod-
ucts (e.g., fresh frozen plasma, platelets) as ordered.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

MAINTENANCE nox; OR INEFFECTIVE HEALTH
MANAGEMENT nox*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain well-being;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen Health system guidance; teaching: individual; teaching:
prescribed medication; teaching: prescribed activity/exercise

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Demonstrated lack of understanding of disease process
and/or the collaborative plan of care; inaccurate follow-
through of instructions

RISK FACTORS
e Denial of disease process
e Cognitive deficiency
e Failure to take action to reduce risk factors

NURSING ASSESSMENT RATIONALE

Assess Cclient’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

for the client’s discharge teaching needs.

*The nurse should select the diagnostic label that is most appropriate

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254 Chapter 6 * The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to pro-

mote venous blood flow and reduce the risk of chronic
venous insufficiency and recurrent thrombus formation.

Independent Actions
Educate the client regarding interventions to reduce the risk Clients identified as at risk for the development of DVT should
of DVT: be educated as to what may precipitate embolic events. In
e Avoid wearing constrictive clothing (e.g., garters, girdles, addition, clients should be taught to recognize that vascular
narrow-banded knee-high hose). changes may indicate serious problems that require prompt
e Avoid sitting and standing in one position for long treatment.
periods.
e Wear graduated compression stockings or support hose
during the day.
e Avoid crossing legs and lying or sitting with pillows under
knees.
e Engage in regular aerobic exercise (e.g., swimming, walk-
ing, bicycling).
e Elevate legs periodically, especially when sitting.
e Dorsiflex feet regularly.
e Maintain an ideal body weight for age, height, and body
frame.
Inform client that smoking and the use of estrogen or oral
contraceptives can increase the risk for recurrent thrombus
formation.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

Independent Actions
Educate the client regarding prescribed medications includ- Taking medications as prescribed ensures that therapeutic drug
ing rationale, food and drug interactions, side effects, levels will be maintained and adverse reactions avoided.
dosing schedule, and importance of taking medications as Clients should be instructed not to discontinue taking medications
prescribed. if they feel better. Clients without financial resources should be
e Coumadin assisted in accessing appropriate resources to obtain needed
e Heparin medications (e.g., pharmacy assistance programs).

THERAPEUTIC INTERVENTIONS RATIONALE

Sse essere

Desired Outcome: The client will demonstrate the ability

to correctly draw up and administer heparin subcutaneously
if prescribed.

Independent Actions
< Eee t
Provide instructions on subcutaneous injection techniques as Return demonstration of skill allows the nurse to evaluate
needed. client’s understanding and implement additional education if
Assess understanding through return demonstration. necessary.

THERAPEUTIC INTERVENTIONS RATIONALE

SS

Desired Outcome: The client will identify precautions

necessary to prevent bleeding associated with anticoagulant
therapy.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 255

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client about ways to minimize risk of bleeding: Actions that reduce the risk of bleeding prevent the development of
e Use an electric rather than straight-edge razor. complications.
e Floss and brush teeth gently; use waxed floss and a soft
bristle toothbrush.
e Avoid putting sharp objects (e.g., toothpicks) in mouth.
e Do not walk barefoot.
e Cut nails carefully.
e Avoid situations that could result in injury (e.g., contact
sports).
e Avoid blowing nose forcefully.
e Avoid straining to have a bowel movement.
Instruct client to control any bleeding by applying firm,
prolonged pressure to the area if possible.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct the client to report the following signs and symp- Early identification of signs and symptoms of bleeding associated
toms to the appropriate health care provider: with drug therapy or the development of DVT allows for prompt
e Recurrent tenderness, pain, distention of superficial veins, intervention by the appropriate health care provider.
or swelling in extremity
e Sudden chest pain accompanied by shortness of breath
e Unusual bleeding
e Discoloration or itching of affected extremity (indicative of
stasis dermatitis associated with chronic venous insufficiency)
e Skin breakdown on affected extremity
Reinforce importance of keeping follow-up appointments Regular health care appointments are important to determine
with health care provider. effectiveness of the prescribed treatment plan.
Reinforce physician’s instructions regarding activity limitations.
Impiement measures to improve client compliance: Involvement of significant others in patient teaching improves
e Include significant others in teaching sessions if possible. adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Everyone does not understand information as presented, so set aside
clarification of information provided. time for questions to allow for clarification ofinformation.
e Provide written instructions regarding future appoint- Written instructions allow the client to refer to instructions as
ments with health care provider, medications prescribed, needed.
activity restrictions, signs and symptoms to report, and
future laboratory studies.

FEMOROPOPLITEAL BYPASS
Lower extremity arterial bypass is performed to treat periph- angioplasty, stent placement, or percutaneous atherectomy
have been unsuccessful.
eral artery insufficiency that has not responded well to con-
servative management. The impaired blood flow can occur as Surgical treatment of the diseased femoropopliteal arterial
a result of acute conditions (e.g., trauma, embolization), but segment can be accomplished by endarterectomy or removal
of the segment and replacement with a synthetic graft, but
most often is caused by atherosclerotic changes in the vessels.
the most commonly performed procedure is to bypass the
The femoropopliteal arterial segment is the most common
segment using a synthetic or an autogenous vein graft.
site of occlusion in persons with lower extremity arterial
The saphenous vein is the preferred autogenous graft for
disease. Surgical intervention is usually indicated when the
femoropopliteal bypass because it is thick walled and has an
client experiences signs and symptoms of severe occlusion
claudication that has become disabling, adequate lumen diameter. Before grafting the saphenous vein
(e.g., intermittent
proximal and distal to the occluded arterial segment, reversal
foot pain that is present at rest, presence of lower extremity
ulcers) and/or when more conservative invasive of the vein or division of its valve cusps is done to allow
ischemic
measures such as balloon angioplasty, laser unimpeded arterial blood flow.
treatment

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 256 Chapter 6 * The Client With Alterations in Cardiovascular Function

This care plan focuses on the adult client with ath- 3. Tolerate expected level of activity .
erosclerotic occlusion of the femoropopliteal arterial 4. Have evidence of normal wound healing
segment who is hospitalized for a femoropopliteal by- 5. Have no signs and symptoms of postoperative compli-
pass. Much of the postoperative information is appli- cations ’
cable to clients receiving follow-up care in an extended 6. Identify ways to prevent or slow the progression of athero-
care facility or home setting. sclerosis
7. Identify ways to promote blood flow in the operative
extremity
OUTCOME/DISCHARGE CRITERIA 8. State signs and symptoms to report to the health care
provider
The client will: 9. Develop a plan for adhering to recommended follow-up care
1. Have adequate circulation in the operative extremity including future appointments with health care provider,
2. Have surgical pain controlled medications prescribed, activity level, and wound care

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

Nursing Diagnosis INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox

Definition: Decrease in blood circulation to the periphery, which may compromise health.

Related to: Diminished blood flow in the affected lower extremity associated with:
e Atherosclerotic changes in the femoral and popliteal arteries
e Thrombus formation in the affected vessel

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of altered sensation to the affected Altered skin characteristics (hair, moisture) or nails; cold
extremity; intermittent claudication; slow healing of extremities; diminished arterial pulses; pale skin upon leg
lesions elevation; pallor; shiny, waxy skin; weak or absent pulses

RISK FACTORS DESIRED OUTCOMES

e Virchow’s triad: venous stasis, endothelial trauma (sur-
The client will not experience further reduction in arterial
gery), blood hypercoagulability
blood flow in the affected lower extremity as evidenced by:
a. No increase in lower extremity pain
b. No further decrease in peripheral pulses
c. No increase in capillary refill time
d. Usual temperature and color of extremity

NOC OUTCOMES NIC INTERVENTIONS

——_——<$<——_———<——— oo SSeeeSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSs
Tissue perfusion: peripheral Circulatory care: arterial insufficiency; circulatory care:
venous insufficiency; lower extremity monitoring
‘
NURSING ASSESSMENT RATIONALE
nn i re ean pn i sem ie npg since acess ane ae a
Assess for and report signs and symptoms of a further Early recognition of signs and symptoms of altered peripheral tissue
reduction in arterial blood flow in the affected lower perfusion allows for prompt intervention.
extremity:
e Intermittent claudication occurring with increased inten-
sity and/or with less activity than previously
 Chapter 6 * The Client With Alterations in Cardiovascular Function 257

NURSING ASSESSMENT RATIONALE

e Development of or increase in intensity of rest pain
(the foot and toe pain that occurs when the client is in a
horizontal position results from decreased blood flow to
the skin and subcutaneous tissue; because it occurs in the
absence of lower extremity muscle activity, it reflects a
severe reduction in the femoropopliteal arterial blood flow)
e Diminishing peripheral pulses
e Increase in usual capillary refill time
e Increased coolness and numbness of foot and lower leg
e Increased pallor or blanching of foot and lower leg when
extremity is elevated
e More rapid appearance of rubor or cyanosis in foot and
lower leg when extremity is in a dependent position

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent further reduction in and/or
improve blood flow in the affected lower extremity: D +
e Discourage positions that compromise blood flow in lower Prevents pooling of blood in the extremities.
extremities (e.g., crossing legs, pillows under knees, use of
knee gatch, elevating legs when in bed, sitting for long
periods).
e Perform actions to prevent vasoconstriction: Reduces vascular response to the neuroendocrine stimulation.
e Implement measures to reduce stress (e.g., maintain a
calm environment, control pain, explain preoperative
and postoperative care).
e Discourage smoking. Stimulates release of norepinephrine.
e Implement measures to keep client from getting cold
(e.g., maintain a comfortable room temperature;
provide adequate clothing, warm socks, and blankets).
e Encourage short walks unless contraindicated. Promotes venous return.

Dependent/Collaborative Actions
Administer the following medications if ordered: Hemorrheologic agents help to improve the flow of blood to the
e A hemorrheologic agent ischemic area. Anticoagulants help to prevent or treat thrombi.
e Anticoagulants
Consult physician if signs and symptoms of further reduction Notification of the appropriate health care provider allows for
in lower extremity tissue perfusion occur. modification of the treatment plan.

Diagnosis |ACUTE/CHRONIC PAIN nox (INTERMITTENT

|Nursing >»...
CLAUDICATION AND REST PAIN)
or potential tissue damage,
Definitions: Acute Pain NDx: Unpleasant sensory and emotional experience associated with actual
damage (Internationa l Association for the Study of Pain); sudden or slow onset of any
or described in terms of such
than 3 months
intensity from mild to severe with an anticipated or predictable end, and with a duration of less
with actual or potential tissue dam-
Chronic Pain NDx: Unpleasant sensory and emotional experience associated
l Association for the Study of Pain); sudden or slow onset of
age, or described in terms of such damage (Internationa
without an anticipated or predicable end and a duration of greater than 3 months.
any intensity from mild to severe
(ischemia results in the release of anaerobic
Related to: Diminished arterial blood flow in the affected lower extremity
metabolites that irritate the nerve endings of the affected lower extremity)

CLINICAL MANIFESTATIONS

Objective .
Subjective
Verbal-self report of pain; helplessness; anxiety Expressions of pain are variable; diaphoresis, B/P and pulse
changes

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 258 Chapter6 * The Client With Alterations in Cardiovascular Function

RISK FACTORS DESIRED OUTCOMES

a ence ee an
e Immobility lower extremity
The client will experience diminished
e Blood hypercoagulability pain as evidenced by:
e Peripheral vascular disease a. Verbalization of same
b. Relaxed facial expression and body positioning

NOC OUTCOMES NIC INTERVENTIONS

Comfort level; pain control Pain management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of pain in the Early recognition of signs and symptoms of acute/chronic pain
affected lower extremity: allows for prompt intervention.
e Intermittent claudication (e.g., verbalization of pain, ach-
ing, and/or cramping [usually in the calf muscle] during
ambulation)
e Rest pain (e.g., awakening at night with reports of severe
burning or aching in foot or toes)
e Grimacing, restlessness, reluctance to move, and/or
rubbing leg or foot
Assess Client’s perception of the severity of pain using a pain
intensity rating scale.
Assess the client’s pain pattern (e.g., location, quality, onset,
duration, precipitating factors, aggravating factors, allevi-
ating factors).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain in the affected extremity: Improves blood flow from the lower extremities.
D+
e Perform actions to prevent further reduction in and/or
improve blood flow in the affected lower extremity:
e Discourage positions that compromise blood flow in
lower extremities (e.g., crossing legs, pillows under
knees, use of knee gatch, elevating legs when in bed,
sitting for long periods).
e Perform actions to reduce fear and anxiety about the pain Fear and anxiety can decrease the client’s threshold and tolerance
experience (e.g., assure client that the need for pain relief for pain and thereby heighten the perception of pain.
is understood, plan methods for achieving pain control
with client).
e Perform actions to reduce the number of episodes of inter- Limiting activity decreases muscle contractions in and subsequent
mittent claudication: ischemia of the affected lower extremity.
e Encourage client to stop activity minutes before symp-
toms are usually experienced (intermittent claudication
is predictable, and clients are often aware of how far or
how long they can ambulate before the discomfort
begins or intensifies).
e Maintain client on bed rest if experiencing severe
intermittent claudication.
e If client is experiencing rest pain in the affected extremity,
perform actions to facilitate gravity flow of arterial blood
to the ischemic area: D+
e Allow client to sleep in a recliner with legs in a depen-
dent position or, if in bed, to hang affected lower leg
over the side of bed.
e Instruct client to avoid horizontal positioning and
elevation of affected extremity for prolonged periods.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 252

THERAPEUTIC INTERVENTIONS RATIONALE

e Provide lightweight blankets or a foot cradle if external
pressure aggravates lower extremity pain.
e Provide or assist with nonpharmacological measures for
relief of pain (e.g., relaxation techniques; position change;
diversional activities such as conversing, watching televi-
sion, or reading). D>

Dependent/Collaborative Actions
Implement measures to reduce pain in the affected extremity:
e Administer analgesics (if ordered). D +
Consult physician if above measures fail to provide adequate Notification of the appropriate health care provider allows for
pain relief. modification of the treatment plan.

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN

~oone eo) RISK FOR INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox

Definition: Susceptible to a decrease in blood circulation to the periphery, which may compromise health.

Related to: Diminished blood flow in the operative extremity associated with:
e Inflammation of the femoral and popliteal arteries at the sites of graft anastomoses
and
e Pressure on vessels in the operative extremity resulting from edema that can occur as a result of decreased venous return
dissection of tissue around perivascular lymphatics
was used for the bypass
e Venous stasis resulting from decreased mobility and decreased venous return if the saphenous vein
graft (can result in impaired venous return until collateral venous circulation improves)
e Graft occlusion
e Hypovolemia resulting from blood loss during surgery and decreased fluid intake

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain unrelieved by analgesics, Diminished or absent pulses; diminished or absent
numbness Doppler flow; coolness/cyanosis of foot; increased edema
in operative extremity; capillary refill time greater than
2 to 3 seconds

RISK FACTORS DESIRED OUTCOMES

: ; <7 3 : ’
seated AUR UTA ae: The client will maintain adequate tissue perfusion in the
a royal enous
gery), blood hypercoagulability operative extremity as evidenced by:
a. Resolution of leg and foot pain
b. Palpable peripheral pulses
c. Adequate Doppler flow readings in operative extremity
d. Absence of coolness, numbness, and cyanosis in foot
and lower leg
. Resolution of edema in operative extremity
(o>)

f. Capillary refill time less than 2 to 3 seconds

NIC INTERVENTIONS
NOC OUTCOMES
Circulatory care: arterial insufficiency; circulatory care:
Tissue perfusion: peripheral
venous insufficiency; lower extremity monitoring

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 260 Chapter6 * The Client With Alterations in Cardiovascular Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of ineffective tissue Early recognition and reporting of signs and symptoms of ineffec-
perfusion in operative extremity: tive peripheral tissue perfusion allow for prompt intervention.
e Pain unrelieved by prescribed analgesics
e Diminished or absent pulses (the pulses may be difficult to
palpate for 4-12 hrs after surgery because of vasospasm
that can occur in the operative extremity)
e Diminished or absent Doppler flow readings over opera-
tive extremity
* Coolness, numbness, or cyanosis of foot and lower leg
e Increase in edema in the operative extremity
¢ Capillary refill time greater than 2 to 3 seconds

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote adequate tissue perfusion in
operative extremity: D+
e Avoid 90-degree flexion of the hip as much as possible Extensive flexing of the hip can reduce perfusion to the operative
(e.g., place client in high-Fowler’s position for meals only, limb.
limit length of time that client is in straight-back chair,
provide recliner for client’s use when sitting up).
e Limit length of time that operative leg is in dependent Sitting for an extended period with legs in a dependent position
position (e.g., allow client to sit up for meals only; encour- may increase peripheral edema, stressing suture line.
age short, frequent walks rather than long walks).
e Instruct client to keep knee in a neutral or slightly flexed
position.
e Perform actions to prevent graft occlusion.
° If lower extremity edema is present, elevate foot of bed Elevation of the edematous operative extremity helps to promote
15 degrees as ordered. venous return without compromising arterial flow.
e Place a bed cradle over lower extremities. Bed cradles help to minimize pressure from bed linens.
e Instruct client to perform active foot and leg exercises
every 1 to 2 hrs while awake.
e Perform actions to prevent vasoconstriction: Vasoconstriction narrows vessel lumens, which results in dimin-
° Implement measures to reduce stress (e.g., control pain, ished blood flow through affected vessels.
maintain a calm environment, explain postoperative Stress stimulates the sympathetic nervous system, which results in
care). vasoconstriction.
e Discourage smoking. Nicotine increases catecholamine output, which subsequently
° Implement measures to keep client from getting cold causes vasoconstriction.
(e.g., maintain a comfortable room temperature; provide When the body is cold, peripheral vasoconstriction occurs in an
adequate clothing, warm socks, and blankets). attempt to conserve heat.

Dependent/Collaborative Actions
Implement measures to promote adequate tissue perfusion in Intravenous fluids and/or blood help maintain vascular volume,
operative extremity: which is essential for adequate tissue perfusion.
e Maintain a minimum fluid intake of 2500 mL/day unless
contraindicated; if oral intake is inadequate or contraindi-
cated, maintain intravenous fluid therapy as ordered.
e Administer blood and blood products as ordered.
Consult physician if signs and symptoms of diminished tissue ee ;
Notification of the appropriate '
health care provider allows for
perfusion in the operative extremity persist or worsen. modification of the treatment plan.
 Chapter 6 "The Client With Alterations in Cardiovascular Function 261

|Collaborative 2)
Diagnosis. RISK FOR COMPARTMENT SYNDROME
Definition: Elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular
function of tissues within that space
Related to: Severe edema of the operative extremity (an infrequent but serious complication that can occur as a result of
surgical site inflammation, reperfusion of the ischemic muscles, or dissection of tissue around the perivascular
lymphatics)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increasing leg pain; new onset or Diminished or absent peripheral pulses; cyanotic, cool leg
increasing numbness of affected extremity; difficulty
moving foot

RISK FACTORS DESIRED OUTCOMES

e Acute arterial occlusion The client will not experience compartment syndrome in
e Prolonged ischemia to tissues the operative extremity as evidenced by:
a. No complaints of increasing leg pain
b. No statements of new or increasing numbness and
tingling in foot or leg, or tightness and tenseness of
thigh or calf muscle
c. Ability to move leg and foot
d. No decrease in or absence of peripheral pulses
e. Absence of cyanosis and coldness of leg and foot

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of compartment Early recognition of signs and symptoms of compartment syndrome
syndrome in the operative extremity: allows for prompt intervention.
e Sudden, severe pain in toes or foot
e Diminishing or absent peripheral pulses
e Capillary refill time greater than 2 to 3 seconds
e Cyanosis, coolness, or diminished sensation in the foot
Assess for and report reddish-brown discoloration of urine. Assessment finding of reddish-brown urine discoloration could
indicate myoglobinuria resulting from the release of myoglobin
from the damaged muscle cells. If an excessive amount of
myoglobin is released, it can get trapped in the renal tubules
and cause renal failure.

THERAPEUTIC OS
INTERVENTIONS RATIONALE
UES cc eee ee ee aEEEEEEEEEEEEE
Dependent/Collaborative Actions
Limit length of time that operative leg is in a dependent posi- Measures help to prevent an increase in edema in operative leg
tion (e.g., limit sitting and walking as ordered). in order to reduce the risk of development of compartment
syndrome.
Elevate operative extremity 15 degrees if ordered.
Administer osmotic diuretics if ordered.
Surgical decompression (fasciotomy) may be necessary to
If signs and symptoms of compartment syndrome occur:
e Maintain client on bed rest. decompress soft tissue and improve circulation.
e Prepare client for a fasciotomy if planned.

Diagnosis RISK FOR SAPHENOUS

Collaborative >: NERVE DAMAGE

Definition: Damage to the saphenous nerve

Related to:
° Inadvertent or unavoidable dissection of the nerve during surgery
e Trauma to the nerve during surgery
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 262 Chapter6 = The Client With Alterations in Cardiovascular Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of numbness and tingling in affected Not applicable
extremity; heightened sensitivity to affected extremity

RISK FACTOR DESIRED OUTCOME

e Vascular surgery
The client will have resolution of or adapt to operative
extremity saphenous nerve damage if it has occurred.

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of saphenous nerve Early recognition of signs and symptoms of saphenous nerve
damage: damage allows for prompt intervention.
e Numbness, tingling
e Hypersensitivity of the operative extremity

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of saphenous nerve damage are
present:
e Adhere to and instruct client in the following safety
precautions:
e Wear shoes or slippers whenever out of bed.
¢ Do not apply heat or cold to the affected extremity.
e Test temperature of bath water before use. Nerve damage eliminates ability to sense temperature changes
e Protect operative extremity from trauma. which can lead to tissue damage.
e Reinforce information from physician regarding perma- These symptoms are permanent if the nerve was severed during
nence of numbness, tingling, or hypersensitivity. surgery; if the nerve was just traumatized, the symptoms are
temporary and expected to resolve within 1 year.
e Consult physician if signs and symptoms increase in Notification of the appropriate health care provider allows for
severity. modification of the treatment plan.

DISCHARGE TEACHING/CONTINUED CARE

«DEFICIENT KNOWLEDGE npx; INEFFECTIVE FAMILY

| HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MANAGEMENT nox*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes
a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health
goals of the
family unit; Ineffective Health Management NDx: Inability to identify, manage, and/or seek out help to
maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inaccurate follow-through of instructions

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching needs.
 Chapter 6 » The Client With Alterations in Cardiovascular Function 263

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; cardiac disease management Health system guidance; teaching: individual; teaching:
disease process; teaching: prescribed diet; teaching:
prescribed activity/exercise

RISK FACTORS
e Denial of disease process
e Cognitive deficiency
e Failure to take action to reduce risk factors

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

or slow the progression of atherosclerosis.

Independent Actions
Inform the client that certain modifiable factors such as After vascular surgery, clients should be educated as to health pro-
elevated serum lipid levels, a sedentary lifestyle, smoking, motion activities that slow the progression of atherosclerosis.
and hypertension have been shown to increase the risk of
atherosclerosis.
Assist client to identify changes in lifestyle that could Making these changes will decrease the incidence of hypertension
reduce the risk for atherosclerosis (e.g., smoking and improve circulatory status to the lower extremities.
cessation, dietary modifications, physical exercise on a
regular basis).
Provide instructions on ways the client can reduce intake of Dietary modifications that reduce saturated fat and cholesterol
saturated fat and cholesterol: intake may slow the progression of arteriosclerosis.
e Reduce intake of meat fat (e.g., trim visible fat off meat;
replace fatty meats such as fatty cuts of steak, hamburger,
and processed meats with leaner products).
e Reduce intake of milk fat (e.g., avoid dairy products con-
taining more than 1% fat).
e Reduce intake of trans fats (e.g., avoid stick margarine and
shortening and foods such as commercial baked goods
that are prepared with these products).
e Use vegetable oil rather than coconut or palm oil in cook-
ing and food preparation.
e Use cooking methods such as steaming, baking, broiling,
poaching, microwaving, and grilling rather than frying.
e Restrict intake of eggs. Recommendations about the number of whole eggs allowed per
week vary depending on the client’s lipid levels
Instruct client to take lipid-lowering agents as prescribed. Lipid-lowering agents help to keep cholesterol within normal limits,
reducing the risk ofatherosclerosis.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to pro-

mote blood flow in the operative extremity.

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 264 Chapter6 = The Client With Alterations in Cardiovascular Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Provide the following instructions about ways to promote Actions reduce the risk of compression of vessels, which may
blood flow in the operative extremity: compromise blood flow.
e Avoid wearing constrictive clothing (e.g., garters, girdles,
narrow-banded knee-high stockings).
Avoid positions that compromise blood flow (e.g., pillows
under knees, crossing legs, sitting or standing for prolonged
periods).
Do active foot and leg exercises for 5 minutes every Dorsiflexion/plantar extension exercises help to stimulate blood
hour while awake. flow to the extremities.
Maintain a regular exercise program (walking and swim-
ming are recommended).
Stop smoking.
Drink at least 10 glasses of liquid per day unless contra- Proper hydration thins circulating blood volume, allowing for
indicated. optimum flow-through vessels.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms: Early identification of signs and symptoms of bleeding associated
e Sudden or gradual increase in operative leg or foot pain with drug therapy or the development of arterial or venous
e Increased swelling or purple discoloration at incision sites thrombosis allows for prompt intervention by the appropriate
e Pallor, coldness, or bluish color of the operative extremity health care provider.
e Diminishing or sudden absence of peripheral pulses (client
may be instructed to monitor his/her peripheral pulses)
e Significant increase in swelling of operative extremity
(edema is expected to resolve gradually within the first
2-8 weeks after surgery)
e Difficulty moving foot on operative side
e Increasing numbness and/or tingling sensation of opera-
tive lower leg or foot
e Any area of persistent skin irritation or breakdown of foot
on operative side

THERAPEUTIC INTERVENTIONS
RATIONALE
eee

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, activity level, and
wound care.

Independent Actions
Collaborate with the client to develop a plan for adherence to
the treatment regimen including:
Reinforce the physician’s instructions regarding:
e Importance of scheduling adequate rest periods Promotes healing.
e Need to avoid sitting or standing for long periods Decreases pooling of blood in the lower extremities.
e Need to take prophylactic antimicrobials before any dental Prevents infection.
work or invasive procedure. Some physicians recommend this for the first 6-12 months after
surgical placement of a synthetic graft.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 265

RELATED CARE PLANS

Standardized Preoperative Care Plan

Standardized Postoperative Care Plan

HEART FAILURE
Heart failure is a syndrome in which the heart is unable backup in the left atrium and pulmonary vasculature. Pulmo-
to pump an adequate supply of blood to meet the body’s nary vascular congestion leads to pulmonary edema with
metabolic needs. To compensate for decreased cardiac output, symptoms such as tachypnea, dyspnea, cough, and abnormal
there is an increase in sympathetic nervous system activity breath sounds. In right-sided failure, the effect of reduced
and stimulation of renin-angiotensin-aldosterone output and function and emptying of the right ventricle is decreased
ADH release. These neurohormonal compensatory mecha- pulmonary blood flow and backup of blood in the right
nisms temporarily aid in maintaining an adequate cardiac atrium. This results in systemic venous congestion, which is
output but are thought to contribute to cardiac remodeling manifested by peripheral edema and signs of major organ
(changes in the structure of the ventricle [e.g., dilation, enlargement and dysfunction. Initially only one side of the
hypertrophy]). The increase in fluid volume that results from heart may fail (more commonly the left side), but as failure
increased aldosterone and ADH causes elevated pressure in progresses, both sides are usually affected.
the cardiac chambers, which stimulates the release of natri- Biomarkers used in initial and serial evaluation of the pres-
uretic peptides (atrial natriuretic factor [ANF] and BNP). These ence and severity of heart failure include B-type natriuretic
hormones counteract the effects of the increased levels of peptide (BNP) and N-terminal pro-B-type natriuretic peptide
norepinephrine, renin, angiotensin II, and aldosterone and (NT-proBNP). BNP is a hormone produced in the heart while
promote sodium and water excretion and vasodilation. NT-proBNP is a non-active prohormone released from the
Chronic distention of the heart chambers eventually exhausts same molecule as BNP. Both biomarkers are released in
stores of these natriuretic hormones and the effects of norepi- response to changes in pressure inside the heart that occur in
nephrine, renin, aldosterone, and ADH prevail, leading to the presence of heart failure and are elevated in patients with
heart failure. heart failure.
Numerous conditions can lead to heart failure including The treatment of heart failure is dependent upon the
CAD, MI, cardiomyopathy, cardiac valve malfunction, hyper- classification of heart failure with the overall goal to improve
tension, congenital heart defects, and systemic conditions performance of the failing heart. Pharmacological treatment
that increase the metabolic rate (e.g., thyrotoxicosis, infec- consists of renin-angiotensin system inhibition with angio-
tion) or cause prolonged or severe hypoxia. Heart failure can tensin converting enzyme inhibitors (ACE-I) or angiotensin
be classified in a number of ways. It is often classified as left- receptor blockers (ARNI). A positive inotropic agent (e.g.,
sided or right-sided, backward or forward, and/or systolic or digitalis) may be used in selected patients to ameliorate
diastolic failure. A functional classification system based on symptoms. Additional medications that may be used in
the relationship between symptoms and the amount of activ- symptomatic patients include beta blockers (e.g., carvedilol)
ity needed to provoke the symptoms was developed by the and aldosterone inhibitors (e.g., spironolactone). Recent stud-
New York Heart Association and is commonly used by many ies have shown that the addition of a beta-adrenergic block-
practitioners. In this system, which has four levels or classes, ing agent and spironolactone also improve the clinical status
a person is said to have class I (mild) heart failure if no symp- of many persons with chronic heart failure. It is thought that
beta blockers, and spironolactone interfere
toms are experienced with ordinary physical activity and ACE inhibitors,
class IV (severe) failure when symptoms occur with any with the compensatory neurohormonal activity that occurs
physical activity and possibly at rest. The American Heart with heart failure and alter the course of cardiac remodeling,
Association and American College of Cardiology classify heart subsequently slowing disease progression. The pharmacologi-
failure by stages from stage A (at risk but without structural cal treatment of heart failure varies somewhat depending on
heart disease or symptoms) to stage D or refractory heart fail- whether the client has systolic failure (an impaired inotropic
ure requiring advanced care measures (e.g., heart transplant). state characterized by inadequate ventricular emptying) or
Current algorithms combine both classification systems when diastolic failure (impaired filling of the ventricle). Positive
recommending treatment by classification/stage. inotropic agents are contraindicated for treatment of diastolic
Signs and symptoms of heart failure are dependent on failure.
which side of the heart is failing as well as whether there is As long as the body’s compensatory mechanisms and/or
forward or backward failure. Symptoms of forward failure are treatment measures are able to maintain cardiac output that
is sufficient to prevent or relieve symptoms, a state of
caused by low cardiac output. Symptoms of backward failure
are associated with the ventricle failing to empty completely,
compensated heart failure exists. If the myocardium is se-
verely damaged and intrinsic compensatory mechanisms and
which results in blood flow backup. In left-sided failure, there
treatment measures fail to maintain adequate cardiac output
is reduced emptying of the left ventricle, which results in
and tissue perfusion, a state of decompensated heart failure
decreased systemic tissue perfusion as well as blood flow

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266 Chapter 6 * The Client With Alterations in Cardiovascular Function

exists. When this state persists and is no longer responsive to 6. Identify modifiable cardiovascular risk factors and ways
medical treatment, it is termed intractable or refractory heart to alter these factors
failure. 7. Verbalize an understanding of the rationale for and
This care plan focuses on the adult client hospital- components of a diet low in sodium
ized for management of heart failure. Much of the in- 8. Demonstrate accuracy in counting pulse
formation is applicable to clients receiving follow-up 9. Verbalize an understanding of medications ordered
care in an extended care facility or home setting. including rationale, food and drug interactions, side
effects, schedule for taking, and importance of taking as
prescribed
OUTCOME/DISCHARGE CRITERIA 10. State signs and symptoms to report to the health care
provider
The client will: 11. Identify community resources that can assist with home
1. Have vital signs within a safe range and evidence of ade- management and adjustment to changes resulting from
quate peripheral circulation heart failure
2. Tolerate expected level of activity without undue fatigue 12. Share feelings and concerns about changes in body
or dyspnea functioning and usual roles and lifestyle
3. Have achieved dry weight and have minimal or no edema 13. Develop a plan for adhering to recommended follow-up
4. Have clear, audible breath sounds throughout lungs care including future appointments with health care
5. Have oxygen saturation within normal limits for provider and activity limitations.
client’s age

USE IN CONJUNCTION WITH THE CARE PLAN ON IMMOBILITY

|r DECREASED CARDIA C OUTPUT nox

Definition: Inadequate blood pumped by the heart to the meet metabolic demands of the body.

Related to:
¢ Alterations in preload, afterload, and myocardial contractility associated with the cardiac condition causing the heart failure
(e.g., ischemia of the myocardium, valve malfunction, cardiomyopathy)
° The effects of sympathetic nervous system and renin-angiotensin-aldosterone stimulation that occur in response to decreased
cardiac output
e Structural changes in the heart (e.g., dilation, hypertrophy) that occur with prolonged activation of neurohormonal adaptive
responses

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue; weakness; dyspnea; Variations in B/P; tachycardia; pulsus alternans; S; heart
orthopnea; dizziness sounds; tachypnea; dry, hacking cough; productive cough
with pink, frothy sputum; abnormal breath sounds (e.g.,
crackles/rales, wheezes); syncope; diminished or absent
pulses; cool extremities; capillary refill time greater than
3 seconds; decreased urine output; nocturia; edema; JVD;
elevated serum levels of BNP and ANF; increased (CVP;
chest radiograph evidence of pulmonary vascular
congestion or pulmonary edema

DESIRED OUTCOMES
The client will have improved cardiac output as evidenced g. Usual mental status
by: h. Absence of dizziness and syncope
. B/P within normal range for client i. Palpable peripheral pulses
. Apical pulse between 60 and 100 beats/min and regular j. Skin warm and usual color
. Resolution of gallop rhythm k. Capillary refill time less than 2 to 3 seconds
. Verbalization of feeling less fatigued and weak 1. Urine output at least 30 mL/h
. Unlabored respirations at 12 to 20 breaths/min m. Decrease in edema and jugular vein distention
@
&
AO
OF
eh. Improved breath sounds n. CVP within normal range
 Chapter 6 * The Client With Alterations in Cardiovascular Function 267

NOC OUTCOMES NIC INTERVENTIONS

Cardiac pump effectiveness; circulation status; Cardiac care: acute; invasive hemodynamic monitoring;
tissue perfusion: peripheral hemodynamic regulation; cardiac risk management;
dysrhythmia management; hypervolemia management;
cardiac care: rehabilitative

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of heart failure and decreased Early recognition of signs and symptoms of heart failure and
cardiac output: decreased cardiac output allows for prompt intervention.
e Dyspnea, orthopnea
Variations in B/P
Tachycardia
e Pulsus alternans
e Ss; heart sounds
e Tachypnea
e Dry, hacking cough
e Productive cough with pink, frothy sputum
e Abnormal breath sounds (e.g., crackles/rales, wheezes)
e Syncope
e Diminished or absent pulses
e¢ Cool extremities
e Capillary refill time greater than 3 seconds
e Decreased urine output
e Nocturia
e Edema
e JVD
Assess chest radiograph results for abnormalities (e.g., pulmo-
nary vascular congestion or pulmonary edema).
Assess serum levels of BNP and NT-proBNP for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve cardiac output: Measures that impact preload, afterload, and contractility help to
e Perform actions to reduce cardiac workload: improve cardiac performance, resulting in increased cardiac
* Place client in a semi- to high-Fowler’s position. D @ + output.
e Instruct client to avoid activities that create a Valsalva
response (e.g., straining to have a bowel movement,
holding breath while moving up in bed).
e Implement measures to promote emotional and
physical rest:
e Maintain a calm, quiet environment.
e Limit the number of visitors.
* Maintain activity restrictions. D @ +
e Implement measures to improve respiratory status: Actions help improve alveolar gas exchange and promote adequate
e Position in semi- to high-Fowler’s position tissue oxygenation to the heart, improving performance.
e Administer supplemental oxygen
° Discourage smoking. D+ Nicotine has a cardiostimulatory effect and causes vasoconstric-
tion; the carbon monoxide in smoke reduces oxygen availability.
° Provide small meals rather than large ones. D + Large meals can increase cardiac workload because they require a
greater increase in blood supply to gastrointestinal tract for
digestion.
° Discourage excessive intake of beverages high in Caffeine is a myocardial stimulant and can increase myocardial
caffeine such as coffee, tea, and colas. D >
oxygen consumption.
e Increase activity gradually as allowed and tolerated. D @ +

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 268 Chapter 6 = The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve cardiac output:
e Perform actions to reduce cardiac workload: Decreasing circulating fluid volume reduces preload, thus reducing
e Implement measures to reduce excess fluid volume. the workload of the heart.
e Administer diuretics (e.g., Lasix) In addition, reducing excess fluid volume helps to decrease pulmo-
e Administer the following medications if ordered: nary vascular congestion.
e Diuretics Reduce sodium and water retention and subsequently reduce
cardiac workload.
e ACE inhibitors—angiotensin-converting enzyme inhibitors Reduce vascular resistance and subsequently decrease cardiac
workload; they also alter the course of cardiac remodeling and
slow disease progression.
e ARBs—angiotensin blockers Block the action of angiotensin II by preventing it from binding to
angiotensin II receptors on the blood vessels. Associated with a much
lower incidence of cough and angioedema than ACE inhibitors.
e Positive inotropic agents To improve myocardial contractility.
e Beta-adrenergic blocking agents To blunt the effects of sympathetic nervous system stimulation on
the heart and kidney.
e B-type natriuretic peptide (nesiritide) To promote diuresis and vasodilation.
e Vasodilators To reduce cardiac workload.
Consult physician if signs and symptoms of decreased cardiac Consulting the appropriate health care provider allows for modifi-
output persist or worsen. cation of the treatment plan.

Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*

Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficient in oxygenation and/or carbon
dioxide elimination at the alveolar—capillary membrane.

Ineffective breathing pattern NDx related to:

e Increased rate of respirations associated with fear and anxiety
e Decreased depth of respirations associated with:
e Weakness, fatigue, and decreased mobility
° Decreased lung compliance (distensibility) as a result of pleural effusion or accumulation of fluid in the pulmonary interstitium
e Pressure on the diaphragm if ascites is present

Ineffective airway clearance NDx related to:

Increased airway resistance associated with edema of the bronchial mucosa and pressure on the airways resulting from
engorgement of the pulmonary vessels
e Stasis of secretions associated with decreased mobility and poor cough effort

Impaired gas exchange NDx related to:

e Impaired diffusion of gases associated with accumulation of fluid in the pulmonary interstitium and alveoli
e Decreased pulmonary tissue perfusion associated with decreased cardiac output

CLINICAL MANIFESTATIONS

Subjective Objective '

Verbal self-reports of dyspnea; orthopnea; restlessness; Rapid, shallow, slow, or irregular respirations; use of acces-
irritability sory muscles when breathing; adventitious breath sounds
(e.g., crackles [rales], wheezes); diminished or absent
breath sounds; dry, hacking cough or cough productive of
frothy or blood-tinged sputum; limited chest excursion;
confusion, somnolence; central cyanosis (a late sign);
significant decrease in oximetry results; abnormal arterial
blood gas values; abnormal chest radiograph results

*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern, ineffective airway clearance and |
impaired gas exchange.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 269

RISK FACTORS 4 DESIRED OUTCOMES

e Fluid volume overload Sa TEE ea) oh ay ETS Pad eR Ray a RE
emstrretiral talve defocte The client will experience adequate respiratory function as
Sawin evidenced by:
a. Normal rate, rhythm, and depth of respirations
b. Decreased dyspnea
c. Usual or improved breath sounds
d. Symmetrical chest excursion
e. Usual mental status
f. Oximetry results within normal range
g. Arterial blood gas values within normal range

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation; airway patency; gas exchange Respiratory monitoring; airway management; chest
physiotherapy; cough enhancement; ventilation assistance;
oxygen therapy; anxiety reduction

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired respiratory function: Early recognition of signs and symptoms of impaired respiratory
e Dyspnea, orthopnea dysfunction allows for prompt intervention.
e Restlessness, irritability
e Rapid, shallow, slow, or irregular respirations
e Use of accessory muscles when breathing
e Adventitious breath sounds (e.g., crackles [rales], wheezes)
e Diminished or absent breath sounds
e Dry, hacking cough or cough productive of frothy or
blood-tinged sputum
e Limited chest excursion
e Confusion, somnolence
e Central cyanosis (a late sign)
Assess results of chest radiograph, pulse oximetry, and arterial
blood gases for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve respiratory status: To improve pulmonary tissue perfusion and reduce fluid accumula-
tion in the lungs.
e Perform actions to reduce fear and anxiety: Decreases respiratory rate and anxiety.
e Maintain a calm, supportive, confident manner when
interacting with the client.
e Instruct client to breathe slowly if hyperventilating.
e Place client in a semi- to high-Fowler’s position unless
contraindicated; position overbed table so client can lean
forward on it if desired. D @+
e Instruct client to change position and deep breathe or use Improves lung expansion and decreases stasis of secretions.
incentive spirometer every 1 to 2 hrs.
Increasing strength and activity help with mobilization and
e Perform actions to increase strength and activity tolerance.
removal of secretions.
e Perform actions to promote removal of pulmonary secretions:
e Instruct and assist client to cough or “huff” every 1 to
2 hrs.
e Humidify inspired air as ordered. D + To keep secretions thin.
e Instruct client:to avoid intake of gas-forming foods (e.g., In order to prevent gastric distention and an increase in pressure on
beans, cauliflower, cabbage, onions), carbonated bever- the diaphragm.
ages, and large meals.

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 270 Chapter6 * The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

e Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause damage to the bronchial and alveolar
walls; the carbon monoxide in smoke decreases oxygen
availability.
e Maintain activity restrictions; increase activity gradually as Improves strength.
allowed and tolerated. D@ +

Dependent/Collaborative Actions
Implement measures to improve respiratory status:
e Perform actions to improve cardiac output:
e Administer positive inotropic agents. Positive inotropic agents increase cardiac output by improving
myocardial contractility.
e Maintain oxygen therapy as ordered. Improves tissue oxygenation.
e Assist with positive airway pressure techniques (e.g., Positive airway pressure techniques help to improve oxygenation by
continuous positive airway pressure [CPAP], bilevel posi- keeping terminal airways and alveoli open. The more alveoli
tive airway pressure [BiPAP], flutter/positive expiratory that remain open, the better the gas exchange.
pressure [PEP] device) if ordered.
e Administer central nervous system depressants judiciously;
hold medication and consult physician if respiratory rate
is less than 12 breaths/min.
e Administer the following medications if ordered:
° Diuretics D + Diuretics help to decrease pulmonary vascular congestion.
e Theophylline D + Theophylline helps to dilate the bronchioles.
¢ Morphine sulfate Morphine has a vasodilatory action that helps to reduce myocar-
dial workload; morphine also reduces apprehension associated
with dyspnea.
e Assist with thoracentesis/paracentesis if performed. Removes excess fluid to allow increased lung expansion.
Consult appropriate health care provider (e.g., physician, Allows for multidisciplinary client care.
respiratory therapist) if signs and symptoms of impaired
respiratory function persist or worsen.

Collaborative Diagnosis
Diagnosis. RISK FOR IMBALANCED FLUID nox AND RISK
FOR ELECTROLYTE IMBALANCE nox
Definition: Risk for Imbalanced Fluid NDx: Susceptible to a decrease, increase, or rapid shift from one to the other of
intravascular, interstitial, and/or intracellular fluid which may compromise health. This refers to body fluid loss,
gain, or both; Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte levels, which
may compromise health.
Related to:
e Excess fluid volume NDx related to:
° Retention of sodium and water associated with a decreased glomerular filtration rate (GFR) and activation of the
renin-angiotensin-aldosterone mechanism (both are a result of the reduced renal blood flow that occurs with decreased
cardiac output)
e Decreased excretion of water associated with increased ADH output (a compensatory response to decreased cardiac
output)
e Third-spacing of fluid related to: ‘
e Increased intravascular pressure associated with excess fluid volume
¢ Low plasma colloid osmotic pressure if serum albumin is decreased as a result of malnutrition or impaired liver function
(occurs with hepatic venous congestion)
e Hyponatremia related to:
e Hemodilution associated with excess fluid volume
¢ Sodium loss associated with diuretic therapy and increased release of natriuretic peptide hormones
 Chapter 6 ® The Client With Alterations in Cardiovascular Function PAIN

CLINICAL MANIFESTATIONS

Subjective Objective
Fluid overload: Verbal self-report of dyspnea; orthopnea Fluid overload: Weight gain of 2% or greater in a short
period; elevated B/P (B/P may not be elevated if cardiac
output is poor or fluid has shifted out of the vascular
space); presence of an S; heart sound; intake greater than
output; change in mental status; crackles (rales); low Hct
(may be normal or even increased if fluid has shifted
out of the vascular space); edema; distended neck veins;
elevated CVP (use internal jugular vein pulsation method
to estimate CVP if monitoring device not present)
Third-spacing: Verbal self-reports of increased dyspnea Third-spacing: Ascites; diminished or absent breath
sounds; evidence of vascular depletion (e.g., postural
hypotension; weak, rapid pulse; decreased urine output)
Hyponatremia: Verbal self-reports of nausea; weakness Hyponatremia: Vomiting; abdominal cramps; confusion;
seizures; low serum sodium level

- DESIRED OUTCOMES
The client will experience resolution of fluid imbalance as h. Decreased dyspnea and orthopnea
evidenced by: i. Decrease in edema and ascites
a. Decline in weight toward client’s normal j. Resolution of neck vein distention
b. B/P and pulse within normal range for client and stable k. CVP within normal range
with position change The client will maintain a safe serum sodium level as
c. Resolution of $3 heart sound evidenced by:
d. Balanced intake and output a. Usual mental status
e. Usual mental status b. Usual muscle strength
f. Improved breath sounds c. Absence of seizure activity
g. Hct returning toward normal range d. Serum sodium level within normal range

NOC OUTCOMES NIC INTERVENTIONS

nnn ee eee eee
Fluid balance; fluid overload severity; electrolyte and Fluid monitoring; fluid/electrolyte management; electrolyte
acid-base balance management: hyponatremia; hypervolemia management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of fluid and electrolyte Early recognition ofsigns and symptoms of fluid and electrolyte
imbalance: imbalance allows for prompt intervention.
e Fluid overload
e Dyspnea, orthopnea
e Weight gain of 2% or greater in a short period
e Elevated B/P (B/P may not be elevated if cardiac output
is poor or fluid has shifted out of the vascular space)
e Presence of an S3 heart sound
e Intake greater than output
* Change in mental status
e Crackles (rales)
° Low Hct (may be normal or even increased if fluid has
shifted out of the vascular space)
e Edema
e Distended neck veins
e Elevated CVP (use internal jugular vein pulsation method
to estimate CVP if monitoring device not present)

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 PLP? Chapter 6 * The Client With Alterations in Cardiovascular Function

Continued...

NURSING ASSESSMENT RATIONALE

e Third-spacing
e Increased dyspnea
e Ascites
e Diminished or absent breath sounds
e Evidence of vascular depletion (e.g., postural hypoten-
sion; weak, rapid pulse; decreased urine output)
e Hyponatremia
e Nausea, weakness
e Vomiting
e Abdominal cramps
e Confusion
e Seizures
e Low serum sodium level
Monitor chest x-ray results for indications of pulmonary vas-
cular congestion, pleural effusion, or pulmonary edema.
Monitor serum albumin levels for abnormalities. Low serum albumin levels result in fluid shifting out of the vascu-
lar space because albumin normally maintains plasma colloid
osmotic pressure.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to restore fluid balance: All actions help to reduce circulating fluid volume, helping to de-
e Perform actions to reduce excess fluid volume: crease preload and reduce the workload of the heart. Decreasing
e Restrict sodium intake as ordered. circulating fluid volume and implementing measures to optimize
e Maintain fluid restrictions if ordered. cardiac output help to restore circulation and improve oxygen-
e Implement measures to improve cardiac output. ation and tissue perfusion to the vital organs.
e If client is receiving numerous and/or large-volume Diuretics help increase excretion of water.
intravenous medications, consult pharmacist about
ways to prevent excessive fluid administration (e.g.,
stop primary infusion during administration of intrave-
nous medications, dilute medications in the minimum
amount of solution).
e Administer diuretics as ordered.
e Perform actions to prevent further third-spacing and
promote mobilization of fluid back into the vascular space:
e Administer albumin infusions if ordered. Increasing colloid osmotic pressure with the infusion of protein-
based fluids pulls accumulated third-spaced fluid back into the
vascular space, reducing edema.
e Assist with thoracentesis or paracentesis if performed. Remove excess fluid from the pleural space or peritoneal cavity.
Implement measures to treat hyponatremia: For hyponatremia induced by water excess, fluid restrictions
e Maintain fluid restrictions if ordered. are implemented to treat the problem.
e Administer intravenous saline solution if ordered (if If hyponatremia is severe and associated with neurological symp-
client’s hyponatremia is thought to be due to “salt toms, 3% saline may be administered to restore sodium levels
wasting,” treatment includes administration of saline and while the body is returning to a normal fluid balance.
discontinuation of diuretics).
e Consult physician about a decrease in or discontinuation Diuretic therapy causes loss of sodium.
of diuretics and temporary discontinuation of dietary
sodium restriction if sodium level is significantly reduced.
Consult physician if signs and symptoms of imbalanced fluid Consulting the appropriate health care provider allows for modifi-
and/or hyponatremia persist or worsen. cation of the treatment plan.
 Chapter 6 = The Client With Alterations in Cardiovascular Function D3}

Collaborative Sones
Diagnosis|RISK FOR RENAL INSUFFICIENCY
Definition: A deficiency in the kidney’s ability to clear waste products; a sign of inadequate glomerular filtration.
Related to: A prolonged or severe decrease in renal blood flow associated with low cardiac output, volume depletion (may
result from third-spacing, increased output of natriuretic hormones, and/or excessive diuretic use), and
vasodilator-induced hypotension

CLINICAL MANIFESTATIONS

Subjective Objective
Not applicable Urine output less than 30 mL/h; urine specific gravity
fixed at or less than 1.010; elevated BUN and serum
creatinine levels; decreased creatinine clearance

RISK FACTORS DESIRED OUTCOMES

e Decreased cardiac output
The client will maintain adequate renal function as
e Volume depletion
evidenced by:
a. Urine output at least 30 mL/h
b. BUN, serum creatinine, and creatinine clearance values
within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired renal Early recognition and reporting of signs and symptoms of renal
function: insufficiency allow for prompt intervention.
e Urine output < 30 mL/h
e Urine specific gravity = 1.010
e Elevated BUN/serum creatinine
e Decreased creatinine clearance
Monitor serum electrolyte, BUN/creatinine results for abnor-
malities.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain adequate renal blood flow: Prerenal causes of renal insufficiency/renal failure include factors
e Perform actions to improve cardiac output. such as decreased cardiac output and hypovolemia, which can
e Perform actions to reduce third-spacing. reduce blood flow to the kidneys, decreasing the glomerular
e Ensure a minimum fluid intake of 1000 mL/day unless perfusion and filtration.
ordered otherwise.
e Consult physician before giving vasodilators and diuretics
if client is hypotensive.
If signs and symptoms of impaired renal function occur:
e Consult physician about possible need to reduce the Digitalis is excreted by the kidney and will quickly reach toxic
digitalis dosage. levels when renal function is impaired.
e Consult physician about lowering the dose of or discon- ACE inhibitors and many diuretics should be used cautiously in
tinuing angiotensin-converting enzyme (ACE) inhibitors persons with impaired renal function because they can have an
and diuretics if BUN and serum creatinine levels continue adverse effect on renal function.
to rise significantly.
e Assess for and report signs of acute renal failure (e.g., oli-
guria or anuria; further weight gain; increasing edema;
increased B/P; lethargy and confusion; increasing BUN
and serum creatinine, phosphorus, and potassium levels).
° Prepare client for dialysis if indicated.

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 274 Chapter 6 ® The Client With Alterations in Cardiovascular Function

Or |Collaborative >>)
Diagnosis. 6RISK FOR CARDIAC DYSRHYTHMIAS
Definition: Irregularities of the heart rate or rhythm.
Related to:
e Impaired nodal function and/or altered myocardial conductivity associated with:
e Hypoxia
e Sympathetic nervous system stimulation (a compensatory response to low cardiac output)
e Structural changes in the myocardium (e.g., dilation, hypertrophy)
e Imbalanced electrolytes (particularly the magnesium and potassium depletion that can result from diuretic therapy)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of lightheadedness/dizziness Irregular apical pulse; pulse rate below 60 or above
100 beats/min; apical-radial pulse deficit; syncope; palpita-
tions; abnormal rate, rhythm, or configurations on ECG

RISK FACTORS DESIRED OUTCOMES

e Diuretic administration 3 : ae : ;
. MI The client will maintain normal sinus rhythm as evi-
denced by:
a. Regular apical pulse at 60 to 100 beats/min
b. Equal apical and radial pulse rates
c. Absence of syncope and palpitations
d. ECG reading showing normal sinus rhythm

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac dys- Early recognition of signs and symptoms of cardiac dysrhythmias
rhythmias: allows for prompt intervention.
e Subjective
e Objective
Monitor ECG for abnormalities.
Monitor serum electrolyte levels for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent cardiac dysrhythmias:
e Perform actions to improve cardiac output. Adequate cardiac output helps to promote adequate myocardial
tissue perfusion and oxygenation. Myocardial ischemia can
lead to dysrhythmias.
e Perform actions to improve respiratory status. Optimum respiratory function helps to improve tissue oxygenation,
reducing the potential for myocardial ischemia.
e Consult physician regarding an order for a potassium (K*) K* and Mg* abnormalities can cause cardiac dysrhythmias.
or magnesium (Mg*) replacement if serum levels of either
are below normal.
If cardiac dysrhythmias occur:
e Initiate cardiac monitoring if not already being done.
e Administer antidysrhythmics if ordered.
e Restrict client’s activity based on client’s tolerance and Decreases stress on the heart.
severity of the dysrhythmia.
e Maintain oxygen therapy as ordered. Increases tissue oxygenation.
e Assess cardiovascular status frequently and report signs
and symptoms of a further decline in cardiac output and
tissue perfusion.
e Prepare client for catheter ablation or insertion of a Decreases fear and anxiety.
pacemaker or ICD if planned.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 275

THERAPEUTIC INTERVENTIONS RATIONALE

° Have emergency cart readily available for cardioversion,
defibrillation, or CPR.

Collaborative =...
Diagnosis |RISK FOR ACUTE PULMONARY EDEMA
Definition: Excess water in the lungs, usually a result of heart failure.

Related to: Accumulation of fluid in the lungs associated with increased hydrostatic pressure in the pulmonary vessels as
a result of blood flow backup in the left ventricle

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Increased crackles (rales) or wheezes; disorientation;
increased restlessness and anxiousness; cough productive
of frothy or blood-tinged sputum; significant decrease in
oximetry results; worsening arterial blood gas results;
chest radiograph showing pulmonary edema

RISK FACTORS DESIRED OUTCOMES

e Acute MI
The client will not develop acute pulmonary edema as
e Decreased cardiac output
evidenced by:
e High afterload
a. Decreased dyspnea
b. Usual or improved breath sounds
c. Usual mental status
d. Arterial blood gas values within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of acute pulmonary Early recognition of signs and symptoms of acute pulmonary
edema: edema allows for prompt intervention.
e¢ Subjective
¢ Objective
Monitor pulse oximetry and arterial blood gas values and
chest radiograph results for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve cardiac output. Improving cardiac output results in a decrease in pulmonary vascu-
lar congestion as the left side of the heart improves performance.
If signs and symptoms of pulmonary edema occur: Interventions for acute pulmonary edema focus on the immediate
e Place client in a high-Fowler’s position unless contra- improvement of oxygenation and relief of pulmonary vascular
indicated. congestion by improving cardiac output and diuresis to reduce
e Maintain oxygen therapy as ordered. fluid accumulation in the lungs.
e Administer the following medications if ordered:
e Diuretics
e Theophylline
e Morphine sulfate Morphine sulfate is very beneficial in acute pulmonary edema be-
cause it helps to reduce anxiety and decrease pulmonary vascular
congestion (increases venous capacitance, which lowers venous
return to the heart).
e Vasodilators Vasodilators help to reduce afterload and improve left ventricular
emptying, which reduces pulmonary blood flow backup.

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276 Chapter6 * The Client With Alterations in Cardiovascular Function

Collaborative >.>
Diagnosis. RISK FOR THROMBOEMBOLISM

Definition: A clot attached to a vessel wall that detaches and circulates within the blood.

Related to:
e Venous stasis in the periphery associated with decreased cardiac output and decreased mobility
e Stasis of blood in the heart associated with decreased ventricular emptying (risk increases if dysrhythmias are present)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-reports of deep vein thrombus: Pain, tenderness Deep vein thrombus: Swelling, unusual warmth, and/or
positive Homans’ sign in extremity
Verbal self-reports of arterial thrombus: Numbness and/ Arterial thrombus: Diminished or absent peripheral
or pain in extremity pulses; pallor, coolness
Cerebral ischemia: Not applicable Cerebral ischemia: Decreased level of consciousness;
alteration in usual sensory and motor function
Verbal self-reports of pulmonary embolism: Sudden Pulmonary embolism: Increased restlessness and
onset of chest pain; increased dyspnea apprehension; significant decrease in arterial oxygen
saturation (SaO>)

RISK FACTORS DESIRED OUTCOMES

e Venous stasis
The client will not develop a thromboembolism as evi-
e Atrial fibrillation
denced by:
e Mural thrombus
a. Absence of pain, tenderness, swelling, and numbness in
extremities
. Usual temperature and color of extremities
. Palpable and equal peripheral pulses
. Usual mental status
. Usual sensory and motor function
. Absence of sudden chest pain and increased dyspnea

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deep vein throm- Early recognition of signs and symptoms of thromboembolism
bus, arterial embolus in an extremity, cerebral ischemia, or allows for prompt intervention.
pulmonary embolism:
e Pain/tenderness in extremity
e Chest pain
e Shortness of breath
e Altered mental status
e Diminished/absent pulses

THERAPEUTIC INTERVENTIONS RATIONALE

SEE

Dependent/Collaborative Actions
Implement additional measures to prevent the development Adequate cardiac output ensures that blood flow continues to the
of thromboemboli: extremities without pooling. Dysrhythmias, especia]ly atrial
e Perform actions to improve cardiac output. fibrillation, allow blood to pool in the atria, leading to
e Perform actions to treat cardiac dysrhythmias if present. clot formation. Anticoagulant therapy is used to prevent clot
e Administer anticoagulants or antiplatelet agents if ordered. formation.
If signs and symptoms of an arterial embolus in an extremity
occur:
e Maintain client on bed rest with affected extremity in a Improves arterial blood flow.
level or slightly dependent position.
 Chapter 6 » The Client With Alterations in Cardiovascular Function Zieh

THERAPEUTIC INTERVENTIONS RATIONALE

° Prepare client for the following if planned: Decreases fear and anxiety.
e Diagnostic studies (e.g., Doppler or duplex ultrasound,
arteriography)
¢ Injection of a thrombolytic agent Anticoagulants work to prevent a thrombus from increasing in size.
e Embolectomy
e Administer anticoagulants as ordered.
If signs and symptoms of cerebral ischemia occur: Actions help to reduce intracranial pressure (ICP) that accompanies
e Maintain client on bed rest; keep head and neck in cerebral ischemia.
neutral, midline position.
e Administer anticoagulants as ordered.

Collaborative oo
Diagnosis 6RISK FOR CARDIOGENIC SHOCK
Definition: Decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.
Related to: Inability of heart, intrinsic compensatory mechanisms, and treatments to maintain adequate tissue perfusion to
vital organs

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increased restlessness, lethargy, or Systolic B/P below 80 mm Hg; rapid, weak pulse; dimin-
confusion ished or absent peripheral pulses; increased coolness
and duskiness or cyanosis of skin; urine output less than
30 mL/h

RISK FACTORS DESIRED OUTCOMES

e Acute MI The client will not develop cardiogenic shock as evidenced
e¢ Cardiomyopathy
by:
. Stable or improved mental status
. Systolic B/P greater than 80 mm Hg
. Palpable peripheral pulses
. Stable or improved skin temperature and color
.@ . Urine output at least 30 mL/h
[O.
23a

NURSING ASSESSMENT RATIONALE

Assess for and immediately report signs and symptoms of Early recognition of signs and symptoms of cardiogenic shock
cardiogenic shock: allows for prompt intervention.
e Confusion
e Hypertension
e Rapid, weak pulse
e Diminished/absent pulse
e Urine output < 30 mL/h

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent cardiogenic shock: Treating dysrhythmias and restoring a stable cardiac rhythm
improves filling time of the ventricles, enhancing cardiac
e Perform actions to improve cardiac output.
e Perform actions to treat cardiac dysrhythmias if present. output.
If signs and symptoms of cardiogenic shock occur:
e Maintain oxygen therapy as ordered. Increases tissue oxygenation.
e Administer the following medications if ordered:
e Sympathomimetics Sympathomimetics increase cardiac output and maintain arterial
pressure.

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278 Chapter6 = The Client With Alterations in Cardiovascular Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Vasodilators If the client’s B/P is not too low, vasodilators can be used to
decrease afterload, reducing cardiac workload.
e Assist with intubation and insertion of hemodynamic Cardiogenic shock unresponsive to drug therapy requires more
monitoring device (e.g., Swan-Ganz catheter) and IABP invasive intervention to obtain numeric values that guide treat-
if indicated. ment or to assist the heart if function continues to deteriorate.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox: INEFFECTIVE FAMILY

HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MANAGEMENT nopx*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the
family unit; Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a thera-
peutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inability to follow-through with instructions

RISK FACTORS
e Denial of disease process
° Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; cardiac disease Health system guidance; teaching: individual; teaching:
management; disease process; medication disease process; teaching: prescribed diet; teaching:
prescribed medication; teaching: prescribed activity/exercise

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn.
Assess meaning of illness to client. Early recognition of readiness to learn and meaning of illness to
client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify modifiable

cardiovascular risk factors and ways to alter these factors.

Independent Actions ‘

Inform client that certain modifiable factors such as elevated Thorough education is a critical component of the care of a client
serum lipid levels, excessive alcohol intake, a sedentary with heart failure. The client must have a thorough understand-
lifestyle, hypertension, and smoking have been shown to ing of the importance of adhering to diet, medication, activity/
increase the risk for CAD and certain forms of heart disease. exercise, and nutritional recommendations to prevent an
exacerbation and control the disease.
Assist client to identify changes in lifestyle that can help the Improves client’s ability to maintain or improve state of health.
client manage the above risk factors (e.g., dietary modifica-
tion, physical exercise on a regular basis, moderation of
alcohol intake, smoking cessation).

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching needs, |
 Chapter 6 * The Client With Alterations in Cardiovascular Function 279

THERAPEUTIC INTERVENTIONS RATIONALE

Encourage client to limit daily alcohol consumption. Current Daily alcohol intake exceeding 1 oz of ethanol may contribute to
recommendations are no more than two drinks per day for the development of hypertension and some forms of heart
men and no more than one drink per day for women and disease.
lighter-weight persons. A “drink” is considered to be % 0z
of ethanol (e.g., 1% oz of 80-proof whiskey, 12 oz of beer,
5 oz of wine).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of the rationale for and components of a diet low in
sodium.

Independent Actions
Explain the rationale for a diet low in sodium. The edema associated with chronic heart failure is often treated
Provide the following information about decreasing sodium with a reduction in dietary sodium. The degree of sodium
intake: restriction depends on the severity of heart failure and the
Read labels on foods/fluids and calculate sodium content effectiveness of diuretic therapy.
of items; avoid those products that tend to have a high
sodium content (e.g., canned soups and vegetables,
tomato juice, commercial baked goods, commercially
prepared frozen or canned entrees and sauces).
¢ Do not add salt when cooking foods or to prepared foods;
use low-sodium herbs and spices if desired.
e Avoid cured and smoked foods.
e Avoid salty snack foods (e.g., crackers, nuts, pretzels,
potato chips).
e Avoid commercially prepared fast foods.
e Avoid routine use of over-the-counter medications with a
high sodium content (e.g., Alka-Seltzer, some antacids).
Obtain a dietary consult to assist client in planning meals
that will meet prescribed dietary modifications.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate accuracy in

counting pulse.

Independent Actions
Teach clients how to count their pulse, being alert to the Educating clients to their baseline heart rate allows for early
regularity of the rhythm. detection of irregularities that warrant immediate attention
Allow time for return demonstration and accuracy check. from a health care provider. Early detection may reduce the
incidence of exacerbation of heart failure.

THERAPEUTIC INTERVENTIONS RATIONALE

i

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, and importance
of taking the medications prescribed. Inform client of
pertinent food and drug interactions.
¢ Digitalis preparations Digitalis is a positive inotrope that improves cardiac contractility,
increasing cardiac output.

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280 Chapter 6 * The Client With Alterations in Cardiovascular Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Diuretics Diuretics help to mobilize edematous fluid, reducing pulmonary
venous pressure and preload.
e ACE inhibitors ACE inhibitors block the effects of ACE, which facilitates the conver-
sion of angiotensin I to angiotensin II, a potent vasoconstrictor.
e Beta-adrenergic blockers Beta-blockers reduce the effects of the sympathetic nervous system
on the failing heart by slowing the heart rate.
e ARBs—angiotensin blockers Block the action of angiotensin II by preventing it from binding to
angiotensin II receptors on the blood vessels. Associated with a
much lower incidence of cough and angioedema than ACE
inhibitors.
Instruct client to take medications on a regular basis and Taking medications as prescribed ensures that therapeutic drug
avoid skipping doses, altering prescribed dose, making up levels will be maintained.
for missed doses, and discontinuing medication without
permission of health care provider.
Instruct client to consult physician before taking other Clients should be instructed not to discontinue taking medications
prescription and nonprescription medications. if they feel better. Clients without financial resources should be
Instruct client to inform all health care providers of medica- assisted in accessing appropriate resources to obtain needed
tions being taken. medications (e.g., pharmacy assistance programs).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report: Reporting signs and symptoms of heart failure to the appropriate
e Weight gain of more than 2 lb in a day or 4 lb in a week provider allows for modification of the treatment plan and
e Increased swelling of ankles, feet, or abdomen possibly can prevent a client’s readmission to the hospital.
e Persistent cough
e Increasing shortness of breath
e Chest discomfort/pain
e Increased weakness and fatigue
e Frequent nighttime urination
e Signs and symptoms of digitalis toxicity
e Side effects of diuretic therapy

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community

resources that can assist with home management and
adjustment to changes resulting from heart failure.

Independent Actions
Provide information regarding community resources that can Heart failure can significantly impact an individual's and family’s
assist with home management and adjustment to changes socioeconomic status. Providing information specific to com-
resulting from heart failure (e.g., Meals on Wheels, home munity resources is important to provide a necessary continuum
health agencies, transportation services, American Heart of care and may impact the client’s health status, preventing
Association, counseling services). future hospitalizations. :

THERAPEUTIC INTERVENTIONS
_—_[——
SSSSSSSSSSSSSSSSFSFSSMSMmmMMHhFeFeseSSSFSSSSSSSSSMFMFFFFSeFs
——— ——
RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider and activity limitations.
 Chapter 6 « The Client With Alterations in Cardiovascular Function 281

THERAPEUTIC INTERVENTIONS RATIONALE ee

Ne

Independent Actions
Collaborate with the client to develop a plan to adhere to the Regular health care appointments are important to determine
treatment regimen that includes: effectiveness of the prescribed treatment plan.
Reinforce the importance of keeping follow-up appointments
with health care provider.
Provide the following instructions regarding activity:
e Increase activity gradually and only as tolerated.
e Stop any activity that causes chest pain, dizziness, or a
significant increase in shortness of breath or fatigue.
e Plan and adhere to rest periods during the day.
e Adhere to physician’s recommendations about activities
that should be avoided.
e Notify physician if activity tolerance declines.
e Reduce dyspnea and fatigue during sexual activity by:
e Avoiding sexual activity when unusually fatigued
e Waiting 1 to 2 hrs after a heavy meal or alcohol
intake before engaging in sexual activity
e
Identifying and using positions that minimize energy
expenditure
e Using portable oxygen during sexual activities
Implement measures to improve client adherence:
e Include significant others in teaching sessions if possible. Involvement of significant others in patient teaching improves
adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Everyone does not understand information as presented, so set aside
clarification of information provided. time for questions to allow for clarification of information.
e Provide written instructions regarding scheduled appoint- Written instructions allow the client to refer to instructions as
ments with health care provider, medications prescribed, needed.
dietary sodium restrictions, and signs and symptoms to
report.
e Ensure client has the necessary financial or social support
resources to meet the conditions of the treatment plan.

ADDITIONAL NURSING DIAGNOSES e Difficulty resting and sleeping associated with dyspnea,
frequent assessments and treatments, fear, and anxiety
RISK FOR FALLS NDx
Related to: RISK FOR IMPAIRED TISSUE INTEGRITY NDx
e Weakness Related to:
e Dizziness and syncope associated with inadequate cerebral e Damage to the skin and/or subcutaneous tissue associated
blood flow resulting from decreased cardiac output and with prolonged pressure on the tissues, friction, and/or
shearing if mobility is decreased
the hypotensive effect of some medications (e.g., ACE in-
e Increased fragility of the skin associated with edema, poor
hibitors, diuretics)
tissue perfusion, and inadequate nutritional status
¢ Getting up without assistance as a result of restlessness,
agitation, forgetfulness, and confusion (can result from
cerebral hypoxia and imbalanced fluid and electrolytes) IMBALANCED NUTRITION: LESS THAN BODY
REQUIREMENTS NDx
DISTURBED SLEEP PATTERN NDx Related to:
Related to: Unfamiliar environment, frequent assessments and e Decreased oral intake associated with:
treatments, decreased physical activity, fear, anxiety, and inabil- e Anorexia and nausea (result from venous congestion in
ity to assume usual sleep position associated with orthopnea the gastrointestinal tract and can occur if digitalis levels
exceed a therapeutic level)
ACTIVITY INTOLERANCE NDx e Weakness, fatigue, dyspnea, and dislike of prescribed diet
Related to: e Elevated metabolic rate associated with the increased oxy-
e Tissue hypoxia associated with impaired alveolar gas gen needs of the heart and the increased work of breathing
exchange and decreased cardiac output e Impaired absorption of nutrients associated with poor
e Inadequate nutritional status tissue perfusion

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282 Chapter 6 = The Client With Alterations in Cardiovascular Function

FEAR/ANXIETY NDx e Stimulation of the chemoreceptor trigger zone by certain

Related to: medications (e.g., digitalis preparations)
e Exacerbation of symptoms and need for hospitalization
e Lack of understanding of diagnostic tests, the diagnosis, DISTURBED THOUGHT PROCESSES NDx
and treatments Related to:
e Cost of hospitalization and lifelong treatment e Cerebral hypoxia associated with impaired alveolar gas
¢ Possibility of early disability and death exchange and inadequate cerebral tissue perfusion (a result
of decreased cardiac output)
NAUSEA NDx e Imbalanced fluid and electrolytes
Related to: Stimulation of the vomiting center associated
with: INEFFECTIVE COPING NDx
e Stimulation of the visceral afferent pathways resulting from Related to: Fear, anxiety, possible need to alter lifestyle, and
vascular congestion in the heart and gastrointestinal tract knowledge that condition is chronic and will require life-
e Stimulation of the cerebral cortex resulting from stress long medical supervision and medication therapy

HEART SURGERY: CORONARY ARTERY BYPASS

GRAFTING OR VALVE REPLACEMENT
Heart surgery is performed for a variety of reasons including less invasive, catheter-based system of CPB. Several techniques
myocardial revascularization, valve repair or replacement, are used to stabilize the operative area during a beating heart
repair of congenital or acquired structural abnormalities, procedure (stabilizer device to “still” certain areas of the heart
placement of a mechanical assist device, and heart transplan- while the rest keeps beating, drugs that decrease the heart rate or
tation. Two common heart surgeries are CABG, which is done cause transient asystole). Because “off pump” and minimally in-
to treat severe CAD, and heart valve replacement. CABG vasive approaches reduce the risk for some of the major complica-
involves removing a segment of a vein from a leg (e.g., saphe- tions (e.g., mediastinitis, emboli associated with cross-clamping
nous, cephalic) or an artery from the chest (e.g., internal the aorta) and shorten hospitalization and rehabilitation time,
mammary, radial, gastroepiploic) to create an anastomosis they promise to become more common.
between the aorta or other major artery and a point on the This care plan focuses on the adult client hospital-
coronary artery distal to the obstruction. Heart valve replace- ized for either CABG or valve replacement surgery.
ment involves replacing the stenotic or regurgitant valve with Much of the postoperative information is applicable to
a mechanical prosthesis or a biological (tissue) valve (porcine clients receiving follow-up care in an extended care
or bovine valve, human valve). facility or home setting.
Heart surgery is usually performed through a median ster-
notomy. Cardiopulmonary bypass (CPB; extracorporeal circula-
tion) is maintained during surgery by a machine that diverts the OUTCOME/DISCHARGE CRITERIA
blood from the heart and lungs, oxygenates the blood and re-
moves carbon dioxide, maintains the desired body temperature, The client will:
filters the blood, and then recirculates the blood into the arterial 1. Have adequate cardiac output and tissue perfusion
system. Systemic hypothermia (provided by the CPB machine) 2. Have clear, audible breath sounds throughout lungs
can reduce tissue oxygen requirements to 50% of normal, which 3. Have evidence of normal healing of surgical wound(s)
affords the major organs additional protection from ischemic 4. Have oxygen saturation within normal limits for client's age
injury. Cold cardioplegia (infusion of a cold alkaline solution 5. Tolerate expected level of activity
containing potassium into the coronary circulation) is used to 6. Have surgical pain controlled
precipitate cardiac arrest and provide additional protection to 7. Have no signs and symptoms of complications
the myocardium during surgery. An isotonic crystalloid solution 8. Identify modifiable cardiovascular risk factors and ways
is used to prime the bypass machine. This dilutes the client’s to alter these factors
blood, which improves blood flow and reduces the risk of micro- 9. Verbalize an understanding of the rationale for and com-
emboli formation. Before closing the chest, pacing electrodes are ponents of a diet restricted in sodium, saturated fat, and
usually placed on the epicardial surface of the heart and brought cholesterol .
out through the chest wall to be used for temporary pacing if 10. Verbalize an understanding of activity restrictions and
needed. A chest tube is placed in the mediastinum to drain the rate of activity progression
blood, and if needed, one is also placed in the pleural space to 11. Verbalize an understanding of medications ordered includ-
promote lung reexpansion. ing rationale, food and drug interactions, side effects, sched-
In addition to the traditional sternotomy approach performed ule for taking, and importance of taking as prescribed
on CPB, heart surgery may be performed “off pump” (referred to 2. State signs and symptoms to report to the health care provider
as off pump coronary bypass [OPCAB]) or using a minimally in- 3. Identify community resources that can assist with cardiac
vasive approach (e.g., small incision in left sternal border, a series rehabilitation and adjustment to having had heart surgery
of holes or “ports” using video-assisted equipment). Minimally 14. Develop a plan for adhering to recommended follow-
invasive procedures such as a MIDCAB (minimally invasive direct up care including future appointments with health care
coronary artery bypass) can be performed without CPB or with a provider, wound care, and pain management
 Chapter 6 = The Client With Alterations in Cardiovascular Function 283

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

SOE eM aoe es trey eerie va eee FEAR npx/ANXIETY nox

Definition: Fear NDx: Response to perceived threat that is recognized as danger; Anxiety NDx: Vague, uneasy feeling of
discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the
individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of
impending danger and enables the individual to take measures to deal with that threat.

Related to:
e Unfamiliar environment and separation from significant others
Lack of understanding of diagnostic tests, preoperative procedures/preparation, planned surgery, and postoperative course
e Anticipated loss of control associated with effects of anesthesia
e Financial concerns associated with surgery and hospitalization
e Anticipated postoperative discomfort and alterations in lifestyle and roles
e Risk of disease if blood transfusions are necessary
e Potential embarrassment or loss of dignity associated with body exposure
e Possibility of death

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN

Nursing Diagnosis DECREASED CARDIAC OUTPUT nox

Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body.

Related to:
e Preexisting compromise in cardiac function
e Trauma to the heart during surgery
e Increased afterload associated with:
e Vasoconstriction resulting from hypothermia and an increase in catecholamine output and plasma renin levels (these
increases occur with CPB and the effect of stressors [e.g., pain, anxiety])
e Fluid overload
e Decreased preload associated with:
e Hypovolemia (can result from blood loss, fluid shifting from the intravascular to interstitial space, loss of fluid from
nasogastric tube, fluid intake, and excessive diuresis)
e Hypotension (can occur if body is warmed rapidly after surgery and as a result of the effect of anesthesia and certain
medications [e.g., narcotic analgesics, beta-adrenergic blockers, vasodilators])
° Effects of anesthesia, hypothermia, hypoxemia, and acid-base and/or electrolyte imbalances on contractility and conductiv-
ity of the heart

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-reports of fatigue and weakness Low B/P; resting pulse rate greater than 100 beats/min;
postural hypotension; cool, pale, or cyanotic skin;
capillary refill time greater than 2 to 3 seconds; diminished
or absent peripheral pulses; urine output less than 30 mL/h;
low CVP; crackles (rales); presence of gallop rhythm;
dyspnea, tachypnea; restlessness, change in mental status;
edema; JVD; chest radiograph results showing pulmonary
vascular congestion, pulmonary edema, or pleural
effusion; abnormal arterial blood gas values; significant
decrease in oximetry results; dysrhythmias

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 284 Chapter 6 * The Client With Alterations in Cardiovascular Function

DESIRED OUTCOMES
eee ES En ad

The client will maintain adequate cardiac output as evi- g. Usual mental status
denced by: h. Absence of dizziness and syncope
. B/P within range of 100/60 to 130/80 mm Hg i. Palpable peripheral pulses
. Apical pulse regular and between 60 and 100 beats/min j. Skin warm and usual color
. Absence of or no increase in intensity of gallop rhythm k. Capillary refill time less than 2 to 3 seconds
. Increased strength and activity tolerance 1. Urine output at least 30 mL/h
. Unlabored respirations at 12 to 20 breaths/min m. Absence of edema and JVD
Oo . Absence of adventitious breath sounds
OOOD
se
@

NOC OUTCOMES NIC INTERVENTIONS

Cardiac pump effectiveness; circulation status; tissue Cardiac care: acute; invasive hemodynamic monitoring;
perfusion: peripheral; cardiac hemodynamic regulation; cardiac risk management;
dysrhythmia management; cardiac care: rehabilitative

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of decreased Early recognition of signs and symptoms of decreased cardiac
cardiac output: output allows for prompt intervention.
¢ Hypotension
Cool, pale, cyanotic skin
Diminished/absent pulses
e Urine output < 30 mL/h
e Jugulovenous distention
° Tachypnea
e Dyspnea
Monitor ECG for dysrhythmias.
Monitor chest radiograph, pulse oximetry, and arterial blood
gas values for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain an adequate cardiac output:
e Perform actions to prevent or treat hypotension: Vasodilation occurs with warming. Warming measures should be
e Avoid rapid rewarming; gradually bring client’s body gradual to prevent hypotension.
temperature to normal if client is hypothermic.
e Perform actions to reduce cardiac workload: Decreasing cardiac workload will help to improve or maintain
° Place client in a semi- to high-Fowler’s position. D @ + cardiac output.
¢ Instruct client to avoid activities that create a Valsalva
response (e.g., straining to have a bowel movement,
holding breath while moving up in bed).
¢ Implement measures to promote rest (e.g., maintain activity
restrictions, limit the number of visitors, reduce anxiety).
e Discourage smoking. Nicotine has a cardiostimulatory effect and causes vasoconstric-
tion; the carbon monoxide in smoke reduces oxygen availability.
e Discourage excessive intake of beverages high in caffeine Caffeine is a myocardial stimulant and can increase myocardial
such as coffee, tea, and colas. oxygen consumption. |
‘
Dependent/Collaborative Actions
Administer prescribed pain medications.
Implement measures to maintain an adequate cardiac output:
° Perform actions to prevent or treat hypovolemia: Actions help to maintain or restore circulating blood volume. An
e Administer blood and/or colloid or crystalloid solutions adequate circulating blood volume is necessary to achieve the
as ordered. optimum preload necessary for effective cardiac output.
e Maintain a minimum fluid intake of 1000 mL/day
unless ordered otherwise.
¢ Implement measures to prevent and control bleeding.
 Chapter 6 = The Client With Alterations in Cardiovascular Function 285

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to prevent or treat hypotension:
e Consult physician before giving negative inotropic agents,
diuretics, and vasodilating agents if client is hypotensive.
e Administer narcotic (opioid) analgesics judiciously; in the Opioids promote vasodilation.
immediate postoperative period, be alert to the synergistic
effect of the narcotic ordered and the anesthetic that was
used during surgery.
e Administer sympathomimetics if ordered. Sympathomimetics may be administered as a temporary measure
to improve B/P if adequate circulating fluid volume has been
restored.
e Administer positive inotropic agents (e.g., dopamine, Positive inotropic agents increase myocardial contractility, improv-
dobutamine, digitalis preparations) if ordered. ing cardiac output.
e Perform actions to prevent or treat cardiac dysrhythmias. Cardiac dysrhythmias can alter ventricular filling time and
e Administer antidysrhythmic medications. significantly reduce cardiac output.
e Replace K*, Mg” electrolytes.
e Perform actions to reduce cardiac workload: Actions help to prevent vasoconstriction associated with hypother-
e Perform actions to prevent or treat hypertension: mia and also prevent shivering, which elevates the metabolic
e Implement measures to gradually rewarm client rate and increases cardiac workload.
(e.g., increased room temperature, radiant heat
lamp, warm blankets) if client is hypothermic.
e Implement measures to reduce stress (e.g., initiate
pain relief measures, reduce fear and anxiety).
e Administer vasodilators if ordered. Reduces vasoconstriction.
e Implement measures to maintain adequate respiratory
function.
e Implement measures to prevent or treat excess fluid Promotes adequate tissue oxygenation.
volume:
e Administer diuretics. Use of diuretics and limiting fluid intake will help to maintain
e Limit excess fluid intake. appropriate vascular volume.
e Increase activity gradually as allowed and tolerated.
Consult physician if signs and symptoms of decreased cardiac Consulting the appropriate health care provider allows for modifi-
output persist or worsen. cation of the treatment plan.

|Nursing >...
Diagnosis RISK FOR IMPAIRED RESPIRATORY FUNCTION*
Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficient in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.

Related to:
Ineffective breathing pattern NDx related to:
e Increased rate of respirations associated with fear and anxiety
effect of anesthesia and some medications (e.g., opioid
* Decreased rate of respirations associated with the depressant
analgesics)
e Decreased depth of respirations associated with:
e Weakness, fatigue, and decreased mobility
° Depressant effect of anesthesia and some medications (e.g., opioid analgesics)
° Reluctance to breathe deeply because of chest incision and fear of dislodging chest tube
e Hemiparesis of the diaphragm if the phrenic nerve was injured
* Decreased lung compliance (distensibility) if pleural effusion is present
Ineffective airway clearance NDx related to:
resulting from the effect of anesthesia, and
© Stasis of secretions associated with decreased activity, depre ssed ciliary function
a weak cough effort
from inhalation anesthetics and endotra-
e Increased secretions associated with irritation of the respiratory tract (can result
cheal intubation)

pattern, ineffective airway clearance, and

*This diagnostic label includes the following nursing diagnoses: ineffective breathing
impaired gas exchange.

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 286 Chapter 6 * The Client With Alterations in Cardiovascular Function

Impaired gas exchange NDx related to ventilation/perfusion imbalances associated with:

e Atelectasis resulting from:
e Deflation of the alveoli while on the CPB machine
e Decreased surfactant production/function (occurs because of lack of alveolar expansion and decreased pulmonary blood
flow during CPB and as a result of a systemic inflammatory response to the bypass machine)
e Postoperative hypoventilation or ineffective clearance of secretions
e Accumulation of fluid in the pulmonary interstitium and alveoli (can occur as a result of excess fluid volume)
e Decreased pulmonary blood flow resulting from decreased cardiac output

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of restlessness; irritability Rapid, shallow, or slow respirations; dyspnea, orthopnea;
use of accessory muscles when breathing; adventitious
breath sounds (e.g., crackles [rales], rhonchi); diminished
or absent breath sounds; asymmetrical chest excursion;
cough; confusion, somnolence; abnormal arterial blood
gas values; significant decrease in oximetry results;
abnormal chest radiograph results

RISK FACTORS DESIRED OUTCOMES

e Immobility
e Atelectasis The client will experience adequate respiratory function as
e Ineffective clearance of secretions evidenced by:
a. Normal rate and depth of respirations
b. Absence of dyspnea
c. Normal breath sounds by third to fourth postoperative
day
d. Symmetrical chest excursion
e. Usual mental status
f. Oximetry results within normal range
g. Arterial blood gas values within normal range

NOC OUTCOMES NIC INTERVENTIONS

eee
Respiratory status: ventilation; airway patency; gas exchange Respiratory monitoring; airway management; chest
physiotherapy; cough enhancement; ventilation assistance;
oxygen therapy; anxiety reduction

NURSING ASSESSMENT RATIONALE

a ee eee
Assess for and report signs and symptoms of impaired respira- Early recognition of signs and symptoms of impaired respiratory
tory function: function allows for prompt intervention.
e Rapid, shallow, or slow respirations
e Dyspnea, orthopnea
e Use of accessory muscles when breathing
e Adventitious breath sounds (e.g., crackles [rales], rhonchi)
e Diminished or absent breath sounds
e Asymmetrical chest excursion
e Cough i
e Confusion, somnolence
Monitor pulse oximetry and arterial blood gas values, and
chest radiograph results for abnormalities.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 287

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate respiratory function:
e Perform actions to decrease fear and anxiety (e.g., explain Actions that decrease fear and anxiety help to prevent the shallow
procedures, interact with client in a confident manner, and/or rapid breathing that can occur with fear and anxiety.
initiate pain relief measures).
e Place client in a semi- to high-Fowler’s position unless Improves lung expansion.
contraindicated.
e If client must remain flat in bed, assist with position Actions help to mobilize secretions and prevent alveolar collapse
change at least every 2 hrs. associated with immobility.
e Instruct and assist client to cough and deep breathe or use Improves lung expansion and prevents stasis of secretions.
incentive spirometer every 1 to 2 hrs; assure client that
chest tube is sutured in place and that these activities
should not dislodge the tube.
e Instruct client to avoid intake of gas-forming foods (e.g., Helps to prevent gastric distention and subsequent pressure on the
beans, cauliflower, cabbage, onions), carbonated bever- diaphragm.
ages, and large meals.
e Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause damage to the bronchial and alveolar
walls; the carbon monoxide in smoke decreases oxygen
availability.

Dependent/Collaborative Actions
Implement measures to maintain adequate respiratory function:
e Monitor mechanical ventilation carefully to ensure that The nurse collaborates with the respiratory therapist to ensure that
ventilatory rate and pressures are correct. mechanical ventilation is delivered therapeutically without
adverse outcomes.
e Perform actions to decrease pain and increase strength and Providing adequate pain relief helps to increase client’s willingness
activity (e.g., administer analgesics before activities that and ability to move, cough, deep breathe, and use incentive
can cause pain). spirometer.
e Perform actions to maintain an adequate cardiac output. Adequate cardiac output ensures pulmonary blood flow, facilitat-
e Administer blood and blood products as ordered. ing gas exchange.
e Perform actions to prevent or treat excess fluid volume Actions help to reduce the risk for pleural effusion and pulmonary
and third-spacing (e.g., administer diuretics as ordered). edema.
e Maintain an adequate fluid intake and humidify inspired Actions help to thin tenacious secretions and reduce dryness of the
air if ordered. respiratory mucous membrane.
e Maintain oxygen therapy as ordered. Maintains tissue oxygenation.
e Maintain activity restrictions as ordered; increase activity
gradually as allowed and tolerated.
e Administer central nervous system depressants judiciously; Prevents decreased tissue oxygenation.
hold medication and consult physician if respiratory rate
is less than 12 breaths/min.
Consulting the appropriate health care provider allows for modifi-
Consult appropriate health care provider (e.g., respiratory
therapist, physician) if signs and symptoms of impaired cation of the treatment plan.
respiratory function persist or worsen.

Diagnosis RISK FOR IMBALANCED FLUID VOLUME nox

|Nursing/Collaborative >.
AND RISK FOR ELECTROLYTE IMBALANCE nox
increase, or rapid shift from one to the other
Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease,
of intravascular, interstitial, and/or intracellula r fluid, which may compromis e health. This refers to body fluid
Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte levels, which
loss, gain, or both;
may compromise health.

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 288 Chapter6 * The Client With Alterations in Cardiovascular Function

Related to:
Excess fluid volume NDx related to:
e Vigorous fluid therapy during and immediately after surgery (the CPB machine is primed with a large amount of crystalloid
solution to decrease blood viscosity and the risk for embolic complications, decrease hemolysis of cells, and help maintain
adequate circulation throughout the body)
e Increased production of ADH (output of ADH is stimulated by trauma, pain, and anesthetic agents)
e Reshifting of fluid from the interstitial space back into the intravascular space approximately 3 days after surgery
e Decreased GFR and activation of the renin-angiotensin-aldosterone mechanism (a result of nonpulsatile renal perfusion
while on the bypass machine and the decreased renal blood flow that can occur with decreased cardiac output)
e Presence of preexisting heart failure
Third-spacing of fluid related to:
e Increased capillary permeability (a result of the systemic inflammatory response that occurs with CPB) and the subsequent
low plasma colloid osmotic pressure associated with decreased plasma proteins
Deficient fluid volume NDx related to:
e Restricted oral intake before, during, and after surgery
e Blood loss during surgery and via chest tube after surgery
e Loss of fluid associated with nasogastric tube drainage and excessive diuresis
e Third-spacing of intravascular fluid
Hypokalemia, hypochloremia, and/or metabolic alkalosis related to:
¢ Loss of electrolytes and hydrochloric acid associated with nasogastric tube drainage (diuretic therapy and the hemodilution
created by priming the bypass machine with large amounts of fluid also contribute to the imbalanced electrolytes)

CLINICAL MANIFESTATIONS

Subjective Objective
Excess fluid volume: Not applicable Excess fluid volume: Weight gain of 2% or greater in a
short period; elevated B/P (B/P may not be elevated if car-
diac output is poor or fluid has shifted out of the vascular
space); presence of an S; heart sound; intake greater than
output; change in mental status; crackles (rales); dyspnea,
orthopnea; edema, distended neck veins; elevated CVP
(use internal jugular vein pulsation method to estimate
CVP if monitoring device is not present)
Third-spacing: Not applicable Third-spacing: Ascites; increased dyspnea and diminished
or absent breath sounds; evidence of vascular depletion
(e.g., postural hypotension; weak, rapid pulse; decreased
urine output)
Deficient fluid volume: Verbal self-report of thirst Deficient fluid volume: Hypotension; tachycardia;
decreased urine output; tenting skin turgor; dry mucous
membranes; thick, tenacious pulmonary secretions

DESIRED OUTCOMES
The client will experience resolution of excess fluid volume f. Improved breath sounds
and third-spacing as evidenced by: g. Decreased dyspnea and orthopnea
a. Decline in weight toward client’s normal h. Decrease in edema and ascites
b. B/P and pulse within normal range for client and stable i. Resolution of neck vein distention
with position change j. CVP within normal range
c. Resolution of S3; heart sound The client will not experience deficient fluid volume,
d. Balanced intake and output hypokalemia, hypochloremia, or metabolic alkalosis,
e. Usual mental status

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; fluid overload severity; electrolyte and acid- Fluid monitoring; electrolyte monitoring; acid-base
base balance monitoring; fluid/electrolyte management: hypokalemia;
acid-base management: metabolic alkalosis
 Chapter 6 * The Client With Alterations in Cardiovascular Function 289

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of excess fluid Early recognition of signs and symptoms of excess fluid volume
volume and third-spacing. and third-spacing allows for prompt intervention.
Monitor chest radiograph for abnormal findings:
e Pulmonary vascular congestion
e Pleural effusion
e Pulmonary edema
Monitor serum albumin levels for abnormal values. Low serum albumin levels result in fluid shifting out of the vascu-
lar space because albumin normally maintains plasma colloid
osmotic pressure.
Monitor postoperative drains (mediastinal tubes/chest tubes) Excessive postoperative drainage can lead to deficient circulating
for amount and consistency of drainage. fluid volume.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to restore fluid balance:
e Perform actions to reduce excess fluid volume:
e Perform actions to maintain adequate renal blood flow. Adequate renal blood flow helps to maintain normal glomerular
e Maintain adequate blood pressure within client’s filtration with subsequent fluid removal.
baseline normal values.
e Administer diuretics if ordered. Decreases fluid volume excess.
e Maintain fluid and sodium restrictions as ordered (2500 mL High sodium levels cause fluid retention.
fluid and 3-4 g sodium restrictions are common).
e Perform actions to prevent further third-spacing and pro-
mote mobilization of fluid back into the vascular space:
e Administer albumin infusions if ordered. Albumin helps to increase colloid osmotic pressure, pulling fluid back
e Administer the following if ordered to treat deficient fluid into the vascular space and helping to reduce third-spacing.
volume and hypokalemia:
¢ Blood and/or colloid or crystalloid solutions Colloid solutions may be used rather than crystalloid solutions because
they help maintain colloid osmotic pressure and subsequently reduce
shifting of fluid from the intravascular to the interstitial space.
e Potassium supplements Keeping the serum potassium at 4.0 to 4.5 mEq/L reduces the risk
for dysrhythmias.
Consult physician if signs and symptoms of excess fluid Allows for prompt alterations in interventions.
volume and third-spacing persist or worsen.

Nursing Diagnosis RISK FOR INFECTION nox

Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
Pneumonia related to:
° Stasis of pulmonary secretions associated with decreased activity
° Depressed ciliary function resulting from the effect of anesthesia
tube
¢ <A poor cough effort resulting from weakness, surgical site pain, and fear of dislodging chest
Wound infection and mediastinitis related to:
surgery
* Wound contamination associated with introduction of pathogens during or after
associated with factors such as inadequate nutritional status and diminished tissue
e Decreased resistance to infection
to wound area (an increased risk if client is elderly or has diabetes or if on CPB a prolonged time or cardiac output
perfusion
is low for a prolonged time)

CLINICAL MANIFESTATIONS

Subjective Objective
Increased temperature; redness; warmth, discharge in
Verbal self-report of increased pain at wound site
close proximity to wound; thick, malodorous pulmonary
secretions

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 290 Chapter 6 = The Client With Alterations in Cardiovascular Function

DESIRED OUTCOMES
The client will not develop pneumonia.
The client will remain free of wound infection and
mediastinitis.

NOC OUTCOMES NIC INTERVENTIONS

Immune status; infection severity; wound healing: primary Infection protection; infection control; cough enhancement;
intention airway management; incision site care

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of sternal wound Early recognition of signs and symptoms of pneumonia or sternal
infection and mediastinitis: wound infection/mediastinitis allows for prompt intervention.
e Fever persisting beyond the fourth postoperative day Signs and symptoms of sternal infection and mediastinitis are
° Grating sound and/or movement of sternum when client often not manifested until the second week after surgery.
moves or coughs
Monitor chest radiograph results for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement additional measures to reduce the risk for pneumonia: Improves lung expansion and decreases stasis ofsecretions.
¢ Perform actions to maintain adequate respiratory function:
e Encourage cough and deep breathing.
e Increase activity as tolerated.
e Have client splint chest incision with a pillow when turning, Splinting the incision helps increase client’s willingness to move,
coughing, and deep breathing. cough, and deep breathe.

Dependent/Collaborative Actions
If signs and symptoms of a sternal wound infection and Treats infection.
mediastinitis occur:
e Administer antimicrobial agents as ordered.
e Prepare client for surgical debridement, drainage, and Decreases fear and anxiety.
antibiotic irrigation of wound if planned.

| Collaborative Diagnosis RISK FOR CARDIAC DYSRHYTHMIAS

Definition: Disturbance of the heart rhythm
Related to: Impaired nodal function and/or altered myocardial conductivity associated with trauma to the heart during
surgery, hypothermia, hypoxia, sympathetic stimulation (can result from anxiety, volume depletion, and pain),
or electrolyte and acid-base imbalances

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of palpitations; lightheadedness Irregular apical pulse; pulse rate below 60 or above 100 beats/
min; apical-radial pulse deficit; syncope; palpitations} ab-
normal rate, rhythm, or configurations on ECG

RISK FACTORS DESIRED OUTCOMES

e Electrolyte imbalances
The client will maintain normal sinus rhythm as evi-
e Myocardial ischemia
denced by:
a. Regular apical pulse at 60 to 100 beats/min
b. Equal apical and radial pulse rates
c. Absence of syncope and palpitations
d. ECG showing normal sinus rhythm
 Chapter 6 « The Client With Alterations in Cardiovascular Function 291

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac Early recognition of signs and symptoms of excess of cardiac
dysrhythmias: dysrhythmias allows for prompt intervention.
e Irregular apical
e Pulse rate < 60 or > 100 beats/min
e Palpitations
Monitor ECG, levels of serum cardiac enzymes/troponin for
abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent cardiac dysrhythmias:
e Perform actions to maintain adequate cardiac output and
myocardial blood flow.
e Maintain oxygen therapy as ordered.
e Monitor serum electrolyte levels; consult physician about
administration of a potassium or magnesium supplement
if serum levels of either are low.
e Perform actions to maintain adequate respiratory function. Optimum respiratory function helps to improve tissue oxygenation
and prevent respiratory acidosis or alkalosis (myocardial
conductivity is altered by hypoxia and acid-base imbalance).
e Administer prophylactic antidysrhythmic agents if ordered.
Ifcardiac dysrhythmias occur: Administration of prophylactic antidysrhythmic agents decrease
e Initiate cardiac monitoring if not still being done. incidence of cardiac dysrhythmias and help to maintain
e Administer antidysrhythmics if ordered. adequate cardiac output.
e Maintain temporary pacemaker function as ordered.
e Restrict client’s activity based on client’s tolerance and
severity of the dysrhythmia.
e Maintain oxygen therapy as ordered.
e Assess cardiovascular status frequently and report signs Allows for prompt changes in treatment regimen.
and symptoms of inadequate tissue perfusion (e.g., de-
crease in B/P, cool skin, cyanosis, diminished peripheral
pulses, urine output less than 30 mL/h, restlessness and
agitation, shortness of breath).
e Have emergency cart readily available for cardioversion,
defibrillation, or CPR.

Diagnosis |RISK FOR CARDIAC

Collaborative >> TAMPONADE

Definition: Pericardial effusion that creates sufficient pressure to cause cardiac compression.
excessive bleed-
Related to: Accumulation of fluid (usually blood) in the pericardial sac and/or mediastinum associated with
ing and/or obstructed drainage of the mediastinal tube

CLINICAL MANIFESTATIONS

Subjective Objective
Not applicable Sudden decrease in chest tube drainage; chest radiograph
report of widening mediastinum; decreased B/P; narrowed
pulse pressure; pulsus paradoxus; distant muffled heart
sounds

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292; Chapter6 * The Client With Alterations in Cardiovascular Function

RISK FACTORS DESIRED OUTCOMES

e Cardiac surgery The client will not experience cardiac tamponade as evi-
e Obstructed postsurgical draining
denced by:
. Stable vital signs
. Audible heart sounds
. Absence of JVD
. Absence of pulsus paradoxus
@ . CVP within
iY
Isr
{hie normal limits

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac tamponade: Early recognition of signs and symptoms of cardiac tamponade
e Decreased blood pressure allows for prompt intervention.
e Pulsus paradoxus
e Muffled heart sounds

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce the risk of cardiac tamponade:
e Perform actions to maintain patency and integrity of chest Prevents pressure buildup on the heart.
drainage system.
e If chest tube becomes obstructed, assist with clearing of Maintains patency.
existing tube and/or insertion of a new tube.
e When removing the pacemaker catheter(s), do it carefully. Avoid trauma to the surrounding vessels and subsequent bleeding.
If signs and symptoms of cardiac tamponade occur:
e Prepare client for echocardiography. Decreases fear and anxiety.
e Administer intravenous fluids and/or vasopressors if ordered. Maintains mean arterial pressure.
e Prepare client for surgical drainage of pericardial fluid. Decreases fear and anxiety.

|Nursing 2)
Diagnosis |RISK FOR BLEEDING nox
Definition: Susceptible to a decrease in blood volume, which may compromise health.
Related to:
e Impaired platelet function associated with mechanical damage to the platelets by the bypass machine and _ possible
heparin-induced thrombocytopenia
¢ Incomplete neutralization of the heparin used during surgery to prevent thrombus formation in the bypass machine
° Decreased release and function of clotting factors associated with systemic hypothermia during surgery
e Anticoagulant therapy (relevant primarily for clients who have had valve replacement and are taking warfarin)
° Inadequate surgical hemostasis or disruption of suture lines associated with hypertension if it occurs

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unusual bruising or bleeding; Excessive amount of bloody drainage from chest tube;
dizziness continuous oozing of blood from incisions; prolonged
bleeding from puncture sites; gingival bleeding; petechiae
’

purpura, ecchymoses; epistaxis, hemoptysis; increase yp

abdominal girth; frank or occult blood in stool, urine, or
vomitus; menorrhagia; restlessness, confusion: significant
drop in B/P accompanied by an increased pulse rate;
decrease in Hct and Hgb levels
 Chapter 6 = The Client With Alterations in Cardiovascular Function 293

DESIRED OUTCOMES
a

The client will not experience unusual bleeding as evi- d. No increase in abdominal girth
denced by: e. Absence of frank and occult blood in stool, urine, and
a. Gradual decrease in amount of bloody drainage from vomitus
chest tube f. Usual menstrual flow
b. Skin and mucous membranes free of active bleeding, g. Usual mental status
petechiae, purpura, and ecchymoses h. Vital signs within normal range for client
c. Absence of unusual joint pain i. Stable or improved Hct and Hgb levels

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of unusual bleeding: Early recognition of signs and symptoms of unusual bleeding
e Excessive amounts of bleeding from chest tubes allows for prompt intervention.
e Decreased B/P
e Increased heart rate
Monitor platelet count and coagulation tests for abnormal
results or results that exceed the therapeutic range for
clients receiving anticoagulant therapy.

NOC OUTCOMES NIC INTERVENTIONS

Blood coagulation; blood loss severity Bleeding reduction; bleeding precautions; bleeding
reduction: wound

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent bleeding:
e When giving injections or performing venous and arterial In order to maintain systolic B/P at a level less than 140 mm Hg
punctures, use the smallest gauge needle possible and and subsequently decrease the risk for disruption of suture lines.
apply gentle, prolonged pressure to the site after the
needle is removed.
Educate client to avoid activities that increase the risk for Prevents injury and potential for increased bleeding.
trauma (e.g., shaving with a straight-edge razor, using stiff
bristle toothbrush or dental floss).
Pad side rails if client is confused or restless.
e Perform actions to reduce the risk for falls (e.g., keep bed
in low position with side rails up when client is in bed,
avoid unnecessary clutter in room, instruct client to wear
shoes/slippers with nonslip soles when ambulating).
e Instruct client to avoid blowing nose forcefully or
straining to have a bowel movement; consult physician
regarding order for a decongestant and/or laxative if
indicated.

Dependent/Collaborative Actions
Early detection of abnormal bleeding and allows for prompt
Test all stools, urine, and vomitus for occult blood if platelet
count and coagulation tests are abnormal. treatment regimen changes.
e If bleeding occurs and does not subside spontaneously:
° Apply firm, prolonged pressure to bleeding area(s) if
possible.
e Maintain oxygen therapy as ordered.
e Autotransfuse blood from the chest drainage device if
ordered.

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 294 Chapter 6 * The Client With Alterations in Cardiovascular Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Administer the following if ordered: Promotes blood clotting.
e Vitamin K or protamine sulfate Vitamin K counteracts the effect of warfarin therapy.
e Whole blood or packed RBCs Protamine sulfate further neutralizes the heparin used to prime the
e Blood products bypass machine.
e Prepare client for return to surgery. Decreases fear and anxiety.

Collaborative Diagnosis RISK FOR NEUROLOGICAL DYSFUNCTION

Definition: Decreased level of consciousness and client’s normal cognitive, sensory, and motor function.

Related to:
e Inadequate cerebral blood flow associated with:
e Decreased systemic arterial pressure while on CPB
e An embolus (can result from dislodgment of atherosclerotic plaque during cross-clamping of the aorta and cannulation
for bypass, dislodgment of debris from calcified valve, incomplete filtration of air by bypass machine, or cardiac thrombus
formation on prosthetic valve or as a result of dysrhythmias)
e Hypotension or low cardiac output postoperatively
e Cerebral edema initiated by a systemic inflammatory response to the CPB machine
e Possible poor cerebral protection during CPB from inadequate temperature regulation (hypothermia must be adequate to
help protect the central nervous system)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of visual disturbances; swallowing Slurred speech, expressive or receptive aphasia; decreased
difficulties; paresthesias level of consciousness, delirium, hallucinations, confusion;
impaired memory, lack of ability to concentrate, difficulty
problem-solving; weakness of extremity, facial droop,
ptosis, paralysis
Decline in client’s normal sensory and motor function

RISK FACTORS DESIRED OUTCOMES

e Thromboembolism
The client will maintain usual neurological functi
e Altered cerebral perfusion during bypass TE
evidenced by:
a. Absence of visual disturbances, swallowing difficulties,
and speech impairments
b. Mentally alert and oriented
. Usual memory and problem-solving abilities
. Normal sensory and motor function
aon

NURSING ASSESSMENT RATIONALE

nnn
ee
Assess for and report signs and symptoms of neurological Early recognition of signs and symptoms of neurological dysfunc-
dysfunction: tion allows prompt intervention.
e Slurred speech i
e Expressive/receptor dysphagia
e Decreased level of consciousness
e Weakness of extremity
e Facial droop
e Ptosis
¢ Swallowing difficulties
 Chapter 6 * The Client With Alterations in Cardiovascular Function 295

THERAPEUTIC INTERVENTIONS RATIONALE g ae gd e teres

fn ep - R aaa aa

Dependent/Collaborative Actions
Implement measures to promote adequate cerebral blood Improves blood flow to the central nervous system.
flow and reduce the risk for neurological dysfunction: To prevent dilation of the cerebral vessels associated with hypoxia
e Keep head of bed flat until B/P is stabilized at a satisfactory and hypercapnia.
level (at least 90 mm Hg systolic).
e Keep head and neck in neutral, midline position.
° Perform actions to maintain adequate cardiac output (e.g.,
administer positive inotropic medications as ordered).
e Perform actions to prevent thrombi and microemboli
formation in the heart.
e Perform actions to reduce the risk for increased ICP:
e Limit activities that can increase ICP (e.g., excessive
suctioning, instruct client to avoid excessive coughing
and straining to have a bowel movement).
e Implement measures to maintain adequate respiratory
function and gas exchange.
If signs and symptoms of neurological dysfunction occur:
e Maintain client on bed rest until physician evaluates
symptoms.
e Maintain oxygen therapy as ordered. Maintains tissue oxygenation.
e Administer anticoagulants if ordered. Decreases potential for thrombi.

Collaborative s----
Diagnosis |RISK FOR IMPAIRED RENAL FUNCTION

Definition: Renal insufficiency refers to a decline in renal function to about 25% of normal.

Related to: Deposit of hemolyzed RBC products in renal tubules or inadequate renal blood flow associated with CPB, low
cardiac output, hypotension, an embolus, or effect of vasopressor drugs (risk is increased if client is elderly or has
preexisting renal disease)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of confusion Urine output less than 30 mL/h; urine specific gravity fixed
at or less than 1.010; elevated BUN and serum creatinine
levels; decreased creatinine clearance

RISK FACTORS DESIRED OUTCOMES

e Decreased cardiac output The client will maintain adequate renal function as evi-
e Thromboembolism denced by:
a. Urine output at least 30 mL/h
b. BUN, serum creatinine, and creatinine clearance values
within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired renal Early recognition of signs and symptoms ofimpaired renal function
function: allows prompt intervention.
e Urine output > 30 mL/h
e Elevated BUN, creatinine values
Monitor serum creatinine levels for abnormalities.

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 296 Chapter6 = The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain adequate renal blood flow:
e Maintain a minimum fluid intake of 1000 mL/day unless Maintains adequate fluid volume.
ordered otherwise.
e Perform actions to maintain adequate cardiac output.
e Perform actions to prevent thrombi and microemboli To reduce the risk for occlusion of the renal artery by an embolus.
formation in the heart.
If signs and symptoms of impaired renal function occur: To increase urine output and subsequently reduce further accumu-
e Administer diuretics. lation of hemolyzed RBC products in the renal tubules.
e Consult physician about discontinuing any potentially Potentially improves renal functioning.
nephrotoxic medications.
e Assess for and report signs of acute renal failure (e.g., oli- Allows for prompt alteration in interventions.
guria or anuria; weight gain; edema; elevated B/P; lethargy
and confusion; increasing BUN and serum creatinine,
phosphorus, and potassium levels).
e Prepare client for dialysis if indicated. Decreases fear and anxiety.

|Collaborative Diagnosis
Diagnosis | RISK FOR PNEUMOTHORAX

Definition: Presence of air or gas in the pleural space caused by rupture of the visceral pleural or the parietal pleura and
chest wall.

Related to: The accumulation of air in the pleural space if the pleura was opened during surgery

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sudden pleural pain; verbalization of Tachypnea; dyspnea; absent or decreased breath sounds;
shortness of breath hyperresonance to percussion on affected side; chest
radiograph abnormalities; abnormal arterial blood gas
values

RISK FACTORS DESIRED OUTCOMES

e Surgical procedures within the chest cavity
The client will experience normal lung re-expansion as
e Invasive line placement in great vessels (e.g., subclavian)
evidenced by:
a. Audible breath sounds and a resonant percussion note
over lungs by third to fourth postoperative day
b. Unlabored respirations at 12 to 20 breaths/min
(me! . Arterial blood gas values returning toward normal

d. Chest radiograph showing lung reexpansion

NURSING ASSESSMENT RATIONALE

————— ee eeeSeSeSSSSeSSSSSSSSFSFSFSMSSsssee

Assess for and immediately report signs and symptoms of Early recognition of signs and symptomis of apneumothorax allows
pneumothorax: prompt intervention.
e Subjective
e Objective
Assess for malfunction of chest drainage system:
e Respiratory distress
e Excessive bubbling in water seal chamber
e Significant increase in subcutaneous emphysema
Monitor chest radiograph results.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 297

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Perform actions to maintain patency and integrity of chest
drainage system:
¢ Maintain fluid level in the water seal and suction cham- Measures help to promote lung reexpansion and prevent further
bers as ordered. lung collapse.
° Maintain occlusive dressing over chest tube insertion site. Maintains negative pressure.
° Tape all connections securely. To reduce the risk of inadvertent removal of the tube.
¢ Tape the tubing to the chest wall close to insertion site.
e Position tubing to promote optimum drainage (e.g., coil
excess tubing on bed rather than allowing it to hang down
below the collection device, keep tubing free of kinks).
¢ Drain any fluid that accumulates in tubing into the collection Dislodges clots.
chamber and milk tube gently if indicated to dislodge clots.
e Keep drainage collection device below level of client’s Prevents backflow and stasis of drainage.
chest at all times.
Perform actions to facilitate the escape of air from the pleural Promotes full lung expansion.
space (e.g., maintain suction as ordered, ensure that the air
vent is open on the drainage collection device if system is
to water seal only).
Perform actions to maintain adequate respiratory function: Promotes lung expansion and prevents stasis of secretions.
e Encourage use of incentive spirometer every 2 hrs.
e Increase activity as tolerated.
If signs and symptoms of further lung collapse occur:
e Maintain client on bed rest in a semi- to high-Fowler’s position. Improves ability for lung expansion.
e¢ Maintain oxygen therapy as ordered. Maintains tissue oxygenation.
e Assess for and immediately report signs and symptoms of Allows for prompt alterations in interventions.
tension pneumothorax (e.g., severe dyspnea, increased rest-
lessness and agitation, rapid and/or irregular pulse rate, hypo-
tension, neck vein distention, shift in trachea from midline).
e Assist with clearing of existing chest tube and/or insertion
of a new tube.

|Nursing eco)
Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY
HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MANAGEMENT npx*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes
a program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of
the family unit; Ineffective Health Management NDx: Inability to identify, manage, and/or seek out help to
maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inability to follow instructions

RISK FACTORS
e Denial of disease process
° Cognitive deficiency
e Failure to take action to reduce risk factors

teaching needs.
*The nurse should select the nursing diagnostic label that is most appropriate for the client’s discharge

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298 Chapter6 * The Client With Alterations in Cardiovascular Function

NOC OUTCOMES NIC INTERVENTIONS

ii eee eee

Knowledge: treatment regimen; cardiac disease manage- Health system guidance; teaching: individual; teaching:
ment; disease process disease process; teaching: prescribed diet; teaching:
prescribed medication; teaching: prescribed activity/exercise

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
client allows for implementation of the appropriate teaching
interventions.
Assess meaning of illness to client.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: In collaboration with the nurse, client

will identify modifiable cardiovascular risk factors and ways
to alter these factors.

Independent Actions
Inform client that certain modifiable factors such as elevated Thorough education is a critical component of the care of a
serum lipid levels, a sedentary lifestyle, hypertension, exces- client after open heart surgery. Continued lifestyle modifications
sive alcohol intake, and smoking have been shown to in- consistent with recommendations for clients with cardiovascular
crease the risk for CAD and certain forms of heart disease. disease are necessary to maintain patency of vessel grafts. The
client must have a thorough understanding of the importance of
adhering to diet, medication, activity/exercise, and nutritional
recommendations to prevent an exacerbation and control the
disease.
Assist clients to identify changes in lifestyle that can help
them to eliminate or reduce the above risk factors (e.g.,
dietary modification, physical exercise on a regular basis,
moderation of alcohol intake, smoking cessation).
Encourage client to limit daily alcohol consumption. Current Daily alcohol intake exceeding 1 oz of ethanol may contribute to the
recommendations are no more than two drinks per day for development of hypertension and some forms of heart disease.
men and no more than one drink per day for women and A “drink” is considered to be 2 oz of ethanol (e.g., 1% oz of
lighter-weight persons. 80-proof whiskey, 12 oz of beer, 5 oz of wine).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of the rationale for and components of a diet restricted in
sodium, saturated fat, and cholesterol.

Independent Actions
Explain the rationale for a diet restricting sodium, saturated Current daily dietary sodium intake is less than 2400 mg.
fat, and cholesterol intake. Excessive sodium intake causes water to be retained, resulting
in increased circulating fluid volume, increased cardiac
workload, and hypertension.
Provide the following information about decreasing sodium Understanding of disease limitations improves client adherence to
intake: treatment regimen.
‘
e Read labels on foods/fluids and calculate sodium content
of items; avoid those products that tend to have a high
sodium content (e.g., canned soups and vegetables,
tomato juice, commercial baked goods, commercially
prepared frozen or canned entrees and sauces).
¢ Do not add salt when cooking foods or to prepared foods;
use low-sodium herbs and spices if desired.
e Avoid cured and smoked foods.
 Chapter 6 « The Client With Alterations in Cardiovascular Function 299

THERAPEUTIC INTERVENTIONS RATIONALE

e Avoid salty snack foods (e.g., crackers, nuts, pretzels, potato
chips).
e Avoid commercially prepared fast foods.
e Avoid routine use of over-the-counter medications with a
high sodium content (e.g., Alka-Seltzer, some antacids).
Provide instructions on ways the client can reduce intake of The risk of CAD is associated with a serum cholesterol level of
saturated fat and cholesterol: more than 200 mg/dL or a fasting triglyceride level of more
e Reduce intake of meat fat (e.g., trim visible fat off meat; than 150 mg/dL. Elevated serum lipid levels are one of the most
replace fatty meats such as fatty cuts of steak, hamburger, firmly established risk factors for CAD.
and processed meats with leaner products).
e Reduce intake of milk fat (e.g., avoid dairy products
containing more than 1% fat).
° Reduce intake of trans fats (e.g., avoid stick margarine and
shortening and foods such as commercial baked goods
that are prepared with these products).
e Use vegetable oil rather than coconut or palm oil in cook-
ing and food preparation.
e Use cooking methods such as steaming, baking, broiling,
poaching, microwaving, and grilling rather than frying.
e Restrict intake of eggs. Recommendations about the number of whole eggs allowed per
week vary depending on the client’s lipid levels.
Obtain a dietary consult to assist client in planning meals
that will meet the prescribed restrictions of sodium, satu-
rated fat, and cholesterol.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of activity restrictions and the rate of activity progression.

Independent Actions
Reinforce physician’s instructions regarding activity. Instruct While the benefits of physical activity are an integral part of
client to: cardiac rehabilitation, the level of activity should be increased
e Gradually rebuild activity level by adhering to a planned gradually. Physical activity guidelines after acute coronary
exercise program (often begins with walking and light syndromes focus on frequency, intensity, type, and time of
household activities). activity.
e Take frequent rest periods for 4 to 6 weeks after surgery.
e Avoid lifting heavy objects in order to allow incision to
heal and prevent a sudden increase in cardiac workload.
e Avoid driving a car and riding a bicycle, motorcycle, lawn
mower, tractor, or a horse for 4 to 6 weeks; if minimally
invasive surgery was performed, these activities will prob-
ably be allowed much sooner.
e Check with physician or cardiac rehabilitation therapist be-
fore resuming sexual activity (usually permitted 3-4 weeks
after surgery once able to walk two blocks or climb two
flights of stairs without shortness of breath).
e Stop any activity that causes chest pain, shortness of breath,
palpitations, dizziness, or extreme fatigue or weakness.
e Participate in a cardiac rehabilitation program if recom-
mended by physician.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

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THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Explain the rationale for, side effects of, and importance of Taking medications as prescribed ensures that therapeutic drug
taking medications prescribed. Inform client of pertinent levels will be maintained. Clients should be instructed not
food and drug interactions. to discontinue taking medications if they feel better. Clients
e Warfarin (Coumadin) without financial resources should be assisted in accessing
appropriate resources to obtain needed medications (e.g.,
pharmacy assistance programs).
Instruct client to inform physician before taking other
prescription and nonprescription medications.
Instruct client to inform all health care providers of medica-
tions being taken.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms: Reporting concerning signs and symptoms to the appropriate
provider allows for modification of the treatment plan.
e Chest pain that seems unrelated to incisional discomfort May indicate a pulmonary embolism.
e Development of or increased shortness of breath May indicate decreased cardiac output.
e Dizziness, fainting
e Increased fatigue and weakness
e Weight gain of more than 2 lb in a day or 4 lb in a week May indicate decreased renal function.
e Swelling of feet or ankles
e Persistent cough, especially if productive of yellow, green, May indicate infection or pulmonary embolism.
rust-colored, or frothy sputum
e Significant change in pulse rate or rhythm (check with May indicate decreased cardiac output.
physician about client’s need to monitor pulse at home)
e Persistent low-grade fever or temperature above 101°F May indicate dehydration and/or infection.
(38.3°C) for more than 1 day
e Depression or problems with concentration or memory A common feature after bypass surgery, but it should be resolved by
that last more than 6 weeks 6 weeks.
e A fever in combination with chest pain and malaise occur- May be indicative of postpericardiotomy syndrome and require
ring 1 week to 1 month after surgery treatment with anti-inflammatory agents.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community

resources that can assist with cardiac rehabilitation and
adjustment to having had heart surgery.

Independent Actions
Provide information about community resources that can Cardiac disease can significantly impact an individual’s and
assist client with cardiac rehabilitation and adjustment family’s socioeconomic status. Providing information. specific
to having had heart surgery (e.g., American Heart Associa- to community resources is important to provide a Hecessary
tion, Mended Hearts Club, counseling services). continuum of care and may impact the client’s health status,
preventing future hospitalizations.

THERAPEUTIC INTERVENTIONS RATIONALE

—_———_——
SSS
DS

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, wound care, and pain management.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 301

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Collaborate with the client to develop a plan for adherence Regular health care appointments are important to determine
with the medial regimen that includes: effectiveness of the prescribed treatment plan.
Provide the client with routine postoperative instructions and
measures to improve adherence.
If valve replacement surgery was done, instruct the client to: Actions are important to prevent the development of endocarditis.
° Not have dental work for 6 months.
° Inform health care providers of valve surgery so prophy-
lactic antimicrobials may be started before any dental
work, invasive diagnostic procedures, or surgery.
e Perform good oral hygiene in order to reduce the risk for
infective endocarditis.

ADDITIONAL NURSING DIAGNOSES RELATED CARE PLANS

ACTIVITY INTOLERANCE NDx Standardized Preoperative Care Plan
Related to: Standardized Postoperative Care Plan
e Tissue hypoxia associated with decreased cardiac output,
impaired alveolar gas exchange, and anemia (results from
hemodilution, blood loss, and red cell hemolysis [red cells
are traumatized by the CPB machine])
e Difficulty resting and sleeping associated with frequent
assessments and treatments, discomfort, fear, and anxiety

HYPERTENSION
Or High blood pressure is categorized by the American College of 65 developed hypertension during their lifetimes (prevalence
Cardiology and the American Heart Association as normal, ele- based on earlier definitions of hypertension). Additional risk
vated, or stage 1 or stage 2 hypertension on the basis of average factors associated with the development of hypertension
BP measured in a healthcare setting. In adults, normal blood include family history, obesity, sedentary lifestyle, tobacco
pressure is classified as a systolic BP < 120 mm Hg and a diastolic use, heavy use of alcohol, stress, and certain chronic condi-
BP < 80 mm Hg. Elevated blood pressure in adults is defined as tions such as kidney disease, diabetes, and sleep apnea.
a systolic BP between 120 and 129 mm Hg and a diastolic BP The two major types of hypertension are primary (essen-
< 80 mm Hg. Hypertension is categorized into two stages with tial) hypertension and secondary hypertension. Primary
stage 1 hypertension defined as a systolic BP between 130 and hypertension, which constitutes approximately 95% of the
139 mm Hg or diastolic BP between 80 and 89 mm Hg. Stage cases, has an unknown etiology. Secondary hypertension
2 hypertension is defined as a systolic BP = 140 mm Hg or a tends to appear suddenly and has identifiable causes, which
diastolic = 90 mm Hg. Hypertensive crisis, defined as a systolic include renal parenchymal or vascular disease, Cushing syn-
BP > 180 mm Hg and/or a diastolic BP > 120 mm Hg, is a drome, certain neurological disorders, pheochromocytoma,
medical emergency and requires immediate medical attention. primary aldosteronism, coarctation of the aorta, and use of
Based on current definitions, approximately 46% of the US certain drugs (e.g., adrenal steroids, oral contraceptives, non-
general adult population (=20 years of age) have stage 1 or steroidal anti-inflammatories, cyclooxygenase-2 inhibitors,
stage 2 hypertension with the prevalence higher in males, sympathomimetics such as decongestants and anorexiants,
higher in African Americans than in whites, Asians, and amphetamines, cocaine).
Hispanic Americans, and rising dramatically with increasing The pathological hallmark of hypertension is an increase
age. In the landmark Framingham Heart Study, approxi- in systemic vascular resistance. In order to sustain adequate
mately 90% of adults free of hypertension at age 55 or at age tissue perfusion when vascular resistance is increased, the

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302 Chapter 6 = The Client With Alterations in Cardiovascular Function

heart must pump harder. A prolonged increase in cardiac

workload eventually leads to ventricular hypertrophy and OUTCOME/DISCHARGE CRITERIA
heart failure. The prolonged increase in vascular pressure
causes widespread pathological changes in the blood vessels. The client will:
The end result of all the changes in the cardiovascular system 1. Have B/P within a safe range
is a decreased blood supply to the tissues, with target organ 2. Have evidence of adequate tissue perfusion
damage occurring most often in the eyes, kidneys, brain, and 3. Have no signs and symptoms of complications
heart. This target organ damage is often what causes the 4. Verbalize a basic understanding of hypertension and its
initial symptoms in the person with hypertension. effects on the body
Initial treatment of hypertension may be nonpharmaco- 5. Identify modifiable risk factors for hypertension and
logic and consists of lifestyle modifications such as weight ways to alter these factors
reduction, regular aerobic exercise, and moderation of dietary 6. Verbalize an understanding of medications ordered includ-
sodium and alcohol intake. If these measures do not achieve ing rationale, food and drug interactions, side effects, sched-
the desired control of blood pressure, pharmacological ther- ule for taking, and importance of taking as prescribed
apy is initiated. Primary pharmacological agents used to treat 7. Verbalize an understanding of the rationale for and com-
hypertension include thiazide diuretics, ACE inhibitors, an- ponents of the recommended diet
giotensin II receptor blockers (ARBs), and CCBs. If the per- 8. State signs and symptoms to report to the health care provider
son’s blood pressure is inadequately controlled by the initial 9. Identify community resources that can assist in making life-
drug, a second drug from another class is added or another style changes necessary for effective control of hypertension
drug is substituted until the desired control of blood pressure 10. Develop a plan for adhering to recommended follow-
is achieved with a minimum of side effects. up care including future appointments with health care
This care plan focuses on the adult client hospital- provider
ized with severe hypertension that is either newly
diagnosed or uncontrolled.

| Nursing Diagnosis ‘INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox

Definition: Decrease in blood circulation to the periphery, which may compromise health.

Related to:
e Increased peripheral vascular resistance
e Atherogenic changes in the blood vessels associated with the effects of prolonged or excessive elevation of B/P
e Possible decrease in cardiac output associated with the increased cardiac workload and eventual myocardial hypertrophy that
result from elevated B/P
e Excessive lowering of B/P by antihypertensive medications

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain, numbness, or tingling in the Altered mental status, restlessness, confusion, cold extrem-
extremities at rest or while walking. ities, diminished pulses, pallor in extremities, absent bowel
sounds, abdominal pain, anemia, elevated BUN

RISK FACTORS DESIRED OUTCOMES

e Peripheral vascular disease
The client will maintain adequate tissue perfusion as evi-
e Atherosclerosis
denced by:
e Decreased hemoglobin
a. B/P declining toward normal range for client ¢
e Interruption of blood flow
b. Usual mental status
c. Extremities warm with absence of pallor and cyanosis
d. Palpable peripheral pulses
e. Capillary refill time less than 2 to 3 seconds
f. Absence of exercise-induced pain
g. Urine output at least 30 mL/h
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NOC OUTCOMES NIC INTERVENTIONS

_—SE SS nnn... ee ee ee ee

Circulation status; tissue perfusion Vital signs monitoring; hypertension management

NURSING ASSESSMENT RATIONALE

Assess for and report the following: Early recognition of signs and symptoms of ineffective tissue
° Further increase in B/P, failure of B/P to decline in response perfusion allows for prompt intervention.
to antihypertensive agents, or rapid or excessive decline
in B/P.
° Signs and symptoms of diminished tissue perfusion:
e Restlessness
e Confusion
° Cool extremities
e Pallor or cyanosis of extremities
e Diminished or absent peripheral pulses
e Low capillary refill
e Angina
e Increasing BUN and serum creatinine levels
° Oliguria
Assess and monitor B/P.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce anxiety (e.g., provide a calm, Identified independent nursing actions help to reduce sympathetic
restful environment). nervous system stimulation, which could increase B/P and
Implement measures to relieve headache (e.g., minimize heart rate.
environmental stimulation).
Implement measures to promote rest: D @ +
e Maintain a calm environment.
e Limit the number of visitors.
e Maintain activity restrictions.
Discourage excessive intake of beverages high in caffeine such Caffeine has a vasoconstrictive effect.
as coffee, tea, and colas. D Vasoconstriction reduces the size/diameter of arterial vessel walls,
increasing systemic vascular resistance or afterload. As a result
of an increase in afterload, B/P must be increased to maintain
adequate tissue perfusion.
Discourage smoking. Nicotine causes vasoconstriction, which elevates B/P by increasing
afterload/systemic vascular resistance.
Maintain dietary sodium restrictions as ordered. D> Restricting sodium intake helps to reduce fluid retention, which can
increase preload and B/P.
Dependent/Collaborative Actions
Administer the following medications if ordered: D > Medications are administered to reduce B/P in order to improve
e Adrenergic inhibiting agents tissue perfusion.
e Centrally acting adrenergic inhibitors Persistent, untreated hypertension leads to myocardial hypertrophy
e Alpha-adrenergic blockers and possibly heart failure.
e Peripheral adrenergic inhibitors
e Beta-adrenergic blockers
¢ Combined alpha-adrenergic and beta-adrenergic blockers
° Vasodilators for immediate reduction in B/P
e ACE inhibitors
e Calcium-channel blocking agents
e Angiotensin II receptor antagonists
e Diuretics
Consult physician:
e Before administering antihypertensive medications if A rapid drop in B/P of more than 20% to 25% in a person with
client has an excessive or rapid drop in B/P severe hypertension can reduce perfusion to vital organs.
e If signs and symptoms of diminished tissue perfusion Notification of the appropriate health care provider allows for
persist or worsen. modification of the treatment plan.

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304 Chapter 6 = The Client With Alterations in Cardiovascular Function

|Nursing =o)
Diagnosis |ACUTE PAIN nox (HEADACHE)
in
Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described
such terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity
from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Related to: Distention of the cerebral blood vessels associated with increased vascular pressure

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain such as “pressure, Mu
squeezing Increased B/P; increased heart rate
tightness” in the skull, face, or both

RISK FACTORS DESIRED OUTCOMES

e Increased B/P The client will obtain relief of headache as evidenced by:
e Increased cerebral blood flow
a. Verbalization of same
b. Relaxed facial expression and body positioning
c. Increased participation in activities

NOC OUTCOMES NIC INTERVENTIONS

Comfort level; pain control Pain management; environmental management: comfort;

analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of headache: Early recognition of signs and symptoms of acute headache pain
e Statements of same allows for prompt intervention.
e Restlessness
e Irritability
e Grimacing
e Rubbing head
e Avoidance of bright lights and noises
e Reluctance to move
Assess client’s perception of the severity of the headache
using a pain intensity rating scale.
Assess the client’s pain pattern (e.g., location, quality,
onset, duration, precipitating factors, aggravating factors,
alleviating factors).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to reduce fear and anxiety about the pain Fear and anxiety can stimulate the sympathetic nervous system,
experience. causing an increase in B/P and heart rate.
Decreasing fear and anxiety helps to promote relaxation and
increase the client’s threshold and tolerance for pain.
Provide a quiet environment. D @ Patients with migraine-type headaches can benefit from a Yimly lit
Avoid jarring bed or startling client to minimize risk of environment.
sudden movements. D @ +
Provide or assist with nonpharmacological measures for
headache relief: D +
e Cool cloth to forehead
e Back and neck massage
e Elevation of head
e Relaxation exercises
e Diversional activities
 Chapter 6 * The Client With Alterations in Cardiovascular Function 305

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Perform actions to reduce B/P: Elevated B/P, if extreme, can cause headaches in some individuals.
e Administer ordered antihypertensive medications. D +
Administer analgesics as ordered and before headache be-
comes severe. D
Consult appropriate health care provider (e.g., pharmacist, Notification of the appropriate health care provider allows for
physician) if above measures fail to relieve headache. modification of the treatment plan.

Se ee) RISK FOR CEREBROVASCULAR ACCIDENT/

HYPERTENSIVE ENCEPHALOPATHY
Definition: Death of brain cells due to ischemia (lack of blood flow) to a part of the brain, or hemorrhage into the brain.
Related to:
Cerebrovascular accident related to cerebral thrombosis, embolism, or hemorrhage associated with injury to the arterial
walls resulting from atherosclerosis and/or a prolonged increase in pressure in the cerebral vessels

Hypertensive encephalopathy related to cerebral edema associated with hyperperfusion of the brain (excessive cerebral blood
flow results from decompensation of the cerebral blood flow autoregulatory mechanism in response to markedly elevated B/P)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty swallowing Speech difficulty, impaired mobility, decreased level of
consciousness, facial droop, ptosis

RISK FACTORS DESIRED OUTCOMES

e Hypertension
The client will not experience a cerebrovascular accident
e Cerebrovascular disease
or hypertensive encephalopathy as evidenced by:
e Smoking
a. Absence of dizziness, syncope, visual disturbances, and
¢ Obesity
speech impairments
¢ Metabolic syndrome
b. Absence or resolution of headache
c. Absence of vomiting
d. Mentally alert and oriented
e. Pupils equal and normally reactive to light
f. Normal sensory and motor function

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of cerebrovascular accident/ Early recognition of signs and symptoms of cerebrovascular
hypertensive encephalopathy: accident and/or hypertensive encephalopathy allows for prompt
e Dizziness, syncope intervention.
e Visual disturbances (e.g., diplopia, blurred vision, loss of
vision)
e Slurred speech, aphasia
e Persistent or increasing headache
e Vomiting
e Decreased level of consciousness
e Unequal pupils or a sluggish or absent pupillary reaction
to light
e Paresthesias, facial droop, ptosis, weakness of extremity,
paralysis
e Seizures

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Perform actions to reduce B/P: Collectively, all collaborative actions help to reduce the risk of a
e Administer medications as ordered. D + cerebrovascular accident and hypertensive encephalopathy.
Instruct client to avoid activities that create a Valsalva Actions help to prevent a sudden increase in ICP and dislodgment
response (e.g., straining to have a bowel movement, of an existing thrombus.
holding breath while moving up in bed).
Keep head of bed elevated at least 30 degrees and encourage Actions help to promote adequate venous return from the cerebral
client to keep head and neck in neutral, midline position. vessels.
pDe+
If signs and symptoms of a cerebrovascular accident or hyper-
tensive encephalopathy occur:
e Administer antihypertensive agents if ordered: Provides for rapid B/P reduction.
e Vasodilators Medications help to reduce ICP.
e Maintain client on bed rest.
e Initiate appropriate safety measures (e.g., side rails up,
seizure precautions).
e Administer osmotic diuretics and corticosteroids if ordered.

|Collaborative ~
Diagnosis |RISK FOR IMPAIRED RENAL FUNCTION
Definition: Renal insufficiency refers to a decline in renal function to about 25% of normal.

Related to: Vascular changes in the kidneys associated with effects of prolonged or severe hypertension

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Oliguria; fluid and electrolyte imbalances; weight gain;
elevated B/P; crackles/rales

RISK FACTORS DESIRED OUTCOMES

e MI
The client will maintain adequate renal function as
e Hypertension
evidenced by:
e Arteriosclerosis
a. Urine output at least 30 mL/h
b. Absence of proteinuria
c. BUN, serum creatinine, and creatinine clearance values
within normal range

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired renal function: Early recognition of signs and symptoms of impaired renal function
e Nocturia allows for prompt intervention.
e Urine output less than 30 mL/h
e Urine specific gravity fixed at or less than 1.010
e Proteinuria
Assess BUN/serum creatinine levels for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Perform actions to reduce B/P: Collaborative actions help to improve renal blood flow.
e Administer antihypertensive agents.
e Maintain an adequate fluid intake to reduce risk of dehy-
dration.
e Encourage oral fluid intake.
e Administer intravenous fluids as ordered.
 Chapter 6 = The Client With Alterations in Cardiovascular Function 307

THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of impaired renal function occur:
e Consult physician about lowering the dose of or discon- ACE inhibitors should be used cautiously in persons with impaired
tinuing ACE inhibitors if BUN and serum creatinine levels renal function because they can have an adverse effect on renal
continue to rise significantly. function.
e Prepare client for dialysis if indicated. Decreases fear and anxiety.

Collaborative ooo
Diagnosis. RISK FOR AORTIC DISSECTION |
Definition: A tear in the wall of the aorta that allows blood to flow between the layers of the wall of the aorta, forcing the
layers apart.
Related to: Weakening and degeneration of the aortic media associated with a severe or prolonged increase in pressure in the
aorta

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of tearing, stabbing, or shearing-type Widening of the mediastinum; hemodynamic instability;
pain that is severe with sudden onset lack of peripheral pulses

RISK FACTOR DESIRED OUTCOMES

e Hypertension
The client will not experience dissection of the aorta as
evidenced by:
a. Absence of sudden, severe chest pain
b. Palpable peripheral pulses with no change in pulse
pattern
. Usual sensory and motor function
. Usual mental status
. Stable vital signs
. Skin warm and usual color
moan

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of aortic dissection: Early recognition of signs and symptoms of aortic dissection allows
e Sudden, severe chest pain that may radiate to back for prompt intervention.
e Abnormal pulse pattern in extremities
e Sudden lack of pulse in an extremity
Assess for signs and symptoms of hypovolemic shock:
e Restlessness
e Agitation
e Significant decrease in B/P
e Rapid, weak pulse
e Cool skin
e Pallor
¢ Diminished or absent pulses

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Perform actions to reduce B/P: Actions help to prevent aortic dissection.
e Administer antihypertensives.
e Alleviate pain.
e Alleviate anxiety.

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THERAPEUTIC INTERVENTIONS RATIONALE

Instruct client to avoid activities that create a Valsalva re- Increases intrathoracic pressure.
sponse (e.g., straining to have a bowel movement, holding
breath while moving up in bed).
If signs and symptoms of aortic dissection occur:
e Maintain client on strict bed rest. Helps to maintain B/P.
e Monitor vital signs frequently.
e Administer oxygen as ordered. Maintains tissue oxygenation.
e Prepare client for diagnostic studies (e.g., transesophageal Decreases fear and anxiety.
echocardiogram, computed tomography) if planned.
e Administer antihypertensive agents. Decreases B/P.
e Prepare client for surgery if planned. Decreases fear and anxiety.

|Nursing Diagnosis
Diagnosis INEFFECTIVE FAMILY HEALTH MANAGEMENT npx
Definition: A pattern of regulating and integrating into family processes a program for the treatment of illness and its
sequelae that is unsatisfactory for meeting specific health goals of the family unit.

Related to:
e Lack of understanding of the implications of not following the prescribed treatment plan
e Difficulty modifying personal habits (e.g., alcohol intake, dietary preferences)
e Undesirable side effects of some antihypertensive agents
e Insufficient financial resources

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty with regulating one or more Acceleration of illness symptoms; choice of daily living
prescribed regimens for treatment and illness; not taking ineffective for meeting goals of a treatment program
action to include treatment regimen in daily routines

RISK FACTORS DESIRED OUTCOMES

e Complex therapeutic regimen
% The client will demonstrate the probability of effective
e Excessive demands ‘
management of the therapeutic regimen as evidenced by:
a. Willingness to learn about and participate in treat-
ments and care
b. Statements reflecting ways to modify personal habits
c. Statements reflecting an understanding of the implica-
tions of not following the prescribed treatment plan

NOC OUTCOMES NIC INTERVENTIONS

Compliance behavior; treatment behavior: illness or Self-modification assistance; medication management;

injury; knowledge: treatment regimen; health beliefs: values clarification; exercise promotion; smoking cessation
perceived resources; knowledge: cardiac disease manage- assistance; teaching: prescribed diet; weight reduction
ment; health beliefs: perceived ability to perform assistance; financial resource assistance
'
NURSING ASSESSMENT RATIONALE
Ee
Assess for indications that the client may be unable to effec- Identification of indications of the inability to effectively manage
tively manage the therapeutic regimen: a therapeutic regimen allows for implementation of the appro-
e Statements reflecting inability to manage care at home priate support/interventions.
e Failure to adhere to treatment plan (e.g., not adhering to
dietary modifications, refusing medications)
e Statements reflecting a lack of understanding of factors
that may cause progression of hypertension
e Statements reflecting an unwillingness or inability to
modify personal habits
 Chapter6 = The Client With Alterations in Cardiovascular Function 309

NURSING ASSESSMENT RATIONALE

e Statements reflecting view that hypertension will reverse
itself or that the situation is hopeless and efforts to comply
with the therapeutic regimen are useless
e Statements reflecting that the side effects of medications
are too uncomfortable and that the client feels better
when not taking medication
e Statements reflecting that medications are too expensive

THERAPEUTIC INTERVENTIONS RATIONALE

Ss

Independent Actions
Implement measures to promote effective management of the To promote effective management of a therapeutic regimen, the
therapeutic regimen: nurse must ensure that the client understands expectations. In
e Explain hypertension in terms the client can understand; addition, the nurse must ensure that the client has the appropri-
stress that hypertension is a chronic condition and that ate resources to adhere to the treatment plan (e.g., financial,
adherence to the treatment plan is necessary in order to social support).
delay and/or prevent complications.
e Encourage questions and clarify misconceptions client has
about hypertension and its effects, and the side effects of
medications.
e Provide instructions on and encourage client to participate
in the treatment plan (e.g., calculating sodium intake,
monitoring B/P); determine areas of misunderstanding
and reinforce teaching as necessary.
e Provide client with written instructions about dietary
modifications, signs and symptoms to report, medication
therapy, B/P monitoring, and exercise regimen.
e Assist client to identify ways medication regimen, exercise,
and dietary modifications can be incorporated into life-
style; focus on modifications of lifestyle rather than com-
plete change.
e Assist client to identify a reward system for self that will
assist him/her to effect necessary change(s).
e Initiate and reinforce discharge teaching.
e Provide information about and encourage utilization of
community resources that can assist client to make neces-
sary lifestyle changes (e.g., cardiovascular fitness, weight
loss, and smoking cessation programs; stress management
classes).
e Encourage client to discuss concerns about the cost of
medications and visits with health care provider; obtain a
social service consult to assist with financial planning and
to obtain financial aid if indicated.
e Encourage client to attend follow-up educational classes
e Reinforce behaviors suggesting future compliance with the
therapeutic regimen (e.g., statements reflecting plan for
adhering to treatment plan, statements reflecting an un-
derstanding of hypertension and its long-term effects).
e Include significant others in explanations and teaching
sessions and encourage their support; reinforce the need
for client to assume responsibility for managing as much
of care as possible.

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., social worker, Consulting the appropriate health care provider allows for
physician) regarding referrals to community health modification of discharge teaching/continued care.
agencies if continued instruction or support is needed.

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310 Chapter 6 * The Client With Alterations in Cardiovascular Function

7 DEFICIENT KNOWLEDGE nox OR INEFFECTIVE HEALTH

MAINTENANCE nox*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain
well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inability to accurately follow instructions

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; cardiac disease management Health system guidance; teaching: individual; teaching:
prescribed diet; teaching: prescribed medication

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
client allows for implementation of the appropriate teaching
interventions.
Assess meaning of illness to client.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize a basic under-

standing of hypertension and its effects on the body.

Independent Actions
Explain hypertension and its effects in terms client can un- Educating clients in terms they understand regarding their
derstand. Use available teaching aids (e.g., pamphlets, underlying disease process can facilitate understanding as to the
videotapes). importance of adhering to a treatment plan.
Inform client that hypertension is often asymptomatic and
that absence of symptoms is not a reliable indication that
B/P is within a safe range.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify modifiable risk

factors for hypertension and ways to alter these factors.

Independent Actions
Inform client that certain modifiable factors such as elevated Thorough education is a critical component of the care of a client
serum lipid levels, excessive alcohol intake, a sedentary with hypertension. The client must have a thorough under-
lifestyle, smoking, and excess body weight have been standing of the importance of adhering to diet, medication,
shown to increase the risk for cardiovascular disease and activity/exercise, and nutritional recommendations tot prevent
hypertension. an exacerbation and control the disease.
Assist client to identify changes in lifestyle that can help the
client to manage hypertension (e.g., dietary modification,
physical exercise on a regular basis, smoking cessation,
moderation of alcohol intake, weight loss if overweight).
Encourage client to limit daily alcohol consumption (daily Current recommendations are no more than two drinks per day for
alcohol intake exceeding 1 oz of ethanol may contribute men and no more than one drink per day for women and lighter-
to the development of hypertension). weight persons. A “drink” is considered to be % oz of ethanol
(e.g., 1% 0z of80-proof whiskey, 12 0z of beer, 5 oz of wine).

*The nurse should select the nursing diagnostic label that is most appropriate for the client’s discharge teaching needs.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 311

THERAPEUTIC INTERVENTIONS RATIONALE

Instruct client to participate in a regular aerobic exercise Decreases weight and improves cardiovascular stamina.
program (e.g., walking, swimming) and avoid isometric
exercise (e.g., weight training). Caution client to consult
physician before beginning an exercise program.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, and importance of Taking medications as prescribed ensures that therapeutic drug
taking medications prescribed. Inform client of pertinent levels will be maintained.
food and drug interactions. Clients should be instructed not to discontinue taking medications
Diuretics if they feel better. Clients without financial resources should be
Beta-adrenergic blockers assisted in accessing appropriate resources to obtain needed
ACE inhibitors medications (e.g., pharmacy assistance programs).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an under-

standing of the rationale for and components of the recom-
mended diet.

Independent Actions
Explain the rationale for the recommended dietary modifica- Reducing sodium intake to a recommended 2.4 g/day can help
tions: control hypertension by reducing the fluid retention associated
e Reduced sodium intake with increased intake.
e Reduced intake of saturated fat and cholesterol
° Include the recommended daily allowances of potassium,
calcium, and magnesium in diet.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symptoms

to report to the health care provider.

Independent Actions
Instruct the client to report: Reporting signs and symptoms indicative of hypertension to the
e Persistent headache or headache present upon awakening appropriate provider allows for modification of the treatment
¢ Sudden and continued increase in B/P (if B/P is monitored plan and may prevent complications.
at home)
Chest pain
Shortness of breath
° Significant weight gain or swelling of feet or ankles
Changes in vision
Frequent or uncontrollable nosebleeds
° Persistent dizziness, lightheadedness, or fainting
° Persistent side effects experienced from use of antihyperten-
sive medications (e.g., impotence; dry mouth; depression;
persistent dry cough; swelling of the tongue, face, or neck)
e Side effects of diuretic therapy

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312 Chapter6 = The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community

resources that can assist in making lifestyle changes necessary
for effective control of hypertension.

Independent Actions
Provide information regarding community resources and sup- Hypertension can significantly impact an individual’s and family’s
port groups that can assist client in making lifestyle changes socioeconomic status. Providing information specific to com-
that are necessary for effective control of hypertension (e.g., munity resources is important to provide a necessary continuum
cardiovascular fitness, weight loss, and smoking cessation of care and may impact the client’s health status, preventing
programs; stress management classes). future hospitalizations.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider.

Independent Actions
Reinforce the importance of keeping follow-up appointments Regular health care appointments are important to determine
with health care provider and continuing lifelong medical effectiveness of the prescribed treatment plan.
supervision.

RELATED NURSING DIAGNOSES

FEAR/ANXIETY NDX
e Unfamiliar environment
Related to: e Persistent or severe headache
e Necessity for urgent treatment e Lack of understanding of diagnostic tests, diagnosis, and
e Possibility of severe disability or sudden death treatment plan

IMPLANTABLE CARDIAC DEVICES

Implantable cardiac devices are surgically implanted for use and on some occasions, for treatment of tachydysrhythmias
in rhythm control. Pacemakers and ICDs are small battery- that have been unresponsive to other forms of therapy.
powered devices that monitor the heart rate and deliver Pacemakers are either temporary or permanent. Tempo-
electrical impulses to the heart to help correct dysrhythmias. rary pacemakers are used to regulate the heart rate in emer-
Both pacemakers and [CDs consist of a pulse generator gency or short-term situations. In most instances, temporary
(contains the battery and electronic circuitry) and electrode pacing is done using external transcutaneous pacing elec-
catheters (leads). Both devices can be implanted during a trodes or using temporary pacemaker electrodes that have
minor surgical procedure under local anesthesia. The leads been placed on the epicardium during thoracic surgery (e.g.,
are inserted into the heart transvenously via the subclavian, heart surgery). Temporary pacemakers are attached to and
jugular, or cephalic vein. The leads are then tunneled under regulated by an external power source. Permanent pacemakers
the skin and attached to the pulse generator that is implanted are used for long-term management of certain dysrhythmias.
in a subcutaneous pocket created in the subclavicular area or, There are a number of permanent pacemakers available. Their
less commonly, in the abdomen. A combined pacemaker and functional capabilities are described by a three- or five-letter
cardioverter-defibrillator is also available. code that specifies the chamber being paced, the chamber be-
A pacemaker is used to stimulate the heart electrically ing sensed, mode of response, programmability/rate respon-
when the heart fails to initiate or conduct intrinsic electrical siveness, and antitachycardia functions.
impulses at a rate that is sufficient to maintain adequate Most pacemakers used now are dual-chambered pacemak-
perfusion. Pacemaker insertion is indicated for treatment ers with leads in both the atrium and ventricle. Dual-chamber
of symptomatic bradydysrhythmias (e.g., sinus bradycardia, pacing allows for the physiological timing between atrial
second- and third-degree heart block, sick sinus syndrome) systole and ventricular systole to be maintained, which
 Chapter 6 The Client With Alterations in Cardiovascular Function 313

improves cardiac output. Present-day pacemakers can also be

programmed externally, and most operate in a synchronous OUTCOME/DISCHARGE CRITERIA
mode (a chamber of the heart is triggered to fire or is inhib-
ited by the intrinsic activity of the heart) or a rate-responsive The client will:
mode. The most frequently used rate-responsive systems I. Have adequate cardiac output
have an activity sensor in the pulse generator that detects Dy Have no signs and symptoms of postoperative complica-
movement and then appropriately increases or decreases the tions
pacing rate. . Verbalize a basic understanding of the rationale for and
ICDs are used to treat life-threatening dysrhythmias. They function of an ICD/pacemaker
are indicated for persons who have survived one or more . Demonstrate knowledge of how to monitor ICD function
incidents of sudden cardiac death, persons with recurrent . Verbalize an understanding of appropriate actions to take
ventricular tachycardia or ventricular fibrillation, and for if the ICD delivers a shock
persons with demonstrated risk factors for sudden cardiac . Verbalize an understanding of recommended activity
death. The sensing lead of an ICD monitors the heart's restrictions
electrical activity and if the heart rate exceeds the generator’s . Identify appropriate safety precautions associated with
programmed rate, the generator delivers a burst of antitachy- having an ICD/pacemaker
cardia pacing (ATP) to override the heart’s pacemaker. If after . State signs and symptoms to report to the health care
a programmed number of ATP therapies the rate continues provider
to exceed the desired rate, the ICD device then delivers low- . Develop a plan for adhering to recommended follow-up
energy and high-energy cardioversion shocks. If ventricular care including future appointments with health care
fibrillation is present, defibrillation shocks are delivered. provider, medications prescribed, and wound care
This care plan focuses on the adult client with a
symptomatic dysrhythmia hospitalized for implanta-
tion of either a cardioverter-defibrillator or perma-
nent pacemaker.

Nursing/Collaborative Diagnosis PREOPERATIVE USE IN CONJUNCTION WITH

THE STANDARDIZED PREOPERATIVE CARE PLAN

|Nursing ~~
Diagnosis RISK FOR DECREASED CARDIAC OUTPUT nox
Definition: Susceptible to inadequate blood pumped by the heart to meet metabolic demands of the body, which may
compromise health.

Related to:
e A slow heart rate (if client has a bradydysrhythmia)
e Decreased diastolic filling time associated with a rapid and/or irregular heart rate (if client has a tachydysrhythmia)
e Decreased diastolic filling time and ineffective ventricular contractions if client has sustained ventricular tachycardia
or ventricular fibrillation
« Related factors will depend upon the type of device implanted and underlying dysrhythmias

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of anxiety; fatigue; weakness; dizziness; Change in mental status; B/P less than 90 mm Hg systolic
syncope; exertional dyspnea or below normal for patient; irregular or absent pulses;
diminished peripheral pulses; tachypnea; cool, pale skin;
cool extremities; increased capillary refill time

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 314 Chapter 6 * The Client With Alterations in Cardiovascular Function

RISK FACTOR DESIRED OUTCOMES

e Cardiac dysrhythmias The client will maintain an adequate cardiac output as
evidenced by:
a. Systolic B/P of at least 90 mm Hg
b. Palpable peripheral pulses
c. No increase in number or duration of dizziness or
syncopal episodes
d. Baseline mental status
e. Absence of cyanosis
f. Urine output at least 30 mL/h

NOC OUTCOMES NIC INTERVENTIONS

Circulation status; cardiac pump effectiveness Cardiac care; cardiac risk management; dysrhythmia
management; tissue perfusion: cardiac

NURSING ASSESSMENT RATIONALE

Assess client upon admission for baseline data regarding

status of cardiac output.
Assess for and report signs and symptoms of decreased cardiac Early recognition and reporting of signs and symptoms of decreased
output: cardiac output allow for prompt intervention.
Change in mental status
B/P less than 90 mm Hg systolic or below normal for
patient
Irregular or absent pulses
Diminished peripheral pulses
Tachypnea
Cool, pale skin
Cool extremities
Increased capillary refill time
Verbal reports of anxiety, fatigue, weakness, dizziness,
syncope, exertional dyspnea
Assess for and report ECG rhythm abnormalities that may
alter cardiac output:
e Bradydysrhythmias
Tachydysrhythmias
e Ventricular tachycardia/fibrillation

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain an adequate cardiac output
before surgery:
e Perform actions to reduce cardiac workload:
e Place client in a semi- to high-Fowler’s position unless
systolic B/P is less than 90 mm Hg (then head of bed
should be flat).
e Implement measures to promote rest (e.g., reduce fear
and anxiety, maintain activity restrictions, limit the ‘
number of visitors).
e Discourage smoking. Nicotine has a cardiostimulatory effect and causes vasoconstric-
tion; the carbon monoxide in smoke reduces oxygen availability.
e Instruct client to avoid activities that create a Valsalva Valsalva maneuvers can increase vagal stimulation, resulting in
response (e.g., straining to have a bowel movement, slowing of the heart rate. In addition, Valsalva maneuvers can
holding breath while moving up in bed). also lead to a sudden increase in cardiac workload.
e Notify physician if serum potassium level is abnormal. Abnormal potassium levels affect myocardial conductivity.
 Chapter 6 « The Client With Alterations in Cardiovascular Function 315

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain an adequate cardiac output
before surgery:
e Perform actions to reduce cardiac workload:
¢ Maintain oxygen therapy as ordered.
e Administer the following medications if ordered: Anticholinergic drugs increase the heart rate by blocking the action
e Antidysrhythmics of the vagal nerve in patients with symptomatic bradycardia.
e Anticholinergics
e Consult physician before giving prescribed digitalis prepara- Digitalis preparations can increase ventricular irritability.
tions if client has heart block or ventricular dysrhythmias. Prevents further compromise of cardiac output by decreasing
heart rate.
e Prepare for and assist with cardioversion or defibrillation if Decreases fear and anxiety.
performed.
e Maintain temporary pacing if ordered. Maintains cardiac output.

NURSING/COLLABORATIVE DIAGNOSIS: POSTOPERATIVE

USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN

Collaborative --.
Diagnoses |RISK FOR PACEMAKER/IMPLANTABLE CARDIOVERTER-
DEFIBRILLATOR MALFUNCTION
Definition: Failure of the implanted device to maintain cardiac output.

Related to: Improper placement or dislodgment of the leads, break in or faulty attachment of the leads, or pulse generator
malfunction

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of receiving multiple shocks without ECG showing rapid and/or irregular rate without accompa-
ECG evidence of tachydysrhythmia; dizziness; nying ATP; presence of sustained ventricular tachycardia
lightheadedness or fibrillation on ECG; absence of pacer spikes when heart
rate falls below the programmed pacing rate; pacer spikes
present with normal P waves and QRS complexes; absence
of P wave or QRS complex after a pacer spike; presence of
ectopic beats; apical pulse less than programmed pacing
rate; significant decrease in B/P; syncope; dyspnea

DESIRED OUTCOMES
a

The client will experience normal cardioverter-defibrillator b. Stable B/P

function as evidenced by: c. Absence of dizziness, syncope, and dyspnea
a. Absence of sustained ventricular dysrhythmias on ECG d. ECG showing pacer spikes before the P wave and/or QRS
b. Client reports of receiving internal shocks when ven- complex when the pulse rate falls below the programmed
tricular tachycardia or fibrillation is evident on the ECG pacing rate
The client will experience normal pacemaker function as
evidenced by:
a. Regular pulse at a rate equal to or greater than the
programmed pacing rate

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 316 Chapter 6 * The Client With Alterations in Cardiovascular Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardioverter- Early recognition and reporting of signs and symptoms of device
defibrillator/pacemaker malfunction: malfunction allow for prompt intervention.
¢ Multiple shocks without ECG evidence of tachydysrhyth-
mia; dizziness; lightheadedness; significant decrease in BP;
syncope; dyspnea
e ECG with regular/irregular pulse rate without pacing spikes
e Symptoms will depend upon type of implantable device.
Ascertain the type of ICD/pacemaker the client has and how
it is programmed (including the rate at which pacing
should occur if a combination pacemaker cardioverter-
defibrillator was implanted).
Have information available about problem-solving techniques
and activation and deactivation of the specific device.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for breakage and Limiting movements during the first 48 hrs after surgery allows for
dislodgment of the ICD leads in order to prevent ICD leads to embed in the myocardium.
malfunction:
e Maintain activity restrictions as ordered.
e Instruct client to limit movement of the arm and shoulder
on the side that the ICD was inserted for the first 48 hrs
after surgery.
If signs and symptoms of pacemaker malfunction occur:
e Turn the client to either side. In the event of a pacemaker malfunction, such as failure to
capture, turning the client to the left side may help facilitate
placement of the lead(s) against the myocardium.

Dependent/Collaborative Actions
If signs and symptoms of ICD malfunction occur: Allows for prompt intervention and prevention of a deleterious
e If the device is activated and ventricular fibrillation or outcome.
pulseless ventricular tachycardia occurs:
¢ Notify the physician.
e Proceed with external defibrillation (the defibrillation
paddles should be positioned at least 3-4 inches away
from the pulse generator).
e Administer antidysrhythmics.
e If the device is activated and delivering inappropriate The physician or other trained personnel may need to deactivate
shocks: the device.
e Notify the physician.
If signs and symptoms of pacemaker malfunction occur:
e Follow manufacturer’s suggestions for problem solving:
e Have a pacemaker magnet available.
e If client has a temporary pacemaker, adjust sensitivity Increasing the sensitivity or output (mA) may help improve pacer
and/or output (milliamperes [mA]) within prescribed capture of the myocardial wall, producing ventricular or atrial
limits until capture occurs. contraction.
e Prepare client for chest radiograph to check placement of Decreases fear and anxiety.
leads.
e Prepare client for surgical repair or replacement of pulse
generator if indicated.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 317

Collaborative 2
Diagnoses|RISK FOR CARDIAC TAMPONADE |
Definition: Rapid collection of blood in the pericardial sac that compresses the myocardium, preventing the heart from
pumping effectively.

Related to: Perforation of the atria or ventricle by the pacemaker leads

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pericardial pain; sense of fullness in Pericardial friction rub; significant decrease in B/P;
chest narrowed pulse pressure; pulsus paradoxus; distant or
muffled heart sounds; JVD

RISK FACTOR DESIRED OUTCOMES

e Lead malposition
The client will not experience cardiac tamponade as evi-
denced by:
a. Stable vital signs
b. Audible heart sounds
c. Absence of JVD

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac perfora- Early recognition and reporting of signs and symptoms of cardiac
tion/cardiac tamponade: tamponade allow for prompt intervention.
e Decrease in B/P
e Pulsus paradoxus
e Narrow pulse pressure
e Muffled heart sounds
Assess chest radiograph results/echocardiogram results for
abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent dislodgment of the pacemaker/ Actions reduce the risk for perforation of the heart wall.
ICD leads:
e Maintain activity restrictions as ordered.
e Instruct client to limit movement of the arm and shoulder
on the side that the ICD was inserted for the first 48 hrs
after surgery.

Dependent/Collaborative Actions
If signs and symptoms of cardiac perforation or tamponade
occur:
e Prepare client for chest radiograph and echocardiogram.
e Prepare client for repositioning or replacement of the lead(s),
repair of perforation, and/or pericardiocentesis if planned.

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318 Chapter 6 * The Client With Alterations in Cardiovascular Function

Collaborative =
Diagnoses RISK FOR PNEUMOTHORAX
Definition: Air in the pleural space with resulting collapse of the lung.

Related to: Accumulation of air in the pleural space associated with accidental puncture of the pleura during subclavian
insertion of the cardioverter-defibrillator leads

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sudden onset of chest pain Absent breath sounds with hyperresonant percussion
note over involved area; rapid, shallow, and/or labored
respirations; tachycardia; restlessness; confusion; significant
decrease in oximetry results; abnormal arterial blood gas
values; chest radiograph results showing lung collapse

RISK FACTOR DESIRED OUTCOMES

e Surgical implantation in close proximity to lung
The client will have resolution of pneumothorax if it
occurs as evidenced by:
a. Audible breath sounds and a resonant percussion note
over lungs
b. Normal respiratory rate and pattern
(@) . Usual mental status

d. Arterial blood gas values returning to normal range

NURSING ASSESSMENT RATIONALE

Assess for and immediately report signs and symptoms of Early recognition and reporting of signs and symptoms of a
pneumothorax: pneumothorax allow for prompt intervention.
e Absent breath sounds
e Dyspnea
e Tachycardia
e Restlessness
e Confusion
Assess for and immediately report signs and symptoms of A tension pneumothorax is a rapid accumulation of air in the
tension pneumothorax with mediastinal shift: pleural space that can result from a pneumothorax.
e Severe dyspnea Compression of the great vessels can result in altered cardiac
e Increased restlessness and agitation output. This complication is a medical emergency.
e Rapid and/or irregular heart rate
e Hypotension
e Neck vein distention
e Shift in trachea from midline

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If signs and symptoms of pneumothorax occur: Promotes lung expansion.
e Maintain client on bed rest in a semi- to high-Fowler’s position

Dependent/Collaborative Actions
If signs and symptoms of pneumothorax occur:
e Maintain oxygen therapy as ordered. Maintains tissue oxygenation.
e Prepare client for insertion of chest tube if indicated. A chest tube will evacuate accumulated air from the pleural space
and reexpand the lung.
 Chapter 6 = The Client With Alterations in Cardiovascular Function 319

=. sSRISK FOR UNDESIRED STIMULATION OF THE HEART

~ AND/OR CERTAIN NERVES AND MUSCLES
Definition: Adverse stimulation of the heart and nerves which may cause dysrhythmias, pain, or breathing problems.
Related to: The presence of a foreign body in the heart and the emission of electrical impulses from the pacemaker lead(s) to
nearby muscles and nerves such as the diaphragm, intercostal muscles, and phrenic nerve

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal or chest wall twitching Ventricular ectopic beats on ECG; hiccups

RISK FACTOR DESIRED OUTCOMES

es nour OF teads The client will have resolution of ventricular irritability
and undesired nerve and muscle stimulation as evidenced
by:
a. Absence of ventricular ectopic beats
b. Absence of hiccups
c. Absence of abdominal and intercostal muscle twitching

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of ventricular Early recognition and reporting of signs and symptoms of ventricu-
irritability and undesired nerve or muscle stimulation. lar irritability and undesired nerve or muscle stimulation allow
for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms persist: Turning the client to the left side may help facilitate placement of
e Consult physician. the lead(s) against the myocardium.
e Turn client to left side.
e Prepare client for the following procedures if planned:
e Chest x-ray to determine placement of lead(s)
e Repositioning of the lead(s)

DISCHARGE TEACHING/CONTINUED CARE

Diagnosis DEFICIENT KNOWLEDGE

|Nursing >. nox; INEFFECTIVE FAMILY
HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MANAGEMENT nox*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: Pattern of regulating and integrating into family processes
a therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health
goals of the family unit; Ineffective Health Management NDx: Inability to identify, manage, and/or seek out
help to maintain well-being.

needs.
*The nurse should select the diagnosis that is most appropriate for the client's discharge teaching

D = Delegatable Action @ = UAP + =LVN/LPN ©P = Go to @volve for animation

NDx = NANDA Diagnosis
320 Chapter 6 * The Client With Alterations in Cardiovascular Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inability to accurately follow instructions

RISK FACTORS
e Denial of disease process
° Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen Teaching: individual; teaching: prescribed activity/exercise

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
client allows for implementation of the appropriate teaching
interventions.
Assess meaning of treatment plan with client.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize a basic under-

standing of the rationale for and function of an ICD/
pacemaker.

Independent Actions
Reinforce preoperative teaching regarding the rationale for Ensuring client’s understanding preoperatively helps to reinforce
and basic function of an ICD/pacemaker. necessity of the treatment plan and allows for additional client
concerns to be addressed.

THERAPEUTIC INTERVENTIONS RATIONALE

Se ee
Desired Outcome: The client will demonstrate knowledge
of how to monitor ICD/pacemaker function.

Independent Actions
Inform the client with a combined pacemaker/cardioverter- Proper education enables the client to monitor for possible device
defibrillator device of the pacemaker’s programmed pacing malfunction and seek out the appropriate health care provider
rate and, if appropriate, provide instructions about how to if concerning signs and symptoms develop.
take pulse and monitor both the rate and regularity. (Many
physicians prefer that their clients not monitor their own
pulse because of the confusion between paced beats and
spontaneous beats.)
Instruct client with an ICD to monitor for and report the May indicate malfunction of the ICD.
following:
e Signs of a heart rhythm disturbance such as dizziness, ;
fainting, shortness of breath, unexplained fatigue, or
feeling that heart is fluttering.
 Chapter 6 * The Client With Alterations in Cardiovascular Function eo

THERAPEUTIC INTERVENTIONS RATIONALE

Instruct the client with a pacemaker to have pulse generator Decreases potential for malfunction and allows for alterations in
function checked regularly per physician’s instructions or settings as indicated.
if experiencing symptoms such as dizziness, fainting, un-
explained fatigue, or shortness of breath. Inform the client
that monitoring may be done at the physician’s office or
by telephone monitoring device.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify appropriate

safety precautions associated with having an ICD/pacemaker.

Independent Actions
Instruct client to adhere to the following safety precautions: Safety precautions are necessary to maintain proper functioning of
e Inform all health care providers about the device (certain device at all times.
medical equipment such as a magnetic resonance imaging
[MRI] machine, radiation therapy machine, and electrocau-
tery equipment may actually damage the pulse generator
and/or interfere with normal function of these devices).
e Avoid close proximity with strong magnets (e.g., MRI ma-
chine, large industrial magnets), high-voltage electrical equip-
ment (e.g., arc welder, running car engine), and large electro-
magnetic fields (e.g., radio and television transmitters).
e Move away from any electrical device if dizziness or light-
headedness occurs.
e If planning to travel, obtain name of a physician and/or
pacemaker/ICD clinic at point(s) of destination.
e Alert airport personnel to device (it may set off the security
alarm).
e Always wear a medical alert bracelet or tag and carry an
identification card that includes the name of the manufac-
turer, model number, mode of operation, and insertion
date of the device.
e Clients with ICDs should adhere to restrictions on driving;
typically, clients are not allowed to drive until they have
had a 6-month discharge-free period (this is a law in some
states for persons with ICDs).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of appropriate actions to take if the ICD delivers a shock.

Independent Actions
e Instruct client to call an ambulance or emergency rescue
service and then to lie down if the ICD delivers a shock.
° Instruct family members to call the client’s physician and the Delivery of a shock indicates a potentially life-threatening dys-
ambulance or emergency rescue service if the client’s ICD rhythmia has occurred. The appropriate health care provider
delivers a shock while they are present. Instruct them to get should be notified for possible alteration of the treatment plan
CPR training and to initiate CPR if the client is having symp- or hospitalization for further evaluation and stabilization of
toms such as an irregular and rapid pulse along with dizzi- client’s condition.
ness, shortness of breath, chest pain, sweatiness, or loss of
consciousness and the device fails to fire after 30 seconds or
if the device fires unsuccessfully 4 to 7 times.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
 322 Chapter 6 = The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of recommended activity restrictions.

Independent Actions
Provide the following instructions about activity restrictions Activity restrictions serve to ensure that the service wires embed in
after ICD/pacemaker insertion: the appropriate position in the myocardium to achieve maxi-
e Limit movement of the arm and shoulder on the operative mum device function. Additional restrictions serve to prevent
side for the first 48 hrs after surgery. the formation of a wound hematoma, wound infection, or
e Limit activities that put undue stress on the incision site device damage.
(e.g., using arms over head, bowling, racquetball, tennis,
lifting over 25 Ib) until cleared by physician (usual time is
1-2 months).
e Avoid letting anything rub on or hit the device.
e Do not rub or “play with” the device under the skin.
e Avoid immersing the device insertion site in water for at
least 3 days after surgery.
e Avoid activities that can cause blunt trauma to the pulse
generator (e.g., contact sports, firing a rifle with the butt
end of the gun against affected shoulder).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms Reporting signs and symptoms of device malfunction to the appro-
to health care provider: priate provider allows for modification of the treatment plan
e Increased irregularity of pulse (if self-monitoring is being and may prevent life-threatening complications.
done) or episodes of feeling that heart is fluttering
e Unexplained fatigue
e Lightheadedness, dizziness, fainting
e Shortness of breath
e Redness, swelling, drainage, or increased soreness at May indicate infection.
implant site
e Unexplained fever
e Swelling of arm on the side of the device May indicate venous thrombosis associated with insertion/presence
of leads in vein.

THERAPEUTIC INTERVENTIONS RATIONALE

——————————————————————— eee

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, and wound care.

Independent Actions '

Collaborate with the client to develop a plan for adherence Regular health care appointments are important to determine
including: effectiveness of the prescribed treatment plan.
The importance of keeping scheduled appointments with
pacemaker/ICD clinic and for chest radiograph verification
of lead placement.
Allow adequate time for questions and clarification of infor-
mation provided.
 Chapter 6 «The Client With Alterations in Cardiovascular Function 325)

ADDITIONAL NURSING DIAGNOSES RELATED CARE PLANS

FEAR NDx /ANXIETY NDx Standardized Preoperative Care Plan
Related to unfamiliar environment, lack of understanding of Standardized Postoperative Care Plan
surgical procedure, anticipated postoperative discomfort, pos-
sibility of ICD/pacemaker malfunction, and possible changes
in lifestyle as a result of having an ICD/pacemaker

MYOCARDIAL INFARCTION
An Mis an acute coronary syndrome resulting from prolonged coronary blood flow. This can be accomplished by injection
ischemia of the heart muscle and occurs when blood flow to an of a thrombolytic agent to dissolve the clot obstructing the
area of the myocardium is insufficient to meet the myocardial coronary artery or by a coronary angioplasty. In addition to
oxygen requirements. Sustained ischemia causes tissue necrosis early restoration of coronary blood flow, treatment with an
and irreversible cellular damage, which results in disturbances antiplatelet agent, a beta blocker, an ACE inhibitor, and an
in mechanical, biochemical, and electrical function in the ne- HMG-CoA (3-hydroxy-3-methylglutaryl-coenzyme A) reduc-
crotic or infarcted area. The degree of altered function depends tase inhibitor has been found to significantly reduce mortal-
on the area of the heart involved and the size of the infarct. ity after an MI. The prognosis for a client who has had an MI
MIs may be classified in a number of ways. A transmural MI is largely influenced by size and location of the infarct, con-
is characterized by ischemic necrosis of the full thickness of the current cardiovascular status, and promptness and effective-
myocardium. A nontransmural MI is characterized by ischemic ness of treatment.
necrosis that is limited to the endocardium or to the endocar- This care plan focuses on the adult client hospital-
dium and myocardium. A more common classification distin- ized during an episode of intense chest pain for
guished MI types based on electrocardiographic findings with definitive diagnosis and management of a MI.
one type marked by ST elevation (STEMI) and one that is not
(NSTEMI). In addition to these classification systems, many
practitioners also describe an MI by the area of the heart that OUTCOME/DISCHARGE CRITERIA
has been damaged (e.g., anterior MI, lateral MI, inferior MI).
Across MI types, the presence of Q waves or ST-segment eleva- The client will:
tion is associated with higher early mortality and morbidity. 1. Have adequate cardiac output and tissue perfusion
Most MIs are caused by rupture of atherosclerotic plaque in 2. Tolerate prescribed activity without a significant change
a coronary artery, which leads to the release of substances that in vital signs, chest pain, dyspnea, dizziness, or extreme
activate platelet aggregation and clotting factors and cause fatigue or weakness
local vasoconstriction. Other less common causes include 3. Verbalize a basic understanding of an MI
severe, persistent spasm of a coronary artery; severe or pro- aN . Demonstrate accuracy in counting pulse
longed hypotension; a rapid ventricular rate; and cocaine use. 5. Identify modifiable cardiovascular risk factors and ways
The classic symptom of an MI is intense retrosternal chest to alter these factors
pain/discomfort. It is often described as a tight, heavy, squeez- 6. Verbalize an understanding of the rationale for and com-
ing, or crushing sensation or “heartburn,” may radiate to the ponents of a diet designed to lower serum cholesterol and
left arm, neck, jaw, or back; lasts longer than 20 minutes; and triglyceride levels
is unrelieved by nitroglycerin and rest. However, 15% to 25% 7. Verbalize an understanding of medications ordered includ-
of infarctions go unrecognized because clients have only mild ing rationale, food and drug interactions, side effects, sched-
or no chest discomfort or may be asymptomatic. Asymptom- ule for taking, and importance of taking as prescribed
atic MIs are more likely to be experienced by diabetic patients. 8. Verbalize an understanding of activity restrictions and
Other signs and symptoms may include shortness of breath, the rate at which activity can be progressed
diaphoresis, dizziness, weakness, pallor, nausea, and vomiting.
9, State signs and symptoms to report to the health care provider
As with men, women most commonly experience some chest 10. Identify community resources that can assist with cardiac
rehabilitation and adjustment to the effects of an MI
pain or discomfort, however, women are more likely than men
11. Share feelings and concerns about changes in body func-
to experience other common symptoms particularly shortness
of breath, nausea/vomiting, and back or jaw pain. tioning and usual roles and lifestyle
12. Develop a plan for adhering to recommended follow-up care
The extent of myocardial damage can be limited by early
including future appointments with health care provider
(within 4-6 hrs of the onset of symptoms) restoration of

Diagnosis |RISK FOR DECREASED

|Nursing >... CARDIAC OUTPUT nox |
of the body, which may
Definition: Susceptible to inadequate blood pumped by the heart to meet metabolic demands
compromise health.
with the myocardial damage that
Related to: Possible decreased contractility and altered conductivity of the heart associated
has occurred with infarction

D = Delegatable Action @ = UAP + =LVN/LPN © = Go to ©volve for animation

NDx = NANDA Diagnosis
 324 Chapter6 * The Client With Alterations in Cardiovascular Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of anxiety; fatigue; weakness; dizziness; Change in mental status; B/P less than 90 mm Hg systolic
syncope; exertional dyspnea or below normal for patient; irregular or absent pulses;
diminished peripheral pulses; tachypnea; cool, pale skin;
cool extremities; increased capillary refill time

DESIRED OUTCOMES
—_e——Xx—a—X«K<kFrFroeeeeeeh nk ks»$=SS—e Oo ee

The client will have adequate cardiac output as evidenced g. Usual mental status
by: h. Absence of dizziness and syncope
. B/P within normal range for client i. Palpable peripheral pulses
. Apical pulse between 60 and 100 beats/min and regular j. Skin warm and usual color
. Resolution of gallop rhythm(s) k. Capillary refill time less than 2 to 3 seconds
. No reports of fatigue and weakness 1. Urine output at least 30 mL/h
. Unlabored respirations at 12 to 20 breaths/min m. Absence of edema and JVD
©.
Be
Oo
OG Clear, audible breath sounds

NOC OUTCOMES NIC INTERVENTIONS

Cardiac pump effectiveness; circulation status; tissue Cardiac care: acute; hemodynamic regulation; cardiac risk
perfusion: peripheral; cardiac management; dysrhythmia management; cardiac care:
rehabilitative

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of decreased cardiac output: Early recognition and reporting ofsigns and symptoms of an MI
° Variations in B/P (may be increased because of pain or allow for prompt intervention.
compensatory vasoconstriction; may be decreased when
compensatory mechanisms and pump fail)
e Tachycardia
e Presence of gallop rhythm(s)/S, heart sound
e Fatigue and weakness
e Dyspnea, orthopnea, tachypnea
e Crackles (rales)
e Restlessness, anxiousness, confusion, or other change in
mental status
e Dizziness, syncope
e Diminished or absent peripheral pulses
¢ Cool extremities
e Pallor or cyanosis of skin
¢ Capillary refill time greater than 2 to 3 seconds
e Oliguria
e Edema
e JVD
* Chest radiograph results showing pulmonary vascular
congestion, pulmonary edema, or pleural effusion
e Abnormal arterial blood gas values
° Significant decrease in oximetry results
Assess for diagnostic findings indicative of an MI:
e Elevated serum creatine kinase (CK)-MB level
e Elevated serum troponin level
e Elevated serum lactate dehydrogenase (LDH) level with an
LDH, level that is higher than the LDH; (a reliable indica-
tor of an acute MI)
e ECG showing ST-segment elevation or depression, inversion
of T waves, and/or presence of abnormal Q waves (there may
be no Q waves if client has had a subendocardial infarction)
 Chapter 6 * The Client With Alterations in Cardiovascular Function Bas)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to reduce cardiac workload: Elevation of client’s upper body reduces cardiac workload by
e Place client in a semi- to high-Fowler’s position. D+ decreasing venous return from the periphery and subsequently
reducing preload.
e Instruct client to avoid activities that create a Valsalva When a client exhales after the Valsalva maneuver, the intratho-
response (e.g., straining to have a bowel movement, hold- racic pressure falls, causing a sudden increase in venous return
ing breath while moving up in bed). and a subsequent increase in preload and cardiac workload.
e Implement measures to promote rest and conserve energy. Physical rest reduces cardiac workload by lowering the body’s
pe+¢+ energy requirements and subsequent need for oxygen.
e Discourage smoking. Nicotine has a cardiostimulatory effect and causes vasoconstric-
tion; the carbon monoxide in smoke reduces oxygen availability.
e Provide small meals rather than large ones. Large meals require a greater increase in blood supply to the
gastrointestinal tract for digestion.
e Discourage excessive intake of beverages high in caffeine Caffeine is a myocardial stimulant and can increase myocardial
such as coffee, tea, and colas. oxygen consumption.
e Restrict sodium intake if ordered. Restricting sodium helps to prevent fluid retention.
e Increase activity gradually as allowed and tolerated. A gradual increase in activity prevents a sudden increase in cardiac
workload.

Dependent/Collaborative Actions
Implement measures to maintain an adequate cardiac output
e Prepare client for procedures that may be performed to Decreases fear and anxiety.
improve coronary blood flow:
e Injection of a thrombolytic agent
e Percutaneous coronary intervention
e Insertion of an IABP
e Maintain oxygen therapy as ordered. D + When tissue oxygenation is adequate, the heart does not need to
e Administer the following medications if ordered: work as hard to supply oxygen to the tissues; thus more oxygen
is available for myocardial use.
e Nitrates Nitrates decrease cardiac workload and myocardial oxygen
demands by relaxing peripheral veins and, to a lesser extent,
arterioles.
e Beta-adrenergic blocking agents Beta-adrenergic blockers reduce cardiac workload by blocking
sympathetic nervous system stimulation of beta receptors in the
heart.
e ACE inhibitors ACE. inhibitors/angiotensin II receptor antagonists block the
vasoconstrictor effect of angiotensin II, which causes a decrease
in aldosterone output.
e Antidysrhythmics Antidysrhythmics improve cardiac output by correcting automatic-
ity and/or conduction abnormalities in the heart.
e Anticoagulants Anticoagulants help to restore/improve coronary blood flow.
Consult physician if signs and symptoms of decreased cardiac Notifying the physician allows for modification of the treatment
output persist or worsen. plan.

Diagnosis |ACUTE PAIN nox (CHEST PAIN/DISCOMFORT THAT MAY

|Nursing »-..
RADIATE TO ARM, NECK, JAW, OR BACK)
in
Definition: Unpleasant sensory and emotional experience associated with actual on potential tissue damage, or described
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

metabolism; the
Related to: Myocardial ischemia (a decreased oxygen supply forces the myocardium to convert to anaerobic
end products of anaerobic metabolism act as irritants to myocardial neural receptors)

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation
 326 Chapter6 = The Client With Alterations in Cardiovascular Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain Grimacing; rubbing neck, jaw, or arm; reluctance to move;
clutching chest; restlessness; diaphoresis; increased B/P
and/or tachycardia

RISK FACTORS DESIRED OUTCOMES

e Coronary artery disease
The client will experience relief of chest pain/discomfort
e Increase in oxygen demand
as evidenced by:
a. Verbalization of same
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

_————:.:.:. a —————————————————

Comfort level; pain control Pain management; analgesic administration; oxygen therapy

NURSING ASSESSMENT RATIONALE

eee

Assess signs and symptoms of chest pain/discomfort: Early recognition and reporting of signs and symptoms of chest
e Verbalization of pain pain allow for prompt intervention.
e Grimacing
e Rubbing neck, jaw, or arm
e Reluctance to move
e Clutching chest
e Restlessness
e Diaphoresis
e Increased B/P
e Tachycardia
Assess Client's perception of the severity of the pain/discomfort
using an intensity rating scale.
Assess the client’s pattern of pain/discomfort (e.g., location,
quality, onset, duration, precipitating factors, aggravating
factors, alleviating factors).

THERAPEUTIC INTERVENTIONS
RATIONALE
eee
Independent Actions
Implement measures to relieve pain/discomfort:
e Maintain client on bed rest in a semi- to high-Fowler’s Bed rest helps to reduce myocardial oxygen demands by reducing
position. D® + cardiac workload.
e Provide or assist with nonpharmacological measures for Nonpharmacological interventions are effective because they stim-
pain relief (e.g., relaxation techniques, restful environ- ulate closure of the gating mechanism in the spinal cord and
ment). D subsequently block the transmission of pain impulses.

Dependent/Collaborative Actions
Implement measures to relieve pain/discomfort:
e Administer the following medications if ordered: Intravenous rather than an intramuscular route should be used
e Intravenous narcotis opioid analgesics because intramuscular injections are poorly absorbed iftissue
e Nitrates perfusion is decreased; intramuscular injections also elevate
some serum enzyme levels, which may interfere with assess-
ment of myocardial damage.
e Maintain oxygen therapy as ordered. D * Oxygen therapy helps to increase the myocardial oxygen supply.
 Chapter 6 » The Client With Alterations in Cardiovascular Function SYA

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to maintain an adequate cardiac output:

Prepare client for procedures that may be performed to im- Decreases fear and anxiety.
prove coronary blood flow:
e Injection of a thrombolytic agent
e Percutaneous coronary intervention
e Insertion of an IABP
Consult physician if pain/discomfort persists or worsens. Notifying the physician allows for modification of the treatment
plan.

|Nursing =>
Diagnosis |6RISK FOR ACTIVITY INTOLERANCE nox
Definition: Susceptible to experiencing insufficient physiological or psychological energy to endure or complete required or
desired daily activities, which may compromise health.

Related to:
e Tissue hypoxia if cardiac output is decreased
e Difficulty resting and sleeping associated with discomfort, frequent assessments and treatments, fear, and anxiety

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue or weakness Abnormal heart rate or B/P response to activity; exertional
discomfort or dyspnea; ECG changes reflecting ischemia

RISK FACTORS DESIRED OUTCOMES

e Increased oxygen demand The client will not experience activity intolerance as evi-
e Immobility denced by:
e Generalized weakness a. No reports of fatigue or weakness
b. Ability to perform activities of daily living without
exertional dyspnea, chest pain, diaphoresis, dizziness,
and a significant change in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance; energy conservation, self-care: activities Energy management; oxygen therapy; cardiac care: rehabili-
of daily living tative; sleep enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition and reporting ofsigns and symptoms of activity
e Statements of fatigue or weakness intolerance allow for prompt intervention.
2 Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping activ-
ity, change from regular to irregular rate)
e Significant change of 15-20 mm Hg in B/P with activity.

D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation

’ NDx = NANDA Diagnosis
 328 Chapter 6 = The Client With Alterations in Cardiovascular Function

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent activity intolerance:
e Perform actions to promote rest and/or conserve energy: Cells use oxygen and fat, protein, and carbohydrates to produce the
e Maintain activity restrictions as ordered. energy needed for all body activities. Rest and activities that
e Minimize environmental activity and noise. D + conserve energy result in a lower metabolic rate, which preserves
e Organize nursing care to allow for periods of uninter- nutrients and oxygen for necessary activities.
rupted rest.
e Limit the number of visitors and their length of stay.
e Assist client with self-care activities as needed. D >
e Keep supplies and personal articles within easy reach.
e Instruct client in energy-saving techniques (e.g., using
shower chair when showering, sitting to brush teeth or
comb hair).
¢ Implement measures to reduce fear and anxiety.
e Implement measures to promote sleep:
e Encourage relaxing diversional activities in the evening.
e Allow client to continue usual sleep practices unless
contraindicated.
e Reduce environmental distractions.
e Implement nonpharmacological measures to relieve
pain/discomfort. D+
Instruct client to:
e Report a decreased tolerance for activity.
e Stop any activity that causes chest pain, shortness of
breath, dizziness, or extreme fatigue or weakness.

Dependent/Collaborative Actions
Implement measures to prevent activity intolerance: Conservation of energy allows the patient to rest and improve
e Perform actions to promote rest and/or conserve energy: ability to increase activity.
e Implement measures to promote sleep:
e Administer prescribed sedative-hypnotics.
e Administer prescribed analgesics.
e Perform actions to maintain an adequate cardiac output if Sufficient cardiac output is necessary to maintain an adequate
decreased cardiac output is contributing to client’s activity blood flow and oxygen supply to the tissues. Adequate tissue
intolerance. oxygenation promotes more efficient energy production, which
subsequently improves the client’s activity tolerance.
e Maintain oxygen therapy as ordered. Maintains tissue oxygenation.
e Increase client’s activity gradually as allowed and tolerated. Improves cardiac stamina.
Consult appropriate health care provider (e.g., cardiac reha- Notifying the physician allows for modification of the treatment
bilitation therapist, physician) if signs and symptoms of plan.
activity intolerance persist or worsen.

|Collaborative .-.
Diagnosis|RISK FOR CARDIAC DYSRHYTHMIAS
Definition: Disturbance of heart rhythm.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of palpitations; lightheadedness Irregular apical pulse; pulse rate below 60 or above 100 beats/
min; apical-radial pulse deficit; syncope; palpitations; abnor-
mal rate, rhythm, or configurations on ECG
 Chapter 6 * The Client With Alterations in Cardiovascular Function 329

RISK FACTORS DESIRED OUTCOMES

e Electrolyte abnormalities
e Drug toxicities : The client will maintain normal sinus rhythm as evidenced by:
e¢ Myocardial ischemia . Regular apical pulse at 60 to 100 beats/min
. Equal apical and radial pulse rates
. Absence of syncope and palpitations
fst). ECG showing normal sinus rhythm
(er
Tey
fan

NURSING ASSESSMENT RATIONALE

Assess frequently for and report signs and symptoms of car- Early recognition of dysrhythmias allows for prompt intervention.
diac dysrhythmias:
e Irregular apical pulse
e Syncope
e Palpitations

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If cardiac dysrhythmias occur: Monitoring should be implemented in order to identify dysrhythmias
e Initiate cardiac monitoring if not currently being done. that could cause further deterioration of the client’s condition.
e Restrict client’s activity based on client’s tolerance and Rest reduces the workload of the injured heart.
severity of the dysrhythmia.

Dependent/Collaborative Actions
Implement measures to maintain an adequate cardiac output. Adequate cardiac output promotes adequate myocardial tissue perfusion
and oxygenation and reduces the risk of cardiac dysrhythmias.
Ifcardiac dysrhythmias occur: The most common complication after an MI is dysrhythmias due
e Administer antidysrhythmics if ordered. to the irritability of the heart muscle. Dysrhythmias are not
e Maintain oxygen therapy as ordered. usually treated unless they are life-threatening.
e Prepare client for the following if planned:
¢ Cardioversion
e Insertion of a pacemaker or ICD
e Catheter ablation of irritable site
e Have emergency cart readily available for defibrillation
or CPR.

|Collaborative »Diagnosis.
~~ RISK FOR THROMBOEMBOLISM |
Definition: A clot attached to a vessel/cardiac chamber wall that becomes dislodged, circulating within the blood. After an
acute MI, a thromboembolism may result from debris and clots that collect inside dilated aneurismal sacs in the
ventricle or from infarcted endocardium.

Related to:
e Venous stasis in the periphery associated with decreased cardiac output and decreased mobility
e Stasis of blood in the heart associated with decreased ventricular emptying (risk increases if dysrhythmias are present)

CLINICAL MANIFESTATIONS*

Subjective Objective
Verbal self-report of pain; apprehension; anxiety Deep vein: Tenderness; swelling; positive Homans’ sign;
increased warmth
Arterial: Diminished or absent peripheral pulses; pallor,
coolness, numbness, and/or pain in extremity
Cerebral: Decreased level of consciousness; alteration in
usual sensory and motor function
Pulmonary: Sudden onset of chest pain, dyspnea,
increased restlessness, and significant decrease in arterial
oxygen saturation (SaO2)

in the
*Clinical manifestations vary depending upon the location of the embolus and may occur in the veins and arteries located
legs, brain, and pulmonary system.

~ NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 330 Chapter6 = The Client With Alterations in Cardiovascular Function

RISK FACTORS DESIRED OUTCOMES

e Immobility
The client will not develop a thromboembolism as evi-
e Ventricular aneurysms
denced by:
e MIs
a. Absence of pain, tenderness, swelling, and numbness in
e Hypercoagulability
extremities
. Usual temperature and color of extremities
. Palpable and equal peripheral pulses
. Usual mental status
. Usual sensory and motor function
& . Absence of sudden chest pain and dyspnea
moan

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deep vein, arterial, Early recognition of signs and symptoms of thromboembolism
cerebral, or pulmonary thromboembolism: allows for prompt intervention.
Monitor results of echocardiogram and report findings of a
cardiac thrombus.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If signs and symptoms of an arterial embolus in an extremity Positioning helps to improve arterial blood flow.
occur:
° Maintain client on bed rest with affected extremity in a Bed rest should be maintained until it is determined that clot is
level or slightly dependent position. stable and solidified.
If signs and symptoms of cerebral ischemia occur: Positioning helps to facilitate venous drainage of the head, reduc-
e Maintain client on bed rest; keep head and neck in neu- ing the risk of increased ICP.
tral, midline position.

Dependent/Collaborative Actions
Implement measures to prevent the development of throm- The goal of dependent nursing actions is to prevent the formation
boemboli: of a thrombus by maintaining adequate blood flow and pre-
e Perform actions to reduce the risk of thrombus formation venting venous stasis, reducing hypercoagulability of the blood,
in the heart: and limiting damage to the vessel linings.
e Implement measures to maintain an adequate cardiac Procedures will help improve coronary blood flow and improve
output. cardiac output.
° Prepare client for procedures to improve coronary Reduces the risk of dysrhythmias that allow pooling of blood in the
blood flow (e.g., PCTA, insertion of IABP—intraaortic heart (e.g., atrial fibrillation).
balloon pump).
e Implement measures to treat dysrhythmias if present.
e Administer antiarrhythmic medications.
e Administer anticoagulants and antiplatelet agents if
ordered.
If signs and symptoms of an arterial embolus in an extremity Procedures act to restore blood flow to affected vessel.
occur:
° Prepare client for diagnostic studies.
° Doppler or duplex ultrasound
e Arteriography
° Prepare client for the following if planned:
e Injection of a thrombolytic agent
e Embolectomy
e Administer anticoagulants as ordered.
 Chapter 6 = The Client With Alterations in Cardiovascular Function 331

Collaborative Diagnosis RISK FOR RUPTURE OF A PORTIONOF THE HEART (E.G., _

VENTRICULAR FREE WALL, INTERVENTRICULAR SEPTUM,
PAPILLARY MUSCLE)
Definition: Tearing of cardiac tissues within the heart.

Related to: Weakening of cardiac tissue from ischemia and/or necrosis

CLINICAL MANIFESTATIONS*

Subjective Objective
Not applicable Papillary muscle rupture: Holosystolic murmur; dyspnea;
evidence of papillary muscle rupture on echocardiography
or cardiac catheterization
Ventricular septal defect: Holosystolic murmur; paraster-
nal thrill; finding of septal defect on echocardiography or
cardiac catheterization
Cardiac tamponade: Significant decrease in B/P; narrowed
pulse pressure; pulsus paradoxus; distant or muffled heart
sounds; JVD; increased CVP

RISK FACTOR DESIRED OUTCOME

e MI or damage
The client will not experience rupture of any portion of
the heart as evidenced by absence of signs of acute heart
failure and/or cardiogenic shock.

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of papillary muscle Early recognition of signs and symptoms of rupture of heart
rupture, ventricular septal defect, and cardiac tamponade: structures allows for prompt intervention.
e Holosystolic murmurs
e Dyspnea
Assess for and immediately report signs and symptoms of
acute heart failure and/or cardiogenic shock:
e Increased restlessness/confusion
e Systolic B/P less than 80 mm Hg
e Rapid, weak pulse
e Diminished or absent pulses
e Increase coolness and duskiness of skin
e Urine output less than 30 mL/h

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce cardiac workload and increase Reducing cardiac workload helps to reduce risk of rupture of the
activity as allowed. Add the following actions: papillary muscle and ventricular free wall or septum.
e Place client in semi-Fowler’s position.
e Instruct client to avoid activities that create a Valsalva
response (e.g., straining).
e Discourage smoking. Nicotine increases vasoconstriction and increases cardiac workload.
If signs and symptoms of rupture of a portion of the heart The client may become hemodynamically unstable and therefore
occur: should be maintained on bed rest.
e Maintain client on bed rest.

Dependent/Collaborative Actions
If signs and symptoms of rupture of a portion of the heart occur:
e Assist with pericardiocentesis if performed. Cardiac tamponade is treated with pericardiocentesis.
e Assist with measures to treat heart failure or cardiogenic shock.

*Clinical manifestations will vary depending upon which structures are affected.

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 B32 Chapter 6 «= The Client With Alterations in Cardiovascular Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Prepare client for surgical intervention if planned: Decreases fear and anxiety.
e Valve replacement
e Repair of ventricular septal defect

|Collaborative “RISK
Diagnosis FOR PERICARDITIS
Definition: Inflammation of the pericardium.
Related to:
e Exposure to pathogens
e Death of tissue

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of precordial pain that frequently radi- Pericardial friction rub; persistent temperature elevation;
ates to shoulder, neck, back, and arm; is intensified during further increase in white blood cell (WBC) count and
deep inspiration, movement, and coughing; and usually is sedimentation rate
relieved by sitting up and leaning forward

RISK FACTORS DESIRED OUTCOMES

e MI
The client will experience resolution of pericarditis if it
e Myocardial necrosis
develops as evidenced by:
e Infection
a. Fewer reports of pericardial pain
b. Absence of pericardial friction rub
c. Temperature declining toward normal
d. WBC count and sedimentation rate declining toward
normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of pericarditis: Early recognition ofsigns and symptoms of pericarditis allows for
e Pericardial friction rub prompt intervention.
e Elevated temperature
e Pericardial pain
Monitor erythrocyte sedimentation rate, WBC and differen-
tial cell counts for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

eee
Independent Actions
If signs and symptoms of pericarditis occur:
e Allay client’s anxiety. The client may believe that symptoms indicate recurrent MI.
e Assist client to assume position of comfort. Pericarditic pain is best relieved with the patient sitting or leaning
forward.
'
Dependent/Collaborative Actions
If signs and symptoms of pericarditis occur:
e Administer anti-inflammatory agents if ordered. Pain and inflammation associated with pericarditis are usually
treated with anti-inflammatory agents.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 333

Collaborative Diagnosis
=. |RISK FOR INFARCTION EXTENSION OR RECURRENCE __
Definition: Expansion of tissue death from the MI and/or secondary MI.

Related to: Inadequate treatment of original MI

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chest pain Changes in vital signs; increase in cardiac enzyme levels;
increase in ECG abnormalities (ST-segment elevation/
Q waves)

RISK FACTOR DESIRED OUTCOMES

e Previous MI
The client will not experience infarct extension or recur-
rence as evidenced by:
a. No further episodes of persistent chest pain
b. Stable vital signs
c. Cardiac enzyme levels declining toward normal range
d. Improved ECG readings

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of infarct extension Early recognition of signs and symptoms of reinfarction allows for
or recurrence (e.g., changes in vital signs; increase in car- prompt intervention.
diac enzyme levels; ECG changes [ST-segment elevation/
Q waves]}).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions The goal of dependent nursing actions is to reduce the workload of
If client experiences signs and symptoms of infarct extension the heart, optimize function, and improve perfusion to the
or recurrence: myocardium.
e Administer medications ordered: Act to optimize cardiac performance and reduce the risk of
e Medications such as nitrates, ACE inhibitors, beta- reinfarction
blocking agents, aspirin, and heparin. These medications optimize cardiac performance, reduce blood
clotting activity and reduce the risk for reinfarction.
e Prepare the client for coronary angiogram, thrombolytic Decreases fear and anxiety.
therapy, or revascularization procedure (e.g., percutaneous
transluminal coronary angioplasty [PTCA], CABG) if
planned.

|Collaborative =>
Diagnosis |RISK FOR CARDIOGENIC SHOCK
Definition: Decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.

Related to:
e Inability of the heart to effectively provide perfusion to the tissues
e Cardiac tissue ischemia and/or necrosis

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of lethargy; restlessness Systolic B/P below 80 mm Hg; rapid, weak pulse; dimin-
ished or absent peripheral pulses; increased coolness
and duskiness or cyanosis of skin; urine output less than
30 mL/h

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 334 Chapter 6 * The Client With Alterations in Cardiovascular Function

RISK FACTORS DESIRED OUTCOMES

¢ Myocardial ischemia The client will not develop cardiogenic shock as evidenced
e MI
by:
° Heart failure
. Stable or improved mental status
e Pericardial infections
. Systolic B/P greater than 80 mm Hg
. Palpable peripheral pulses
. Stable or improved skin temperature and color
aq
oo
os . Urine output at least 30 mL/h

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiogenic Early recognition of signs and symptoms of cardiogenic shock
shock: allows for prompt intervention.
° Systolic B/P <80 mm Hg
° Weak pulse
e Diminished peripheral pulses
° Cyanosis of skin
e Urine output <30 mL/h

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent cardiogenic shock: Cardiogenic shock that is unresponsive to therapy has a high
° Perform actions to maintain an adequate cardiac output mortality rate.
(e.g., administer inotropic agents). Medications geared toward optimizing cardiac performance and
° Perform actions to treat cardiac dysrhythmias if present improving cardiac output are necessary. Cardiac assist devices
(e.g., administer antiarrhythmics). support the failing heart when medication therapy is ineffective.
° Perform actions to treat heart failure if it occurs.
° Perform actions to treat rupture of any portion of the heart
if it occurs.
If signs and symptoms of cardiogenic shock occur:
° Maintain oxygen therapy as ordered.
e Administer medications: Inotropic agents act to increase myocardial contractility and
° Positive inotropic agents improve heart failure.
e Administer the following if ordered:
° Sympathomimetics
e Vasodilators
e Intravenous fluids
° Assist with intubation and insertion of hemodynamic
monitoring devices and/or cardiac assist devices:
° Swan Ganz
e IABP

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox OR INEFFECTIVE S-HEALTH

MANAGEMENT npx*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of unfamiliarity with information Inability to follow-through with instructions

*The nurse should select the nursing diagnostic label that is most appropriate for the client's discharge teaching needs.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 335

RISK FACTORS
° Denial of disease process
° Cognitive deficiency
e Failure to take action to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; disease process; cardiac Health system guidance; teaching: individual; teaching:
disease management disease process; teaching: prescribed activity/exercise;
teaching: prescribed medication

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to client
allows for implementation of the appropriate teaching interven-
tions.
Assess meaning of illness to client.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize a basic under-

standing of an MI.

Independent Actions
Explain an MI in terms the client can understand. Use appro- Clients vary in physical and cognitive ability to learn. When edu-
priate teaching aids (e.g., pictures, videotapes, heart mod- cating clients, nurses need to determine a client’s ability to
els). Inform client that it takes approximately 6 to 8 weeks read and understand written materials. If literacy barriers are
for the heart to heal after an MI. present, alternative educational materials should be provided.
Better understanding of the clinical problem may enhance
adherence.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate accuracy in

counting pulse.

Independent Actions
Teach client how to count his/her pulse, being alert to the Educating clients to assess their baseline pulse allows for early
regularity of the rhythm. detection of irregularities warranting immediate attention from
Allow time for return demonstration and accuracy check. a health care provider. Early detection may reduce the incidence
of sudden death.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify modifiable car-

diovascular risk factors and ways to alter these factors.

Independent Actions
Inform client that certain modifiable factors such as elevated Thorough education is a critical component of the care of a client
serum lipid levels, a sedentary lifestyle, hypertension, and after an MI. Continued lifestyle modifications consistent with
smoking have been shown to increase the risk for CAD. recommendations for clients with cardiovascular disease are
necessary to prevent coronary reocclusion. The client must have
a thorough understanding of the importance ofadhering to diet,
medication, activity/exercise, and nutritional recommendations
to prevent an exacerbation and control the disease.

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THERAPEUTIC INTERVENTIONS RATIONALE

Assist client to identify changes in lifestyle that can help the
client to eliminate or reduce the above risk factors and to
help prevent a recurrent MI (e.g., dietary modification,
physical exercise on regular basis, moderation of alcohol
intake, smoking cessation).
Encourage client to limit daily alcohol consumption. Daily Current recommendations are no more than two drinks per day for
alcohol intake exceeding 1 oz of ethanol may contribute men and no more than one drink per day for women and
to the development of hypertension and some forms of lighter-weight persons. A “drink” is considered to be Y2 oz of
heart disease. ethanol (e.g., 1% 0z of 80-proof whiskey, 12 oz ofbeer, 5 oz of
wine).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of the rationale for and components of a diet designed to
lower serum cholesterol and triglyceride levels.

Independent Actions
Provide instructions on ways the client can reduce intake of The risk of CAD is associated with a serum cholesterol level of
saturated fat and cholesterol: more than 200 mg/dL or a fasting triglyceride level of more
e Reduce intake of meat fat (e.g., trim visible fat off meat; than 150 mg/dL. Elevated serum lipid levels are one of the most
replace fatty meats such as fatty cuts of steak, hamburger, firmly established risk factors for CAD.
and processed meats with leaner products).
e Reduce intake of milk fat (e.g., avoid dairy products
containing more than 1% fat).
e Reduce intake of trans fats (e.g., avoid stick margarine and
shortening and foods such as commercial baked goods
that are prepared with these products).
e Use vegetable oil rather than coconut or palm oil in cook-
ing and food preparation.
e Use cooking methods such as steaming, baking, broil-
ing, poaching, microwaving, and grilling rather than
frying.
e Restrict intake of eggs. Recommendations about the number of whole eggs allowed per
e Encourage client to increase intake of omega-3 fatty acids week vary depending on the client’s lipid levels.
(e.g., flaxseed, cold water ocean fish such as salmon and
halibut) to help lower triglyceride levels and increase HDL
levels.

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, and importance of Taking medications as prescribed ensures that therapeutic drug
taking the medications prescribed. Inform client of perti- levels will be maintained. Clients should be instructed not to
nent food and drug interactions. discontinue taking medications if they feel better. Clients
without financial resources should be assisted in accessing
appropriate resources to obtain needed medications (e.g.,
pharmacy assistance programs).
 Chapter 6 The Client With Alterations in Cardiovascular Function Ba

THERAPEUTIC INTERVENTIONS RATIONALE

Educate the client on the proper administration, dosing regi-
men, side effects, precautions, and storage of the following
medications if ordered:
Nitrates/nitrate patches/nitrate paste
Beta-adrenergic blockers
ACE inhibitors
Lipid-lowering agents
Instruct the client to notify physician provider before taking
other prescription medications and to inform all health
care providers of medications being taken.

THERAPEUTIC INTERVENTIONS RATIONALE

a Sn sy rhs rr nu ptegapssesneeinpeecnepe

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct the client to report: Reporting concerning signs and symptoms to the appropriate
Chest, arm, neck, jaw, or back discomfort unrelieved by provider allows for modification of the treatment plan.
nitroglycerin
Shortness of breath
Significant weight gain or swelling of feet or ankles
Irregular pulse or a significant unexpected change in the
pulse rate
Persistent impotence or decreased libido (can be a side
effect of certain medications or result from anxiety, depres-
sion, or fatigue)
Inability to tolerate prescribed activity
Increase in severity or frequency of episodes of angina

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of activity restrictions and the rate at which activity can
be progressed.

Independent Actions
Reinforce physician’s instructions about activity. Instruct While the benefits of physical activity are an integral part of
client to: cardiac rehabilitation, the level of activity should be increased
Gradually increase activity by adhering to a regular aerobic gradually. Physical activity guidelines after acute coronary
exercise program (often begins with walking). syndromes focus on frequency, intensity, type, and time of
Take frequent rest periods for about 4 to 8 weeks after activity.
discharge.
Avoid physical conditioning programs such as jogging and
aerobic dancing until advised by physician.
Avoid strenuous exercise and activities that involve push-
ing or lifting heavy objects (e.g., weightlifting).
Avoid exercising for at least an hour after eating and when
the environmental temperature is extremely hot or cold.
Avoid tobacco use before exercise.
Stop any activity that causes chest pain, shortness
of breath, palpitations, dizziness, or extreme fatigue or
weakness.
Begin a cardiovascular fitness program if recommended by
physician.

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THERAPEUTIC INTERVENTIONS RATIONALE

Reinforce instructions regarding sexual activity:
e Sexual activity with usual partner can be resumed after the
prescribed length of time (many physicians consider a cli-
ent ready to resume sexual activity when the client is able
to climb two flights of stairs briskly without dyspnea or
angina).
e Assume a comfortable and unstrenuous position for inter-
course (e.g., side-lying, partner on top).
e Anew sexual relationship can be started but may result in
greater energy expenditure until it becomes a more famil-
iar or usual experience.
e Take nitroglycerin before sexual activity if angina occurs
with sexual activity.
e Avoid intercourse for at least 1 to 2 hrs after a heavy meal
or alcohol consumption.
e Avoid sexual activity when fatigued or stressed.
e Avoid hot or cold showers just before and after intercourse.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources that can assist with cardiac rehabilitation and adjust-
ment to the effects of an MI.

Independent Actions
Provide information on community resources and support Cardiac disease can significantly impact an individual’s and
groups that can assist client with cardiac rehabilitation family’s socioeconomic status. Providing information specific
and adjustment to the effects of an MI (e.g., American to community resources is important to provide a necessary
Heart Association, “coronary clubs,” counseling services). continuum of care and may impact the client’s health status,
preventing future hospitalizations.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended fol-
low-up care including future appointments with health care
provider.

Independent Actions
Collaborate with the client to develop a plan for adherence to Regular health care appointments are important to determine
treatment regimen that includes: effectiveness of the prescribed treatment plan.
The importance of keeping follow-up appointments with
health care provider and for exercise stress testing and
laboratory studies to monitor serum lipid levels.
Implement measures to improve client adherence:
° Include significant others in teaching sessions if possible. Involvement of significant others in patient teaching improves
adherence to discharge instructions.
e Encourage questions and allow time for reinforcement and Everyone does not understand information as presented, so set aside
clarification of information provided. time for questions to allow for clarification of information.
e Provide written instructions on future appointments with Written instructions allow the client to refer to instructions as
health care provider, dietary modifications, activity pro- needed.
gression, medications prescribed, and signs and symptoms
to report.
¢ Obtain social service consult as needed to help client
obtain financial assistance.
 Chapter 6 * The Client With Alterations in Cardiovascular Function 339

ADDITIONAL NURSING DIAGNOSES e Unfamiliar environment and separation from significant

others
e Lack of understanding of diagnostic tests, diagnosis, and
DISTURBED SLEEP PATTERN NDx
Related to: treatment
° Symptoms being experienced with the MI (e.g., chest dis- e Financial concerns about the cost of hospitalization and
future treatment
comfort, shortness of breath)
e Frequent assessments and treatments
e Fear and anxiety
GRIEVING NDx
Related to:
¢ Loss of normal function of the heart
FEAR/ANXIETY NDx
¢ Possible changes in lifestyle, occupation, and roles
Related to:
e Uncertainty of prognosis
* Symptoms being experienced with the MI (e.g., chest dis-
comfort, arm pain, and/or shortness of breath)
° Possible future disability, change in roles and lifestyle,
and/or death associated with severe damage to the heart
See Bibliography at the back of the book.

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 CHAPTER

The Client With Alterations

in Neurological Function

ALZHEIMER'S DISEASE/DEMENTIA
©p> Alzheimer’s disease is a slow, progressive, degenerative brain obesity in midlife, and diabetes), traumatic brain injury
disease that is characterized by difficulty with memory, lan- (TBI), and chronic traumatic encephalopathy (CTE). Other
guage, problem solving, and other cognitive skills that affect modifiable risk factors known to decrease risk include more
the ability to perform everyday activities. More than 5 million formal years of education, and remaining socially and cog-
Americans are currently living with Alzheimer’s disease, with nitively engaged.
a predicted increase to 16 million by 2050. It is the most com- Alzheimer’s disease affects the brain structures. Changes
mon cause of dementia and affects more women than men that occur in the brain are the development of neurofibrillary
(possibly because women live longer), and older African tangles, amyloid or neurotic plaques, and the loss of connec-
Americans and Hispanics are more likely than older whites to tion between neurons. The plaques develop initially in the
have Alzheimer’s. areas of the brain responsible for memory and cognitive func-
Although the cause of disease is unknown, multiple tioning. Over time, the plaques develop in the cerebral cortex
nonmodifiable and modifiable factors are associated with the in the areas that control language and reasoning.
development of the disease. The greatest risk factors for late- Research suggests that the brain changes associated with
onset Alzheimer’s are older age, family history, and carrying Alzheimer’s may begin 20 years or more before the first symp-
the APOE-e4 gene. toms occur. Based on the patterns of symptom progression,
Age is one of the most important factors in the develop- several methods of staging have been developed to help
ment of Alzheimer’s disease with the vast majority of people families and health care professionals make better care deci-
with Alzheimer’s being over the age of 65 years. Though sions. The Global Deterioration Scale (GDS) outlines key
not considered a normal part of aging, the percentage of symptoms in seven stages, ranging from unimpaired to very
Alzheimer’s dramatically increases with age: 3% of people severe cognitive decline.
ages 6S to 74; 17% of people ages 75 to 84; and 32% of people In the early stages of Alzheimer’s disease (stages 1 to 4), the
85 years of age or older. individual may appear healthy, but experiences forgetfulness,
The second greatest risk factor is family history. An indi- short-term memory loss, mild impairment in judgment, and
vidual who has a first-degree relative—a sister, brother, or becoming progressively moody and withdrawn with greater
parent—with Alzheimer’s is at a greater risk for developing difficulty performing complex tasks such as managing fi-
the disease. The risk increases even more if more than one nances or paying bills. Loss of initiative and interest, de-
family member has the illness. creased ability to make judgment, and geographic disorienta-
The third greatest risk factor is carrying the apolipoprotein tion are also experienced. These clinical manifestations
E-e4 gene (APOE-e4). This form of APOE gene is one of three in develop over time; the initial memory deterioration is so
the body (e2, e3, or e4) and is responsible for the development subtle that it may not be noticed. The timeframe for the early
of proteins in the blood that carry cholesterol. The presence of stages is 2 to 4 years.
APOE-e4 increases the risk of developing the disease, including In the middle stages (S to 6), the clinical manifestations of
developing the disease at an earlier age; however, the presence the disease become more pronounced with moderate to se-
of this gene does not mean development of the disease is cer- vere cognitive decline. The client may experience inability to
tain. Individuals who inherit a copy of the APOE-e4 gene are recognize close family or friends, impairment of cognitive
simply at increased risk for developing Alzheimer’s. If the functions, disorientation to person, place, and time, agita-
individual inherits two copies of the gene (one from each par- tion, confusion, possible paranoia hallucinations, and delu-
ent), he or she has an even greater risk of developing the dis- sions. Affected individuals may wander away from their reg-
ease; however, again inheriting the APOE-e4 gene is not a ular environment and become lost; they may experience
guarantee that the individual will develop Alzheimer’s disease. mood swings and exhibit aggressive behaviors. The individ-
Additional risk factors, modifiable in nature, have been ual’s lack of concern about personal hygiene and appearance
identified as increasing the risk for the development of also become more noticeable.
Alzheimer’s disease. Modifiable risk factors include the pres- In the final late stage (stage 7), impairment is severe. Clients
ence of cardiovascular disease risk factors (e.g., smoking, are unable to interact with or respond to their environment.
 Chapter 7 «= The Client With Alterations in Neurological Function 341

They become bedridden and are totally dependent upon others severe stages. The fifth medication, memantine + donepezil,
for activities of daily living. They are unable to carry on a approved for use in moderate to severe Alzheimer’s combines
conversation and have no recognition of self or others. This a cholinesterase inhibitor with memantine. Other medica-
stage lasts until the individual dies. On average, people with tions may be used in conjunction with these medications to
Alzheimer’s live 8 years after diagnosis but may survive any- control the symptoms of insomnia, agitation, depression,
where from 3 to 20 years. and anxiety.
There is no cure for Alzheimer’s disease. Treatment fo- This care plan focuses on the adult client with
cuses on retaining memory, cognitive and physical func- Alzheimer’s disease who has been hospitalized. How-
tioning, and slowing the progression of the disease. Drug ever, much of the information is also applicable to
therapy consists of five medications that have been ap- clients with dementia who are receiving follow-up care
proved by the US Food and Drug Administration: donepezil in an extended care facility or home setting.
(Aricept), rivastigmine (Exelon), galantamine (Razadyne),
memantine (Namenda), and the combination memantine +
donepezil (Namzaric). Three of the five available medica- OUTCOME/DISCHARGE CRITERIA
tions are cholinesterase inhibitors (donepezil, galantamine,
rivastigmine) that prevent the breakdown of a chemical The client will:
messenger in the brain important for learning and memory. . Maintain cognitive functioning as long as possible
Both galantamine (Razadyne) and rivastigmine (Exelon) are . Have a decline in number of wandering incidents
approved for the treatment of mild to moderate stages of Have minimal episodes of aggressive behavior
Alzheimer’s while donepezil (Aricept) is approved for use in Avoid behaviors that may harm self or others
the treatment of all stages. Memantine regulates the activity . Participate in activities of daily living
of a different chemical messenger also important for learn- . Engage in appropriate social interaction with others
ing and memory and is approved for use in moderate to Engage in a regular exercise program

TE CHRONIC CONFUSION nox |

Definition: Irreversible, progressive, insidious, and long-term alteration of intellect, behavior, and personality, manifested by
impairment in cognitive functions (memory, speech, language, decision making, and executive function), and
dependency in execution of daily activities.

Related to: Degeneration of the CNS and cognitive functioning

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Inaccurate interpretation of environment and time; short-
term/long-term memory loss; alteration in behavior (e.g.,
lability, hostility, irritability, inappropriate affect); inability
to make decisions or problem solve; changes in attention
span; disorientation; inappropriate social behavior; pro-
gressive cognitive impairment

RISK FACTORS DESIRED OUTCOMES

e Physiologic changes from progression of Alzheimer’s
The client will:
disease
a. Remain calm and display minimal aggressive behaviors
b. Have limited disorientation to person, place, and time

NOC OUTCOMES NIC INTERVENTIONS

Agitation level; cognition; cognitive orientation; distorted Calming technique; memory training; reality orientation;
thought self-control; safe wandering; information processing environmental management; behavioral management

NURSING ASSESSMENT RATIONALE

Assess for episodes of disorientation to person, place, and time, Early recognition of signs and symptoms of confusion allows for
episodes of inappropriate behavior, impaired decision- prompt intervention.
making ability, impaired memory and judgment, delusions,
impaired attention span.

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THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain client orientation to person,
place, and time:
e Maintain a structured environment with routine activities, A predictable environment helps client maintain a sense of security.
while continuing to monitor the client.
e Orient to person, place, and time frequently. D ® + Frequent orientation may help improve client’s sense of orientation.
e When speaking to the client, use his/her name. D @ + Use of the client’s name during communication decreases potential
for misunderstanding.
e Place familiar objects and personal belongings of the client Having familiar objects in the client’s room increases client’s sense
in his/her room. D @/+ of security and comfort level in a strange environment.
e When interacting with the client, maintain a calm These actions improve potential for client understanding and
demeanor, speak slowly, and maintain eye contact. D @ + demonstrates respect.
e Give client information and/or directions in a simple man- Clients’ ability to process information decreases as the disease
ner. Provide only one piece of information at a time. progresses. They are unable to process more than one piece of
information at a time.
e Refer to current events when interacting with the Discussion of current events grounds client in the present and helps de-
client. D@ + crease disorientation, because client is not focusing on unreal events.
e Allow client time to formulate responses to questions Allowing time for client responses demonstrates respect, encourages
and during interactions. Allow for periods of silence by the a response, and helps improve communication.
client. D @ + With progression of the disease, the client may have difficulty pro-
cessing information and formulating an appropriate response.
e Use attentive listening when interacting with the client even
when what is being said is confusing or gibberish. D @
e Allow hoarding of objects as long as they will not be harm- Allowing client to horde objects provides a sense of security.
ful to the client. D @ +
e Allow client to interact with other patients, while moni- Allows the nurse to observe client’s social interaction.
toring client for inappropriate behavior.
e Monitor for cyclic changes in cognition and behaviors Cyclic changes in cognition indicate client may be experiencing
(e.g., wandering, hoarding items, evening confusion, pick- “sundowner” syndrome.
ing at clothing).
e Maintain client on an appropriate schedule for sleep and Maintaining a schedule for the client decreases incidence of fatigue
rest. Turn off lights when client is in bed. Use a nightlight and promotes a sense of well-being.
if needed. D @+

|Nursing =
Diagnosis |WANDERING nox
Definition: Meandering, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruent with
boundaries, limits, or obstacles.

Related to:
e Alteration in cognitive function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of “wanting to go home” and or threat- Appears frightened; weeping; pacing; searching behaviors;
ening to leave shadowing a caregiver’s locomotion; long periods of loco-
motion without an apparent destination; impaired ability
to locate landmarks in a familiar setting; hyperactivity;
continuous movement from place to place

RISK FACTORS DESIRED OUTCOMES

e Alteration in sleep-wake cycle
The client will not experience wandering as evidenced by:
e Overstimulating environment
a. No reported occurrences of leaving institution/
e Desire to go home
residence unattended
e Separation from familiar environment
b. No reported attempts to leave secure area

NOC OUTCOMES NIC INTERVENTIONS

—_—
ees

Elopement occurrence; elopement propensity risk Elopement precautions; environmental management safety
 Chapter 7 * The Client With Alterations in Neurological Function 343

NURSING ASSESSMENT RATIONALE

Assess Client’s cognitive functioning (e.g., disorientation) Early recognition of signs and symptoms of altered cognitive function
(e.g. confusion, identity confusion, impaired judgement, loss of
short-term or long-term memory) allows for prompt intervention.
Assess client’s potential for elopement: Early recognition of elopement behaviors allows for prompt inter-
¢ Verbal indicators vention.
e Loitering near exits
° Wearing of multiple layers of clothing
° Packing belongings
e Homesickness

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to decrease client anxiety.
° Familiarize client with the environment. Familiarizing client with the environment and related routines can
e Provide reassurance/comfort. reduce anxiety associated with risk for elopement.
e Encourage client to seek care providers for assistance when Discussing feelings the client may be experiencing may decrease
experiencing feelings that may lead to elopement (e.g., anxiety/fear and reduce the risk of elopement.
anxiety, anger, fear).
Implement measures to decrease the risk of elopement: Implementing measures to reduce risk for elopement may also prevent
e Limit client to a physically secure environment as needed. client injury/harm.
e Provide appropriate level of supervision to monitor client. Reduces the risk for elopement.
Increasing supervision when client is outside the secure
environment.
e Provide adaptive devices (e.g., side rails, restraints) while Use of adaptive devices such as restraints help limit client’s exposure
maintaining the least restrictive environment as possible. to harmful situations. When using restraints, appropriate justifi-
cation must be documented including efforts to use alternative
measures (e.g., sitters) before the decision to implement restraints.
e Provide adaptive devices that monitor client’s remote loca-
tion (e.g., electronic sensors that trigger alarms or locks).
Record client physical descriptors: Physical descriptors will be helpful to reference in the event of
° Height/weight elopement.
° Hair/eye/skin color
Engage the client in structured activities appropriate for setting
(e.g., music therapy, reading, painting, drawing).
Educate family/caregivers regarding risk factor for patient Client’s with memory problems are at risk for wandering—even in
elopement and strategies to reduce risk for wandering in the early stages of dementia.
the home environment.
e Identify times of day wandering most likely to occur.
e Avoid busy places that may cause confusion.
° Place locks out of the line of site.
e Use motion detectors/devices that trigger when a door or
window is opened.
° Keep car keys out of sight.
Assist family/caregivers in the development of a plan to be The stress experienced by family members/caregivers during a wan-
implemented in the event of elopement: dering episode is significant. Having a plan in place in advance
e Keep emergency list of who to call for help. will help focus recovery efforts potentially reducing the risk for
e Ask neighbors, friends, or family to call if they see client alone. injury/harm.
° Keep a recent, close-up photo and updated medical infor-
mation on hand.
e Know the local neighborhood/areas where client may be
easily lost.
° Keep a list of the places the client may wander (e.g., past
jobs, former homes, place of worship, restaurants).
e Know client’s dominant hand.
e Provide client with ID jewelry.
e If elopement occurs, search area for no more than 15 min-
utes before contacting 911.

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 344 Chapter 7 =" The Client With Alterations in Neurological Function

Nursing Diagnosis SELF-CARE DEFICIT: DRESSING, BATHING, FEEDING,

AND TOILETING nox
Definition: Self-Care Deficit: Dressing NDx: Inability to independently put on or remove clothing; Self-Care Deficit: Bathing
NDx: Inability to independently complete cleansing activities; Self-Care Deficit: Feeding NDx: Inability to eat
independently; Self-Care Deficit: Toileting NDx: Inability to independently perform tasks associated with
bowel and bladder elimination.
Related to:
e Inability to make decisions
e Loss of cognitive understanding
e Altered thought processes
e Difficulty in processing information

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of problem Inability to determine what to wear; inability to feed self;
inability to run bath water or clean self after micturition or
defecation

RISK FACTORS DESIRED OUTCOMES

e Neuromuscular impairment
The client will be able to perform activities of daily living
e Altered cognitive functioning
as evidenced by:
e Impaired ability to perceive spatial relationships
a. Ability to appropriately dress and groom self with no
or minimal assistance
b. Ability to feed self with no or minimal assistance
c. Ability to care for personal hygiene with no or minimal
assistance

NOC OUTCOMES NIC INTERVENTIONS

Self-care: activities of daily living; bathing, dressing, eating, Self-care assistance: bathing, dressing/grooming, feeding,
hygiene, toileting toileting

NURSING ASSESSMENT RATIONALE

Assess Cclient’s current self-care habits. Provides a baseline of client’s ability and where interventions
should be implemented.
Assess client’s cognitive and physical ability to perform self- When a client’s cognitive abilities are impaired, the client is unable
care habits. to determine self-care needs.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to involve client in activities of daily
living: D ®+
e Allow client time for dressing and bathing in a quiet envi- Allowing a client time for ADLS in a quite environment decreases
ronment. the client’s stress and frustration.
e Follow a consistent routine for bathing, dressing, and Routines may prevent confusion, require less decision-making, and
grooming. may decrease client’s frustration.
e Assist as needed in bathing and perineal care. Appropriate bathing and perineal care helps prevent skin break-
down.
e Limit clothing choices by putting together complete out- Limiting choices decreases frustration if clothing is easy to put on
fits that are easy to put on and to take off. and remove. |
e Lay out or give client clothing in the order in which it will When helping a client dress, this establishes a routine and simpli-
be put on. Start with the bottom half and then top half. fies the dressing process.
 Chapter 7 = The Client With Alterations in Neurological Function 345

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client independence when dressing; provide Preserves client’s independence as long as possible.
assistance as needed.
° Assist client in selecting foods that will provide appropri- Client self-selection of food helps maintain client’s nutritional sta-
ate nutrients. Allow client to choose foods he/she likes. tus and decreases frustration if client receives foods he/she likes.
e If assisting client, serve only two foods at a time. Keeping food selections to a minimum decreases frustration because
client may not be able to decide which food to eat first.
e Place food in a bowl rather than on a plate, or offer finger A bowl is easier for the client to eat from and helps maintain client’s
foods if client has impaired coordination. independence and decreases frustrations in trying to feed self.

|Nursing 2)
Diagnosis |IMPAIRED HOME MAINTENANCE nox
Definition: Inability to independently maintain a safe and growth-promoting immediate environment.

Related to:
e Alteration in cognitive functioning

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty in maintaining household; Impaired ability to maintain home; unsanitary/unhygienic
family member request for assistance in caring for the environment
client in their home

RISK FACTORS DESIRED OUTCOMES

e Insufficient support systems
The client will not experience impaired home mainte-
e Financial crisis
nance as evidenced by:
e Insufficient knowledge of neighborhood resources
a. Maintains a clean and safe home
e Insufficient knowledge of home maintenance
b. Use of neighborhood resources
c. Engaged support systems (family/friends)

NOC OUTCOMES NIC INTERVENTIONS

Family functioning; safe home environment; social support Family involvement promotion; home maintenance assistance

NURSING ASSESSMENT RATIONALE

Assess client’s sensory, motor, and cognitive functioning. Early recognition of signs and symptoms that client is not able to
Assess Cclient’s ability to maintain a safe household (e.g., abil- independently maintain his/her household without assistance
ity to lock doors at night, smell smoke, recognize safety allows for prompt intervention.
hazards).
Assess ability of family to support client in the home environ-
ment.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Develop a plan for home maintenance with family and client:
e Implement measures to maintain client safety in his/her This equipment provides security and may decrease wandering
home: activities.
e Encourage family to install smoke detectors, a security
system, and easy-to-use door locks.
e Encourage client to wear a medic alert bracelet. Helps client be quickly identified ifclient becomes lost.
e Assist client and family to develop a sleep/rest schedule. Schedules help decrease client’s fatigue, which may increase client’s
coping abilities.

~ NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation
346 Chapter 7 * The Client With Alterations in Neurological Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client and family members to identify safety con- These actions help protect the client from injury.
cerns in the home (e.g., lots of throw rugs, poor lighting).
e Install child safety devices to prevent client from wander-
ing into areas where injury might occur (e.g., decks, swim-
ming pools, stairs).
e Assist family in identifying community support services Community support assists caregivers in caring for the client and
(e.g., Meals on Wheels, adult day care, support groups, promotes client independence.
respite services).

Susceptibility to difficulty in fulfilling care responsibilities,

expectations, and/or behaviors for family or significant others,
which may compromise health.

ADDITIONAL NURSING DIAGNOSES

IMPAIRED SOCIAL INTERACTIONS NDx RISK FOR INJURY NDx

Related to: Related to:
e Alterations in cognition e Alteration in cognitive functioning
e Memory deficits e Alteration in psychomotor functioning
e Impaired judgment
e Inappropriate, hostile, and bizarre behaviors GRIEVING NDx
Related to:
e Awareness of disease and disease progression

CEREBROVASCULAR ACCIDENT
A cerebrovascular accident (CVA, stroke, brain attack) is the stroke within 1 year. As many as 10% to 15% of people will
result of an interruption in the blood flow in areas of the brain have a major stroke within 3 months of experiencing a TIA.
and is characterized by the sudden development of neurologi- This care plan focuses on the adult client hospital-
cal deficits. These deficits range from mild symptoms such as ized with signs and symptoms of a CVA. Much of the
tingling, weakness, and slight speech impairment to more se- information is also applicable to clients receiving
vere symptoms such as hemiplegia, aphasia, dysphagia, loss of follow-up care in an extended care or rehabilitation
portions of the visual field, spatial-perceptual changes, altered facility or home setting. This care plan focuses on the
cognitive function, and loss of consciousness. Clinical manifes- more common problems that occur as a result of a
tations depend on factors such as the area(s) of the brain af- CVA. The reader should refer to neurological texts for
fected, the adequacy of collateral cerebral circulation, and the additional information about specific speech, motor,
extensiveness of subsequent cerebral edema. and sensory deficits that can occur.
CVAs are classified according to etiology. The major clas-
sifications are ischemic and hemorrhagic. Ischemic CVAs are
most frequently the result of a thrombosis (which is usually OUTCOME/DISCHARGE CRITERIA
associated with atherosclerosis) or an embolus. Conditions
most often associated with a hemorrhagic CVA are extreme The client will:
hypertension, cerebral aneurysm, or arteriovenous malforma- 1. Have improved or stable neurological function
tion. Treatment after a CVA is determined by the etiology and . Have no signs or symptoms of complications
the neurological deficits that are present. Transient ischemic nd . Identify ways to manage
Ww sensory and speech impairments
attacks (TIAs), sometimes referred to as “mini strokes,” differ and disturbed thought processes
from major types of cerebrovascular accidents in that blood 4. Identify ways to improve ability to swallow
flow to the brain is interrupted for a short time usually no 5. Identify ways to manage urinary incontinence
more than 5 minutes. More than one-third of people that 6. Demonstrate measures to facilitate the performance of
experience a TIA and do not get treatment experience a major activities of daily living and increase physical mobility
 Chapter 7 = The Client With Alterations in Neurological Function 347

7. Communicate an awareness of signs and symptoms to re- 9. Develop a plan for adhering to recommended follow-up
port to the health care provider and share thoughts and care including regular laboratory studies, future ap-
feelings about the effects of the CVA on lifestyle, roles, and pointments with health care providers, and medications
self-concept prescribed.
8. Communicate knowledge of community resources that
can assist with home management and adjustment to
changes resulting from the CVA

“7 DECREASED INTRACRANIAL ADAPTIVE CAPACITY nox

Definition: Compromise in intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial
volumes, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety
of noxious and non-noxious stimuli.
Related to: Changes in the CNS blood flow associated with thrombus, bleeding, alterations in blood pressure, and/or hypoxia

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of headache Increases in ICP for greater than 5 minutes after stimuli;
baseline ICP greater than 10 mm Hg; altered level of con-
sciousness (early); changes in vital signs/cardiac rhythm
(late), changes in papillary response, generalized weakness;
Positive Babinski sign, seizures

RISK FACTORS DESIRED OUTCOMES

* Brain injury The client will demonstrate improved neurological status
e Decreased cerebral perfusion <S0 to 60 mmHg as evidenced by:
e Sustained increase in ICP of 10 to 15 mm Hg a. Stable/normalized ICP
e Systemic hypotension with intracranial hypertension b. Absence of seizures

NOC OUTCOMES NIC INTERVENTIONS

Neurological status: autonomic; central motor control; ICP monitoring; cerebral perfusion promotion; cerebral
consciousness edema management; tube care: ventriculostomy; seizure pre-
cautions

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms of increased intracranial As ICP increases, neurological assessment will change.
pressure: Most sensitive indicator of increased ICP is level of consciousness.
° Self-report of headache
Changes in level of consciousness
Changes in pupillary response
e Positive Babinski Reveals upper motor neuron lesion indicating corticospinal tract
injury.
e Generalized weakness
e Seizures
e Assess vital signs for the presence of Cushing triad
e Assess ICP and cerebral perfusion pressure (CPP) Irregular breathing, widening pulse pressure, and decreased heart
rate (Cushing triad) are late signs of increased ICP.
Assessing for values indicating elevation of ICP and decreases in
cerebral perfusion pressure allow for prompt intervention. Eleva-
tions of ICP can indicate deterioration in neurological status.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN © = Goto ©volve for animation
348 Chapter7 = The Client With Alterations in Neurological Function

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain or decrease increased intra- Elevations in PaCO; can lead to cerebral vasodilation, which further
cranial pressure. increases ICP.
e Maintain patent airway.
e Maintain neutral neck position. Elevate head of bed no Neutral head position and head elevation both facilitate venous
more than 30 degrees avoiding extreme hip flexion. D + drainage of head and aid in lowering ICP.
e Do not group caregiving activities such as bathing, suc- Spacing activities minimizes sustained elevations in ICP.
tioning, and dressing changes. D @
e Institute seizure precautions: Seizures are possible with elevated ICP, and client safety must be
° Keep Ambu bag at bedside considered.
e Keep oral/nasopharyngeal airway at bedside
° Keep side rails up

Dependent/Collaborative Actions
Administer medications such as osmotic diuretics, loop Medications act to reduce swelling of cerebral tissues or volume of
diuretics, and corticosteroids. cerebrospinal fluid (CSF), thereby decreasing ICP.
Administer anticonvulsants as ordered. In the presence of increased ICP, anticonvulsants may be ordered to
prevent seizures.
Drain CSF fluid via ventriculostomy as ordered. Draining CSF fluid via ventriculostomy reduces the volume of CSF
¢ Monitor amount, rate, and characteristics of CSF drainage. fluid in the head, lowering ICP. CSF fluid should be clear presence
of blood or cloudy appearance can indicate further complications
and/or the presence of infection.
Consult physician if signs and symptoms of increased intra- Notifying the physician allows for modification of the treatment
cranial pressure persist. plan

Nursing Diagnosis RISK FOR INEFFECTIVE CEREBRAL TISSUE PERFUSION nox

Definition: Susceptible to a decrease in cerebral tissue circulation, which may compromise health.
Related to:
e Embolism
° Coagulopathy
¢ Cerebral aneurysm
° Carotid stenosis
e Hypertension

CLINICAL MANIFESTATIONS

Subjective Objective
May not be able to self-report symptoms; verbal self-report Altered neurological status; altered level of consciousness;
of headache changes in motor response; behavioral changes; changes in
pupillary reactions; difficulty swallowing

RISK FACTORS DESIRED OUTCOMES

iene
Ng irseat eet clare ay
° Trauma The client will improve cerebral tissue perfusion as
e Recent myocardial infarction evidenced by:
a. Improved or return to client’s baseline neurologicakstatus
b. Improved or return to client’s baseline sensory and mo-
tor function

NOC OUTCOMES NIC INTERVENTIONS

ee eee
Neurological status: consciousness; cranial sensory/ Cerebral perfusion promotion; neurological monitoring;
motor function; tissue perfusion: cerebral seizure precautions
 Chapter 7 = The Client With Alterations in Neurological Function 349

NURSING ASSESSMENT RATIONALE

Assess neurological status hourly (or more frequently as con- Provides baseline assessment data and determines signs of de-
dition warrants) during acute phase (e.g., dizziness, visual creased tissue perfusions. Changes may be reflective of increased
disturbances, aphasia, irritability, restlessness, decreased intracranial pressure.
level of consciousness, paresthesias, weakness, paralysis,
seizure activity).
Assess vital signs hourly or more frequently as indicated dur- Vitals signs must be maintained at a level that supports adequate
ing the acute phase. oxygenation and perfusion of cerebral tissues.
Assess baseline prothrombin time (PT) and partial thrombo- Assessment of baseline values allows for modification of the treat-
plastin time (PTT). ment plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to promote increased cerebral tissue perfu- Increased intracranial pressure reduces blood flow to the brain be-
sion (e.g., encourage client to not cough, avoid neck flex- cause of the closed nature of the skull. Coughing causes an in-
ion or extreme hip or knew flexion). crease in intracranial pressure while extreme neck flexion pre-
vents venous drainage from the brain further risking increased
intracranial pressure decreasing cerebral tissue perfusion.
Client positioning should ensure patent airway and effective gas
Ensure client positioning facilitates a patent airway and opti- exchange. Optimum elimination of carbon dioxide with effec-
mum gas exchange. tive ventilation/patent airway is necessary to prevent vasocon-
striction, further reducing perfusion to the brain.

Dependent/Collaborative Actions
Implement measures to improve cerebral tissue perfusion:
e Maintain blood pressure (B/P) within optimum range us- B/P must be maintained within optimum range to keep cerebral
ing antihypertensive, sympathomimetics, and/or fluid perfusion pressure at a level that promotes oxygenation of cere-
therapy (volume expansion). bral tissues. Exact values may vary.
e Administer calcium channel blockers. Calcium channel blockers reduce cerebral vasospasm, which im-
proves perfusion to the cerebral tissues.
e Administer anticoagulant, antiplatelet and/or thrombo- Anticoagulant, antiplatelet, and/or thrombolytic therapy reduces or
lytic therapy. prevents clot formation, which restores blood flow to the brain.
e Consult with physician to determine optimal head of bed Elevation of the HOB improves venous drainage and reduces intracra-
(placement). nial pressure. Type of injury and location in the brain determines
optimum head elevation and should be determined by the physician.

|Nursing “RISK
Diagnosis | FOR ASPIRATION nox
Definition: Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the
tracheobronchial passages, which may compromise health.

Related to: Changes in neuromuscular functioning

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Cough; tachypnea; dyspnea; tachycardia; dull percussion
noted over affected lung area; presence of food in aspirate

RISK FACTORS DESIRED OUTCOMES

e Reduced level of consciousness The client will not aspirate secretions or foods/fluids as
e Depressed cough and gag reflexes evidenced by:
e Impaired swallowing in an acute neurological insult a. Clear breath sounds
b. Resonant percussion over lungs
c. Absence of cough, tachypnea, and dyspnea

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
350 Chapter 7 * The Client With Alterations in Neurological Function

NOC OUTCOMES NIC INTERVENTIONS

Ce eee ee eee eee ee ee

Respiratory status Aspiration precautions; respiratory monitoring; swallowing

therapy

NURSING ASSESSMENT RATIONALE

Assess level of consciousness. Alterations in level of consciousness place a patient at risk for
aspiration.
Assess for the presence of a cough or gag reflex. Lack of protective reflexes places patient at risk for aspiration.
Assess for the presence of nausea or vomiting. Increases the risk of aspiration of gastric contents in the setting of
an acute neurological event.
Assess respiratory system for signs and symptoms of aspira- Early recognition of objective assessment findings allows for
tion of secretions or foods/fluids: prompt treatment and recognition.
e Auscultate breath sounds for wheezes or crackles.
Monitor chest radiograph results. Evidence of pulmonary infiltrates on chest radiograph results can
indicate that aspiration has occurred.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for aspiration:
e Keep suction equipment readily available at bedside. Necessary to maintain patency of airway.
e Place conscious, impaired patient in a side-lying position Oral secretions accumulate in the mouth, allowing for easier expec-
unless contraindicated. D@ + toration or removal by suctioning.
e Position patient in high-Fowler’s positions before initiating This position uses gravity to facilitate movement of food/fluids
feeding. Maintain patient in an upright position 30 to 45 through the pharynx into the esophagus.
minutes after eating. D @
e Supervise administration of oral intake. D > Supervision allows for observation of potential swallowing diffi-
culty and implementation of actions to improve swallowing.
e Offer foods with a thicker consistency, which facilitates Semisolid foods are more readily swallowed. Thin fluids are diffi-
swallowing. D + cult for patients with dysphagia to manage.
e Place foods/medications on unaffected side of the mouth. Chewing on the unaffected side of the mouth facilitates effective
De+ swallowing of food.
e Encourage eat slowly and to client to thoroughly chew Taking adequate time to eat, thoroughly chewing food, makes food
food. D easier to swallow, and decreases incidence of aspiration.
e Provide oral care after feedings. Good oral hygiene and inspection of the oral cavity after meals
e Inspect for “pocketing” of food. D @ + results in removal of any remaining food that could enter the
pharynx and be aspirated into the lungs.

Dependent/Collaborative Actions
Administer prokinetic agents as ordered. D + Prokinetic agents enhance gastric motility.
Consult appropriate health care provider for swallowing dif- Dysphagia assessment can establish techniques to prevent aspira-
ficulties. tion in patients with impaired swallowing.

| ~Nursing «UNILATERAL
Diagnosis NEGLECT nox
Definition: Impairment in sensory and motor response, mental representation, and spatial attention of the body, and the
corresponding environment, characterized by inattention to one side and overattention to the opposite side.
Left-side neglect is more severe and persistent than right-side neglect.
‘
Related to: Ischemia primarily of the parietal lobe of the nondominant cerebral hemisphere
 Chapter7 = The Client With Alterations in Neurological Function 351

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of feeling as though one part of the body Inattention to stimuli applied to affected side; lack of
does not belong to own self awareness of affected side/inattention to safety; failure to
use the affected side after being reminded to do so; failure
to notice people approaching from the neglected side;
marked deviation of the eyes to the non-neglected side to
stimuli and activities on that side

RISK FACTORS DESIRED OUTCOMES

e Stroke The client will experience a reduction in and/or demonstrate
e Smoking beginning adaptation to unilateral neglect as evidenced by:
e Hypertension a. Awareness of stimuli on affected side
b. Awareness of the affected side of the body

NOC OUTCOMES NIC INTERVENTIONS

Sensory function: proprioception; self-care activities of daily Unilateral neglect management; self-care assistance; self-care
living; body positioning: self-initiated assistance: transfer

NURSING ASSESSMENT RATIONALE

Assess baseline mental status including comprehension. Determines ability of client to understand information and follow
instructions.
Assess for presence of unilateral neglect: Determines extent of impairment and how the patient acknowl-
e Client responses to sensory stimuli bilaterally (visual, tactile) edges senses on the affected side.
e Distorted spatial-perceptual relationships
e Denial of body parts (have client point to body parts) Determines the lack of recognition of body parts or distorted aware-
ness of body parts; important to identify plan safe care of the
patient.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If unilateral neglect is present:
e Ensure affected extremities are positioned properly at all Protects extremities from development of contractures.
times. D@ +
e Protect affected extremities from pressure/injury/burns. Lack of extremity recognition increases risk of injury.
De+
Provide active/passive range of motion. Range-of-motion activities promote circulation in affected extremities.
e Touch and move affected extremities. D @ >
Encourage client to touch and use affected body part. Provision ofsensory stimulation can help client experience normal
movement patterns.
e Approach patient from unaffected side during acute phase. Diminishes fear and anxiety in a client with difficulty in interpret-
De¢+ ing the environment in its entirety.
Provide mirror for client during self-care activities. D @ + Use of a mirror helps improves recognition of affected side.
Gradually focus client’s attention to affected side as client Following the acute phase, to enhance recovery and improve aware-
demonstrates ability to compensate for neglect: ness of the client’s recovering side, begin activities to increase
e Gradually move personal items to affected side. D @ > awareness of the neglected side.
e Stand on affected side when ambulating with client. D @ +>
e Assist with activities of daily living from affected side Placing items on the affected side assists the client to recognize that
including bathing and grooming. D@ + the extremities are part of his/her body.
° Assist patient to groom on affected side.
e Focus tactile and verbal stimulation on affected side. D@ >

Dependent/Collaborative Actions
Consult physical therapy/occupational therapy as appropriate. PT/OT can prescribe exercises that aid the client in client develop-
ment of adaptive skills.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP > =LVN/LPN © = Go to @volve for animation
 352 Chapter 7 = The Client With Alterations in Neurological Function

|Nursing =>)
Diagnosis |IMPAIRED VERBAL COMMUNICATION nox

Definition: Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.

Related to: Damage to Broca motor (expressive) or Wernicke (receptive) speech centers in the brain

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty expressing self Unable to speak dominant language; speaks or verbalizes
with difficulty; cannot speak; slurring/stuttering; difficulty
forming words and sentences; difficulty in comprehending
statements

RISK FACTOR DESIRED OUTCOME

e Central nervous system impairment The client will communicate needs and desires effectively.

NOC OUTCOMES NIC INTERVENTIONS

Communication: receptive; communication: expressive Communication enhancement: speech deficit; active listening

NURSING ASSESSMENT RATIONALE

Assess for motor speech impairment or difficulty forming Provides a baseline assessment of client’s impairment.
words (expressive).
Assess for inability to understand words (receptive). Type of impairment will depend on area of the brain involved.
Assess for total loss of ability to comprehend and speak
(global aphasia).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to facilitate communication:
e Approach communication with client as an adult. D @ Approaching the client in this manner prevents startling the client.
e Ask questions that require short answers and allow time The client will need more time to process information. Short, sim-
for the patient to respond. D @ + ple answers will reduce client’s frustration, allowing for easier
communication.
e Face client when speaking, using short statements, speak- Facing the client when speaking enhances understanding and
ing slowly, and presenting one thought at a time. D @ + allows client to concentrate on one thing at a time.
Create a calm, quiet environment. D @ + In a quiet environment, the client can concentrate on communica-
Provide rest periods before speech therapy. tion efforts, does not have to speak loudly, and is able to hear
others more clearly.
Rest periods help conserve client’s energy to maximize communica-
tion ability during therapy.
Provide assistive communication aids such as pad/pencil, Communication aids help facilitate communication.
computer, word cards, or picture boards. D @
e Encourage family to communicate with patient. D + Family involvement will reinforce consistency of communication
measures.

Dependent/Collaborative Actions
Consult speech pathologist. Multidisciplinary plan of care can be developed.

Nursing Diagnosis SELF-CARE DEFICIT nox (BATHING, FEEDING, DRESSING, TOILETING)

Definition: Self-Care Deficit: Bathing NDx: Inability to independently complete cleansing activities; Self-Care Deficit:
Feeding NDx:
Inability to eat independently; Self-Care Deficit: Dressing NDx: Inability to independently put on or
remove clothing;
Self-Care Deficit: Toileting NDx: Inability to independently perform tasks associated with bowel and bladder
elimination.
Related to:
e Impaired physical mobility
e Visual and spatial-perceptual impairments
e Apraxia
e Unilateral neglect
e Disturbed thought processes
 Chrapternyaua The Client With Alterations in Neurological Function 353

CLINICAL MANIFESTATIONS
a
Subjective Objective
Verbal self-report of inability to independently bath, feed, Inability to prepare food, handle or use containers and/or
dress, or complete tasks associated with toileting. utensils; inability to handle a glass or cup; inability to
bathe or access the bathtub or shower; inability to dress
self, use button closures; inability to get to the toilet or
manipulate clothing; inability to provide appropriate per-
sonal hygiene

RISK FACTORS DESIRED OUTCOME

e Weakness The client will perform self-care activities within cognitive
e Loss of neuromuscular activity and physical limitations.
e Bed rest
NOC OUTCOMES NIC INTERVENTIONS
Self-care: activities of daily living Self-care assistance; self-care assistance: bathing, dressing/
grooming, feeding, toileting; exercise therapy: ambulation,
balance, joint mobility, muscle control

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to perform activities of daily living: Identification of client’s self-care deficits will guide the nurse in the
e Dressing development of the plan of care.
e Toileting
e Preparing food
e Eating
e Providing hair and/or nail care

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Interventions
Implement additional measures to facilitate client’s ability to
perform self-care activities:
e If apraxia is present, explain and demonstrate use of Demonstrating the skill while explaining it will help the client in
items such as toothbrush, comb, and washcloth as often relearning skills for activities of daily living.
as necessary.
e Encourage client to wear eyepatch or opaque lens if diplo- Without an eyepatch, client will be unable to correctly focus on
pia is present. and/or have difficulty in using objects necessary for activities of
daily living.
e Perform actions to enable client to feed self:
e Place foods/fluids within client’s visual field until client Food/fluids should be placed where client can easily see it.
learns to effectively use scanning techniques. D @ +
e Place only a few items on the tray at one time if spatial- When there are too many items on the tray, the client is unable to
perceptual deficits are present. D @ + focus on a specific item.
e Identify where items are placed on the plate and tray The client should know where each item is placed. Cutting food
and open containers, cut meat, and butter bread as into small sizes helps prevent overfilling of the mouth, thus re-
indicated. D@ + ducing the risk for choking.
e Perform actions to enable client to dress self: These actions help the client maintain a degree ofindependence.
e Encourage use of assistive devices such as button
hooks, long-handled shoehorns, and pull loops for
pants.
e Encourage client to select clothing that is easy to put
on and remove (e.g., shirts with zippers or Velcro clo-
sures rather than buttons, loose-fitting clothing, pants
with an elastic waistband or Velcro closures, shoes with
Velcro fasteners or elastic laces).
° If client has difficulty distinguishing right from left,
mark outer aspect of shoes with tape.

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 354 Chapter 7 «= The Client With Alterations in Neurological Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to increase mobility (e.g., turn every Increasing mobility and exercise further facilitates the client’s abil-
2 hrs, perform active and passive range of motion, ambu- ity to perform self-care activities.
late client as able). D @>
e Reinforce exercises and activities recommended by the
occupational therapist to improve fine motor skills.
Assist the client with activities he/she is unable to perform
independently. D @+
Inform significant others of client’s abilities to perform own Encouraging client’s family to allow the client to care for his or her
care. Explain importance of encouraging and allowing self helps the client maintain some degree of independence.
client to maintain an optimal level of independence.

Dependent/Collaborative Interventions
Implement additional measures to facilitate client’s ability to
perform self-care activities:
e Consult with occupational therapist about assistive devices Provides multidisciplinary approach to care.
available (e.g., broad-handled utensils, rocker knife, non-
slip tray mat, plate guard); reinforce use of these devices.

Nursing Diagnosis “ACUTE CONFUSION nox; CHRONIC CONFUSION nox

Definition: Acute NDx: Reversable disturbances of consciousness, attention, cognition and perception that develop over a
short period of time, and which last less than 3 months; Chronic NDx: Irreversible, progressive, insidious, and
long-term alteration of intellect, behavioral and personality, manifested by impairment in cognitive functions
(memory, speech, language, decision-making, and executive function), and dependency in execution of daily
activities.

Related to: Cerebral vascular accident

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Inaccurate interpretation of environment and time; mem-
ory loss; altered mood states (e.g., lability, hostility, irrita-
bility, inappropriate affect); inability to make decisions or
problem solve; changes in attention span; disorientation;
inappropriate social behavior

RISK FACTOR DESIRED OUTCOMES

e Cerebral edema
The client will experience less confusion as evidence by:
a. Improved attention span, memory, and problem-
solving abilities
b. Improved level of orientation
c. Reduction in instances of inappropriate responses

NOC OUTCOMES NIC INTERVENTIONS

Information processing; neurological status: consciousness; Reality orientation; cognitive stimulation; presence; behav-
cognitive orientation; memory ior management i

NURSING ASSESSMENT RATIONALE

ee eeSSSSSSSSSSSSSSSSsSs—S——S———sSsS—
Assess client for changes in level of confusion and orientation Early recognition of signs and symptoms of confusion allows for
(e.g., shortened attention span, impaired memory, de- prompt intervention.
creased ability to problem solve, confusion, inappropriate
response, mood changes).
Ascertain from significant others client’s usual level of cogni-
tive and emotional functioning.
 Chapter 7 The Client With Alterations in Neurological Function 355

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If client shows evidence of confusion and/or disorientation:
e Reorient to person, place, and time as necessary. D @ These techniques help keep client oriented to environment, self,
others, and current reality.
e Address client by name. D@ + Helps client recognize self.
e Place familiar objects, clock, and calendar within client’s Having familiar things surrounding the client increases his/her
view. D ® + comfort level.
e Face client when conversing with client. D @ These techniques will help decrease client’s frustration when com-
e Approach client in a slow, calm manner; allow adequate municating with others.
time for communication. D @+
e Repeat instructions as necessary using clear, simple lan- Repetition of information helps client process information when
guage and short sentences. D@ + thinking is impaired.
e Keep environmental stimuli to a minimum but avoid sen- Overstimulation may cause the client to become anxious or
sory deprivation. D @ + Aggressive.
e Maintain a consistent and fairly structured routine. D @ + Maintenance of a structured routine helps the client maintain ori-
entation and sense of reality.
e Provide written or audio recorded information whenever Written or audio recorded instructions provide a resource for the
possible for client to review as often as necessary. client concerning appropriate care.
e Have client perform only one activity at a time and allow Prevents client from being frustrated with many activities at one
adequate time for performance of activities. D @ + time.
e Encourage client to make lists of planned activities, ques- Provides a mechanism for the client to organize thoughts.
tions, and concerns.
e Implement measures to stop emotional outbursts and in- These techniques help the client refocus and decreases inappropri-
appropriate responses if they occur (e.g., provide distrac- ate responses.
tion by clapping hands, handing client an object to look
at or hold, or turning on the radio or television). D @ +
e Maintain realistic expectations of client’s ability to learn, Don't ask clients to do things beyond their ability. Reinforce infor-
comprehend, and remember information provided. mation as needed.
e Encourage significant others to be supportive of client; Significant others need to learn coping mechanisms and how to
instruct them in methods of dealing with client’s dis- work with client.
turbed thought processes.
e Discuss physiological basis for disturbed thought processes Understanding what occurred helps the client and significant others
with client and significant others; inform them that cogni- work toward improving cognitive and emotional functioning.
tive and emotional functioning may improve gradually
during the next 6 to 12 months.

Dependent/Collaborative Interventions
e Consult physician if disturbed thought processes worsen. Notifying the physician allows for modification ofthe treatment plan.

>.)
|Nursing »Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT npx; OR INEFFECTIVE HEALTH MAINTENANCE* nox

Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal requests for information; client statements reflect
Inadequate follow-through of instruction; inappropriate
misunderstanding or exaggerated behaviors

teaching.
*The nurse should select the diagnostic label that is most appropriate for the client’s discharge

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 356 Chapter7 * The Client With Alterations in Neurological Function

RISK FACTOR
¢ Cognitive limitations or unfamiliarity of situation

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen; health Teaching: individual; teaching: disease process; teaching:
resources psychomotor skills; teaching: prescribed activity

NURSING ASSESSMENT RATIONALE

Assess for stroke-related factors that may impede the learning Client may not be emotionally or physically able to learn.
process.
Assess client/family understanding of disease process. The nurse’s understanding of the client’s and significant other’s
knowledge-based aids in formulating an educational plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will communicate an aware-

ness of ways to decrease the risk of a recurrent CVA.

Independent Actions
Assist client in recognizing factors that contributed to the Knowledge of disease process and how to decrease the impact of
stroke (e.g., hypertension, elevated serum lipids, diabetes, risk factors helps the client and family understand what life-
atrial fibrillation, use of oral contraceptives). style changes decrease the incidence of a recurrent CVA.
Identify appropriate actions that client can take to decrease risk
of a recurrent CVA (e.g., take medications as prescribed, de-
crease stress, stop smoking, modify diet, adhere to medical
treatment, plan to control hypertension and diabetes, use
another form of birth control if taking oral contraceptives).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

sensory and speech impairments and disturbed thought processes.

Independent Actions
Instruct client regarding ways to adapt to visual impairments: These interventions reduce the risk of injury from a visual deficit.
e Use scanning techniques if visual field cut is present.
e Arrange home setting so that when in favorite chair or bed,
stimuli other than wall or furniture are within visual fields.
e Wear eye patch or opaque lens if double vision persists.
Reinforce use of established communication techniques and Continued use ofestablished communication techniques helps the
continuation with speech therapy if indicated. client maintain current level of functioning.
If client is experiencing spatial perceptual deficits and/or uni- Decreases client frustration and risk for injury.
lateral neglect, stress need for assistance with usual daily
activities and strict adherence to safety measures.
Reinforce methods of adapting to impaired memory and This helps foster independence and decreases client’s frustration
shortened attention span (e.g., make lists of planned ac- with changes due to illness.
tivities, review taped or written instructions frequently).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to improve

ability to swallow.

Independent Actions
Reinforce instructions regarding appropriate swallowing These techniques promote effective swallowing and reduce the risk
techniques: of aspiration.
e Sit upright for meals and snacks.
° Tilt head and neck forward slightly when eating.
¢ Place food on unaffected side of mouth.
 Chapter 7 The Client With Alterations in Neurological Function 357

THERAPEUTIC INTERVENTIONS RATIONALE

e Do not put a lot of food in the mouth at one time.
e Thicken foods to promote ease of swallowing.
Reinforce food selection/preparation of foods and fluids (e.g.,
avoid sticky foods, use “Thick It,” gelatin, or baby cereal to
thicken liquids that are thin; moisten dry foods with gravy
or sauces).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

urinary incontinence.

Independent Actions
Reinforce instructions regarding client’s bladder training Continue implementation of the bladder training program reduces the
program, stressing the importance of adhering to the risk of incontinence and allows client a sense of independence.
program.
Demonstrate procedures that are included in client’s bladder Improves self-care abilities of the patient.
training program (e.g., intermittent catheterization, ap-
plication of an external catheter).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate measures

to facilitate the performance of activities of daily living and
increase physical mobility.

Independent Actions
Instruct on measures to increase ability to perform activities Increases client muscle tone and ability to perform activities of
of daily living: daily living.
e Use of assistive devices and mobility aids
e Continue concentration on body positioning, balance,
and movement
e Participation in an exercise program

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will communicate an aware-

ness of signs and symptoms to report to the health care provider.

Independent Actions
e Instruct client to report the development of or increase in These clinical manifestations may indicate a subsequent stroke.
these signs and symptoms:
e Weakness or loss of sensation in extremities
e Visual disturbances such as tunnel vision, blurred
vision, or transient blindness
e Lethargy, irritability, or confusion
e Difficulty chewing or swallowing
° Difficulty speaking or understanding verbal and non-
verbal communication
e Difficulty maintaining balance
Seizures Seizures can begin to occur months after the CVA as scar tissue
forms in the ischemic area.

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THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will communicate knowl-

edge of community resources that can assist with home man-
agement and adjustment to changes resulting from the CVA.

Independent Actions
Provide information about community resources that can as- Most stroke clients and significant others have some degree of
sist client and significant others with home management disability that requires additional support.
and adjustment to impairments in motor and sensory
function and disturbed thought processes resulting from
the CVA (e.g., home health agencies, stroke support groups,
Meals on Wheels, social and financial services, local chap-
ter of the American Heart Association, local service groups
that can help obtain assistive devices, individual and fam-
ily counselors).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: Develop, in collaboration with the

nurse, a plan for adhering to recommended follow-up care
including regular laboratory studies, future appointments
with healthcare providers, and medications prescribed.

Independent Actions
Reinforce the importance of keeping follow-up appointments Recovery from a stroke requires long-term activities to restore and
with health care provider and physical, occupational, and improve health status.
speech therapy.
Teach client the rationale for, side effects of, drug-to-drug in- Client’s and significant others’ understanding of medication regi-
teractions, food-drug interactions, and importance of tak- men helps improve regimen adherence and reduces the risk of a
ing prescribed medications (e.g., anticoagulants, platelet subsequent stroke.
aggregation inhibitors, antihypertensives).

ADDITIONAL NURSING DIAGNOSES

IMBALANCED NUTRITION: LESS THAN BODY FEAR/ANXIETY NDx

REQUIREMENTS NDx Related to:
Related to: ¢ Impaired verbal communication and/or motor and sen-
e Decreased oral intake associated with difficulty chewing, sory function unfamiliar environment
swallowing, and feeding self ¢ Lack of understanding of diagnosis, diagnostic tests, and
treatments
RISK FOR CONSTIPATION NDx e Uncertain prognosis
Related to: * Disturbed thought processes
° Decreased GI motility associated with decreased activity e Financial concerns
e Decreased intake of fluids and foods high in fiber associ- * Anticipated effect of the CVA on future lifestyle and roles
ated with difficulty chewing, swallowing, and feeding self
e Failure to respond to the urge to defecate associated with GRIEVING NDx
decreased level of consciousness or inability to recognize Related to changes in motor and sensory function and thought
sensation of rectal fullness processes, and the effect of these changes on future lifestyle
and roles
SEXUAL DYSFUNCTION NDx
Related to: IMPAIRED SWALLOWING NDx
e Alteration in usual sexual activities associated with im- Related to weakness or paralysis of the swallowing muscles on
paired motor function the affected side and diminished or absent swallowing reflex
e Decreased libido and/or impotence associated with im-
paired motor and sensory function, fear of urinary incon-
tinence, depression, disturbed self-concept, and fear of
rejection by partner
 Chapter 7 = The Client With Alterations in Neurological Function S09

IMPAIRED PHYSICAL MOBILITY NDx DISTURBED BODY IMAGE NDx

Related to: y Related to:
e Activity limitations associated with decreased motor func- e Change in appearance (e.g., hemiplegia, facial droop, ptosis)
tion and spatial-perceptual impairments e Lifestyle and role changes associated with motor and spatial-
e Loss of muscle tone during period of flaccidity of affected perceptual impairments and disturbed thought processes
extremities (flaccid paralysis is usually present during the e Impaired verbal communication
first few days after a CVA) e Loss of self-control (e.g., automatic speech, emotional la-
e Hypertonia of affected extremities (as muscle tone returns bility, inappropriate behavior) or exaggerated emotional
after period of flaccidity, it often progresses to spasticity responses
within about 6-8 weeks) e Urinary incontinence
e Reluctance to move associated with fear of injuring self (oc- e Dependence on others to meet basic needs
curs mainly with ischemia of the dominant hemisphere)
e Loss of muscle mass, tone, and strength associated with INEFFECTIVE COPING NDx
prolonged disuse Related to:
e Fear
IMPAIRED URINARY ELIMINATION NDx e Anxiety
Related to: e Depression
e Increased reflex activity of the bladder and loss of volun- e Decreased ability to communicate verbally
tary control of urinary elimination associated with upper e Changes in motor and sensory function, thought pro-
motor neuron involvement if it has occurred cesses, and future lifestyle and roles
e Decreased ability to control urination associated with de- e Need for lengthy rehabilitation
creased level of consciousness or inability to recognize
sensation of bladder fullness INTERRUPTED FAMILY PROCESSES NDx
e Inability to get to bedside commode or bathroom in a Related to:
timely manner associated with: e Change in family roles and structure associated with a
e Delay in obtaining assistance resulting from inability to family member’s verbal, motor, and sensory impairments
communicate the urge to urinate e Disturbed thought processes
e Impaired physical mobility e Need for lengthy rehabilitation

TRAUMATIC BRAIN INJURY/CRANIOTOMY

Traumatic brain injury (TBI) is defined as an alteration in brain fractures. A classification of Definite Moderate-Severe TBI is
function, or other evidence of brain pathology caused by an made if one of the following were present: death due to this
external force. The leading causes of traumatic brain injury are TBI, loss of consciousness of 30 minutes or more, PTA of
falls, being struck by or against an object, motor vehicle or traf- 24 hrs or more, worst Glasgow Coma Scale score in the first
fic accidents, and assault/self-harm events. Additional injuries 24 hrs of <13 as well as evidence of hematoma, contusion,
that can result from traumatic brain injury include skull frac- penetrating TBI, hemorrhage, or brain stem injury on neuro-
ture, dural tear, cerebral contusion, concussion, and laceration, imaging. Probable Mild TBI is made if one or more of the
diffuse axonal injury (DAI), brainstem damage, and intracra- following were present: momentary loss of consciousness to
nial hemorrhage. Brain damage can occur during the initial 30 minutes with PTA not extending beyond 24 hrs. If neuro-
injury and/or as a result of subsequent cerebral damage result- imaging identifies a depressed, basilar, or linear skull fracture,
ing from factors such as cerebral hematoma, infection, and TBI is still classified as probable. Finally, TBI is classified as
edema; seizure activity; and/or obstruction of the flow of CSF. possible is made if one or more of the following were present:
There are several different systems used to classify trau- blurred vision, confusion, dizziness, focal neurological symp-
matic brain injuries. The Mayo system classifies TBI into one toms, headache, and/or nausea.
of three categories: Definite Moderate-Severe TBI, Probable To repair additional injuries associated with TBI, surgery
Mild TBI, and Possible TBI. To classify TBI, multiple indicators may be required via a craniotomy or surgical opening of the
are evaluated including loss of consciousness, Glasgow Coma skull to gain access to the brain. Reasons for the surgery in-
Scale score, length of posttraumatic amnesia (PTA), presence clude removing a hematoma, bone fragments, or foreign object
of abnormalities on neuroimaging, and the presence of skull (e.g., bullet); controlling cerebrovascular bleeding associated

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 360 Chapter 7 * The Client With Alterations in Neurological Function

with TBI. In addition, a craniotomy may be performed for care in an extended care or rehabilitation facility or home
conditions other than TBI including removing a tumor or ab- setting. Nursing care and discharge teaching need to be indi-
scess, repairing a vascular abnormality (e.g., aneurysm, arterio- vidualized according to the areas of the brain affected and the
venous malformation), and improving ventricular drainage. extensiveness of the tissue damage. Use in conjunction with
Decompressive craniectomy (excision of a portion of the Preoperative and Postoperative Care Plan if the patient under-
skull) may be performed for the purpose of relieving elevated went surgery. If the client has sustained more severe cranioce-
intracranial pressure in an effort to improve outcomes in pa- rebral trauma, refer also to the Care Plan on Cerebrovascular
tients with TBI. The portion of the removed skull is replaced Accident.
(using the preserved bone or a synthetic substance), some-
time in the future after there are no longer concerns about
increased ICP and/or cerebral infection. OUTCOME/DISCHARGE CRITERIA
After traumatic brain injury, a person may have a distur-
bance in consciousness ranging from a brief loss of conscious- The client will:
ness to persistent coma. As the level of consciousness improves, 1. Have improved cerebral tissue perfusion
clients often experience headache, dizziness, and alterations in 2. Have improved or stable neurological function
thought processes. These signs and symptoms tend to subside 3. Have an adequate nutritional status
gradually but can persist for weeks to years. Additional signs 4. Have no signs or symptoms of complications
and symptoms after craniocerebral trauma vary depending on 5. Identify ways to adapt to neurological deficits that may
the area of the brain that has been affected. For example, tissue persist after craniocerebral trauma and/or surgery
damage in the frontal lobe could result in loss of voluntary mo- 6. Identify ways to reduce headache
tor control, personality changes, and/or expressive aphasia; 7. State signs and symptoms to report to the health care
damage to the occipital lobe could cause visual disturbances; provider
and damage to the temporal lobe could result in receptive apha- 8. Share thoughts and feelings about residual neurological
sia and/or hearing impairment. Many of the disturbances noted impairments
above may also occur after a craniotomy. 9. Identify community resources that can assist with home
This care plan focuses on the adult client hospitalized after management and adjustment to changes resulting from
craniocerebral trauma and/or surgery. It deals mainly with craniocerebral trauma and/or craniotomy
nursing and collaborative diagnoses appropriate for a client 10. Develop a plan of care for adhering adhering to recom-
who has regained consciousness after sustaining a moderate mended follow-up care including future appointments
injury or undergoing an uncomplicated craniotomy. Much of with health care provider and therapists and medications
the information is also applicable to clients receiving follow-up prescribed

|Nursing Diagnosis
Diagnosis |
‘DECREASED INTRACRANIAL ADAPTIVE CAPACITY nox
Definition: Compromise in intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial
volumes, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of
noxious and non-noxious stimuli.

Related to:
e Cerebral hemorrhage resulting from laceration of blood vessels at the time of injury or loss of integrity of the ligated vessels
¢ Compression of cerebral vessels resulting in hematoma formation, cerebral edema, or accumulation of blood in cerebral
hemispheres
° Spasm of the cerebral vessels resulting from trauma to and/or stretching of the vessels during surgery
e Hypotension resulting from hypovolemia and peripheral pooling of blood

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of headache Decreased level of consciousness; baseline ICP >10 mm Hg;
repeated increases in ICP >10 mm Hg for 5 minutes
following external stimuli; vomiting; confusion; agitation;
inappropriate affect; lethargy; speech impairment;
pupil changes and asymmetry; cerebral perfusion
pressure <SO to 60 mm Hg
 Chapter 7 * The Client With Alterations in Neurological Function 361

RISK FACTORS DESIRED OUTCOME

¢ Traumatic brain injury
The client will maintain adequate cerebral adaptation as
e Hypertension
evidenced by:
° Smoking
a. Absence or reduction of neurological deficits
b. Improved sensory and motor function
c. Improved mental status

NOC OUTCOMES NIC INTERVENTIONS

Neurological status; consciousness; cranial/sensory Cerebral edema management; neurological monitoring; ICP
monitoring; seizure precautions;

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms of changes in cerebral Early recognition of signs and symptoms of changes in cerebral
perfusion: perfusion allows for prompt intervention.

Alterations in: Use a coma scale such as the Glasgow Coma Scale to assess eye
e Level of consciousness opening, position and movement, pupil size and changes, and
e Orientation to person, place, and time consciousness/mental status. Low scores in persons with severe
e Pupil size and reaction to light head injury indicate impaired cerebral perfusion requiring
¢ Motor function prompt intervention.
e Paresthesias Abnormal movements, posturing, and abnormal flexion of ex-
e Decreased motor movement tremities indicate diffuse cerebral damage.
e Altered reflexes
° Posturing
e Variability in B/P Changes in B/P impact cerebral perfusion pressure. Maintain systolic
BP >100 mm Hg for clients 50 to 69 years of age or >110 for
clients 15 to 49 years or over 70 years of age.
O WEP Normal ICP ranges between 0 and 10 mm Hg. Treatment of ICP
values >10 mm Hg are based upon individualized values
(rather than generic values) that consider client characteristics,
pathology, and a risk-benefit analysis of treating ICP.
e Speech and thought processes Impaired thought processes indicate damage to the cerebral cortex.
e PaQOz less than 70 mm Hg Hypoxemia causes cerebrovascular dilation further increasing cere-
bral blood flow which may reduce cerebral perfusion.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve cerebral tissue perfusion:
* Elevate head of bed 30 degrees unless contraindicated. Elevating head of bed 30 degrees decreases ICP while maintaining
adequate cerebral pressure.
* Note: If surgery was performed using the infratentorial ap- Keeping the head of bed flat after surgery reduces the pressure on
proach, head of bed is usually kept flat postoperatively. the brainstem.
° Position client on side not operated on if bone flap and/or This helps prevent an increase in ICP and venous congestion in the
large mass was removed. operative area.
e Align head and neck in the midline position; avoid flex- Maintaining the head in midline position maximizes venous
ion, extension, and rotation of head and neck. return.
e Prevent hip flexion of 90 degrees or more. Hip flexion of 90 degrees or greater may maintain blood in the
abdominal space, thus increasing abdominal and intrathoracic
pressure, which reduces venous outflow from the head.
Perform actions to prevent cerebral hypoxia and the subse-
quent vasodilation and cerebral edema:
° Implement measures to maintain patent airway and suc- A patent airway is necessary for optimum ventilation necessary for
tion if necessary. both oxygen delivery and the prevention of hypoxia.
Implement measures to decrease ICP:
° Reorient to staff and environment. D @ + Relieves anxiety and helps maintain or lower ICP.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Instruct client to avoid activities that result in isometric Isometric exercises increase ICP.
muscle contractions (e.g., pushing feet against footboard,
tightly gripping side rails).

Dependent/Collaborative Actions
Implement measures to improve cerebral tissue perfusion:
e Administer osmotic and/or loop diuretics. Osmotic diuretics lower ICP by creating an osmotic force in the ce-
rebral vasculature that draws edematous fluid out of the brain.
Loop diuretics decrease body fluid volume, which helps decrease
cerebral edema. Corticosteroids decrease inflammation.

e Administer a laxative, antitussive, and/or antiemetic if Prevents straining, coughing, or vomiting that can increase the in-
ordered. trathoracic pressure, which subsequently impedes venous return
from the brain.
e Administer central nervous system depressants judiciously; Hypoxemia increases cerebral vasodilation causing increased ICP.
hold medication and consult physician if respiratory rate
is less than 12 breaths/min.
e Administer calcium channel blockers if ordered. Reduces cerebral vasospasm (the calcium that is released by the
injured neural cells can cause vasospasm).
e Administer oxygen as ordered and before and after tra- Administration of oxygen decreases cerebral hypoxia. It is not rou-
cheal suctioning. tine to hyperventilate the client before suctioning; however, hy-
perventilation that maintains PaCO 2between 30 and 35 mm
Hg may be used to prevent cerebral hypoxia.
¢ If the client is hypotensive, administer sympathomimetic Sympathomimetics and IV fluid therapy help maintain adequate
agents and maintain intravenous fluid therapy. blood pressure, which is required to maintain cerebral perfu-
sion. Improves cerebral blood flow.
If signs and symptoms of increased ICP are present:
e Initiate seizure precautions. Protects client from injury.
Prepare client for:
e Insertion of ICP monitoring device Provides direct measurement ofICP, which guides treatment plan.
° Surgical intervention (i.e., ligation of bleeding vessels, re- Decreases ICP and prevents further compromise of cerebral tissue.
pair of blocked shunt, removal of bone flap or hematoma)

‘Nursing Diagnosis :“ACUTE PAIN Nox (HEADACHE)

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and a duration of less than 3 months.
Related to:
e Trauma to the cerebral tissue associated with the surgical procedure
° Stretching or compression of cerebral vessels and tissue associated with increased ICP if it occurs
¢ Irritation of the meninges associated with bleeding from meningeal vessels into the CSF and/or inflammation of the
meninges

CLINICAL MANIFESTATIONS

Subjective Objective '

Verbal self-report of pain. Restlessness; irritability; grimacing; rubbing source of pain;
avoidance of bright lights and noises; reluctance to move

RISK FACTORS DESIRED OUTCOMES

e Edema The client will obtain relief from pain as evidenced by:
° Positioning
a. Verbalization of pain relief
° Hypertension b. Relaxed facial expression and body positioning
e Trauma
 Chapter 7 = The Client With Alterations in Neurological Function 363

NOC OUTCOMES NIC INTERVENTIONS

a IRAE ee
Comfort level; pain control Pain management: acute; analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain: Early recognition of signs and symptoms of a pain allows for
e Verbalization of pain prompt interventions.
e Restlessness
e Irritability
e Grimacing
e Rubbing affected area
e Avoidance of bright lights and noises
e Reluctance to move
Assess client’s perception of the severity of the pain using a An awareness of the severity of pain being experienced helps deter-
pain intensity rating scale. mine the most appropriate interventions for pain management.
Use of a pain intensity rating scale gives the nurse a clearer
understanding of the pain being experienced and promotes con-
sistency when communicating with others about the client’s
pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identification
duration, precipitating factors, aggravating factors, allevi- of effective pain management interventions.
ating factors).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to relieve pain Fear and anxiety decrease a client’s threshold for pain.
e Perform actions to reduce fear and anxiety about the pain
experience (e.g., assure client that the need for headache
relief is understood, plan methods for relieving pain with
client).
Assure client that staff members are nearby; respond to call
signal as soon as possible.
e Perform actions to minimize environmental stimuli (e.g., Decreased environmental stimuli promotes relaxation and subse-
provide a quiet environment, limit number of visitors and quently increases the client’s threshold and tolerance for pain.
their length of stay, dim lights).
e Avoid jarring bed or startling client. Minimizes risk of sudden movements.
e Provide or assist with nonpharmacologic measures for Nonpharmacologic measures provide relief of pain without sedation.
pain relief (e.g., cool cloth to forehead, progressive relax-
ation exercise, repositioning).

Dependent/Collaborative Actions
Implement measures to relieve pain:
e Administer analgesics before activities and procedures that Analgesics prevent pain from becoming too severe, which may pre-
can cause pain and before pain becomes severe. vent client from participating in activities and procedures.
e Administer nonnarcotic analgesics or codeine if ordered. Opioid narcotics are usually contraindicated because they have a
greater depressant effect on the central nervous system.
Consult appropriate health care provider (e.g., physician, Notifving the appropriate health care provider allows for modifica-
pharmacist, pain management specialist) if above mea- tion of the treatment plan.
sures fail to provide adequate pain relief.

|Nursing »Diagnosis RISK FOR ACUTE CONFUSION nox 7 ) |

Definition: Susceptible to reversible disturbances of consciousness, attention, cognition and perception that develop over a
short period of time, which may compromise health.

Related to: Damage to cerebral tissue associated with cerebral edema

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 364 Chapter 7 = The Client With Alterations in Neurological Function

CLINICAL MANIFESTATIONS

Subjective Subjective
N/A Inaccurate interpretation of environment and time; mem-
ory loss; altered mood states (e.g., lability, hostility, irrita-
bility, inappropriate affect); inability to make decisions or
problem solve; changes in attention span; disorientation;
inappropriate social behavior

RISK FACTOR DESIRED OUTCOMES

e Trauma The client will experience less confusion as evidence by:
a. Improved attention span, memory, and problem-solving
abilities
b. Improved level of orientation
c. Reduction in instances of inappropriate responses

NOC OUTCOMES NIC INTERVENTIONS

Information processing; neurological status cognitive ability; Reality orientation; cognitive stimulation; dementia man-
memory agement; presence; behavior management

NURSING ASSESSMENT RATIONALE

Assess client for changes in level of confusion and orientation Early recognition of signs and symptoms of confusion allows for
(e.g., shortened attention span, impaired memory, de- prompt intervention.
creased ability to problem solve, confusion, inappropriate
response. mood changes).
Ascertain from significant others client’s usual level of cogni-
tive and emotional functioning.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If client shows evidence of confusion and/or disorientation:
e Reorient to person, place, and time as necessary. D @ + These techniques help keep client oriented to environment, self,
e Address client by name. D@ + others, and current reality.
e Place familiar objects, clock, and calendar within client’s
view. D @ >
e Face client when conversing with client. D @ Facing the client when speaking helps improve communication
e Approach client in a slow, calm manner; allow adequate with the client and decreases the client’s stress concerning com-
time for communication. D @+ munication.
e Repeat instructions as necessary using clear, simple lan- Repeating information helps client process information when
guage and short sentences. D @ thinking is impaired.
e Keep environmental stimuli to a minimum but avoid sen- Overstimulation may cause the client to become anxious or aggres-
sory deprivation. D@ + sive and can block communication.
e Maintain a consistent and fairly structured routine. D@ + A structured routine helps client maintain orientation to place and
time, and provides a sense of reality.
e Provide written or taped information whenever possible. Written or taped instructions allow client to review information as
often as necessary.
e Have client perform only one activity at a time and allow Prevents client from being frustrated with having to perform many
adequate time for performance of activities. D @ activities at one time
e Encourage client to make lists of planned activities, ques- Making lists provides a mechanism with which the client ckn orga-
tions, and concerns. nize thoughts.
e Implement measures to stop emotional outbursts and in- Distraction helps client refocus and decreases inappropriate responses.
appropriate responses if they occur (e.g., provide distrac-
tion by clapping hands, handing client an object to look
at or hold, or turning on the radio or television). D @
e Maintain realistic expectations of client's ability to learn, Don’t ask clients to do things beyond their ability.
comprehend, and remember information provided.
 Chapter 7 * The Client With Alterations in Neurological Function 365

THERAPEUTIC INTERVENTIONS RATIONALE

© Encourage significant others to be supportive of client; Significant others need to learn coping mechanisms and how to
instruct them in methods of dealing with client’s dis- deal with psychological change.
turbed thought processes.
° Discuss physiological basis for disturbed thought processes Understanding what occurred helps the client and significant others
with client and significant others; inform them that cogni- work toward improving cognitive and emotional functioning.
tive and emotional functioning may improve gradually
during the next 6 to 12 months.

Dependent/Collaborative Actions
Consult physician if symptoms worsen. Notifying the physician allows for modification of the treatment plan.

Collaborative =
Diagnosis |RISK FOR MENINGITIS

Definition: Infection of the meninges.

Related to:
° Irritation of the meninges associated with trauma to the meningeal vessels or presence of blood in the CSF
° Introduction of pathogens into the meninges or CSF associated with a tear in the dura (more likely to occur with a com-
pound fracture of the skull, a linear fracture of the frontal or temporal bone, and/or penetration of the skull by an object
such as a bullet) and presence of an intracranial monitoring devices and/or external ventricular drain

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of persistent headache Fever; chills; nuchal rigidity; photophobia; positive Kernig
sign (inability to straighten knee when hip is flexed); posi-
tive Brudzinski sign (flexion of hip and knee in response to
forward flexion of the neck); cloudy CSF; elevated CSF
pressure; CSF analysis showing increased white blood cell
(WBC) count and protein levels

RISK FACTOR DESIRED OUTCOMES

e Exposure to pathogens as a result of trauma The client will not develop meningitis as evidenced by:
a. Absence of fever and chills
b. Absence of nuchal rigidity and photophobia
c. Negative Kernig and Brudzinski signs
d. Normal CSF analysis

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of CSF leak: CSF leak indicates a tear in the dura and should be reported
immediately.
e Presence of glucose in clear drainage from nose, ear, or This is one method of determining origin ofthe fluid draining from
wound as shown by positive results on a glucose reagent strip the nose.
e Yellowish ring (“halo”) around bloody serosanguineous Yellowish ring indicates cerebrospinal fluid.
drainage on dressing or pillowcase
° Constant swallowing May indicate increased post nasal drip which may be composed ofCSF.
Assess for and report signs and symptoms of meningitis: Early recognition of signs and symptoms of meningitis allows for
e Fever, chills prompt intervention.
e Increasing or persistent headache
e Nuchal rigidity
e Photophobia
° Positive Kernig sign (inability to straighten knee when hip
is flexed)
e Positive Brudzinski sign (flexion of hip and knee in
response to forward flexion of the neck)
¢ The presence of cloudy CSF following a spinal tap or inser-
tion of a drain.

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 366 Chapter 7 * The Client With Alterations in Neurological Function

Continued...

NURSING ASSESSMENT RATIONALE

e Elevated CSF pressure Pressure is often elevated with meningitis.

e CSF analysis showing increased WBC count and protein Indicates possible infection of the CSF.
levels

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent meningitis: These techniques and interventions prevent the introduction of
bacteria into the brain tissue.
e Assist with thorough cleansing and debridement of head
wound if indicated.
° Use sterile technique when changing dressings and working
with ICP monitoring device and external ventricular drain.
e Instruct client to keep hands away from head wound,
drainage tube(s), and dressing; apply wrist restraints or
mittens if necessary.
e Ifa CSF leak is present:
e Instruct client to avoid excessive movement and activ- Prevention of excessive movement prevents further stress on the
ity (bed rest is usually ordered). torn dura.
e Instruct client to avoid coughing, blowing nose, or These activities raise ICP and can cause extension of the dural tear.
straining to have a bowel movement).
° If CSF is leaking from nose: Elevating the head of the bed facilitates venous drainage.
1. Position client with head of bed elevated at least 20
degrees unless contraindicated.
2. If client needs to sneeze, instruct to do so with Withholding a sneeze can force the bacteria backward through the
mouth open. torn dura and into the brain tissue.
oo Instruct client to avoid putting finger in nose. These actions potentially introduce bacteria into the brain tissue.
4. Do not perform nasal suctioning or insert a nasogas-
tric tube.
5. Do not attempt to clean nose unless ordered by
physician.
e If CSF is leaking from ear:
1. Position client on side of CSF leakage unless contra- This position allows the fluid to drain.
indicated.
2. Instruct client to avoid putting finger in ear. These actions potentially introduce bacteria into the brain tissue.
3. Do not attempt to clean ear unless ordered by physician.
° Do not pack dressing into area of CSF leakage (nose, ear, Packing the wound interferes with drainage of fluid.
or wound).
°
Place a sterile pad over area of CSF leakage to absorb This helps prevent bacteria from being introduced into the brain
drainage and change pad as soon as it becomes damp. tissues.
If signs and symptoms of meningitis occur:
e Initiate seizure precautions. Cerebral irritation can cause seizures. Seizure precautions help
prevent client injury if a seizure does occur.
° Provide a quiet environment with dim lighting. This reduces headaches and photophobia.

Dependent/Collaborative Actions
Implement measures to prevent meningitis:
e Assist with thorough cleansing and debridement of head It is important to remove dead tissue so the wound does not become
wound if indicated. infected. ’
e Ifa CSF leak is present:
° Consult physician regarding an order for an antitussive, These medications decrease potential coughing, blowing the nose,
decongestant, and laxative if indicated. and straining, which can increase ICP.
° Prepare client for surgical repair of the torn dura if the Prevents introduction of pathogens into the CNS.
leak does not heal spontaneously.
If signs and symptoms of meningitis occur:
e Administer antimicrobials as ordered. Treats and/or prevents infection.
 Chapter 7 * The Client With Alterations in Neurological Function 367

|Collaborative Piscac
Diagnossis |RISK FOR SEIZURES

Definition: Transient, uncontrolled electrical activity in the brain that may be exhibited in physical and/or psychological signs
and symptoms.
Related to: Altered activity of the cerebral neurons associated with irritation of the brain tissue resulting from the injury,
surgery, increased ICP, and/or meningitis

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of feelings of general discomfort and Dependent upon the type of seizure: focal/motor; tempo-
feeling “out of sorts” (i.e., malaise), headache, or sense of ral lobe or psychomotor; grand mal
depression (prodromal) Excessive muscle tone phase (tonic); alternating contraction/
relaxation of muscles (clonic)

RISK FACTORS DESIRED OUTCOME

e Edema
The client will not experience seizure activity or injury if
e Tissue irritation
seizures Occur.

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of seizure activity Cerebral irritation places the patient at risk for seizure activity.
(e.g., twitching [usually of face or hands], clonic-tonic Risks for seizures are greater with head injuries.
movements).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent seizures:
e Perform actions to prevent and treat increased ICP and men- Increased ICP and meningitis are associated with seizures.
ingitis (e.g., maintain fluid restrictions, elevated head of bed
30 degrees, keep head and neck in neutral position).
Initiate and maintain seizure precautions: Placing the client on seizure precautions helps prevent injury if and
e Have oral airway and suction equipment readily available. when seizures occur.
e Pad side rails with blankets or soft pads.
e Keep bed in low position with side rails up when client is
in bed.
If seizures do occur: These measures help protect the client from further injury.
e¢ Implement measures to decrease risk of injury:
e Ease client to the floor if client is sitting in chair or
ambulating at onset of seizure.
e Remain with but do not restrain client during seizure activity.
* Do not force any object between clenched teeth or try
to pry mouth open.
e Clear area of objects that may cause injury.
e Place towel under client’s head if client is on floor.
e As seizure activity subsides, perform actions to main-
tain a client’s airway (e.g., turn client on side, insert an
oral airway, suction as needed).
¢ Observe for and report characteristics of seizures (e.g., pro-
gression, time elapsed).

Dependent/Collaborative Actions
Implement measures to prevent/treat seizures:
e If seizures are occurring, administer IV anticonvulsants IV anticonvulsants decrease seizure activity.
(i.e., benzodiazepines or diazepam).
e To prevent reoccurrence of seizures: Medication prescribed depends on the type of seizures experienced
e Administer antiepileptic medications (i.e., carbamazepine, by the client.
phenytoin, valproic acid).

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 368 Chapter 7 * The Client With Alterations in Neurological Function

|Collaborative =o}
Diagnosis |6RISK FOR DIABETES INSIPIDUS
Definition: A condition in which kidneys are unable to conserve water from impaired release of antidiuretic hormone (ADH).
Related to: Decreased production and/or impaired release of ADH associated with trauma to the hypothalamus and/or the
posterior lobe of the pituitary gland (can occur as a result of trauma or postoperative edema or hematoma in
that area)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of extreme/continuous thirst and fre- Polyuria; nocturia; polydipsia; low urine specific gravity;
quent urination low urine osmolality; high serum plasma osmolality

RISK FACTORS DESIRED OUTCOMES

e Trauma The client will not experience diabetes insipidus as evi-
e Edema denced by:
a. Absence of polyuria
b. Absence of intense thirst (polydipsia)

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of diabetes insipidus: Signs and symptoms of hypovolemia and decreased urine specific
e Polyuria (urine output can range from 4 to 10 L/day or gravity indicate diabetes insipidus and require prompt treatment
more) to prevent further impact on other systems in the body.
e Reports of intense thirst (if oral fluids are allowed and
tolerated, the client’s intake is often an amount that cor-
responds to the high volume of urine output)
e A decrease in urine specific gravity (often 1.005 or less)
Assess for and report signs and symptoms of water deficit: Early recognition of signs and symptoms of water deficit allows for
e Decreased skin turgor prompt intervention.
e Dry mucous membranes
e Weight loss of 2% or greater over a short period
e Postural hypotension and/or low B/P
e Weak, rapid pulse
e Elevated serum sodium level and osmolality

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of diabetes insipidus occur:
e Maintain fluid intake equal to output. Decreases edema of the hypothalamus, pituitary gland, and sur-
rounding tissue and subsequently reduces the risk of the devel-
opment of diabetes insipidus
e Administer an ADH replacement (e.g., vasopressin, desmo- Administration of vasopressin and desmopressin provides replace-
pressin [DDAVP]) if ordered. ment for absent endogenous ADH.

Collaborative RISK
Diagnosis | FOR SYNDROME OF INAPPROPRIATE ANTIDIURETIC
HORMONE
Definition: A condition in which ADH is not released appropriately.

Related to:
° Increased production and/or release of ADH associated with altered function of the hypothalamus or the posterior lobe of
the pituitary gland as a result of trauma and/or postoperative edema or hematoma in that area
e Stimulation of ADH output associated with pain, trauma, and/or stress
 Chapter7 = The Client With Alterations in Neurological Function 369

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of loss of appetite, headaches, nausea Hyponatremia; hypoosmolarity; concentrated urine; an-
orexia; dyspnea on exertion; fatigue, vomiting; diarrhea;
cramping; hostility, confusion; lethargy; muscle twitching,
change in level of consciousness, and/or convulsions

RISK FACTORS DESIRED OUTCOMES

e Pain
The client will not develop SIADH as evidenced by:
e Trauma
. Stable weight
e Stress
. Balanced intake and output
. Stable or improved mental status
. Stable or improved muscle strength
. Absence
Off
oan of cellular edema, abdominal cramping, nau-
sea, vomiting, and seizure activity
f. Urine and serum sodium and osmolality levels within
normal limits

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of SIADH: Early recognition of the signs and symptoms of SIADH allows for
e Weight gain of 2% or greater over a short period prompt intervention.
e Intake greater than output
e Increased irritability or confusion
e Increasing muscle weakness
e Reports of persistent or increased headache
e Fingerprint edema over sternum (reflects cellular edema)
e Abdominal cramping, nausea, or vomiting
e Seizures
e Elevated urine sodium and osmolality levels
e Low serum sodium and osmolality levels

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for the development
of SIADH:
e Perform actions to reduce pain. Pain, fear, and anxiety increase the production of ADH.
e Perform actions to reduce fear and anxiety (e.g., assure
client that staff members are nearby, respond to call signal
as soon as possible).

Dependent/Collaborative Actions
Implement measures to reduce the risk for the development
of SIADH:
e Administer osmotic diuretics (e.g., mannitol), loop diuret- Osmotic diuretics decrease cerebral edema, which may decrease
ics (e.g., furosemide), and/or corticosteroids (e.g., dexa- pressure on the pituitary and hypothalamus, thus decreasing
methasone) if ordered. SIADH; loop diuretics decrease circulating fluid volume; cortico-
steroids decrease swelling reducing pressure on the hypothala-
mus, pituitary gland, and surrounding tissue.
If signs and symptoms of SIADH occur:
e Maintain fluid restrictions if ordered (typically this is a Fluid restriction helps decrease vascular fluid volume.
restriction of free water).
e Encourage intake of foods/fluids high in sodium (e.g., to- A high sodium intake improves the sodium and vascular fluid
mato juice, cured meats, processed cheese, canned soups, (water) balance and increases fluid osmolality.
ketchup, canned vegetables, dill pickles, bouillon) if oral
intake is allowed and tolerated.

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Initiate seizure precautions.

e Administer the following if ordered:
e Diuretics (usually furosemide) Loop diuretics promote water excretion and retention of sodium,
thus improving the sodium/vascular fluid (water) balance.
e Intravenous infusion of a hypertonic saline solution Improves vascular fluid (water)/sodium balance.
e Demeclocycline Demeclocycline increases urine output, thus decreasing free water
and improving sodium/vascular fluid (water) balance.

Collaborative ~Diagnosis |RISK FOR GASTROINTESTINAL BLEEDING

Definition: Bleeding in the esophagus, stomach, or duodenum.

Related to:
¢ The development of an ulcer (often referred to as a stress-induced ulcer, stress-related mucosal damage, or Cushing ulcer)
associated with:
° Gastric ischemia resulting from vasoconstriction (occurs with sympathetic nervous system stimulation that can result from
cerebral injury)
e Hypersecretion of hydrochloric acid resulting from parasympathetic nervous system stimulation that can occur with cere-
bral injury and stress

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal pain and fullness Bloody vomitus (bright red or coffee ground); black, tarry
stools; frank bright red blood from the rectum; trace
amounts of blood in gastric secretions

RISK FACTORS DESIRED OUTCOMES

* ‘Trauma The client will not experience GI bleeding as evidenced by:
* Stress a. No reports of epigastric discomfort and fullness
b. Absence of frank and occult blood in stool and gastric
contents
c. B/P and pulse within normal range for client
d. Red blood cell (RBC) count, hematocrit (Hct), and
hemoglobin (Hgb) levels within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of GI bleeding (e.g., Early recognition of signs and symptoms of GI bleeding allows for
reports of epigastric discomfort or fullness; frank or occult prompt intervention.
blood in stool or gastric contents; decreased B/P; increased
pulse; decreasing RBC count, Hct, and Hgb levels).

THERAPEUTIC INTERVENTIONS RATIONALE

a ee eS eS ee ee oe eee
Independent Actions
Implement measures to prevent ulceration of the gastric and
duodenal mucosa: i
e Perform actions to decrease fear and anxiety (e.g., assure Fear and anxiety increase gastric acid production.
client that staff members are nearby, respond to call signal
as soon as possible).
e When oral intake is allowed:
e Instruct client to avoid coffee; caffeine-containing tea These foods/fluids stimulate hydrochloric acid secretion or directly
and colas; spices such as black pepper, chili powder, irritate the gastric mucosa.
and nutmeg.
 Chapter 7 = The Client With Alterations in Neurological Function 371

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent ulceration of the gastric and
duodenal mucosa:
e When oral intake is allowed:
e Administer ulcerogenic medications (e.g., corticoste- Decreases gastric irritation, which can occur when taking certain
roids, phenytoin) with meals or snacks. medications on an empty stomach.
e Administer histamine -receptor antagonists (e.g., ranit- Histamine receptor antagonists and proton-pump inhibitors sup-
idine, famotidine), proton-pump inhibitors (e.g., press secretion of gastric acid. Antacids neutralize stomach acid
omeprazole, rabeprazole), antacids, and/or cytoprotec- and cytoprotective agents create a protective barrier against
tive agents (e.g., sucralfate)if ordered. D> stomach acid and pepsin.

If signs and symptoms of GI bleeding occur:

e Insert nasogastric tube and maintain suction as ordered. D Insertion of an HG tube and suction removes gastric acid and pres-
sure on the gastric lining.
e Administer blood products and/or volume expanders if Hypotension may occur. Administration of blood and/or volume
ordered. expanders may be needed to maintain adequate blood pressure
and tissue perfusion.
e Assist with measures to control bleeding (e.g., gastric lavage, These interventions decrease or stop GI bleeding.
endoscopic electrocoagulation) if planned.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

MAINTENANCE nox; OR INEFFECTIVE FAMILY HEALTH
MANAGEMENT nox*
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help maintain well-being;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the
family unit.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; inability Inaccurate follow-through with instructions; inappropriate
to follow prescribed regimen behaviors; experience of preventable complications of spi-
nal cord injury

RISK FACTORS
°* Cognitive deficit e Inability to care for oneself
e Financial concerns e Difficulty in modifying personal habits and integrating
e Failure to take action to reduce risk factors treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; health behavior; health Health system guidance; teaching: individual; teaching: pre-
resources scribed activity/exercise; teaching: prescribed medications

NURSING ASSESSMENT RATIONALE

Assess client’s willingness to learn and knowledge related to The client’s willingness to learn and knowledge base provides the
the disease process. basis for education.
Assess for indications that the client may be unable to effec- Early recognition of inability to understand disease process or self-care
tively manage the therapeutic regimen. allows for change in the teaching plan.

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching.

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 372 Chapter 7 * The Client With Alterations in Neurological Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to adapt

to neurological deficits that may persist after craniocerebral
trauma and/or surgery.

Independent Actions
Instruct client in ways to adapt to neurological deficits result- These techniques provide a mechanism that helps the client adapt
ing from craniocerebral trauma: to neurological changes while maintaining as much indepen-
dence as possible.
e Wear an eye patch or opaque lens if double vision is a Eye patch alleviates double vision.
problem.
e Use scanning techniques if visual field cut is present. Visual scanning techniques provide a more complete view of the
environment for a client with a visual deficit.
e Use paper and pencil, Magic Slate, computer, pictures, and These techniques help improve communication.
gestures to express self if verbal communication is impaired.
e Make lists, write or record messages and reminders, and Helps maintain activities of daily living when client experiences
refer to written instructions repeatedly if experiencing dif- difficulty in concentrating and remembering.
ficulty concentrating or remembering.
e Request assistance when problem solving and setting pri- Client is able to validate decision making.
orities, and seek validation of decisions if reasoning ability
is impaired.
e Continue with techniques and exercises to improve swal- Improves swallowing ability and decreases risk of aspiration.
lowing if indicated.
e Prepare meals that are visually appealing to help stimulate This helps maintain adequate nutritional status when sense of
appetite if senses of smell and/or taste are impaired. smell and/or taste are impaired.
e Use assistive devices (e.g., broad-handled eating utensils, Use of assistive devices helps client maintain as much independent
plate guard) and mobility aids (e.g., wheelchair, cane, functioning as possible.
walker) if motor function is impaired.
e Plan daily activities to allow for adequate rest periods. Planning daily activities reduces irritability that often occurs after
craniocerebral trauma and/or surgery.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to protect

the surgical site from injury (if required).

Independent Actions
Instruct the client in ways to protect the surgical site from These techniques aid in the promotion of healing and decrease the
injury: potential of infection.
Wear a scarf, turban, hat, or cap until hair has grown back. Prevents sunburn and irritation to the scalp.
Do not shampoo hair until the incision has healed (usu- Prevents fluid and soap from getting into the surgical area.
ally 7 to 10 days after surgery).
e When shampooing hair, avoid vigorous scrubbing; pat Vigorous scrubbing may irritate and scratch scalp.
surgical site dry rather than rubbing.
e Avoid use of hair dryer on hot setting, curling iron, and Direct heat can burn the unprotected scalp.
hot curlers at or near surgical site until hair has grown
back. ‘
e Avoid scratching the surgical site; if it itches as the inci- Scratching the surgical site can increase risk of infection. Use of
sion heals and the hair grows back, apply light pressure to light surgical site pressure and distractions can help decrease
the surgical site or distract self with activities like taking a urge to scratch the surgical site.
walk or watching television.
e If the bone flap was not replaced, avoid bumping or put- Prevents further client injury.
ting excessive pressure on the surgical site (if the skull de-
pression is large, client may need to wear a protective
helmet as level of activity increases).
 Chapter 7 = The Client With Alterations in Neurological Function 373

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

headaches.

Independent Actions
Instruct client in ways to reduce headache, which may persist These techniques decrease incidence of headaches and pain experi-
for months after injury/surgery: enced.
e Dim environmental lighting if possible or wear sunglasses
when light is bright.
e Reduce environmental noise whenever possible (e.g.,
lower volume on TV and radio).
e Avoid situations that increase stress.
e Advise client to take analgesics as prescribed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
e Instruct client to report the following signs and symptoms: All of these signs may indicate increased ICP and should be re-
e Increased drowsiness unrelated to a significant increase ported to a health care provider immediately.
in activity or decrease in amount of sleep obtained
e Increased irritability or restlessness
e Changes in behavior, increased difficulty remembering
or concentrating
e New or increased weakness of extremities
e Decreased sensation in extremities
e Severe headache
e Difficulty speaking or understanding what others are
saying
e Difficulty chewing or swallowing
e Changes in vision (e.g., double vision, blurred vision,
visual field cut)
e Increased dizziness, difficulty maintaining balance
e Seizures
e Bloody, yellowish, or clear drainage from nose or ear May indicate a leak of CSF.
e Stiff neck May indicate an irritation of the meninges.
e Sudden weight gain or loss, excessive thirst, and/or Indicative of SIADH or diabetes insipidus.
unusual increase or decrease in amount of urination
e Unexplained fever May indicate an infection.
e Exaggerated startle response; angry outbursts; dimin- These are signs and symptoms of posttraumatic stress disorder
ished interest or participation in significant activities; (PTSD) that may occur for weeks to months after involvement
feeling of detachment from others; and recurrent, in- in a traumatic event.
trusive, disturbing images and thoughts of the event
that resulted in the craniocerebral trauma/surgery

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources that can assist with home management and adjustment
to changes resulting from craniocerebral trauma or surgery.

NDx = NANDA Diagnosis D = Delegatable Action @ =UAP @ =LVN/LPN ©) = Go to @volve for animation
 374 Chapter 7 * The Client With Alterations in Neurological Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Inform client and significant others of community resources that Provides for continuum of care postdischarge from the acute care
can assist with home management and adjustment to changes facility,
resulting from craniocerebral trauma (e.g., home health agen-
cies, Meals on Wheels, social and financial services, brain in-
jury support groups, local service groups that can help obtain
assistive devices, individual and family counseling services).
Initiate a referral if indicated.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: In collaboration with the nurse,

develop a plan for adhering to recommend follow-up care
including future appointments with health care provider,
therapists, and prescribed medication regimen.

Independent Actions
Reinforce the importance of keeping follow-up appointments Keeping follow-up appointments helps the client have continued
with health care provider and physical, occupational, and progress in improving health status.
speech therapists.
Teach client the rationale for, side effects of, schedule for tak- Knowledge of the medication regimen and the impact of these
ing, and importance of taking medications prescribed medications on the system, as well as how the medication regi-
(e.g., anticonvulsants, analgesics, antimicrobials). Inform men can be incorporated into the client’s lifestyle, allows the
client of pertinent food and drug interactions. client some mechanism of control of his/her disease and the
ability to have an active part in treatment and care.
Implement measures to improve client compliance:
e Include significant others in teaching sessions if possible. Significant others may be able to assist client as needed.
e Encourage questions and allow time for reinforcement and Helps significant others learn what ways they can assist the client.
clarification of information provided.
e Provide written instructions on scheduled appointments An informed client and family are better able to adhere to a treat-
with health care provider and occupational, physical, and ment regimen.
speech therapists; medications prescribed; and signs and
symptoms to report.

ADDITIONAL NURSING DIAGNOSES

RISK FOR INEFFECTIVE AIRWAY CLEARANCE FEAR/ANXIETY* NDx

Related to: Related to:
e Alteration in consciousness e Impaired motor and/or sensory function
e Alteration in respiratory ineffective cough e Disturbed thought processes
e Excessive sputum e Uncertainty as to permanence of neurological deficits
e Presence of an artificial airway e Unfamiliar environment
* Lack of understanding of diagnostic tests, diagnosis, and
INEFFECTIVE THERMOREGULATION NDx treatments
Related to direct trauma to the hypothalamus and/or pressure
on the hypothalamus associated with hematoma formation
RISK FOR POST-TRAUMA SYNDROME NDx
or edema of the surrounding tissue
Related to having experienced a situation that resulted in
physical injury and involved intense feelings of fear and help-
IMPAIRED PHYSICAL MOBILITY NDx
Related to:
lessness '
¢ Motor and spatial-perceptual impairments if present
RISK FOR INJURY NDx: (FALLS, BURNS,
° Activity restrictions imposed by the treatment plan
AND LACERATIONS)
e Reluctance to move because of headache
Related to:
BATHING SELF-CARE DEFICIT; DRESSING SELF- e Dizziness
CARE DEFICIT; TOILETING SELF-CARE DEFICIT NDx * Motor, visual, and/or spatial-perceptual impairments if
Related to: present
° Impaired physical mobility * Quick, impulsive behavior (can occur with injury involv-
e Disturbed thought processes ing the nondominant cerebral hemisphere)
e Visual impairments if present * Ataxia (can occur with cerebellar injury)

*The nurse should select the diagnostic label that is most appropriate based onthe client's clinical manifestations.
 Chapter 7 y= The Client With Alterations in Neurological Function 375

DISTURBED BODY IMAGE NDx INEFFECTIVE COPING NDx

Related to: Related to:
e Change in appearance (e.g., periocular edema and ecchy- ° Persistent headache
mosis, loss of hair on head if an area was shaved for sur- e Changes in motor and sensory function and thought processes
gery or to repair lacerations) ° Possibility of lengthy rehabilitation and changes in future
e Changes in motor and sensory function lifestyle and roles
e Dependence on others to meet basic needs
e Anticipated changes in lifestyle and roles associated with INTERRUPTED FAMILY PROCESSES NDx
sensory and motor impairments and disturbed thought Related to change in family roles and structure associated with
processes a family member’s motor and sensory impairments, disturbed
thought processes, and possible need for lengthy rehabilitation

SPINAL CORD INJURY

Spinal cord injury (spinal cord trauma) is most often the re- speak and use the diaphragm; however, breathing will be
sult of sudden, external trauma (e.g., motor vehicle accident, weakened. With rehabilitation, the client may be able to do
fall, sports or recreational injury, act of violence), although it things such as operate an electric wheelchair and a manual
can be caused by a tumor or conditions affecting the verte- wheelchair with hand rim projections (quad pegs), feed self
brae (e.g., stenosis, pathologic fractures). Spinal cord injuries using assistive devices, use reflex activity to achieve an erec-
are Classified in general terms as being neurologically com- tion and stimulate bowel and bladder elimination, accom-
plete or incomplete based upon sacral sparing (presence of plish some change in body position, and operate some equip-
sensory or motor function in the most caudal sacral seg- ment (e.g., computer, telephone) using assistive devices.
ments). A complete injury is defined as the absence of sacral Much of the information provided in this care plan
sparing (sensory and motor function) in the lowest sacral seg- is also applicable to spinal cord-injured clients in ex-
ments, whereas an incomplete injury is defined as the presence tended care, rehabilitation, and home settings.
of sacral sparing (some perseveration of sensory and motor Although the focus is on injury at the C5 level, the infor-
function). A five-point scale is used to grade the degree of im- mation can easily be individualized to plan nursing care for
pairment in spinal cord injury: A = Complete; B = Sensory clients with injury to other segments of the spinal cord.
Incomplete; C = Motor Incomplete, D = Motor Incomplete;
E = Normal. Additional incomplete syndromes, not part of
the classification system, include central cord syndrome (in- felunnaeliaapikve
F\ te aesinaaty
complete injury with greater weakness in the upper limbs vs.
lower limbs); Brown-Sequard syndrome (ipsilateral loss of The client will:
proprioception, vibration, and motor control at and below 1. Have clear, audible breath sounds throughout lungs
the level of injury; sensory loss at level of injury; contralateral . Have no evidence of tissue irritation or breakdown
loss of pain and temperature sensation); anterior cord syn- . Have an adequate nutritional status
drome (loss of motor function, pain sensation and tempera- . Experience optimal control of urinary and bowel elimination
ture at and below level of injury with preservation of light . Direct own care and perform or participate in self-care
wWhd
ner

touch and joint position sense); and cauda equina syndrome when possible
(flaccid paralysis of lower extremities and motor/sensory 6. Have adequate tissue perfusion and thermoregulation
function to the bladder). 7. Have no signs and symptoms of complications resulting
Immediately after traumatic injury to the spinal cord, spi- from the spinal cord injury and decreased mobility
nal shock (loss of motor, sensory, autonomic, and reflex activ- 8. Identify ways to prevent complications associated with
ity below the level of the injury) occurs. Spinal shock usually spinal cord injury and decreased mobility
lasts between 1 and 6 weeks but can persist for months. The 9. Demonstrate the ability to correctly use and maintain as-
neurological impairments that remain after the period of spi- sistive devices
nal shock depend upon the level of the cord injury (the 10. Identify ways to manage altered bowel and bladder function
higher the level, the greater the loss of body function) and 11. State signs and symptoms to report to the health care
the degree of cord involvement (complete/incomplete). provider
This care plan focuses on the adult client hospital- 12. Identify resources that can assist with financial needs,
ized with a complete injury of the spinal cord at the home management, and adjustment to changes resulting
level of the fifth cervical vertebra (CS). from spinal cord injury
After the period of spinal shock, a client with a complete 13. Share thoughts and feelings about the effects of spinal
cord injury at the CS level experiences loss of voluntary mo- cord injury on self-concept, lifestyle, and roles
tor function below the clavicles; however, full neck, upper 14. Develop a plan for adhering to recommended follow-up
shoulder, and some bicep control and elbow flexion are re- care including future appointments with health care
tained. Sensory function is intact above the clavicles and in provider and occupational and physical therapists and
certain areas of the deltoids and forearms. The client can medications prescribed

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation
376 Chapter 7 = The Client With Alterations in Neurological Function

|Nursing eee)
Diagnosis |INEFFECTIVE BREATHING PATTERN nox
Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
e Neuromuscular impairment
e Decreased energy/fatigue
e Respiratory muscle fatigue
e Immobility
e Pain related to spinal cord injury/invasive procedures

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty breathing Dyspnea; orthopnea; respiratory rate (adults [ages =14
years], <11 or >24 breaths/min; infants, <25 or >60
breaths/min; ages 1 to 4 years, <20 or >30 breaths/min;
ages 5 to 14 years, <14 or >25 breaths/min); depth of
breathing (tidal volume: adults, 500 mL at rest; infants,
6 to 8 mL/kg); decreased inspiratory/expiratory pressure;
decreased minute ventilation; decreased vital capacity;
nasal flaring; use of accessory muscles to breathe; altered
chest excursion; pursed-lip breathing; prolonged expira-
tion phases; increased anterior-posterior chest diameter;
decreased pulse oximetry readings

RISK FACTOR DESIRED OUTCOMES

* Spinal cord injury at or above C-S level The client will maintain effective breathing pattern as
evidenced by:
a. Rate and depth of respirations within normal range
for client
b. Symmetrical chest excursion
c. Oxygen saturation within normal ranges for client

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status; ventilation; airway patency Airway management; respiratory monitoring; cough en-
hancement; ventilation assistance

NURSING ASSESSMENT RATIONALE

poe
er ee eee
Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern (e.g., shallow respirations, tachypnea, limited pattern allows for prompt intervention.
chest excursion, dyspnea, use of accessory muscles when
breathing).
Monitor for and report a significant decrease in oximetry Oximetry is a noninvasive method of measuring arterial oxygen
results. saturation. The results assist in evaluating respiratory status.

THERAPEUTIC INTERVENTIONS RATIONALE

SS ae hal ane geet anne a et La

Independent Actions
Implement measures to decrease fear and anxiety (e.g., assure Fear and anxiety may cause a client to breathe shallowly or to
client that breathing deeply will not dislodge tubes or hyperventilate. Decreasing fear and anxiety allows the client to
cause incision to break open, interact with client in a con- focus on breathing more slowly and taking deeper breaths.
fident manner).
Place client in a semi- to high-Fowler’s positions unless con- A semi- to high-Fowler’s positions allows for maximal diaphrag-
traindicated. Position with pillows to prevent slumping. matic excursion and lung expansion. Prevention of slumping is
De essential because slumping causes the abdominal contents to be
pushed up against the diaphragm and restricts lung expansion.
 Chapter 7 = The Client With Alterations in Neurological Function 377

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to increase strength and activity toler- An increase in strength and activity tolerance enables the client to
ance if client is weak and fatigued (e.g., provide uninter- breathe more deeply and participate in activities to improve
rupted rest periods, maintain optimal nutrition). D + breathing pattern.
If client must remain flat in bed, assist with position change Compression of the thorax and subsequent limited chest wall and
at least every 2 hrs. D @ lung expansion occur when the client lies in one position. Fre-
quent repositioning promotes maximal chest wall and lung
expansion.
Instruct client to deep breathe or use incentive spirometer Deep breathing and use of an incentive spirometer promote maxi-
every 1 to 2 hrs. D > mal inhalation and lung expansion. Deep inhalation also
stimulates surfactant production, which lowers alveolar surface
tension and subsequently increases lung compliance and ease of
inflation.

Dependent/Collaborative Actions
Administer prescribed analgesics before planned activity. D+ Pain reduction enables the client to breathe more deeply.
Assist with positive airway pressure techniques (e.g., continu- Positive airway pressure techniques increase intrapulmonary (i.e.,
Ous positive airway pressure [CPAP], bilevel positive airway alveolar) pressure, which helps reexpand collapsed alveoli and
pressure [BiPAP], flutter/positive expiratory pressure [PEP] prevent further alveolar collapse.
device), if ordered.
Increase activity as allowed and tolerated. D During activity, the client usually takes deeper breaths, thus
increasing lung expansion.
Consult appropriate health care provider (e.g., physician, respi- Notifying the appropriate health care provider allows for modifica-
ratory therapist) if ineffective breathing pattern continues. tion of treatment plan.

ive are mBIE Laventhy IMPAIRED PHYSICAL MOBILITY nox

Definition: Limitation in independent, purposeful movement of the body or of one or more extremities.

Related to:
e Activity limitations associated with quadriplegia and immobilization of the spine
e Spasticity after the period of spinal shock associated with stimulation of the reflex arcs below the level of the injury
e Decreased motivation associated with fatigue and the physiological response to the extensive motor and sensory losses that
have occurred
e Pain
e Loss of muscle mass, tone, and strength in areas of existing motor function (biceps, upper shoulders, and neck) associated
with prolonged disuse (more likely to occur when Client is in skeletal traction and must remain in bed)
e Contractures (if they develop)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; discomfort; fatigue Difficulty moving; supporting the affected limb; exertional
dyspnea; contractures; limited ability to perform gross and
fine motor skills; limited range of motion (ROM); move-
ment-induced tremor; postural instability; uncoordinated
movements

RISK FACTORS DESIRED OUTCOMES

e Neuromuscular impairment related to spinal cord injury The client will improve mobility as evidenced by:
e Sensory-perceptual impairment a. Increased physical activity
b. Movement of affected limb or limbs
c. Participation in activities of daily living (ADLs)
d. Demonstration of appropriate use of assistive devices
to improve movement
oO . Absence of contractures

f. Absence of redness/irritation to skin-no skin break-

down

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to @volve for animation
 378 Chapter 7 * The Client With Alterations in Neurological Function

NOC OUTCOMES NIC INTERVENTIONS

eS

Immobility consequences: physiological; neurological status: Positioning; exercise therapy: joint mobility; exercise therapy:
peripheral; spinal sensory/motor function muscle control

NURSING ASSESSMENT RATIONALE

Assess client’s movement ability and activity tolerance. Use a tool Assessment of mobility is used to best determine how to facilitate
such as the Assessment Tool for Safe Patient Handling and movement. Assessment of activity tolerance provides a baseline
Movement or the Functional Independence Measures (FIM). for patient strength and endurance with movement.
Assess circulation, motion, and feeling in digits. Circulation may be compromised by edema of extremities, which
can lead to tissue necrosis and/or contractures.
Determine risk for skin breakdown using a risk assessment Identification of clients at risk for skin breakdown allows for imple-
tool (e.g., Norton Scale, Braden Scale, Gosnell Scale). mentation of nursing interventions to prevent breakdown from
occurring. Use of a scale provides for more accurate assessment.
Inspect the skin (especially bony prominences, dependent Early recognition of signs and symptoms of skin impairment allows
and/or edematous areas, perineum, area underneath halo for prompt intervention.
vest, and areas of sensory loss) for pallor, redness, and
breakdown.
Assess need for assistive devices. Determine client’s needs for assistive devices as well as proper use
of wheelchairs, walkers, canes, and so on, to reduce incidence
of falls.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage and implement strength training activities: Inactivity contributes to muscle weakening. Contractures can de-
e Active and/or passive ROM velop as early as & hrs of immobility. These activities maintain
e Ambulation and increase the client’s strength and ability to move.
e Use of trapeze for pull-ups
¢ ADIsD®
Use assistive devices that are appropriate for the mobility Assistive devices help the caregivers decrease the potential for falls
level of the client. Assistive devices may include: and/or injuries.
e Crutches
° Gait belt
¢ Walker D ® +
Cluster treatments and care activities to allow for uninter- Increases client’s tolerance and strength for activities.
rupted periods of rest. D @
Encourage patient with positive reinforcement during A positive approach to activities supports the client’s accomplish-
activities. D@ + ment, engagement in new activities, and improves self-esteem.
Implement falls protocol. Client safety is a priority.
Maintain the bed in low position and keep side rails up. D @ Reduces prolonged pressure on tissues, decreasing potential for
tissue ischemia and pressure sores.
Implement measures to maintain healthy, intact skin: Healthy, intact skin reduces the risk of pressure sores and infection.
e Keep skin lubricated, clean, and dry.
e Assist patient to turn and reposition every 2 hrs. Turning clients allows for appropriate circulation to tissues.
e Keep bed linens dry and wrinkle-free). D @
e Position client with appropriate devices (wedges, pillows,
kinetic bed, air bed, gel mattress). D@
e If client is wearing a halo vest:
e Ensure the vest lining and skin beneath it are kept dry Reduces prolonged pressure on tissues, decreasing potential for tis-
and intact sue ischemia and pressure sores
e Make sure clothing worn under the vest is wrinkle free, Skin will become macerated from accumulation of moisture on the
and made of cotton vest lining.
e Cover all rough edges of vest with tape Rough edges on the vest can cause lacerations of the skin.
 Chapter 7 The Client With Alterations in Neurological Function 379

THERAPEUTIC INTERVENTIONS RATIONALE

Maintain an optimal nutritional status. Increase protein Adequate nutrition is needed to maintain adequate energy level.
intake.
Assist client with acceptance of immobility. Helps patient accept limitations and focus on a new quality of life.

Dependent/Collaborative Actions
Consult appropriate health care provider: dietitian, physi- These individuals provide specific activities and exercise programs
cian, and occupational therapist. to improve strength and mobility.
Administer pain medications before activities. D+ Reduces muscle stiffness and tension, allowing the client to par-
ticipate in activities.
Notify appropriate health care provider (e.g., wound care Wound care specialists can provide individualized treatment to
specialist, physician). improve healing of skin breakdown.

|Nursing =...
Diagnosis |INEFFECTIVE THERMOREGULATION nox.
Definition: Temperature fluctuation between hypothermia and hyperthermia.
Related to:
e Interruption in the feedback system between the area below the level of cord injury and the hypothalamus, and loss of
vasomotor tone below the level of the injury (these conditions result in the loss of compensatory responses to temperature
changes [i.e., vasodilation, sweating, vasoconstriction, shivering, and piloerection])
e Reduction in heat generation associated with limited body movement (especially during period of spinal shock)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of feeling too warm or too cold Excessively warm or cool skin below the level of injury;
temperature above or below normal range; tachycardia;
hypotension/hypertension; shivering; skin cool to touch;
pallor; slow capillary refill; cyanotic nail beds; piloerection;
warm to touch; flushed skin; hypercapnia; seizures

RISK FACTORS DESIRED OUTCOMES

e Environmental temperature The client will experience effective thermoregulation as
e Edema evidenced by:
e Trauma a. Verbalization of comfortable body temperature
b. Absence of excessively warm or cool skin below the
level of the injury
c. Temperature within normal range

NOC OUTCOMES NIC INTERVENTIONS

Thermoregulation Temperature regulation: environmental management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of ineffective thermoregula- Early recognition of the signs and symptoms of inefficient thermo-
tion (e.g., reports of feeling too warm or too cold, exces- regulation allows for prompt intervention.
sively warm or cool skin below the level of the injury,
temperature above or below normal range).

-NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
 380 Chapter 7 = The Client With Alterations in Neurological Function

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain effective thermoregulation:
e Perform actions to prevent hypothermia: The client is not able to regulate body temperature due to loss of
e Maintain room temperature at 70°F. sympathetic control. These interventions focus on keeping the
° Provide extra clothing and bedding as necessary. D @ + client’s temperature as close to normal as possible.
e Protect client from drafts. D@ +
e Provide warm liquids for client to drink. D @ +
e Avoid taking client outdoors when it is very cold. D @ +
e Perform actions to prevent hyperthermia:
° Maintain room temperature at 70°F. D @ +
° Avoid use of excessive clothing and bedding. D @ +
e Remove extra clothing during physical and occupa-
tional therapy sessions.
e Avoid taking client outdoors when it is very hot (espe-
cially if the humidity is high). D@ +

Dependent/Collaborative Actions
Implement measures to maintain effective thermoregulation:
e Apply warming and cooling blanket as ordered. D @ +
Consult physician if above measures fail to maintain effective Notifying the physician allows for modification of the treatment
thermoregulation. plan.

| __ RISK FOR AUTONOMIC DYSREFLEXIA nox

Definition: Susceptible to life-threatening, uninhibited response of the sympathetic nervous system, post-spinal shock, in an in-
dividual with spinal cord injury or lesion at the 6th thoracic vertebra (T6) or above (has been demonstrated in patients
with injuries at the 7th thoracic vertebra [T7] and the 8th thoracic vertebra [T8]), which may compromise health.

Related to:
Related to loss of autonomic nervous system control below the level of the cord injury (can occur once reflect activity returns
after period of spinal shock):
e Cardiopulmonary stimuli—Deep vein thrombosis and pulmonary emboli
e GI stimuli—Bowel distention, constipation, digital stimulation, enemas, esophageal reflux, fecal impaction, gall stones,
gastric ulcers, hemorrhoids, suppositories
° Musculoskeletal-integumentary stimuli—Cutaneous stimulation, pressure over bony prominences, pressure over genitalia,
range-of-motion exercises, spasm, sunburns, wounds
° Neurological stimuli—Irritating stimuli below of injury, painful stimuli below level of injury
e Regulatory stimuli—Extreme environmental temperatures, temperature fluctuations
° Reproductive stimuli—Ejaculation, labor and delivery, menstruation, pregnancy
° Situational stimuli—Constrictive clothing, drug reactions, narcotic/opiate withdrawal, positioning, surgical procedures
¢ Urological stimuli—Bladder distension and spasm, calculi, catheterization, cystitis, epididymitis, surgery, urinary tract infection

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of a sudden pounding headache; blurred Sudden onset of severe hypertension; bradycardia; flushing
vision; nausea; feelings of apprehension above the lesion; pale extremities below the level of the le-
sion; profuse diaphoresis above level of injury; piloerettion

RISK FACTORS DESIRED OUTCOMES

ea ee ee ee Se
e Trauma The client will not experience autonomic dysreflexia as
e Any stimulus that irritates or increases pressure below the evidenced by:
level of injury a. Vital signs within normal range for client
b. Skin dry and usual color above the level of the injury
c. No reports of pounding headache, nasal congestion,
and blurred vision
 Chapter 7: The Client With Alterations in Neurological Function 381

NOC OUTCOMES NIC INTERVENTIONS

Tn
Symptom severity Dysreflexia management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of autonomic dysreflexia: Autonomic dysreflexia is considered a medical emergency that may
e Sudden rise in B/P (systolic pressure may go as high as occur after the resolution of spinal shock. Early recognition of
300 mm Hg) the signs and symptoms of autonomic dysreflexia allows for
e Bradycardia prompt intervention.
e Flushing and profuse diaphoresis above level of injury
e Pounding headache
e Nasal congestion
e Blurred vision

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent stimulation of the sympa-
thetic nervous system below the level of the cord injury to
prevent autonomic dysreflexia.
e Perform actions to prevent distention of the bladder and Problems with the bladder and bowel are the two most frequent
bowel: causes of autonomic dysreflexia.
e Attempt to initiate voiding periodically by stimulating These interventions promote regular bladder and bowel emptying.
the trigger zones of the reflex sacral arc (e.g., tap supra-
pubic area, stroke inner thigh, perform anal sphincter
stretching, pull pubic hair); if voiding occurs, repeat
stimulus as necessary to empty the bladder.
e If possible, place client on bedside commode or toilet Gravity promotes emptying of the bladder.
when triggering voiding reflex.
e Instruct client to space fluid intake evenly throughout the If the bladder fills rapidly and frequency of emptying is not in-
day, rather than drinking a large quantity at one time. creased, bladder distention occurs.
e Instruct client to limit intake of alcohol and beverages Alcohol and caffeine have a mild diuretic effect and act as irritants
containing caffeine such as colas, coffee, and tea. to the bladder; the increased urine production can result in blad-
der distention if the frequency of bladder emptying is not also
increased, and the bladder irritation can trigger bladder spasms
and subsequent incontinence.
e Limit oral fluid intake in the evening. D @ + Limiting oral intake in the evening prevents the bladder from be-
coming overdistended during the night. As rehabilitation pro-
gresses, most clients do not perform intermittent catheterization
or attempt to trigger voiding during the night.
e Instruct client and others to avoid stimulating the voiding This reduces the risk of incontinence.
reflex trigger zones at times other than during bladder care.
e Implement measures to prevent constipation:
e Encourage client to drink hot liquids before scheduled Drinking hot liquids prior to a bowel evacuation helps stimulate
bowel evacuation. peristalsis.
e Assist client to eat at scheduled times and adhere to a A scheduled eating and defection routine helps maintain conti-
routine time for defecation; follow client’s preinjury nence.
pattern if possible. D@ +
e Perform actions to prevent pressure on any area of the Pressure below the level of injury may stimulate autonomic dysre-
client’s body below the level of the cord injury. flexia.
e Instruct and assist client to change positions frequently. These actions decrease pressure on the non-innervated areas of the
body.
e Ensure that overbed tray is not resting on chest. D @ +
e Ensure that clothing is not constrictive and shorts are
not too tight.
e Perform good nail care. Long fingernails may stimulate the sympathetic nervous system.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
e Perform actions that prevent pressure on any area of the These actions prevent the bladder from becoming distended and
client’s body below the level of cord injury. placing the client at increased risk for autonomic dysreflexia.
e Perform intermittent catheterization or insert indwelling
catheter as ordered.
e Maintain patency of indwelling catheters. D +
e Apply a topical anesthetic agent to any existing pressure Use anesthetic ointment to decrease the risk of aggravating the
ulcer. autonomic dysreflexia.
e Apply a local anesthetic (e.g., Nupercainal ointment) if
ordered before performing actions that can result in an
exaggerated sympathetic response (e.g., urinary catheter-
ization, removal of a fecal impaction, administration of an
enema, care of any wound below the level of the injury).
If signs and symptoms of autonomic dysreflexia occur:
e Immediately implement measures to promote venous Immediate treatment is important to prevent a hypertensive stroke.
pooling and subsequent decrease in B/P (e.g., raise head of These actions decrease B/P.
bed and lower client’s legs unless contraindicated; remove
abdominal binder, antiembolism stockings, and intermit-
tent pneumatic compression device if present).
e Administer antihypertensives (e.g., diazoxide, hydrala- Antihypertensive medications decrease blood pressure, which is
zine, nitroprusside) as ordered. important in stroke prevention.
e Monitor B/P and pulse frequently (usually every 3 to
5 minutes until treatments and/or medication take effect).
e Notify physician immediately if signs and symptoms per- These complications can have a very deleterious impact on the
sist or if complications resulting from severe hypertension body and should be treated immediately to prevent further in-
occur (e.g., seizures, intraocular hemorrhage, cerebrovas- sult to the body.
cular accident, myocardial infarction).
e Notify all persons participating in client's care of the episode The client’s treatment plan may need to be altered to address other
of autonomic dysreflexia because such episodes can reoccur. effects of autonomic dysreflexia.

:Nursing Diagnosis | SELF-CARE DEFICIT nox (BATHING, DRESSING, FEEDING,

ae ~ AND TOILETING)
Definition: Self-Care Deficit: Bathing NDx: Inability to independently complete cleansing activities; Self-Care Deficit:
Dressing NDx: Inability to independently put on or remove clothing; Self-Care Deficit: Feeding NDx: Inability
to eat independently; Self-Care Deficit: Toileting NDx: Inability to independently perform tasks associated with
bowel and bladder elimination.

Related to: Impaired physical mobility associated with quadriplegia, spasticity, decreased motivation, pain, weakness, and
activity restrictions imposed by treatment plan

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain and/or weakness Inability to move upper and/or lower extremities due to
injury; muscle spasticity

DESIRED OUTCOME
The client will demonstrate increased participation in self-
care activities within the limitations imposed by the treat-
ment plan and effects of the spinal cord injury.

NOC OUTCOMES NIC INTERVENTIONS

Self-care: activities of daily living; bathing; dressing; eating; Self-care assistance: dressing/grooming; self-care assistance:
self-care hygiene; toileting feeding; self-care assistance: toileting; self-care assistance:
transfer
 Chapter7 = The Client With Alterations in Neurological Function 383

Sree
NURSING ASSESSMENT
ee
RATIONALE eee

Assess readiness to engage in self-care activities. Determine The level of client interest, motivation, and family support will
level of motivation and family support. determine when and how much self-care the client can assume.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
e With client, develop a realistic plan for meeting daily Engaging client in self-care activities will demonstrate to client that
physical needs. Inform client that with rehabilitation and he or she will be able to care for self after discharge.
use of assistive devices, he/she may be able to accomplish
activities such as:
e Feeding self once meal has been set up
e Washing face and chest
e Combing front and sides of hair, brushing teeth, and shav-
ing with an electric razor
e Participating in dressing upper body D @ +
Schedule care at a time when client is most likely to be able If the client is tired or experiencing pain, he/she will not be able to
to participate (e.g., when analgesics are at peak effect, after participate in activities of daily living, which may cause a de-
rest periods, not immediately after physical therapy ses- crease in morale if client has been previously successful in
sions or meals). completing tasks.
Keep objects client can use independently within easy reach. Provides the client a way to be independent will improve morale
De+ and decrease recovery time.
Allow adequate time for accomplishment of self-care activi- Be sure not to rush the client. Learning new ways of caring for self
ties. D @ > may require additional time.
Encourage client to perform as much of self-care as possible Allows client the ability to see that he/she can care for self and
within physical limitations and activity restrictions im- promotes self-confidence.
posed by the treatment plan. D ® +
Perform for client the self-care activities that he/she is unable
to accomplish. D@ +
Inform significant others of client’s abilities to participate in Explain the importance to significant others of encouraging and
own care. allowing client to achieve an optimal level of independence.

Dependent/Collaborative Actions
When condition stabilizes and physician allows, implement
measures to facilitate client’s ability to perform self-care
activities:
e Perform actions to increase mobility (e.g., tilt table, active These actions increase client’s ability to become more mobile and
and passive range of motion [ROM]). to perform self-care activities.
e Consult occupational therapist regarding assistive devices Consulting an occupational therapist allows for interdisciplinary
available; reinforce use of these devices, which may include: care and use of tools and techniques to improve and enhance
e Rocker feeder, overhead sling, plate guard, sandwich self-care abilities.
holder, and broad-handled and/or swivel utensils for
feeding self
e Flexor-hinge splint or universal cuff to aid in brushing
teeth, combing hair, and shaving with electric razor
e Bath mitt for bathing face and chest
e Velcro fasteners to facilitate dressing upper body

|Nursing +>
Diagnosis «RISK FOR INJURY nox
Definition: Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and
defensive resources, which may compromise health.

Related to:
e Falls related to loss of motor function, use of kinetic bed, altered sitting balance if wearing a halo device (the structure and
weight of the device alter the client’s center of gravity), and unexpected body movements resulting from spasticity
e Burns related to loss of motor and sensory function and unexpected body movements resulting from spasticity

-NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation
 384 Chapter 7 * The Client With Alterations in Neurological Function

RISK FACTORS
e Changes in balance
e Weakness
e Loss of neuromuscular functioning

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Inability to move upper and/or lower extremities due to
injury; muscle spasticity

DESIRED OUTCOME
The client will not experience falls or burns.

NOC OUTCOMES NIC INTERVENTIONS

Fall prevention behavior; falls occurrence Fall prevention; environmental management; peripheral
sensation management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms that client is at risk for injury. Early recognition of signs and symptoms that place the client at
risk for injury allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for injury:
e Perform actions to prevent falls: These actions will decrease the client’s risk for falls and potential
e If client is in a standard hospital bed, keep bed in low injury.
position with side rails up. D@ +
e If client is in a kinetic bed, use safety measures such as
safety straps and padded side pieces. D @ +
e Keep safety belts securely fastened when client is on a
stretcher or in a wheelchair. D @
e Obtain adequate assistance when moving client; follow
instructions from physical therapist on correct transfer
techniques. D @+
e Implement measures to increase client’s stability when
in a wheelchair (e.g., use wheelchair equipped with an
antitipping device, fasten safety belt around upper
body and chair to stabilize trunk, use H-straps to keep
legs positioned properly).
e Do not rush client; allow adequate time for the accom-
plishment of transfers and position changes. D @ +
Perform actions to prevent burns:
e Let hot foods and fluids cool slightly before serving. Client may accidentally spill liquids; without ability to feel hot or
De+ cold, client may inadvertently cause a burn.
e Supervise client while smoking; do not place ashtray on The cigarette could roll off the ashtray onto the client’s clothing
client’s lap. causing a fire and subsequent burns.
e Assess temperature of bath water before and during use. The client has lost sense of feeling and may not be aware that
De+ water is too hot and can cause burning.
e When client is in a wheelchair, instruct the client to avoid This will cause the sides of the wheelchair to become hot and burn
placing self next to sources of heat (e.g., heater, stove). the client’s skin.
e Encourage client to request assistance whenever needed; Stretching to reach a call light may cause the client to lose balance
have a specially adapted call signal available to client at all and fall out of bed.
times.
e Perform actions to decrease spasticity (e.g., avoid stimulat- It is important to reduce the risk ofunexpected body movements to
ing extremities or muscle groups; assist client to change prevent injury.
position and perform ROM activities).
 Chapter7 = The Client With Alterations in Neurological Function 385

_ THERAPEUTIC INTERVENTIONS RATIONALE

Include client and significance others in planning and imple- Significant others should be informed on how to help prevent client
menting measures to prevent injury. injury.
If injury does occur, initiate appropriate first aid and notify Notification of the physician allows for modification of the treat-
physician. ment plan.

|Nursing Diagnosis
2ee RISK FOR VENOUS THROMBOEMBOLISM nox
Definition: Susceptible to the development of a blood clot in a deep vein, commonly in the thigh, calf or upper extremity,
which can break off and lodge in another vessel, which may compromise health.
Related to:
e Venous stasis associated with decreased mobility and decreased vasomotor tone below the level of the injury
° Hypercoagulability associated with increased blood viscosity (if fluid intake is inadequate) and increased levels of calcium
in the blood from bone demineralization (can result from prolonged immobility)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain or tenderness in an extremity Increase in circumference of extremity; distention of super-
ficial vessels in extremity; unusual warmth of extremity

RISK FACTORS DESIRED OUTCOME

e Impaired mobility
Client will not develop a deep vein thrombosis.

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of a deep vein Early recognition of signs and symptoms of deep vein thrombus
thrombus: allows for prompt intervention.
e Pain or tenderness in extremity
e Increase in circumference of extremity
e Distention of superficial vessels in extremity
e Unusual warmth of extremity

NOC OUTCOMES NIC INTERVENTIONS

Immobility consequences: physiological; tissue perfusion: Embolus precautions; embolus care: peripheral
peripheral

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate blood flow in legs Adequate blood flow in the legs reduces the risk for thrombus
to reduce the risk for thrombus formation and prevent a formation and prevents a thromboembolus from occurring.
pulmonary embolism (e.g., maintain adequate fluid in-
take, use of thromboembolic disorder [TED] hose, position
firm pillow between client’s legs if spasms tend to cause
legs to cross; instruct client to obtain assistance to reposi-
tion legs properly, if they do cross).
If signs and symptoms of a deep vein thrombus occur:
e Maintain client on strict bed rest in a semi- to high- Avoid putting pressure on the posterior knees because this action
Fowler’s positions. will compress the leg veins, increasing turbulent blood flow, and
e Do not exercise, or massage any extremity known to have increasing the risk of thrombus formation. If a thrombus is
a thrombus. suspected, elevate the affected extremity and do not massage the
area because of the danger ofdislodging the thrombus.

e Caution client to avoid activities that create a Valsalva re- Valsalva response changes pressure in the chest cavity, which may
sponse (e.g., holding breath while moving up in bed). dislodge a venous thrombus.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to prevent autonomic dysreflexia:
e Perform measures to decrease incidence of a distended A full bladder or bowel is a major precipitator of autonomic dysre-
bladder and/or bowel. flexia.
e Prevent pressure on any area of the client’s body below Autonomic dysreflexia changes systemic B/P and may dislodge a
the level of cord injury because this may lead to auto- clot from a vessel wall.
nomic dysreflexia.

Collaborative/Dependent Actions
Implement measures to prevent deep vein thrombus
formation:
e Apply mechanical devices designed to increase venous These sequential compression devices and TED stockings decrease
return in the immobile patient: venous stasis in the lower extremities and increase venous Te-
e Sequential compression devices turn through the deep leg veins, which are prone to the forma-
e Thromboembolic (TED) stockings D + tion of a thrombus.
e Maintain a minimum fluid intake of 2500 mL/day (unless Adequate hydration helps reduces blood viscosity and decreases the
contraindicated). D + incidence of deep vein thrombus.
If signs and symptoms of a deep vein thrombus occur:
e Administer anticoagulants: Anticoagulants, if indicated, help suppress the formation of clots.
e Low- or adjusted-dose heparin
e Fondaparinux
e Warfarin
e Low-molecular-weight heparin
e Prepare client for diagnostic studies (e.g., d-dimer venog- Additional studies may be indicated to confirm the presence of a
raphy, duplex ultrasound, impedance plethysmography). deep vein thrombus, so the appropriate interventions can be
implemented.
e Maintain oxygen therapy as ordered. D+ Supplemental oxygen helps maintain adequate tissue oxygenation.

|Nursing ~Diagnosis |SEXUAL DYSFUNCTION nox

Definition: A state in which an individual experiences a change in sexual function during the sexual response phases of
desire, excitation, and/or orgasm, which is viewed as unsatisfying, unrewarding, or inadequate.
Related to:
e Decreased libido associated with:
° Loss of sensory and voluntary motor function below the level of spinal cord injury
e Presence of a urinary catheter and/or fear of urinary and bowel incontinence
e Depression, disturbed self-concept
e Fear of rejection by partner
° Fear of autonomic dysreflexia (genital stimulation can cause dysreflexia)
° Decreased ability to control and maintain an erection associated with loss of ability to have a psychogenic erection (only
reflexogenic erection is possible)
e Altered ejaculatory flow associated with impaired nerve function in the bladder neck (can result in retrograde ejaculation)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sexual dysfunction; stated inability Limitations imposed by quadriplegia specific to sexual
to achieve sexual satisfaction or feelings of being sexually dysfunction
unattractive ‘

RISK FACTORS DESIRED OUTCOMES

e Fear
eee Lena ena ee eae, Sse eS a
e Trauma The client will demonstrate beginning acceptance of
changes in sexual functioning as evidenced by:
° Loss of control of body
a. Verbalization of a perception of self as sexually accept-
able and adequate
b. Statements reflecting beginning adjustment to the ef-
fects of the spinal cord injury on sexual functioning
c. Maintenance of relationship with significant other
 Chapter 7. The Client With Alterations in Neurological Function 387

NOC OUTCOMES NIC INTERVENTIONS

Sexual identity; sexual functioning Sexual counseling; support group

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of sexual dysfunction (e.g., Recognition that the spinal cord injury patient will experience sex-
verbalization of sexual concerns or inability to achieve ual dysfunction will alert the nurse to assess for both physical
sexual satisfaction, alteration in relationship with significant and mental alterations.
other, limitations imposed by paraplegia/quadraplegia).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote an optimal level of sexual Communication between partners about how the physical changes
functioning: will affect their sexual relationship is important.
e Facilitate communication between client and partner; fo-
cus on the feelings the couple share and assist them to
identify changes that affect their sexual relationship.
e Discuss ways to be creative in expressing sexuality (e.g., Client will require education on ways that he or she can express
massage, fantasies, cuddling). sexuality.
e Suggest alternative methods of sexual gratification and use Learning different ways of maintaining a sexual relationship will
of assistive devices if appropriate; encourage partner to take time.
explore erogenous areas on the client’s lips, neck, and ears.
e Arrange for uninterrupted privacy if desired by the Arranging time for couples to explore their sexual relationship fos-
couple. D> ters closeness between partners.
e Inform male client and his partner of techniques for elicit- Sexual activity in clients with spinal cord injury requires different
ing and maintaining reflexogenic erection (e.g., stimulate approaches and the possible use of assistive devices.
genitalia, stroke inner thigh, pull on pubic hairs, stimulate
the rectum, manipulate the urinary catheter).
e If client has difficulty maintaining an erection, encourage
him to discuss various treatment options (e.g., vacuum
erection aids, penile prosthesis) with physician if desired.
e If client experiences episodes of autonomic dysreflexia, To decrease the incidence of autonomic dysreflexia during sex, the
instruct client to consult physician about ways to prevent client should be instructed to have the partner apply a local
it during sexual activity (e.g., have partner apply a local anesthetic to client’s genitalia.
anesthetic to client’s genitalia).
e Inform female client that vaginal lubrication can occur by Female clients may need to use a water-soluble lubricant.
local stimulation or can be enhanced by using a water-
soluble lubricant.
e If incontinence of urine is a concern, instruct client to:
e Limit fluid intake 2 to 4 hrs before sexual activity. These actions limit urinary incontinence during sexual activity.
e Have bladder emptied immediately before sexual activity.
e Instruct client to perform bowel care several hours before This action reduces the risk of bowel incontinence if anal or rectal
sexual activity. stimulation occurs during sexual activity.
e If appropriate, involve partner in care of client. Involvement of partner of client helps the partner adjust to the changes
in the client’s appearance and body functioning and subsequently
decreases the possibility of partner’s rejection of the client.
e Encourage client to rest before sexual activity. The client needs to conserve energy before sexual activity to avoid fatigue.
e Instruct client and partner to establish a relaxed, unhur- Providing an unhurried atmosphere for sexual activity allows the
ried atmosphere for sexual activity. client and partner to explore what activities will provide sexual
gratification including varying positions, use of explicit films
and assist devices.
° Discuss positions that may facilitate sexual activity (e.g.,
lying on side, client in supine position).
e Provide explicit films and literature if desired by client
and/or partner.
e Include partner in above discussions and encourage con- Changes in the client’s functioning has a great impact on the part-
tinued support of the client. ner, and to improve chances of a positive sexual relationship,
the partner should be included in discussions on sexual activity.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions . Cbedl
Consult appropriate health care provider (e.g., sex counselor, The expertise of a sexual counselor will provide a multidisciplinary
physician) when client is ready for sexual counseling and/ approach to a client’s sexual activity.
or sexual counseling appears indicated.

|Nursing »--*
Diagnosis INTERRUPTED FAMILY PROCESSES nox
Definition: Break in the continuity of family functioning which fails to support the well-being of its members.
Related to:
e Change in family roles and structure associated with a family member’s sudden, catastrophic injury, permanent disability,
and need for extensive rehabilitation

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of being unable to accept client’s quadri- Disruptive family interactions; inability to use coping
plegia or paraplegia strategies; refusal to participate in client’s care

RISK FACTORS DESIRED OUTCOMES

e Situational crisis
e Situational transition
The family members/significant others, will demonstrate
beginning adjustment to changes in functioning of a family
member and family roles and structure as evidenced by:
a. Meeting client’s needs
b. Verbalization of ways to adapt to required role and
lifestyle changes
c. Active participation in decision-making and client's
rehabilitation
d. Positive interactions with one another

NOC OUTCOMES NIC INTERVENTIONS

Family coping; family functioning; family resiliency; family Family involvement promotion; family integrity promo-
normalization tion; family process maintenance; family support; family
mobilization

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of interrupted family processes Early recognition of signs and symptoms of interrupted family pro-
(e.g., inability to meet client’s needs, statements of not cesses allows for prompt intervention.
being able to accept client’s quadriplegia or make neces-
sary role and lifestyle changes, inability to make decisions,
inability or refusal to participate in client’s rehabilitation,
negative family interactions).
Identify components of the family and the patterns of com-
munication and role expectations.

THERAPEUTIC INTERVENTIONS RATIONALE i

Independent Actions
Implement measures to facilitate family members’ adjust-
ment to client’s diagnosis, changes in client’s functioning
within the family system, and altered family roles and
structure:
° Encourage verbalization of feelings about the client's Verbalization of feelings promotes communication and support for
quadriplegia and its effect on family structure; actively family members and may positively impact coping.
listen to each family member and maintain a non-
judgmental attitude about feelings shared.
 Chapter 7.) The Client With Alterations in Neurological Function 389

THERAPEUTIC INTERVENTIONS RATIONALE

e Reinforce physician’s explanations of the effects of the Information helps the client’s family understand what is happen-
injury and planned treatment and rehabilitation. ing and keeps them informed of the management of care.
e Assist family members to gain a realistic perspective of cli- Keep the family informed concerning what is occurring, answer
ent’s situation, conveying as much hope as appropriate. questions as needed, assist in their understanding of a spinal
cord injury while maintaining hope for the future.
e Provide privacy for the client and family and stress the It is important that the client and family share feelings as they deal
importance of and facilitate the use of good communica- with the client’s body changes.
tion techniques.
e Assist family members to progress through their own The client’s injury has a major impact on the life of the family, and
grieving process; explain that they may encounter times family members will go through a grieving process. They need
when they need to focus on meeting their own needs to be reassured as they work through the changes that have oc-
rather than the client’s needs. curred in the family processes.
e Emphasize the need for family members to obtain ade- Family members need to take care of themselves so that they are
quate rest and nutrition and to identify and use stress better able to emotionally and physically deal with the changes
management techniques. and losses experienced.
e Encourage and assist family members to identify coping Reinforce family members’ regular coping mechanisms and imple-
strategies for dealing with the client’s body changes and ment new techniques as needed.
the effects on the family.
e Assist family members to identify realistic goals and ways The setting of realistic goals will help the family feel that they have
of reaching those goals. some control over the situation and their ability to care for the
client once discharged.
e Include family members in decision-making about the Including the family in the care of the client and decision-making
client and care; convey appreciation for their input and helps improve family members’ confidence in their ability to
continued support of client. care for the client.
e Encourage and allow family members to participate in
client’s care and rehabilitation.
e Assist family members in identifying resources that can Community resources can provide mental support, respite care, and
assist them in coping with their feelings and meeting their information that can help the family reach rehabilitation goals.
immediate and long-term needs (e.g., counseling and so-
cial services; caregiver assistance programs; pastoral care;
service, church, and spinal cord injury groups); initiate a
referral if indicated.

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., psychiatric Consultation with other health care providers may increase the
nurse clinician, physician) if family members continue to family members’ success in adapting to changes in the client’s
demonstrate difficulty adapting to changes in client’s functioning and in the family structure.
functioning and family structure.

|Collaborative >.
Diagnosis. RISK FOR ASCENDING SPINAL CORD INJURY

Definition: Extension of damage from the original spinal cord injury that ascends up the spinal cord.

Related to: Further damage to and/or ischemia of the cord above the CS level associated with vasospasm of damaged vessels,
progressive edema, bleeding, compression of cord by hematoma or bone fragments, and/or ineffective immobiliza-
tion of an unstable cord injury

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Increased dyspnea; shallow respirations; dusky or cyanotic
skin color; drowsiness; confusion; decreased B/P and heart
rate; progressive loss of sensory and motor function

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 390 Chapter 7 * The Client With Alterations in Neurological Function

RISK FACTORS DESIRED OUTCOMES

e Trauma
The client will not experience spinal cord injury above the
e Changes in hemodynamic status
level of C5 as evidenced by:
a. Stable respiratory status
b. Stable B/P and pulse
c. No further loss of motor and sensory function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of ascending spinal Early recognition of signs and symptoms of ascending spinal cord
cord injury: injury allows for prompt intervention.
e Respiratory failure (e.g., rapid, shallow respirations; dusky
or cyanotic skin color; drowsiness; confusion)
e Significant decrease in B/P and pulse
e Further loss of motor and sensory function

THERAPEUTIC INTERVENTIONS RATIONALE

rn]

Independent Actions
Implement measures to prevent spinal cord injury above the
level of CS:
° Perform actions to maintain immobilization of the spine
until stabilization has been accomplished:
e Do not release or adjust skeletal traction or halo device Appropriate healing should occur before changes/adjustments in
unless ordered. traction occur, because the changes may extend the area of spi-
nal cord injury.
e If skeletal traction is present, keep traction rope and If weights are not hanging freely, the level of traction changes and
weights hanging freely. may further the spinal cord injury.
e Always use turn sheet and adequate assistance when Use of a turn sheet helps maintain the spine in proper alignment
repositioning client. when repositioning the client.
e Never use the rods of the halo device as handles. D @ + Use of rods on the halo device to move a client places undue stress
on the spinal cord and may further spinal cord injury.
e Check pin sites of halo or traction device every shift; Changes in the tightness of the halo pins or traction devices may
notify physician if pins are loose. D+ extend the area of spinal cord injury.
e If immobilization device fails (e.g., pins fall out, trac- Stabilize the client’s head, neck, and shoulders with any means
tion weights drop, rods on halo device disconnect): possible to prevent further injury.
1. Stabilize client’s head, neck, and shoulders with
hands, sandbags, or cervical collar.
2. Notify physician immediately. The physician must be notified to reestablish traction as soon as
possible, thus preventing further injury.
e Use the jaw thrust method rather than hyperextending Hyperextending the client’s neck may extend the spinal cord injury.
client’s neck if respiratory distress occurs.

Collaborative/Dependent Actions
e Perform actions to prevent ascending spinal cord ischemia:
e Implement measures to maintain adequate tissue Anything that alters spinal cord tissue perfusion may cause spinal
perfusion. cord ischemia.
e Prepare client for decompression of the spinal cord Decreases pressure on the spinal cord and improves circulation.
(e.g., removal of hematoma or bone fragments) if
planned. '
e Prepare client for surgical stabilization (e.g., fusion) if Administration of high doses of methylprednisolone within the first
planned. 8 hrs after spinal cord injury appears to be the most effective
way of slowing the development of ischemia above the level of
injury.
e Administer corticosteroids and calcium channel blockers if Calcium channel blockers decrease vasospasms.
ordered.
If signs and symptoms of ascending spinal cord injury occur, Ascending spinal cord injuries may compromise the client’s neuro-
be prepared to assist with intubation or tracheostomy and logical stimulation to the lungs. Emergency care may be neces-
mechanical ventilation. sary to prevent death.
 Chapter 7) y= The Client With Alterations in Neurological Function 391

Collaborative Diagnosis RISK FOR PARALYTIC ILEUS

Definition: Paralysis of the intestines resulting in blockage of the intestines.
Related to: Absence of neural stimulation of the intestine associated with absence of autonomic nervous system and reflex
activity below the level of the spinal cord injury during period of spinal shock

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of persistent abdominal pain and cramping Firm, distended abdomen; absent bowel sounds; failure to
pass flatus; abdominal x-ray showing distended bowel

RISK FACTORS DESIRED OUTCOMES

e Inability to follow treatment regimen
The client will not develop a paralytic ileus as evidenced
e Lack of fiber and food in diet
by:
a. Absence or resolution of abdominal pain and cramping
b. Soft, nondistended abdomen
c. Gradual return of bowel sounds
d. Passage of flatus

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of paralytic ileus: Early recognition of signs and symptoms of a paralytic ileus allows
e Development of or persistent abdominal pain and cramping prompt intervention.
e Firm, distended abdomen
e Absent bowel sounds
e Failure to pass flatus
Monitor results of abdominal x-ray. An abdominal x-ray that demonstrates distended bowel and may
be indicative of a paralytic ileus.

THERAPEUTIC INTERVENTIONS RATIONALE

Collaborative/Dependent Actions
If signs and symptoms of paralytic ileus occur: Paralytic ileus results in cessation of normal peristalsis. The client
e Withhold all oral intake. should have nothing by mouth (NPO) and have a nasogastric tube
e Insert nasogastric tube and maintain suction as ordered. D + in place to facilitate gastric decompression until the ileus is resolved.
Perform actions to maintain adequate tissue perfusion:
e Administer GI stimulants (e.g., metoclopramide) if GI stimulants help maintain adequate blood supply to the bowel.
ordered. D

Collaborative Diagnosis
|— ORISK FOR GASTROINTESTINAL BLEEDING

Definition: Bleeding that occurs in the gastrointestinal (GI) tract.

Related to:
e Erosions of the gastric and duodenal mucosa (can develop as a result of the increased output of hydrochloric acid that oc-
curs with stress)
e Irritation of the gastric mucosa associated with side effect of certain medications (e.g., corticosteroids)

~ NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 392 Chapter 7 = The Client With Alterations in Neurological Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shoulder pain, abdominal pain Frank/occult blood in stool or gastric contents; decreased
B/P, increased heart rate; decreasing RBC count, Hgb and
Het levels

RISK FACTORS DESIRED OUTCOMES

SRS TESS
The client will not experience GI bleeding, as evidenced
e Anxiety
by:
e Medication regimen
a. No reports of shoulder pain
b. Absence of frank and occult blood in stool and gastric
contents
c. B/P and pulse within normal range for client
d. RBC count, Hct and Hgb levels within normal range

NURSING ASSESSMENT RATIONALE

—_—___—_—_—_—__—_—
—— ———°:.0.0000 0.jQ

Assess for and report signs and symptoms of GI bleeding (e.g., Early recognition of signs and symptoms of GI bleeding allows for
reports of shoulder pain [referred]; frank or occult blood in prompt intervention.
stool or gastric contents; decreased B/P; increased pulse
rate; decreasing RBC count, Hct and Hgb levels).

THERAPEUTIC INTERVENTIONS RATIONALE

553 eee
Independent Actions
Implement measures to prevent ulceration of the gastric and
duodenal mucosa:
e Perform actions to decrease fear and anxiety (e.g., intro- These actions decrease fear, anxiety, and stress, thus decreasing the
duce client to staff, place call bell within client’s hand, release of endogenous steroids.
answer call promptly).
e Instruct client to avoid acidic foods/fluids that stimulate Acidic foods/fluids increase acidity in the GI tract and risk for
hydrochloric acid secretions or irritate the gastric mucosa GI bleeding.
(e.g., coffee, caffeine-containing tea and colas; spices such
as black pepper, chili powder, and nutmeg).

Dependent/Collaborative Actions
Implement measures to prevent ulceration of the gastric and
duodenal mucosa:
e Administer histamine,-receptor antagonists, proton-pump
Histamine receptor antagonists and proton-pump inhibitors Sup-
inhibitors, antacids, and/or cytoprotective agents, if
press secretion of gastric acid. Antacids neutralize stomach acid
ordered.
and cytoprotective agents create a protective barrier against
stomach acid and pepsin.
If signs and symptoms of GI bleeding occur:
e Insert nasogastric tube and maintain suction as ordered.
Insertion ofan NG tube to facilitate suction removes gastric acid
and pressure on the gastric lining.
e Administer blood products and/or volume expanders if Hypotension may occur; administration of blood and/or volume
ordered.
expanders may be needed to maintain adequate blood bressure
and tissue perfusion.
Assist with measures to control bleeding (e.g., gastric lavage, These interventions decrease or stops GI bleeding.
endoscopic electrocoagulation) if planned.
 Chapter 7 = The Client With Alterations in Neurological Function 393

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY HEALTH

MANAGEMENT nox; OR INEFFECTIVE HEALTH MAINTENANCE*?
NDx

Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition; Ineffec-
tive Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family
unit; Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; verbalizes Inaccurate follow-through with instructions; inappropriate
inability to follow prescribed regimen behaviors; experience of preventable complications of spi-
nal cord injury

RISK FACTORS
° Cognitive deficit e Inability to care for oneself
e Financial concerns e Difficulty in modifying personal habits and integrating
e Failure to take action to reduce risk factors for complica- treatments into lifestyle
tions of spinal cord injury

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; health behavior; health Teaching: individual; teaching: prescribed exercise; teaching:
resources; treatment procedure(s) psychomotor skills; health system guidance; financial
resource assistance; support system enhancement

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
learn changes based on situations, physical and emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

complications associated with spinal cord injury and de-
creased mobility.

Independent Actions
Instruct client in ways to prevent complications associated
with spinal cord injury:
e Position firm pillow between legs if spasms tend to cause Use offirm pillows between legs helps prevent thrombus formation
legs to cross. and adduction contractures.
e Wear an abdominal binder when changing from a reclin- An abdominal binder supports the abdominal muscles and helps
ing to a sitting position and take vasoconstrictor drugs if prevent injury.
prescribed to prevent dizziness and fainting.
e Elevate legs periodically during the day. Elevation of the legs prevents blood from pooling in the lower ex-
tremities and decreases the incidence oforthostatic hypotension.

needs.
*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching
tAlthough the client will not be able to perform many of the following actions independently, he/she must be knowledgeable about
and attendant and maintain an active role in the rehabilitation process.
them in order to provide proper instruction to significant others

-NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation
 394 Chapter 7 * The Client With Alterations in Neurological Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Implement measures to reduce severe spasticity (e.g., avoid These actions improve mobility and prevent contractures.
fatigue and chills, change position at least every 2 hrs, take
muscle relaxants as prescribed).
e Use full-length and long-handled mirrors to examine all Daily skin assessment helps identify pressure areas to prevent skin
skin surfaces in the morning and the evening; increase breakdown.
pressure relief measures if any areas of redness or pallor
develop.
e Obtain a kinetic bed for home use if possible. Use of a kinetic bed helps prevent skin breakdown.
e Wear shoes when in wheelchair. Wearing shoes helps prevents injury to feet.
e Avoid putting items such as coins, keys, and wallet in skirt These items can cause pressure on underlying skin areas when
or pant pockets. placed in skirt or pants pockets.
e Avoid wearing tight-fitting belts, clothing, shoes, and jew- These actions assure that there is no unnecessary pressure on the
elry; make sure that urine collection leg bag straps are not skin that may lead to skin breakdown.
too tight.
e Replace wheelchair cushions when they become worn-out.
e Implement measures to prevent hyperthermia (e.g., avoid The client is unable to maintain body temperature. These interven-
excessive clothing and bedding, limit length of time in tions help prevent hyperthermia injuries.
direct sunlight in hot weather, wear a wide-brimmed hat
when in direct sun, park your car or van in the shade in
hot weather and open the doors to let the vehicle cool
down before getting inside).
¢ Implement measures to prevent hypothermia (e.g., wear These actions help the client maintain appropriate body temperature.
adequate amounts of clothing, wear a hat when in a cold
environment, drink warm liquids).
e Implement measures to prevent falls (e.g., always use These interventions help prevent client injuries.
safety belt during transfers and when in chair, be certain
to have adequate assistance for transfer activity).
e Implement measures to prevent burns: These actions help prevent hyperthermia injuries.
e Always check temperature of shower or bath water be-
fore use (can use bath water thermometer or have at-
tendant check water temperature).
e Never smoke when alone; do not place ashtray in lap.
e Let hot foods/fluids cool slightly before attempting to
feed self.
e Never position self next to a stove, heater, or other
major source of heat; be aware of where feet and legs
are in relation to car heater when it is on.
e Never use an electric heating pad or electric blanket.
e Implement measures to prevent autonomic dysreflexia: Autonomic dysreflexia is a life-threatening emergency requiring
e Continue with effective bladder and bowel programs to immediate treatment. These actions help prevent autonomic
prevent urinary retention and constipation/impaction. dysreflexia. Bladder and bowel distention are the primary
e Change position frequently. causes of dysreflexia and should be prevented.
e Seek medical attention at first sign of infection, persis-
tent pressure area, or ingrown toenail.
e Apply a local anesthetic (e.g., Nupercainal ointment) to
area being stimulated before procedures/activities that
have previously resulted in episodes of autonomic dys-
reflexia (e.g., urinary catheterization, administration of
an enema, sexual activity).
 Chapter 7.4" The Client With Alterations in Neurological Function 395

THERAPEUTIC INTERVENTIONS RATIONALE

Demonstrate the following procedures to client, significant The client’s family members should provide a return demonstration
others, and attendant: on client care and prevention of injuries so that they are able to
° Assisted coughing technique (quad-cough) perform these correctly and may help the client maintain func-
e Heimlich maneuver tional status.
e Skin care
e Proper positioning and padding
e Transfer techniques
e Active and passive range-of-motion exercises
e Application of elastic stockings, abdominal binder, and
heel and elbow protectors
e Emergency treatment of autonomic dysreflexia (e.g., ele-
vate head of bed and lower client’s legs, alleviate causative
factor, administer an antihypertensive agent)
Allow time for questions, clarification, and return demonstration.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to correctly use and maintain assistive devices.

Independent Actions
Reinforce instructions from physical and occupational thera- Clarification of information and understanding of how to improve
pists regarding use of assistive devices. Allow time for health status.
questions, clarification, and return demonstration.
Instruct and demonstrate for client proper maintenance of as- Assist devices need to be kept in good working order to prevent client
sistive devices (e.g., replace parts that are worn out or bro- injury and help the client maintain independence and self-care.
ken, clean wheel hubs and crossbars of wheelchairs per
manufacturer’s instructions, keep wheelchair tires properly
inflated).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

altered bowel and bladder function.

Independent Actions
Reinforce bladder and bowel training programs. Proper bladder and bowel elimination are important in preventing
autonomic dysreflexia and other possible complications.
Demonstrate bowel care (e.g., digital stimulation, insertion of
suppositories, administration of enemas) and bladder care
(e.g., stimulation techniques, intermittent catheterization,
application of leg bag and bedside drainage bag, emptying
of urinary collection bag).
Allow time for questions, clarification, and return demonstration.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
e Instruct the client to report the following:
e Cloudy or foul-smelling urine Client and significant others should be instructed on the clinical
e Nausea and. vomiting manifestations of infections and other changes in health status,
° Cough productive of purulent, green, or rust-colored and to inform their health care practitioner to prevent further
sputum injury or decline in health status.

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 396 Chapter 7 = The Client With Alterations in Neurological Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Difficulty breathing or increased shortness of breath with

activity
e Sudden or persistent shoulder pain (this can be a referred
pain)
e Fever
e Chills or profuse sweating (can occur above the level of
the injury)
e Increase in spasticity (could indicate an infection below
the level of the injury)
e Unsuccessful bowel and/or bladder programs
e Redness in any extremity
e Swelling that appears suddenly, occurs only in one ex-
tremity, or does not subside overnight
e Increased restriction of any joint motion
e Persistent swelling over a joint
e Signs and symptoms of autonomic dysreflexia (e.g.,
pounding headache, sudden rise in B/P, blurred vision,
slow pulse, flushing and sweating above level of injury,
nasal congestion) that do not subside once the stimulus is
removed
e Any area of persistent skin irritation or breakdown
e Indications of pregnancy (stress that appropriate prenatal
care should be initiated as soon as possible)

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify resources that

can assist with financial needs, home management, and ad-
justment to changes resulting from spinal cord injury.

Independent Actions
Inform client and significant others about resources that can Community resources may provide the client and family with multi-
assist with financial needs, home management, and ad- ple levels of assistance (e.g., financial, social support, counseling).
justment to changes resulting from spinal cord injury
(e.g., spinal cord injury support and social groups; state
and federally funded financial programs; home health
agencies; community health agencies; local service groups;
financial, individual, family, and vocational counselors).
Initiate a social service referral if indicated. A referral may be required for the client and family to access com-
munity resources.

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider and occupational and physical therapists, and
medications prescribed.

Independent Actions
Reinforce the importance of keeping scheduled follow-up The client requires life-long care and follow-up appointments help
visits with health care provider, occupational and physical maintain health status.
therapists.
Explain the rationale for, side effects of, drug-to-drug and Knowledge of the medication regimen and the impact of these
drug-to-food interactions, and importance of taking medi- medications on the system, as well as how the medication regi-
cations as prescribed. men can be incorporated into the client’s lifestyle, allows the
client some mechanism of control of his/her disease and the
ability to have an active part in treatment and care.
 Ghapten aa The Client With Alterations in Neurological Function 397

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures designed to improve client adherence:
e Include significant others and caregivers in teaching An informed client and family are better able to adhere to a treat-
sessions. ment regimen.
e Encourage questions and allow time for reinforcement
and clarification of information provided.
° Provide written instructions on scheduled appointments Understanding the impact of medications on the individual will
with health care provider and occupational and physical allow the client to recognize changes and inform his/her health
therapists, medications prescribed, and signs and symp- care practitioner as needed.
toms to report.

ADDITIONAL NURSING DIAGNOSES

FEAR AND ANXIETY NDx RISK FOR ASPIRATION NDx

Related to: Related to:
e Extensive loss of motor and sensory function e Decreased ability to clear tracheobronchial passages associ-
e Application of immobilization device to stabilize and align ated with inability to cough forcefully resulting from
the cervical spine weakness of the diaphragm and paralysis of the abdominal
e Lack of understanding of diagnostic tests, diagnosis, and and intercostal muscles
treatment e Difficulty swallowing associated with neck hyperextension
e Unfamiliar environment and/or horizontal body positioning during the time that
e Financial concerns the cervical spine is immobilized
e Anticipated effects of the spinal cord injury on lifestyle
and roles RISK FOR POWERLESSNESS NDx
Related to:
ACUTE/CHRONIC PAIN NDx © Quadriplegia
e Headache related to contractures of the neck muscles (can e Dependence on others
occur in response to stress and/or neck pain) e Changes in roles, relationships, and future plans
e Neck pain related to nerve root irritation at the site of
spinal cord injury, muscle stiffness while immobilization GRIEVING NDx
device is in place, and muscle strain associated with in- Related to extensive loss of motor and sensory function and
creased use of neck muscles after removal of immobiliza- the effects of this loss on future lifestyle and roles
tion device
e Upper arm and shoulder pain related to muscle strain RISK FOR LONELINESS NDx
associated with increased use of biceps and shoulders as Related to inability to participate in usual activities, decreased
activity progresses contact with significant others and friends while in the hos-
pital and extended care or rehabilitation facility, depression,
IMBALANCED NUTRITION: LESS THAN BODY and withdrawal from others
REQUIREMENTS NDx
Related to: IMPAIRED URINARY ELIMINATION NDx
e Decreased oral intake associated with: Retention related to:
e Dietary restrictions during period of spinal shock if e Atony of bladder wall during period of spinal shock
paralytic ileus develops e Spasticity of the external urinary sphincter and/or loss of
e Anorexia resulting from fatigue, depression and social ability to coordinate bladder contraction and relaxation of
isolation, the effect of negative nitrogen balance, and the external urinary sphincter after period of spinal shock
early satiety that occurs with decreased GI motility e Incomplete bladder emptying associated with horizontal
e Difficulty swallowing resulting from neck hyperexten- positioning (in this position, the gravity needed for com-
sion and/or horizontal body position during the time plete bladder emptying is lost)
that the cervical spine is immobilized Incontinence related to:
e Difficulty feeding self e Spasticity of the bladder after period of spinal shock and
e Increased nutritional needs associated with an imbalance loss of ability to contract the external urinary sphincter
in the rate of catabolism and anabolism (Catabolic pro- voluntarily (incontinence can occur if the bladder con-
cesses occur at a faster rate than anabolic processes in tracts strongly when the external urinary sphincter is
persons who have sustained a spinal cord injury and in relaxed)
those who are immobile.) e Inadvertent stimulation of the voiding reflex

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 398 Chapter7 * The Client With Alterations in Neurological Function

RISK FOR CONSTIPATION NDx e Skull pin site infection related to introduction of patho-
Related to: gens during or after insertion of skull pins
e Decreased GI motility associated with:
e Loss of autonomic nervous system function below the DISTURBED BODY IMAGE
level of the injury during period of spinal shock Related to:
e Decreased activity ¢ Dependence on others to meet self-care needs
e Lack of awareness of stool in rectum associated with sen- e Feelings of powerlessness
sory loss below the level of the injury e Change in appearance associated with temporary presence
e Loss of central nervous system control over defecation reflex of devices to immobilize the spine, necessity of wheelchair
e Decreased gravity filling of lower rectum associated with use, and spasticity after period of spinal shock
horizontal positioning e Infertility (in males) associated with:
e Decreased intake of fluids and foods high in fiber e Possibility of retrograde ejaculation (can result from
impaired nerve function in the bladder neck)
RISK FOR INFECTION NDx e Decreased sperm formation and viability resulting from
e Pneumonia related to: testicular atrophy and impaired temperature regulation
e Stasis of secretions associated with decreased activity in the testes
and decreased ability to clear tracheobronchial passages e Changes in body functioning, lifestyle, and roles
(Client is unable to cough forcefully as a result of weak-
ness of the diaphragm and paralysis of the abdominal INEFFECTIVE COPING NDx
and intercostal muscles.) Related to:
° Aspiration of foods/fluids (impaired swallowing can oc- e Depression, fear, anxiety, feelings of powerlessness, and
cur as a result of neck hyperextension and/or horizon- ongoing grieving associated with spinal cord injury and its
tal body positioning during the time that the cervical effects on body functioning, lifestyle, and roles
spine is immobilized) e Dependence on others to meet basic needs
e Urinary tract infection related to: e Lack of personal resources to deal with spinal cord injury
e Growth and colonization of pathogens associated with and its effects
urinary stasis e Need for extensive rehabilitation
e Introduction of pathogens associated with presence of
an indwelling catheter and/or performance of intermit-
tent catheterizations

PARKINSON DISEASE
Parkinson disease (PD) is a neurodegenerative disease that leads bradykinesia, and postural changes. During the early stage of
to impairment of an individual’s motor functioning. PD affects PD, these manifestations may develop alone or in combina-
approximately 1 million individuals in the United States and 10 tion; however, as the disease progresses, all of these manifesta-
million worldwide. An estimated 4% of individuals with Parkin- tions are usually present. PD has an insidious onset that makes
son disease are diagnosed before the age of 50 with the rate of the diagnosis of the disease difficult until more pronounced
newly diagnosed cases increasing with age. The prevalence of symptoms appear. Other clinical manifestations seen as the
the disease ranges from 41 per 100,000 people in the 4th decade disease progresses include shuffling gait; postural changes; loss
of life to more than 1,900 per 100,000 among those 80 years of of facial expressions; slurred speech; difficulty writing, eating,
age and older. PD is slightly more prevalent in whites than chewing, and swallowing; drooling; gastric retention; constipa-
other ethnic groups, with men 1% times more likely than tion; orthostatic hypotension; and urinary retention. Depres-
women to have the disease. While the exact cause of PD is un- sion is often seen in individuals with PD.
known, experts agree that the condition results from a combi- While there is no definitive diagnostic test for PD, various
nation of both genetic and environmental factors. Genetic risk symptoms and diagnostic tests can be used in combination.
factors include autosomal dominant genes (e.g., ANCA and Researchers have identified lower levels of a_protein-
LRRK2), autosomal recessive genes (e.g., PARK7, PINK1, PRKN), neurofilament light chain protein (NfL) in people with the
and risk factor modifier genes (e.g., GBA). Identified environ- disease and in healthy individuals versus people with other
mental risk factors include age (>60 years of age), gender parkinsonian disorders. To consider a PD diagnosistwo of
(greater in men), chemicals from occupational exposure (e.g., the four main symptoms must be present over a period of
farming, military), and head injury/traumatic brain injury. time: shaking or tremor, slowness of movement (bradykinesia),
The symptoms of PD develop from an imbalance of acetyl- stiffness or rigidity of the arms or legs, and/or trouble with
choline and dopamine in the brain. Injury to the dopamine- balance and possible falls (postural instability). Significant
producing neurons in the substantia nigra and the basal improvement in response to medication therapy confirms a
ganglia lead to loss of dopamine. In normal movement, there diagnosis of PD.
is a balance between dopamine, an inhibitory neurotransmit- There is no cure for PD. The standard treatment focuses on
ter, and acetylcholine, an excitatory neurotransmitter. When correcting the imbalance of neurotransmitters with medica-
this balance is lost, the individual with PD experiences the tion. The medications approved for treatment of PD focus on
classic clinical manifestations of tremors, rigidity, akinesia or improving the release of dopamine or blocking the effects of
 Chapter 7a The Client With Alterations in Neurological Function B99

acetylcholine. The categories of medications used in PD are This care plan focuses on the adult client hospitalized
anticholinergics, dopamine precursors, dopamine agonists, with signs and symptoms of PD. Much of the information
monoamine oxidase B (MAO-B) inhibitors, and catechol-O- is also applicable to clients receiving follow-up care in an
methyltransferase inhibitors. Additional treatment may in- extended care or rehabilitation facility or home setting.
clude exercise to maintain the client’s health status as long as
possible. Specific exercises may be prescribed to maintain
muscle tone, decrease rigidity, and improve the ability to OUTCOME/DISCHARGE CRITERIA
swallow and speak. Clients with advanced PD or with unsta- The client will:
ble responses to medication, deep brain stimulation may be 1. Participate in activities of daily living
offered, which may stabilize medication fluctuations, reduce 2. Engage in a regular exercise program to maintain strength
or halt involuntary movements, reduce tremor, reduce rigid- 3. Maintain optimal nutritional status to meet caloric needs
ity, and improve slowing of movements. Even with treat- 4. Understand medication regimen
ment, the disease is progressive, and ultimately clients will 5. Develop a plan of care for adhering to recommended
lose the ability to care for themselves. follow-up care

|Nursing o>)
Diagnosis |IMPAIRED PHYSICAL MOBILITY nox
Definition: Limitation in independent, purposeful physical movement of the body or of one or more extremities.
Related to: Physiological changes associated with Parkinson disease

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; discomfort; fatigue Decreased reaction time; rigidity of muscles with move-
ment; tremors of upper extremities; limited ability to per-
form gross and fine motor skills; limited range of motion;
intentional movement-—induced tremor; postural instability;
uncoordinated movements

RISK FACTORS DESIRED OUTCOMES

e Lack of motivation The client will improve mobility as evidenced by:
e Weakness a. Increased physical activity
e Depression b. Movement of affected limb or limbs
c. Participation in activities of daily living
d. Demonstration of appropriate use of assistive devices
to improve movement

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance; fall prevention behavior; endurance Ambulation; joint mobility; fall precautions; exercise therapy

NURSING ASSESSMENT RATIONALE

Assess client’s movement ability and activity tolerance. Use a Assessment of mobility is used to best determine how to facilitate
tool such as the Assessment Tool for Safe Patient Handling movement. Assessment of activity tolerance provides a baseline
and Movement or the FIM. for patient strength and endurance with movement.
Assess for hallmark signs of PD:
e Tremors Tremors are more prominent at rest or during emotional Stress.
e Changes in handwriting, “pill-rolling,
”
shaking of the Tremors are due to a central nervous system imbalance between
head acetylcholine and dopamine.
° Rigidity
¢ Jerky quality of movement with passive range of motion May be observed unilaterally or bilaterally.
e Bradykinesia
e Decreased movement in blinking of eyelids, decreased
movement of the arms while ambulating, difficulty with
swallowing saliva, decreased facial expressions and move-
ments of the hands, changes in posture

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NURSING ASSESSMENT RATIONALE

Assess emotional response to immobility. Determine client’s acceptance of limitations. This impacts imple-
mentation of therapeutic interventions.
Assess need for assistive devices. Determine client’s needs for assistive devices as well as proper use
of wheelchairs, walkers, cane, and so on to reduce incidence of
falls.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage and implement strength-training activities:
e Active and/or passive range of motion Inactivity contributes to muscle weakening. Regular exercise de-
e Ambulation creases muscle rigidity and contractures while maintaining joint
e Activities of daily living D @ + mobility and physical strength.
Use assistive devices to help client with movement:
e Crutches Assistive devices help caregivers decrease the potential for falls and/
e Gait belt or injuries.
e Walker D @ +
Cluster treatments and care activities to allow for uninter- Adequate rest increases client’s tolerance and strength for activities.
rupted periods of rest. D @
Encourage patient with positive reinforcement during activities. A positive approach to activities supports the client’s accomplish-
De+ ment and engagement in new activities, and improves self-
esteem.
Implement falls protocol.
e Maintain the bed in low position and keep side rails up. These actions help prevent client falls.
De+
Use sequential compression devices or antiembolic stockings. These devices improve venous circulation and help prevent the de-
De+ velopment of thrombophlebitis in lower extremities.
Implement measures to maintain healthy, intact skin (e.g., These actions help client maintain healthy, intact skin and reduce
keep skin lubricated, clean, and dry; instruct or assist the risk of pressure sores and infection.
client to turn every 2 hrs; keep bed linens dry and wrinkle-
free). D@® +
Maintain an optimal nutritional status: Adequate nutrition is needed to maintain adequate energy level.
e Increase protein intake.
e Increase fluid intake to 2000 to 3000 mL/day unless con- Increased fluid intake maintains adequate hydration and helps
traindicated. prevent constipation and hardening of the stool.
Encourage coughing and deep breathing exercises and use of Prevents buildup of secretions and promotes lung expansion.
incentive spirometry.

Dependent/Collaborative Actions
Consult appropriate health care provider:
e Dietitian and physician and occupational therapists These individuals provide specific activities and exercise programs
to improve strength and mobility.
e Administer pain medications before activities. Pain medications reduce muscle stiffness and tension, allowing the
client to participate in activities.

|Nursing o>
Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs. i
Related to:
e Decreased oral intake associated with anorexia and nausea
e Loss of nutrients associated with vomiting if present
e Difficulty in swallowing
 Chapter 7 = The Client With Alterations in Neurological Function 401

CLINICAL MANIFESTATIONS

Subjective objective
Verbal self-report of lack of appetite; fatigue; difficulty Choking episodes; vomiting of food or fluids through the
swallowing nares; loss of weight with adequate food intake; body
weight 20% or more under ideal weight; capillary fragility;
pale conjunctiva and mucous membranes; constipation;
poor muscle tone; increased blood urea nitrogen (BUN) and
serum creatinine levels; decreased serum albumin and preal-
bumin levels; decreased Hct and Hgb levels, and WBC count

RISK FACTORS
e Lack of appetite
e Fatigue
e Depression

NOC OUTCOMES NIC INTERVENTIONS

Appetite; body image; bowel elimination; compliance Nutritional monitoring; nutritional counseling; nutritional
behavior: prescribed diet; hydration; weight maintenance Management; aspiration precautions; weight management
behavior

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition and reporting of signs and symptoms of malnutri-
e Weight significantly below client’s usual weight or below tion allows for prompt intervention.
normal for client’s age, height, and body frame
e Decreased BUN and serum albumin, prealbumin, Hct,
Hgb, and lymphocyte levels
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Assess for physical difficulty with eating: Physical changes resulting from PD can lead to malnutrition.
e Difficulty swallowing
e Decreased gag reflex
e Choking episodes
e Vomiting from nares
Monitor percentage of meals and snacks client consumes. An awareness of the amount of foods/fluids the client consumes
Report a pattern of inadequate intake. alerts the nurse to deficits in nutritional intake. Reporting an
inadequate intake allows for prompt intervention.
Perform or assist with anthropometric measurements such as Anthropometric measurements provide information about the
skinfold thickness, body circumferences (e.g., hip, waist, amount of muscle mass, body fat, and protein reserves the client
mid-upper arm), and bioelectrical impedance analysis if has. These assessments assist in evaluating the client’s nutri-
indicated. Report results that are lower than normal. tional status.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent choking and/or vomiting Choking and vomiting result in actual loss ofnutrients.
(e.g., eliminate noxious sites and odors). D @ +
Implement measures to improve oral intake:
e Perform actions to reduce nausea, pain, fear, and anxiety if Nausea, pain, fear, and anxiety all decrease client’s appetite and
present. D @ + oral intake.
e Perform actions to relieve GI distention if present (e.g., Distention of the GI tract (especially the stomach and duodenum)
encourage and assist client with frequent ambulation can result in stimulation of the satiety center and subsequent
unless contraindicated). D@ + inhibition of the feeding center in the hypothalamus. This
effect, along with the discomfort that occurs with distention,
decreases appetite.

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 402 Chapter 7 * The Client With Alterations in Neurological Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Increase activity as allowed and tolerated. D@ + Activity usually promotes a general feeling of well-being, which
can result in improved appetite.
e Maintain a clean environment and a relaxed, pleasant Noxious sites and odors can inhibit the feeding center in the hypo-
atmosphere. D@ > thalamus. Maintaining a clean environment helps prevent this
from occurring. In addition, maintaining a relaxed, pleasant at-
mosphere can help reduce the client’s stress and promote a feeling
of well-being, which tends to improve appetite and oral intake.
e Encourage a rest period before meals if indicated. D ® ++ The physical activity of eating requires some expenditure of energy.
Fatigue can reduce the client’s desire and ability to eat.
e Provide oral hygiene before meals. D@ Oral hygiene moistens the oral mucous membrane, which may
make it easier to chew and swallow. It freshens the mouth and
removes unpleasant tastes. This can improve the taste of foods/
fluids, which helps stimulate appetite and increase oral intake.
e Serve foods/fluids that are appealing to the client and ad- Foods/fluids that appeal to the client’s senses (especially sight and
here to personal and cultural (e.g., religious, ethnic) prefer- smell) and are in accordance with personal and cultural prefer-
ences whenever possible. D @ + ences are most likely to stimulate appetite and promote interest
in eating.
e Serve frequent, small meals rather than large ones if client Providing small rather than large meals can enable a client who is
is weak, fatigues easily, and/or has a poor appetite. D @ + weak or fatigues easily to finish a meal. A client who has a poor
appetite is often more willing to attempt to eat smaller meals
because they seem less overwhelming than larger ones. If
smaller meals are served, the number of meals per day should
be increased to help ensure adequate nutrition.
e Encourage significant others to bring in client’s favorite A client’s favorite foods/fluids tend to stimulate his/her appetite
foods unless contraindicated and eat with him/her if client more than institutional foods/fluids. The presence of significant
desires. others during meals helps create a familiar social environment
that can stimulate appetite and improve oral intake. In addi-
tion, relieving dyspnea decreases the client’s anxiety about and
preoccupation with breathing efforts and increases the ability to
focus on eating and drinking.
¢ Place client in a high-Fowler’s positions for eating and drinking. Placing client in a high-Fowler’s positions to eat reduces the risk for
aspiration.
¢ Provide foods that can be easily chewed and provide thick- These actions improve the client’s ability to swallow foods and
ened liquids. decrease incidence ofchoking and potential for aspiration.
e Allow adequate time for meals; reheat foods/fluids if neces- A client who feels rushed during meals tends to become anxious,
sary. D @ lose his/her appetite, stop eating, and possibly choke.
e Limit fluid intake with meals unless the fluid has a high When the stomach becomes distended, its volume receptors stimu-
nutritional value. D@ + late the satiety center in the hypothalamus and the clients re-
duces his/her oral intake. Drinking liquids with meals distends
the stomach and may cause satiety before an adequate amount
of food is consumed.
e Ensure that meals are well balanced and high in essential The client must consume a diet that is well balanced and high in
nutrients. essential nutrients in order to meet his/her nutritional needs.
Dietary supplements are often needed to help accomplish this.
e Allow the client to assist in the selection of foods/fluids The client who is actively involved in menu planning is more likely
that meet nutritional needs. to adhere to the diet plan. Involvement in meal selection in-
creases the client’s sense of control, which promotes a feeling of
well-being and can lead to an increased oral intake.

Dependent/Collaborative Actions
Implement measures to improve oral intake and nutritional
status:
e Administer medications that may be ordered to improve Medications such as antiemetic, antidiarrheals, and GI stimulants
client’s nutritional status (e.g., antiemetics, antidiarrheals, may relieve vomiting, diarrhea, and distention of the GI tract,
GI stimulants, and vitamins and minerals). D+ which decreases the discomfort that occurs with each of these
signs and symptoms. Vitamins and minerals are needed to
maintain metabolic functioning. If the client’s dietary intake
does not provide adequate amounts of them, oral and/or paren-
teral supplements may be necessary.
 Chapter The Client With Alterations in Neurological Function 403

THERAPEUTIC INTERVENTIONS RATIONALE

e Obtain a dietary consult if necessary. A dietitian is best able to evaluate whether the foods/fluids selected
will meet the client’s nutritional needs.
e Obtain a speech therapy consult. Speech therapists can work with the client to improve his/her abil-
ity to swallow.
e Perform a calorie count if ordered. Report information to A calorie count provides information about the caloric and nutri-
the dietitian and physician. tional value of the foods/fluids the client consumes. The infor-
mation obtained helps the dietitian and physician determine
whether an alternative method of nutritional support is needed.
e Consult the physician about an alternative method of If the client’s oral intake is inadequate, an alternative method of
providing nutrition (e.g., parenteral nutrition, tube feed- providing nutrients needs to be implemented.
ing) if client does not consume enough food or fluids to
meet nutritional needs.

|Nursing Diagnosis
»eo-="|RISK FOR ASPIRATION nox

Definition: Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheobron-
chial passages, which may compromise health.
Related to:
e Impaired swallowing
e Decreased gag reflex
e Decreased facial muscle tone

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Cough; tachypnea; dyspnea; tachycardia; dull percussion
noted over affected lung area; presence of foods in aspirate

RISK FACTORS DESIRED OUTCOMES

e Weakness The client will not aspirate secretions or foods/fluids as
e Eating too fast evidenced by:
a. Clear breath sounds
b. Resonant percussion over lungs
c. Absence of cough, tachypnea, and dyspnea

NOC OUTCOMES NIC INTERVENTIONS

Risk control: aspiration; body positioning: self-initiated; Aspiration precautions; respiratory monitoring; swallowing
GI function; nausea and vomiting control; respiratory therapy; airway suctioning
status; swallowing status

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of aspiration of Early recognition of signs and symptoms ofaspiration allows for
secretions or foods/fluids: prompt intervention.
e Rhonchi
e Dull percussion note over affected lung area
e Cough
e Tachypnea
e Dyspnea
e Tachycardia
e Presence of tube feeding in tracheal aspirate
Assess for difficulty in swallowing and a decreased gag reflex. Allows for interventions to be implemented to decrease risk of
aspiration.

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NURSING ASSESSMENT RATIONALE

Assist with diagnostic studies to determine whether aspira- Aspiration of foods/fluids during swallowing process is evident on
tion is occurring during swallowing (e.g., videofluoros- studies such as videofluoroscopy. Knowing when aspiration oc-
copy). curs during the swallowing process aids in the development of
an individualized plan of care to prevent further aspiration.
Monitor chest radiograph results. Report findings of pulmo- Evidence of pulmonary infiltrate on chest radiograph can indicate
nary infiltrate. that aspiration has occurred.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to decrease the risk of aspiration:
e Keep suction equipment readily available at bedside. This equipment is necessary to maintain patency of airway.
e Position patient in high-Fowler’s positions before initiat- This position uses gravity to facilitate movement of food/fluids
ing feeding. through the pharynx into the esophagus.
e Maintain patient in an upright position 30 to 45 minutes Allows for observation of potential swallowing difficulty.
after eating. D@ >
e Supervise administration of oral intake. Semisolid foods are more readily swallowed. Watery fluids are
e Offer foods with a thicker consistency, which facilitates difficult for patients with dysphagia to manage.
swallowing.
e Encourage client to chew each bite slowly and completely, Complete mastication of food products improves the client’s ability
and to eat slowly during meals. D@ + to swallow food.
e Place foods/medications on unaffected side of the mouth. This action facilitates effective swallowing of food.
De+
e Provide oral care after feedings. D @ + Good oral hygiene after meals results in removal of any remaining
food that could enter the pharynx and be aspirated into the
lungs.
e If client is receiving tube feedings, check tube placement Verification of feeding tube placement ensures that the tube feeding
before each feeding or on a routine basis if tube feeding is solution goes into the alimentary tract rather than the lungs.
continuous.

Dependent/Collaborative Actions
Perform actions to decrease the risk of aspiration:
e Monitor chest radiograph results. Evidence of pulmonary infiltrates on chest radiograph can indicate
that aspiration has occurred.
e Administer antiemetics as ordered to prevent vomiting. D + Antiemetics reduce the risk of vomiting.
e Consult appropriate speech therapist for swallowing Dysphagia assessment can establish techniques to prevent aspira-
difficulties. tion in patients with impaired swallowing.

|Nursing --....
Diagnosis |CONSTIPATION nox
Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or
pas-
sage of excessively hard, dry stool.
Related to: Physiological changes that alter normal bowel functioning

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of straining with defecation; feeling of rectal fullness Infrequent bowel movements; dry, hard, formed stool!
or pressure; inability to pass stool; headache; indigestion hyperactive/hypoactive bowel sounds; distended abdomen;
,

percussed abdominal dullness; severe flatus; hypoactive

or hyperactive bowel sounds; palpable abdominal mass;
oozing liquid stool
 Chapter aa The Client With Alterations in Neurological Function 405

RISK FACTORS DESIRED OUTCOMES

e Lack of fiber in diet ~
The client will maintain usual bowel elimination pattern
e Abdominal muscle weakness
as evidenced by:
e Physical inactivity
a. Usual frequency of bowel movements
e Decreased fluid intake
b. Passage of soft, formed stool
e Side effects of medications
c. Absence of abdominal distention and pain, feeling of rec-
tal fullness or pressure, and straining during defecation

NOC OUTCOMES NIC INTERVENTIONS

Bowel elimination; GI function; hydration; symptom Constipation/impaction management
control

NURSING ASSESSMENT RATIONALE

Ascertain client’s usual bowel elimination habits. Knowledge of the client’s usual bowel elimination habits is essen-
tial in determining whether constipation is present because the
frequency of defecation varies among individuals.
Assess for signs and symptoms of constipation: Early recognition of signs and symptoms of constipation allows for
e Decrease in frequency of bowel movements prompt intervention.
e Passage of hard, formed stools
e Anorexia
e Abdominal distention and pain
e Feeling of fullness or pressure in rectum
e Straining during defecation
Assess bowel sounds. Report a pattern of decreasing bowel Bowel sounds are produced by peristaltic activity. A pattern of de-
sounds. creasing bowel sounds indicates a decrease in bowel motility,
which can lead to and be present with constipation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote optimum bowel elimination:
e Encourage client to defecate whenever the urge is felt. D @ + Repeated inhibition of the defecation reflex results in progressive
weakening of the reflex. In addition, when the defecation reflex
is inhibited, feces remain in the colon longer and water contin-
ues to be absorbed from the feces, making the stool drier, harder,
and subsequently more difficult to evacuate.
e Assist client to toilet or bedside commode or place in high- A sitting position aids in the expulsion ofstool by taking advantage
Fowler’s positions on bedpan for bowel movements unless of gravity. This position also enhances the client’s ability to per-
contraindicated. D@ + form the Valsalva maneuver, which increases intra-abdominal
pressure and forces the fecal contents downward and into the
rectum, where the defecation reflex is then elicited.
e Encourage client to relax, provide privacy, and have call If the client is able to relax during attempts to defecate, he/she will
signal within reach during attempts to defecate. D @ + be able to relax the levator ani muscle and external anal sphinc-
ter, thus facilitating the passage of stool.
e Encourage the client to establish a regular time for defeca- Attempting to have a bowel movement within an hour after a meal,
tion, preferably within an hour after a meal. D + particularly breakfast, takes advantage of mass peristalsis,
which occurs only a few times a day and is strongest after
meals. Mass peristalsis is stimulated by the gastrocolic reflex,
which is initiated by the presence of foods/fluids in the stomach
and duodenum.
e Instruct client to increase intake of foods high in fiber Foods high in fiber provide bulk to the fecal mass and keep the stool
(e.g., bran, whole grain breads and cereals, fresh fruits and soft because of the ability of fiber to absorb water. The increased
vegetables) unless contraindicated. bulkiness (mass) of the stools stimulates peristalsis, which pro-
motes more rapid movement of stool through the colon.
The shorter the time that feces remains in the intestine, the less
water is absorbed from it, which helps prevent the formation of
hard, dry stools that are difficult to expel.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to drink hot liquids (e.g., coffee, tea) These interventions can stimulate peristalsis.
upon arising in the morning.
e Encourage client to maintain regular exercise.
e Encourage client to perform isometric abdominal strength-
ening exercises unless contraindicated.

Dependent/Collaborative Actions
Implement measures to promote optimum bowel elimination:
e Instruct client to maintain a minimal fluid intake of Inadequate fluid intake reduces the water content of feces, which
2500 mL/day unless contraindicated. results in hard, dry stool that is difficult to evacuate.
e Increase activity as allowed and tolerated. D @ + Ambulation stimulates peristalsis, which promotes the passage of
stool through the intestines.
e When appropriate, encourage the use of nonnarcotic rather Opioid analgesics slow peristalsis, which delays transit of intesti-
than opioid analgesics for pain management. nal contents. This delay also results in increased absorption of
fluid from the fecal mass with the subsequent formation of
hard, dry stool.
e Administer laxatives as ordered. D Laxatives/cathartics act in a variety of ways to soften the stool,
increase stool bulk, stimulate bowel motility, and/or lubricate
the fecal mass and thereby promote the evacuation of stool.
e Administer cleansing and/or oil retention enemas if A cleansing enema stimulates peristalsis and evacuation of stool by
ordered. D @+ distending the colon with a large volume of solution and/or by
irritating the colonic mucosa. An oil retention enema facilitates
the passage of stool by softening the fecal mass and lubricating
the rectum and anal canal.
e Consult physician about checking for an impaction and An impaction prohibits the normal passage of feces. Digital re-
digitally removing stool if the client has not had a bowel moval of an impacted fecal mass may be necessary before nor-
movement in 3 days, if the client is passing liquid stool, or mal passage of stool can occur.
if other signs and symptoms of constipation are present.

Nursing Diagnosis IMPAIRED VERBAL COMMUNICATION nox

Definition: Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.

Related to:
e Decreased tone in facial muscles
e Slow and/or slurred speech
e Decreased facial expression
e Decreased mobility of the tongue
e Decreased tone of voice

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty of expressing self Unable to speak dominant language; speaks or verbalizes
with difficulty; cannot speak; slurring/stuttering; difficulty
forming words and sentences

RISK FACTORS DESIRED OUTCOME '

e Depression The client will maintain positive interactions with others.
e Embarrassment
e Change in muscle tone

NOC OUTCOMES NIC INTERVENTIONS

Communication: expressive Communication enhancement: speech deficit; active listening
 Chapter 7 = The Client With Alterations in Neurological Function 407

NURSING ASSESSMENT. RATIONALE

Assess for motor speech impairment or difficulty forming Provides a baseline assessment of client’s status and allows for the
words. implementation of appropriate interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain positive communication:
e Approach communication with client as an adult. D @ + Inability to communicate can be frustrating. The client should be
treated with dignity.
e Ask questions that require short answers and allow time The client will need more time to express himself/herself. Short,
for the patient to respond. D@ + simple answers will reduce client’s frustration, allowing for
easier communication.
e Face client and maintain eye contact when client is In a calm, quiet environment the client can concentrate on com-
speaking. D@ > munication efforts and can hear others more clearly.
e Create a calm, quiet environment.
e Provide rest periods before speech therapy. D @ +
e Encourage client to routinely perform face and tongue These actions help the client maintain muscle tone, reduces rigidity
exercises. and helps facilitate communication while decreasing frustration
e Encourage client to sign or read out loud to self or family with the process.
members.
e Provide assistive communication aids such as pad/pencil,
computer, word cards, or picture boards. D@ +
e Encourage family to communicate with client. D> Family involvement will reinforce consistency of communication
measures.

Dependent/Collaborative Actions
Implement measures to maintain positive communication: Multidisciplinary plan of care can be developed.
e Consult speech pathologist.

~~ DISTURBED SELF-CONCEPT*
Definition
Disturbed Body Image NDx: Confusion in mental picture of one’s physical self.
Situational Low Self-Esteem NDx: Development of a negative perception of self-worth in response to a current situation.
Ineffective Role Performance NDx: A pattern of behavior and self-expression that does not match the environmental context,
norms, and expectations.
Related to:
e Loss of independent functioning
e Difficulty in communication

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of negative feelings about self Lack of participation in activities of daily living; with-
drawal from significant others; lack of planning to adapt
to necessary changes in lifestyle

*This diagnostic label includes the nursing diagnoses of disturbed body image, low self-esteem, and ineffective role performance.

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 408 Chapter 7 * The Client With Alterations in Neurological Function

RISK FACTORS DESIRED OUTCOMES

e Changes in physical appearance The client will demonstrate beginning adaptation to
e Poor self-esteem changes in appearance, body functioning, and lifestyle as
evidenced by:
a. Verbalization of feelings of self-worth
b. Maintenance of relationships with significant others
c. Active participation in activities of daily living
d. Verbalization of a beginning plan for integrating
changes in appearance and body functioning into
lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Body image; personal autonomy; self-esteem; psychosocial Body image enhancement; self-esteem enhancement; emo-
adjustment: life change tional support; support system enhancement; role enhance-
ment; counseling

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of a disturbed self-concept Early recognition of signs and symptoms of a disturbed self-concept
(e.g., verbalization of negative feelings about self, with- allows for prompt treatment.
drawal from significant others, lack of participation in ac-
tivities of daily living, lack of plan for adapting to neces-
sary changes in lifestyle).
Determine the meaning of changes in appearance, body func- An understanding of what the change means to the client provides
tioning, and lifestyle to the client by encouraging verbal- a basis for planning care.
ization of feelings and by noting nonverbal responses to
the changes experienced.

THERAPEUTIC INTERVENTIONS RATIONALE

———————
eee

Independent Actions
Be aware that client may grieve the loss of normal body func- Allows client and significant others to grieve loss of normal body
tioning and change in appearance. Provide support during functioning; helps client work through changes that are occurring.
the grieving process.
Discuss client’s feelings about disease symptoms. Discussion of feelings about the disease process helps the client in
dealing with his/her physiological changes.
Instruct client in ways to maintain health status as long as
possible:
e Maintain regular exercise program. These actions help the client maintain health status, decrease
e Maintain optimal diet. muscle rigidity, and improve muscle strength.
° Maintain performance of activities of daily living.
Encourage significant others to allow client to do what he/she This improves client’s confidence in ability to care for self and
is able. enhances client’s feelings of self-worth and assists with the
development of a positive self-concept.
Assist client’s and significant others’ adjustment by listening, These actions facilitate client and family acceptance of changes
facilitating communication, and providing information. and changes in lifestyle.
Encourage visits and support from significant others.
Encourage client to pursue usual roles and interests and to Pursuit of usual roles and activities helps the client maintain inde-
continue involvement in social activities as much as pendence and social interaction as long as possible.
possible.
Refer client and family to support groups Support groups may help client and family work through La
related to the disease process.
Refer client and family to community organizations. Allows for continuity of care and support once discharged from an
acute care facility.
 Chapter 7 = The Client With Alterations in Neurological Function 409

DISCHARGE TEACHING/CONTINUED CARE

| «DEFICIENT KNOWLEDGE npx; INEFFECTIVE FAMILY

HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE npx*t
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit;
Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; verbalizes Inaccurate follow-through with instructions; inappropriate
inability to follow prescribed regimen behaviors; experience of preventable complications of Par-
‘ kinson disease

RISK FACTORS
e Cognitive deficit e Inability to care for oneself
e Financial concerns e Difficulty in modifying personal habits and integrating
e Failure to take action to reduce risk factors for complica- treatments into lifestyle
tions of Parkinson disease

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; health behavior; health Teaching: individual; teaching: prescribed activity/exercise;
resources; treatment procedure(s) teaching: psychomotor skills; health system guidance;
financial resource assistance; support system enhancement

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching stands the importance of what is to be learned. Readiness to
learn changes based on situations, physical and emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will understand disease pro-

cess and prognosis.

Independent Actions
Reinforce information concerning the disease and treatment Knowledge of disease process and treatment helps the client and
modalities. family understand the changes that are occurring and the im-
portance of treatment in maintaining health status as long as
possible. This improves the client’s adherence to treatment regi-
men and allows the client to maintain a level of independence
for as long as possible. Knowledge of the disease process may
help with the client’s ability to cope with physical changes.

*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching needs.
+Although the client will not be able to perform many of the following actions independently, he/she must be knowledgeable about
them in order to provide proper instruction to significant others and attendant and maintain an active role in the rehabilitation process.

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 410 Chapter 7 * The Client With Alterations in Neurological Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an under-

standing of the rationale for and components of the recom-
mended diet and the importance of maintaining optimal
nutritional status.

Independent Actions
Provide instructions regarding ways to maintain an optimal
nutritional status:
e Maintain an adequate diet with the appropriate mix of Adequate nutritional status is required for the body to work
nutrients. efficiently and maintain optimal muscle strength and en-
ergy to perform activities of daily living as long as possible.
e Reinforce instructions related to taking small bites and These actions improve the client’s ability to swallow foods and
chewing food thoroughly. decrease the risk of aspiration.
e Inform client that eating small, frequent meals rather than
three large meals may help achieve the recommended
calorie intake.
e Reinforce the benefits of eating when rested and in a re- Eating in a relaxed environment improves the client’s ability
laxed atmosphere. to maintain nutritional status and decreases risk of aspira-
tion. When a client is anxious or rushed, there is an
increased risk for aspiration.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to main-

tain optimal muscle tone.

Independent Actions
Instruct client in ways that will maintain muscle strength for
as long as possible:
e Maintain a regular exercise routine. Regular exercise including exercise of the facial muscles, im-
e Encourage client to maintain exercises that work the facial proves balance, maintains muscle strength, and improves
muscles (i.e., sing or read aloud, stick out tongue, move flexibility and mobility and the client’s ability to verbally
tongue from side to side). communicate.

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Desired Outcome: The client will verbalize an under-

standing of medication regimen, including rationale, food
and drug interactions, side effects, schedule for taking, and
importance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, food and drug inter- Knowledge of medications and how they impact the system
actions, and the importance of taking medications as pre- improves client adherence and helps enhance the client’s
scribed. The client should understand which side effects understanding of the importance of adhering to the pre-
require notification of the health care provider. scribed medication regimen. The client must be able to
recognize alterations in functioning related to medication
administration.
Reinforce importance of taking medications as prescribed. Missing doses of medications or not taking them as prescribed
may adversely impact mobility.
Types of medications to treat PD include:
e Anticholinergics Anticholinergics help control muscle activity.
 Chapter 7 * The Client With Alterations in Neurological Function 411

THERAPEUTIC INTERVENTIONS RATIONALE

° Dopamine agonists Dopamine agonists, monoamine oxidase B inhibitors, and cate-
¢ Monoamine oxidase B inhibitor chol-O-methyl-transferase inhibitors increase the amount of
e Catechol-O-methyltransferase inhibitor CNS dopamine available for use, which decreases muscle rigid-
ity and tremors.
Instruct client to inform physician before taking other pre- Over-the-counter (OTC) medications may impact prescription med-
scription and nonprescription medications. ications and should not be taken without a health care provid-
er’s approval.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify resources that

can assist in the adjustment to changes resulting from PD and
its treatment.

Independent Actions
Provide information about resources that can assist the client Client may need assistance from community organizations for
and significant others in adjusting to PD and its effects both emotional and financial support, once discharged
(e.g., local support groups, Parkinson disease foundations, from the acute care facility.
counseling services).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended fol-
low-up care including future appointments with health care
provider and activity level.

Independent Actions
Reinforce importance of keeping follow-up appointments PD is a chronic illness and requires appropriate follow-up with
with health care provider. health care providers.
Implement measures to improve client’s compliance:
e Include significant others in teaching sessions if possible. Support from client’s significant others is important in maintaining
adherence to the therapeutic regimen.
e Encourage questions and allow time for reinforcement Improves client’s and family’s understanding of disease process and
and clarification of information provided. what to do to remain healthy.
e Provide written instructions on future appointments with Written instructions allow the client to refer to them after discharge
health care provider, medications prescribed, signs and as needed.
symptoms to report, and future laboratory studies.

ADDITIONAL NURSING DIAGNOSES

ACTIVITY INTOLERANCE NDx BATHING SELF-CARE DEFICIT NDx; DRESSING

Related to muscle weakness and fatigue SELF-CARE DEFICIT NDx; FEEDING SELF-CARE
DEFICIT NDx; TOILETING SELF-CARE DEFICIT NDx
RISK FOR INJURY NDx Related to:
Related to altered gait and muscle weakness e Muscle weakness
e ‘Tremors
CAREGIVER ROLE STRAIN NDx e Rigidity of movements
Related to:
° Level of illness experienced by the client
e Duration of care required
e Complexity of care
e Caregiver isolation

~ NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Go to ©volve for animation
 CHAPTER

The Client With Alterations in

Hematologic and Immune Function

HUMAN IMMUNODEFICIENCY VIRUS INFECTION

AND ACQUIRED IMMUNE DEFICIENCY SYNDROME
Acquired immune deficiency syndrome (AIDS) is an infec- period of chronic infection, the person may be asymptomatic
tious disease of the immune system and is considered the or continue to experience mild symptoms such as fatigue,
last phase of the clinical spectrum of infection by the hu- headache, and lymphadenopathy. This early period often
man immunodeficiency virus (HIV). HIV is a retrovirus that lasts as long as 10 years, depending on the rate of viral repli-
affects the immune system cells in the body that have a CD4 cation and the rapidity of CD4+ T-lymphocyte destruction.
receptor on their surface. The immune cells with the CD4 During this stage, the individual may not have any symp-
receptor include T helper cells, monocytes, macrophages, toms, but is still able to pass the HIV-related symptoms
and dendritic cells. The CD4+ T lymphocytes (also called T4 and spread the virus to others. AIDS is the last stage of HIV
or T-helper cells) have the greatest number of CD4 receptors infection. In addition to the symptoms experienced in the
and are consequently the major target of HIV. These lym- previous stages, AIDS is diagnosed when immune suppression
phocytes are ultimately destroyed by HIV, which results in decreases to a CD4+ T-lymphocyte count <200 cells/mm?
severely impaired cell-mediated immunity in the host. and the presence of one or more illnesses as specified by the
Humoral immune function is also impaired because the B Centers for Disease Control and Prevention (CDC). These
lymphocytes are unable to respond appropriately to the AIDS-indicator conditions include a wide variety of immuno-
presence of a new antigen without the help of normal CD4+ suppression-related illnesses.
T lymphocytes. Macrophages and monocytes are the cells There is no cure for HIV infection. Significant advances
that are active in the immune response and are greatly have been made in antiretroviral therapy and prevention of
impacted by HIV infection. opportunistic infections. These have increased the long-term
HIV has been isolated from all body fluids, but at this survival of individuals with HIV infection. Earlier treatment
point, transmission has been associated only with blood, se- and the use of antiretroviral therapy, which consists of a com-
men, amniotic fluid, vaginal secretions, and breast milk. The bination of at least three or more antiretroviral agents, have
known routes of transmission are by intimate sexual contact, made significant differences in sustaining viral suppression,
mucous membrane or percutaneous exposure to infected slowing disease progression, and reducing drug resistance.
blood or blood products, and perinatal transmission from Because of the side effects of the antiretroviral agents and lack
mother to child. In the United States, HIV is spread primarily of adherence to the drug regimen, current federal guidelines
through sexual contact with someone who has HIV without suggest that treatment be offered early following exposure.
using a condom, as well as sharing intravenous drug equip- This care plan focuses on the adult client with HIV infec-
ment. Transmission to recipients of blood/blood products is tion hospitalized for treatment of a probable opportunistic
rare. Occupational exposure and fetus exposure from women infection and progression to an AIDS diagnosis. Much of the
who are HIV positive have significantly decreased over the information is applicable to clients receiving follow-up care
past several years. in an extended care facility or home setting.
Progression of HIV infection to a diagnosis of AIDS pro-
gresses in stages and is based on symptoms and CD4 cell
levels. OUTCOME/DISCHARGE CRITERIA
Infection with HIV, and the subsequent clinical expres-
sion, is attributed to either the effects of the virus itself or the The client will:
consequences of CD4+ T-lymphocyte depletion. Initial symp- 1. Maintain adequate respiratory status
toms during the acute retroviral infection may occur as early 2. Maintain adequate nutritional status
as 2 to 4 weeks after exposure to HIV. During this phase, some 3. Perform activities of daily living without undue fatigue or
individuals experience flu-like symptoms such as fever, head- dyspnea
ache, myalgias, lymphadenopathy, rash, fatigue, and a sore 4. Demonstrate evidence that opportunistic infection, if
throat that may persist for a week or longer. The second phase present, is resolving
of HIV infection is the chronic infection stage. In the early n . Manage signs and symptoms of neurological dysfunction

412
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 413

6. Maintain pain relief at an acceptable level 13. Discuss concerns and feelings about changes in mental
7. Show evidence that skin and oral mucous membranes are and physical functioning and the social isolation and
intact or healing appropriately loneliness that may result from having AIDS
8. Have fewer episodes of diarrhea 14. Identify resources that can assist with financial needs and
9. Implement actions to prevent the spread of HIV adjustment to changes resulting from the diagnosis of AIDS
10. Implement actions to decrease the risk for developing 15. Develop a plan for adhering to recommended follow-
opportunistic infections up care including regular laboratory studies, future
11. Develop a plan to maintain an optimal nutritional status appointments with health care providers, and medica-
12. State signs and symptoms to report to the health care provider tions prescribed.

|Nursing seers
Diagnosis |RISK-PRONE HEALTH BEHAVIOR nox
Definition: Impaired ability to modify lifestyle and/or actions in a manner that improves the level of wellness.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of inability to adhere to health care providers’ Smoking, alcohol and IV drug abuse;
recommendations; statements that imply non-acceptance Demonstrated hostility to health care providers; missing
of health status changes; continue unsafe sexual habits scheduled health care appointments

RISK FACTORS DESIRED OUTCOMES

e Economically disadvantaged The client will experience improved health status as evi-
e History of health risk behaviors denced by:
e Lack of understanding of seriousness of disease 1. Verbalization of acceptance of condition
e Insufficient social support 2. Initiation of lifestyle changes consistent with disease process
3. Developing a plan for improved health status

NOC OUTCOME NIC INTERVENTIONS

Risk Identification; Health Education Self-Efficacy enhancement; self-acceptance
Health Education: Risk factor reduction; health care plan;
identification of resources; mechanisms to reduce health risk
behaviors

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of risk-prone health Early recognition of client’s risk-prone behavior allows for prompt
behavior: intervention.
e Identify client’s understanding of risky health behavior
e Identify client’s understanding of barriers to positive
health behavior
e Identify client’s understanding of illness and sequelae if
health behaviors are not improved

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Evaluate client’s understanding of disease diagnosis and of Provides a starting point to develop a plan of action.
behaviors required to maintain optimal health.
Encourage client to discuss concerns and challenges to Allows patient to express beliefs, fears, and potential challenges in
implementing behaviors to maintain optimal health. adhering to health behaviors and required regimen.
Collaborate with client to identity support systems and avail- Allows client to have input into plan of care and identification of
able community resources. available support and resources. By involving the client, it can
also demonstrate to the nurse the level of involvement and
interest in making behavioral changes.

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 414 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Encourage client to utilize known and practice new coping Provides reinforcement of what has worked in the past and helps
mechanisms. the client to develop new mechanisms to support behavioral
changes. Practicing coping mechanisms with the nurse will
improve client self-confidence.
Discuss high-risk behaviors including unsafe sexual practices, Client may be uncomfortable discussing these issues with persons
sharing of injection drug needles, and failure to follow known to them. The nurse can discuss these issues in a non-
prescribed medication regimen. judgmental manner and assist client’s understanding of what
behaviors need to change and how to implement required changes.

Collaborative Actions
Refer client to HIV specialists, social workers, and community Client may benefit from working with individuals specifically
resources trained to deal with clients diagnosed with HIV.

a Nursing Diagnosis. INEFFECTIVE HEALTH MANAGEMENT nox

(MEDICATION MANAGEMENT)
Definition: Pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its
sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of not taking medications; confusion about Continued decrease in serum CD4+T cell levels; experi-
medication regimen; lack of financial resources to pay for ence of opportunistic diseases
medication; complaint of experience of medication
side effects

RISK FACTORS DESIRED OUTCOMES

* Socioeconomic status
e Medication side effects The client will demonstrate ability to adhere to medica-
¢ Poor understanding of medication regimen tion regimen by:
° Insufficient knowledge of therapeutic regimen 1. Taking medications as prescribed
° Insufficient social support 2. Set up a plan to assure refill and renewal of prescriptions
° Difficulty navigating complex health care systems 3. Improving CD4+T cell levels

NOC OUTCOMES NIC INTERVENTIONS

Medication administration; Self-care Self-Efficacy Enhancement; medication administration;
Health Education: medication management; support system
enhancement

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of lack of adher- Early recognition of client’s lack of medication adherence allows for
ence to medication regimen: prompt intervention.
° Assess client’s feelings about and understanding of medi-
'
cation regimen
e Assess client’s understanding of what can occur if not
adhering to medication regimen
° Assess for experienced side effects that may lead to non-
adherence with medication regimen
e Assess client’s financial concerns related to medications
prescribed
 Chapter8 = The Client With Alterations in Hematologic and Immune Function 415

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions ~
Discuss rationale for the prescribed medication regimen. Understanding of the short- and long-term outcomes of the role
of antiretroviral medications may help improve compliance.
Missing medications or altering drug regimen may lead to
increased viral load and/or cause the HIV to become resistant
to the prescribed medications.
Collaborate with client to develop a schedule for medication Helps to decrease confusion related to polypharmacy and drug
administration. administration requirements.

Collaborate with client in developing a plan to find and Involvement of the client in plan development may improve imple-
access community financial and social support. mentation.

Collaborative Actions
Discuss ways of decreasing specific antiretroviral side Inform the client that milder medication side effects may decrease
effects: over time.
e Encourage eating several small meals per day or drinking
nutritional smoothies
e Decrease intake of greasy, fatty, spicy, and dairy food; Helps to decrease impact of anorexia, nausea, and vomiting.
decrease intake of vegetables, whole grains and nuts that
are high in insoluble fiber
e Increase nutritious foods that provide energy; increase ac- These actions may decrease the incidence of diarrhea.
tivity tolerance; avoid smoking and alcohol
e Increase activity tolerance These actions may decrease the incidence of fatigue.
e Moisturize skin daily, take cool/lukewarm showers; use Actions decrease the incidence of a rash.
laundry detergents that are non-irritating; wear clothing
from natural fiber
e Avoid caffeine after 2:00 pm; avoid taking naps; exercise Actions decrease problems with sleeping.
regularly
e Decrease amount of fat and sugars in diet, eat foods high Actions address increased cholesterol and blood glucose levels.
in omega-3 fatty acids; monitor blood glucose and choles-
terol levels
With approval from health care provider, explore alternative
health care interventions (i.e., acupuncture, acupressure,
relaxation techniques, etc.)
Consult the appropriate health care provider (i.e., dietitian, Consulting the appropriate health care provider allows for modifi-
physical therapist, physician, etc.) for additional informa- cation of the treatment regimen.
tion and support in decreasing medication side effects

Diagnosis IMBALANCED
|Nursing >». NUTRITION: LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with:
e Anorexia resulting from malaise, fatigue, fear, anxiety, pain, depression, increased levels of certain cytokines that depress
appetite (e.g., tumor necrosis factor [TNF]), and some antiretroviral agents
e Nausea, dyspnea, and cognitive impairment if present
* Oral pain and/or dysphagia resulting from opportunistic lesions in the mouth, pharynx, and esophagus
° Impaired utilization of nutrients associated with:
that occurs
* Accelerated and inefficient metabolism of nutrients resulting from an increased resting energy expenditure
with infection and increased levels of certain cytokines (e.g., TNE, interleukin-1)
° Decreased absorption of nutrients if HIV and/or opportunistic infection involve the intestine
° Loss of nutrients associated with persistent diarrhea and vomiting if present

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 416 Chapter 8 * The Client With Alterations in Hematologic and Immune Function

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of inadequate food intake; reported lack of Body weight 20% or more under ideal body weight; loss of
food; aversion to eating; lack of interest in food weight with adequate food intake; weakness of muscles
required for swallowing or chewing; sore, inflamed buccal
cavity; hyperactive bowel sounds; diarrhea; vomiting,
excessive hair loss

RISK FACTORS DESIRED OUTCOMES

e Inability to digest food
e Inability to absorb nutrients The client will maintain an adequate nutritional status as
e Biological factors evidenced by:
e Disease progression a. Weight within normal range for client
e Insufficient dietary intake b. Normal blood urea nitrogen (BUN) and serum albu-
min, prealbumin, hematocrit (Hct), and hemoglobin
(Hgb) levels and lymphocyte count
c. Usual strength and activity tolerance
d. Healthy oral mucous membranes

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status; weight control Nutritional monitoring; nutritional management; nutrition
therapy; exercise promotion: strength training

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
° Weight significantly below client’s usual weight or below prompt intervention.
normal for client’s age, height, and body frame
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
e Lower-than-normal anthropometric measurements:
e Skinfold thickness
° Body circumferences (e.g., hip, waist, mid-upper arm)
e Bioelectrical impedance analysis
Monitor percentage of meals and snacks client consumes.
Report a pattern of inadequate intake.
Monitor BUN, serum prealbumin, albumin, Hct, and Hgb Abnormal BUN, low serum prealbumin, albumin, Hct, and Hgb
levels levels may indicate malnutrition. Because of the long (20-day)
half-life of albumin, the value is a late indicator of malnutri-
tion. Prealbumin has a half-life of 2 days and is a more timely,
sensitive indicator of protein status.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain an adequate nutritional status:
e Perform actions to improve oral intake:
e Implement measures to prevent breakdown of the oral Actions help to reduce oral/pharyngeal pain and improve swallowing.
mucous membrane and promote healing of existing lesions: '
¢ Lubricate lips frequently. D+ Maintains moisture and helps prevent breakdown.
e Rinse mouth frequently with salt and warm water; Alkalinizes the mouth and helps decrease bacteria count, soothes
baking soda and warm water; or a solution of salt, oral mucosa.
baking soda, and warm water. D + Dry crackers and other foods help to soothe stomach and decrease
nausea.
° Implement measures to reduce nausea: The client may be oversensitive to strong odors and when exposed
* Encourage client to eat dry foods when nauseated. D @ + to them can cause nausea.
° Avoid serving foods with an overpowering aroma. Nausea is associated with the pain experience and relief of pain
e Implement measures to reduce pain. may decrease/eliminate nausea.
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 417

THERAPEUTIC INTERVENTIONS RATIONALE

e Increase activity as tolerated. Activity promotes a sense of well-being, which can improve appe-
tite. Immobility is associated with negative nitrogen balance
which increases anorexia.
e If client is having difficulty swallowing, assist him/her Fluids and soft foods may be less irritating to the GI mucosa and
to select nutritional foods/fluids that are easily chewed decrease incidence of nausea. High nutrient fluids will help to
and swallowed (e.g., eggs, custard, macaroni and cheese, improve nutritional status.
baby foods) and avoid serving foods that are sticky
(e.g., peanut butter, soft bread).
e Encourage a rest period before meals to minimize fatigue. Provides energy for client to eat meals.
e Maintain a clean environment and a relaxed, pleasant Decreases noxious odors and subsequent nausea.
atmosphere. D @
e Provide oral hygiene before meals. D @ Oral hygiene moistens the mouth, which may make it easier to
chew and swallow; it also removes unpleasant tastes, which
often improves the taste of foods/fluids.
e Serve frequent, small meals rather than large ones if Small frequent meals enhance nutritional status and help client to
client is weak, fatigues easily, and/or has a poor appetite. conserve energy.
e If client is dyspneic, place in a high-Fowler’s positions
for meals and provide supplemental oxygen therapy
during meals. D@ +
e If client’s sense of taste is altered, suggest adding extra Implement only if the client is not experiencing nausea, as this
sweeteners and flavorings/seasonings to foods. may increase it.
e Encourage significant others to bring in client’s favorite Client may be more likely to eat when favorite foods are available
foods and eat with him/her. and in the presence of supportive company.
e Assist client with meals if indicated. D @ Support with eating and providing a calm, relaxed atmosphere may
e Allow adequate time for meals; reheat foods/fluids as help the client to relax and enjoy meal time, thus increasing
necessary. D@ + nutritional status.
e Perform actions to control diarrhea: Collaborate with client to identify foods and fluids that can stimu-
e Instruct client to avoid foods/fluids that may stimulate late diarrhea. Avoiding these foods will decrease incidence.
or irritate the bowel or cause the stool to be more liquid.

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional status:
e Perform actions to improve oral intake:
e Administer prescribed antiemetics. Decreases incidence of nausea.
e Obtain a dietary consult if necessary. Can provide for additional nutritional support and ideas for meal
times and required caloric intake
e Ensure that meals are well balanced and high in essential nutri- High-density foods will improve client’s nutritional imbalance.
ents; offer high-protein, high-calorie dietary supplements:
e Elemental formulas
e Nutrient-dense candy bars and soups if indicated
e Administer the following if ordered: Helps to maintain nutritional status until client can maintain
e Vitamins and minerals appropriate weight.
e Appetite stimulants Appetite stimulants and anabolic agents increase appetite and
e Anabolic agents stimulate increased muscle mass.
Perform a calorie count if ordered. Report information to Provides baseline for collaboration in determining client’s caloric
dietitian and physician. needs and potential interventions to improve weight gain.
Consult physician or physical therapist about a progressive Exercise is necessary to promote the maintenance/buildup of
exercise program. lean body mass and help prevent wasting and improves blood
nitrogen balance, thus decreasing anorexia.
Consult physician about an alternative method of providing Consulting the appropriate health care provider allows for modifi-
nutrition if client does not consume enough food or fluids cation of the treatment plan.
to meet nutritional needs: These supplemental methods support client’s nutritional needs
e Parenteral nutrition until they are able to improve oral intake.
e Tube feedings

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 418 Chapter 8 * The Client With Alterations in Hematologic and Immune Function

SRISK FOR INFECTION nox (OPPORTUNISTIC INFECTION)

Definition: Susceptible to invasive and multiplication of pathogenic organisms, which may compromise health.
Related to:
e Decreased resistance to infection associated with:
e Cellular and humoral immune deficiencies associated with HIV infection
e Inadequate nutritional status
e Myelosuppression resulting from medications (e.g., zidovudine, antineoplastic agents, trimethoprim-sulfamethoxazole,
ganciclovir, pyrimethamine)
° Stasis of respiratory secretions and/or urinary stasis if mobility is decreased
° Changes in integrity of skin associated with frequent invasive procedures

CLINICAL MANIFESTATIONS*

Subjective Objective
Verbal self-reports of pain at areas of impaired skin Fever, chills, tachycardia, warm discharge over areas of
integrity impaired skin integrity

DESIRED OUTCOMES
The client will remain free of additional opportunistic 7. Voiding clear urine without reports of frequency,
infection as evidenced by: urgency, and burning
1. Return of temperature toward client’s normal range 8. Maintenance of skin integrity
2. Decrease in number of episodes of chills and diaphoresis 9. Stable or gradual increase in body weight
3. BP and heart rate within normal range for client 10. No reports of increased weakness and fatigue
4. Normal or improved breath sounds 11. White blood cell (WBC) and differential counts return-
5. Absence or resolution of dyspnea ing toward normal range
6. Stable or improved mental status 12. Negative results of cultured specimens

NOC OUTCOMES NIC INTERVENTIONS

Infection protection Infection control; monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of additional op- Early recognition of signs and symptoms of infection allows for
portunistic infection (be alert to subtle changes in client, prompt intervention.
since the signs of infection may be minimal as a result of
immunosuppression; also be aware that some signs and
symptoms vary depending on the site of infection, the
causative organism, and the age of the client):
° Increase in temperature above client’s usual level
° Increase in episodes of chills and diaphoresis
° Hypotension (a symptom of sepsis)
° Tachycardia development or worsening of abnormal
breath sounds
° Development or worsening of dyspnea
e Development or worsening of cough
e Changes in mental status
e Cloudy urine
t
° Reports of frequency, urgency, or burning when urinating
e Urinalysis showing a WBC count greater than 5, positive
leukocyte esterase or nitrites, or presence of bacteria
e Vesicular lesions particularly on face, lips, and perianal
area
° New or increased reports of pain in and/or itching of skin
lesions and surrounding tissue

*Specific objective and subjective symptoms will depend on site of infection and causative
organism.
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 419

NURSING ASSESSMENT RATIONALE

e Further increase in weight loss, fatigue, or weakness
e Visual disturbances
e New or increased heat, pain, redness, swelling, or un-
usual drainage in any area
e New or increased irritation or ulceration of oral mucous
membrane
e Dysphagia
e Significant change in WBC count and/or differential
¢ Positive results of cultured specimens (e.g., urine, vaginal
drainage, stool, sputum, blood, drainage from lesions)
Assess results of complete blood cell count (CBC) with differ-
ential, and of all cultured specimens for positive results.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent further infection:
e Use good hand hygiene and encourage client to do the First line of defense in breaking the chain of infection and prevents
same. D @ > cross-contamination.
e Protect client from others with infection Anyone with any illness should not engage with the client.
e Maintain isolation precautions as indicated Reduces exposure to pathogens.
e Maintain a clean, well-ventilated environment Decreases stasis of secretions and risk for a respiratory infection.
e Encourage frequent deep breathing or use of incentive
spirometry and ambulation
e Maintain aseptic and/or sterile technique during all The use of aseptic/sterile technique reduces the risk of introduction
invasive procedures: of pathogens into the body.
e Urinary catheterization
e Venous and arterial punctures
e Injections
e Anchor catheters/tubings: Securing catheters and tubings reduces trauma to the tissues and
e Urinary risk for introduction of pathogens associated with the in-and-
e Intravenous out movement of the tubing.
e Change equipment, tubings, and solutions used for treat- Decreases potential for organism growth.
ments such as intravenous infusions, respiratory care, irriga-
tions, and enteral feedings according to hospital policy.
e Maintain a closed system for drains (e.g., urinary catheter) Prevents contamination of a closed system.
and intravenous infusions whenever possible.
e Provide a low-microbe diet (e.g., thoroughly cooked foods, Prevents exposure to pathogens from fresh fruits and vegetables.
fruits and vegetables that have been washed thoroughly).
¢ Perform actions to prevent stasis of respiratory secretions: Actions decrease stasis of secretions and potential for excretions of
e Assist client to turn, cough, and deep breathe. D @ + secretions.
e Increase activity as allowed and tolerated.
e Instruct and assist client to take a daily shower, perform good Actions decrease potential for infection.
perineal care routinely and after each bowel movement.
e Perform actions identified in this care plan to reduce stressors, Reducing stress helps to prevent an increase in secretion of cortisol
such as discomfort, dyspnea, and fear and anxiety. (cortisol interferes with some immune responses).
e Perform actions to prevent breakdown of oral mucous Salt water/baking soda mouth rinses help to alkalinize the mouth,
membrane and promote healing of existing lesions: which reduces bacteria, as bacteria thrive in acidic environ-
e Have client rinse mouth frequently with salt and warm ments.
water; baking soda and warm water; or a solution of
salt, baking soda, and warm water.
e Perform actions to prevent or treat skin breakdown. Healthy, intact skin reduces the risk of infection.
e Implement measures to relieve pruritus. Decrease risk of tissue injury and potential for introduction of
organisms.
e Perform actions to prevent urinary retention: Urinary retention increases risk for a urinary tract infection.
e Instruct client to urinate when the urge is first felt. Accumulation of urine creates an environment conducive to the
e Promote relaxation during voiding attempts. growth and colonization oforganisms.

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* NDx = NANDA Diagnosis
 420 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent further infection: Agents to reduce the rate of replication of HIV.
e Administer the following if ordered: Agents to stimulate production/enhance activity of the WBCs.
e Antiretroviral agents Agents to treat current infection or prevent additional opportunistic
¢ Immunomodulating agents (e.g., interleukin-2, colony- infection.
stimulating factors such as filgrastim and sargramostim)
e Antimicrobial agents (prophylaxis for Pneumocystis cari-
nii pneumonia, Mycobacterium tuberculosis, toxoplasmo-
sis, and Mycobacterium avium complex is recommended
for all clients with a CD4+ cell count below a critical
level)
e Vaccines (e.g., hepatitis A, hepatitis B, pneumococcal Supports immune system.
pneumonia, influenza)
e Maintain a fluid intake of at least 2500 mL/day unless Helps to prevent dehydration and stasis of secretions.
contraindicated.
e Perform actions to maintain an adequate nutritional status: Supports immune system.
e Obtain a dietary consult, if necessary, to assist client in
selecting foods/fluids that meet nutritional needs.

|Nursing 2
Diagnosis DISTURBED BODY IMAGE nox
Definition: Confusion in mental picture of one’s physical self.

Related to: Diagnosis of HIV/AIDS:

e Alteration in self-perception
° Fear of reactions by others to diagnosis and chronic illness
e Alteration in body function
Treatment regimen

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of concerns about physiological function- Lack of engagement in self-care
ing and changes; expression of fear of reaction by others;
powerlessness; preoccupation with diagnosis

RISK FACTOR DESIRED OUTCOMES

e Diagnosis of HIV/AIDS ——————————————— Eee
e Chronic illness The client will experience improvement in body image as
evidenced by:
a. Verbalization and understanding of changes in health
status
b. Identification of coping mechanisms to improve self-
perception

NOC OUTCOMES NIC INTERVENTIONS ,

Body image enhancement Crisis Intervention: counseling; strengthening coping
mechanisms

NURSING ASSESSMENT RATIONALE

Assess client for disturbed body image: Early recognition and report of signs and symptoms of disturbed
e Expression of negative thoughts about self and self- body image allows for prompt intervention.
functioning
e Lack of engagement in self-care
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 421

THERAPEUTIC INTERVENTIONS RATIONALE

nnn eee SSS aS

Independent Actions
Discuss and encourage verbalization of client’s concerns Demonstrates acceptance of client and will help client discuss
disease process and concerns related to potential lifestyle and
social interaction changes.
Acknowledge client’s feelings common following diagnosis Demonstrates acceptance of the individual and normalcy of feel-
of chronic illness ings/experiences.
Perform care in a nonjudgmental, accepting manner Health care providers should not allow personal feelings about
the client or client’s diagnosis to impact the client’s care or to
support the client’s negative thoughts of self.
Discuss meaning of diagnosis, treatment, and potential Provides the nurse with a basis to develop a plan to support patient
body functioning changes in psychological and physiological changes, and client teaching
concerning disease process and self-care.
Reinforce coping mechanisms that have worked for the client in the
past.
Identify coping mechanisms utilized in previous illnesses Developing and practicing new coping mechanisms adds to the
or with major life changes; collaborate with client to client’s ability to deal with current changes being experienced.
develop and practice new coping mechanisms Can strengthen client’s relationship with significant others, can help to
Involve significant other in discussion about illness, coping determine support that can be provided, and areas where more is
mechanisms, and plan of care (if client allows) needed. Allows client and significant others to develop realistic ex-
pectations related to the client’s diagnosis and long-term support.
Dependent and Collaborative Actions
e Recommend participation in support groups and identi- Allows client and significant others to engage with others going
fication of community support services. through the same experience. Provides for sense of community
with others. Supports continuum of care once client is dis-
charged from a health care facility.

|Nursing Diagnosis
2s |6RISK FOR DEFICIENT FLUID VOLUME nox AND RISK
FOR ELECTROLYTE IMBALANCE nox
Definitions: Risk for Deficient Fluid Volume NDx: Susceptible to experiencing decreased intravascular, interstitial, and/or
intracellular fluid volumes, which may compromise health; Risk for Electrolyte Imbalance NDx: Susceptible to
changes in serum electrolyte levels, which may compromise health.
Related to
e Risk for deficient fluid volume NDx:
e Excessive loss of fluid associated with diarrhea, diaphoresis, and vomiting if present
e Decreased oral intake associated with anorexia, weakness, nausea, and oropharyngeal pain
e Hypokalemia:
e Excessive loss of potassium associated with diarrhea and vomiting if present
e Decreased oral intake
e Hyponatremia:
e Excessive loss of sodium associated with diarrhea, profuse diaphoresis, and vomiting if present
° Water retention associated with increased antidiuretic hormone (ADH) output resulting from opportunistic disease
involvement of the lungs or central nervous system; potential alterations in renal function and adrenal insufficiency

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of weakness; confusion; complaints of dry Change in mental status; decreased skin turgor; postural
mouth hypotension; tachycardia; decreased urine output; cardiac
dysrhythmias; nausea and vomiting; diarrhea

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RISK FACTORS DESIRED OUTCOMES

e Abdominal ascites
The client will maintain fluid and electrolyte balance as
e Sepsis
evidenced by:
e Active fluid loss
a. Normal skin turgor
e Pharmaceutical agent
b. Moist mucous membranes
¢ Compromised regulatory mechanism
c. Stable weight
d. BP and pulse within normal range for client and stable
with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. Balanced intake and output
h. Usual muscle strength
i. Soft, nondistended abdomen with normal bowel sounds
j. Absence of nausea, vomiting, diarrhea, abdominal
cramps, and seizure activity
k. BUN, Hct, and serum potassium and sodium levels
within normal range

NOC OUTCOMES NIC INTERVENTIONS

Fluid/electrolyte monitoring Fluid management; electrolyte management: hypokalemia;
electrolyte management: hyponatremia

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of: Early recognition of signs and symptoms of fluid deficit and elec-
° Deficient fluid volume trolyte imbalance allow for prompt intervention.
e Decreased skin turgor, dry mucous membranes, thirst Thirst is an early symptom of dehydration.
e Thirst Body weight changes of 1 kg (2.2 Ibs) equal a fluid loss of 1 liter.
e Weight loss of 2% or greater over a short period Cardiovascular changes of hypotension and tachycardia are signs
e Postural hypotension and/or low BP of dehydration.
e Weak, rapid pulse May not change in clients with fever.
e Capillary refill time greater than 2 to 3 seconds Monitor I and O to provide for early identification of fluid loss.
e Change in mental status
e Decreased urine output (reflects an actual rather than
potential fluid deficit)
° Hypokalemia Indications of hypokalemia are non-specific and primarily involve
e Cardiac dysrhythmias changes in muscle and cardiac function. Weakness and fatigue
¢ Postural hypotension are the most common symptoms.
e Muscle weakness
e Nausea and vomiting
e Abdominal distention
e Hypoactive or absent bowel sounds
e¢ Hyponatremia Indications of hyponatremia involve proper muscle and nerve func-
e Nausea and vomiting tion. Clinical manifestations range from nausea and malaise to
e Malaise obvious neurological changes.
e Abdominal cramps
e Lethargy
e Confusion
e Weakness
e Seizures
Monitor serum electrolyte, BUN, creatinine levels Can identify changes over time and implement actions to prevent
symptomology from occurring

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent or treat imbalanced fluid
and electrolytes:
° Perform actions to control diarrhea:
e Instruct client to avoid foods/fluids that may stimulate Persistent or severe diarrhea results in excessive loss of fluid and
or irritate the bowel or cause the stool to be more liquid. electrolytes.
 Chapter 8 * The Client With Alterations in Hematologic and Immune Function 423

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to improve oral intake (e.g., prevent Foods or fluids that stimulate the bowel lead to increased intesti-
breakdown of oral mucous membrane). D@ + nal motility and excessive mucus production that increases the
e Provide fresh water and other fluids at easy access, if oral liquidity of the intestinal contents.
fluids are allowed. D@ Helps to maintain integrity of oral mucosa.
e Perform actions to reduce fever (e.g., tepid sponge bath, Helps to maintain adequate intake of fluids. Weight gain is a
cool cloths to groin and axillae). sensitive indicator of fluid volume changes.
Decreases fluid loss.
e Encourage intake of foods/fluids high in potassium: Helps to maintain adequate potassium levels.
e Bananas, avocado, sweet potatoes, orange juice, raisins
e Avocado
e Potatoes
e Raisins
e Cantaloupe
e Encourage intake of foods/fluids high in sodium Helps maintain adequate sodium levels.
e Processed cheese, canned soups, canned vegetables
Canned soups
e
Canned vegetables
Bouillon
Encourage intake of probiotics or live-culture yogurt or Improves bowel bacteria that when out of balance due to disease
supplements with lactobacillus acidophilus processes or treatment may lead to diarrhea.
Dependent/Collaborative Actions
Implement measures to prevent or treat imbalanced fluid
and electrolytes:
e Administer antiemetics if ordered to control vomiting. Nausea can cause the client to decrease fluid intake. Treating
e Administer antidiarrheal agents if ordered vomiting helps to prevent loss of fluid and electrolytes.
e Administer antipyretics if fever is present Diarrhea leads to fluid and electrolyte loss.
Helps to reduce body temperature and increased metabolic state
associated with fever.
e Maintain a fluid intake of at least 2500 mL/day unless con- Adequate fluid intake needs to be provided to ensure adequate
traindicated; if oral intake is inadequate or contraindicated, hydration to support vascular fluid volume.
maintain intravenous and/or enteral therapy as ordered.
e Administer electrolyte replacements if ordered. Serum electrolytes such as sodium and potassium have narrow
therapeutic ranges, must be kept within normal limits for nor-
mal body functioning.
Consult physician if signs and symptoms of imbalanced Consulting the appropriate health care provider allows for modifi-
fluid and electrolytes persist or worsen. cation of the treatment plan.

Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*

Definition: Ineffective Breathing Pattern NDx: Inspiration and/or expiration that does not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstruction from the respiratory tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.
Related to
Ineffective breathing pattern NDx: Changes in rate and depth of respirations associated with fear, anxiety, weakness, fatigue,
infection, increased metabolic rate, and chest pain
Ineffective airway clearance NDx
° Increased production of secretions associated with some opportunistic infections of the lungs
° Stasis of secretions associated with decreased activity and poor cough effort resulting from fatigue and pain
Impaired gas exchange NDx
A decrease in effective lung surface associated with:
© Presence of infiltrates and/or cavities in the lung tissue resulting from opportunistic infection of the lungs (e.g., pneumococ-
cal pneumonia [PCP], tuberculosis, histoplasmosis, etc.)
° Compression and/or replacement of lung tissue if an AIDS-related cancer such as Kaposi sarcoma or non-Hodgkin
lymphoma is present

clearance, and
*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern, ineffective airway
impaired gas exchange.

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CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of difficulty vocalizing; verbal reports of Dyspnea; tachypnea, orthopnea; diminished breath
restlessness sounds; adventitious breath sounds; cough productive and
non-productive; change in respiratory rate and rhythm

RISK FACTORS DESIRED OUTCOMES

uot Infecion The client will experience adequate respiratory function as

e Immunosuppression
evidenced by:
: BS ocysts jitoved! ee teeaaet tat a. Normal rate and depth of respirations
e Mycobacterium tuberculosis b. Decreased dyspnea
° Alveolocapillary membrane changes c. Improved breath sounds
° Respiratory muscle fatigue d. Symmetrical chest excursion
Retained SSS NOLES e. Usual mental status
pe pcessive mucus f. Oximetry results within normal range
g. Arterial blood gas values within normal range

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: airway patency: ventilation; gas Respiratory monitoring; airway management; chest physio-
exchange therapy; cough enhancement; ventilation assistance; oxygen
therapy; medication administration

a
neNURSING ASSESSMENT RATIONALE
ee ee eee eee
Assess for and report signs and symptoms of impaired respira- Early recognition of signs and symptoms of impaired respiratory
tory function: function allows for prompt intervention.
e Rapid, shallow respirations
e Dyspnea, orthopnea
e Use of accessory muscles when breathing
e Abnormal breath sounds (e.g., diminished, bronchial,
crackles [rales], wheezes)
e Asymmetrical chest excursion
° Cough (can be productive or dry and nonproductive de-
pending on the opportunistic disease present)
Monitor SaO, levels, arterial blood gas values, chest x-ray results.

THERAPEUTIC INTERVENTIONS RATIONALE

eee
Independent Actions
Implement measures to improve respiratory status:
e Place client in a semi- to high-Fowler’s positions unless High-Fowler’s positions allow for maximum diaphragmatic excur-
contraindicated; position with pillows to prevent slump- sion and lung expansion. Prevention of slumping is essential
ing. D@® + because slumping causes abdominal contents to be pushed up
and decreases lung expansion.
e Instruct client to breathe slowly if hyperventilating. Slowing the client’s breathing will decrease incidence of lightheadedness
° If client must remain flat in bed, assist with position Repositioning helps to mobilize secretions.
change at least every 2 hrs. D @>
e Instruct client to deep breathe or use incentive spirometer Deep breathing and use of an incentive spirometer promote maxi-
every 1 to2 hrs. D@® mal inhalation, lung expansion, improve sputum expectoration,
and decrease incidence of serious lung infections.
e Perform actions to promote removal of pulmonary secretions. Coughing or “huffing” accelerates airflow through the airways,
e Instruct and assist client to cough or “huff” every 1 to 2 hrs. helps mobilize and clear mucus and foreign matter from the
respiratory tract.
e Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause damage to the bronchial and alveolar
walls; the carbon monoxide decreases oxygen availability.
 Chapter 8 * The Client With Alterations in Hematologic and Immune Function 425

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve respiratory status:
° Maintain activity restrictions as ordered to reduce oxygen Helps to prevent shortness of breath.
needs.
° Assist with positive airway pressure techniques (e.g., Positive pressure airway techniques increase intrapulmonary
continuous positive airway pressure [CPAP], bilevel posi- (alveolar) pressure, which helps re-expand alveoli and prevent
tive airway pressure [BiPAP], flutter/positive expiratory further alveolar collapse.
pressure [PEP] device) if ordered.
e Perform actions to promote removal of pulmonary secretions:
¢ Implement measures to thin tenacious secretions and
reduce dryness of the respiratory mucous membrane: Adequate hydration and humidified inspired air help thin secre-
e Maintain a fluid intake of at least 2500 mL/day unless tions, thus facilitating mobilization and expectoration of
contraindicated. secretions.
¢ Humidify inspired air as ordered.
e Assist with administration of mucolytics (e.g., acetylcyste- Mucolytics and diluent or hydrating agents are mucokinetic sub-
ine) and diluent or hydrating agents (e.g., water, saline) via stances that reduce the viscosity of mucus, thus making it easier
nebulizer if ordered. for the client to mobilize and clear secretions from the respira-
e Assist with or perform postural drainage therapy (PDT) if tory tract. Postural drainage and suctioning help prevent stasis
ordered. of secretions and their removal from the respiratory tract.
° Perform suctioning if ordered.
e Administer expectorants (e.g., guaifenesin) if ordered.
e Perform actions to reduce pain and fatigue: Reducing pain enables the client to breathe more deeply and par-
e Administer analgesics before activities and procedures ticipate in activities to improve respiratory status.
that can cause pain and before pain becomes severe.
° Maintain oxygen therapy as ordered. D > Supplemental oxygen helps to support tissue oxygenation requirements.
e Administer central nervous system depressants judiciously; Central nervous system depressants such as opioid narcotics cause de-
hold medication and consult physician if respiratory rate pression of the respiratory center and cough reflex. This can result in
is less than 12 breaths/min. stasis of secretions and hypoventilation with impaired gas exchange.
e Administer the following medications if ordered: Bronchodilators dilate terminal airways, improving oxygen delivery
e Bronchodilators and ventilation.
e Antimicrobials Antimicrobials may be given to prevent pneumonia.
* Corticosteroids Corticosteroids decrease pulmonary inflammation and are usually
reserved for moderate to severe cases of PCP due to risk of fur-
ther immunosuppression.
Consult appropriate health care provider (e.g., respiratory Consulting the appropriate health care provider allows for modifi-
therapist, physician) if signs and symptoms of impaired cation of the treatment plan.
respiratory function persist or worsen.

Nursing Diagnosis ACUTE/CHRONIC PAIN nox

Definition: Acute Pain NDx: Unpleasant sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any
intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.
Chronic Pain NDx: Unpleasant sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any
intensity from mild to severe, constant or recurring without an anticipated or predictable end, and a duration of greater
than 3 months.
Oral, pharyngeal, and/or esophageal pain related to the presence of aphthous ulcers in the mouth and/or infections
involving the oropharyngeal and esophageal mucosa (e.g., candidiasis, herpes simplex).
Abdominal pain related to nonspecific gastritis and opportunistic infection or neoplastic involvement of the intestine.
Neuropathic pain related to the effect of HIV, some opportunistic infections, and impact of medications (e.g.,
didanosine, zalcitabine, isoniazid) on the peripheral nerves.

Headache related to:

° Cranial inflammation/pressure associated with an opportunistic infection involving the sinuses or brain or the presence of
a cerebral neoplasm
e Vasoactive cytokines that are present with HIV infection

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 426 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Chest pain related to:

e Inflammation of the parietal pleura associated with an opportunistic infection of the lungs
e Muscle strain associated with excessive coughing if present

Skin and local tissue pain related to:

e Skin lesions associated with opportunistic infection and/or Kaposi sarcoma
e Skin breakdown in perianal area associated with diarrhea

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal report of pain identifying changes in level of in- Inability to breathe deeply, ambulate, sleep, or perform
tensity using a pain rating scale; reported loss of appetite activities of daily living; crying; muscle rigidity; diaphore-
sis; blood pressure (BP) or pulse changes; increase in the
rate and depth of breathing

RISK FACTORS DESIRED OUTCOMES

e Chronic physical disability
The client will experience diminished pain as evidenced by:
e Chronic psychosocial disability
a. Verbalization of a decrease in or absence of pain
e Medication side effects
b. Relaxed facial expression and body positioning
e Disease processes fatigue
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES
ee NIC INTERVENTIONS
ee ee ee ee ee ee ee
Comfort level; pain control; pain: disruptive effects Pain management; acute and chronic; environmental man-
agement: comfort; analgesic administration

a NURSING ASSESSMENT RATIONALE

ae ree ee
Assess for and report signs and symptoms of pain: Early recognition of signs and symptoms of acute or chronic pain
e Verbalization of pain allows for prompt intervention.
e Grimacing
e Reluctance to move or breathe deeply
e Rubbing head
° Reluctance to eat
e Restlessness
e Diaphoresis
e Increased BP
e Tachycardia
Assess client’s perception of the severity of pain using a pain Provides a more objective measure of pain experienced and a
intensity rating scale. consistent standard for communication concerning pain.
Assess the client’s pain pattern:
e Location
° Quality
° Onset
e Duration
e Precipitating factors
e Aggravating factors
e Alleviating factors
Ask the client to describe previous pain experiences and
methods used to manage pain effectively.
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 427

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain: D +
° Perform actions to reduce fear and anxiety about the Actions help promote relaxation and subsequently increase the
pain experience: client’s threshold and tolerance for pain.
* Assure client the need for pain relief is understood.
e Plan methods for achieving pain control with client
“including adjuvant methods of pain relief.”
e Perform actions to reduce fear and anxiety: Measures to promote relaxation and decrease anxiety (i.e., relax-
e Instruct client in relaxation techniques and encourage ation techniques, guided imagery), acupuncture, distraction, etc.
participation in diversional activities. can enhance relief of pain with or without drug interventions.
e Administer analgesics before activities and procedures Pain relief improves client’s ability to independently perform
that can cause pain and before pain becomes severe. activities of daily living and increase activities, and will help to
decrease difficulty in sleep.
e Perform actions to reduce fatigue: Actions help to increase the client’s threshold and tolerance for
e Organize nursing care to allow for uninterrupted pain.
periods of rest.
Collaborate with client to implement actions to achieve Collaborating with clients regarding pain control strategies pro-
pain control vides the client a sense of control over the pain experience.
e Perform actions to prevent and treat oral mucous mem- Provides additional moisture, removes bacteria, and improves oral
brane and skin lesions: mucosal integrity.
e Lubricate lips frequently. D@® +
e Have client rinse mouth frequently with salt and
warm water. D @ +

Dependent/Collaborative Actions
Implement measures to reduce pain:
e Administer the following if ordered: Nonopioid analgesics interfere with the transmission of pain
e Nonopioid (nonnarcotic) analgesics such as salicylates impulses by inhibiting prostaglandin synthesis.
and other nonsteroidal anti-inflammatory agents
e Opioid (narcotic) analgesics Opioid analgesics act by altering the client’s perception of pain and
emotional response to the pain experience.
e Tricyclic antidepressants (e.g., amitriptyline) and/or Tricyclic antidepressants and anticonvulsant medications are used
anticonvulsants (e.g., carbamazepine, gabapentin) to treat painful neuropathies.
e Topical anesthetic/analgesic ointments (e.g., capsaicin) Topical anesthetics help alleviate skin and superficial neuropathic
e Oral anesthetic and/or protective agents (e.g., sucralfate, pain.
viscous xylocaine mixed with diphenhydramine elixir Anesthetic agents help control pain by inhibiting the initiation and
and a magnesium or aluminum antacid) conduction of pain impulses along sensory pathways.
e Corticosteroids Corticosteroids can decrease pain associated with some central
nervous system lesions, sinusitis, and peripheral neuropathies.
e Antimicrobials and/or antineoplastic agents These agents may be given to treat HIV infection and/or opportunistic
disease(s) causing the pain.
Consult appropriate health care provider if adequate pain Consulting the appropriate health care provider allows for modification
relief cannot be achieved with the above measures. of the treatment plan.

|Nursing _Diagnosis SPIRITUAL DISTRESS nox |

Definition: A state of suffering related to the impaired ability to experience meaning in life through connections with self,
others, the world, or a superior being.

CLINICAL MANIFESTATIONS

Subjective Objective
Self-reports of inability to forgive; ineffective relationships

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428 Chapter 8 * The Client With Alterations in Hematologic and Immune Function

RISK FACTORS DESIRED OUTCOMES

e Sir ess The client will maintain:
e Anxiety A sense of self-worth
e Chronic illness
Positive self-esteem
e Fear of dying
Connections with others
Connections with the world
Connections to a higher power than self

NOC OUTCOMES NIC INTERVENTIONS

Spiritual well-being Spiritual support; Spiritual Growth Facilitation

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of spiritual distress: Early recognition ofsigns and symptoms ofspiritual distress allows
Determine engagement in life activities that involve others for prompt intervention.
Expressions of feelings of hopelessness, futility, and powerlessness
Expressions of spiritual loss

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Discuss client’s engagement in spiritual religious activities. Allows nurse to determine what type of support client may require
based on beliefs and level of engagement in spiritual/religious
activities.
Supports client’s expression of anger, frustration, lack of The nurse should reassure the client that these feelings are normal
spiritual connection, and feelings of loss, powerlessness, when diagnosed with a terminal illness. The nurse should
and fear. provide non-judgmental care and allow the client to work
through feelings.
Collaborate with client in identify beliefs and values used to Helps client to clarify beliefs, values, and life goals.
guide behavior.

Collaborative Actions
Determine client’s engagement with formalized religion and Helps to engage others in supporting client. Provides post-discharge
identity family and community resources including pas- support for client and family.
toral staff, grief and crisis counselors.
Identify and refer to community support groups with indi-
viduals of the same religious faith or spiritual convictions.
Engage significant others in client’s journey working through
spiritual issues.

|Nursing Diagnosis
Diagnosis. INEFFECTIVE HEALTH MANAGEMENT nox; INEFFECTIVE FAMILY
HEALTH MANAGEMENT np»
Definition: Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic regi-
men for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals; Ineffective
Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the
treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit.

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of the desire to manage illness; self-report of Failure to include treatment regimen in daily routines;
difficulty with prescribed regimen failure to take action to reduce risk factors; makes choices
in daily living ineffective for meeting health goals; inade-
quate follow-through of instruction
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 429

RISK FACTORS
° Complex medication and treatment regimen ¢ Economically disadvantaged
° Lack of recall e Family conflict
e Unfamiliarity with information, resources

NOC OUTCOMES NIC INTERVENTIONS

Health Education Health system guidance; teaching: disease process; teaching:
prescribed diet; teaching: prescribed medication; communi-
cable disease management; financial resource assistance

NURSING ASSESSMENT RATIONALE

Assess the client’s baseline understanding of: Understanding the client’s knowledge base allows for teaching
e Disease process appropriate information.
e Therapeutic regimen
e Health prevention measures
Assess the client’s access to resources to help with successful Early identification of barriers to therapeutic regimen management
implementation of the treatment plan. allows for implementation of the appropriate interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

the spread of HIV.

Independent Actions
Instruct client in ways to prevent the spread of HIV to others: HIV is a fragile virus that is transmitted only under specified condi-
tions. They include when client comes in contact with infected
body fluids including blood, vaginal secretions, and breast milk.
HIV is transmitted through sexual intercourse with an infected
partner, exposure to infected body fluids, and perinatal trans-
mission during pregnancy, at the time of delivery, or through
breast-feeding.
If a spill of blood or other body fluids occurs, cleanse area HIV is rapidly destroyed after being exposed to chemical germicides
with hot, soapy water or a household detergent and then such as household bleach.
disinfect with a solution of 1 part bleach to 10 parts water. Prevents further contamination.
Dispose of water used to clean up body fluid spills in the toilet. Prevents transmission of HIV.
Do not share eating utensils, toothbrushes, razors, enema Consulting health care provider allows for early intervention.
equipment, or sexual devices.
Avoid getting pregnant, but if pregnancy occurs, consult
health care provider about antiretroviral therapy (e.g., zid-
ovudine) to reduce the risk of perinatal transmission of
HIV to infant.
Do not breast-feed infant.
Do not donate blood, sperm, or body organs.
If an intravenous drug user: Drug use in and of itself does not cause HIV.
e Get involved in a needle and syringe exchange program. The major risk for HIV infection with drug use is the sharing of
° Do not share drug-injecting equipment (e.g., needles, drug paraphernalia that may contain the blood of an infected
syringes, cookers, cotton, rinse water). individual. These interventions prevent exposure to other patho-
e Discard disposable needles and syringes after one use or gens and transmission of HIV.
clean them with household bleach and rinse thor-
oughly with water.
If sexually active with a partner: Safe sexual activity decreases the risk of exposure to HIV in semen
e Avoid multiple sexual partners and partners with risky and vaginal secretions. Abstinence is the most effective method.
sexual behaviors; be honest with desired partner about
HIV infection.
e Modify techniques so that both partners are protected
from contact with body fluids.
e Avoid unsafe sexual practices:
e Sharing sex toys
e Allowing ejaculate to come in contact with broken skin
or mucous membranes

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 430 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Intercourse without a condom
e Any activity that could cause tears in lining of vagina,
rectum, or penis
e Mouth contact with penis, vagina, or anal area
e Avoid vaginal intercourse during menstruation (the con-
tact with blood increases the risk of HIV transmission).
e Instruct the client in effective use of condoms: Barriers should be used when engaging in insertive sexual
e Always use a barrier (male and/or female condom) dur- activity. The effectiveness of male condoms is 80% to 90%.
ing anal, vaginal, and oral penetration (condom should
be applied before a body orifice is entered because HIV
is found in preseminal fluid).
e Use latex or polyurethane condoms (HIV can penetrate
other types of materials).
e Use condoms with a receptacle tip to reduce the risk of
spillage of semen; if that type is unavailable, create a
receptacle for ejaculate by pinching tip of condom as it
is rolled on erect penis.
e Lubricate outside of condom and area to be penetrated
to minimize possibility of condom breakage.
e Avoid lubricants made of mineral oil or petroleum dis-
tillates such as Vaseline or baby oil (these products
weaken latex).
¢ Hold condom at base of penis during withdrawal and
use caution during removal of condom to prevent spill-
age of semen (penis should be withdrawn and condom
removed before the penis has totally relaxed).
e Dispose of condom immediately after use (a new one
should be used for subsequent sexual activity).
e Store condoms in a cool place to prevent them from
drying out and breaking during use.
e Do not use a condom if the expiration date on the
package has passed, the package looks worn or punc-
tured, or if the condom looks brittle or discolored or is
sticky.

THERAPEUTIC INTERVENTIONS RATIONALE

——— eeeeoeaoewen

Desired Outcome: The client will identify ways to de-

crease the risk for developing opportunistic infections.

Independent Actions
Instruct client in ways to decrease risk for developing an op- HIV disease progression may be delayed by promoting a healthy
portunistic infection: immune system.
e Cleanse kitchen and bathroom surfaces regularly with a Actions that result in avoiding exposure to new infections are
disinfectant to prevent growth of pathogens. useful.
e If respiratory equipment (e.g., inhalers, humidifier) is Prevents exposure to other pathogens.
used at home, cleanse it as instructed and change water in
humidifier daily.
e Wear gloves when gardening and when in contact with
human or pet excreta (e.g., cleaning litter boxes, bird
cages, and aquariums).
e Avoid exposure to body fluids during sexual activity and use
latex or polyurethane condoms during sexual intercourse.
e Reduce the risk of food-borne illness.
e Thoroughly wash hands and food preparation items
and surfaces (e.g., knives, cutting board, countertop)
before and after cooking, especially when working with
raw meat, poultry, and fish.
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 431

THERAPEUTIC INTERVENTIONS RATIONALE

e Avoid intake of foods/fluids with a high microorganism
content (e.g., raw or undercooked poultry, seafood, meats,
or eggs; unwashed fruits and vegetables; unpasteurized
dairy products or fruit juices; raw seed sprouts; soft
cheeses; anything that has passed its expiration date).
e Cook leftover foods or ready-to-eat foods (e.g., hot
dogs) until steaming hot before eating.
e Avoid foods from delicatessen counters (e.g., prepared
meats, salads, cheeses) and refrigerated patés and other
meat spreads, or reheat these foods until steaming
before eating.
¢ Do not drink water directly from lakes or rivers.
e Boil water for a full minute if a community “boil water”
advisory is issued.
e Avoid activities such as cleaning, remodeling, or demolish- Old buildings, damp areas may be source of molds or environmen-
ing old buildings; exploring caves; disturbing soil beneath tal contaminants. Other areas may be considered to be endemic
bird-roosting sites or cleaning chicken coops; being around areas for histoplasmosis and coccidioidomycosis.
disturbed native soil at building excavation sites or dust Action reduces the risk of exposure to environmental contaminants
storms. that may lead to viral or bacterial infection.
e Wash hands after handling pets and avoid contact with Supports immune system.
reptiles (e.g., snakes, lizards, turtles), baby chickens, and Many vaccines are composed of live viruses and create a health risk
ducklings. for those with compromised immune systems.
e Avoid swimming in lakes, rivers, and public pools.
e Keep living quarters well ventilated and change furnace
filters regularly to reduce exposure to airborne disease.
e Avoid contact with persons who have an infection and
those who have been recently vaccinated.
e Maintain an adequate balance between activity and rest.
e Drink at least 10 glasses of liquid each day unless contra-
indicated.
e Contact health care provider before undergoing vaccinations.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to main-

tain optimal nutritional status.

Independent Actions
Provide instructions regarding ways to maintain an optimal Proper nutrition is essential to maintain body mass and ensure the
nutritional status: necessary levels of vitamins and nutrients.
e Eat foods that are high in protein and calories. Each of these actions help to maintain nutritional status. Supple-
e Try to eat a snack or a small meal or drink a nutritional ments may be required to stimulate appetite or provide additional
supplement every 2 to 3 hrs. nutritional support.
e Take prescribed vitamins, appetite stimulants (e.g., meges-
trol acetate), and anabolic agents (e.g., oxandrolone).
e Participate in a progressive exercise program if possible.

THERAPEUTIC INTERVENTIONS RATIONALE

i wr

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Stress importance of notifying the health care provider if the Clients must notify the health care provider of signs and symptoms
following signs and symptoms occur or if these existing of disease progression and/or the development of opportunistic
signs and symptoms worsen: infections so the treatment plan can be modified.
e Persistent fever or chills
e Night sweats

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Persistent headache or different type of headache
e Swollen glands
e Skin lesions or significant rash
e Reddish purple patches or nodules on any body area
e Ulcerations or white patches in the mouth
e Difficulty swallowing
e Persistent diarrhea or vomiting
e Perianal or vulvovaginal itching and/or pain
e Frequency, urgency, or burning on urination
e Cloudy or foul-smelling urine
e Dry cough or a cough productive of purulent, green, or
rust-colored sputum
e Progressive shortness of breath
e Increasing weakness, fatigue, or weight loss
e Change in vision, spots that appear to drift in front of eye
(floaters)
e Decline in mental function or level of consciousness
e Loss of strength and coordination in extremities
e Inability to maintain an adequate fluid intake
e Yellow discoloration of skin
e Bleeding from rectum that is not related to hemorrhoids
e Severe depression or anxiousness or feelings of being a
danger to self or others
e Seizures

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify resources that

can assist with financial needs and adjustment to changes
resulting from the diagnosis of HIV/AIDS.

Independent Actions
Provide information to client and significant others about Provides client and family with knowledge of resources to sustain
private, local, state and federally funded financial pro- therapeutic regimen ifexperiencing financial difficulties.
grams and resources that can assist in adjustment to the
diagnosis of AIDS (e.g., Ryan White HIV/AIDS Program,
hospice programs, community support groups, HIV/AIDS
Hotline, Project Inform).

THERAPEUTIC INTERVENTIONS RATIONALE

oo EEEEEEESESESESSSSSSSSSSSFSFSMSMSMsMsmsseF

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including regular laboratory studies, future
appointments with health care providers, and prescribed
medication regimen.

Independent Actions
Stress the importance of adhering to the prescribed treatment
regimen. prove outcomes, and aid in maintaining optimal health status.
Reinforce the importance of keeping scheduled follow-up ap- Helps health care professionals support client in maintenance of
pointments for laboratory studies and with health care health and provides early recognition of disease process changes.
providers. The medication regimen for clients with HIV/AIDS is very complex,
Explain the rationale for, side effects of, and importance of has many side effects, and can be expensive. The more clients
taking medications prescribed (e.g., antiretroviral agents, understand their medication regimen, the more successful they
antimicrobial agents, hematopoietic agents, anabolic may be in adherence.
agents, appetite stimulants). Experience of side effects is one reason for non-adherence. Knowing
Inform client of techniques to decrease medication side actions that can decrease incidence will help adherence to
effects. regimen.
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 433

THERAPEUTIC INTERVENTIONS RATIONALE

Inform client of pertinent food and drug interactions and Providing this information allows the client to assume some con-
ways to decrease the experience of drug side effects. trol of their health care regimen and may improve adherence.
Reinforce the importance of strictly adhering to the antiretro- Helps client understand the importance of taking medications as
viral regimen prescribed (usually consists of a combination prescribed.
of at least three antiretroviral agents). Full adherence to medication regimen prevents potential for
Explain that not adhering to the prescribed regimen will limit resistance to retroviral medications.
the effectiveness of subsequent regimens. Antimicrobials such as trimethoprim-sulfamethoxazole [TMP-SMX ])
Explain the importance of taking the full dose of any antimi- may be necessary to prevent some opportunistic infections if the
crobial agents prescribed. Reinforce the possibility that CD4+ cell count is critically low.
lifelong treatment with antimicrobials may be necessary.
Implement measures to improve client compliance: Including significant others in client teaching will help improve
¢ Include significant others in teaching sessions if possible. support for client and provides time for clarification of informa-
e Encourage questions and allow time for reinforcement and tion.
clarification of information provided. Written instructions provide informational resources for client and
e Provide written instructions regarding scheduled appoint- family to use once discharged from the acute care facility.
ments with health care providers and laboratory, medica- Client engagement in developing the plan of care allows some con-
tions prescribed, signs and symptoms to report, and ways trol over the process, boosts confidence in their ability to man-
to prevent infection. age health status, and improves adherence.
¢ Collaborate with client and significant others to develop a
plan for integration of health care regimen into activities
of daily living.

ADDITIONAL NURSING DIAGNOSES

DIARRHEA NDx FEAR NDx/ANXIETY

Related to: A direct effect of HIV on the intestine or oppor- Related to:
tunistic disease involvement of the intestine e Threat of permanent worsening of health status; possible
e Side effect of some antiretroviral agents (e.g., protease disability and death
inhibitors, didanosine) e Threat to self-concept associated with changes in physical
and mental functioning (e.g., wasting syndrome, gait dif-
IMPAIRED COMFORT NDx (PRURITUS) ficulty, poor coordination, dementia)
Related to: e Stigma associated with having AIDS
e Dry skin associated with deficient fluid volume e Financial concerns
e Pruritic folliculitis e Separation from support system
e Dermatological disorders such as seborrheic dermatitis, e Possibility of transmitting disease to others
photodermatitis, and psoriasis
e Side effects of some antimicrobials INEFFECTIVE COPING NDx
e Oral and vulvovaginal candidiasis Related to:
e Depression, fear, anxiety, and ongoing grieving associated
IMPAIRED ORAL MUCOUS MEMBRANE NDx with the diagnosis of HIV/AIDS and long-term illness
Related to: e Need for permanent change in lifestyle associated with
e Malnutrition and deficient fluid volume impaired immune system functioning and potential for
e Infections such as candidiasis, herpes simplex, oral hairy disease transmission to others
leukoplakia, and bacterial gingivitis/periodontitis e Uncertainty of disease process and feelings of powerless-
e Kaposi sarcoma or lymphoma in the oral cavity ness Over course of disease
e Need for disclosure of diagnosis with possibility of subse-
RISK FOR IMPAIRED SKIN INTEGRITY NDx quent rejection and/or distancing by others and loss of
Related to: employment and health benefits
Presence of cutaneous infections e Guilt associated with past behavior and/or possibility of
e Presence of skin disorders having transmitted HIV to others
e Skin lesions associated with Kaposi sarcoma if present e Lack of personal resources to deal with disability and pre-
Excessive scratching associated with pruritus mature death associated with youth
* Multiple losses (e.g., death of close friends with AIDS; loss
e Increased skin fragility associated with malnutrition
e Persistent contact with irritants associated with diarrhea of normal body functioning, family support, financial se-
e Damage to the skin and/or subcutaneous tissue associ- curity, and/or usual lifestyle and roles)
ated with prolonged pressure on tissues, friction, or e Chronic symptoms (e.g., pain, diarrhea, fatigue) if present
shearing if mobility is decreased

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 434 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

RISK FOR LONELINESS NDx INEFFECTIVE SEXUALITY PATTERN NDx

Related to: Related to:
e Fear of associating with others because of possibility of e Rejection by desired partner associated with his/her fear of
contracting an infection contracting HIV/AIDS
e Stigma and discrimination associated with the diagnosis of *« Need to disclose to new partner(s) the diagnosis of
HIV/AIDS and others’ fear of contracting HIV HIV/AIDS
e Decreased participation in usual activities because of weak- e Decreased sexual desire associated with fatigue, pain,
ness, pain, fatigue, and fear of falls weakness, anxiety, depression, and fear of transmitting or
e Withdrawal from others associated with fear of embar- contracting disease
rassment resulting from decline in physical and mental
functioning POWERLESSNESS NDx
Related to:
INTERRUPTED FAMILY PROCESSES NDx e The disabling and terminal nature of AIDS
Related to: e Increasing dependence on others to meet basic needs
e Diagnosis of terminal, communicable disease in family e Changes in roles, relationships, and future plans
member
e Fear of disclosure of diagnosis with subsequent rejection of GRIEVING NDx
family unit Related to:
e Change in family roles and structure associated with pro- e Having an incurable illness with an uncertain course and
gressive disability and eventual death of family member a high probability of premature death
e Financial burden associated with extended illness and e Changes in body functioning, appearance, lifestyle, and
progressive disability of client roles associated with the disease process
e Fear of contracting disease from client
e Decisions made by client and his/her significant other about HYPERTHERMIA NDx
such issues as treatment plan, life support, and disposition of Related to: Stimulation of the thermoregulatory center in
property that may conflict with the client’s family of origin the hypothalamus by endogenous pyrogens that are released
e Anticipatory grief in an infectious process

FATIGUE NDx
DISTURBED SLEEP PATTERN NDx Related to:
Related to: Fear, anxiety, depression, frequent assessments and e Difficulty with sleep and rest patterns
treatments, pain, diarrhea, pruritus, chills, night sweats, cough- e Increased energy utilization associated with the elevated
ing and dyspnea (may occur if respiratory infection is present), metabolic rate that is present with infection
unfamiliar environment, and the effect of some medications e Malnutrition

Sepsis, as defined by the American College of Chest Physicians and increased capillary permeability. This chain of events can
and Society of Critical Care Medicine, is a “life-threatening lead to maldistribution of circulating blood with hypoten-
organ dysfunction caused by a dysregulated host response to sion, hypoperfusion, and organ dysfunction. Septic shock,
infection” (Singer et.al., p. 804). The new criteria for a diagnosis disseminated intravascular coagulation (DIC), and multiple
of sepsis are altered mental status, rapid respiratory rate organ dysfunction syndrome (MODS) can develop if this
(>22 breaths/min), and low blood pressure (=100 mm Hg chain of events is not reversed.
systolic). Blood tests are no longer required for the diagnosis. According to the CDC, more than 1.5 million individuals
Clients with two of the three criteria are considered to be septic. will get sepsis each year in the United States. One in three
The most common sites of infection that lead to sepsis patients who die in the hospital have sepsis. Indiviquals at
are the lungs, blood, abdominal/pelvic cavity, and the uri- highest risk for sepsis are infants, children, the elderly, and
nary tract. people who have serious injuries or medical problems such as
Once the causative organism enters the blood (referred to diabetes, an impaired immune system, cancer, or liver disease.
as septicemia or bacteremia), the toxins produced by the Sepsis occurs due to the failure of the body’s defense mecha-
pathogens initiate a widespread inflammatory and immune nisms to an infection caused by bacteria, viruses, or fungi.
response commonly referred to as the systemic inflammatory However, bacterial infections are the most common cause.
response syndrome. This inflammatory response is designed The Quick Sepsis-related organ failure assessment (qSFOA)
to be a protective process but if uncontrolled, triggers the re- score is used to identify anyone who has an infection to iden-
lease of many inflammatory mediators that subsequently tify clients at high risk for sepsis. The score utilizes the three
cause widespread vasodilation, injury to the endothelium, criteria utilized to diagnose sepsis: altered mental status, rapid
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 435

respiratory rate (>22 breaths/min), and low blood pressure

(=100 mm Hg systolic). Scores range from 0 to 3 points. The OUTCOME/DISCHARGE CRITERIA
presence of two or more qSOFA indicators at onset of infec-
tion has been associated with a prolonged stay in the ICU or The client will:
a greater risk of death. The qSOFA is a risk identification tool 1. Demonstrate evidence that infection is resolving
to help determine who may be at risk for the development of 2. Maintain stable vital signs
sepsis. The nurse should assess anyone who is suspected of 3. Experience no signs and symptoms of complications
having an infection using the qSOFA. Early recognition and 4. Verbalize understanding of ways to promote continued
prompt treatment are critical to decreasing the incidence of resolution of the existing infection
sepsis and improving client mortality. . Discuss ways to reduce the risk for recurrent infections
This care plan focuses on care of the adult client hospital- . List signs and symptoms to report to the health care provider
ann

ized for treatment of sepsis. 7. Develop a plan for adhering to recommended follow-up
care including future appointments with health care pro-
vider, medications prescribed, and activity limitations

= sRRISK FOR INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox

RISK FOR INEFFECTIVE CEREBRAL TISSUE PERFUSION nox
RISK FOR DECREASED CARDIAC TISSUE PERFUSION nox
Definition: Risk for Ineffective Peripheral Tissue Perfusion NDx: Susceptible to a decrease in blood circulation to the periphery,
which may compromise health; Risk for Ineffective Cerebral Tissue Perfusion NDx: Susceptible to a decrease in
cerebral circulation, which may compromise health; Risk for Decreased Cardiac Tissue Perfusion NDx: Susceptible
to a decrease in cardiac (coronary) circulation, which may compromise health.
Related to:
¢ Maldistribution of circulating fluid volume associated with vasodilation, fluid shift that occurs with increased capillary per-
meability, and selective vasoconstriction occurring in response to inflammatory mediators (e.g., cytokines, complement,
histamine, kinins)
e Hypovolemia associated with deficient fluid volume resulting from decreased fluid intake, excessive loss of fluid (e.g., dia-
phoresis, hyperventilation, vomiting, and/or diarrhea if present), and the fluid shift that occurs with increased capillary
permeability
e Decreased cardiac output (occurs late in severe sepsis and shock) associated with the depressant effect of lactic acidosis, myo-
cardial dysfunction related to inflammatory mediators (e.g., cytokines)

CLINICAL MANIFESTATIONS

Subjective Objective
Restlessness Decreased BP; confusion; cool extremities; pallor or cyano-
sis of extremities; diminished or absent peripheral pulses;
slow capillary refill; edema; oliguria

RISK FACTORS DESIRED OUTCOMES

e Smoking The client will maintain adequate tissue perfusion as evi-
e Hyperlipidemia denced by:
e Sedentary lifestyle a. BP within normal range for client
e Underlying infection b. Usual mental status
c. Extremities warm with absence of pallor and cyanosis
d. Palpable peripheral pulses
e. Capillary refill time less than 2 to 3 seconds
f. Absence of edema
g. Urine output at least 30 mL/h

NOC OUTCOMES NIC INTERVENTIONS

Circulation status; tissue perfusion: cardiac, cerebral and Circulatory care: arterial insufficiency; circulatory care:
peripheral venous insufficiency; cerebral perfusion promotion; hypovo-
lemia management; cardiac care: acute and rehabilitative

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 436 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of diminished Early recognition of signs and symptoms of ineffective tissue perfu-
tissue perfusion: sion allows for prompt intervention.
e Decreased BP
e Changes in heart rate and rhythm
e Confusion
e Cool, pale or cyanotic extremities
e Diminished or absent peripheral pulses
e Slow capillary refill >2 to 3 seconds
e Edema
e Oliguria <30 mL/h
Monitor hemodynamic status:
e Vital signs
e Urine output
e Central venous pressure (if applicable)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
e Perform actions to maintain adequate tissue perfusion: Maintaining adequate vascular volume helps to ensure adequate
e Administer intravenous fluids (colloids/crystalloids) as tissue perfusion. The massive vasodilation that occurs during
ordered. sepsis results in a relative hypovolemia or distributive shock.
e Administer vasopressors and positive inotropic agents if Adequate volume replacement must occur first. If BP remains
ordered to maintain adequate perfusion pressure and low after volume has been replaced, vasopressors and/or inotro-
cardiac output. pes may be added to support circulation. Adequate tissue perfu-
e Perform actions to prevent or treat deficient fluid volume: sion promotes delivery of oxygen at the tissue level.
e Control diarrhea if present.
e Reduce nausea and vomiting if present.
e Administer antimicrobial agents as ordered. Antimicrobial agents help to resolve the infectious process and
control the systemic inflammatory response.
Consult appropriate health care provider if signs and symp- Allows for timely modification of the treatment plan
toms of diminished tissue perfusion persist or worsen.

|Nursing =...
Diagnosis |RISK FOR IMBALANCED FLUID VOLUME nox
Definition: Susceptible to a decrease, increase, or rapid fluid shift from one to the other of intravascular, interstitial, and/or
intracellular fluid, which may compromise health. This refers to body fluid loss, gain, or both.
Related to:
e Decreased oral intake associated with anorexia, fatigue, and nausea if present
e Increased insensible fluid loss associated with diaphoresis and hyperventilation if present
e Excessive loss of fluid associated with vomiting and/or diarrhea if present with initial infection or as a side effect of anti-
microbial therapy
e Fluid shift from the intravascular to interstitial space associated with the increased capillary permeability that occurs with a
systemic inflammatory response

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Decreased BP; decreased pulse pressure; decreased skin
turgor; dry mucous membranes; tachycardia; elevated Hct;
increased body temperature; decreased urine output;
increased urine concentration; dependent edema; increased
urine specific gravity
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 437

DESIRED OUTCOMES
The client will not experience deficient fluid volume as evi- e. Usual mental status
denced by: f. BUN and Het values within normal range
a. Normal skin turgor g. Balanced intake and output
b. Moist mucous membranes h. Urine specific gravity within normal range
c. Stable weight
d. BP and heart rate within normal range for client and
stable with position change

NOC OUTCOMES NIC INTERVENTIONS

Fluid management: adequate hydration Hypovolemia management; intravenous therapy; fever treat-
ment; diarrhea management; nausea management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of imbalanced fluid Early recognition of signs and symptoms of imbalanced fluid
volume: volume allows for prompt intervention.
e Decreased skin turgor
e¢ Dry mucous membranes, thirst
e Weight loss of 2% or greater over a short period
e Postural hypotension and/or low BP
e Weak, rapid pulse
e Neck veins flat when client is supine
e Change in mental status
e Decrease in urine output with increased specific gravity
Monitor BUN and Het values.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent or treat imbalanced fluid
volume
Monitor blood pressure and heart rate. Decreased vascular fluid volume leads to decreased blood pressure
and subsequent tachycardia. May demonstrate shift of fluid
from intravascular to interstitial compartments.
Monitor and document intake and output, correlating these Decreased urine output with increased specific gravity is indicative
findings with daily weight; measure urine specific gravity. of hypovolemia. Correlation of changes in weight with I & O
may indicate increased vascular permeability leading to edema.
Monitor and document decreased peripheral pulses. May indicate changes in vascular fluid volume.
Monitor and document incidence and level of edema. Indicates shift of vascular fluid volume into the interstitial tissues;
increasing level of edema may indicate worsening fluid volume
deficit.

Dependent/Collaborative Actions
Implement measures to prevent or treat imbalanced fluid
volume:
e Encourage oral intake of fluid if client is not on NPO; keep Helps to maintain fluid volume; helps to maintain oral cavity
ice chips and water easily accessible to client. integrity; easy accessibility of water and ice chips provides
e Perform actions to reduce nausea and vomiting if present: clients a measure of control over care
e Administer antimicrobial agents with food unless con- Helps to prevent further loss of fluid.
traindicated. Helps client tolerate medications.
e Administer prescribed antiemetics. Decreases incidence of nausea and vomiting.
e Perform actions to control diarrhea if present: Prolonged diarrhea can lead to excessive fluid loss and exacerbate
e Consult physician about another antimicrobial agent if dehydration.
onset of diarrhea seems related to initiation of anti-
microbial therapy.
e Administer prescribed antidiarrheal agents.

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438 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to reduce fever. Actions help to reduce insensible fluid loss associated with diapho-
resis and hyperventilation.
e Administer antimicrobial agents as ordered to treat the in- Decreasing the release of inflammatory mediators associated with
fection and decrease the release of inflammatory mediators. infection decreases capillary permeability and the resultant
fluid shift.
° Maintain a fluid intake of at least 2500 mL/day unless Maintains adequate vascular volume to support cardiac functioning.
contraindicated; if oral intake is inadequate or contraindi-
cated, maintain intravenous fluid therapy as ordered.

IMPAIRED GAS EXCHANGE nox

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Related to: Decreased pulmonary blood flow associated with a reduction in systemic tissue perfusion resulting from
inflammatory-mediated vasodilation, fluid shift with increased capillary permeability, and selective vasoconstriction
° Loss of effective lung surface associated with:
e Hypoventilation-associated atelectasis and decrease in surfactant production with diminished blood flow to the lungs
e Accumulation of secretions in the lungs subsequent to decreased mobility, poor cough effort, and increased production
of secretions
e Fluid accumulation in the lungs resulting from generalized endothelial damage and increase in capillary permeability that
occur with a systemic inflammatory response

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-reports of shortness of breath; visual disturbances; Confusion; restlessness; dyspnea; irritability; somnolence;
headache upon awakening abnormal pulse oximetry and arterial blood gas values;
abnormal skin color; abnormal breathing patterns; tachy-
cardia; diaphoresis

RISK FACTORS DESIRED OUTCOMES

e Alveolocapillary membrane changes
The client will experience adequate oxygen/carbon diox-
e Ventilation perfusion abnormalities
ide exchange as evidenced by:
° Smoking
a. Usual mental status
° Respiratory infection
. Unlabored respirations at 12 to 20 breaths/min
. Oximetry results within normal range
. Arterial blood gas values within normal range
© . Maintain clear lung sounds
oan

NOC OUTCOMES NIC INTERVENTIONS

—————_—————————————————————————————————————————————————————————————————————————————————————

Respiratory status: gas exchange Respiratory monitoring; cough enhancement; chest physio-
Acid-base balance therapy; oxygen therapy; airway management
Acid-base management: respiratory pattern; electrolyte
imbalance; HCO, deficit

eee
NURSING ASSESSMENT RATIONALE '
Assess for and report signs and symptoms of impaired gas Early recognition of signs and symptoms of impaired gas exchange
exchange: allows for prompt intervention.
° Restlessness, irritability
* Confusion, somnolence
e Tachypnea, dyspnea
e Significant decrease in oximetry results
° Decreased partial pressure of arterial oxygen (PaO2) and/or
increased partial pressure of arterial carbon dioxide (PaCO;)
Monitor pulse oximetry and arterial blood gas values
 Chapter 8 * The Client With Alterations in Hematologic and Immune Function 439

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve gas exchange: D +
° Place client in a semi- to high-Fowler’s positions unless Improves lung expansion, and decreases potential for aspiration.
contraindicated.
° Instruct and assist client to change position, deep breathe, Provides for mobilization of secretions.
and cough at least every 2 hrs.
° If severely dyspneic and physically able, assist client to Decreases gastric pressure on the diaphragm and allows improved
assume the tripod position (leaning forward, with elbows lung expansion.
supported on the bedside table).
° Discourage smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can damage the bronchial and alveolar walls; the
carbon monoxide decreases oxygen availability.

Dependent/Collaborative Actions
Implement measures to improve gas exchange: Maintaining adequate tissue perfusion helps to ensure adequate
° Perform actions to maintain adequate tissue perfusion: pulmonary blood flow.
e Administer intravenous fluids (colloids/crystalloids) as The massive vasodilation that occurs during sepsis results in a
ordered. relative hypovolemia or distributive shock. Adequate volume
° Administer vasopressors and positive inotropic agents if replacement must occur first. If BP remains low after volume
ordered to maintain adequate perfusion pressure and has been replaced, vasopressors and/or inotropes may be added
cardiac output. to support circulation. Adequate tissue perfusion promotes de-
° Monitor intake and output. livery of oxygen at the tissue level.
Fluid balance is critical in sepsis. Intake and output must be
measured to assure fluid balance. Fluid overload in the first
48-96 hrs is associated with increased mortality.
e Assist with positive airway pressure techniques (e.g., con- All actions help to open terminal airways/alveoli, increasing the
tinuous positive airway pressure [CPAP], bilevel positive surface area available for gas exchange to occur, resulting in
airway pressure [BiPAP], flutter/positive expiratory pres- improved oxygenation.
sure [PEP] device) if ordered.
¢ Maintain activity restrictions as ordered; increase activity Restricting activity lowers the body’s oxygen requirements and
gradually as allowed and tolerated. decreases cardiovascular energy requirement.
e Administer antimicrobial agents as ordered. Antimicrobial agents help to resolve the infectious process and
control the systemic inflammatory response.
Consult appropriate health care provider (respiratory thera- Allows for modification of the treatment plan.
pist, physician) if signs and symptoms of impaired gas
exchange persist or worsen.

|Nursing *Diagnosis |HYPERTHERMIA nox

Definition: Core body temperature above the normal diurnal range due to failure of thermoregulation.

Related to: Stimulation of the thermoregulatory center in the hypothalamus by endogenous pyrogens that are released in an
infectious process

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of chills Flushed skin; increase in body temperature; tachycardia;
tachypnea; warm to touch

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 440 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

RISK FACTORS DESIRED OUTCOMES

e Illness or trauma
The client will experience resolution of hyperthermia as
e Increased metabolic rate
evidenced by:
e Dehydration
a. Skin usual temperature and color
e Infection or Sepsis
b. Pulse rate between 60 and 100 beats/min
e Burns
c. Respiratory rate 12 to 20 breaths/min
d. Normal body temperature

NOC OUTCOMES NIC INTERVENTIONS

Thermoregulation Hyperthermia treatment: fever treatment

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of hyperthermia: Early recognition and reporting of signs and symptoms of hyper-
e Warm, flushed skin thermia allow for prompt intervention.
e Tachycardia
e Tachypnea
e Elevated temperature

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fever:
e Perform actions to resolve the infectious process: D + Preserves energy to focus on underlying condition causing an
e Implement measures to promote rest (assist client increased temperature.
with activities of daily living, provide uninterrupted
rest periods, limit visitors).
e Encourage client to eat a well-balanced diet high in Helps to fight off infection.
essential nutrients.
e Administer tepid sponge bath and/or apply cool cloths to Decreases body temperature.
groin and axillae if indicated. D@
e Use a room air conditioner and room fan to provide cool, Cool, ambient temperature helps other measures to decrease body
circulating air. temperature. It is important to prevent shivering as this will
increase oxygen consumption.

Dependent/Collaborative Actions
Implement measures to reduce fever:
e Perform actions to resolve the infectious process:
e Maintain a fluid intake of at least 2500 mL/day unless Dehydration can lead to increased body temperature.
contraindicated.
e Administer antimicrobials as ordered. Treats/prevents infection.
e Apply cooling blanket if ordered Decreases core body temperature.
e Administer antipyretics if ordered.
Consult physician if temperature remains higher than 38.5°C. Allows for prompt alteration in interventions.

|Nursing 4
Diagnosis «RISK FOR INFECTION nox (SUPERINFECTION)
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health. ‘

Related to:
e Decreased resistance to infection associated with depletion of immune mechanisms resulting from the current infection and
treatment with antimicrobial agents
e Stasis of respiratory secretions and/or urinary stasis if mobility is decreased or with dehydration
e Break in skin integrity associated with frequent venipunctures or presence of invasive lines
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 441

CLINICAL MANIFESTATIONS

Subjective a Objective
Verbal self-reports of pain at areas of impaired skin Increased body temperature; redness, warmth; discharge
integrity over areas of impaired skin integrity

RISK FACTORS DESIRED OUTCOMES

e Prol italizati
euTr eee Be MORE Ceio The client will have resolution of existing infection and
* Smoking remain free of superinfection as evidenced by:
* Aging a. Return of temperature toward normal range
° Suppressed inflammatory response b. Decrease in episodes of chills and diaphoresis
* Invasive procedure c. Pulse rate returning toward normal range
Oe Chronic iliness d. Normal or improved breath sounds
* Immunosuppression e. Absence or resolution of dyspnea and cough
f. Stable or improved mental status
g. Voiding clear urine without reports of frequency, urgency,
and burning
h. No reports of increased weakness and fatigue
i. Absence or resolution of heat, pain, redness, swelling,
and unusual drainage in any area
j. Absence of oral mucous membrane lesions and ulceration
k. WBC and differential counts returning toward normal
range
Il. Negative results of cultured specimens

NOC OUTCOMES NIC INTERVENTIONS

Risk identification: immune status; infection severity Infection control; infection protection

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of superinfection (be Early recognition of signs and symptoms of an infection allows for
alert to subtle changes in client since the signs of infection prompt intervention.
may be minimal as a result of immunosuppression; signs
and symptoms may vary depending on the site of the infec-
tion, the causative organism, and the age of the client):
e Increase in body temperature
e Increase in episodes of chills and diaphoresis
e Increased pulse rate
e Development or worsening of abnormal breath sounds
e Development or worsening of dyspnea and/or cough
e Decline in mental status
e Cloudy urine; client reports of frequency, urgency, burn-
ing when urinating
e Further increase in fatigue or weakness
e New or increased heat, pain, redness, swelling, or unusual
drainage in any area
e Development or worsening of lesions or ulceration of oral
mucous membrane
e New or increased episodes of diarrhea and abdominal
cramping or pain
Monitor CBC with differential; culture results; urinalysis;
chest x-ray results.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent superinfection:
e Use good hand hygiene and encourage client to do the Prevents spread of infection and cross-contamination.
same. D@® >

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 442 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Protect client from others with infection. Decreases client’s potential for infection and decreases cross-
contamination.
e Encourage client to eat a well-balanced diet high in essen- Necessary to produce cells that fight infection.
tial nutrients; provide dietary supplements if indicated.
e Maintain sterile technique during all invasive procedures. Prevents entrance of pathogens into the body.
e Change intravenous insertion sites according to hospital Decreases potential for infection.
policy.
e Anchor catheter/tubings securely. Securely anchoring tubes/catheters reduces trauma to the tissues
e Change equipment, tubings, and solutions used for treat- and the risk for introduction of pathogens associated with
ments such as intravenous infusions, respiratory care, irriga- movement of the tubing. Intravenous devices are known to be a
tions, and enteral feedings according to hospital policy. cause of hospital-acquired infections.
e Maintain a closed system for drains (e.g., urinary catheter) Prevents introduction of pathogens into the body and reduces risk
and intravenous infusions whenever possible. for nosocomial infections.
e Perform actions to prevent stasis of respiratory secretions: Improves lung expansion and motility and potential excretion of
e Assist client to turn, cough, and deep breathe. secretions.
e Instruct and encourage client to regularly use incentive Prevents cross-contamination.
spirometry
e Increase activity as allowed and tolerated.
e Use universal precautions if infection is present
e Perform actions to prevent urinary retention/stasis:
e Urinate when urge is felt.
e Promote relaxation when voiding.
e Instruct and assist client to perform good perineal care Prevents stasis of urine, which increases the potential for infection.
routinely and after each bowel movement. Urinary tract infections are a common cause ofsepsis.
e If client has open lesions or wound drains, perform actions Prevents contamination from bacteria from the rectum and helps
to prevent wound infection: client to completely empty bladder.
e Maintain sterile technique during wound care. Prevents cross-contamination.
e Instruct client to avoid touching wounds. Prevents cross-contamination and improves healing.

Dependent/Collaborative Actions
Implement measures to prevent superinfection:
e Maintain a fluid intake of 2500 mL/day unless contraindi- Helps to maintain adequate vascular fluid volume.
cated.
e Consult physician about discontinuing urinary catheter if Decreases risk for hospital-acquired infection.
one is present.
e Consult physician about: Maintains nutritional status. TPN has a high glucose content,
e Enteral feeding rather than total parenteral nutrition which provides a rich medium for bacterial growth. Monitor
(TPN) if nutritional replacement is necessary. insertion site closely and change dressings using sterile tech-
Obtain cultures as ordered. nique and per facility policy for frequency. Specific antimicro-
bial therapy is determined by culture and sensitivity.
e Use of sucralfate rather than antacids and histamine>- These agents increase the pH of the stomach contents, which pro-
receptor antagonists. motes bacterial overgrowth; aspiration of gastric contents with
a high bacteria content increases the risk for pneumonia.
e Administer antimicrobial agents as ordered. Until culture and sensitivity results are obtained, the client should
be treated with a broad- spectrum antibiotic. Monitor and treat
potential side effects from antibiotic therapy.

POTENTIAL COMPLICATIONS OF SEPSIS seensneunsccsnsnesinanessants a 7 +

Collaborative
SEPTIC Diagnosis | SHOCK
Definition: Sepsis-induced hypotension or the requirement for vasopressors or inotropes to maintain BP despite adequate
fluid volume resuscitation combined with the presence of perfusion abnormalities that may include lactic acidosis,
oliguria, and/or acute alteration in mental status.

Related to: Systemic hypoperfusion associated with maldistribution of circulating blood, deficient fluid volume, and/or
decreased myocardial contractility resulting from an uncontrolled systemic inflammatory response to severe
infection
 Chapter 8 = The Client With Alterations in Hematologic and Immune Function 443

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of confusion Low arterial pressure; low systemic vascular resistance; sys-
temic edema; tachycardia; temperature instability; oliguria;
decreased SaOz; changes in ABGs; cyanosis

DESIRED OUTCOMES
nn

The client will not develop septic shock as evidenced by: d. Extremities warm and usual color
a. Systolic BP equal to or higher than 90 mm Hg e. Capillary refill time less than 2 to 3 seconds
b. Usual mental status f. Palpable peripheral pulses
c. Urine output at least 30 mL/h

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of septic shock: Early recognition of signs and symptoms of septic shock allows for
e Hyperdynamic or compensatory phase prompt intervention.
e Widened pulse pressure with the diastolic pressure
dropping and little change in the systolic pressure
e Restlessness
e Tachycardia
e Warm, flushed skin
e Hypodynamic or progressive phase
e Systolic BP less than 90 mm Hg or a reduction of greater
than 40 mm Hg from baseline
e Cool, clammy skin
e Change in level of consciousness
e Decreased urine output
e Rapid, shallow breathing
e Rapid, thready pulse
Monitor serum lactate levels. Indicates improving or declining client status.
Monitor acid-base status

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain adequate tissue perfusion: Supports intravascular volume and cardiovascular status.
e Administer intravenous fluids (crystalloids/colloids) as
ordered.
If signs and symptoms of septic shock occur:
e Maintain intravenous fluid therapy as ordered. Treatment for septic shock focuses on the expansion of circulating
volume to improve tissue perfusion. Fluid volume support is
often not adequate to maintain blood pressure and cardiac
output. Vasopressors and inotropic agents improve perfusion
Administer vasopressors and positive inotropic agents pressures and cardiac output.
e Maintain oxygen therapy as ordered. Oxygenation needs are increased, and supplemental support is
required to decrease incidence of extreme lactic acidosis.
e Administer antimicrobials as ordered. Antimicrobial agents are required to address infection. May start
with a broad spectrum and change education based on culture
and sensitivity results.
e Prepare client for transfer to critical care unit. The patient often requires transfer to a critical care unit for inva-
sive monitoring of hemodynamic status (Swan-Ganz catheter;
central venous pressure; arterial line).

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 444 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

Diagnosis. RISK FOR DISSEMINATED

Sl Collaborative vocie-. INTRAVASCULAR COAGULATION
Definition: A systemic blood clotting disorder most commonly associated with sepsis.
Related to: Widespread inflammation and the resulting endothelial damage associated with sepsis results in inappropriate
triggering of the coagulation cascade due to the presence of tissue factor that is released by damaged or dead tissues

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of restlessness; agitation; confusion Bleeding: rapid development of oozing from venipuncture
sites, arterial lines, surgical wounds; ecchymotic lesions;
bleeding in conjunctiva, nose, and gums
Thrombosis: cyanosis of fingers/toes, nose, breast; symptoms
of organ failure

DESIRED OUTCOMES
The client will not develop DIC as evidenced by: d. Fibrin degradation products (FDPs) and D-dimer
a. Absence of petechiae, ecchymoses, and frank or occult results within normal range
bleeding e. Fibrinogen level, platelet count, activated partial throm-
b. Usual color and temperature of extremities boplastin time (APTT), prothrombin time (PT), and
c. Usual mental status thrombin time within normal range

NURSING ASSESSMENT RATIONALE

i TD I IO I a a tt a re
Assess for and report signs and symptoms of DIC: Early recognition of signs and symptoms of DIC allows for prompt
e Petechiae, ecchymoses intervention.
e Frank or occult bleeding (e.g., oozing from venipuncture
sites or surgical incisions, epistaxis, hematuria, gingival
bleeding)
e Cool, mottled extremities
e Restlessness, agitation, confusion
Monitor results of PT/PTT; FDP; fibrinogen level, D-dimer.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If DIC occurs: The body has depleted its clotting factors; thus, after any invasive
e Implement safety precautions to prevent further bleeding: procedure, excessive bleeding may occur. All these interventions
e Avoid injections. will decrease or prevent increased bleeding.
e Avoid invasive procedures.
e Discontinue any invasive lines with extreme caution.
e Use electric rather than straight-edge razor for shaving.

Dependent/Collaborative Actions
Implement measures to control infection and reduce the risk Treat/prevent infections
for an uncontrolled systemic inflammatory response in
order to reduce the risk for DIC:
e Administer antimicrobial agents as ordered.
e Perform actions to reduce the risk for superinfection. '
If DIC occurs: Blood clotting products replace deficit endogenous products and
e Administer fresh frozen plasma, platelets, and/or cryopre- work to enhance clotting and decrease bleeding.
cipitate if ordered.
e Administer medications to interrupt clotting: Low-dose heparin can partially inhibit active coagulation in sepsis.
° Heparin Antithrombin III inhibits thrombin-mediated microvascular
e Antithrombin III dysfunction and vascular injury associated with sepsis.
Heparin is contraindicated if platelet count is less
than 50,000.
 Chapter 8 «= The Client With Alterations in Hematologic and Immune Function 445

|Collaborative »Diagnosis
0" |RISK FOR ORGAN ISCHEMIA/DYSFUNCTION (MULTIPLE |
~ ORGAN DYSFUNCTION SYNDROME)
Definition: The progressive and potentially reversible dysfunction of two or more organ or organ systems resulting from an
uncontrolled inflammatory response to severe illness or injury. Mortality increases as the extent of organ failure
increases.

Related to:
e Hypoperfusion of major organs associated with shock
e Microvascular thrombosis associated with DIC

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Low-grade fever; tachycardia; dyspnea; altered mental status;
individual organ failure; changes in acid-base balance

RISK FACTORS DESIRED OUTCOMES

e Bowel infarction
The client will not develop organ ischemia/dysfunction as
e Inadequate or delayed resuscitation
evidenced by:
e Persistent infection
a. Usual mental status
e Significant tissue injury
eee b. Urine output at least 30 mL/h
7 c. Unlabored respirations at 12 to 20 breaths/min
d. Audible breath sounds without an increase in adventitious
e Acute pancreatitis
sounds
e Circulatory shock
e. Absence of new or increased abdominal pain, distention,
e Adult respiratory distress syndrome
nausea, vomiting, and diarrhea
e Necrotic tissue
f. BUN, creatinine, aspartate aminotransferase (AST),
alanine aminotransferase (ALT), and lactate dehydro-
genase (LDH) levels within normal range
g. Maintain acid-base balance
h. Maintain SaO, at >90

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of: Early recognition of signs and symptoms of multiple organ dys-
e Cerebral ischemia (e.g., change in mental status) function syndrome (MODS) allows for prompt intervention.
e Urine output less than 30 mL/h (elevated BUN and creati-
nine levels)
e Acute respiratory distress syndrome (e.g., dyspnea, increase in
respiratory rate, low arterial oxygen saturation [SaOg], crackles)
e Gastrointestinal ischemia (e.g., hypoactive or absent bowel
sounds, abdominal pain and distention, nausea, vomiting,
diarrhea, hematemesis, blood in stool)
e Liver dysfunction (e.g., increased AST, ALT, and LDH
levels; jaundice)
Monitor results of chest x-ray, complete metabolic panel, and ABGs.

*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching needs.

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 446 Chapter 8 = The Client With Alterations in Hematologic and Immune Function

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce the risk for organ ischemia/ Correction of vascular fluid volume with overload helps to decrease
dysfunction: physiological impact of sepsis.
e Perform actions to maintain adequate tissue perfusion
e Maintain fluid balance
e Provide supplemental oxygenation Supplemental oxygen is required to address hypoxemia associated
with sepsis and potential organ dysfunction.
e Maintain appropriate nutritional status Nutritional support provides energy to fight infection and maintain
body functions.
e Monitor and document lab values and ABGs, noting sig- Monitoring ABGs and lab values provides insight on changes in
nificant trends over time client’s condition over time and should be correlated with other
e Monitor and document vital signs, noting significant client assessment findings.
trends over time
e Perform actions to prevent and treat DIC Incidence of DIC is a contributing factor to MODS. Prevention and
rapid treatment help to decrease the severity of organ dysfunction.
Notify appropriate health care provider if client condition Allows for prompt interventions.
changes.

ADDITIONAL NURSING DIAGNOSES

FEAR NDx/ANXIRTY NDx
Related to:
e Severity of current condition
e Unfamiliar environment
e Threat of death
e Separation from significant others

SPLENECTOMY
Splenectomy is the surgical removal of the spleen. The most
common indication for removal of the spleen is organ rup- OUTCOME/DISCHARGE CRITERIA
ture. Causes of rupture include penetrating or blunt trauma
The client will:
to the spleen, operative trauma to the spleen during surgery
on nearby organs, and damage to the spleen as a result of
1. Have surgical pain controlled
disease (e.g., mononucleosis, tuberculosis of the spleen). A . Have evidence of normal healing of surgical wound
splenectomy may also be indicated if the spleen is removing . Have no signs and symptoms of infection
excessive quantities of platelets, erythrocytes, or leukocytes
hd
fw . Have no signs and symptoms of postoperative complica-
tions
from the circulation (hypersplenism). Conditions associated
with hypersplenism include infections such as mononucleo- 5. Identify appropriate safety measures to follow because of
sis, liver disease including hepatitis B, blood diseases charac-
increased risk for infection
terized by abnormal blood cells, and problems with the 6. State signs and symptoms to report to the health care pro-
vider
lymphatic system. Additionally, splenectomy may be per-
7. Develop a plan for adhering to recommended follow-up care
formed to treat splenic cysts and neoplasms. When feasible, a
including future appointments with health care provider,
partial splenectomy is performed so that some of the spleen’s
immunological function is maintained. medications prescribed, wound care, and activity level
This care plan focuses on the adult client hospitalized for
a splenectomy. The care plan will need to be individualized For a full, detailed care plan on this topic, go to
according to the client’s underlying disease process or the http://evolve.elsevier.com/Haugen/careplanning/.
extensiveness of abdominal trauma necessitating the surgery. See Bibliography at the back of the book.
 CHAPTER

oie Client With Alterations

in Metabolic Function

DIABETES MELLITUS
Diabetes mellitus is a chronic, multisystem disease character- A sequence of pathophysiological events occurs in diabetes.
ized by alterations in carbohydrate, fat, and protein metabo- When an insulin deficiency exists, glucose cannot be trans-
lism resulting from abnormal insulin production, impaired ported into the cells for energy metabolism. As a result, glucose
insulin utilization, or both. The hallmark of this metabolic accumulates in the blood and starts to spill into the urine once
disorder is hyperglycemia. the level exceeds the renal threshold (>180 mg/dL). The high
Diabetes* is often complicated by structural and functional blood glucose acts as an osmotic diuretic, which leads to exces-
abnormalities in the blood vessels and nerves. The atheroscle- sive diuresis and subsequent deficient fluid volume. Because
rotic changes that frequently occur in the large vessels (mac- the glucose cannot be used as an energy source by many cells,
roangiopathy) affect the cardiac, cerebral, and peripheral circu- fat and protein are broken down to provide a source of energy
lation. Thickening of the basement membrane of the capillaries for the starving cells. The free fatty acids that are mobilized
(microangiopathy) can also occur and is especially significant from adipose tissue are converted by the liver to ketones to be
when it involves the vessels in the eyes and kidneys. The neu- used as an energy source. The ketones are strong acids and
rological involvement can be manifested in a wide variety of eventually deplete the body’s buffer system and respiratory
ways and is referred to as diabetic neuropathy. Several different compensatory ability, leading to a state of metabolic acidosis.
mechanisms are thought to contribute to the development The simultaneous increase in glucagon and epinephrine re-
of diabetic neuropathy. These include reduced blood flow to lease that occurs with an insulin deficiency exacerbates the
the nerves as a result of angiopathies and a metabolic defect in hyperglycemia and ketogenesis. Continuation of these meta-
the polyol pathway resulting in accumulation of sorbitol in the bolic derangements leads to life-threatening imbalances.
nerves, which subsequently alters nerve function. The most This care plan focuses on the adult client who has
common neuropathy is peripheral sensorimotor polyneuropa- had diabetes for many years and is being hospitalized
thy, which has a gradual onset of sensory manifestations such because of difficulty stabilizing blood glucose levels.
as numbness and tingling, burning or shooting pain sensa- Many of the long-term vascular and neurological com-
tions, and/or hyperesthesia. Neuropathy of the autonomic plications have been included in this care plan and
nervous system is also common. should be individualized based on the client’s current
Parasympathetic involvement often occurs earlier and is status. Much of the information in this care plan is
more profound than sympathetic nervous system involvement, applicable to clients receiving follow-up care in an
and manifestations vary depending on the system involved. extended care facility or home setting.
The two major types of diabetes are type 1 and type 2. This care plan should be used in conjunction with the care
Individuals with type 1 diabetes have an absolute insulin plans on heart failure, myocardial infarction, cerebrovascular
deficiency and are dependent on insulin replacement. The accident, hypertension, and/or chronic renal failure if the
insulin deficiency is usually due to an immune-mediated client is also being treated for one of these vascular complica-
destruction of the pancreatic beta-cells in a person with a tions of diabetes.
genetic predisposition and a triggering environmental insult
(e.g., viral infection). Individuals with type 2 diabetes have
a relative deficiency of insulin caused by decreased tissue OUTCOME/DISCHARGE CRITERIA
responsiveness to insulin (insulin resistance), a defect in
insulin secretion, and inappropriate hepatic glucose produc- The client will:
tion. Heredity plays a role in development of type 2 diabetes. 1. Have blood glucose stabilized within a desired range
Additional risk factors for type 2 diabetes include a history of 2. Have signs and symptoms of vascular and neurological
gestational diabetes mellitus or impaired glucose tolerance, complications at a manageable level
increasing age, obesity, and a sedentary lifestyle. 3. Verbalize a basic understanding of diabetes mellitus

*Diabetes mellitus will be referred to as diabetes throughout the care plan.

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 448 Chapter9 * The Client With Alterations in Metabolic Function

4. Verbalize an understanding of medications ordered and \o . Identify appropriate safety measures to follow because of
demonstrate the ability to correctly draw up and adminis- the diagnosis of diabetes
ter insulin if prescribed 10. State signs and symptoms of hypoglycemia and ketoacido-
S. Verbalize an understanding of the principles of dietary sis and appropriate actions for prevention and treatment
management and be able to calculate and plan meals 11. State signs and symptoms to report to the health care provider
within the prescribed caloric distribution 12. Share feelings and concerns about diabetes and its effect
6. Demonstrate the ability to perform blood glucose and on lifestyle
urine tests correctly and interpret results accurately 13. Identify resources that can assist in the adjustment to and
7. Verbalize an understanding of the role of exercise in the management of diabetes
management of diabetes 14. Develop a plan for adhering to recommended follow-up
8. Identify health care and hygiene practices that should be care, including future appointments with health care
integrated into lifestyle provider and for laboratory studies

|Nursing oo)
Diagnosis |RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL nox
Definition: Susceptible to variation in serum levels of glucose from the normal range, which may compromise health.

Note: The following national definitions represent clinical conditions marked by variations in serum glucose levels:
e Hyperglycemia—blood glucose value >140 mg/dL
° Hypoglycemia—blood glucose value <70 mg/dL
e Diabetic ketoacidosis (DKA)—blood glucose value >250 mg/dL
° Hyperglycemic hyperosmolar nonketotic (HHNK)—blood glucose >600 mg/dL
Related to:
e Inadequate insulin production
e Ineffective action of insulin
e Inadequate insulin therapy/medication management
e Nonadherence to prescribed treatment plan (e.g., medication, diet, exercise)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue, weakness, nausea, blurred Objective findings depend upon the severity of variation of
vision, loss of appetite, and paresthesias serum glucose from normal levels and can include but are
not limited to polydipsia, polyuria, ketonuria, weight loss,
dry mucous membranes, poor skin turgor, tachycardia,
hypotension, Kussmaul respirations, acetone breath, nausea,
vomiting, abdominal pain, altered level of consciousness.

RISK FACTORS DESIRED OUTCOMES

e Stress
The client will experience normal or near-normal blood
e Obesity
e Excessive weight loss glucose levels as evidenced by:
e Infection a. Blood glucose levels <180 mg/dL at all times
° Prescribed medications that release counter regulatory hor- b. Fasting blood glucose levels <110 mg/dL
c. Hemoglobin A1C <7%
mones (¢.g., corticosteroids, thiazide diuretics, sympatho-
mimetic agents, second generation antipsychotic agents)
e Drug use (e.g., cocaine)
e Alcohol abuse

NOC OUTCOMES NIC INTERVENTIONS i

Hyperglycemia severity; hypoglycemia severity; Hyperglycemia management; hypoglycemia management

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of unstable glucose levels: Early recognition of signs and symptoms of variations in serum
e Altered neurological status (e.g., lethargy, headache, dis- Slucose levels allows for prompt intervention.
orientation, seizures, decreased level of consciousness)
e Excessive urine output
e Excessive hunger
 Chapter9 = The Client With Alterations in Metabolic Function 449

Continued...

NURSING ASSESSMENT RATIONALE

e Acetone breath
e Nausea
e Vomiting
e Abdominal pain
e Blurred vision
Assess baseline/admission blood glucose levels: Assessing the client’s blood glucose levels determines effectiveness
e Point-of-care finger stick (capillary specimen) of glucose control and allows for adjustment to the treatment
e Serum hemoglobin A1C (if not performed within the plan.
last 3 months)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to maintain blood glucose at a near-normal
level:
¢ Monitor percentage of meals and snacks client consumes. Pattern of inadequate or excessive intakes will indicate need for
e Provide meals and snack at regular intervals further dietary teaching.
e Monitor fluid status (1 & O), encourage oral intake as
appropriate.
e Report a pattern of inadequate or excessive intake. D +
e Minimize client’s exposure to emotional and physiological Stress causes an increased output of epinephrine, glucagon, and
stress cortisol all of which increase blood pressure.
e Restrict exercise when blood glucose levels are greater than If blood sugar is >250, the client should not exercise until fast-
250 mg/dL, especially if ketones are present. acting insulin has been administered. In the presence of hyper-
glycemia, if the body does not produce enough insulin to use the
glucose, body cells will continue to signal that they need glucose
for fuel and will continue to signal the liver to produce more
glucose elevating blood levels further.

Dependent/Collaborative Actions
Implement measures to maintain blood glucose at a near-
normal level, achieve ideal weight, and provide necessary
nutrients:
Monitor blood glucose levels using point-of-care testing at Ongoing serial monitoring of blood glucose levels is necessary to
intervals appropriate to dietary intake: evaluate effectiveness of treatment plan and allow for modifica-
e Clients who are eating: tion and evaluation of treatment plan.
* Blood glucose before meals (AC) and at bedtime (HS)
e Clients who are not eating:
e Every 4 to 6 hrs
e Administer insulin and antihyperglycemic agents as ordered. 2017 American Diabetes Association guidelines for in-hospital care
of diabetic clients identifies insulin as the preferred treatment for
glycemic control. Basal insulin or basal insulin plus bolus cor-
rection is the preferred treatment for non-critically-ill clients with
poor oral intake or those taking nothing by mouth.
Monitor for signs and symptoms of hypoglycemia (e.g., Hypoglycemia in hospitalized clients is associated with adverse
shakiness, tremor, sweating, weakness, dizziness). short-term and long-term outcomes including but not limited to
e Implement hypoglycemic protocol: macro-microvascular events and even death. Early identifica-
e Administer glucagon (if able to take PO). tion and treatment can prevent further deterioration to a more
e Provide simple carbohydrate as indicated. severe episode with adverse outcomes.
e Provide complex carbohydrate/protein as indicated.
e Administer IV glucose as indicated (if unable to take PO).
Maintain IV access as appropriate. Depending on the blood glucose level, a functioning IV may be
e Administer IV insulin as ordered for hyperglycemia. necessary for the administration of medications necessary to
e Administer IV glucose (Ds) for hypoglycemia. correct extreme blood glucose values.
e Consult dietitian to develop a diet/meal plan and/or rein- Improves clients’ ability to care for themselves and maintain
force dietary education. appropriate blood glucose levels.
e Perform a calorie count if ordered. A calorie count helps determine appropriate volume of calories
needed to maintain adequate nutrition and blood glucose levels.

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 450 Chapter9 = The Client With Alterations in Metabolic Function

= RISK FOR DEFICIENT FLUID VOLUME npx 7

Definition: Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may
compromise health.

Related to: Excessive loss of fluid associated with the osmotic diuresis resulting from uncontrolled blood glucose levels

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of thirst, weakness Polyuria; weight loss; dry buccal mucosa; sunken eye balls;
poor skin turgor; tachycardia; hypotension; shock

RISK FACTORS DESIRED OUTCOMES

e DKA
The client will maintain fluid balance as evidenced by:
e HHNK syndrome
e Vital signs within client’s normal range
e Renal insufficiency associated with diabetes
e Balanced intake/output
¢ Serum BUN/creatinine within client’s normal range

NOC OUTCOMES NIC INTERVENTIONS

—__———.:.:—n—n— nnn n———————

Fluid balance; shock severity: hypovolemic Fluid monitoring; fluid management; hypovolemia manage-
ment; intravenous therapy

NURSING ASSESSMENT RATIONALE

Assess vital signs for signs of excessive fluid loss: Osmotic diuresis associated with uncontrolled glucose levels can
e BP—Hypotension lead to dehydration. Identification of signs of excessive fluid
e HR—Tachycardia loss allows for prompt intervention.
e RR—Tachypnea
Assess for symptoms of excessive fluid loss: Identification of symptoms of fluid loss allows for prompt
e Thirst intervention.
e Dizziness
e Changes in mentation
e Dry mucous membranes
e Orthostatic hypotension
° Quality of peripheral pulses
e Capillary refill >3 seconds
e Dry skin turgor
e Urine output—color, quantity
Assess baseline laboratory values for evidence of excessive Baseline laboratory tests are valuable in cases of severe hydration.
fluid loss: Baseline values allow for comparisons for monitoring the
e Elevated BUN effectiveness of treatment.
e Elevated creatinine
e Urinalysis—elevated specific gravity
e Elevated hematocrit
e Osmolality—elevated urine and blood
e Electrolytes for imbalance
e Elevated glucose

THERAPEUTIC INTERVENTIONS
RATIONALE
eee
Independent Actions
Implement measures to restore optimum fluid balance.
Monitor vital signs as appropriate. Allows for monitoring effectiveness of treatment regimen.
 Chapter9 = The Client With Alterations in Metabolic Function 451

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Monitor hydration status as appropriate, including maintain- Helps restore circulating fluid volume.
ing accurate intake and output records:
e Weigh daily at consistent times.
e Monitor color, quantity, and specific gravity of urine.
Promote oral intake between meals as appropriate offering
fluids every 1 to 2 hrs unless contraindicated.

Dependent/Collaborative Actions
Implement measures to restore optimum fluid balance.
Establish and maintain patent IV access.
Administer ordered IV fluids: Restores extracellular circulating fluid volume.
e Monitor for fluid overload during administration (e.g.,
crackles, neck vein distention edema).
Monitor additional laboratory results as ordered. Evaluates response to therapy and guides treatment regimen.
Consult with physician if signs and symptoms of fluid vol- Allows for modification of the treatment regimen.
ume deficit persist.

RIE RS IIE EI LEIS STOLE LONNIE TOI OE LNT

Nursing Diagnosis RISK FOR ELECTROLYTE IMBALANCE nox

Definition: Susceptible to changes in serum electrolyte levels, which may compromise health.

Related to: Increased serum osmolality and resulting movement of water out of the cells and associated metabolic acidosis
associated with uncontrolled blood glucose levels.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness; nausea; abdominal pain Lethargy; fatigue; agitation, restlessness, confusion, nausea,
vomiting, dysrhythmias; diarrhea; constipation; convul-
sions; seizures; acetone (fruity) odor on breath

RISK FACTORS DESIRED OUTCOMES

e DKA The client will maintain electrolyte balance as evidenced
e HHNK by:
e Conditions associated with diabetes: ¢ Vital signs within normal range for client
e Impaired renal function e Serum electrolyte values within normal range
e Malabsorption syndrome ¢ Blood glucose level <180 mg/dL
e Acid-base disorders e Normal blood pH/acid-base balance (arterial blood
e Multidrug regimens gases [ABGs] and bicarbonate levels within normal
range
e Normal serum osmolality
e Absence of serum and urine ketones

NOC OUTCOMES NIC INTERVENTIONS

Electrolyte balance; electrolyte and acid base balance Acid-base management; acid-base management: metabolic
acidosis; electrolyte management; electrolyte management:
electrolyte monitoring; fluid/electrolyte management

NURSING ASSESSMENT RATIONALE

Early recognition of unstable vital signs allows for prompt
Assess vital signs for evidence of electrolyte imbalances:
e Blood pressure intervention.
e Hypotension—associated — with hypermagnesemia;
associated metabolic acidosis

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 452 Chapter9 * The Client With Alterations in Metabolic Function

NURSING ASSESSMENT RATIONALE

e Heart rate
e Irregularity/dysrhythmias associated with hyper/
hypokalemia; hypermagnesemia
e Respirations
¢ Kussmaul respirations associated with metabolic acido-
sis; acetone (fruity) odor on breath
Assess for signs and symptoms of electrolyte imbalances: Early recognition of signs and symptoms of electrolyte imbalances
e Neurological—lethargy, fatigue, agitation; confusion; rest- allows for prompt intervention.
lessness; convulsion, seizures
e Cardiac—dysrhythmias (irregular heart rate; tachycardia;
life-threatening dysrhythmias)
Assess EKG tracings as indicated for changes related to
electrolyte abnormalities (potassium).
e Gastrointestinal—nausea; vomiting; abdominal pain; con-
stipation; diarrhea
e Musculoskeletal—muscle weakness; cramping; tetany;
numbness; tingling
Assess baseline laboratory values for additional abnormal Extreme variations in blood glucose levels can be accompanied
electrolyte values. by life-threatening alterations in electrolytes caused by hyperto-
e Hyper/hypokalemia nicity induced movement of water out of the cells and related
e Hyper/hyponatremia dilution of serum electrolytes; osmotic diuresis; shift of electro-
e Increase serum osmolality lytes into the cells related to administration of medications
e Decreased serum bicarbonate (e.g., insulin); associated metabolic acidosis.
e Elevated serum ketones
e Elevated urine ketones
e Anion gap metabolic acidosis (>30 mEq/L)
¢ ABG/blood pH for metabolic acidosis

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to maintain electrolytes/acid-base balance at
a near-normal levels:
Monitor intake and output. D@ + Osmotic diuresis associated with uncontrolled glucose levels
contributes to electrolyte abnormalities.
Provide diet appropriate for client’s electrolyte imbalance Adequate dietary intake of electrolytes can help maintain normal
(e.g., potassium rich; low sodium; low carbohydrate) levels.
Provide a safe environment for the client with neurologi- Neuromuscular effects of electrolyte imbalances can increase the
cal and/or neuromuscular manifestations of electrolyte risk of injury (e.g., falls due to confusion).
imbalance.
¢ Hourly rounding
e Bed at lowest level
e Side rails as appropriate for confusion

Dependent/Collaborative Actions
Implement measures to maintain serum electrolytes/acid-base
balance at a near-normal levels:
Monitor serial serum electrolyte values for abnormalities. Ongoing monitoring of laboratory values allows for evaluation
and
adjustment of the treatment plan.
Monitor for associated acid-base imbalances: Extreme elevation of blood glucose levels can result in metabolic
e Decreased serum bicarbonate acidosis as the body breaks down fat and muscle for energy
e Anion gap metabolic acidosis (>30 mEq/L) producing excessive ketones and fatty acids. Metabolic acidosis
e Blood pH <7.35 contributes to further electrolyte abnormalities, which may
be
life-threatening.
Place on cardiac monitor as appropriate. Monitor EKG Hypomagnesemia, hyperkalemia, and hypokalemia are
associated
tracings as indicated for changes related to abnormal with dysrhythmias that may be life-threatening.
electrolyte levels (potassium, magnesium).
 Chapter 9 = The Client With Alterations in Metabolic Function 453

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Maintain patent IV access as appropriate. Intravenous administration of electrolyte replacements is the
e Administer IV solutions containing electrolytes as ordered. appropriate route to correct critical values. A patent IV must
e Administer supplemental electrolytes as ordered. be obtained.
Administer electrolyte-binding or electrolyte-excreting resins Renal insufficiency, often associated with diabetes, may interfere
(sodium polystyrene sulfonate (Kayexalate) as ordered. with the appropriate regulation of electrolyte abnormalities
such as hyperkalemia. Administration of binding or excreting
resins may be necessary to normalize critical values.
Administer HCO; as indicated: Administration of HCO 3 corrects metabolic acidosis. Administra-
e Oral, if able to take PO tion should be carefully guided by laboratory values.
e IV, if unable to take PO
Consult dietitian to develop a diet/meal plan and/or reinforce Improves clients’ ability to care for themselves and maintain
dietary education. appropriate blood glucose levels
Consult with physician on administration of electrolyte- Diuretic therapy contributes to electrolyte imbalances. Conversion
sparing medications (e.g., spironolactone) as appropriate. to potassium-sparing medications may be warranted in the
presence of hypokalemia.
Consult physician if signs and symptoms of electrolyte imbal- Allows for appropriate modification of the treatment plan.
ance persist or worsen.

Nursing Diagnosis INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox

Definition: Decreased blood circulation to the periphery, which may compromise health.

Related to:
e Peripheral polyneuropathy and/or peripheral vascular insufficiency associated with diabetes mellitus

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of burning, pain, numbness, tingling Cool skin; decreased or absent lower extremity pulses; de-
and/or increased sensitivity to sensory stimuli layed capillary refill; edema; delayed in peripheral wound
healing

RISK FACTORS DESIRED OUTCOMES

e Consistently high blood glucose levels The client will sustain tissue perfusion to lower extremities
e Hypertension as evidenced by:
e Sedentary lifestyle a. Verbalization of decreased or absent extremity pain in
e Smoking lower extremities
e Wearing of tight shoes or constrictive clothing b. Verbalization of decreased or absence of paresthesia
(numbness/tingling) in lower extremities
c. Presence of peripheral pulses
d. Capillary refill time <3 seconds
e. Normal range for 6-minute walk test

NOC OUTCOMES NIC INTERVENTIONS

Comfort status: physical; pain control; tissue perfusion: Pain management: chronic; environmental management:
peripheral; peripheral artery disease severity comfort; peripheral sensation management; circulatory care:
venous insufficiency

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NURSING ASSESSMENT RATIONALE

Assess for: Early recognition of signs and symptoms of peripheral neuropathy
e Signs and symptoms of peripheral neuropathy (e.g., re- and vascular insufficiency allows for prompt intervention.
ports of persistent burning; sharp, shooting pain; numb-
ness; tingling; or increased sensitivity to sensory stimuli
[hyperesthesia])
e Signs and symptoms of peripheral vascular insufficiency
(e.g., reports of cramping in calves precipitated by ambula-
tion [intermittent claudication], delayed capillary refill,
cold feet, dependent rubor, diminished or absent pulses;
edema)
e Stasis ulcers and tissue breakdown
e Nonverbal signs of pain/discomfort (e.g., grimacing,
guarding of affected area, reluctance to move, restlessness,
diaphoresis, increased B/P, tachycardia)
Assess Client’s perception of the severity of the pain/discom-
fort using an intensity rating scale.
Assess the client’s pattern of pain/discomfort (e.g., location, Provides a baseline to measure changes in discomfort pattern.
quality, onset, duration, precipitating factors, aggravating May indicate worsening of neuropathies.
factors, alleviating factors).
Ask the client to describe the methods used to manage the
pain/discomfort effectively.

THERAPEUTIC INTERVENTIONS
RATIONALE
ee
Independent Actions
Implement measures to reduce discomfort:
e Perform actions to reduce fear and anxiety about pain/ These actions promote relaxation and subsequently increases
discomfort (e.g., assure client that the need for relief client’s threshold and tolerance for discomfort.
of pain /discomfort is understood; plan methods for con-
trol of discomfort with client).
e Perform actions to reduce stress (e.g., explain procedures,
maintain a calm environment).
e If client has hyperesthesia, implement measures to Use of a bed cradle keeps bedding off affected extremities to
protect extremity from injury: decrease pressure on the skin. Sheepskin under feet/legs helps
e Provide a bed cradle D @ decrease pressure reducing the risk of pressure ulcers. Well-fitted
Sheepskin under feet/lower legs shoes, made of soft materials with shock absorbing soles, help
Well-fitted shoes protect the feet from injury.
° Protect extremities from extremes in temperature
e Assist client with ambulation if walking relieves dis- Walking often relieves lower extremity discomfort associated with
comfort. D @ + neuropathies.
e Ifclient is experiencing intermittent claudication, encourage Longer walks exacerbate pain associated with vascular insufficiency.
short, more frequent walks.
e Provide or assist with additional nonpharmacologic mea- Use of nonpharmacologic measures provides relief
of pain without
sures for relief of pain/discomfort (e.g., position change, sedation.
relaxation exercises, guided imagery, quiet conversation,
restful environment).

Dependent/Collaborative Actions
Implement measures to reduce pain/discomfort:
‘
e Perform actions to maintain blood glucose at a near- Maintaining optimal glycemic control can actually alleviate or re-
normal level (e.g., appropriate diet, exercise, blood glucose duce neuropathic discomfort and the progression of neuropathy.
monitoring).
e Administer the following medications if ordered to Provides pain relief through a variety of mechanisms:
control discomfort:
e Analgesics Analgesics and tricyclic antidepressants work via the central nervous
e Tricyclic antidepressants system (CNS).
e Anticonvulsants (i.e., gabapentin or carbamazepine) These anticonvulsants have been used to treat sharp or stabbing
superficial burning pain.
 Chapter9 = The Client With Alterations in Metabolic Function 455

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THERAPEUTIC INTERVENTIONS RATIONALE

e Capsaicin cream Capsaicin cream is useful in treatment of superficial pain.
e Hemorrheologic agents (e.g., pentoxifylline) Hemorrheologic agents can improve peripheral blood flow and
reduce discomfort associated with intermittent claudication.
e Skeletal muscle relaxants or quinine sulfate Quinine sulfate can be used to treat leg cramps.
e Consult appropriate health care provider (e.g., pharmacist, If pain relief is inadequate, consultation with other member of
pain management specialist, physician) if above measures the health care team provides a multidisciplinary approach to
fail to provide adequate relief of discomfort pain management

|Nursing »Diagnosis |RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY nox

Definition: Susceptible to increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system,
which may compromise health.

Related to: Delayed emptying of the stomach associated with autonomic neuropathy involving the gastrointestinal tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal gas, heart burn, fullness, Palpable distended abdomen; decreased or absent bowel
bloating, and nausea sounds

RISK FACTORS DESIRED OUTCOMES

e Stress The client will experience adequate gastric motility as
e Diabetes
evidenced by:
e Lack of exercise a. Verbalization decreased or absent abdominal pain/
discomfort
b. Relaxed facial expression and body positioning

NOC OUTCOMES NIC INTERVENTIONS

Comfort level; symptom control Environmental management: comfort; nausea management;

hyperglycemia management

NURSING ASSESSMENT RATIONALE

Assess client for: Early recognition of signs and symptoms of gastric discomfort
e Verbal reports of gastric discomfort (e.g., gastric fullness, allows for prompt intervention.
postprandial bloating, nausea)
e Nonverbal signs of discomfort (e.g., grimacing, rubbing
upper abdomen, restlessness, reluctance to move)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce gastric discomfort:
e Perform actions to reduce the accumulation of gas and
fluid in the stomach:
e Encourage and assist client with frequent position changes Activity stimulates gastrointestinal motility.
and ambulation as tolerated.
e Have client sit up during meals and for 1 to 2 hrs after Gravity promotes passage of food and fluid through the gastroin-
meals. D @ > testinal tract.
e Provide small, frequent meals rather than three large ones; Small, frequent meals decrease abdominal fullness after meals.
instruct client to ingest foods and fluids slowly. D @ +

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 456 Chapter9 * The Client With Alterations in Metabolic Function

THERAPEUTIC INTERVENTIONS RATIONALE

e Instruct client to avoid foods high in fat. Foods high in fat delay gastric emptying.
e Instruct client to avoid activities such as chewing gum, Avoiding these activities decreases air swallowing.
drinking through a straw, and smoking.
e Instruct client to avoid intake of carbonated beverages and Avoiding these foods/fluids reduces production of gas.
gas-producing foods (e.g., cabbage, onions, beans).
e Encourage client to eructate whenever the urge is Burping helps remove gas from the stomach.
felt. D@® +
e Perform actions to reduce nausea if present:
e Encourage client to take deep, slow breaths when nauseated. Slow, deep breaths help alleviate nausea.
e Instruct client to avoid foods/fluids that irritate the gastric Foods that irritate the gastric mucosa increase the incidence of
mucosa (e.g., spicy foods; caffeine-containing beverages esophageal reflux and heartburn.
such as coffee, tea, and colas).
e Eliminate noxious sights and odors from the environ- Noxious stimuli can cause stimulation of the vomiting center.
ment. D @ +
e Instruct and assist client to change positions slowly. D @ Rapid movement can result in stimulation of the chemoreceptor
trigger zone and subsequent excitation of the vomiting center.
e Avoid serving foods with an overpowering aroma; remove Powerful smells may stimulate the nausea center.
lids from hot foods before entering room. D @ +
e Instruct client to eat dry foods (e.g., toast, crackers) and These actions help settle the client’s stomach when nauseated.
avoid drinking liquids with meals when feeling nauseated.
e Perform actions to maintain blood glucose at a near- Maintaining optimal glycemic control seems to improve gastric
normal level. (e.g., establishing an exercise routine, adher- emptying.
ing to a diabetic diet).

Dependent/Collaborative Actions
Implement measures to reduce gastric discomfort:
e Perform actions to reduce the accumulation of gas and
fluid in the stomach:
e Administer medications that enhance gastric motility Metoclopramide stimulates gastric motility, which improves
(e.g., metoclopramide) if ordered. D+ gastric emptying.
e Perform actions to reduce nausea if present:
e Administer antiemetics as ordered. D + Antiemetics decrease nausea and emesis.
Consult physician if gastric discomfort persists or worsens. Notification of the physician allows for modification of the
treatment plan.

|Nursing /Diagnosis |INEFFECTIVE FAMILY HEALTH MANAGEMENT wox

Definition: A pattern of regulating and integrating into family processes a program for the treatment
of illness and its
sequelae that is unsatisfactory for meeting specific health goals of the family unit.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage care at home; lack Refusing medications; nonadherence to dietary restrictions
of understanding of factors that contribute to acute and
chronic complications; unwillingness or inability to mod-
ify personal habits and integrated treatments into lifestyle;
statements reflecting a view that diabetes is curable or that
the situation is hopeless and adherence will not improve
health
 Chapter9 = The Client With Alterations in Metabolic Function 457

RISK FACTORS DESIRED OUTCOMES

° Lack of understanding of the implications of not following
The client will demonstrate the probability of effective
the prescribed treatment plan
therapeutic regimen management as evidenced by:
° Feeling of lack of control over disease progression despite
a. Willingness to learn about and participate in treat-
efforts to follow prescribed treatment plan
ments and care
e Difficulty modifying personal habits and integrating nec-
b. Statements reflecting ways to modify personal habits
essary treatments and dietary regimen into lifestyle
and integrate treatments into lifestyle
e Insufficient financial resources
c. Statements reflecting an understanding of the implica-
tions of not following the prescribed treatment plan

NOC OUTCOMES NIC INTERVENTIONS

Adherence behavior; self-management: diabetes; knowledge: Self-modification assistance; medication management;
treatment regimen; health beliefs: perceived resources; health values clarification; teaching: disease process; teaching:
beliefs: perceived ability to perform prescribed diet; weight reduction assistance; financial
resource assistance; support system enhancement

NURSING ASSESSMENT RATIONALE

Assess for indications that client may be unable to effectively Provides a baseline for client and family teaching and what
manage the therapeutic regimen or may require further specific concerns, lack of understanding, or level of acceptance
education: is being experienced.
¢ Statements reflecting inability to manage care at home
e Failure to adhere to treatment plan (e.g., refusing medica-
tions, not adhering to dietary restrictions)
e Statements reflecting a lack of understanding of factors
that contribute to acute and chronic complications
e Statements reflecting an unwillingness or inability to
modify personal habits and integrate necessary treatments
into lifestyle
e Statements reflecting the view that diabetes is curable or
that the situation is hopeless and that efforts to comply
with treatments are useless

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote effective therapeutic man-
agement:
e Determine client’s understanding of diabetes; clarify mis- Adherence to the treatment regimen will preserve the client’s health
conceptions and stress that diabetes is a chronic condition for a longer period and may prevent some complications from
and adherence to the treatment plan may delay and/or occurring.
prevent complications; caution the client that some com-
plications may occur despite strict adherence to treatment
plan.
e Encourage client to participate in assessment and treat- Through observation of the client’s adherence to treatment regi-
ments (e.g., blood glucose monitoring, selection of diet, men, the nurse can determine client’s ability to care for self.
insulin administration).
e Provide client with written instructions about future ap- Written instructions provide the client an information resource
pointments with health care provider, diet, medications, once discharged.
exercise, signs and symptoms to report, and foot care.
e Discuss with client the difficulties of incorporating treat- Portrays a true picture of diabetes management and allows the
ments into lifestyle; assist client in identifying ways to client to determine what lifestyle modifications are feasible.
modify lifestyle rather than completely change it. This improves the client’s ability to adhere to the treatment
regimen.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to discuss concerns about the cost of Diabetes can have a significant financial impact on clients and
medications, food, and supplies; obtain a social service their families and should be discussed openly to assist clients
consult to assist with financial planning and obtain finan- with treatment management.
cial aid if indicated.
e Encourage client to attend follow-up diabetic education Continued education improves client’s understanding about diabe-
classes. tes and interventions to improve health.
e Provide information about and encourage utilization of Provides for continuum of care once discharged from the acute care
resources that can assist client to make necessary lifestyle facility,
changes (e.g., diabetes support groups, counseling services,
American Diabetes Association, diabetic cookbooks, and
publications).
e Reinforce behaviors suggesting future compliance with the Provides client feedback and can increase confidence in client’s
therapeutic regimen (e.g., participation in the treatment ability to care for self and adhere to treatment regimen.
plan, statements reflecting plans for integrating treat-
ments into lifestyle).
e Include significant others in explanations and teaching Informed family members can support the client in lifestyle
sessions and encourage their support; reinforce the need changes and treatment regimen management.
for client to assume responsibility for managing as much
of care as possible.

Nursing Diagnosis DEFICIENT KNOWLEDGE

npx OR INEFFECTIVE HEALTH
MANAGEMENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regime for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness or inability Inaccurate follow-through with instructions; inappropri-
to follow prescribed regimen ate behaviors; experience of preventable complications of
diabetes

RISK FACTORS
° Cognitive deficit
e Financial concerns
e Failure to take action to reduce modifiable risk factors
e Inability to care for oneself
° Difficulty in modifying personal habits and integrating
treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; health behavior; health Teaching: individual; teaching: prescribed exercise; teaching:
resources; treatment procedure(s) psychomotor skills; health system guidance; financial re-
source assistance; support system enhancement
‘

NURSING ASSESSMENT RATIONALE

Assess Client’s ability to learn and readiness to learn. Learning is more effective when client is motivated and under-
Assess client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
Assess client’s ability for self-care. learn changes based on situations and physical and emotional
challenges.

*The nurse should select the diagnostic label that is most appropriate for the client's discharge
teaching needs.
 Chapter9 = The Client With Alterations in Metabolic Function 459

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize a basic under-

standing of diabetes and of medications ordered and demon-
strate the ability to correctly administer insulin if prescribed.

Independent Actions
Determine client’s understanding of diabetes mellitus. Baseline understanding is important in developing client teaching plan.
Clarify misconceptions and reinforce teaching as necessary. A variety of teaching methods are more effective, as individuals
Use available teaching aids (e.g., pamphlets, videotapes). have varying styles of learning.
Explain the rationale for, side effects of, storage and care of, Knowledge of medications and how they impact the system im-
method of administration of, and importance of taking proves client adherence. Help enhance the client’s understand-
medications prescribed. ing of the importance of adhering to the prescribed medication
regimen. The client must be able to recognize alterations in
functioning related to medication administration.
Provide instructions if client is to self-administer insulin. Client and family members should be taught how to correctly
administer insulin.
If client is discharged with an insulin pump device, provide Client should not leave health care institution without an under-
instructions regarding its management (e.g., changing the standing of how to appropriately use the insulin pump to prevent
insertion site, filling syringes, changing batteries in pump). or decrease the number of hyperglycemic and hypoglycemic events.
Allow time for practice and return demonstration. Demonstration provides the nurse time to provide client feedback
and improves client’s confidence in ability to care for self.
Instruct client to consult pharmacist or health care provider Over-the-counter medications may affect the hypoglycemic agent
before taking other prescription and nonprescription med- taken by the client.
ications (e.g., over-the-counter cold preparations).
Instruct client to inform all health care providers of medica- This action prevents drug interactions when health care provider is
tions being taken. prescribing new medications.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an under-

standing of the principles of dietary management and be
able to calculate and plan meals within the prescribed caloric
distribution.

Independent Actions
Reinforce dietary instructions regarding the prescribed dia- Knowledge of dietary instructions helps the client to determine
betic diet and methods of calculating the foods/fluids appropriate foods to eat and to maintain proper blood glucose
allowed (e.g., exchange list, consistent carbohydrate diet, levels and nutritional status.
Food Guide Pyramid).
Have client plan sample menus before discharge to ensure Planning sample menus provides client with an understanding of
that he/she is able to calculate the diet correctly. diet regulations and the ability to care for self.
Explain the purpose of weight reduction if client has been Fasting or fad diets may impact client’s ability to prevent hypergly-
placed on a caloric restriction to reduce weight. Reinforce cemic or hypoglycemic events.
need to avoid fasting and fad diets.
Instruct client on appropriate dietary adjustments that should Dietary adjustments help control blood glucose levels while main-
be made if meal schedule or activity level has been signifi- taining adequate nutritional status.
cantly altered.
Reinforce the following principles of good dietary management:
e Eat three meals each day about 4 to 5 hrs apart and close Eating regularly timed meals helps prevent large variations in
to the same time each day; do not skip meals. blood glucose levels.
e Limit intake of concentrated sweets (e.g., sugar, candy, An intake of concentrated sweets may precipitate a hyperglycemic
syrups, jams, jellies, cakes, pies, pastries, fruits packed in event.
heavy syrup). |
e Avoid foods high in saturated fat and cholesterol (e.g., but- Foods high in saturated fat increase the development of atheroscle-
ter, cheese, eggs, ice cream, red meat) and trans fats (e.g., rosis, hypertension, and coronary artery disease.
stick margarine and shortening and foods such as commer-
cial baked goods that are prepared with these products).

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THERAPEUTIC INTERVENTIONS RATIONALE

e Increase intake of foods high in soluble fiber (e.g., fruits, A high-fiber diet decreases blood glucose levels.
whole-grain cereals, green leafy vegetables).
e Read food/fluid labels and limit intake of those that con- Client needs to understand what is in foods to prevent inadvertent
tain significant amounts of sugar, honey, and nutritive increases in blood glucose levels.
sweeteners such as xylitol, sorbitol, and fructose (nutritive
sweeteners are usually labeled as “sugar free” but are only
“sucrose free,” not carbohydrate free; however, they are
not digested and absorbed as well as other carbohydrates
and therefore contribute only 2 kcal/g as compared with
4 kcal/g of other carbohydrates).
e Use artificial (nonnutritive or noncaloric) sweeteners such Client can use a sweetener without an increase in blood glucose
as saccharin (e.g., Sweet and Low), acesulfame (e.g., Sunett), levels.
and aspartame (e.g., Equal, NutraSweet) when possible.
e Eat an afternoon carbohydrate snack (e.g., fresh fruit, Appropriate snacks help maintain adequate blood glucose levels.
’% bagel, 1 cup skim milk) if taking an intermediate-acting
insulin in the morning, and a snack at bedtime that in-
cludes protein and carbohydrate (e.g., milk and graham
crackers, % meat sandwich, cheese and crackers) if taking
an oral glucose-lowering agent or insulin in the evening.
e If alcoholic beverages are consumed:
e Drink alcohol with food. Alcohol can decrease blood glucose levels shortly after drinking
and for § to 12 hrs afterward. Alcohol can also block effects of
diabetic medications.
e Avoid liqueurs, sweet wines, wine coolers, and sweet mixes Wines with high levels of carbohydrates will increase blood sugar
that contain large amounts of carbohydrates. levels without any nutritional value.
e Do not substitute alcohol for anything in prescribed diet. Alcohol is not an adequate exchanger for any food type in a
prescribed diet.
Alcohol may interfere with the liver’s ability to produce glucose.
If on a weight-control diet, client should avoid alcohol because
it adds calories without any nutritional value.
e Limit alcohol intake to two drinks per day for men and If a client chooses to drink, he/she should drink only the recom-
one drink per day for women (a “drink” is considered to be mended amount for clients with diabetes.
1% oz of liquor, 12 oz of beer, or 5 oz of wine).

THERAPEUTIC INTERVENTIONS RATIONALE

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Desired Outcome: The client will demonstrate the ability

to perform blood glucose and urine tests correctly and inter-
pret results accurately.

Independent Actions
Review with client how and when to perform a blood glucose Reinforces what client knows and provides an opportunity to
measurement and calibrate and maintain a glucose moni- expand client’s understanding.
toring device.
Have client demonstrate blood glucose measurement. Rein- Client demonstration of blood glucose measurement provides cli-
force teaching as necessary. ents with confidence that they can appropriately monitor blood
Slucose levels and allows the nurse time to reinforce teaching.
Instruct client to keep a record of test results and take the Maintenance of a test results record can provide the heqlth care
record of results to appointments with the health care provider with a long-term view of client’s adherence to therapeu-
provider. tic regimen and control of blood glucose level.
Provide instructions on actions client should take when test Written instructions provide an ongoing resource for client to use in
results are abnormal. (Some clients are instructed to adjust controlling blood glucose level.
insulin dose and dietary intake; others are instructed to
notify appropriate health care provider).
 Chapter9 = The Client With Alterations in Metabolic Function 461

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of the role of exercise in the management of diabetes.

Independent Actions
Explain how exercise affects blood sugar levels. Exercise improves insulin’s effectiveness, lowers hemoglobin A1c,
Provide the following instructions about exercise and diabe- promotes weight loss, and decreases cardiovascular risk factors.
tes management:
e Maintain a regular exercise program, making sure to start A regular program gives client an indication of how exercise affects
exercise slowly and build up gradually. blood glucose levels before increasing exercise intensity and
length of time.
e Avoid exercising during insulin peak action time. This may precipitate a severe hypoglycemic episode.
e Try to exercise about 1 hr after a meal and about the same Promotes better processing of glucose through increased insulin
time of the day. sensitivity.
° Avoid giving insulin in a site that will be heavily exercised. Increased circulation to the injection area will increase utilization
of insulin, potentially causing a hypoglycemic event.
e Adjust insulin dosage before exercise according to physi- Adjusting the dosage helps decrease the potential for a hypoglyce-
cian’s instructions. mic event during exercise.
e Consume extra carbohydrates before vigorous exercise Extra carbohydrate before vigorous exercise helps prevent the poten-
and supplement carbohydrate intake (15-30 g) at 30- to tial for a hypoglycemic event.
60-minute intervals during vigorous prolonged exercise.
e Maintain adequate hydration during periods of intense Adequate hydration is needed to prevent dehydration.
exercise.
e¢ Consume an extra bedtime snack on days that exercise has Doing so helps prevent hypoglycemic events.
been prolonged or unusually vigorous.
e Do not exercise in extreme heat or cold. Hot and cold weather affect how the body uses insulin.
e Do not exercise at times when blood sugar is >250 mg/dL Strenuous exercise is perceived by the body as a stressor, leading
and ketones are present in urine or if blood sugar is to an increased output of counter regulatory hormones and a
>300 mg/dL. further increase in blood glucose.
Perform blood glucose tests more frequently during peri- More frequent blood glucose testing during exercise helps prevent
ods of significant variation in activity level. large variations in blood glucose level.
e Carry a rapid-acting carbohydrate source (e.g., hard candy, Doing so helps prevent hypoglycemic events.
glucose tablets) during exercise (especially if using insulin
and if exercise is expected to be prolonged or vigorous).
Stop any activity that causes extreme weakness, trembling, Client should be aware of clinical manifestations of hypoglycemia
incoordination, or nausea. and stop exercising.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify health care and

hygiene practices that should be integrated into lifestyle.

Independent Actions
Reinforce the importance of adhering to the following health
care practices:
e Perform oral hygiene including brushing and flossing at Individuals with diabetes are at higher risk for cavities, gum dis-
least twice a day. eases, and oral infections. Good oral hygiene and regular dental
e Have regular dental appointments at least every 6 months. appointments help prevent these from occurring.
e Have annual eye examinations (beginning 5S years after Diabetes is the number one cause ofblindness in the United States.
onset for type 1 and at onset for type 2 diabetes). Regular eye examinations allow for early recognition and treat-
ment of changes and potentially decrease deleterious effects of
diabetes.
e Avoid smoking. Smoking increases the risk for cardiovascular disease.
e Have feet examined by health care provider annually. Early identification of peripheral vascular changes helps prevent
neuropathies, foot ulcers, and risk of infection.
Provide instructions about foot care:
e Inspect feet daily for cuts, redness, cracks, blisters, corns, and Daily foot inspection allows for early identification of alterations
calluses; use a mirror to check bottoms of feet if necessary. that increase the risk ofinfections that may lead to amputation.

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 462 Chapter9 * The Client With Alterations in Metabolic Function

THERAPEUTIC INTERVENTIONS RATIONALE

e Wash feet daily with a mild soap and warm water and dry Doing so prevents breakdown of skin, particularly between toes.
gently but thoroughly.
e Apply lanolin or other lubricating lotion to feet (except Lubricants replace moisture lost from the skin. Lotion should have
between toes) daily. a low alcohol content to prevent skin dryness.
e Keep feet dry by wearing cotton socks and avoiding shoes Cotton socks absorb moisture from perspiration, decreasing risk
with rubber or plastic soles. of fungal infection. Shoes with rubber or plastic soles cause
the feet to sweat.
¢ Cut nails after a bath or shower; cut them straight across The skin is softer after a shower, and proper cutting of nails helps
and smooth them with an emery board after cutting. prevent injury to the feet, decreasing the risk for infection.
e See a podiatrist rather than using home remedies to treat Professional foot care helps prevent injury and decrease the risk for
corns, calluses, and ingrown nails or if help is needed with infection.
routine nail care.
e Avoid wearing socks, stockings, or garters that are tight. These garments may further compromise peripheral blood flow.
e Buy shoes that fit well and break them in gradually; it is Peripheral neuropathy and loss of sensation increase the risk of foot
best to buy shoes in the late afternoon when feet are at injury from ill-fitting shoes.
their largest.
e Do not wear open-toed shoes, sandals, high heels, or These types of shoes increase the risk for trauma.
thongs.
¢ Do not walk barefoot; wear shoes or slippers when walking. Wearing shoes or slippers prevents foot injury.
e Do not use a heating pad or hot water bottle on feet; test Peripheral neuropathy and loss of pain and temperature sensation
bath water with bath thermometer, wrist, or elbow be- increase the risk for burns and other injuries.
fore immersing feet (temperature should be 30°C-32°C
[84°F—-90°F]).
e Protect feet from extreme cold to prevent vasoconstriction
and possible frostbite.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify appropriate

safety measures to follow because of the diagnosis of diabetes.

Independent Actions
Teach client the following safety precautions:
e Always carry an identification card or wear a medical alert Carrying identification allows for prompt and appropriate treat-
bracelet or tag identifying self as a diabetic patient; identi- ment ifclient is alone and unable to speak.
fication card should have the name of health care pro-
vider, the type and dose of insulin and/or oral agent(s),
and measures to take if found behaving abnormally or
unconscious.
° Always carry a rapid-acting carbohydrate, such as glucose A rapid-acting carbohydrate is necessary to reverse hypoglycemic
tablets or instant glucose gel. events.
° If insulin-dependent, always have insulin readily available Insulin is necessary to reverse hyperglycemic events.
(carry in purse or briefcase).
e If traveling by plane, bus, or train:
° Carry a letter from health care provider indicating the A letter from a health professional prevents problems with security
necessity of having syringes, blood glucose monitoring when traveling with syringes and other supplies.
equipment, and medication.
° Keep snack items, a quick-acting source of carbohydrate, a These supplies are necessary to maintain adequate nutrition and
full day’s supply of food, blood glucose monitoring equip- appropriate blood glucose levels. ;
ment, and an extra supply of insulin, injection equipment,
and oral agents in carry-on luggage.
* Consult physician about plans for pregnancy and main- Pregnancy impacts the way a client controls diabetes, and this
tain close prenatal supervision. should be monitored by a health care practitioner.
° Keep a glucagon kit readily available and know how and A glucagon kit can be used for severe hypoglycemic events.
when to use it; make sure significant other is also trained
in how to use it.
 Chapter 90e= The Client With Alterations in Metabolic Function 463

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THERAPEUTIC INTERVENTIONS RATIONALE

e If ill but able to tolerate some foods/fluids:
° ‘Take usual dose of insulin or oral glucose-lowering agent
unless blood glucose is low.
° Check blood glucose every 4 hrs or a minimum of four IlIness places an additional stress on blood glucose levels. To main-
times a day. tain adequate control, blood glucose levels need to be monitored
more frequently.
° If blood glucose is >240 mg/dL, test urine for ketones. Testing for ketones with a blood glucose >240 mg/dL provides
early detection of DKA.
e Drink 8 to 12 oz of caffeine- and alcohol-free fluid (oy Caffeine and alcohol increase urine output and may increase risk
broth, fruit juice, regular or diet soda, water, Gatorade) for dehydration.
every hour.
e If not able to tolerate solid foods, substitute liquids and Liquids and soft food can provide adequate nutrition.
easily digested soft foods.
° Do not exercise. Exercise may cause hypoglycemia.
° Notify physician if:
e Unable to eat for >24 hrs Not eating or vomiting may significantly decrease blood glucose
levels and increases client’s risk for injury.
e Vomiting or severe diarrhea persists for >4 hrs.
° Blood glucose level is >300 mg/dL or ketones are present Increased blood glucose levels with presence of ketones in the urine
in urine. may indicate DKA.
e Having difficulty breathing or a change in mental status These signs and symptoms are indicative of DKA and should be
occurs treated immediately.
¢ Symptoms of dehydration, such as unusual thirst, dry
mouth, or fever occur
e Inform all health care providers of diabetic conditions. This helps the health care team provide the most appropriate care
in a timely manner.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms of hypoglycemia and ketoacidosis and appropriate
actions for prevention and treatment.

Independent Actions
Reinforce the following information about hypoglycemia:
e Factors that precipitate hypoglycemia (e.g., too much in- The client should be able to identify clinical manifestations of
sulin or oral hypoglycemic agent, insufficient oral intake, hyperglycemic or hypoglycemic events and the treatment neces-
excessive exercise, excessive alcohol intake) sary to regain appropriate blood glucose levels.
* Signs and symptoms of hypoglycemia (e.g., shakiness,
nervousness, weakness, hunger, sweating, nightmares,
early-morning headache, incoordination, blood glucose
<70 mg/dL)
e Actions to take if signs and symptoms of hypoglycemia
occur:
° Test blood glucose if possible and if <70 mg/dL (or if The client needs to base interventions on blood glucose levels.
symptoms are present but glucose testing is not possible),
take 15 g of rapid-acting carbohydrate (e.g., half a glass of
regular [sugar-containing] soft drink, three glucose tab-
lets, half a tube of instant glucose); if taking acarbose
(Precose) or miglitol (Glyset), only the glucose tablets or
instant glucose will correct hypoglycemia quickly.
e Retest glucose level in 15 minutes, and if still <70 mg/dL, Retesting of glucose levels provides follow-up information, so client
take another 15 g of rapid-acting carbohydrate; if blood may determine next actions based on blood glucose levels.
glucose level remains <70 mg/dL and/or symptoms persist
for >30 minutes, consult health care provider.

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 464 Chapter9 = The Client With Alterations in Metabolic Function

THERAPEUTIC INTERVENTIONS RATIONALE

e After the hypoglycemic episode, consume a snack (e.g., Eating appropriate foods is important to maintain blood glucose
graham crackers and a glass of milk, half a sandwich and level after the hypoglycemic event and prevent continued varia-
half a glass of milk) if it will be longer than 30 minutes tions in blood glucose levels.
until the next meal.
Teach significant others how to treat hypoglycemia: Family members should know what to do in a hypoglycemic event
e Ifclient is awake but groggy, put corn syrup, honey, cake icing, if client is unable to care for self.
or instant glucose in client’s mouth between cheek and gum.
e If client loses consciousness, administer glucagon injection.
Reinforce the following information about ketoacidosis:
e Factors that precipitate ketoacidosis (e.g., emotional stress, Helps client avoid situations in which client is at increased risk for
infection, failure to take insulin or oral glucose-lowering ketoacidosis.
agent)
e Signs and symptoms of impending or actual ketoacidosis If client and family are able to recognize signs and symptoms
(e.g., unusual thirst; excessive urination; weakness; warm, of ketoacidosis, they will be able to seek treatment early and
flushed skin; blood glucose level >250 mg/dL; ketones in prevent negative effects of ketoacidosis.
urine; abdominal pain; nausea and vomiting)
e Immediate actions to take if signs and symptoms of keto-
acidosis occur:
e Drink a cup or more of broth or sugar-free liquid if able to Immediate actions decrease the level of blood glucose and improve
tolerate it. recovery time frame from ketoacidosis.
e Administer insulin (if previously instructed in insulin
coverage based on blood glucose results).
e Contact health care provider.

THERAPEUTIC INTERVENTIONS RATIONALE

——
SSS

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report the following: These events should be reported to the client’s health care practitioner
e Unexplained episodes of hypoglycemia and ketoacidosis to prevent further complications and for prompt implementation
e Unusual variations in blood glucose results of therapeutic interventions.
e Accut, scratch, or burn that becomes red, swollen, or ten-
der or does not start to heal within 24 hrs
e Nausea and vomiting or severe diarrhea that lasts >4 hrs
e Temperature elevation that lasts >2 days
e Change in vision
e Development or worsening of symptoms that are indica-
tive of long-term complications (e.g., burning or aching
pain in extremity, decreased sensation in extremity, persis-
tent gastric discomfort, frequent urination of small
amounts, impotence, gait disturbances, chest pain, ex-
treme fatigue, persistent dizziness, or lightheadedness)

THERAPEUTIC INTERVENTIONS RATIONALE

a
eeeeeeeeeeeeeeeoeaeaeaeaeaeaeaen

Desired Outcome: The client will identify resources that

‘
can assist in the adjustment to and management of diabetes.

Independent Actions
Provide information about resources that can assist client and Giving client resources provides for a continuum of care once client
significant others in adjustment to and management of dia- is discharged from the acute care facility.
betes (e.g., American Diabetes Association, diabetic education
classes, weight loss programs, diabetes support groups, coun-
seling services, publications such as Diabetes Forecast, Inter-
net sites [www.diabetes.org]). Initiate a referral if indicated.
 Chapter9 = The Client With Alterations in Metabolic Function 465

THERAPEUTIC INTERVENTIONS RATIONALE

—_—_——————————————— eee
Desired Outcome: The client, in collaboration with the
nurse, will develop a plan for adhering to recommended fol-
low-up care including future appointments with health care
provider and for laboratory studies.

Independent Actions
Reinforce the importance of keeping follow-up appointments Follow-up appointments allow for early recognition and treatment
with health care provider and for laboratory studies. to help prevent or delay the macrovascular and microvascular
complications of diabetes.

ADDITIONAL CARE PLANS

DIARRHEA NDx IMBALANCED NUTRITION: LESS THAN BODY

Related to: Effects of autonomic neuropathy on intestinal motility REQUIREMENTS NDx
Related to:
RISK FOR FALLS NDx e Decreased cellular uptake and utilization of glucose and a
Related to: compensatory increase in metabolism of fat and protein
e Gait abnormalities (may result from impaired propriocep- stores associated with insulin deficiency
tion and muscle weakness and loss of normal structure of e Decreased oral intake associated with nausea and feeling of
the foot) and muscle weakness and diminished reflexes in fullness resulting from delayed gastric emptying if diabetic
one or more lower extremity associated with motor and gastroparesis is present
sensory neuropathies that may be present
e Dizziness and syncope associated with postural hypoten- URINARY RETENTION NDx
sion that may be present as a result of autonomic neuropathy Related to: Loss of bladder sensation and diminished con-
e Diminished visual acuity tractility of the detrusor muscle associated with autonomic
neuropathy involving the genitourinary system
RISK FOR INJURY NDx
Burns related to: CONSTIPATION NDx
e Decreased sensation in extremities (may be present as a Related to: Colonic atony or dilatation associated with auto-
result of peripheral polyneuropathy) nomic neuropathy involving the large bowel

SEXUAL DYSFUNCTION NDx RISK FOR INFECTION NDx

Related to: Autonomic neuropathy and angiopathies that Related to:
may occur (men may experience impotence and ejaculatory e Decreased efficiency of leukocyte function in a hyperglyce-
changes; women may experience changes in arousal pattern, mic environment
vaginal lubrication, and orgasm) e Delayed healing of any break in skin integrity associated
with decreased tissue perfusion and altered nutritional
INEFFECTIVE COPING NDx
status (There is diminished protein synthesis and tissue
Related to:
repair when insulin is deficient.)
e Fear of complications and inability to manage them
e Discomfort
e Need to alter lifestyle
e Feeling of powerlessness
e Knowledge that condition is chronic and will require life-
long medical supervision, dietary regulation, and medica-
tion therapy

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 CHAPTER

The Client With Alterations

in the Gastrointestinal Tract

ABDOMINAL TRAUMA
Abdominal trauma involves injury to the body structures Life-threatening injuries are identified and treated. Emergency
located between the diaphragm and the pelvis. Injury to ab- care focuses on establishing or maintaining a patent airway,
dominal contents occurs from a direct impact or movement establishing or maintaining an effective breathing pattern,
of organs within the body as a result of rapid deceleration, pain relief, fluid replacement, and prevention of shock and
causing rupture, lacerations, and/or tears in organs or blood other potential complications. The initial resuscitation phase
vessels. Organs injured with abdominal trauma include the focuses on maintaining hemodynamic stability. In a hemody-
spleen, liver, stomach, large and small intestines, pancreas, namically unstable patient, rapid diagnostic evaluation can be
kidneys, and urinary bladder. The large vessels in the abdomen, accomplished by means of a diagnostic peritoneal lavage or the
the aorta and vena cava, may also be injured. focused assessment with sonography for trauma (FAST). An
Abdominal trauma occurs as the result of blunt or penetrat- exploratory laparotomy with repairs of injuries is required in
ing trauma. Blunt trauma is the result of motor vehicle acci- hemodynamically unstable clients who have a penetrating
dents, assaults, sports injuries, or falls. In blunt trauma injury, abdominal injury. After stabilization of the client, care focuses
the liver and spleen are the most commonly affected organs. on structural healing and prevention of complications.
Liver and splenic injuries can lead to profuse bleeding because This care plan focuses on the adult client hospital-
these organs are highly vascular. The client with injuries to these ized for treatment of abdominal trauma. Some of the
organs may have upper right quadrant pain, abdominal rigidity information is applicable to clients receiving follow-up
and guarding with rebound tenderness, loss of bowel sounds, care at home.
signs of hemorrhagic shock, and Kehr sign, which is seen with
splenic rupture. Injury to the intestines leads to leakage of intes-
tinal contents, leading to abdominal distention, pain, peritoni- OUTCOME/DISCHARGE CRITERIA
tis, and sepsis, and may lead to multiple organ dysfunction
syndrome (MODS). Other injuries that may be seen in individu- The client will:
als with abdominal trauma include pancreatic trauma, diaphrag- 1. Have evidence of normal healing of trauma and/or
matic rupture, urinary bladder rupture, tears in the great vessels, surgical wound
renal injury, and stomach and intestinal rupture. Have clear, audible breath sounds
Penetrating abdominal trauma can be caused by stabbing, Tolerate prescribed diet
gunshot, or impalement. In an individual with a penetrating Have surgical pain controlled
injury it is important to determine the entry and exit point or a Have no signs and symptoms of complications
the trajectory of a stab wound. The external injury may mask 6. State signs and symptoms to report to the health care
extensive internal injury. provider
A person admitted to the emergency department with 7. Develop a plan for adhering to recommended follow-up care
an abdominal trauma is assessed using the “ABCDE” method: including future appointments with health care provider,
airway, breathing, circulation, and exposure disability. medications prescribed, activity level, and wound care.
‘

INEFFECTIVE BREATHING PATTERN nox

Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
e Increased rate of respirations associated with:
e Fear and anxiety
e Pressure on the diaphragm from abdominal distention

466
 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract 467

Decreased rate of respirations associated with injury and/or the depressant effect of anesthesia and some medications (e.g.,
narcotic [opioid] analgesics, some antiemetics)
e Decreased depth of respirations associated with:
e Reluctance to breathe deeply because of pain
e Fear, anxiety, weakness, and fatigue
° Restricted chest expansion resulting from positioning and elevation of the diaphragm if abdominal distention is present

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Dyspnea; orthopnea; increased respiratory rate; decreased
depth of breathing; decreased minute ventilation;
decreased vital capacity; nasal flaring; use of accessory
muscles to breathe; altered chest excursion; pursed-lip
breathing; decreased oxygen saturation; arterial blood
gas (ABG) values: respiratory acidosis

RISK FACTOR DESIRED OUTCOMES

e Abdominal injury soo RR I aL Mk Tar OORT WET PRMMER RES a
The client will maintain an effective breathing pattern as
evidenced by:
a. Normal rate and depth of respirations
b. Absence of dyspnea

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation Ventilation assistance; respiratory monitoring

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern: pattern allows for prompt intervention.
e Shallow or slow respirations
e Limited chest excursion
e Tachypnea or dyspnea
e Use of accessory muscles when breathing
Assess/monitor pulse oximetry (arterial oxygen saturation Monitoring continuous SaOz readings allows for the early detection
[SaO.]), ABG values as indicated. of hypoxia.
Assessment of ABG values allows for a more direct measurement
of both the partial pressure of oxygen in arterial blood (PaQz)
and the partial pressure of carbon dioxide in arterial blood
(PaCOz), both of which reflect the adequacy of ventilation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve breathing pattern:
e Perform actions to reduce fear and anxiety: Reducing fear and anxiety helps to prevent shallow and/or rapid
e Promote a calm environment. breathing.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
e Reposition client for comfort. breathe more deeply.
e Instruct client to support incision with hands or a
pillow when moving or coughing.
e Instruct client to bend knees while coughing and deep Relieves tension on abdominal muscles and incision.
breathing.
e Perform actions to reduce the accumulation of gas and Reducing the accumulation of gas in the GI tract decreases pressure
fluid in the gastrointestinal (GI) tract: on the diaphragm, facilitating more effective ventilation.
e Maintain patency of nasogastric (NG), gastric, or
intestinal tubes if present.

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 468 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Have client deep breathe or use incentive spirometer every Deep breathing and use of an incentive spirometer promote
1 to 2 hrs. maximal inhalation and lung expansion.
e Instruct client to breathe slowly if hyperventilating. Hyperventilation is an ineffective breathing pattern that can lead
to respiratory alkalosis.
Clients can often slow breathing rate if they concentrate on
doing so.
e Place client in a semi- to high-Fowler’s position unless A semi- to high-Fowler’s position allows for maximal diaphrag-
contraindicated. matic excursion and lung expansion.
If client develops signs and symptoms of respiratory distress Improves tissue oxygenation.
and impaired gas exchange (e.g., restlessness, confusion,
significant decrease in oximetry results, decreased PaO,
and increased PaCO, levels):
e Prepare client for intubation and mechanical ventilation.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
e Maintain oxygen as ordered. Improves oxygen saturation if the client is unable to maintain
normal oxygen saturation.
e Assist with positive airway pressure techniques if ordered: Positive airway pressure techniques increase intrapulmonary
e Continuous positive airway pressure (CPAP). (alveolar) pressure, which helps re-expand collapsed alveoli and
e Bilevel positive airway pressure (BiPAP). prevent further alveoli collapse.
e Flutter/positive expiratory pressure (PEP) device.
e Administer central nervous system depressants judiciously: Central nervous system depressants cause depression of the respira-
° Hold medication and consult physician if respiratory tory center in the brainstem, which can result in a decreased
rate is less than 12 breaths/min. rate and depth of respiration.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
e Administer analgesics before activities and procedures breathe more deeply.
that can cause pain and before pain becomes severe.

|Nursing 2s
Diagnosis |RISK FOR IMBALANCED FLUID VOLUME nox;
RISK FOR ELECTROLYTE IMBALANCE* nox
Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease, increase, or rapid shift from one to the
other
of intravascular, interstitial, and/or intracellular fluid, which may compromise health. This refers to body fluid
loss, gain, or both. Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte levels, which
may compromise health.
Related to:
° Deficient fluid volume NDx related to excessive blood loss, loss of fluid associated with vomiting and NG tube drainage
(if present)
° Hypokalemia and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with blood loss,
vomiting, and NG tube drainage

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea; headache Hypotension; tachycardia; prolonged capillary refill
>2 to 3 seconds; decreased urine output; vomiting;
abnormal serum electrolyte levels; flat neck veins when
client is flat; increased urine specific gravity; increased
blood urea nitrogen (BUN) and hematocrit (Hct) values

*The nurse should select the diagnostic label that is most appropriate based on the assessment of the
client.
 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract 469

RISK FACTORS DESIRED OUTCOMES

e¢ Injury ,
e Possible surgical procedure The client will maintain fluid and electrolyte balance as
° Ineffective fluid level and electrolyte replacement therapy evidenced by:
a. Blood pressure (BP) and pulse within normal range for
client and stable with position change
b. Capillary refill time less than 2 to 3 seconds
c. Usual mental status
d. Balanced intake and output (I&O)
e. Urine specific gravity within normal range
f. Soft, nondistended abdomen with active bowel sounds
g. Absence of cardiac dysrhythmias, muscle weakness,
paresthesias, twitching, spasms, and dizziness
h. BUN, Hct, serum electrolyte, and ABG values within
normal range

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; electrolyte and acid-base balance Fluid management; electrolyte management: hypokalemia;
electrolyte management: hypocalcemia; acid-base
management: metabolic acidosis

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of fluid and electrolyte
volume: imbalance allows for prompt treatment.
Postural hypotension and/or low BP
Weak, rapid pulse
Capillary refill time longer than 2 to 3 seconds
Neck veins flat when client is supine
Change in mental status
Decreased urine output with increased specific gravity
(reflects an actual rather than potential fluid deficit)
Significant increase in BUN and Hct above previous levels
Hypokalemia (e.g., cardiac dysrhythmias, postural hypoten-
sion, muscle weakness, nausea and vomiting, abdominal
distention, hypoactive or absent bowel sounds
Metabolic acidosis (e.g., drowsiness; disorientation; stupor;
rapid, deep respirations; headache; nausea and vomiting;
cardiac dysrhythmias; low pH and carbon dioxide [CO]
content)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to treat fluid volume deficit:
e Perform actions to improve hypovolemia associated with Clients who experience abdominal injuries often experience
recent abdominal injury: excessive bleeding. Replacement fluids are necessary to main-
e Rapidly infuse warmed fluids. tain vascular volume.
e Administer blood and blood products as ordered. Replaces lost blood volume and improves oxygenation to the
tissues.
e Perform actions to prevent nausea and vomiting (e.g., Decreases loss of electrolytes.
medicate as needed for pain relief).
e If a nasogastric (NG) tube is present and needs to be Irrigation of an NG Tube with normal saline decreases the loss of
irrigated frequently and/or with large volumes of solution, electrolytes.
irrigate it with normal saline rather than water.
e When oral intake is allowed and tolerated, assist client to Maintains fluid volume and increases potassium intake.
choose foods/fluids high in potassium (e.g., bananas,
orange juice, potatoes, raisins, cantaloupe, tomato juice).
After initial fluid volume resuscitation, maintain a fluid Maintains vascular fluid volume status.
intake of at least 2500 mL/day unless contraindicated.

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 470 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

° Monitor I&O and administer replacements as ordered. Maintains vascular fluid volume.
e Administer electrolyte replacements (e.g., magnesium Helps prevent fluid volume deficit and maintains electrolyte levels.
sulfate, sodium bicarbonate, potassium) if ordered.
If signs and symptoms of hypovolemic shock occur:
e Place the client flat in bed with legs elevated unless contra- Placing client flat on the bed and elevating the legs increases fluid
indicated. return to the heart to maintain cardiac output.
¢ Monitor vital signs frequently. Changes in vital signs indicate improvement or worsening of
hypovolemic shock.
e Administer oxygen as ordered. Improves tissue oxygenation.
e Administer blood products and/or volume expanders as Replaces fluid and/or blood cells, which improves cardiac output
ordered. and tissue oxygenation.
° Prepare client for insertion of hemodynamic monitoring Improves ability to monitor hemodynamic changes.
devices (e.g., central venous catheter, intra-arterial catheter)
if planned.
e Administer vasopressor medications as ordered. Improves BP and reduces heart rate.

INEFFECTIVE PERIPHERAL TISSUE

PERFUSION nox
Definition: Decrease in blood circulation, which may compromise health.
Related to:
° Hypovolemia secondary to blood loss due to injury and/or subsequent surgical procedure

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea, abdominal pain, or Hypoactive or absent bowel sounds; nausea; abdominal
tenderness; dizziness and lightheadedness distention; abdominal pain or tenderness; tachycardia;
hypotension; cyanotic, pale skin; oliguria; capillary refill
time greater than 2 to 3 seconds; elevated BUN and serum
creatinine level; decreasing oxygen saturation

RISK FACTORS DESIRED OUTCOMES

e Decreased cardiac output
The client will maintain adequate tissue perfusion as
e Trauma
evidenced by:
° Inadequate therapeutic regimen
a. BP within normal range and stable with position
change
b. Usual mental status
c. Extremities warm with absence of pallor and cyanosis
d. Palpable peripheral pulses
e. Capillary refill time less than 2 to 3 seconds
f. BUN and serum creatinine levels within normal limits
g. Urine output at least 30 mL/h

NOC OUTCOMES NIC INTERVENTIONS

Circulation status; tissue perfusion: abdominal organs; Circulatory care: arterial insufficiency; circulatory care:
cardiac; cerebral; peripheral; pulmonary venous insufficiency; cerebral perfusion promotion;
hypovolemia management
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 471

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of diminished tis- Early recognition of signs and symptoms of diminished GI tissue
sue perfusion: perfusion allows for prompt intervention.
° Significant decreased BP
° Restlessness, confusion, or other change in mental status
° Reports of dizziness or lightheadedness or occurrence of
syncopal episodes
° Cool, pale, or cyanotic skin
e Diminished or absent peripheral pulses
° Increasing abdominal girth
° Capillary refill time greater than 2 to 3 seconds
e Elevated BUN and serum creatinine levels
e Oliguria

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain adequate tissue perfusion:
e Administer intravenous fluids and blood as ordered. Intravenous (IV) fluids and blood help to maintain adequate
circulatory status and tissue perfusion.
e Apply thromboembolism deterrent (TED) hose or a Prevents pooling of blood in the extremities.
sequential compression device.
e If the client is hypothermic, apply warming blankets to Hypothermia inhibits platelet function and decreases coagulation.
increase temperature.
e Administer coagulation factors as ordered. Coagulation factors improve body’s ability to clot blood and
decrease bleeding.
e Administer supplemental oxygen. Helps to improve tissue oxygenation.
e Prepare client for surgery to further control the bleeding.

Nursing Diagnosis ACUTE PAIN nox.

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and a duration of less than 3 months.

Related to:
e Injury
e Surgery

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain Grimacing; diaphoresis; changes in BP; tachypnea;
tachycardia; restlessness; grading behaviors

RISK FACTORS DESIRED OUTCOMES

The client will experience diminished pain as evi-
e Abdominal trauma, bleeding into the abdomen, and surgical
intervention denced by:
a. Verbalization of decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

Pain control: comfort level Analgesic administration; pain management acute;

patient-controlled analgesia (PCA) assistance

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 472 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (e.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
pain, grimacing, reluctance to move, restlessness, diapho- intervention and improved pain control.
resis, increased BP, tachycardia).
Assess client’s perception of the severity of pain using a pain
intensity rating scale.
Assess specific area of pain (e.g., location and quality); note
that a finding of pain radiating to the left shoulder may
indicate splenic bleeding (Kehr sign).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety are experienced after a traumatic event. Reassur-
client that the need for pain relief is understood; plan ance that the client’s issues are understood will help to control
methods for achieving pain control with client; provide a pain.
calm environment).

Dependent/Collaborative Actions
Administer analgesics as ordered. Pharmacological therapy is an effective method of reducing or
relieving pain. Use opioids with care because they decrease
gastric motility.
Postoperative pain: consult physician about an order for PCA The use of PCA allows the client to self-administer analgesics
if indicated. within parameters established by the physician. This method
facilitates pain management by ensuring prompt administra-
tion of the drug when needed, providing more continuous pain
relief, and increasing the client’s control over the pain.
Consult appropriate health care provider (e.g., physician, Allows for alterations in treatment plan.
pharmacist, pain management specialist) if above measures
fail to provide adequate pain relief.

|Collaborative >»
Diagnosis RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum.

Related to:
° Release of intestinal contents into the peritoneal cavity resulting from abdominal trauma
e Exposure of abdominal contents to pathogens associated with a penetrating abdominal wound

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increasing abdominal pain, rebound Temperature above 38°C; rigid abdomen; diminished or
tenderness, and nausea absent bowel sounds; tachycardia; hypotension; tachypnea;
elevated white blood cell (WBC) count

RISK FACTOR DESIRED OUTCOMES

e Exposure to pathogens
The client will not develop peritonitis as evidenced hy:
a. Temperature stable and less than 38°C
b. Soft, nondistended abdomen
c. No increase in abdominal pain and tenderness, nausea,
and vomiting
d. Normal bowel sounds
e. Stable vital signs
 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract 473

NURSING ASSESSMENT RATIONALEFT

a oe 8 EO

Assess for and report signs and symptoms of peritonitis (e.g., Early recognition of signs and symptoms of peritonitis allows for
further increase in temperature or temperature above prompt intervention.
38°C; distended, rigid abdomen; increase in severity of
abdominal pain; rebound tenderness; increased nausea
and vomiting; diminished or absent bowel sounds; tachy-
cardia; tachypnea; hypotension; a WBC count greater than
15,000/mm/?).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent peritonitis:
e Administer antimicrobials as ordered. Prevents and/or treats infections.
e Perform actions to prevent inadvertent removal of wound
drain if present:
e Use caution when changing dressings surrounding Prevents accidental dislodgment of a drain ifpresent.
drain. D +
e Provide extension tubing if necessary. D + Use of extension tubing enables client to move without placing
tension on the drain.
e Instruct client not to pull on drain and drainage tubing. Prevents accidental dislodgement of the drain.
D+
e Maintain sterile technique during dressing changes and Prevents introduction of bacteria into the wound.
wound care. D >
e Keep abdominal dressing clean and dry. D + Prevents stasis of drainage and decreases potential for infection.
If signs and symptoms of peritonitis occur:
e Withhold oral intake as ordered. D > Withholding oral intake decreases further increase in abdominal
contents.
e Place client on bedrest in a semi-Fowler’s position. D + Putting the client in a semi-Fowler’s position assists in pooling or
e Prepare client for diagnostic tests (e.g., abdominal radiograph, localizing GI contents and urine in the pelvis rather than under
peritoneal aspiration, computed tomography, ultrasonogra- the diaphragm.
phy) if planned.
e Insert an NG tube and maintain suction as ordered. D + Decreases potential for GI distention.
e Administer intravenous fluids and/or blood volume Maintains circulatory volume and prevents the increased capillary
expanders if ordered to prevent or treat shock. permeability that occurs with inflammation and the subsequent
escape of protein, fluid, and electrolytes from the vascular space
into the peritoneal cavity.
e Prepare client for surgical intervention (e.g., drainage and Decreases client’s fear and anxiety and promotes understanding of
irrigation of peritoneum) if indicated. what is to happen.

|Collaborative coe
Diagnosis |RISK FOR SEPTIC SHOCK

Definition: A life-threatening medical condition that involves decreased tissue perfusion resulting from a systemic infection.
Related to:
e Systemic hypoperfusion associated with maldistribution of circulating blood, deficient fluid volume, and decreased
myocardial contractility resulting from uncontrolled systemic inflammatory response to severe infection

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Hypotension; tachycardia; widening pulse pressure;
restlessness; warm, flushed skin; change in level of
consciousness; capillary refill greater than 2 to 3 seconds;
significant decrease in pulse oximetry values; changes in
ABG values

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 474 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

RISK FACTORS DESIRED OUTCOMES

P er The client will not develop septic shock as evidenced by:
pasa caroe a. Systolic BP equal to or higher than 90 mm Hg
e Decreased cardiac output A tere ae A re
e Failure of regulatory mechanisms c. Urine output at least 30 mL/h
d. Extremities warm and usual color
e. Capillary refill time less than 2 to 3 seconds
f. Palpable peripheral pulses

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of septic shock: Early recognition of signs and symptoms of septic shock allows for
¢ Hyperdynamic or compensatory phase (e.g., widened prompt intervention.
pulse pressure with the diastolic pressure dropping and
little change in the systolic pressure; restlessness; tachycar-
dia; warm, flushed skin)
° Hypodynamic or progressive phase (e.g., systolic BP less
than 90 mm Hg or a reduction of greater than 40 mm Hg
from baseline; cool, clammy skin; change in level of con-
sciousness; decreased urine output; rapid, shallow breath-
ing; rapid, thready pulse)

THERAPEUTIC INTERVENTIONS
—_———————————————————eeeeeeeeeeeeeeeeeeeeeeSeeeeeeeEEEeEeEEEEEEEEEeEEeEEeEeEeEeE
RATIONALE
eEEeEeEeEeEEEEEEEEEEEeeeeeeeee

Dependent/Collaborative Actions
Implement measures to maintain adequate tissue perfusion in
order to reduce the risk for septic shock:
e Administer intravenous fluids and blood as ordered. IV fluids and administration of blood help maintain adequate
circulatory status and tissue perfusion.
e Apply TED hose or a sequential compression device. Prevents pooling of blood in the extremities.
e If the client is hypothermic, apply warming blankets to Hypothermia inhibits platelet function and decreases coagulation.
increase temperature.
e Administer coagulation factors as ordered. Coagulation factors improve the body’s ability to clot blood and
decrease bleeding.
e Administer supplemental oxygen. Helps to improve tissue oxygenation.
If signs and symptoms of septic shock occur:
° Maintain intravenous fluid therapy as ordered. Helps maintain adequate perfusion, blood pressure, and cardiac output.
e Maintain oxygen therapy as ordered. Provides supplemental oxygen.
e Administer antimicrobials as ordered. Treats infection, which helps decrease vasodilation caused by the
systemic infection.
e Administer vasopressors and positive inotropic agents Vasopressors increase blood pressure and positive inotropic agents
(dopamine, dobutamine, norepinephrine) as ordered. increase heart rate to maintain circulatory status.

Collaborative Diagnosis RISK FOR ORGAN ISCHEMIA/DYSFUNCTION

(MULTIPLE ORGAN DYSFUNCTION SYNDROME)
Definition: A life-threatening syndrome in which the body is unable to maintain homeostasis without
intervention.
Related to:
e Hypoperfusion of major organs associated with septic shock '
e Microvascular thrombosis associated with disseminated intravascular coagulation (DIC) if it occurs

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Severe hypotension; tachycardia; urine output less than
30 mL/h; dyspnea, tachypnea; altered ABG values with
low PaO,; elevated BUN and serum creatinine levels;
crackles throughout lungs; changes in mental status
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 475

RISK FACTORS DESIRED OUTCOMES

Decreased cardiac output
The client will not develop organ ischemia or dysfunction
Infection oft
as evidenced by:
Decreased vascular fluid volume
a. Usual mental status
Failure of regulatory mechanisms
b. Urine output at least 30 mL/h
c. Unlabored respirations at 12 to 20 breaths/min
d. Audible breath sounds without an increase in adventi-
tious sounds
e. Absence of new or increased abdominal pain, disten-
tion, and diarrhea
f. BUN, creatinine, aspartate aminotransferase (AST),
alanine aminotransferase (ALT), and lactate dehydroge-
nase (LDH) levels within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of: Early recognition of signs and symptoms of MODS allows for
Cerebral ischemia (e.g., change in mental status) prompt intervention.
Renal insufficiency (e.g., urine output <30 mL/h, elevated
serum BUN and creatinine levels)
Acute respiratory distress syndrome (ARDS) (e.g., dyspnea,
increase in respiratory rate, low SaOz, crackles)
GI ischemia (e.g., hypoactive or absent bowel sounds,
abdominal pain and distention, nausea, vomiting, diar-
rhea, hematemesis, blood in stool)
Liver dysfunction (e.g., increased serum AST, ALT, and
LDH levels; jaundice)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce the risk for organ ischemia/
dysfunction:
Administer antimicrobial agents as ordered. Prevents/treats infections.
Maintain fluid intake of 2500 mL/day unless contraindi- Maintains adequate vascular fluid volume.
cated.
Use good hand hygiene. Decreases transmission of infectious agents.
Maintain adequate nutritional status. Required for healing and to fight off infections.
Maintain sterile technique during all invasive procedures Decreases transmission of infectious agents.
(e.g., urinary catheterization, venous and arterial punc-
tures, injections).
Consult physician about discontinuing urinary catheter if A urinary catheter is another avenue by which the body’s defenses
one is present. can be breached and increases the risk for infection.
Anchor catheter/tubings securely. Prevents movement and accidental removal.
Change equipment, tubings, and solutions according to Decreases potential for infection.
hospital policy.
Maintain a closed system for drains (e.g., urinary catheter) Prevents introduction of infectious agents.
and intravenous infusions whenever possible.
Administer recombinant activated protein C (drotrecogin Drotrecogin alfa has antithrombotic, anti-inflammatory, and
alfa) if ordered. profibrinolytic activity and may reduce the risk of MODS.

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 476 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

|Nursing pee
Diagnosis=|DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY
HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition.
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of
the family unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to
maintain well-being.

CLINICAL MANIFESTATION

Subjective Objective
Verbal requests for information; verbal statements Inadequate follow-through of instruction; inappropriate
indicating misunderstanding or exaggerated behaviors

RISK FACTORS
° Cognitive limitations or unfamiliarity of situation

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; health behavior; health Health system guidance; teaching: individual; teaching:
resources prescribed activity/exercise; teaching: prescribed medications

NURSING ASSESSMENT RATIONALE

Assess client’s willingness to learn and knowledge related The client’s willingness to learn and knowledge base provides the
to the disease process. basis for education.
Assess for indications that the client may be unable to Early recognition of inability to understand disease process or
effectively manage the therapeutic regimen. self-care allows for change in the teaching plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

postoperative infection.

Independent Actions
Instruct client in ways to prevent postoperative infection/ injury:
* Continue with coughing and deep breathing every 2 hrs These activities improve lung expansion.
while awake.
* Continue to use incentive spirometer if activity is limited.
° Increase activity as ordered.
° Avoid contact with persons who have infections. Decreases potential for infection.
° Avoid crowds during flu and cold seasons.
e Decrease or stop smoking. Nicotine intake can increase cardiac workload and myocardial
oxygen use, thereby decreasing the amount of oxygen necessary
to fight infection.
° Drink at least 10 glasses of liquid per day unless contrain- Adequate hydration is necessary to maintain fluid balance
dicated.
e Maintain a balanced nutritional intake. Balanced nutritional intake is required for healing.
° Maintain proper balance of rest and activity. Promotes healing.
° Maintain good personal hygiene (especially oral care, These activities decrease the potential for an infection.
hand washing, and perineal care).
° Avoid touching any wound unless it is completely healed. Prevents introduction of pathogens and decreases potential for
* Maintain sterile or clean technique as ordered during infection.
wound care.
*The nurse should select the diagnostic label that is most appropriate for the client's discharge
teaching needs,
 Chapter 10 » The Client With Alterations in the Gastrointestinal Tract 477

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report the following signs and symptoms:
e Persistent low-grade fever or significantly elevated Signs and symptoms indicate the client may be experiencing
(238.3°C [101°F]) temperature. complications from the abdominal injury and/or surgery. Signs
e Difficulty breathing. and symptoms indicate possible infection of the surgical area or
e Chest pain. other body systems and possible thromboembolism.
e Productive cough of purulent, green, or rust-colored
sputum.
e Increasing weakness or inability to tolerate prescribed
activity level.
e Increasing discomfort or discomfort not controlled by
prescribed medications and treatments.
e Continued nausea or vomiting.
e Increasing abdominal distention and/or discomfort.
e Separation of wound edges.
e Increasing redness, warmth, pain, or swelling around
wound.
e Unusual or excessive drainage from any wound site.
e Pain or swelling in calf of one or both legs.
e Urine retention.
e Frequency, urgency, or burning on urination.
e Cloudy or foul-smelling urine.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, activity level, and
wound care.

Independent Actions
Collaborate with client to develop a plan that includes: Reinforcing information improves understanding and adherence to
Importance of keeping scheduled follow-up appointments treatment regimen and for follow-up care.
with the health care provider.
How to follow physician’s instructions on suggested activity Maintenance of treatment plan is important for continued healing
level and treatment plan. and maintenance of health.
Explanation of rationale for, side effects of, and importance Knowledge of medications and how they impact the system
of taking medications as prescribed. Inform client of improves client adherence and helps enhance the client's
pertinent food and drug interactions. understanding of the importance of adhering to the prescribed
medication regimen. The client must be able to recognize
alterations in functioning related to medication administration.
Include significant others in teaching sessions if possible. Involvement of the client’s significant others improves the client's
potential for success in maintaining the treatment regimen.
Encourage questions and allow time for reinforcement and Helps improves client’s understanding ofdischarge information.
clarification of information provided.
Provide written instructions on scheduled appointments with Written instructions provide ongoing access to information once
health care provider, dietary modification, activity level, client is discharged from the acute care facility.
treatment plan, medications prescribed, and signs and
symptoms to report.

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 478 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

APPENDICITIS/APPENDECTOMY
Acute appendicitis is one of the most common indications This care plan focuses on the adult client with
for emergency abdominal surgery. The appendix is a small suspected appendicitis who is hospitalized for a
fingerlike pouch that extends from the inferior part of the possible appendectomy.
cecum and is usually located in the right iliac region. The
most common cause of appendicitis is obstruction of
the lumen by a fecalith, a foreign body, an appendiceal OUTCOME/DISCHARGE CRITERIA
calculus, a tumor, or intramural thickening caused by
lymphoid hyperplasia. Obstruction of the appendix leads The client will:
to increased luminal pressure, vascular congestion, bacte- Have evidence of normal healing of surgical wound
rial invasion, and ultimately, necrosis and perforation of Have clear, audible breath sounds
the appendix. Tolerate prescribed diet
An appendectomy is the surgical removal of the appen- Have surgical pain controlled
dix. It can be done via a laparotomy or laparoscopy. Have no signs and symptoms of postoperative complications
A laparoscopic appendectomy offers the advantage of State signs and symptoms to report to the health care provider
shorter hospitalization and decreased morbidity and IS Develop a plan for adhering to recommended follow-up care
Se)
ee
Car
ey
Sul
mortality but is contraindicated in persons with extensive including future appointments with health care provider,
intraperitoneal adhesions or other intestinal problems medications prescribed, activity level, and wound care
that would impede mobilization and dissection of the For a full, detailed care plan on this topic, go to http://
appendix. evolve.elsevier.com/Haugen/careplanning/

BOWEL DIVERSION: ILEOSTOMY

An ileostomy is the diversion of the ileum from the abdominal the rectal stump is sutured across the top; the rectum stays intact
cavity through an opening created in the abdominal wall. It may and secretes mucus that is expelled via the anus.
be performed after abdominal trauma or to treat conditions such This care plan focuses on the adult client with
as familial polyposis, intestinal cancer, and most commonly, inflammatory bowel disease hospitalized for bowel
inflammatory bowel disease that is refractory to conservative diversion with creation of a permanent ileostomy.
management. An ileostomy can be temporary or permanent. Much of the postoperative information is applicable to
A temporary ileostomy is usually created to allow the bowel clients receiving follow-up care in an extended care
to heal after traumatic abdominal injury or to permit healing facility or home setting.
of a newly constructed ileoanal reservoir (pouch). The ileoanal
reservoir is a treatment option for some persons with inflam-
matory bowel disease or familial polyposis. In the initial sur- OUTCOME/DISCHARGE CRITERIA
gery, the diseased portion of the intestine is removed, a tempo-
rary ileostomy is performed, and a reservoir is created in the The client will:
rectal area using a portion of the ileum. After 2 to 4 months, 1. Have surgical pain controlled
the ileostomy is closed, and intestinal continuity is established 2. Have evidence of normal healing of the surgical wound
between the remaining intestine and the ileoanal reservoir. 3. Have a medium pink to red, moist stoma and intact peri-
There are two types of permanent ileostomies. The standard stomal and perianal skin
(Brooke) ileostomy is the most common one. It is created by 4. Have no evidence of fluid and electrolyte imbalances
bringing a portion of the terminal ileum through the abdominal S. Maintain an adequate nutritional status
wall, usually in the right lower quadrant. The ileostomy drains 6. Have no signs and symptoms of postoperative complications
intermittently but, because it cannot be regulated, a collection 7. Verbalize a basic understanding of the anatomical changes
device must be worn over the stoma at all times. Another type that have occurred as a result of the bowel diversion
of permanent ileostomy is the continent ileostomy (abdominal 8. Identify ways to maintain fluid and electrolyte balance
pouch). In this procedure, the terminal ileum is used to con- 9. Verbalize ways to maintain an optimal nutritional status
struct an intra-abdominal reservoir (Kock pouch). Initially, the 10. Identify methods of controlling odor and sound associ-
reservoir drains via a catheter that is placed through the stoma ated with ileostomy drainage and gas '
and a surgically constructed one-way valve. After the surgical 11. Demonstrate the ability to change the pouch system,
area heals, the catheter is removed, and the reservoir only needs maintain integrity of the peristomal and perianal skin,
to be drained periodically. If the system functions properly, the and maintain adequate stomal integrity
client does not need to wear a collection device over the stoma. 12. Demonstrate the ability to properly use, clean, and store
The type of permanent ileostomy constructed depends on the ostomy products
client’s age, underlying disease process, and preference and ex- 13. Demonstrate the ability to drain and irrigate a continent
pertise of the surgeon. A proctocolectomy (removal of the colon, ileostomy if present
rectum, and anus) is often done at the same time as a permanent 14. Identify ways to prevent and treat blockage of the stoma
ileostomy to treat the disease process or to prevent future bowel IS. State signs and symptoms to report to the health care
changes that could occur. If a proctocolectomy is not performed, provider
 Chapter 10 «= The Client With Alterations in the Gastrointestinal Tract 479

16. Share thoughts and feelings about the effect of altered 18. Develop a plan for adhering to recommended follow-up
bowel function on self-concept and lifestyle care including future appointments with health care
17. Identify appropriate community resources that can assist provider, wound care, activity level, and medications
with home management and adjustment to changes prescribed
resulting from the bowel diversion

USE IN CONJUNCTION WITH STANDARDIZED PREOPERATIVE CARE PLAN

|Nursing ~
Diagnosis |DEFICIENT KNOWLEDGE nox
Definition: Absence of cognitive information related to a specific topic, or its acquisition.

RISK FACTORS
e Lack of knowledge regarding the surgical procedure, phys- appearance and function of the ileostomy, and postopera-
ical preparation for the bowel diversion, sensations that tive care and management of the ileostomy
normally occur after surgery and anesthesia, expected

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; treatment procedure(s) Health system guidance; teaching: individual; teaching:
procedure/treatment

NURSING ASSESSMENT RATIONALE

Assess client's understanding of surgical procedure and outcome. Client’s understanding of what may occur will decrease anxiety.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understanding

of the surgical procedure, preoperative care, and postoperative
sensations and care of the ileostomy; verbalize an understanding
of the appearance, function, and management of the ileostomy.

Independent Actions
Provide information regarding specific preoperative care and Improves client’s understanding of what will occur during the
postoperative sensations and care for clients having a operative procedure and what to expect during recovery.
bowel diversion with ileostomy: Information helps to decrease fear and anxiety and improve
e Explain the preoperative bowel preparation (e.g., low- postoperative adherence to treatment regimen.
residue or clear liquid diet, cleansing enemas, laxatives,
antimicrobial therapy).
e If proctocolectomy is planned, inform client that:
e A perineal wound drain will be present after surgery.
e Occasional feelings of pressure in the perineal area are expected
after surgery and that these will subside as edema decreases.
e Ifacontinent ileostomy is planned, inform client that:
e A catheter will be inserted into the reservoir during This keeps the reservoir from becoming distended while the suture
surgery and will extend from the stoma and drain into lines are healing.
an external collection device; stress that this is a tempo-
rary measure (usually for 2-4 weeks).
e The reservoir will need to be irrigated periodically The bowel used to construct the reservoir initially secretes quite a
(especially in the early postoperative period) to remove bit of mucus.
mucus that accumulates in the reservoir.
e After removal of the stomal catheter, a catheter will be This is to drain the reservoir so that an external collection device
inserted into the stoma at regularly scheduled intervals. will not be needed.
Allow time for questions and clarification of information provided.
Arrange for a visit with an enterostomal therapy (ET) nurse if The client should be well informed about what will occur before the
available. procedure and what to expect in the postoperative period and
Reinforce information provided by physician and/or ET nurse subsequent changes that may occur following discharge.
about the appearance and function of the ileostomy:
e The stoma will be medium pink to red and will be moist.

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 480 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e The stoma will shrink in size as edema resolves during the
first 6 weeks after surgery (final stoma height is usually
1.5-2.5 cm [about % to 1 inch] from the skin surface).
° Slight bleeding of the stoma is expected when it is wiped
with tissue.
e For the first day or two after surgery, the stoma will drain
a small amount of clear to white, blood-tinged fluid
containing some mucus; after a few days, the color of the
drainage will change to green and then light to medium
brown as the diet progresses.
° When the ileostomy begins to function (usually 2-3 days
after surgery), the drainage will be watery and high
volume (up to 1-2 L/day), but within a couple of weeks the
amount will begin to decrease (expected amount of output
after 2-3 months is 500-800 mL/day) and develop a
thicker, paste-like consistency.
Provide basic information about peristomal skin care, ways to Allows client more time to process information when given before
control intestinal gas and odor of the effluent, products surgery.
the client will be using after surgery, and irrigation and
drainage of the reservoir (if a continent ileostomy is
planned).
Provide visual aids and allow client to handle ileostomy ap- The client should become familiar with how to use the appliances
pliances that will be used in the immediate postoperative to decrease stress postoperatively when using the appliances.
period. Provide a pouch clamp so that client can practice
putting it on and taking it off an empty pouch.
Encourage client to try wearing a pouch system partially filled Allows the client to know what the pouch will feel like when
with water in order to experience how it feels and to deter- working with a full pouch.
mine whether the planned stoma site will be adequate for
successful adhesion of the pouch.
Allow time for questions and clarification of information
provided.

USE IN CONJUNCTION WITH POSTOPERATIVE CARE PLAN

s- &..) RISK FOR IMBALANCED FLUID VOLUME nox;

RISK FOR ELECTROLYTE IMBALANCE* nox
Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease, increase,
or rapid shift from one to the other
of intravascular, interstitial and/or intracellular fluid, which may compromis
e health. This refers to body fluid loss,
gain, or both. Risk for Electrolyte Imbalance NDx: Susceptible to changes
in serum electrolyte levels, which may
compromise health.
Related to:
Risk for imbalanced fluid volume NDx:
° Restricted oral fluid intake before, during, and after surgery
e Blood loss
° Loss of fluid associated with vomiting, NG tube drainage, and/or high-volume ileostomy
output
Risk for electrolyte imbalance NDx: Hypokalemia, hypomagnesemia,
: . . .

and hypochloremia related to loss of electrolytes ‘

associated with vomiting, NG tube drainage, decreased oral intake, and/or

high-volume ileostomy output
Metabolic alkalosis related to:
° Loss of hydrochloric acid associated with vomiting and NG tube drainage
e Loss of bicarbonate ions associated with high-volume ileostomy output (effluent contains bicarbonate ions that would
normally be absorbed throughout the large intestine)

*The nurse should determine the most appropriate nursing diagnoses based on client
assessment.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 481

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness; confusion, nausea Change in mental status; decreased skin turgor; postural
hypotension; weak, rapid pulse; decreased urine output;
cardiac dysrhythmias; nausea and vomiting; absent bowel
sounds; decreased urine output; capillary refill =2 to
3 seconds; decreased electrolyte levels, decreased pH and
CO, levels; positive Chvostek and Trousseau sign

RISK FACTORS DESIRED OUTCOMES

e Inadequate fluid replacement
The client will not experience deficient fluid volume,
e Surgery
hypokalemia, hypochloremia, hypomagnesemia, and
acid-base imbalance as evidenced by:
a. Normal skin turgor
b. Moist mucous membranes
c. Stable weight
d. BP and pulse rate within normal range for client and
stable with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. Balanced I&O within 48 hrs after surgery
h. Urine specific gravity within normal range
i. Return of peristalsis within expected time
j. Absence of cardiac dysrhythmias, twitching, muscle
weakness, paresthesias, dizziness, headache, nausea,
and vomiting
k. Negative Chvostek and Trousseau sign
1. BUN, serum electrolyte, and ABG values within normal
range

NOC OUTCOMES NIC INTERVENTIONS

a

Fluid balance; electrolyte and acid-base balance Fluid monitoring; electrolyte management: hypokalemia;
electrolyte management: hypomagnesemia; fluid/electrolyte
management; acid-base monitoring; acid-base management:
metabolic alkalosis; acid-base management: metabolic
acidosis

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of fluid volume deficit
volume, hypokalemia, hypochloremia, hypomagnesemia, and electrolyte imbalance allow for prompt intervention.
and metabolic alkalosis:
e Decreased skin turgor, dry mucous membranes, thirst
° Weight loss of 2% or greater over a short period
e Postural hypotension and/or low BP
° Capillary refill time greater than 2 to 3 seconds
e Neck veins flat when client is supine
¢ Change in mental status
e Continued low urine output 48 hrs after surgery with a Specific gravity will usually increase with an actual fluid volume
change in specific gravity deficit but may be decreased depending on the cause of the
deficit.

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 482 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

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NURSING ASSESSMENT RATIONALE

a

° Excessive ileostomy output (after bowel activity returns) After bowel activity returns, expected output may be as high as
e Elevated BUN 2000 mL/day, and then in 10 to 14 days it should begin to
e Changes in serum electrolyte levels gradually decrease to 500 to 800 mL/day within 2 to 3 months.
e Drowsiness
e Disorientation
e Stupor
e Rapid, deep respirations
e Headache
° Nausea and vomiting
° Low pH and CO,

THERAPEUTIC INTERVENTIONS
RATIONALE
eee

Independent Actions
Implement measures to prevent or treat fluid volume deficit:
° Perform actions to prevent nausea and vomiting (e.g., Nausea often causes the client to have decreased fluid volume
assist client to ingest food/fluid slowly, eliminate noxious intake. Persistent vomiting results in excessive loss of fluid.
sights and odors, medicate as needed for pain relief). D
e If an NG tube is present and needs to be irrigated Irrigation of the NG tube helps prevent fluid volume deficit and
frequently and/or with large volumes of solution, irrigate maintains electrolyte levels.
it with normal saline rather than water. D +
e When oral intake is allowed and tolerated, assist client to Helps to maintain electrolyte levels.
choose foods/fluids high in potassium (e.g., bananas,
orange juice, potatoes, raisins, cantaloupe, tomato juice).
° Encourage intake of foods that may thicken effluent (e.g., Foods that thicken fluid in the bowel help slow its progress through
applesauce, bananas, boiled rice, tapioca, pretzels, creamy the bowel and allow for increased absorption of fluid and
peanut butter, pasta). electrolytes.
° Maintain a fluid intake of at least 2500 mL/day unless Maintains fluid volume.
contraindicated. D+
° Monitor I&O and administer fluid replacements as Monitoring I &O provides baseline for fluid volume replacement.
ordered.
* Perform actions to reduce fever if present (e.g., sponge Reduction of a fever prevents diaphoresis and subsequent loss of
client with tepid water, remove excessive clothing or fluid.
bedcovers). D @ +
° Instruct client to avoid excessive intake of foods/fluids Foods high in fiber, those that are spicy, very hot or cold, or with
that may cause diarrhea (e.g., raw fruits and vegetables; caffeine may induce diarrhea.
prune juice; fatty, spicy, or extremely hot or cold items;
coffee).

Dependent/Collaborative Actions
Implement measures to prevent or treat fluid volume deficit:
e Administer antipyretics. Antipyretics are given to reduce fever.
e Administer electrolyte replacements (e.g., magnesium Electrolyte replacements help to normalize fluid and electrolyte
sulfate, sodium bicarbonate, potassium) if ordered. levels.
e
Administer antidiarrheal agents (e.g., loperamide, Antidiarrheal medications prevent/treat diarrhea.
diphenoxylate hydrochloride) if ordered. D +
Consult physician if signs and symptoms of deficient fluid Notification of the physician allows for prompt alterations in the
volume and electrolyte imbalances persist or worsen. treatment plan.

_Nursing Diagnosis RISK FOR IMPAIRED TISSUE INTEGRITY nox

Definition: Susceptible to damage to mucous membrane, cornea, integumentary
system, muscular fascia, muscle, tendon,
bone, cartilage, joint capsule, and/or ligament, which may compromise health.

Related to:
° Disruption of tissue associated with the surgical procedure
e Delayed wound healing associated with factors such as decreased nutritional status and inadequate blood supply to
wound area
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 483

e Irritation of skin associated with:

e
Contact with wound drainage, ileostomy output (effluent is rich in proteolytic enzymes), soap residue and perspiration
under the pouch, and/or mucus drainage from the anus (occurs if rectum was left intact)
e Frequent or improper removal of tape, adhesives, or other substances used to secure pouch to the skin
e Aggressive cleansing of peristomal area
° Sensitivity to tape, pouch material, ostomy paste, and/or substances used to secure pouch to the skin (e.g., adhesive disk,
skin barrier, adhesive spray)
e Pressure from tubes, appliance belt, and/or pouch drainage valve or clamp

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Redness of skin around suture line and stoma; redness
of skin where tape or skin barrier had been removed;
swelling of ileostomy stoma; drainage from wound

RISK FACTORS DESIRED OUTCOMES

e Surgical procedure
The client will experience normal healing of surgical
e Preoperative nutritional deficit
wounds as evidenced by:
e Delayed nutritional therapy postoperatively
a. Gradual reduction in periwound swelling and redness
b. Presence of granulation tissue if healing by secondary
or tertiary intervention
c. Intact, approximated wound edges if healing is by
primary intention
The client will maintain integrity of peristomal and peri-
anal skin and skin in contact with wound drainage, tape,
and tubings as evidenced by:
a. Absence of redness and irritation
b. No skin breakdown

NOC OUTCOMES NIC INTERVENTIONS

Wound healing: primary intention; ostomy self-care; tissue Skin surveillance; pressure ulcer prevention; skin care:
integrity: skin and mucous membranes topical treatment; incision site care; ostomy care

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired wound Early recognition of signs and symptoms of impaired wound
healing (e.g., increasing periwound swelling and redness, healing allows for prompt treatment.
pale or necrotic tissue in wounds healing by secondary or
tertiary intention, separation of wound edges in wounds
healing by primary intention).
Assess for signs and symptoms of:
e Peristomal irritation or breakdown (e.g., redness, inflam-
mation, and/or excoriation of peristomal skin; reports of
itching or burning under the pouch seal; inability to keep
pouch on)
e Perianal irritation or breakdown (e.g., redness, inflamma-
tion, and/or excoriation of perianal skin; reports of itching
or burning in perianal area).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote wound healing:
e Ensure that dressings are secure enough to keep them from Secure dressings help protect the wound from mechanical injury.
rubbing and irritating wound.
These actions decrease stress on the surgical area and support
* Carefully remove tape and dressings when performing
wound care. wound healing.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Remind client to keep hands away from the wound. Prevents cross contamination.
e Instruct and assist client to support the surgical area when Support surgical area. Helps to decrease discomfort and support
moving. incision area.
° Instruct and assist client to splint wound when coughing. Helps to prevent infection.
e Apply abdominal binder during periods of activity if
ordered.
e Encourage the client to eat a diet with adequate amounts Supports immune system and wound healing to prevent infection.
of protein. D+
Implement measures to prevent tissue irritation and break-
down in areas in contact with wound drainage, tape, and
tubings:
° Inspect dressings, wounds, and areas around drains; These actions prevent wound drainage from contacting or remain-
cleanse wound and change dressings when appropriate. ing on the skin.
° Maintain patency of drainage tubes.
° Apply a collection device over drains that are draining Helps to decrease infections and supports wound healing.
copiously.
e Apply a protective barrier product to skin that is likely to
be in frequent contact with drainage.
° When positioning client, ensure that he/she is not lying Pressure on the skin can compromise circulation to that area; if
on tubings. D+ drainage tubing is occluded, there is an increased risk for
leakage of drainage around the tubing.
e Anchor all tubing securely. D+ Anchoring tubing prevents excessive movement of tubes against
tissues.
° Apply a water-soluble lubricant to external nares every Decreases irritation from NG tube and nasal airway or cannula.
2 to 4 hrs. D>
e Use Montgomery straps or tubular netting. D+ Using Montgomery straps or netting helps avoid repeated
application and removal of tape if frequent dressing changes are
anticipated.
e When removing tape, pull it in the direction of hair Prevents irritation to skin when removing tape.
growth; use adhesive solvents if necessary. D +
Implement measures to prevent peristomal irritation and
breakdown:
e Shave or clip hair from peristomal skin if necessary. Helps achieve an adequate pouch seal and reduce irritation when
D+ the pouch system is removed.
¢ Patch test all products that will come in contact with the The client may be allergic to products used against the skin. Patch
skin (e.g., sealant, ostomy paste, barrier, adhesive, and testing them will prevent allergic reaction at the suture line or
solvent) before initial use; do not use products that cause stoma Site.
redness, rash, itching, or burning.
° Change entire pouch system only when necessary (Ee, ii Too frequent changes of the pouch system cause unnecessary
pouch seal is leaking, if client reports burning or itching of irritation to the peristomal site.
the peristomal skin, when the stoma size changes); pouch
system is usually changed every 3 days in early postopera-
tive period and then should be able to remain in place for
S to 7 days.
° Use a two-piece pouch system (e.g., faceplate and pouch, This type of system allows the pouch to be removed to assess the
wafer with flange and pouch) during the initial postopera- stoma without having to remove the adhesive from the skin.
tive period.
° Perform actions to reduce peristomal irritation during
removal of the pouch:
° Place drops of warm water or solvent where the pouch These actions facilitate the removal of the pouch and dbcrease
system adheres to the skin; allow time for adhesive to potential for drainage to contact the skin.
loosen before removing pouch.
e Remove pouch system gently and in direction of hair
growth; hold skin adjacent to the skin barrier taut and
push down slightly on skin.
 Chapter 10 » The Client With Alterations in the Gastrointestinal Tract 485

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to prevent effluent from contacting the
skin when changing the pouch system or pouch or when
the pouch system is on:
e Change the pouch or pouch system when the ileos-
tomy is least active (e.g., upon awakening in the morn-
ing, before meals, 2-4 hrs after eating, before retiring
at night).
e Place a wick (rolled gauze pad or tampon) on the stoma
opening when the pouch system or pouch is off.
e Cleanse peristomal skin thoroughly with mild soap and Prevents burning the skin.
water, rinse completely, and pat dry; use tepid rather
than hot water.
e Apply skin sealant to the clean, dry peristomal skin Protects skin from the irritating effects of the adhesive.
before applying the skin barrier.
e Always use a skin barrier (e.g., Reliaseal, Stomahesive). Protects skin from the proteolytic enzymes in the effluent.
D+
e Measure the diameter of the stoma; cut skin barrier the Creates a barrier that is close to the size of the stoma, decreasing
same size as stoma and select a pouch with an opening potential for contact between skin and proteolytic enzymes.
that is not more than 0.3 cm ('/s inch) larger than the
stoma (it may be necessary to create a pattern to use for
cutting barrier and pouch openings if stoma has an
irregular shape and cannot be measured using appli-
ance manufacturer’s standard measuring guide).
e Implement measures to achieve an adequate pouch
seal:
(1) Avoid use of ointments or lotions on peristomal Ointments and lotions can interfere with adequate adhesive bonding.
skin.
(2) Follow manufacturer’s instructions when applying Prevents potential injury to skin and poor adhesive bonding.
skin products and pouch system.
(3) Use products such as ostomy paste to skin in irregu- Allows for an adequate seal in areas where there are body folds or
larities around stoma site before applying pouch scars.
system.
(4) Apply firm pressure and remove air pockets when Increases tautness of skin surface during application and increases
applying pouch system; place client in a supine adequate pouch seal.
position.
e Empty pouch when it is one third full of effluent or A heavy or inflated pouch can cause the pouch system to separate
inflated with gas. D> from the skin.
e Position pouch so gravity flow facilitates drainage away Prevents effluent stasis or backflow, which increases the chance of
from stoma and peristomal skin. irritation to the skin.
e Rinse out bottom of drainable pouch after emptying it Prevents leakage of effluent
and then close pouch clamp securely.
e Use a drainable pouch, 2-piece pouch system, and/or These actions prevent effluent from seeping out of the pouch and
pouch with a release valve if gas is a problem; never causing skin irritation.
puncture or cut the pouch to release gas.
e Ifa belted pouch system is used, fasten the belt so that two Use of a belted pouch system prevents excessive pressure on the skin
fingers can slip easily between belt and skin. and potential skin irritation.
e Instruct and assist client to check pouch periodically to
ensure that pouch clamp is not placing pressure on the
skin. D+
Implement measures to prevent perianal irritation and
breakdown:
e Keep perianal area dry and clean. Prevents irritation and potential breakdown.
e Instruct client to regularly perform perineal exercises (e.g., Increases anal sphincter tone and reduces the risk of mucus
relaxing and tightening perineal and gluteal muscles). leakage.
e Place absorbent pads in client underwear if needed and Prevents irritation ofanal area and potential skin breakdown.
change pads when they become damp.
e Apply moisture-barrier ointment to perianal area as
ordered. D@ +

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THERAPEUTIC INTERVENTIONS RATIONALE

—_—_eeoO

If signs and symptoms of peristomal or perianal skin irritation

or breakdown occur:
e Cleanse areas gently with warm water. Decreases further skin irritation.
e Avoid use of any product that may have caused the irrita- Prevents adverse skin reactions.
tion or breakdown.
° Perform skin care as ordered or according to hospital Usual care may include exposing affected area to air for 20 to
procedure. 30 minutes, applying an antifungal agent or corticosteroid
preparation to affected skin, and/or covering all irritated skin
with a solid skin barrier. This promotes skin healing.
Consult appropriate health care provider (e.g., wound care Allows for prompt alteration in treatment plan.
specialist, ET nurse, physician) if area of irritation or
breakdown does not improve within 48 hrs.

RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum.
Related to:
e Wound infection (a client with inflammatory bowel disease often has a decreased resistance to infection as a result of long-
term preoperative corticosteroid use and decreased nutritional status)
° Leakage of intestinal contents into the peritoneum during surgery and/or postoperatively associated with loss of integrity of
the sutures at sites of anastomoses or separation of the peristomal skin from the stoma (retraction of the stoma can occur as
a result of slippage of sutures, impaired healing of surgical site, or shrinkage of the supporting tissues)
e Accumulation of wound drainage in the peritoneum

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increasing abdominal pain; rebound Hyperthermia, rigid abdomen, vomiting, tachycardia,
tenderness tachypnea, hypotension, decreased or absent bowel
sounds, increased WBC count or failure to decrease to
normal levels

RISK FACTORS DESIRED OUTCOMES

e Surgery
e Exposure to pathogens The client will not develop peritonitis as evidenced by:
e Exposure of abdomen to intestinal fluids and content . Gradual resolution of abdominal pain
. Soft, nondistended abdomen
. Temperature declining toward normal
. Stable vital signs
. Absence of nausea and vomiting
. Gradual return of normal bowel sounds
WBC count declining toward normal
Mmoandds

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of peritonitis (e.g., Early recognition of signs and symptoms of peritonitis allows for
increase in severity of abdominal pain; rebound tender- prompt intervention.
ness; distended, rigid abdomen; increase in temperature;
tachycardia; tachypnea; hypotension; nausea; vomiting;
continued or diminished or absent bowel sounds; WBC
counts that increase or fail to decline toward normal).
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 487

THERAPEUTIC INTERVENTIONS RATIONALE

LN ——————————
a EEE

Independent Actions ~
Implement measures to prevent peritonitis:
e Implement measures to prevent wound infection:
e Maintain an optimal nutritional status. Adequate nutrition is needed to maintain normal function of the
immune system.
e Do not apply dressing too tight. Dressings that are too tight decrease circulation to the surgical area
and decrease healing.
e Ensure dressings are secure enough to keep them from Prevents irritation to the wound.
rubbing the wound.
e Carefully remove tape from the wound. Decreases potential for injury to the stoma.
e Perform measures to maintain patency of wound drain if
present:
e Keep tubing free of kinks. D+ Allows drainage to flow away from the wound and prevents disten-
tion of the conduit.
e Empty collection device as often as necessary. D> Prevents stress on the wound and stasis of drainage and prevents
distention of the conduit.
e Maintain suction as ordered. Prevents stasis of secretions and prevents distention of conduit.
e Perform measures to prevent inadvertent removal of the These actions prevent accidental dislodgement of a drain ifpresent
tube: and enables the client to move without placing unnecessary
e Use caution when changing dressings surrounding tension on the drain.
drain. D +
e Provide extension tubing if necessary. D +
e Instruct client not to pull on drain and drainage tubing.
D+
Dependent/Collaborative Actions
Implement measures to prevent peritonitis:
e Perform actions to prevent distention of the internal reser- Distention can cause strain on the suture lines and subsequent
voir (if client has a continent ileostomy) or remaining leakage of effluent into the peritoneal cavity.
segment of the ileum:
e Implement measures to prevent stomal obstruction:
(1) Irrigate stoma if ordered. Removes excessive mucus that could block stoma.
(2) Maintain a fluid intake of 2500 mL/day. Keeps effluent from becoming too thick and maintains fluid
volume.
(3) Administer oral medications crushed and mixed in Undigested pills can block stoma.
water or in liquid or chewable form.
e Instruct client to avoid activates such as drinking car- Prevents accumulation of air and gas in the remaining intestine or
bonated beverages, chewing gum, smoking, and eating internal reservoir.
gas-producing foods (e.g., cabbage, onions, broccoli,
beans, cucumbers)
e Use only the prescribed amount of irrigating solution Prevents accumulation of fluid in the remaining intestine or
(e.g., 20-30 mL) when irrigating the stoma or internal internal reservoir.
reservoir.
e Maintain patency of stomal catheter (e.g., keep stomal Promotes gravity drainage and prevents stasis or backflow of
catheter and drainage bag below level of reservoir, keep drainage.
catheter free of kinks, irrigate catheter as ordered).
e Change pouch system carefully. D + Helps prevent unintentional dislodgement of the stomal catheter.
e If client has a continent ileostomy and the stomal cath- Prevents accumulation ofdrainage in the internal reservoir.
eter is removed before discharge, assist client with
drainage of the internal reservoir at scheduled intervals
and when client feels increased abdominal pressure.
e Do not reposition the stomal catheter. Repositioning could disrupt the suture line.
e If the peristomal skin separates from the stoma: Appropriate wound care facilitates the formation of granulation
e Perform wound care as ordered. tissue in the affected area.
e Prepare client for surgical reconstruction of the stoma if
planned.
e Administer antimicrobials if ordered. Antimicrobials prevent and treat infections.

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THERAPEUTIC INTERVENTIONS RATIONALE

e If signs and symptoms of peritonitis occur:
e Withhold oral intake as ordered. D+ Prevents increased pressure in the abdomen.
e Place client on bedrest in a semi-Fowler’s position. D+ Positioning in a semi-Fowler’s position assists in pooling or
localizing GI contents in the pelvis rather than under the
diaphragm.
e Prepare client for diagnostic tests (e.g., abdominal radio- Decreases client’s fear and anxiety.
graph, peritoneal aspiration, computed tomography,
ultrasonography) if planned.
e Insert an NG tube and maintain suction as ordered. Insertion of an NG tube to suction decreases potential for GI
D+ distention.
e Administer intravenous fluids and/or blood volume Administration of IV fluids maintains circulatory volume and
expanders if ordered to prevent or treat shock. prevents the increased capillary permeability that occurs with
inflammation and the subsequent escape of protein, fluid, and
electrolytes from the vascular space into the peritoneal cavity.
e Prepare client for surgical intervention (e.g., drainage Decreases client’s fear and anxiety.
and irrigation of peritoneum, repair of sites of anasto-
moses) if indicated.

| «RI
Collaborative Diagnosis
SK | FOR STOMAL CHANGES
Definition: Changes in the structure of the stoma.
Related to:
Necrosis related to intraoperative and/or postoperative interruption of blood supply to the stoma

Excessive bleeding related to irritation associated with aggressive cleansing of stoma and/or improper fit or application of
pouch system
Prolapse related to loss of integrity of the sutures or pressure around the stoma

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Changes in color of stoma to pale or dark blue, black, or
purple; increased stoma height; increased stoma bleeding
and/or edema

RISK FACTORS DESIRED OUTCOMES

e Surgery
e Preoperative poor skin integrity The client will maintain stomal integrity as evidenced by:
e Inadequate or inappropriate stomal/skin therapy a. Medium pink to red stomal coloring
b. Expected stomal height
c. Absence of excessive bleeding and increasing edema of
the stoma

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired stomal Early recognition of signs and symptoms of impaired’ stomal
integrity: integrity allows for prompt treatment.
e Pale, dark red, dusky blue, blue-black, or purple color of
stoma
e Increased height of stoma
e Increased stomal edema or bleeding
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 489

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Use clear pouches during immediate postoperative period. Clear pouches allow for easy visibility and assessment of the
Implement measures to maintain integrity of stoma: stoma.
e Perform actions to maintain adequate stomal circulation: Prevents pressure on and around the stoma.
e Ensure that the openings of the skin barrier, faceplate,
and pouch are not too small and that the stoma is
centered in the openings.
° Instruct client to avoid wearing clothing that puts pressure
on the stoma.
¢ Apply pouch system securely. D+ Prevents it from slipping and irritating or shearing stoma.
° Cleanse stoma gently using a soft cloth, gauze, or tissue. These actions prevent skin irritation and decrease risk for infection
D+ and injury.
If signs and symptoms of impaired stomal integrity occur:
¢ Perform stomal care as ordered.
¢ Prepare client for surgical revision of stoma if indicated.

|Collaborative yore
Diagnosis |RISK FOR STOMAL OBSTRUCTION
Definition: Inability of fecal material to pass through the stoma.
Related to:
¢ Stomal edema and/or blockage of stoma

Subjective Objective
Verbal self-report of abdominal cramping; nausea or Less than expected output; thin, watery effluent
increased feeling of fullness consistency

RISK FACTORS DESIRED OUTCOMES

¢ Surgery The client will not develop stomal obstruction as evi-
e Inadequate flushing denced by:
¢ Lack of peristalsis a. Expected amount and consistency of ileostomy output
¢ Immobility b. No reports of abdominal cramping, nausea, or in-
creased feeling of fullness
c. Absence of vomiting

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of stomal obstruction: Early recognition of signs and symptoms of stomal obstruction
allows for prompt intervention.
¢ Less than expected amount of ileostomy output After return of peristalsis, output may be as high as 2000 mL/day
and will gradually decrease to about 500 to 800 mL/day.
¢ Change in effluent consistency from a thicker consistency Postoperatively, effluent gradually becomes thicker; a return to
to a thin, watery liquid thin, watery consistency may indicate blockage ofstoma.
¢ Reports of abdominal cramping, nausea, or increased
feeling of fullness
¢ Vomiting

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent stomal obstruction:
° Irrigate stoma if ordered. D + Stomal irrigation removes excessive mucus that could block stoma.
e Administer oral medications crushed and mixed in water Undigested pills can block stoma.
or in liquid or chewable form. D +

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THERAPEUTIC INTERVENTIONS RATIONALE

e When oral intake is allowed, perform actions to prevent
blockage of stoma by food:
e Encourage client to eat small, frequent meals rather Small meals help keep effluent from becoming too thick and allow
than three large ones. body time to more fully digest smaller amounts of food.
e Instruct client to chew food thoroughly. Chewing thoroughly will increase absorption of food.
e Instruct client to avoid or eat only small amounts of Fibrous foods absorb water in the intestinal tract.
foods that are high in fiber.
e Instruct client to avoid or eat only small amounts of Hard-to-digest foods increase abdominal distention.
foods that are hard to digest (e.g., popcorn, coconut,
raw vegetables, fruits with seeds, celery, bean sprouts,
bamboo shoots, whole kernel corn, potato skins, bran,
nuts, fruit skins).
If food particles or mucus seem to be obstructing the stoma,
implement measures to promote flow of effluent through
the stoma:
e Perform actions to relax the abdominal muscle that These actions decrease the stricture around the stoma from a
surrounds the stoma (e.g., apply warm compresses to the contracted abdominal muscle.
abdomen unless contraindicated, encourage participation
in relaxing activities such as reading and listening to
music).
¢ Perform actions to break up or shift foods or mucus:
e Encourage fluid intake unless contraindicated. Adequate fluid intake liquefies secretions, improving effluent flow
out of the stoma.
e Instruct and assist client to assume a knee-chest position. Positioning in the knee-chest position may break up or shift stomal
blockage.
¢ Gently massage peristomal area unless contraindicated. Gentle massage may stimulate peristalsis to move fecal material
e Assist with or gently perform digital dilation of stoma through the colon.
if ordered. Provides manual removal of blockage.
e Irrigate ileostomy if ordered. Irrigation of the ileostomy may flush out blockage.

Dependent/Collaborative Actions
° Maintain fluid intake of 2500 mL/day unless contraindicated. Keeps effluent from becoming too thick.
If stomal edema seems to be obstructing the stoma, consult
physician about gently inserting a catheter through the
stoma into the ileal segment.
If signs and symptoms of stomal obstruction persist:
e Withhold oral intake as ordered. Prevents food from further obstructing stoma.
e Maintain intravenous fluid therapy. Prevents fluid volume deficit and increased viscosity of effluent.
e Insert an NG tube and maintain suction as ordered. An NG tube to suction removes contents from stomach.
¢ Prepare client for surgical intervention to remove obstruc- Decreases fear and anxiety.
tion if indicated.

|Nursing Diagnosis
Diagnosis _ INEFFECTIVE SEXUALITY PATTERNS nox
Definition: Expressions of concern regarding own sexuality.

Related to:
° Decreased libido associated with feelings of loss of femininity/masculinity and sexual attractiveness
° Fear of offensive odor or leakage of effluent and gas
° Fear of rejection by partner
e Discomfort resulting from surgical incision
e Depression

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sexual concerns; expression of fear of N/A
rejection by partner
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 491

RISK FACTORS DESIRED OUTCOMES

e Changes in body
e Embarrassed by physical appearance
The client will demonstrate beginning acceptance of
changes in sexual functioning as evidenced by:
a. Verbalization of a perception of self as sexually accept-
able and adequate
b. Statements reflecting beginning adjustment to the
effects of the ileostomy on sexual functioning

NOC OUTCOMES NIC INTERVENTIONS

Body image; personal well-being; sexual functioning Body image enhancement; sexual counseling

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of sexual dysfunction (e.g., Early recognition of signs and symptoms of changes in sexual
verbalization of sexual concerns, alteration in relationship functioning allows for prompt intervention.
with significant other, reports of anticipated changes in
sexual activities or behaviors).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote optimal sexual functioning:
e Facilitate communication between client and partner; Allows client and partner to explore concerns and work through
focus on the feelings the couple share and assist them to issues related to changes that affect their sexual relationship.
identify changes that may affect their sexual relationship.
e Perform actions to promote a positive self-concept (e.g., Improves self-concept and self-esteem.
use odor-proof pouches, change appliance regularly).
e Instruct client in ways to reduce risk of leakage of effluent
during sexual activity:
e Empty the pouch or drain internal reservoir (if present) These actions prevent leakage.
before sexual activity.
e Secure appliance seal with tape for added security. Prevents inadvertent dislodgement of the appliance and subsequent
leakage.
e If client is concerned about odor, instruct client to:
e Shower or bathe before sexual activity. These actions prevent odor from effluent from being noticed during
e Use an odor-proof pouch or pouch deodorant. sexual activity, making the client less self-conscious.
e Use cologne or perfume if desired.
e Keep room well ventilated.
e If client is concerned about the presence of the stoma and
pouch system, discuss the possibility of:
e Using opaque or patterned pouches or decorative pouch Makes client less self-conscious about wearing the appliance.
covers
e Wearing underwear with the crotch removed (for Wearing crotchless underwear provides support for and covers the
females), boxer shorts (for males), or a cummerbund or appliance during sexual activity.
stretch tube top around abdomen during sexual activity
e If client is concerned that operative site discomfort will
interfere with usual sexual activity:
e Assure client that discomfort is temporary and will
diminish as the incision heals.
e Encourage alternatives to intercourse or use of positions Decreases pressure on the surgical site or pressure from a partner on
that decrease pressure on surgical site (e.g., side lying). top of the client during sexual activity.
If appropriate, involve partner in ileostomy care. Facilitates partner’s adjustment to the changes in client’s
appearance and body functioning and subsequently decreases
the possibility ofa partner’s rejection of client.
Encourage client to obtain written information regarding Provides for continuum of care and resources for the client once
sexual activity from the United Ostomy Association and discharged from the acute care environment.
from manufacturers of ostomy products.
Include partner in above discussion and encourage contin- Allows client and partner to work through physical changes and
ued support of the client. emotional concerns together.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., ET nurse, Provides for a multidisciplinary approach to client care.
psychiatric nurse clinician, sex therapist, physician) if
counseling is indicated.

|Nursing ei)
Diagnosis DISTURBED SELF-CONCEPT*
Definition: Disturbed Body Image: NDx Confusion in mental picture of one’s physical self.
Situational Low Self-Esteem: NDx Development of a negative perception of self-worth in response to a current
situation.
Ineffective Role Performance: NDx A pattern of behavior and self-expression that do not match the
environmental context, norms, and expectations.

Related to:
e Change in appearance associated with presence of stoma and pouch system
e Embarrassment associated with sounds and odor resulting from gas and effluent
e Dependence (usually temporary) on others for assistance with ileostomy management
¢ Loss of control over bowel elimination if client has conventional ileostomy
e Loss of ability to urinate normally
e Change in appearance associated with the presence of a stoma and appliance
e Changes in usual sexual functioning
° Possibility of impotence if nerve damage occurred during a proctocolectomy (use of nerve-sparing surgical techniques has
greatly reduced the occurrence of nerve damage and subsequent impotence)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of negative feelings about self Lack of participation in activities of daily living; withdrawal
from significant others; refusal to look at or touch stoma;
lack of planning to adapt to necessary changes in lifestyle

RISK FACTORS DESIRED OUTCOMES

e Physical changes
The client will demonstrate beginning adaptation to
e Depression
e Surgery changes in appearance, body functioning, and lifestyle as
evidenced by:
e Inability to perform perceived family role
a. Verbalization of feelings of self-worth
b. Maintenance of relationships with significant others
c. Active participation in activities of daily living
d. Verbalization of a beginning plan for integrating changes
in appearance and body functioning into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Body image; personal autonomy; self-esteem; psychosocial Body image enhancement; self-esteem enhancement;
adjustment: life change emotional support; support system enhancement; role
enhancement; counseling
4
NURSING ASSESSMENT RATIONALE
Assess for signs and symptoms of a disturbed self-concept (e.g., Early recognition of signs and symptoms of a disturbed self-concept
verbalization of negative feelings about self, withdrawal allows for prompt treatment.
from significant others, lack of participation in activities of
daily living, refusal to look at or touch stoma, lack of plan
for adapting to necessary changes in lifestyle).

*This diagnostic label includes the nursing diagnoses of disturbed body image, situational low self-esteem,
and ineffective role
performance.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 493

NURSING ASSESSMENT RATIONALE

Determine the meaning of changes in appearance, body An understanding of what the change means to the client provides
functioning, and lifestyle to the client by encouraging a basis for planning care.
verbalization of feelings and by noting nonverbal
responses to the changes experienced.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Be aware that client may grieve the loss of usual bowel func- Allow client and significant others to grieve loss of normal body
tion and change in appearance. Provide support during functioning; helps to work through changes that are occurring.
the grieving process.
Emphasize the positive effects of the surgery on future life- Unrealistic expectations may lead to difficulty in dealing with the
style (e.g., the discomfort and frequent diarrhea associated physical changes that have occurred.
with inflammatory bowel disease and the side effects of
medications such as corticosteroids usually have had a
disruptive effect on many aspects of the client’s life).
Implement measures to promote optimal sexual functioning Sexual activity may have a positive effect on self-esteem.
(e.g., ways to support stoma during sexual activity; proper
positioning during sexual activity; ways to decrease odor
from the stoma during sexual activity).
Instruct and assist client in ways to reduce gas formation:
e Avoid activities that can cause air swallowing (e.g., chew- Prevents abdominal distention related to gas from air swallowing.
ing gum, smoking).
e Limit intake of carbonated beverages and gas-producing These foods cause gas production and abdominal distention.
foods (e.g., cabbage, onions, beans, radishes, broccoli,
cucumbers).
Instruct client in and assist with measures to reduce the odor These interventions are effective in reducing noticeable pouch
of ileostomy drainage and/or gas: system odor.
e Use odor-proof pouches and change appliance regularly.
e Empty pouch regularly, rinse inside of pouch, and clean
off any effluent before closing pouch.
e Drain the reservoir of continent ileostomy at scheduled
intervals and when it feels full to reduce possibility of
leakage from stoma.
e Use a disposable pouch and change it regularly, or clean
reusable pouch thoroughly.
e Perform actions to achieve an adequate pouch seal (e.g.,
patch test all products that come into contact with the
skin, change/empty pouch when necessary, place a drop
of warm water on the skin to increase adherence of the
appliance, measure diameter of the stoma and cut skin
barrier to prevent exposure to the effluent).
e Limit intake of foods that cause effluent to have a strong
odor (e.g., onions, fish, eggs, strong cheeses, asparagus).
e Increase intake of foods/fluids that control odor (e.g.,
spinach, parsley, yogurt, buttermilk).
e Change bed linens and clothing promptly if they become
soiled.
Inform client that pouch and clothing muffle sounds of Assures client that bowel sounds may not be noticed by others.
bowel activity.
Assure client that once stomal edema and discomfort associ- Realistic expectations about appearance and/or body functioning
ated with the surgery have resolved, the client will be able facilitate goal setting and are essential for positive adaptation
to dress as before with minor, if any, modifications. to the changes experienced and integration of these changes into
self-concept.
Show client and significant others some of the attractive Helps reduce client self-consciousness.
ileostomy products that are available (e.g., opaque or
patterned pouches, pouch covers).

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THERAPEUTIC INTERVENTIONS RATIONALE

Encourage participation in activities that can assist client to Supporting behaviors indicative of positive adaptation to changes
integrate physical changes that have occurred (e.g., ileos- encourages the client to repeat these behaviors. Repetition of
tomy care, bathing). positive adaptive behaviors facilitates the development of a
positive self-concept.
Demonstrate acceptance of client using techniques such as Frequent visits and the use of touch convey a feeling of acceptance
touch and frequent visits. to the client. This enhances feelings of self-worth and assists
with the development of a positive self-concept.
Support behaviors suggesting positive adaptation to changes Improves client’s confidence in ability to care for self. This
that have occurred (e.g., willingness to care for ileostomy, enhances client’s feelings of self-worth and assists with the
compliance with the treatment plan, verbalization of development of a positive self-concept.
feelings of self-worth, maintenance of relationships with
significant others).
Encourage significant others to allow client to do what he/she Demonstrates to the client that independence can be re-established
is able. and/or self-esteem redeveloped.
Assist client’s and significant others’ adjustment by listening, Demonstrates acceptance of physical changes by significant others
facilitating communication, and providing information. and enhances self-worth.
Encourage visits and support from significant others.
If acceptable to client, arrange for a visit with an ostomate of Demonstrates that client is not alone in the changes experienced
similar age and same sex who has successfully adjusted to and ability to have a positive future.
an ileostomy.
Encourage client to pursue usual roles and interests and to The ability to pursue usual roles and activities has a positive effect
continue involvement in social activities. on the client’s self-esteem.
Provide information about and encourage utilization of com- Provides for continuum of care once the client has been discharged
munity agencies and support groups (e.g., ostomy groups; from the acute care setting.
sexual, family, individual, and/or financial counseling).
If nerve damage that could result in impotence is believed to Helps client realize there are options if nerve damage has occurred.
have occurred during a proctocolectomy, encourage client
to discuss it and various treatment options (e.g., vacuum
erection aids, penile prosthesis) with physician.

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., psychologist, Allows for multidisciplinary interventions.
psychiatric nurse clinician, ET nurse, physician) if client
seems unwilling or unable to adapt to changes resulting
from the bowel diversion.

|Nursing 2.)
Diagnosis |DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY
HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE? nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition.
Ineffective Family Health Management NDx: A attern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals
of the
family unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to mainjain
well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

*The nurse should select the diagnostic label that ismost appropriate for the client’s discharge teaching needs.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 495

RISK FACTORS
° Denial of disease process and physical changes
° Cognitive deficiency
° Failure to participate in self-care while hospitalized

NOC OUTCOMES NIC INTERVENTIONS

eea eee eee a ee Bee

Knowledge: ostomy care; treatment regimen; diet Health systems guidance; teaching: individual; teaching:
disease process; teaching: prescribed diet; teaching:
prescribed medication

NURSING ASSESSMENT RATIONALE

Assess client’s knowledge base related to the disease process. The client’s knowledge base provides the basis for education.
Assess for indications that the client may be unable to effec- Early recognition of inability to understand disease process or
tively manage the therapeutic regimen: self-care allows for change in teaching modality.
° Statements reflecting inability to manage care at home
° Failure to adhere to treatment plan

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize a basic under-

standing of anatomical changes that have occurred as a result
of the bowel diversion.

Independent Actions
Reinforce teaching regarding the anatomical changes that Improves client’s understanding of surgery and subsequent physical
have occurred as a result of the bowel diversion. Use and lifestyle changes as a result of surgery.
appropriate teaching aids (e.g., pictures, videotapes,
anatomical models).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to main-

tain fluid and electrolyte balance.
Instruct client to drink at least 10 glasses of liquid per day These actions provide client with methods to maintain adequate
unless contraindicated and to increase fluid intake during fluid volume during weather and physical changes.
hot weather, during and after intense physical activity,
when perspiring profusely, if urine is dark yellow, and
during episodes of diarrhea; inform client that pale yellow
urine is a good indicator of adequate fluid intake.
Instruct client to perform the following actions to prevent Excessive ileostomy output may cause changes in fluid and electro-
excessive ileostomy output: lyte balance. These actions help prevent increased and excessive
Avoid excessive intake of foods/liquids that may cause ileostomy output.
diarrhea (e.g., raw fruits and vegetables, prune juice, fatty
foods, spicy foods, coffee).
* Do not take laxatives or excessive amounts of magnesium-
containing antacids (e.g., Milk of Magnesia, Mylanta,
Maalox).
e Take antidiarrheal agents (e.g., loperamide, diphenoxylate
hydrochloride) as prescribed.
If ileostomy output increases or becomes more watery,
instruct client to:
e Increase intake of foods that may thicken effluent (e.g., Foods that thicken fluid in the bowel help to slow its progress and
applesauce, bananas, boiled rice, tapioca, pretzels, creamy allow for more fluid and electrolytes to be absorbed.
peanut butter, pasta).
e Increase intake of foods/liquids such as fruit juices, Gato- These actions help maintain electrolyte balance.
rade, potatoes (without skins), bananas, and bouillon.
e Drink a mixture of baking soda and water (usually 4 to 2
teaspoon baking soda in 1 cup of water) if prescribed by
physician.

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THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to main-

tain an optimal nutritional status.

Independent Actions
Provide instructions regarding ways to maintain an optimal
nutritional status:
e Stress the importance of eating a well-balanced diet. Eating a well-balanced diet is necessary for postoperative healing
and normal body functions.
e Stress the need to chew food thoroughly. Thoroughly chewing foods enhances digestion and subsequent
absorption of nutrients.
e Stress the importance of taking vitamins and minerals as Vitamin and mineral supplements enhance nutritional status.
prescribed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify methods of

controlling odor and sound associated with ileostomy
drainage and gas.

Independent Actions
Reinforce instructions regarding ways to reduce gas formation These actions prevent abdominal distention related to gas from air
and odor associated with ileostomy drainage and gas (e.g., swallowing or intake of gas-producing foods. Reduction of odor
avoid activities that can cause air swallowing, limit intake and excessive bowel sounds help improve client’s self-esteem.
of carbonated beverages, use odor-proof pouches, change
pouch regularly).
Inform client that the ostomy pouch and clothing will muffle
the sounds from the ileostomy.

THERAPEUTIC INTERVENTIONS RATIONALE

—_e——ooo———
EEESSSSSSSS ee
SSSSFSSSSSSSSSSSSSSSMMMMMMeeF

Desired Outcome: The client will demonstrate the ability

to change the pouch system, maintain integrity of the
peristomal and perianal skin, and maintain adequate stomal
integrity.

Independent Actions
Reinforce teaching regarding application of the pouch
system, prevention of peristomal and perianal skin irrita-
tion and breakdown, and maintenance of adequate stomal
integrity:
e Shave or clip hair from peristomal skin as necessary. Helps achieve an adequate pouch seal and reduces irritation when
the pouch system is removed.
Patch test all products to prevent irritation or allergic Helps prevent skin irritation surrounding the stoma.
reaction when used.
Change entire pouch system only when necessary.
e Place drops of warm water or solvent where the pouch Facilitates removal of pouch system.
system adheres to the skin.
e Remove pouch system gently and in direction of hair Facilitates separation of pouch system and client’s skin.
growth; hold skin adjacent to the skin barrier taut and ‘
push down on skin slightly.
Support client’s efforts to decrease odor of effluent and gas Excessive pouch system changing and emptying causes skin and
but discourage excessive changing and emptying of pouch stoma irritation.
or pouch system.
Instruct and assist client to establish a routine for emptying A routine for emptying and changing the pouch system reduces the
and changing pouch or emptying ileostomy. risk of leakage of effluent and skin irritation.
Instruct client to follow special precautions for products used Skin sealants used on reddened and excoriated skin can cause
(e.g., skin sealants should be used only on healthy peristo- further irritation.
mal skin).
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 497

THERAPEUTIC INTERVENTIONS RATIONALE

Allow time for questions, clarification, practice, and return Improves client’s self-confidence in ability to care for self.
demonstration of emptying the pouch, changing the
pouch system, and performing appropriate stoma and
skin care.

THERAPEUTIC INTERVENTIONS RATIONALE

ee
e = ESee
Desired Outcome: The client will demonstrate the ability
to properly use, clean, and store ostomy products.

Independent Actions
Instruct client regarding proper use of ostomy products that Improves client’s self-confidence in ability to care for self.
will be used after discharge.
Demonstrate appropriate pouch system cleansing. Emphasize These actions in caring for the pouch system help decrease odors
importance of: and prevent leakage of effluent onto the skin.
e Rinsing inside of pouch each time it is emptied.
e Soaking reusable pouch according to manufacturer’s in-
struction and allowing it to dry thoroughly before reusing.
Instruct client to avoid reusing disposable products and to
discard a reusable pouch if it retains an odor after thor-
ough cleansing or it becomes brittle.
Discuss recommended methods of storing ostomy products
based on manufacturer’s recommendations.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to drain and irrigate a continent ileostomy if present.

Independent Actions
Explain the gradual and progressive clamping routine if Initially, the reservoir will need to be drained for 5 to 15 minutes
catheter will still be in the stoma of a continent ileostomy every 3 to 4 hrs, but after about 6 months, it may need
at time of discharge. emptying only 2 to 3 times a day.
If the stomal catheter has been removed, demonstrate the
correct method of and explain the schedule for stomal
catheter insertion.
Demonstrate the correct technique for irrigating a continent Avoids overdistending and damaging the internal reservoir.
ileostomy. Caution client to use only the prescribed
amount of irrigant (usually 20-30 mL).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

and treat blockage of the stoma.

Independent Actions
Instruct client in ways to prevent blockage of the stoma:
e Drink at least 10 glasses of liquid per day unless contrain- Adequate hydration helps liquefy stool.
dicated.
e Chew food thoroughly. Thoroughly chewing food prevents food particles from blocking
stoma.
e Avoid or eat only small amounts of foods that are high in These foods can block the stoma.
fiber or hard to digest (e.g., popcorn, coconut, raw vegeta-
bles, bean sprouts, bamboo shoots, celery, caraway seeds,
whole kernel corn, potato skins, fruit with seeds, nuts,
fruit skins).

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THERAPEUTIC INTERVENTIONS RATIONALE

Ensure that skin barrier and pouch openings are large Appropriate sizing and placement of pouch system prevents the
enough to prevent mechanical constriction of the stoma. stoma from becoming blocked due to lack of appropriate
Instruct client in ways to unblock the stoma: drainage of effluent.
Apply a warm compress to abdomen. These actions help relax abdominal muscles around the stoma and
Participate in relaxing activities (e.g., warm bath, reading). enhance removal of what is blocking the stoma.
Assume a knee-chest position.
Gently message the peristomal area.
Irrigate the stoma or gently perform digital dilation of the
stoma if prescribed.
Demonstrate techniques and have client provide a return Enhances client’s self-esteem and confidence in ability to care
demonstration of massage of the abdomen, irrigation of for self.
stoma, and digital dilation of stoma if appropriate.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Educate the client on signs and symptoms to report to the
health care provider:
Difficulty breathing. May indicate a thromboembolism.
Productive cough of discolored sputum. May indicate an infection.
Unusual or excessive drainage from the wound site.
Pain or swelling in the calf of one or both legs. May indicate a deep vein thrombus.
Unusual and continuous abdominal or pelvic pain. May indicate that pain has not been well controlled or possible
injury to the client.
Temperature above 38°C (100.4°F). May indicate an infection or dehydration.
Absence of or reduction in urinary output despite an May indicate a urinary tract infection.
adequate fluid intake.
Dark red, dusky blue, blue-black, purple, or pale stoma. May indicate strangulation of the stoma.
Change in color, consistency, or odor of effluent that is May indicate a blockage in the bowel.
not readily identified as a response to food or fluid intake.
Unexplained change in shape, size, or height of stoma (use May indicate injury, infection, or improper healing.
diagrams and descriptive terms so client does not confuse
decreasing stoma size due to resolving edema with actual
stomal retraction).
Excessive bleeding of stoma or bloody drainage from stoma. May indicate injury.
Difficulty accomplishing ileostomy care. May indicate lack ofacceptance of physical changes or understand-
ing of self-care.
Persistent skin irritation and breakdown. May lead to an infection.
Bright red, bumpy, itchy rash or white-coated area on skin May indicate an allergic reaction or yeast infection.
around stoma.
Persistent thirst, dry mucous membranes, dizziness, or May indicate dehydration/inadequate fluid volume.
decreased urine output.
Irregular pulse, muscle weakness and cramping, nausea, May indicate decreased serum potassium levels.
and vomiting.
Headache, abdominal cramping, fatigue, and irritability. May indicate decreased serum sodium levels.
Thin, watery ileostomy output; absence of ileostomy out- These indicate a possible blockage of bowel above the storga.
put; unusual foul odor of gas; abdominal distention and/or
nausea and vomiting that does not resolve within 2 hrs of
implementing measures to relieve stomal blockage.
Persistent leakage of pouch systems. May indicate lack of understanding of self-care.
Persistent leakage of effluent from stoma if client has a
continent ileostomy.
Fever; pain or cramping in reservoir area; pain when drain- May indicate inflammation of the internal reservoir (pouchitis),
ing the reservoir; and/or persistent watery, high-volume which is a long-term complication that can develop in the client
ileostomy output. with a continent ileostomy.
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THERAPEUTIC INTERVENTIONS RATIONALE

° Difficulty adjusting to changes in appearance and body May indicate depression and place the client at risk for poor
functioning. self-care.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify appropriate com-

munity resources that can assist with home management and
adjustment to changes resulting from the bowel diversion.

Independent Actions
Provide information about community resources that can Provides for continuum of care once client is discharged from the
assist the client and significant others with home manage- acute care facility.
ment and adjustment to changes resulting from the bowel
diversion (e.g., local ostomy support groups; community
health agencies; ET nurse; home health agencies; financial,
individual, and family counseling services).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, wound care, activity level, and medications
prescribed.

Independent Actions
Collaborate with client to develop a plan to include:
How to adhere to instructions regarding activity limitations:
e Avoid strenuous exercise and lifting objects more than Prevents potential injury to suture line and to stoma.
10 lbs. for at least 6 weeks.
e Avoid participating in contact sports.
Provide client with a list of ostomy products he/she is using Provides for continuum of care once client is discharged from acute
(including product name, size, and number) and where care facility.
these supplies can be obtained.
Explanation of the rationale for, side effects of, food and drug Knowledge of medications and how they impact the system im-
interactions, and the importance of taking medications proves client adherence to treatment regimen and understanding
as prescribed (e.g., electrolyte supplements, vitamins, of the importance of adhering to the prescribed medication
antimicrobials). regimen. The client must be able to recognize alterations in
functioning related to medication administration and what
clinical manifestations that should be reported to the health
care provider.
Stress that oral medications should be crushed or in liquid, Medications should be in liquid, chewable, crushed, uncoated, or
chewable, uncoated, or sugar-coated form rather than sugar-coated so absorption can take place before the medication
enteric-coated tablets or timed-release capsules. is excreted. Unabsorbed medications may cause stomal
blockage.

ADDITIONAL NURSING DIAGNOSES e Decreased absorption of nutrients associated with loss of

absorptive surface of the bowel resulting from surgical
IMBALANCED NUTRITION: LESS THAN BODY removal of a large portion of the intestine
REQUIREMENTS NDx e Increased nutritional needs associated with the increased
Related to: metabolic rate that occurs during wound healing
° Decreased oral intake associated with prescribed dietary
modifications; pain; weakness; fatigue; nausea; and fear of INEFFECTIVE COPING NDx
excessive ileostomy output, gas, and/or odor Related to:
e Inadequate nutrition replacement therapy e Fear, anxiety, and depression associated with loss of control
e Loss of nutrients associated with vomiting and excessive over bowel elimination (especially with a conventional
ileostomy output ileostomy) and possibility of rejection by others

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e Difficulty performing ileostomy care and incorporating GRIEVING NDx

the care into lifestyle e Related to loss of usual manner of bowel elimination and
e Need for lifelong medical supervision change in appearance associated with the ileostomy

ENTERAL NUTRITION
Malnutrition, defined as an imbalance in the essential compo- hemoglobin (Hgb) levels and the lymphocyte count provide
nents of a healthy diet, is common in clients with acute and additional values that assist in understanding a client’s current
chronic illnesses cared for in both long-term and acute care nutritional state. Anthropometric measurements such as skin-
settings. Left untreated, malnutrition can lead to compromise fold thickness, body circumferences, and bioelectrical imped-
of the immune system, decreased respiratory ability, and muscle ance analysis can provide information about the amount of
and adipose tissue wasting. Enteral nutrition, also known as muscle mass, body fat, and protein reserves the client has.
tube feeding, is one method of providing nutritional support Enteral nutrition, or feeding through the GI tract, is the
for malnourished clients who have a functioning GI tract but preferred route of nutrient delivery in hospitalized and
are unable to take any or enough oral nourishment. critically ill clients. Enteral nutrition helps to prevent villous
Categories of malnutrition include protein-calorie malnu- atrophy and promotes the local immune function of the
trition (PCM), marasmus, kwashiorkor, and micronutrient gut. Enteral nutrition is delivered via an NG tube (short-
malnutrition, the less visible form of malnutrition resulting term), or a tube placed in the duodenum or jejunum (long-
from deficiencies of vitamins and minerals. PCM can result term). Enteral nutrition can be delivered continuously or
from either primary or secondary factors. Primary PCM re- cyclically by pump, or intermittently by gravity or syringe
sults from poor eating habits, whereas secondary PCM bolus. The type of formula used for enteral nutrition varies
results from alterations in normal ingestion, digestion, absorp- depending upon the clinical diagnosis of the client.
tion, or metabolism. Marasmus, which results from caloric and This care plan focuses on the adult client undergo-
protein deficiencies, can lead to the loss of both muscle and ing enteral nutritional therapy in an acute care,
body fat. Kwashiorkor results from a protein deficiency that extended care, or long-term care environment.
occurs within the setting of a catabolic stress event such as
surgery, burns, or infectious diseases. Micronutrient malnutrition
results from deficiencies in vitamins A, B, C, D, and calcium, iron, OUTCOME/DISCHARGE CRITERIA
and iodine, and other necessary nutrient components.
Several diagnostic studies can assist in assessment of a The client will:
client’s nutritional state. Serum albumin, the most frequently . Progressively gain weight toward desired goal
assessed value, with a half-life of 20 to 22 days, is not the best . Weigh within normal weight for height and age
indicator of a client’s current state of malnutrition because the Consume adequate nutrition to meet metabolic needs
value lags behind a client’s current protein deficiency by as . Be free of signs of malnutrition
much as 14 days. Serum prealbumin, with a half-life of ap- . Maintain adequate fluid volume status
proximately 2 days, is a much better indicator of a client’s . Recognize factors contributing to malnutrition/underweight
current nutritional state. Serum transferrin, BUN, Hct, and . Be free of complications related to enteral feeding

| «RISK
Nursing Diagnosis FOR ASPIRATION nox
Definition: Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the
tracheobronchial passages, which may compromise health.

Related to:
e Decreased gastric motility
e Delayed gastric emptying
e Presence of a GI tube
e Residual gastric volumes
e Impaired swallowing
e Decreased level of consciousness

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Rhonchi; cough; dyspnea; tachycardia; presence of tube
feeding in aspirate; dull percussion note over affected
lung area
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 501

RISK FACTORS DESIRED OUTCOMES

e Presence of endotracheal tube
e Depressed cough and gag reflex The client will
e Tracheostomy ¢ Swallow and digest oral, NG, or gastric feeding without
aspiration
e Maintain patent airway and lung sounds

NOC OUTCOMES NIC INTERVENTIONS

Aspiration prevention Aspiration precautions; respiratory monitoring; swallowing
therapy; airway suctioning

NURSING ASSESSMENT RATIONALE

naa
aN es ee et hs Se
Assess client’s level of consciousness, cough reflex, gag reflex, Reduced level of consciousness, depressed gag or cough reflexes,
and swallowing ability. and alterations in normal swallowing increase the risk for
aspiration.
Assess for and report signs and symptoms of aspiration: Early recognition of signs and symptoms of aspiration allows for
e Crackles prompt intervention.
e Cough
e Tachycardia
e Presence of tube feeding aspirate
e Dyspnea
e Dull percussion note over affected area
Assess client for signs of gastric retention: Gastric retention can increase the risk for aspiration.
e Feelings of fullness
e Nausea/vomiting
e Abdominal distention
Monitor chest radiograph results. Report findings of pulmo- Evidence of pulmonary infiltrate on chest radiograph can indicate
nary infiltrate. that aspiration has occurred.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Confirm tube placement before each feeding (for intermittent The greatest risks associated with enteral nutrition are malposition
feedings) or at 4-hr intervals for continuous feedings (or of feeding tubes and aspiration. Secondary marking of the tube
per organizational policy): after initial radiographic confirmation of proper placement
e Aspirate stomach contents to verify tube placement. allows for additional visual confirmation of tube placement
e Check pH of gastric contents. before administering medications or feeding.
e After radiographic confirmation of placement, mark the Measuring the pH offeeding tube aspirate is of limited benefit with
feeding tube with indelible ink at the exit site from the lip continuous tube feedings because the feedings buffer gastric
or naris. secretions.
e Observe for changes in the length of the external por-
tion of the feeding tube.
Implement measures during feeding to prevent aspiration:
D+
e Elevate the head of the bed 30 degrees to 45 degrees at all Head-of-bed elevation helps to prevent the regurgitation of gastric
times during feeding. contents.
e Keep head of the bed elevated for 30 to 60 minutes after
intermittent feeding.
e Discontinue feeding 30 to 60 minutes before placing the
client in a supine position.
Check residual gastric volumes every 4 to 6 hrs: D # Checking residual volumes helps to assess gastric emptying. Residual
e Holding of enteral nutrition should not occur for gastric volumes increase with delayed gastric emptying. High gastric re-
residual volumes <S00 mL in the absence of other signs of sidual volumes increase the risk for aspiration of tube feeding
intolerance. Consult organizational policy. formula. Clients are monitored closely for signs of intolerance.

Dependent/Collaborative Actions
Obtain a chest radiograph to confirm placement of an NG or Radiography is the “gold standard” for ruling out respiratory
orogastric feeding tube after insertion. placement of blindly inserted enteral feeding tubes.

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 502 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

If client has an artificial airway (e.g., tracheostomy or endo- Maintaining adequate cuff pressure helps to secure the airway and
tracheal tube), maintain proper cuff inflation. prevent aspiration.
Notify the appropriate health care provider if signs and symp- Notifying the appropriate health care provider allows for modifica-
toms of aspiration develop. tion of the treatment plan.

|Nursing pos<
Diagnosis |IMBALANCED NUTRITION: LESS THAN BODY
REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to: The presence of biological, economical, or psychological factors that prevent the ingestion, digestion, or
absorption of nutrients necessary to meet metabolic needs

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal cramping; abdominal pain; Body weight 20% or more under ideal; diarrhea;
aversion to eating; lack of interest in food; perceived hyperactive bowel sounds; weight loss with adequate food
inability to eat food; altered taste sensation intake; poor muscle tone; pale mucous membranes; sore
buccal cavity; capillary fragility; excessive hair loss

RISK FACTOR DESIRED OUTCOMES

Stress of illness
The client will:
a. Progressively gain weight toward ideal body weight
b. Consume adequate nourishment
c. Be free of signs of malnutrition

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status: biochemical measures; energy; food and Nutritional therapy; nutritional monitoring; nutritional
fluid intake; nutrient intake management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of intolerance of Early recognition of signs and symptoms of problems with enteral
enteral feeding: feeding allows for prompt intervention.
e Vomiting
e Diarrhea
¢ Abdominal pain/distention
° Constipation
e Absence of bowel sounds
Perform or assist with anthropometric measurements such as Anthropometric measurements provide information about a client’s
skinfold thickness if indicated. Report lower than normal muscle mass, body fat, and protein reserves.
values.
Monitor albumin, prealbumin, transferrin, BUN, Hct, and Laboratory values assist in determining the nutritional gtatus of
Hgb levels and lymphocyte counts, reporting abnormal the client.
values.
Monitor bedside glucose values. After initiation of tube feeding, a client is at risk for hyperglycemia.
Bedside glucose checks should be assessed. Elderly clients often
have difficulty handling high glucose loads and should be
monitored closely.
Assess daily weights. Daily weight values will determine whether adjustments to caloric
intake are necessary.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 503

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Ensure patency of enteral tube:
° Irrigate with water before and after intermittent feedings. Feeding tube occlusions are often caused by coagulation of protein-
D+ based formulas.
° Routinely flush tubes every 4 hrs with 20 to 100 mL sterile Routine water flushes with water are necessary to maintain tube
water. patency.
Monitor client tolerance of tube feeding: Tube feedings should not be automatically discontinued because of
° If gastric residual volume greater than 200 to 250 mL, hold a single elevated residual volume. The feeding should be held
tube feeding for 1 hr and recheck residual. D + for 1 hr and the client assessed for symptoms of gastric
distress. Gastric residual volumes less than 200 mL can be
replaced. Any amount greater than 200 mL should be discarded
and documented as output. Refer to institutional policy as to
current practice regarding residual volumes, as_ protocols
may vary.

Dependent/Collaborative Actions
Consult dietician to determine the number of calories and Enteral formulas may vary based on client diagnosis.
type of nutrients needed.
Administer enteral feedings as ordered. Tube feedings are initiated slowly, increasing gradually during the
Continuous feedings should be administered via a pump. first 24 to 48 hrs to minimize side effects (e.g., nausea/
D+ diarrhea).
Administer prokinetic agents. D+ In the presence of high gastric volumes, prokinetic agents can
be administered to promote gastric motility and prevent unnec-
essary cessation of tube feeding.
Administer pancreatic enzyme solution if tube becomes Pancreatic enzyme solution with sodium bicarbonate has been
clogged. successful in unblocking feeding tubes and in prolonging
the time to occlusion. Other methods such as soft drinks and
cranberry juice have not been consistently effective.
Minimize interruptions to continuous tube feedings: Nutritional goals for enteral nutrition are often not met because of
¢ Maintain enteral feedings until the start of medical or frequent interruption of feeding. Refer to institutional policy.
diagnostic procedures.
° Restart tube feeding within 1 hr unless contraindicated.
If signs and symptoms of intolerance to tube feeding develop, Notifying the appropriate health care provider allows for modifica-
consult appropriate health care provider. tion of the treatment plan.

|Nursing os)
Diagnosis «RISK FOR DEFICIENT FLUID VOLUME nox
Definition: Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may
compromise health.

Related to: Diarrhea, vomiting, or inadequate fluid intake

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness Change in mental status; decreased urine output; increased
urine concentration; decreased capillary refill; increased
body temperature; elevated Hct; decreased skin turgor;
dry skin/mucous membranes; increased pulse rate;
decreased BP

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 504 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

RISK FACTORS DESIRED OUTCOMES

e Active fluid volume loss The client will not experience a deficient fluid volume as
e Failure of regulatory mechanisms evidenced by:
. Normal skin turgor
. Moist mucous membranes
. Stable weight
BP and pulse rate within normal range for client
. Capillary refill time less than 2 to 3 seconds
Usual mental status
. BUN and Hct within normal limits
© . Balanced [&O
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joy
ao

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance Fluid monitoring; fluid management; hypovolemia manage-
ment; intravenous therapy

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of deficient fluid volume
volume: allows for prompt intervention.
e Change in mental status
e Decreased urine output
e Increased urine concentration
e Hyperthermia
e Elevated Hct
e Decreased skin turgor
e Dry mucous membranes
e Increased pulse rate
e Decreased BP

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to decrease diarrhea: Diarrhea is a common problem associated with enteral feeding.
e Check for medications that may contribute to diarrhea. Feeding too fast, medications such as antibiotics, contamina-
e Administer tube feeding at room temperature. D + tion offeeding formula, and type of formula can be contributing
e Decrease the risk of contamination of tube feeding factors.
formula: Contamination of tube feeding could introduce microbes, which
¢ Wash hands with an antimicrobial soap or alcohol-based could lead to development of diarrhea.
hand rub for 10 seconds before preparing, handling, and
assembling any portion of the tube feeding system.
e Discard feedings that have been infusing more than
8 to 12 hrs or follow manufacturer’s guidelines. D +
e Disinfect tube feeding container with 70% isopropyl
alcohol, disinfecting the opening of the can and the
rim before opening.
e Refrigerate unused formula and record the date of
opening.
e Use closed systems when possible.
e Change tubing every 24 hrs.

Dependent/Collaborative Actions
Implement measures to decrease diarrhea:
e Slow tube feeding rate or decrease the strength of the
formula.
Implement measures to prevent dehydration: The more calorically dense the formula, the greater the need for
e Increase supplemental fluids (water) via feeding tube or supplemental fluids.
mouth as ordered. Protein content greater than 16% can lead to dehydration.
° Monitor bedside glucose level upon initiation of feeding.
 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract 505

THERAPEUTIC INTERVENTIONS RATIONALE

Consult the appropriate health care personnel (e.g., physi-
cian, dietician) if diarrhea persists, for a change in formula:
e Formula with more fiber content
Consult physician if signs and symptoms of deficient fluid Notifying the appropriate health care provider allows for modifica-
volume persist or worsen. tion of the treatment plan.

DISCHARGE TEACHING/CONTINUED CARE

«DEFICIENT KNOWLEDGE npx; INEFFECTIVE FAMILY

HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE? nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition. Ineffec-
tive Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family
unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to follow prescribed regimen Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
e Denial of disease process
e Cognitive deficiency
e Failure to reduce risk factors
e Lack of recall
e Information misinterpretation
e Unfamiliarity with information resources

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; infection control Teaching: individual; teaching: psychomotor skill

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of nutritional
Assess meaning of nutritional therapy to client. therapy to client allows for implementation of the appropriate
teaching interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will be able to demonstrate

proper technique in mixing and handling of solutions and
administration sets.

Independent Actions
Instruct client and family on the proper way to mix, handle, Enteral feeding should be refrigerated to prevent bacterial growth.
and store enteral feedings.
e Allow time for return demonstration.
Instruct client and family on proper care of enteral feeding Changing administration sets every 24 hrs helps prevent bacterial
administration sets: growth.
e Discard enteral feeding sets every 24 hrs.
e Allow time for return demonstration.

*The nurse should select the nursing diagnostic label that is most appropriate for the client’s discharge teaching needs

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 506 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will be able to demonstrate

proper care of gastrostomy or jejunostomy tube.

Independent Actions
Instruct the client and family to inspect the skin surrounding The skin surrounding the feeding tube site may become irritated
the feeding tube site on a daily basis. by gastric juices. The client should be instructed to report any
redness or maceration.
Instruct client and family on protective skin care measures Actions help to protect the skin surrounding the feeding tube,
around the feeding tube site: preventing breakdown and infection.
e Initially rinse with sterile water and dry.
e After healed, the client may wash with mild soap and water.
e A protective ointment may be used around the insertion
site (zinc oxide, Karaya paste) until site is healed.
e Site should be kept clean and dry.
Instruct client to report the following signs and symptoms to These signs and symptoms may be a result of infection, contami-
health care provider: nated formula, inappropriate formula, or signs of an infection
e Diarrhea at the feeding tube insertion site. The appropriate health care
e Vomiting provider must be notified to determine whether a change in
e Constipation formula is necessary or whether an infection has developed.
e Redness or purulent drainage around gastrostomy or jeju-
nostomy site
e Dislodgement of the tube

RELATED CARE PLANS

RISK FOR CONSTIPATION NDx RISK FOR INFECTION NDx

Related to: Related to:
e Poor fluid intake ¢ Bacterial contamination of tube feeding formula during
e Formula components preparation or administration
* Bacterial contamination of tube feeding delivery system
e Skin breakdown around jejunostomy or gastrostomy feed-
ing tube site

GASTRECTOMY
Gastrectomy is the surgical removal of all or part of the stomach. continuity is re-established by anastomosis of the remaining
There are two main types of gastrectomy; total or full gastrectomy stomach to the duodenum (gastroduodenostomy, or Billroth I)
and partial gastrectomy. A gastrectomy procedure is performed to or jejunum (gastrojejunostomy, or Billroth II). In the latter
treat numerous conditions including benign or cancerous tu- procedure, the duodenal stump is left intact so that bile and
mors, bleeding, inflammation, perforations in the stomach wall, pancreatic secretions can enter the jejunum. The decreased
polyps or growths, and severe peptic or duodenal ulcers. output of gastric secretions that results from a partial gastrec-
A total gastrectomy involves removal of the entire stom- tomy can be enhanced by a vagotomy (truncal, selective, or
ach and anastomosis of the esophagus to the jejunum (esoph- highly selective), which is often performed concurrently to
agojejunostomy). [t may be considered as treatment for further reduce stimulation of gastric secretions. A truncal va-
advanced stomach cancer or Zollinger-Ellison syndrome that gotomy (resection of the vagal nerve trunks at the level of the
is not controlled by more conservative measures. A total esophageal hiatus) is the most effective in reducing gastric
gastrectomy is performed infrequently because it is so difficult secretions; however, the extensive denervation also greatly
to maintain an adequate nutritional status postoperatively. suppresses gastric motility and impairs normal functioning of
The more common type of gastrectomy performed is a par- the pancreas, gallbladder, and small intestine. Because of this,
tial gastrectomy. This less extensive surgery is most often done a selective vagotomy (which preserves the hepatic and celiac
to treat cancers of the stomach, peptic ulcer disease that con- branches of the vagus nerve) or highly selective vagotomy
tinues to be symptomatic despite conservative management, (which only affects the parietal cell mass) is performed more
or to treat complications that develop as a result of the disease frequently.
(e.g., perforation, gastric outlet obstruction, hemorrhage). This care plan focuses on the adult client who is
A partial gastrectomy usually involves excision of 40% to hospitalized for a partial gastrectomy. Much of the
75% of the distal stomach including the antrum (which con- postoperative information is applicable to clients
tains the gastrin-secreting cells) and a portion of the body of the receiving follow-up care in an extended care facility or
stomach that contains much of the parietal cell mass. GI home setting.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 507

7. Identify ways to control postvagotomy diarrhea if it occurs

OUTCOME/DISCHARGE CRITERIA
8. Identify ways to manage dumping syndrome if it occurs
9. State signs and symptoms to report to the health care
The client will:
provider
1. Have surgical pain controlled
10. Develop a plan for adhering to recommended follow-up care
. Have evidence of normal healing of the surgical wound
including future appointments with health care provider,
. Have clear, audible breath sounds throughout lungs
medications prescribed, activity level, and wound care
. Have no signs and symptoms of postoperative complications
For a full, detailed care plan on this topic, go to http://
. Tolerate prescribed diet
evolve.elsevier.com/Haugen/careplanning/.
. Verbalize an understanding of ways to maintain an ade-
fPwWhHD
Dn

quate nutritional status

BARIATRIC SURGERY
©p Bariatric surgery is performed to control obesity by restricting the can be adjusted by filling the band with sterile saline injected
amount of food that the stomach can hold, causing malabsorp- through a port placed under the skin. Reducing the size of the
tion of nutrients, or by a combination of both gastric restriction opening is done gradually over time, reducing hunger and de-
and malabsorption. The most common bariatric surgical proce- creasing caloric consumption. In general, all bariatric surgical
dures are gastric bypass, biliopancreatic diversion, sleeve gastrec- procedures cause favorable changes in gut hormones that sup-
tomy, and adjustable gastric band. Most weight loss surgical pro- press hunger, reduce appetite, and improve satiety.
cedures today are done using minimally invasive techniques. Clients undergoing bariatric surgery are carefully screened
The Roux-en-Y procedure, a gastric bypass procedure that physically and psychologically and must meet certain criteria
produces 60% to 80% excess weight loss, is considered the gold before undergoing gastric reduction surgery. Qualifying crite-
standard of weight loss surgery. The procedure consists of two ria for bariatric surgery in most areas include body mass index
components. The first component involves the creation of a 30 (BMI) = 4 m, or more than 100 lbs overweight, BMI = 35 and
mL stomach pouch by dividing the top of the stomach from the at least one or more obesity-related co-morbidities such as
rest of the stomach. The second component involves the divi- type 2 diabetes, hypertension, sleep apnea, and other respira-
sion of a small portion of the intestine with the bottom portion tory disorders, and/or an inability to achieve a healthy weight
of the divided small intestine brought up to connect to the new loss sustained for a period of time with prior weight loss ef-
stomach pouch and the top portion of the divided small intes- forts. The client must also be emotionally stable, have no
tine connected to a more distal portion of the small intestine. As uncontrolled or severe major illness, verbalize a willingness to
a result, stomach acids and digestive enzymes from the bypassed adhere to lifelong dietary modifications, and have access
stomach pass from the pouch directly into the jejunum, eventu- to adequate follow-up medical care.
ally mixing with food. The significantly smaller, newly created This care plan focuses on the adult client hospital-
stomach pouch facilitates smaller meals, resulting in fewer con- ized for gastric reduction surgery. Much of the infor-
sumed calories. In addition, the food stream is rerouted with less mation is relevant to the client receiving continued
digestion of food in the smaller stomach pouch, resulting in less care in the home setting.
absorption of calories and nutrients.
The biliopancreatic diversion with duodenal switch also con- OUTCOME/DISCHARGE CRITERIA
sists of two components: creation of a small tubular stomach
pouch by removing a portion of the stomach and bypassing a The client will:
large portion of the small intestine. Similar to other bariatric 1. Have evidence of normal healing of surgical wounds
procedures, this procedure helps to reduce the volume of food . Have clear, audible breath sounds throughout lungs
consumed. Unlike other bariatric procedures, approximately %4 . Tolerate prescribed diet
of the small intestine is bypassed by the food stream. This sur- . Have no signs and symptoms of postoperative complications
gery is considered the most effective procedure for the treatment an
WN . Identify ways to prevent excessive stretching of the
of diabetes, resulting in great weight loss and the ability of cli- gastric pouch
ents to consume more normal meals. However, this procedure 6. Verbalize an understanding of ways to maintain an
requires a longer hospitalization and carries the highest compli- adequate nutritional status
cation rate and risk for mortality than other bariatric procedures. 7. Identify ways to reduce the risk of consuming excessive
Sleeve gastrectomy,—performed via a laparoscopic ap- amounts of food, fluid, and calories
proach, removes approximately 80% of the stomach, leaving 8. Demonstrate the ability to accurately calculate and
a remaining pouch the size of a banana. This procedure does measure the allotted amounts of food and fluid
not involve the use of implantable foreign objects and 9. State signs and symptoms to report to the health care provider
induces a rapid, significant weight loss of >S0%. 10. Identify community resources that can assist in the
The adjustable gastric band, a minimally invasive procedure adjustment to prescribed dietary modifications and
with a hospital stay usually less than 24 hrs, involves place- future changes in body image
ment of an inflatable band around the upper portion of the . Develop a plan for adhering to recommended follow-up care
stomach, creating a small pouch above the band and leaving including future appointments with health care provider,
the rest of the stomach below the band. The size of the stomach activity level, medications prescribed, and wound care

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Goto ©volve for animation
 508 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

PREOPERATIVE USE IN CONJUNCTION WITH PREOPERATIVE AND POSTOPERATIVE CARE

PLANS FOR ADDITIONAL DIAGNOSES

| DISTURBED SELF-CONCEPT*
Definition: Disturbed Body Image NDx: Confusion in mental picture of one’s physical self.
Situational Low Self-Esteem NDx: Development of a negative perception of self-worth in response to a current
situation.

Related to: Obesity and inability to lose weight by more conventional methods

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of feelings or perceptions that reflect an Lack of involvement in preoperative care or self-care
altered view of one’s body in appearance, structure, or
function; current challenges to self-worth; self-negating
verbalizations; indecisive, nonassertive behavior

RISK FACTORS DESIRED OUTCOMES

¢ Obesity
The client will demonstrate a positive self-concept as
e Poor self-esteem
evidenced by:
e Ineffective dieting
a. Verbalization of feelings of self-worth
b. Positive statements regarding anticipated effects of
surgical procedure
c. Maintenance of relationships with significant others
d. Active participation in preoperative care and self-care

NOC OUTCOMES NIC INTERVENTIONS

CC rere eee eee eee SSeS
Body image; self-esteem Body image enhancement; self-esteem enhancement;
emotional support; support system enhancement

NURSING ASSESSMENT
a RATIONALE
a ee ee ee ee es
Assess for signs and symptoms of a disturbed self-concept: Early recognition of signs and symptoms of a disturbed self-concept
e Verbalization of negative feeling about self allows for prompt intervention.
e Withdrawal from significant others
e Lack of participation in preoperative care or self-care

THERAPEUTIC INTERVENTIONS
RATIONALE
eee
Independent Actions
Implement measures to assist client to increase self-esteem (e.g., Self-esteem is a major component of one’s view of self. An increase
limit negative self-assessment, encourage positive comments in self-esteem has a positive effect on the client’s self-concept.
about self, assist to identify strengths, give positive feedback
about accomplishments, provide positive feedback about
decision to have the surgery and lose weight).
Implement measures to reduce client’s embarrassment about
obesity:
‘
e Obtain information from physician regarding client’s If the equipment is obtained ahead of time, it helps the client feel
height and weight so that oversized equipment and sup- more comfortable in the health care environment.
plies (e.g., bed, chair, commode, BP cuff, gowns, bathrobe)
can be obtained before client is admitted.
e Remove unnecessary furniture and equipment from room Improves client’s mobility.
so client can move around easily. D @ +
° Provide privacy when weighing client. D @+ Privacy while weighing the client decreases client embarrassment.

*This diagnostic label includes the nursing diagnoses of disturbed body image and chronic low self-esteem.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 509

THERAPEUTIC INTERVENTIONS RATIONALE

e Transfer client to and from operating room in own hospi- Prevents embarrassment when trying to transfer client to a regular-
tal bed rather than attempting to use a regular-sized sized stretcher.
stretcher.
Allow client to wear own clothes rather than hospital gown Provides client some control over the situation.
before and after surgery if desired.
Assure client that he/she will be assisted with usual grooming Decreases anxiety concerning postoperative care.
and makeup habits after surgery if necessary.
Arrange for a visit from an individual who has achieved Provides client with an experiential perspective on postoperative
weight loss after gastric reduction surgery if client desires. care and lifestyle changes.
If client is expressing concerns about the amount of excess Decreases fear and anxiety concerning postoperative and lifestyle
skin that will be present after the majority of weight loss changes.
occurs (usually after 1-1% years), provide information
about various clothing styles that may be most flattering
(e.g., long-sleeved shirts or blouses) and reconstructive
surgery that is available to remove excess skin from
abdomen, breasts, upper arms, and thighs.

Dependent/Collaborative Interventions
Consult physician if client has unrealistic expectations of Provides additional time for the physician to address client’s
postoperative weight loss and dietary management. concerns related to surgery and subsequent lifestyle changes.

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED

POSTOPERATIVE CARE PLAN

|Nursing >Diagnosis
=. INEFFECTIVE BREATHING PATTERN npx
Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
e Increased rate of respirations associated with fear and anxiety
e Decreased rate of respirations associated with the depressant effect of anesthesia (effect lasts longer in the obese client
because adipose tissue more readily absorbs and stores anesthetic agents) and some medications (e.g., narcotic [opioid]
analgesics, some antiemetics)
e Decreased depth of respirations associated with:
e Depressant effects of anesthesia and some medications (e.g., narcotic [opioid] analgesics, some antiemetics)
e Reluctance to breathe deeply because of pain and fear of dislodging tubes
e Fear, anxiety, weakness, and fatigue
e Restricted chest expansion resulting from:
(1) Limited diaphragmatic excursion (occurs because of the large amount of abdominal adipose tissue and postoperative
abdominal distention)
(2) Decreased activity (chest expansion is restricted by the bed surface when client is lying in bed)
(3) Increased weight of the chest wall of an obese client (especially in women with large, pendulous breasts)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Limited chest excursion; tachypnea; dyspnea; use of
accessory muscles when breathing; decreased pulse
oximetry less than 85%

RISK FACTORS DESIRED OUTCOMES

e Surgical procedure The client will maintain an effective breathing pattern as
e Obesity evidenced by:
e Immobility a. Normal rate and depth of respirations
b. Absence of dyspnea

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 510 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation Respiratory monitoring; ventilation assistance

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of an ineffective Early recognition of signs and symptoms of an ineffective breathing
breathing pattern: pattern allows for prompt intervention.
e Complaints of feeling short of breath
e Shallow or slow respirations
e Limited chest excursion
e Tachypnea
e Dyspnea
e Use of accessory muscles when breathing
Monitor for and report a significant decrease in oximetry Oximetry is a noninvasive method of measuring SaO>. The results
results. assist in evaluating respiratory status.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce chest or abdominal pain if A client with upper abdominal pain often guards respiratory efforts
present (e.g., splint incision with pillow during coughing and breathes shallowly to prevent additional discomfort.
and deep breathing). D @+
Implement measures to decrease fear and anxiety (e.g., assure Fear and anxiety may cause a client to breathe shallowly or to
client that breathing deeply will not dislodge tubes hyperventilate.
or Cause incision to break open, interact with client in a Decreasing fear and anxiety allows the client to focus on breathing
confident manner). D @ more Slowly and taking deeper breaths.
Implement measures to increase strength and activity toler- An increase in strength and activity tolerance enables the client to
ance if client is weak and fatigued (e.g., provide uninter- breathe more deeply and participate in activities to improve
rupted rest periods, maintain optimal nutrition). D @ + breathing pattern.
Assist client to deep breathe or use incentive spirometer every Deep breathing and use of an incentive spirometer promote
1to2 hrs. De + maximal inhalation and lung expansion.
Instruct client to breathe slowly if hyperventilating. Hyperventilation is an ineffective breathing pattern that can
eventually lead to respiratory alkalosis. The client can often
slow breathing rate by concentrating on doing so.
Position client with head of bed elevated at least 30 degrees This position allows for maximal diaphragmatic excursion and
at all times. D @ > lung expansion.
Instruct and assist client to use overhead trapeze and turn at Repositioning promotes maximal chest wall and lung expansion.
least every 2 hrs.
Add extensions to tubings if necessary. Enables client to turn and move without fear of dislodging tubes.
Instruct client to bend knees while coughing and deep Relieves tension on abdominal muscles and incision.
breathing.
Instruct and assist client to splint incision with hands or Provides support to the abdomen and helps to decrease discomfort
pillow when coughing and deep breathing. when coughing and deep breathing.

Collaborative 2.
Diagnosis. «RISK FOR OVERDISTENTION OF THE GASTRIC POUCH
Definition: Enlarged, expanded, or stretched.

Related to:
e Accumulation of gas and fluid in the pouch associated with:
e Decreased peristalsis and/or impaired functioning of NG or gastrostomy tube '
e Obstruction of the pouch outlet (the channel between the pouch and distal stomach if gastroplasty performed or the
opening between the pouch and jejunal loop if gastric bypass performed) resulting from edema and/or ingestion of
medications or fluids that are too thick to pass through pouch outlet
e Excessive oral intake

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of frequent epigastric fullness and nausea Vomiting
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 511

RISK FACTORS DESIRED OUTCOMES

e Physiological changes
e Inappropriate diet and intake The client will not experience overdistention of the gastric
pouch as evidenced by:
a. Decreased reports of epigastric fullness
b. Absence of nausea and vomiting

NURSING ASSESSMENT RATIONALE

SS

Assess for and report signs and symptoms of overdistention Early recognition of signs and symptoms of overdistention of the
of the gastric pouch (e.g., increasing reports of epigastric gastric pouch allows for prompt intervention.
fullness, nausea, vomiting).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent overdistention of the gastric
pouch:
e Maintain patency of NG or gastric tube; irrigate the tube Reduces gas and fluid accumulation during period of decreased
only if ordered and with no more than prescribed amount peristalsis.
of solution. D+
e Encourage and assist client with frequent position changes Activity stimulates peristalsis, which promotes passage of food
and ambulation as soon as allowed and tolerated. D@ > through the GI tract and decreases distention of the gastric
pouch.
e Instruct the client to avoid activities such as chewing gum Reduces air swallowing.
and smoking.
e Do not change position of NG or gastric tube unless The NG tube is usually positioned at the pouch outlet to help
ordered. prevent obstruction of the opening into the distal stomach (if
gastroplasty performed) or jejunal loop (if gastric bypass is
performed).
e When oral intake is allowed:
e Adhere strictly to prescribed oral intake schedule The stomach size is reduced and the client will have to eat smaller
(clients usually begin with hourly liquid feedings of meals to prevent overdistention of the stomach.
30 mL and, over at least 6 weeks, progress to 5 or
6 small [1-2 oz] liquid meals per day with 1-2 oz of
water allowed periodically between meals).
e Provide client with allotted amounts of fluids at the This is done so the client does not ingest feedings too close together,
proper times; discard skipped “meals.” D @ + as this will cause overdistention of the stomach.
e Instruct client to adhere to the liquid or blenderized Oral intake that is too thick can block the pouch outlet, which may
diet as ordered. be narrower in the early postoperative period because of edema.
e Administer oral medication in liquid or chewable form Prevents blockage of the pouch outlet.
or crushed thoroughly. D@ +
e Encourage client to eructate whenever the urge is felt. Releases gas from the stomach
e Encourage use of nonnarcotic analgesics once severe pain Opioid analgesics depress GI motility.
has subsided.
If signs and symptoms of overdistention occur:
Withhold all oral intake as ordered. D@ + Helps to reduce stomach distention.
e Prepare client for upper abdominal radiographs to check Determines appropriate placement oftubes and whether manipula-
placement of NG or gastric tube if present. tion of them is required.
e Assist physician with adjustment or reinsertion of the NG
or gastric tube if indicated.

|Collaborative »Diagnosis
>.>) RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum.

Related to:
° Leakage of gastric contents into the peritoneum associated with disruption of the staple line (if gastroplasty performed) or
proximal anastomosis (if gastric bypass performed)

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 S12 Chapter 10. = The Client With Alterations in the Gastrointestinal Tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal pain Nausea and vomiting; distended and rigid abdomen;
diminished or absent bowel sounds; fever; tachypnea;
increased WBC count

RISK FACTORS DESIRED OUTCOMES

e Surgery
The client will not develop peritonitis as evidenced by:
e Exposure to pathogens
Gradual resolution of abdominal pain
e Exposure of abdominal contents to irritating fluids
Soft, nondistended abdomen
Temperature declining toward normal
Stable vital signs
Absence of nausea and vomiting
Gradual return of normal bowel sounds
WBC count declining toward normal
Mmoansp

NURSING ASSESSMENT RATIONALE

Se—— ——————— e

Assess for and report signs and symptoms of peritonitis (e.g., Early recognition of signs and symptoms of peritonitis allows for
increase in severity of abdominal pain; generalized prompt intervention.
abdominal pain; rebound tenderness; distended, rigid
abdomen; increase in temperature; tachycardia; tachy-
pnea; hypotension; nausea; vomiting; continued dimin-
ished or absent bowel sounds; WBC count that increases
or fails to decline toward normal).

THERAPEUTIC INTERVENTIONS RATIONALE

eee
Dependent/Collaborative Actions
Implement measures to prevent peritonitis:
e Implement measures to prevent wound infection:
e Maintain an optimal nutritional status. Adequate nutrition is needed to maintain normal function of the
e Administer vitamins and minerals as ordered. D > immune system. Vitamin and mineral supplements may be
required to maintain nutritional status.
e Do not apply dressing too tight. D + Tight dressings decrease circulation to the surgical site.
e Ensure dressings are secure enough to keep them from Applying secure dressings prevents wound irritation.
rubbing the wound.
e Carefully remove tape from the wound. D + Prevents irritation of surgical site and damage to surrounding skin.
e Maintain adequate fluid volume of 2500 mL/day unless Maintains adequate circulatory volume.
contraindicated. D
e Perform measures to maintain patency of wound drain if
present.
e Keep tubing free of kinks. D+ Allows drainage to flow away from the wound and prevents disten-
tion of the conduit.
e Empty collection device as often as necessary. D+ Prevents stress on the wound and stasis of drainage and prevents
distention of the conduit.
e Maintain suction as ordered. D > Prevents stasis of secretions and prevents distention of conduit.
e Perform measures to prevent inadvertent removal of the
tube:
e Use caution when changing dressings surrounding Prevents accidental dislodgement of a drain if present.
drain. D
e Provide extension tubing if necessary. D + Enables client to move without placing tension on the drain.
Instruct client not to pull on drain and drainage tubing. D + Prevents accidental dislodgement of the drain.
e Perform actions to prevent stress on and subsequent
leakage of gastric contents from the staple line or site
of proximal anastomosis.
e Implement measures to prevent overdistention of Distention can cause strain on the suture lines, which may permit
gastric pouch. subsequent leakage ofgastric contents into the peritoneal cavity.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 513

THERAPEUTIC INTERVENTIONS RATIONALE

° Implement measures to prevent nausea and vomiting Prevents pressure and strain on the abdominal wound and the
(e.g., maintain patency of NG or gastric tube, eliminate proximal anastomosis.
noxious sights and odors from the environment,
instruct client to change positions slowly, administer
antiemetics and/or GI stimulants as ordered).
e Do not adjust position of NG or gastric tube unless Adjustment of the NG tube or gastric tube may cause disruption of
ordered. staples or perforation at the site of proximal anastomosis.
If signs and symptoms of peritonitis occur:
e Withhold oral intake and jejunostomy tube feedings as Prevents further leakage of food content into the abdominal cavity.
ordered.
° Place client on bedrest in a semi-Fowler’s position. Assists in pooling or localizing gastric contents in the pelvis rather
than under the diaphragm.
e Prepare client for diagnostic tests (e.g., abdominal radio- Decreases fear and anxiety.
graph, computed tomography, ultrasound) if necessary.
e Assist physician with insertion of NG tube or gastric tube Removes secretions from the stomach.
and maintain to suction as ordered.
e Administer antimicrobials as ordered. Treats infection.
e Administer intravenous fluids and/or blood volume IV fluids/blood volume expanders prevent or treat shock, which can
expanders if ordered. result from the increased capillary permeability that occurs with
inflammation and the subsequent escape of protein, fluid, and
electrolytes from the vascular space into the peritoneal cavity.
e Prepare client for surgical intervention (e.g., repair of Decreases fear and anxiety.
perforation) if planned.

|Nursing »-
Diagnosis
~~ |RISK FOR VENOUS THROMBOEMBOLISM nox
Definition: Susceptible to the development of a blood clot in a deep vein, commonly in the thigh, calf, or upper extremity,
which can break off and lodge in another vessel, which may compromise health.
Related to:
e Venous stasis associated with decreased activity, increased blood viscosity (can result from deficient fluid volume), and pres-
sure on abdominal vessels from excessive adipose tissue and abdominal distention
e Hypercoagulability associated with increased release of thromboplastin into the blood (occurs as a result of surgical trauma)
and hemoconcentration and increased blood viscosity (can occur as a result of deficient fluid volume)
e Trauma to vein walls during surgery

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain or tenderness in an extremity Increase in circumference of extremity; distention of
superficial vessels in extremity; unusual warmth of
extremity

RISK FACTORS DESIRED OUTCOMES

e Immobility The client will not develop a deep vein thrombus as
e Inadequate fluid intake evidenced by:
e Ineffective treatment regimen a. Absence of pain, tenderness, swelling, and distended
superficial vessels in extremities
b. Usual temperature of extremities

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: peripheral Embolus precautions; embolus care: peripheral

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514 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of a deep vein Early recognition of signs and symptoms of a deep vein thrombus
thrombus: allows for implementation of the appropriate interventions.
e Pain or tenderness in extremity
e Increase in circumference of extremity
e Distention of superficial vessels in extremity
e Unusual warmth of extremity
e Pain in area where thromboembolus lodged

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent thrombus formation: D +
e Perform actions to prevent peripheral pooling of blood Leg and ankle exercises help promote venous return and reduce the
such as leg exercises: risk of venous thromboembolism.
e Ankle rotation These actions facilitate venous return to the heart.
e Alternate dorsiflexion and plantar extension of both
feet
If signs and symptoms of a deep vein thrombus occur:
D+
e Maintain client on bedrest until activity orders received. Avoid putting pressure on the posterior knees because this action will
e Elevate foot of bed 15 to 20 degrees above heart level if compress leg veins, increasing turbulent blood flow, and increase the
ordered. risk of thromboembolism formation. If a thrombus is suspected,
° Discourage positions that compromise blood flow (e.g., avoid activity, elevate the affected extremity, and do not massage the
pillows under knees, crossing legs, sitting for long periods). area because of the danger of dislodging the thrombus.

Dependent/Collaborative Actions
Implement measures to prevent thrombus formation:
e Apply mechanical devices designed to increase venous These devices decrease venous stasis in the lower extremities and
return in the immobile patient: D + increase venous return through the deep leg veins, which are
e Sequential compression devices prone to the formation of a thromboembolism. These devices
e Thromboembolic (elastic) stockings should remain in place until the patient is ambulatory.
e Maintain a minimum fluid intake of 2500 mL/day (unless Adequate hydration helps to reduce blood viscosity, which may
contraindicated). contribute to the formation ofa thrombus.
If signs and symptoms of a deep vein thrombus occur:
e Administer anticoagulants: Anticoagulants, if indicated, help to suppress the formation of
e Low- or adjusted-dose heparin clots.
e Fondaparinux
e Warfarin
e Low-molecular-weight heparin
Prepare client for diagnostic studies (e.g., venography, duplex Additional studies may be indicated to confirm the presence of
ultrasound, impedance plethysmography). a thromboembolism, so the appropriate interventions can be
implemented.
If signs and symptoms of embolism occur:
e Maintain client on strict bedrest in a semi- to high- Improves lung expansion and provides supplemental oxygen.
Fowler’s position.
e Maintain oxygen therapy as ordered.
e Prepare client for diagnostic tests (e.g. blood gases, D-
dimer level, ventilation-perfusion lung scan; pulmonary
angiography).
e Prepare client for the following if planned: ‘
e Vena caval interruption Decreases client fear/anxiety to prevent further pulmonary emboli.
e Embolectomy Removal of emboli.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 515

DISCHARGE TEACHING/CONTINUED CARE

Weber eee DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY

HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition.
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of
the family unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to
maintain well-being.

RISK FACTORS
e Financial concerns related to lifestyle change
e Cognitive difficulty
e Inability to integrate exercise and diet into lifestyle

CLINICAL MANIFESTATIONS

Subjective
Verbal self-report of difficulty in implementing lifestyle changes; expressed financial concerns; refusal to participate in
self-care

NOC OUTCOMES NIC INTERVENTIONS

Compliance behavior; adherence behavior; health beliefs: Weight reduction assistance; teaching: prescribed diet;
perceived ability to perform; perceived control; behavior modification; support system enhancement;
knowledge: prescribed diet; treatment regimen health system guidance; teaching: individual; teaching:
prescribed diet; support system enhancement

NURSING ASSESSMENT RATIONALE

a

Assess for indications that the client may be unable to Early recognition of signs and symptoms of inability to effectively
effectively manage the therapeutic regimen: manage the therapeutic regimen allows for prompt intervention.
Failure to adhere to treatment plan while in the hospital
(e.g., not adhering to dietary modifications and fluid
restrictions, refusing to increase activity).
Statements reflecting a lack of understanding of dietary
modifications and factors that will cause stretching of
the gastric pouch.
Verbalization of an inability to integrate necessary dietary
modifications and exercise program into lifestyle.
Statements reflecting the belief that the surgical procedure
will result in continued weight loss even without
adherence to the prescribed dietary modifications.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of the lifestyle changes that need to be maintained as a
result of gastric reduction surgery.
Explain the surgical procedure and importance of dietary Understanding of surgical procedure will help client maintain
modifications and a balanced exercise program in terms diet and exercise program, as these will help client meet weight
the client can understand; emphasize that adherence to reduction goals.
the treatment program is necessary if an optimal weight is
to be attained.

needs.
*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching

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THERAPEUTIC INTERVENTIONS RATIONALE

Inform the client that prescribed food and fluid modifications After 6 to 8 weeks, the client has more dietary choices than those
are not as strict after the surgical area has healed (usually available in the early postoperative period.
6-8 weeks).
Stress the positive effects of compliance with dietary modifi- Compliance with dietary modification and exercise program is
cations and exercise program (e.g., weight loss resulting in important to continued weight reduction and subsequent
change in appearance; decreased risk of development or maintenance.
worsening of conditions such as diabetes mellitus, cardio-
vascular disease, respiratory problems, and arthritis).
Encourage activities other than eating to cope with stress Stress eating will interfere with dietary regimen.
(e.g., exercise).
Provide written instructions about future appointments with Provides an information resource for the client once discharged
health care provider, dietary modifications, and signs and from the acute care facility.
symptoms to report.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

excessive stretching of the gastric pouch.

Independent Actions
Instruct client in ways to prevent excessive stretching of the
gastric pouch:
e Decrease risk of blockage of the pouch outlet by: Liquids and blenderized foods will exit the stomach quicker than
e Limiting oral intake to liquids and blenderized foods solid food.
for about 6 to 8 weeks after surgery
e Taking all prescription and nonprescription medications Unabsorbed pills may block output from the pouch.
in liquid or chewable form or crushing them thoroughly
e Chewing food thoroughly Thoroughly chewing food breaks it down into small particles,
which improves digestion and helps the bolus move more
quickly out of the stomach.
° Do not exceed prescribed volume of food/fluid intake. Limiting the volume ofintake prevents overdistention of the stomach.
e Do not make up for skipped meals while on an hourly Provides potential for overeating and stretching of the gastric
drinking/eating schedule. pouch.
e fat and drink slowly. Eating and drinking slowly increases satiety, as this occurs
approximately 20 minutes after beginning a meal.
e Avoid intake of carbonated beverages for 6 to 8 weeks after Carbonated beverages increase gas in the stomach and_ the
surgery and limit intake of these beverages after that time. potential for overdistention.
e When solid foods are allowed, consume fluids between Fluids will fill the stomach quickly and when combined with a
rather than with meals. meal can cause over distention of the stomach.

THERAPEUTIC INTERVENTIONS
RATIONALE
eee

Desired Outcome: The client will verbalize an understand-

ing of ways to maintain an adequate nutritional status.

Independent Actions
Instruct client regarding ways to maintain an adequate
nutritional state:
¢ Do not skip meals. Skipping meals will decrease caloric intake and can negatively
affect nutritional status. '
* Consume foods/fluids from each food group daily as diet Daily consumption from all the food groups provides for nutri-
advances. tional balance in the diet.
¢ Consume adequate amounts of protein (e.g., blenderized Prevents over distention of the stomach while maintaining
drinks containing peanut butter, pureed meats and fish, nutritional status.
cottage cheese) as diet advances.
e Take vitamin and mineral supplements as prescribed. Dietary supplements may be required to maintain nutritional status.
° Obtain dietary consult if indicated to assist client in plan- Meal planning should include foods the client likes while providing
ning meals. the appropriate nutrition.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 517

fa
THERAPEUTIC INTERVENTIONS a
RATIONALE
a SSS SSS

Desired Outcome: The client will identify ways to reduce

the risk of consuming excessive amounts of food, fluid, and
calories through accurately calculating and measuring the
allotted amounts of foods and fluid.

Independent Actions
Instruct client in ways to reduce the risk of consuming exces-
sive amounts of food, fluid, and calories:
e Limit food/fluid intake to prescribed volume. Consumption of excessive food/fluid and calories can lead to
overdistention of the stomach and weight gain.
e Prepare food ahead of time, freeze in 1-oz portions using Helps with meal planning and for eating the appropriate amount
plastic ice cube trays or plastic bags, and then reheat only of food.
allowed amounts at mealtime.
e Have jars of prepared strained baby food products rather These preparations are easily digested and won't overdistend the
than high-calorie puddings and snacks on hand. stomach.
e Have only low-calorie drinks available (other than the Prevents increased caloric intake.
required high-protein supplements).
e Decrease the risk of hunger by adhering to a schedule of Adhering to a schedule for meals provides for adequate nutrition
5S or 6 meals per day as diet advances (each meal will without client becoming hungry between meals.
usually consist of 2-4 tablespoons of food).
e Serve food on a small plate. Eating from a small plate provides an illusion that meals are larger
than they really are.
e Eat and drink very slowly (use techniques such as putting Allows satiety center of the brain to register fullness before
fork down between bites of food and putting glass down overeating.
between sips of fluid). Allows the client to eat with party without feeling deprived.
e If going out to dinner, order an appetizer and have it
served with everyone else’s entrée.
e Avoid excessive intake of high-calorie foods/fluids. It is possible to maintain or gain weight if only high-calorie
substances are consumed.
e Demonstrate ways to measure foods/fluids accurately These help the client understand the size of servings using common
using measuring spoons and a cup with 1-oz markings. kitchen items.
e Allow time for questions, clarification, and return Having a client do a return demonstration improves client’s
demonstration. self-esteem and ability to be successful in lifestyle changes.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Educate the client on signs and symptoms to report to the
health care provider:
e Difficulty breathing These clinical manifestations indicate a variety of complications
e Productive cough of discolored sputum from the surgery including deep vein thrombosis, thromboembo-
e Unusual or excessive drainage from the wound site lism, infection, and dehydration.
e Pain or swelling in the calf of one or both legs
e Unusual and continuous abdominal or pelvic pain
e Temperature above 38°C (100.4°F)
e Absence of or reduction in urinary output despite an
adequate fluid intake
e Nausea and vomiting after consuming prescribed amount Client may be experiencing dumping syndrome.
of foods/fluids
e Inability to adhere to dietary modifications Increases potential weight gain.
e Weight gain Indicates problems maintaining lifestyle changes.
e Inability to lose weight or excessive weight loss (expected
weight loss is usually about 10 Ibs. per month for the first
year or 30% of preoperative body weight by the end of the
first year)

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THERAPEUTIC INTERVENTIONS RATIONALE

e Abdominal cramping, flushing, palpitations, weakness, May indicate dumping syndrome, which sometimes occurs after
and/or dizziness within 30 minutes after eating bypass when the client begins to eat solid food; if dumping
syndrome does occur, symptoms are usually mild and self-
limiting or easily controlled with minor dietary modifications.
Reinforce the physician’s instructions regarding need to Regular moderate exercise improves activity tolerance and weight
adhere to a schedule of moderate exercise (clients are usu- loss.
ally instructed to begin a walking program and should be
walking 1-2 miles/day by the fourth week after discharge).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources that can assist in the adjustment to prescribed dietary
modifications and future changes to body image.

Independent Actions
Provide information about community resources that can Provides for continuum of care once client is discharged from the
assist the client with adjustment to prescribed dietary acute care facility.
modifications and future changes in body image (e.g.,
weight reduction groups, counseling services, support
groups of persons who have had the same or similar
surgery).
Initiate a referral if needed.

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, activity level, medications prescribed, and
wound care.

Independent Actions
Collaborate with the client to develop a plan for adherence Follow-up visits to the health care provider improve the potential
that includes: for a client’s adherence to treatment regimen and lifestyle
The importance of follow-up appointments with the health changes.
care provider.
Including significant others in teaching sessions if possible. Knowledge of the required lifestyle changes improves the significant
Encouraging questions and allow for reinforcement and clari- other’s ability to support client’s adherence to the treatment
fication of information provided about treatment regimen. regimen.
Providing written instructions on scheduled appointments Provides an information resource for the client after discharge from
with health care provider, dietary modifications, activity the acute care facility.
level, treatment plan, medications, and signs and symp-
toms to report.

ADDITIONAL NURSING DIAGNOSES:

IMBALANCED NUTRITION: LESS THAN ACTUAL/RISK FOR IMPAIRED TISSUE i
BODY REQUIREMENTS NDx INTEGRITY NDx
Related to: Related to:
e Decreased oral intake associated with nausea, pain, weak- * Disruption of tissue associated with the surgical procedure
ness, fatigue, prescribed dietary modifications, and early e Delayed wound healing associated with factors such as
satiety resulting from small gastric pouch and delayed decreased nutritional status and inadequate blood supply
pouch emptying to wound area
e Inadequate nutritional replacement therapy * Irritation of skin associated with contact with wound
e Increased nutritional needs associated with the increased drainage, pressure from tubes, and use of tape
metabolic rate that occurs during wound healing ° Difficulty keeping deep skinfold areas dry
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 519

e Damage to the skin and/or subcutaneous tissue associated

with:
e Friction or shearing when moving in bed
e Pressure on tissue as a result of excessive body weight
and decreased activity

GASTROINTESTINAL BLEED,
GI bleeding, a symptom of a disorder in the digestive tract, weakness, shortness of breath, abdominal pain, and pale
accounts for a significant number of hospital admissions each appearance.
year. The causes of GI bleeding are classified based on the Most people who experience a GI bleed spontaneously
location of the bleeding in the GI tract (upper vs. lower). stop bleeding. However, treatment is initiated immediately in
Causes of bleeding in the upper GI tract include peptic ulcers cases of massive bleeding and consists of endoscopic hemo-
(usually located in the stomach or duodenum), esophageal stasis of the bleeding vessel. Vasoactive medications such as
varices (swelling of the veins in the esophagus or stomach), epinephrine, octreotide, or vasopressin may also be adminis-
Mallory-Weiss tear (tear in the esophagus or stomach most tered to help stop the bleeding. Gastric lavage may be done
often due to severe vomiting or retching), and gastritis (gen- before endoscopy to remove blood from the stomach and
eral inflammation of the stomach lining usually from in- improve endoscopic visualization. If bleeding continues,
gested materials). Additional risk factors that may contribute surgery may be necessary. Subsequent treatment to prevent
to the development of gastritis include regular use of NSAIDs rebleeding depends on the cause of the bleeding.
or nonsteroidal anti-inflammatory drugs and/or steroids, This care plan focuses on the adult client hospital-
chronic or excessive alcohol intake, burns, and trauma. ized with a massive upper GI bleed. It should be used
Causes of lower GI bleeding include diverticulosis (small out- in conjunction with the care plans on peptic ulcer and
pockets that form in a weakened portion of the bowel wall), cirrhosis if it is determined that the client’s bleed is
cancer, inflammatory bowel disease (e.g. Crohn disease, ulcer- associated with either of these conditions.
ative colitis), infectious diarrhea, angiodysplasia (malforma-
tion of blood vessels in the wall of the GI tract), polyps,
hemorrhoids, and fissures. OUTCOME/DISCHARGE CRITERIA
Acute GI bleeding first appears as vomiting of blood,
bloody bowel movements, or black, tarry stools depending The client will:
upon the location of the bleed. The severity of the bleeding 1. Have adequate tissue perfusion
ranges from slight oozing to frank, profuse hemorrhage and 2. Tolerate prescribed activity without a significant change in
depends on whether the source is arterial, venous, or capil- vital signs, chest pain, dizziness, or extreme fatigue or
lary. Significant bleeding is almost always arterial in nature. A weakness
GI bleed is considered massive if the bleed results in hemody- 3. Have no signs and symptoms of complications
namic instability, acute anemia, and/or the need for blood ns . Identify ways to reduce the risk for rebleeding
transfusion. Hematemesis of bright red or “coffee ground” 5. State signs and symptoms to report to the health care
vomitus is often the initial symptom of an upper GI bleed. provider
Melena (dark, tarry stools) can also indicate upper GI bleed- 6. Develop a plan for adhering to recommended follow-up
ing that is occurring at a slower rate. Additional symptoms care including future appointments with health care
associated with blood loss from a GI bleed include fatigue, provider, medications prescribed, and dietary restrictions

|Nursing RISK
Diagnosis FOR SHOCK nox | |

Definition: Susceptible to an inadequate blood flow to the body’s tissues that may lead to life-threatening cellular
dysfunction, which may compromise health.

Related to: Hypovolemia/hypotension associated with GI bleeding

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea, abdominal pain or tenderness; Hematemesis; bright red/maroon stool, hypoactive or
dizziness and lightheadedness absent bowel sounds; nausea; abdominal distention;
abdominal pain or tenderness; tachycardia; hypotension;
cyanotic, pale skin; oliguria; capillary refill time greater
than 2 to 3 seconds; elevated BUN and serum creatinine
levels

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 520 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

RISK FACTORS DESIRED OUTCOMES

e Active GI bleeding
The client will maintain adequate tissue perfusion as
e Inadequate fluid and/or blood volume replacement
evidenced by:
a. BP within normal range and stable with position
change
. Usual mental status
. Extremities warm with absence of pallor and cyanosis
. Palpable peripheral pulses
. Capillary refill time less than 2 to 3 seconds
. BUN and serum creatinine levels within normal limits
a . Urine output at least 30 mL/h
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Cis]
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@sKe)

NOC OUTCOMES NIC INTERVENTIONS

Blood loss severity; circulation status; tissue perfusion: Bleeding reduction: GI; blood product administration;
abdominal organs; cellular shock management; hypotension management;
hypovolemia management

NURSING ASSESSMENT RATIONALE

Assess for and report signs of active or continued GI bleeding: Early recognition of active or continued GI bleeding allows for
e Hematemesis prompt intervention.
e Bright red or maroon stool
Assess for and report signs and symptoms of diminished Early recognition of signs and symptoms of diminished GI tissue
tissue perfusion: perfusion allows for prompt intervention before shock develops.
e Decreased BP
e Decline in systolic BP of more than 15 mm Hg when client
changes from a lying to a sitting or standing position
e Restlessness, confusion, or other change in mental status
e Reports of dizziness or lightheadedness or occurrence of
syncopal episodes
e Cool, pale, or cyanotic skin
e Diminished or absent peripheral pulses
e Capillary refill time greater than 2 to 3 seconds
e Elevated BUN and serum creatinine levels
e Oliguria
Assess baseline CBC, serum chemistry values. Assessing baseline laboratory values allows for evaluation of
effectiveness of interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

—————eeEeEeeeeeseseseseoeoaeaen
Independent Actions
Implement measures to maintain adequate tissue perfusion:
e Maintain a minimum fluid intake of 2500 mL/day if able. Maintains adequate circulatory volume and tissue perfusion.
e Instruct client to change from a supine to an upright Allows time for autoregulatory mechanisms to adjust to the change
position slowly. in distribution of blood associated with an upright position
e Maintain a comfortable room temperature and provide Exposure to cold causes generalized vasoconstriction.
client with adequate clothing and blankets. D @ +

Dependent/Collaborative Actions
Implement measures to maintain adequate tissue perfusion:
e Prepare client for measures that may be performed to Processes that will obliterate bleeding varices. '
control bleeding:
e Endoscopic thermocoagulation, sclerotherapy, or banding
of bleeding varices
e Intra-arterial or intravenous administration of vasoactive
medications (e.g., epinephrine, octreotide, vasopressin)
e Surgery
e Administer intravenous fluids and/or blood products as Maintains adequate circulatory status and tissue perfusion.
ordered.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 521

THERAPEUTIC INTERVENTIONS RATIONALE

¢ Administer the following medications if ordered to reduce These medications decrease acid production and irritation of the
the risk of rebleeding: stomach lining.
° Proton pump inhibitors (e.g., omeprazole, lansopra-
zole, pantoprazole, esomeprazole)
° Histamine2-receptor antagonists (e.g., famotidine,
ranitidine, nizatidine) D +
Histamine receptor antagonists and proton-pump inhibitors sup-
press secretion of gastric acid.
Consult appropriate health care provider if signs and symp- Allows for prompt alterations in interventions.
toms of diminished tissue perfusion persist or worsen.

|Nursing »Diagnosis | RISK FOR ELECTROLYTE IMBALANCE nox |

Definition: Susceptible to changes in serum electrolyte levels, which may compromise health.
Related to:
¢ Hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with
vomiting and NG tube drainage

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea; headache Vomiting; positive Chvostek and Trousseau sign; abnormal
serum electrolyte levels; metabolic alkalosis

RISK FACTORS DESIRED OUTCOMES

Chienici ee
y Seated. ness The client will maintain fluid and electrolyte balance as
evidenced by:
e Infection
a. Normal skin turgor
e Inadequate therapeutic regimen
b. Moist mucous membranes
c. Stable weight
d. BP and pulse rate within normal range for client and
stable with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. Balanced I&O
h . Urine specific gravity within normal range
ii. Soft, nondistended abdomen with normal bowel
sounds
j. Absence of cardiac dysrhythmias, muscle weakness,
paresthesias, twitching, spasms, and dizziness
k. BUN, Het, serum electrolyte, and ABG values within
normal range

NOC OUTCOMES NIC INTERVENTIONS

Electrolyte and acid-base balance Electrolyte management: hypokalemia; electrolyte

management: hypocalcemia; electrolyte management:
hypomagnesemia; acid-base management: metabolic
alkalosis; diarrhea management

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching needs.

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 522 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of electrolyte Early recognition of signs and symptoms of electrolyte imbalance
imbalance: allows for prompt intervention.
e Hypokalemia (e.g., cardiac dysrhythmias, postural hypo-
tension, muscle weakness, nausea and vomiting, abdomi-
nal distention, hypoactive or absent bowel sounds)
e Hypomagnesemia and/or hypocalcemia (e.g., anxiousness;
irritability; cardiac dysrhythmias; positive Chvostek and
Trousseau signs; numbness or tingling of fingers, toes, or
circumoral area; hyperactive reflexes; tetany; seizures)
e Metabolic alkalosis (e.g., confusion, hand tremor, lighthead-
edness, muscle twitching, nausea, vomiting, numbness or
tingling in face, hands, or feet; prolonged muscle spasms)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent or treat imbalanced fluid and
electrolytes:
e Perform actions to prevent nausea and vomiting:
e Insert NG tube and maintain suction and/or perform Maintaining an NG tube to suction removes blood from the
gastric lavage if ordered. stomach, reducing the stimulus to vomit.
e Administer antiemetics if ordered. D + Antiemetics decrease nausea and vomiting, which decreases fluid
and electrolyte loss.
° If gastric lavage is being done or NG tube is being irrigated Water is sometimes preferred because it breaks up clots better than
frequently with large volumes of solution, consult physi- saline, but irrigation with large volumes of water may create
cian about using saline rather than water. electrolyte imbalance.
e Administer intravenous fluid and electrolytes as ordered. IV fluids maintain adequate circulatory balance.
Consult physician if signs and symptoms of imbalanced fluid Notification of the physician allows for prompt alteration in
and electrolytes persist or worsen. interventions.

Nursing Diagnosis RISK ASPIRATION no x

Definition: Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the
tracheobronchial passages, which may compromise health.

Related to: hematemesis and possible decreased level of consciousness

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Rhonchi; dull percussion note over affected lung area;
cough; tachypnea; dyspnea; tachycardia; chest radiograph
results showing pulmonary infiltrate

RISK FACTORS DESIRED OUTCOMES

e Depressed gag reflex
e Increased gastric residual volume
The client will not aspirate as evidenced by:
a. Clear breath sounds
e Increased intragastric pressure
b. Resonant percussion note over lungs
e Impaired swallowing
c. Absence of cough, tachypnea, and dyspnea

NOC OUTCOMES NIC INTERVENTIONS

a eeeeeeSSSSSe
Respiratory status: airway patency; gas exchange Respiratory monitoring; aspiration precautions; airway
suctioning
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 523

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of aspiration (e.g., Early recognition of signs and symptoms of aspiration allows for
thonchi, dull percussion note over affected lung area, prompt intervention.
cough, tachypnea, dyspnea, tachycardia, chest radiograph
results showing pulmonary infiltrate).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for aspiration:
* Keep head of bed elevated at least 45 degrees if vital signs This position uses gravity to facilitate movement of foods/fluids
are stable, or position client on side (if client is hypoten- through the pharynx into the esophagus, where the risk of aspi-
sive, elevating the head of bed is contraindicated). ration is greatly reduced.

Dependent/Collaborative Actions
Implement measures to reduce the risk for aspiration:
e Perform actions to prevent nausea and vomiting (e.g., These actions decrease incidence of nausea and vomiting, thus
insert NG tube, provide oral hygiene, eliminate noxious decreasing the risk of aspiration.
odors, administer antiemetics as needed). D
Withhold oral foods/fluids as ordered. D@ + Keeps the stomach empty, decreasing the chance of aspiration.
e Perform oropharyngeal suctioning and provide oral Suctioning and frequent oral hygiene remove any blood and
hygiene as often as needed. D @+ vomitus and keeps oropharynx clean.
If signs and symptoms of aspiration occur:
e Perform tracheal suctioning. Removes aspirate.
e Withhold oral intake. Keeps the stomach empty.
e Prepare client for chest radiograph. Shows where the aspirate has lodged and potential damage to the
lungs.

Nursing Diagnosis RISK FOR ACTIVITY INTOLERANCE nox

Definition: Susceptible to experiencing insufficient physiological or psychological energy to endure or complete required or
desired daily activities, which may compromise health.
Related to:
e Anemia resulting from blood loss
e Hypoxia associated with anemia
° Difficulty resting and sleeping associated with assessment and treatments, fear, and anxiety

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of feeling tired; chest pain Dyspnea on exertion; tachycardia with exertion; BP
increase with exertion

RISK FACTORS DESIRED OUTCOMES

e Fatigue The client will not experience activity intolerance as
e Shortness of breath evidenced by:
e Pain a. No reports of fatigue or weakness
b. Ability to perform activities of daily living without
exertional dyspnea, chest pain, diaphoresis, dizziness,
and a significant change in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance; energy conservation; self-care activities of Energy management; oxygen therapy; sleep enhancement
daily living

D = Delegatable Action @ =UAP @ =LVN/LPN ©) = Go to ©volve for animation

NDx = NANDA Diagnosis
 524 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention.
e Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping
activity, change from regular to irregular rate)
e Significant change (15-20 mm Hg) in BP with activity

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent activity intolerance:
e Perform actions to promote rest and/or conserve energy: Cells use oxygen and fat, protein, and carbohydrate to produce the
e Maintain prescribed activity restrictions. energy needed for all body activities. Rest and activities that
e Minimize environmental activity and noise. D @ + conserve energy result in a lower metabolic rate, which preserves
e Organize care to provide uninterrupted rest periods. D @ + nutrients and oxygen for necessary activities.
e Assist with self-care activities. D @ +
e Keep supplies and personal articles within easy reach.
De+
e Limit the number of visitors.
e Instruct client in energy-saving techniques (e.g., using
a shower chair when showering, sitting to brush teeth
or comb hair).
e Implement measures to promote sleep (e.g., allow client
to continue usual sleep practices unless contraindicated,
administer sedative-hypnotic as ordered).
e Discourage smoking and excessive intake of beverages Both nicotine and excessive caffeine intake can increase cardiac
high in caffeine such as coffee, tea, and colas. workload and myocardial oxygen utilization, thereby decreasing
the amount of oxygen necessary for energy production.
Instruct client to report a decreased tolerance for activity and These symptoms indicate that insufficient oxygen is reaching
to stop any activity that causes chest pain, shortness of the tissues and that activity has been increased beyond a
breath, dizziness, or extreme fatigue or weakness. therapeutic level.

Dependent/Collaborative Actions
Implement measures to prevent activity intolerance:
e Administer the following if ordered to treat anemia if Anemia reduces the oxygen-carrying capacity of the blood. Resolu-
present: tion of anemia increases oxygen availability to the cells, which
e Iron supplements increases the efficiency of energy production and subsequently
e Packed red blood cells improves activity tolerance.
e Maintain oxygen therapy as ordered. D Provides supplemental oxygen.
e Implement measures to maintain an adequate nutritional Metabolism is the process by which nutrients are transformed
status (e.g., provide a diet high in essential nutrients, into energy. If nutrition is inadequate, energy production is
provide dietary supplements as indicated, administer decreased, which subsequently reduces one’s ability to tolerate
vitamins and minerals as ordered). activity.
Vitamins and minerals may be required to support nutritional
Status.
e Increase client’s activity gradually as allowed and A gradual increase in activity helps prevent a sudden increase
tolerated. D @+ in cardiac workload and myocardial oxygen consumption
and the subsequent imbalance between oxygen supply and
demand.
Consult physician if signs and symptoms of activity intoler- Notifying the physician allows for modification of the treatment
ance persist. plan.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 525

DISCHARGE TEACHING/CONTINUED CARE

2) DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY HEALTH

MANAGEMENT nox; or INEFFECTIVE HEALTH MAINTENANCE?* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition.
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the
family unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to maintain
well-being.

Subjective Objective
Verbal self-report of inability to manage illness; inability to Inaccurate follow-through with instructions; inappropriate
follow prescribed regimen behaviors; unwillingness to participate in self-care

RISK FACTORS
° Cognitive deficit
e Financial concerns
e Inability to care for oneself
e Difficulty in modifying personal habits and integrating
treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen Health system guidance; teaching: individual; teaching:
disease process; teaching: prescribed diet; teaching:
prescribed medication

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of bleeding.

Independent Actions
Instruct client on how to reduce the risk for rebleeding: These drinks/foods irritate GI lining, slow down healing, and/or
e Drink decaffeinated or caffeine-free tea and colas rather may cause re-ulceration.
than those containing caffeine
e Avoid drinking coffee and alcohol or drink these beverages
only in small amounts during or immediately following a
meal
e Avoid ingestion of foods known to irritate gastric mucosa
directly or increase gastric acid production (e.g., whole
grains, chocolate, rich pastries, spicy foods, meat extracts,
extremely hot foods)
e Avoid intake of any foods and fluids that cause gastric Neutralizes gastric acid.
distress

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching.

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526 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Eat three regularly scheduled meals (moderate-sized, rather
than large) and snacks each day; do not skip meals
° Eat slowly and chew food thoroughly A large bolus of food causes an increased output of hydrochloric
e Maintain a calm, pleasant atmosphere at mealtime and acid and pepsin.
whenever possible Decreases stress and production of gastric acid.
° Stop smoking Smoking may cause ulcers, lowers healing, and contributes to
¢ Maintain a balance of physical activity and rest reccurrence.
e Avoid stressful situations whenever possible Reduces stress and promotes healing.

e Avoid ingestion of over-the-counter medications such as aspi-

rin and ibuprofen; if it is necessary to take these or other
ulcerogenic medications (e.g., corticosteroids), take them
with antacids or food unless contraindicated and/or take
enteric-coated or buffered preparations of the drugs if available
e If it is necessary to take an NSAID, consult health care Physiological stress can lead to stress gastritis which results in
provider about taking it with a medication that helps pro- inflammation of the stomach lining. In more serious cases, this
tect the gastric mucosa (e.g., misoprostol, sucralfate) and/or can lead to the development of erosions and bleeding which
switching to an NSAID known to be less irritating to the may be further exacerbated with the ingestion of NSAIDS, aspi-
mucosa (e.g., a COX-2 inhibitor selective agent such as rin and/or ibuprofen.
celecoxib, valdecoxib, and rofecoxib)
e Take medications for ulcer treatment as prescribed Many medications cause gastric irritation and should be avoided or
taken with antacids or food.
Enhances ulcer healing and reduces recurrence.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report: Indication of bleeding should be reported immediately to allow for
° Bloody or “coffee-ground” vomitus prompt intervention.
e Black or tarry stools
° Persistent epigastric fullness or bloating, nausea and/or vomiting
° Abdominal distention
° Persistent or increased epigastric or abdominal pain
e Persistent weakness and fatigue

THERAPEUTIC INTERVENTIONS RATIONALE

eee

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, and dietary restriction.

Independent Actions
Collaborate with client to develop a plan adherence that includes: The client should be monitored for a period of time to ensure ade-
The importance of keeping follow-up appointments with quate healing.
health care provider. '
Explanation of the rationale for, side effects of, and impor- Knowledge of the medication regimen and the impact of these
tance of taking prescriptions as prescribed. Inform client of medications on the system, as well as how the medication
pertinent food and drug interactions. regimen can be incorporated into the client’s lifestyle, allows the
client some mechanism of control of his/her disease and the
ability to have an active part in treatment and care.
Physician’s instruction regarding dietary restrictions such as Irritants to the GI tract may increase potential for rebleeding.
caffeinated beverages, alcohol, and spicy foods.
Providing written instructions about future appointments Provides a resource for information once the client has been
with health care provider, prescribed medications, dietary discharged from the acute care facility.
restrictions, and signs and symptoms to report.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract ey,

ADDITIONAL NURSING DIAGNOSIS

FEAR/ANXIETY NDx e Concern that bleeding may not be controlled

Related to: e Lack of understanding of the cause of the bleeding, diag-
e Presence of large amount of blood in vomitus and NG tube nostic tests, treatment plan, and prognosis
drainage ° Possible need to change lifestyle in order to prevent rebleeding

INFLAMMATORY BOWEL DISEASE: ULCERATIVE COLITIS

AND CROHN DISEASE
Crohn disease and ulcerative colitis are idiopathic chronic in- mercaptopurine, and the newest class of approved drugs—the
flammatory bowel diseases often jointly referred to as inflamma- biologics. Research indicates that there may be a defect in im-
tory bowel disease. Prolonged inflammation associated with munoregulation of inflammation in Crohn disease. This has
these diseases results in damage to the GI tract. Crohn disease led to the use of monoclonal antibodies that neutralize a
most often affects a portion of the small intestine, with damaged cytokine (specifically, tumor necrosis factor-a) to treat persons
areas appearing as patches next to areas of healthy tissue, and with Crohn disease who have not been responsive to conven-
inflammation that may reach through multiple layers of the GI tional therapy or who have draining enterocutaneous fistulas.
tract wall, while ulcerative colitis occurs in the large intestine. This care plan focuses on the adult client with severe
The exact cause of inflammatory bowel disease is unknown abdominal pain and diarrhea who is hospitalized for
but is the result of a defective immune system. The classic clini- medical management of inflammatory bowel disease.
cal manifestations of inflammatory bowel disease include persis- Much of the information is applicable to clients receiving
tent diarrhea, abdominal pain and cramping, rectal bleeding/ follow-up care in an extended care facility or home setting.
bloody stools, weight loss, and fatigue. The severity and pattern
of signs and symptoms depend on the portion(s) of the bowel
affected and depth of bowel wall involvement. Ulcerative colitis OUTCOME/DISCHARGE CRITERIA
primarily involves the mucosa of the bowel wall, extending to
the submucosa only in severe cases. It typically starts in the The client will:
rectum and sigmoid colon and progresses in a continuous pat- 1. Have decreased abdominal pain
tern through the colon. It rarely involves the small intestine. 2. Have fewer episodes of diarrhea
Crohn disease can occur anywhere in the GI tract. The most 3. Tolerate prescribed diet and have an improved nutri-
frequent sites of involvement are the terminal ileum and right tional status
colon. The entire thickness of the bowel wall is involved, and it 4. Be free of signs and symptoms of complications
has a segmental, discontinuous pattern of progression. 5. Identify ways to reduce the incidence of disease exacerbation
Clients with either condition may experience a number of 6. Verbalize ways to maintain an optimal nutritional status
the same complications; however, those with ulcerative coli- 7. State ways to prevent perianal skin breakdown
tis have a higher incidence of toxic megacolon and bowel 8. Verbalize an understanding of medications ordered includ-
perforation, whereas clients with Crohn disease have a higher ing rationale, food and drug interactions, side effects, sched-
incidence of perianal involvement and fistula formation. ule for taking, and importance of taking as prescribed
Some clients also experience extraintestinal manifestations 9. State signs and symptoms to report to the health care provider
such as liver and biliary involvement; kidney stones; arthritis; 10. Identify resources that can assist in the adjustment to changes
and skin, eye, and oral lesions. Clients with inflammatory resulting from inflammatory bowel disease and its treatment
bowel disease may require hospitalization during periods of 11. Share feelings and thoughts about the effects of inflam-
exacerbation or if complications are suspected. matory bowel disease on lifestyle and self-concept
Cornerstones of medical treatment have traditionally in- 12. Develop a plan for adhering to recommended follow-up
cluded corticosteroids, sulfasalazine, nonsulfa-aminosalicy- care including future appointments with health care
lates, immunomodulator agents such as azathioprine and provider and activity level

Nursing/Collaborative Diagnosis RISK FOR IMBALANCED FLUID VOLUME nox AND RISK
FOR ELECTROLYTE IMBALANCE nopx*

Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease, increase, or rapid shift from one to the other
of intravascular, interstitial and/or intracellular fluid, which may compromise health. This refers to body fluid loss,
gain, or both. Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte levels, which may
compromise health.

*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching needs.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN ©) = Goto ©volve for animation
 528 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

Related to:
e Risk for Imbalanced Fluid Volume NDx; Risk for Electrolyte Imbalance NDx: hypokalemia, hypomagnesemia, and
hypocalcemia related to:
e Prolonged inadequate oral intake associated with pain, fatigue, prescribed dietary restrictions, and fear of precipitating an
attack of abdominal cramping and diarrhea.
e Impaired absorption of fluid and electrolytes associated with inflammation and scarring of the intestine
e Excessive loss of fluid and electrolytes associated with persistent diarrhea (loss of potassium can occur as a result of treat-
ment with corticosteroids)
e Metabolic acidosis related to excessive loss of bicarbonate associated with persistent diarrhea

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea; headache Poor skin turgor; dry, cracked mucous membranes;
hypotension; weight loss; prolonged capillary refill greater
than 2 to 3 seconds; decreased urine output; increased
urine specific gravity; vomiting; positive Chvostek and
Trousseau sign; abnormal electrolytes; metabolic acidosis

RISK FACTORS DESIRED OUTCOMES

e Chronic illness
The client will maintain fluid and electrolyte balance as
e Failure of regulatory mechanisms
evidenced by:
e Inadequate diet and fluid intake
a. Normal skin turgor
b. Moist mucous membranes
c. Stable weight
d. BP and pulse rate within normal range for client and
stable with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. Balanced intake and output
h. Urine specific gravity within normal range
i. Soft, nondistended abdomen with active bowel sounds
j. Absence of cardiac dysrhythmias, muscle weakness,
and seizure activity
k. Absence of headache, nausea, and vomiting
l. Negative Chvostek and Trousseau signs
m. Decreased serum electrolytes and ABGs within normal
range

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; electrolyte and acid-base balance Fluid management; electrolyte management: hypokalemia;
electrolyte management: hypocalcemia; electrolyte manage-
ment: hypomagnesemia; acid-base management: metabolic
acidosis; diarrhea management

NURSING ASSESSMENT RATIONALE

ec ee ee, Se
Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of fluid and/or electrolyte
volume: imbalances allows for prompt treatment. i
e Decreased skin turgor, dry mucous membranes, thirst
e Weight loss of 2% or greater over a short period
e Postural hypotension and/or low BP
e Weak, rapid pulse
e Capillary refill time longer than 2 to 3 seconds
e Neck veins flat when client is supine
e Change in mental status
e Decreased urine output with increased specific gravity
(reflects an actual rather than potential fluid deficit)
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 529

NURSING ASSESSMENT RATIONALE

a EE ee
a a

Significant increase in BUN and Hct above previous levels

e Hypokalemia (e.g., cardiac dysrhythmias, postural hypo-
tension, muscle weakness, nausea and vomiting, abdomi-
nal distention, hypoactive or absent bowel sounds)
e Hypomagnesemia and/or hypocalcemia (e.g., anxiousness;
irritability; cardiac dysrhythmias; positive Chvostek and
Trousseau signs; numbness or tingling of fingers, toes, or
circumoral area; hyperactive reflexes; tetany; seizures)
e Metabolic acidosis (e.g., drowsiness; disorientation; stupor;
rapid, deep respirations; headache; nausea and vomiting;
cardiac dysrhythmias; low pH and CO); content)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent or treat imbalanced fluid and
electrolytes:
e Perform actions to control diarrhea (e.g., restrict intake as Clients with Crohn disease may have an intolerance to lactose-rich
needed, reduce stress, avoid milk and milk products, foods foods because of a deficiency of lactase.
high in fat, those high in fiber or residue, high in caffeine, The foods listed stimulate the bowel and increase the incidence of
spicy foods, extremely hot or cold fluids). D @ + diarrhea.
e When oral intake is allowed: Oral intake of foods high in potassium are necessary to maintain
e Assist client to select foods/fluids within the prescribed adequate electrolyte balance.
dietary regimen that would replenish electrolytes (be
aware that many foods/fluids high in potassium and
magnesium are contraindicated on a low-residue diet)
De+
(1) Foods high in potassium (e.g., bananas, avocado,
raisins, potatoes, cantaloupe)
(2) Foods high in magnesium (e.g., seafood)

Dependent/Collaborative Actions
Implement measures to prevent or treat imbalanced fluid and
electrolytes:
e Administer the following if ordered:
e Maintain a fluid intake of at least 2500 mL/day unless Required to prevent the client from becoming dehydrated.
contraindicated. Replenishes electrolytes.
e If oral intake is inadequate or contraindicated, maintain
intravenous and/or enteral fluid therapy as ordered.
e Electrolyte replacements (e.g., potassium chloride, mag-
nesium sulfate, calcium gluconate, calcium carbonate)
e Vitamin D preparations D+ Increases intestinal absorption of calcium.
If signs and symptoms of hypomagnesemia or hypocalcemia Low levels of magnesium and calcium have been associated with
occur, institute seizure precautions. D @ > increased seizure activity.
Consult physician if signs and symptoms of imbalanced fluid Notification of the physician allows for alterations in treatment
and electrolytes persist or worsen. plan.

Diagnosis |IMBALANCED
|Nursing >»... NUTRITION: LESS THAN BODY REQUIREMENTS nox

Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with pain, fatigue, prescribed dietary restrictions, and the knowledge that eating often
precipitates abdominal cramping and diarrhea
° Decreased absorption of nutrients associated with inflammation and scarring of the bowel
e Loss of nutrients associated with diarrhea and protein exudation from the inflamed bowel
e Impaired folate absorption associated with treatment with sulfasalazine
° Increased metabolism of nutrients associated with the increased metabolic rate that may be present during periods of exacerbation

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 530 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness and fatigue; lack of appetite; Weight significantly below client’s usual weight or below
irritability; poor self-esteem normal for client’s age, height, and body frame; abnormal
BUN and low serum prealbumin, albumin, Hct, Hgb, and
folate levels and low lymphocyte count; pale conjunctiva

RISK FACTORS DESIRED OUTCOMES

e Treatment regimen
The client will have an improved nutritional status as
e Inadequate/inappropriate diet
evidenced by:
a. Weight approaching a normal range for client
b. Improved BUN and serum prealbumin, albumin, Hct,
Hgb, and folate levels and lymphocyte count
. Increased strength and activity tolerance
ao. Healthy oral mucous membranes

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status Nutritional monitoring; nutrition management; nutrition

therapy; total parenteral nutrition (TPN) administration;
enteral tube feeding

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of malnutrition: Early recognition of signs and symptoms of imbalanced nutrition
e Weight significantly below client’s normal or below allows for prompt intervention.
normal for client’s age, height, and body frame
e Abnormal BUN and low serum prealbumin, albumin, Hct,
Hgb, and folate levels and low lymphocyte count
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
When oral intake is allowed, monitor the percentage of meals The client’s intake should be monitored to ensure adequate calories
and snacks client consumes. D @ + and nutrients.
Report a pattern of inadequate intake. D @ +

Dependent/Collaborative Actions
Implement measures to improve nutritional status:
e Administer TPN or enteral tube feeding if ordered. Provides adequate nutrition until oral intake may be resumed.
e Perform actions to reduce inflammation and hypermotility These actions reduce episodes of diarrhea and increase absorption
of the bowel (restrict intake; limit activity to bedrest as of nutrients.
needed; limit milk and milk products, those high in fats,
fiber, caffeine, spicy foods, extremely hot or cold foods/
fluids).
e Maintain activity restrictions as ordered (usually bedrest Reduces caloric requirements.
with bedside commode or bathroom privileges)
e When food or fluid is allowed:
e Provide elemental formulas (e.g., Vivonex, Criticare Helps rest the bowel; these formulas are high in calories and
HN) if ordered. nutrients, free of lactose and fiber, and absorbed in the
e Progress diet as tolerated (usual progression is from proximal small bowel.
elemental formulas to a low-residue, high-calorie, high-
protein diet). D@ +
¢ Implement measures to reduce pain (e.g., encourage a rest Minimizes fatigue.
period before meals). D @+
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 531

THERAPEUTIC INTERVENTIONS RATIONALE

¢ Maintain a clean environment and a relaxed, pleasant Eliminates noxious odors, which may decrease appetite.
atmosphere. D @ +
¢ Provide oral hygiene before meals. D@ > Oral hygiene removes unpleasant tastes, which often improves the
taste of foods/fluids.
¢ Implement measures to improve the palatability of A variety of measures help them to become more palatable.
elemental formulas (e.g., offer a variety of flavors, serve
chilled).
e Obtain a dietary consult if necessary to assist client in Improves nutritional status while allowing individuals to eat foods
selecting foods/fluids that are appealing and adhere to they like.
personal and cultural preferences as well as the prescribed
dietary modifications.
e Serve frequent, small meals rather than large ones if client Small, frequent meals promote better nutritional status for the
is weak, fatigues easily, or has a poor appetite. D @ > client who tires easily.
e Allow adequate time for meals; reheat foods/fluids if Clients who feel rushed during meals tend to become anxious, lose
necessary. D@ their appetite, and stop eating. Appetite is also suppressed if
foods/fluids normally served hot or warm become cold and then
do not appeal to the client.
e Administer the following if ordered: Oral iron preparations may not be effective during an acute attack
e tron because they may be poorly absorbed from the inflamed bowel.
e Vitamin preparations (e.g., fat-soluble vitamins, vitamin Supplements of these vitamins may be required because they may
Biz, folic acid) not be adequately absorbed from the inflamed bowel.
Perform a calorie count if ordered. Report information to Monitors client’s nutritional status.
dietitian and physician. D+
Consult physician and/or dietitian if nutritional status Notification of the physician allows for alterations in treatment
continues to decline. plan.

Nursing Diagnosis ACUTE/CHRONIC PAIN nox

Definition: Acute Pain NDx: Unpleasant sensory and emotional experience arising from actual or potential tissue damage, or
described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any
intensity from mild to severe with an anticipated or predictable end, and a duration of less than 3 months.
Chronic Pain NDx: Unpleasant sensory and emotional experience arising from actual or potential tissue damage,
or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any
intensity from mild to severe, constant or recurring, without an anticipated or predictable end, and a duration of
greater than 3 months.

Related to:
e Abdominal pain and cramping related to:
e Inflammation and ulceration of the bowel
e Interference with the flow of intestinal contents associated with narrowing of the intestinal lumen as a result of inflam-
mation and hypertrophy and fibrosis of the bowel wall if present
° Joint pain related to extraintestinal involvement of the joints (peripheral arthritis, ankylosing spondylitis, and sacroiliitis
are the most common joint disorders that occur)
¢ Perianal pain related to irritation and breakdown of the skin in the perianal area associated with persistent diarrhea and/or
the presence of an anorectal abscess or fistula

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of reluctance to move; pain Grimacing; rubbing abdomen, back, or joints; diaphoresis;
increased BP; tachycardia; restlessness

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532 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

RISK FACTOR DESIRED OUTCOMES

e Chronic illness The client will experience diminished pain as evi-
denced by:
a. Verbalization of same
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

Comfort level: pain control Environmental management: comfort; analgesic

administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (e.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
pain, grimacing, reluctance to move, restlessness, diapho- intervention and improved pain control.
resis, increased BP, tachycardia).
Assess Client’s perception of the severity of pain using a pain An awareness of the severity ofpain being experienced helps determine
intensity rating scale. the most appropriate interventions for pain management. Use of a
pain intensity rating scale gives the nurse a clearer understanding
of the pain being experienced and promotes consistency when com-
municating with others about the client’s pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identification
duration, precipitating factors, aggravating factors, of effective pain management interventions.
alleviating factors).
Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex, Cop-
methods used to manage pain effectively. ing style, previous experience with pain, culture, cause of pain).
Knowledge of the client’s usual response to pain and methods
previously used to manage pain effectively enables the nurse to
evaluate the client’s pain more accurately and facilitates the
identification of effective strategies for pain management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that the need for pain relief is understood, plan for pain and thereby heighten the perception of pain. In addi-
methods for achieving pain control with client, provide a tion, pain management methods are not as effective ifthe client
calm environment). D@ is tense and unable to relax.
Implement measures to promote rest (e.g., minimize environ- Fatigue can decrease the client’s threshold and tolerance for pain
mental activity and noise). D@ + and thereby heighten the perception of pain. A well-rested client
Perform actions to reduce inflammation and hypermotility of often experiences decreased pain and increased effectiveness of
the bowel: pain management measures.
e Perform actions to rest the bowel:
e Restrict oral intake; maintain NPO during acute stage. Restricting intake and placing the client on NPO rests the bowel
and conserves the individual’s energy.
e
Maintain activity restrictions (initially may be limited to Enhances healing of the bowel.
bedrest with bedside commode or bathroom privileges).
When oral intake is allowed, diet usually progresses from Elemental formulas are absorbed in the proximal small bowel and
elemental formulas to a low-residue diet. D @ thereby minimize stimulation of the bowel.
e Instruct the client to avoid the following foods/fluids Clients with Crohn disease may have an intolerance to lactose-rich
that may be poorly digested or can act as irritants to the foods because of a deficiency of lactase.
inflamed bowel:
(1) Milk and milk products These foods cause an increase in the potential for diarrhea and
(2) Foods high in fat (e.g., fried foods, gravies) irritation of the colon.
(3) Foods high in fiber (e.g., whole-grain cereals, nuts,
raw fruits and vegetables)
(4) Foods high in caffeine (e.g., coffee, tea, colas)
(S) Spicy foods
(6) Extremely hot or cold foods/fluids
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 533

THERAPEUTIC INTERVENTIONS RATIONALE

Perform actions to relieve perianal pain if present: These actions help to decrease pain and irritation.
e Clean perianal area with medication wipes such as “Tucks”
after each bowel movement.
e Apply protective ointment or cream to perianal area after
each bowel movement. D @ +
Instruct client to add new foods one at a time. Adding one food at a time allows client to determine which foods
cause more discomfort.
Provide small, frequent meals rather than three large ones. Small, frequent meals are tolerated better than three large meals.

Dependent/Collaborative Actions
Perform actions to relieve perianal pain if present:
¢ Consult physician about order for sitz baths. These actions decrease pain experienced in the perianal area.
e Apply anesthetic preparation (e.g., Nupercainal, Trono-
lane) to perianal area or into rectum as ordered.
Consult physician regarding measures to help relieve joint Braces and splints support the joints and help to reduce pain.
pain if present (e.g., application of brace/splint to affected
joint, application of heat to affected joints).
Perform actions to reduce inflammation and hypermotility of
the bowel:
e Administer anti-inflammatory medications:
e Corticosteroids Corticosteroids and sulfasalazine or non-sulfa-aminosalicylates
e Sulfasalazine or non-sulfa-aminosalicylates reduce bowel inflammation.
e Antidiarrheal agents D> Antidiarrheal agents slow intestinal motility; however, these medi-
cations should be used with caution because of the risk of
megacolon.
Administer analgesics before activities and procedures that The administration of analgesics before a pain-producing event
can cause pain and before pain becomes severe. D + helps minimize the pain that will be experienced. Analgesics are
also more effective if given before pain becomes severe because
mild to moderate pain is controlled more quickly and effectively
than severe pain.
Provide or assist with nonpharmacological methods for pain Nonpharmacological pain management includes a variety of inter-
relief. Examples include: ventions. It is believed that most of these are effective because
e Cutaneous stimulation measures (e.g., pressure, massage, they stimulate closure of the gating mechanism in the spinal
heat and cold applications, transcutaneous electrical nerve cord and subsequently block the transmission of pain impulses.
stimulation [TENS], acupuncture) In addition, some interventions are thought to stimulate the
e Relaxation techniques (e.g., progressive relaxation exer- release of endogenous analgesics (e.g., endorphins) that inhibit
cises, meditation, guided imagery) the transmission of pain impulses and/or alter the client’s per-
e Distraction measures (e.g., listening to music, conversing, ception of pain. Many of the nonpharmacological interventions
watching television, playing cards, reading) also help decrease pain by promoting relaxation.
e Position change Pharmacological therapy is an effective method of reducing or re-
lieving pain.
Administer the following medications as ordered:
e Opioid analgesics Opioid analgesics act mainly by altering the client’s perception of
pain and emotional response to the pain experience.
¢ Nonopioid analgesics such as acetaminophen and salic- Nonopioid analgesics are thought to interfere with the transmission
ylates and other NSAIDs (e.g., ketorolac, ibuprofen, of pain impulses by inhibiting prostaglandin synthesis.
naproxen)
e Anesthetic agents (e.g., bupivacaine, etidocaine) Anesthetics help control pain by inhibiting the initiation and con-
duction of pain impulses along the sensory pathways at and
near the infusion site.
Consult physician about an order for PCA if indicated. The use of PCA allows the client to self-administer analgesics
within parameters established by the physician. This method
facilitates pain management by ensuring prompt administra-
tion of the drug when needed, providing more continuous pain
relief and increasing the client’s control over the pain.
Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
pharmacist, pain management specialist) if above mea- tion of the treatment plan.
sures fail to provide adequate pain relief.

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 534 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

|Nursing eeeoece)
Diagnosis |RISK FOR INFECTION nox
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
e Ulcerations in the bowel wall
e Lowered resistance to infection associated with malnutrition and treatment with corticosteroids and/or immunosuppressive
agents
¢ Stasis of respiratory secretions and urine associated with decreased mobility if activity restrictions are prescribed

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chills; malaise; lethargy; confusion; Fever; tachycardia; loss of appetite; abnormal breath
frequency, urgency, or burning with urination sounds; productive cough of purulent, green, or rust-
colored sputum; cloudy urine; urinalysis showing a WBC
count greater than 5 per high-power field, positive
leukocyte esterase or nitrites, or presence of bacteria;
elevated WBC count and/or significant change in
differential

RISK FACTORS DESIRED OUTCOMES

e Exposure to pathogens
The client will remain free of infection as evidenced by:
e Treatment regimen
a. Temperature declining toward normal
slacks otexercise
b. Absence of chills
e Inadequate fluid intake
c. Pulse rate within normal limits
d. Normal breath sounds
e. Usual mental status
f. Cough productive of clear mucus only
g. Voiding clear urine without reports of frequency,
urgency, and burning
h. No increase in episodes of diarrhea and abdominal
cramping and pain
i. Absence of heat, pain, redness, swelling, and unusual
drainage in any area
j. No reports of increased weakness and fatigue
k. WBC and differential counts returning toward normal
1. Negative results of cultured specimens

NOC OUTCOMES NIC INTERVENTIONS

Immune status; infection severity Infection control; infection protection

NURSING ASSESSMENT RATIONALE

pa
ee ne eee ee ee
Assess for and report signs and symptoms of infection (be Early recognition of signs and symptoms of infection allows for
aware that some signs and symptoms vary depending on prompt intervention.
the site of infection, the causative agent, and the age and
immune status of the client):
e Elevated temperature :
°¢ Chills
e Increased pulse rate
e Malaise, lethargy, acute confusion
¢ Loss of appetite
e Abnormal breath sounds
¢ Productive cough of purulent, green, or rust-colored sputum
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 535)

NURSING ASSESSMENT RATIONALE

SS

e Cloudy urine
° Reports of frequency, urgency, or burning when urinating
° Urinalysis showing a WBC count greater than 5 per high-
power field, positive leukocyte esterase or nitrites, or pres-
ence of bacteria
Heat, pain, redness, swelling, or unusual drainage in any area
e Elevated WBC count and/or significant change in differential
Obtain specimens (e.g., urine, wound drainage, vaginal drain- Cultures are done to identify the specific organism(s) causing the
age, sputum, blood) for culture as ordered. Report positive infection. Culture results provide information that helps
results. determine the most effective treatment.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Maintain a fluid intake of at least 2500 mL/day unless contra- Adequate hydration helps prevent infection by:
indicated. D @ + ¢ Helping maintain adequate blood flow and nutrient supply to
the tissues
¢ Promoting urine formation and subsequent voiding, which
flushes pathogens from the bladder and urethra
e Thinning respiratory secretions so that they can more easily be
removed by coughing or suctioning (respiratory secretions
provide a good medium for growth and colonization of micro-
organisms)
Use good hand hygiene and encourage client to do the same. Good hand hygiene removes transient flora, which reduces the risk
De+ of transmission of pathogens. Use of products such as an
antibacterial soap, a chlorhexidine solution, or an alcohol-
based handrub agent can actually inhibit the growth of or kill
microorganisms, which further reduces infection risk.
Adhere to the appropriate precautions established to prevent Adhering to the appropriate precautions that have been established
transmission of infection to the client (standard precau- to help prevent the transmission of microorganisms reduces the
tions, transmission-based precautions on other clients, client’s risk of infection.
neutropenic precautions). D @ +
Use sterile technique during invasive procedures (e.g., urinary Use of sterile technique reduces the possibility of introducing
catheterizations, venous and arterial punctures, injections, pathogens into the body.
tracheal suctioning, wound care) and dressing changes.
Anchor catheters/tubings (e.g., urinary, intravenous, wound Catheters/tubings that are not securely anchored have some degree
drainage) securely. D @ + of in-and-out movement. This movement increases the risk of
infection because it allows for the introduction of pathogens
into the body. It can also cause tissue trauma, which can result
in colonization of microorganisms.
Change equipment, tubings, and solutions used for treat- The longer that equipment, tubings, and solutions are in use, the
ments such as intravenous infusions, respiratory care, greater the chance of colonization of microorganisms, which
irrigations, and enteral feedings according to hospital can then be introduced into the body.
policy. D+
Maintain a closed system for drains (e.g., wounds, chest Each time a drainage or infusion system is opened, pathogens from
tubes, urinary catheters) and intravenous infusions the environment have an opportunity to enter the body.
whenever possible. Maintaining a closed system decreases this risk, which reduces
the possibility of infection.
Change peripheral intravenous line sites according to Peripheral intravenous line sites are changed routinely to reduce
hospital policy. persistent irritation of one area of a vein wall and the resultant
colonization of microorganisms at that site.
Proper wound care facilitates wound healing and reduces the
Provide appropriate wound care (e.g., use dressing materials
number of pathogens that enter or are present in the wound,
that maintain a moist wound surface, assist with debride-
which reduces the risk of the wound becoming infected.
ment of necrotic tissue, use dressing materials that absorb
excess exudate, protect granulating tissue from trauma
and contamination, maintain patency of wound drains).
D+

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536 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Protect client from others with infections. D@ + Protecting the client from others with infections reduces the client’s
risk of exposure to pathogens.
Implement measures to maintain healthy, intact skin (e.g., Healthy, intact skin reduces the risk for infection by:
keep skin lubricated, clean, and dry; instruct or assist e Providing a physical barrier against the introduction of
client to turn every 2 hrs; keep bed linens dry and wrinkle- pathogens into the body
free). D @+ ¢ Removing many of the microorganisms on the surface of the
skin by means of the constant shedding of the epidermis
¢ Inhibiting the growth of some bacteria on the surface of the skin
(sebum contains fatty acids, which create a slightly acidic
environment that inhibits the growth of some bacteria)
Implement measures to reduce stress (e.g., reduce fear, anxi- Stress causes an increased secretion of cortisol. Cortisol interferes
ety, and pain; help client identify and use effective coping with some immune responses, which subsequently increases the
mechanisms). D @ client’s susceptibility to infection.
Instruct and assist client to perform good perineal care The perineal area contains a large number of organisms. Routine
routinely and after each bowel movement. D @ + cleansing of the area reduces the risk of colonization of organisms
and subsequent perineal, urinary tract, and/or vaginal infection.
Instruct and assist client to perform good oral hygiene as Frequent oral hygiene helps prevent infection by removing most of the
often as needed. D @+ food, debris, and many of the microorganisms that are present in
the mouth. It also helps maintain the integrity of the oral mucosa,
which provides a physical and chemical barrier to pathogens.
Implement measures to prevent urinary retention (e.g., A client experiencing urinary retention is at increased risk for
instruct client to urinate when the urge is felt, promote urinary tract infection because:
relaxation during voiding attempts). D+ ¢ The urine that accumulates in the bladder creates an environment
conducive to the growth and colonization of microorganisms.
¢ Voiding does not occur, so microorganisms are not flushed from
the mucous lining of the urethra; these microorganisms can
colonize and ascend into the bladder.
Implement measures to prevent stasis of respiratory secre- Respiratory secretions provide a good medium for growth of micro-
tions (e.g., assist client to turn, cough, and deep breathe; organisms. By preventing stasis, there is less chance of coloniza-
increase activity as allowed and tolerated; perform tracheal tion of microorganisms and a decreased risk for development of
suctioning if indicated). D+ respiratory tract infection.
Instruct client to receive immunizations (e.g., influenza Immunizations are often recommended to reduce the possibility of
vaccine, pneumococcal vaccine) if appropriate. some infections in high-risk clients (e.g., those clients who are
immunosuppressed, elderly, or have a chronic disease).

Dependent/Collaborative Actions
Maintain an optimal nutritional status. Administer vitamins Adequate nutrition is needed to maintain normal function of the
and minerals as ordered. D+ immune system.
Perform actions to reduce inflammation of the bowel: These medications are given to prevent further ulceration of the
e Administer corticosteroids, _aminosalicylates, and/or bowel and subsequently reduce the risk of intestinal infection.
immunomodulating agents as ordered.
Consult appropriate health care provider regarding initiation Most antimicrobials disrupt cell wall synthesis, which halts the
of antimicrobial therapy if indicated. Administer antimi- growth of or kills microorganisms. This can effectively reduce
crobials if ordered (antimicrobials are generally given only the client’s risk for infection.
if surgery is planned or if the client has severe colitis and
is at high risk for infection; however, metronidazole or
ciprofloxacin may be prescribed by some practitioners for
the relief of symptoms).

|Collaborative »Diagnosis
oe |RISK FOR RENAL CALCULI

Definition: Crystallized stones in the urinary tract.

Related to:
° Crystalline deposits in the urine associated with:
° Increased serum oxalate levels (dietary oxalate normally binds with calcium in the intestine and is excreted in the stool;
in clients with inflammatory bowel disease, calcium is bound with the poorly absorbed fat and oxalate becomes available
for absorption)
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 537

e Decreased flushing of solutes from the urinary tract if urine formation is reduced as a result of deficient fluid volume
e Treatment with sulfasalazine

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of flank pain; verbalization of nausea Hematuria; vomiting

RISK FACTORS DESIRED OUTCOMES

e Chronic disease
The client will not develop renal calculi as evidenced by:
e Treatment regimen
a. Absence of flank pain, hematuria, nausea, and
vomiting
b. Clear urine without calculi

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of renal calculi Early recognition of signs and symptoms of renal calculi allows for
(e.g., dull, aching or severe, colicky flank pain; hematuria; prompt intervention.
nausea; vomiting).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent renal calculi: Providing adequate hydration helps maintain adequate blood flow
e Maintain a minimum fluid intake of 2500 mL/day unless to the kidneys to maintain glomerular filtration rate.
contraindicated. D @+
e Encourage client to decrease intake of foods/fluids high Decreases absorption of oxalate from the intestine.
in oxalate (e.g., tea, instant coffee, peanuts, chocolate,
spinach).
e Encourage client to adhere to a low-fat diet. A low-fat diet reduces the amount of fat available to bind calcium,
thereby freeing calcium to bind with oxalate.

Dependent/Collaborative Actions
If signs and symptoms of renal calculi occur:
e Strain all urine and save any calculi for analysis; report Straining the urine helps to determine whether the client has
finding to physician. passed a renal calculus.
e Maintain a minimum fluid intake of 2500 mL/day unless Helps to flush out the urinary tract and helps to pass a renal
contraindicated. calculi.
e Administer analgesics and antispasmodic agents (e.g., oxy- Analgesics and antispasmodic agents decrease/eliminate pain
butynin) as ordered. experienced with renal calculi.
e Prepare client for removal of calculi (e.g., extracorporeal Explain procedures to client and provide required preprocedure or
shock wave lithotripsy, percutaneous nephrolithotomy, preoperative interventions.
ureteroscopy with lithotripsy and stone extraction) if
planned.
Implement measures to reduce inflammation of the bowel These agents decrease inflammation and are used to put the
(e.g., administer corticosteroids, aminosalicylates, and/or disease in remission.
immunomodulating agents as ordered).

Collaborative Diagnosis RISK FOR PERIRECTAL, RECTOVAGINAL, ENTEROVESICAL,

AND ENTEROENTERIC ABSCESSES AND FISTULAS
of pus in tissues or a body cavity.
Definition: Fistula, ulceration, or tear in the intestinal wall; abscess—an accumulation

Related to: Extension of a mucosal fissure or ulcer through the intestinal wall

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538 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increased or constant abdominal Fever; perianal redness, swelling, and bleeding; foul-
pain; verbalization of rectal pain smelling vaginal discharge; increased WBC count

RISK FACTOR DESIRED OUTCOMES

* Chronic illness The client will have resolution of any abscesses and fistulas
that develop as evidenced by:
a. Temperature declining toward normal
b. Resolution of abdominal pain
c. Absence of perianal redness, swelling, and pain
d. No unusual vaginal drainage
e. Clear, yellow urine
f. WBC count declining toward normal

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of abscess and/or Early recognition of signs and symptoms of abscess and/or fistula
fistula formation (e.g., further increase in temperature; formation allows for prompt intervention.
increased or more constant abdominal pain; perianal red- Corticosteroids, aminosalicylates, and/or immunomodulating
ness, swelling, and pain; foul-smelling vaginal discharge or agents reduce bowel inflammation.
passage of stool from vagina; dysuria; fecaluria; further
increase in WBC count).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce inflammation of the bowel Promotes healing of the intestinal mucosa and subsequently
(e.g., administer corticosteroids, aminosalicylates, and/or decreases the risk for the development of abscesses and fistulas.
immunomodulating agents as ordered).
If signs and symptoms of abscesses or fistulas occur:
e Prepare client for diagnostic studies (e.g., computed Decreases client anxiety.
tomography, ultrasonography, barium enema).
e Administer the following medications if ordered:
e Antimicrobial agents (e.g., metronidazole, ciprofloxacin) Antimicrobials treat/prevent infection.
e Immunomodulator agents such as azathioprine, mercap- Decreases inflammation and promotes healing.
topurine, or a monoclonal antibody (e.g., infliximab)
e If a cutaneous fistula is present, perform wound care as
ordered.
e Prepare client for surgical intervention (e.g., incision and Explain procedures to client and provide required preoperative
drainage of abscess, resection of involved area) if planned. interventions.

“| RISK FOR TOXIC MEGACOLON

Definition: A life-threatening complication of inflammatory bowel diseases in which there is segmental or total dilation of the
colon as a result of inflammation or infection.
Related to: :
° Loss of colonic muscle tone associated with the effects of widespread inflammation in the bowel, use of some medications
(e.g., opiates, anticholinergics), and hypokalemia

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increasing abdominal pain and Hypoactive or absent bowel sounds; abdominal percussion
tenderness reveals tympany; sudden episodes of diarrhea; tachycardia;
fever; increased WBC count
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 539

RISK FACTORS DESIRED OUTCOMES

Chronic illness
The client will not develop toxic megacolon as evi-
Treatment regimen
denced by:
. Absence of abdominal distention
. Gradual resolution of abdominal pain
. Active bowel sounds
. Gradual resolution of diarrhea
. Temperature and WBC count declining toward normal
Cee
O-O.0

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of toxic megacolon: Early recognition of signs and symptoms of toxic megacolon allows
Abdominal distention and increased abdominal pain and for prompt intervention.
tenderness
Hypoactive or absent bowel sounds with tympanic percus-
sion note over abdomen
Sudden decrease in episodes of diarrhea
Fever (usually >38.6°C) and tachycardia
Increase in WBC count
Abdominal radiograph showing colonic dilation

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent development of toxic
megacolon:
Perform actions to reduce inflammation of the bowel These medications reduce inflammation, which will help prevent
(e.g., administer corticosteroids, aminosalicylates, and/or toxic megacolon.
immunomodulating agents as ordered).
Administer medications that slow GI motility (e.g., Opioid analgesics, anti-diarrheal agents and anticholinergics may
opioid analgesics, antidiarrheal agents, anticholinergics) cause constipation, thereby contributing to toxic megacolon.
judiciously.
Perform actions to prevent or treat hypokalemia (e.g., eat Helps prevent megacolon.
foods high in potassium, take potassium supplements).
If signs and symptoms of toxic megacolon occur:
Withhold oral intake as ordered. Withholding oral intake helps decompress the colon.
Consult physician about discontinuing any medications Increasing motility helps to decompress the colon.
that slow GI motility (e.g., narcotic analgesics, antidiar-
rheal agents, anticholinergics).
Insert NG tube and maintain suction as ordered. Insertion of an NG tube provides decompression of the GI tract.
Administer the following if ordered: IV fluids are given to maintain adequate vascular volume (third-
e Intravenous fluids space fluid shifting occurs as a result of increased capillary
permeability associated with the inflammation and increased
intraluminal pressure that are present with toxic megacolon).
* Corticosteroids Steroids reduce intestinal inflammation.
e Antimicrobials (e.g., metronidazole) Antimicrobials help prevent infection, which is important because
the risk of perforation is increased when toxic megacolon
develops.
Prepare client for surgical intervention (¢.g., colectomy) if If above treatment is not effective in decompressing the colon,
planned. surgery is indicated.
Implement measures to reduce inflammation of the bowel These actions reduce intestinal narrowing and scar tissue
corticosteroids, aminosalicylates, and/or formation.
(e.g., administer
immunomodulating agents as ordered).

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 540 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

|Collaborative >
Diagnosis |RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum.

Related to: Perforation of the bowel or leakage from an abscess or fistula

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal pain Nausea and vomiting; distended and rigid abdomen;
diminished or absent bowel sounds; fever; tachypnea;
increased WBC count

RISK FACTORS DESIRED OUTCOMES

e Exposure to pathogens
The client will not develop peritonitis as evidenced by:
e Treatment regimen
. Temperature declining toward normal
. Soft, nondistended abdomen
. Gradual resolution of abdominal pain
Gradual return of normal bowel sounds
. Absence of nausea and vomiting
. Stable vital signs
WBC count declining toward normal
emoeanse

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of peritonitis (e.g., Early recognition of signs and symptoms of peritonitis allows for
increase in severity of abdominal pain; generalized abdomi- prompt intervention.
nal pain; rebound tenderness; distended, rigid abdomen;
increase in temperature; tachycardia; tachypnea; hypoten-
sion; nausea; vomiting; continued diminished or absent
bowel sounds; WBC count that increases or fails to decline
toward normal).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of peritonitis occur:
e Withhold oral intake as ordered. Oral intake irritates the colon and increases pain associated with
peritonitis.
° Place client on bedrest in a semi-Fowler’s position. This position assists in pooling or localizing intestinal contents in
the pelvis rather than under the diaphragm.
e Prepare client for diagnostic tests (e.g., abdominal radio- Provide preprocedure information as required by the client.
graph, computed tomography, ultrasonography) if planned.
e Insert NG tube and maintain suction as ordered. Decompresses the GI tract.
e Administer antimicrobials (e.g., metronidazole) as ordered. Helps decrease infection in the GI tract.
e Administer intravenous fluids and/or blood volume IV fluids and/or blood volume expanders prevent or treat shock
expanders if ordered. that can result from the increased capillary permeability
that occurs with inflammation and the subsequent escape of
protein, fluid, and electrolytes from the vascular space into the
peritoneal cavity.
° Prepare client for surgical intervention (e.g., repair of per-
foration, bowel resection) if planned.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 541

|Nursing ec)
Diagnosis |DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT nox; OR INEFFECTIVE HEALTH MAINTENANCE*® nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic or its acquisition.
Ineffective Family Health Management: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family
unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to maintain well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of the problem Inaccurate follow-through of instructions; inappropriate
behaviors

RISK FACTORS
e Denial of disease process
e Cognitive deficiency
e Failure to reduce risk factors

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: diet; medication; treatment regimen Health system guidance; teaching: individual; teaching:
disease process; teaching: prescribed diet; teaching:
prescribed medication

NURSING ASSESSMENT RATIONALE

Assess client’s ability and readiness to learn. Learning is more effective when the client is motivated and
Assess the client’s understanding of teaching. understands the importance of what is to be learned. Readiness
to learn changes based on situations and physical and
emotional challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the incidence of disease exacerbation.

Independent Actions
Reinforce the importance of adhering to the prescribed treat-
ment regimen.
Instruct the client regarding ways to reduce bowel irritation:
° Reduce intake of or avoid foods/fluids likely to be poorly Irritation of the bowel may cause nausea and vomiting as well as
digested or that may irritate the bowel (e.g., raw fruits and an exacerbation of the disease.
vegetables, whole-grain cereals, gravy, fried foods, spicy
foods, milk and milk products, caffeine-containing bever-
ages, extremely hot drinks, iced drinks, alcohol).
e Avoid use of laxatives.
Explain that stress can precipitate periods of exacerbation. Encourage client to find ways of reducing stress in his/her life, as
this will decrease exacerbations of the disease.
Provide information about stress management classes and
counseling services that may assist client to manage stress.

INTERVENTIONS RATIONALE
THERAPEUTIC eee
ee
GEL
Desired Outcome: The client will verbalize ways to main-
tain an optimal nutritional status.

te for the client's discharge teaching needs.

*The nurse should select the diagnostic label that is most appropria

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 542 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Provide instructions regarding ways to maintain an optimal
nutritional status:
e Reinforce instructions regarding prescribed diet (a low-residue, Maintenance of nutritional status and the appropriate diet is
high-calorie, high-protein diet is often recommended). important in decreasing exacerbations of the disease and
e Inform client that eating small, frequent meals rather than maintaining nutritional status.
three large meals may help achieve the recommended
high-calorie intake.
e Reinforce the benefits of eating when rested and in a
relaxed atmosphere.
e Stress the importance of taking vitamins and minerals as
prescribed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state ways to prevent

perianal skin breakdown.

Independent Actions
Provide the following instructions about ways to prevent Each of these interventions prevents skin breakdown, which subse-
perianal skin breakdown: quently decreases the risk of infection and pain.
Use soft toilet tissue for wiping after each bowel movement.
Cleanse perianal area with a mild soap and warm water
after each bowel movement; dry thoroughly.
Apply a protective ointment or cream to perianal area after
skin has been cleansed.

THERAPEUTIC INTERVENTIONS RATIONALE

5558S

Desired Outcome: The client will verbalize an understand-

ing of medications ordered including rationale, food, and
drug interactions, side effects, schedule for taking, and impor-
tance of taking as prescribed.

Independent Actions
Explain rationale for, side effects of, and importance of taking Knowledge of the medication regimen and the impact of these
medications prescribed. Inform client of pertinent food medications on the system, as well as how the medication regi-
and drug interactions. men can be incorporated into the client’s lifestyle, allows the
Examples: client some mechanism of control of his/her disease and the
e Sulfasalazine ability to have an active part in treatment and care.
e Corticosteroid
Instruct client to inform physician before taking other pre- Over-the-counter medications may impact prescription medications
scription and nonprescription medications. and should not be taken without a health care provider's approval.

THERAPEUTIC INTERVENTIONS RATIONALE

een

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
t
Instruct client to report the following signs and symptoms: The client and significant others should be aware of what
e Recurrent episodes of diarrhea and abdominal pain and symptoms are associated with exacerbations of the disease or
cramping infection and to report these to the health care provider.
e Increasing abdominal distention
e Persistent vomiting
e Unusual rectal or vaginal drainage
e Burning on urination or brownish, foul-smelling urine
e Pain, swelling, or open sores in perianal area
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 543

THERAPEUTIC INTERVENTIONS RATIONALE

e Continued weight loss
Constipation
Yellowing of skin, flank pain, change in vision, eye pain, or
joint pain or swelling (can indicate extraintestinal involvement)

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify resources that

can assist in the adjustment to changes resulting from inflam-
matory bowel disease and its treatment.

Independent Actions
Provide information about resources that can assist the client Client may require assistance from community organizations for
and significant others in adjusting to inflammatory bowel both emotional and financial support once discharged from the
disease and its effects (e.g., local support groups, Crohn’s acute care facility.
and Colitis Foundation of America, counseling services,
stress management classes).
Reinforce importance of keeping follow-up appointments Inflammatory bowel disease is a chronic illness and requires ap-
with health care provider. propriate follow-up with health care providers.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider and activity level.

Independent Actions
Collaborate with the client to develop a plan for adherence Allows body to heal.
that includes:
e Importance of frequent rest periods throughout the day.
Implementing measures to improve client compliance: Support from client’s significant others is important in maintaining
e Include significant others in teaching sessions if possible compliance to the therapeutic regimen.
e Encouraging questions and allow time for reinforcement Improves client’s and family’s understanding of disease process and
and clarification of information provided. what to do to remain healthy.
° Providing written instructions on future appointments Written instructions allow the client to refer to them after discharge
with health care provider, medications prescribed, signs as needed.
and symptoms to report, and future laboratory studies.

ADDITIONAL NURSING/COLLABORATIVE
DIAGNOSIS
DISTURBED SLEEP PATTERN NDx DISTURBED SELF-CONCEPT
Related to frequent need to defecate, pain, fear, and anxiety Related to:
e Dependence on others to meet self-care needs
FEAR NDx e Embarrassment associated with diarrhea
ANXIETY NDx e Changes in sexual functioning associated with pain,
Related to: fatigue, and weakness
e Symptoms being experienced (e.g., abdominal pain, persis- ¢ Changes in lifestyle associated with pain and chronic diarrhea
tent diarrhea, fever)
e Lack of understanding of diagnosis, diagnostic tests, and RISK FOR IMPAIRED TISSUE INTEGRITY NDx
treatment Related to:
e Concern about need for surgery if disease condition can- * Damage to the skin and/or subcutaneous tissue associated
not be medically controlled with prolonged pressure on the tissues, friction, and shear-
Anticipated changes in future lifestyle because of inability ing that can occur when mobility decreased
e
to control symptoms e Frequent contact with irritants associated with persistent
diarrhea
° Concern about expense of hospitalization and treatment
for a chronic disease e Increased fragility of skin associated with malnutrition

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 544 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

e Hyperthermia related to stimulation of the thermoregula- e Tissue hypoxia associated with anemia resulting from:
tory center in the hypothalamus by endogenous pyrogens e Blood loss from the ulcerated bowel
that are released in an inflammatory process e Decreased oral intake and impaired absorption of iron,
vitamin B,2, and folate
ACTIVITY INTOLERANCE NDx e Increased energy expenditure associated with the increased
Related to: metabolic rate that may be present during period of
e Inadequate nutritional status exacerbation
e Difficulty resting and sleeping associated with pain, fre-
quent need to defecate, fear, and anxiety

INTESTINAL OBSTRUCTION AND BOWEL RESECTION

Intestinal (bowel) obstruction is a condition in which the This care plan focuses on the adult client hospital-
intestinal contents fail to move through the bowel. The ob- ized with an intestinal obstruction and addresses
struction can be partial or complete and can develop slowly what postoperative care is required if a bowel resec-
or rapidly. It can occur as a result of any factor that narrows tion is required. Some of the information is applicable
the lumen of the intestine or interferes with peristalsis. to clients receiving follow-up care in an extended care
Narrowing of the lumen results in a mechanical obstruction facility or home setting.
and can be caused by factors such as adhesions, tumors, in-
flammatory bowel disease, hernias, fecal impaction, intussus-
ception, a volvulus, and strictures. In a nonmechanical OUTCOME/DISCHARGE CRITERIA
obstruction, the bowel lumen remains open, but the intesti-
nal contents are not propelled forward. Factors that can The client who does not have surgery will:
cause this paralytic (adynamic) ileus include abdominal Have absence of or minimal abdominal pain
surgery, effects of anesthesia and some medications (e.g., Have gradual return of normal bowel function
narcotic [opioid] analgesics, some antiemetics, anticholiner- Tolerate prescribed diet
gics, antidiarrheals), electrolyte imbalances such as hypokale- Have no signs and symptoms of complications
mia, decreased blood flow to the intestine (can occur with panes
SA
ee
SINS) Verbalize an understanding of ways to reduce the risk for
conditions such as hypovolemia or blockage of mesenteric recurrent intestinal obstruction
vessels as a result of an embolus, thrombus, or arteriosclerosis), 2 State signs and symptoms to report to the health care
spinal cord injury, and peritonitis. provider
Signs and symptoms of intestinal obstruction vary N . Develop a plan for adhering to recommended diet, prescribed

depending on the location, cause, and degree of the obstruc- medications, ways to prevent recurrent intestinal obstruction,
tion. Common clinical manifestations include abdominal and future appointments with health care provider
pain and distention, nausea, and vomiting. Hyperactive,
high-pitched bowel sounds are present early in the develop-
ment of a mechanical obstruction. Bowel sounds are absent POSTOPERATIVE
or hypoactive in nonmechanical obstruction and as mechan-
ical obstruction worsens. The client will:
Treatment of intestinal obstruction is directed toward re- 1. Have absence of or minimal abdominal postoperative pain
lieving symptoms, managing fluid and electrolyte imbal- Have gradual return of normal bowel function
ances, preventing complications, and determining and treat- Tolerate prescribed diet
ing the cause of the obstruction. Most cases of nonmechanical lS Have no signs and symptoms of postoperative complica-
poe
obstruction do not necessitate surgery. Some mechanical ob- tions
structions can be treated nonsurgically (e.g., enemas and S. Have clear, audible breath sounds throughout lungs
laxatives to remove fecal impaction, dilatation of obstructed 6. Have evidence of normal healing of surgical wound(s)
portion of bowel via endoscopy, radiation, or chemotherapy 7. Verbalize an understanding of ways to reduce the risk for
to reduce tumor size, gentle instillation of barium to resolve recurrent intestinal obstruction
an intussusception or reverse a sigmoid volvulus). Surgical oe). State signs and symptoms to report to the health care
intervention (intestinal resection with re-anastomosis or cre- provider ;
ation of an ileostomy or colostomy) is indicated when it 9. Develop a plan for adhering to recommended diet, pre-
is necessary to remove an obstruction that persists despite scribed medications, ways to prevent recurrent intestinal
conservative management or to remove a segment of bowel obstruction, and future appointments with health care
that is strangulated or necrotic. provider
 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract 545

|Nursing/Diagnosis RISK FOR IMBALANCED FLUID VOLUME no:;

RISK FOR ELECTROLYTE IMBALANCE*
Definition: Risk for Imbalanced Fluid Volume NDx: Susceptible to a decrease, increase, or rapid shift from one to the other
of intravascular, interstitial, and/or intracellular fluid, which may compromise health. This refers to body fluid
loss, gain, or both. Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte levels, which
may compromise health.
Related to:
Risk for Imbalanced Fluid Volume NDx:
e Increased capillary permeability that results from increased intraluminal pressure in the distended bowel

Risk for Electrolyte Imbalance NDx; hypokalemia, hypochloremia, and metabolic alkalosis related to:
e Decreased absorption of intestinal fluid into the vascular space associated with inflammation and distention of the bowel
(the sequestering of fluid in the intestine is a major factor with obstructions of the small intestine and proximal portion of
the large intestine)
e Restricted oral intake
e Excessive loss of fluid and electrolytes associated with vomiting and NG tube drainage

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea, headache, and abdominal pain Poor skin turgor; dry, cracked mucous membranes;
hypotension; weight loss; prolonged capillary refill greater
than 2 to 3 seconds; decreased urine output; increased
urine specific gravity; abdominal distention; vomiting;
positive Chvostek and Trousseau signs; abnormal serum
electrolyte levels; cardiac dysrhythmias, muscle weakness,
paresthesias, twitching, spasms, and dizziness; increased
BUN and Hct

RISK FACTORS DESIRED OUTCOMES

e Failure of regulatory mechanisms The client will maintain fluid and electrolyte balance as
e Inadequate fluid/food intake evidenced by:
e Immobility a. Normal skin turgor
b. Moist mucous membranes
c. Stable weight
d. BP and pulse rate within normal range for client and
stable with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. Balanced I&O
h. Urine specific gravity within normal range
i. Abdomen less distended and bowel sounds returning
toward normal
j. Absence of cardiac dysrhythmias, muscle weakness,
paresthesias, twitching, spasms, and dizziness
k. BUN, Hct, serum electrolyte, and ABG values within
normal range

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; electrolyte and acid-base balance Fluid management; electrolyte management: hypokalemia;
electrolyte management: hypocalcemia; electrolyte manage-
ment: hypomagnesemia; acid-base management: metabolic
acidosis; diarrhea management

based on assessment of the client.

*The nurse must determine the appropriate nursing diagnosis

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 546 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of electrolyte imbalance
volume: allows for prompt treatment.
e Decreased skin turgor, dry mucous membranes, thirst
e Weight loss of 2% or greater over a short period
e Postural hypotension and/or low BP
e Weak, rapid pulse
e Capillary refill time longer than 2 to 3 seconds
e Neck veins flat when client is supine
e Change in mental status
e Decreased urine output with increased specific gravity
(reflects an actual rather than potential fluid deficit)
¢ Significant increase in BUN and Hct above previous levels
e Hypokalemia (e.g., cardiac dysrhythmias, postural hypo-
tension, muscle weakness, nausea and vomiting, abdomi-
nal distention, hypoactive or absent bowel sounds)
° Hypomagnesemia and/or hypocalcemia (e.g., anxiousness;
irritability; cardiac dysrhythmias; positive Chvostek and
Trousseau signs; numbness or tingling of fingers, toes, or
circumoral area; hyperactive reflexes; tetany; seizures)
° Metabolic acidosis (e.g., drowsiness; disorientation; stupor;
rapid, deep respirations; headache; nausea and vomiting;
cardiac dysrhythmias; low pH and CO, content)
e Third-spacing
e Ascites
e Evidence of vascular depletion (e.g., postural hypotension,
weak, rapid pulse; decreased urine output)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent or treat imbalanced fluid and
electrolytes:
e Perform actions to reduce nausea and vomiting (e.g., These interventions decrease nausea and vomiting, helping to
eliminate noxious stimuli, have patient change positions maintain positive fluid and electrolyte balance.
slowly, provide oral hygiene after each meal). D @
If an NG tube is present and needs to be irrigated frequently Provides decompression of the stomach, and irrigation with normal
and/or with large volumes of solution, irrigate it with nor- saline causes less irritation of the gastric mucosa.
mal saline rather than water. D >

Dependent/Collaborative Actions
Implement measures to prevent or treat imbalanced fluid and
electrolytes:
e Maintain intravenous fluid therapy as ordered. Prevents dehydration.
e Administer electrolyte replacement as ordered. Helps to maintain appropriate electrolyte balance.
e Administer albumin infusions if ordered. Increases colloid osmotic pressure and promotes mobilization of
third-space fluid back into the vascular space.
e When oral intake is allowed, assist client to select foods/ Oral intake of foods high in potassium is necessary to maintain
fluids within the prescribed dietary regimen that would adequate electrolyte balance.
replenish electrolytes. D +
Consult physician if signs and symptoms of imbalanced fluid Notification of the physician allows for prompt alteration, in the
and electrolytes persist or worsen. treatment plan.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 547

poles eee ACUTE PAIN nox (ABDOMINAL)

Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms
of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild
to severe with an anticipated or predictable end, and a duration of less than 3 months.

Related to:
e Distention of the intestinal lumen associated with the accumulation of gas and fluid
e Inflammation of the intestine (can occur as a result of the underlying cause of the obstruction [e.g., inflammatory bowel
disease])

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain Autonomic responses (e.g., diaphoresis; changes in BP,
respiration, pulse rate; pupillary dilatation); expressive
behavior (e.g., restlessness, moaning, crying, vigilance,
irritability, sighing); changes in appetite and eating;
protective gestures; guarding behavior; facial mask; sleep
disturbance (eyes lack luster, fixed or scattered movement,
beaten look, grimace); self-focus; narrowed focus (altered
time perception, impaired thought processes, reduced
interaction with people and environment); distraction
behavior (e.g., pacing, seeking out other people and/or
activities, repetitive activities)

RISK FACTOR DESIRED OUTCOMES

a
e Chronic illness The client will experience diminished pain as evi-
denced by:
fab). Verbalization of same
b. Relaxed facial expression
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

Pain control; minimizing pain’s disruptive effects Pain management; environmental management: comfort;
analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (€.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
intervention and improved pain control.
pain, grimacing, reluctance to move, restlessness, diapho-
resis, increased BP, tachycardia).
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps determine
intensity rating scale. the most appropriate interventions for pain management. Use of a
pain intensity rating scale gives the nurse a clearer understanding
of the pain being experienced and promotes consistency when
communicating with others about the client’s pain experience.
Knowledge of the client’s pain pattern assists in the identification
Assess the client’s pain pattern (e.g., location, quality, onset,
of effective pain management interventions.
duration, precipitating factors, aggravating factors, allevi-
ating factors).
Many variables affect a client’s response to pain (e.g., age, Sex, Cop-
Ask the client to describe previous pain experiences and
ing style, previous experience with pain, culture, cause of pain).
methods used to manage pain effectively.
Knowledge of the client’s usual response to pain and methods
previously used to manage pain effectively enables the nurse to
evaluate the client’s pain more accurately and facilitates the
identification of effective strategies for pain management.

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NDx = NANDA Diagnosis D = Delegatable Action
 548 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety (e.g., assure Fear and anxiety can decrease the client’s threshold and tolerance
client that the need for pain relief is understood, plan for pain and thereby heighten the perception of pain. In addi-
methods for achieving pain control with client, provide a tion, pain management methods are not as effective if the client
calm environment). is tense and unable to relax.
Prevent actions that will increase the accumulation of intestinal These actions can increase air swallowing and subsequent gas
gas and fluid (e.g., using a straw, chewing gum). D @ production.
Implement measures to promote rest (e.g., minimize environ- Fatigue can decrease the client’s threshold and tolerance for pain
mental activity and noise, provide care to allow for periods and thereby heighten the perception of pain. A well-rested client
of uninterrupted rest). D@ + often experiences decreased pain and increased effectiveness of
pain management measures.
When oral intake is allowed, advance diet slowly and instruct Reduces gas in the GI tract.
client to avoid intake of carbonated beverages and gas-
producing foods (e.g., cabbage, onions, beans).

Dependent/Collaborative Actions
Insert NG tube and maintain suction as ordered. Provides decompression and prevents gas accumulation in the
stomach.
Administer GI stimulants (e.g., metoclopramide) if ordered. Promotes intestinal motility (may be ordered if obstruction is not
D+ complete or is the result of a paralytic ileus).
Administer analgesics as ordered (the use of opioid analgesics The administration of analgesics before a pain-producing event
is often avoided until the cause of the obstruction is deter- helps minimize the pain that will be experienced. Analgesics are
mined). D also more effective if given before pain becomes severe because
mild to moderate pain is controlled more quickly and effectively
than severe pain.
Provide or assist with nonpharmacological methods for pain Nonpharmacological pain management includes a variety of inter-
relief. Examples include: ventions. It is believed that most of these are effective because
° Cutaneous stimulation measures (e.g., pressure, massage, they stimulate closure of the gating mechanism in the spinal
heat and cold applications, TENS, acupuncture) cord and subsequently block the transmission ofpain impulses.
e Relaxation techniques (e.g., progressive relaxation exer- In addition, some interventions are thought to stimulate the
cises, meditation, guided imagery) release of endogenous analgesics (e.g., endorphins) that inhibit
e Distraction measures (e.g., listening to music, conversing, the transmission of pain impulses and/or alter the client’s
watching television, playing cards, reading) perception of pain. Many of the nonpharmacological interven-
e Position change tions also help decrease pain by promoting relaxation.
Consult appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
pharmacist, pain management specialist) if above tion of the treatment plan.
measures fail to provide adequate pain relief.

|Nursing Diagnosis
eso NAUSEA nox

Definition: A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which
may or may not
result in vomiting.

Related to:
e Stimulation of the vomiting center associated with:
e Stimulation of the visceral afferent pathways resulting from inflammation and distention of the intestine
° Stimulation of the cerebral cortex resulting from pain and stress

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea Gagging; retching (dry heaving)
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 549

RISK FACTORS DESIRED OUTCOMES

e Chronic illness
The client will experience relief of nausea and vomiting as
e Gastric irritation
evidenced by:
a. Verbalization of relief of nausea
b. Absence of vomiting

NOC OUTCOMES NIC INTERVENTIONS

Nausea and vomiting severity Nausea management; vomiting management;

environmental management: comfort

NURSING ASSESSMENT RATIONALE

Assess for nausea and vomiting. Identification of the signs and symptoms of nausea and vomiting
Determine: allows for prompt intervention.
e Duration
e Frequency
e Severity

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce nausea and vomiting: Food/fluid restrictions and insertion of an NG tube decreases
e Maintain food and oral fluid restrictions as ordered. pressure within the abdomen.

Dependent/Collaborative Actions
e Insert NG tube and maintain suction as ordered. Insertion of an NG tube will help to decompress the stomach and
alleviate nausea and vomiting.
e Eliminate noxious sights and odors from the environment. Noxious stimuli can cause stimulation of the vomiting center.
° Instruct client to change positions slowly. D @ + Rapid movements can result in chemoreceptor trigger zone stimula-
tion and subsequent excitation of the vomiting center.
Provide oral hygiene after each emesis. D@ + Oral hygiene removes the taste of emesis from the mouth and helps
to decrease subsequent nausea.
Reduce pain via medications, positioning, or distractions. D + Pain may stimulate chemoreceptor trigger zone and produce nausea.
e Perform actions to reduce fear and anxiety (e.g., assure client Fear and anxiety may produce nausea.
that staff are nearby; provide a calm, restful environment;
explain all tests and procedures).
Encourage Client to take deep, slow breaths when nauseated. Taking slow, deep breaths helps to relax the client and reduce
De+ stress.

Dependent/Collaborative Actions
Implement measures to reduce nausea and vomiting:
Administer antiemetics as ordered. D + Antiemetics raise the threshold of the chemoreceptor trigger zone,
thus decreasing nausea.
° When oral intake is allowed, advance diet slowly. Initially Oral intake helps maintain nutritional status and should be
encourage bland floods such as Jello, rice, broth, toast, and
advanced slowly to decrease the incidence of nausea.
dry crackers.
Consult a physician or a pharmacist if nausea continues. Allows for continued intervention to decrease/eliminate nausea.

- ..) RISK FOR

|Collaborative/Nursing »Diagnosis PERITONITIS

Definition: Inflammation of the peritoneum.

with perforation of the bowel if it occurs
Related to: Release of intestinal contents into the peritoneal cavity associated

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal pain Nausea and vomiting; distended and rigid abdomen;
diminished or absent bowel sounds; fever; tachypnea;
increased WBC count

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RISK FACTORS DESIRED OUTCOMES

e Exposure to pathogens
The client will not develop peritonitis as evidenced by:
e Chronic illness
a. Temperature stable and less than 36°C
b. Abdomen less distended and firm
c. No increase in abdominal pain and tenderness, nausea,
and vomiting
d. Gradual return of normal bowel sounds
e. Stable vital signs
f. No increase in WBC count

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of peritonitis (e.g., Early recognition of signs and symptoms of peritonitis allows for
further increase in temperature or temperature >38°C, prompt intervention.
abdomen more distended and firm, increase in severity of
abdominal pain, rebound tenderness, increased nausea
and vomiting, tachycardia, hypotension, increase in WBC
count)

THERAPEUTIC INTERVENTIONS RATIONALE

SSS ———
Dependent/Collaborative Actions
¢ Implement measures to prevent peritonitis:
¢ Perform actions to reduce the risk for perforation of the
bowel:
e Implement measures to decrease the accumulation These actions maintain decompression of the gut.
of intestinal gas and fluid (e.g., insert an NG tube
and attach to suction, avoid carbonated beverages,
avoid gas-producing foods).
e Continue with actions to treat the underlying cause of the
obstruction (e.g., anti-inflammatory agents to treat inflam-
matory bowel disease, chemotherapeutic agents to reduce
tumor size).
e Administer antimicrobials if ordered. Antimicrobials reduce/prevent infection.
If signs and symptoms of peritonitis occur:
e Withhold oral food and fluids as ordered. Decreases pressure within the abdomen.
Place client on bedrest in a semi-Fowler’s position. Assists in pooling or localizing GI contents in the pelvis rather than
the diaphragm.
e Prepare client for diagnostic tests (e.g., abdominal radio- Decreases client’s fear and anxiety.
graph, computed tomography) if planned.
e Administer antimicrobials as ordered. Antimicrobials reduce infection.
e Administer fluids and/or blood volume expanders if Fluid volume and/or blood expanders prevent or treat shock that can
ordered. result from the increased capillary permeability that occurs with
inflammation and the subsequent escape of protein, fluid, and
electrolytes from the vascular space into the peritoneal cavity.
e Prepare client for surgery (e.g., drainage and irrigation of If infection is not controlled, a bowel resection may be required.
the peritoneum, bowel resection) if planned.

Collaborative »--
Diagnosis. RISK FOR INTESTINAL NECROSIS ,
Definition: Death of intestinal tissue.

Related to:
e Obstruction of blood flow in the affected area associated with:
e Inflammation and distention of the bowel lumen
e Hypovolemia
° Mesenteric vessel thrombosis or embolus (can be a cause of nonmechanical obstruction)
¢ Strangulation of a portion of the intestine (especially if obstruction is a result of a
hernia, strictures, adhesions, or a volvulus)
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 551

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of severe abdominal pain Bloody diarrhea; increased WBC count

RISK FACTORS DESIRED OUTCOMES

e Exposure to pathogens
The client will not experience intestinal necrosis as evi-
e Chronic illness
denced by:
e Lack of exercise
a. Decreased abdominal pain
b. Absence of bloody diarrhea
c. No increase in WBC count

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of intestinal necro- Early recognition of signs and symptoms of complications of intes-
sis (e.g., severe, continuous abdominal pain; bloody diar- tinal obstruction allows for prompt intervention.
thea; WBC count that increases or fails to decline toward
normal).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Interventions
Implement measures to improve blood flow to the intestine
in order to prevent intestinal necrosis:
e Perform actions to prevent and treat deficient fluid volume Maintenance of fluid volume is necessary to maintain adequate
(e.g., provide antiemetics for nausea and vomiting, insert circulation to the gut.
NG tube as needed, maintain intravenous fluids as
ordered, administer electrolytes as needed).
e Perform actions to reduce the accumulation of intestinal Decreases intestinal gas and fluid, which may decrease intestinal
gas and fluid (e.g., instruct client not to chew gum, suck blood flow.
on ice or hard candy; insert NG tube as needed; avoid
carbonated beverages).
e Prepare client for treatment of the underlying cause of If obstruction is not resolved, surgery may be necessary. The type of
vascular obstruction (e.g., mesenteric thrombectomy or surgical intervention depends upon the underlying cause of the
embolectomy; surgery to repair hernia, release adhesions, obstruction.
or correct volvulus) if planned.
If signs and symptoms of intestinal necrosis occur:
e Administer antimicrobials if ordered. Prevention of infection.
e Prepare client for surgical resection of the affected bowel. Usually performed if the client has extensive tissue necrosis or
gangrenous patches have developed.

DISCHARGE INFORMATION IF CLIENT DOES NOT REQUIRE SURGERY

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY HEALTH

MANAGEMENT npx; OR INEFFECTIVE HEALTH MAINTENANCE*® nox
related to specific topic, or its acquisition;
Definition: Deficient Knowledge NDx: Absence of cognitive information
Ineffective Family Health Manageme nt NDx: A pattern of regulating and integrating into family processes a
specific health goals of the
program for the treatment of illness and its sequelae that is unsatisfactory for meeting
to identify, manage, and/or seek help to maintain
family unit; Ineffective Health Maintenance NDx: Inability
well-being.

client assessment.
*The nurse must determine the appropriate diagnosis based on

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552 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; inability Inaccurate follow-through with instructions; inappropriate
to follow prescribed regimen behaviors; experience of preventable complications of
abdominal trauma

RISK FACTORS
e Cognitive deficit
e Financial concerns
e Failure to reduce risk factors for complications of abdomi-
nal trauma
e Inability to care for oneself
e Difficulty in modifying personal habits and integrating
treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen Health system guidance; teaching: individual; teaching:
disease process; teaching: prescribed diet; teaching:
prescribed medication

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to health care providers.

Independent Actions
Instruct client to report the following signs and symptoms: Client awareness of what changes require health care intervention
e Recurrent episodes of abdominal pain will improve timeliness of treatment for complications.
e Increasing abdominal distention
e Nausea or vomiting
e Constipation
e Elevated temperature

THERAPEUTIC INTERVENTIONS RATIONALE

eee
———————
eee
Desired Outcome: The client will verbalize an understand-
ing of ways to minimize the risk of recurrence of intestinal
obstruction.

Independent Actions
Collaborate with client to develop a plan for adherence that Reinforcement of information provided by the physician allows for
includes: clients to ask questions and improve their understanding of the
The physician’s instructions regarding ways to prevent the causes of recurrence of bowel obstruction, and_the* dietary
risk for recurrent intestinal obstruction. For example: interventions to help prevent further complications.
e Follow-up radiation and/or chemotherapy if obstruction
was caused by a tumor
e Dietary and medication management if obstruction was
caused by inflammatory bowel disease
e Bowel care regimen if obstruction was caused by a fecal
impaction.
 Chapter 10 "= The Client With Alterations in the Gastrointestinal Tract 553

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: Theclient, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including recommended diet, prescribed med-
ications, ways to prevent recurrent intestinal obstruction, and
future appointments with health care provider.

Independent Actions
Develop a plan for adherence that includes:
The importance of keeping follow-up appointments with Allows for health care provider to monitor progress and alter inter-
health care provider. ventions as needed.
Reinforcing physician’s instructions regarding dietary restric- Important to maintain nutritional status and to promote healing.
tions and advancement of diet.
Reinforcing physician’s instructions regarding prescribed Adherence to the regimen is increased with education about
medications. prescribed medications.
Include significant others in teaching sessions if possible. Significant others may provide support to clients as they implement
treatment regimen.
Encouraging questions and allow time for reinforcement and Allows client to internalize information and clarify any areas of
clarification of information provided. confusion.
Providing written instructions on future appointments with Allows quick reference once the client has been discharged.
health care provider, dietary restrictions, medications
prescribed, and signs and symptoms to report.

POSTOPERATIVE INTERVENTIONS

Nursing Diagnosis INEFFECTIVE BREATHING PATTERN nox

Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
° Reluctance to breathe deeply due to pain, weakness, and a large abdominal incision
° Decreased rate and depth of respirations associated with the depressant effect of anesthesia

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty breathing Alterations in depth of breathing; altered chest excursion;
bradypnea; decreased minute ventilation; use of accessory
muscles to breathe; dyspnea

RISK FACTOR DESIRED OUTCOMES

———————————————————EEE
SS
een piece The client will maintain an effective breathing pattern as
evidenced by:
a. Normal rate and depth of respirations
b. Absence of dyspnea

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation Ventilation assistance; respiratory monitoring

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 554 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern: pattern allows for prompt intervention.
e Shallow or slow respirations
e Limited chest excursion
e Tachypnea or dyspnea
e Use of accessory muscles when breathing
Assess/monitor pulse oximetry (SaO,.) and ABG values as Monitoring continuous SaOz readings allows for the early detection
indicated. of hypoxia. Assessment of ABG values allows for a more direct
measurement of both the PaOz and the PaCOz, which reflect
the adequacy of ventilation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve breathing pattern: Reducing the client’s fear and anxiety helps to prevent shallow and/or
e Perform actions to reduce fear and anxiety: rapid breathing.
e Promote a calm, restful environment.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
e Reposition client for comfort. breathe more deeply.
e Instruct client to support incision when moving or
coughing.
e Perform actions to reduce the accumulation of gas and Reducing the accumulation of gas in the GI tract decreases pressure
fluid in the GI tract: on the diaphragm, facilitating more effective ventilation.
e Maintain patency of NG, gastric, or intestinal tubes if
present.
e Perform actions to increase strength and improve activity Increasing activity tolerance enables the client to breathe more
tolerance (e.g., increase activity as tolerated; provide for deeply and participate in activities to improve breathing
periods of rest; maintain adequate nutrition). pattern.
e Implement measures to conserve energy.
e Have client deep breathe or use incentive spirometer every Deep breathing and use of an incentive spirometer promote maxi-
1to2hrs.D + mal inhalation and lung expansion.
e Instruct client to breathe slowly if hyperventilating. Hyperventilation is an ineffective breathing pattern that can lead
to respiratory alkalosis.
A client can often slow breathing rate by concentrating on doing so.
e Place client in a semi- to high-Fowler’s position unless A semi- to high-Fowler’s position allows for maximal diaphrag-
contraindicated. D+ matic excursion and lung expansion.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
e Increase activity as allowed and tolerated. During activity, especially ambulation, the client usually takes
deeper breaths, thus increasing lung expansion.
° Assist with positive airway pressure techniques if ordered: Positive airway pressure techniques increase intrapulmonary (al-
*« CPAP veolar) pressure, which helps re-expand collapsed alveoli and
e BiPAP prevent further alveoli collapse.
e Flutter/ PEP device
e Administer central nervous system depressants judiciously. Central nervous system depressants cause depression of the respira-
° Hold medication and consult physician if respiratory tory center in the brainstem, which can result in a decreased
rate is less than 12 breaths/min. rate and depth of respiration.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
e Administer analgesics before activities and procedures that breathe more deeply.
can cause pain and before pain becomes severe. D +
Consult appropriate health care provider if: Notifying the appropriate health care provider allows for modifica-
° Ineffective breathing pattern continues. tion of treatment plan.
° Client develops signs and symptoms of impaired gas
exchange such as restlessness, irritability, confusion,
significant decrease in oximetry results, decreased PaO,
and increased PaCO, levels.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 555

Nursing Diagnosis : INEFFECTIVE AIRWAY CLEARANCE nox

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Related to:
e Stasis of secretions associated with:
e Decreased activity
e Depressed ciliary function due to anesthesia
e Inability to produce an effective cough effort due to abdominal incision and depressant effect of anesthesia and pain
medications

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty breathing Dyspnea, orthopnea; diminished breath sounds; adventi-
tious breath sounds (crackles, rhonchi, wheezes); cough,
ineffective or absent sputum production; difficulty
vocalizing; wide-eyed; restlessness; changes in respiratory
rate and rhythm; cyanosis

RISK FACTORS DESIRED OUTCOMES

e Surgical procedure The client will maintain clear, open airways as evi-
e Positioning inactivity
denced by:
e Normal breath sounds
e Normal rate and depth of respirations
e Absence of dyspnea

NOC OUTCOMES NIC INTERVENTIONS

i
Respiratory status: ventilation; airway patency Respiratory monitoring; airway management; cough
enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of ineffective airway clearance: Early recognition of signs and symptoms of ineffective airway
e Abnormal breath sounds clearance allows for prompt intervention.
e Rapid, shallow respirations
e Dyspnea
¢ Cough
Assess/monitor pulse oximetry (SaO2) and ABG values as Monitoring continuous SaO> readings allows for the early detection
indicated. of hypoxia.
Assessment of ABG values allows for a more direct measure-
ment of both PaOz and PaCOz, which reflect the adequacy of
ventilation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote effective airway clearance:
* Position client on side and/or insert an artificial airway if Positioning the client on the side will help open the airway by al-
necessary. leviating any obstruction causes by the tongue. An artificial
airway helps prevent obstruction ofairway by the tongue.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
* Reposition client for comfort. D@ + breathe more deeply.
eInstruct client to support incision when moving or
coughing.
Repositioning helps mobilize secretions.
Instruct and assist client to change position at least every
2 hrs while in bed. D@ +

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THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to promote the removal of secretions:
e Assist client to deep breathe and cough every 1 to Deep breathing and coughing can help loosen secretions and
2 hrs. enhance the effectiveness of coughing.
e Support abdominal incision when coughing. D + Provides incisional support while coughing.
e Discourage smoking. Irritants in smoke increase mucus production, impair ciliary
function, and can cause inflammation and damage to the bron-
chial walls.
e Perform suctioning if needed. Suctioning removes secretions from the large airways. It also
stimulates coughing, which helps clear airways of mucus and
foreign matter.

Dependent/Collaborative Actions
Implement measures to promote effective airway clearance:
e Implement measures to thin tenacious secretions and
reduce drying of the respiratory mucous membrane:
e Maintain a fluid intake of at least 2500 mL/day unless Adequate hydration and humidified inspired air help thin
contraindicated. secretions, which facilitates the mobilization and expectoration
e Humidify inspired air as ordered. D+ of secretions.
These actions also reduce dryness of the respiratory mucous
membrane, which helps enhance mucociliary clearance.
e Assist with administration of mucolytics and diluent or Mucolytics and diluents or hydrating agents are mucokinetic
hydrating agents via nebulizer if ordered: substances that reduce the viscosity of mucus, thus making it
(1) Acetylcysteine easier for the client to mobilize and clear secretions from the
(2) Water, saline respiratory tract.
e Increase activity as allowed and tolerated. D @ > Activity helps to mobilize secretions and promotes deeper
breathing.
e Administer central nervous system depressants judiciously. Central nervous system depressants depress the cough reflex, which
can result in stasis of secretions.
Consult appropriate health care provider such as a physician Notifying the appropriate health care provider allows for modifica-
or respiratory therapist if: tion of the treatment plan.
e Signs and symptoms of ineffective airway clearance persist
e Signs and symptoms of impaired gas exchange are present:
e Restlessness
e Irritability
e Confusion
e Significant decrease in oximetry results
e Decreased PaO, and increased PaCO,

|Nursing ~..
Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Inability to ingest food due to lack of bowel sounds
e Decreased oral intake associated with pain, weakness, fatigue, and nausea
e Increased nutritional needs associated with increased metabolic rate that occurs during wound healing

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of abdominal cramping or pain; Inadequate food intake; inability to ingest food; diarrhea;
aversion toward eating; lack of interest in food; altered hypoactive or absent bowel sounds; weakness of muscles
taste sensation of mastication
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 557

RISK FACTORS DESIRED OUTCOMES

¢ Poor preoperative nutritional status
The client will maintain an adequate nutritional status as
e Delayed postop nutritional therapy
evidenced by:
a. Weight within normal range for client
b. Normal BUN and serum albumin, Hct and Hgb levels
and lymphocyte count
c. Usual strength and activity tolerance
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status Nutritional monitoring; nutrition management; nutrition
therapy; diet staging

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
e Weight significantly below client’s usual weight or below prompt intervention.
normal for client’s age, height, and body frame
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Assess for return of bowel function every 2 to 4 hrs. Once the client begins to expel flatus, the physician should be
notified so oral intake can be resumed as soon as possible.
Monitor serum albumin, prealbumin, total protein, ferritin, Serum albumin levels less than 3.5 3/100 mL are considered a risk
transferrin, Hgb, Hct, and electrolyte levels as indicated. for poor nutritional status. Early recognition of abnormal lab
values reflective of the client’s overall nutritional state allows
for prompt intervention.
When oral intake is allowed, monitor percentage of meals An awareness of the amount of foods/fluids a client consumes
and snacks client consumes. Report pattern of inadequate alerts the nurse to deficits in nutritional intake. Reporting
intake. inadequate intake allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
When food or oral fluids are allowed, implement measures to The presence of nausea can decrease the appetite. Preventing
maintain an adequate nutritional status: nausea and vomiting can improve the client’s appetite. These
e Implement measures to prevent nausea and vomiting: actions reduce nausea.
De+
e Eliminate noxious sights and odors from the environ-
ment.
e Encourage the client to take deep, slow breaths when
nauseated.
e Instruct client to change positions slowly.
¢ Apply a cold washcloth to the client’s forehead.
e Implement measures to reduce pain: The presence of pain decreases the appetite.
e Instruct client to support incision with movement.
D+
Implement measures to reduce the accumulation of gas and The subsequent feeling of fullness that accompanies gas accumula-
tion leads to an early feeling of satiety. These actions stimulate
fluid in the GI tract and prevent constipation. D +
peristalsis and move gas and fluid through the bowel.
e Encourage frequent position changes.
e Encourage ambulation.
e Encourage a rest period before meals. To conserve energy for consuming meals, rest periods before eating
e Provide nursing assistance during meals. D @ should be encouraged.
e Maintain a clean environment and a relaxed, pleasant A pleasant environment helps to promote adequate intake.
atmosphere. D @
e Provide oral hygiene before meals. D @ Good oral hygiene enhances appetite. A moist oral mucosa makes
chewing and swallowing easier. Oral hygiene can also remove
unpleasant tastes, improving the taste of foods/fluids.

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THERAPEUTIC INTERVENTIONS RATIONALE

Serve frequent, small meals rather than large ones if client is Small, frequent meals are better tolerated in clients with a poor
weak, fatigues easily, and/or has a poor appetite. D + appetite.
e Encourage significant others to bring in client’s favorite Allowing a client to eat foods they prefer enhances intake and
foods unless contraindicated. D+ nutritional status.
e Allow adequate time for meals; reheat foods/fluids if Research has demonstrated that it takes 35 minutes to feed the
necessary. D ® client who is willing to eat.
e Limit fluid intake with meals (unless the fluid has high A high fluid intake with meals promotes a feeling of fullness and
nutritional value). D + early satiety that may decrease actual food intake.

Dependent/Collaborative Actions
When food or oral fluids are allowed, implement measures to
maintain an adequate nutritional status:
e¢ Implement measures to prevent nausea and vomiting: The presence of nausea can decrease the appetite. Preventing
e Administer antiemetics as ordered. D + nausea and vomiting can improve the client’s appetite.
Implement measures to reduce pain:
¢ Administer pain medications as ordered. D > The presence of pain decreases the appetite.
e Increase activity as tolerated and allowed. D @ Activity promotes gastric emptying, which reduces the feeling of
gastric fullness; it also usually promotes a sense of well-being,
which can improve appetite.
¢ Obtain a dietary consult if necessary to assist client in A dietician or nutritional support team can help clients individual-
selecting foods/fluids that meet nutritional needs, are ize their diet within prescribed dietary restrictions. Providing
appealing, and adhere to personal and cultural prefer- food in line with client’s preferences can enhance adherence to
ences as well as the prescribed dietary modifications. prescribed diet.
e Ensure that meals are well balanced and high in essen- Dietary supplements have shown a positive relationship with weight
tial nutrients; offer dietary supplements if indicated. gain, reduced mortality, and reduced length of hospitalization.
e Administer vitamins and minerals if ordered. D + Vitamins and minerals are essential to many metabolic processes
in the body.
e Perform a calorie count if ordered. Report information Information gathered from an accurate calorie count is used to
to dietitian and physician. D determine the adequacy of a client’s daily diet or the need for
nutritional support.
Consult physician about an alternative method of providing Notifying the physician allows for modification of the treatment
nutrition if client does not consume enough food or fluids plan.
to meet nutritional needs:
e Enteral tube feedings
e Parenteral nutrition

POTENTIAL COMPLICATIONS AFTER SURGERY _

Collaborative >»
Diagnosis RISK FOR ATELECTASIS

Definition: Collapse of lung tissue caused by hypoventilated alveoli.

Related to:
e Shallow respirations
e Stasis of secretions in the alveoli and bronchioles

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty breathing Diminished or absent breath sounds; dull percussion over
affected area; increased respiratory rate; dyspnea;
tachycardia; elevated temperature
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 559

RISK FACTORS DESIRED OUTCOMES

° Immobili
o. Gintss yy The client will not develop atelectasis as evidenced by:
a. Clear, audible breath sounds
e Lack of adequate cough effort
b. Resonant percussion note over lungs
c. Unlabored respirations at 12 to 20 breaths/min
. Pulse rate within normal range for client
o.
a Afebrile status

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of atelectasis: Early recognition of signs and symptoms of atelectasis allows for
e Diminished or absent breath sounds implementation of the appropriate interventions.
e Dull percussion note over affected area
e Increased respiratory rate
e Dyspnea
e Tachycardia
e Elevated temperature
Monitor pulse oximetry as indicated. Pulse oximetry is an indirect measure of SaOz. Monitoring pulse
oximetry (SaO2) allows for early detection of hypoxia and
implementation of the appropriate interventions.
Monitor chest radiograph results. Chest radiograph provides confirmation of atelectasis.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent atelectasis: D + Lack of movement places a client at risk for atelectasis. Changing
e Perform actions to improve breathing pattern: positions frequently, coughing, and deep breathing help to
e Encourage client to deep breathe. expand the lungs, enhancing alveolar expansion.
e Incentive spirometry
e Perform actions to promote effective airway clearance:
e Turn, cough, and deep breathe.
If signs and symptoms of atelectasis occur:
e Increase frequency of position change, coughing or “huff-
ing,” deep breathing, and use of incentive spirometer.
Consult physician if signs and symptoms of atelectasis persist Notifying the appropriate health care provider will allow for
or worsen. modification of the treatment plan.

|Nursing »-.--
Diagnosis |RISK FOR VENOUS THROMBOEMBOLISM nox
Definition: Susceptible to the development of a blood clot in a deep vein, commonly in the thigh, calf, or upper extremity,
which can break off and lodge in another vessel, which may compromise health.

Related to:
e Venous stasis associated with decreased activity
e Positioning during and after surgery
e Abdominal distention that may put pressure on the abdominal vessels
e Increased blood viscosity from deficient fluid volume

CLINICAL MANIFESTATIONS

Objective .
Subjective
Increase in circumference of extremity; distention of
Verbal self-report of pain or tenderness in an extremity
superficial vessels in extremity; unusual warmth of
extremity

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560 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

RISK FACTORS DESIRED OUTCOMES

e Immobility a deep vein thrombus as
The client will not develop
e Inadequate fluid replacement
evidenced by:
a. Absence of pain, tenderness, swelling, and distended
superficial vessels in extremities
b. Usual temperature of extremities
c. Pain in area where thromboembolism lodged

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of a deep vein Early recognition of signs and symptoms of thrombus allows for
thrombus: implementation of the appropriate interventions.
e Pain or tenderness in extremity
e Increase in circumference of extremity
e Distention of superficial vessels in extremity
e Unusual warmth of extremity

NOC OUTCOMES NIC INTERVENTIONS

Risk control: thrombus; tissue perfusion: peripheral Embolus precautions; embolus care: peripheral

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent thrombus formation: D + Sequential compression devices and leg and ankle exercises promote
e Use of sequential compression device during and after venous return and reduce the risk of venous thromboembolism.
surgery until ambulatory
e Perform actions to prevent peripheral pooling of blood
such as leg exercises:
e Ankle rotation
e Alternate dorsiflexion and plantar flexion of both feet
If signs and symptoms of a deep vein thrombus occur: D +
e Maintain client on bedrest until activity orders received. Avoid putting pressure on the posterior knees, as this action will
e Elevate foot of bed 15 to 20 degrees above heart level if compress leg veins, increasing turbulent blood flow, and
ordered. increase the risk of thromboembolism formation. If a thrombus
e Discourage positions that compromise blood flow (e.g., is suspected, elevate the affected extremity and do not massage
pillows under knees, crossing legs, sitting for long periods). the area because of the danger of dislodging the thrombus.

Dependent/Collaborative Actions
Implement measures to prevent thrombus formation:
e Apply mechanical devices designed to increase venous These devices decrease venous stasis in the lower extremities and
return in the immobile patient: D+ increase venous return through the deep leg veins, which are
e Sequential compression devices prone to the formation of a thromboembolism. These devices
e Thromboembolic (elastic) stockings should remain in place until the patient is ambulatory.
e Maintain a minimum fluid intake of 2500 mL/day (unless Adequate hydration helps to reduce blood viscosity and decrease
contraindicated). the incidence of a thromboembolism.
If signs and symptoms of a deep vein thrombus occur:
e Administer anticoagulants: Anticoagulants, if indicated, help to suppress the formation of
e Low- or adjusted-dose heparin clots.
e Fondaparinux
e Warfarin
e Low-molecular-weight heparin
e Prepare client for diagnostic studies (e.g., venography, Additional studies may be indicated to confirm the presence of a
duplex ultrasound, impedance plethysmography). thromboembolism, so the appropriate interventions can be
implemented.
 Chapter 10 « The Client With Alterations in the Gastrointestinal Tract 561

THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of embolism occur:
e Maintain on strict bedrest in a semi- or high-Fowler’s Decreases pressure of the abdomen and help to increase lung
position expansion.
e Maintain oxygen therapy as ordered Provides supplemental oxygenation.
e Prepare client for diagnostic tests (e.g., blood gases, D- Identification of physiological changes due to embolism.
dimer level, ventilation, perfusion lung scan; pulmonary
angiography)
e Prepare client for the following, if planned: Decreases client fear/anxiety.
e Vena caval interruption Prevents further emboli.
e Embolectomy Removal of emboli.

|Collaborative ees’)
Diagnosis|RISK FOR PARALYTIC ILEUS
Definition: Paralysis of the intestines resulting in blockage of the intestines.
Related to:
e Manipulation of intestines during abdominal surgery
e Depressant effect of anesthesia and some medications on bowel motility

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of persistent abdominal pain and Firm, distended abdomen; absent bowel sounds; failure
cramping to pass flatus; abdominal radiograph showing distended
bowel

RISK FACTORS DESIRED OUTCOMES

e Inadequate exercise
The client will not develop a paralytic ileus as evi-
e Surgery
denced by:
a. Absence or resolution of abdominal pain and cramping
b. Soft, nondistended abdomen
c. Gradual return of bowel sounds
d. Passage of flatus

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of paralytic ileus: Early recognition of signs and symptoms of a paralytic ileus allows
e Development of or persistent abdominal pain and cramping for prompt intervention.
e Firm, distended abdomen
e Absent bowel sounds
e Failure to pass flatus
Monitor results of abdominal radiograph. An abdominal radiograph that demonstrates distended bowel may
be indicative of a paralytic ileus.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent paralytic ileus: Early ambulation in a postoperative client promotes the return of
e Increase activity as soon as allowed and tolerated. peristalsis.
e Perform actions to prevent hypokalemia. Hypokalemia promotes atony of the intestinal wall, which results
in a decrease in peristalsis.

Dependent/Collaborative Actions
If signs and symptoms of paralytic ileus occur: Paralytic ileus results in cessation ofnormal peristalsis. The client
e Withhold all oral intake. should have nothing by mouth (NPO) and have an NG tube in
e Insert NG tube and maintain suction as ordered. place to facilitate gastric decompression until the ileus is resolved.

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THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of paralytic ileus occurs:
e Administer GI stimulants (e.g., metoclopramide) if GI stimulants help to maintain adequate blood supply to the
ordered. bowel.

Collaborative o-oo)
Diagnosis |6RISK FOR DEHISCENCE

Definition: Pulling apart of a surgical wound at the suture line.

Related to:
e Inadequate wound closure
e Stress on incision line associated with persistent coughing
¢ Poor wound healing associated with decreased tissue perfusion of wound area and inadequate nutritional status

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of something “popping” or “giving way” Separation of edges of the wound
at the incision site

RISK FACTORS DESIRED OUTCOME

e Poor preoperative nutritional status
e Surgery The client will not experience dehiscence as evidenced by
e Delayed postoperative nutritional therapy intact, approximated wound edges.

NURSING ASSESSMENT RATIONALE

Assess for and report evidence of wound dehiscence: Early recognition of evidence of wound dehiscence allows for
e Separation of edges of the wound implementation of the appropriate interventions.
Assess for and immediately report signs and symptoms of Total separation of wound layers sometimes results in dehiscence.
evisceration: This is an emergency situation that requires surgical
e Sudden profuse drainage of serosanguineous fluid from intervention.
wound
e Protrusion of intestinal contents

THERAPEUTIC INTERVENTIONS RATIONALE

———————————————————————————————— eee

Independent Actions
Implement measures to promote wound healing: Proper wound healing decreases the risk ofdehiscence.
e Implement measures to reduce stress on the wound: Decreasing stress on the incision reduces the risk of wound
e Limit movement of affected area. dehiscence.
e If client has a chest or abdominal incision, instruct
client to avoid coughing.
¢ If client has an abdominal incision, place on bedrest in
a semi-Fowler’s position with knees slightly flexed.

Dependent/Collaborative Actions
If dehiscence occurs:
¢ Cover wound with a sterile, nonadherent dressing. A wound that has dehisced requires a sterile, nonadherent dressing.
The choice of a dry dressing or wet dressing will depend upon
the presence of evisceration.
e Apply skin closures (e.g., butterfly tape, Steri-Strips) to the
incision line if appropriate.
e Assist with re-suturing the wound if indicated.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 563

DISCHARGE TEACHING

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY

HEALTH MANAGEMENT nox; OR INEFFECTIVE HEALTH
MAINTENANCE* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic or its acquisition.
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the
family unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to maintain
well-being.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; inability Inaccurate follow-through with instructions; inappropriate
to follow prescribed regimen behaviors; experience of preventable complications of
wound dehiscence

RISK FACTORS
e Cognitive deficit
e Financial concerns
e Inability to care for oneself
e Difficulty in modifying personal habits and integrating
treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen Teaching: individual; teaching: prescribed activity/exercise;

teaching: prescribed medication; health system guidance

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

postoperative infection.

Independent Actions
Instruct client in ways to prevent postoperative infection: These actions work to expand the lungs, mobilize secretions, and

e Continue with coughing (unless contraindicated) and provide adequate oxygenation for healing.
deep breathing every 2 hrs while awake.
e Continue to use incentive spirometer if activity is limited.
e Increase activity as ordered.
e Avoid contact with persons who have infections. Decreases client’s exposure to infectious agents.
e Avoid crowds during flu and cold seasons.
e Decrease or stop smoking. The irritants in smoke increase mucus production, impair ciliary
function, and can cause inflammation and damage to the bron-
chial and alveolar walls; the carbon monoxide decreases oxygen
availability.
e Drink at least 10 glasses of liquid per day unless contrain- Maintains adequate fluid for circulation.
dicated.
Protein is required for appropriate wound healing.
e Maintain a balanced nutritional intake.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Maintain proper balance of rest and activity. Supports wound healing and recovery from surgery.
e Maintain good personal hygiene (especially oral care, Prevents cross contamination, contamination of the surgical
hand washing, and perineal care). wound, and potential for infection.
e Avoid touching any wound unless it is completely healed.
e Maintain sterile or clean technique as ordered during
wound care.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to perform wound care.

Independent Actions
Discuss the rationale for, frequency of, and equipment neces- Client adherence is improved if client understands what to do and
sary for the prescribed wound care. how to use equipment as needed.
Provide client with the necessary supplies (e.g., dressings, Improves adherence to wound care.
irrigating solution, tape) for wound care and with names
and addresses of places where additional supplies can be
obtained.
Demonstrate wound care and proper cleansing of any reus- Improves client’s confidence in ability to care for self.
able equipment. Allow time for questions, clarification,
and return demonstration.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct the client to report the following signs and symptoms:
e Persistent low-grade fever or significantly elevated These clinical manifestations indicate complications that include
(=38.3°C [101°F]) temperature infection, thromboembolism, and poor nutritional status.
e Difficulty breathing
e Chest pain
e Cough productive of purulent, green, or rust-colored sputum
e Increasing weakness or inability to tolerate prescribed
activity level
e Increasing discomfort or discomfort not controlled by May indicate increasing problems or tolerance to medication.
prescribed medications and treatments
e Continued nausea or vomiting
e Increasing abdominal distention and/or discomfort May indicate a recurrence of the bowel obstruction.
e Separation of wound edges
e Increasing redness, warmth, pain, or swelling around wound
e Unusual or excessive drainage from any wound site
e Pain or swelling in calf of one or both legs
e Urine retention
e Frequency, urgency, or burning on urination May indicate dehydration or urinary tract infection.
e Cloudy or foul-smelling urine

THERAPEUTIC INTERVENTIONS RATIONALE

=
eea
Desired Outcome: The client, in collaboration with the
nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, dietary modifications, activity level, treatments,
and medications prescribed.
 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract 565

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Collaborate with client in developing a plan for adherence Improves adherence to treatment regimen and for follow-up care.
that includes:
The importance of keeping scheduled follow-up appoint-
ments with the health care provider.
Physician’s instructions about dietary modifications. Obtain a Important for continued healing and maintenance of health.
dietary consult for client if needed.
The physician’s instructions on suggested activity level and Improves adherence if client understands what to do for self-care.
treatment plan.
The rationale for, side effects of, and importance of taking Knowledge of medications and how they impact the system im-
medications prescribed. proves client adherence to treatment regimen and understanding
Inform client of pertinent food and drug interactions. of the importance of adhering to the prescribed medication regi-
men. The client must be able to recognize alterations in func-
tioning related to medication administration and what clinical
manifestations should be reported to the health care provider.
Implement measures to improve client compliance:
e Include significant others in teaching sessions if possible. Improves the ability of significant others to support client adher-
ence to the treatment regimen.
e Encourage questions and allow time for reinforcement and Improves client understanding of discharge information.
clarification of information provided.
e Provide written instructions on scheduled appointments Provides an information resource for the client after discharge from
with health care provider, dietary modifications, activity the acute care facility.
level, treatment plan, medications prescribed, and signs
and symptoms to report.

ADDITIONAL NURSING DIAGNOSES

IMPAIRED ORAL MUCOUS MEMBRANE NDx e Introduction of pathogens associated with an indwelling
Related to: catheter if present
e Deficient fluid volume associated with restricted oral intake
and fluid loss resulting from vomiting and NG tube drainage RISK FOR FALLS NDx
e Decreased salivation associated with deficient fluid vol- Related to:
ume, restricted oral intake, and the effect of some medica- e Weakness and fatigue
tions (e.g., narcotic [opioid] analgesics, some antiemetics) e Dizziness or syncope associated with postural hypotension
e Mouth breathing when NG tube is in place resulting from peripheral pooling of blood and blood loss
during surgery
RISK FOR CONSTIPATION NDx e Central nervous system depressant effect of some medica-
Related to decreased GI motility associated with manipulation tions (narcotic [opioid] analgesics, some antiemetics)
of bowel during abdominal surgery, depressant effect of anes- e Presence of tubing or equipment
thesia and narcotic (opioid) analgesics, and decreased activity
RISK FOR ASPIRATION NDx
DISTURBED SLEEP PATTERN NDx Related to:
e Decreased level of consciousness and absent or diminished
Related to fear, anxiety, discomfort, inability to assume usual
gag reflex associated with depressant effect of anesthesia
sleeping position, and frequent assessments and treatments
and narcotic (opioid) analgesics
RISK FOR INFECTION NDx e Supine positioning
secretions and e Increased risk for gastroesophageal reflux associated with in-
Pneumonia related to stasis of pulmonary
creased gastric pressure resulting from decreased GI motility
aspiration (if it occurs)

Wound infection related to: FEAR/ANXIETY NDx

e Contamination associated with introduction of pathogens Related to:
during or after surgery e Unfamiliar environment
e Decreased resistance to infection associated with factors e Pain
such as diminished tissue perfusion of wound area and e Lack of understanding of surgical procedure performed,
inadequate nutritional status diagnosis, and postoperative treatment plan
Urinary tract infection related to: * Possible change to body image and roles
e Increased growth and colonization of microorganisms e Financial concerns
associated with urinary stasis

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 566 Chapter 10 * The Client With Alterations in the Gastrointestinal Tract

PARENTERAL NUTRITION
Early nutritional therapy, implemented within 48 hrs of sodium, 1 to 2 mEq/kg potassium, and chloride as needed to
either hospital admission or surgery, is supported by various maintain acid-base balance.
consensus statements and professional guidelines as critical to A common metabolic complication associated with the
reducing patient morbidity and mortality. Early enteral nutri- administration of parenteral nutrition is hyperglycemia. Both
tion, advocated for the preservation of the mucosal barrier of hyperglycemia and insulin resistance can occur in clients re-
the gut, is associated with both lower hospital costs and shorter ceiving parenteral nutrition. Parenteral nutrition solutions
hospital lengths of stay. However, certain clinical conditions have high glucose concentrations that range between 20%
may interfere with the client’s ability to ingest, digest, or and 50%. As a result, clients receiving parenteral nutrition
absorb nutrients, resulting in the need for parenteral nutrition. should have blood glucose levels checked every 4 to 6 hrs,
Parenteral nutrition is defined as the delivery of nutrients maintaining target blood glucose levels between 100 and
by a route other than the GI system (e.g., bloodstream). The 150 mg/dL or as indicated by institutional protocol. To avoid
primary goal of parenteral nutrition is to provide the nutri- hypoglycemic episodes, parenteral infusions should not be
ents necessary to meet the metabolic needs of the client and abruptly discontinued for any reason.
allow for growth of new tissue. Clinical conditions that neces- Parenteral nutrition, prepared using strict aseptic tech-
sitate the use of parenteral nutrition include chronic, severe niques by a pharmacist, can be administered through a
diarrhea and/or vomiting, complicated surgery or trauma, Gl peripherally inserted catheter or centrally inserted device.
obstruction, GI tract anomalies, severe anorexia, severe Central administration is indicated for long-term support, or
malabsorption, and short bowel syndrome. when the client has high protein and caloric requirements
Parenteral nutrition is composed of both a base solution of necessitating the administration of hypertonic solutions
dextrose and protein in the form of amino acids and pre- (>20% glucose concentration) that are caustic to peripheral
scribed levels of electrolytes, vitamins, and trace elements. veins. Parenteral nutrition administered through peripheral
The caloric intake requirement of clients in need of parenteral veins can be safely accomplished with minimal vein irritation
nutrition therapy far exceeds the 1200 to 1500 cal/day neces- using solutions with an osmolarity of up to 900 mOsm/L.
sary to maintain normal physiological function. Carbohy- Safe, effective preparation, administration, and storage of
drates in the form of dextrose and fat emulsions supply the parenteral solutions require a multidisciplinary health care
calories that compose parenteral nutrition. While exact team. Prescribing, preparing, and administering parenteral
parenteral nutrition formulations are based upon individual therapy require the expertise of physicians, pharmacists, di-
client nutritional requirements, disease states, metabolic con- eticians, and nurses. This care plan focuses on the adult
ditions, and medication use, there are accepted standard client undergoing parenteral nutritional therapy in an acute
ranges of parenteral nutrition elements based on age and care, extended care, or long-term care environment.
normal physiological requirements.
To minimize complications associated with nonfeeding,
total caloric recommendations include 20 to 30 kcal/kg/day, OUTCOME/DISCHARGE CRITERIA
daily protein of 1.5 to 2 g/kg/day, and fluid requirements of
30 to 40 mL/kg/day in clients who are stressed. Standard The client will:
distribution of nonprotein calories includes 70% to 85% from Progressively gain weight toward desired goal
carbohydrates and 15% to 30% supplied by fats. Fat content Weigh within normal weight for height and age
of parenteral solutions is not to exceed Food and Drug Consume adequate nutrition to meet metabolic needs
Administration recommendations of 2.5 g/kg/day. Fats are Be free of signs of malnutrition
administered slowly over 12 to 24 hrs using concentrations of ORwWN
Maintain adequate fluid volume status
10%, 20%, or 30% fat emulsion solutions. Standard electro- 6. Recognize factors contributing to malnutrition/under-
lyte requirements include 10 to 15 mEq calcium, 8 to 20 mEq weight
magnesium, 20 to 40 mmol phosphorous, 1 to 2 mEq/kg 7. Be free of complications related to parenteral feeding

_Nursing Diagnosis RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL nox

Definition: Susceptible to variation in serum levels of glucose from the normal range, which may compromise health.

Related to: i
e Insulin resistance associated with the stress of illness and/or diabetes
¢ Administration of hypertonic parenteral solutions
e Interruption in administration of parenteral nutritional therapy
e Inadequate blood glucose monitoring
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 567

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of hyperglycemia: thirst; dizziness; Hyperglycemia: polyuria; elevated serum glucose level;
blurred vision; nausea vomiting; dehydration
Verbal reports of hypoglycemia: hunger Hypoglycemia: sweating; weakness; tremors

RISK FACTORS DESIRED OUTCOME

e Physical health status
The client will maintain blood glucose level between
e Weight loss
90 and 130 mg/dL or close to 110 mg/dL in the critically
ill client.

NOC OUTCOMES NIC INTERVENTIONS

Blood glucose levels; electrolyte and acid-base balance; Hyperglycemia management; hypoglycemia management
hyperglycemia severity; hypoglycemia severity

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms of hyper/hypoglycemia: Early recognition of signs and symptoms of hyper/hypoglycemia
-
e Hyperglycemia: thirst, dizziness, blurred vision, polyuria, in- allows for prompt intervention.
creased serum glucose level, nausea/vomiting, dehydration
e Hypoglycemia: hunger, weakness, sweating, tremors
Assess serum blood glucose every 4 to 6 hrs during adminis- Because of the high dextrose concentration of most parenteral nu-
tration of parenteral nutrition. tritional solutions, and possible insulin resistance in diabetic
clients, blood glucose monitoring is warranted during therapy.
Hypoglycemia may occur with abrupt cessation of parenteral
nutrition because of the steady production of insulin by the
pancreas in response to the high glucose concentration of
parenteral solutions.
Assessment determines the patient’s tolerance of the infusion.
Assess serum electrolyte levels for imbalances and report any The exact amount of electrolytes needed in a parenteral solution
deviations from normal. will vary by client condition. Blood testing of serum electrolyte
levels should occur several times a week to ensure electrolyte
values remain therapeutic.
Refeeding syndrome, characterized by electrolyte imbalances
and fluid retention, can be associated with long-standing
malnutrition.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement interventions to reduce the risk of hypoglycemia: The pancreas becomes accustomed to producing insulin at a level
e Administer infusion using an infusion pump. necessary to keep blood glucose levels within a normal range.
° Ensure patency of infusion site (e.g., peripheral or central Any abrupt cessation of an infusion of TPN places the client at risk
catheter). for hypoglycemia.
* Monitor bedside serum glucose levels every 4 to 6 hrs. Administration of parenteral nutrition using an infusion pump
allows for appropriate hourly rate regulation and detection of
interruption of infusion when/if infusion site becomes occluded
or obstructed.

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Infuse a 10% or 20% dextrose solution (based on the amount Administration of dextrose-containing solutions helps to prevent
in the parenteral solution) if the formula bag is empty hypoglycemia in a client whose system has adjusted to the high
before the next solution is available. levels of glucose in parenteral solutions.
Administer insulin as prescribed. Supplemental insulin in accordance with a sliding scale may be
necessary, as an increase in serum blood glucose level is
expected after initiation of parenteral nutritional therapy.
Implement hypoglycemic protocol for blood glucose level less The brain requires a constant supply of glucose to properly
than 70 mg/dL: function. Untreated hypoglycemia can lead to loss of conscious-
e For the conscious patient, ingestion of 15 to 20 g of simple ness, seizures, coma, and/or death.
carbohydrate (e.g., 4-6 oz fruit juice)
e In acute care settings, or with patients who are uncon-
scious, administer 20 to 50 mL of 50% dextrose IV push.
e Recheck blood glucose level 15 minutes after intervention
and repeat treatment if client’s blood glucose level remains
less than 70 mg/dL.
Notify the appropriate health care provider if signs and symp- Notifying the appropriate health care provider allows for modifica-
toms of hyperglycemia or hypoglycemia, or other electro- tion of the treatment plan.
lyte imbalances develop:
e Physician provider
e Dietician/nutritional consultant

|Nursing =<
Diagnosis |RISK FOR INFECTION nox

Definition: Susceptible to invasion and multiplication of pathogenic organism, which may compromise health.
Related to:
e Administration of fluids that support bacterial growth
e Placement of central venous catheter (invasive procedure)
e Malnutrition
e Decreased defense mechanisms

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of nausea; malaise; chills Erythema, tenderness, and exudate at venous access site;
increased temperature; increased WBC count, abnormal
differential count; positive blood and/or wound cultures

RISK FACTORS DESIRED OUTCOMES

e Chronic illness a ee ee Oe et ee Ges ed Foe ee ee
The client will:
e Inadequate immune response
a. Remain free from symptoms of infection
e Exposure to pathogens
b. Maintain WBC and differential count within normal
range
c. Demonstrate appropriate care of infection-prone site
d. State signs and symptoms of infection of which to be
aware
‘

NOC OUTCOMES NIC INTERVENTIONS

eee eS
Infection severity Infection control; infection protection
 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract 569

NURSING ASSESSMENT RATIONALE

Assess client’s venous access site for signs and symptoms of Early recognition of signs and symptoms of infection allows for
infection: ‘ prompt intervention.
e Nausea
e Malaise
e Erythema
e Tenderness and exudate at venous access site
e Chills
e Fever
e Increased WBCs
e Abnormal differential count
e Positive blood/wound cultures
Monitor complete blood count, blood and wound culture
results for abnormalities.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Wash hands before and after each patient encounter.
Maintain aseptic technique when administering solution: Parenteral nutritional therapy, because of the high glucose concen-
e Administer parenteral solutions not containing fat emul- trations, provides an excellent environment for microbial
sion through a 0.22-micron Millipore filter. growth.
e Administer parenteral solutions containing fat emulsions The use of in-line filters helps reduce or eliminate the infusion
through a 1.2-micron filter. of particulates, microprecipitates, microorganisms, pyrogens,
e Change filters and tubing in accordance with institutional and air.
policy, marking the date and time of initiation of use:
e Change every 24 hrs if lipid emulsions are used.
e Change every 72 hrs if amino acids and dextrose is
used.
Visually inspect solution before administration for any visual If any abnormalities are suspected, the solution should be returned
indication of precipitates, color changes (turbidity), or to the pharmacy promptly for replacement.
leaks.
Change peripheral IV sites and dressings in accordance with Catheter-related infection and septicemia can occur in patients
institutional policy/Centers for Disease Control and Pre- receiving parenteral nutrition through both central and periph-
vention (CDC) guidelines for infection prevention. eral access devices.
Complete all parenteral solution infusions at the ordered rate At room temperature, parenteral solutions and fat emulsions
within 24 hrs of initiation. provide a medium for bacterial growth.

Dependent/Collaborative Actions
Obtain blood cultures as indicated.
Obtain culture of venous access device catheter tip if discon-
tinued.
Notify physician provider if signs and symptoms of systemic Notifying the appropriate health care provider allows for modifica-
or site infection develop. tion of the treatment plan.

Diagnosis DEFICIENT KNOWLEDGE

|Nursing >... nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT nox; OR INEFFECTIVE HEALTH MAINTENANCE®* nox
topic or its acquisition. Ineffec-
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific
tive Family Health Managemen t NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family
unit. Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek help to maintain well-being.

the client’s discharge teaching needs.

*The nurse should select the nursing diagnostic label that is most appropriate for

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NDx = NANDA Diagnosis
 570 Chapter 10 = The Client With Alterations in the Gastrointestinal Tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness; verbalizes Inaccurate follow-through with instructions; inappropriate
inability to follow prescribed regimen behaviors

RISK FACTORS
° Cognitive deficit
e Financial concerns
e Inability to care for oneself

NIC OUTCOMES NOC INTERVENTIONS

Knowledge: treatment regimen; knowledge: infection Teaching: individual; teaching: psychomotor skill
management

NURSING ASSESSMENT RATIONALE

Assess Client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of nutritional
Assess meaning of nutritional therapy to client. therapy to client allows for implementation of the appropriate
teaching interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the proper

technique when changing infusion tubing and parenteral
solution bags.

Independent Actions
Instruct client and family on the proper way to mix, handle, Proper care of parenteral feedings is necessary to prevent contami-
and store parenteral feedings. nation.
e Allow time for return demonstration.
Instruct client and family on proper care of parenteral solu- Given the high glucose concentration found in parenteral solutions,
tion administration sets: proper filtration and line maintenance is necessary to prevent
e Administer solution using appropriate filter. bloodstream infections.
e Discard administration sets every 72 hrs for solutions with
amino acids/dextrose.
e Discard administration sets every 72 hrs for solutions con-
taining lipid emulsions.
Instruct client and family on the proper handling and storage Parenteral nutritional therapy, because of the high glucose concen-
of solutions: trations, provides an excellent environment for microbial
e Solutions must be infused within 24 hrs. growth.
e Mixed solutions must be refrigerated until % hr before use. The use of in-line filters helps reduce or eliminate the infusion of
particulates, microprecipitates, microorganisms, pyrogens, and
air. At room temperature, parenteral solutions and_ fat
emulsions provide a medium for bacterial growth.

THERAPEUTIC INTERVENTIONS RATIONALE

een NN

Desired Outcome: The client will demonstrate proper care

of venous access device.

Independent Actions
Instruct client and family on the proper method of changing Sterile dressing care of long-term venous access devices is necessary
central line or venous access dressings. to prevent the development of catheter line sepsis.
Allow time for return demonstration.
 Chapter 10 The Client With Alterations in the Gastrointestinal Tract 571

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize signs and

symptoms of infection to report to health care provider.

Independent Actions
Instruct client and family to report any signs and symptoms Notifying the appropriate health care provider allows for modifica-
of systemic or localized (catheter site) infection to the tion of the treatment plan.
health care provider immediately.

RELATED CARE PLAN

PEPTIC ULCER
A peptic ulcer is a break in the continuity of the GI mucosa medically controlled; if ulcers recur frequently; or if compli-
that is exposed to acidic digestive secretions. The areas most cations such as hemorrhage, perforation, or obstruction occur
often involved are the stomach and duodenum. Erosion of in the ulcerated area(s).
these areas can result from direct damage to the mucosa or This care plan focuses on the adult client hospital-
from an increase in mucosal permeability, which allows ized for evaluation and medical treatment of a peptic
gastric acids to diffuse through the mucosal barrier into the ulcer that has become increasingly symptomatic. Much
underlying tissue. The two most common causes of peptic of the information presented here is applicable to
ulcers are infection with Helicobacter pylori (H. pylori) and use clients receiving care in an extended care facility or
of aspirin or other NSAIDs. Other factors believed to have a home setting.
role in ulcer development, exacerbation, and/or recurrence
include ingestion of alcohol, coffee, certain foods and spices,
and caffeine; medications such as corticosteroids and some OUTCOME/DISCHARGE CRITERIA :
chemotherapeutic agents; smoking; stress; hypovolemia (can
result in ischemia of the GI mucosa and subsequent alteration The client will:
in mucosal permeability); certain disease conditions (e.g., 1. Have pain controlled
Zollinger-Ellison syndrome, chronic obstructive pulmonary 2. Have no signs and symptoms of complications
pancreatitis, chronic renal failure); and genetic 3. Verbalize a basic understanding of peptic ulcer disease and
disease,
the importance of adhering to the prescribed treatment
predisposition.
Peptic ulcers are usually classified by location (e.g., gastric, plan
4. Identify ways to promote healing of the existing ulcer and
duodenal) and by the extensiveness of erosion (e.g., acute
prevent recurrence of peptic ulcer
[superficial erosion with minimal inflammation], chronic
5. Verbalize an understanding of medications ordered
[erosion of mucosa and submucosa with scar tissue forma-
including rationale, food and drug interactions, side
tion]). Causative factors and the relationship between eating
and occurrence of pain vary depending on the location and effects, schedule for taking, and importance of taking as
prescribed
extensiveness of the ulcer. The characteristic symptom of a
peptic ulcer is chronic, intermittent epigastric pain that is 6. State signs and symptoms to report to the health care
provider
described as burning, aching, gnawing, or cramping.
Medical treatment of a peptic ulcer focuses on eradicating 7. Develop a plan for adhering to recommended follow-up
care including future appointments with health care
H. pylori infection if present, decreasing the degree of gastric
provider
acidity, and promoting mucosal integrity and regeneration.
For a full, detailed care plan on this topic, go to http://evolve.
Surgical intervention (e.g., vagotomy, pyloroplasty, partial
elsevier.com/Haugen/careplanning/.
gastrectomy) may be indicated if symptoms cannot be

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NDx = NANDA Diagnosis
 CHAPTER

Nursing Care of the Client With

Disturbances of the Liver, Biliary
Tract, and Pancreas

CHOLECYSTECTOMY
©p A laparoscopic cholecystectomy is the standard surgical ap- OUTCOME/DISCHARGE CRITERIA
proach for removal of the gallbladder. It is performed to treat
symptomatic cholecystitis or cholelithiasis, or both. A chole- The client will be able to:
cystectomy can be done via laparoscopy or through a right 1. Have pain controlled at a level that ensures client’s com-
subcostal incision (i.e., open cholecystectomy). A laparo- fort while not interfering with activities of daily living.
scopic cholecystectomy is the procedure of choice because of 2. Tolerate prescribed diet
the short hospitalization (<2 days), reduced postoperative 3. Have evidence of normal healing of surgical wound(s) and
pain, and a more rapid return to usual activities. An open normal skin integrity around T-tube site
cholecystectomy is indicated when the client is in the last 4. Maintain clear, audible breath sounds throughout the
trimester of pregnancy or has a gangrenous or perforated lungs
gallbladder, a suspected gallbladder malignancy, a history of 5. Have no signs and symptoms of postoperative complica-
multiple abdominal surgeries, severe inflammation that ob- tions
scures the structures of the hepatobiliary triangle, or large 6. Demonstrate the ability to appropriately care for T-tube
stones in the biliary ducts or is morbidly obese. An open cho- and surrounding skin if T-tube is present
lecystectomy may also be performed when problems are en- 7. Verbalize understanding of the rationale for and compo-
countered during a laparoscopic cholecystectomy. If common nents of a low- to moderate-fat diet if prescribed
bile duct stones are present, they can often be extracted en- 8. State signs and symptoms to report to the health care
doscopically, but a choledocholithotomy may be necessary if provider
the stones are large. After a choledocholithotomy, a T-tube is 9. Develop a plan for adhering to recommended follow-up
placed in the common bile duct to maintain adequate flow or care including future appointments with health care pro-
drainage of bile until ductal edema subsides. vider, wound care, medications prescribed, and activity
This care plan focuses on the adult client hospital- level
ized for an open cholecystectomy with common bile See Care Plan on Cholelithiasis/Cholecystitis and the
duct exploration. Standardized Preoperative and Postoperative Care Plans for
additional diagnoses.

|Nursing -Diagnosis |INEFFECTIVE BREATHING PATTERN nox

Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
e Increased rate of respirations associated with:
° Decreased rate of respirations associated with depressant effect of anesthesia and other medications
(e.g., opioid analgesics)
e Decreased depth of respirations associated with:
° Depressant effect of anesthesia and other medications (e.g., opioid analgesics)
e Reluctance to breathe deeply because of pain
e Fear, anxiety, weakness, and fatigue
e Restricted chest expansion resulting from positioning and elevation of the diaphragm if abdominal
distention is present
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 573

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal reports of shortness of breath Dyspnea; bradypnea, tachypnea; decreased depth of
breathing; decreased inspiratory/expiratory pressure;
decreased minute ventilation; use of accessory muscles;
altered chest excursion

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will maintain an effective breathing pattern, as
e Immobility evidenced by:
e Fatigue a. Normal rate and depth of respirations
e Pain b. Absence of dyspnea
e Anxiety c. Oxygenation adequate for client needs

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation Respiratory monitoring

NURSING ASSESSMENT RATIONALE

(Ee
. Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern: pattern allows for prompt intervention.
e Shallow or slow respirations Shallow, rapid respirations, lack of chest excursion, and holding
e Limited chest excursion one’s breath may lead to inadequate oxygenation and atelectasis.
e Tachypnea or dyspnea
e Use of accessory muscles when breathing
Assess/monitor pulse oximetry (arterial oxygen saturation Monitoring continuous SaO2 readings allows for the early detection
[SaOo]), of hypoxia.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions Reducing fear and anxiety helps to minimize shallow and/or rapid
Implement measures to improve breathing pattern: breathing.
e Perform actions to reduce fear and anxiety:
e Promote a calm, restful environment. D @ +
e Perform actions to reduce pain: Pain reduction increases the client’s willingness to move and
e Reposition client for comfort. breathe deeply.
e Instruct client to support incision with hands or a pil- Supporting abdominal incision will decrease muscle tension and
low when moving or coughing. D@ + potential pain and discomfort when moving or coughing.
e Assist client to bend knees while coughing and deep Relieves tension on abdominal muscles and incision allowing for
breathing. D @ better chest expansion.
e Perform actions to increase strength and improve activity Increasing activity tolerance enables the client to breathe deeply
tolerance: and participate in activities to improve breathing pattern.
e Implement measures to conserve energy. D @ +
e Have client deep breathe or use incentive spirometer Deep breathing and use of an incentive spirometer promote maxi-
every 1 to 2 hrs. D coe mal inhalation and lung expansion.
* Instruct client to breathe slowly if hyperventilating. D+ Hyperventilation is an ineffective breathing pattern that can lead
to respiratory alkalosis. A client can often slow breathing rate
through focused concentration.
° Place client in a semi- to high-Fowler’s position unless A semi- to high-Fowler’s position allows for maximal diaphrag-
matic excursion and lung expansion.
contraindicated.
e If client must remain flat in bed, assist with position Compression of the thorax and subsequent limited chest wall expan-
change at least every 2 hrs. D + sion occur when the client lies in one position. Frequent reposi-
tioning promotes maximal chest wall and lung expansion.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
During activity, especially ambulation, encourage the client to
e Increase activity as allowed and tolerated.
takes deep breaths, thus increasing lung expansion.

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NDx = NANDA Diagnosis
 574 Chapter 11 » Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Administer central nervous system depressants judiciously: Central nervous system depressants cause depression of the respira-
e Hold medication and consult physician if respiratory tory center in the brainstem, resulting in decreased rate and
rate is less than 12 breaths/min. depth of respiration.
e Perform actions to reduce pain: Reducing pain helps to increase the client’s willingness to move and
e Administer analgesics before activities and procedures breathe more deeply.
than can cause pain and before pain becomes severe. D +
Consult appropriate health care provider if: Notifying the appropriate health care provider allows for modifica-
e Ineffective breathing pattern continues. tion of treatment plan.
e Client develops signs and symptoms of impaired gas ex-
change such as restlessness, irritability, confusion, signifi-
cant decrease in oximetry results, decreased partial pressure
of oxygen in arterial blood (PaO,) and increased partial
pressure of carbon dioxide in arterial blood (PaCO;) levels.

Collaborative Diagnosis RISK FOR ABSCESS FORMATION

Definition: An accumulation of pus in any area of the body.

Related to:
e Accumulation of drainage in the surgical area and subsequent invasion area by microorganisms and neutrophils

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of pain in the surgical area Redness, swelling, and/or warmth in the surgical area; fe-
ver; tachycardia; increased white blood cell (WBC) count

RISK FACTORS DESIRED OUTCOMES

e Surgery
The client will not develop an abscess, as evidenced by:
e Exposure to pathogens
a. Lack of redness, warmth, or swelling of the surgical
site
b. Temperature declining toward normal
c. WBC count declining toward normal

NURSING ASSESSMENT
RATIONALE
ee
Assess for and report signs and symptoms of infection or ab- Early recognition of signs and symptoms of infection or abscess
scess (e.g., increased or more constant abdominal pain, allows for prompt intervention.
increase in temperature and pulse rate, further increase in
WBC count).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent infection and or accumula-
tion of drainage in the surgical area:
e Keep surgical site and puncture wounds clean and dry. Prevents development of infection,
e Monitor surgical wound or puncture sites for any drainage The surgical wounds may initially drain serous-sanguineous fluid,
e Change dressings as ordered but this should decrease in the hours following SUuTgery.
Dressing changes allow for assessment of the wound, help to pro-
vide protection from bile fluids that can cause skin breakdown.
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas Sy/s)

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to maintain patency of wound drain and/ Promotes drainage of fluids from the wound, preventing stasis of
or T-tube, if present: fluids and reducing the risk for abscess formation and skin
e Implement measures to prevent stasis and reflux of breakdown.
drainage: D + Drainage may initially contain blood; this should change to green-
e Monitor color and characteristics of NG and T-tube ish brown in the first few hours following surgery.
drainage, if present:
(1) Keep drainage tubing free of dependent loops and Maintains appropriate drainage and prevents it from leaking into
kinks (prevent kinking by placing a gauze roll under the abdomen.
the drain tube and anchoring it to the skin or dress-
ing with tape).
(2 4 Keep collection device(s) below drain insertion site(s) Reduces loss ofbile.
unless ordered otherwise (physician may order
T-tube collection device to be positioned just slightly
below, level with, or above drain insertion site).
(3) Empty collection device(s) as often as necessary and Prevents stasis of fluids.
at least every shift. D @
Implement measures to prevent inadvertent removal of
wound drain and/or T-tube:
e Instruct client not to pull on drain(s) and drainage tubing. These actions prevent the T-tube from becoming dislodged, which
e Use caution when changing dressings surrounding drain(s). can introduce bacteria into the body.
e Attach collection device(s) securely to abdominal dressing. Removes drainage from site and contact with skin—helps to main-
tain skin integrity
e Maintain client in a semi- to high-Fowler’s position as Improves lung expansion and promotes drainage of respiratory
much as possible when in bed. D + secretions.

Dependent/Collaborative Actions
If signs and symptoms of an abscess occur:
e Prepare client for diagnostic tests (e.g., ultrasonography, Alleviates fear and anxiety.
computed tomography, culture and sensitivity of wound).
e Administer antimicrobials if ordered. Alleviate infections.
e Prepare client for surgical intervention (e.g., incision and Alleviates fear and anxiety.
drainage of abscess) if planned.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis nox; OR INEFFECTIVE HEALTH

DEFICIENT KNOWLEDGE
MANAGEMENT™ nox
topic, or its acquisition:
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific
t NDx: Pattern of regulating and integrating into daily living a therapeutic
Ineffective Health Managemen
for the treatment of illness and its sequelae that is unsatisfacto ry for meeting specific health goals.
regimen

Related to:
e Insufficient interest in learning
e Misinformation provided by others
e Difficulty managing complex treatment regimen
° Difficulty navigating complex health care systems
e Insufficient social support

CLINICAL MANIFESTATIONS

Objective
Subjective
Inaccurate follow-through with instructions; inappropri-
Verbalizes inability to manage illness; verbalizes inability
to follow prescribed regimen ate behaviors; experience of preventable complications of
surgery

te for the client’s discharge teaching needs.

*The nurse should select the diagnostic label that is most appropria

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NDx = NANDA Diagnosis
 576 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

RISK FACTORS
e Cognitive deficit
e Financial concerns
e Failure to take action to reduce risk factors for complica-
tions of surgery (if performed)
e Inability to care for oneself
e Difficulty in modifying personal habits and integrating
treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: Treatment regimen; health behaviors; health Teaching individualized prescribed medication, diet, activities;
resources; Treatment procedures. teaching: health system guidance; teaching: support systems.

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to learn
changes based on situations, physical, and emotional challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability The client demonstration is important to ensure that the client
to appropriately care for T-tube and surrounding skin if T-tube understands how to care for the T-tube and prevent complica-
is present. tions following surgery and hospital discharge.

Independent Actions
If the client is to be discharged with a T-tube in place, instruct
regarding care of the T-tube and surrounding skin:
Cleanse the skin around the T-tube insertion site daily, and These actions help to prevent infection and skin breakdown.
cover the site with a dry sterile dressing; apply zinc oxide
cream to skin around insertion site if skin is irritated.
Keep the T-tube drainage collection device in the position Helps to maintain drainage patency and promote drainage.
prescribed (usually slightly below the insertion site).
Keep the tubing pinned to the dressing and avoid any Prevents unnecessary pressure or pulling on the T-tube.
kinks or tension on the tubing.
Empty the drainage collection device at least twice daily or Monitors output, noting changes in volume.
more often if needed; keep a record of the amount of drainage.
When emptying the drainage collection device, check to If tube becomes dislodged, client should contact the health care
see that the tube has not become dislodged (this can be provider.
easily monitored if the tube is marked at the skin line be-
fore discharge).
e Clamp T-tube only as instructed. Clamping the T-tube helps prevent bile leakage.
Allow time for questions, clarification, and return demonstra- Improves client’s confidence in ability to care for self.
tion of care of T-tube and surrounding skin.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand- If the client understands the rationale for diet requirements and
ing of the rationale for and components of a low- to moderate- what may occur when they are not followed. This may improve
fat diet if prescribed client adherence.

Independent Actions
Explain the rationale for avoiding excessive fat intake for the Initially large amounts of fat can cause gastric upset and gastric
first 4 to 6 weeks after surgery (many physicians instruct discomfort. Over time, the client will learn the amount of fat
client to just avoid foods that cause epigastric discomfort). that causes gastric discomfort.
Instruct client to increase fat intake gradually and introduce Gradual increase in fat intake allows the body to become used to
foods/fluids high in fat (e.g., butter, cream, whole milk, ice absorbing fats, without severe epigastric discomfort.
cream, fried foods, gravies, nuts) one at a time.
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 577

THERAPEUTIC INTERVENTIONS RATIONALE

When the client understands what needs to be monitored and
Desired Outcome: The client will state signs and symp-
reported, it may improve client adherence with contacting their
toms to report to the health care provider.
health care provider.

Independent Actions
Instruct the client to report the following signs and symp-
toms to health care provider:
e Persistent low-grade fever or significantly elevated tem- These clinical manifestations indicate that the client may be expe-
perature (=38.8°C [101°F]) riencing complications from surgery, ifperformed. They indicate
e Difficulty breathing possible infection of the surgical area or other body systems and
e Chest pain possible thromboembolism.
e Cough productive of purulent, green, or rust-colored Indication of a respiratory infection.
sputum
e Increased weakness or inability to tolerate prescribed activity Could indicate a poor diet, as well as an infection.
level
e Increasing discomfort or discomfort not controlled by May indicate something has changed in the client’s condition and
prescribed medications and treatments should be reported to the health care provider.
e Nausea and vomiting May indicate increased consumption of fatty foods or potential
blockage of T-tube, ifpresent.
e Decreased urine output Indicates a possible urinary tract infection or decrease fluid intake.
e Frequency, urgency, or burning on urination
e Cloudy or foul-smelling urine
e Urine retention
e Clay-colored stools or dark amber urine These changes indicate bile leaking into the abdomen and onto the
e Development of increased itchiness or yellowing of skin client’s skin.
e When the T-tube drainage subsides or after the T-tube has May indicate a blockage or an infection.
been removed, purulent drainage from the T-tube or
green-brown drainage around T-tube or from wound site
e A significant increase in or more than 500 mL/day of This change may indicate increased bile production or infection.
drainage from T-tube
e A sudden marked decrease in T-tube drainage or increase These changes may indicate T-tube has become dislodged or is
in length of the T-tube (may indicate that the T-tube has blocked.
become dislodged)
e Abdominal distention or rigidity May indicate consumption of too many fatty foods or potential
abdominal abscess.
e Persistent heartburn, feeling of bloating, or nausea May indicate consumption of a high level of fat in the diet.
e Loose stools that continue for longer than 2 to 3 months
Instruct client in ways to prevent postoperative infection: Understanding rationale may improve adherence to treatment
regimen.
e Continue with coughing unless contraindicated and deep Coughing and deep breathing exercises help to improve oxygen-
breathing every 2 hrs while awake. ation to the tissues, expand the lungs, and prevent stasis of
* Continue to use incentive spirometer if activity is limited. secretions.
e Increase activity as ordered. These actions prevent thromboembolism and improve ability to
resume normal activities.
e Avoid contact with persons who have infections. Prevents exposure of client to others who are ill and decreases the
risk for an infection.
e Avoid crowds during flu and cold seasons.
° Drink at least 10 glasses of liquid per day, unless contrain- Maintains adequate hydration and vascular fluid volume.
dicated.
e Maintain a balanced nutritional intake. An appropriate diet with adequate protein improves the body’s abil-
ity to heal.
* Maintain proper balance of bedrest and activity.
These actions help prevent infection.
e Maintain good personal hygiene (e.g., oral care, hand-
washing, and perineal care).
e Maintain sterile or clean technique as ordered during
wound care.
Improves client’s adherence to treatment regimen and decreases
e Provide client with supplies necessary for wound care.
potential for infection.
The client should not do any heavy lifting until approved by the
Instruct client to avoid heavy lifting for 4 to 6 weeks.
health care provider. Lifting may cause a rupture of suture line.

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NDx = NANDA Diagnosis
 578 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Important so the nurse knows that the client understands what is
Desired Outcome: The client, in collaboration with the
expected postoperatively.
nurse, will develop a plan for adhering to recommended fol-
low-up care including future appointments with health care
provider, wound care, medications prescribed, and activity
level

Independent Actions
Explain the rationale for, side effects of, schedule for taking, Knowledge of disease process and treatment helps the client and
and importance of taking medications prescribed. Inform family understand the changes that are occurring and the im-
client of pertinent food and drug interactions. portance of treatment in maintaining health status. This im-
proves client’s adherence to treatment regimen and allows client
to maintain a level of independence.
If the client has had a laparoscopic cholecystectomy, mild Appropriate positioning postoperatively helps relieve pain.
shoulder pain may persist for a week after surgery until the
carbon dioxide used during surgery is completely ab-
sorbed. Inform client that lying on his/her left side with
the right knee flexed may help relieve this pain.

Cirrhosis is a chronic liver disease that is caused by extensive of increasing ascites and peripheral edema. Much of
destruction of the parenchymal cells in the liver. These cells the information is applicable to clients receiving
are eventually replaced by fibrous scar tissue with subsequent follow-up care in an extended care facility or home
change in liver structure and functioning. These structural setting.
changes impair portal blood flow that results in venous con-
gestion in other organs and systems such as the spleen and
gastrointestinal tract.
OUTCOME/DISCHARGE CRITERIA
The most common causes of cirrhosis include chronic in-
fection with hepatitis B and C viruses and alcohol use. The client will:
Laennec cirrhosis, alcohol-induced, is the second most com-
1. Maintain adequate nutritional intake
mon form of the disease. Other causes include exposure to 2. Perform activities of daily living without extreme fatigue
toxic chemicals or drugs, genetic causes of cirrhosis (including or dyspnea
alphal-antitrypsin deficiency, Wilson disease, and hemochro- Maintain reduced or resolution of ascites and edema
matosis), heart failure, and conditions that cause persistent Have no evidence of life-threatening complications
bile flow obstruction (e.g., primary biliary cirrhosis, primary Discuss ways to prevent further liver damage
sclerosing cholangitis). YWDAME
Discuss the for and components of the recommended
All types of cirrhosis have similar signs and symptoms. diet
Clinical manifestations are reflective of the degree of im- 7. Reduce stress or trauma to the esophageal blood vessels
paired liver function and portal hypertension-induced ve- 8. Describe ways to prevent bleeding
nous congestion. Alcohol-related cirrhosis may have addi- 9. Implement ways to reduce the risk of infection
tional manifestations such as cerebral degeneration and 10. Describe methods to relieve pruritus
demyelinating neuropathies thought to be a direct result of 11. State signs and symptoms to report to the health care
the toxic effects of alcohol and/or associated vitamin defi- provider
ciencies. Treatment of cirrhosis is supportive and directed at 12, List community resources that can assist with home man-
slowing the progression of liver scar tissue and decreasing the agement and adjustment to lifestyle changes necessary
incidence and/or severity of complications. The primary for effective management of cirrhosis
goals of treatment are to eliminate or manage the factors/ 13. Discuss concerns and feelings about the diagnosig of cir-
conditions that contributed to the development of cirrhosis, rhosis; prognosis; and effects of the disease process and
provide a high nutrient diet, reduction of further liver dam- its treatment on self-concept, lifestyle, and roles
age, and rest to reduce the metabolic demands on the liver. 14. Develop plan for adhering to recommended follow-up
A liver transplant may be indicated to treat end-stage liver care including future appointments with health care pro-
disease. vider, medications prescribed, and activity level
This care plan focuses on the adult client with alco-
holic (Laennec) cirrhosis hospitalized for management
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 579

Nursing Diagnosis INEFFECTIVE BREATHING PATTERN nox

Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Related to:
e Increased rate of respirations associated with fear and anxiety
e Decreased depth of respirations associated with:
e Weakness and fatigue
° Decreased lung compliance (distensibility) resulting from pleural effusion (hepatic hydrothorax) that occurs due to excess
fluid volume and passage of ascetic fluid into the pleural space
e Restricted chest expansion resulting from positioning and pressure on the diaphragm as a result of ascites

CLINICAL MANIFESTATIONS

Subjective Objective
Complaints of shortness of breath Dyspnea; orthopnea; bradypnea, tachypnea; decreased
depth of breathing; decreased inspiratory/expiratory pres-
sure; decreased minute ventilation; decreased vital capac-
ity; nasal flaring; use of accessory muscles; use of three-
point position; altered chest excursion; pursed-lip
breathing; prolonged expiration phases

RISK FACTORS DESIRED OUTCOMES a

ne eR EE a
e Chronic illness The client will have an improved breathing pattern, as
e Failure of body’s regulatory mechanisms evidenced by:
e Respiratory muscle fatigue a. Regular rate and depth of respirations
b. Decreased dyspnea
c. Symmetric chest excursion
d. Arterial blood gas (ABG) and vital capacity within
acceptable range

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation Ventilation assistance; respiratory monitoring

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern allows for prompt intervention.
pattern:
e Shallow or slow respirations Change in breathing rate and depth may be due to presence of fluid
e Limited chest excursion accumulation in the abdomen causing pressure on the lungs
e Tachypnea or dyspnea and decreased diaphragmatic excursion. This leads to increased
respiratory rate and possible use of accessory muscles.
e Use of accessory muscles when breathing
Monitoring continuous SaO> readings allows for the early detection
Assess/monitor pulse oximetry (arterial oxygen saturation
of hypoxia.
[SaO2]), ABG values as indicated.
Assessment of ABG values provides a more direct measurement of
both the partial pressure ofoxygen in arterial blood (PaQ2) and
the partial pressure of carbon dioxide in arterial blood (PaCO3),
which reflect the adequacy of ventilation.

RATIONALE
THERAPEUTIC INTERVENTIONS
Independent Actions
Implement measures to improve breathing pattern:
e These actions provide longer rest periods and may increase a cli-
* Perform actions to increase strength and activity toleranc
ent’s willingness and ability to move, deep breathe, and use
(e.g., maintain activity restrictions, maintain a calm environ-
incentive spirometer.
ment, organize nursing care to provide for periods of rest,
limit number of visitors and their length of stay). De+

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 580 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

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THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to restore fluid balance: Reduces fluid accumulation in the peritoneal cavity and pleural
e Restrict sodium intake as ordered. space, thus decreasing pressure on the diaphragm.
e Maintain fluid restriction.
e Encourage client to periodically rest in a recumbent Lying down reduces peripheral pooling of blood, which increases
position. effective circulating volume and renal blood flow and subse-
quently promotes diuresis.
e Place client in a semi-Fowler’s position (a high-Fowler’s Decreases less compression on the diaphragm from an extended
position is uncomfortable if ascites is severe). D @ + abdomen.
e Instruct client to deep breathe or use incentive spirometer Deep breathing and use of an incentive spirometer promote maxi-
every 1 to 2 hrs. mal inhalation and lung expansion, which reduces incidence of
atelectasis and enhances mobilization of secretions
e Instruct client to avoid intake of gas-forming foods (e.g., Avoidance of gas-forming foods prevents gastric distention and
beans, cauliflower, cabbage, onions), carbonated bever- additional pressure on the diaphragm.
ages, and large meals.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
e Assist with positive airway pressure techniques (e.g., con- Positive airway pressure techniques increase intrapulmonary
tinuous positive airway pressure [CPAP], bilevel positive (alveolar) pressure, which helps expand collapsed alveoli and
airway pressure [BiPAP], flutter/positive expiratory pres- prevent further alveoli collapse.
sure [PEP] device), if ordered.
e Administer central nervous system depressants judiciously; Reducing pain helps to increase the client’s willingness to move and
hold medication and consult physician if respiratory rate breathe more deeply.
is less than 12 breaths/min.
e Assist with thoracentesis and/or paracentesis if performed. Removal of pleural and/or peritoneal fluid allows for increased
chest and lung expansion.
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care provider allows for prompt
therapist, physician) if: modification of treatment plan.
e Ineffective breathing pattern continues.
e Signs and symptoms of impaired gas exchange (e.g., rest-
lessness, irritability, confusion, significant decrease in ox-
imetry results, decreased PaO, and increased PaCO, levels)
are present.

Nursing/Collaborative Diagnosis: RISK FOR IMBALANCED FLUID VOLUME nox RISK FOR
ELECTROLYTE IMBALANCE nox AND THIRD-SPACING
Definition: Risk for Imbalanced fluid volume NDx: Susceptible to a decrease, increase, or rapid shift from
one to the other
of intravascular, interstitial and/or intracellular fluid, which may compromise health. This refers
to body fluid loss,
gain, or both; Risk for electrolyte imbalance NDx: Susceptible to changes in serum electrolyte
levels, which may
compromise health.

Related to:
e Sodium and water retention associated with an increased serum aldosterone level resulting from:
e Inability of the liver to metabolize aldosterone
e Activation of the renin-angiotensin-aldosterone mechanism as a result of decreased renal blood flow (occurs because of a
decrease in intravascular volume that results from vasodilation and from third-spaci
ng and sequestration of fluid in the
splanchnic system)
* Low plasma colloid osmotic pressure associated with hypoalbuminemia (a result
of decreased hepatic synthesis of albumin
and prolonged inadequate nutrition)
e Compromised regulator mechanisms '
Increased pressure in the portal system and hepatic lymph system associated with
blood flow backup resulting from struc-
tural changes in the liver
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 581

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of shortness of breath Jugular venous distention; decreased hemoglobin (Hgb)
and hematocrit (Hct); weight gain over short period of
time; dyspnea; intake exceeds output; pleural effusion;
orthopnea; S; heart sound; pulmonary congestion; change
in respiratory pattern; change in mental status; blood pressure
changes; pulmonary artery pressure changes; oliguria;
specific gravity changes; azotemia; electrolyte imbalance;
restlessness; anxiety; adventitious breath sounds (crackles);
edema, may progress to anasarca; increased central
venous pressure; positive hepatojugular reflex; paroxysmal
nocturnal dyspnea

RISK FACTORS DESIRED OUTCOMES

ee a a ee
e Hyperaldosteronism The client will experience resolution of fluid and electro-
e Poor nutritional status lyte imbalance fluid, as evidenced by:
e Portal hypertension a. Decline in weight toward client’s normal weight
e Hepatomegaly b. B/P and pulse rate within normal range for client and
e Compromised regulatory mechanism stable with position change
e Ascites c. Absence or resolution of S3 heart sound or Electrocar-
diogram (ECG) changes
d. Balanced intake and output
e. Usual mental status
f. Electrolyte (e.g., sodium and potassium) levels return-
ing toward normal range
g. Decreased dyspnea, peripheral edema, and neck vein
distention
. Improved breath sounds
. Resolution of ascites
. Usual muscle tone and strength
Sn. Absence of nausea and vomiting
fer
Paps

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; fluid overload severity; electrolyte and Fluid/electrolyte management

acid-base balance

NURSING ASSESSMENT RATIONALE

Assess for and report: Early recognition of signs and symptoms of fluid and electrolyte
imbalance allows for prompt treatment.
° Signs and symptoms of excess fluid volume:
e Weight gain of 2% or greater in a short period Rapid fluid gain may be noted in changes in daily weight.
Signs and symptoms of abnormal potassium and sodium levels Change in potassium and sodium impacts cardiac functioning and
fluid volume.
e Elevated blood pressure B/P elevates with increase in vascular fluid volume and decreases
if fluid has shifted out of the vascular space.
e Development or worsening of S; heart sound; ECG changes
S; heart sounds indicate vascular fluid overload ECG changes indi-
cate decreased potassium levels.
e Intake greater than output Indicates increased fluid retention.
e Change in mental status May reflect impending hepatic encephalopathy.
e Low serum sodium level May result from diuretic therapy and a low-sodium diet.
Indicates increased pulmonary congestion.
e Dyspnea, orthopnea, crackles (rales), diminished or absent
breath sounds
e Peripheral edema Indicates changes in capillary status.
Increased vascular fluid volume.
e Distended neck veins

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NURSING ASSESSMENT RATIONALE

e Signs and symptoms of third-spacing: Early recognition of signs and symptoms of third-spacing allows for
e Ascites prompt treatment.
e Dyspnea and diminished or absent breath sounds
e Evidence of vascular depletion (e.g., postural hypotension; Indications of potential changes in vascular fluid status and/or loss
weak, rapid pulse; decreased urine output) of vascular integrity.
e Chest radiograph results showing pulmonary vascular Confirmation of increased vascular fluid retention.
congestion, pleural effusion, or pulmonary edema
e Low serum albumin levels Results in fluid shifting out of the vascular space because albumin
is required to maintain plasma colloid osmotic pressure.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to restore fluid balance: Sodium and fluid restriction helps to minimize fluid retention in
e Perform actions to reduce excess fluid volume: extravascular tissues.
e Restrict sodium intake as ordered.
e Maintain fluid restrictions if ordered.
e Encourage client to rest periodically in a recumbent Lying down reduces peripheral pooling of blood, which increases
position. D @ + effective circulating volume and renal blood flow and subse-
quently promotes diuresis.
e Administer diuretics if ordered (e.g., potassium-sparing Potassium-sparing diuretics reduce fluid volume by increasing uri-
diuretics such as spironolactone and amiloride). D nary output and decrease retention of sodium.
e Perform actions to promote mobilization of fluid back into Improves renal blood flow, which increases water excretion
the vascular space and to prevent further third-spacing: and reduces activation of the renin-angiotensin-aldosterone
mechanism.
e Administer albumin infusions, if ordered. Albumin infusions increase vascular colloid osmotic pressure and
pulls fluid back into the vascular system.
Monitor serum Na* and K* levels. Maintenance of Na and K levels is important to maintain adequate
Administer electrolyte replacements as ordered. cardiac functioning. When administering potassium replace-
ments, it is important to monitor the infusion carefully to
prevent further complication.
Consult physician if signs and symptoms of imbalanced fluid Notifying the appropriate health care provider allows for prompt
and electrolytes persist or worsen. modification of treatment plan.

|Nursing ~-_
Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
° Reduced oral intake associated with dyspepsia, fatigue, dyspnea, dislike of the prescribed diet, and feeling
of fullness from
ascites
° Reduced metabolism and storage of nutrients by the liver associated with a reduction of functional liver
tissue
° Malabsorption of fats and fat-soluble vitamins associated with impaired bile production and flow.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of lack of appetite; fatigue; sore buccal mem- Loss of weight with adequate food intake; body weight
brane irritability; abdominal cramping/pain 20% or more under ideal weight; inflamed buccal cavity;
capillary fragility; pale conjunctiva and mucous mem-
branes; poor muscle tone; excessive hair loss; amenorthea
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 583

RISK FACTORS DESIRED OUTCOMES

e Chronic illness The client will maintain an adequate nutritional status, as
e Anorexia evidenced by:
e Poor nutritional status a. Dry weight approaching normal for the client (dry
e Poor dietary habits weight achieved after fluid volume excess has been
e Economically disadvantages resolved)
e Inability to absorb nutrients b. Normal blood urea nitrogen (BUN) and serum
albumin, prealbumin, hematocrit (Hct), and hemoglobin
(Hgb) levels, and normal lymphocyte count
c. Improved strength and activity tolerance
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status Nutritional monitoring; nutritional counseling; nutritional

management; nutritional therapy

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition and reporting of signs and symptoms of malnutri-
e Weight significantly below client’s usual weight or below tion allows for prompt intervention.
normal for client’s age, height, and body frame
e Decreased serum prealbumin, BUN, a albumin, Hct and
Hgb levels and decreased lymphocyte count
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Monitor percentage of meals and snacks client consumes. An awareness of the amount of food/fluid the client consumes
Report a pattern of inadequate intake. alerts the nurse to deficits in nutritional intake. Reporting an
inadequate intake allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve nutritional status:
e Implement measures to reduce dyspepsia (e.g., keep head Elevation of the head of the bed after eating decreases pressure on
of bed elevated for 2-3 hrs after eating; provide small, fre- abdomen, which may improve appetite. Small frequent meals
quent meals; encourage client to ingest foods slowly; avoid and refraining from the use of carbonated beverages or a straw
carbonated beverages; do not use a straw). D@ > decrease pressure in the abdomen.
Encourages a rest period before meals. D @ > Minimizes fatigue.
e Provide a clean environment and a relaxed, pleasant atmo- A clean environment and a relaxed, pleasant atmosphere can help
sphere. D @ + to reduce the client’s stress and promote a feeling ofwell-being,
which tends to improve appetite and oral intake.
e Serve frequent, small meals if client is weak, fatigues easily, Providing small rather than large meals can enable a client who is
and/or has a poor appetite. D@ + weak or fatigues easily to finish a meal. In addition, a client
who has a poor appetite is often more willing to attempt to eat
smaller meals because they seem less overwhelming than larger
ones. If smaller meals are served, the number ofmeals per day
should be increased to help ensure adequate nutrition.
e Elevate the head of bed as tolerated for meals. D @ Roa Helps reduce dyspnea and feeling of fullness (a high-Fowler’s
position may be too uncomfortable ifascites is severe).
Provide adequate time for meals; reheat foods/fluids if Appetite is also suppressed if foods/fluids normally served hot or
°
necessary. D @ + warm become cold and do not appeal to the client.
Drinking liquids with meals distends the stomach and may cause
° Reduce fluid intake with meals unless the fluid has a high
nutritional value. D + satiety before an adequate amount of food is consumed.
Activity usually promotes a sense of well-being, which can improve
e Increase activity as allowed and tolerated. D @ +
appetite.

Assist and instruct client to adhere to the following dietary The client should understand what foods and fluids will improve
°
nutritional status.
recommendations:

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 584 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

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THERAPEUTIC INTERVENTIONS RATIONALE

e Avoid skipping meals. Skipping meals reduces caloric intake.
e Consume a diet high in calories (2000-3000 calories/ A high-calorie and high-carbohydrate diet will improve the client’s
day) and carbohydrates. nutritional status.
e Limit protein intake with hepatic encephalopathy. Changes in the client’s metabolism due to liver failure can cause
hepatic encephalopathy, because ammonia is not metabolized
and passes through the liver unchanged and can become a cere-
bral toxin.
e Consume meals that are well balanced and high in essen- The client must consume a diet that is well balanced and high in
tial nutrients. essential nutrients to meet nutritional needs.

Dependent/Collaborative Actions
Implement measures to improve nutritional status:
e Implement measures to restore fluid volume (e.g., restrict Reduces fluid in the peritoneal cavity and subsequently reduces the
sodium intake; maintain fluid restrictions as ordered; ad- feeling of fullness
minister diuretics as ordered).
e Administer vitamins and minerals (e.g., fat-soluble vita- Vitamins and minerals are needed to maintain metabolic function-
mins, thiamine, folic acid, iron), if ordered. ing. If the client’s dietary intake does not provide adequate
amounts of them, oral and/or parenteral supplements may be
necessary.
e Instruct client to use herbs, spices, and salt substitutes (if Use of spices makes low-sodium diet more palatable.
approved by a physician).
e Obtain a dietary consult if necessary. A dietitian is best able to evaluate whether the foods/fluids selected
will meet the client’s nutritional needs.
e Perform a calorie count if ordered. Report information to A calorie count provides information about the caloric and nutri-
the dietitian and physician. tional value of the foods/fluids the client consumes. This infor-
mation helps the dietitian and physician determine whether an
alternative method of nutritional support is needed.
e Consult physician about an alternative method of provid- If the client’s oral intake is inadequate, an alternative method of
ing nutrition (e.g., parenteral nutrition, tube feeding) if providing nutrients needs to be implemented.
client does not consume enough food or fluids to meet
nutritional needs.

|Nursing ~__
Diagnosis IMPAIRED COMFORT
nox (PRURITUS)
Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, cultural, and/or
social
dimensions.

Related to: Stimulation of itch receptors in the skin by bile acid metabolites that accumulate in the blood as a result of bile
flow obstruction

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of skin itching Persistent scratching or rubbing of skin

RISK FACTOR DESIRED OUTCOMES

e Illness-related symptoms
The client will experience relief of pruritus, as evidenced
by:
a. Verbalization of same ‘
b. No scratching or rubbing of skin

NOC OUTCOMES NIC INTERVENTIONS

Comfort status: symptom control Pruritus management
 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 585

NURSING ASSESSMENT RATIONALE

Assess for the following: Early recognition of signs and symptoms of pruritus allows for
e Reports of itchiness prompt intervention.
e Persistent scratching or rubbing of skin

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client in and/or implement measures to relieve pruritus:
° Apply cool, moist compresses to pruritic areas. D @ > Cold/cool compresses provide a counter sensation that decreases
the urge to rub or scratch the area.
e Apply emollient creams or ointments frequently. D @ Creams and ointments prevent dryness.
e Add emollients, cornstarch, or baking soda to bath water. Use of these products in bath water reduces skin dryness and
bpe+ provides a protective barrier.
° Use tepid water and mild soaps for bathing. D @ + Use of tepid water and mild soaps decreases skin dryness.
e Pat skin dry after bathing, making sure to dry thoroughly. Rubbing of the skin with a towel after a bath can stimulate itching.
De+
° Maintain a cool environment. D @ + A cool environment provides a counter sensation that decreases
urge to rub or scratch.
e Encourage participation in diversional activity including Distracts client from focusing on the itch.
watching TV, listening to music, mindfulness-based
relaxation.
e Implement cutaneous stimulation techniques (e.g., mas- Cutaneous stimulation blocks the neurotransmission of the itch
sage, pressure, vibration, stroking with soft brush) at sites sensation.
of itching or acupressure points.
e Encourage client to wear loose cotton garments and avoid Wearing loose clothing and non-wool blankets decreases skin
clothes or blankets made from wool. irritation.

Dependent/Collaborative Actions
Instruct client in and/or implement measures to relieve pruritus:
e Administer the following medications if ordered:
e Antihistamines (e.g., diphenhydramine, hydroxyzine Antihistamines block histamine, which stimulates itchy sensa-
{Atarax]) tions.
e Bile acid-sequestering agents (e.g., cholestyramine). Bile acid-sequestering agents bind with the bile acids in the intes-
tines, prevent absorption, and enhance elimination, thereby
decreasing itch sensations.
Consult appropriate health care provider (e.g., clinical nurse Notification of the appropriate health care provider allows for
specialist, physician) if aforementioned measures fail to prompt modification in treatment plan.
alleviate pruritus or if the skin becomes excoriated.

Diagnosis |VITY
|Nursing ACTI INTOLERANCE nx
or desired daily activities.
Definition: Insufficient physiologic or psychological energy to endure or complete required

Related to:
e Tissue hypoxia associated with anemia resulting from:
and absorption of vitamins and miner-
e Decreased production of red blood cells (RBCs), resulting from a decreased intake
als and an inability of the liver to store vitamins and minerals
has resulted in splenomegaly, the spleen
° Excessive RBC destruction resulting from hypersplenism (if venous congestion
will destroy RBCs faster than usual)
e Blood loss if bleeding has occurred
disuse if mobility has been limited for an extended
° Loss of muscle mass, tone, and strength associated with malnutrition and
period
glucose, fats, and proteins properly
° Decrease in available energy associated with inability of the liver to metabolize
associated with dyspnea, discomfort , frequent assessment s and treatments, fear, anxiety, and
° Difficulty resting and sleeping
unfamiliar environment

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 586 Chapter 11. * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of fatigue or weakness Abnormal heart rate or B/P response to activity; exertional
discomfort or dyspnea; ECG changes reflecting dysrhyth-
mias or ischemia; unable to speak during physical activity

RISK FACTORS DESIRED OUTCOMES

e Chronic illness The client will demonstrate an increased tolerance for ac-
e Poor nutritional status tivity, as evidenced by:
e Immobility a. Verbalization of feeling less fatigued and weak
e Impaired digestive processes b. Ability to perform activities of daily living without ex-
ertional dyspnea, chest pain, diaphoresis, dizziness,
and significant changes in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Rest; energy conservation; activity tolerance Energy management; oxygen therapy; nutrition manage-
ment; sleep enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of signs and symptoms of activity intolerance
e Statements of fatigue or weakness allows for prompt intervention.
e Exertional dyspnea, chest pain
e Diaphoresis or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 3 minutes after stopping activ-
ity, change from regular to irregular rate)
e Significant change (15-20 mm Hg) in B/P with change in
activity level.

THERAPEUTIC INTERVENTIONS RATIONALE

eee
Independent Actions
Implement measures to improve activity tolerance:
e Perform actions to promote rest and/or conserve energy Cells use oxygen and fat, protein, and carbohydrate to produce the
¢ Maintain prescribed activity restrictions. energy needed for all body activities. Rest and activities that
e Minimize environmental activity and noise. D @ conserve energy result in a lower metabolic rate, which preserves
e Provide uninterrupted rest periods. D @ + nutrients and oxygen for necessary activities. These actions
e Assist with care. D@ promote energy conservation and rest.
° Keep supplies and personal articles within easy reach. D @ + Avoids stress due to inability to obtain desired objects and prevents
e Limit the number of visitors. potential for client injury.
e Instruct client in energy-saving techniques (e.g., using a Allows for rest and decreases exposure to potential infectious
shower chair when showering, sitting to brush teeth or organism.
comb hair). These techniques help client to maintain activities of daily living
while decreasing fatigue.
e Implement measures to reduce fear and anxiety (e.g., as- Fear and anxiety interfere with a client’s ability to rest.
sure client that staff are nearby, explain all tests and pro-
cedures, encourage verbalization of fear and anxiety).
° Implement measures to promote sleep (e.g., elevate head Increased hours of sleep improve the client’s ability to increase level
of bed and support arms on pillows to facilitate breathing; of activity. '
discourage intake of fluids high in caffeine, especially in
the evening; encourage relaxing diversional activities in
the evening).
° Implement measures to reduce discomfort (e.g., proper Decreasing discomfort improves the client’s ability to perform
positioning). D+ activities and to rest.
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THERAPEUTIC INTERVENTIONS RATIONALE

e Discourage smoking and excessive intake of beverages Both nicotine and excessive caffeine intake can increase cardiac
high in caffeine such as coffee, tea, and colas. workload and myocardial oxygen utilization, thereby decreasing
the amount of oxygen necessary for energy production.
e Implement measures to improve respiratory status (e.g., Altered respiratory function can lead to inadequate tissue oxygen-
encourage use of incentive spirometer; elevate head of ation, which results in less efficient energy production and a
bed; assist with turning, coughing, and deep breathing) if reduced ability to tolerate activity. Improving respiratory status
ineffective breathing pattern, ineffective airway clearance, increases the amount of oxygen available for energy produc-
or impaired gas exchange is contributing to client’s activ- tion. It also eases the work of breathing, which reduces energy
ity intolerance. expenditure.

Dependent/Collaborative Actions
Implement measures to improve activity tolerance:
e Implement measures to maintain an adequate nutritional Metabolism is the process by which nutrients are transformed into
status (e.g., provide a diet high in essential nutrients, pro- energy. If nutrition is inadequate, energy production is de-
vide dietary supplements as indicated, administer vita- creased, which subsequently reduces one’s ability to tolerate
mins and minerals as ordered). activity.
e Implement measures to treat anemia, if present (e.g., ad- Anemia reduces the oxygen-carrying capacity of the blood. Resolu-
minister prescribed iron, folic acid, and/or vitamin By; tion of anemia increases oxygen availability to the cells, which
administer packed RBCs as ordered). increases the efficiency of energy production and subsequently
improves activity tolerance.
-© Implement measures to promote sleep (e.g., maintain Improves tissue oxygenation.
oxygen therapy during sleep, administer sleep aids and Improves client’s ability to rest/sleep.
analgesics).
e Increase client’s activity gradually as allowed and tolerated. Progressive activity helps strengthen the myocardium, which en-
Instruct client to report a decreased tolerance for activity and hances cardiac output and improves activity tolerance.
to stop any activity that causes chest pain, a marked in- Changes in a client’s activity tolerance may indicate worsening
crease in shortness of breath, dizziness, or extreme fatigue disease process or inadequate treatment regimen.
or weakness.
Consult physician if signs and symptoms of activity intoler- Notification of the physician allows for prompt modification of the
ance persist or worsen. treatment plan.

Collaborative/Nursing Diagnosis ACUTE CONFUSION nox AND CHRONIC CONFUSION nox

Definition: Acute Confusion NDx: Reversible disturbances of consciousness, attention, cognition and perception that
develop over a short period of time, and which last less than 3 months; Chronic Confusion NDx: Irreversible,
progressive, insidious, and long-term alteration of intellect, behavior and personality, manifested by impairment
in cognitive functions (memory, speech, language, decisionmaking, and executive function), and dependency
in execution of daily activities
substances (e.g., ammo-
Related to: Disturbances in central nervous system functioning associated with accumulation of toxic
and
nia) in the brain, toxic effects of long-term alcohol use, deficiencies of certain vitamins (e.g., thiamine),
hypoxia if anemia is moderate to severe

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Alteration in behavior, personality, short- and long-term
memory, social functioning, inability to perform at least
one daily activity; and cognitive impairment

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 588 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

RISK FACTORS DESIRED OUTCOMES

e Alcohol use The client will demonstrate decreased confusion, as evi-
e Inability of body to remove toxins denced by:
e Poor nutritional status a. Improved ability to grasp ideas
Impaired metabolic functioning Improved short- and long-term memory
Functional impairment Longer attention span
Age > 60 years old Absence or resolution of inappropriate behavior
Infection Se
Oi Oriented to person, place, and time

NOC OUTCOMES NIC INTERVENTIONS

Cognitive orientation Environmental management; environmental management:
safety behavioral management

NURSING ASSESSMENT RATIONALE

Assess for episodes of disorientation to person, place, and Early recognition of signs and symptoms of confusion allows for
time; episodes of inappropriate behavior; impaired deci- prompt intervention.
sion-making ability; impaired attention span, inability to
perform one or more daily activities

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain optimal thought processes:
e Perform actions to improve nutritional status (e.g., pro- Provides vitamins and minerals that are essential for normal neu-
vide a diet high in essential nutrients, provide dietary rologic functioning and treatment of anemia which improves
supplements as indicated, administer vitamins and miner- oxygenation.
als as ordered). D >
Perform actions to prevent or manage hepatic coma (e.g., These actions eliminate or control levels of ammonia and other
prevent constipation, decrease potential for gastrointesti- nitrogenous substances which impair cognitive functioning.
nal hemorrhage, maintain fluid and electrolytes).
Administer central nervous system depressants such as Liver damage associated with cirrhosis reduces normal drug me-
opioids, sedative-hypnotics, and antianxiety agents with tabolism and may lead to increased serum blood levels/toxicity
extreme caution; question any order for a normal adult of these medications. Medications may also cause cognitive
dose of these medications. D + impairment.
e Administer thiamine if ordered. D> Thiamine is essential for appropriate neurologic functioning and
binds with iron which helps to decrease the iron load on the
liver.
Maintain oxygen therapy as ordered. Helps maintain appropriate tissue oxygenation.

If client shows evidence of confusion or disorientation:

e Speak to the client by name. D@ + The client may respond to name even when unable to recognize
others.
Reorient client to person, place, and time as necessary D @ + Frequent reorientation may provide the client with a sense of security.
Place familiar objects, clock, and calendar within client’s Placing familiar objects helps to orient client and provides a sense
view. D @ + of security.
Approach client in a slow, calm manner; allow adequate These actions help the client remain calm and increase appropriate
time for communication. D @ communication.
e Repeat instructions as necessary using clear, simple lan- Repetition of information increases potential for client understanding.
guage and short sentences.
e Maintain a consistent and fairly structured routine, and Structure provides a sense of security and ability to cope with cogni-
write out a schedule of activities for client to refer to if tive changes.
desired.
‘
e Have client perform only one activity at a time, and allow Decreases client’s risk of becoming confused and subsequently frus-
adequate time for performance of activities. D @ + trated in performing multiple activities.
e Encourage client to make lists of planned activities, ques- Structure provides the client with a sense of security.
tions, and concerns.
e Assist client to problem solve if necessary. Provides client some control over the situation.
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THERAPEUTIC INTERVENTIONS RATIONALE

¢ Maintain realistic expectations of client’s ability to learn, Decreases frustration of client, significant others, and nurses.
comprehend, and remember information provided; pro-
vide client with a written copy of instructions.
e Encourage significant others to be supportive of client. In- Decreases client and family frustration and agitation. Allows cli-
struct them in methods of dealing with client’s confusion. ent’s significant others to be involved in care and improves their
understanding of the situation,
¢ Inform client and significant others that cognitive and Provides hope to client and significant others for the client’s future
emotional functioning may to improve with treatment. cognitive abilities.
Consult physician if disturbed thought processes worsen. Notification of the physician allows for prompt modification of the
treatment plan.

|Nursing 2)
Diagnosis |6RISK FOR BLEEDING nox
Definition: Susceptible to a decrease in blood volume, which may compromise health.

Related to:
e Decreased production of clotting factors associated with impaired liver function and decreased available vitamin K (can occur
from malnutrition, antimicrobials that suppress activity of intestinal flora, and impaired absorption of vitamin K as a result
of bile flow obstruction)
e Thrombocytopenia associated with hypersplenism (if venous congestion has resulted in splenomegaly, the spleen will
destroy platelets faster than usual)

NOC OUTCOMES NIC INTERVENTIONS

Blood coagulation Bleeding precautions; blood products administration

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of unusual joint pain and fatigue Petechiae, purpura, and ecchymoses; gingival bleeding;
prolonged bleeding from puncture sites; epistaxis, hemop-
tysis; further increase in abdominal girth; frank or occult
blood in the stool, urine, or vomitus; menorrhagia; rest-
lessness, confusion; hypotension and tachycardia; decrease
in Hct and Hgb levels

RISK FACTORS DESIRED OUTCOMES

* Poor nutritional status The client will not experience unusual bleeding, as
¢ Lack of clotting factors evidenced by:
* Early destruction of blood cells a. Skin and mucous membranes free of petechiae, pur-
* Gastrointestinal condition pura, ecchymoses, and active bleeding
° Impaired liver function b. Absence of unusual joint pain
c. No further increase in abdominal girth
d. Absence of frank and occult blood in stool, urine, and
vomitus
Usual menstrual flow
. Vital signs within normal range for client
. Stable or improved Hct and Hgb levels
soa
HO. No change in client’s energy status

D = Delegatable Action @=UAP @ =LVN/LPN © = Go to ©volve for animation

NDx = NANDA Diagnosis
 590 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

NURSING ASSESSMENT RATIONALE

Assess client for and report signs and symptoms of unusual Early recognition of signs and symptoms of bleeding allows for
bleeding: prompt intervention.
e Petechiae, purpura, ecchymoses
° Gingival bleeding
e Prolonged bleeding from puncture sites
e Epistaxis, hemoptysis
e Unusual joint pain
e Further increase in abdominal girth
e Frank or occult blood in the stool, urine, or vomitus
° Menorrhagia
e Restlessness, confusion
° Decreasing B/P and increased pulse rate
e Decrease in Hct and Hgb levels
Monitor platelet count and coagulation test results (e.g., pro-
thrombin time or international normalized ratio [INR],
activated partial thromboplastin time, bleeding time).
Report abnormal values.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce bleeding:
° Perform actions to reduce risk of bleeding from esophageal These actions reduce pressure or irritation on esophageal vessels.
varices (e.g., reduce excess fluid volume; avoid straining to
have a bowel movement, coughing, sneezing, lifting heavy
objects; avoid spicy foods or ones that may cause trauma
to the esophagus).
° Avoid giving injections whenever possible; consult physi- May cause increased and unnecessary bleeding.
cian about prescribing an alternative route for medications
ordered to be given intramuscularly or subcutaneously.
e When giving injections or performing venous or arterial Helps to decrease bleeding from puncture sites.
punctures, use the smallest-gauge needle possible and ap-
ply gentle, prolonged pressure to the site after the needle
is removed.
° Caution client to avoid activities that increase the risk for Cuts or mucous membrane irritation, even minor ones, may cause
trauma (e.g., shaving with a straight-edge razor, using stiff excessive bleeding.
bristle toothbrush or dental floss).
° Whenever possible, avoid intubations (e.g., nasogastric) Decreases bleeding associated with trauma.
and procedures that can cause injury to the rectal mucosa
(e.g., taking temperature rectally, inserting a rectal sup-
pository, administering an enema).
° Pad side rails if client is confused or restless. Decreases risk for client injury.
° Perform actions to prevent injury (e.g., keep bed in low
position; keep needed items within easy reach; assist with
ambulation; keep floor clear of clutter; provide ambula-
tory aids).
° Instruct client to avoid blowing nose forcefully or strain- Reduces pressure in esophageal vessels.
ing to have a bowel movement; consult physician about
an order for a decongestant and/or laxative if indicated.
e Administer the following if ordered: Administration of these medications improves clotting ability.
e Vitamin K injections
° Platelets ‘
¢ Fresh frozen plasma (FFP)
° Cryoprecipitate
If bleeding occurs and does not subside spontaneously: Each action enhances the body’s clotting ability.
e Apply firm, prolonged pressure to bleeding area(s) if |
possible.
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THERAPEUTIC INTERVENTIONS RATIONALE

° If epistaxis occurs, place client in a high-Fowler’s position Application of pressure and ice packs to the nose increases potential
and apply pressure and ice pack to nasal area. for clotting.
e Maintain oxygen therapy as ordered. Improves oxygenation.
° Administer vitamin K (e.g., phytonadione) injections, Enhances or replaces clotting factors.
whole blood, or blood products (e.g., FFP, platelets) as
ordered.
° Assess for and report signs and symptoms of hypovolemic Notifying the physician allows for prompt modification of the treat-
shock (e.g., restlessness; confusion; significant decrease in ment plan.
B/P; rapid, weak pulse; rapid respirations; cool skin; urine
output <30 mL/h).

Collaborative =o)
Diagnosis |RISK FOR ASCITES

Definition: An abnormal accumulation of fluid in the peritoneal cavity.

Related to:
¢ Low plasma colloid osmotic pressure associated with hypoalbuminemia (a result of decreased hepatic synthesis of albumin
and prolonged inadequate nutrition)
e Increased pressure in the portal system and hepatic lymph system associated with blood flow backup resulting from struc-
tural changes in the liver
e A generalized increase in hydrostatic pressure associated with excess fluid volume

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of abdominal pressure and discomfort Increasing abdominal girth; dull percussion note over the
abdomen; abdominal fluid wave; protruding umbilicus;
bulging flanks; dyspnea

RISK FACTORS DESIRED OUTCOMES

e Poor nutritional status The client will have decreased ascites, if present, as
e Chronic illness evidenced by:
e Impaired synthesis of proteins a. Decrease in abdominal girth
e Hyperaldosteronism b. Abdominal percussion note more tympanic
e Alcoholism

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of ascites: Early recognition of the signs and symptoms of ascites allows for
e Increase in abdominal girth (daily measurement of ab- prompt treatment.
dominal girth should be done at the same time and in the
same location on the abdomen with client in the same
position)
¢ Dull percussion note over abdomen with finding of shift-
ing dullness
e Presence of abdominal fluid wave
e Protruding umbilicus and bulging flanks

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Perform actions to reduce excess fluid volume, promote These actions decrease fluid retention.
mobilization of fluid back into the vascular space, and
prevent further third-spacing by:
e Restrict sodium intake as ordered.
e Maintain fluid restrictions if ordered.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to rest periodically in a recumbent posi- Lying down reduces peripheral pooling of blood, which increases
tion. D + effective circulating volume and renal blood flow and subse-
quently promotes diuresis.
e Administer diuretics if ordered (e.g., potassium-sparing Diuretics reduce fluid volume by increasing urinary output, and
diuretics such as spironolactone and amiloride are often improve renal blood flow, which increases water excretion and re-
used initially). D+ duces activation of the renin-angiotensin-aldosterone mechanism.
If signs and symptoms of ascites are present and persist or
worsen:
e Consult physician. Notification of the physician allows for prompt modification of
treatment plan.
e Assist with paracentesis. Paracentesis removes fluid from abdomen.
e Administer albumin infusions if ordered. Albumin increases colloid osmotic pressure and pulls fluid back
into the vascular system.
e Prepare client for a portal systemic shunt procedure (e.g., Informing clients about the procedure helps to reduce anxiety.
transjugular intrahepatic portosystemic shunt [TIPS]), if This procedure decreases portal hypertension and subsequently
planned. reduces ascites.
e Administer vitamin K and blood products, if ordered. Vitamin K and blood products improve the body’s clotting ability.
If signs and symptoms of bleeding esophageal varices occur:
e Turn client on side and suction as necessary. Reduces risk of aspiration.
e Maintain oxygen therapy as ordered. Improves cellular oxygenation.
e Assist with administration of octreotide (Sandostatin) or Octreotide and vasopressin cause constriction of the splanchnic
vasopressin, if ordered (nitroglycerin is often given with vessels and reduce blood flow to the portal vein.
vasopressin). Nitroglycerin lowers portal pressure and reduces vasoconstrictor
side effects of vasopressin.
e Prepare client for endoscopic sclerotherapy or ligation of Knowing what may happen during a procedure may reduce fear
varices, if planned. and anxiety.
e Assist with insertion of a gastroesophageal balloon tube A gastroesophageal balloon tube places pressure on the esophageal
(e.g., Sengstaken-Blakemore tube); maintain balloon pres- varices to decrease bleeding and increase clotting.
sure and suction and perform lavage as ordered.
e Administer vitamin K (e.g., phytonadione) injections, Vitamin K, blood, and blood products increase the body’s clotting
whole blood, or blood products (e.g., FFP, platelets) as ability.
ordered.
e Prepare client for a TIPS or surgery (e.g., esophageal tran- Reduces client’s fear and anxiety.
section with reanastomosis, distal splenorenal shunt), if
planned.

| “oo
Collaborative Diagnosis dMRISK FOR HEPATIC (PORTAL-SYSTEMIC) ENCEPHALOPATHY
(HEPATIC COMA)
Definition: Central nervous system damage associated with liver disease.
Related to:
e Altered brain function associated with:
e The effect of toxic end products of intestinal protein digestion (e.g., ammonia) on the brain
e Replacement of true neurotransmitters by false neurotransmitters
° Increased brain sensitivity to certain substances (e.g., benzodiazepines, y-aminobutyric acid [G ABA])
e Decreased activity of urea cycle enzymes if zinc deficiency is present

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of weakness and lethargy Changes in fine motor movements such as handwriting
and drawing; asterixis; slowed or slurred speech; emotional
liability; agitation; belligerence; disorientation; fetor hepat-
icus; unresponsiveness; increased serum ammonia level
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 593

RISK FACTORS DESIRED OUTCOMES

e Inability of body to remove toxins
The client will not develop hepatic encephalopathy, as
e Hypokalemia
evidenced by:
e Medication regimen
. Usual speech and handwriting
. Usual mental status
. Absence of asterixis and fetor hepaticus
@)
wp
eh . Serum ammonia level within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of hepatic encepha- Early recognition of signs and symptoms of hepatic encephalopathy
lopathy (e.g., change in handwriting, inability to draw simple allows for prompt intervention.
figures or numbers, asterixis, slow or slurred speech, inability
to concentrate, emotional lability, disordered sleep, agitation,
belligerence, disorientation, lethargy, fetor hepaticus [musty
or fruity odor on breath], unresponsiveness).
Monitor serum ammonia levels; report elevated values. Increased serum ammonia levels are an indication of declining liver
function, and it is no longer able to change ammonia to urea.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
_ Implement measures to reduce the risk for hepatic coma:
e Perform actions to eliminate or control the following
conditions that increase levels of ammonia and other
nitrogenous substances:
e Constipation Results in increased formation and absorption of ammonia and
mercaptans from the gut.
e Gastrointestinal hemorrhage Intestinal bacteria convert the protein in blood to ammonia and
other nitrogenous substances.
e Hypokalemia and/or metabolic alkalosis These conditions contribute to increased levels of ammonia.
e Renal failure Decreases excretion of ammonia.
e Excessive protein intake Intestinal bacteria convert protein to ammonia and other nitroge-
e Eat small frequent meals nous substances. Ammonia levels increase when the liver is
unable to change ammonia to urea.
Small meals prevent protein loading.
e Infection Bacteria that produce urease break urea into ammonia.
e Dehydration/hypovolemia Reduced blood flow to the liver results in decreased detoxification
of ammonia and other toxins.
e If client is to receive blood transfusions, request fresh Stored blood contains more ammonia and citrate.
rather than stored blood.
e Consult physician about discontinuation of prescribed Discontinuation of hepatotoxic medications prevent further liver
medications that are potential hepatotoxins (e.g., iso- damage.
niazid, amiodarone, 6-mercaptopurine, erythromycin,
phenytoin).
e Administer central nervous system depressants such as Many of these agents are metabolized in the liver and may pre-
opioids, sedative-hypnotics, and antianxiety agents with cipitate nonnitrogenous coma.
extreme caution.
If signs and symptoms of hepatic encephalopathy occur:
e Maintain client on strict bedrest. Rest reduces metabolic demands on the liver.
e Maintain dietary protein restrictions as ordered; increase Vegetable proteins are less ammonia genic.
protein intake slowly as encephalopathy resolves Protein loading increases production of ammonia.
e Encourage intake of vegetable proteins rather than animal
proteins.
e Ensure a high carbohydrate (CHO) intake or administer A high CHO intake or IV glucose provides a rapid energy source
intravenous (IV) glucose or tube feedings as ordered. and decreases metabolism of endogenous proteins.
e Administer enemas and/or cathartics as ordered. Enemas and/or cathartics hasten expulsion of intestinal contents
so that bacteria have less time to convert proteins to ammonia
and other nitrogenous substances.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Administer the following medications if ordered:

e Antimicrobials that suppress activity of the intestinal Antimicrobials suppress activity of intestinal flora, which decreases
flora (e.g., neomycin, metronidazole) protein breakdown in the intestine and thus reducing the pro-
duction of ammonia.
e Lactulose Promotes excretion of ammonia in the stool, decreases the pH value
of colon to less than 6, thereby decreasing absorption of am-
monia, promotes growth of healthy bacteria, decreases ammo-
nia production, and increases assimilation of nitrogenous
products by bacteria.
e Probiotics Probiotics may enhance tolerance the protein load, lower ammonia
levels, and improve neurologic symptoms
e Zinc supplements Stimulates ureagenesis (several enzymes in the urea cycle are zinc
dependent) and improves psychometric performance in patients
with hepatic encephalopathy.
Zinc supplementation might play an important role in the prevention
of hepatic encephalopathy by activating glutamine synthetase.
e Institute general safety precautions Prevents client injury.

|Nursing "Diagnosis
- |RISK FOR SPIRITUAL DISTRESS nox
Definition: Susceptible to an impaired ability to experience and integrate meaning and purpose in life through connectedness
within self, literature, nature, and/or a power greater than oneself, which may compromise health.
Related to:
e Chronic illness
e Increased dependence upon others
e Increased risk of death
e Loss of normal body function

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of hopelessness; despair, spiritual distress Disengagement in activities that used to bring client joy;
change in client’s routine activities; depression, inability to
forgive; changes in relationships

RISK FACTORS
e Chronic illness e Increased risk of death
e Loss of independence e Failure of body’s regulatory mechanisms

NOC OUTCOMES NIC INTERVENTIONS

SS — ee eae ee ae
Spiritual Health Spiritual Support

NURSING ASSESSMENT
——— RATIONALE
Observe client for actions that indicate difficulties in finding Early recognition of signs and symptoms of spiritual distress allows
meaning and purpose in life for prompt interventions.

THERAPEUTIC INTERVENTIONS
' RATIONALE
eeeeeeseseseseaeaeaeaeaeaeaoao
Independent Actions
Identify client’s religious or spiritual beliefs. Provides a baseline for understanding client’s preferences and
planning of care.
Provide a calm, peaceful environment. May allow client and family to express feelings.
Be actively present and listen to client’s concerns related to It is important to understand client and family perspective.
loss of independence, hopelessness, and helplessness.
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THERAPEUTIC INTERVENTIONS RATIONALE

Use therapeutic communication skills of nonjudgmental May help client to verbalize concerns and determine solutions.
active listening.
Brovide opportunities for client and family to participate in Provides for healing of past and present client concerns.
mediation, prayer, and spiritual activities.

Dependent/Collaborative Actions
Consult client’s spiritual advisor (if present), pastoral care, or Provides others to help support client and family in dealing with
crisis counseling. illness and its impact on the individual and family.
Encourage client and family to participate in support groups. Allows client and family members to interact and communicate
with others experiencing same or similar situations.

|Nursing 2
Diagnosis OU
INEFFECTIVE FAMILY HEALTH MANAGEMENT nox
Definition: A pattern of regulating and integrating into family processes a program for the treatment of illness and its
sequelae of illness that is unsatisfactory for meeting specific health goals of the family unit.

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of inability to manage illness; verbalizes inabil- Inaccurate follow-through with instructions; inappropriate
ity to follow prescribed regimen behaviors

RISK FACTORS DESIRED OUTCOMES

e Ineffective family process The client and significant other will demonstrate the prob-
e Change in lifestyle ability of effective therapeutic regimen management, as
e Chronic illness i evidenced by:
* Economically disadvantaged a. Willingness to learn about and participate in treat-
ment plan and care
b. Statements reflecting ways to modify personal habits
and integrate treatments into lifestyle
c. Statements reflecting an understanding of the implica-
tions of not following the prescribed treatment plan

NOC OUTCOMES NIC INTERVENTIONS

a ee ee ee eee ee
Compliance behavior; treatment behavior: illness or injury; Self-modification assistance; values clarification; substance
knowledge: treatment regimen; health beliefs: perceived use treatment; teaching: prescribed diet; financial resource
resources; perceived ability to perform assistance; support system enhancement

NURSING ASSESSMENT RATIONALE

Assess for indications that the client and significant others may Allows the nurse to tailor the client’s education based on client’s
be unable to manage the therapeutic regimen effectively: and significant others’ abilities and concerns.
° Statements reflecting inability to manage care at home
e Failure to adhere to treatment plan (e.g., not adhering to
dietary modifications and fluid restrictions, refusing medi-
cations)
° Statements reflecting a lack of understanding of the factors
that will cause further progression of liver failure
e Statements reflecting an unwillingness or inability to
modify personal habits and integrate necessary treatments
into lifestyle
e Statements reflecting the view that cirrhosis has resolved
once he/she is feeling better or that there is no way to
control the disease and efforts to comply with treatments
are useless

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THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote effective therapeutic regi-
men management:
e Explain cirrhosis in terms the client and significant others Increased knowledge about the disease process and self-care will
can understand; stress that cirrhosis is a chronic disease improve adherence.
and adherence to the treatment plan is necessary to delay
and/or prevent complications.
e Encourage questions and clarify misconceptions about
cirrhosis and its effects.
e Encourage participation in the treatment plan. Improves sense of control and ability to care for self once dis-
charged
e Provide instructions on weighing self and calculating Important to know whether a significant weight gain is occurring,
dietary sodium and protein content; allow time for return which can represent increased fluid retention.
demonstration.
e Determine areas of difficulty and misunderstanding and Increasing knowledge about the disease process and self-care will
reinforce teaching as necessary. improve adherence.
e Provide written instructions about scheduled appointments Provides information resource for client and significant others to
with health care provider, medications, signs and symp- refer to as needed after discharge.
toms to report, weighing self, and dietary modifications.
e Assist client and significant others to identify ways treat- Improves adherence to treatment regimen if client and significant
ments can be incorporated into lifestyle; focus on modifi- others determines how lifestyle can be modified.
cations of lifestyle rather than complete change.
e Encourage client and significant others to discuss concerns Allows for clarification of issues and support in dealing with
about the cost of hospitalization, medications, and lifelong chronic illness.
follow-up care; obtain a social service consult to assist with
financial planning and to obtain financial aid if indicated.
e Provide information about and encourage utilization of Provides ongoing assistance following discharged.
community resources that can assist client to make neces-
sary lifestyle changes (e.g., drug and alcohol rehabilitation
programs).
e Reinforce behaviors suggesting future compliance with the Enhances client’s and significant others’ self-confidence for self-
therapeutic regimen (e.g., statements reflecting plans for care and adherence to treatment regimen.
integrating treatments into lifestyle, participation in diet
planning, statements reflecting an understanding of the
importance of eliminating alcohol intake).
e Include significant others in explanations and teaching Enhances potential for adherence to the treatment regimen.
sessions and encourage their support; reinforce the need
for client to assume responsibility for managing as much
of care as possible.
Consult appropriate health care provider (e.g., social worker, Provides a multidisciplinary approach to care following discharge.
physician) about referrals to community agencies if con-
tinued instruction, support, or supervision is needed.

DISCHARGE TEACHING/CONTINUED CARE

|Nursing 2)
Diagnosis |6DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH
MANAGEMENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition. ,
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

*The nurse should select the diagnostic label thatismost appropriate for the client’s discharge teaching needs.
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 597,

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of inability to manage illness; verbalizes inabil- Inaccurate follow-through with instructions; inappropri-
ity to follow prescribed regimen ate behaviors; experience of manageable complications of
cirrhosis

RISK FACTORS
° Cognitive deficit
e Financial concerns
° Failure to take action to reduce risk factors for complica-
tions of cirrhosis
Inability to care for oneself
Difficulty in modifying personal habits and integrating
treatments into lifestyle
e Difficulty navigate complex health care systems

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: diet; disease process; treatment regimen Health system guidance; teaching: individual; teaching: dis-
ease process; teaching: prescribed diet; teaching: prescribed
activity/exercise substance abuse treatment

NURSING ASSESSMENT RATIONALE

Assess the client’s ability to learn and readiness to learn. Learning is more effective when the client is motivated and under-
Assess the client’s understanding of teaching. stands the importance of what is to be learned. Readiness to
learn changes based on situations and physical and emotional
challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

further liver damage.

Independent Actions
Provide the following instructions regarding ways to prevent
further liver damage:
Avoid the following hepatotoxic agents: Hepatotoxic substances increase liver problems in processing pro-
e Alcohol teins and medications.
¢ Cleaning agents containing carbon tetrachloride and
solvents (these are toxic even when inhaled)
e Industrial chemicals such as nitrobenzene, disulfide,
and tetrachloroethane
e Take acetaminophen (e.g., Tylenol) only when necessary Acetaminophen is processed through the liver and can impact liver
and do not exceed the recommended dose. functioning.
e Adhere to the following precautions to prevent hepatitis:
e Eat only in restaurants that have been inspected and Foods must be appropriately prepared and under appropriate hy-
approved by health authorities. gienic conditions.
e If blood transfusions are anticipated, arrange to donate Prevents exposure to blood products that may carry hepatitis.
and receive autologous blood rather than commercially
obtained blood, if possible.
° Avoid sharing food or eating utensils and handling These actions prevent sharing of body fluids, which increases po-
toiletry items of others. tential for exposure to hepatitis A and/or B, which can further
e Practice safe sex (e.g., condom use for intercourse). compromise liver functioning.
e Avoid anal sex.
* Do not share drug paraphernalia (e.g., needles, syringes,
cookers, rinse water, straws for intranasal inhalation).

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THERAPEUTIC INTERVENTIONS RATIONALE

° Get vaccinations for hepatitis A and B if recommended Decreases risk if exposed to hepatitis A and/or B.
by health care provider.
e If traveling to a developing country:
(1) Receive immune globulin and vaccines for hepatitis
(e.g., hepatitis B vaccine, hepatitis A vaccine) as
recommended by health care provider.
(2) Drink only bottled water, and avoid eating raw
fruits and vegetables washed or prepared with local
water when in the country.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understanding

of the rationale for and components of the recommended diet.

Independent Actions
Explain the rationale for a diet low in sodium, and teach the Increased sodium intake leads to retention of fluid, which may
client how to identify sodium in the diet and decrease increase the incidence of ascites and lower extremity edema.
sodium intake:
e Read food labels and calculate sodium content of items;
avoid those products that tend to have high sodium con-
tent (e.g., canned soups and vegetables, tomato juice,
commercial baked goods, commercially prepared frozen or
canned entrees and sauces).
¢ Do not add salt when cooking foods or to prepared foods;
use low-sodium herbs and spices, if desired.
e Avoid cured and smoked foods, salty snacks, and commer-
cially prepared foods.
e Avoid routine use of over-the-counter medications with a
high sodium content (e.g., some antacids, Alka-Seltzer).
Obtain a dietary consult to assist client in planning meals Provides multidisciplinary approach to client care.
that will meet prescribed dietary modifications.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

stress on or trauma to the esophageal blood vessels.

Independent Actions
Provide the following instructions about ways to reduce stress
on or trauma to the esophageal blood vessels:
Adhere to prescribed measures to reduce fluid retention (e.g., Prevents increased fluid volume that puts increased pressure on the
fluid restriction, low-sodium diet, diuretics). esophageal vessels.
Avoid activities that increase intra-abdominal pressure (e.g., These activities increase intrathoracic pressure, which places ad-
straining to have a bowel movement, coughing, sneezing, ditional pressure on the esophageal vessels.
lifting heavy objects).
Avoid eating foods that might cause mechanical trauma to May cause tearing of the esophageal vessels.
the esophageal varices (e.g., chips).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

bleeding.

Independent Actions
Instruct client about ways to minimize risk of bleeding:
e Avoid taking aspirin and other nonsteroidal antiinflamma- Aspirin blocks platelet adherence, which is necessary for clotting,
tory agents (e.g., ibuprofen) on a regular basis. and will increase bleeding.
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THERAPEUTIC INTERVENTIONS RATIONALE

° Use an electric rather than a straight-edge razor. These actions decrease the risk of injury.
° Floss and brush teeth gently.
° Cut nails carefully. '
° Avoid situations that could result in injury (e.g., contact sports).
° Avoid putting sharp objects (e.g., toothpicks) in mouth.
° Do not walk barefoot.
° Avoid blowing nose forcefully. Avoiding these actions decreases pressure on esophageal vessels.
° Avoid straining to have a bowel movement.
Instruct client to control any bleeding by applying firm, pro- Improves body’s blood clotting ability.
longed pressure to the area, if possible.

~THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of infection

Independent Actions
Instruct client in ways to reduce risk of infection:
° Maintain coughing and deep breathing exercises or use of Improves lung expansion and decreases stasis of secretions.
incentive spirometer every 2 hrs while awake as long as
activity is limited.
e Increase activity as tolerated.
¢ Avoid contact with persons who have an infection. Decreases risk for exposure to infection.
¢ Avoid crowds, especially during flu and cold seasons.
° Decrease or stop smoking. Smoking decreases ciliary activity and the ability to expel infec-
tious agents with coughing.
¢ Drink at least 10 glasses of liquid per day unless on a fluid Maintains adequate hydration and vascular fluid volume.
restriction.
e Adhere to recommended diet. Malnutrition decreases the client’s ability to fight off infection.
¢ Take supplemental vitamins and minerals as prescribed.
e¢ Maintain good personal hygiene. Prevents cross-contamination.
e Receive immunizations (e.g., influenza vaccine, pneumo- Enhances body’s immune system and resistance to infection.
coccal vaccine, hepatitis vaccines) if approved by health
care provider.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to relieve

pruritus.

Independent Actions
Instruct client in and/or implement measures to relieve pruritus:
e Apply cool, moist compresses to pruritic areas. Cool/cold compresses provide a counter sensation that decreases
the urge to rub or scratch the area.
e Apply emollient creams or ointments frequently. Creams and ointments prevent dryness and subsequent itchy skin.
e Add emollients, cornstarch, or baking soda to bath water. Adding these products to bath water decreases skin dryness and
provides a protective barrier.
e Use tepid water and mild soaps for bathing. Use of tepid water and mild soaps decreases skin dryness.
e Pat skin dry after bathing, making sure to dry thoroughly. Rubbing of the skin with a towel after a bath can stimulate itching.
° Maintain a cool environment. A cool environment provides a counter sensation that decreases
urge to rub or scratch.
e Encourage participation in diversional activity. Distracts client from focusing on the itch.
¢ Use relaxation techniques—progressive muscle relaxation; Helps to decrease stress and anxiety.
mindfulness-based relaxation.
e Use cutaneous stimulation techniques (e.g., massage, pres- Cutaneous stimulation decreases itching sensations by blocking
sure, vibration, stroking with soft brush) at sites of itching neurotransmission of the sensation.
or acupressure points.
e Encourage client to wear loose cotton garments and avoid Decreases skin irritation.
clothes or blankets made from wool.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Take medications as prescribed:

e Antihistamines (e.g., diphenhydramine, hydroxyzine Antihistamines block histamine, which stimulates itchy sensations.
{Atarax])
e Bile acid-sequestering agents (e.g., cholestyramine) Bile acid—sequestering agents bind with the bile acids in the intes-
tines, prevent absorption, and enhance elimination, thereby
decreasing itch sensations.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Stress the importance of reporting the following signs and
symptoms:
Rapid weight gain or loss Indicates changes in protein levels and retention of fluid volume.
Increasing size of abdomen May indicate ascites.
Increased swelling of lower extremities Indicates potential changes in vascular status.
Increasing shortness of breath May indicate heart failure.
Increased itchiness or yellowing of skin Indicates jaundice or increasing retention of bile acids.
Temperature elevation lasting more than 2 days Indicates infection.
Red, rust-colored, or smoky urine; bloody or tarry stools; Indicates inability of the body’s clotting factors to control bleeding.
blood in sputum or vomitus; persistent bleeding from
nose, mouth, or skin; prolonged or excessive menses; ex-
cessive bruising; severe or persistent headache; or sudden
abdominal or back pain
Tremors or changes in behavior, speech, or handwriting Indicates changes in neurologic status.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources to support lifestyle changes and support home man-
agement for effective management of cirrhosis

Independent Actions
Provide information regarding community resources that can Provides for continuation of care after discharge from the acute care
assist client and significant others with lifestyle changes facility.
and home management of chronic disease (e.g., Meals on
Wheels, home health agencies, transportation services, drug
and alcohol rehabilitation programs, counseling services).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan to adhere for recommended follow-
up care including future appointment with health care pro-
vider, medications prescribed, and activity level.

Independent Actions
Reinforce the importance of keeping follow-up appointments Cirrhosis is a chronic illness, and follow-up appointments are im-
with health care provider. portant to maintain health status.
Explain the rationale for, side effects of, and food and drug Knowledge of medications and how they impact the system improves
interactions and importance of taking medications pre- client adherence to treatment regimen and understanding of the
scribed. importance of adhering to the prescribed medication regimen.
The client must be able to recognize alterations in functioning
related to medication administration and what clinical manifes-
tations that should be reported to the health care provider.
Reinforce physician's instructions regarding activity level. Important in maintaining health status and ability to maintain
Stress the importance of rest. activities of daily living.
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ADDITIONAL NURSING DIAGNOSES

RISK FOR INFECTION NDx INEFFECTIVE COPING NDx

Related to: Related to:
e Lowered resistance to infection associated with: e Changes in appearance (e.g., edema, ascites, jaundice, spider
e Diminished function of the Kupffer cells in the liver angiomas, gynecomastia)
(these cells normally phagocytize bacteria) e Alterations in sexual functioning (e.g., impotence, de-
e Malnutrition creased libido)
° Leukopenia resulting from hypersplenism (if venous e Dependence on others to meet self-care needs
congestion has resulted in splenomegaly, the spleen e Disturbed thought processes
will destroy leukocytes faster than usual) e Stigma of having a chronic illness
e Serum complement deficiency resulting from decreased e Possible changes in lifestyle and roles
production of complement proteins by the liver
° Colonization of bacteria in the ascetic fluid (spontaneous DISTURBED SLEEP PATTERN NDx
bacterial peritonitis) Related to: Unfamiliar environment, frequent assessments
° Stasis of secretions in the lungs and urinary stasis if mobil- and treatments, decreased physical activity, discomfort, fear,
ity is decreased anxiety, and inability to assume usual sleep position because
of orthopnea
RISK FOR INJURY NDx
Falls related to: FEAR AND ANXIETY NDx
e Weakness Related to:
e Dizziness (can result from anemia and the postural hypo- e Difficulty breathing
tension that occurs with third-spacing) e Unfamiliar environment and separation from significant
e Balance and gait disturbances that can occur with deficien- others
cies of thiamine and/or vitamin B,> e Lack of understanding of the diagnosis, diagnostic tests,
e Disturbed thought processes (e.g., agitation, confusion) and treatments
Burns and lacerations related to: e Uncertainty of prognosis
e Paresthesias that can occur with deficiencies of thiamine e Financial concerns
and vitamin By, e Possibility of changes in lifestyle and roles
e Tremors and jerky, restless movements associated with
delirium tremens (“DTs”), if present

HEPATITIS |
Hepatitis is the inflammation of the liver and remains a world- the person has very mild symptoms or is asymptomatic. Ele-
wide concern. Inflammation of the liver impacts its ability to vated serum aminotransferases (alanine aminotransferase [ALT]
detoxify substances, metabolize medications, produce clotting and aspartate aminotransferase [AST]) are hallmarks of acute
factor, synthesize plasma protein, metabolize proteins, fats, hepatitis. Other signs and symptoms include flulike symptoms,
and carbohydrates, activate enzymes, and store glycogen. nausea, fatigue, mild-to-moderate right upper quadrant pain,
Hepatitis is most commonly caused by a virus. Other causes and symptoms of bile flow obstruction (e.g., jaundice, pruritus,
of hepatitis include alcohol abuse, exposure to some prescrip- dark amber urine, light-colored stools). The only definitive way
tions, over-the-counter medications, toxins, or autoimmune to distinguish the various forms of viral hepatitis is by the pres-
diseases. The five major causative viruses are hepatitis A virus ence of antigens and antigenic subtypes and the subsequent
(HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepa- development of antibodies to these antigens.
titis E virus (HEV), and the delta virus or hepatitis D virus Hospitalization of persons with hepatitis is usually not
(HDV). Other viruses that can also cause liver inflammation indicated except for some high-risk individuals (e.g., the el-
include cytomegalovirus (CMV), Epstein-Barr virus (EBV), and derly, immunocompromised persons, persons with other dis-
yellow fever. Less common causes of viral hepatitis include ease conditions that are complicated by the treatment of
adenovirus, CMV, EBV, and, rarely, herpes simplex virus (HSV). hepatitis) and persons with severe disease. Signs and symp-
Hepatitis A and E are both spread by the fecal-oral route. toms of severe disease include a marked prolongation of pro-
Hepatitis B is transmitted sexually, perinatally, and parenterally thrombin time, a serum bilirubin level more than 10 times
(primarily in IV drug users who share needles). In the United normal, symptoms of encephalopathy, the presence of edema
States, hepatitis A, B, and C are responsible for more than 90% and/or ascites, or an inability to maintain adequate hydra-
of US cases of acute viral hepatitis. Hepatitis A and B are the tion. Chronic hepatitis may result in cirrhosis with portal
most common cases of acute hepatitis in the United States. hypertension and subsequent liver failure.
Hepatitis C is the most common cause of chronic hepatitis. The treatment of acute hepatitis is primarily supportive
The various forms of hepatitis have similar clinical manifesta- and directed toward reducing the metabolic demands on the
tions. Signs and symptoms vary in severity and are based on the liver and promoting cell regeneration. If the client has hepa-
level of liver involvement. Many cases go undetected because titis B, C, or D, close follow-up should be encouraged to

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602 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

determine whether medication therapy is indicated to pre- . Maintain adequate nutritional intake
vent and treat chronic hepatitis. . Perform activities of daily living without fatigue
This care plan focuses on the adult client with . Describe ways to prevent the spread of hepatitis to others
acute viral hepatitis hospitalized because of persistent . Identify ways to prevent further liver damage
nausea, worsening of liver function test results, and a . Develop a plan to adhere to the recommended diet
prolonged prothrombin time. Much of the information CON
BS
W
DN . State signs and symptoms to report to the health care
is applicable to clients receiving follow-up care in an provider
extended care facility or home setting. . Develop a plan for adhering to recommended follow-up
care including activity level, medications prescribed, and
future appointments with health care provider and for
OUTCOME/DISCHARGE CRITERIA laboratory studies

The client will:

1. Remain free of nausea
2. Have no evidence of bleeding or progressive liver degen-
eration

| Nursing Diagnosis RISK FOR DEFICIENT FLUID VOLUME nox

Definition: Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may
compromise health.

Related to:
e Decreased oral intake associated with anorexia and nausea
e Excessive loss of fluid if diaphoresis and/or persistent vomiting is present

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of thirst; dry mouth, feeling weak Decreased urine output; increased urine concentration;
weight loss; decreased venous filling; increased body tem-
perature; decreased pulse volume/pressure; change in men-
tal status; elevated Hct; decreased skin/tongue turgor; dry
skin/mucus membranes; tachycardia; decreased B/P

RISK FACTORS DESIRED OUTCOMES

e Inadequate fluid intake The client will not experience a deficient fluid volume, as
e Exposure to pathogens evidenced by:
e Medication regimen a. Normal skin turgor
e Nausea and vomiting b. Moist mucous membrane
c. Stable weight
d. B/P and heart rate within normal range for client and
stable with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. BUN and Het within appropriate range for the client
h. Balanced intake and output

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; hydration Fluid management; IV therapy

NURSING ASSESSMENT RATIONALE :

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of fluid volume deficit
volume: allows for prompt intervention.
Decreased skin turgor, dry mucous membranes, thirst
Weight loss of 2% or greater over a short period
Postural hypotension and/or low B/P
Weak, rapid pulse
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NURSING ASSESSMENT RATIONALE

° Capillary refill time greater than 2 to 3 seconds
e Flat neck veins when supine
° Decreased urine output with increased specific gravity
(reflects an actual rather than potential fluid deficit)
e Change in mental status
e Increased BUN and Hct values

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent deficient fluid volume:
° Perform actions to reduce nausea and prevent vomiting: Nausea often causes the client to have decreased fluid intake. Per-
° Instruct client to ingest food/fluid slowly. sistent vomiting results in excessive loss of fluid. These actions
e Eliminate noxious sights and odors. D @ help prevent the experience of nausea.
e Perform actions to improve oral intake:
e Encourage rest before meals. Minimizes fatigue.
e Provide oral hygiene before meals. D @ Removes unpleasant tastes, which often improves the taste of
foods/fluids.
e Allow adequate time for meals; reheat foods and fluids Improves client’s ability to enhance oral fluid intake.
as needed. D@ >
e Perform actions to reduce fever, if present (administer Reduction of fever decreases fluid loss from diaphoresis.
tepid sponge bath, administer antipyretics, if ordered).
* Maintain fluid intake of at least 2300 mL/day unless con- Adequate fluid intake needs to be provided to ensure adequate
traindicated; if oral intake is inadequate or contraindi- hydration.
cated, maintain IV and/or enteral fluid therapy as ordered.

~ IMBALANCED NUTRITION:
LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with anorexia and nausea
¢ Loss of nutrients associated with persistent vomiting, if present
e Reduced metabolism and storage of nutrients by the liver associated with an alteration in normal liver function as a result
of inflammation
* Malabsorption of fats and fat-soluble vitamins associated with impaired bile flow resulting from inflammation of the liver
* Increased utilization of nutrients associated with the increased metabolic rate that is present with infection
e Insufficient interest in food
e Inability to absorb nutrients

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report lack of appetite; fatigue; irritability; poor self- Loss of weight with adequate food intake; body weight
esteem 20% or more under ideal weight; sore, inflamed buccal cav-
ity; capillary fragility; pale conjunctiva and mucous mem-
branes; poor muscle tone; excessive hair loss; amenorrhea

RISK FACTORS DESIRED OUTCOMES

° Chronic illness The client will maintain an adequate nutritional status, as
e Change in normal digestive process evidenced by:
° Treatment regimen a. Weight within normal range for the client
e Anorexia, nausea, vomiting, diarrhea b. Normal BUN and serum albumin, prealbumin, Hct
and Hgb levels, and normal lymphocyte count
c. Improved strength and activity tolerance
d. Healthy oral mucous membrane

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NOC OUTCOMES NIC INTERVENTIONS

Nutritional monitoring; nutrition management; nutrition

Nutritional status
therapy; nutritional counseling; nausea management

NURSING RATIONALE
e
pT SANDEI I ASSESSMENT
A SI AT e
Assess for and report signs and symptoms of malnutrition: Early recognition and reporting of signs and symptoms of malnutri-
° Weight significantly below client’s usual weight or below tion allow for prompt intervention.
normal for client’s age, height, and body frame
e Abnormal BUN and low serum albumin, prealbumin, Hct,
Hgb, and ammonia levels and low lymphocyte count
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Monitor percentage of meals and snacks client consumes. An awareness of the amount of food/fluid the client consumes
Report a pattern of inadequate intake. alerts the nurse to deficits in nutritional intake. Reporting an
inadequate intake allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain an adequate nutritional
Status:
e Perform actions to improve oral intake:
e Implement measures to prevent nausea and vomiting if Nausea may prevent a client from eating. Vomiting results in ac-
indicated (e.g., eliminate noxious sights and odors). D @ + tual loss of nutrients and fluid volume.
e Implement measures to control diarrhea, if present Increased intestinal motility that occurs with or causes diarrhea
(e.g., discourage intake of spicy foods and foods high in results in a decreased absorption of nutrients in the bowel.
fiber or lactose).
e Maintain a clean environment and a relaxed, pleasant Noxious sights and odors can inhibit the feeding center in the hypo-
atmosphere. D@ + thalamus. Maintaining a clean environment helps prevent this
from occurring, which may improve appetite and oral intake.
e Encourage a rest period before meals. Minimizes fatigue, which decreases client’s ability to complete a meal.
° Provide oral hygiene before meals. D @ + Removes unpleasant tastes, which often improves the taste of
foods/fluids.
e Serve foods/fluids that are appealing to the client and Foods/fluids that appeal to the client’s senses (especially sight and
adhere to personal and cultural (e.g., religious, ethnic) smell) and are in accordance with personal and cultural prefer-
preferences whenever possible. ences are most likely to stimulate appetite and promote interest
in eating.
e Serve frequent, small meals rather than large ones if client Providing small rather than large meals can enable a client who is
is weak, fatigues easily, and/or has a poor appetite. weak or fatigues easily to finish a meal.
e Provide adequate time for meals; reheat foods and fluids Clients who feel rushed during meals tend to become anxious, lose
as needed. D @ + their appetite, and stop eating. Appetite is also suppressed if
foods/fluids normally served hot or warm become cold and do
not appeal to the client.
e Limit fluid intake with meals unless the fluid has high Limiting fluid intake with meals reduces early satiety and subse-
nutritional value. quent decreased food intake.
e Increase activity as allowed and tolerated. D @ + Activity promotes a sense of well-being, which can improve appetite.
° Encourage client to consume meals that are well balanced The client must consume a diet that is well balanced and high in
and high in essential nutrients; offer dietary supplements essential nutrients to meet nutritional needs. entetary supple-
if client’s caloric intake is inadequate. ments are often needed to help accomplish this.
e Assist and instruct client to adhere to the following dietary
recommendations:
e Avoid skipping meals. Skipping meals may decrease caloric and nutritional intake.
* Consume a diet high in calories (2000-3000 calories/day) Consumption of adequate calories is required to maintain nutri-
and carbohydrates; if unable to tolerate food, suck on tional status.
hard candy and drink fruit juices and regular soft drinks.
° Maintain a moderate to high protein intake (unless Adequate protein intake promotes healing of the liver.
serum ammonia level is high or clinical evidence of
encephalopathy is present).
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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional
status:
e Administer medications that may be ordered to improve These medications decrease incidence of nausea, vomiting, and
client’s nutritional status (e.g., antiemetics, antidiarrheals, diarrhea. Vitamin and minerals may be required to maintain
vitamins and minerals). D > adequate nutritional status
e Obtain a dietary consult if necessary. A dietitian is best able to evaluate whether the foods/fluids selected
will meet the client’s nutritional needs.
e Perform a calorie count if ordered. Report information to A calorie count provides information about the caloric and nutri-
the dietitian and physician. tional value of the foods/fluids the client consumes. The infor-
mation obtained helps the dietitian and physician to determine
whether an alternative method of nutritional support is needed.
Consult the physician about an alternative method of provid- If the client’s oral intake is inadequate, an alternative method of
ing nutrition (e.g., parenteral nutrition, tube feeding) if providing nutrients needs to be implemented.
client does not consume enough food or fluids to meet
nutritional needs.

See eee) NAUSEA nox

Definition: A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which may or may not
result in vomiting.

Related to: Stimulation of the vomiting center associated with stimulation of the visceral afferent pathways as a result of:
e Inflammation of the gastrointestinal tract resulting from immune complex—mediated tissue responses to the viral infection
e Gaseous distention resulting from impaired fat digestion if bile flow is obstructed
e Sour taste
e Anxiety
e Noxious tastes

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of nausea N/A

RISK FACTORS DESIRED OUTCOME

e Chronic illness The client will experience relief of nausea as evidenced by
e Treatment regimen verbalization of same.
e Liver capsule stretch

NOC OUTCOMES NIC INTERVENTIONS

Nausea and vomiting control Nausea management; environmental management

NURSING ASSESSMENT RATIONALE

Assess for complaints of nausea. Early recognition ofnausea allows for prompt treatment.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce nausea and prevent vomiting:
e Eliminate noxious sights and odors from the environ- Noxious stimuli can cause stimulation of the vomiting center.
ment. D @® +
e Instruct client to change positions slowly. Rapid movement can result in stimulation of the chemoreceptor
trigger zone and subsequent excitation of the vomiting center.
e Encourage client to take deep, slow breaths when nause- Provides relaxation and helps to decrease nausea.
ated. D >

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THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to avoid intake of foods/fluids high in fat Avoiding foods/fluids high in fat prevents a delay in gastric empty-
(e.g., butter, cream, whole milk, ice cream, fried foods, ing and reduces nausea associated with impaired fat digestion.
gravies, nuts).
e Avoid serving foods with an overpowering aroma; remove Noxious stimuli can cause stimulation of the vomiting center.
lids from hot foods before entering room. D @ +
e Instruct client to eat dry foods (e.g., toast, crackers) and Eating dry foods and avoidance of drinking liquids with meals
avoid drinking liquids with meals if nauseated. decrease the incidence of nausea.
e Provide small, frequent meals; instruct client to ingest Eating small frequent meals and eating slowly prevent overdisten-
foods and fluids slowly. tion of the stomach and stimulation of the chemoreceptor trig-
ger zone and subsequent excitation of the vomiting center.
e Instruct client to avoid foods/fluids that irritate the gastric Avoidance of foods that irritate the gastric mucosa decreases the
mucosa (e.g., spicy foods; caffeine-containing beverages incidence of nausea.
such as tea, coffee, and colas).

Dependent/Collaborative Actions
Implement measures to reduce nausea and prevent vomiting:
e Administer antiemetics, if ordered (phenothiazines are con- Antiemetics decrease nausea and/or vomiting.
traindicated because of their potential cholestatic effects).
Consult physician if aforementioned measures fail to control Notification of the physician allows for prompt alterations in treat-
nausea. ment plan.

Nursing Diagnosis RISK FOR BLEEDING nox.

Definition: Susceptible to a decrease in blood volume, which may compromise health.

Related to:
e Decreased production of clotting factors associated with impaired liver function
e Impaired vitamin K absorption if bile flow is obstructed (normal bile flow is necessary for absorption of vitamin K)

DESIRED OUTCOMES
The client will not experience unusual bleeding, as
evidenced by:
a. Skin and mucous membranes free of petechiae, purpura,
ecchymoses, and active bleeding
b. Absence of unusual joint pain
oO . No increase in abdominal girth
d. Absence of frank and occult blood in stool, urine, and
vomitus
e. Usual menstrual flow
=_. Vital signs within normal range for client

g. Stable or improved Hct and Hgb values

NURSING ASSESSMENT RATIONALE

Assess client for and report signs and symptoms of unusual Early recognition of signs and symptoms of bleeding and progressive
bleeding: liver degeneration allows for prompt intervention.
e Petechiae, purpura, ecchymoses
e Gingival bleeding
e Prolonged bleeding from puncture sites, epistaxis, hemop-
tysis
e Unusual joint pain
e Increase in abdominal girth
e Frank or occult blood in stool, urine, or vomitus
e Menorrhagia
e Restlessness, confusion
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 607

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent bleeding:
e Avoid giving injections whenever possible; consult health Giving the client injections increases risk of bleeding when clotting
care provider for alternative routes for medication admin- factors are diminished.
istration
e When giving injections or performing venous or arterial These actions help to decrease bruising and improve clotting at the
punctures, use the smallest-gauge needle possible and ap- injection site.
ply gentle, prolonged pressure to the site after the needle
is removed.
e Encourage client to avoid activities that increase the risk Trauma increases the risk of bleeding when clotting factors are di-
for trauma (e.g., shaving with a straight-edge razor, using minished.
stiff bristle toothbrush or dental floss).
e Pad side rails if client is confused or restless. D @ + Decreases potential for client injury.
e Whenever possible, avoid intubations (e.g., nasogastric) Trauma during procedures increases the risk of bleeding when clot-
and procedures that can cause injury to the rectal mucosa ting factors are diminished.
(e.g., inserting a rectal suppository or tube, administering
an enema).
e Perform actions to reduce the risk for falls (e.g., avoid un- Placing client on risk for falls protocol decreases risk for injury.
necessary clutter in room, instruct client to wear shoes/
slippers with nonslip soles when ambulating). D @
e Instruct client to avoid blowing nose forcefully or strain- These actions may rupture small blood vessels and increase the
ing to have a bowel movement; consult physician about incidence of bleeding.
an order for a decongestant and/or laxative if indicated.
e Administer the following if ordered to improve clotting Administration of vitamin K, platelets, and FFP replaces deficient
ability: clotting factors.
e Vitamin K injections D+
e Platelets
se EE
If bleeding occurs and does not subside spontaneously:
e Apply firm, prolonged pressure to bleeding area(s) if Application of pressure to the bleeding site improves clotting ability.
possible.
e If epistasis occurs, place client in a high-Fowler’s position, Proper positioning helps to prevent aspiration of blood from the
have client lean forward and apply pressure and/or ice nasal cavity. Application of pressure or ice to the nasal area
pack to nasal area. D@ + improves clotting.
e Maintain oxygen therapy as ordered. D + Provides supplemental oxygenation to the tissues.
e If esophageal bleeding occurs:
e Turn client on side and suction as necessary. D+ These actions reduce the risk for aspiration.
e Assist with administration of octreotide (Sandostatin) Octreotide/vasopressin constricts splanchnic vessels and reduces
or vasopressin, if ordered. blood flow to the portal vein, decreasing pressure on esophageal
varices.
e Prepare client for endoscopic sclerotherapy or ligation Decreases client’s fear and anxiety.
of varices if planned.
e Assist with insertion of a gastroesophageal balloon tube The gastroesophageal balloon tube places pressure on bleeding
(eer Sengstaken-Blakemore tube,); maintain balloon varices, which improves clotting.
pressure, suction client, and perform lavage, if ordered.
e Administer vitamin K injections, whole blood, or blood Administration of vitamin K, blood, FFP, and platelets replaces
products (e.g., FFP, platelets) as ordered.
deficient clotting factors.
* Assess for and report signs and symptoms of hypovolemic Allows for prompt alteration in treatment plan.
shock (e.g., restlessness; confusion; significant decrease in
B/P; rapid, weak pulse; rapid respirations; cool skin; urine
output <30 mL/h).

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608 Chapter 11. = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

Diagnosis RISK FOR PROGRESSIVE LIVER DEGENERATION (E.G.,

|Collaborative ».....
FULMINANT HEPATITIS, CHRONIC ACTIVE HEPATITIS
Definition: Degradation of liver cells.

Related to: Viral infection

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of weakness, itching Increased jaundice, weakness, and pruritus
Edema, ascites, bleeding
Encephalopathy (e.g., change in handwriting, slow or
slurred speech, emotional lability, agitation, asterixis,
disorientation, lethargy)
Further increase in prothrombin time
Further elevation of serum AST, ALT, alkaline phosphatase,
and bilirubin; low serum albumin

RISK FACTORS DESIRED OUTCOMES

° Chronic illness The client will not experience progressive liver degenera-
e Inadequate/ineffective treatment regimen tion, as evidenced by:
* Nonadherence to treatment regimen a. Remaining free of signs and symptoms of hepatitis
disease progression
b. Absence of edema, ascites, and bleeding
(@) . Usual mental status
d. Coagulation test results and serum AST, ALT, alkaline
phosphatase, bilirubin, and albumin levels within or
returning toward normal limits

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of progressive liver degen- Early recognition of signs and symptoms of progressive liver
eration: degeneration allows for prompt intervention.
e Worsening of signs and symptoms (e.g., increased jaun-
dice, weakness, and pruritus)
e Edema, ascites
e Bleeding
e Encephalopathy (e.g., change in handwriting, slow or
slurred speech, emotional lability, agitation, asterixis,
disorientation, lethargy)
e Further increase in prothrombin time
e Further elevation of serum AST, ALT, alkaline phosphatase,
and bilirubin levels
e Low serum albumin level

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of progressive liver degeneration occur:
e Implement measures to decrease levels of ammonia and Neomycin attacks the ammonia-forming bacteria in the pron 3
other nitrogenous substances (e.g., administer neomycin if tinal tract. Lactulose draws ammonia from the blood stream into
ordered, administer lactulose if ordered, maintain pre- the colon for excretion. A low-protein diet reduces the buildup of
scribed dietary protein restriction). D > nitrogen metabolites and ammonia in the blood stream.
e Implement measures to reduce the risk for injury (e.g., Implement hospital protocols to reduce risk for injury.
keep side rails up, maintain seizure precautions). D @
e Prepare client for liver transplant if planned. Decreases client’s fear and anxiety and improves client understand-
ing of procedure.
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 609

|Nursing ese)
Diagnosis | 6=DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH
MANAGEMENT; INEFFECTIVE FAMILY HEALTH
MANAGEMENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic or its acquisition.
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and the sequelae that is unsatisfactory for meeting specific health goals of the family unit.

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of inability to manage illness; verbalizes inabil- Inaccurate follow-through with instructions; inappropri-
ity to follow prescribed regimen ate behaviors; experience of preventable complications of
hepatitis

RISK FACTORS
Cognitive deficit
Economically disadvantaged
Failure to take action to reduce risk factors for complica-
tions of hepatitis
Inability to care for oneself
Difficulty in modifying personal habits and integrating
treatments into lifestyle
Complex treatment regimen

NOC OUTCOMES NIC INTERVENTIONS

nnn nnnee EEE EEEEEEEE
Knowledge: disease process; treatment regimen; Health education; teaching: disease process; teaching:
health behavior; infection control and prevention prescribed diet; teaching: prescribed medication; teaching:
individual

NURSING ASSESSMENT RATIONALE

Assess client’s knowledge base related to the disease process. The client’s knowledge base provides the basis for education.
Assess for indications that the client may be unable to effec- Early recognition of inability to understand disease process or self-
tively manage the therapeutic regimen: care allows for change in teaching modality.
Statements reflecting inability to manage care at home
Failure to adhere to treatment plan (e.g., refusing medi-
cations)
Statements reflecting a lack of understanding of factors
that may cause further progression hepatitis
Statements reflecting an unwillingness or inability to
modify personal habits and integrate necessary treatments
into lifestyle
Statements reflecting view that there is not a cure for most
forms of hepatitis or that the situation is hopeless, and ef-
forts to comply with the treatment plan are useless

the client's discharge teaching needs.

*The nurse should select the diagnostic label that is most appropriate for

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THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

the spread of hepatitis to others.

Independent Actions
Provide the following instructions on ways to prevent the
spread of hepatitis to others:
e If client has hepatitis A, provide instructions on how to These actions by the client prevent exposure of others to the client’s
adhere to the following precautions for 1 to 2 weeks after blood and/or body fluids.
the onset of jaundice:
e Wash hands thoroughly after having a bowel move- Prevents cross-contamination and decreases disease exposure to
ment. others.
e Use separate toilet facilities if possible; if separate toilet
facilities are not available, clean toilet seat with a chlo-
rine solution after use.
e Wash bedding, towels, and underwear in hot, soapy
water; wash them separately from other articles.
¢ Do not donate blood or work in food services until
approved by physician.
e If client has hepatitis B, C, or D, instruct him/her to adhere
to the following precautions until health care provider
states that transmitting hepatitis to others is no longer a
risk:
e Wash hands thoroughly after urinating and having a
bowel movement.
¢ Donot share personal articles (e.g., toothbrush, straight- Prevents personal injury.
edge razor, thermometer, washcloth).
e Do not share food, cigarettes, or eating utensils.
e If any injections (e.g., insulin, vitamin Bz) are given at Reduces the risk of others exposure to contaminated needles.
home, use disposable equipment and dispose of it prop-
erly to reduce the risk of others coming in contact with
contaminated needles.
e Do not share drug paraphernalia (e.g., needles, straws Prevents spread of disease.
for intranasal inhalation).
eUse disposable eating utensils or wash utensils sepa-
rately in hot, soapy water.
e Avoid intimate sexual contact; once sexual activity is
resumed, avoid intercourse during menstruation and
intermenstrual bleeding and make sure that a condom
is used during intercourse.
e Do not donate blood.
Instruct client to inform household and sexual contacts to see Allows for testing and appropriate treatment of individuals who
health care provider for appropriate immunization and have been exposed to the individual with hepatitis.
testing for early detection of hepatitis.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will describe methods of

preventing further liver damage

Independent Actions
Provide the following instructions regarding ways to prevent
further liver damage:
e Avoid alcohol intake for a minimum of 6 months. Alcohol is hepatotoxic and will exacerbate the clinical manifesta-
tions of hepatitis.
e Avoid contact with known liver toxins (e.g., cleaning These agents are hepatotoxic and should be avoided.
agents containing carbon tetrachloride, solvents, indus-
trial chemicals such as nitrobenzene, disulfide, and tetra-
chloroethane).
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 611

THERAPEUTIC INTERVENTIONS RATIONALE

e Take acetaminophen (e.g., Tylenol) only when necessary, Acetaminophen at high doses is hepatotoxic, and, when combined
and do not exceed the recommended dose or take it after with alcohol, the two substances compete for the substrates of
drinking alcohol because of its potential toxic effect. metabolism.
e Take precautions to prevent recurrent hepatitis: These actions decrease the client’s exposure to other viral types of
e Avoid unnecessary transfusions; if transfusions are nec- hepatitis or individuals with other viral infections.
essary, arrange to donate and receive autologous blood
rather than commercially obtained blood if possible.
e Practice safe sex (e.g., condom use during intercourse);
if sexual partner is a carrier, consult health care pro-
vider about receiving a hepatitis B vaccination.
e Avoid sharing food, eating utensils, and toiletry items.
e Avoid sharing drug paraphernalia (e.g., needles, syringes,
cookers, rinse water, straws for intranasal inhalation).
e Eat only in restaurants that have been inspected and
approved by health authorities.
e Get vaccinations for hepatitis A and B if recommended
by health care provider.
e Avoid anal sex.
e Inform all health care providers of history of hepatitis be- Informing all health care providers of history of hepatitis prevents
cause a number of medications (e.g., chlorpromazine, ac- unintended prescription of medications that may be hepato-
etaminophen, allopurinol, amiodarone, erythromycin, toxic.
6-mercaptopurine, phenytoin) can be hepatotoxic and
should not be prescribed if alternatives are available.

THERAPEUTIC INTERVENTIONS RATIONALE

Lb
eee a
Desired Outcome: The client will develop a plan to adhere
to the prescribed diet

Independent Actions
Collaborate with the client to develop a plan to adhere to the Developing a plan that includes foods on a required diet and the
prescribed diet. impact of this diet on the system gives the client tools to have
more control of the disease process and maintain an active role
in treatment and care.

THERAPEUTIC INTERVENTIONS RATIONALE

ee eS
Desired Outcome: The client will state signs and symp-
toms to report to the health care provider

Independent Actions
Stress the importance of reporting the following signs and These are signs and symptoms of progression of liver disease, and
symptoms: the client’s health care professional should be notified to initiate
prompt interventions.
e Persistent or recurrent loss of appetite, nausea, fatigue, or
weight loss.
e Vomiting.
e Increased itchiness or yellowing of skin.
° Swelling of lower extremities, rapid weight gain, or in-
creased size of abdomen.
e Red, rust-colored, or smoky urine; bloody or tarry stools;
blood in sputum or vomitus; prolonged or excessive bleed-
ing from nose, mouth, or skin; prolonged or excessive
menses; excessive bruising; severe or persistent headache;
or sudden abdominal or back pain.
e Changes in behavior, speech, or handwriting.

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612 Chapter 11 » Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop plan for adhering to recommended
follow-up care including activity level, medications prescribed,
and future appointments with health care provider and for
laboratory studies

Independent Actions
Collaborate with the client in developing a plan for progres- Rest is critical for client healing and prevention of further liver
sive increased activity based on a physician’s instructions damage.
regarding activity level. Stress the importance of rest dur-
ing convalescent phase (from 6 weeks to 6 months).
Collaborate with the client to develop a schedule for follow- Follow-up is critical because this is a long-term illness that requires
up appointments with health care provider and for labora- various tests and evaluations to be treated properly.
tory studies
Collaborate with the client to develop a schedule for medica- Knowledge of the medication regimen and the impact of these
tion administration. medications on the system, as well as how the medication regi-
Educate the client on the rationale for prescribed medications men can be incorporated into the client’s lifestyle, allows the
and what side effects to monitor for and which ones client some mechanism of control of his/her disease and the
should be reported to the health care provider. ability to have an active part in treatment and care.
Schedule time for the client to demonstrate the ability to Encourages adherence with treatment regimen.
perform subcutaneous injections, if required.
Provide client with information about and encourage par- Reduces further liver damage and potential infections.
ticipation in drug and alcohol rehabilitation programs if
indicated.
Implement measures to improve client’s adherence:
e Include significant others in teaching if possible. Involvement of the client’s significant others helps them to support the
client and improves client’s adherence to the treatment regimen.
e Encourage questions, and allow time for reinforcement Improves client understanding of treatment regimen and reinforces
and clarification of information provided. self-reliance and confidence in ability to care for self.
e Provide written instructions regarding scheduled appoint- Provides the client and significant others a resource of information
ments with health care provider and for laboratory studies, following discharge from the acute care facility.
medications prescribed, activity restrictions, and signs and
symptoms to report.

ADDITIONAL NURSING DIAGNOSES

ACUTE PAIN NDx FEAR AND ANXIETY NDx

e Right upper quadrant related to inflammation of the liver Related to:
e Myalgias/arthralgias related to the presence of circulating e Unfamiliar environment and lack of understanding of
immune complexes and activation of the complement diagnosis and diagnostic tests
system associated with viral infection ° Lack of definitive treatment for hepatitis and the possibility
ot serious complications
RISK FOR ACTIVITY INTOLERANCE NDx * Possible transmission of disease to others and rejection by
Related to: others because of their fear of contracting hepatitis
e Inadequate nutritional status * Temporary restrictions of some usual activities (e.g., vigor-
e Increased energy utilization associated with the increased ous exercise, contact sports, sexual activity, alcohol con-
metabolic rate present in an infectious process sumption) $
e Difficulty resting and sleeping associated with frequent
assessments and treatments, discomfort, anxiety, and
unfamiliar environment
 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 613

PANCREATITIS, ACUTE
©p> Acute pancreatitis is an inflammation of the pancreas with pancreatitis may not experience any pain and generally pres-
premature activation of enzymes that cause local damage to ent with abdominal fullness, indigestion, hiccups, fever, hy-
the organ, autodigestion, and fibrosis. These changes can lead potension, and tachycardia.
to life-threatening complications including shock, diabetes, The goal of treatment is to prevent further autodigestion of
acute respiratory distress syndrome (ARDS), and end-organ the pancreas and prevent systemic complications. If the cause
dysfunction and failure. of pancreatitis is gallstones, surgery is performed after pancre-
After an episode of mild to moderate acute pancreatitis, atic inflammation has subsided and the patient is stable.
the structure and function of the pancreas often return to This care plan focuses on the adult client hospital-
normal. However, with more severe and/or recurrent episodes ized with acute pancreatitis. Some of the information
of acute pancreatitis, irreversible changes can occur and is applicable to clients receiving follow-up care in an
chronic pancreatitis can develop. extended care facility or home setting.
The most common causes of acute pancreatitis are biliary tract
obstruction caused by gallstones and long-term alcohol abuse.
Some less frequent causes include external trauma to the OUTCOME/DISCHARGE CRITERIA
abdomen, trauma to the pancreas during pancreatic endos- The client will:
copy or abdominal surgery, bacterial and viral infections, 1. Have no clinical manifestations of complications
some antibiotics, and metabolic disorders such as chronic 2. Maintain relief of severe pain
hypercalcemia and genetic hyperlipidemia. 3. Maintain adequate nutritional and fluid intake
Often the presenting symptom of acute pancreatitis is sud- 4. Describe methods to prevent overstimulation and further
den onset of epigastric in the upper left quadrant or abdo- trauma to the pancreas
men, radiating to the back or shoulder. Pain increases with . Develop a plan to implement dietary modifications
coughing, movement, and deep breathing, and pain may be NN. State signs and symptoms to report to the health care provider
associated with nausea, vomiting, and anorexia. As the 7. Develop a plan for adhering to recommended follow-up
disease progresses, shock, renal failure, and end-organ dys- care including future appointments with health care pro-
function/failure may occur. Patients with alcohol-induced vider and medications prescribed.

Nursing Diagnosis ACUTE PAIN nox (EPIGASTRIC WITH RADIATION TO THE BACK)
Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity
from mild to severe with an anticipated or predictable end, and a duration of less than 3 months.

Related to:
e Distention of the pancreas associated with inflammation and obstruction of pancreatic ducts
e Peritoneal irritation associated with escape of activated pancreatic enzymes into the peritoneum

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal or coded report of pain; difficulty sleeping due to Autonomic responses (e.g., diaphoresis; changes in B/P,
experience of pain; respiration, pulse; pupillary dilatation); expressive behav-
ior (e.g., restlessness, moaning, crying, vigilance, irritabil-
ity, sighing); changes in appetite and eating; protective
gestures; guarding behavior; facial mask; evidence of sleep
disturbance (eyes lack luster, fixed or scattered movement,
beaten look, grimace)

RISK FACTORS DESIRED OUTCOMES

Inflammation of the pancreas The client will experience diminished pain, as evidenced
by:
a. Verbalization of a decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

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NOC OUTCOMES NIC INTERVENTIONS

eeSS eS SSS SS

Pain Level; pain control Pain management; analgesic administration; patient-

controlled analgesia (PCA) assistance; nonpharmacologic
interventions

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain (e.g., verbalization of Early recognition of signs and symptoms of pain allows for prompt
pain, grimacing, reluctance to move, restlessness, diapho- intervention and improved pain control.
resis, increased B/P, tachycardia).
Assess client’s perception of the severity of pain using a pain An awareness of the severity of pain being experienced helps deter-
intensity rating scale. mine the most appropriate interventions for pain management.
Use of a pain intensity rating scale gives the nurse a clearer
understanding of the client’s pain experience, changes in pain
over time, and promotes consistency when communicating with
others.
Assess the client’s pain pattern (e.g., location, quality, onset, Knowledge of the client’s pain pattern assists in the identification
duration, precipitating factors, aggravating factors, allevi- of effective pain management interventions.
ating factors).
Ask the client to describe previous pain experiences and Many variables affect a client’s response to pain (e.g., age, Sex, cop-
methods used to manage pain effectively. ing style, previous experience with pain, culture, cause of pain).
Understanding of the client’s usual response to pain and meth-
ods previously used to manage pain effectively enables the nurse
to evaluate the client’s pain more accurately and facilitates the
identification of effective strategies for pain management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain:
e Implement measures to reduce fear and anxiety (e.g., as- Promotes relaxation and subsequently increases the client’s
sure client that the need for pain relief is understood, col- threshold and tolerance for pain.
laborate with client on methods for achieving pain con-
trol, provide a calm, restful environment). D +
e Perform actions to promote rest (e.g., minimize environ- These actions reduce fatigue and subsequently increase the client’s
mental activity and noise). D@ + threshold and tolerance for pain.
Collaborate with client on nonpharmacologic measure to Decreases pancreatic stimulation, thus reducing client’s pain
decrease pain (e.g., Mindfulness based stress reduction experience.
(MBSR), distraction, guided imagery). Enhances patient’s coping skills
Allow client to sit or lie with knees and trunk flexed. This position relieves pressure on the inflamed pancreas

Dependent/Collaborative Actions
Implement measures to reduce pain:
e Administer analgesics before activities and procedures that Improves ability to perform activities of daily living without dis-
can cause pain and before pain becomes severe. comfort and promotes rest.
e Administer IV analgesics before pain becomes too severe. Severe, prolonged pain is more difficult to relieve and increases
e Consider PCA pain administration. anxiety and fear.
Provides client more control over pain relief and promotes client
involvement in care.
e Perform actions to reduce pancreatic stimulation:
e Withhold all food and oral fluid as ordered. D + Food and fluid cause the release of secretin and/or cholechstokinin,
which stimulate the output of pancreatic secretions.
e Implement measures to reduce the amount of hydro- When hydrochloric acid enters the duodenum, it stimulates the
chloric acid in the stomach: release of pancreatic enzymes.
(1) Insert a nasogastric tube and maintain suction, if Removes fluid and hydrochloric acid from the stomach.
ordered.
(2) Administer histamines-receptor antagonists, if Histamine receptor antagonists and proton pump inhibitors sup-
ordered. press secretion of gastric acid.
e Minimize client’s exposure to odor and sight of food Prevents stimulation of gastric secretions and the subsequent out-
until oral intake is allowed. put of pancreatic secretions.
 Chapter11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 615

THERAPEUTIC INTERVENTIONS RATIONALE

e When oral intake is allowed:
(1) Advance diet slowly. Slow advancement increases tolerance to oral intake.
(2) Provide small, frequent meals rather than three Small, frequent meals decrease stretch of the stomach and subse-
large ones. D> quent discomfort.
(3) Avoid foods/fluids high in fat (e.g., butter, cream, These foods cause release of pancreatic enzymes, which cause pain.
whole milk, ice cream, fried foods, gravies, nuts),
spicy foods, and caffeine-containing beverages (e.g.,
coffee, tea, colas), if ordered.
e Provide or assist with additional nonpharmacologic mea- Nonpharmacologic pain management includes a variety of inter-
sures for pain relief (e.g., massage; position change; pro- ventions. It is believed that most of these are effective because
gressive relaxation exercises; restful environment; diver- they stimulate closure of the gating mechanism in the spinal
sional activities such as watching television, reading, or cord and subsequently block the transmission of pain impulses.
conversing). In addition, some interventions are thought to stimulate the
release of endogenous analgesics (e.g., endorphins) that inhibit
the transmission of pain impulses and/or alter the client’s per-
ception of pain. Many of the nonpharmacologic interventions
also help to decrease pain by promoting relaxation.
e If client is receiving epidural analgesia, perform actions to Use of epidural analgesia helps to decrease pain without causing
maintain patency of the system (e.g., keep tubing free of increased sedation.
kinks, tape catheter securely, use caution when moving
client to avoid dislodging catheter).
e Assist with peritoneal lavage if performed. Removes activated pancreatic enzymes and debris that cause peri-
toneal irritation and subsequent pain
Consult appropriate health care provider (e.g., pharmacist, Allows for prompt alterations in the treatment plan.
pain management specialist, physician) if aforementioned
measures fail to provide adequate pain relief.

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS nox

Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with nausea, pain, prescribed dietary restrictions, and feeling of fullness resulting from ab-
dominal distention
e Loss of nutrients associated with vomiting
e Decreased utilization of nutrients associated with impaired digestion of fats, proteins, and carbohydrates resulting from loss
of normal outflow of pancreatic enzymes
e Increased nutritional needs associated with the increased metabolic rate that occurs with pancreatitis

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of lack of appetite; fatigue; irritability; poor Weight loss; body weight 20% or more under ideal weight;
self-esteem pale conjunctiva and mucous membranes; excessive hair
loss; amenorrhea

RISK FACTORS DESIRED OUTCOMES

e Impaired digestion The client will maintain an adequate nutritional status, as
e Insufficient dietary intake evidenced by:
e Treatment regimen a. Weight within normal range for the client
e Inability to absorb nutrients b. Normal BUN and serum albumin, prealbumin, Het
and Hgb levels, and normal lymphocyte count
c. Usual strength and activity tolerance
d. Healthy oral mucous membrane

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NOC OUTCOMES NIC INTERVENTIONS

i
Nutritional status Nutritional monitoring; nutrition management; nutrition
therapy; nausea management; pain management; total
parenteral nutrition (TPN) administration

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition:

e Weight significantly below client’s usual weight or below Early recognition and reporting of signs and symptoms of malnutri-
normal for client’s age, height, and body frame tion allows for prompt intervention.
e Abnormal BUN and low serum albumin, prealbumin, Hct,
and Hgb levels and low lymphocyte count
e Weakness and fatigue
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Monitor and report changes in percentage of meals and An awareness of the amount of foods/fluids the client consumes
snacks client consumes. alerts the nurse to deficits in nutritional intake. Reporting an
inadequate intake allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

a

Independent Actions
Implement measures to maintain an adequate nutritional
status:
e Limit activity as ordered. Limiting activity decreases energy utilization and metabolic rate.
e When food or oral fluids are allowed perform actions to
improve oral intake:
e Implement measures to reduce ascites and accumulation These actions reduce abdominal distention and the subsequent
of gas and fluid in the gastrointestinal tract (e.g., proper feeling offullness and early satiety.
positioning, encourage client not to eat or drink foods
that cause gas production [caffeine, beans, drinking with
a straw, chewing gum]).
e Implement measures to reduce nausea and vomiting: Decreasing nausea and vomiting will prevent fluid and electrolyte
e maintain fluid and food restrictions as ordered, loss. Providing oral hygiene may decrease nausea and enhance
e provide oral hygiene at regular intervals appetite.
e reduce pain, Reduction ofpain decreases potential for nausea and vomiting.
Maintain a clean environment and relaxed, pleasant atmo- Noxious sites and odors can inhibit the feeding center in the hypo-
sphere. thalamus. Maintaining a clean environment helps prevent this
from occurring. In addition, maintaining a relaxed, pleasant
atmosphere can help reduce the client’s stress and promote a
feeling of well-being, which tends to improve appetite and oral
intake
e Increase activity as allowed and tolerated. D @ Activity usually promotes a sense of well-being, which can improve
appetite.
e Allow adequate time for meals; reheat foods/fluids if neces- Clients who feels rushed during meals tend to become anxious, lose
sary.D @ + their appetite, and stop eating. Appetite is also suppressed if
foods/fluids normally served hot or warm become cold and do
not appeal to the client.
e Limit fluid intake with meals (unless the fluids have high Intake of oral fluids with meals causes stomach distention and can
nutritional value). D > cause satiety before an adequate amount of food is consumed.
e Ensure that meals are well balanced and high in essential Maintenance of nutritional status.
nutrients.

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional
status:
e Administer nasogastric feeding or TPN, if ordered. Provides nutrition ifclient is unable to tolerate oral intake.
e Administer vitamins and minerals. Vitamins, minerals, and supplements are needed to maintain
metabolic functioning.
 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 617

THERAPEUTIC INTERVENTIONS RATIONALE

° Administer pancreatic enzymes Supplemental pancreatic enzymes aid in the digestion of foods.
e Administer albumin Albumin increases osmotic pressure and pulls fluid into the vascu-
Implement measures to reduce pain (position properly, ad- lar compartment.
minister pain meds as ordered). D + Pain reduction increases a client’s appetite and ability to tolerate
diet.
° Perform a calorie count, if ordered. Report information to A dietitian is best able to evaluate whether the foods/fluids selected
dietitian and physician. will meet the client’s nutritional needs.
Reassess nutritional status on a regular basis and report Allows for prompt alterations in treatment plan.
decline.

poe
es ee 6RISK FOR IMBALANCED FLUID VOLUME nox RISK
FOR ELECTROLYTE IMBALANCE nox
Definition: Risk for Imbalance Fluid Volume NDx: Susceptible to a decrease, increase, or rapid shift from one to the other of
intravascular, interstitial, and/or intracellular fluid, which may compromise health. This refers to body fluid loss,
gain, or both; Risk for Electrolyte Imbalance NDx: Susceptible to changes in serum electrolyte balance, which
may compromise health.

Related to:
e Risk for imbalanced fluid volume NDx related to:
e Disease process
e Decreased oral intake
e Excessive loss of fluid associated with vomiting and nasogastric tube drainage
e Third-spacing related to increased vascular permeability associated with the inflammatory response and activation of kinin
peptides such as bradykinin and kallidin (occurs when the pancreatic enzyme trypsin enters systemic circulation)

Related to:
Risk for electrolyte imbalance NDx
° Hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with
vomiting and nasogastric tube drainage
e Hypocalcemia related to:
° Binding of calcium to the undigested fats in the intestine (enzymes such as lipase and phospholipase A are not released
into the intestinal tract to digest fats so calcium binds with the free fats and is excreted in the stool)
Hypoalbuminemia associated with increased vascular permeability that occurs with inflammation

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of fatigue and weakness; complaints of dizzi- Decreased skin turgor; dry mucous membranes; weight loss
ness; anxiousness; irritability; complaints of numbness and of 2% or greater over a short period; postural hypotension;
tingling of fingers, toes, or circumoral area weak rapid pulse; flat neck veins when supine; changes in
mental status; capillary refill greater than 2 to 3 seconds;
decreased urine output with increased specific gravity; car-
diac dysrhythmias; vomiting; hypoactive or absent bowel
sounds; muscle twitching; positive Chvostek and Trous-
seau sign; hyperactive reflex

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Go to ©volve for animation
618 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

RISK FACTORS DESIRED OUTCOMES

e Failure of regulatory mechanisms
The client will not experience an imbalance in fluid vol-
e Chronic illness
ume or electrolytes, as evidenced by:
e Inadequate intake a. Normal skin turgor
e Exposure to pathogens b. Moist mucous membranes
e Mechanical loss of electrolytes c. Stable weight
d. B/P and pulse rate within normal range for client and
stable with position change
e. Capillary refill time less than 2 to 3 seconds
f. Usual mental status
g. Balanced intake and output
h. Urine specific gravity within normal range
i. Soft, nondistended abdomen with normal bowel
sounds
j. Absence of cardiac dysrhythmias, muscle weakness,
paresthesias, muscle twitching or spasms, dizziness,
tetany, and seizure activity
k. Negative Chvostek and Trousseau signs
|. BUN, Hct, serum electrolyte, and ABG values within
normal range

NOC OUTCOMES NIC INTERVENTIONS

Maintain fluid/electrolyte balance Fluid/electrolyte management: hypokalemia; electrolyte

management: hypocalcemia; acid-base monitoring; acid-base
management: metabolic alkalosis

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of fluid and electro- Early recognition of signs and symptoms of imbalanced fluid and
lyte imbalance: electrolytes allows for prompt intervention.
¢ Monitor cardiovascular status (i.e., changes in blood pres-
sure and for postural hypotension, heart rate, rhythm,
capillary refill time, flat or distended neck veins, changes
in urine output)
¢ Monitor respiratory status (i.e., changes in breath sounds
with the development of adventitious sounds).
e Changes in mental status
e Decreased skin turgor, dry mucous membranes, thirst
¢ Weight loss or gain of 2% over a short period
e Monitory I&O
e Monitor serum electrolytes (i.e., potassium, calcium)
e¢ Monitor intake and output (I & O), BUN, and creatinine and
Hct levels and changes in blood pressure from client’s normal

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent or treat fluid volume and
'
electrolyte imbalance:
e Perform actions to reduce nausea and vomiting (maintain These actions prevent loss of fluid and electrolytes and alterations
fluid and food restrictions as ordered; reduce pain, eliminate in metabolic status.
noxious sights and odors from the environment). D @
e If a nasogastric tube is present and needs to be irrigated Maintains patency ofnasogastric tube.
frequently and/or with large volumes of solution, irrigate
it with normal saline rather than water.
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 619

THERAPEUTIC INTERVENTIONS RATIONALE

e Administer fluid and electrolyte replacements as ordered. Replaces lost fluid and electrolytes to normalize values.
° Maintain a fluid intake of at least 2500 mL/day unless Adequate fluid intake is required to maintain adequate circulatory
contraindicated. D @®> volume.
e When oral intake is allowed:
e Assist client to select the following foods/fluids:
(1) For potassium deficits teach client about foods that Maintains adequate level of potassium.
are high in potassium (e.g., bananas, potatoes, can-
taloupe, avocados, raisins)
(2) For calcium deficit, teach client about foods that are Maintains adequate level of calcium.
high in calcium such as milk and milk products (if
client is on a low-fat diet, items such as ice cream,
whole milk, butter, and cream should be omitted)
e Administer pancreatic enzymes (e.g., pancreatin, pancreli- Promotes fat digestion so that there is less fat available to bind
pase) if ordered. with calcium.
Consult physician if signs and symptoms of fluid volume and Notification of the physician allows for prompt alterations in treat-
electrolyte imbalances persist or worsen. ment plan.
Monitor serum albumin levels. Report below-normal levels. Low serum albumin levels result in fluid shifting out of the vascu-
Implement measures to prevent further third-spacing and/or lar space because albumin normally maintains plasma colloid
wr
promote mobilization of fluid back into vascular space: osmotic pressure.
e Administer albumin infusions if ordered. Albumin increases colloid osmotic pressure which pulls fluid into
the vascular compartment.
e Perform actions to decrease pancreatic stimulation; with- Food and fluid, especially those that are acidic or have a high
hold all food and oral fluid as ordered. D + protein or fat content, upon entering the duodenum cause the
release of secretin and/or cholecystokinin, which stimulate the
output of pancreatic secretions.
Implement measures to reduce hydrochloric acid in the As hydrochloric acid enters the duodenum, it stimulates the release
stomach. of secretin, which may stimulate significant output of pancre-
atic secretions.
e Insert a nasogastric tube and maintain suction as ordered. Placing a nasogastric tube to suction removes the acid from the
stomach.
e Administer histamine receptor antagonists if ordered. Histamine receptor antagonists inhibit the action of histamine on
the parietal cells, which blocks gastric acid secretion.
e Minimize client’s exposure to odor and sight of food until Decreasing the client’s exposure to the sight and odor of food pre-
oral intake is allowed. vents stimulation of gastric secretions and the subsequent out-
put of pancreatic secretions.
Consult physician if signs and symptoms of third-spacing Notification of the physician allows for prompt alterations in treat-
persist or worsen. ment plan.

72 RISK FOR INFECTION nox (SEPSIS) |

Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
e Release of bacteria into the blood associated with:
e Presence of infected necrotic areas or leakage of infected pseudocysts or abscesses into the blood stream (necrotic areas,
pseudocysts, and abscesses can develop as a result of destruction of pancreatic and surrounding tissue by the activated
proteolytic enzymes)
e Peritonitis (if it occurs)
° Decreased resistance to infection associated with decreased nutritional status
e Break in skin integrity associated with frequent venipunctures or presence of invasive lines

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620 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of chills/lethargy; loss of appetite Elevated temperature; diaphoresis; tachypnea; tachycardia;
confusion increase in WBC count above previous levels
and/or significant change in differential; positive blood
cultures

RISK FACTORS DESIRED OUTCOMES

gi osure to pathogens The client will not experience sepsis, as evidenced by:
Pee cre Ob Tratar response a. No further increase in temperature
coe de nal tats b. Absence of chills and diaphoresis
c. Pulse and respiratory rate within normal range for
client
d. WBC and differential counts returning to normal
e. Negative blood culture results

NOC OUTCOMES NIC INTERVENTIONS

ES
ania a pict
Immune status; infection severity Infection protection; infection control

NURSING ASSESSMENT RATIONALE

SS
Assess for and report signs and symptoms of sepsis (e.g., in- Early recognition of signs and symptoms of sepsis allows for
crease in temperature, chills, diaphoresis, tachypnea, prompt intervention.
tachycardia, increase in WBC count above previous levels
and/or significant change in differential, positive cultures).

THERAPEUTIC INTERVENTIONS RATIONALE

a

Dependent/Collaborative Actions
Implement measures to prevent sepsis:
e Perform actions to decrease pancreatic stimulation (e.g., These actions reduce pancreatic enzyme stimulation which de-
keep client NPO; maintain nasogastric tube to suction, crease destruction of pancreatic and peripancreatic tissue, thus
remove noxious sights and smells). preventing subsequent development of necrotic areas, pseudo-
cysts, and abscesses.
e Perform actions to prevent and treat peritonitis (e.g., keep Prevents and decreases incidence of peritonitis.
client NPO, place client in a semi-Fowler’s position,
administer antimicrobials).
e Prepare client for drainage of an abscess or pseudocyst or Prevents spread of infection and decreases incidence of sepsis.
surgical resection of necrotic tissue if planned.
e Maintain strict aseptic and sterile technique during all in- Limits external bacteria being introduced in the system.
vasive procedures (e.g., venous and arterial punctures,
prompt dressing changes).
e Maintain an adequate nutritional status (e.g., provide fre- Adequate nutrition is necessary for cellular development and a ro-
quent small, highly nutritious meals; maintain a clean bust immune response to pathogens.
environment and a relaxed, pleasant atmosphere)
e Perform actions to reduce pain and anxiety (e.g., adminis- Pain and anxiety reduction prevents an increase in secretion of
ter pain medication as needed and before pain becomes cortisol, which interferes with some immune responses.
severe; provide a calm, restful environment; explain diag- '
nostic tests and treatment plan).
e Change IV line sites, tubing, and solutions using aseptic Decreases potential for the introduction of foreign bacteria into the
technique according to hospital policy and maintain a system.
closed system for IV infusions, whenever possible.
e Anchor catheters/tubings (e.g., IV) securely. Reduces trauma to the tissues and the risk for introduction of
pathogens associated with in-and-out movement of the tubing.
 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 621

THERAPEUTIC INTERVENTIONS RATIONALE

e Administer antimicrobials as ordered. Antimicrobials prevent and/or treat infections.
If signs and symptoms of sepsis occur, assess for and immedi- Allows for prompt alterations in treatment plan.
ately report signs and symptoms of septic shock (e.g.,
systolic B/P < 90 mm Hg; rapid, weak pulse; restlessness;
agitation; confusion; urine output < 30 mL/h; cool, pale,
mottled, and/or cyanotic extremities; capillary refill time
>3 seconds; diminished or absent peripheral pulses).

|Nursing Boe)
Diagnosis | INEFFECTIVE BREATHING PATTERN nox |
Definition: Inspiration and/or expiration that does not provide adequate ventilation.
Related to:
° Increased rate of respirations associated with fear and anxiety
e Decreased depth of respirations associated with:
° Depressant effects of some medications (e.g., narcotic [opioid] analgesics, some antiemetics)
+
° Reluctance to breathe deeply due to abdominal pain
° Restricted chest expansion resulting from positioning and abdominal pressure on the diaphragm

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of shortness of breath; inability to breathe Dyspnea; increased respiratory rate; decreased depth of
deeply breathing; use of accessory muscles to breathe; altered
chest excursion; prolonged expiration phases; decreased
SaOz

RISK FACTORS DESIRED OUTCOMES

e Abdominal distention and pain The client will have an improved breathing pattern, as
evidenced by:
a. Normal rate and depth of respirations
b. Decreased dyspnea
c. Symmetric chest excursion
d. Oxygenation saturation >90%

NOC OUTCOMES NIC INTERVENTIONS

eS
———————————————

Respiratory status: ventilation, vital signs Ventilation assistance; respiratory monitoring; breathing
patterns

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of an ineffective breathing Early recognition of signs and symptoms of an ineffective breathing
pattern: pattern allows for prompt intervention.
e Shallow or slow respirations
e Limited chest excursion
* Tachypnea or dyspnea
° Use of accessory muscles when breathing

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Continued...

NURSING ASSESSMENT RATIONALE

Assess/monitor pulse oximetry (arterial oxygen saturation Monitoring continuous SaQz readings allows for the early detection
[SaO.]), ABG values as indicated. of hypoxia.
Assessment of ABG values provides a more direct measurement of
both the partial pressure of oxygen in arterial blood (PaO2) and
the partial pressure of carbon dioxide in arterial blood (PaCOd),
which reflect the adequacy of ventilation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve breathing pattern:
¢ Perform actions to reduce fear and anxiety (e.g., assure cli- Prevents the shallow and/or rapid breathing that can occur with
ent that staff is nearby; provide a calm, restful environ- fear and anxiety.
ment; explain all tests and procedures). D +
e Perform actions to reduce pressure on the diaphragm:
e Implement measures to reduce gas and fluid accumula- These actions decrease incidence of abdominal distention and pres-
tion in the gastrointestinal tract (avoid carbonated bever- sure on the diaphragm.
ages and chewing gum; avoid gas-producing foods). D +
¢ Position client in a semi- to high-Fowler’s position unless Prevents slumping and decreases pressure on the diaphragm which
contraindicated; support with pillows. D + prevents adequate lung expansion.
e If client must remain flat in bed, assist with position Changing position while on bed rest prevents stasis of lung secre-
change at least every 2 hrs. D @ + tion and skin breakdown
e Instruct and assist client to deep breathe or use incentive Deep breathing and use of incentive spirometry improve lung ex-
spirometer every 1 to 2 hrs. pansion. Presence of the nurse may be helpful in decreasing
e Reinforce splinting of abdomen with deep breathing and client anxiety and assures appropriate use of the incentive
coughing spirometer.
Abdominal splinting may enhance client’s deep breathing and
cough effort.

Dependent/Collaborative Actions
e Implement measures to prevent diaphragmatic pressure Decreasing pressure on the diaphragm will allow for improved lung
from abdominal distention-insertion of nasogastric tube expansion.
and maintain to suction, if ordered. Insertion of a nasogastric tube will reduce stimulation of the pan-
creas and removes hydrochloric acid from the stomach.
e Increase activity as allowed and tolerated. D + Movement enhances circulation and lung expansion, decreases
dyspnea, and increases activity tolerance.
¢ Schedule rest periods around times of increased activity. Helps to conserve client’s energy and ability to participate in
desired activities.
e Administer central nervous system depressants judiciously; Central nervous system depressants can significantly reduce respi-
hold medication and consult physician if respiratory rate ratory rate and subsequently cause a significant decrease in
is less than 12 breaths/min. oxygenation.
e Administer supplemental oxygen as ordered. Improves ability to maintain adequate oxygenation to body
tissues
Consult appropriate health care provider (e.g., respiratory Notifying the appropriate health care provider allows for prompt
therapist, physician) if: modification of treatment plan.
e Ineffective breathing pattern continues, Each of these clinical manifestations may indicate worsening
¢ Signs and symptoms of atelectasis (e.g., diminished or condition
absent breath sounds, dull percussion note over af-
fected area, increased respiratory rate, dyspnea, tachy-
cardia, elevated temperature) develop.
e Signs and symptoms of impaired gas exchange (e.g., rest-
lessness, irritability, confusion, significant decrease in ox-
imetry results, decreased PaO, and increased PaCO, levels)
are present.
 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 623

sosbe eos RISK FOR SHOCK nox pes

Definition: Susceptible to an inadequate blood flow to the body’s tissues that may lead to life-threatening cellular dysfunction,
which may compromise health.
Related to:
Deficient fluid volume associated with restricted oral intake and fluid loss resulting from vomiting and nasogastric tube
drainage
° Peripheral vasodilation and increased vascular permeability with subsequent third-spacing subsequent to activation of kinin
peptides such as bradykinin and kallidin (occurs when the pancreatic enzyme trypsin enters systemic circulation)

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of feeling agitated; anxiety; thirst Changes in mental status; agitation; confusion; hypoten-
sion; tachycardia; cool skin; restlessness; rapid respirations;
pallor and cyanosis; oliguria, dry mucous membranes

RISK FACTORS DESIRED OUTCOMES

‘ e Inadequate fluid intake The client will not develop hypovolemic shock, as evi-
e Increased toxins in the blood denced by:
e Failure of regulatory mechanisms . Usual mental status
. Stable vital signs
Skin warm and usual color
. Palpable peripheral pulses
. Urine output at least 30 mL/h
. Moist mucous membranes
moans».

NOC OUTCOMES NIC INTERVENTIONS

Shock prevention Shock management: cardiac; vasogenic; volume

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of: Early recognition of signs and symptoms of hypovolemic shock
e Deficient fluid volume and third-spacing: allows for prompt intervention.
Decreased skin turgor, dry mucous membranes, thirst
Weight loss of 2% or greater over a short period
Postural hypotension and/or low B/P
Weak, rapid pulse
Capillary refill time greater than 2 to 3 seconds
Flat neck veins when supine
Change in mental status
Decreased urine output with increased specific gravity
(reflects an actual rather than potential fluid volume
deficit)
Increased BUN and Hct
e Bleeding (e.g., gray-blue discoloration around umbilicus
[Cullen sign], green-blue or purple-blue discoloration of
flanks [Grey Turner sign], increased abdominal or back
pain, increased abdominal girth, decreasing B/P and
increased pulse rate, decreased Hct and Hgb levels)

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624 Chapter 11 =" Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

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NURSING ASSESSMENT RATIONALE

e Hypovolemic shock: Indicate deteriorating client condition and could be life threatening.
e Restlessness, agitation, confusion, or other change in
mental status
e Significant decrease in B/P
e Postural hypotension
e Rapid, weak pulse
e Rapid respirations
e Cold, clammy skin
e Pallor, cyanosis, decreasing SaOz
e Diminished or absent peripheral pulses
¢ Urine output less than 30 mL/h

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent hypovolemic shock:
¢ Monitor fluid volume and electrolytes: Maintenance of vascular fluid volume and treatment of changes as
e Measure 1 & O required decrease potential for hypovolemic shock.
e¢ Monitor IV or oral fluid intake
¢ Monitor serum electrolytes as ordered
e Perform actions to reduce pancreatic stimulation (e.g., Actions that decrease the amount of elastase that is activated and
withhold all food and oral fluid intake as ordered; insert a released into the tissue and systemic circulation. This decreases
nasogastric tube and maintain to suction as ordered; ad- the risk for bleeding and loss of vascular fluid volume.
minister histamine receptor antagonists).
If signs and symptoms of hypovolemic shock occur:
e Place client flat in bed with legs elevated, unless contrain- Placing the client in this position increases B/P and helps to main-
dicated. tain blood flow to the vital organs.
¢ Monitor blood pressure, heart rate, and SaO2. Monitors changes in client’s status.
e Administer oxygen as ordered. Maintains tissue oxygenation.
e Administer whole blood, blood products, and/or volume Administration of blood and blood products increases vascular
expanders, if ordered. fluid volume and B/P.
e Prepare client for transfer to the critical care unit and Central monitoring of central hemodynamic status allows for more
insertion of hemodynamic monitoring devices (e.g., central rapid intervention and should done in the critical care unit.
venous catheter, intra-arterial catheter), if indicated.

|Collaborative >
Diagnosis |«RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum.

Related to:
e Escape of activated pancreatic enzymes from the pancreas into the peritoneum
e Leakage of necrotic substances into the peritoneum associated with rupture of an infected pancreatic or peripancreatic
abscess or pseudocyst
e Suppuration in areas of pancreatic and peripancreatic necrosis

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of increasing abdominal pain; rebound Temperature greater than 38°C; rigid abdomen; dinfinished
tenderness; nausea or absent bowel sounds; tachycardia; hypotension; tachy-
pnea; elevated WBC count
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 625

RISK FACTOR DESIRED OUTCOMES

Exposure to pathogens
The client will not develop peritonitis, as evidenced by:
a. Gradual resolution of abdominal pain
b. Soft, nondistended abdomen
c. Temperature declining toward normal
d. Stable vital signs
e. Decreased nausea and vomiting
f. Gradual return of normal bowel sounds
8g. WBC count declining toward normal

NURSING ASSESSMENT RATIONALE

(a en SE i a ge Fa

Assess for and report signs and symptoms of peritonitis (e.g., in- Early recognition of signs and symptoms of peritonitis allows for
crease in severity of abdominal pain; generalized abdominal prompt intervention.
pain; rebound tenderness; distended, rigid abdomen; further
increase in temperature; tachycardia; tachypnea; hypotension;
increased nausea and vomiting; diminished or absent bowel
sounds; WBC count that increases or fails to decline toward
normal).

-
THERAPEUTIC INTERVENTIONS RATIONALE
Dependent/Collaborative Actions
Implement measures to prevent peritonitis:
Perform actions to reduce pancreatic stimulation (e.g., These actions decrease activation of the pancreatic enzymes
maintain food and oral fluid restrictions, if ordered; place within the pancreas and reduce the risk for their escape into the
client in a semi-Fowler’s position). D+ peritoneum.
Administer antimicrobials, if ordered. Antimicrobials treat and/or prevent infections.
Prepare client for drainage or removal of infected pseudo- Decreases client’s fear and anxiety.
cysts and abscesses and resection of necrotic tissue if
planned.
If signs and symptoms of peritonitis occur: Decrease activation of the pancreatic enzymes within the pancreas.
Withhold oral intake as ordered.
Place client on bedrest in a semi-Fowler’s position. Proper positioning assists in pooling or localizing gastrointestinal
contents in the pelvis rather than under the diaphragm.
Prepare client for diagnostic tests (e.g., abdominal radio- Decreases client’s fear and anxiety.
graph, computed tomography, ultrasonography) if planned.
Insert a nasogastric tube and maintain suction as ordered. Removal of the gastric contents decreases activation of the pancre-
atic enzymes within the pancreas and reduces the risk for fur-
ther leakage into the peritoneum.
Administer antimicrobials as ordered. Antimicrobials treat infection.
Administer IV fluids and/or blood volume expanders if Administration of IV fluids or blood expanders increase vascular
ordered, to prevent or treat shock. fluid volume.
Prepare client for and assist with peritoneal lavage if Peritoneal lavage removes toxins from the peritoneal cavity.
performed.

Diagnosis |RISK FOR UNSTABLE

Collaborative >>> BLOOD GLUCOSE LEVEL nox

Definition: Susceptible to variation in serum levels of glucose from the normal range, which may compromise health.

Related to:
° Increased glucagon and decreased insulin output associated with pancreatic enzyme damage to the islet cells
e The increased glucagon, cortisol, and catecholamine output associated with stress

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of feeling hungry and tired Polydipsia; polyuria; polyphagia; change in mental status;
blood glucose level greater than 200 mg/dL

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626 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

RISK FACTORS
e Decreased dietary intake
e Failure of regulatory mechanisms
e Inadequate treatment regimen

NOC OUTCOMES NIC INTERVENTIONS

Hyperglycemia severity; hypoglycemia severity, Hyperglycemia management; hypoglycemia management;

blood glucose monitoring blood glucose monitoring

DESIRED OUTCOMES
The client will maintain a safe blood glucose level, as
evidenced by:
a. Absence of polydipsia, polyuria, and polyphagia
b. Usual mental status
c. Serum glucose between 60 and 200 mg/dL

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of hyperglycemia Early recognition of signs and symptoms of hyperglycemia allows
(e.g., polydipsia, polyuria, polyphagia, change in mental for prompt intervention.
status, blood glucose levels >200 mg/dL the parameter
specified by the health care provider).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent hyperglycemia:
e Perform actions to reduce pancreatic stimulation (e.g., Decreases activation of the pancreatic enzymes within the pancreas
maintain food and oral fluid restrictions if ordered, place and prevents further damage to the pancreatic islet cells.
client in a semi-Fowler’s position, administer antimicrobials).
e
Perform actions such as relieving discomfort, explaining Stress causes an increased output of epinephrine, norepinephrine,
all tests and procedures, and providing a restful environ- glucagon, and cortisol that result in a further increase in blood
ment to reduce stress. glucose levels.
If signs and symptoms of hyperglycemia occur:
e Administer insulin or oral hypoglycemic agents, if ordered. Insulin and oral hypoglycemic agents decrease blood glucose levels.
Appropriate insulin administration may prevent development of
ketoacidosis.
e Assess for and report signs and symptoms of ketoacidosis Notification of the physician of signs and symptoms of ketoacido-
(e.g., warm, flushed skin; thirst; weakness; lethargy; hypo- sis allows a for modification of the treatment plan.
tension; increased abdominal pain; fruity odor on breath; When pancreatitis is resolved, the extent ofpancreatic destruction
Kussmaul respirations; blood glucose >250 mg/dL; ke- will determine which medications the client will need upon
tones in blood and urine; low serum pH and CO, content). discharge from the hospital.
e If client does not have a history of diabetes or chronic
pancreatitis, offer assurance that the hyperglycemia is
expected to resolve as the pancreatitis does.

Collaborative »-—
Diagnosis RISK FOR ORGAN ISCHEMIA/DYSFUNCTION
Definition: A life-threatening syndrome in which the body is unable to maintain homeostasis without intervention.

Related to:
e Hypoperfusion of major organs associated with hypovolemic and/or septic shock, if present, and decreased myocardial
contractility (can occur as a result of the release of myocardial depressant factor in response to the inflammatory process
that occurs in pancreatitis)
e Microvascular thrombosis associated with disseminated intravascular coagulation (DIC) if it occurs (activation of clotting
mechanisms can occur in response to the presence of activated proteolytic enzymes in the blood vessels and/or the proco-
agulant effects of some inflammatory mediators)
 Chapter 11 = Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 627

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Severe hypotension; tachycardia; urine output less than
30 mL/h; dyspnea, tachypnea; decreasing SaO,; altered
ABG values with low PaO;; elevated serum BUN and creati-
nine levels; crackles throughout lungs; changes in mental
status

RISK FACTORS DESIRED OUTCOMES

e Failure of regulatory mechanisms
The client will not develop organ ischemia/dysfunction, as
evidenced by:
a. Usual mental status
b. Urine output at least 30 mL/h
c. Unlabored respirations at 12 to 20 breaths/min
d. Audible breath sounds without an increase in adventi-
tious sounds
e. Absence of new or increased abdominal pain, disten-
tion, nausea, vomiting, and diarrhea
f. BUN and serum creatinine, AST, ALT, and lactate dehy-
drogenase (LDH) levels within normal range
g. SaOz > 90

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of organ ischemia/ Early recognition of organ ischemia/dysfunction allows for prompt
dysfunction: intervention.
e Cerebral ischemia (e.g., change in mental status)
e Renal insufficiency (e.g., urine output <30 mL/h, elevated
BUN and serum creatinine levels)
e Acute respiratory distress syndrome (e.g., dyspnea, in-
crease in respiratory rate, low SaQOz, crackles)
e Gastrointestinal ischemia (e.g., increasing and severe ab-
dominal pain, nausea, and abdominal distention; contin-
ued hypoactive or absent bowel sounds; development of
or increased episodes of vomiting; diarrhea; hematemesis;
blood in stool)
e Liver dysfunction (e.g., increased serum AST, ALT, and
LDH levels)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce the risk for organ ischemia/ When pancreatic tissue dies, pancreatic enzymes and blood may
dysfunction: escape into the abdomen, causing sepsis, which subsequently
e Perform actions to prevent hypovolemic shock (adminis- leads to systemic hypoperfusion. Prompt identification and
ter fluids and electrolytes as ordered; maintain fluid intake intervention may prevent patient from progressing to organ
of at least 2500 mL/day). ischemia/dysfunction.
¢ Perform actions to prevent sepsis (administer antimicrobi- These actions prevent introduction of bacteria into the system; nu-
als as ordered; maintain aseptic or sterile technique on all trition is important for the body’s ability to fight offinfections.
procedures; maintain adequate nutrition status).
e Perform actions to treat DIC if it occurs (e.g., implement Actions maintain fluid volume, replace used clotting factors, and
safety precautions to prevent further bleeding; administer prevent injury to client.
FEP, platelets, and/or cryoprecipitate, if ordered; adminis-
ter medications such as heparin and antithrombin III if
ordered, to interrupt clotting).
e Maintain IV therapy as ordered. Maintains adequate vascular fluid volume.

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628 Chapter 11 + Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

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THERAPEUTIC INTERVENTIONS RATIONALE

e Maintain oxygen therapy as ordered. Maintains adequate oxygenation of tissues.

e Administer vasopressors (e.g., dopamine, norepinephrine) Vasopressors and positive inotropic agents cause vasoconstriction
and/or positive inotropic agents (e.g., dobutamine) as and increase the force of cardiac contractions to maintain ade-
ordered. quate tissue perfusion and cardiac output.
If signs and symptoms of organ ischemia/MODS occur, pre- Client requires intensive monitoring and care that will be received
pare client for transfer to critical care unit. in the intensive care unit.

Diagnosis |DEFICIENT KNOWLEDGE

|Nursing Diagnosis nox; INEFFECTIVE HEALTH
MANAGEMENT nox; OR INEFFECTIVE FAMILY HEALTH
MANAGEMENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes
a program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of
the family unit.

Related to:
e Specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condition/
treatment/lifestyle changes
e Pattern of regulating and integrating into daily living and family processes a therapeutic treatment regimen.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalizes inability to manage illness; verbalizes inability Inaccurate follow-through with instructions; inappropriate
to follow prescribed regimen behaviors; experience of preventable complications of pan-
creatitis

RISK FACTORS DESIRED OUTCOMES

° Cognitive deficit The client will:
e Financial concerns a. Identify ways to prevent overstimulation of and
e Failure to take action to reduce risk factors for complica- further trauma to the pancreas
tions of pancreatitis b. Develop a plan to implement recommended dietary
e Inability to care for oneself modifications
° Difficulty in modifying personal habits and integrating c. State signs and symptoms to report to the health care
treatments into lifestyle and family processes provider
d. Develop a plan for adhering in recommended follow-
up care

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; diet; disease process Health Education

Health system guidance; teaching: individual; teaching: dis-
ease process; teaching: prescribed diet; teaching: prescribed
medication

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching needs.
 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas 629

NURSING ASSESSMENT RATIONALE

Assess client’s and family’s knowledge base related to the dis- The client’s and family’s knowledge base provides the basis for
ease process. education.
Assess for indications that the client and family may be un- Early recognition of inability to understand disease process or
able to effectively manage the therapeutic regimen: self-care allows for change in teaching modality.
° Statements reflecting inability to manage care at home
e Failure to adhere to treatment plan (e.g., refusing medications)
° Statements reflecting a lack of understanding of factors
that may cause further progression of pancreatitis
° Statements reflecting an unwillingness or inability to
modify personal habits and integrate necessary treatments
into lifestyle

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client and family will identify ac-

tions to prevent overstimulation of and further trauma to the
pancreas

“Independent Actions
Instruct client and family on actions that prevent overstimu-
lation of and further trauma to the pancreas:
e Maintain a balanced program of rest and exercise. Decreases stimulation of the pancreas.
e Avoid drinking alcohol. Alcohol can cause blockage of pancreatic ducts that drain into the
pancreatic duct.
e Adhere to recommended dietary modifications. Prevents overstimulation of the pancreas.
If indicated, provide information about and encourage use of Provides continuum of care post discharge from the acute care
community resources that can assist client to make neces- facility.
sary lifestyle changes (e.g., alcohol rehabilitation program).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client and family will develop a

plan to implement recommended dietary modifications

Independent Actions
Instruct client and family regarding dietary modifications Enhances client’s knowledge of recommended foods that the client
necessary to prevent overstimulation of the pancreas can eat and tolerate. Client and family need to identify food
during the recovery period: preferences and ones that are allowed on the recommended diet.
Eat small, frequent meals rather than three large ones. Smaller meals require less pancreatic enzymes and energy by the
patient to consume.
Avoid foods/fluids high in fat (e.g., butter, cream, whole Foods/fluids high in fat increase the release of pancreatic enzymes.
milk, ice cream, fried foods, gravies, nuts).
Avoid spicy foods and caffeine-containing beverages (e.g., Spicy foods can simulate increased release of pancreatic enzymes.
coffee, tea, colas).
Obtain a dietary consult if client needs assistance in planning A dietitian can work with the client and family to integrate into
meals that incorporate dietary modifications. meals plans foods that the client likes and are part of the
recommended diet.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client and family will state signs

and symptoms to report to the health care provider

Independent Actions
Instruct client to report:
e Stools that float and are grayish, greasy, and foul-smelling Indicates a very high fat content resulting from impaired flow of
e Persistent or recurrent abdominal or back pain the pancreatic enzyme lipase into the intestinal tract.
May indicated continued disease processes.

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN © = Goto ©volve for animation
630 Chapter 11 * Nursing Care of the Client With Disturbances of the Liver, Biliary Tract, and Pancreas

Continued...

THERAPEUTIC RATIONALE
h
LER TELUS INTERVENTIONS
UNTIL NSLS NS e
rrr
e Nausea or vomiting May indicate recurrence of pancreatitis, as well as the complica-
e Abdominal distention or increasing feeling of fullness tions of bleeding and infection.
e Excessive thirst or excessive urination These symptoms may indicate decreased insulin production and
e Irritability or confusion increased serum glucose levels.
e Continued or unexplained weight loss
e Bluish areas on the back or abdomen May indicate bleeding within the abdomen.
e Persistent or recurrent temperature elevation These symptoms may indicate an infection or progression of
e Fever, chills disease processes.
e Difficulty breathing

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client and family, in collaboration

with the nurse, will develop a plan for adhering in recom-
mended follow-up care including future appointments with
heath care provider and medications prescribed

Independent Actions
Reinforce the importance of keeping follow-up appointments Allows the health care provider to monitor client’s health status.
with health care provider. Client should develop and post
in a prominent site a calendar of follow-up appointments.
Explain the rationale for, side effects of, and importance of Knowledge of medications and how they impact the system im-
taking medications prescribed (e.g., vitamins, antimicrobi- proves client adherence to treatment regimen and understanding
als, pancreatic enzymes). Inform client of pertinent food of the importance of adhering to the prescribed medication regi-
and drug interactions. men. The client and family should be able to recognize altera-
Client should develop a schedule for medication adminis- tions in functioning related to medication administration and
tration. know what clinical manifestations should be reported to the
health care provider.
Implement measures to improve client’s compliance:
e Include significant others in teaching sessions if possible. Allows for others to support client as needed.
e Encourage questions and allow time for reinforcement and Allows for a more complete understanding of the client’s condition
clarification of information provided. by client and significant others and for the nurse to evaluate
client’s knowledge of the treatment regimen.
° Provide written instructions on scheduled appointments Written instructions provide an information resource following
with health care provider, medications prescribed, and discharge from the acute care facility.
signs and symptoms to report.

ADDITIONAL DIAGNOSES
IMPAIRED ORAL MUCOUS MEMBRANE NAUSEA NDx
INTEGRITY NDx
Definition: A subjective phenomenon of an unpleasant
Related to: feeling in the back of the throat and stomach, which may or
e Fluid volume deficit associated with restricted oral intake may not result in vomiting.
and fluid loss resulting from vomiting and nasogastric
Related to:
tube drainage
e Stimulation of the vomiting center associated with:
e Decreased salivation associated with deficient fluid volume,
¢ Stimulation of the visceral afferent pathways from ab-
restricted oral intake, and the side effect of some medica-
dominal distention and inflammation of the pancreas
tions (e.g., narcotic [opioid] analgesics, some antiemetics)
e Stimulation of the cerebral cortex resulting from pain
¢ Mouth breathing if nasogastric tube is in place
and stress
FEAR NDx AND ANXIETY NDx
Definition:

Related to:
e Severe pain
e Unfamiliar environment
e Lack of understanding of diagnostic tests, treatment plan,
and prognosis
 CHAPTER

RN ie

The Client With Alterations

in the Kidney and Urinary Tract

UROLITHIASIS (RENAL STONES

Urolithiasis is the development of stones from crystalized into smaller, passible fragments. Conscious sedation or gen-
solute in the urinary tract. Nephrolithiasis refers to stones eral anesthesia is used during the procedure. The client is
that form in the kidney and ureterolithiasis refers to stones in typically discharged a few hours following the procedure. The
the ureters. Renal stones occur more frequently in men than client will be required to drink lots of fluid, and to strain or
in women, and in Caucasians than in Blacks. In the United filter the urine to obtain stone fragments for testing.
States, these stones occur more frequently in the southeastern For large (>2 cm), odd shaped, or stones not resolved by
area of the country and during the summer months. This ESWL, the client may undergo a percutaneous nephrolithot-
area-specific incidence is thought to be associated with dehy- omy and percutaneous nephrolithotripsy. These procedures
dration associated with humidity, sweating, and decreased involve percutaneous access to the kidney. In the nephroli-
consumption of water. thotomy, the stone is removed directly from the kidney. If a
There are four main types of kidney stones. Calcium percutaneous nephrolithotripsy is done, the stone can be
stones, which are the most common type, are composed of broken up using high-frequency sound waves and then the
calcium and/or oxalate and phosphorus. Uric acid stones fragments are removed. Both procedures are conducted using
form when the urine is too acidic and can be composed of general anesthesia and may require a short hospital stay. Al-
just uric acid or combined with calcium. Struvite stones are though these procedures are minimally invasive, there is a
associated with urinary tract infections where the bacteria risk for infection, bleeding, and complications associated
produce ammonia, and are made up of magnesium, ammo- with general anesthesia.
nium, and phosphate. The rarest type of stone is a cysteine Discharge teaching should focus on action that will pre-
stone and occurs in individuals with a genetic disorder that vent recurrence of kidney stones. The client should be taught
allows cysteine to leak from the kidney into the urine. Re- about adequate hydration, dietary restrictions (depending on
gardless of the type of stone, it may lodge anywhere within the type of stone), and follow-up care.
the kidneys, ureters, bladder, or urethra. Kidney stones may This care plan focuses on the adult client having a
form anywhere in the urinary tract. They may be asymptom- kidney stone and surgical removal.
atic until the stone lodges in the ureter or if there is urinary
obstruction. The most common area for stones to obstruct
urine flow and elimination from the body is in the uretero- OUTCOME/DISCHARGE CRITERIA
pelvic junction, where the urine exits the kidney and the lower
third of the ureter. Unless the stone is passed or removed, The client will:
blockage of urine elimination can cause severe complications Maintain pain-free status
including pyelonephritis, urosepsis, and irreversible renal Maintain adequate urine output
damage. Surgical removal of the stone is required if the stone Have no evidence of wound or urinary tract infection
is large and causing severe urine obstruction. The type of Have no signs and symptoms of postoperative complications
procedure performed depends on the stone’s size, location, Demonstrate the ability to strain/filter urine if ordered
and critical nature of the blockage. A ureteroscopy is used for State signs and symptoms to report to the health care provider
large stones in the lower end of the ureter. The extracorporeal eh
e=
AISDevelop a plan for adhering to recommended follow-up
shock-wave lithotripsy (ESWL) is used for smaller stones care including prevention recurrence of kidney stones,
(between 2 and 4 mm) in the kidney or ureter. In the ESWL follow-up care with the heath care provider, medication
procedure, the client is placed on a water-filled cushion. The regimen, and measures to prevent complications
surgeon uses x-rays to identify the precise location of the Preoperative—Refer to Standardized Preoperative Care Plan
stone. High-energy sound waves are used to break the stone Postoperative—Refer to Standardized Postoperative Care Plan

NDx = NANDA Diagnosis D = Delegatable Action @ =UAP + = LVN/LPN © = Go to ©volve for animation 631
oT yA *) ws zs INTO ETI OS)
632 Chapter 12 * The Client With Alterations in the Kidney and Urinary Tract

vos eee) ACUTE PAIN nox

damage, or described in
Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue
terms of such damage (Internationa l Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Related to:
e Partial or complete obstruction within the urinary tract
e Fear and anxiety specific to inability to pass stone
e Stone removal procedure if performed

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain, expression of fear and anxiety Facial expressions of grimacing, restlessness, increased
blood pressure (BP) and heart rate

RISK FACTORS DESIRED OUTCOMES

e Kidney stone The client will experience decreased pain as evidenced by:
e Surgery a. Verbalization of decrease or absence of pain
b. Stable vital signs
c. Decreased or absent restlessness and grimacing

NOC OUTCOMES NIC INTERVENTIONS

ee
Pain level Acute pain management: patient-controlled analgesia (PCA)
assistance, analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain Early recognition ofsigns and symptoms of pain allows for prompt
e Verbalization of pain intervention and improved pain control.
e Grimacing Assessment of the severity of pain being experienced helps
e Restlessness determine the most appropriate intervention. Use of a pain
e Increased BP intensity rating scale provides the nurse a clear understanding
e Tachycardia of the pain being experienced and promotes consistency when
e Assess client’s perception of the severity of pain using a communicating with others.
pain intensity rating scale Knowledge of client’s pain pattern assists in the identification of
e Assess client’s pain pattern (e.g., location, onset, quality, effective pain management intervention.
duration, aggravating factors) Knowledge of client’s usual pain response and effective methods to
e Ask client to describe previous pain experience and meth- alleviate pain supports the identification of effective pain man-
ods that were effective in relieving pain agement.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce fear and anxiety. Fear and anxiety can increase the clients experience of pain and
e Provide a calm environment. interventions may not be as effective if the patient is unable to
e Answer call light quickly when notified of experience of relax.
pain. D@ +
e Assure client pain experience is understood and will be
addressed.
e Implement measures to promote rest. D @ + Fatigue can decrease client tolerance for pain. Rest often helps
e Minimize environmental activity, light, and noise. decrease the experience of pain and enhance effectiveness of
pain interventions.
 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract 633

THERAPEUTIC INTERVENTIONS RATIONALE

Provide or assist with adjuvant nonpharmacological methods These nonpharmacological interventions are thought to be effective
of pain relief. D @+ as they stimulate the closure of the gating mechanism in the
e Relaxation techniques (e.g., progressive relaxation exercises, spinal cord, thus blocking pain transmission. Other interven-
mindfulness-based stress reduction (MBSR), meditation, tions may increase endorphin levels and promote relaxation.
focused breathing, guided imagery).
e Distraction measures (e.g., music, conversing, watching
TV, reading). D @ +
e Position changes. D @ +
e Provide warm blankets or heating pad to pain location.
Encourage 2 to 3 L/day of fluid unless contraindicated. Pain from kidney stones is colicky in nature and may worsen when
Document episodes of increased or persistent pain. lying in the supine position.
Hydration increases urine production and output, preventing
urinary stasis and promoting passing of the stone
This may indicate increasing or complete obstruction of urine flow
and may require immediate surgical intervention.

Dependent/Collaborative Actions
Administer analgesics as indicated (e.g., opioids, oxycodone, Kidney stone pain is acute and colicky in nature. Parenteral narcotics
* acetaminophen, ibuprofen, ketorolac). Administer on a are best to address this type of pain. Nonsteroidal anti-
routine schedule to prevent pain from becoming too inflammatory drugs (NSAIDs) can also be effective when used
severe. alone or in combination with other medications for mild to
moderate pain.
Request PCA device. Allows client to maintain control of pain medication.
Administer antispasmodics; calcium channel blockers, and These medications help decrease spasms of the urinary tract and
alpha-adrenergic blockers. may facilitate stone passage.
Notify the health care provider of increased episodes of pain May indicate passing of stone or possible blockage. Notification of
or persistent pain. health care provider allows for prompt intervention.

|Nursing ss
Diagnosis |«IMPAIRED URINARY ELIMINATION nox
Definition: Dysfunction in urine elimination.

Related to: Obstruction to urine flow and output caused by renal calculus
Postoperative edema of the urinary tract

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of continued or persistent pain and Changes in urine output volume, color, and consistency;
difficulty in voiding, bladder fullness, increased frequency increased frequency in voiding pattern; distended bladder;
of attempting to void changes in blood urea nitrogen (BUN) and creatinine
levels

RISK FACTORS DESIRED OUTCOMES

e Age The client will maintain adequate urine output and elimi-
e Surgery nation pattern as evidenced by:
e Kidney stone a. Usual frequency of urination
e Poor bladder tone b. Output >30 mL/h
io) . Voiding clear urine

d. Absence of pain or burning upon urination

a?) . BUN and creatinine clearance levels within client’s

normal range

NOC OUTCOMES NIC INTERVENTIONS

Urinary elimination Urinary management, urinary retention care

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Goto @volve for animation
634 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract

NURSING ASSESSMENT e RATIONALE

B
Assess for and report the following: Early recognition of signs and symptoms of urinary retention
Normal urinary elimination patterns allows for prompt intervention.
Possible urinary retention: Knowledge of client’s voiding pattern may help to identify subtle
e Reports of frequent urgency to empty bladder changes that indicate urinary retention.
e Bladder distention A palpable bladder provides evidence of urinary retention.
e Post-void residual bladder fullness A post-void residual bladder scan can indicate if client is able to
e Urine output <30 mL/h fully empty bladder.
Note color, clarity, and consistency of urine Changes in the color, clarity, and consistency of the urine may
indicate stasis or possible urinary tract infection.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage increased fluid intake, if not contraindicated. Increased hydration dilutes the urine and may support passage of
the stone or other debris.
Instruct client to urinate when the urge is felt. Helps to prevent stasis.
Implement measures to promote relaxation during voiding A client who is relaxed when trying to urinate is better able to relax
attempts (e.g., provide privacy, hold a warm blanket the pelvic floor muscles and external urinary sphincter and
against abdomen, place client’s hands in warm water). allow voiding to occur.
Assist client to assume a normal position for voiding (usually A sitting or standing position uses gravity to facilitate bladder
sitting for females and standing for males) unless contra- emptying. Allowing client to assume their routine voiding
indicated. D @+ position also promotes relaxation and facilitates voiding.
Strain urine and document any passage of stones and send to Helps to determine client’s ability to pass the stone or stone
the laboratory for analysis. D@ + fragments. Analysis of the type of stone is important in deter-
mining choice of therapy.

Dependent/Collaborative Actions
Administer medications as ordered:
a-Adrenergic blockers (i.e., tamsulosin, terazosin, doxazosin) For small distal ureteral stones, «-adrenergic blockers and calcium
Calcium channel blockers (i.e., nifedipine). channel blockers have been shown to relax the smooth muscles
of the ureter and decrease colic events, thus facilitating stone
passage. Decreasing colicky events may decrease need for
analgesic medications.
Corticosteroids (i.e., deltasone). Steroids reduce inflammation and neutrophil-induced damage to
the ureter. When used in combination with a-adrenergic
blockers and/or calcium channel blockers, steroids improve
stone passage and decrease expulsion time.
Monitor, document, and report any changes in lab values: Changes in BUN and creatinine indicate kidney dysfunction.
BUN and creatinine. Determines presence of infection and causative agents. Sensitivity
determines appropriate antibiotic therapy.

Culture and sensitivity results. Provides client information on what to expect and helps to alleviate
fear and anxiety.
Prepare client for surgical procedures to remove the stone
including:
Ureteroscopy for stone removal and potential stent
placement.
Extracorporeal shockwave lithotripsy (ESWL)
Percutaneous nephrolithotomy.

|Nursing ~~.
Diagnosis |RISK FOR INFECTION nox (URINARY TRACT)
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to: Increased growth and colonization of microorganisms associated with urinary stasis
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 635

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of frequency, urgency, and burning upon Elevated temperature: urinalysis showing increased white
urination blood cells (WBCs) and presence of bacteria; positive urine
cultures

RISK FACTORS DESIRED OUTCOMES

e Poor hygiene The client will remain free of urinary tract infection as
e Stasis of urine from inability to pass kidney stone evidenced by:
e Gender a. Clear urine
e Suppressed immune system b. Absence of frequency, urgency, and burning on
urination
c. Absence of chills and fever
d. Urinalysis slowing <S WBCs, negative leukocyte
esterase and nitrates and presence of bacteria
e. Negative urine culture

_ NOC OUTCOMES NIC INTERVENTIONS

Infection Protection Infection Control

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of urinary tract Early recognition of signs and symptoms of urinary tract infection
infection: allows for prompt intervention.
Presence of cloudy urine
Self-reports of frequency, urgency, or burning upon
urination
Chills
Elevated temperature
Urinalysis showing >5 WBCs; positive leukocyte esters or
nitrates or presence of bacteria
Positive urine culture

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage client to increase fluid intake if not contraindi- Increased hydration dilutes urine and stimulates more frequent
cated. D @ urination, which allows for bacteria to be flushed from the
system.
Helps to prevent urinary stasis.
Encourage client to urinate when urge is first felt. D @ + Perineal hygiene performed in this manner reduces risk for urinary
tract infection.
Teach female client to wipe from front to back after urinating Prevents exposure to new bacteria and prevents cross-contamination.
or defecating. D+
Encourage client to wash hands before and after urinating Vaginal deodorant sprays, douches, and powders in the genital
and defecating. D+ area can irritate the urethra.
Avoid use of irritating feminine products.
Monitor and document urine output, color, clarity, and Changes in volume of urine output, color, clarity and verbalization
verbalization of frequency, urgency, or burning. D @ + of frequency, urgency, or burning may indicate urinary tract infec-
tion. Decreased urine output may also indicate dehydration.

Dependent/Collaborative Actions
Increased hydration will increase frequency of voiding and help to
Administer intravenous fluids if ordered.
flush out debris and bacteria.
Obtain lab studies: Positive cultures indicate a urinary infection.
Urine culture and sensitivity.
Serum complete blood count (CBC). Elevated WBCs may indicate an infection and need for antibiotics.
Allows for timely modification of treatment regimen.
Notify health care provider if signs and symptoms occur.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Goto ©volve for animation
636 Chapter 12 * The Client With Alterations in the Kidney and Urinary Tract

Diagnosis RISK FOR DEFICIENT

|Nursing >... FLUID VOLUME nox

Definition: Susceptible to experiencing decreased intravascular, interstitial, and or/intracellular fluid volumes, which may
compromise health.

Related to:
e Fluid loss due to vomiting
e Decreased intake due to nausea
e Post-procedure and/or post-stone passage diuresis

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of thirst and dry mouth Weight loss, increased body temperature, increased
hematocrit (Hct), decreased skin turgor, increased heart
rate, decreased BP; capillary refill >3 seconds

RISK FACTORS DESIRED OUTCOMES

e Active fluid loss The client will not experience a deficient fluid volume as
e Failure of regulatory mechanisms evidenced by:
e Aging-loss of thirst and fluid volume reserve a. Normal skin turgor
b. Moist mucous membranes
c. Stable weight
d. BP and heart rate within normal range for client and
stable with position change
e. Capillary refill time <2 to 3 seconds
f. Het within normal limits
g. Balanced intake and output (I&O)

NOC OUTCOMES NIC INTERVENTIONS

Fluid management; hydration Fluid monitoring; fluid support

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of fluid volume deficit: Early recognition ofsigns and symptoms of deficit in fluid volume
e Decreased skin turgor allows for prompt intervention.
e Dry mucous membranes, verbalization of thirst
e Weight loss of 2% or greater over a short period of time
e Postural hypotension and/or decreased blood pressure
e Weak rapid pulse
Capillary refill time >2 to 3 seconds
Increased Hct levels

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor and document I & O and correlate with daily weight. A change in body weight of 1 kg (2.2 Ibs) equals 1 L fluid loss.
Decreased urine output may indicate dehydration.
Monitor color, clarity, and consistency of urine output and As urine output decreases, urine becomes darker and_ specific
urine osmolality. gravity and osmolality increase. A specific gravity @f > 1.030
indicates hypovolemia.
Document incidence of nausea, vomiting, and diarrhea. Clients who have a kidney stone and have not passed it may expe-
rience nausea, vomiting, and diarrhea associated with pain, as
the celiac ganglion innervates both the stomach and kidneys.
Encourage increased fluid intake up to 3-4 L/day if not Maintains vascular fluid volume and may help to flush out renal
contraindicated. D@ + stones and any bacteria or debris present.
Monitor and document changes in heart rate, blood pressure, All are indicators of fluid volume status.
skin turgor, and capillary refill.
Dependent/Collaborative Actions
Administer antiemetic and antidiarrheal medications. Decreases fluid volume loss.
Administer IV fluids as ordered. Supports hemodynamic status and fluid volume replacement, and
improves renal perfusion.
 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract 637

THERAPEUTIC INTERVENTIONS RATIONALE

eg Te

Monitor and document trends in Hct levels. Provides feedback on status of hydration and effectiveness of
hydration interventions.
Encourage appropriate dietary intake including liquids and Provides fluid and nutrients to maintain balance. Spicy foods
avoid spicy foods. irritate the gastrointestinal (GI) tract and may increase
incidence of nausea and vomiting.

oe ee) DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

MANAGEMENT nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT* nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals
of the family unit.

L
CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of concerns about potential recurrence of Inconsistent follow-through with treatment regimen;
illness and inability to follow prescribed regimen lack of engagement in self-care or inclusion of family in
client education; frequent questioning about therapeutic
regimen

RISK FACTORS
e Cognitive deficit
e Multifaceted health care regimen
e Difficulty modifying personal habits and integration of treatment regimen into lifestyle
e Lack of family support
e Lack of financial resources

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen Discharge planning, health education: teaching: disease
process; teaching; diet; teaching: prescribed medication;
teaching: prescribed exercise

NURSING ASSESSMENT RATIONALE

Assess client’s ability to learn and readiness to learn Learning is more effective when the client is motivated and under-
Assess client’s understanding of teaching stands the importance of what is to be learned. Readiness to
Assess client’s psychomotor skills to assure ability to perform learn changes based on situations and physical and emotional
required actions challenges.

THERAPEUTIC INTERVENTIONS RATIONALE

pare rg ek SS
Desired Outcome: The client will demonstrate ability to Knowledge of the purpose for treatment regimen is the starting
strain urine as part of treatment regimen. point for patient education and knowledge enhancement.

Independent Action
Assess Client’s knowledge of the purpose for voided urine straining.
Discuss with client the importance of straining all voided The client should strain all voided urine to determine when the
urine specimens, and to notify the health care provider stone has passed out of the urinary tract.
when stone has passed.

client’s discharge teaching needs.

*The nurse should select the diagnostic label that is most appropriate for the

NDx = NANDA Diagnosis D = Delegatable Action @=UAP 4 =LVN/LPN ©P = Go to @volve for animation
638 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Demonstrate and request a return demonstration of how to Demonstration of what is required of client supports learning of a
strain voided urine and how to clean strainer. new skill. The return demonstration provides the nurse with
information on how well the client understands what is
required and time for feedback to improve skills. Cleaning of
strainer prevents cross-contamination.
Provide the client with written instructions on how to strain Provision of written instructions provides a resource for client to use
voided urine. post discharge from acute care setting.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client and significant other will Provides baseline understanding of disease process and what can
develop a plan to implement required lifestyle changes to be done to prevent kidney stone recurrence.
prevent recurrence of kidney stone development.

Independent Actions
Assess client understanding of the correlation between
lifestyle and stone formation.
Assist the client in developing a plan to implement life style
changes:
e Maintain adequate fluid intake to assure urine output of Adequate hydration is required to maintain renal perfusion and
2 to 3 L/day development of urine output to a level that reduces stone
e Increase intake of water-filled fruits and vegetables formation.
e Have client develop a plan to increase fluid intake through- Increasing hydration during these times is important, as urine
out the day, particularly with meals and following solute load is highest following meals and increased physical
increased physical activity activity.
e Review dietary recommendations as appropriate: Dietary recommendation changes depend on the type of kidney
stone.
e To decrease the incidence of uric acid stones: Decrease intake of uric acid precursors.
e Limit intake or cut down on high-purine foods such as Foods that are high in purines predispose the client for uric acid
red meat, organ meats, and shellfish and follow a stones.
healthy diet that contains mostly vegetables and fruits,
whole grains, and low-fat dairy products.
e For oxalate stones: Research indicates that eating and drinking calcium and oxalate-
e Eat and drink calcium and oxalate-rich foods together rich foods together is better than entirely limiting oxalate and
during a meal or limit oxalate-rich foods (e.g., peanuts, calcium intake. When eaten together, oxalate and calcium bind
rhubarb, spinach, beets, sesame seeds, chocolate, and to one another in the stomach and intestines before they can
sweet potatoes). reach the kidneys, thus making it less likely that kidney stones
will form.
e For calcium stones: There are no studies that support calcium limitations in reducing
e No diet limitations at present; take calcium citrate stone formation. Calcium citrate binds with oxalates and im-
supplements as needed proves calcium absorption
e Encourage client to decrease sodium intake Sodium in the diet may lead to dehydration and a high-sodium diet
increases the amount of calcium in the urine.
Increase intake of vitamin B, and magnesium-rich foods. Supplemental intake of magnesium (~200-400 mg/day) and
vitamin B6 (~100 mg/day) reduce kidney stone development.
Provides client time with a nutritional expert who can help in
choosing appropriate foods and menu development.
Request consultation with the dietitian to assist client in Provides for assessment of client’s understanding of dietary recom-
developing appropriate menus for an appropriate intake. mendations and ability to implement appropriate dietary
Have the client put together 3 days of menus. changes.
Encourage regular physical activity and development of an With decreased activity, the bones increase calcium release;
exercise program. additionally, exercise can help maintain appropriate weight
Have the client write out a plan on how to increase physical for height and decrease incidence of high blood pressure, a
activity and to maintain an exercise routine. condition that increases the risk for kidney stones.
Encourage client to avoid all over-the-counter medications Decreases incidence of drug interactions.
and discuss use of herbal supplements with physician. Smoking may contribute to the development ofkidney stones, as it
Encourage client to quit smoking if applicable; assist in plan increases levels of calcium in the body.
development or referral to community resources.
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 639

THERAPEUTIC INTERVENTIONS RATIONALE

Allow client to ask questions and express concerns related to Lifestyle changes can be stressful and anxiety producing. Providing
therapeutic regimen and lifestyle changes. an accepting and open environment helps client work through
feelings concerning changes without fear of judgment. It also
enhances client’s sense of confidence in ability to make changes
and control over changes.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: This client will verbalize signs and Client should understand the incidence of stone recurrence is 15%
symptoms to be reported to the health care provider. at 1 year and 50% at 10 years. Knowledge of signs and
symptoms and notification of the health care provider allows
for prompt intervention.
Independent Actions
Review with client and provide a written list of what signs and Indicates potential dehydration and/or infection.
symptoms should be reported to the health care provider.
Increased temperature
Chills Indicates potential stone blockage of urine flow. If not resolved, can
Decreased urine output lead to kidney damage.
Presence of cloudy, dark urine Indicates trauma or kidney damage.
Recurrent pain Indicates fluid imbalance.
Presence of blood in urine
Weight gain or loss over a short period of time

THERAPEUTIC INTERVENTIONS RATIONALE

Desired outcome: The client, in collaboration with the

nurse, will a develop plan for adhering to recommended fol-
low-up care including future appointments with health care
provider, medications prescribed, activity level, wound care.

Independent Actions
Reinforce physician’s instructions regarding Reinforcing information improves client understanding of require-
Post-procedure care: ments following discharge.
e Increase activity as tolerated
e Avoid lifting objects over 7 Ibs. or strenuous exercise until
approved by health care provider.
Maintain adequate hydration Decreases potential for re-occurrence of stones.
Develop schedule for administration of medications if ordered Improves potential for adherence to medication regimen.
Collaborate with family members for follow-up Appointments Improves potential for attendance at follow-up appointments.

CYSTECTOMY WITH URINARY DIVERSION

Cystectomy is the surgical removal of the bladder to treat a Removal of the bladder requires reconstruction of the uri-
malignancy of the bladder, congenital bladder anomalies, neu- nary tract. All three available methods involve using seg-
rogenic bladder, and irreparable bladder trauma. A cystectomy ments of the GI tract for reconstruction of the removed areas
may also be performed to prevent further deterioration of renal of the urinary tract. There are three main types of urinary
function associated with chronic bladder infection. A cystec- diversions. They include ileal conduit, creation of a pouch
reservoir, and neobladder-to-urethra diversion.
tomy may involve removal of just the bladder (simple cystec-
In the first method, the ileal conduit method, the ureters
tomy); however, when there is an invasive malignancy, a more
are implanted in a segment of the intestine. The end of the
radical procedure is performed. In men, the procedure is called
a radical cystoprostatectomy and involves removal of the blad- segment is then brought through the abdominal wall, creat-
der, prostate, seminal vesicles, lower ureters and, in some Cases, ing a stoma. The second method involves the creation of an
internal reservoir (e.g., Kock pouch, Mainz pouch, Indiana
the urethra and some or all the pelvic lymph nodes. In women,
pouch). In this method, the ureters are implanted in a re-
the procedure is called radical cystectomy or anterior exentera-
tion and usually includes removal of the bladder, urethra, sected portion of intestine that has been remodeled to create
uterus, fallopian tubes, ovaries, anterior vaginal wall, lower a reservoir. Another segment of the reservoir is used to create
ureters, and often some or all the pelvic lymph nodes. the stoma that is brought out through the abdominal wall.
Removal of the bladder requires reconstruction of the Urinary reflux from the reservoir back through the ureters
lower urinary tract. and the uncontrolled flow of urine from the reservoir through

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NDx = NANDA Diagnosis
640 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract

the stoma are prevented by the surgical positioning of the ure- 2. Maintain surgical pain control
ters, reservoir, and stoma or by the construction of one-way ~ Have evidence of normal healing of surgical wound
valves at these sites. After healing occurs, a catheter is inserted 4. Have a medium pink to red, moist stoma and intact peri-
into the stoma at regularly scheduled intervals (usually every stomal skin
4-6 hrs once the reservoir stretches to its full capacity) to 5. Have no. signs and symptoms of postoperative
drain the reservoir. If the system functions properly, the client complications
does not need to wear a urinary collection appliance over the 6. Verbalize a basic understanding of the anatomical
stoma. The last type of urinary diversion involves reconstruc- changes that occurred as a result of surgery
tion of a segment of the intestine into a “new” bladder. The 7. Demonstrate the ability to change the urostomy appli-
ureters are connected to the “new” bladder and voiding ance and maintain stomal and peristomal skin integrity
requires contraction of the abdominal muscles. if present
The type of urinary diversion selected depends on many 8. Demonstrate the ability to properly clean reusable
factors including the client’s preference, age, body build, abil- urostomy equipment, if ostomy is present
ity to learn about and participate in care of the urinary diver- 9. Demonstrate the ability to drain and irrigate a continent
sion, prognosis, and ability to tolerate lengthy surgery; the internal reservoir if present
integrity of the client’s ureters, kidneys, and intestinal tract; 10. Identify ways to control odor of the urostomy drainage
the advice of the enterostomal therapy nurse; and the exper- and appliance if present
tise of the surgeon. 11. Discuss ways to prevent urinary tract infection
This care plan focuses on the adult client hospitalized for 12. State signs and symptoms to report to the health care
a cystectomy with urinary diversion by means of a conven- provider
tional conduit. Some additional nursing interventions are 13. Share thoughts and feelings about altered urinary elimi-
also included for the client with a continent internal reser- nation and its effect on body image and lifestyle
voir. Much of the postoperative information is applicable to 14. Identify and connect with appropriate community
clients receiving follow-up care in an extended care facility resources that can assist with home management and
or home setting. adjustment to changes resulting from the urinary
diversion
15. Develop plan for adhering to recommended follow-up
OUTCOME/DISCHARGE CRITERIA care including future appointments with health care
provider, wound care, activity level, and medications
The client will: prescribed
1. Maintain an adequate urine output via the urinary For a full, detailed care plan on this topic, go to http://evolve.
diversion elsevier.com/Haugen/careplanning/.

NEPHRECTOMY
Nephrectomy is the surgical removal of all or part of a kidney. This care plan focuses on the adult client hospitalized for
Indications for a nephrectomy include renal carcinoma, mas- a simple unilateral nephrectomy. Much of the postoperative
sive traumatic injury to the kidney, polycystic kidney disease information is applicable to clients receiving follow-up care
(especially if the kidney is bleeding or severely infected), in an extended care facility or home setting. The care plan
calculi, pyelonephritis, glomerulonephritis, and renal sclero- will need to be individualized according to the client’s diag-
sis resulting from hypertension. The kidney may also be nosis, prognosis, and plans for subsequent treatment.
removed for the purpose of donation.
The surgical approach used to perform a nephrectomy
depends on the extensiveness of the planned surgery; the OUTCOME/DISCHARGE CRITERIA
client’s age, body build, and physiological status; the underly-
ing pathology; and prior surgical incisions. The approach The client will:
commonly used for a simple nephrectomy (removal of just 1. Have evidence of normal healing of the surgical wound
the kidney) is the flank approach. Other open procedure 2. Have adequate functioning of the remaining kidney
approaches (e.g., thoracoabdominal, transabdominal, dorso- 3. Have clear, audible breath sounds throughout lungs
lumbar) may be necessary when greater visualization, im- 4. Have no signs and symptoms of postoperative complications
proved access, or a radical nephrectomy (removal of the kid- 5. Verbalize ways to maintain health of the remaining kidney
ney, renal artery and vein, adrenal gland, proximal ureter, 6. State signs and symptoms to report to the health care provider
regional lymph nodes, and surrounding fat and fascia) is 7. Share thoughts and feelings about the loss of the kidney
necessary. Although it is most often necessary to remove the 8. Develop plan for adhering to recommended follow-up
entire kidney, advances in renal imaging, earlier diagnosis of care including future appointments with health care
renal disease, and improved surgical techniques have provider, medications prescribed, activity level, wound
provided surgeons with an option of performing a partial care, and plans for subsequent treatment of the underlying
nephrectomy (nephron-sparing nephrectomy) in some in- disorder.
stances. In these situations, a laparoscopic rather than an See Standardized Preoperative and Postoperative Care
open approach is often feasible. Plans for additional diagnoses.
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 641

|Nursing 2s)
Diagnosis 6INEFFECTIVE BREATHING PATTERN nox |
Definition: Inspiration and/or expiration that does not provide adequate ventilation.
Related to:
e Increased rate of respirations associated with fear and anxiety
Decreased rate of respirations associated with the depressant effect of anesthesia and some medications (e.g., narcotic
[opioid] analgesics, some antiemetics)
e Decreased depth of respirations associated with:
e Depressant effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics, some antiemetics)
e Reluctance to breathe deeply resulting from incisional pain and fear of dislodging chest tube if present
e Positioning, weakness, fatigue, and elevation of the diaphragm (can occur if abdominal distention is present)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal report of shortness of breath and difficulty Alterations in rate and depth of breathing; altered chest
breathing excursion; bradypnea; decreased minute ventilation; use
of accessory muscles to breathe; decreased SaO, and
changes in arterial oxygenation measured via arterial
blood gases (ABGs)

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will maintain an effective breathing pattern as
e Obesity evidenced by:
e Immobility a. Normal rate and depth of respirations
b. Absence of dyspnea
c. SaOz > 92%

NOC OUTCOMES NIC INTERVENTIONS

———————————————

Respiratory status: ventilation Respiratory monitoring; ventilation assistance

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of the following: Early recognition of signs and symptoms of an ineffective breathing
e Ineffective breathing pattern pattern allows for prompt intervention.
e Shallow or slow respirations
e Limited chest excursion
e Tachypnea or dyspnea
e Use of accessory muscles when breathing
Assess/monitor pulse oximetry (arterial oxygen saturation Monitoring continuous SaOz readings allows for the early detection
[SaO.]), ABG values as indicated. and treatment of hypoxia.
Assessment of ABG values allows for a more direct measurement
of both the partial pressure of oxygen in arterial blood (PaQ2)
and the partial pressure of carbon dioxide in arterial blood
(PaCO,), which reflect the adequacy of ventilation.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve breathing pattern:
e Perform actions to reduce fear and anxiety: Reducing fear and anxiety helps prevent shallow and/or rapid
e Promote a calm, restful environment. D @ aa breathing.
e Assure client that deep breathing will not dislodge
chest tube if present. D+

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NDx = NANDA Diagnosis
642 Chapter 12 * The Client With Alterations in the Kidney and Urinary Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to reduce pain: Reducing pain helps increase the client’s willingness to move and
e Reposition client for comfort. D @ + breathe more deeply.
e Instruct and assist client to support incision when
moving or coughing.
e Provide adjuvant methods of pain control including
relaxation techniques, guided imagery, distraction.
e Perform actions to reduce the accumulation of gas and Reducing the accumulation of gas in the GI tract decreases pressure
fluid in the GI tract: on the diaphragm, facilitating more effective ventilation.
e Maintain patency of nasogastric (NG), gastric, or intes-
tinal tubes if present. D+
e Perform actions to increase strength and improve activity Increasing activity tolerance enables the client to breathe more
tolerance: deeply and participate in activities to improve breathing
e Implement measures to conserve energy. D @ + pattern.
e Ambulate as able following surgery.
e Assist client to deep breathe or use incentive spirometer Deep breathing and use of an incentive spirometer promote
every 1 to 2 hrs. D > maximal inhalation and lung expansion.
e Instruct client to breathe slowly if hyperventilating. Hyperventilation is an ineffective breathing pattern that can lead
e Provide with a paper bag if lightheadedness occurs. to respiratory alkalosis. A client can often slow breathing rate
by concentrating on doing so. Lightheadedness with hyperven-
tilation indicates decreased blood carbon dioxide levels
e Place client in a semi- to high-Fowler’s position unless A semi- to high-Fowler’s position allows for maximal diaphrag-
contraindicated. D@ + matic excursion and lung expansion.
e If client must remain flat in bed, assist with position Compression of the thorax and subsequent limited chest wall
change at least every 2 hrs. D @+ expansion occur when the client lies in one position. Frequent
repositioning promotes maximal chest wall and lung
expansion.
e Provide pillow support between lower costal margin and Decreases strain on flank incision and subsequently increases the
iliac crest when client is lying on operative side. D @ + ease of deep breathing.

Dependent/Collaborative Actions
Implement measures to improve breathing pattern:
e Increase activity as allowed and tolerated. D @ + During activity, especially ambulation, the client usually takes
e Assist with ambulation. deeper breaths, thus increasing lung expansion.
e Assist with positive airway pressure techniques if ordered: Positive airway pressure devices increase intrapulmonary (alveolar)
e Continuous positive airway pressure (CPAP) pressure, which helps re-expand collapsed alveoli and prevent
e Bilevel positive airway pressure (BiPAP) further alveoli collapse.
Flutter/positive expiratory pressure (PEP) device
e Oscillating Positive Expiratory Pressure (OPEP) device.
e Administer central nervous system (CNS) depressants CNS depressants cause depression of the respiratory center in the
judiciously: brainstem, which can result in a decreased rate and depth of
e Hold medication and consult physician if respiratory respiration.
rate is less than 12 breaths/min. D+
e Perform actions to reduce pain: Reducing pain increase the client’s willingness to move and breathe
e Administer analgesics before activities and procedures more deeply.
that can cause pain and before pain becomes severe.
D+
e May require round-the-clock routine medication Prevents pain from becoming uncontrollable.
administration in early postoperative period.
e Request PCA. PCA is a method of pain control and provides some coutrol over
situation
Consult appropriate health care provider if: Notifying the appropriate health care provider (e.g., physician,
e Ineffective breathing pattern continues. respiratory therapist) allows for modification of treatment plan.
e Client develops signs and symptoms of impaired gas
exchange such as restlessness, irritability, confusion,
significant decrease in oximetry results, decreased PaO,
and increased PaCQ; levels.
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 643

Oe RISK FOR SHOCK nox | |

Definition: Susceptible to an inadequate blood flow to the body’s tissues that may lead to life-threatening cellular dysfunction,
which may compromise health.

Related to: Excessive blood loss during surgery (the renal area is highly vascular) and hemorrhage after surgery

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of feeling lightheaded or dizzy; weakness Confusion; agitation; restlessness; hypotension;
tachycardia; urine output <30 mL/h; cool, clammy skin;
diminished or absent peripheral pulses; pallor; cyanosis

RISK FACTORS DESIRED OUTCOMES

e Failure of regulatory mechanisms The client will not develop hypovolemic shock as evi-
e Inadequate fluid volume replacement
denced by:
. Usual mental status
. Stable vital signs
. Skin warm and usual color
. Palpable peripheral pulses
Warm, dry skin
. Urine output at least 30 mL/h
Te
®
dd . Stable weight at client’s normal range
moan

NOC OUTCOMES NIC INTERVENTIONS

ee
Fluid balance; fluid management Fluid monitoring; fluid management: fluid administration

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of hypovolemic Early recognition of signs and symptoms of hypovolemic shock
shock: allows for prompt of intervention.
e Restlessness, agitation, confusion, or other change in
mental status
e Significant decrease in blood pressure (BP)
e Postural hypotension
e Rapid, weak pulse
e Rapid respirations
e Cool, clammy skin
e Pallor, cyanosis
e Diminished or absent peripheral pulses
e Urine output less than 30 mL/h
e Change in weight greater than 2 lbs
Monitor hemoglobin (Hgb), Hct, and prothrombin time (PT)/ Elevated clotting times may contribute to postoperative hemorrhage
partial thromboplastin time (PTT) values and hypovolemic shock. Monitoring Hgb/Hct and PT/PTT will
allow for implementation of the appropriate interventions.
Monitory hemodynamic values if present: If present, hemodynamic values are beneficial in guiding fluid
resuscitation and preventing fluid volume overload.
e Central venous pressure (CVP)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor I&O and correlate findings with daily weight. Helps to determine fluid preplacement needs. Body weight changes
of 1 kg (2.2 lbs) represent a fluid loss of 1 L.
Encourage fluid intake if not contraindicated.
Provides support for vascular fluid volume.
Keep fluids easily accessible to client.
Monitor vital signs. Maintenance of oral intake keeps oral mucosa moist and improves
gastric functioning while supporting vascular fluid volume.
Assess and document indications of hypovolemia (e.g., dry
mucous membranes, verbalization of thirst). Increased heart rate, decreased blood pressure, and dry mucous
membranes are indicative of dehydration.

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644 Chapter 12 * The Client With Alterations in the Kidney and Urinary Tract

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent hypovolemic shock: These actions prevent further loss of blood or vascular fluid
volume, which may contribute to hypovolemic shock.
e If bleeding occurs, apply firm, prolonged pressure to area Promotes clotting.
if possible.
e Perform actions to prevent deficient fluid volume. Provides vascular fluid volume replacement which may include
e Maintain intravenous access and administration of fluid; volume expanders.
may require large-bore access or a peripherally inserted
central (PIC) line.
e Instruct client to splint incisional area with hands or Splinting the incision area when turning and coughing reduces
pillow when turning and coughing. stress on the surgical wound to reduce risk for hemorrhage.
e Implement measures to reduce pain, nausea and vomiting Retching action with vomiting places stress on the surgical
(e.g., administer medications for pain, eliminate noxious wound. Preventing nausea and vomiting reduces this stress on
sights and odors, reduce fear and anxiety, instruct to the incision.
change position slowly).
If signs and symptoms of hypovolemic shock occur:
e Place client flat in bed with legs elevated unless contrain- Elevation of legs facilitates the return of blood pooled in the
dicated. extremities to the central circulation, improving blood flow to
e Monitor vital signs frequently. the vital organs.
If signs and symptoms of hypovolemic shock occur:
e Administer oxygen as ordered. Supplemental oxygen is beneficial because oxygen delivery to the
tissues is compromised in shock states.
e Administer blood and/or volume expanders if ordered. Blood and/or fluid volume expanders will help restore circulating
volume. The agent of choice is driven by laboratory values and
oxygen levels.
e If not already present, prepare client for insertion of Hemodynamic monitoring devices can measure preload/filling
hemodynamic monitoring devices: pressures, which are low in hypovolemic shock states.
e Central venous catheter.
e Intra-arterial catheter.

Collaborative »Diagnosis
> |RISK FOR PARALYTIC ILEUS
Definition: Paralysis of the intestines resulting in blockage of the intestines.

Related to:
e Manipulation of the bowel during surgery
¢ Depressant effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics, some antiemetics) on bowel motility
e Hypovolemia if it occurs can cause decreased blood supply to the intestine

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal reports of persistent abdominal pain and cramping, Firm, distended abdomen; absent bowel sounds; failure
loss of appetite; nausea to pass flatus; abdominal radiograph showing distended
bowel; nausea and vomiting

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will not develop a paralytic ileus as evi-
e Inadequate fluid volume replacement denced by:
e Immobility a. Absence or resolution of abdominal pain and cramping
b. Soft, nondistended abdomen
c. Gradual return of bowel sounds
d. Passage of flatus
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 645

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of paralytic ileus: Early recognition of signs and symptoms of paralytic ileus allows
e Development of or persistent abdominal pain and cramping for prompt intervention.
e Firm, distended abdomen
e Absent bowel sounds
e Failure to pass flatus
e Abdominal radiograph showing distended bowel
e Lack of appetite
e Nausea and vomiting

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent paralytic ileus:
e Increase activity as soon as allowed and tolerated follow- Activity increases peristalsis.
ing surgery.
e Perform actions to prevent hypokalemia if present (e.g., Prevention of hypokalemia is important because it prevents
prevent nausea and vomiting, administer fluid and elec- resultant decrease in peristalsis.
trolytes as ordered, when oral intake is allowed help client
to select foods high in potassium).
e Perform actions to maintain adequate tissue perfusion Maintains adequate vascular fluid volume that supports blood
(e.g., maintain fluid intake of 2500 mL/day unless contra- supply to the bowel.
indicated, administer blood and blood products as Increased activity promotes peristalsis.
ordered, instruct and assist client to perform active foot
and leg exercises every 1-2 hrs while awake).
e Administer GI stimulants (e.g., metoclopramide) if ordered. GI stimulants stimulate peristalsis.
e Administer medications to decrease experience of nausea Decreases fluid and electrolyte loss.
and vomiting.
If signs and symptoms of paralytic ileus occur:
e Withhold all oral intake. Decreases potential for a bowel obstruction.
e Insert NG tube and maintain suction as ordered. Placement of an NG tube to facilitate suction helps remove fluid
and gastric secretions from the stomach and decreases potential
for a bowel obstruction.

|Collaborative >.
Diagnosis RISK FOR PNEUMOTHORAX

Definition: An accumulation of air space between the lung and chest wall which causes the lung to collapse.

Related to: An accumulation of air in the pleural space associated with surgical opening of the pleura (occurs most frequently
with thoraco-abdominal and flank approaches) and/or malfunction of chest tube if present

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of shortness of breath Absent breath sounds; hyperresonant percussion; rapid,
shallow, and/or labored respirations; restlessness; agita-
tion; confusion; ABG values that have worsened; decreas-
ing SaO, levels, chest radiograph showing a lung collapse

DESIRED OUTCOMES SS SS
RISK FACTORS Minti ess Wii ee
e Surgery The client will experience normal lung re-expansion if
e Central line placement pneumothorax occurs as evidenced by:
e Immobility a. Audible breath sounds and resonant percussion note by
e Ineffective cough effort the third to fourth postoperative day
e Obesity . Unlabored respirations at 12 to 20 breaths/min
ABG values returning toward normal
. SaO2 > 90%
. Chest radiograph showing lung re-expansion
SGhee

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646 Chapter 12 © The Client With Alterations in the Kidney and Urinary Tract

NURSING ASSESSMENT RATIONALE

Assess for and immediately report signs and symptoms of: Early recognition of the signs and symptoms of pneumothorax
e Malfunction of the chest drainage system, if present (e.g., allows for prompt intervention.
respiratory distress, lack of fluctuation in water seal
chamber without evidence of lung re-expansion, excessive
bubbling in water seal chamber, significant increase in
subcutaneous emphysema)
e Further lung collapse (e.g., extended area of absent breath
sounds with hyperresonant percussion note; rapid, shal-
low, and/or labored respirations; tachycardia; increased
chest pain; restlessness; confusion; ABG results that have
worsened; significant decrease in oximetry results)
e Monitor ABGs and SaQO,z levels
Monitor chest radiograph results. Report findings of delayed
lung re-expansion or further lung collapse

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote lung re-expansion and pre-
vent further lung collapse:
e Perform actions to maintain patency and integrity of chest
drainage system:
e Maintain fluid levels in the water seal and suction Maintains negative pressure within the lungs.
chambers as ordered.
e Maintain occlusive dressing over chest tube insertion An occlusive dressing over the chest tube insertion site maintains
site. negative pressure seal.
e Tape all connections securely. Securely taping the tubings/connections prevents tubing from being
disconnected and maintains a closed drainage system.
e Tape the tubing to the chest wall close to insertion site. Taping the tubing to the chest wall reduces the risk of inadvertent
removal of the chest tube.
e Position tubing to promote optimum drainage (e.g., These actions promote chest tube drainage.
coil excess tubing on bed rather than allowing it to
hang down below the collection device, keep tubing
free of kinks).
e Drain fluid that accumulates in tubing into the collec- Maintains patency of the drainage system.
tion chamber.
e Avoid clamping, stripping, or milking of chest tubes. If Clamping chest tubing prevents the escape of air or fluid increasing
ordered with visible clots, manipulate the tubing using risk of tension pneumothorax.
a hand-over-hand method while moving along the Chest tube stripping or milking causes extreme negative pressures
drainage tube. in the tube and pleural space and may damage lung tissues.
e Keep drainage collection device below level of client’s Maintaining the drainage device below the level of the client’s chest
chest at all times. prevents backflow of drainage into the lungs.
e Perform actions to facilitate the escape of air from the Helps to maintain expansion or re-expand lung tissue following a
pleural space (e.g., maintain suction as ordered, ensure pneumothorax.
that the air vent is open on the drainage collection
device if system is set to water seal only).
e Perform actions to improve breathing pattern and These actions improve lung expansion and removal of secretions.
facilitate airway clearance (e.g., encourage client to
cough and deep breathe every 1-2 hrs; use incentive
spirometry every 2 hrs; ambulate as ordered and as tol-
erated).
If signs and symptoms of further lung collapse occur:
e Maintain client on bedrest in a semi- to high-Fowler’s Positioning the client in a semi- to high-Fowler’s position
position. improves the client’s ability to expand the lungs and decreases
abdominal pressure on the diaphragm.
e Maintain oxygen therapy as ordered. Supplemental oxygen helps maintain tissue oxygenation.
 Chapter 12. = The Client With Alterations in the Kidney and Urinary Tract 647

THERAPEUTIC INTERVENTIONS RATIONALE

e Assess for and immediately report signs and symptoms of Emergency treatment is required to prevent further respiratory
tension pneumothorax (e.g., severe dyspnea, increased rest- difficulty and prevent further complications.
lessness and agitation, rapid and/or irregular pulse rate,
hypotension, neck vein distention, shift in trachea from
midline).
e Assist with clearing of existing chest tube and/or insertion Reestablishes a closed drainage system.
of a new tube.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

MANAGEMENT np; INEFFECTIVE FAMILY HEALTH
MANAGEMENT* npx
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
<
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic regimen
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals; Ineffective
Family Health Management NDx: A pattern of regulating and integrating into family processes a program for the
treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalizes inability to manage illness; verbalizes inability Inaccurate follow-through with instructions; inappropriate
to follow prescribed regimen behaviors; experience of preventable complications of
surgery and living with one kidney.

RISK FACTORS
e Cognitive deficit
e Financial concerns
e Failure to reduce risk factors for complications of surgery
e Inability to care for oneself
° Difficulty in modifying personal habits and integrating treatments into lifestyle

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; disease management Teaching: individual; teaching: disease process; teaching:
prescribed activity/exercise; teaching: prescribed medication;
health system guidance

NURSING ASSESSMENT RATIONALE

a
Assess Client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

eee
/__
Desired Outcome: The client will verbalize ways to main-
tain health of the remaining kidney.

the client’s discharge teaching needs.

*The nurse should select the diagnostic label that is most appropriate for

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648 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract

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THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client regarding ways to maintain health of the
remaining kidney:
e Adhere to precautions to prevent a urinary tract infection:
e Perform actions to prevent urinary stasis:
(1) Drink at least 10 glasses of liquid per day unless Hydration is required to maintain vascular fluid volume and
contraindicated. adequate blood flow to the kidneys.
(2) Urinate whenever the urge is felt. Prevents stasis of urine in the bladder.
(3) Avoid long periods of inactivity (if unable to main- Activity improves circulation and helps to prevent urine stasis.
tain a program of moderate activity, be sure to
change positions frequently).
e Wipe from front to back after urinating and defecating Appropriate perineal hygiene prevents urinary tract exposure to
(if female). vaginal or rectal bacteria. Moisture provides a medium for
e Keep perineal area clean and dry. growth of bacteria.
e Immediately report signs and symptoms of a urinary tract Urinary tract infections require prompt intervention.
infection (e.g., chills; fever; urgency, frequency, or burning
on urination; cloudy or foul-smelling urine).
e Notify physician if a cold or other infection persists for Hydration is important to maintain fluid volume and adequate
more than 2 to 3 days or if unable to maintain an adequate blood flow to the kidneys.
fluid intake.
e Inform other health care providers about the nephrectomy Helps prevent infections.
so that prophylactic antimicrobials may be initiated before
dental work and invasive procedures such as cystoscopy
and minor surgeries.
e Avoid activities that might cause trauma to the remaining Prevents injury.
kidney (e.g., contact sports, horseback riding).
e Inform physician of all prescription and nonprescription Many medications are nephrotoxic and should not be taken.
medications being taken and before taking any new medi- Knowledge of medications and supplements helps to prevent
cations since they might cause damage to the remaining drug-to-drug interactions
kidney (e.g., ibuprofen, ciprofloxacin, captopril, quinine,
naproxen, lithium, neomycin, gentamicin, pentamidine,
vancomycin, cyclosporine).
e Consult health care provider before undergoing any diag- Some agents used during these procedures can damage the remain-
nostic test involving the use of contrast media. ing kidney.
e If nephrectomy was performed because of renal calculi, Prevents formation of stones in the remaining kidney, and provides
reinforce physician’s instructions about diet, drug therapy, adequate hydration. Dietary recommendations help to decrease
and daily fluid requirements. incidence and recurrence of kidney stones.
e If surgery was necessary because of renal hypertension, re- Client needs to control BP to prevent destruction of the nephrons on
inforce the physician’s instructions about methods of con- the remaining kidney.
trolling BP (e.g., dietary modification, medication, physical
exercise on regular basis, weight loss if overweight).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report signs and symptoms to their health These clinical manifestations should be reported to the Realth care
care provider: provider because they require prompt intervention.
e Difficulty breathing May indicate a pulmonary embolism.
e Productive cough of discolored sputum May indicate dehydration or respiratory infection.
e Unusual or excessive drainage from the wound site May indicate an infection.
e Pain or swelling in the calf of one or both legs May indicate a deep vein thrombosis.
e Unusual and continuous abdominal or pelvic pain May indicate an infection.
e Temperature above 38°C (100.4°F)
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 649

THERAPEUTIC INTERVENTIONS RATIONALE

e Unexplained weight gain May indicate loss of or changes in kidney function, dehydration, or
e Decreased urine output development of a kidney stone.
e Flank pain on the nonoperative side
e Blood in the urine

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will a develop plan for adhering to recommended
follow-up care including future appointments with health care
provider, medications prescribed, activity level, wound care,
and plans for subsequent treatment of the underlying disorder.

Independent Actions
Reinforce physician’s instructions regarding activity:
e Gauge activity according to tolerance and allow adequate These actions prevent unnecessary stress on the suture line. Helps
rest periods. to conserve energy.
e Avoid lifting objects over 7 to 10 lbs, pushing heavy ob- Prevents stress/injury to suture line and abdominal tissues.
jects, and exercising strenuously for specified length of
time (usually 4-8 weeks).
Clarify plans for follow-up visits and subsequent treatment of Clarity of information improves client’s understanding of long-
the underlying disorder (e.g., chemotherapy, radiation term care and adherence to treatment regimen.
therapy) if appropriate. Provides for continuum of care following discharge from acute care
Collaborate with client to develop a schedule of appoint- facilities.
ments for follow-up care.
Refer client to community support groups

ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE

p> Acute kidney injury (AKI) is an abrupt decline in kidney func- phase begins with the insult to the kidneys and continues
tion. Symptoms range from very subtle changes in renal func- until signs and symptoms begin. This phase can last from
tion to complete renal failure. The majority of cases of AKI are hours to days. Prevention of permanent injury may be possi-
reversible with early diagnosis and treatment. The causes of ble within this phase. The maintenance or oliguric phase
AKI may be classified as prerenal, intrarenal, and postrenal begins when the urine output is decreased to less than
failure. Prerenal AKI is the most common type of AKI. It 400 mL/day. The decline in urine output indicates renal dam-
occurs when blood flow to the kidneys has been significantly age that does not respond to compensatory mechanisms.
decreased so the kidneys are no longer able to concentrate The diuretic phase begins with a gradual increase in daily
urine. The loss of renal blood flow can be caused by condi- urine output of at least 1 to 3 L/day. In this phase, the kidneys
tions such as hypovolemia due to blood loss from trauma, are beginning to recover waste excretion processes but cannot
severe hypotension from sepsis, cardiac failure, massive concentrate urine.
pulmonary embolism, and renal artery clamping or stenosis. In the recovery phase, the BUN and serum creatinine levels
Intrarenal AKI results from an injury to the kidney itself. begin to decline and glomerular filtration rates (GFRs) increase.
Potential causes of intrarenal failure include acute tubular Recovery is gradual and can take up to 1 year for renal function
necrosis, acute glomerulonephritis, malignant hypertension, to stabilize. In many cases, there is some permanent loss of
and injury to the glomerulus from nephron-toxic medica- renal function. AKI is reversible in most cases, but it can lead
tions and/or dye used during procedures. Postrenal AKI to chronic kidney disease (CKD). This is a progressive, irrevers-
results from a blockage of urine outflow from the kidneys. ible loss of kidney function that usually develops gradually
Causes of postrenal failure include kidney stones, tumors, over many years. The leading causes of CKD are diabetes mel-
injury, and/or edema that block the ureters. litus and hypertension. CKD can also develop after acute renal
failure (ARF) that has resulted in irreversible renal damage.
Diagnosis and treatment of AKI focuses on the cause of the
There are five stages in CKD that are delineated by the
failure. A thorough client history will help identify the under-
GER. Normal GFR is 125 mL/min. Stage 1 may maintain a
lying cause of renal failure. Diagnostic studies used to diag-
or high GFR (GFR > 90 mL/min). Although kidney
nose AKI include urinalysis, serum BUN and creatinine levels normal
and ratio, and the fractional excretion of sodium. The results dysfunction is occurring, it may be undiagnosed due to lack
of these studies vary depending upon the type of AKI present. of symptoms. In stage 2, there is a mild reduction of GFR to
AKI and recovery of renal function progress in phases: 60 to 89 mL/min. Symptoms that may occur during this
initiation, oliguric, diuresis, and recovery. The initiation stage are hypertension, polyuria, or nocturia. Otherwise, the

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650 Chapter 12 = The Client With Alterations in the Kidney and Urinary Tract

individual remains asymptomatic. GFR in stage 3 is reduced 3. Maintain fluid, electrolyte, and acid-base balance within
to 30 to 59 mL/min. The individual remains asymptomatic; a safe range for the client
however, fluid and electrolyte changes are occurring. In stage . Tolerate expected level of activity
4, the GFR decreases to 15 to 29 mL/min. The client experi- . Have no evidence of infection
ences symptoms related to metabolic acidosis, hyperphospha- . Maintain adequate nutritional status
temia, anemia, elevated triglycerides, and fluid and electro- . Verbalize a basic understanding of AKI and CKD
lyte imbalances. . Identify ways to slow the progression of kidney
CONAN

In stage 5, the last stage of CKD, the GRF will decrease to damage
less than 15% of normal. This stage is also known as end stage 9. Develop a plan to maintain fluid restrictions and dietary
renal disease (EDSR). modifications
There is a buildup of nitrogenous substances (e.g., urea, 10. Demonstrate the ability to accurately weigh self, measure
creatinine) to levels high enough to cause toxic effects on fluid I&O, and monitor own BP
other body systems. Typical signs and symptoms can include 11. List ways to reduce the risk of infection
lethargy, irritability, extreme fatigue and weakness, pruritus, 12. Identify ways to manage signs and symptoms that often
nausea and vomiting, muscle cramping, and stomatitis. Fluid, occur as a result of CKD
electrolyte, and acid-base imbalances also worsen, and dialy- 13. Share feelings and concerns about the effects of renal
sis or kidney transplantation is necessary for survival. failure on lifestyle and roles
This care plan focuses on the adult client with AKI 14. State signs and symptoms to report to the health care
who has progressed to the oliguric phase and is hospi- provider
talized for treatment and further evaluation of renal 15. Identify community resources that can assist with adjust-
function. Much of the information is also applicable ment to changes resulting from CRF
to clients in an extended care facility or home setting. 16. Develop a plan for adhering to recommended follow-up
care including future appointments with health care pro-
vider and medications prescribed
OUTCOME/DISCHARGE CRITERIA :
The client will:
1. Not exhibit signs and symptoms of uremic syndrome
2. Maintain BP within a safe range

|Nursing *Diagnosis |EXCESS FLUID VOLUME nox

Definition: Surplus intake and/or retention of fluid.

Related to:
e Compromised regulatory mechanisms
e Fluid intake in excess of prescribed restrictions

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of shortness of breath Weight gain of 2% or greater over a short period; hyper-
tension; presence of an S3 heart sound; tachycardia; intake
greater than output; changes in mental status; crackles
(rales) and diminished or absent breath sounds; dyspnea,
orthopnea; peripheral edema; distended neck veins; chest
radiograph showing pulmonary vascular congestion,
pleural effusion, or pulmonary edema

RISK FACTOR DESIRED OUTCOMES

e Compromised regulatory mechanisms The client will experience resolution of excess fluid
e Acute renal injury volume as evidenced by:
¢ CKD a. Decline in weight toward client’s normal
b. BP within normal range for client
c. Absence of an S3 heart sound
d. Balanced I&O
e. Usual mental status
f. Normal breath sounds
g. Absence of dyspnea, orthopnea, peripheral edema,
and distended neck veins
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 651

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance; electrolyte and acid-base balance; fluid Fluid/electrolyte monitoring; fluid management
overload severity

a NURSING ASSESSMENT ea a RATIONALE

athe ah ee eT
Assess for and report signs and symptoms of excess fluid volume: Early recognition of signs and symptoms of excess fluid volume
e Weight gain of 2% or greater over a short period allows for prompt intervention.
e Elevated BP (BP may not be elevated if fluid has shifted out
of vascular space)
e Presence of an S3 heart sound
¢ Bounding pulse
e Intake greater than output
e Changes in mental status
e Crackles (rales) and diminished or absent breath sounds
e Dyspnea, orthopnea
e Peripheral edema
e Distended neck veins
e Chest radiograph showing pulmonary vascular conges-
tion, pleural effusion, or pulmonary edema

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Weigh client daily at the same time of day using the same Daily weights are important for comparisons. A sudden weight
scale and with similar weight of clothing. D + gain may be an indication of fluid volume excess.
Monitor I&O and correlate with daily weight A change in body weight of 1 kg (2.2 lbs) equals 1 L of fluid. In-
I&O should include all oral and parenteral intake of fluid. creased weight over a short period of time may indicate declining
Output should include an estimate all insensible losses kidney function. Insensible water loss is estimated to be between
temperature will have increased. 40 and 600 mL in an adult under normal circumstances.
Monitor and document urine specific gravity, noting trends Urine specific gravity is used to measure kidney function. Findings
over time. less than 1.010 indicate declining kidney function.
Instruct client in ways to decrease thirst and keep oral mucous Ability to alleviate thirst and keep oral mucous membranes moist
membranes moist (e.g., space fluid intake evenly through- promotes compliance with oral fluid restrictions. Allows client
out the hours client is awake, rinse mouth frequently with to have fluid intake throughout a 24-hrs period and to
water, breathe through nose rather than mouth). maintain a sense of control.
Monitor lab and diagnostic studies values and analyze trends Monitoring trends over time helps to identify level of declining
over time: Potassium, sodium, BUN and creatinine, H&H; kidney function.
serial chest x-rays; arterial pH.

Dependent/Collaborative Actions
Implement measures to reduce excess fluid volume: Reduction of excess fluid volume reduces stress on the heart and
e Maintain fluid restrictions as ordered (intake allowed is vascular system.
usually 500-700 mL plus the amount of urine output in Ability to alleviate thirst and keep oral mucous membranes moist
the previous 24 hrs). D+ promotes compliance with oral fluid restrictions.
e If client is receiving numerous and/or a large volume of Prevents fluid volume excess.
intravenous medications, consult the pharmacist to
prevent excessive fluid administration (e.g., stop primary
infusion during administration of intravenous medications,
dilute medication in the minimum amount of solution).

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THERAPEUTIC INTERVENTIONS RATIONALE

e Restrict sodium intake as ordered. D > Reducing sodium intake decreases fluid retention.
e Administer diuretic if ordered. D + Diuretics increase excretion of water and some solutes.
e Administer vasodilators and antihypertensive agents as These agents may be ordered to decrease systemic vascular
ordered. resistance (SVR) and maintain or increase renal perfusion.
e Prepare client and assist with dialysis, if ordered (e.g., hemo- Dialysis is done to decrease fluid volume while correcting electro-
dialysis, peritoneal dialysis, or continuous renal replace- lyte and acid-base balance. Determination of the type of dialy-
ment therapy). sis utilized depends on degree of kidney functioning and client’s
ability to tolerate the procedure.
Consult physician if signs and symptoms of excess fluid Notification of the physician allows for prompt alterations in treat-
volume persist or worsen. ment plan.

Nursing Diagnosis RISK FOR DECREASED CARDIAC OUTPUT nox

Definition: Susceptible to inadequate blood pumped by the heart to meet metabolic demands of the body, which may com-
promise health.

Related to:
e Fluid volume changes from declining kidney functioning
e Electrolyte imbalances and metabolic acidosis
e Changes in afterload and preload
e Impaired cardiac contractility
e Alteration in preload and stroke volume

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of fatigue, restlessness Changes in blood pressure and heart rate; changes in
electrocardiogram (ECG); development of $3 & S4 heart
sounds; changes in fluid, electrolytes and metabolic
status; changes in ECG patterns

RISK FACTORS DESIRED OUTCOMES

e AKI The client will maintain adequate cardiac output as evi-
e CKD denced by:
a. Blood pressure and heart rate with normal range for
client
b. Strong and palpable peripheral pulses
c. Maintained mental status appropriate for client
d. Maintained preload and stroke volume
e. Absence of adventitious lung sounds
f. Capillary refill <2 to 3 seconds

NOC NIC

Cardiopulmonary status: Hemodynamic status: fluid volume Hemodynamic regulation; fluid regulation; electrofyte
management
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 653

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of decreased cardiac Early recognition of signs and symptoms of decreased cardiac
output: output will allow for prompt treatment.
Changes in blood pressure and heart rate
Presence of S3 & S4 heart sounds
ECG rhythm changes
Intake greater than output
Changes in mental status
Crackles (rales) and diminished or absent breath sounds
Dyspnea, orthopnea
Peripheral edema
Distended neck veins
Capillary refill >3 seconds
Changes in serum electrolyte levels

NURSING INTERVENTIONS RATIONALE

Independent Actions
Monitor BP and heart rate. Increased fluid volume associated with hypertension and renal
e failure, subsequent uremia, and increased SVR decrease cardiac
output. In clients with AKI, heart failure may be reversible.
Monitor and document ECG changes. A client with declining renal filtration may experience multiple
electrolyte changes.
Hypokalemia—ECG-flattened T-wave, peaked P wave, develop-
ment of U waves
Hyperkalemia—ECG-peaked T wave, widened QRS complex,
prolonged R-R interval, flattened T wave
Hypokalemia—prolonged QT interval
Client may development additional heart sounds associated with
excess fluid volume.
Auscultate heart sounds. Declining kidney function also impacts the production of erythro-
Assess skin color and nail beds and capillary refill time, and poietin. With decreased erythropoietin, there is a decrease in
SaO> levels. circulating red blood cells (RBCs). Additionally, decreased
SaO> levels may occur with fluid volume excess.
Early identification of respiratory congestion and heart enlarge-
ment is associated with declining kidney function.
Monitor serial chest x-rays and/or reports. Decreases oxygen consumption and cardiac workload.
Encourage bedrest and appropriate rest periods.
Schedule nursing interventions and procedures to allow for
prolonged periods of rest.

Dependent/Collaborative Action
Administer medications are ordered:
Sodium bicarbonate Hyperkalemia of 6.5 mEq or higher constitutes a medical emergency.
Administration of sodium bicarbonate will temporarily decrease
potassium levels by shifting potassium back into the cell.
Inotropic agents Increases myocardial contractility and stroke volume.
Calcium Gluconate Given for hypocalcemia and to stabilize the cell membrane from
depolarization in a hyperkalemic state.
Monitor serum electrolyte levels, noting trends over time: A potassium level of >6.5 mEq is considered a medical emergency
Potassium and requires prompt intervention.
Calcium Calcium is involved in maintenance of heart rate and rhythm.
Calcium deficit increases toxic effects of potassium.
Administer and restrict fluid as indicated.
Adequate cardiac functioning requires the appropriate level of
vascular fluid volume.
Provide supplemental oxygen as ordered. Provides supplemental oxygen to support appropriate cardiac
functioning.

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654 Chapter 12 * The Client With Alterations in the Kidney and Urinary Tract

RISK FOR ELECTROLYTE IMBALANCE nvx

Definition: Susceptible to changes in serum electrolyte levels, which may compromise health.

Related to:
° Hyponatremia
e Excessive fluid intake in relation to output that causes a delusional hyponatremia
e Loss of sodium associated with diuretic therapy
° Hypernatremia
° Decreased ability of the kidneys to excrete sodium
° Increased aldosterone output associated with activation of the renin-angiotensin-aldosterone mechanism if decreased
renal blood flor has occurred as a result of the underlying disease process
e Dietary sodium intake in excess of prescribed restrictions.
e Hyperkalemia
e Decreased ability of the kidneys to excrete potassium
° Increased cellular release of potassium associated with progressive renal tissue damage and metabolic acidosis
e Dietary intake of potassium in excess of prescribed restrictions
e Use of potassium-sparing diuretics or medications
© Use of salt substitutes containing potassium
° Hypocalcemia
¢ Decreased intestinal absorption of calcium associated with inability of the kidneys to activate vitamin D to its active
metabolite that is required tO stimulate calcium absorption from the small intestines
¢ Hypophosphatemia that causes a reciprocal drop in calcium
e Hypermagnesemia
° Decreased ability of the kidneys to excrete magnesium
e Excessive intake of magnesium-containing antacids, laxatives or both
° Hyperphosphatemia
° Hypocalcemia causes an increase in phosphorus
° Decreased ability of the kidneys to excrete phosphorus

CLINICAL MANIFESTATIONS

Subjective Objective
Hyponatremia: Self-report of nausea, abdominal cramps Hyponatremia: Vomiting, confusion, seizures, low serum
and weakness sodium level
Hypernatremia: Self-report of thirst, weakness Hypernatremia: Dry, sticky mucous membranes; restless-
ness, elevated temperature; seizures; elevated serum sodium
level
Hyperkalemia: Self-report of muscle weakness Hyperkalemia: Bradycardia with irregular pulse; diarrhea
and intestinal colic,; Electrocardiogram (ECG) showing
peaked T wave, prolonged PR interval, and/or widened
QRS; elevated potassium level
Hypocalcemia: Self-report of feeling anxious, numbness Hypocalcemia: Irritability; Chovstek’s and Trousseau’s
or tingling in fingers, toes, or circumoral area sign; hyperactive reflexes; tetany; seizures; serum calcium
level lower than normal
Hypermagnesemia: Self-report of nausea and weakness Hypermagnesemia: Flushed, warm skin, vomiting; drowsi-
ness; hypotension; bradycardia; bradypnea; higher than
normal serum magnesium level
Hyperphosphatemia: Self-report of numbness or tingling Hyperphosphatemia: Tetany; seizures; elevated serum
in hands and feet phosphorus level
 Chapter 12 * The Client With Alterations in the Kidney and Urinary Tract 655

RISK FACTORS DESIRED OUTCOMES

° Disease process that effects the kidney’s ability to excrete Thoiolicnmeciiinot . | eoiebol
Secrolyte: client will not experience an electrolyte imbalance as
° Prescribed drugs — diuretics and laxatives cae): er pat
Meee evel of vitaain D a. Serum electrolyte values within normal limits
b. Absence of seizure activity, vomiting, abdominal
e Failure of physiological regulatory mechanisms
cramps, diarrhea, and thirst
e Excessive potassium salt substitutes
. Normal ECG with a regular pulse 60 to 80 beats/min.
° Poor adherence to dietary regimen
e Use of OTC medications . Usual muscle tone and strength
. Negative Chvostek’s and Trousseau’s sign
Oo
a
> . Absence of numbness and tingling in fingers, toes and
circumoral area,; hyperreflexia, and tetany

NOC OUTCOMES NIC INTERVENTIONS

Electrolyte balance; Fluid balance Fluid/electrolyte monitoring; Fluid/electrolyte management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of: Early recognition of signs and symptoms of electrolyte imbalance
¢ Hyponatremia: Nausea. Vomiting, abdominal cramps, allows for prompt intervention.
lethargy, confusion, weakness, seizures, and low serum
sodium level
Hypernatremia: Thirst, drug stick mucous membranes,
restlessness; lethargy; weakness; elevated temperature, sei-
zures, elevated serum sodium level
Hyperkalemia: Slow or irregular pulse, paresthesias; mus-
cle weakness and flaccidity; diarrhea and intestinal colic
ECG showing peaked T waves, prolonger PR interval, and/
or widened QRS, elevated serum potassium levels
Hypocalcemia: Anxiousness; irritability; positive Chvostek’s
and Trousseau’s sign; numbness or tingling of fingers, toes or
circumoral area; hyperactive reflexes; tetany; seizures; serum
calcium level that is lower than normal
Hypermagnesemia: Flushed, warm skin; nausea; vomit-
ing; muscle weakness; drowsiness; lethargy; hypotension;
bradypnea; bradycardia; higher than normal serum mag-
nesium level
Hyperphosphatemia: Paresthesia; tetany; seizures; seizures,
higher than normal serum phosphorus level

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent or treat hyponatremia:
¢ Maintain fluid restriction as ordered. Maintenance of fluid restrictions prevents dilutional hyponatremia.
e Increase dietary allotment of sodium if ordered. D @ + Increased intake ofsodium decrease the dilutional effects ofvascu-
lar fluid retention.
e Administer loop diuretics. Loop diuretics promote excretion of water.
Implement measures to prevent or treat hypernatremia:
e Maintain maximum fluid intake allowed. D Maintain appropriate balance between vascular fluid volume and
e Maintain dietary sodium restriction if ordered. sodium volume.
e Administer thiazide diuretics if ordered. Thiazide diuretics increase excretion ofsodium and water.
Notification of the health care provider allows for prompt alterna-
tion in treatment plan.

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THERAPEUTIC INTERVENTIONS RATIONALE

Consult health care provider if high serum sodium levels

persist.
Implement measures to prevent or treat hyperkalemia:
e Maintain dietary restrictions of potassium by limiting in- Restricting intake of potassium-rich foods helps maintain a normal
take of foods/ fluids such as bananas, potatoes, raisings level of serum potassium.
avocados and orange juice, and use of salt substitutes.
e Instruct client to consult health care provider or a dietitian Most salt substitutes contain potassium. The client would be
about which salt substitutes can be safely used. taught which ones are safe for them to use.
e Perform actions to reduce the cellular release of potassium:
(1) Encourage client to consume the amount of dietary During the breakdown of proteins, potassium is released.
protein allowed.
(2) Provide allotted amount of carbohydrates. Ingestion of carbohydrates spares protein by providing a quick en-
(3) Perform actions to prevent infection: ergy source.
e use sterile technique when doing invasive proce- Prevention of an infection prevents an increase in the metabolic
dures, rate and a subsequent increase in protein catabolism.
e use good handwashing and encourage client do to
the same
e rotate intravenous line sites according to hospital
policy
e Implement measure to prevent or treat metabolic acidosis In metabolic acidosis, potassium is moved out of the cell in
(e.g., administer sodium bicarbonate). exchange for hydrogen, thus increasing the extracellular
potassium level.
e If signs and symptoms of hyperkalemia are present, con- Prevents increased potassium levels.
sult health care provider before administering prescribed
potassium supplements and other medications that can
increase potassium levels (e.g., potassium penicillin G,
potassium-sparing diuretics, some beta-blockers, and an-
giotensin-converting enzyme (ACE) inhibitors, and Angio-
tensin II receptor ARBS blocker).
Administer the following mediations if ordered:
e Loop diuretics
e Cation-exchange resins (e.g., sodium polystyrene sulfo- Increases renal excretion of potassium.
nate [Kayexalate]) Administration of sodium polystyrene sulfonate increases potas-
sium excretion via the intestines (action exchanging sodium for
potassium).
e Intravenous insulin and hypertonic glucose solutions. Infusion of hypertonic glucose solutions and insulin enhances
transport of potassium back into the cells.
If signs and symptoms of hyperkalemia persist or worsen: Notification of the healthcare provider allows for prompt altera-
e Consult health provider. tions in the treatment plan.
e Have intravenous calcium preparation (e.g., calcium glu- Administration of calcium gluconate counteracts the effect of a
conate) readily available. high potassium level on the heart.
Implement measure to prevent or treat hypercalcemia:
e Provide dietary sources of calcium (e.g., mile and milk Ensures calcium is present in the client’s diet.
products). D@ +
e Administration of vitamin D (e.g., paricalcitol, calcitriol) Vitamin D is required for the absorption of calcium.
and calcium supplements if ordered. D @ + Calcium and phosphate have an inverse relationship, and a high
e Perform measures to prevent or treat hyperphosphatemia phosphate level leads to hypocalcemia.
(e.g., restrict phosphorus intake).
e Avoid rapid or aggressive treatment of acidosis. Rapidly reversing acidosis can results in decreased iohization of
If signs and symptoms of hypocalcemia occur: calcium.
e Institute seizure precautions. Prevents client injury
e Administer calcium preparations (e.g. calcium gluconate, Increases calcium levels.
calcium carbonate) as ordered.
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 657

THERAPEUTIC INTERVENTIONS RATIONALE

a en cen pgp ej

Implement measure to prevent or treat hypermagnesemia: Magnesium is absorbed from these agents.
e Avoid giving laxatives and antacids that contain magne-
sium (e.g., Milk of Magnesia, Gelusil, Mylanta, Maalox).
e Maintain dietary restrictions if ordered by limiting intake Because the kidneys are unable to regular the electrolytes, decreas-
of foods/fluids such as seafood, green leafy vegetables and ing intake of magnesium is the most appropriate way to main-
legumes. tain decreased magnesium levels.
Consult health care provider if signs and symptoms of hyper- Notification of the health care provider allows for prompt altera-
Mmagnesemia persist or worsen. tion in the treatment plan.
Implement measures to prevent or treat hyperphosphatemia:
e Restrict dietary intake of phosphorus if ordered by limiting Administration of phosphate-binding medications binds with
intake of foods/fluids such as poultry, nuts, mile, mile phosphate and decreases the free phosphate levels available in
products, eggs, legumes, and some cola beverages. the body.
e Administer phosphate-binding medication such as sevela- These foods and fluids contain phosphate and will increase blood
mar (Renagel), aluminum-containing agents (e.g., Amphojel, phosphate levels.
Basaljel), calcium acetate (e.g., PhosLo), and calcium carbon-
ate (e.g., Tums), if ordered.
e Consult that health care provider if signs and symptoms of Notification of the health care provider allows for prompt altera-
hyperphosphatemia persist or worsen. tion in treatment plan.

|Nursing »----
Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with fatigue and dislike of prescribed diet
e Prescribed dietary modifications (especially protein restrictions that are necessary in order to control the serum levels of
nitrogenous substances)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of lack of appetite, fatigue, poor self-esteem Loss of weight with adequate food intake; sore, inflamed
buccal cavity; capillary fragility; irritability; pale conjunc-
tiva and mucous membranes; poor muscle tone; excessive
hair loss; amenorrhea

RISK FACTORS DESIRED OUTCOMES

e Poor adherence to dietary regimen The client will maintain an adequate nutritional status as
e AKI evidenced by:
e CKD a. Weight within normal range for the client
b. Serum albumin, prealbumin, Hct, and Hgb levels and
lymphocyte count within normal range
c. Usual or improved strength and activity tolerance
d. Healthy oral mucous membrane

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NOC OUTCOMES NIC INTERVENTIONS

Nutritional status: weight maintenance Nutritional monitoring; nutritional counseling; nutritional

management; nutrition therapy; weight gain assistance;
weight management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition and reporting ofsigns and symptoms of malnutri-
° Weight significantly below client’s usual weight or below tion allows for prompt intervention.
normal for client’s age, height, and body frame
e Low serum albumin, prealbumin, Hct, and Hgb levels and
low lymphocyte count
e Weakness and fatigue (may also reflect decreasing renal function)
e Sore, inflamed oral mucous membranes
e Pale conjunctiva
Monitor percentage of meals and snacks client consumes. An awareness of the amount of foods/fluids the client consumes
Document and report a pattern or inadequate intake alerts the nurse to deficits in nutritional intake. Reporting an
inadequate intake allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to improve oral intake:
e Increase activity as allowed and tolerated. D@ + Activity usually promotes a general feeling of well-being, which
can result in improved appetite.
e Maintain a clean environment and a relaxed, pleasant Noxious sites and odors can inhibit the feeding center in the hypo-
atmosphere. D @ + thalamus. Maintaining a clean environment helps prevent this
from occurring. In addition, maintaining a relaxed, pleasant at-
mosphere can help reduce the client’s stress and promote a feeling
of well-being, which tends to improve appetite and oral intake.
e Encourage a rest period before meals if indicated. The physical activity ofeating requires some expenditure of energy.
Fatigue can reduce the client’s desire and ability to eat.
° Provide oral hygiene between and before meals. D @ + Oral hygiene moistens the oral mucous membrane and stimulates
e Offer frequent mouth care. saliva production, which may make it easier to chew and swal-
e Allow client to chew gum, use of breath mints, sugarless low. It also freshens the mouth and removes unpleasant tastes.
hard candy. This can improve the taste of foods/fluids, which helps stimu-
late appetite and increase oral intake.
e Serve foods/fluids that are appealing to the client and adhere Foods/fluids that appeal to the client’s senses (especially sight and
to personal and cultural preferences whenever possible. smell) and are in accordance with personal and cultural prefer-
ences are most likely to stimulate appetite and promote interest
in eating.
e Serve frequent, small meals rather than large ones if client Providing small rather than large meals can enable a client who is
is weak, fatigues easily, and/or has a poor appetite. D + weak or fatigues easily to finish a meal.
e Allow adequate time for meals; reheat foods/fluids if Clients who feel rushed during meals tend to become anxious, lose
necessary. D@ + their appetite, and stop eating.
e Encourage client to eat the maximum amount of protein Client needs to have protein to maintain normal body functions.
allowed; instruct client to satisfy protein requirements
with foods/fluids that are complete proteins and contain
essential amino acids (e.g., eggs, milk, meat, poultry) if
serum phosphorus level is not too high.
e Weigh daily at same time with same clothing. Analyze Allows for a more accurate weight to be obtained.
trends over time
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 659

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Consult dietitian. Assist client to identify highly nutritious foods within prescribed diet.
Perform a calorie count if ordered. Report information to the The client must consume a diet that is well balanced and high in
dietitian and physician. essential nutrients in order to meet nutritional needs. Dietary
supplements are often needed to help accomplish this.
Consult the physician about an alternative method of provid- Notification of the physician allows for prompt alteration in the
ing nutrition (e.g., parenteral nutrition, tube feeding) if treatment plan.
client does not consume enough food or fluids to meet
nutritional needs.

|Nursing 2°
Diagnosis |RISK FOR INFECTION nox

Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
“e Lowered resistance to infection associated with:
e Immunosuppression secondary to uremia
e Malnutrition
e Stasis of secretions in the lungs and urinary stasis if mobility is decreased
e Invasive procedures and insertion of IV lines and urinary catheter

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of chills/lethargy; loss of appetite Elevated temperature; diaphoresis; tachypnea; tachycardia;
confusion; increase in WBC count above previous levels
and/or significant change in differential; positive blood
cultures

RISK FACTORS DESIRED OUTCOMES

e Exposure to pathogens The client will not experience an infection as evi-
e Failure of immune response denced by:
¢ Poor nutritional status a. Temperature with normal limits
e AKI b. Absence of chills and diaphoresis
¢ CKD c. Pulse and respiratory rate within normal range for client
. WBC and differential within normal limits
Oo. Negative blood culture results

NOC OUTCOMES NIC INTERVENTIONS

a ne EEUU UEEEEEESEEE ESSERE

Immune status; infection severity Infection protection; infection control

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NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of infection: increase Early recognition of signs and symptoms of an infection allows for
in temperature, chills, diaphoresis, tachypnea, tachycardia, prompt intervention.
increase in WBC and differential count and/or significant
change in differential, positive blood cultures.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent the development of an infection:
Maintain good handwashing technique. Teach client appro- Reduces risk of exposure and cross-contamination.
priate handwashing technique:
e Minimize the use of invasive procedures when possible. Prevents induction of bacteria into the system.
e Change dressings, IV tubing, and invasive lines using asep-
tic technique and as directed by facility policy.
e Anchor catheters/tubings (e.g., intravenous) securely. Reduces trauma to the tissues and the risk for introduction of
pathogens associated with in-and-out movement of the tubing.
e Encourage deep breathing exercises, coughing and/or use Enhances mobilization and excretion of respiratory secretions,
of incentive spirometry, frequent position changes, and thereby reducing the risk of respiratory infection.
ambulation if able.
e Perform actions to maintain an adequate nutritional status Adequate nutrition is necessary for cellular development and to
(e.g., increase activity as tolerated; maintain a clean envi- fight off infection.
ronment and a relaxed, pleasant atmosphere; serve several
small meals rather than three large ones).
e Perform actions to reduce stress (e.g., reduce pain and nau- Stress reduction prevents an increase in secretion of cortisol, which
sea; provide a calm, restful environment; explain diagnostic interferes with some immune responses.
tests and treatment plan).
° Monitor vital signs. D @ + Elevated temperature, BP, and heart rate may indicate an infection.

Dependent/Collaborative Actions
e Monitor WBC with differential. Leukocytosis is associated with AKI and kidney injury. In the
differential, a high number of immature WBCs are indicative
of an infection (i.e., shift to the left).
e Administer antimicrobials as ordered. Antimicrobials prevent and/or treat infections. Dosage may need to
be adjusted due to impaired renal clearance.
Obtain culture and sensitivity as ordered. Allows for prompt and appropriate treatment for an infection.

|Nursing »Diagnosis
~~ |«@RISK FOR DEFICIENT FLUID VOLUME nox
Definition: Susceptible to experiencing decreased intravascular, interstitial, and or/intracellular fluid volumes, which may
compromise health.

Related to:
e Excessive diuresis in diuretic phase of AKI
e Inadequate fluid intake

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of thirst and dry mouth Weight loss, increased body temperature, increased Hct,
decreased skin turgor, increased heart rate, decreased
blood pressure; capillary refill >3 seconds
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 661

RISK FACTORS DESIRED OUTCOMES

e Acute kidney failure
e Aging-loss of thirst and fluid volume reserve The client will not experience a deficient fluid volume as
evidenced by:
a. Normal skin turgor
b. Moist mucous membranes
c. Stable weight
d. BP and hear rate within normal range for client and
stable with position change
e. Capillary refill time <2 to 3 seconds
f. Hct within normal limits
g. Balanced I&O

NOC OUTCOMES NIC INTERVENTIONS

Fluid management; hydration status Fluid monitoring; fluid support

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of fluid volume deficit: Early recognition of signs and symptoms of deficit fluid volume
e Decreased skin turgor allows for prompt intervention.
e Dry mucous membranes, verbalization of thirst
e Weight loss of 2% or greater over a short period of time
e Postural hypotension and/or decreased blood pressure
° Weak rapid pulse
e Capillary refill time >2 to 3 seconds
e Increased Hct levels

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor and document I&O and correlate with daily weight. A change in body weight of 1 kg (2.2 Ibs) equals 1 L fluid loss.
Calculate insensible fluid loss. Decreased urine output may indicate dehydration. Insensible
fluid loss is approximately 400 to 660 mL in a normal adult.
Encourage and monitor fluid intake. Provide client easy During the diuresis stage of AKI, close monitoring of fluid intake
access to fluids to support increased fluid needs. D @ + and output (I/O) helps to prevent fluid volume overload.
Monitor and document changes in heart rate, BP, dry mucous Orthostatic hypotension and tachycardia are indicative of hypovo-
membranes, skin turgor, and capillary refill. lemia. Dry mucous membranes, poor skin turgor, and delayed
capillary refill indicate dehydration and may indicate inade-
quate fluid volume replacement.

Dependent/Collaborative Actions
Monitor and document trends in Hct levels. Elevation may indicate dehydration.
Monitor serum sodium levels. Increased sodium loss occurs in the diuretic phase of AKI. Increased
sodium in the kidneys increases fluid loss. Sodium restrictions
may be indicted to decrease the volume ofongoing fluid loss.

Collaborative Diagnosis RISK FOR METABOLIC ACIDOSIS

Definition: Elevated level of serum acidity (pH < 7.35).
Related to:
° Decreased ability of the kidneys to excrete hydrogen ions and reabsorb bicarbonate
e Hyperkalemia (the body attempts to compensate for high serum potassium levels by shifting hydrogen ions into the vascular
space in exchange for potassium ions)

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CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of fatigue, headache, and nausea Drowsiness; disorientation; stupor; rapid, deep respirations;
vomiting; cardiac dysrhythmias; pH <7.35; increased anion
gap (>12 mEq/L)

RISK FACTORS DESIRED OUTCOMES

e Changes in regulatory mechanisms
The client will not experience metabolic acidosis as evi-
e AKI
denced by:
* CKD
a. Usual mental status
b. Unlabored respirations at 12 to 20 breaths/min
c. Absence of headache, nausea, vomiting, and cardiac
dysrhythmias
d. ABG values within a safe range for client (pH 7.35-7.45)
e. Serum anion gap within a normal range (3-11 mEq/L)

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of metabolic acido- Early recognition of signs and symptoms of metabolic acidosis
sis (e.g., drowsiness; disorientation; stupor; rapid, deep allows for prompt intervention.
respirations; headache; nausea; vomiting; cardiac dys-
rhythmias; pH <7.35 and CO, content; increased anion
gap [>12 mEq/L]).

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent or treat metabolic acidosis:
e Perform actions to prevent or treat hyperkalemia (e.g., Decreases potassium levels in the system or prevents elevated
maintain dietary restrictions of potassium, limit use of salt potassium levels from occurring.
substitutes, limit intake of dietary protein). D +
e Administer sodium bicarbonate if ordered. Administration of bicarbonate decreases acidosis of the blood.
Consult physician if signs and symptoms of acidosis persist or Notification of the physician allows for prompt alterations in
worsen. treatment plan.

Collaborative Diagnosis RISK FOR UREMIC SYNDROME

Definition: A syndrome associated with progressive renal failure.

Related to: Accumulations of serum nitrogenous substances (e.g., creatinine, urea) associated with extensive loss of renal
function (signs and symptoms usually occur when the GER falls to <10% of normal)

CLINICAL MANIFESTATIONS

Subjective Objective
Self-reports of inability to concentrate; increasing weak- Increasing serum BUN and creatinine levels; cardiac
ness and fatigue; hallucinations; nausea; itching; muscle dysrhythmias; confusion; sallow or grayish bronze gkin;
cramps; restless feelings in the legs during rest; joint pain; stomatitis; vomiting; unusual bleeding; pericarditis; fever;
metallic or bitter taste in mouth asterixis; seizures
 Chapter 12. * The Client With Alterations in the Kidney and Urinary Tract 663

RISK FACTOR DESIRED OUTCOMES

° Failure of regulatory mechanisms The client will not experience uremic syndrome as evi-
denced by:
Pulse regular at 60 to 100 beats/min
Usual mental status
Usual skin color
Improved strength and activity tolerance
eo)
i
ASF No reports of nausea, insomnia, itching, muscle cramp-
Terme
ing, joint pain, paresthesia, and/or taste alterations
f. Intact oral mucous membrane
g. Absence of vomiting, unusual bleeding, pericarditis,
asterixis, and seizure activity

NURSING ASSESSMENT RATIONALE

Assess for and report the following: Early recognition of signs and symptoms of uremic syndrome al-
e Increasing BUN and serum creatinine levels lows for prompt intervention.
e Decreasing creatinine clearance levels
e Signs and symptoms of uremic syndrome:
° Cardiac dysrhythmias
e Difficulty concentrating, lethargy, confusion, or hallu-
cinations
e Sallow or grayish bronze skin
e Increased weakness or fatigue
e Reports of nausea, insomnia, itching, muscle cramps, joint
pain, paresthesias, restless feeling in legs during periods of
inactivity, or metallic or bitter taste in mouth
e Stomatitis
e Vomiting
e Unusual bleeding (e.g., ecchymoses; prolonged bleeding
from puncture sites; gingival bleeding; frank or occult
blood in stool, urine, or vomitus)
e Pericarditis (e.g., chest pain that frequently radiates to
shoulder, neck, back, and arm [usually left]; pericardial
friction rub; elevated temperature)
e Asterixis, seizures

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the levels of serum nitroge-
nous substances to prevent uremic syndrome:
e Perform actions to maintain an adequate nutritional status These actions assist the client in maintenance of an adequate
(e.g., serve small, frequent meals; allow adequate time to nutritional status while reducing catabolism of body proteins,
complete meals; eat the appropriate amount of proteins; which contribute to uremic syndrome.
take dietary supplements if indicated). D @ +
e Consult a dietitian. Assists client to identify foods appropriate for a protein-restricted diet.
e Perform actions to prevent infection (e.g., maintain ade- Prevention of infection prevents an increase in the metabolic rate
quate fluid intake, use sterile technique during all invasive and subsequent cellular catabolism.
procedures, promote good handwashing, change periph-
eral intravenous line sites according to hospital policy).
e Implement measures as ordered to control disease conditions Prevents further renal damage.
such as diabetes that have caused or contributed to renal
failure.

Dependent/Collaborative Actions
e Consult the physician before administering medications Client shouldbe inform ed
of medications that are nephrotoxic and
that are known to be nephrotoxic (e.g., NSAIDs, aminogly- should not take any over-the-counter medications without
cosides). consulting his/her health care provider.

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

If signs and symptoms of uremic syndrome occur:
e Prepare client for dialysis if planned. Dialysis removes toxins from the blood.
e Maintain a safe environment for client (e.g., side rails up Implementation of hospital policy related to falls and other precau-
while in bed, assistance with ambulation as needed, tions decreases potential for client injury.
constant supervision if indicated, seizure precautions).
e Administer antidysrhythmics as ordered; restrict activity if Treats cardiac dysrhythmias.
indicated. D+
e Administer antiemetics as ordered. D > Antiemetics decrease the incidence of nausea.
e Provide small, frequent meals; instruct client to ingest
foods/fluids slowly.
e Use tepid water and mild soap for bathing; apply emol- Use of tepid water for bathing and creams and ointments reduce
lient creams or ointments frequently. D @ + the incidence of pruritus.
e Administer antihistamines if ordered. D + Antihistamines block the release of histamines, which stimulate
itchy sensations.
e Instruct client to push feet against a hard surface when leg Actions help control muscle cramps.
cramps occur; apply warm packs to affected areas.
e Instruct client to avoid substances such as extremely hot, Avoidance of hot, spicy, and/or acidic foods reduces the severity of
spicy, or acidic foods/fluids; assist with frequent oral hy- stomatitis.
giene; apply oral protective pastes as ordered.
e Apply gentle, prolonged pressure after injections and These actions prevent and/or decrease incidence of bleeding.
venous and arterial punctures; instruct client to use an
electric rather than a straight-edge razor and to use a soft
bristle toothbrush for oral hygiene.
° Apply firm, prolonged pressure to bleeding area if possible; Administration ofclotting factors and/or vitamin K helps improve
administer clotting factors or vitamin K if ordered. body’s clotting ability and control bleeding.
e Maintain activity restrictions as ordered; administer an Anti-inflammatory agents treat pericarditis. Analgesics decrease
anti-inflammatory agent and analgesics if ordered. D > sensation of pain.

|Nursing »Diagnosis
6 DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT nox INEFFECTIVE HEALTH MANAGEMENT* nox
Definition: Deficient knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating into family processes a program for the
treatment of illness and its sequelae that is unsatisfactory for meeting specific health goal of the family unit;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

Related to:
e Specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condi-
tion/treatment/lifestyle changes

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalizes inability to manage illness; verbalizes inability Inaccurate follow-through with instructions; inappropriate
to follow prescribed regimen behaviors; experience of preventable complications of
renal failure

*The nurse should select the diagnostic label that is most appropriate for the client's discharge _
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 665

RISK FACTORS
e Cognitive deficit
e Financial concerns
e Failure to reduce risk factors for complications of renal failure
e Inability to care for oneself
° Difficulty in modifying personal habits and integrating treatments into lifestyle
e Insufficient knowledge of therapeutic regimen

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; diet; infection control; Health system guidance; teaching: individual; teaching:
cardiac medication disease process; teaching: prescribed activity/exercise;
teaching: prescribed medication

NURSING ASSESSMENT RATIONALE

Assess Client’s readiness and ability to learn Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize understanding

of AKI and CKD.

Independent Actions
Explain renal failure in terms that client can understand. Use Client’s understanding of the disease process will increase adher-
appropriate teaching aids (e.g., pictures, videotapes, ence with treatment regimen.
kidney models).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to slow

the progression of kidney damage.

Independent Actions
Provide instructions regarding ways to slow the progression
of kidney damage:
e Control hypertension by adhering to dietary modifica- Prevents further damage to the kidneys and decreases impact of
tions and taking medications as prescribed. vascular fluid volume changes on the heart.
e Reduce the risk of urinary tract infection by:
e Cleaning perineal area thoroughly after each bowel Proper perineal hygiene prevents urinary tract exposure to vaginal
movement or rectal bacteria.
e Wiping from front to back after urination and defeca-
tion (if female)
e Consuming the maximum amount of fluids allowed. Maintenance of appropriate fluid intake maintains vascular fluid
e Reduce the risk of nephrotoxic reactions by: volume.
e Consulting the appropriate health care provider before:
(1) Taking any additional prescription and nonpre- Many over-the-counter and prescription medications are nephro-
scription drugs toxic.
(2) Undergoing diagnostic testing that requires use of a Inform health care provider of renal failure, as dyes used in diag-
contrast medium nostic testing can be nephrotoxic.
(3) Resuming any occupation or hobby involving ex- Fumes may be nephrotoxic and can cause further kidney injury.
posure to chemicals or fumes.
e Avoid contact with products such as antifreeze, pesti- Free radicals associated with these materials increase destruction
cides, carbon tetrachloride, mercuric chloride, lead, ar- of renal tissue.
senic, and creosote.
Assist client and significant others to identify ways in which Allows client control of how he/she will be able to care for self post-
the above-described health care measures can be incorpo- discharge. It will also provide confidence in his/her ability to
rated into lifestyle. care for self.

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THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will develop a plan to adhere

to fluid restrictions and dietary modifications.

Independent Actions
Reinforce the importance of adhering to and following physi- The client should understand the impact of following prescribed
cian’s instructions about fluid restrictions and dietary fluid restrictions and dietary modification as well as the impact
modifications. on the system when the restrictions and modifications are not
followed.
Reinforce dietitian’s instructions on how to calculate and Allows client to determine appropriate meals based on treatment
measure dietary allotments. Have client develop sample regimen.
menus.
If client is on a protein- and sodium-restricted diet, inform Provides client with options for diet and flavoring of foods. Devel-
him/her that numerous salt-free and protein-free products oping a list and a plan to adhere to diet restrictions provides
are available. Provide names of local stores that carry these client some level of control.
products.
Collaborate with client to develop a list of foods they like that
meet the diet restriction requirements.
If client is on a fluid restriction, instruct to:
¢ Take oral medications with soft foods (e.g., applesauce, This allows client to take medications without using liquids.
pudding).
e Reduce thirst by:
e Sucking on sugar-free hard candy, popsicles, or ice Maintains moist oral mucous membranes without fluid volume
cubes made with favorite juices. Rinse oral cavity with excess and decreases thirst. Caution client that the fluid volume
non-alcoholic rinses. of the popsicle and ice cubes must be considered as oral fluid
intake.
e Spacing fluids evenly throughout the hours client is Spacing fluid intake throughout the day helps maintain moist oral
awake. mucous membranes and improves client adherence to fluid
restrictions.
e Set out the 24-hrs allotment of liquids in the morning in Helps client determine when are the best times to drink fluid
order to visualize the amount allowed for the day. allotment.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability to

accurately weigh self, measure fluid I&O, and monitor own BP.

Independent Actions
If client needs to monitor weight, instruct client to weigh at Weight measurements should be performed daily at the same time
the same time, on the same scale, and with similar and under the same conditions for more precise measurements.
amounts of clothing on.
Demonstrate how to measure and record fluid intake and Accurate documentation and monitoring are important to deter-
urinary output if indicated. Stress that any substance mine appropriate amount of fluid intake.
that is liquid at room temperature is counted as fluid
intake.
If client needs to monitor BP, provide instructions on how to Regular monitoring of blood pressure helps prevent hypertension
take, read, and record it. and its deleterious effects on the kidneys.
Allow time for questions, clarification, practice, and return Allowing time for questions, clarification, and return demonstra-
demonstration. Instruct client to take record of weights, tions allows the nurse to evaluate the effectiveness af teaching
fluid intake, urinary output, and BP readings to appoint- and make the appropriate adjustments to the teaching plan. It
ments with health care provider. also improves client’s self-confidence in his/her ability to care
for self and manage disease process.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of infection.
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 667

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client in ways to reduce the risk of infection:
e Avoid contact with persons who have an infection. These actions prevent exposure to individuals who may have an
e Avoid crowds during the flu or cold season. infection or improve the client’s ability to fight infections.
e Decrease or stop smoking. Smoking weakens the immune system and causes irritation of the
e Drink allotted amounts of liquids. mouth and respiratory system.
* Maintain good personal hygiene. Oral hygiene moistens mucous membranes and promotes the pro-
e Maintain a good nutritional status. duction ofsaliva. These help to maintain good oral health.
e Maintain an adequate balance between activity and rest. Required to maintain an adequate functioning immune system.
Sleep deprivation may decrease the production of cytokines in the
immune system.
e Take antimicrobials as prescribed before scheduled dental Prevents infection from normal body flora.
work, invasive diagnostic procedures, or surgery. Dosages may require adjustment based on level of renal injury

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

signs and symptoms that often occur as a result of chronic
“ renal failure.
Independent Actions
Provide instructions regarding ways to manage the following Knowledge of disease process and how to decrease the impact of
signs and symptoms that often occur as a result of chronic risk factors and disease progression helps the client and family
renal failure: understand why lifestyle changes are required to maintain
e Weakness and fatigue health status. This improves client’s adherence to treatment
e Schedule frequent rest periods throughout the day. regimen and allows client to maintain a level of independence
for as long as possible.
Important to conserve energy.
¢ Maintain a good nutritional status. Provides energy for desired activities.
e Dry mouth
e Space fluid allotments evenly throughout waking hours. Dry mouth increases the client’s risk for infection.
e Perform oral hygiene frequently.
e Decreased libido (can occur as a result of weakness, fatigue,
depression, and side effects of some medications)
e Schedule rest periods before and after sexual activity.
e Explore creative ways of expressing sexuality (e.g., mas- May need to plan activities to assure appropriate rest prior to
sage, fantasies, cuddling). activity.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report the following: These clinical manifestations should be reported to the health care
provider and require prompt attention.
° Weight gain of more than 0.5 kg (1 Ib) per day or a contin- This level of weight gain indicates fluid volume excess.
ued weight loss.
e Persistent nausea or vomiting. Persistent nausea and vomiting may indicate changes in serum
electrolyte levels.
e Increasing fatigue or weakness. These clinical manifestations indicate a decreased ability of the
Difficulty concentrating and making decisions. kidneys to remove toxins from the body.
°
e Confusion. Increasing confusion may reflect declining kidney functioning and
reflect increased uremia.
e Persistent or severe headache. Indicates increased B/P or vascular fluid volume.
e Palpitations or chest pain.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Red, rust-colored, or smoky urine; bloody or tarry stools; May indicate infection, anemia, or decreased level of clotting
blood in sputum or vomitus; persistent bleeding from factors.
nose, mouth, or any cut; prolonged or excessive menses;
excessive bruising; or sudden abdominal or back pain.
e Fever or chills. Indicates an infection.
e Numbness or tingling in extremities, persistent restless May indicate anemia and/or changes in electrolyte levels.
feeling in legs during periods of inactivity.
e Change in skin color (e.g., bronze, yellow-gray, brownish May indicate anemia or dialysis-related hemochromatosis.
gray, increased pallor).
e Impotence, infertility, or amenorrhea. Could indicate hormonal imbalances caused by increasing serum
levels of nitrogenous substances.
e Increasing BP. Increasing blood pressure may indicate excess vascular fluid
volume and/or increased sodium levels.
e Swelling of feet, ankles, or hands. Reflects declining ability of the kidneys.
e Shortness of breath.
e Diarrhea or constipation. Diarrhea and/or constipation can occur as a side effect of antacid
therapy; physicians generally recommend alternating antacids
containing magnesium with those containing aluminum or
calcium to prevent these bowel problems.
e Persistent itching. May indicate high plasma calcium levels.
¢ Oral pain or breakdown of oral mucous membrane. Indicates increased uremia.
e Muscle pain or cramping. Decreased serum potassium/magnesium.
e Twitching or seizures. May indicate uremic encephalopathy.
e Joint or bone pain. Could indicate renal osteodystrophy resulting from effects of hypo-
calcemia and hyperphosphatemia.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources that can assist with adjustment to changes resulting
from chronic renal failure.

Independent Actions
Provide information about community resources that can as- Provides for continuum of care and support of the client after
sist the client and significant others to adjust to changes discharge from the acute care facility.
resulting from chronic renal failure (e.g., local chapter of
the American Kidney Association, vocational rehabilita-
tion, social services, counseling services).
Initiate a referral if indicated. May be required for client to receive service or coverage by health
care insurance/Medicare/Medicaid.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended fol-
low-up care including future appointments with health care
provider and medications prescribed.

Independent Actions ‘
Reinforce the importance of keeping follow-up appointments Client should understand that he/she has a chronic illness and
with health care provider. Collaborate with the client to should be monitored by a health care professional to maintain
develop a plan for attendance at follow-up appointments. level ofhealth as long as possible.
 Chapter 12 The Client With Alterations in the Kidney and Urinary Tract 669

THERAPEUTIC INTERVENTIONS RATIONALE

Explain the rationale for, side effects of, and importance of Knowledge of medications and how they impact the system
taking prescribed medications. Inform client of pertinent improves client adherence to treatment regimen and under-
food and drug interactions. standing of the importance of adhering to the prescribed medi-
Reinforce the importance of consulting the appropriate cation regimen. The client must be able to recognize alterations
health care provider (e.g., pharmacist, nurse practitioner, in functioning related to medication administration and what
physician) before taking any prescription and non- clinical manifestations should be reported to the health care
prescription drugs. Explain that: provider.
¢ Some drugs such as ibuprofen, neomycin, and naproxen Nephrotoxic medications hasten the progression of renal failure.
are nephrotoxic and can hasten the progression of renal
failure.
e Some drugs such as aspirin and digoxin are excreted by the Some drugs quickly build up to toxic levels because they are
kidneys and can rapidly build to toxic levels in the body excreted by the kidneys.
(usual dosages may need to be reduced or a different
medication may need to be taken).
e Some drugs contain ingredients that affect electrolyte
balance and elevate BP (e.g., many cold remedies).
Include significant others in explanations and teaching Including significant others in teaching helps them understand
sessions and encourage their involvement in plan how to appropriately support the client and improves adherence
s development. to the treatment regimen.
Reinforce the need to the client to assume responsibility for Improves client’s confidence in ability to care for self and maintain
managing as much of care as possible. independence as long as possible.

ADDITIONAL NURSING DIAGNOSES

ACTIVITY INTOLERANCE NDx IMPAIRED ORAL MUCOUS MEMBRANE NDx

Related to: Related to:
e Inadequate tissue oxygenation associated with anemia re- e Injury to lips and oral mucosa
sulting from: e Bad taste in mouth
e Decreased secretion of erythropoietin as a result of im- e Stomatitis
paired renal function (erythropoietin stimulates the e Lack of saliva
bone marrow to produce RBCs)
e Shortened survival time of RBCs (as renal failure pro- FEAR AND ANXIETY NDx
gresses, the nitrogenous substances in the blood in- Related to:
crease and cause increased hemolysis of RBCs) e Prescribed fluid restriction
e Inadequate nutritional status e Lack of understanding of diagnosis, diagnostic tests, and
treatment plan
RISK FOR CONSTIPATION NDx e Uncertainty as to extensiveness of loss of renal function
Related to: e Anticipated change in health status, lifestyle, and roles as
e Decreased intake of foods high in fiber and fluids associ- a result of progressive loss of renal function
ated with prescribed restrictions e Awareness of probable future need for dialysis or renal
e Decreased GI motility associated with decreased activity transplantation
and the effect of some medications (e.g., those containing e Financial concerns
aluminum or calcium, iron preparations)
GRIEVING NDx
Related to: Progressive loss of kidney function and the effects
of this on lifestyle and roles

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
 CHAPTER

The Client With Alterations

in Musculoskeletal Function

AMPUTATION
An amputation is the surgical removal of all or part of a OUTCOME/DISCHARGE CRITERIA
limb. Amputation of an upper or lower extremity may be
performed to treat conditions such as tumors, uncontrolla- The client will:
ble infection, or gangrene and may be indicated in situa- 1. Maintain pain relief
tions involving tissue destruction resulting from trauma or 2. Have evidence of normal healing of the surgical wound
thermal injury (e.g., frostbite, electrocution, burns). The 3. Achieve expected level of mobility
majority of amputations are performed on the lower ex- 4. Not exhibit signs and symptoms of postoperative compli-
tremities of persons with severe peripheral vascular disease. cations
In these instances, the ischemic limb is removed to prevent 5. Demonstrate ways to prevent contractures, increase
life-threatening infection and/or relieve severe, persistent strength, and improve mobility
discomfort. The location of a limb amputation (e.g., above 6. Demonstrate correct transfer and ambulation techniques
the knee, below the knee) is determined by factors such as and proper use of ambulatory aids
the adequacy of circulation in the involved extremity; the 7. Identify ways to maintain health of the remaining lower
client’s age, general health, anticipated mobility; and the extremity
requirements for proper fit and optimal function of the pros- 8. Demonstrate the ability to care for the residual limb
thetic device. 9. Identify ways to manage phantom limb pain if it occurs
There are two types of surgical amputations performed: 10. State signs and symptoms to report to the health care
open and closed. The open type is performed if the client has provider
an infected limb. The wound is left open with wound treat- 11, Share feelings and thoughts about the change in body
ments applied until the infection resolves. The wound is then image and effects of the amputation on lifestyle and roles
closed during a second surgical procedure. An open amputa- 12. Identify community resources that can assist with home
tion may also be done if the client has a high risk for develop- management and adjustment to changes resulting from
ing a wound or bone infection postoperatively. A closed am- the amputation
putation, which consists of soft tissue flaps sutured over the 13. Develop a plan for adhering to recommended follow-up
bone, is the type of amputation most frequently performed. care including future appointments with health care
The basic techniques for postoperative management of the provider, prosthetist, and physical therapist; medications
residual limb after a closed amputation include use of a soft prescribed; and activity level
compression or rigid dressing. The technique selected depends This care plan focuses on the adult client hospital-
on the client’s underlying disease process and physiological ized for a planned below-the-knee, closed amputation.
status and whether the prosthetic fitting will be immediate, Refer to the preoperative care plan for information
early (usually within 10 to 30 days), or delayed or is not ex- for preparation for surgery. Much of the postoperative
pected to occur (unplanned). information is applicable to clients receiving follow-up
care in an extended care facility or home setting.
‘

Nursing Diagnosis DEFICIENT KNOWLEDGE nox

Definition: Absence of cognitive information related to a specific topic, or its acquisition.

Related to:
e Surgical procedure
e Hospital routines associated with surgery
e Physical preparation for the amputation

670
 Chapter 13 = The Client With Alterations in Musculoskeletal Function 671

e Sensations that may occur after surgery and anesthesia

e Postoperative care and management of the residual limb
e Postoperative activity and exercises

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of concerns about loss of lower limb Inaccurate follow-through of instructions, exaggerated
Questioning about how to live in the future behaviors

RISK FACTORS DESIRED OUTCOMES

e Cognitive limitations
e Unfamiliar with surgical procedure
e Grieving
e Age
e Chronic illness
e Fear of unknown

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; prescribed activity Amputation care; teaching: individual;

teaching: preoperative; teaching: prescribed exercise

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn, meaning of illness to client,
Assess Client’s understanding of scheduled procedure. and understanding of schedule procedure allows for implemen-
Assess meaning of current illness and future changes to client. tation of the appropriate teaching interventions.

NURSING INTERVENTIONS RATIONALE

Independent Actions
Allow time for client to express fear, anxiety, and grief over Allowing client to express concerns and grieve over loss prior to
loss of limb and subsequent lifestyle changes. teaching concerning postoperative care can improve client's abil-
ity to understand and engage in care and surgical preparation.
Assess for understanding of procedure and postoperative plan Provides baseline for patient education.
of care.
Explain that after surgery, the client will experience actual Residual limb pain is pain originating from the site of the ampu-
limb pain and may experience phantom limb sensation. tated limb. It is felt during the early post-amputation period
This type of pain may be described as: and may decrease with wound healing.
e Tingling.
e Throbbing.
e Feeling of pins/needles in the amputated limb.
Provide the following information about postoperative phan- Phantom limb is a sensation that pain felt in the amputated area
tom limb pain, including: of the limb. This pain may reduce in frequency and intensity
e It does not occur in all clients. over time but may persist for several years.
° The type of pain experienced varies from client to client and
can be similar to pain experienced before the amputation
e It may be triggered by pressure on other body areas. The client needs to be assured that the nurse understands about
° Measures will be implemented to provide effective control phantom limb pain, and that all pain will be appropriately
of the pain if it occurs. treated.
Provide instructions on ways to prevent residual limb con- Information about phantom limb pain provides client with a basis
tractures that will be implemented following surgery: for the pain and increases the potential that the client will be
e Avoid sitting for long periods. able to recognize pain and what may cause it and possible
treatments.
e Avoid placing pillows under residual limb.
e Maintain residual limb in proper alignment.

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672 Chapter 13 * The Client With Alterations in Musculoskeletal Function

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NURSING INTERVENTIONS RATIONALE

Inform the client of the need to lie prone several times during Limb contractures can result from prolonged flexion of the knee or
the day prolonged flexion, hyperextension, abduction, adduction, or
external rotation of the hip.
e Perform range-of-motion exercises as instructed Lying prone several times a day promotes hip flexion and decreases
e Assure client that support will be provided to do range- incidence of hip contractures.
of-motion exercises Range of motion exercises helps to maintain muscle strength and
flexibility as well as improving circulation.
Provide the client time for return demonstration in the
following exercises:
e Range-of-motion exercises
e Strengthening exercises for the upper extremities, chest,
residual limb, unaffected lower extremity, and abdominal
muscles.
Assure client that support will be provided to do range- Stressing importance of and demonstrating exercises prior to
of-motion exercises. surgery will decrease anxiety following surgery when client will
be expected to move and complete range-of-motion exercises
which help to reduce incidence of contractures.
Provide instructions regarding:
e Use of overhead trapeze. Proper instruction regarding the use of assistive devices reduces the
e Transfer techniques. risk of further injury. Ability to use supportive devices will allow
e Use of mobility aids (e.g., crutches, cane, walker). client some measure of self-care.
Reinforce the physician’s explanation about the type of pros-
thesis and dressings planned.
If an immediate prosthetic fitting (immediate postoperative Adequate education regarding immediate or delayed prosthetic
prosthesis [IPOP]) is planned, inform client that: fitting enables the client to know what to expect in the post-
e A rigid dressing (plastic or plaster) will be placed on the operative period, reducing the fear of the unknown.
residual stump during surgery, and the pylon (temporary
artificial limb) will attach to the socket on the end of this
dressing.
e In addition to providing a means of securing the pylon,
the rigid dressing will help shape the residual limb, reduce
edema and support tissue in the surgical area, minimize
pain during activity, and promote maturation of the
residual limb.
e Ambulation using the temporary prosthesis usually begins
24-48 hrs after surgery and progresses from walking be-
tween parallel bars to using ambulatory aids such as a
walker, cane, or crutches if needed.
If there are no plans for an immediate prosthetic fitting,
inform client that:
e A soft compression dressing (soft dressing covered by an Ambulatory aids may be needed ifclient’s gait is not steady or only
elastic bandage or sock) will be placed on the residual limb partial weight-bearing is allowed as the surgical area heals.
during surgery.
e The elastic bandage or sock will be reapplied if it slips, The dressing will help reduce edema and support tissue in the
wrinkles, or loosens. surgical area and shape the stump for future prosthetic fitting
¢ Mobility will be accomplished using a wheelchair, walker, if planned.
and/or crutches.
e Fitting for a temporary prosthesis (if planned) will not
occur until after the surgical site has healed (usually 3 to
6 weeks after surgery).
Allow adequate time for client questions and return demon- Helps client to understand although the prosthesis is not immedi-
strations. ately available, it is expected that the client will be out of bed
and moving following surgery. Client may need time to learn
techniques to perform return demonstrations. Allowing client
time to do this helps to decrease anxiety and confidence in
ability to perform required actions following surgery.
 Chapter 13. = The Client With Alterations in Musculoskeletal Function 673

|Nursing 2)
Diagnosis |6ACUTE/CHRONIC PAIN nox
Definition: Acute Pain NDx: Unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow
onset of any intensity from mild to severe with anticipated or predictable end, and with a duration of less than
3 months.
Chronic Pain NDx: Unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow
onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end, and
with a duration of greater than 3 months.

Related to:
e Incisional pain related to tissue trauma and reflex muscle spasms associated with the amputation, irritation from drainage
tube, and stress on surgical area associated with movement
Phantom limb pain related to altered neural transmission associated with interruption in usual nervous system pathways
resulting from the amputation

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of pain in affected limb; verbalization of Restlessness; diaphoresis; increased BP; tachycardia,
phantom pain with and/or reluctance to move or tachypnea, grimacing with movement and guarding
participate in self-care behaviors

RISK FACTORS DESIRED OUTCOMES

e Inadequate pain relief The client will experience diminished pain as evidenced
e Altered mobility/limited mobility by:
e Muscle spasms a. Self-report of decreased pain
e Chronic illness b. Vital signs within normal range for client
e Fear/anxiety c. No guarding actions or grimacing with movement, or
restlessness

NOC OUTCOMES NIC INTERVENTIONS

a ——<—<—— q_—
Pain control; comfort status Pain management; analgesic administration

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of acute/chronic Early recognition of signs and symptoms of acute/chronic pain
pain: allows for prompt intervention.
e Verbal reports of pain
e Restlessness
e Diaphoresis
e Increased BP
e Increased heart rate
e Grimacing with movement

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674 Chapter 13 * The Client With Alterations in Musculoskeletal Function

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NURSING ASSESSMENT RATIONALE

e Guarding actions Assessment of the severity of pain experienced helps determine
e Assess client’s perception of the severity of pain using a most appropriate interventions. Use of a pain intensity rating
pain intensity rating scale scale provides the nurse a clear understanding of the pain being
e Assess client’s pain pattern (e.g., location, onset, quality, experienced and promotes consistency when communicating
duration, aggravating factors) with others.
e Ask client to describe previous pain experience and Knowledge of client’s usual pain response and effective methods
methods that were effective in relieving pain to alleviate pain supports the identification of effective pain
management.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Assess pain using a pain scale including severity, quality, Provides baseline for pain experience and use of a standard tool
intensity, radiation, and onset of new and different pain. improves communication among health care team. Change in
type of pain experienced may indicate developing complications
(e.g., compartment syndrome).
Provide adjuvant methods of acute pain relief: Adjuvant pain relief refocuses attention, and relaxation techniques
e Relaxation techniques (e.g., mindfulness-based stress reduc- help to relax muscles. Use of known coping mechanisms rein-
tion [MBSR]). forces effectiveness and client self-confidence in using them.
e Guided imagery.
e Music/watching TV.
e Support client’s preferred coping mechanisms.
Implement measures to reduce phantom limb pain if it occurs:
e Instruct client to apply pressure on residual limb by walk- Phantom limb pain occurs in approximately 80% of individuals
ing on pylon or pressing limb against a firm surface unless and may occur early in the postoperative period. The client
contraindicated. taught about the syndrome and methods to reduce and cope
e Encourage participation in diversional activities. D > with the pain.
e Reposition limb to decrease excessive pressure on any part
of the body. D +
For chronic phantom limb pain, consider alternative methods
of pain control:
e Acupuncture Phantom pain is a common complication following limb amputa-
e Massage tion. It is thought that phantom pain results from a combina-
e Virtual reality therapy tion of peripheral, spinal, central and psychological factors.
e Mirror box therapy Alternative therapies for this type of pain have been shown to
e Transcutaneous electrical nerve stimulation (TENS) be effective including acupuncture and area massage. The client
should be encouraged to explore what alternative treatments
will help to control pain.

Dependent/Collaborative Actions
Administer medication to decrease pain and phantom pain:
Opioids; NSAIDs, topical, oral, and IV methods of administra- Multiple types of pain medication may be used to provide pain
tion; prevent pain from becoming so severe that it takes a relief. The goal is to maintain pain control and preventing the
long time to provide relief; consider scheduling pain pain to become too severe.
medication administration at set hours for the first 24 hrs
following surgery.
Tricyclic antidepressants Tricyclic antidepressants help to alter the transmission of pain
impulses and/or the client’s perception of pain.
Anticonvulsants Anticonvulsants help to inhibit neurotransmission | of pain
sensation.
Request order for patient-controlled pain analgesia (PCA) Allows client control over administration of pain medication.
Consult appropriate health care provider (e.g., physician, Consultation with the appropriate health care provided can assist
pain management specialist) about use of TENS, biofeed- client improving both short-term and long-term pain control
back, acupuncture, hypnosis, and/or other methods of and relief.
pain control
 Chapter 13 = The Client With Alterations in Musculoskeletal Function 675

Nursing Diagnosis IMPAIRED TISSUE INTEGRITY /RISK FOR IMPAIRED

TISSUE INTEGRITY nox
Definition: Impaired Tissue Integrity NDx: Damage to the mucous membrane, cornea, integumentary system, muscular
fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament: Risk for Impaired Tissue Integrity NDx:
Susceptible to damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon,
bone, cartilage, joint capsule, and/or ligament, which may compromise health.

Related to:
e Disruption of tissue associated with the amputation
e Delayed wound healing associated with factors such as:
e Decreased nutritional status
Decreased blood supply to wound area resulting from the underlying disease process, edema of the residual limb, and/or
excessive or prolonged pressure on operative site (may occur as a result of noncompliance with weight-bearing limita-
tions, improper residual limb wrapping, and/or slippage of the residual limb dressing)
e Irritation of skin associated with contact with wound drainage, pressure from tubings, and use of tape
e Damage to the skin and/or subcutaneous tissue associated with prolonged pressure on tissues, friction, and/or shearing while
mobility is decreased

CLINICAL MANIFESTATIONS
-

Subjective Objective
N/A Increased periwound swelling and redness; pale or
necrotic tissue in wound healing by secondary intention;
separation of wound edges in wounds healing by primary
intention

RISK FACTORS DESIRED OUTCOMES

e Altered mobility The client will:
e Decreased tissue perfusion a. Experience normal healing of the surgical wound
e Altered nutritional status b. Maintain tissue integrity as evidenced by absence of
e Smoking redness and irritation, and no skin breakdown

NOC OUTCOMES NIC INTERVENTIONS

Wound healing: primary intention; wound secondary Wound care; skin surveillance; pressure ulcer care; pressure
intention ulcer prevention; positioning

NURSING ASSESSMENT RATIONALE

Early recognition ofsigns and symptoms of impaired skin integrity
Assess for and report signs and symptoms of impaired skin
integrity: allows for prompt intervention.
e Increased periwound swelling and redness
e Pale or necrotic tissue in wounds healing by secondary or
tertiary intention
° Separation of wound edges in wounds healing by primary
intention
Assess the following for pallor, redness, irritation, and break-
down:
e Skin areas in contact with wound drainage, tape, and tubings
e Back, coccyx, and buttocks
e Elbows and remaining heel

RATIONALE
THERAPEUTIC INTERVENTIONS
Independent Actions
e Elevate limb for the first 24-48 hrs.
Stable vital signs and no changes in strength and intensity of
° Monitor vital signs, palpate pulses, capillary refill.
pulses are indications of perfusion.

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676 Chapter 13 = The Client With Alterations in Musculoskeletal Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Assess neurovascular status of extremities—movement, Changes in skin color, temperature, sensation, and movement may
sensations, color, temperature. indicate any of the following: tissue edema or hematoma at
suture line that may lead to tissue necrosis; circulation to
wound may be decreased if a pressure dressing is applied.
e Monitor dressing (soft pressure wrap or rigid), noting Clients on anticoagulants may have increased bleeding and be at risk
amount and color of drainage. for a hematoma. Increased drainage from the wound may also
require increased fluid intake to maintain cardiovascular status.
¢ Monitor pain status, noting any increase or inability to Hematoma or deep venous thrombosis (DVT) formation may lead
obtain pain relief or sudden changes. to increased pain or sudden changes in pain characteristics.
Implement measures to prevent tissue irritation and break-
down resulting from decreased mobility:
e Assist client to turn at least every 2 hrs unless contraindi- Prolonged and/or excessive pressure on the skin obstructs capillary
cated. D@ + blood flow to that area. The resultant hypoxia, impaired
e Position client properly; use pressure-reducing or pressure- flow of nutrients, and accumulation of waste products in the
relieving devices (e.g., pillows, gel or foam cushions, alter- area of obstructed flow make that tissue more susceptible to
nating pressure mattress, kinetic bed, air-fluidized bed) if breakdown.
indicated. D@ +
e Instruct client to use overhead trapeze to lift self and shift Measures that prevent excessive pressure or ensure that pressure is
weight at least every 30 minutes. relieved often enough to avoid obstruction of capillary blood
e Lift and move client carefully using a turn sheet and flow help maintain skin integrity.
adequate assistance.
Keep bed linens dry and wrinkle-free. D @ +
e Apply a protective covering such as a hydrocolloid or Prevents maceration and decreases potential breakdown when
transparent membrane dressing to areas of the skin suscep- client is on bedrest.
tible to breakdown (e.g., coccyx, heel, elbows). Reduces the risk of pressure ulcers over bony prominences or depen-
dent areas.
e Encourage early range-of-motion exercises and ambulation. Improves circulation and complications associated with prolonged
bedrest. Improves client’s self-confidence in ability to ambulate
post amputation.
e Monitor client’s nutritional status. D@ + Adequate nutritional status promotes wound healing.
e Encourage fluid intake. D@ + Maintenance of vascular fluid volume is required to provide
adequate circulation.

Dependent/Collaborative Actions
e Maintain intravenous fluid or blood products as ordered. Supports vascular fluid volume to maintain adequate circulatory status.
e Apply antiembolic hose or sequential compression device Supports venous return to the heart and prevention of DVT.
on nonoperative limb.
e Administer anticoagulants if ordered. Prevention of DVT and hematoma formation.
Monitor laboratory values:
e Hemoglobin and hematocrit. An increased H & H may indicate dehydration, which impairs
tissue perfusion.
If tissue integrity changes:
e Notify appropriate health care provider (e.g., wound care Allows for prompt revision in treatment regimen.
specialist, physician).

|Nursing »Diagnosis
«IMPAIRED| PHYSICAL MOBILITY nox
‘
Definition: Limitation in independent, purposeful movement of the body or of one or more extremities.

Related to:
e Surgical procedure - below-knee amputation
e Insufficient muscle strength and/or nutritional status
e Insufficient understanding of how to use adaptive equipment
e Changes in sense of balance
e Sedentary lifestyle
e Pain
e Reluctance to initiate movement
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 677

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of inability to perform range-of-motion Lack of engagement in activities of daily living (ADLs),
exercises; fear of falling refusal to participate in range-of-motion activities or
ambulation with or without support

RISK FACTORS DESIRED OUTCOMES

e Trauma
The client will demonstrate adequate status as evidenced
e Surgery
by:
e Nutritional status
. Participation in ADLs as able
e Lack of interest
. Begin ambulation with assistance as ordered
. Perform range-of-motion and/or resistance exercises
iY . Demonstration and use of adaptive equipment (e.g.,
(er
(ey
fan
wheelchair, prosthesis, crutches, walker)

NOC OUTCOMES NIC INTERVENTIONS

Ambulation; exercise participation; knowledge of body Exercise therapy: ambulation, balance, muscle control; self-
mechanics: performance; self-care: ADLs care: ADLs; body mechanics: positioning and strengthening

NURSING ASSESSMENT RATIONALE

e Assess client’s ability and activity tolerance Provides understanding of client’s ability and desire to participate
e Assess client’s understanding on how to do range-of- in self-care and to enhance mobility.
motion and resistance exercises
e Assess client’s desire and motivation to maintain physical Determine client’s acceptance of permanent physical changes and
mobility subsequent limitations.
e Assess client’s muscle strength and ability to use adaptive Determine client’s ability to use assistive devices; provides a
equipment baseline for further education.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
e Demonstrate and encourage client to participate in range- Inactivity contributes to muscle weakness and positional skin
of-motion, resistance, and isometric exercises for affected breakdown. If mobility is impaired, contractures can develop and
and unaffected limb. D@ + will limit client’s ability to maintain self-care, mobility, and
independence. Resistance and isometric exercises maintain
and enhance muscle strength.
° Assist client in prone positioning at least 2 to 3 times/day, Helps to prevent hip contractures and skin injury if client is on
providing support for affected limb. D @ + bedrest.
e Assist client in ADLs, allowing client to do as much self- Improves client self-confidence in ability to care for self. Provides
care as possible. D@ > the nurse time to assess if more support or teaching ofappropri-
ate techniques is required.
e Teach client transfer techniques from bed to wheel chair, Ambulation and moving out ofbed improve circulation and muscle
bed to chair, and how to support affected limb; use of strength. Improves client self-confidence in ability to maintain
crutches, walker, and other assistive devices. independence. Appropriate use of assistive devices prevents con-
tractures and improves confidence in ability to care for self.
Required to maintain muscle strength and wound healing.
e Provide appropriate nutrition and calorie intake. De+¢+

Dependent/Collaborative Actions
Provides a collaborative approach to client care.
Collaborate with and consult appropriate health care
provider to support client learning, abilities, and level of
independence (rehabilitation, prosthesis fitting, physical
therapy, etc.).

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678 Chapter 13. = The Client With Alterations in Musculoskeletal Function

|Nursing =>
Diagnosis RISK FOR SURGICAL SITE INFECTION nox

Definition: Susceptible to invasion of pathogenic organisms at surgical site, which may compromise health.

Related to:
e Surgical procedure
e Inadequate primary defenses
e Environmental exposure to pathogens—hospitalization
e General anesthesia

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of chills, loss of energy, fatigue Elevated temperature; increased heart rate; adventitious
lung sounds, positive cultures;
Increased WBC and differential; heat, swelling, and/or
drainage from wound

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will remain free of infection as evidenced by:
e Chronic illness
. Absence of fever and chills
e Malnutrition
. Pulse rate within normal limits for client
e Obesity
. Usual mental status
. Normal breath sounds
. Free of productive cough
Oo
©
&
AO
ae. Absence of heat, pain, redness, or swelling from surgi-
cal wound or any other area
g. WBC within normal limits
h. Negative results of culture specimens

NOC OUTCOMES NIC INTERVENTIONS

Wound healing: primary intention; secondary intention; Infection control; wound care nutrition management
infection status: infection severity

NURSING ASSESSMENT RATIONALE

Assess and report signs and symptoms of infection: Early recognition of signs and symptoms of infection allows for
e Elevated temperature prompt intervention.
e Chills and fever
Increased heart rate
e Malaise, lethargy, confusion
e Loss of appetite
e Adventitious breath sounds
e Productive cough with purulent sputum
e Cloudy urine
e Elevated WBC count with changes in differential Changes in WBC’s may indicate an infection.
e Obtain culture specimens; report positive results Culture results identify the specific organism(s) causing the
infection. Culture and sensitivity results provide inkormation
that helps determine the most effective intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

ie rts hn eee ee Te en ee ee
Independent Actions
e Monitor vital signs. Monitor changes over time that may indicate infection.
e Maintain good hand hygiene and teach client to do the same. Hand hygiene is important in preventing infections.
e Monitor surgical site. Note wound healing and any changes that indicate an infection—
redness, swelling, increased temperature and drainage.
 Chapter 13. ® The Client With Alterations in Musculoskeletal Function 679

THERAPEUTIC INTERVENTIONS RATIONALE

e Change dressings using aseptic techniques. Prevents cross-contamination and prevents introduction of new
bacteria.
e Encourage fluid intake and provide adequate nutrition. Hydration maintains adequate tissue perfusion. Supports mainte-
De+ nance of immune system and supports wound healing.
e Use sterile techniques during invasive procedures. Reduces the possibly of introducing pathogens into the body.
e Change dressings, IV sites, and line tubing as ordered and The longer equipment, tubing, and solutions are in use, the greater
per hospital policy. the chance of colonization of microorganisms, which can be
introduced into the body.
e Protect client from others with infection. Reduces exposure to new pathogens.
e Encourage client to turn, cough, deep breath, and use Prevents skin breakdown, promotes movement and excretion of
incentive spirometry at regular intervals. secretions.

Dependent/Collaborative Actions
e Obtain culture and sensitivity of wound, drainage, urine, Allows for prompt and appropriate intervention for infection.
or sputum as ordered.
e Administer/increase IV fluids as ordered. Hydration supports vascular fluid volume and nutrient supply to
tissues; promotes urine formation and voiding, flushing out
system.
.° Administer antibiotics as ordered. Sensitivity obtained with specimen culture identifies the most
effective antibiotic to use. A broad-spectrum antibiotic may be
ordered until sensitivity results are obtained.

|Nursing ~Diagnosis DISTURBED BODY IMAGE nox

Definition: Confusion in mental picture of one’s physical self.

Related to:
e Alteration in body function
e Surgical procedure
e Alteration in self-perception

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of loss; negative self concept; fear of Uninvolved in care; not looking at or touching residual
others’ reactions limb; refusal to discuss loss

RISK FACTORS DESIRED OUTCOMES

peal
Siesta yiet) ee
e Culture The client will have improving body image as evidenced
e Surgery by:
e Lack of social support a. Verbalization of acceptance of self with change in
e Depression physical body
. Verbalization of feelings of self-worth
. Maintenance of relationship with others
. Involvement in self-care activities
@ . Engagement and understanding of lifestyle changes
Aiwa:
required due to amputation
= Appropriate use adaptive devices or prostheses

NOC OUTCOMES NIC INTERVENTIONS

Body image; health status; amputation care Body image enhancement; amputation care: engagement,
health status: acceptance; self-esteem: enhancement

@=UAP + =LVN/LPN ©) = Go to ©volve for animation

NDx = NANDA Diagnosis |D = Delegatable Action
680 Chapter 13 = The Client With Alterations in Musculoskeletal Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of disturbed body Early recognition of signs and symptoms of disturbed body image
image: allows for prompt intervention.
e Verbalization of negative feelings about self
e Withdrawal from significant others
e Lack of participation in ADLs
e Refusal to look at or touch the residual limb
e Lack of plan for adapting to necessary changes in lifestyle

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
e Allow client to express feelings of loss and change in self- Demonstrates acceptance of client and their physical changes.
image. Helps in developing a trusting therapeutic relationship.
e Stay with client during the first dressing change to provide Provides support to client, shows acceptance, and gives the client
support as the client views the residual limb for the first an opportunity to ask questions while viewing the residual limb.
time.
e Discuss with client the availability of a natural-looking
prosthesis.
e Clarify misconceptions about future limitations on physi- A change in appearance can initiate a grieving response and change
cal activity. Emphasize that a high level of mobility can be in self-image. Successful resolution of grief assists the client to
achieved with a prosthesis in place and/or use of crutches, accept changes and experience and integrate the changes into
walker, or cane. self-image.
e Encourage client’s participation in activities that can assist Activities that help clients acknowledge and deal with the changes
in the integration of the physical changes that have that have occurred in their body facilitate the incorporation of
occurred (e.g., exercise, bathing, wrapping residual limb). changes into the brain’s schemata of the body.
Provide assistance as needed.
e Demonstrate acceptance of client using techniques such as Frequent visits and the use of touch convey a feeling of acceptance
touch and frequent visits. to the client. This enhances feelings of self-worth and assists in
e Encourage significant others to do the same. the development of a positive self-esteem and body image.
e Avoid referring to the residual limb as a “stump” unless
that is a term the client prefers.
e Support behaviors suggesting positive adaptation to the Supporting behaviors indicative of positive adaptation to change
amputation (e.g., willingness to care for residual limb, encourages the client to repeat these behaviors. Repetition of
compliance with treatment plan, verbalization of feelings positive adaptive behaviors facilitates the development of a
of self-worth, maintenance of relationships with signifi- positive self-esteem and body image.
cant others).
e Encourage significant others to allow client to do what he/ Allowing clients to do as much as they are able facilitates the
she is able so that independence can be re-established and/ re-establishment of independence, which enhances feelings of
or self-esteem redeveloped. self-esteem.
e Encourage client to have contact with others so that client
can test and establish a new self-image.
e Assist client’s and significant others’ adjustment by listening, Allows client to see how others react to them and helps to develop
facilitating communication, and providing information. new Self-image.
e Assist client and significant others to have similar expecta- Enhances relationships and provides emotional support.
tions and understanding of future lifestyle and to identify
ways that personal and family goals can be adjusted rather
than abandoned.
e Encourage visits and support from significant others. Assures client and significant others have the same understanding
and are working toward the same goals. Helps to decrease future
conflict and frustration.
e Encourage client to continue involvement in social activi- Enhances relationships and provides emotional support.
ties and to pursue usual roles and interests. If previous Shows that some aspects of life will remain the same. Enhances
roles, interests, and hobbies cannot be pursued, encourage self-esteem in that not all aspects of life have changed.
development of new ones.
e If acceptable to client, arrange for a visit with an individ- Helps client understand that they are not alone. Allows for client
ual who has successfully adjusted to the loss of a limb. to ask questions and what mechanisms/adaptive techniques are
effective.
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THERAPEUTIC INTERVENTIONS RATIONALE

e Provide information about and encourage utilization of Community agencies and support groups provide the opportunity
community agencies and support groups (e.g., National for clients to see that they are not experiencing a unique prob-
Amputation Foundation; vocational rehabilitation; family, lem, to share feelings and concerns, to profit from the experience
individual, and/or financial counseling). of others with similar difficulties, and to learn new skills neces-
sary to rebuild self-esteem. All these factors help the client to
establish a positive self-concept, body image, and self-esteem.

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., psychiatric Consulting the appropriate health care provider allows for modifi-
nurse clinician, social worker, physical therapist physi- cation of the treatment plan.
cian) if client seems unwilling or unable to adapt to
changes resulting from the amputation.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH MANAGEMENT

px: INEFFECTIVE FAMILY HEALTH MANAGEMENT nox*
Definition: Deficit Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic regimen
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals; Ineffective
Family Health Management NDX: A pattern of regulating and integrating into family processes a program for the
treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit.

Related to:
e Insufficient knowledge of therapeutic regimen
e Changes in health status
¢ Loss of limb
e Inability to manage treatment regimen
e Family conflict

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalizes inability to manage illness, verbalizes inability Inaccurate follow-through of instructions, inappropriate/
to follow prescribed treatment regimen exaggerated behaviors

RISK FACTORS DESIRED OUTCOME

Se ee
e Grieving The client will demonstrate appropriate wound care and
° Loss of self-esteem ways to prevent contractures, increase strength, and
e Lack of desire to improve health status improve mobility.
¢ Cognitive deficit
¢ Inability to care for oneself
° Difficulty integrating treatment into lifestyle and family
processes
e Economically disadvantaged

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: fall prevention; prescribed activity; treatment Health system guidance; teaching: individual; teaching:
regimen prescribed activity/exercise

discharge teaching needs.

*The nurse should select the nursing diagnostic label that is most appropriate for the client’s

D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation

NDx = NANDA Diagnosis
682 Chapter 13 * The Client With Alterations in Musculoskeletal Function

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to client
Assess meaning of illness to client. allows for implementation of the appropriate teaching interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client in the following ways to prevent contractures,
increase strength, and/or improve mobility:
Performing range-of-motion exercises of residual limb and Inactivity contributes to muscle weakening. Contractures can
other extremities. develop as early as & hrs of immobility. Actions help to main-
Require client to provide return demonstration range-of- tain and increase client’s strength and ability to move.
motion exercises of residual limb and other extremities.
Lying prone several times a day with pillow under Lying prone several times a day promotes hip flexion and decreases
abdomen and residual limb. incidence of hip contractures. Improves lower body muscle tone
and promotes improved balance when using prosthesis.
Performing knee bends, standing on toes, balancing Facilitates use of ambulatory aids and increases upper body
on the unaffected leg without support, and performing strength to support movement.
quadriceps- and gluteal-setting exercises.
Performing pushups, flexion and extension of arms
holding weights, and arm pulley exercises.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate correct

transfer and ambulation techniques and proper use of ambu-
latory aids.

Independent Actions
e Reinforce instructions about correct transfer and ambula- Ensuring the client’s understanding of the use of assistive
tion techniques, amount of weight-bearing allowed, and devices reduces the risk of additional injury. Allow time for
proper use of ambulatory aids (e.g., crutches, walker, questions and return demonstration to assess the need for
cane). further instruction.
Allow time for client to demonstrate ability to use ambula-
tory aids.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to main-

tain health of the remaining lower extremity.

Independent Actions
Instruct client in ways to maintain health of the remaining
lower extremity:
Wear a well-fitting shoe to protect foot from pressure and Shoes should be modified by an orthopedist to ensure that body
trauma. weight is evenly distributed when prosthesis is used.
Perform foot and nail care using appropriate technique. Helps to prevent infection and skin breakdown.
Avoid breaks in the skin to reduce risk of infection. Client should be taught to monitor feet skin and nails to note when skin
changes occur and notify the appropriate health care individul.
Stop smoking. Smoking causes vasoconstriction, which reduces hood flow,
compromising oxygen and nutrient delivery to tissues.
Avoid sitting with legs crossed and wearing socks, stock- Helps to reduce the risk of compromising peripheral blood flow.
ings, or garters that are tight.
Adhere to regular follow-up care if diabetes or peripheral vas- Helps prevent further loss of viable tissue and potential further loss
cular disease was a factor leading to the need for amputation. of extremity.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to care for the residual limb.
 Chapter 13 » The Client With Alterations in Musculoskeletal Function 683

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct client in ways to care for the residual limb while
dressing is in place:
If client has a soft compression dressing (soft dressing covered
by an elastic bandage or sock) over the residual limb:
e Demonstrate the technique for rewrapping or changing Action should be performed routinely during the day and if the
the elastic bandage or sock. dressing slips or the elastic bandage or sock becomes soiled or
wrinkled.
e Demonstrate and allow for return demonstration of the Improves client’s self-confidence in self-care and allows nurse to
technique for changing the dressing if client is expected to make any corrections to technique prior to discharge.
do this after discharge.
If client has a rigid dressing over the residual limb:
e Stress the importance of removing the pylon when in bed.
e Explain that the dressing should be positioned securely be- Reduces the risk of twisting the residual limb.
fore applying the pylon (a belt may be needed to maintain
the proper position of the rigid dressing during ambulation).
* Caution client to adhere to weight-bearing restrictions Careful positioning prevents injury to residual limb and prevents
until the surgical area heals completely. irritation or discomfort when ambulating.
e Require return demonstration of technique. Allows complete healing of the surgical site and decreases potential
for injury.
Inform client about expected care of the residual limb once Improves client’s self-confidence in self-care and allows nurse to
the dressings are no longer needed: make any corrections to technique prior to discharge.
e The limb will need to be inspected daily using a hand It is important to monitor suture line for changes and surrounding
mirror if necessary. skin for injury or infection.
e The residual limb will need to be washed and patted dry Prevents irritation when bathing and potential for skin injury.
daily. Moist skin provides potential for infection and skin breakdown.
e Emollients and powders should not be applied to the Prevents potential for infection or irritation.
residual limb.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize how to care for

the prosthesis and residual limb if a permanent prosthesis is
planned.

Independent Actions
Provide the client with information about anticipated care of
the prosthesis and residual limb if a permanent prosthesis
is planned:
e After the incision heals, the residual limb should be tough- A toughened limb is more resistant to irritation and breakdown
ened by massaging it, pushing it against a firm surface, from the constant pressure exerted on it by the prosthesis
and/or pulling on it with a hand-held towel.
e A residual limb sock should be worn next to the skin. Helps to reduce friction between residual limb and the socket.
e Only residual limb socks recommended by the prosthetist Actions help to prevent skin injury, irritation, and infection.
should be used; socks should be changed daily, laundered
gently in cool water with a mild soap, and laid flat to dry.
Replace worn or damaged residual limb socks. They should Area ofmending will cause irritation, breakdown and potential for
not be mended. infection.
° A prosthetist should examine the prosthesis on a regular Assures appropriate fit and decreases potential for further injury
basis and monitor the fit of the socket so that repairs and or falls.
adjustments can be made when necessary (e.g., as the re-
sidual limb continues to shrink, if a weight loss or gain of
5 to 10 Ibs occurs).
e The socket should be cleansed daily with a damp cloth and
dried thoroughly.
e Care should be taken to keep the leather or metal compo-
nents of the prosthesis dry.

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684 Chapter 13 * The Client With Alterations in Musculoskeletal Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Shoes worn with the prosthesis should be kept in good repair. Helps to prevent skin breakdown and potential for infection.
e If skin breakdown occurs, the prosthesis should not be Shoes should remain in good repair help to maintain a steady, even
worn until the area has been checked by the physician gait, prevent injury from a fall, and to avoid damage to the
and/or prosthetist. prosthesis.
e The prosthesis should be applied on arising and worn for Pressure from prosthesis prevents residual limb edema.
the prescribed length of time.
e An elastic sock may need to be worn over the residual limb The sock helps prevent development of edema in the residual limb
whenever the prosthesis is removed. and subsequent difficulty in reapplication of the prosthesis.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

phantom limb pain if it occurs.

Independent Actions
Instruct client in ways to manage phantom limb pain if it Educating the client regarding varying pain management modali-
occurs: ties provides the client with options for a choice of treatment
e Apply intermittent pressure to residual limb by walking on that best meets individualized pain management needs.
pylon or pressing the limb against a firm surface.
e Participate in diversional activities, watching TV, listening Diversional activities help to refocus client’s attention.
to music
e Take medications as prescribed. Many of these interventions decrease muscle tension and can be
e Encourage client to consult appropriate health care pro- used independent or as adjuvant to medications for pain relief.
vider about the use of therapies such as TENS, biofeedback,
acupuncture, guided imagery mindfulness-based stress
reduction (MBSR), and hypnosis to assist in pain control if
indicated.
e Reassure client that phantom limb pain usually disap- Client should be made aware that phantom limb pain can change
pears, but caution that it may take months to years. over time. Pain is a subjective experience and the time frame for
phantom pain to disappear is very individualized.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms:
e Development of and/or persistent phantom limb pain Educating the client regarding signs and symptoms to report to the
e Persistent or increased residual limb swelling health care provider allows for implementing appropriate
e Difficulty with full extension of residual limb interventions, altering the plan of care, and reducing the risk of
potential complications.
e Inability to maintain balance May require more physical therapy for muscle strengthening.
e Change in color of residual limb (e.g., pallor, cyanosis, May indicate a clot causing decreased circulation.
duskiness)
e Persistent slippage or increased tightness of elastic ban- Requires further evaluation to assure proper prosthesis fit.
dage or sock
e Loosening of rigid dressing
e Drainage from the wound Should be reported immediately, as these symptoms nhay indicate
e Experience of chills, fever an infection.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources that can assist with home management and adjust-
ment to changes resulting from the amputation.
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 685

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Provide information about community resources that can as- Social support can aid the client in obtaining necessary resources to
sist the client and significant others with home manage- adapt to physical changes and obtain the necessary long-term
ment and adjustment to changes resulting from the ampu- assistance to maintain independence.
tation (e.g., home health agency; social services; individual,
family, and occupational counseling; amputee support
groups; National Amputation Foundation).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, prosthetist, and physical therapist; medications
prescribed; and activity level.

Independent Actions
Emphasize the importance of adhering to prescribed weight- Adherence to a plan of care reduces the risk of complications.
. bearing restrictions and exercise program. Attendance at follow-up appointments allows health care
providers ongoing assessment and evaluation, and allows for
modification of treatment regimen as required.
Collaborate with client in developing a plan for follow-up Provides the client a sense of control in relation to their life and
appointments, schedule for exercises, list of medications, how they can assure adherence with treatment regimen.
exercises, and side effects to monitor.

ADDITIONAL NURSING DIAGNOSIS

RISK FOR FALLS NDx e Difficulty with balance, prosthesis control, and transfer
Related to: and ambulation techniques
e Weakness and fatigue
e Dizziness or syncope associated with postural hypotension GRIEVING NDx
resulting from peripheral pooling of blood and blood loss Related to:
during surgery e Loss of a limb
e Central nervous system (CNS) depressant effect of some e Changes in body image and usual lifestyle and roles
medications (e.g., narcotic [opioid] analgesics)

FRACTURE (HIP) WITH INTERNAL FIXATION

OR PROSTHESIS INSERTION
p A fractured hip is the term used to describe a fracture of femur osteoporosis and falls in the elderly population. Although a
close to the hip bone. Hip fractures are classified according to the fractured hip can be treated by traction, the preferred treat-
specific location of the fracture. A common Classification system ment is surgery because it allows earlier mobility.
divides hip fractures into three types: femoral neck fractures (also Surgery involves insertion of a femoral head prosthesis or
referred to as proximal or intracapsular fractures), intertrochan- reduction and internal fixation of the fracture with an intra-
teric fractures, and subtrochanteric fractures (the latter two types medullary fixation device, cannulated screws, or a dynamic
are sometimes referred to as extracapsular fractures). compression hip screw with a plate assembly. Internal fixa-
A fractured hip is one of the most common orthopedic tion with preservation of the femoral head is the preferred
injuries in the elderly related to the increased incidence of treatment for hip fractures, but the femoral head and neck

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
686 Chapter 13 The Client With Alterations in Musculoskeletal Function

can be replaced with a prosthetic device (e.g., Austin Moore 4. Have adequate fracture reduction and healing
prosthesis) if an intracapsular fracture has occurred and fac- n . Maintain hip pain controlled

tors are present that increase the risk for avascular necrosis 6. Have no signs and symptoms of infection or postopera-
and/or nonunion. Ideally, surgery is performed within 12 to tive complications
24 hrs after the injury, especially if the client has a 7. Demonstrate correct transfer and ambulation techniques
displaced femoral neck. During the preoperative period, trac- and proper use of ambulatory aids
tion is usually applied to stabilize and reduce the fracture and 8. Demonstrate the ability to correctly perform the
reduce muscle spasms and pain. prescribed exercises
This care plan focuses on the elderly adult client 9. Verbalize an understanding of activity and position
who is hospitalized for surgical repair of a hip frac- restrictions necessary to prevent dislocation of the pros-
ture. Much of the postoperative information is appli- thesis or internal fixation device
cable to clients receiving follow-up care in an extended 10. Identify ways to reduce the risk of falls in the home
care facility or home. environment
11. State signs and symptoms to report to the health care
provider
OUTCOME/DISCHARGE CRITERIA 12. Identify community resources that can assist with home
management and provide transportation
The client will: 13. Develop a plan for adhering to recommended follow-up
1. Show evidence of normal healing of the surgical wound care including future appointments with health care
2. Maintain clear, audible breath sounds throughout lungs provider and physical therapist, medications prescribed,
3. Maintain expected level of mobility activity level, and wound care

PREOPERATIVE CARE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE

CARE PLAN

PREOPERATIVE NURSING/COLLABORATIVE DIAGNOSIS

“Nursing Diagnosls ACUTE PAIN NDx

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Related to:
e Fracture of the bone
e Tissue trauma
e Muscle spasm

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of pain Grimacing; reluctance to move; clutching hip/thigh;
restlessness; diaphoresis; increased BP; tachycardia,
tachypnea

RISK FACTORS DESIRED OUTCOMES

e Trauma
The client will experience diminished hip pain as evi-
e Dislocation
denced by: ry
e Fractures a. Verbalization of a reduction in pain
e Muscle spasms
b. Relaxed facial expression and body positioning
e Stress and anxiety c. Stable vital signs
d. Respiratory rate within normal limits

NOC OUTCOMES NIC INTERVENTIONS

Comfort level; pain control Analgesic administration; pain management: acute
environmental management; calming technique
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NURSING ASSESSMENT _ er ee
RATIONALE
ee ee ee eee eee eee
(a

Assess for and report signs and symptoms of pain Early recognition of signs and symptoms of acute hip pain allows
e Verbalization of pain for prompt intervention.
° Grimacing, clutching hip, diaphoresis, increased BP, tachycardia
Assess the client’s pain using a standardized pain scale and Use of a pain intensity rating scale gives the nurse a clearer under-
pain location, quality, onset, duration, precipitating fac- standing of the client’s pain being experienced, changes in pain
tors, aggravating factors, alleviating factors over time, and promotes consistency when communicating with
others.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain:
e Perform actions to reduce fear and anxiety about the pain Promotes relaxation and subsequently increases the client’s
experience: threshold and tolerance for pain.
e Assure client that the need for pain relief is understood; Collaboration provides client some method of control over care.
plan methods for achieving pain control with client.
D+
e Perform actions to reduce fear and anxiety: D @ +
e Reduce environmental stimulation.
e Provide explanation prior to procedures. Having client focus on something other than pain. Understanding
e Maintains a calm, supportive demeanor. what will occur will help to decrease client’s anxiety,
e Perform actions to promote rest: Actions help to reduce fatigue and subsequently increase the
e Minimize environmental activity and noise. D @ + client’s threshold and tolerance for pain.
e Limit the number of visitors and their length of stay. Too much activity and noise may be stressful for the client. The
nurse should collaborate with the client to determine the num-
ber and frequency of visitors.
Provide or assist with additional nonpharmacological mea-
sures for pain relief.
e Relaxation exercises (e.g., guided imagery, progressive Relaxes muscle tension and decreases anxiety. Strengthens or
relaxation, MBSR) provides for new coping mechanisms.
e Diversional activities such as watching television, reading, Distraction techniques refocus client on something other than pain.
listening to music or conversing D @ +

Dependent/Collaborative Actions
Implement measures to reduce pain:
e Administer analgesics and muscle relaxants if ordered Administering analgesics before activities and procedures that can
(Opioids: morphine; NSAIDS: ketorolac; muscle relaxants: cause pain and before pain becomes severe improves mobility.
cyclobenzaprine). Ketorolac is effective in treating pain with fewer side effects.
e Provide medication at regular intervals. Pain medication provided at regular intervals decreases incidence
e Request a PCA administration of medications. of episodes of severe pain Providing PCA pain administration
allows client control over pain relief.
e Perform actions to maintain effective traction on the Client is usually placed in Buck’s traction preoperatively to stabi-
injured extremity. lize and reduce the fracture and reduce muscle spasms and
e Ensure that weights are hanging freely. pain.
¢ Do not allow footplate or ropes to rest on end of bed. Traction is not maintained when the weights are not hanging
freely, the footplates or ropes are resting on the bed, or the rope
knots are on the pulley. Muscle spasms can occur when traction
is not maintained.
° Keep affected heel off bed. Protect the heel from skin breakdown.
e Keep knots away from pulley device.
¢ Do not remove traction unless specifically ordered. Maintenance of traction on affected side also can decrease
experience of pain.
¢ Do not lift the weights in order to facilitate moving the This reduces traction force and can cause severe muscle spasms.
client or performing other care.
e Limit head of bed elevation to 20 to 25 degrees except for Actions help to maintain the prescribed traction force.
meals and toileting. D@ +
e Place a trochanter roll or sandbag firmly against the lateral Trochanter rolls/sandbags help to maintain leg in proper alignment.
aspect of injured hip and upper thigh (should extend from
iliac crest to mid-thigh).

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©) = Goto ©volve for animation
688 Chapter 13 = The Client With Alterations in Musculoskeletal Function

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THERAPEUTIC INTERVENTIONS RATIONALE

e Consult physician if extremity appears out of alignment; An attempt to realign the extremity may cause further tissue
do not attempt to realign extremity. trauma.
° Move client carefully, keeping injured extremity well Prevents further injury; decreases client pain and anxiety when
supported. D@ + moving.
If turning is allowed, place pillow between legs before In order to prevent adduction and further strain on the fracture site.
turning. D ®+
Consult appropriate health care provider if above measures Notifving the appropriate health care provider allows for modifica-
fail to provide adequate pain relief: tion of the treatment plan.
e Physician, pharmacist.
e Pain management specialist.

>
Diagnosis
|Nursing >. RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION nox
(FRACTURED EXTREMITY)
Definition: Susceptible to disruption in the circulation, sensation, and motion of an extremity, which may compromise
health.

Related to:
e Trauma to or excessive pressure on the nerves or blood vessels as a result of the injury
e Displaced bone fragments
e Blood accumulation and edema at fracture site
e Improper alignment, application of skin traction device, or traction on the injured extremity
e Fear and anxiety

CLINICAL MANIFESTATIONS (IF NEUROVASCULAR DYSFUNCTION OCCURS)

Subjective Objective
Self-report of numbness or tingling in leg or foot; increased Diminished or absent pedal pulses; capillary refill time
pain in extremity or buttock in toes greater than 2 to 3 seconds; pallor, cyanosis, or
coolness of the extremity; inability to flex or extend foot
or toes

RISK FACTORS DESIRED OUTCOMES

e Immobilization The client will maintain normal neurovascular function in
e Fracture the injured extremity as evidenced by:
e Mechanical compression . Palpable pedal pulses
e Vascular obstruction . Capillary refill time in toes less than 2 to 3 seconds
e Chronic illness . Extremity warm and usual color
. Ability to flex and extend foot and toes
Absence of numbness and tingling in leg and foot
2 . No increase in pain in extremity or buttock
ST
moan

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: peripheral neurological status Circulatory care: arterial insufficiency; circulatory care:
venous insufficiency; positioning; lower extremity monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of neurovascular Early recognition of signs and symptoms of neurovascular
dysfunction in the injured extremity: dysfunction allows for prompt intervention.
Numbness or tingling in leg or foot
Increased pain in extremity or buttock
Diminished or absent pedal pulses
Capillary refill time in toes greater than 2 to 3 seconds
Pallor, cyanosis, or coolness of the extremity
Inability to flex or extend foot or toes
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 689

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Assess affected limb, compare findings to noninjured limb,
document and report changes.
Assessment of the 6 P’s is appropriate for any type of fracture:
° Pain: Assess using a pain scale including severity, quality, An increase in pain or inability to control pain with medication
intensity, radiation, and onset of new and different pain. and increased pain experienced with passive stretching may
indicate compartment syndrome.
° Pulses: Monitor and document pulses distal to the injury. Change in pulses within injured limb and differences noted
Use a rating scale for intensity of palpable pulses. between injured and noninjured limb may indicate changes in
blood flow distal to the injury.
e Paresthesia: Assess sensations proximal and distal to the Decreased feeling or “pins and needles” feeling report by client may
site injury using light touch to the skin. Ask client about indicate nerve damage and indicate compartment syndrome.
changes in sensation. Report any “pins and needles”
feelings.
e Pallor: Assess capillary refill, color, and warmth distal to Irreversible damage may occur if not resolved.
the injury. Track findings over time and report any decline Decreasing color, capillary refill time, and warmth to the extremity
in findings. indicate arterial insufficiency and should receive immediate
intervention.
* Paralysis: Ask client to dorsiflex or plantar flex the foot. Decreased movement or no movement is indicative of compartment
Note: decreases in movement or inability to perform. syndrome and requires timely intervention.
e Pressure or edema: Assess for changes in firmness or Edema or increased tightness of the skin correlates with increased
swelling of the extremity distal to the injury. internal pressure on the muscles and tissues and indicative of
compromised circulation distal to site of injury.
Implement measures to prevent neurovascular dysfunction in
injured extremity:
e Place a trochanter roll or sandbag firmly against lateral Proper positioning is required to maintain appropriate traction
aspect of injured hip and upper thigh (should extend from tension.
the iliac crest to mid-thigh). D+
e Make sure skin traction device (e.g., elastic wraps, foam Prevents further injury due to dislocation of hip trochanter and
boot with Velcro strap) is applied properly (if necessary to potential for pain and discomfort.
reapply, obtain assistance so that one person can maintain
traction on the leg during the reapplication process). D +
e Make sure that excessive or prolonged pressure is not Decreases potential for further injury and increased pain.
exerted on Achilles tendon and medial and lateral aspects
of knee and ankle. D+
If signs and symptoms of neurovascular dysfunction occur:
e Notify physician if the signs and symptoms persist or Allow for prompt treatment of client changes.
worsen.
e Prepare client for surgical intervention (e.g., internal Compartment syndrome, if untreated for more than 6 hrs, can
fixation, insertion of hip prosthesis). result in permanent injury.

The rest of the postoperative care for the client with a hip
fracture with prosthesis or internal fixation is the same as a
total joint replacement.
Refer to Total Joint Arthroscopy Care Plan.

TOTAL JOINT REPLACEMENT/ARTHROSCOPY— HIP/KNEE

A joint replacement (arthroplasty) is a surgical procedure in femoral head. The hip socket or acetabulum is replaced with
which the diseased, injured, or malfunctioning part of the a metal socket where the new femoral head articulates with
joint is replaced with a prothesis. A total hip replacement is the hip bone. A spacer or liner, made of metal, plastic, or
performed to relieve joint pain that has been resistant to ceramic, may be placed between the new ball and socket to
conservative management and/or improve joint mobility in provide a smooth gliding surface. A partial hip replacement
persons with severe arthritis. In a total hip replacement, the involves replacing the top of the femur with a prosthesis and
damaged femoral head is replaced with a metal prosthesis ball that fits into the hip joint, but the hip socket or acetabu-
that is cemented or fit into the femur. On the top of this lum is not replaced. The type of replacement depends on the
prosthesis is attached a metal or ceramic ball that replaces the level of damage or injury to the hip.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Goto ©volve for animation
690 Chapter 13 = The Client With Alterations in Musculoskeletal Function

A total knee replacement is a surgical procedure in which

the knee joint and articulating surfaces of the tibia, femur, and
OUTCOME/DISCHARGE CRITERIA
patella are replaced with mental and plastic prosthetic devices.
The client will:
These devices are held together either using cement or a porous
1. Have evidence of normal healing of the surgical wound
prosthesis is used that allows for endogenous bone growth and
. Maintain clear, audible breath sounds throughout lungs
over time will hold the joint together. A knee replacement is
. Have reduced/controlled joint pain
performed to relieve joint pain that has not been controlled by
. Have expected degree of mobility of replaced joint
conservative management and/or to improve joint mobility in
nN
PWN. Exhibit no signs and symptoms of infection or postopera-
persons with severe arthritis, congenital knee deformity, hemo-
tive complications
philic arthropathy, or severe intra-articular injury.
6. Demonstrate correct transfer and ambulation techniques
Joint replacement surgery may involve traditional open
and proper use of ambulatory aids if required.
procedure or robotic-assisted minimally invasive surgery.
7. Demonstrate the ability to correctly perform the
Minimally invasive joint replacement has a decreased inci-
prescribed exercises
dence of complications including less tissue trauma, blood
8. Verbalize an understanding of activity and position
loss, and a smaller scar. Clients also experience a decreased
restrictions necessary to prevent dislocation of prosthesis
length of hospital stay and shorter recovery time. The deter-
9. Identify ways to reduce the risk of loosening prosthesis
mination of which approach to use for joint replacement is a
10. Identify ways to reduce the risk of falls in the home
decision made by the physician and client. It is based on
environment
multiple client factors including but not limited to age, level
11. State signs and symptoms to report to the health care
injury or disease process, and previous hip/knee surgery.
provider
Hip and knee replacements are the most commonly per-
12. Identify community resources that can assist with home
formed joint replacements, but replacement surgery can be
management and provide transportation
performed on other joints, as well, including the ankle, wrist,
13. Develop a plan for adhering to recommended follow-up
shoulder, and elbow.
care including future appointments with health care
This care plan focuses on the adult client hospital-
provider and physical therapist, medications prescribed,
ized for a total hip/knee replacement. Much of the
activity level, and wound care
postoperative information is applicable to client care
following a joint replacement and receiving care in an
extended care facility or home setting.

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE

CARE PLAN

: Nursing Diagnosis ACUTE PAIN nox

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Related to: Surgical procedure—injury to bone and tissues

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of pain Grimacing; reluctance to move; restlessness; diaphoresis;
increased BP; tachycardia, tachypnea, grimacing with
movement i

RISK FACTORS DESIRED OUTCOMES

e Trauma The client will experience diminished hip pain as evi-
e Dislocation denced by:
e Fractures a. Verbalization of a reduction in pain
e Muscle spasms b. Relaxed facial expression and body positioning
e Fear and anxiety c. Stable vital signs
d. Respiratory rate within normal limits
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 691

NOC OUTCOMES NIC INTERVENTIONS

eeeeee EB
Comfort level; pain control Analgesic administration; pain management: acute
environmental management; calming technique

NURSING ASSESSMENT RATIONALE

(a a Ee a a aa a a

Assess for and report signs and symptoms of pain Early recognition of signs and symptoms of acute pain allows for
e Verbalization of pain prompt intervention.
e Grimacing, diaphoresis, increased BP, tachycardia, tachypnea
Assess the client’s pain using a standardized pain scale and Use of a pain intensity rating scale gives the nurse a clearer under-
location, quality, onset, duration, precipitating factors, standing of the client’s pain experienced, changes in pain over
aggravating factors, alleviating factors time, and promotes consistency when communicating with others.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain:
e Perform actions to reduce fear and anxiety about the pain Promotes relaxation and subsequently increases the client’s thresh-
experience: old and tolerance for pain.
e Assure client that the need for pain relief is understood;
plan methods for achieving pain control with client.
e Provide explanation prior to procedures.
e Maintains a calm, supportive demeanor.
Provide or assist with additional nonpharmacological
measures for pain relief.
e Relaxation exercises (e.g., guided imagery, progressive Having client focus on something otherthan pain. Understanding
relaxation, MBSR) what will occur will help to decrease client’s anxiety.
e Diversional activities such as watching television, reading, Relaxation techniques relax muscle tension and decrease anxiety.
listening to music or conversing Strengthens or provides for new coping mechanisms. Distraction
techniques refocus client on something other than pain.
Maintain appropriate positioning/alignment of affected Decreases incidence of muscle spasms, pain, and tension on the
extremity. operative site.

Dependent/Collaborative Actions
Implement measures to reduce pain:
Administering analgesics before activities and procedures that can
cause pain and before pain becomes severe improves mobility.
Administer pain medication every 3 to 4 hrs during the first 24 hrs Pain medication provided at regular intervals decreases incidence
postoperatively and prior to physical therapy or exercises of episodes of severe pain.
e Analgesics (opioids: morphine; etc.
e NSAIDS: ketorolac IV) Ketorolac IV is as effective in treating pain and has less side effects
that opioids.
Intermittently apply ice packs to surgical area if ordered Cold numbs sore tissues, decreases localized swelling, and decreases va-
sodilation, thus decreasing pain-producing chemical transmission.
Consult appropriate health care provider if above measures
fail to provide adequate pain relief or client reports sudden
severe pain:
e Physician, pharmacist; pain management specialist Notifying the appropriate health care provider allows for modifica-
tion of the treatment regimen.

}Nursing >...
Diagnosis |IMPAIRED PHYSICAL MOBILITY nox
Definition: Limitation in independent, purposeful movement of the body or of one or more extremities.

Related to:
e Pain and weakness in weight-hearing extremity associated with surgery
e Prescribed activity and weight-bearing restrictions following surgery
e Generalized weakness associated with surgery
° Depressant effect of anesthesia and some pain medications
e Fear of falling, dislodging drainage tubes if present, dislocating prosthesis and compromising surgical wound

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN ©P = Go to ©volve for animation
692 Chapter 13 = The Client With Alterations in Musculoskeletal Function

CLINICAL MANIFESTATIONS

Subjective Objective
Expression of fear about moving Deceased reaction time, difficulty turning, limited ability
to perform gross motor movements, limited range of
motion, postural instability, slowed and/or uncoordinated
movements

RISK FACTORS
Malnutrition
e Musculoskeletal impairment
Pain
e Fear and anxiety

NOC OUTCOMES NIC INTERVENTIONS

ae
Mobility; joint movement; ambulation; bone healing Musculoskeletal rehabilitation participation;
joint mobility; exercise therapy participation and ambulation

DESIRED OUTCOMES
The client will maintain maximum physical mobility as
evidenced by:
a. Participation in prescribed exercises
b. Participation in ambulation within prescribed weight-
bearing limitations

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired physi- Early recognition of causes of impaired mobility allows for prompt
cal mobility: intervention.
e Assess fear/anxiety and client’s concerns about increasing
activity and ambulation
e Assess client’s gross motor skill and range of motion and
determine limitations to implementing prescribed exer-
cises and weight-bearing ambulation restrictions
e Assess client’s understand concerning required activity
and ambulation
e Assess client’s postural stability

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Allow client to express fears and concerns about exercise and Decreasing anxiety and fear about postsurgical exercises and
activities following surgery. ambulation allows client to focus on correct technique.
Encourage client to use overhead trapeze to move self. Engages client in self-care and strengthens self-confidence in ability.
Reinforce physical therapist’s instructions regarding muscle Actions when practiced increase muscle strength and increase
strengthening exercises, transfer and ambulation tech- confidence and skill in activities and techniques.
niques, and use of ambulatory aids.
Encourage client to perform prescribed exercises on affected Increases client’s self-confidence in completing the exercises and
and unaffected limb. increases muscular strength.
Hip Replacement:
Perform actions and instruct client in ways to prevent Decreases incidence ofpain and dislocation of hip joint. Movement
extreme (beyond 90 degrees) hip flexion or bending at the precautions should be utilized for at least 6 weeks or until
waist: removed by the physician.
e Instruct client not to learn forward to reach objects out of The client should not bend the hip more than a 90-degree angle
reach or at the foot of the bed and should not bend from the waist. This movement may
e Do not elevate operative leg when client is sitting in the dislodge hip joint and delay healing.
chair
 Chapter 13 » The Client With Alterations in Musculoskeletal Function 693

THERAPEUTIC INTERVENTIONS RATIONALE

e Turn patient using an abduction device or pillows between Prevents dislocation of the hip joint and decreases pain and
the legs. The client should not be positioned on the surgi- discomfort.
cal side and should maintain pillows between legs when
lying on the nonoperative side. Do not allow the operative
limb to cross the midline of the body. D @ +
e Support foot with a pillow when lying on nonoperative Prevents the foot from dangling, twisting, and increasing pressure
side. D@ + on the hip.
e Never cross ankles or legs when sleeping in supine Increases risk for dislocation of hip joint.
position. D@
e Do not allow the client to sleep in a prone position. In this position there may be the tendency to turn the leg outward
De+ or flex at the hip, which increases the risk for dislocation.
Knee Replacement:
e Monitor and appropriately align client limbs when using a Use of CPM device to improve range of motion, improve wound
continuous passive movement (CPM) machine. healing, and decrease the incidence of adhesions in the
operative knee. However, research shows that the use of CPM
minimally improves the ability to bend knee.
e When in bed and if not in a CPM device, support the Supports/promotes full-leg extension.
operative knee by placing a pillow under the calf.
“e Assist with and encourage client to perform weight- Support ambulation with restricted weight-bearing and _ sitting
bearing exercises and sitting in a chair with legs dependent. in the chair. Legs should not be propped up but placed in a
dependent position.

Dependent/Collaborative Actions
Consult the appropriate health care provider (i.e., physical Allows for modification of treatment regimen.
therapist, physician) if client is unable to achieve expected
level of mobility

Nursing Diagnosis RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION npx

(OPERATIVE EXTREMITY)
Definition: Susceptible to disruption in the circulation, sensation, and motion of an extremity, which may compromise
health.

Related to:
Hip
e Trauma to or excessive pressure on the nerves or blood vessels during surgery
e Blood accumulation and edema in the surgical area
e Improper alignment of operative extremity
e Dislocation of the prosthesis(es)
Knee
e Trauma to or excessive pressure on the nerves or blood vessels during surgery
e Blood accumulation and edema in the surgical area
e Improper alignment of operative extremity
e Pressure exerted by the dressing, knee immobilizer, or CPM machine
e Dislocation of the prosthesis(es)

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of increased pain in the extremity; numbness or Diminished or absent pedal pulses; capillary refill time
tingling in the foot or toes (knee); pain in the foot during in toes greater than 2 to 3 seconds; pallor, cyanosis, or
passive motion of toes or foot; numbness or tingling in coolness of the extremity; inability to flex or extend knee,
the leg or foot (hip) foot, or toes (knee)

NDx = NANDA Diagnosis D = Delegatable Action @ =UAP @ =LVN/LPN © = Go to ©volve for animation
694. Chapter 13° * The Client With Alterations in Musculoskeletal Function

RISK FACTORS DESIRED OUTCOMES

e Immobilization The client will maintain normal neurovascular function in
¢ Mechanical compression (brace) the operative extremity as evidenced by:
e Vascular obstruction Palpable pedal pulses
e Hypovolemia Capillary refill time in toes less than 2 to 3 seconds
e Chronic illness Extremity warm and usual color
No increase in pain in extremity
Ability to flex and extend knee, foot, and toes (hip)
Absence of numbness and tingling in leg or foot (hip)
Ability to flex and extend foot and toes (knee)
Ta Absence of numbness and tingling in foot and toes
moans
(knee)
_ Absence of foot pain during passive movement of toes
and foot (knee)

NOC OUTCOMES NIC INTERVENTIONS

Nee ee ee ee eee ee ee eee a EEE

Tissue perfusion: peripheral; Neurological status: peripheral Circulatory care: arterial insufficiency; circulatory care:
venous insufficiency; lower extremity monitoring;
positioning; pressure management; heat/cold application

NURSING ASSESSMENT RATIONALE

Assess for and report signs of neurovascular dysfunction in Early recognition of signs and symptoms of neurovascular dysfunc-
the operative extremity: tion allows for prompt intervention.
e Increased pain in the extremity
e Numbness or tingling in the foot or toes (knee)
e Pain in the foot during passive motion of toes or foot
¢ Numbness or tingling in the leg or foot (hip)
e Diminished or absent pedal pulses
¢ Capillary refill time in toes greater than 2 to 3 seconds
e Pallor, cyanosis, or coolness of the extremity
e Inability to flex or extend knee, foot, or toes (hip, knee)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Assess affected limb, compare findings to noninjured limb,
document and report changes.
Assessment of the 6 P’s is appropriate for any type of joint
replacement surgery:
e Pain: Assess using a pain scale including severity, quality, An increase in pain or inability to control pain with medication
intensity, radiation, and onset of new and different pain. and increased pain experienced with passive stretching may
indicate compartment syndrome.
e Pulses: Monitor and document pulses distal to the injury. Change in pulses within injured limb and _ differences noted
Use a rating scale for intensity of palpable pulses. between injured and noninjured limb may indicate changes in
blood flow to distal to the injury.
e Paresthesia: Assess sensations proximal and distal to the Decreased feeling or “pins and needles” feeling report by client may
site of surgery using light touch to the skin. Ask client indicate nerve damage and indicate compartmenta\ syndrome.
about changes in sensation. Report any “pins and needles”
sensations.
e Pallor: Assess capillary refill, color, and warmth distal to Irreversible nerve damage may occur ifnot resolved.
the injury. Monitor trends over time and report any
decline in findings.
e Paralysis: Ask client to dorsiflex or plantar flex the feet, Decreasing color, capillary refill time, and warmth to the extremity
note decreases in movement or inability to perform. indicates arterial insufficiency and should receive immediate
intervention.
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 695

THERAPEUTIC INTERVENTIONS RATIONALE

e Pressure or edema: Assess for changes in firmness or swell- Decreased movement or no movement is indicative of compartmen-
ing of the extremity distal to the injury. Measure calf size tal syndrome and requires immediate intervention.
if indicated Edema or increased tightness of the skin correlates with increased
internal pressure on the muscles, nerves, and tissues and is
indicative of compromised circulation distal to site of surgery.
Maintain patency of wound drainage system, if present (e.g., Helps to maintain vascular fluid volume.
prevent kinking of tubing, empty collection devices as
needed, keep collection device below the level of surgical
site, maintain suction as ordered).
Encourage client intake of oral fluids if not contraindicated. Maintaining patency of a drainage system reduces the accumula-
tion of fluid in the surgical area, decreasing pressure on the
surgical site and surrounding tissues.
Hip Arthroplasty: Dehydration increases the risk of deep vein thrombosis and poten-
tial for neurovascular insult.
e Assure that straps on abductor wedge are not exerting pres- Excessive pressure on the popliteal space compresses arteries,
sure on the popliteal space, Achilles tendon, and medial nerves, and veins, decreasing perfusion and increasing the risk
aspects of the heel and ankle. for nerve damage. In addition, the risk for deep vein thrombosis
e Encourage client in range-of-motion exercises and ambulation. increases because of altered perfusion.
‘Knee Arthroplasty: Promotes circulation and maintains muscle strength.
e Elevate operative leg when not in CPM machine by plac- Elevation of the affected limb reduces edema in surgical area.
ing pillow under calf. Limiting knee flexion reduces pressure on peroneal nerve.
e If using CPM or immobilizer, assure the straps are not too Decreases circulation and pressure on skin, decreasing the
tight and placing excessive pressure on the affected limb. incidence of skin injury.

Dependent/Collaborative Actions
Apply intermittent ice pack or cooling pad to operative site. Cold therapy facilitates vasoconstriction, thereby decreasing bleed-
ing, swelling, and pain at the surgical site.
Notify health care provider if signs and symptoms of neuro- Allows for prompt modification of the treatment regimen.
vascular dysfunction occur.
Prepare client for surgical intervention. Information about what is happening as part of the treatment plan
decreases fear and anxiety concerning condition.

Nursing Diagnosis IMPAIRED TISSUE INTEGRITYNpx/RISK FOR IMPAIRED

TISSUE INTEGRITY nox
Definition: Impaired Tissue Integrity NDx: Damage to the mucous membrane, cornea, integumentary system, muscular
fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament; Risk for Impaired Tissue Integrity NDx:
Susceptible to damage to the mucous membranes, cornea, integumentary system, muscular fascia, muscle,
tendon, bone, cartilage, joint capsule and/or ligament, which may compromise health.

Related to:
e Disruption of tissue associated with the surgical procedure
* Delayed wound healing associated with factors such as decreased nutritional status and inadequate blood supply to wound area
e Irritation of skin associated with contact with wound drainage, pressure from tubes, and use of tape
° Excessive or prolonged pressure on tissues from balanced suspension device, straps on abductor wedge, and elastic wraps or stockings
e Damage to the skin and/or subcutaneous tissue associated with prolonged pressure on tissues, friction, and shearing while
mobility is decreased

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Pallor and/or redness of skin in the following areas: skin
in contact with wound drainage, tape, or tubing; back,
coccyx, and buttocks; elbows and/or heels; skin in areas at
edges of compression dressing or joint immobilizer; areas
in contact with CPM machine; areas under elastic wraps
or compression stockings

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN © = Go to ©volve for animation
696 Chapter 13 * The Client With Alterations in Musculoskeletal Function

RISK FACTORS DESIRED OUTCOMES

mieitatererenprnane
enneee me bos ee
e Imbalanced nutrition The client will:
Immobility a. Experience normal healing of the surgical wound
Mechanical pressure b. Maintain tissue integrity as evidenced by absence of
Surgical procedure redness and irritation, and no skin breakdown

NOC OUTCOMES NIC INTERVENTIONS

Tissue integrity: skin and mucous membranes; wound Incision site care; skin surveillance; positioning; pressure ulcer
healing: primary intention prevention; pressure management; skin care: topical treatments

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of skin breakdown: Early recognition of signs and symptoms of actual or impaired skin
e Pallor and/or redness of skin in the following areas: integrity allows for prompt intervention.
e Skin in contact with wound drainage, tape, or tubing
e Back, coccyx, and buttocks
e Elbows and/or heels
e Skin in areas at edges of compression dressing or joint
immobilizer
e Areas in contact with CPM machine
e Areas under elastic wraps or compression stockings

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent tissue irritation and breakdown
in areas in contact with wound drainage, tape, and tubings:
e Maintain patency of drainage tubes. D + Maintaining patency of drainage tubes helps to prevent the possi-
bility of leakages around tubes.
e Apply collection device over drains and incisions that are Removes fluid from tissues and decreases pressure on the suture
draining continuously. D+ line and surrounding skin.
e Ensure client is not lying on drainage tubes. D + @ Prevents drainage tube blockage and backup into tissues.
e Perform actions to decrease skin irritation from tape: Pressure on the skin may compromise circulation to that area.
e Use only the necessary amount of tape. D + Tape irritates the skin and some clients have tape allergies.
e Use hypoallergenic tape. Decreases incidence of skin irritation and allergic reactions.
e Use Montgomery straps or tubular netting. Decreases exposure of the skin to avoid repeated application and
removal of tape.
Implement measures to prevent tissue breakdown associated
with decreased mobility:
e Position client properly; use pressure-reducing or pressure- Actions help to reduce constant pressure on skin and bony promi-
relieving devices (e.g., pillows, alternating pressure mat- nences, improving circulation to skin.
tress) if indicated. D + @
e Instruct client to use overhead trapeze to lift self and shift Actions prevent shearing injury to client’s skin.
weight at least every 30 minutes.
e Gently massage around reddened areas at least every Actions stimulate circulation to the skin.
2 hrs. D+
e Lift and move client carefully using a turn sheet and ade- Prevents shearing forces against client’s skin.
quate assistance. D @
e Perform actions to keep client from sliding down in bed Decreases pressure on COCcyX. i
(e.g., limit length of time client is in a semi-Fowler’s posi-
tion to 30-minute intervals). D @
e If turning is allowed, turn client every 2 hrs, maintaining Turning from side to side decreases constant pressure on bony
proper alignment. D @ prominences.
Implement measures to prevent irritation and breakdown on Actions help to reduce the risk of skin surface abrasion and shear-
elbows and heels: ing and decrease the potential for skin injury. Also, can improve
° Massage elbows and heels with lotion. D + @ client comfort.
e Encourage client to use overhead trapeze to move self
rather than pushing up with heel and elbows.
e Provide elbow and heel protectors if indicated. D @
 Chapter 13 « The Client With Alterations in Musculoskeletal Function 697

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to prevent tissue breakdown under elas-
tic wraps or stockings:
e Remove elastic wraps or stockings at least twice daily, bathe Moisture facilitates skin breakdown.
and thoroughly dry skin, and reapply smoothly. D + @
e Check wraps or stockings frequently and reapply if they Wrinkles under skin will increase pressure and increase risk of
have slipped or become wrinkled. D + breakdown.
* If areas of redness develop under wraps or stockings, con-
sult physician before reapplying.
Hip arthroplasty:
Implement measures to prevent tissue breakdown associated
with excessive pressure caused by balanced suspension
device or abductor wedge:
e Make sure metal parts on suspension device are not resting Balanced suspension devices or abductor wedges may promote tis-
on any area of extremity. sue breakdown via increased tissue pressure. Straps and tape
e Maintain proper alignment of extremity in suspension can be irritating to the skin and compromise circulation if they
device. D > are too tight.
e Make sure that straps holding abductor wedge in place are
not too tight. D+
‘Knee arthroplasty:
Implement measures to prevent tissue breakdown in areas in
contact with the compression dressing, knee immobilizer,
and CPM machine:
Improves circulation.
e Loosen straps on knee immobilizer if they appears to be Keeping the dressing dry decreases potential for tissue maceration.
too tight. D +
e Keep dressing dry.
e Position the operative extremity so the knee immobilizer
and CPM machine are not causing excessive pressure on
any area. D>
e Ensure CPM machine is padded appropriately. D+ Decreases pressure on skin and decreases incidence for skin injury.

Dependent/Collaborative Actions
If tissue breakdown occurs:
e Notify appropriate health care provider (e.g., physician, Notifying the physician allows for modification of the treatment
wound care specialist). plan.
e Perform care of involved areas as ordered or per standard
hospital procedure.

|Nursing >.
Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH
MANAGEMENT nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT?® nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition; Ineffec-
tive Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic regimen for
the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals; Ineffective Family
Health Management NDx: A pattern of regulating and integrating into family processes a program for the treat-
ment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit.

Related to:
e Decisional conflict
e Difficulty managing complex treatment regimen
e Family conflict
e Insufficient knowledge of therapeutic regimen
e Powerlessness

*The nurse should select the nursing diagnostic label that is most appropriate for the client’s discharge teaching needs.

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698 Chapteralsiaen The Client With Alterations in Musculoskeletal Function

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of lack of understanding Demonstrated lack of knowledge about basic health
practices; demonstrated lack of adaptive behaviors;
impaired personal support systems; inaccurate follow-
through of instructions

RISK FACTORS
e Cognitive limitations
e Economically disadvantaged
Inadequate support system
Family conflict
e Lifting objects or excessive twisting

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: fall prevention; prescribed activity; Health system guidance; teaching: individual; teaching:
treatment regimen prescribed activity/exercise

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate correct

transfer and ambulation techniques and proper use of ambu-
latory aids.

Independent Actions
Reinforce instructions about correct transfer and ambulation Performing transfer techniques and using assistive devices correctly
techniques and proper use of walker, quad cane, or crutches. reduces the risk of injury.
Reinforce physician’s instructions about amount of weight- Early weight bearing may cause increased pain and discomfort.
bearing on operative extremity.
Allow time for questions, clarification, and practice of transfer Allows the nurse to reinforce patient education and to evaluate the
and ambulation techniques. need for further instruction.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to correctly perform the prescribed exercises.

Independent Actions
Reinforce the physical therapist’s instructions on prescribed Regular physical activity helps to maintain bone mass, increase
exercises and the importance of continuing the exercises lean muscle mass, and increase muscular strength, improving
for the prescribed length of time. overall function and range of motion.
Allow time for questions, clarification, and return demonstra- Allows the nurse to reinforce patient education and to Avaluate the
tion of prescribed exercises. need for further instruction.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of loosening of the prosthesis(es).
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 699

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Hip arthroplasty:
Instruct client to adhere to the following activity and position These actions are important for the client to adhere to prevent
restrictions (length of time the restrictions are necessary dislocation of the prosthesis.
varies but ranges from 2 to 6 months): Anything that requires joint flexion beyond 90 degrees should be
e Turn only as directed by physician (many physicians allow avoided.
client to turn to nonoperative side only).
e Instruct client to keep pillow between legs when lying on Prevents overextension and increases comfort.
back or side and when turning.
e Never cross legs. Actions prevents dislocation.
° Do not sit on low chairs, stools, or toilets; place a cushion
on low chairs, rent or purchase an elevated toilet seat for
home use, and use the high toilets designated for the
handicapped when in public facilities.
e Do not elevate operative leg higher than hip when sitting.
e Sit in chairs with arms and use the arms to raise self off chair.
e Support weight on nonoperative leg when raising self from
a sitting position.
e Use assistive devices (e.g., long-handled shoe horn, long- Assistive devices can improve patients ability to care for self.
handled grabber) to assist with activities that require flex-
ing hip beyond 90 degrees (e.g., putting on shoes and
socks, reaching objects on the floor or in low cupboards or
drawers, pulling bed covers up from end of bed).
e Keep operative leg in proper alignment and avoid extreme
internal and external rotation of leg.
e Do not drive until approved by physician (usually about Prevents injury to self and potential injury to others.
6 weeks after surgery).
e When riding in a car:
e Sit on a firm pillow or cushion to prevent hip flexion of Prevents overextension and increases comfort.
more than 90 degrees.
° Keep operative leg extended (a sudden impact of the knee
against the dashboard can dislodge the prosthesis(es).
e When sexual activity is resumed, avoid positions that in- Lifting objects or excessive twisting puts patient at risk for adding
volve extreme rotation of the operative leg, flexing hip be- stress to operative site.
yond 90 degrees, and moving operative leg past the midline.
e Avoid lifting heavy objects, excessive twisting and turning
of body, and activities that place excessive strain on hip
(e.g., jogging, jumping).
Knee arthroplasty:
Inform client of the possibility of loosening of the prosthesis Provides information to the client that they should be aware of
(usually does not occur until 2 to 3 years after surgery). following surgery.
Instruct client to report increasing pain or instability of May indicate loosening of the prosthesis.
operative knee
e Adhere to weight-bearing restrictions if prescribed. Decreases undue pressure on the prosthetic joint and prevents
e Avoid unusual twisting of knee. injury to residual limb.
e Avoid contact sports.
e Do not force knee beyond comfortable degree of flexion
and avoid kneeling.
e Avoid placing undue stress on knees (e.g., do not lift and
carry heavy objects, maintain ideal body weight, avoid
activities such as jogging).

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700 Chapter 13 = The Client With Alterations in Musculoskeletal Function

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of falls in the home environment.

Independent Actions
Provide the following instructions on ways to reduce risk of Actions reduce potential causes of in-home falls and increases ease
falls at home: of movement.
e Keep electrical cords out of pathways.
e Remove unnecessary furniture and provide wide pathways
for ambulation.
e Remove scatter rugs.
e Provide adequate lighting at all times.
e Avoid unnecessary stair climbing.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms: Educating the client regarding signs and symptoms to report to the
e Persistent or increased pain or spasms in operative extremity health care provider allows for implementing appropriate
e Loss of sensation or movement in operative extremity interventions, altering the plan of care, and reducing the risk of
e Inability to bear expected amount of weight on operative potential complications.
extremity
e Inability to maintain operative extremity in a neutral position
e Instability of operative extremity (feeling of knee “giving
out”) or shortening of the operative extremity (noticed as
a limp in a hip client)
¢ Chills
See Lever
e Increase or change in wound drainage

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community

resources that can assist with home management and provide
transportation.

Independent Actions
Provide information about community resources that can as- Social support can aid the client in obtaining necessary resources to
sist client and significant others with home management adapt to physical changes and obtain the necessary long-term
and provide transportation (e.g., home health agencies, assistance to maintain independence.
Meals on Wheels, church groups, transportation services).
Initiate a referral if indicated.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider and physical therapist, medications prescribed,
activity level, and wound care.

Independent Actions
Collaborate with clients to develop a plan to adhere to health Provides client the confidence that they can adhere to treatment
care provider prescribed exercises, medications and side regimen.
effects, and follow-up appointments.
Reinforce the importance of keeping appointments with Adherence to a plan of care reduces the risk of complications and
physical therapist. improves patient outcomes.
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THERAPEUTIC INTERVENTIONS RATIONALE

Teach client the rationale for, side effects of, schedule for tak- Helps client to understand the importance of adherence to medica-
ing, and importance of taking prescribed medications. tions and know what to expect related to side effects.
Instruct client to inform other health care providers of his- Allows for maintenance of appropriate care and prevents potential
tory of total joint arthroplasty so prophylactic antimicro- for injury.
bials can be started before any dental work, invasive diag-
nostic procedures, or surgery is performed.
Inform client that the prosthetic device may activate metal Decreases embarrassment and prevents unnecessary Stress.
detector alarms. Recommend carrying an identification/
information card verifying presence of the device.

RELATED CARE PLANS ACTIVITY INTOLERANCE NDx

Related to:
Preoperative e Tissue hypoxia associated with anemia (there can be sig-
Postoperative nificant blood loss because the hip is a very vascular area)
e Difficulty resting and sleeping associated with discomfort,
position restrictions, fear, and anxiety
ADDITIONAL NURSING DIAGNOSIS
RISK FOR FALLS NDx
“RISK FOR INFECTION NDx Related to:
Related to: e Weakness, fatigue, and postural hypotension associated
e Introduction of pathogens into the wound during or after with the effects of major surgery and physiological changes
surgery that may have occurred if client is elderly
Hematoma formation (increases the likelihood of infec- e CNS depressant effect of some medications (e.g., narcotic
tion by providing a good medium for growth of pathogens [opioid] analgesics, centrally acting muscle relaxants, some
and compromising blood flow to the area) antiemetics)
Increased susceptibility to infection associated with de- e Weakness and pain in weight-bearing extremity associated
creased effectiveness of immune system if client is elderly with surgery on the hip
and immunosuppression if client has been taking cortico- e Difficulty with transfer and ambulation techniques
steroids to treat the joint disorder necessitating the surgery
(e.g., rheumatoid arthritis)
e Hematogenous seeding of wound from distant sites (e.g.,
urinary tract)

LAMINECTOMY/DISCECTOMY WITH OR WITHOUT FUSION

A laminectomy is the surgical removal of the lamina of a ver- Clinical manifestations of cervical disk herniation can include
tebra. It may be performed to allow for removal of a neoplasm neck pain that radiates to the shoulder, arm, and fingers on the
or bone fragments that are putting pressure on nerve roots or affected side; stiff meck; muscle spasms in the neck; and/or
the spinal cord or to enable a rhizotomy or cordotomy to be muscle weakness, diminished biceps and triceps reflexes,
performed to treat intractable pain. Most commonly, a lami- numbness, or tingling in the affected upper extremity.
nectomy is performed to gain access to a herniated nucleus A discectomy is usually indicated if conservative measures
pulposus (HNP, “ruptured disk”) so that a discectomy (removal such as rest, heat or cold applications, anti-inflammatory medi-
of the herniated portion of the disk) can be accomplished. cations, analgesics, muscle relaxants, and local steroid injections
Disk herniation is usually the result of trauma (e.g., falls, fail to control pain or if neurological deficits persist or worsen.
vehicular accidents) or strain caused by factors such as im- Disk removal is usually accomplished by a microdiscectomy or
proper or repeated lifting of heavy objects, twisting, sneezing, laminectomy and can be performed using an anterior and/or
or coughing. Age-related degenerative changes in the disks, posterior approach. The surgical procedure performed depends
supporting ligaments, and vertebrae make the disks more on the location and size of the herniated disk and physician
prone to rupture. The most common sites of disk herniation preference. If the vertebral column in the surgical area is unsta-
are C5—6, C6-7, L4—-5, and L5-S1. These areas of the spine are ble, a spinal fusion may be performed along with a laminec-
the most flexible and therefore are subjected to a greater tomy. The surgical immobilization of the unstable area is accom-
amount of movement and strain. Signs and symptoms of lum- plished using a bone graft (autograft [usually from the iliac
bar disk herniation can include low back pain that radiates crest], allograft, or bone substitute) or implanted fixation devices
down the buttock, thigh, calf, and ankle on the affected side; such as cages, plates, screws, and rods.
muscle spasms in the lower back; muscle weakness, diminished This care plan focuses on the adult client admitted
knee and ankle reflexes, numbness, or tingling in the affected for a laminectomy that is being performed to remove an
lower extremity; constipation; and/or urinary retention. HNP. The care of a client hospitalized for a laminectomy

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702 Chapter 13. * The Client With Alterations in Musculoskeletal Function

with spinal fusion is also discussed. Much of the post- . Have pain controlled
operative information is applicable to clients receiving . Have no signs and symptoms of postoperative complications
follow-up care in an extended care facility or home . Identify ways to prevent recurrent disk herniation
setting. . Demonstrate the ability to correctly apply and remove
NDS
the stabilization device if one is required
OUTCOME/DISCHARGE CRITERIA 8. Verbalize an understanding of ways to maintain skin
integrity when wearing a stabilization device
9. State signs and symptoms to report to the health care
The client will:
provider
1. Have improved neurological function
10. Develop a plan for adhering to recommended follow-up care
2. Have evidence of normal healing of the surgical wound
including future appointments with health care provider,
3. Have intact skin under the stabilization device if one is
medications prescribed, activity level, and wound care
present

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

RELATED PREOPERATIVE NURSING/COLLABORATIVE DIAGNOSIS:
DEFICIENT KNOWLEDGE NDx
Definition: Absence of cognitive information related to a specific topic, or its acquisition.

Related to: The surgical procedure, routines associated with surgery, physical preparation for laminectomy and spinal fusion
(if planned), sensations that normally occur after surgery and anesthesia, and postoperative care.

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED

POSTOPERATIVE CARE PLAN

_ Nursing Diagnosis RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION nox

Definition: Susceptible to disruption in circulation, sensation, or motion of an extremity, which may compromise health.

Related to:
e Trauma to the nerves or blood vessels during surgery
e Blood accumulation and inflammation in the surgical area
e Dislocation of the bone graft or implanted fixation devices (if a fusion was performed)
e Excessive external pressure on the nerves or blood vessels associated with improper fit or application of the stabilization
device (e.g., cervical collar, back brace, corset)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of numbness or tingling in extremities; Diminished or absent peripheral pulses; capillary refill
development of or increase in pain in extremities time greater than 2 to 3 seconds; pallor, cyanosis, or cool-
ness of extremities; inability to flex or extend feet, toes,
hands, or fingers; diminished or absent reflexes in extremi-
ties; development of or increase in muscle weakness

RISK FACTORS DESIRED OUTCOMES ;

e Mechanical compression
The client will have usual or improved peripheral neuro-
e Vascular obstruction
vascular function as evidenced by:
e Immobilization a. Palpable peripheral pulses
b. Capillary refill time less than 2 to 3 seconds
c. Extremities warm and usual color
d. Ability to flex and extend feet, toes, hands, and fingers
e. Usual or improved reflexes, muscle tone, and sensa-
tion in extremities
f. No new or increased pain in extremities
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NOC OUTCOMES NIC INTERVENTIONS

Neurological status: spinal sensory/motor function; tissue Neurological monitoring; positioning: neurological; circula-
perfusion: peripheral tory care: arterial insufficiency; circulatory care: venous
insufficiency

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of peripheral Early recognition of signs and symptoms of peripheral neurovascu-
neurovascular dysfunction (check upper extremities after lar dysfunction allows for prompt intervention.
surgery on the cervical area and lower extremities after
surgery on the lumbar area):
e Numbness or tingling in extremities
e Development of or increase in pain in extremities
e Diminished or absent peripheral pulses
e Capillary refill time greater than 2 to 3 seconds
e Pallor, cyanosis, or coolness of extremities
e Inability to flex or extend feet, toes, hands, or fingers
e Diminished or absent reflexes in extremities
e Development of or increase in muscle weakness

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for peripheral neuro- Reducing strain on the surgical area helps to prevent bleeding and
vascular dysfunction: subsequent hematoma formation in the surgical area and to
e Perform actions to reduce strain on the surgical area: D + reduce the risk for dislocation of the bone graft or implanted
e Keep spine in proper alignment. fixation devices (if fusion was performed).
e Prevent hyperextension, extreme flexion, or twisting of
spine.
e Position to maintain flattening of lumbosacral spine:
1. Side lying with knees flexed
2. Supine with slight knee flexion
e Maintain wound suction and patency of wound drain. Reduces the accumulation of blood in the surgical area and
subsequently prevents increased pressure on nerves and blood
vessels.
e Apply stabilization device properly; notify orthotist if it Prevents injury.
appears to create excessive pressure on any area.

Dependent/Collaborative Actions
Implement measures to reduce the risk for peripheral neuro-
vascular dysfunction:
e Perform actions to reduce strain on the surgical area. Actions help to stabilize surgical area and decrease incidence of
e Ensure client is always positioned with spine in proper complications.
alignment.
e Apply stabilization device.
e Administer corticosteroids if ordered. Corticosteroids help to reduce inflammation in the surgical area.
If signs and symptoms of peripheral neurovascular dysfunc-
tion occur:
e Assess for and correct improper body alignment and exter- Allows for prompt intervention to reduce complications resulting
nal cause of excessive pressure (e.g., tight or improperly in permanent nerve dysfunction (e.g., hematoma, dislocated
applied stabilization device). bone graft).
° Notify physician if signs and symptoms persist or worsen.
° Prepare client for surgical intervention (e.g., evacuation of
hematoma, repositioning of dislocated bone graft or
implanted fixation devices) if planned.

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704 Chapter 13. * The Client With Alterations in Musculoskeletal Function

vee eee) ACUTE PAIN nox |

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.
Related to:
e Tissue trauma and reflex muscle spasms associated with the surgery
e Removal of bone if an autograft was used to achieve spinal fusion (the bone is usually taken from the client’s iliac crest)
e Stretching and compression of sensory nerves associated with blood accumulation and inflammation in the surgical area
e Irritation from drainage tube (wound drain may be present, especially after a spinal fusion)
e Stress on surgical area associated with movement
e Release of pressure on compressed spinal nerve root after removal of the HNP (improved sensory nerve function can cause a
temporary increase in pain in area[s] of previously ditminished sensation).

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain; reluctance to move Grimacing; restlessness; diaphoresis; increased BP;
tachycardia

RISK FACTORS DESIRED OUTCOMES

e Altered limited mobility
The client will experience diminished pain.
e Inadequate pain relief

NOC OUTCOMES NIC INTERVENTIONS

Pain control; comfort level Pain management; analgesic administration

NURSING ASSESSMENT RATIONALE

Assess the patient for signs and symptoms of pain: Early recognition of signs and symptoms ofpain allows for prompt
e Verbalization of pain intervention.
e Reluctance to move
e Grimacing
e Restlessness
e Diaphoresis
e Increased BP
e Tachycardia

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement additional measures to reduce pain:
e Perform actions to reduce strain on the surgical area: D+ Reducing strain on the surgical area helps to prevent bleeding and
e Ensure that client is always positioned with spine in subsequent hematoma formation in the surgical area and to
proper alignment. D + reduce the risk for dislocation of the bone graft or implanted
fixation devices (iffusion was performed).
e Apply stabilization device if ordered. Stabilization helps to provide additional support to surgical area.
e If stabilization device loosens, reapply it or tighten Prevents chance for injury. i
straps or screws if allowed, or consult orthotist about
adjustment of the device.
e Implement measures to prevent hyperextension, ex-
treme flexion, and/or twisting of spine (e.g., instruct
and assist client to logroll when turning; put needed
items within easy reach; if a cervical laminectomy was
performed, place a small pillow or folded pad under
client’s head rather than a full-size pillow; assist with
bathing and dressing as needed). D + @
 Chapter 13. = The Client With Alterations in Musculoskeletal Function 705

THERAPEUTIC INTERVENTIONS RATIONALE

e If lumbar laminectomy was performed, assist client to Interventions help to reduce injury from stretching of the nerves
maintain a position that results in flattening of the and muscles in the lower back.
lumbosacral spine (e.g., slight knee flexion when
supine, knees flexed while in side-lying position, feet
elevated on footstool when sitting in chair). D +@
e Instruct client to avoid sitting or standing for longer
than 20- to 30-minute intervals (some physicians in-
struct clients to sit only during meals and ambulate
only short distances when progressive activity begins).
e Instruct client to avoid straining to have a bowel move- Helps to reduce tension on incision lines.
ment (especially after lumbar laminectomy) and vigor-
ous coughing; consult physician about an order for a
laxative and antitussive if indicated.
e If appropriate, perform actions to reduce pressure on
bone graft donor site (e.g., position client so he/she
is not lying on site, protect the site with padding if
stabilization device is worn over it).

Dependent/Collaborative Actions
Implement additional measures to reduce pain:
e Administer corticosteroids if ordered. Steroids help to reduce inflammation in the surgical area.

Nursing Diagnosis IMPAIRED SKIN INTEGRITY nox: RISK FOR IMPAIRED

SKIN INTEGRITY nox
Definition: Impaired Skin Integrity NDx: Altered epidermis and/or dermis; Risk for Impaired Skin Integrity NDx: Susceptible
to alteration in epidermis and/or dermis, which may compromise health.

Related to:
e Disruption of tissue associated with the surgical procedure
e Irritation of skin associated with contact with wound drainage, use of tape, and pressure from tubes and/or stabilization
device if present

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain Color changes, redness, swelling, warmth (signs of
infection); surgical incisions; abrasions/tears

RISK FACTORS DESIRED OUTCOMES

e Physical immobility The clientwill:

* Shearing forces a. Experience normal healing of the surgical wound

* Pressure over bony prominence b. Maintain tissue integrity in areas in contact with wound
* Inadequate nutrition drainage, tape, tubings, and stabilization device as evi-
denced by absence of redness and irritation, and no
skin breakdown

NOC OUTCOMES NIC INTERVENTIONS

Wound healing: primary intention; tissue integrity: skin and Skin surveillance; positioning; wound care; pressure
mucous membranes management

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706 Chapter 13) = The Client With Alterations in Musculoskeletal Function

NURSING ASSESSMENT RATIONALE

Assess the patient for signs and symptoms of skin irritation Early recognition of signs and symptoms of actual or impaired skin
and breakdown: integrity allows for prompt intervention.
e Areas in contact with wound drainage, tape, and tubings
e Area under stabilization device
e Color changes, redness, swelling, warmth (signs of infection)
e Surgical incisions
e Abrasions/tears
Assess the site of impaired tissue integrity and determine the
cause

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent skin irritation and break-
down under stabilization device:
e Apply stabilization device securely enough to keep it from Constant pressure applied to the skin reduces blood flow to the
rubbing and irritating the skin but not too tightly. D + tissues.
e Position client so that stabilization device is not causing
excessive pressure on any area. D >
e Assist client to put a cotton T-shirt on under back brace or Actions improve comfort when wearing the stabilization device and
corset and ensure that the shirt is dry and wrinkle-free. decreases incidence for injury.
D+@e
e Apply a thin layer of a dry lubricant such as powder or
cornstarch to skin under stabilization device in order to
reduce friction. D+ @
e Pad areas over bony prominences before applying stabili-
zation device.
e Instruct client to refrain from inserting anything under
the stabilization device.
e Consult physician or orthotist if stabilization device is
putting excessive pressure on the skin.
If tissue breakdown occurs:
e Notify appropriate health care provider (e.g., physician, Notifying the appropriate health care provider allows for modifica-
wound care specialist). tion of the treatment plan.
e Perform care of involved area(s) as ordered or per standard
hospital procedure.

Collaborative Diagnosis RISK FOR RESPIRATORY DISTRESS

Definition: Severe difficulty breathing.

Related to:
e Trauma to the phrenic nerve during surgery and/or compression of the phrenic nerve after surgery associated with inflam-
mation or accumulation of blood in the surgical area (can occur with a cervical laminectomy because the phrenic nerve arises
at the C3-5 level)
e Tracheal compression associated with inflammation or accumulation of blood in the surgical area after a cervical laminec-
tomy (particularly if the anterior approach was used)
° Closure of the glottis associated with paralysis of the vocal cords (can occur as a result of injury to the bilateral, recurrent
laryngeal nerves during an anterior cervical laminectomy)

CLINICAL MANIFESTATIONS

Subjective Objective
Cervical laminectomy: statements of difficulty swallowing Cervical laminectomy: increased swelling in the neck or
or choking sensation bulging of the wound; rapid and/or labored respirations,
stridor, sternocleidomastoid muscle retraction, restlessness,
agitation; abnormal arterial blood gas values; decrease in
pulse oximetry values
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 707

RISK FACTORS DESIRED OUTCOMES

e Coagulopathy
The client will not experience respiratory distress as evi-
e Elevated blood pressure
denced by:
e Third spacing of fluid
a. Unlabored respirations at 12 to 20 breaths/min
b. Absence of stridor and sternocleidomastoid muscle
retraction
c. Usual mental status
d. Oximetry results within normal range
e. Arterial blood gas values within normal range

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms of respiratory distress: Early recognition of signs and symptoms of respiratory distress
e Verbalization of difficulty swallowing allows for prompt intervention.
e Swelling in neck; rapid, labored respiration, stridor, retrac-
tions, agitation
Monitor pulse oximetry and arterial blood gas values for
abnormalities

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Have tracheostomy and suction equipment readily available Provides ready access to life support equipment if required.
after cervical laminectomy.
Implement measures to prevent respiratory distress after a
cervical laminectomy:
e Implement measures to reduce strain on the surgical area: Actions help to reduce inflammation and/or prevent bleeding and
e Keep neck in proper alignment. D + subsequent hematoma formation in the surgical area.
e Ensure that cervical collar is applied correctly.
e Instruct and assist client to support neck when moving.
e Elevate head of bed 30 to 45 degrees unless contraindicated. Application of ice reduces postsurgical swelling along incision site.
e Apply ice pack to incisional area as ordered. D + @ Corticosteroids help to prevent edema at the site which decrease
strain on the surgical area.
Dependent/Collaborative Actions
e Administer corticosteroids if ordered. D +
e Maintain wound suction and patency of wound drain. Patent drains help to prevent the accumulation of blood in the
D+ surgical area.
If signs and symptoms of respiratory distress occur:
e Place client in a high-Fowler’s position unless contraindicated. Improves lung expansion.
e Loosen neck dressing or cervical collar if it appears tight. Prevents increased pressure on trachea which may decrease airflow.
e Administer oxygen as ordered. Provides supplemental tissue oxygenation.
e Assist with intubation or emergency tracheostomy if performed. Provides temporary maintenance of airway.
° Prepare client for surgical evacuation of hematoma or
repair of the bleeding vessel(s) if planned.

Diagnosis: RISK FOR CEREBROSPINAL FLUID LEAK

Collaborative SP" |
CNS compartment.
Definition: Leakage of the cerebrospinal fluid (CSF) into the tissues and out of the
during surgery to keep the dura intact;
Related to: Inadvertent damage to and/or incomplete closure of the dura (care is taken
the involved nerve)
however, it is sometimes necessary to incise dura that extends along

CLINICAL MANIFESTATIONS

Subjective Objective
Clear drainage from the incision; presence of glucose
Verbal self-report of headache
in wound drainage as shown by positive results on a
glucose reagent strip (be aware, blood will test positive
for glucose); yellowish ring (“halo”) around bloody or
serosanguineous drainage on lower back or neck dressing,
sheet, or pillowcase (CSF dries in concentric circles)

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708 Chapter 13 = The Client With Alterations in Musculoskeletal Function

RISK FACTORS DESIRED OUTCOMES

e Surgical Damage The client will have resolution of CSF leak if it occurs as
e Injury
evidenced by:
a. Absence of CSF drainage from lower back or neck incision
b. No reports of headache

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of a CSF leak: Early recognition of signs and symptoms of CSF leak allows for
e Reports of headache prompt intervention.
e Clear drainage from incision
e Presence of glucose in wound drainage

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce strain on the surgical area. Actions help to promote healing of the dura and subsequent resolu-
e Keep neck in proper alignment. tion of CSF leak.
e Instruct and assist client when moving.
If signs and symptoms of CSF leak occur:
e Maintain activity restrictions as ordered to reduce stress on Prevents further damage and decreases incidence of infection.
the meningeal tear. D+ @
Change dressing as soon as it becomes damp; maintain Keeps area clean and dry as much as possible.
meticulous sterile technique when changing dressing. D
Administer antimicrobials if ordered. D+
Assess for and report signs and symptoms of meningitis Decreases potential for and consequences of infection.
(e.g., fever; chills; new, increasing, or persistent headache;
nuchal rigidity; photophobia; positive Kernig and Brudz-
inski signs).
Prepare client for surgical repair of the torn dura if planned Requires change in treatment regimen.
(usually the torn dura heals spontaneously within a few
days).

|Collaborative -..
Diagnosis |RISK FOR LARYNGEAL NERVE DAMAGE
Definition: Injury to one or both of the nerves that are attached to the voice box.

Related to: Surgical trauma or pressure on the nerve(s) associated with inflammation or accumulation of blood in the surgical
area (can occur with an anterior cervical laminectomy)

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of voice changes (hoarseness; weak, whispery Respiratory distress (rapid and/or labored respirations,
voice; inability to speak) stridor, sternocleidomastoid muscle retraction, restlessness,
agitation; abnormal arterial blood gas values; decrease in
pulse oximetry values)

RISK FACTORS DESIRED OUTCOMES

e Hematoma at surgical site
The client will experience resolution of laryngeal nerve
e Edema/swelling at surgical site
damage if it occurs as evidenced by:
a. Improved voice tone and quality
b. Gradual resolution of hoarseness
c. Absence of respiratory distress
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NURSING ASSESSMENT RATIONALE

Assess for the following indications of laryngeal nerve Early recognition of signs and symptoms of laryngeal nerve damage
damage: allows for prompt intervention.
e Hoarseness
e Weak, whispery voice
e Respiratory distress
e Stridor
e Retractions
e Restlessness
e Agitation

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pressure on the laryngeal Maintains patent airway and decreases potential for injury.
nerves (e.g., elevated head of bed, ice to surgical site,
monitor for swelling).
Assess arterial blood gases for abnormal values and pulse Monitors oxygenation status.
oximetry.
e Encourage client to avoid unnecessary talking. D + @ Action helps to rest the vocal cords.
“e Implement measures to facilitate communication (e.g., Allows for ongoing communication when resting the voice.
provide pad and pencil, flash cards, or Magic Slate; ask
questions that require a short answer or nod of head).
D+e
Reinforce physician’s explanation regarding the permanence Helps client understand need for resting the voice and may improve
of voice changes (voice tone and quality usually return to adherence.
normal as inflammation subsides).
If signs and symptoms of laryngeal nerve damage occur:
e Notify physician immediately if signs and symptoms of Notifying the physician allows for modification of the treatment
respiratory distress occur, client is unable to speak, or plan.
hoarseness or voice changes worsen.

|Collaborative >.
Diagnosis RISK FOR PARALYTIC ILEUS |

Definition: Paralysis of the intestinal musculature caused by trauma, peritonitis, electrolyte imbalance, or spasmolytic agent

Related to:
e Impaired innervation of the intestinal tract after a lumbar laminectomy associated with stimulation of sympathetic nerves
and/or loss of parasympathetic nerve function in the operative area
e Depressant effect of anesthesia and some medications (€.g., centrally acting muscle relaxants, narcotic [opioid] analgesics,
some antiemetics)

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of persistent abdominal pain and cramping Firm, distended abdomen; absent bowel sounds; failure to
pass flatus

RISK FACTORS DESIRED OUTCOMES

* Immobility The client will not develop a paralytic ileus as evidenced

e Medication administration by:
a. Absence or resolution of abdominal pain and cramping
b. Soft, nondistended abdomen
c. Gradual return of bowel sounds
d. Passage of flatus

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710 Chapter 13. * The Client With Alterations in Musculoskeletal Function

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of paralytic ileus: Early recognition of signs and symptoms of paralytic ileus allows
e Abdominal pain for prompt intervention.
e Cramping
e Distended abdomen
e Absent bowel sounds
e Failure to pass stool
Monitor results of abdominal radiographs for abnormalities
(distended bowel)

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent paralytic ileus: Ambulation helps to stimulate motility of the GI tract.
e Increase activity as soon as allowed and tolerated.
e Administer gastrointestinal (GI) stimulants. GI stimulants increase peristalsis without adding a purgative effect.

DISCHARGE TEACHING/CONTINUED CARE

_ Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE FAMILY

HEALTH MANAGEMENT jnox; OR INEFFECTIVE HEALTH
MAINTENANCE? nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the
family unit; Ineffective Health Maintenance NDx: Inability to identify, manage, and/or seek out help to main-
tain well-being.

Related to:
e Insufficient information for self-care
e Insufficient knowledge of resources
e Difficulty navigating complex health care system
e Difficulty managing complex treatment regimen
e Family conflict

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of the problems and concerns with treat- Demonstrated lack of knowledge about basic health
ment regimen practices; demonstrated lack of adaptive behaviors;
impaired personal support systems; inaccurate follow-
through of instructions

RISK FACTORS
© Cognitive deficit
e Financial concerns
e Inability to care for oneself

NOC OUTCOMES NIC INTERVENTIONS

_
SSS

Knowledge: treatment regimen Health system guidance; teaching: individual; teaching:

prescribed activity/exercise

*The nurse should select the nursing diagnostic label that is most appropriate for the client’s discharge teaching needs.
 Chapter 13 * The Client With Alterations in Musculoskeletal Function 711

NURSING ASSESSMENT RATIONALE

Assess Client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

recurrent disk herniation.

Independent Actions
Inform client about ways to reduce back and/or neck strain and
subsequently reduce the risk of recurrent disk herniation:
Lose weight if overweight. Maintaining a normal body weight reduces stress/strain on the
back.
Support the spine adequately (e.g., sleep on a firm mat- Appropriate alignment reduces risk for injury.
tress; sit on firm, straight-backed or contoured chairs; wear
stabilization device as prescribed).
e Use proper body mechanics (e.g., bend at the knees rather Use of proper body mechanics reduces the risk of injury.
% than waist, push rather than pull heavy objects, carry
items close to body).
e Keep spine in good alignment (e.g., avoid excessive bend- Reduces stress on back, reducing the risk of injury.
ing or twisting, maintain good posture).
e Wear flat or low-heeled shoes; avoid wearing high heels. Helps to maintain proper posture.
e Adhere to prescribed, progressive exercise program to Stronger, well-developed muscles provide better support to bony
strengthen back, neck, shoulders, arms, legs, and abdomi- spine.
nal muscles.
Provide a dietary consult regarding a weight reduction pro- Helps client to develop a plan including foods client likes to eat.
gram if indicated.
Refer client to an occupational therapist and/or vocational Provides assistance in modifying daily routines or pursuing
rehabilitation specialist. different job opportunities, if indicated.
Allow time for client to practice proper body alignment when Ensuring client’s understanding of proper body mechanics reduces
sitting, standing, and walking; proper positioning when the risk of additional injury. Allow time for questions and
resting; and any exercises allowed in immediate postopera- return demonstration to assess the need for further instruction.
tive period. Encourage client to think about and plan
movements before doing them.

THERAPEUTIC INTERVENTIONS RATIONALE

a

Desired Outcome: The client will demonstrate the ability

to correctly apply and remove stabilization device if one is
required.

Independent Actions
Reinforce instructions on the correct way to apply and remove Reduces the risk of injury associated with improper use of stabiliza-
stabilization device (e.g., cervical collar, back brace, corset) tion devices.
if client needs to wear one after discharge.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understanding

of ways to maintain skin integrity when wearing a stabilization
device.

Independent Actions
If client is to be discharged with a stabilization device, in- Early, prompt recognition of potential areas of skin breakdown
allows for prompt intervention.
struct client to examine skin daily when device is off (if
device should not be removed, demonstrate how to exam-
ine underneath it using a mirror and flashlight).

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£12 @hapten sis The Client With Alterations in Musculoskeletal Function

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Instruct client in ways to maintain skin integrity if a stabiliza-
tion device needs to be worn:
e Apply device properly and maintain spine in good align-
ment to avoid undue pressure in any area.
e Wear a cotton T-shirt under back brace or corset and keep
shirt dry and wrinkle-free.
e Apply a thin layer of powder or cornstarch to skin under
stabilization device to reduce irritation caused by friction.
e Avoid inserting anything under the device.
e Place padding between stabilization device and bony
prominences.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms: Educating the client regarding signs and symptoms to report to
e Decreased movement or sensation in extremities. the health care provider allows for implementing appropriate
e Coolness or bluish color of extremities. interventions, altering the plan of care, and reducing the risk of
e Increasing or recurrent numbness, tingling, or pain in potential complications.
surgical area or extremities.
e Difficulty standing up straight (after lumbar surgery) or
keeping neck straight (after cervical surgery).
e Persistent and/or severe headache.
e Drainage of clear or bloody fluid from incision.
e Persistent hoarseness or difficulty swallowing (after cervi-
cal laminectomy).
e Reddened or irritated area on skin underneath stabiliza-
tion device.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended follow-
up care including future appointments with health care
provider, medications prescribed, activity level, and wound care.

Independent Actions
Reinforce physician’s instructions regarding activity (the re- Following activity restrictions allows for healing of surgical site
strictions will vary depending on extensiveness of surgery, and increased muscle strength and tolerance for activity.
client’s condition, and physician preference):
e Avoid lifting objects weighing more than 5 to 10 Ibs.
e Progress through exercise program as prescribed.
e Avoid sitting or standing for longer than 30 minutes at a
time (especially after surgery on lumbar area).
e Schedule adequate rest periods.
e Avoid driving a car (causes increased flexion of the spine)
and taking long car rides (the vibrations can jar the spine
and long periods without significant changes in position
can increase stiffness and discomfort) until allowed.
e Do not participate in contact sports.

RELATED CARE PLANS

e Preoperative
e Postoperative
 CHAPTER

ee

The Client With Alterations in

the Breast and Reproductive System

HYSTERECTOMY
Hysterectomy is the surgical removal of the uterus. It is per- OUTCOME/DISCHARGE CRITERIA
formed to treat a variety of conditions including malignant
and nonmalignant growths in the uterus and cervix, symp- The client will:
tomatic endometriosis, uterine prolapse, intractable pelvic in- 1. Have evidence of normal healing of surgical wound
fection, irreparable rupture of the uterus, and dysfunctional or 2. Have clear, audible breath sounds throughout lungs
life-threatening uterine bleeding. Both the uterus and cervix 3. Maintain adequate urine output
are removed in a total hysterectomy. A panhysterectomy is the 4. Have surgical pain controlled
removal of the uterus, cervix, fallopian tubes, and ovaries and 5.Have no signs and symptoms of postoperative complications
is often referred to as a total abdominal hysterectomy with bi- 6. Verbalize an understanding of the effects of surgical
lateral salpingectomy and oophorectomy (TAH-BSO). A radical menopause
hysterectomy is done to treat some cancers of the cervix. It 7. Identify ways to achieve sexual satisfaction
involves removal of the uterus, cervix, ligaments, and part of 8. Verbalize an understanding of medications ordered in-
the vagina as well as dissection of the pelvic lymph nodes. cluding the rationale for the prescription, food and drug
A vaginal or abdominal approach can be used to perform interactions, side effects, schedule for taking, and impor-
a hysterectomy. Minimally invasive robotic surgery is also tance of taking as prescribed
used to perform a hysterectomy. Not everyone is a candidate 9. State signs and symptoms to report to the health care
for minimally invasive surgery. The approach used depends provider
on factors such as the woman’s pelvic anatomy and size of the 10. Share feelings about the loss of reproductive ability
uterus, whether repairs to the vaginal wall or pelvic floor are 11. Develop a plan for adhering to recommended follow-up
needed, the presence of other medical conditions, previous care including future appointments with health care pro-
abdominal surgeries, and the diagnosis. vider, activity limitations, and wound care
This care plan focuses on the adult client hospital-
ized for a TAH with salpingectomy and oophorectomy.

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED

POSTOPERATIVE CARE PLAN

|Nursing >
Diagnosis URINARY RETENTION nox
Definition: Inability to empty bladder completely.

Related to:
e Obstruction of the urinary catheter
e Impaired urination after removal of catheter associated with:
° Decreased perception of bladder fullness associated with the depressant effect of anesthesia and some medications (e.g.,
narcotic [opioid] analgesics)

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RUIN CY,
714 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

fear,
e Increased tone of the urinary sphincters associated with sympathetic nervous system stimulation resulting from pain,
and anxiety
© Relaxation of the bladder muscle associated with nerve trauma and/or edema in the bladder area resulting from surgical
manipulation; the depressant effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics); stimulation of
the sympathetic nervous system (can result from pain, fear, and anxiety)

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of bladder fullness or suprapubic discomfort; Bladder distention, absence of fluid in urinary drainage
inability to empty bladder tubing, output that continues to be less than intake
48 hrs after surgery; frequent voiding of small amounts
(25 to 60 mL) of urine

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will not experience urinary retention as
e Medication regimen evidenced by:
e Age a. No reports of bladder fullness and suprapubic discom-
fort
b. Absence of bladder distention
c. Balanced intake and output (I&O) within 48 hrs after
surgery
d. Voiding adequate amounts at expected intervals after
removal of the catheter

NOC OUTCOMES NIC INTERVENTIONS

Urinary elimination Urinary retention care; Urinary elimination management;

Urinary catheterization; Urinary retention care

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of urinary retention: Early recognition of signs and symptoms of urinary retention
e Normal voiding pattern allows for prompt intervention.
e Verbal reports of bladder fullness or suprapubic discomfort
e Palpable bladder distention
e Absence of fluid in urinary drainage tubing
Output that continues to be less than intake 48 hrs after
surgery
Frequent voiding of small amounts (20-60 mL) of urine
Bladder scan of residual > 100 mL urine after voiding

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent urinary retention if client has
'
a catheter:
Keep drainage tubing free of kinks. D @ + Actions help prevent urinary retention by maintaining patency of
urinary catheter.
Keep collection container below level of bladder. D @ + Promotes catheter drainage.
Anchor catheter tubing securely to prevent inadvertent Prevents injury and in-and-out movement which decreases intro-
removal. D@ + duction of microbes.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 715

THERAPEUTIC INTERVENTIONS RATIONALE

After removal of catheter:
° Instruct client to urinate when the urge is first felt. Actions help prevent urinary retention after removal of urinary
e Promote actions that facilitate relaxation during voiding catheter.
attempts. Relaxation of perineal muscles supports voiding efforts.
e Provide privacy. D @ +
° Hold a warm blanket against abdomen. D @ +
e Run water in sink. D ® +
e Pour warm water over perineum. D @
e Allow client to assume a normal position for voiding if
allowed. D@ +
Consult physician if urinary retention persists or if actions Notifying the physician allows for modification of the treatment
fail to alleviate urinary retention. plan.

|Nursing ~Diagnosis RISK FOR INEFFECTIVE PERIPHERAL TISSUE PERFUSION nox

Definition: Susceptible to a decrease in blood circulation to the periphery, which may compromise health.

Related to:
e Trauma to pelvic veins during surgery
e Venous stasis associated with:
e Decreased activity
e Increased blood viscosity that can result from decreased fluid volume
e Pelvic congestion resulting from inflammation in the surgical area
e Abdominal distention (the distended intestine may put pressure on the abdominal vessels)
e Pressure on the pelvis and calf vessels during surgery if a vaginal approach was used
e Hypercoagulability associated with increased release of tissue thromboplastin into the blood from surgical trauma and
hemoconcentration and increased blood viscosity from decreased fluid volume.

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of pain and tenderness in lower extremities; Calf swelling; unusual warmth, and/or increase in calf
and sudden onset of chest pain diameter; decreased or absent peripheral pulses; coolness
in extremities; decreased level of consciousness; increased
restlessness; decreasing SaOz

RISK FACTORS DESIRED OUTCOMES

* Immobility The client will not develop decreased peripheral tissue

° Age perfusion as evidenced by:
° Smoking a. Absence of pain, tenderness, swelling, and numbness
e Inadequate fluid volume in extremities
e Surgery b. Usual temperature and color of extremities
° Decreased venous return c. Palpable peripheral pulses
d. Usual mental status
e. Usual sensory and motor function
f. Absence of sudden chest pain and dyspnea

NOC OUTCOMES NIC INTERVENTIONS

Circulation status; risk control: thrombus Tissue perfusion management; Fluid management

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716 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

NURSING ASSESSMENT RATIONALE

Assess for impaired peripheral circulation: Early recognition of signs and symptoms of impaired peripheral
circulation allows for prompt intervention.
e Assess peripheral pulses and compare side to side Changes indicate possible impaired circulation.
e Assess for pain, tenderness, swelling, unusual warmth or Possible development of thrombus.
positive Homan sign in extremities
e Assess for numbness, pallor, and coolness in extremities Possible indication of arterial insufficiency.
e Assess for sudden onset of chest pain, dyspnea, increasing Possible indication of thromboembolism.
restlessness, apprehension
e Declining SaOz levels

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions:
e Monitor dressings and perineal pads, documenting Increased blood on dressing and perineal pads and increased
amount of bleeding, color, amount, and odor of drainage. drainage may indicate potential for alterations in clotting and
possible hemorrhage.
e Support and encourage client with frequent turning, Prevents stasis of respiratory secretions and promotes oxygenation
coughing, deep breathing and use of incentive spirometry to tissues.
every 2 hrs.
e Encourage ambulation as soon as possible.
e When client is in bed, encourage range of motion exercises Improves circulation and supports venous return to the heart. Helps
and food and leg exercises. to prevent venous stasis complications.
e Encourage fluid intake, if not contraindicated. Enhances venous return and prevents venous Stasis.
e Avoid high-Fowler’s positions and crossing legs when in Supports vascular volume.
bed or sitting. Prevents venous stasis and pooling of blood in pelvis and extremities

Dependent/Collaborative Actions:
e Maintain adequate fluid volume of at least 2500 mL/day Adequate hydration supports circulating volume, reducing risk for
unless contraindicated. thrombus formation.
e Apply antiembolic stockings and/or sequential compres- Supports venous return to the heart and decreases venous stasis.
sion devices if client is inactive and on bedrest. D @ +
e Notify health care provider if signs and symptoms of Allows for prompt alteration in treatment regimen.
impaired peripheral perfusion occur.

| Nursing
Nursing ~Diagnosis |RISK FOR SITUATIONAL LOW SELF-ESTEEM nox
Definition: Susceptible to developing a negative perception of self-worth in response to a current situation, which may
compromise health.

Related to:
e Surgical procedure that removes ability to bear children
e Age of individual at time of surgery
e Number of children or desire to have children at time of surgery
e Change in sexual identity
e Change in femininity

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of feeling less than others due to loss of N/A
childbearing capabilities
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 717

RISK FACTORS DESIRED OUTCOMES

e Age
The client will not experience situational self-esteem as
e Marital/partner status
evidenced by:
e Religious beliefs
a. Verbalization of concerns and ways to address them
b. Verbalization of changed body/self-image
c. Engagement in care and interaction with significant
others
d. Verbalization of acceptance of self and new body image

NOC OUTCOMES NIC INTERVENTIONS

Self-esteem enhancement Self-esteem monitoring

NURSING ASSESSMENT RATIONALE

e Assess client’s emotional status and changes in interac- Early recognition of decreased self-esteem allows for prompt inter-
tions with others vention.
e Assess client’s willingness to discuss body-image changes.

_ THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions:
e Provide time to listen to client’s concerns about changes in Provides an accepting environment for client to express concerns,
lifestyle and self-image. hopes, and fears.
e Determine meaning of the loss to client and significant Provides opportunity to understand client’s expectations and clarify
other. any areas of concern or misunderstanding.
e Identify with client’s coping mechanisms that have worked in Helps to strengthen client’s ability to deal with change and possibly
the past and identification of new ones if client is interested. add to currently used coping mechanisms.
Provide accepting and open communication allowing Allows client to discuss feelings, fears, etc. without fear of judgment.
client to discuss concerns about physical changes.
e Refer client to community services or support groups. Provides for continuation of care.

Dependent/Collaborative Actions:
Request consultation for professional counseling. Provides for continuum of care following discharge.

DISCHARGE TEACHING/CONTINUED CARE

1 DEFICIENT KNOWLEDGE nox

Definition: Absence of cognitive information related to specific topic, or its acquisition.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness and/orto Inaccurate follow-through with instructions; inappropriate
follow prescribed regimen; expresses concern about behavior; refusal to participate in care
physical and functional changes

RISK FACTORS
¢ Cognitive deficit
e Inability to care for self

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; prescribed activity; prescribed Health system guidance; teaching: individual; prescribed
medications; sexual functioning medication; prescribed exercise; prescribed medication
regimen; sexuality

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718 Chapter 14 = The Client With Alterations in the Breast and Reproductive System

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will verbalize an under-

standing of the effects of surgical menopause.

Independent Actions
Reinforce the physician’s explanation of surgical menopause Having a greater understanding of the physiological effects of surgery
and its possible effects (e.g., hot flashes, facial hair growth, will aid the client in understanding potential effects of surgery and
decrease in vaginal lubrication, insomnia, fatigue, ner- allow for time to grieve, develop effective coping skills, and seek out
vousness, palpitations, depression). the social support necessary to adjust to the effects of surgery.
Explain the probable effects of the surgery on sexual functioning Provides information to client on how physiological changes
(e.g., decreased libido, vaginal dryness, painful intercourse). impact sexual functioning.
Instruct client on methods available to address physical Assists client in identification of resources and methods to support
changes specific to sexual functioning. sexual functioning and decrease impact of menopause changes.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will identify ways to achieve

sexual satisfaction.

Independent Actions
Instruct client in ways to promote sexual satisfaction:
e Use a water-soluble lubricant in the vagina to prevent pain The amount of vaginal lubrication decreases as a result of the
during intercourse. effects of surgically induced menopause.
e Take hormone replacements (e.g., estrogen) as prescribed. Hormone replacement is not available from all health care provid-
ers. If client is interested in hormone replacement, they should
discuss this with their health care provider.
e Try different positions for intercourse to determine Provide accepting environment to allow client to explore various
whether some positions are more comfortable than others. methods of obtaining sexual satisfaction for self and partner.
Reinforce physician’s instructions regarding when client can Waiting to resume sexual intercourse provides time for appropriate
resume sexual intercourse (usually 4—6 weeks). healing.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will verbalize an under-

standing of medications ordered including rationale for pre-
scription, food and drug interactions, side effects, schedule
for taking, and importance of taking as prescribed.

Independent Actions
Explain the rationale for, side effects of, schedule for taking, Taking medications as prescribed is important to achieve
and importance of taking hormone replacement therapy maximum benefits of therapy and prevent adverse effects.
as prescribed. Understanding the purpose and side effects of medications
Inform client of pertinent interactions between estrogen and improves adherence.
other medications she is taking.
Instruct client to inform physician of any other prescription Decreases potential for adverse drug effects.
and nonprescription medications she is taking and to in-
form all health care providers of medications being taken.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will state signs and symp-

toms to report to the health care provider.
 Chapter 14 * The Client With Alterations in the Breast and Reproductive System 719

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Instruct the client to report these additional signs and symptoms: These clinical manifestations are indications of infection, trauma,
e Foul-smelling vaginal discharge (it is normal to have an and other complications. These should be reported to the health
increased amount of discharge about 2 weeks postopera- care provider for modification of the treatment plan.
tively when internal sutures are absorbed).
° Heavy, bright-red vaginal bleeding or the passage of clots
that are thumb-size or larger.
e Excessive depression or difficulty dealing with changes in May require consultation with psychologist or other trained
body image. professional.
Excessive discomfort associated with effects of surgical May require increased or change in pain medications or implemen-
menopause. tation of adjuvant methods of pain control/support.
Adverse reactions to estrogen replacement therapy.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
‘care provider, activity limitations, and wound care.

Independent Actions
Collaborate with the client in developing a plan to imple- Adhering to a prescribed treatment plan helps promote positive
ment physician’s discharge instructions. outcomes and prevents complications.
e Client should understand activity restrictions and impor- Client may become easily fatigued and should be aware that this is
tance of increasing activity over time. normal. The client should plan gradual resumption of activities.
e Avoid lifting objects over 10 pounds, sitting for long peri- Avoiding heavy lifting allows for appropriate physical healing.
ods, stair climbing, and strenuous physical activity (e.g., Prevents strain on surgical area.
vacuuming, aerobics) for 6 to 8 weeks postoperatively.
e Avoid driving for at least a week after surgery. Decreases potential for vaginal or incisional infections.
Avoid douching, using tampons, tub baths and having sexual
intercourse for 4 to 6 weeks postoperatively.
e Stress importance of increasing fiber and fluid in diet. Prevention of constipation and potential straining with a bowel
e Stress importance of maintenance of appropriate complex movement. Straining could cause increased bleeding and delay
carbohydrates, protein, and low fat in diet. healing time.
Nutritional intake including protein promotes healing.
Reinforce importance of keeping follow-up appointments Follow-up appointments are important to monitor progress.
with the health care provider.
Implement measures to improve client adherence:
* Include significant others in teaching sessions if possible. Involving the client’s significant other improves client adherence to
e Encourage questions and allow time for reinforcement and treatment regimen.
clarification of information.
e Provide written instructions.

ADDITIONAL CARE PLANS

ACUTE PAIN NDx RISK FOR INFECTION NDx
Related to: Related to:
e Tissue trauma and reflex muscle spasms associated with e Wound contamination associated with introduction of
the surgical procedure pathogens during or following surgery
e Decreased resistance to infection associated with factors
DISTURBED BODY IMAGE NDx such as age and an inadequate nutritional status
Related to: e Increased growth and colonization of microorganisms
e Loss of reproductive organs with subsequent inability to associated with urinary stasis
bear children * Introduction of pathogens associated with the presence of
e Feeling of loss of femininity and sexuality an indwelling catheter
GRIEVING NDx
Related to:
° Loss of reproductive ability, early menopause, diagnosis of
cancer (if present), and the possibility of premature death

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720 Chapter 14 = The Client With Alterations in the Breast and Reproductive System

A mastectomy is the surgical removal of all or part of the This care plan focuses on the female adult client
breast. It is most commonly conducted to treat breast cancer. hospitalized for a modified radical mastectomy. Much
The type of mastectomy is based on factors such as the loca- of the postoperative information is applicable to
tion, type, and size of the tumor; the number of tumors; clients receiving follow-up care in a home setting.
breast size; axillary lymph node status; whether the client has
received prior irradiation of the breast; and client preference.
The two major types of surgeries performed to treat breast OUTCOME/DISCHARGE CRITERIA
cancer are a modified radical mastectomy and breast-conserving
surgery (e.g., lumpectomy, quadrantectomy). The client will:
A modified radical mastectomy includes removal of the breast 1. Have evidence of normal healing of surgical wounds
and an axillary node dissection. The pectoral muscles and sur- . Maintain clear, audible breath sounds throughout lungs
rounding nerves are left intact. This allows the client to retain the . Maintain adequate surgical pain relief
shape of her breast and avoid the shoulder and arm limitations . Have no signs and symptoms of postoperative complications
and skin graft requirements that accompany a radical mastec- wh
ne. Identify ways to reduce the risk of trauma to and infec-
tomy. Leaving the muscles and nerves intact facilitates recon- tion in the arm on the operative side
structive surgery, which may be performed at the time of the 6. Identify ways to prevent and treat lymphedema of the
mastectomy or delayed for several months, depending on physi- arm on the operative side
cian and client preference and additional treatment planned. 7. Demonstrate the ability to care for wound drainage
Post breast surgery, additional treatment (e.g., chemo- device if present
therapy, hormone therapy, external radiation therapy) may 8. Demonstrate the ability to perform the prescribed
be considered after a modified radical mastectomy. Treatment exercises and verbalize an understanding of additional
depends on factors such as the immunological and meno- exercises to be done once the incision has healed
pausal status of the client, tumor type and size, and amount 9. Verbalize the importance of and demonstrate the ability
of lymph node involvement. to perform a breast self-examination (BSE) on the remain-
Breast-conserving surgery is an option for many women ing breast and operative site
with stage I or stage II breast cancer. It involves excision of 10. State the factors to consider in selecting a breast pros-
the tumor, a surrounding margin of normal tissue, and an thesis
axillary lymph node dissection. It is often followed by a 11. State signs and symptoms to report to the health care
course of radiation therapy to eradicate any residual tumor provider
and reduce the risk for tumor recurrence. 12. Share thoughts and feelings about the change in body
Axillary node dissection has traditionally been performed image
with all invasive breast cancer to stage the tumor. Sentinel 13. Identify community resources that can assist with adjust-
node biopsy (lymphatic mapping) is used to identify axillary ment to the diagnosis of cancer and the loss of a breast
node involvement and avoid unnecessary lymph node dissec- 14. Develop a plan for adhering to recommended follow-up
tion. This procedure can be done the day of surgery. If care including future appointments with health care pro-
the sentinel node is negative for cancer cells, an axillary vider, medications prescribed, activity level, wound care,
dissection is not necessary, which eliminates the need for and plans for subsequent treatment
axillary drains and reduces the risk for lymphedema.

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

|Nursing »Diagnosis «DEFICIENT KNOWLEDGE nox

Definition: Absence of cognitive information related to a specific topic, or its acquisition.

Related to:
e Surgical procedure
e Changes in body image
e Diagnosis that required surgical intervention
e Postoperative care

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of a lack of understanding of what is going Exaggerated behaviors
to occur
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RISK FACTORS DESIRED OUTCOMES

e Unfamiliar environment
e Anxiety about the future The client will:
e Barriers in culture or communication e Verbalize an understanding of the surgical procedure,
e Diagnosis preoperative care, and postoperative sensations and
care
e Demonstrate the ability to perform activities designed
to prevent postoperative complications

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen Teaching: preoperative; teaching: individual; teaching:
prescribed exercise

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
‘ interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Provide the following information about sensations that may Clients vary in physical and cognitive ability to learn. When
occur after a mastectomy: educating clients, nurses need to determine a client’s ability to
Explain to client that it is common to have sensations of read and understand written materials. If literacy barriers are
pain, numbness, and tingling in the operative area (these present, alternative educational materials should be provided.
sensations usually subside over time and may last for a Allow time for questions, clarification, and return demonstra-
year). tion of any learned actions.
e Assure client that the sense that both breasts are present
and phantom breast sensation is common.
e Explain to client that she may feel a change in balance at
first, particularly if breasts are large.
Provide additional instructions regarding ways to prevent
complications after a mastectomy:
e Inform the client that she must keep upper arm on opera- Prevents tension on the suture lines and subsequent hematoma
tive side close to her body for a few days after surgery formation and seroma formation.
(length of time will vary according to physician prefer-
ence).
e Demonstrate recommended postmastectomy exercises These are essential to facilitate and improve lymphatic and blood
(e.g., squeezing a ball, flexion and extension of the fingers circulation, maintain muscle tone, and prevent contractures.
and wrist, wall climbing, rope pulley exercises, arm swings,
rope turning); inform client that hand and wrist exercises
are usually begun the day after surgery with gradual pro-
gression to full range-of-motion exercises of arm and
shoulder on operative side when incision has healed.
Instruct client on ways to minimize or prevent lymphedema
of the arm on operative side:
° Keep arm on operative side elevated on pillows with elbow Supports lymphatic drainage.
above heart level and hand higher than elbow in the early
postoperative period.
e Perform recommended postmastectomy exercises as soon These procedures increase the risk of infection or trauma and
as allowed. subsequent lymphedema.
e Avoid having BP measurements, injections, blood draws,
and intravenous infusions in arm on operative side.

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POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED

POSTOPERATIVE CARE PLAN

Nursing Diagnosis ACUTE PAIN nox (CHEST AND ARM ON OPERATIVE SIDE)
Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end, and a duration of less than 3 months.
Related to:
e Tissue trauma and reflex muscle spasms associated with surgery
e Irritation from drainage tubes
e Strain on the surgical area postoperatively

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain Grimacing; reluctance to move; restlessness; diaphoresis;
increased BP; tachycardia; dyspnea

RISK FACTORS DESIRED OUTCOMES

e Surgical procedure The client will experience diminished pain in the chest
e Fear and anxiety and arm on the operative side as evidenced by:
a. Verbalization of a decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. Increased participation in activities
d. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

Pain control; comfort level; pain: adverse psychological Pain management; analgesic administration
reaction

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of pain: Early recognition ofsigns and symptoms of pain allows for prompt
e Verbalization of pain intervention.
e Grimacing
e Reluctance to move
e Restlessness
e Diaphoresis
e Increased BP
e Tachycardia
e Dyspnea

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Assess pain using a standardized pain scale that includes loca- Provides for a baseline of experienced pain and a standardized
tion, duration, frequency, and intensity of pain. method for communication to the health care team.
Discuss phantom breast pain. Assure client that sensations are occurring and discuss the physi-
ological reasons they occur. Assure client it is not just their
imagination. They will be treated accordingly.
Perform actions that will help prevent or alleviate pain:
e Place client in a semi-Fowler’s position during the immedi- Actions help reduce pain in the chest and arm on the operative side.
ate postoperative period.
e Elevate the arm on the operative side on pillows, keeping Improves vascular and lymph return and decreases extremity
elbow above the level of the heart and hand higher than edema.
the elbow. D+
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THERAPEUTIC INTERVENTIONS RATIONALE

e Do not use arm on the operative side for intravenous Actions help decrease tension on the incision, promote circulation,
therapy, blood draws, injections, and BP measurements. and prevent venous congestion in affected arm. Also prevents
De+ potential for infection and decreased lymphatic return.
° Move the operative extremity gently. D@ + Movement may increase client’s pain.
e Reinforce the importance of adhering to arm and shoulder Decreases pain, and supports venous and lymphatic return.
movement restrictions.
e Maintain patency of wound drainage system (e.g., prevent Actions help prevent fluid accumulation in the operative site,
kinking of tubing, empty collection device as needed, thereby reducing pain.
maintain suction as ordered, keep collection device below
surgical wound). D@
e Securely anchor drainage tubes and collection device. Prevents in-and-out movement of tube that decreases potential for
injury and potential for the introduction of bacteria.
e If a sling is ordered, apply it to the client’s arm before Action reduces pain by supporting the affected arm and reducing
client gets out of bed. strain on the surgical site.
e Instruct client to get out of bed on the unaffected side. Action helps reduce pain by reducing strain on the surgical site.
Action promotes the use of the unaffected arm rather than the arm
on the operative side.
e Place needed items within easy reach. Prevents stretching/straining to reach desired object.
Provide nonpharmacologic measures to decrease pain: guided Promotes relaxation, refocuses attention, and augments clients
imagery, relaxation exercises, distraction—listening to current coping mechanisms while implementing new ones.
music, watching TV

Dependent/Collaborative Actions
Administer analgesics as ordered: Opioid, non-opioid analgesics, and NSAIDs are used for pain relief.
e Opioid analgesics
e Non-opioid analgesics
e Nonsteroidal anti-inflammatory agents (NSAIDs)
Consult appropriate health care provider if above measures Notifying the appropriate health care provider allows for modifica-
fail to provide adequate pain relief. tion of the treatment plan.

~~ FRISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION npx

Definition: Susceptible to disruption in the circulation, sensation, and motion of an extremity, which may compromise
health.
Related to: Chronic swelling or feeling of tightness in the arm or hand due to an accumulation of lymphatic fluid in the soft
tissue of the arm
Interruption in usual lymph flow associated with surgical removal of axillary lymph nodes and channels, edema in
the operative area, and infection of or trauma to operative arm

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of numbness, tingling, pain, sensation of Edema (measure arm on operative side at points S to
heaviness or tightness or weakness, or decreased move- 10 cm above and below elbow); decreased or inability to
ment in affected arm move arm on the surgical side
Diminished pulses in arm; pallor or cyanosis

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724. Chapter 14 * The Client With Alterations in the Breast and Reproductive System

RISK FACTORS DESIRED OUTCOMES

me
e Surgical procedure The client will not develop ineffective peripheral tissue
e Exposure to pathogens perfusion or neurovascular changes of the arm on the
e Age operative side as evidenced by:
a. Absence or gradual resolution of numbness, tingling,
and weakness of the arm
b. Absence of pain and feeling of heaviness and tightness
in the arm
Absence of edema in the arm
Capillary refill < 2 to 3 seconds
Extremity maintains usual warmth and color
No decrease in movement of affected arm
moan

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: peripheral Circulatory care: arterial insufficiency; circulatory care:

venous insufficiency; positioning; upper extremity
monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of ineffective Early recognition of signs and symptoms of ineffective peripheral
peripheral tissue perfusion of the arm on the operative side: tissue perfusion or neurovascular changes allows for prompt
e Verbal reports of numbness, tingling, pain, sensation intervention.
of heaviness or tightness or weakness or paralysis in
affected arm
° Capillary >2 to 3 seconds
e Edema (measure arm on operative side at points S-10 cm
above and below elbow)
e Peripheral pulses

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor the 6 P’s of neurovascular changes:
e Pain: Assess using a pain scale including severity, quality, An increase in pain or inability to control pain with medication
intensity, radiation, and onset of new and different pain. and increased pain experienced with passive movement may
indicate compartmental syndrome.
e Pulses: Monitor and document pulses on the upper ex- Change in pulses within injured limb and differences noted
tremity on the surgical side; use a rating scale for intensity between injured and noninjured limb may indicate changes in
of palpable pulses. blood flow to distal to the injury.
e Paresthesia: Assess sensations on the upper extremity on Decreased feeling or “pins and needles” feeling report by client may
the surgical side. Ask client about changes in sensation. indicate nerve damage and/or indicate compartmental syn-
Report any “pins and needles” feelings. drome.
e Pallor: Assess capillary refill, color, and warmth of the Irreversible damage may occur if not resolved. Decreasing color,
upper extremity on the surgical side. Track findings over capillary refill time, and warmth to the extremity indicates arte-
time and report any decline in findings. rial insufficiency and should receive immediate intervention.
e Paralysis: Ask client to squeeze nurse’s hand; note decrease Decreased movement or no movement is indicative of compartment
in movement or inability to perform. syndrome and requires timely intervention.
e Pressure or edema: Assess for changes in firmness or swell- Edema or increased tightness of the skin correlates with increased inter-
ing of the surgical side extremity. nal pressure on the muscles and tissues and is indicativaof compro-
mised circulation on the upper extremity on the surgical side.
Perform actions to prevent ineffective tissue perfusion:
e Place client in a semi-Fowler’s position during the immedi- Measures help prevent lymphedema of arm on operative side.
ate postoperative period.
e Elevate arm on the operative side on pillows, keeping Enhances lymph and venous return to the heart.
elbow above the level of the heart and hand higher than
elbow. D+
e Place a sign above bed to remind personnel not to use arm Actions help decrease risk of infection or trauma and subsequent
on operative side for intravenous therapy, blood draws, lymphedema.
injections, and BP measurements. D @ +
 Chapter 14 * The Client With Alterations in the Breast and Reproductive System 725

THERAPEUTIC INTERVENTIONS RATIONALE

Perform actions to prevent wound infection:
° Instruct and assist client to perform postmastectomy exer-
Actions help promote lymphatic drainage.
Cises as soon as allowed.

Dependent/Collaborative Actions
If signs and symptoms of lymphedema occur:
° Notify the appropriate health care provider. Notifying the appropriate health care provider allows for modifica-
e Apply an elastic pressure gradient sleeve to the affected tion of the treatment plan.
arm if ordered to reduce edema.
e Assist and instruct client in manual massage of the
affected arm and/or use of sequential compression device
on affected arm if ordered.
e Administer antimicrobial agents if ordered. Medications help prevent or treat cellulitis and lymphangitis.

|Nursing 2
Diagnosis IMPAIRED PHYSICAL MOBILITY nox
Definition: Limitation in independent, purposeful movement of the body or of one or more extremities.

Related to: Transection of or trauma to the nerves during surgery; pressure on nerves associated with lymphedema if
it
occurs; nonadherence with prescribed exercise program

CLINICAL MANIFESTATIONS

Subjective Objective
Reports of new or increased numbness, tingling, or weak- Inability to move joints through expected range of motion
ness in arm

RISK FACTORS DESIRED OUTCOMES

e- Surgery
The client will have expected mobility of the arm and
e Fatigue
shoulder on the operative side as evidenced by:
e Edema
a. Ability to put hand, arm, and shoulder through ex-
pected range of motion
b. No reports of new or increased numbness, tingling, or
weakness in arm

NOC OUTCOMES NIC INTERVENTIONS

Mobility status Mobility monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of motor and/or physi- Early recognition of signs and symptoms of impaired physical
cal impairment of the arm and shoulder on operative side: mobility allows for prompt intervention.
e Reports of new or increased numbness, tingling, change in
sensations, or weakness in arm from surgical side
e Inability to move joints through expected range of motion
e Capillary refill <2 to 3 seconds

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to prevent lymphedema: Measures help prevent arm and shoulder dysfunction. Interventions
e Initiate postmastectomy exercises as soon as allowed. aimed at prevention of lymphedema reduce pressure on
surrounding nerves.

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726 Chapter 14 = The Client With Alterations in the Breast and Reproductive System

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage use of arm on operative side to perform activi- Improves circulation, decreases edema, improves muscle strength,
ties of daily living as soon as allowed, such as feeding, and enhances ability to care for self. Exercises help to strengthen
combing hair, washing face muscles.
e Assist with ambulation when able and range-of-motion
exercises if on bed rest.

Dependent/collaborative Actions Rationale

Administer medications as ordered:
e Analgesics Analgesics decrease pain and should be given before exercises.
e Diuretics Diuretics help to decrease edema.
If signs and symptoms of impaired arm or shoulder function Prompt notification of changes allows for modification of treat-
occur, consult occupational therapist or physical therapist. ment regimen.

Collaborative Diagnosis IMPAIRED TISSUE INTEGRITY nox

Definition: Damage to mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage,
joint capsule, and/or ligament.

Related to: Delayed or impaired flap adherence associated with irregular shape of chest wall, impaired wound drainage, and
excessive movement of operative area with arm and shoulder use

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Unusual swelling around incision site, less than expected
amount of drainage in collection device, continued
drainage from incision

RISK FACTORS DESIRED OUTCOMES

e Ineffective therapeutic regimen The client will not develop impairment of skin integrity at
e Excessive movement of upper extremities the surgical site as evidenced by:
e Age a. No unusual swelling around incision
b. Expected amount of wound drainage in collection
device
c. Absence of continued drainage from incision

NOC OUTCOMES NIC INTERVENTIONS

___————
oO

Skin integrity; wound healing: primary intention Skin surveillance; wound monitoring

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of seroma forma- Early recognition of signs and symptoms of seroma formation
tion: allows for prompt intervention.
e Unusual swelling around incision site
e Less than expected amount of drainage in collection
device
e Continued drainage from incision

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote healing:
e Maintain compression dressing over operative site if one is Action helps promote skin flap adherence so that fluid cannot ac-
in place. D+ cumulate in any dead space beneath the flap.
 Chapter 14 * The Client With Alterations in the Breast and Reproductive System Tah

THERAPEUTIC INTERVENTIONS RATIONALE

e Maintain patency of wound drainage system (e.g., prevent
Prevents blockage and helps to promote drainage and helps to
kinking of tubing, empty collection device as needed, keep
decrease edema.
collection device below surgical wound, maintain suction
as ordered). D >
e Place needed items within easy reach to prevent excessive
Decreases stretching of arms, which decreases wound healing.
arm and shoulder movement. D @
° Ifa sling is ordered, apply it to client’s arm before client Supports the arm and reduces strain on the surgical site.
gets out of bed.
° Reinforce importance of adhering to arm and shoulder Decreases strain/pulling at the surgical site.
movement restrictions.
e Encourage appropriate diet with complex carbohydrates Promotes wound healing.
and quality proteins.
° Encourage ambulation and frequent position changes. Promotes circulation and decreases risk of immobility and poten-
tial skin breakdown.
° Use aseptic/sterile technique with dressing changes. Prevents cross contamination.
e Encourage adequate rest and sleep. Helps to promote healing and decreases fatigue.

Dependent/Collaborative Actions
_If tissue breakdown occurs or seroma formation occurs:
° Notify the appropriate health care provider. Notifying the appropriate health care provider allows for modifica-
e Prepare client for needle aspiration of fluid if hematoma or tion of the treatment plan.
seroma occurs.
e Assist with application of compression dressing if not Protects surgical wound and surrounding tissues.
already present.
e Administer antimicrobials if ordered. Treatment of infections.

Nursing Diagnosis DISTURBED SELF-CONCE PT*

Definitions: Disturbed Body Image NDx: Confusion in mental picture of one’s physical self; Situational Low
Self-Esteem NDx: Development of a negative perception of self-worth in response to a current situation;
Grieving NDx: A normal, complex process that includes emotional, physical, spiritual, social, and intellectual
responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated,
or perceived loss into their daily lives.

Related to: Loss of a breast; temporary dependence on others for assistance with self-care associated with restricted arm
movement; possible altered sexuality patterns associated with decreased libido, perceived loss of femininity, and
fear of rejection by partner
CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of negative feelings about self Lack of participation in activities of daily living, refusal to
look at mastectomy site, withdrawal from significant
others; frequent crying

RISK FACTORS DESIRED OUTCOMES

e Surgical procedure
The client will demonstrate beginning adaptation to the
¢ Loss of image of self loss of her breast and integration of the change in body
e Age image as evidenced by:
a. Verbalization of feelings of self-worth and sexual
adequacy
b. Active participation in activities of daily living
(o) . Willingness to look at surgical site

d. Maintenance of relationships with significant others

*The nurse should select the diagnostic label that is most appropriate for the client.

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NOC OUTCOMES NIC INTERVENTIONS

Body image; self-esteem; psychosocial adjustment: Body-image enhancement; grief work facilitation; self-
life change; sexual functioning; sexual identity esteem enhancement; role enhancement; counseling:
emotional support; support system enhancement; sexual
counseling

NURSING EI) ASSESSMENT RATIONALE

r
ANNA SNS e
Assess for signs and symptoms of a disturbed self-concept: Early recognition of signs and symptoms of disturbed self-concept
e Verbalization of negative feelings about self allows for prompt intervention.
e Lack of participation in activities of daily living
e Refusal to look at mastectomy site
e Withdrawal from significant others
e Expression of concern about personal sexuality

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to facilitate the grieving process:
Assist the client to identify and use coping techniques that A change in body appearance can initiate a grieving response.
have been helpful in the past. Resolution of grief assists the client to accept changes experi-
Discuss grieving process and assist client to accept the phases enced and integrate the changes into self-concept.
of grieving as an expected response to loss of breast tissue.
Allow client to verbalize expressions of anger and/or sadness Involving partner in care of the client can help facilitate partner's
about changes in body image and self-concept. Involve adjustment to the change in client’s appearance and subse-
partner/significant other in discussion if client is willing. quently decrease the possibility of partner's rejection of client.
Implement measures to facilitate client’s adjustment to the
effects of the loss of a breast on her sexuality:
e Facilitate communication between client and_ partner; Allows for discussions in safe, supportive environment.
focus on feelings the couple share and assist them to iden-
tify factors that may affect their sexual relationship.
e Arrange for uninterrupted privacy during hospital stay if
desired by the couple.
e Assist client with usual grooming and makeup habits. Engages client in self-care and may help improve acceptance of
body changes.
e Demonstrate acceptance of client using techniques such as Establishes trust with client.
touch and frequent visits.
e Encourage significant others to visit frequently and to use Allows client to visualize a more “normal” future.
touch when interacting with the client.
e Stay with client during first dressing change and encour- Provides support to client. Maintain an accepting countenance
age her to express feelings about appearance of incision when working with client.
and change in body. If the client is reluctant to look at the
surgical site, provide support and encouragement to do so
before discharge.
e Encourage client’s participation in activities that can assist Enhances self-care ability, improves circulation, and increases muscle
her to integrate the physical change that has occurred strength. Increases client’s confidence in ability to care for self.
(e.g., exercise, grooming, bathing, wound care). Explores options available for client following healing process.
If breast reconstruction has not been performed:
e Encourage client to discuss possibilities for future recon-
struction of breast with physician if desired.
e Discuss the variety of prostheses available and ways to
obtain one.
e Assist client’s and significant others’ adjustment by listening, Provides client/family support following discharge from acute care
facilitating communication, and providing information. facility.
e Support behaviors suggesting positive adaptation to the Enhances ability to work through grieving process.
loss of a breast (e.g., willingness to look at and care for
wound, compliance with exercise program, maintenance
of relationships with significant others).
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 729

THERAPEUTIC INTERVENTIONS
RATIONALE
e Reinforce the temporary nature of Operative side arm
Prevents injury.
movement restrictions.
e Encourage client contact with others so that she can test
and establish a new self-image.
¢ Encourage visits and support from significant others.
Helps client to feel supported and accepted by significant others.
e Encourage client to pursue usual roles and interests and to
continue involvement in social activities.
e Provide information about and encourage use of commu-
Helps client understand that life goes on and supports her ability
nity agencies and support groups (e.g., Reach to Recovery;
to maintain engagement in things the client likes to do.
sexual, family, and individual counseling services).
Provides for continuum of care and support from individuals who
have experienced a mastectomy.
Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse clinician, physician) if client seems unwilling or tion of the treatment plan.
unable to adapt to the loss of her breast.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

MANAGEMENT nox*
Definition: Deficient Knowledge NDx: Absence or deficiency of cognitive information related to specific topic or its
acquisition; Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a
therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific
health goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalizes inability to manage illness and inability to Inaccurate follow-through with instructions; inappropriate
follow prescribed regimen behavior; refusal to participate in care

RISK FACTORS
° Cognitive deficit
e Failure to reduce risk factors
e Inability to care for self
e Unfamiliar with resources
e Economically disadvantaged
e Lack of social support

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen; treatment Health system guidance; teaching: individual; teaching:
procedure(s); health resources; sexual functioning; sexual disease process; teaching: prescribed exercise; teaching:
identity prescribed medication; teaching: psychomotor skill;
teaching: sexuality; sexual counseling

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Early recognition of readiness to learn and meaning of illness to
Assess meaning of illness to client. client allows for implementation of the appropriate teaching
interventions.

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching needs.

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730 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

THERAPEUTIC INTERVENTIONS
eeRATIONALE
e
ee NEED
eee EEUU UEEENEE EESEEREESE EEE ERE
nnn

Desired Outcome: The client will identify ways to reduce

the risk of trauma to and infection in the arm on the opera-
tive side.

Independent Actions
Provide the following instructions: Actions help reduce the risk of trauma to and infection in the arm
e Avoid cuts by pushing cuticles back instead of cutting on operative side.
them and trimming fingernails carefully.
e Wear heavy work gloves when gardening and rubber Prevents exposure to new bacteria.
gloves when in contact with steel wool, harsh chemicals,
abrasive compounds, or water for prolonged periods.
e Wear insulated gloves when reaching into a hot oven or Prevents injury and potential for infection.
handling hot items.
e Use a thimble when sewing to avoid pinpricks.
e Keep pressure off the affected arm (e.g., avoid wearing tight Promotes circulation and lymph drainage.
jewelry and clothes with constricting bands, carry heavy
objects such as purse or packages with the unaffected arm).
e Offer only the unaffected arm for blood pressure readings, Helps to maintains skin integrity and decreases potential for cross-
injections, blood drawing, and intravenous therapy. contamination.
e Wash any break in the skin on the affected arm with soap Prevention of injury and risk for bleeding.
and water and cover the area with a protective dressing.
e Use an electric rather than a straight-edge razor when
shaving underarm area.
e Use insect repellant when in an area where stinging or
biting insects may be located.
e Avoid prolonged exposure to the sun to prevent burns.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

and treat lymphedema of the arm on the operative side.

Independent Actions
Instruct client in ways to prevent lymphedema of the arm on These actions help facilitate lymph drainage by gravity.
operative side:
e Elevate the affected arm on pillows for 30 to 45 minutes
at least 3 times a day for the prescribed length of time
(usually 6-12 weeks).
e Sleep on unaffected side or back with affected arm elevated
for the prescribed length of time (usually 6-12 weeks).
e Avoid placing the affected extremity in a dependent posi- Prevents development ofedema.
tion for extended periods.
Reinforce physician’s instructions regarding ways to treat These actions decrease lymphedema and promotes lymph return.
lymphedema if present:
e Perform manual massage of the affected arm if prescribed.
e Wear an elastic pressure gradient sleeve as recommended.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will demonstrate the ability

to care for wound drainage device if present.

Independent Actions
If the client is to be discharged with wound drain(s) and a Proper wound care is necessary to prevent infection and promote
suction device, demonstrate how to empty and establish optimum wound healing. Allow time for return demonstration
negative pressure in the collection device and provide to assess client understanding of instructions and the need for
these additional instructions: further education.
e Keep the collection device positioned below the insertion Decreases edema, stasis of fluid, and potential for infection.
site.
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THERAPEUTIC INTERVENTIONS RATIONALE

° Keep the tubing pinned to the dressing and avoid kinks
Monitor changes in drainage, as this may indicate a change in
and strain on the tubing. condition. Increases or change in consistency or color should be
° Empty the collection device at least twice daily or more reported to the health care provider.
often if needed.
Keep a record of the amount of drainage (drains will typi-
cally be removed once the drainage is <20-30 mL in
24 hrs).

THERAPEUTIC INTERVENTIONS RATIONALE

a ee ee
Desired Outcomes: The client will demonstrate the ability
to perform the prescribed exercises and verbalize an under-
standing of additional exercises to be done once the incision
has healed.

Independent Actions
Reinforce teaching about postmastectomy exercises: Postoperative exercises are necessary to prevent contraction and
e Emphasize the need to perform hand and elbow exercises promote return of optimum range of motion.
regularly and begin full range-of-motion exercises of the
arm and shoulder once the incision has healed.
Encourage appropriate diet with complex carbohydrates Appropriate nutrition is required to provide energy for activities and
and quality proteins. to promote healing.
Encourage client to maintain adequate fluid intake. Supports circulatory volume
Encourage client to maintain adequate rest/sleep pattern. Provides energy to maintain exercise regimen and decreases inci-
dence of fatigue.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will verbalize the impor-

tance of and demonstrate the ability to perform a BSE on the
remaining breast and operative site.

Independent Actions
Explain the reasons for monthly BSE of the remaining breast Performance of preventative screening measures at regular intervals
and operative site. can alert clients to findings that require further evaluation by a
Explore with client ways to remember to carry out BSE. health care provider.
The examination should be done a week after conclusion
of menses or on a specific date if postmenopausal.
Demonstrate, using a model, film, or chart, how to do a
BSE.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will state the factors to con-

sider in selecting a breast prosthesis.

Independent Actions
If acceptable to client, invite a Reach to Recovery volunteer or Selection of a prosthetic will be a very personal choice by the
prosthetist to share information about the various pros- client and including members of a social support network may
theses available. facilitate appropriate selection.
Suggest that client wear a soft, temporary prosthesis until
complete healing of the incision has occurred.
Encourage the client to take significant other or a close friend
with her for the initial fitting of the prosthesis in order to
provide emotional support.
Emphasize that it is important to select or make a prosthesis
that will balance the chest to avoid difficulties with pos-
ture and subsequent back, shoulder, and neck discomfort.

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THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms: Educating the client regarding signs and symptoms requiring evalu-
New or increased sensations of numbness, tingling, ation by a health care provider can help to reduce the occurrence
heaviness, or tightness in hand, arm, or shoulder on of complications and improve health outcomes.
operative side.
Increasing weakness of the affected arm.
Decreased ability to move shoulder or arm on operative
side (full range of motion should be regained within
3-6 months).
Warmth or redness of the affected arm. Lymphedema may not occur in the immediate postoperative period.
Increase in size of arm on affected side (client may be in- It may occur up to 2 years following surgery. The client should
structed to measure arm circumference weekly at points be informed of what to monitor and to notify health care
about 2-4 inches above and below elbow and compare with provider when it occurs.
unaffected arm); inform client that transient edema may
occur as she increases use of the affected arm and that this
should subside as collateral lymphatic circulation develops.
Increased swelling around incision(s). May indicate infection.
Purulent, foul-smelling drainage from incision site(s) or May indicate infection and/or delayed wound healing.
wound drain insertion site.
Dressings that become saturated with drainage more than
once a day.
Unexpected increase in or absence of drainage in collec-
tion device.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client will identify community

resources that can assist with adjustment to the diagnosis of
cancer and the loss of a breast.

Independent Actions
Provide information about community resources that can Identification of a social support network can assist the client in
assist the client and significant others with adjustment selection of the appropriate type of support system to meet the
to the diagnosis of cancer and the mastectomy (e.g., adjustment needs of the individual.
American Cancer Society, Reach to Recovery, National
Lymphedema Network, National Breast Cancer Coalition,
home health agencies, individual and family counselors).
Initiate a referral if appropriate.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcomes: The client, in collaboration with the

nurse will, develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, activity limitations,
exercises, wound care, and plans for subsequent treatment.

Independent Actions
Collaborate with client to develop a plan for adhering to Helps client to have confidence in ability to care for self.
discharge instructions.
Reinforce physician’s explanations and instructions regarding Ensuring the client understands the importance of adhering to a
future treatment (e.g., chemotherapy, radiation therapy, treatment plan may reduce the occurrence of adverse outcomes.
hormone therapy such as tamoxifen, breast reconstruc- The client should be given time to clarify and ask questions
tion) if planned. as appropriate.
Explain the importance of having follow-up breast exams
and mammography as prescribed.
 Chapter 14 * The Client With Alterations in the Breast and Reproductive System 733

THERAPEUTIC INTERVENTIONS RATIONALE

Reinforce the physician’s instructions regarding activity limi-
tations. Instruct client to:
e Avoid lifting heavy objects (over 5-10 pounds) until Prevents injury, develops muscle strength slowly.
wound has healed (usually about 4-6 weeks).
e Avoid driving until approved by physician (usually about Prevents strain on surgical site/side and decreases risk for potential
2 weeks). injury.
Review physician’s instructions regarding exercises (eran Assure the client understand how and when to do exercises.
squeezing a ball, bending and flexing wrist and elbow, A written plan provides a resource for client following discharge.
hand wall climbing, pulley exercises, rope turning, arm
swings, elbow pull-in, scissors). Instructions should in-
clude when to start exercises, frequency, and a written
description and/or pictures of how to perform them.

ADDITIONAL CARE PLANS

BATHING SELF-CARE DEFICIT/DRESSING INEFFECTIVE COPING NDx

SELF-CARE DEFICIT NDx Related to:
- Related to: e Perceived loss of femininity and embarrassment associated
e Impaired physical mobility associated with pain, the depres- with loss of a breast
sant effect of anesthesia and some medications (e.g., narcotic e Fear of rejection by significant others
[opioid] analgesics, some antiemetics), fear of dislodging ° Fear, anxiety, and feelings of loss of control associated with
tubes and compromising surgical wound, and prescribed arm the diagnosis of cancer, subsequent treatment (e.g., exter-
movement restrictions on the operative side nal radiation therapy, chemotherapy, hormone therapy) if
planned, and possibility of disease recurrence

RADICAL PROSTATECTOMY
)p A radical prostatectomy is performed to treat cancer of the OUTCOME/DISCHARGE CRITERIA
prostate. The surgery includes removal of the prostate gland,
prostatic capsule, seminal vesicles, and part of the vas defer- The client will:
ens. In addition, a portion of the bladder neck is sometimes 1. Maintain adequate urine output
removed before the anastomosis of the remaining urethra to 2. Have normal healing of the surgical wound
the bladder neck. A pelvic lymphadenectomy is usually per- 3. Have surgical pain controlled
formed concurrently if the cancer has spread into the pelvic 4. Have no signs and symptoms of infection or postopera-
lymph nodes. A radical prostatectomy is accomplished via tive complications
several methods. The retropubic or perineal approach is used 5. Demonstrate the ability to perform care related to the
depending on the size and position of the prostate, the anti- urinary catheter and drainage system
cipated extensiveness of surgery, and physician preference. A 6. Identify ways to manage urinary incontinence if it occurs
laparoscopic or robotic-assisted laparoscopic approach may after catheter removal
also be used. 7. Identify ways to manage bowel incontinence if present
Occasionally, the client will receive external radiation 8. Share feelings and concerns about the diagnosis of can-
therapy before surgery to reduce the tumor size. If there is cer, the prognosis, and changes in body functioning that
evidence of lymph node involvement, a course of external may occur as a result of a radical prostatectomy
radiation therapy may be done after the client recovers from 9. Discuss methods of obtaining sexual gratification if per-
the surgery. manent damage occurs.
This care plan focuses on the adult client with cancer of 10. State signs and symptoms to report to the health care pro-
the prostate who is admitted for a radical prostatectomy. vider
Much of the postoperative information is applicable to cli- 11. Develop a plan for adhering to recommended follow-up
ents receiving follow-up care in an extended care facility or care including future appointments with health care pro-
home setting. vider, medications prescribed, activity level, wound care,
and plans for subsequent treatment

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734 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED

Nursing Diagnosis URINARY RETENTION nox

Definition: Inability to empty bladder completely.

Related to:
e Blockage in the urinary tract
e Injury following surgery

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of bladder fullness or suprapubic discomfort Bladder distention, absence of urine in urinary catheter
drainage tubing, output that continues to be less than
intake 48 hrs after surgery

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will not experience urinary retention as evi-
e Strictures of the urethra denced by:
a. No_ reports of bladder fullness and suprapubic
discomfort
b. Absence of bladder distention
c. Balanced I&O within 48 hrs of surgery

NOC OUTCOMES NIC INTERVENTIONS

Urinary elimination Tube care: urinary; bladder irrigation

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of urinary retention: Early recognition ofsigns and symptoms of urinary retention allow
e Report of bladder fullness or suprapubic discomfort for prompt intervention.
e Bladder distention
e Absence of urine in the urinary catheter drainage tubing
e Output less than intake 48 hrs after surgery

THERAPEUTIC INTERVENTION RATIONALE

Independent Actions:
Monitor I&O. D@ + Indicates fluid balance. When client is receiving bladder irrigation,
the intake of irrigation fluid should be subtracted from catheter
output, thus equaling urine output.
Monitor vital signs and monitor changes. Increased or decreased vital signs indicate fluid volume increases or
dehydration. i
Note any behavioral changes including restlessness and May indicate increased cerebral edema from excessive solution
confusion. absorbed from bladder irrigation and decreased urine output.
Monitor bladder irrigation [&O. Flushes bladder of bacteria and clots from surgical procedure.
Monitor catheter drainage, noting color, volume of clots. Bright red urine with clots indicated bleeding. The physician
should be notified, as aggressive treatment is required.
Assure catheter tubing is free of kinks, and maintain collec- Dark red/burgundy urine indicates venous clots and does not require
tion bag below bladder and off floor. intervention, as it usually subsides without additional therapy.
Maintains patency of catheter to prevent urinary retention.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 735

THERAPEUTIC INTERVENTION RATIONALE

Dependent/Collaborative Actions:
Monitor laboratory values: For evaluation of ongoing bleeding or decrease in bleeding. A
e Hct/Hgb decrease in H/H may also indicate increased fluid volume.
¢ Coagulation studies Indicates bleeding and consumption of clotting factors.
Anchor catheter to thigh or abdomen. Anchoring catheter decreases in-and-out movement, and anchoring
the catheter to the abdomen places traction on arterial blood
supply to the prostate, decreases bleeding, prevents introduction
of microbes, and prevents inadvertent removal.
Release traction every 4 to 6 hrs. Prevents tissue damage or injury from prolonged pressure.
Administer stool softeners or laxative if ordered. Prevents constipation and straining associated with defecation,
which may increase bleeding.
Notify health care provider if bleeding remains bright red and Notification of health care provider allows for prompt change in
there is an increase of clots. treatment regimen.

Nursing Diagnosis RISK FOR INFECTION nox

_Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related to:
e Wound infection:
e Wound contamination associated with introduction of pathogens during or after surgery (especially with a perineal
approach because incision is close to the anus)
e Delayed wound healing associated with factors such as diminished tissue perfusion of wound area (especially if client
received external radiation therapy before surgery) and decreased nutritional status (if present)
e Urinary tract infection:
e Introduction of pathogens associated with presence of indwelling catheter
e Increased growth and colonization of microorganisms associated with urinary stasis (can occur with decreased activity
and catheter obstruction)

CLINICAL MANIFESTATIONS

Subjective Objective
Perineal wound infection: report of increased pain in Perineal wound infection: chills, fever, redness, heat,
wound area swelling in wound area, unusual wound drainage; foul
smelling odor from wound area, persistent elevation in
WBC count; change in differential count; positive wound
cultures
Urinary tract infection: verbal reports of frequency, Urinary tract infection: cloudy urine; positive urine
urgency and burning on urination culture, abnormal urinalysis

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will remain free of wound and urinary tract in-
e Poor preoperative nutrition fection as evidenced by:
e Catheterization a. Absence of chills/fever
b. Absence of redness, heat, swelling, and increased pain
in wound area
c. Usual drainage from wounds
d. Clear urine
e. White blood cell (WBC) and differential counts return-
ing toward normal
f. Urinalysis showing fewer than 5 WBCs, negative leuko-
cyte esterase and nitrites, and absence of bacteria
g. Negative cultures of wound drainage
h. Negative urine cultures

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736 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

NOC OUTCOMES NIC INTERVENTIONS

SA a ee ee
Immune severity; infection status; wound healing: primary Infection protection; infection control; wound care; tube
intention care: urinary

NURSING ASSESSMENT RATIONALE

Perineal wound infection: Early recognition of signs and symptoms of infection allows for
e Increased wound pain prompt intervention.
e Chills
e Fever
e Redness
e Heat
e Swelling in wound area
e Persistent elevation in WBC count
e Change in differential count
e Positive wound culture
Urinary tract infection:
Frequency; urgency; burning on urination; cloudy urine;
positive urine culture; abnormal urinalysis

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions:
Implement measures to prevent urinary tract infection:
e Maintain sterile technique during bladder irrigations if Actions to prevent urinary retention and subsequent stasis of urine.
performed. D
e Perform catheter care as often as needed. D @ + Actions help prevent accumulation of mucus and blood around the
meatus.
° Keep urine collection container below bladder level at all Actions help prevent reflux or stasis ofurine.
times. D @ +
e Anchor tubing securely. Actions help reduce the amount of in-and-out movement of the
If a perineal approach was used, implement additional mea- catheter (this movement can result in the introduction of
sures to prevent wound infection: pathogens into the urinary tract and can cause tissue trauma,
e Instruct and assist client to perform good perineal care which can result in colonization of microorganisms).
immediately after bowel movements.
e Use a double-tailed T-binder, scrotal support, or jockey Movement of loose dressings can cause skin irritation and subse-
shorts to secure perineal dressings. quent breakdown.

Dependent/Collaborative Actions
Implement measures to prevent urinary tract infection: Actions help promote urine formation and subsequent flushing of
pathogens from the bladder.
e Maintain a fluid intake of at least 2500 mL/day unless Maintenance of a closed system helps to prevent infections.
contraindicated.
e If frequent bladder irrigations are necessary, consult
physician about initiation of continuous, closed system
irrigation (frequent intermittent irrigations increase the
risk of introduction of pathogens).
e Increase activity as allowed. Improves circulation
e Administer antimicrobials as ordered. Antimicrobials prevent/treat infection.
e If signs and symptoms of urinary tract infection are Notifying the appropriate health care provider allows fdr modifica-
present, notify health care provider tion of the treatment plan.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 737

|Nursing 2-5"
Diagnos)is |DISTURBED SELF-CONCEPT*
|
Definition: Disturbed Body Image* NDx: Confusion in mental picture of one’s physical self; Situational
Low
Self-Esteem* NDx: Development of a negative perception of self-worth in response to a current situation;
Sexual Dysfunction* NDx: A state in which an individual experiences a change in sexual function during the
sexual response phases of desire, and or/orgasm, which is viewed as unsatisfying, unrewarding, or inadequate.
Related to: Temporary presence of urinary catheter (the catheter is usually not removed until 2-3 weeks after surgery);
bowel
incontinence if present and possible urinary incontinence after removal of the catheter; sterility and absence of
ejaculation associated with removal of the prostate gland, seminal vesicles, and a portion of the vas deferens;
possibility of impotence (especially after a perineal approach)

CLINICAL MANIFESTATIONS RATIONALE

Subjective Objective
Verbalization of negative feelings about self and sexual Lack of participation activities of daily living; refusal to
function perform catheter care; withdrawal from significant others
and partner

RISK FACTORS DESIRED OUTCOMES

© Changes i irouri ona EE ae eT SN A
ges in genitourinary functioning The client will demonstrate beginning adaptation to
changes in body functioning as evidenced by:
a. Verbalization of feelings of self-worth and sexual
adequacy
b. Maintenance of relationships with significant others
c. Active participation in activities of daily living
d. Discuss with partner potential changes in sexual func-
tioning

NOC OUTCOMES NIC INTERVENTIONS

Body image; personal autonomy; self-esteem; psychosocial Body-image enhancement; grief work facilitation; self-
adjustment: life change; sexual functioning esteem enhancement; role enhancement; counseling;
emotional support; counseling: sexuality; support system
enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of a disturbed self-concept: Early recognition of signs and symptoms of disturbed self-concept
e Negative feelings about self allows for prompt intervention.
e Lack of participation in activities of daily living
e Refusal to perform catheter care
e Withdrawal from significant others
e Changes in sexual functioning

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions:
Implement measures to facilitate the grieving process:
e Discuss with client improvements in bowel, bladder, and Working through the grieving process helps the client work through
sexual function that can realistically be expected. their physical changes.
° Assist client to identify and use coping techniques that Helps the client understand the healing process and functional
have been helpful in the past. ability over time.
Reinforces client’s normal defense mechanisms.

*The nurse should select the nursing diagnostic label that is most appropriate for the client’s discharge teaching needs.

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Inform client that when he is discharged, he will be able Helps client understand that he can care for self and no one will be
to connect his urinary catheter to a leg bag and that this aware of the leg bag.
bag will allow easier mobility and will not be visible when
wearing long pants.
If client is incontinent of stool and/or if incontinence of
urine is an anticipated problem after catheter removal:
e Reinforce the importance of doing perineal exercises when Improves bowel and bladder control.
allowed.
e Assist him to establish a routine bowel care program. Reduces the risk of bowel incontinence.
e Instruct in ways to minimize incontinence (e.g., placing Allows for social interaction without wearing a catheter.
disposable liners in underwear, wearing absorbent under-
garments such as attends).
Because sterility is expected, discuss alternative methods of Allows client to make appropriate decisions related to family
becoming a parent (e.g., adoption) if of concern to client. planning and potential future sexual functioning.
Reinforce physician’s explanation about the temporary or Allows time and a supportive environment for client to ask
permanent nature of the impotence; if it is expected to be questions concerning nature of changes and available actions
permanent, encourage client to discuss various treatment they can take to maintain sexual functioning.
options (e.g., medication, vacuum erection aids, penile
prosthesis) with physician if appropriate.
e Suggest alternative methods of sexual gratification if Assist client in exploring alternative methods of sexual gratification.
appropriate.
e Discuss ways to be creative in expressing sexuality (e.g.,
massage, fantasies, cuddling).
Support behaviors suggesting positive adaptation to changes
that have occurred (e.g., verbalization of feelings of self-
worth, compliance with treatment plan, maintenance of
relationships with significant others).
Assist client’s and significant others’ adjustment by listening, Improves communication between client and significant others
facilitating communication, and providing information. related to physical changes.
e Encourage visits and support from significant others.
e Encourage client to pursue usual roles and interests and to
continue involvement in social activities.
e Provide information about and encourage use of commu- Provides for continuum of care once discharged from the acute care
nity agencies and support groups (e.g., sexual, family, or facility.
individual counseling).

Dependent/Collaborative Actions:
Consult appropriate health care provider (e.g., psychiatric Notifying the appropriate health care provider allows for modifica-
nurse clinician, physician, sexual counseling) if client tion of the treatment plan.
seems unwilling or unable to adapt to changes resulting
from the radical prostatectomy.

DISCHARGE TEACHING/CONTINUED CARE

| Nursing _ DEFICIENT KNOWLEDGE nox; INEFFECTIVE HEALTH

MANAGEMENT nox; INEFFECTIVE FAMILY HEALTH
MANAGEMENT® nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting health goals; Ineffective
Family Health Management NDx: A pattern of regulating and integrating into family processes for the treatment
of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit.

*The nurse should select the diagnostic label that is most appropriate for the client’s discharge teaching needs.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 739

CLINICAL MANIFESTATIONS

Subjective Objective
Self-report of inability to manage illness and inability to Inaccurate follow-through with instructions; inappropriate
follow prescribed regimen behavior; refusal to participate in care

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen; Health system guidance; teaching: individual; teaching:
exercise; medication regimen; sexual functioning; disease process; teaching: prescribed exercise; teaching:
sexual identity psychomotor skill; pelvic muscle exercise

NURSING ASSESSMENT RATIONALE

e Assess client’s readiness and ability to learn Early recognition of readiness to learn and meaning of illness to
e Assess meaning of illness to client client allows for implementation of the appropriate teaching
interventions.
RISK FACTORS
° Cognitive deficits e Financial concerns
e Failure to take action to reduce risk factors e Lack of social support
~e Inability to care for self

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability to Ensuring that the client understands proper care of the catheter and
perform care related to the urinary catheter and drainage system. drainage system will help prevent infection.

Independent Actions:
Instruct client regarding care related to the urinary catheter
and drainage system including:
Washing the urinary meatus with soap and water at least Maintains perineal integrity and decreases incidence for infection.
twice a day.
Anchoring catheter tubing securely. Prevents in-and-out activity and decreases introduction of microbes.
Keep catheter and collection bag tubing free of kinks. Prevents stasis of urine and potential for infection.
Keep urine collection bag below the level of the bladder. Ensures urine flow out of the bladder and prevents backup into the
kidney.
Changing the leg bag to bedside collection bag when Prevents stasis of urine in the bag and decreases potential for infection.
laying down for more than a few hours.
Regular emptying the leg bag and the bedside collection Monitors urine output to assure that client has adequate urine
bag. production.
Measuring and recording the amount of urine output if Prevents decreased intake and subsequent decreased urine production.
prescribed.
Monitor fluid intake as prescribed.
Allow time for return demonstration and involve signifi- Increases client’s confidence in ability to care for self and for the
cant other in teaching if appropriate or client allows. nurse to assess when further instruction is required. Involving
the client’s significant other allows them to engage in client’s
care and support prescription for self-care.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

urinary incontinence if it occurs after catheter removal.

Independent Actions:
Provide information about ways to reduce the risk of urinary Incontinence can occur as a result of trauma to urinary sphincters
incontinence after removal of the urinary catheter: during surgery and/or irritation from the urinary catheter,
damage to the pelvic nerves during surgery, and/or a temporary
decrease in bladder function while the catheter was in place.
e Teach client to attempt to urinate every 2 to 3 hrs and Bladder training to begin urinating regularly following catheter
when the urge is felt. removal.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Urinate in a standing or sitting position. Facilitates complete bladder emptying.
e Avoid drinking large quantities of liquid over a short Increases urine production and increases potential for incontinence.
period of time.
e Limit intake of alcohol and caffeine-containing beverages. Alcohol and caffeine have a mild diuretic effect and act as irritants
to the bladder; products containing alcohol and caffeine may
make urinary control more difficult.
e Stop drinking liquids a few hours before bedtime. Reduces risk of nighttime incontinence.
e Avoid activities that make it difficult to empty bladder as May increase the incidence of incontinence.
soon as the urge is felt (e.g., long car rides, lengthy meetings)
e Reinforce the importance of performing perineal exercises These activities strengthen the pelvic floor and can decrease
regularly when allowed (e.g., stopping and starting urine or eliminate the incidence of incontinence. They should be
stream during voiding without holding breath or tensing practiced daily for the rest of the client's life.
muscles in buttocks, legs, or abdomen; squeeze buttocks
together and then relaxing muscles; develop a Kegel
exercise plan).
e If incontinence occurs, the client should wash and dry Decreases incidence of infection.
perineal area after each episode.
e Wear disposable underwear liners or absorbent undergar- Keeps perineal area clean and dry, prevents irritation and potential
ments. for infection.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: Discuss methods of obtaining sexual

gratification if permanent damage occurs.

Independent Actions:
Provide time for client and significant other to discuss the
following:
Impact of physical changes on their lives.
Discussion of new methods to provide sexual gratification Allows for expression of concerns, grief, and loss in a safe, pro-
agreeable to both parties. tected environment.
Allow time for client and partner to grieve loss of function
due to surgery.
Provide time and privacy, if interested, to explore and
possibly experiment prior to discharge.
Consult sex therapist to work with client and partner. Consult with an expert that can assist client and partner to explore
options for sexual gratification.
Refer client to community resources or groups that are Provides for continuum of care and support from others who have
dealing with post radical prostatectomy changes that experienced the same changes.
impact quality of life.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions:
Instruct the client to report the following signs and symp-
toms: ¢
+ ;
Urinary or bowel incontinence that persists longer than Educate the client regarding signs and symptoms requiring evalua-
expected, worsens, or interferes with daily life. tion by a health care provider can help reduce the occurrence of
Persistent or unexpected impotence. complications and improve health outcomes.
Difficulty coping with the diagnosis of cancer and/or the Indicates possible urinary tract infection and/or system blockage.
effects of the radical prostatectomy on body functioning.
Fever, chills, elevated temperature.
Cloudy urine.
Decreased urine output.
 Chapter 14 * The Client With Alterations in the Breast and Reproductive System 741

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions:
The client, in collaboration with the nurse, will develop a
plan for adhering to recommended follow-up care includ-
ing future appointments with health care provider, medi-
cations prescribed, activity level, wound care, and plans
for subsequent treatment.
° Collaborate with client to develop a daily and weekly Assures that client has a written plan in place for follow-up, under-
schedule integrating all prescribed activities required to stands all instructions, and has a schedule for implementation
promote recovery and improved health. of exercise plan, self-care, and follow-up appointments with
Discuss appropriate diet and exercises to implement. health care provider. This also allows the nurse additional time
e Encourage client to stop smoking, if appropriate, and to reinforce information, support, and access to community
provide community resources for success. resources post discharge.
Reinforce health care provider’s instructions, prescrip-
tions, and answer any follow-up questions.
Explain importance of follow-up appointments with
health care provider.
Instruct client to avoid lifting heavy objects (over 5 Ibs)
until allowed by health care provider.
e Avoid driving until allowed by health care provider.
Discuss importance of adhering with follow-up appoint-
ments with health care provider.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions:
Instruct the client to report the following signs and symptoms:
e Urinary or bowel incontinence that persists longer than Educate the client regarding signs and symptoms requiring evalua-
expected, worsens, or interferes with daily life. tion by a health care provider can help reduce the occurrence of
Persistent or unexpected impotence. complications and improve health outcomes.
Difficulty coping with the diagnosis of cancer and/or the
effects of the radical prostatectomy on body functioning.
Fever, chills, elevated temperature.
Cloudy urine.
Changes in urine output or increase in bleeding or expel-
ling clots.
Continued bladder fullness after voiding. Possible infection
Unable to pass urine. Possible urinary tract infection and/or system blockage.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to manage

bowel incontinence if present.

Independent Actions:
If the client is experiencing bowel incontinence, instruct to:
e Adhere to a routine bowel care program.
° Perform perineal exercises regularly when allowed (e.g., Prevent or decrease potential for uncontrolled defecation.
stopping and starting urine stream during voiding without
holding breath or tensing muscles in buttocks, legs, or
abdomen; squeeze buttocks together and then relax
muscles; develop a Kegel exercise plan).
° Wash and dry perineal area following each episode of Improves sphincter control and decreases potential for inability to
incontinence. hold urine.
° Wear disposable underwear liners or absorbent undergar- Prevents potential cross contamination and infection.
ments such as Attends if needed. Prevents potential embarrassing events.

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742 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

TRANSURETHRAL RESECTION OF THE PROSTATE

Transurethral resection of the prostate (TURP) is the surgical transurethral vaporization, and transurethral microwave ther-
removal of a prostatic adenoma through the urethra, while motherapy. Factors influencing the treatment method se-
leaving the true prostate and its fibrous capsule intact. It may lected include the client’s age and health status, size of the
be performed to remove a small cancerous prostatic tumor but enlarged prostate, presence of complications, and physician/
most frequently is done to remove a benign prostatic neoplasm client preference and physician expertise.
that has enlarged enough to block the bladder neck or urethra. This care plan focuses on the adult client with
Benign prostatic hyperplasia (BPH) is common in men BPH who is undergoing a TURP. The information is
over 50 years of age and results from age-associated changes applicable to clients having surgery in a hospital or
in androgen levels. Hyperplasia usually occurs gradually and outpatient (e.g., surgical care center) setting.
involves the medial portion of the prostate gland, which sur-
rounds the urethra. Treatment is indicated when signs and
symptoms of prostatism (e.g., urgency, frequency, hesitancy, OUTCOME/DISCHARGE CRITERIA
decreased force of urinary stream, nocturia, post-void drib-
bling) become problematic or when complications such as The client will:
recurrent urinary tract infection, urinary retention, hematu- 1. Maintain adequate urine output
ria, renal calculi, or hydronephrosis occur. 2. Have bladder spasms controlled
TURP is the most common surgical method for treating 3. Exhibit no signs and symptoms of infection or postopera-
BPH. If the prostate gland is very large, an open prostatec- tive complications
tomy using a suprapubic or retropubic approach may be 4. Identify ways to decrease or prevent bleeding in the surgi-
necessary. There are a variety of methods to treat BPH. Medi- cal area
cal therapy includes pharmacological intervention with doxa- 5. Practice exercises to regain or maintain control of bladder
zosin, tamsulosin, terazosin, or finasteride. When medical emptying
intervention is no longer effective, surgery is indicated. There 6. State signs and symptoms to report to the health care
are a variety of surgical procedures to treat BPH. These include provider
but are not limited to laser incision or removal of prostatic 7. Develop a plan for adhering to recommended follow-up
tissue, transurethral resection “roto rooter,” placement of a care including future appointments with health care pro-
stent or coil in the prostatic urethra, balloon dilation, vider, medications prescribed, and activity level

POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED

POSTOPERATIVE CARE PLAN

: Nursing Diagnosis IMPAIRED URINARY ELIMINATION nox

Definition: Dysfunction in urine elimination.

Related to: Retention:

e Obstruction of the urinary catheter
¢ Difficulty urinating after removal of the catheter associated with:
e Loss of bladder muscle tone resulting from hypertrophy of the detrusor muscle as BPH developed, overdistention of the
bladder preoperatively, and/or decompression of the bladder when the catheter was present
e Relaxation of the bladder muscle resulting from stimulation of the sympathetic nervous system (can result from surgical
site discomfort, fear, and anxiety) and the depressant effect of some medications (e.g., narcotic [opioid] analgesics)
e Decreased perception of bladder fullness resulting from the depressant effect of some medications (e.g., narcotic
[opioid] analgesics)
e Obstruction of the urethra and bladder neck by blood clots, tissue debris, and/or edema (can occur as a result of surgical
instrumentation, irritation from the urethral catheter, and/or pressure from the catheter balloon if traction was applied
postoperatively)
Incontinence after catheter removal: Trauma to the urinary sphincter(s) associated with surgical instrumentation, irritation
from the urethral catheter, and/or pressure from the catheter balloon if traction was applied postoperatively
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 743

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal reports of bladder fullness; increasing need to strain
Bladder distention; absence of urine in urinary drainage
to empty bladder; increasing urgency; feeling of bladder
bag; output that continues to be less than intake 48 hrs
fullness after voiding after surgery; voiding frequent small amounts of urine
(after removal of catheter)

RISK FACTORS DESIRED OUTCOMES

e Surgical procedure
The client will:
e Preoperative urinary retention
° Medication regimen a. Not experience impaired urinary elimination as
e Age evidenced by:
e No reports of bladder fullness and suprapubic
discomfort
e Absence of bladder distention
e Balanced I&O within 48 hrs after surgery
e Voiding adequate amounts at expected intervals
after catheter removal
b. Experience urinary continence

NOC OUTCOMES NIC INTERVENTIONS

i

Urinary continence; urinary elimination Urinary incontinence care; urinary retention care; bladder
irrigation; catheter care: urinary; pelvic muscle exercise

NURSING ASSESSMENT RATIONALE

Assess for and report signs of impaired urinary elimination: Early recognition of signs and symptoms of impaired urinary
e Reports of bladder fullness elimination allows for prompt intervention.
e Increasing need to strain to empty bladder
e Increasing urgency
e Bladder distention
e Absence of urine in urinary drainage bag
e Output that continues to be less than intake 48 hrs after
surgery
e Voiding frequent small amounts of urine (after removal of
catheter)
e Experience of incontinence

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain patency of the urinary Maintaining patency of urinary catheter helps prevent urinary
catheter: retention.
¢ Keep drainage tubing free of kinks. D @ + Prevents backup of urine into the kidney.
e Keep collection container below level of bladder. Promotes urine drainage.
e Tape catheter securely to abdomen or thigh. D + Prevents inadvertent removal of the catheter.
Monitor I&O. To assure adequate urine output particularly when client is receiv-
ing continuous bladder irrigation.
Implement measures to prevent trauma to the urinary Prevents excessive movement of the catheter. In-and-out movement
sphincter(s) while the catheter is in place to reduce the risk of the catheter may introduce microbes into the bladder.
of urinary incontinence after removal of the catheter:
e Anchor catheter securely to client’s abdomen or thigh. D +
After removal of the catheter, implement measures to reduce
the risk of urinary incontinence:
e Offer urinal or assist client to bathroom every 2 to 4 hrs if Encourages voiding to prevent status of urine.
indicated. D® > Prevents the bladder becoming too full and overstretching prior to
¢ Keep urinal within easy reach of client. voiding.

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744 Chapter 14 = The Client With Alterations in the Breast and Reproductive System

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Instruct client to urinate when the urge is first felt. A hypotonic bladder can be easily distended and client needs to
become more aware of urge to void following catheter removal.
e Perform actions to promote relaxation during voiding Actions promote relaxation of the bladder sphincter and promote
attempts (e.g., provide privacy, have client sit to void, hold voiding.
a warm blanket against abdomen).
e Perform actions that may help trigger the micturition
reflex and promote a sense of relaxation during voiding
attempts (e.g., run water, place client’s hands in warm wa-
ter, encourage client to urinate when in shower). D @ +
e Allow client to assume a normal position for voiding un-
less contraindicated. D@ +
e Instruct client to perform perineal exercises (e.g., stopping Actions help strengthen pelvic floor muscles and improve tone of
and starting stream during voiding; squeezing buttocks the external urinary sphincter that leads to better bladder
together, then relaxing the muscles) regularly. elimination control.
° Limit oral fluid intake in the evening. D + Actions help decrease the possibility of nighttime incontinence.
e Instruct client to limit intake of alcohol and beverages Alcohol and caffeine have a mild diuretic effect and act as irritants
containing caffeine. to the bladder; these factors may make urinary control more
difficult.
e Instruct client to space fluids evenly throughout the day Rapid filling of bladder can result in increased urine production
rather than drinking a large quantity at one time. and the potential for incontinence.

Dependent/Collaborative Actions
e Perform and monitor bladder irrigations as ordered. Promotes excretion of clots and debris from surgical procedure.
If signs and symptoms of urinary retention occur after removal Notifying the appropriate health care provider allows for modifica-
of the catheter, consult physician about intermittent cath- tion of the treatment plan.
eterization or reinsertion of an indwelling catheter.
If continued bleeding occurs during bladder irrigation or uri- Allows for prompt modification of treatment plan.
nary incontinence persists, consult physician regarding
intermittent catheterization, reinsertion of an indwelling
catheter, or use of external collection device (e.g., condom
catheter).

|Nursing =.
Diagnosis IMPAIRED COMFORT nox (BLADDER SPASMS), ACUTE PAIN nox

Definition: Impaired Comfort NDx: Perceived lack of ease, relief, and transcendence in physical, psychospiritual,
environmental, cultural, and/or social dimensions; Acute Pain NDx: Unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage, or described in terms of such damage (International
Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated
or predictable end, and with a duration of less than 3 months.

Related to: Irritation of the bladder wall associated with tissue trauma during surgery, presence of urinary catheter, rapid
infusion of irrigation solution, and distention of the bladder (can occur if urine flow becomes obstructed);
increased pressure on the bladder neck and prostatic fossa if traction is applied to the urethral catheter (traction
may be applied to pull the catheter balloon into the prostatic fossa to put pressure on bleeding vessels)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of suprapubic discomfort; urgent need to Leakage of urine around the urinary catheter; intermittent
urinate or defecate; verbal self-report of pain periods of increase in bloody urine/bladder irrigation
 Chapter 14 * The Client With Alterations in the Breast and Reproductive System 745

RISK FACTORS DESIRED OUTCOMES

e Surgery
e Three-way urinary catheterization The client will experience relief of impaired comfort and
e Bladder irrigation pain as evidenced by:
a. Verbalization of relief of suprapubic discomfort and
pain
b. No reports of an urgent need to urinate or defecate
c. No leakage of urine around the urinary catheter

NOC OUTCOMES NIC INTERVENTIONS

Comfort level; symptom control; comfort status: physical Medication administration; catheter care

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of altered comfort: Early recognition of signs and symptoms of altered comfort/bladder
bladder spasms: spasms allows for prompt intervention.
e Suprapubic discomfort
e Urgent need to urinate or defecate
Leakage of urine around the urinary catheter
e Intermittent periods of increase in bloody urine/bladder
irrigation
° Assess for and report symptoms of acute pain:
e Assess the client’s pain using a standardized pain scale Use of a pain intensity rating scale gives the nurse a clearer
including location, quality, onset, duration, precipitating understanding of the client’s pain experienced, changes in
factors, aggravating factors, alleviating factors pain over time, and promotes consistency when communicat-
ing with others.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Maintain patency of the urinary catheter (e.g., irrigate as Maintains flow and prevents stasis of urine.
needed, keep tubing free of kinks).
Perform actions to reduce movement of the catheter: Actions help decrease the impaired comfort and pain including risk
e Anchor catheter securely to client’s abdomen or thigh. of bladder spasms and prevent bladder distention.
e Instruct client to avoid pulling on and twisting the catheter. Decreases ongoing irritation of the urethra and bladder.
Release traction on the catheter every 4 to 5 hrs or more Reduces pressure on the bladder neck and fossa.
frequently as ordered. D +
Do not increase frequency of bladder irrigations or speed up Excessive or rapid bladder irrigation can irritate the bladder
continuous irrigation unless bleeding is noted or blood mucosa.
clots or tissue debris are present. D +
Instruct client to avoid attempting to urinate around the Attempts to forcefully contract bladder can stimulate bladder
catheter and straining to urinate after catheter is removed. spasms.
If bladder spasms occur: Reduces muscle tension, refocuses client’s attention, and provides
Encourage client to take deep breaths, use guided imagery, relaxation that may decrease bladder spasms.
watch Tv or listen to music.
e Encourage client to take short, frequent walks unless Walking seems to reduce spasms.
contraindicated. D +
e Decrease the rate of continuous bladder irrigation if urine May decrease bladder spasms and client’s feeling of bladder
is not red and blood clots and tissue debris are not present. fullness and pressure.

Dependent/Collaborative Actions
If bladder spasms occur: Reduces spasm of the bladder muscle and the client’s perception of
e Administer belladonna and opium (B&O) rectal supposito- pain and discomfort; it is only prescribed when the urinary
ries if ordered (this is a combination of an antimuscarinic catheter is present because it can cause urinary retention.
and narcotic analgesic).
e Anticholinergics: Propantheline bromide. Relieves bladder spasms while client has a catheter.
Consult physician if above measures fail to control bladder Notifying the appropriate health care provider allows for modifica-
spasms. tion of the treatment plan.

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746 Chapter 14 = The Client With Alterations in the Breast and Reproductive System

Nursing Diagnosis RISK. FOR BLEEDING NDx

Definition: Susceptible to a decrease in blood volume, which may compromise health.

Related to: Surgical procedure of the prostate gland, which is very vascular

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Bright red drainage (could indicate arterial bleeding) or
persistent darker drainage (venous bleeding) and blood
clots in urinary catheter; persistent redness of and blood
clots in urine after removal of the catheter; significant
decrease in RBC, Hct, and Hgb levels; tachypnea; hypoten-
sion; tachycardia; decreased urine output; pallor; cool,
clammy skin; anxiety; confusion; agitation; capillary
refill > 2 to 3 seconds; declining SaO,

RISK FACTORS DESIRED OUTCOMES

e Inadequate fluid volume replacement The client will not develop excessive bleeding as evi-
e Trauma from surgery denced by:
° Age a. Usual mental status
e History of taking NSAIDS, anticoagulants b. Stable vital signs
c. Skin warm and usual color
d. Palpable peripheral pulses
e. Urine output at least 30 mL/h

NOC OUTCOMES NIC INTERVENTIONS

Blood loss severity Bleeding precautions; bleeding reduction; bladder irrigation

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of excessive bleed- Early recognition of signs and symptoms of excessive bleeding
ing: allows for prompt intervention.
e Bright red drainage (could indicate arterial bleeding) or
persistent darker drainage (venous bleeding) and blood
clots in urine.
e After removal of the catheter; significant decrease in RBC,
Hct, and Hgb levels.
e Tachypnea; hypotension; tachycardia; decreased urine
output; pallor; cool, clammy skin; anxiety; confusion and
agitation.
e Capillary refill >2 to 3 seconds.
e Declining SaOQz.
Assess serum Hgb/Hct and report any abnormalities. Changes indicate extent of blood loss.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions ,
Monitor I&O, noting color, consistency, and volume of clots. Indicates fluid balance and ifreplacement is required. When client
is on bladder irrigation, monitoring of the volume of clots and
color and consistency of urine is an indication of bleeding.
Bright red indicates arterial bleeding; dark red/burgundy with
increased viscosity and clots indicate venous bleeding, which
may decrease without intervention.
Monitor vital signs: Decreased blood pressure and increased heart rate are indications
BP; heart rate, respirations, and capillary refill. of hypovolemia. Compare these findings to IXO and extent of
bleeding noted in urinary drainage. Increased capillary refill
time and increased reparations may indicate excessive bleeding
and decreased fluid volume.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 747

THERAPEUTIC INTERVENTIONS
RATIONALE
Monitor for any behavioral changes, restlessness. or
Indicates declining fluid volume and cerebral perfusion pressure,
confusion.
which may be associated with increased bleeding.
Encourage fluid intake greater than 2000 mL/day if not con-
Helps to maintain vascular fluid volume.
traindicated once catheter is removed.
Instruct client to take short rather than long walks and to
Ambulation improves circulation and venous return.
avoid sitting for long periods.
Instruct client to avoid straining to have a bowel movement.
Prevents stress on surgical site.
Implement measures to prevent urinary retention.
Actions help prevent distention of the bladder and subsequent pres-
sure on the newly coagulated blood vessels in the operative area.
Instruct client to return to bed and limit activity for a few Rest decreases pressure on bladder and surgical area.
hours if urine has increased redness when ambulating or
sitting in chair.

Dependent/Collaborative Actions:
Monitor laboratory values:
Hgb/Hct. Decrease in values may indicate dilutional results or based on I&O
could indicate active bleeding.
Coagulation studies and platelet count. Decrease in findings indicates active bleeding and consumption of
clotting factors.
Administer IV fluids and blood products as ordered. Replacement for vascular volume and oxygen-carrying capabilities.
Maintain traction on the urethral catheter as ordered (pro- Measures help to prevent or control hemorrhage to prevent hypovo-
vides direct pressure on the bleeding vessels). lemic shock.
e Anchor catheter tubing securely to client’s abdomen or Actions help to prevent trauma to and/or unnecessary pressure on
thigh to minimize movement of catheter. the prostatic area, thereby reducing the risk of hemorrhage.
e Administer stool softeners if indicated. Decreases risk of constipation and potential for straining with a
bowel movement, thus decreasing pressure on surgical site and
risk for bleeding.

~ ---s«& RISK FOR IMBALANCED FLUID VOLUME nox

Definition: Susceptible to a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or
intracellular fluid, which may compromise health. This refers to body fluid loss, gain, or both.
Related to:
e Vigorous fluid therapy during and immediately after surgery; increased secretion of antidiuretic hormone (output of antidi-
uretic hormone [ADH] is stimulated by trauma, pain, and anesthetic agents); excessive absorption of irrigation solution via
the prostatic veins during and after surgery. “TUR syndrome” resulting from the absorption of large volumes of bladder ir-
rigation fluid in surgery and early postoperative period.
e Potential for bleeding during and after surgical procedure
e Increased diuresis following removal of prostate and opening of urinary tract

CLINICAL MANIFESTATIONS

Subjective Objective
Fluid volume excess: reports of dyspnea; orthopnea, Fluid volume excess: elevated BP; presence of S3 heart
confusion sound; bounding pulse, change in mental status; intake
greater than output; decreased BUN, Hct, serum sodium
and osmolality; chest radiograph results demonstrating
pulmonary congestion
Fluid volume deficit: complaints of thirst and dry mouth Fluid volume deficit: decreased blood pressure, normal or
high serum sodium and osmolality; increased Hct, and
urine osmolality

NDx = NANDA Diagnosis D = Delegatable Action @=UAP @ =LVN/LPN © = Go to @volve for animation
748 Chapter 14 = The Client With Alterations in the Breast and Reproductive System

RISK FACTORS DESIRED OUTCOMES

e Surgery The client will not experience imbalanced fluid volume as
e Excessive bladder irrigation evidenced by:
e Endocrine response to trauma . Stable weight
Ace . Stable BP
. Absence of S3 heart sound
. Normal pulse volume
. Balanced I&O within 48 hrs after surgery
Usual mental status
ds»BUN, Hct, serum
amoan
sodium, and osmolality within nor-
mal range
3. Absence of dyspnea, orthopnea, edema, and distended
neck veins

NOC OUTCOMES NIC INTERVENTIONS

Fluid overload severity; fluid balance; fluid volume Fluid monitoring; fluid management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of fluid volume Early recognition of signs and symptoms of fluid volume imbalance
excess: allows for prompt intervention.
e Dyspnea, orthopnea
e Increased blood pressure
e §, heart sound: bounding pulse, change in mental status
e Intake greater than output
Assess serum electrolytes, BUN, Hct, serum sodium, and
osmolality, reporting any abnormal values.
Assess chest radiograph results, reporting any abnormalities.
Assess for and report fluid volume deficit:
e Decreased blood pressure, heart rate
e High serum sodium and osmolality
e Increased Hct and urine osmolality
e Complaints of thirst and dry mouth

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions:
Monitor I&O. While patient is on bladder irrigation, the potential for increased
fluid volume is great and strict IXO will alert the health care
team of changes.
Monitor vital signs, documenting and analyzing trends. Both dehydration and fluid volume excess require prompt interven-
tion to prevent shock.
Monitor mental status, noting restlessness, confusion, or Changes in mental status and behavior reflect cerebral perfusion
change in behavior. and edema from excessive bladder irrigation fluids.
Monitor catheter drainage, noting extent and continuation of Bleeding may occur with the first 24 hrs following surgery. Ongoing
bleeding. or excessive bleeding should be reported due to potential vascu-
lar deficit and depletion of clotting factors.

Dependent/Collaborative Actions ' : t

Monitor laboratory values: Indicate fluid volume status and impact of bleeding, if occurring.
e Hct/Hgb and sodium.
e Urine osmolality.
* Coagulation studies. Indicates status of clotting factors.
Administer IV fluids as ordered. Maintain vascular fluid volume status.
Infuse packed red blood cells (RBCs) if ordered. May be required due to excessive bleeding.
Maintain traction on urinary catheter by taping to abdomen Traction on catheter applies pressure on the artery supply to the
or thigh. prostate and helps to control bleeding.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 749

THERAPEUTIC INTERVENTIONS
RATIONALE
Release traction every 4 to 5 hrs or per hospital policy.
Continuous traction may cause long-term or permanent nerve
damage.
Diuretics are given to decrease excess fluid volume.
Administer medication as ordered:
Stool softeners are given to decrease straining with bowel move-
e Diuretics
ment. Straining increases pressure on the perineum and may
° Stool softeners cause increased bleeding.
Use normal saline rather than hypotonic solutions for blad-
Decreases fluid volume shifts.
der irrigations.
Do not increase frequency of bladder irrigations or increase
Actions help reduce absorption of fluid via the prostatic veins to
speed of continuous irrigation unless indicated.
further reduce the risk for excess fluid volume and/or water
intoxication.
Notify physician if signs and symptoms of fluid deficit or Notifying the appropriate health care provider allows for modifica-
overload develop. tion of the treatment plan.

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx, INEFFECTIVE FAMILY HEALTH

MANAGEMENT, INEFFECTIVE HEALTH MANAGEMENT? nox
Definition: Deficient Knowledge NDx: Absence of cognitive information related to specific topic, or its acquisition;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family process a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of
the family unit; Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a
therapeutic regimen for treatment of illnesses and its sequelae that is unsatisfactory for meeting specific health
goals.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to manage illness and Inaccurate follow-through with instructions; inappropriate
inability to follow prescribed regimen behavior; refusal to participate in care

RISK FACTORS
° Cognitive deficit
e Failure to reduce risk factors
e Inability to care for oneself
e Difficulty in modifying personal habits and integrating
treatments into lifestyle
e Changes in body functioning

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen Health system guidance; teaching: individual; teaching:
disease process; teaching: prescribed exercise; pelvic muscle
exercise; teaching: catheter care

*The nurse should select the nursing diagnostic label that

is most appropriate for the client’s discharge teaching needs.

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750 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

NURSING ASSESSMENT RATIONALE

Assess client’s ability to learn and readiness to learn Learning is more effective when the client is motivated and under-
Assess understanding of patient teaching stands the importance of what is to be learned. Readiness to learn
is based on situations and physical and emotional challenges.

THERAPEUTIC INTERVENTIONS RATIONALE —$$§$S

e
era e

Desired Outcomes: The client will identify ways to pre-

vent bleeding in the surgical area.

Independent Actions
Instruct client in ways to prevent bleeding in the surgical
area:
e Avoid straining during defecation (provide instructions Prevents stress on perineum and surgical site.
about increasing fluid intake and intake of foods high in
fiber if client tends to be constipated).
e Avoid long walks, prolonged sitting, long car rides, run- Increased pressure on perineal area will increase potential for
ning, climbing stairs quickly, strenuous exercise, sexual bleeding. Client should increase activity slowly over time.
intercourse, and lifting objects over 10 pounds for as long
as recommended by physician (usually for 2-6 weeks after
discharge).
e Consult physician before resuming preoperative medica- These medications impact blood clotting and may increase
tions such as aspirin and other NSAIDs, warfarin, and risk for bleeding.
clopidogrel (physicians often recommend waiting 1-2 weeks
after surgery if possible before resuming these medications).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to regain

or maintain control of bladder and bowel emptying.

Independent Actions
Instruct client in ways to regain or maintain control of blad-
der emptying:
e Try to urinate every 2 to 3 hrs and whenever the urge is felt. Prevents bladder from getting too full and decreases incidence of
incontinence.
e Urinate in a standing or sitting position. Assuming normal voiding position will help to facilitate bladder
e Instruct client in ways to regain or maintain control of emptying.
bowel emptying.
e Attempt to have a bowel movement at routine times con-
sistent with client’s habits before surgery.
e Attempt to have a bowel movement when the urge is first Facilitates bowel evacuation. Will begin to train bowel of when to
felt. defecate and attempting to have frequent bowel movements will
e Begin bowel training routine if necessary. decrease incidence of bowel incontinence.
Eat a well-balanced diet full of fiber and fluids. Adequate fiber is necessary to maintain bowel patterns. May need
to decrease volume of fiber during periods of incontinence.
e Avoid drinking large quantities of liquids over a short period. Increases urine production and the need to void.
e Limit intake of alcohol and caffeine-containing beverages. Alcohol and caffeine have a mild diuretic effect and act as irritants to
the bladder; these factors may make urinary control more difficult.
e Drink fluids at regular times throughout the day. Drink Stop drinking liquids a few hours before bedtime (reduces risk of
less in the evening a few hours before bedtime. urine retention and nighttime incontinence).
e Avoid long car rides, lengthy meetings, etc. that require Avoid activities that make it difficult to empty bladder as soon as
holding urine for an extended period of time. the urge is felt. Prevents risk for increased retention and for in-
continence. This also prevents increased bowel incontinence due
to lack of an available bathroom.
 Chapter 14 = The Client With Alterations in the Breast and Reproductive System 751

THERAPEUTIC INTERVENTIONS
RATIONALE
e Perform perineal exercises (e.g., stopping and
starting Improves bladder and bowel control and muscle strength of
stream during voiding; squeezing buttocks togethe
r, then perineum.
relaxing the muscles) 10 to 20 times/hour while awake
until urinary control is regained.
° Begin routinely practicing Kegel exercises.
If client is experiencing urinary incontinence, instruct
to: Allows client to increase mobility and activity without potential
° Wear disposable underwear liners or absorbent underga
r- embarrassment of incontinence.
ments such as Attends if necessary.

THERAPEUTIC INTERVENTIONS RATIONALE

~PRRE
e I SEIaregDe i
Desired Outcome: S a
The client will state signs and symp-
toms to report to the health care provider.

Independent Actions
Instruct client to report these additional signs and symptoms:
° Persistent burgundy-colored or bright red urine (inform
Educating the client regarding signs and symptoms requiring evalu-
client that some blood is expected intermittently for ation by a health care provider can help reduce the occurrence
- 2-3 weeks after surgery but that urine should become pink of complications and improve health outcomes.
to amber after he rests and increases fluid intake for a
couple of hours).
° Presence of large blood clots or continued passage of Indicates bleeding.
smaller clots.
° Development of or increase in frequency, burning, or pain Indicates possible infection.
when urinating.
e Decrease in urine output or force and caliber of urinary
stream.
e Bladder distention. Indicates possible urinary blockage.
e Unexpected loss of bladder control. Indicates changes in muscular or neurologic control.
e Cloudy urine unrelated to orgasm. It is expected that urine will be cloudy after orgasm if client is
e Persistent or increased bladder spasms. experiencing retrograde ejaculation.
e Chills, fever.
e Difficulty in voiding or inability to urinate.
Consult physician if urinary incontinence persists, worsens, Allows for changes in therapeutic regimen.
or interferes with daily life so that various options (e.g.,
biofeedback, insertion of artificial urinary sphincter) can
be discussed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: Discuss methods of obtaining sexual

gratification if permanent damage occurs.

Independent Actions:
Provide time for client and partner to discuss concerns related to: Explain in terms that the client and partner can understand con-
Urinary incontinence cerning the anatomy of an erection and ejaculation and how
Bowel incontinence that has changed with the surgical procedure.
Retrograde ejaculation
Reinforce information provided by the physician concern- Reinforcement of information provided by the physician provides
ing sexual performance changes. for consistent information and whether changes are permanent.
Encourage client to continue with pelvic strengthening Client needs to be aware that over time these exercises will reduce
exercises and Kegels. or eliminate urinary or bowel incontinence.
Refer client to community resources, support groups, or Provides for continuum of care.
counselor as indicated.
If changes in sexual functioning occur, recommend client to Allows for changes in treatment regimen.
discuss situation with health care provider.

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752 Chapter 14 * The Client With Alterations in the Breast and Reproductive System

THERAPEUTIC e
INTERVENTIONS RATIONALE eee
ee
a

Desired Outcomes: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including future appointments with health
care provider, medications prescribed, and activity level.

Independent Actions
Collaborate with client to develop a written plan that in- Creating a written plan provides the client with a resource to use
cludes prescribed activity, exercises, self-care, and follow- following discharge. It forces client to think about what needs
up appointments. to be done and who will support them in their recovery. Creating
This should include a sample of all daily activities allowed a daily sample plan helps client to see how days will be struc-
and someone to take them to the health care provider's tured and can increase confidence in their ability to care for self.
office.
Reinforce the physician’s instructions regarding the impor- Ensuring the client understands the importance of adhering to a
tance of lying down and increasing fluid intake for a few treatment plan may reduce the occurrence of adverse outcomes.
hours if amount of blood or number of blood clots in the The client should be given time to clarify and answer questions
urine increases. as appropriate.
Explain the importance of having a digital rectal examination Follow-up is critical to assure ongoing health and allows for treat-
and a blood test for prostate-specific antigen (PSA) done ment in therapeutic regimen as needed.
each year (cancer of the prostate and recurrent BPH can
develop because the entire prostate gland is not removed
during a TURP).

ADDITIONAL NURSING DIAGNOSES

RISK FOR INFECTION NDx: URINARY TRACT SEXUAL DYSFUNCTION NDx

Related to: Related to:
e Introduction of pathogens associated with instrumenta- * Urinary incontinence; retrograde ejaculation; altered self-
tion of urinary tract during surgery, presence of indwelling image
catheter, and frequent bladder irrigations
e Increased growth and colonization of microorganisms as-
sociated with urinary stasis resulting from decreased activ-
ity and urinary retention if it occurs
 CHAPTER

The Client Receiving Treatment

for Neoplastic Disorders

p> This care plan focuses on the use of cytotoxic drugs in the treat- follicles, lining of the gastrointestinal tract). Because of this
ment of cancer. Chemotherapy is used alone or in combination lack of selectivity between the cancerous and the normal cell,
with radiation therapy, surgery, and/or biotherapy to achieve a nursing care of the recipient of the drugs is indeed a challenge.
cure, control tumor growth, or provide relief of symptoms as- This care plan focuses on the adult client hospitalized for
sociated with advanced disease (palliation). The success of the an initial or subsequent cycle of chemotherapy and/or man-
therapy depends on the size, type, and location of the tumor in agement of side effects of treatment with cytotoxic agents.
addition to the client’s physiologic and psychologic condition. Much of the information is also applicable to clients receiv-
Cytotoxic drugs are classified according to chemical structure ing chemotherapy and/or follow-up care in an outpatient
(e.g., antimetabolites, mitotic inhibitors [vinca alkaloids, plant facility or home setting.
alkaloids], alkylating agents), primary mode of action (e.g., some
interfere with folic acid synthesis or produce cross-links of DNA
strands), or effect on the cell life cycle. Some drugs are more ef- OUTCOME/DISCHARGE CRITERIA
fective during a specific phase of the cell cycle and are referred
to as cell cycle phase specific or cell cycle specific (e.g., mitotic The client will:
inhibitors, antimetabolites). The cytotoxic agents that interrupt 1. Have no signs and symptoms of toxic effects of cytotoxic
the cell replication process without regard to the phase of the agents
cell cycle are classified as cell cycle phase nonspecific or cell cycle 2. Have side effects of cytotoxic agents under control
nonspecific (e.g., alkylating agents, antitumor antibiotics). 3. Have fatigue at a manageable level
The primary effect of cytotoxic drugs is to interrupt cell 4. Have an adequate or improved nutritional status
replication. It is believed that cytotoxic drugs kill a percentage 5. Identify ways to prevent infection during periods of
of tumor cells with each dose and that tumors with a large lowered immunity
percentage of growing cells will experience greater cell death 6. Demonstrate appropriate oral hygiene techniques
than tumors with a smaller percentage of growing cells. Cells 7. Identify techniques to control nausea and vomiting
in the resting phase are less responsive to chemotherapeutic 8. Verbalize ways to improve appetite and nutritional status
agents and are better able to repair themselves if damaged 9. Verbalize ways to manage and cope with persistent
during treatment. fatigue
More than one anticancer drug is traditionally given for can- 10. Verbalize ways to prevent bleeding when platelet counts
cer treatment in order to prevent the cancer from becoming are low
resistant to treatment. The additive and sometimes synergistic 11. Verbalize ways to adjust to alterations in reproductive
effects that occur when drugs are used together allow an and sexual functioning
increased percentage of tumor cells to be killed without a con- 12. Verbalize ways to promote independence and prevent
comitant increase in drug-induced toxicities. The dose, combi- injury if neuropathies are present
nation, and treatment schedule for the drugs are determined by 13. Demonstrate the ability to care for a central venous
factors such as the physiologic status of the client and the drug’s catheter, a peritoneal catheter, or an implanted infusion
action on the cell cycle, the cell’s metabolism, the drug’s toxic device if in place
effects, and the nadir. Cytotoxic agents are most frequently 14. Demonstrate care and precautions necessary if a peripher-
given intravenously, but routes such as oral, subcutaneous, topi- ally inserted central line is in place
cal, and direct instillation into the target area (e.g., peritoneum, 15. Verbalize an understanding of an implanted infusion
bladder, cerebrospinal fluid) are used when appropriate. pump and precautions necessary if one is in place
Cytotoxic drugs do not discriminate between normal and 16. State signs and symptoms to report to the health care
the cancerous cells; as a result, the client may experience provider
certain side effects and/or toxic effects after their administra- 17. Share thoughts and feelings about changes in body image
tion. The drugs have the greatest effect on rapidly dividing resulting from chemotherapy
cancerous and normal cells (e.g., bone marrow, skin, hair

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754 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders

18. Identify community resources that can assist with home 19. Develop a plan for adhering to recommended follow-up
management and adjustment to the diagnosis of cancer care including medications prescribed and schedule for
and chemotherapy and its effects chemotherapy, laboratory studies, and future appoint-
ments with health care provider

Diagnosis IMBALANCED NUTRITION: LESS THAN BODY

|Nursing Diagnosis
REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with:
e Oral, pharyngeal, and esophageal pain and difficulty swallowing resulting from mucositis if it has developed
altered sense of taste
e Anorexia resulting from factors such as depression, fear, anxiety, fatigue, discomfort, early satiety,
factor)
and smell, and increased levels of certain cytokines that depress appetite (e.g., interleukin-1, tumor necrosis
imbalances, hypoxia, or tumor involvement of the brain)
e Altered mental status (can result from fluid and electrolyte
e Loss of nutrients associated with vomiting and diarrhea if present
e Impaired utilization of nutrients associated with:
e Accelerated and inefficient metabolism of proteins, carbohydrates, and/or fats resulting from factors such as increased
levels of cortisol, glucagon, and certain cytokines (e.g., tumor necrosis factor, interleukin-1)
e Decreased absorption of nutrients resulting from loss of intestinal absorptive surface if mucositis has developed
° Utilization of available nutrients by the malignant cells rather than the host

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness and fatigue Significant weight loss; abnormal blood urea nitrogen
(BUN) and low serum prealbumin, albumin, and transfer-
rin levels; sore, inflamed oral mucous membrane; pale
conjunctiva, anorexia

RISK FACTORS DESIRED OUTCOMES

e Inability to ingest foods The client will have or attain an adequate nutritional
e Inability to absorb nutrients status as evidenced by:
e Inability to digest foods a. Weight within or returning toward normal range for
e Insufficient intake client
b. Normal BUN and serum prealbumin, albumin, and
transferrin levels
c. Usual strength and activity tolerance
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

Nutritional status Nutritional monitoring, nutrition therapy, nausea

management

NURSING ASSESSMENT RATIONALE

ee ee? ae oe ee
eee

Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
e Weakness prompt intervention.
e Fatigue
° Significant weight loss
e Sore, inflamed oral mucous membrane
e Pale conjunctiva
Monitor percentage of meals and snacks client consumes. Provides ability to determine ifclient maintains adequate intake.
Report a pattern of inadequate intake.
Monitor serum BUN and serum prealbumin, albumin, and Possible indication that client may have cachexia and _provides
transferrin levels. indications of adequate intake of diet.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 755

THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to maintain or promote an adequat
e
nutritional status:
e Implement measures to reduce nausea and vomiting
(e.g., Vomiting results in loss of nutrients and these measures can help
provide mints or sour candy for client to suck on to elimi-
to maintain an intact oral mucosa.
nate noxious odors).
* Implement measures to reduce oral, pharyngeal, esopha-
Pain can decrease client’s appetite and result in decreased oral
geal, and abdominal pain (e.g., encourage client to suck on intake.
ice during infusion).
e Implement measures that will help client to adjust psycho-
Improves self-esteem and decreases depression, which may affect a
logically to the diagnosis of cancer and treatment with client’s desire to eat.
chemotherapy (e.g., reassure client hair loss is temporary;
encourage Client to wear wig).
¢ Implement measures to compensate for taste alterations Enhancing the taste of foods/fluids and providing nutritious
that might be present: alternatives to those that taste unpleasant to the client help to
stimulate appetite and improve oral intake.
e
Encourage client to select mild-tasting fish, cold chicken Action helps to stimulate salivation.
or turkey, eggs, and cheese as protein sources if beef or Increases ability to maintain adequate protein intake.
pork tastes bitter or rancid.
e Provide meat for breakfast if aversion to meat tends to May help to increase flavor of food and desire to eat.
increase as day progresses.
e Experiment with different flavorings, seasonings, and May decrease some peculiar tastes.
textures.
e Serve food cold or at room temperature. Decreases impact of metallic taste clients desire to eat.
e Provide client with plastic rather than metal eating Decreased dryness of the oral mucosa decreases difficulty in swal-
utensils if metallic taste is present. D @ lowing food.
If client is having difficulty swallowing:
¢ Implement measures to reduce the severity of stomatitis Decreases discomfort while allowing client to maintain intake.
and/or relieve dryness of the oral mucous membrane (e.g.,
encourage client to suck on sugarless candy).
¢ Help client to select foods that require little or no chewing Sticky and dry foods increase difficulty in swallowing food.
and are easily swallowed (e.g., custard, eggs, canned fruit,
mashed potatoes).
e Avoid serving foods that are sticky (e.g., peanut butter, soft Moisture decreases dependence on saliva to moisten food.
bread, honey).
e Moisten dry foods with gravy or sauces.
° Serve food warm if indicated. D ®@+ Warm food can stimulate sense of smell and subsequent appeal of
certain foods.
* Increase activity as tolerated. D@ + Activity usually promotes a sense of well-being, which can improve
appetite.
¢ Obtain a dietary consult if necessary to assist client in Foods/fluids that appeal to the client’s senses and are in accor-
selecting foods/fluids that are appealing and adhere to dance with personal and cultural preferences are most likely to
personal and cultural preferences. stimulate appetite and promote interest in eating.
e Encourage a rest period before meals. D @ The physical activity ofeating requires some expenditure ofenergy.
Fatigue can reduce the client’s desire and ability to eat.
e Maintain a clean environment and a relaxed, pleasant Noxious sights and odors can inhibit the feeding center in the
atmosphere. D@ + hypothalamus.
Maintaining a clean environment helps prevent this from
occurring. In addition, maintaining a relaxed, pleasant atmo-
sphere can help reduce the client’s stress and promote a feeling
of well-being, which tends to improve appetite.
e Provide oral hygiene before meals. D @ + Oral hygiene moistens' the mouth, which makes it easier to chew
e Provide largest amount of calories and protein when and swallow; it also removes unpleasant tastes, which often
appetite is best (usually at breakfast). improves the taste of foods/fluids.
e Serve frequent, small meals rather than large ones if client Small rather than large meals can enable a client who is weak or
is weak, fatigues easily, and/or has a poor appetite. fatigues easily to finish a meal. Smaller meals also seem less
overwhelming.

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756 Chapter 15 = The Client Receiving Treatment for Neoplastic Disorders

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage significant others to bring in client’s favorite Favorite foods eaten along with family members help to make
foods and eat with him or her. eating more of a familiar social experience.
e Limit fluid intake with meals (unless the fluid has high Limiting fluids helps to reduce early satiety and subsequent
nutritional value). decreased food intake.
Clients who feel rushed during meals tend to become anxious,
e Allow adequate time for meals; reheat foods/fluids if
necessary. lose their appetite, and stop eating.
e Ensure that meals are well balanced and high in essential Clients must consume a diet that is well balanced and high in
nutrients; offer high-calorie, high-protein dietary supple- essential nutrients in order to meet their nutritional needs.
ments (e.g., milkshakes, puddings, or eggnog made with Dietary supplements are often needed to help accomplish this.
cream or powdered milk reconstituted with whole milk;
commercially prepared dietary supplements) if indicated.
e Perform actions to control diarrhea (e.g., avoid foods high Foods may irritate the bowels or cause the stool to be more liquid
in fiber, caffeine, alcohol, spices, or fats). which can lead to fluid and electrolyte losses.
e Encourage the use of relaxation techniques (e.g., visualiza- Relaxation may help to decrease nausea and anorexia. Exercise
tion, guided imagery) and exercise. may stimulate appetite.

Dependent/Collaborative Actions
Implement measures to maintain or promote an adequate
nutritional status:
e Administer appetite stimulants (e.g., megestrol acetate, These drugs can increase appetite.
dronabinol) if ordered.
e Administer vitamins and minerals if ordered. D > Vitamins and minerals are needed to maintain metabolic function.
e Perform a calorie count if ordered. Report information to A calorie count provides information about the caloric intake and
dietitian and physician. nutritional value of the foods/fluids the client consumes. This
information helps the dietician and physician to determine
whether an alternative method of nutritional support is needed.
Evaluation laboratory values: Helps to identify degree of biochemical change with changes in diet
BUN, serum prealbumin, albumin, and transferrin levels and to monitor the adequacy of the client’s diet.
Consult physician regarding an alternative method of provid- Notification of the appropriate health care provider allows for
ing nutrition (e.g., parenteral nutrition, tube feedings) if modification of the treatment plan.
client does not consume enough food or fluids to meet
nutritional needs.

|Nursing "ACUTE
Diagnosis | PAIN nox/CHRONIC PAIN nox
Definitions; Acute Pain NDx: Unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow
onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less
than 3 months; Chronic Pain NDx: Unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage (International Association for the Study of Pain);
sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or
predictable end, and with a duration of greater than 3 months.

Related to:
e Oral, pharyngeal, esophageal, and/or abdominal pain related to mucositis associated with the effects of cytotoxic drugs
on the rapidly dividing cells of the gastrointestinal mucosa
e Muscle and bone pain (the cause is not known but it sometimes occurs in persons receiving paclitaxel and high doses of
vinblastine or etoposide)
e Neuropathic pain related to the effects of some cytotoxic drugs (e.g., paclitaxel, cisplatin, vinca alkaloids) on the
peripheral nerves
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 757,

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of oral, pharyngeal, esophageal, and/or Grimacing; reluctance to eat or move; clutching abdomen;
abdominal pain; statements of painful swallowing; reports restlessness
of gastric pain induced by spicy or acidic foods; reports
of achiness (usually in lower extremities); reports of
numbness, tingling, burning, or shooting pain in an
extremity or extremities

RISK FACTORS DESIRED OUTCOMES

e Chronic disability
e Injurious chemical agents The client will experience diminished pain as evidenced by:
a. Verbalization of a decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. Increased participation in activities

NOC OUTCOMES NIC INTERVENTIONS

Pain control; comfort level Pain management; environmental management: comfort;
analgesic administration; oral health maintenance

NURSING ASSESSMENT RATIONALE

SSS
Eee

Assess for and report signs and symptoms of acute/chronic Early recognition of signs and symptoms of acute/chronic pain
pain. allows for prompt intervention.
Assess client’s perception of the severity of pain using a pain Use of a pain scale provides for a baseline with which to measure
intensity rating scale. pain and facilitates the transfer of knowledge about a client’s
pain experience.
Assess the client’s pain pattern (e.g., location, quality, onset, Each of these affects the treatment of pain.
duration, precipitating factors, alleviating factors).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain:
e Perform actions to reduce fatigue (e.g., schedule frequent The reduction of fatigue helps to increase the client’s threshold and
rest periods; minimize environmental noise). D @ + tolerance for pain.
e Perform actions to reduce fear and anxiety in order to Fear and anxiety can decrease the client’s threshold for pain and
promote relaxation and subsequently increase the client’s thereby heighten the perception of pain.
threshold and tolerance for pain (e.g., maintain calm,
supportive, confident manner).
e Provide or assist with nonpharmacologic methods for Nonpharmacologic interventions may be be effective as they stimu-
pain relief (e.g., massage; position change; progressive late closure of the gating mechanism in the spinal cord and
relaxation exercises; guided imagery; acupuncture; restful block the transmission of pain impulses.
environment; diversional activities such as watching
television, reading, or conversing). D@
e If client has oral, pharyngeal, esophageal, or abdominal
pain:
e Perform actions to reduce the severity of stomatitis Actions help to reduce irritation to dry, inflamed oral mucosa.
(e.g., encourage client to perform oral hygiene fre-
quently using soft-bristle toothbrush or soft-tip swab).
e Instruct client to avoid extremely hot, spicy, or acidic Decreased experience of pain may improve client’s nutritional
foods/fluids; dry or hard foods; raw vegetables. intake. Spicy, hot, and acidic foods cause further irritation to
the oral and GI mucosa
e Offer cool, soothing liquids such as nonacidic juices Decreases discomfort and provides moisture for the oral cavity
and ices. D@® which can help to decrease breakdown.

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758 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders

Continued...

THERAPEUTIC RATIONALE
ME ES INTERVENTIONS
Eee
Dependent/Collaborative Actions
Implement measures to reduce pain:
If client has oral, pharyngeal, esophageal, or abdominal pain, Actions help to soothe the oral mucous membrane.
e Instruct client to gargle with a saline solution every Protects and soothes oral mucosa which can decrease pain and
2 hrs or spray mouth with a solution containing diphen- helps to prevent potential infection.
hydramine and water (1 oz diphenhydramine and 1 qt
water) if ordered.
e Administer topical anesthetics/analgesics and oral protec- Topical anesthetics decrease pain and can help to improve oral
tive agents (e.g., mixture of diphenhydramine, antacid, intake.
and xylocaine viscous; sucralfate oral suspension) if
ordered. D>
e Administer the following medications if ordered to Pharmacologic therapy is an effective method of relieving pain.
manage pain: D+
¢ Nonopioid analgesics Muscle relaxants help to reduce pain associated with muscle
e Skeletal muscle relaxants Spasms.
e Antidepressants Antidepressants are often used to treat neuropathic pain.
° Opioid analgesics or opioid analgesics combined with
N-methyl-b-aspartate receptor antagonists
° Corticosteroids. Steroids help to reduce inflammation, which may cause gain.
e Apply a cooling pad or ice pack to painful extremity unless Action may help reduce mild neuropathic pain.
contraindicated. D@ +
Consult appropriate health care provider (e.g., pharmacist, Notification of the appropriate health care provider allows for
physician, pain management specialist) if pain persists or modification of the treatment plan.
worsens.

‘Nursing Diagnosis IMPAIRED INTEGRITY OF ORAL MUCOUS MEMBRANE nox

Definition: Injury to lips, soft tissue, buccal cavity, and/or oropharynx.

Related to:
e Dryness due to reduced oral intake
e Stomatitis due to:
e Malnutrition and inadequate oral hygiene
e Disruption in the renewal process of mucosal epithelial cells associated with toxic effects of cytotoxic drugs (particularly
antimetabolites, antitumor antibiotics, mitotic inhibitors, and taxanes)
e Infection, particularly gingival, during the period of myelosuppression

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of burning pain in mouth; difficulty Dryness of the oral mucosa; inflamed and/or ulcerated
swallowing; taste changes oral mucosa; viscous saliva; positive results of cultured
specimens from oral lesions

RISK FACTORS DESIRED OUTCOMES

e Chemical irritants The client will maintain a healthy oral cavity as evidenced by:
e Decreased salivation a. Absence of inflammation '
e Barriers to oral self-care
b. Pink, moist, intact mucosa
e Malnutrition
c. No reports of oral dryness and burning
e Medication side effects
d. Ability to swallow without discomfort

NOC OUTCOMES NIC INTERVENTIONS

Oral hygiene; oral health status Oral health maintenance; oral health restoration
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 759

NURSING ASSESSMENT RATIONALE

Assess client for dryness of the oral mucosa and signs and
Early recognition of signs and symptoms of impaired oral mucosa
symptoms of stomatitis: allows for prompt intervention.
° Reports of burning pain in mouth
° Difficulty swallowing
° Taste changes
e Dryness of the oral mucosa
e Inflamed and/or ulcerated oral mucosa
e Viscous saliva
° Positive results of cultured specimens from oral lesions

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent or reduce the severity of stoma- Maintaining moisture in the oral cavity helps to prevent break-
titis and/or relieve dryness of the oral mucous membrane: down.
° Encourage client to chew on ice during chemotherapy
infusion, especially if receiving 5-fluorouracil.
° Reinforce importance of oral hygiene and assist client with Lemon/glycerin or alcohol-containing products have a drying and
this after meals and snacks; avoid use of products that irritating effect on the oral mucous membrane. Client should be
contain lemon/glycerin and mouthwashes containing taught to avoid commercial oral mouthwash unless ingredients
alcohol. do not include glycerin or alcohol.
° Instruct and assist client to perform oral hygiene using a Use of appropriate oral hygiene devices and techniques helps to
soft-bristle toothbrush or sponge-tipped swab and to floss effectively remove food particles and debris from client’s mouth
teeth gently. without causing trauma to the oral mucous membrane.
e Have client rinse mouth frequently with warm saline Increases moisture in the oral cavity and cleans mouth of debris.
solution, baking soda and warm water, chlorhexidine
gluconate (Peridex), or mist oral cavity frequently, using a
spray bottle. D@ +
e Lubricate client’s lips frequently. D @ + Lubricating lips helps prevent drying and cracking.
e Encourage client to suck on sugarless candy or chew Sucking on candy stimulates saliva secretion.
sugarless gum. D@
e Encourage client not to smoke or chew tobacco. Smoking dries the oral mucous membrane.
e Encourage client to use a saliva substitute (such as Salivart) Exogenous saliva helps to decrease oral cavity drying.
if indicated.
e Instruct client to avoid substances that might further Irritation and subsequent inflammation can occur when tobacco is
irritate the oral mucosa (e.g., hot, spicy, or acidic foods/ in contact with the oral mucosa.
fluids).
e Perform actions to promote an adequate nutritional status Actions help to compensate for taste alterations that the client may
(e.g., serve food cold or at room temperature; experiment be experiencing.
with different seasonings, textures).
If stomatitis is not controlled: Removes toxins and bacteria that may increase the potential for
° Increase frequency of oral hygiene. D @ + inflammation or breakdown.
e If client has dentures, remove them and replace only for
meals. D @

Dependent/Collaborative Actions
Implement measures to prevent or reduce the severity of
stomatitis and/or relieve dryness of the oral mucous
membrane:
e Encourage a fluid intake of at least 2500 mL/day unless Adequate hydration helps keep the oral mucosa moist, which
contraindicated. reduces the risk ofcracking and breakdown.
e Provide client with a prophylactic antifungal oral suspen- Prevents development of suprainfection due to destroyed intestinal
sion or lozenge (e.g., nystatin) if ordered. D + flora.
Consult appropriate health care provider (e.g., oncology Notification of the appropriate health care provider allows for
nurse specialist, physician) if signs and symptoms of modification of the treatment plan.
dryness and stomatitis persist or worsen.

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760 Chapter 15 = The Client Receiving Treatment for Neoplastic Disorders

|Nursing »-----
Diagnosis |RISK FOR BLEEDING nox

Definition: Susceptible to a decrease in blood volume, which may compromise health.

Related to: Thrombocytopenia, associated with chemotherapy-induced bone marrow suppression

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Petechiae, purpura, or ecchymoses; gingival bleeding;
prolonged bleeding from puncture sites; epistaxis, hemop-
tysis; unusual joint pain; frank or occult blood in stool,
urine, or vomitus; increase in abdominal girth; menorrha-
gia; restlessness, confusion; decreasing blood pressure (BP)
and increased pulse rate; decrease in hematocrit (Hct) and
hemoglobin (Hgb) levels

RISK FACTORS DESIRED OUTCOMES

neSEEaE UEEIEIDUSERID SISSIES
e Trauma
The client will not experience unusual bleeding, as evi-
denced by:
a. Skin and mucous membranes free of petechiae, pur-
pura, ecchymoses, and active bleeding
b. Absence of unusual joint pain
c. Absence of frank and occult blood in stool, urine, and
vomitus
. No increase in abdominal girth
. Usual menstrual flow
. Usual mental status
. Vital signs within normal range for client
a . Stable or improved Hct and Hgb levels
Dmoaqmeao

NOC OUTCOMES NIC INTERVENTIONS

a
Blood coagulation; blood loss severity Bleeding precautions, administration of blood products

NURSING ASSESSMENT RATIONALE

Assess client for unusual bleeding and report signs and symp- Early recognition ofsigns and symptoms of bleeding allows for
toms such as: prompt intervention.
e Petechiae
e Purpura
e Ecchymoses
e Gingival bleeding
e Prolonged bleeding from puncture sites
e Epistaxis
e Hemoptysis
e Unusual joint pain
e Frank or occult blood in stool, urine, or vomitus
e Increase in abdominal girth
e Menorrhagia
e Restlessness
e Confusion
e Decreasing BP and increased pulse rate
e Decrease in Hct and Hgb levels
Monitor platelet count and coagulation test results (e.g.,
bleeding time). Report significant worsening of values.
If platelet count is low, coagulation test results are abnormal,
or Hct and Hgb levels decrease, test stools, urine, and
vomitus for occult blood. Report positive results.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 761

THERAPEUTIC INTERVENTIONS
RATIONALE
Dependent/Collaborative Actions
Implement measures to prevent bleeding:
Thrombocytopenia predisposes patients to bleeding. Actions that
e Avoid giving injections whenever possible; consult physi-
increase the risk for bleeding should be avoided in clients with
cian about prescribing an alternative route for medications
thrombocytopenia.
ordered to be given intramuscularly or subcutaneously.
e When giving injections or performing venous and arterial
Decreases volume of bleeding with injections or blood draws.
punctures, use the smallest gauge needle possible.
e Apply gentle, prolonged pressure to puncture sites after
Increases coagulation from breaks in the skin.
injections, venous and arterial punctures, and diagnostic
tests such as bone marrow aspiration.
e Take BP only when necessary and avoid overinflating the Decreases trauma and potential for bruising.
cuff.
° Caution client to avoid activities that increase the risk for Decreases incidence of trauma and subsequent bleeding.
trauma (e.g., shaving with a straight-edge razor, using stiff-
bristle toothbrush or dental floss).
e Whenever possible, avoid intubations (e.g., nasogastric) Injuries to these areas are painful and may increase incidence of
and procedures that can cause injury to rectal mucosa bleeding and/or infection.
(e.g., taking temperatures rectally, inserting a rectal sup-
pository or tube, administering an enema).
e Pad side rails if client is confused or restless.
e Perform actions to reduce the risk for falls (e.g., keep bed These measures help to ensure safety and prevent injury.
in low position with side rails up when client is in bed,
avoid unnecessary clutter in room, instruct client to wear
slippers/shoes with nonslip soles when ambulating).
e Instruct client to avoid blowing nose forcefully or strain- These measures prevent trauma and subsequent bleeding.
ing to have a bowel movement; consult physician about
an order for a decongestant and/or laxative if indicated.
e Administer the following if ordered:
e Platelet-stimulating factor Exogenous factors that improve blood clotting ability and decrease
e Estrogen-progestin preparations to suppress menses bleed loss.
e Platelets
If bleeding occurs and does not subside spontaneously, These actions help to decrease bleeding temporarily, support
e Apply firm, prolonged pressure to bleeding area(s) if possible. adequate oxygenation in the presence of loss of red blood cells
(RBCs), and replace deficient blood components.
e If epistaxis occurs, place client in a high-Fowler’s position Helps to stop bleeding with a nose bleed.
and apply pressure and ice pack to nasal area.
e Maintain oxygen therapy as ordered. Increases oxygen provided to the tissues.
e Administer whole blood or blood products (e.g., platelets) Whole blood and blood products increase the blood’s oxygen-
as ordered. carrying capacity as well as vascular volume.

Collaborative =>
Diagnosis |RISK FOR IMPAIRED RENAL FUNCTION
Definition: Inability of the kidney to appropriately concentrate urine and excrete waste products.

Related to:
e Toxic effects of some cytotoxic agents (e.g., cisplatin, high doses of methotrexate, streptozocin) on renal cells
e Nephropathy associated with:
e Excessive uric acid accumulation resulting from the rapid lysis of large numbers of tumor cells
e Precipitation of certain drugs (e.g., high doses of methotrexate) in the renal tubules and collecting ducts as a result of low
urinary pH and inadequate hydration before, during, and after drug administration

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Urine output less than 30 mL/h; urine specific gravity
fixed at or less than 1.010; elevated BUN and serum
creatinine levels; decreased creatinine clearance

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762 @haptensl sae The Client Receiving Treatment for Neoplastic Disorders

RISK FACTORS DESIRED OUTCOMES

i
e Chemotherapeutic agents
The client will maintain adequate renal function, as evi-
e Impaired volume status
denced by:
a. Urine output at least 30 mL/h
b. BUN and serum creatinine levels and creatinine
clearance within normal range

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of impaired renal Early recognition of signs and symptoms of impaired renal function
function: allows for prompt intervention.
e Urine output less than 30 mL/h
e Urine specific gravity fixed at or less than 1.010
e Elevated BUN and serum creatinine levels
e Decreased creatinine clearance
Assess for and report a urine output below 100 mL/h Monitoring of changes can alert the health care team of negative
during and for 24 hrs after administration of nephrotoxic consequences of nephrotoxic drugs.
drugs.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to maintain adequate renal function: Adequate hydration ensures optimum perfusion of the kidney,
which is necessary for the health of the functional nephron
units.
e Hydrate client with at least 150 mL/h of fluid unless Adequate hydration helps to maintain a high rate of glomerular
contraindicated, for 6 to 24 hrs before administering blood flow. Increased blood flow helps to flush the medication
drugs known to be nephrotoxic (e.g., cisplatin, high out of the kidneys and decreases potential damage to the
doses of methotrexate, streptozocin). kidneys.
e Administer intravenous fluids as ordered during
administration of nephrotoxic drugs and for 24 hrs
after. D >
Administer the following medications as ordered:
e Diuretics (e.g., furosemide, mannitol) Diuretics help to promote more rapid plasma clearance of the
cytotoxic agent.
Xanthine oxidase inhibitor (e.g., allopurinol) Xanthine oxidase inhibitors help to decrease the formation of uric
acid.
Sodium bicarbonate Sodium bicarbonate helps to alkalinize the urine and subsequently
increase the solubility of uric acid in the urine, thus preventing
the precipitation of methotrexate in renal tubules and collecting
ducts.
e Leucovorin calcium (e.g., folic acid) Folic acid helps to diminish the toxic effects of cytotoxic agents
such as methotrexate on the renal cells.
Chemoprotectant agent (e.g., amifostine) Chemoprotective agents help to protect the renal cells against
toxicity from some cytotoxic agents (e.g., cisplatin).
If signs and symptoms of impaired renal function occur:
e Assess for and report signs of acute renal failure (e.g., oligu- Recognition of signs and symptoms of impaired renal function
ria or anuria; weight gain of 2% or greater over a short time; allows for prompt intervention and potential presgrvation of
edema; elevated BP; lethargy and confusion; increasing kidney function.
BUN and serum creatinine, phosphorus, and potassium
levels).
e Prepare client for dialysis if indicated.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 763

Collaborative Diagnosis
Diagnosis |RISK FOR HEMORRHAGIC CYSTITIS
Definition: Inflammation of the bladder resulting in bleeding.
Related to: Irritation and ulceration of the bladder mucosa by toxic metabolites of certain cytotoxic
agents, particularly
cyclophosphamide and ifosfamide

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-reports of dysuria; suprapubic pain Frank or occult blood in urine; urinary frequency/urgency

RISK FACTORS DESIRED OUTCOMES

° Chemotherapy
The client will not develop hemorrhagic cystitis as
evidenced by absence of dysuria, urinary frequency and
urgency, suprapubic pain, and hematuria.

NURSING ASSESSMENT RATIONALE

ne

Assess for and report signs and symptoms of hemorrhagic Early recognition of signs and symptoms of hemorrhagic cystitis
cystitis: allows for prompt intervention.
e Dysuria
e Suprapubic pain
e Frank or occult blood in urine
e Urinary frequency/urgency

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent hemorrhagic cystitis:
e Ensure that client is vigorously hydrated; maintain intrave- Adequate hydration ensures ability to reduce the concentration
nous fluids at the rate ordered (often as high as 200 mL/h of toxic drug metabolites in the bladder.
during chemotherapy). D+
e Administer cyclophosphamide early in the day and Actions help to prevent stasis of toxic drug metabolites in the
encourage client to void at least every 4 hrs, before going bladder.
to bed, and at least once during the night.
e Administer mesna (Mesnex) if ordered. Mesna helps to interact with and inactivate the toxic drug metabo-
lites of ifosfamide.
e Maintain continuous bladder irrigation before and after Continuous bladder irrigation helps to flush metabolites from the
administration of cyclophosphamide or ifosfamide if bladder and prevent the formation of obstructive clots should
ordered. bleeding occur.
If signs and symptoms of hemorrhagic cystitis occur, Prevents further bladder injury.
e Discontinue cytotoxic drug administration and notify
physician.
* Continue with fluid administration as ordered. D + Maintains adequate urine production to flush the bladder.
e Administer diuretics as ordered. D + To increase urine output and thereby decrease the concentration of
toxic drug metabolites in the urine.
e Assist with or perform bladder irrigations as ordered.
e Maintain continuous bladder irrigation with silver nitrate Bladder irrigations help to facilitate the removal of drug metabo-
or alum (potassium aluminum sulfate) solution if ordered lites and flush clots from the bladder.
to stop bleeding.
e Prepare client for the following if planned: Prevents further injury.
° Cystoscopy to cauterize bleeding vessels
e Intravesical instillation of formalin to control persis-
tent severe bleeding

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764 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders

|Collaborative >
Diagnosis |«RISK FOR DRUG EXTRAVASATION
Definition: Infiltration of drugs into soft tissues leading to local tissue irritation and sloughing.

Related to: Extravasation of vesicant drugs (e.g., most antitumor antibiotics, teniposide, vinblastine, vincristine, paclitaxel)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of stinging or burning pain at infusion Swelling, blanching, or coolness of skin around infusion
site or along vein site

RISK FACTORS DESIRED OUTCOMES

e Infiltration of intravenous lines
The client will not experience drug extravasation as evi-
e Multiple punctures in the same vein
denced by:
a. Absence of swelling, blanching, and coolness of skin
around infusion site
b. No reports of stinging or burning pain at infusion site
or along the vein

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of drug extravasation: Early recognition of signs and symptoms of drug extravasation
e Reports of stinging or burning pain at infusion site or allows for prompt intervention.
along vein
e Swelling, blanching, or coolness of skin around infusion
site
Ensure that infusion site and surrounding tissue are visible at
all times.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent drug extravasation: Use of a fragile vein and previous use increase the risk for extrava-
e Select the best vein possible for vesicant drug administration: sation.
e Do not use a vein that has been previously used for
vesicant agents.
e Use a large vein in the forearm if possible; avoid the Extravasation in these areas can destroy nerves and tendons.
antecubital fossa and small veins in the hand.
e Do not use an existing peripheral intravenous catheter This prevents excessive damage to the vein and decreases the risk
that is more than 24 hrs old. of extravasation.
e Avoid extremities with compromised circulation.
e Consult physician about insertion of a central venous cath- Vessels with compromised circulation are at increased risk for
eter or Peripherally Inserted Central Catheter (PICC) line if stasis of the medication and vessel damage.
large and/or frequent doses of a vesicant are planned.
e Do not perform multiple punctures in the same vein. Prevents leakage from the vessel after infusion has begun.
e Tape intravenous catheter securely but not too tightly. Prevents skin irritation.
e Do not irrigate catheter forcefully or use a high-pressure Irrigating forcefully may disrupt the integrity of the vessel, resulting
setting on infusion device. in infiltration. '
Perform actions to ensure that the drug is infusing into the vein:
e Test patency of vein before administering a cytotoxic Ensuring adequate blood return prior to the administration of
drug. cytotoxic agents reduces the risk of extravasation.
e Stay with client while a vesicant drug is infusing; check
site every 2 to 3 minutes.
Perform actions to prevent increased irritation of the vein:
e Dilute drug according to manufacturer’s recommenda- High concentration of the medication and rapid administration
tions. will increase trauma to blood vessels.
e Administer drug at recommended rate of infusion.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 765

THERAPEUTIC INTERVENTIONS RATIONALE

° Stop infusion if there is any indication that the drug is not
Prevents injury.
infusing properly.
° When the drug infusion is complete, flush intravenous
Ensures medication is fully administered and prevents injury or
catheter with a minimum of 30 mL of normal saline; apply
leakage of medication onto the skin.
pressure to site for at least 4 minutes after catheter removal
to minimize oozing.
If signs and symptoms of drug extravasation occur: Infusion must be discontinued immediately and area treated per
° Stop infusion immediately. hospital protocol to avoid extensive tissue damage.
e ‘Treat area of extravasation as ordered (treatment varies de-
pending on drug used) or per standard hospital procedure.
° Assess the site frequently for signs of increased inflamma- Document and measure changes to monitor healing. Provides
tion, blistering, and necrosis. information concerning changes over time.
e Administer analgesics as ordered (severe pain is common Decreases pain and discomfort in the area.
after extravasation).

B Nursing Diagnosis
=/ => RISK FOR CARDIAC DYSRHYTHMIAS nox
Definition: Disturbance of the heart rhythm.
Related to: Cardiotoxic effects of certain cytotoxic drugs (e.g., cyclophosphamide, high doses of ifosfamide, doxorubicin,
daunorubicin, paclitaxel)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of light-headedness; palpitations; fainting Irregular apical pulse; pulse rate below 60 or above
100 beats/min; apical-radial pulse deficit; syncope;
palpitations; abnormal rate, rhythm, or configurations
on electrocardiogram (ECG)

RISK FACTORS DESIRED OUTCOMES

e Electrolyte imbalance
The client will experience resolution of cardiac dysrhyth-
mias if they occur as evidenced by:
a. Regular apical pulse at 60 to 100 beats/min
b. Equal apical and radial pulse rates
c. Absence of syncope and palpitations
d. ECG reading showing normal sinus rhythm

NOC OUTCOMES NIC INTERVENTIONS

Cardiac pump effectiveness Dysrhythmia management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of cardiac dys- Early recognition of signs and symptoms of cardiac dysrhythmias
rhythmias: allows for prompt intervention.
e Reports of lightheadedness, palpitations
e Irregular apical pulse
e Pulse rate below 60 or above 100 beats/min
e Apical-radial pulse deficit
e Syncope
e Abnormal rate, rhythm, or configurations on ECG

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766 Chapter 15 = The Client Receiving Treatment for Neoplastic Disorders

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NURSING ASSESSMENT RATIONALE

Monitor liver and kidney function studies and report abnor- Cardiotoxicity can result from delayed metabolism or excretion of
mal results. cytotoxic drugs by the liver or kidneys.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Administer a cardioprotectant agent (e.g., dexrazoxane) if Cardioprotective agents help to reduce the risk of anthracycline-
ordered. induced cardiac damage.
If cardiac dysrhythmias occur: Allows for proper identification of dysrhythmias and the imple-
e Initiate cardiac monitoring and prepare client for an ECG mentation of the appropriate interventions.
if ordered.
e Administer antidysrhythmic agents (e.g., lidocaine, di- If cardiac output decreases, implement safety measures to decrease
goxin, diltiazem, esmolol, amiodarone, atropine) if ordered. risk offalls.
e Monitor client manifestations of decreased cardiac output.
e Restrict client’s activity based on his or her tolerance and Decreases risk of injury.
the severity of the dysrhythmia.
e Maintain oxygen therapy as ordered. Enhances oxygenation.
e Assess cardiovascular status frequently and report signs Allows for prompt changes in treatment regimen.
and symptoms of inadequate tissue perfusion (e.g., de-
crease in BP, cool skin, cyanosis, diminished peripheral
pulses, declining urine output, restlessness and agitation,
shortness of breath).
e Have emergency cart readily available for defibrillation, Life-threatening dysrhythmias such as ventricular fibrillation
cardioversion, or cardiopulmonary resuscitation. require the use of equipment maintained on emergency carts.

Collaborative Diagnosis RISK FOR INFLAMMATION AND FIBROSIS OF LUNG TISSUE

Related to: The effects of some cytotoxic agents on the lung (e.g., busulfan, bleomycin, carmustine, mitomycin).

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath Dry, hacking, persistent cough; fever; tachypnea; dyspnea
on exertion; wheezing; crackles

RISK FACTORS DESIRED OUTCOMES

e Chemotherapeutic agents
The client will experience decreased signs and symptoms
e Radiation therapy
of pulmonary inflammation and fibrosis if they occur as
evidenced by:
a. Decreased coughing
b. Afebrile status
c. Decreased dyspnea
d. Improved breath sounds

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of pulmonary in- Early recognition of signs and symptoms of pulmonary inflamma-
flammation and fibrosis, particularly if client is reaching tion/fibrosis allows for prompt intervention.
total allowable cumulative dose of cytotoxic agent or
agents known to cause pulmonary toxicity:
e Verbal reports of shortness of breath
e Dry, hacking, persistent cough
e Fever
e Tachypnea
e Dyspnea on exertion
e Wheezing
e Crackles
 Chapter 15 = The Client Receiving Treatment for Neoplastic Disorders 767

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of pulmonary inflammation and fibrosis
occur:
e Discontinue infusion of cytotoxic agent as ordered. Discontinuing use of the medication prevents further exposure to
the toxic agents.
e Prepare client for diagnostic studies (e.g., chest radiograph, Maintains supplemental tissue oxygenation.
pulmonary function studies, computed tomography (CT)
or gallium scan, fiberoptic bronchoscopy) if planned.
Maintain oxygen therapy as ordered.
Administer the following medications if ordered:
e Corticosteroids Corticosteroids reduce the inflammatory response.
e Bronchodilators Bronchodilators dilate the bronchi and bronchioles, decrease
airway resistance, and improve airflow.

Collaborative Diagnosis RISK FOR NEUROTOXICITY

Definition: Destructive or poisonous effects on nerve tissue.

Related to: The toxic effects of certain cytotoxic agents (e.g., vincristine, vinblastine, cisplatin, ifosfamide, etoposide, high
doses of methotrexate or cytarabine) on the nerves

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of numbness and tingling of extremities; Constipation; ataxia; gait disturbances; difficulty with fine
burning pain in extremity; unusual muscle weakness; motor movements; foot drop or wrist drop; hearing loss;
blurred vision nystagmus; memory loss; confusion; expressive aphasia;
seizures

RISK FACTORS DESIRED OUTCOMES

pep cbumistration oF Chemotlietapeutic agents The client will adapt to the signs and symptoms of neuro-
toxicity if it occurs and not experience injury associated
with those signs and symptoms.

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of neurotoxicity: Early recognition of signs and symptoms ofneurotoxicity allows for
e Numbness and tingling of extremities prompt intervention.
e Burning pain in extremity
e« Unusual muscle weakness
e Blurred vision
e Constipation
e Ataxia, gait disturbances
e Difficulty with fine motor movements
e Foot drop or wrist drop
e Hearing loss
e Nystagmus
e Memory loss
e Confusion
e Expressive aphasia
® Seizures

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768 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of neurotoxicity occur: Recognition of signs and symptoms of neurotoxicity allows for
e Implement measures to prevent falls: implementation of the appropriate interventions and modifica-
tion of the treatment plan.
e Keep bed in low position. D@ Neurotoxicity can result in ataxia, which may predispose the client
to falls.
Common clinical manifestations associated with neoplastic drugs
include numbness in the extremities (polyneuropathy), which
may interfere with a normal response to hot foods and water.
e Avoid unnecessary clutter in the room. D @ Decreases potential for falls and subsequent injury.
e Implement measures to prevent burns and cuts:
e Let hot foods/fluids cool slightly before serving. Prevents burning of oral mucosa and skin.
e Assess temperature of bath water before bathing.
e Institute seizure precautions if indicated.
e Implement measures to help client adapt to the following
if present:
e Constipation
(1) Encourage fluid intake. D+ Fluid and fiber intake are effective in reducing the incidence of
(2) Increase fiber intake. constipation.
e Pain in extremities Musculoskeletal effects associated with neurotoxicity include myal-
gia, joint stiffness, and muscle weakness.
(1) Assist with position changes. D@ Decreases joint stiffness.
(2) Assist with guided imagery. D@ + Provides alternative methods of pain control.
e Foot drop
(1) Instruct client to perform active foot exercises every Prevents muscle wasting and improves muscle strength.
1 to 2 hrs while awake. D@ +
e Wrist drop
(1) Instruct client to perform active wrist exercises
every 1 to 2 hrs while awake. D @
e Impaired hearing
(1) Face client when speaking. Improves communication between patient and health care provider.
(2) Use gestures.
(3) Provide written information
e Memory loss
(1) Assist to make lists. D @ Actions assist clients with memory loss, visual or auditory halluci-
(2) Repeat information as needed. nations, and the confusion that can result from neurotoxicity.
e Confusion
(1) Decrease environmental stimuli. D @ + Prevents overstimulation of client that can increase confision.
(2) Keep daily routines consistent. D @ + Allows client a level of independence.
e Expressive aphasia
(1) Encourage client to use short words. Take time with client to make sure that they are heard and support
(2) Encourage client to use gestures. their concerns related to this.
Consult physician if signs and symptoms of neurotoxicity Allows for prompt change in treatment regimen.
persist or worsen.

|Nursing »-*)
Diagnosis RISK FOR DISTURBED SELF-CONCEPT*
'
Definition: Disturbed Body Image NDx: Confusion in mental picture of one’s physical self; Situational Low Self-Esteem
NDx: Development of a negative perception of self-worth in response to a current situation.

Related to
e Changes in appearance associated with the side effects of chemotherapy (e.g., alopecia, excessive weight loss, skin and nail
changes) and external drug infusion catheter if present
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 769

Possible alteration in usual sexual activities associated with weakness, fatigue, reduced
levels of testosterone (can occur with
chemotherapy for prostate or testicular cancer or lymphoma), psychologic factors, and vaginal
discomfort (may result from
mucositis and premature menopause if ovarian failure occurs)
Possible temporary or permanent infertility associated with gonadal dysfunction resulting from extensive
therapy with some
cytotoxic drugs (e.g., some alkylating agents)
° Increased dependence on others to meet self-care needs
Changes in lifestyle and roles associated with effects of the disease process and its treatment

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of negative feelings about self; lack of Withdrawal from significant others; lack of participation
plan to adapt to necessary changes in lifestyle in activities of daily living

RISK FACTORS DESIRED OUTCOMES

e Treatment of illness
e Altered body image The client will demonstrate beginning adaptation to
changes in appearance, body functioning, lifestyle, and
roles as evidenced by:
a. Verbalization of feelings of self-worth and sexual
adequacy
b. Maintenance of relationships with significant others
(@). Active participation in activities of daily living

d. Develop a beginning plan for adapting lifestyle to

changes resulting from the disease process and
residual effects of chemotherapy

NOC OUTCOMES NIC INTERVENTIONS

Self-esteem, body image Body image enhancement, self-esteem enhancement,
role enhancement, emotional support, support system
enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of a disturbed self-concept: Early recognition of signs and symptoms of disturbed self-concept
e Verbalization of negative feelings about self allows for prompt intervention.
e Lack of planning to adapt to necessary changes in lifestyle
e Withdrawal from significant others
e Lack of participation in activities of daily living

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to facilitate the grieving process.
Discuss with client improvements in appearance and Allows client to discuss specific concerns they have in relation to
functioning that can realistically be expected. changes that may occur while undergoing chemotherapy.
Implement measures for the following changes in body func- These actions help to assist client to adapt to changes in body
tioning and appearance if appropriate: functioning and appearance.
e Alopecia
e Inform client that hair loss can be expected approxi- Clients may exhibit a range of emotional responses at the prospect of
mately 2 weeks after initiation of chemotherapy; may be losing hair, including anger, grief, embarrassment, and fear. Edu-
sudden, gradual, partial, or complete and can include cating the client regarding hair loss may alleviate anxiety and allow
scalp hair, pubic hair, beard, eyebrows, and eyelashes. the client to explore feelings associated with this side effect. Allow
patient to choose wig and have control during selection process.
e Reassure client that hair loss is temporary (regrowth Helps client to realize that the change is not permanent.
sometimes occurs before cessation of treatment but
usually occurs 2-3 months after it).
e Inform client that hair regrowth may be a different
color, texture, and consistency.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to cut hair very short. Prepares client for potential changes when hair regrowth occurs.
e Brushing hair gently using a soft-bristle brush. Cutting the hair very short helps to decrease the anxiety related
e Shampooing hair only once or twice a week and using to seeing large quantities of hair fall out.
a gentle shampoo and lukewarm water.
e Avoiding use of equipment/products that dry hair (e.g., Helps to prevent hair breakage and subsequent loss. These actions
hot rollers, hair dryers, curling iron, dyes). give the client methods to help control hair loss.
e Avoiding hairstyles that create tension on hair (e.g.,
ponytails, braids).
e Encourage client to wear a wig, scarf, hat, false
eyelashes, or makeup if desired to camouflage hair loss.
e Inform client of community resources that can provide Provides client with choices concerning what to do when hair loss
information and assistance with ways to facilitate occurs. Use of these helps to improve client’s self-esteem.
adjustment to changes in appearance (e.g., American Provides resource for client once discharged from the acute care
Cancer Society, Look Good-Feel Better Program). facility.
e Skin changes (e.g., redness, rashes, peeling, increased sen- Educating the client about skin changes associated with chemo-
sitivity to sun, acne, darkening along the vein used for therapy may help alleviate anxiety and allow client to explore
cytotoxic drug administration). feelings associated with this side effect.
e Inform client that skin and vein hyperpigmentation may Informs client of what to expect when undergoing chemotherapy.
occur if cytotoxic drugs such as bleomycin, busulfan,
methotrexate, and fluorouracil are being administered.
e Inform client that skin and vein discoloration is usually
temporary.
Instruct client to avoid exposure to sunlight and to use sun-
screen.
¢ Help client to identify types of clothing that can be worn Provides client with information to determine type of clothing re-
to camouflage skin changes. quire to prevent an increase in photosensitivity reactions.
e Nail changes
e Inform client that nails may thicken and stop growing, Informing client about nail changes associated with chemotherapy
develop ridges, darken, and detach from nail bed dur- may help to alleviate anxiety. Information received before treat-
ing treatment with certain cytotoxic drugs (e.g., cyclo- ment can help client identify ways to adapt to changes or how
phosphamide, doxorubicin, bleomycin, fluorouracil). to camouflage changes.
e Reassure client that normal nail growth will resume Helps client to understand that changes are temporary.
when chemotherapy is completed.
e Infertility
e Clarify physician’s explanation that infertility is a pos- Educating client about infertility may help alleviate anxiety and
sible permanent effect of chemotherapy. allow client to explore alternative treatments. Or to make repro-
ductive decisions prior to initiating treatment (i.e., Sperm or egg
harvesting and preserving for future use)
eDiscuss alternative methods of becoming a parent (e.g., Educating client about impotence may help alleviate anxiety and
artificial insemination, adoption) if of concern to client. allow client to explore alternative treatments.
e Impotence.
e Encourage client to discuss this with his or her physi- Impotence usually resolves after cessation of chemotherapy.
cian. Discussing this before it occurs may help client be prepared ifof
e Suggest alternative methods of sexual gratification if does occur.
appropriate.
e Discuss ways to be creative in expressing sexuality (e.g., Gives client time to explore other methods of obtaining sexual
massage, fantasies, cuddling). pleasure.
Help client with usual grooming and makeup habits if neces- Client may need assistance in this activity and nursing staff
sary. D @ should be able to help. '
Support behaviors suggesting positive adaptation to changes These actions promote positive self-esteem and client’s ability to
that have occurred (e.g., interest in personal appearance, maintain supportive relationships.
maintenance of relationships with significant others).
Support client’s and significant others’ adjustment to changes Demonstrates accepts of client and provides a resource for client to
by listening, facilitating communication, and providing ask questions and explore feelings about changes.
information.
Encourage significant others to allow client to do what he or Actions help encourage client to be independent and/or develop
she is able. self-esteem.
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THERAPEUTIC INTERVENTIONS RATIONALE

Encourage client contact with others. Contact with others helps client to test and establish a new
Encourage visits and support from significant others. self-image.
Consult appropriate health care provider (e.g., psychiatric Provides additional resources to help client make life changes.
nurse clinician, physician) if client seems unwilling or un-
able to adapt to changes that have occurred as a result of
cancer and its treatment.

DISCHARGE TEACHING/CONTINUED CARE

Sie eee) KNOWLEDGE DEFICIT*npx, INEFFECTIVE HEALTH

MANAGEMENT*npx, INEFFECTIVE FAMILY HEALTH
MANAGEMENT*npx
Definitions: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a
program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of
the family unit.

RISK FACTORS
e Cognitive limitations
e Lack of recall
e Diminished fine/gross motor skills
e Fear and anxiety

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: disease process; treatment regimen; energy Health system guidance; teaching: disease process; teaching:
conservation; treatment procedures prescribed medication; teaching: prescribed exercise;
teaching: procedure/treatment; nutrition management

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of challenges related to learning; verbal Exaggerated behaviors; inaccurate follow-through of
self-report of concerns about one’s ability to care for self instructions

NURSING ASSESSMENT RATIONALE

e Assess client’s willingness to learn and knowledge related The client’s willingness to learn and knowledge base provide the
to the disease and treatment process foundation for education.
e Assess for indications that the client may be unable to Early recognition of inability to understand disease process or
manage the therapeutic regimen effectively provide self-care allows for changes in the teaching plan.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

infection during periods of lowered immunity.

Independent Actions
Explain to client that his or her resistance to infection is Information about what changes occur is important to provide to
reduced when white blood cell (WBC) counts are low. client and family to help prevent the negative sequelae ofcancer
Emphasize the need to adhere closely to recommended treatment.
techniques to prevent infection.

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THERAPEUTIC INTERVENTIONS RATIONALE

Instruct the client in ways to prevent infection:
Avoid crowds, persons with any sign of infection, and Prevents exposure to individuals who may be carrying microbes
persons who have recently been vaccinated. that can have a negative impact on a client undergoing
chemotherapy.
Use good hand hygiene (e.g., wash hands using an anti- Good hand hygiene is paramount in preventing infection.
bacterial soap, use an alcohol-base hand rub).
Wear gloves to protect hands during activities such as Animal feces are often present in garden soil and if ingested can
cleaning and gardening. lead to infection in an immunocompromised Client.
Take axillary rather than oral temperature if stomatitis is Axillary temperature assessment is more comfortable for a client
present. with stomatitis.
Lubricate skin frequently to prevent dryness and subse- Prevents skin breakdown and decreases potential for infection.
quent cracking.
Maintain sterile technique when caring for a central Sterile technique is paramount when dealing with indwelling
venous or peritoneal catheter, an Ommaya reservoir, or an catheters to prevent catheter line sepsis.
implanted infusion device (e.g., MediPort) if in place.
Avoid unnecessary rectal invasion (e.g., temperature Damage or perforation of the bowel can lead to sepsis in an
taking, enemas, suppositories, sexual activity) to prevent immunocompromised client.
rectal trauma.
Avoid constipation to prevent damage to the bowel mu- Adequate hydration helps to prevent constipation.
cosa from hard or impacted stool.
Wash perianal area thoroughly with soap and water after Prevents cross-contamination between the vagina and the rectum.
each bowel movement and after sexual activity; instruct Actions prevent urinary tract contamination from fecal
female client to always wipe from front to back after urina- bacteria.
tion and defecation.
Drink at least 10 glasses of liquid a day unless contra- Helps to maintain adequate hydration.
indicated.
Cough and deep breathe or use incentive spirometer every Supports lung expansion and movement ofsecretions ifpresent.
2 hrs until usual activity is resumed. Coughing and deep breathing keep alveoli expanded, improve gas
exchange, and facilitate expectoration of secretions, preventing
pneumonia.
Stop smoking. Smoking damages the mucociliary system, which helps facilitate
the expectoration of secretions. Prevents chronic lung irritation
and paralysis of the cilia.
Perform meticulous oral hygiene after meals and at bed- Maintains oral hydration and prevents oral infections.
time, change denture care solution daily, and replace
toothbrush routinely.
Avoid douching unless ordered. Douching disturbs normal vaginal flora and may cause trauma to
the vaginal mucosa.
Prevents loss of normal flora.
Maintain an optimal nutritional status (e.g., diet high in Maintains wellness and body’s ability to fight infection.
protein, calories, vitamins, and minerals).
Avoid sharing eating utensils. Prevents infection.
Maintain an adequate balance between activity and rest. Adequate rest will help decrease incidence of fatigue.
Cleanse respiratory equipment as instructed; change water Prevents infection.
in humidifiers daily.
Decrease risk of food-borne illness: Prevents infection or illness from food sources.
e Avoid intake of foods with a high microorganism con-
tent (e.g., unwashed fruits and vegetables; undercooked
eggs, meat, poultry, and seafood).
'
° Be sure that juices and ciders are pasteurized or Prevents unnecessary exposure to microbes in unpasteurized,
processed and that milk and cheese are pasteurized. unclean, or inappropriately prepared foods.
e Thoroughly wash hands, food preparation items, and
surfaces (e.g., knives, cutting board, countertop) before
and after cooking, especially when working with raw
meat, poultry, and fish.
e Thaw food items in the refrigerator rather than on
kitchen counter.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 773

THERAPEUTIC INTERVENTIONS RATIONALE

e Avoid picking up animal waste or cleaning animal litter
These products may contain agents that can be harmful to a
boxes and bird cages. patient undergoing chemotherapy.
Avoid elective surgery and dental work. Decreases risk for bleeding and infection.
Reinforce the importance of taking prescribed medications Medications provide additional support to the immune system to
such as colony-stimulating factors and prophylactic anti- fight off infectious agents.
microbial agents.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate appropri-

ate oral hygiene techniques.

Independent Actions
Explain the rationale for and importance of frequent oral Frequent oral hygiene is necessary in the neutropenic client to keep
hygiene. the oral cavity clean, moist, and free of bacterial infection so
adequate nutritional intake can occur.
Provide instructions regarding oral hygiene techniques:
e Cleanse mouth after eating and at bedtime; increase Helps to flush debris out of the oral cavity, prevent possible gum
frequency to every 2 hrs if stomatitis is present. irritation and potential infection.
Use a soft-bristle toothbrush. Prevents trauma to fragile mucous membranes.
Rinse mouth with the following solutions as prescribed:
e Salt or baking soda and warm water These solutions help to reduce oral dryness.
e Chlorhexidine gluconate (Peridex)
Avoid commercial mouthwashes that have an alcohol base. These agents are drying to the oral mucosa.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to improve

appetite and nutritional status.

Independent Actions
Instruct client in ways to control nausea and vomiting: Nausea and vomiting commonly occur after chemotherapy and/or
e Eat foods that are cool or at room temperature (hot foods radiation. Prevention and control of nausea and vomiting are
frequently have a strong aroma that stimulates nausea). necessary to ensure adequate nutrition.
Eat dry foods (e.g., toast, crackers) or sip cold carbonated Helps to decrease nausea and calm an irritated stomach.
beverages if you are feeling nauseous.
Eat several small meals a day instead of three large ones. Prevents overdistention of the stomach and potential for nausea.
Avoid drinking liquids with meals. Fluids will decrease the amount of food the client may be willing
Select bland foods (e.g., mashed potatoes, cottage cheese) to eat as fluids increase the feeling of fullness.
rather than fatty, spicy foods.
Rest after eating. Spicy food can irritation the stomach and increase the incidence of
nausea.
Avoid offensive odors and sights. Allows for easier digestion of food. Exercising would pull blood
Cleanse mouth frequently. away from the stomach and increase digestion time.
Take deep, slow breaths when nauseated.
Take antiemetics on a regular basis for prescribed length of Increases incidence of nausea and can decrease appetite.
time and if nausea is persistent. Maintains oral hydration.
Deep breathing helps to decrease nausea,
Reduce nausea when taken on a regular basis and before nausea occurs.
Teach client about ways to improve appetite and maintain an Cells of the mucosal lining of the stomach are highly proliferative.
adequate nutritional status: Intestinal mucosa is very sensitive to radiation and chemo-
e Try fish, cheese, chicken, and eggs as protein sources therapy. Nausea, vomiting, diarrhea, mucositis, and anorexia
instead of beef and pork if taste distortion is a problem. are all gastrointestinal effects that can affect a client’s
e Increase amount of sugar or sweeteners and seasonings nutritional status. These actions help to facilitate optimum
usually used in foods and beverages. nutritional status for clients undergoing chemotherapy.
° Use plastic utensils and cook food in glass or plastic con-
tainers if metallic taste is present.
e Eat in a pleasant environment with company if possible. Metallic taste is off-putting and may decrease intake.
e Perform frequent meticulous oral hygiene.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Try recommended methods of controlling nausea. Helps to relax the client and can potentially increase intake.
Eliminates unpleasant taste in mouth that may decrease appetite.
e Eat several high-calorie, high-protein, nutritious small Decreased nausea can lead to increased intake and improvement in
meals each day rather than three large ones; use nutri- nutritional status.
tional supplements if needed. Prevents overdistention of the stomach and increases caloric intake.
Plan ahead for low-energy days (e.g., have some prepared Supplements help to maintain adequate caloric intake.
meals available; maintain an ample supply of nutritious, Having food readily available makes it easier to maintain adequate
minimal preparation foods such as eggs, tuna fish, cheese, nutrition when one is not feeling well or not wanting to cook.
peanut butter, and yogurt; keep nutritious snacks and
beverages within easy reach).
e Take vitamins, minerals, and appetite stimulants (e.g., These supplements increase appetite, support caloric intake, and
megestrol acetate, dronabinol) as prescribed. improve nutritional status.

THERAPEUTIC INTERVENTIONS RATIONALE

The client will verbalize ways to manage and cope with per-
sistent fatigue.

Independent Actions
Instruct client in ways to manage and cope with persistent Fatigue affects most clients undergoing chemotherapy and/or
fatigue: radiation. Fatigue may be related to anemia or side effects of
e View fatigue as a protective mechanism rather than a therapy.
problematic limitation.
e Determine ways in which daily patterns of activity can be Client must identify ways to decrease fatigue and put a plan in
modified to conserve energy and prevent excessive fatigue place to get enough rest and exercise to maintain muscle
(e.g., spread light and heavy tasks throughout the day, take strength.
short rests during an activity whenever possible, sit during
an activity whenever possible, take several short rest peri-
ods during the day instead of one long one).
e Determine whether life demands are realistic in light of
physical state and adjust short- and long-term goals
accordingly.
e Avoid situations that are particularly fatiguing, such as
those that are boring, frustrating, or require prolonged or
strenuous physical activity.
e Participate in a moderate exercise program (e.g., walking Exercise improves muscle strength and may decrease frequency of
or bicycling 20-30 minutes three or four times a week). fatigue.
e Participate in “attention-restoring” activities (e.g., walking
outdoors, gardening).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to pre-

vent bleeding when his or her platelet counts are low.

Independent Actions
Instruct client in ways to minimize risk of bleeding: A client who is thrombocytopenic is at risk for increased bleeding
e Avoid taking aspirin and other nonsteroidal anti- and should be instructed on actions to prevent and/or control
inflammatory agents (e.g., ibuprofen). bleeding.
e Consult health care provider before routinely taking herbs
that can increase the risk of bleeding (e.g., ginkgo, arnica,
chamomile).
e Brush teeth gently using a soft-bristle toothbrush; do not use Prevents oral trauma.
dental floss or put sharp objects (e.g., toothpicks) in mouth. Decreases risk for nicks with shaving.
e Use an electric rather than a straight-edge razor. Prevents bleeding and potential for infection.
Cut nails and cuticles carefully.
e Use caution when ambulating to prevent falls or bumps
and do not walk barefoot.
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THERAPEUTIC INTERVENTIONS RATIONALE

e To reduce the risk of cuts, be attentive when using scissors,
Prevents personal injury and potential for increased bleeding.
knives, and tools.
e Avoid contact sports and other activities that could result
in injury.
e Avoid straining to have a bowel movement.
Avoid blowing your nose forcefully.
Avoid wearing constrictive clothing (e.g., garters, knee-
high stockings).
Use an ample amount of water-soluble lubricant before
sexual intercourse and avoid anal sexual activity, douch-
ing, use of rectal suppositories, and enemas in order to
prevent trauma to the vaginal and rectal mucosa.
e Avoid heavy lifting.
Instruct client to control any bleeding by applying firm, pro-
longed pressure to the area if possible.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to adjust

to alterations in reproductive and sexual functioning.

Independent Actions
Assure client that many of the side effects of chemotherapy Reproductive and sexual dysfunction vary depending on treatment
(e.g., decreased libido, impotence) are temporary or can be protocol. Clients should be educated as to appropriate alterna-
treated. tives to reproductive and sexual dysfunction.
Explain to the female client that ovarian failure during che- Knowledge of what can occur during chemotherapy allows the
motherapy may result in irritability, hot flashes, and other client to plan for what he or she will do to decrease symptoms.
symptoms of premature menopause.
Instruct client in the childbearing years to use contraception Client needs to know that many cytotoxic drugs cause genetic
during chemotherapy and for at least 2 years after comple- abnormalities in the developing fetus.
tion of chemotherapy.
Encourage client to rest before sexual activity if fatigue is a
problem.
Instruct client in measures to decrease discomfort associated Prevents discomfort, potential for trauma and improve sexual
with decreased vaginal secretions and mucositis: satisfaction.
e Use an ample amount of water-soluble lubricant before
intercourse.
Use vaginal steroid cream if prescribed to ease dryness and
inflammation if present.
e Take a sitz bath two or three times a day.
Avoid intercourse until mucositis of the vaginal canal
resolves.
Instruct client to take hormone replacements (e.g., estrogen,
testosterone) as prescribed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to pro-

mote independence and prevent injury if neuropathies are
present.

Independent Actions
Instruct client in measures to promote independence and Helps client to maintain independence as much as possible and
prevent injury if neuropathies are present: prevent injury.
e Use adaptive devices to facilitate performance of activities
of daily living (e.g., zipper pulls; buttoners; molded sock
aids; elastic shoelaces or Velcro straps; special pens,
pencils, or utensils that are easy to grasp).

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THERAPEUTIC INTERVENTIONS RATIONALE

e Take extra precautions to prevent falls (e.g., have handrails
in hallways and tubs and showers, avoid unnecessary clut-
ter in pathways, wear shoes/slippers with nonskid soles,
secure all carpets/rugs).
e Adhere to precautions to prevent burns (e.g., check tem-
perature of bath water [should be <110°F], wear mitts
when handling hot items) and cuts (e.g., shield fingers
when using a sharp knife, avoid the use of motorized tools
such as lawnmowers and saws, use adapted nail clippers).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will demonstrate the ability

to care for a central venous catheter, a peritoneal catheter, or
an implanted infusion device if in place.

Independent Actions
Provide instructions related to care of a central venous Client and significant other should be instructed on the proper care
catheter (e.g., Groshong) if appropriate: of indwelling catheters to avoid catheter-related sepsis.
e Change dressing if present according to protocol using
aseptic technique.
e Observe exit site for changes in appearance, redness, swell- Symptoms of a potential infection should be reported to the health
ing, and unusual drainage. care provider.
e Flush catheter according to protocol to maintain patency. Prevents clotting of indwelling catheter.
e Replace injection cap as directed.
e Tape catheter securely to chest wall. Notify physician if Taping of the indwelling catheter prevents in and out movement of
unable to flush catheter, if signs and symptoms of the catheter which causes irritation to the urinary meatus,
infection occur at exit site, or if catheter appears to be prevents accidental dislodgement and decreases potential for
leaking. infection. Notifying the health care provider allows for prompt
treatment of infection.
Provide instructions related to care of a peritoneal catheter if Proper care of a peritoneal catheter prevents dislodgement, damage,
in place: and infection.
e Change dressing according to protocol using aseptic tech-
nique.
e Keep catheter capped between treatments.
e Keep water below the level of the catheter when taking a
tub bath.
e Observe for and notify physician if any of the following May indicate an infection.
occurs:
e Redness, swelling, or change in appearance of insertion May indicate infection or changes in patency or skin around
site. catheter.
e Unusual drainage from exit site.
e Increasing abdominal pain. May indicate dislodgement or movement of catheter.
e Chills or fever.
e Increased abdominal distention between treatments.
e Persistent nausea or vomiting.
e Dyspnea.
Provide instructions related to care of an implanted infusion Clients should be instructed on the proper maintenance of
device (e.g., MediPort, Port-a-Cath) if in place: implanted infusion devices to ensure catheter pptency and
e Keep appointment to have device flushed or flush as prevent infection.
instructed.
e Avoid trauma to insertion site.
e Notify physician if area around infusion device becomes
reddened or painful.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 777

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-
ing of an implanted infusion pump and precautions neces-
sary if one is in place.

Independent Actions
Reinforce physician’s explanation about the purpose of the Allows for client understanding and ability to care for self while
infusion pump and how it works. maintaining some degree of independence.
Instruct client to avoid activities that could result in abdomi-
nal trauma and dislodgment of pump.
Caution client to notify physician if: The client should carry an explanatory letter since pump may
e Air travel is planned. trigger airport weapon security devices; flow rate of pump may
also need to be adjusted if the flight time is lengthy.
e Redness, swelling, or drainage occurs at incisional or May indicate an infection.
refilling site.
Emphasize importance of keeping appointments to have Permanent blockage of the catheter can occur ifpump is allowed to
pump refilled. empty completely.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct client to observe for and report the following:
e Signs and symptoms of infection (stress that usual signs of Prompt reporting of adverse signs and symptoms allows for
infection are diminished in people with altered bone modification of the treatment plan and may reduce the risk of
marrow function and/or a suppressed immune system and complications. Client must understand the importance of
that it is necessary to monitor closely for the following notifying the health care provider at the first sign of change.
signs and symptoms): This can prevent deleterious outcomes.
e Temperature above 38°C (100.4°F)
e Changes in odor, color, or consistency of urine or pain
with urination
e White patches in mouth
e Crusted ulcerations around or in oral cavity
e Swollen, reddened, coated tongue
e Painful rectal or vaginal area
e Unusual vaginal drainage
e Changes in the appearance or temperature of skin,
particularly around puncture sites
e Persistent productive or nonproductive cough.
e Signs and symptoms of bleeding (e.g., excessive bruising,
black stools, persistent nosebleeds or bleeding from gums,
sudden swelling in joints, red or smoke-colored urine,
blood in vomitus).
e Signs and symptoms of hemorrhagic cystitis (e.g., blood in
urine, pain on urination, urinary frequency or urgency).
e Signs and symptoms of extravasation (e.g., coolness, pain,
swelling, and/or skin changes at infusion site).
e Signs and symptoms of pulmonary dysfunction (e.g.,
shortness of breath; persistent dry hacking cough; fever).
e Signs and symptoms of dehydration (e.g., dry mouth, sig-
nificant weight loss, concentrated urine, light-headedness).
e Signs and symptoms of cardiotoxicity (e.g., irregular or
rapid heart rate, increased weakness and fatigue, shortness
of breath, unexplained weight gain, swelling of extremi-
ties); emphasize that cardiotoxicity can occur several days
to months after administration of drugs known to cause it.

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THERAPEUTIC INTERVENTIONS RATIONALE

e New or increased signs and symptoms of neurotoxicity
(e.g., numbness and tingling of extremities, change in
hearing acuity, blurred vision, constipation, change in
motor function and coordination, burning pain in extrem-
ity, impaired memory or ability to communicate).
e Persistent diarrhea, nausea, vomiting, and/or decreased
oral intake.
e Significant weight loss.
e Inability to cope with the effects of the diagnosis and treatment
Instruct client to keep a record of signs and symptoms, Detailed accounts of signs and symptoms can aid health care
activities at the time the symptoms occur, measures taken practitioners in the formulation of appropriate interventions.
to achieve relief, and the effect of the measures taken.
Instruct client to take the information to each appointment Allows for ongoing evaluation of the client’s condition and provides
with the health care provider. time for client to express concerns and have questions answered.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community re-

sources that can assist with home management and adjustment
to the diagnosis of cancer and chemotherapy and its effects.

Independent Actions
Provide information about and encourage use of community These actions can help clients to cope with the emotional issues
resources that can help client and significant others with associated with chemotherapy. They can help clients manage
home management and adjustment to diagnosis of cancer their illness and normalize their experience.
and chemotherapy and its effects (e.g., American Cancer So-
ciety, counselors, social service agencies, Meals on Wheels,
Make Today Count, Look Good-Feel Better Program, hospice,
community support groups).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including medications prescribed and schedule
for chemotherapy, laboratory studies, and future appoint-
ments with health care provider.

Independent Actions
Collaborate with client to develop a written plan of how to Improves client’s adherence to treatment regimen.
adhere to treatment regimen.
Thoroughly explain rationale for medications, their side
effects, and the importance of taking them as prescribed.
Inform client of pertinent food and drug interactions.
Reinforce physician’s explanation of planned chemotherapy
schedule.
Discuss with client any difficulties with adhering to the sched-
ule and help him or her to plan ways of overcoming these.
Reinforce importance of keeping appointments for chemo-
therapy and laboratory studies.
Reinforce importance of keeping follow-up appointments
with health care provider.
Implement measures to improve client compliance:
e Include significant others in teaching sessions.
e Encourage questions and allow time for reinforcement and
clarification of information provided.
e Provide written instructions regarding ways to maintain
nutritional status, future appointments with health care
provider and laboratory, medications prescribed, and signs
and symptoms to report.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 779

ADDITIONAL NURSING DIAGNOSES e Long-term treatment with corticosteroids (may be used in

treatment of certain types of cancer)
FEAR/ANXIETY NDx e Disruption in normal, endogenous microbial flora result-
Related to: ing from antimicrobial therapy
e Unfamiliar environment ° Impaired immune system functioning resulting from cer-
e Lack of knowledge about chemotherapy including admin- tain malignancies (e.g., Hodgkin’s disease, lymphoma,
istration procedure, expected side effects, and impact on multiple myeloma, leukemia)
usual lifestyle and roles if admitted for chemotherapy e Break in mucosal surfaces
° Need for hospitalization to manage current side effects and/or ¢ Break in skin integrity
toxic effects of chemotherapy and possibility of additional ° Stasis of secretions in lungs
untoward effects with a subsequent cycle of chemotherapy
e Financial concerns GRIEVING NDx
_ © Diagnosis of cancer with potential for premature death Related to:
e Changes in body image and usual roles and lifestyle
NAUSEA NDx e Diagnosis of cancer with potential for premature
Related to: death
Stimulation of the vomiting center associated with:
° The effect of some cytotoxic drugs (those with a high RISK FOR IMPAIRED SKIN INTEGRITY NDx
emetic potential include carboplatin, cisplatin, dacarba- Related to:
zine, mechlorethamine, streptozocin, and carmustine), the e Increased skin fragility associated with malnutrition and
- by-products of cellular destruction, and the foul taste dryness (a result of the effects of cytotoxic drugs on seba-
created by some cytotoxic agents ceous and sweat glands)
e Stimulation of the visceral afferent pathways resulting e Frequent contact of the skin with irritants associated with
from inflammation of the gastrointestinal mucosa if diarrhea if present
mucositis is present e Damage to the skin and/or subcutaneous tissue associated
e Stimulation of the cerebral cortex resulting from stress and with prolonged pressure on tissues, friction, or shearing if
a conditioned response to previous experience with nausea mobility is decreased
and vomiting after the administration of cytotoxic drugs
RISK FOR CONSTIPATION NDx
FATIGUE NDx Related to:
Related to: e Autonomic neuropathy resulting from some cytotoxic
e A buildup of cellular waste products associated with rapid lysis drugs (e.g., vinblastine, teniposide, vindesine, vinorel-
of cancerous and normal cells exposed to cytotoxic drugs bine)
e Difficulty resting and sleeping associated with fear, anxi- e Depressant effect of medications administered to control
ety, and discomfort symptoms such as pain, nausea, and vomiting (e.g., nar-
e Tissue hypoxia associated with anemia (a result of malnutri- cotic [opioid] analgesics, some antiemetics)
tion and chemotherapy-induced bone marrow suppression) e Decreased activity
e Overwhelming emotional demands associated with the e Increased sympathetic nervous system activity resulting
diagnosis of cancer and treatment with chemotherapy from anxiety
e Increased energy expenditure associated with an increase e Decreased intake of fiber and fluids
in the metabolic rate resulting from continuous, active
tumor growth and increased levels of certain cytokines DISTURBED SLEEP PATTERN NDx
(e.g., tumor necrosis factor, interleukin-1) Related to:
e Malnutrition e Nausea, vomiting, and pain
e Side effects of other medications client may be receiving (e.g., e Anxiety, fear, and grief
narcotic [opioid] analgesics, antiemetics, antianxiety agents, e Frequent need to defecate associated with diarrhea if present
biotherapy agents such as interferons and interleukins)
RISK FOR POWERLESSNESS NDx
DIARRHEA NDx Related to:
Related to: e The possibility of disease progression and death despite
Increased peristalsis and disorders of intestinal secretion and treatment
absorption associated with inflammation and ulceration of e Dependence on others to assist with basic needs as a result
the gastrointestinal mucosa resulting from effects of cytotoxic of fatigue, weakness, and discomfort
drugs (particularly many of the antimetabolites, topoisomerase- 1 e Possible alterations in roles, relationships, and future
inhibitors, and antitumor antibiotics) on the rapidly dividing plans associated with changes that occur as a result of
epithelial cells in the intestine the cancer and the side effects/toxic effects of the cyto-
toxic drugs
RISK FOR INFECTION NDx
Related to:
Lowered natural resistance associated with:
e Malnutrition
e Chemotherapy-induced bone marrow suppression

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|Nursing 2-6
Diagnosis |DEFICIENT KNOWLEDGE nox PRE-RADIATION
Definition: Absence or deficiency of cognitive information related to a specific topic, or its acquisition.
Related to: Lack of knowledge regarding how radiation works, preradiation and postradiation routines, what to expect during
actual radiation treatment, and expected side effects of radiation

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of lack of knowledge of proposed Exaggerated behaviors, inaccurate follow-through of
treatment regimen. instructions, inappropriate behaviors (e.g., hostile,
hysterical, agitated, apathetic)

RISK FACTORS DESIRED OUTCOMES

e Unfamiliarity with information
The client will demonstrate understanding of prescribed
e Lack of exposure
procedure as evidenced by:
e Cognitive limitations
a. Verbalization of understanding of what will occur
during radiation treatment
b. Verbalization of required treatment regimen following
treatment

NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; treatment procedure(s) Teaching: treatment/procedure; teaching: individual

NURSING ASSESSMENT RATIONALE

Assess client’s readiness and ability to learn. Assess meaning Early recognition of readiness to learn and meaning of illness to
of illness to client. client allows for implementation of the appropriate teaching
interventions.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of radiation therapy and what to expect before, during,
and after radiation treatments.

Independent Actions
Provide the client with the following information about Clients vary in physical and cognitive ability. When educating
radiation therapy: clients, nurses must determine a client’s ability to read and
e How radiation therapy works and why the total radiation understand written materials. If literacy barriers are present,
dose prescribed is fractionated. alternative educational materials should be provided. Allow
e That the client will be alone in the room during the few time for questions, clarification, and return demonstration of
minutes of therapy but will be observed continuously via any learned actions.
a television monitor, and that communication will be ‘
possible by means of an intercommunication system.
e That the machine may click or make a whirring noise but
no discomfort will be felt during the treatment.
e The possible general side effects of radiation therapy (e.g.,
fatigue; anorexia; itchy, dry, reddened skin; moist desqua-
mation and increase in skin pigmentation at radiation
site), anticipated side effects for the particular site being
irradiated, and when the side effects can be expected to
occur and resolve.
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THERAPEUTIC INTERVENTIONS RATIONALE

° The treatment simulation process that occurs before initia-
tion of therapy (the simulation process is done to accu-
rately determine the treatment field and design devices
such as plastic or plaster molds or lead blocks that will be
used to ensure proper positioning and/or shield vital body
organs within the treatment field).
e The treatment field will include the smallest amount of
normal tissue possible, and the field may be changed or
reduced as the tumor shrinks in size. The vital organs are
shielded during treatment to prevent unnecessary exposure.
e The treatment field will be identified with skin markings
with an indelible dye, ink, or felt tipped markers. These
markings will be replaced by pinpoint tattoos once the
reproducibility of the field is ensured.
Arrange for client and significant others to visit the radiation Exposing clients to unfamiliar care environment can lessen anxiety
department and meet those individuals responsible for associated with unfamiliar situations.
client’s care.
Prepare client for waiting room experiences with others
~ receiving radiation therapy. Emphasize that each individ-
ual has a different treatment plan, response, and prognosis
and that comparisons should be avoided.

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with:
e Anorexia resulting from factors such as depression, fear, anxiety, fatigue, discomfort, early satiety, an altered sense of taste
(often reported by persons with cancer; can also result from damage to the taste buds and salivary glands with radiation to
the head and neck), and increased levels of certain cytokines that depress appetite (e.g., interleukin-1, tumor necrosis factor)
e Impaired swallowing resulting from pharyngitis, esophagitis, dry mouth, and/or viscous oral secretions if present as a result
of radiation treatment to the head, neck, or mediastinum
e Loss or impaired utilization of nutrients associated with vomiting and diarrhea if present
e Accelerated and inefficient metabolism of proteins, carbohydrates, and/or fats resulting from factors such as increased levels
of cortisol, glucagon, and certain cytokines (e.g., tumor necrosis factor, interleukin-1)
e Decreased absorption of nutrients resulting from loss of intestinal absorptive surface if mucositis has developed (can occur
with radiation to the abdomen or lower back)
e Utilization of available nutrients by the malignant cells rather than the host

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness and fatigue Significant weight loss (a loss of 1-2 lb during each week
of radiation therapy is often expected); abnormal BUN
and low serum prealbumin, albumin, hematocrit (Hct),
hemoglobin (Hgb), and transferrin levels; inflamed oral
mucous membrane; pale conjunctiva

NDx = NANDA Diagnosis D = Delegatable Action @ = UAP + =LVN/LPN ©) = Go to @volve for animation
782 Chapter 15. The Client Receiving Treatment for Neoplastic Disorders

RISK FACTORS DESIRED OUTCOMES

i
e Inability to ingest foods
The client will have or attain an adequate nutritional
e Inability to digest foods status as evidenced by:
e Inability to absorb nutrients
a. Weight within or returning toward normal range for
client
b. Normal BUN and serum prealbumin, albumin, Hct,
Hgb, and transferrin levels
c. Usual strength and activity tolerance
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

aT

Nutritional status; appetite Nutritional monitoring; nutrition management; nutrition

therapy; pain management; nausea management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
e Weakness and fatigue implementation of the appropriate interventions.
e Significant weight loss (a loss of 1-2 Ib during each week
of radiation therapy is often expected)
e Inflamed oral mucous membrane
e Pale conjunctiva
¢ Monitor for abnormal BUN and low serum prealbumin, Abnormality in listed lab values can indicate malnutrition and
albumin, Hct, Hgb, and transferrin levels. should be reported to the primary care provider.
¢ Monitor percentage of meals and snacks client consumes.
e Report a pattern of inadequate intake.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain or promote an adequate
nutritional status:
Perform actions to improve oral intake:
Implement measures to control nausea/vomiting:
e Eliminate noxious sights and odors from the environ- Noxious stimuli can cause stimulation of the vomiting center.
ment. D @ +
Implement measures to improve client’s ability to swallow Improves nutritional status, in particular intake of protein.
(e.g., assist client to select foods that are easily swallowed,
such as eggs, custard, canned fruit, and mashed potatoes).
Implement measures to compensate for taste alterations if present:
e Encourage client to select mild-tasting fish, cold turkey or Loss of sense of taste often occurs within 2 weeks of initiation of
chicken, eggs, and cheese as protein sources if beef or pork radiation treatment to head and neck, may persist for 4 to 6 weeks
tastes bitter or rancid. after completion of therapy, and usually is not permanent.
e Provide meat for breakfast if aversion to meat tends to in- Improves intake of protein.
crease during day.
e Marinate meats in red wine or sweet-and-sour sauce. Enhances flavors that may improve intake.
e Add extra sweeteners to foods if acceptable to client.
e Experiment with different flavorings, seasonings, and tex-
tures.
¢ Serve food cold or at room temperature (can decrease some
peculiar tastes). D @ +
Encourage a rest period before meals. Rest helps to minimize fatigue and improve appetite.
Maintain a clean environment and a relaxed, pleasant atmo- Allows client to take time while eating and may improve caloric
sphere. D @ . intake.
Provide oral hygiene before meals. D@ + Oral hygiene moistens the mouth, which makes it easier to chew
and swallow; it also removes unpleasant tastes, which often
improves the taste of foods/fluids.
Provide largest amount of calories and protein when appetite Assures client is able to maintain caloric intake.
is best (usually at breakfast). D@ +
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 783

THERAPEUTIC INTERVENTIONS
RATIONALE
Serve frequent, small meals rather than large ones
if client is Prevents gastric distention and potential for nausea, vomiting, and
weak, fatigues easily, and/or has a poor appetite. D @ +
feeling of being full.
Allow adequate time for meals; reheat foods/fluids if necessar
y. Provides client ability to take time while eating and not feel rushed.
De+ Reheating food may increase intake.
Dependent/collaborative actions
Implement measures to maintain or promote an adequate
nutritional status;
° Perform actions to improve oral intake.
° Increase activity as tolerated. Activity usually promotes a sense of well-being, which can improve
appetite.
° Obtain a dietary consult if necessary to help client select
Provides information over time that the dietitian or nutritionist can
foods/fluids that meet nutritional needs, are appealing, use to develop a client specific diet.
and adhere to personal and cultural preferences.
° Encourage significant others to bring in client’s favorite Favorite foods eaten along with family members help to make
foods and eat with client. eating more of a familiar social experience.
e Limit fluid intake with meals (unless the fluid has high Limiting fluids help to reduce early satiety and subsequent
nutritional value). D + decreased food intake.
* Administer appetite stimulants if ordered. D + Appetite stimulates increase hunger and enhance caloric intake.
° Ensure that meals are well balanced and high in essential Ensures adequate nutrition.
nutrients; offer high-protein, high-calorie dietary supple-
ments (e.g., milkshakes, puddings, or eggnog made with
cream or powdered milk reconstituted with whole milk;
commercially prepared dietary supplements) if indicated.
e Avoid foods/fluids that stimulate or irritate the bowel (Gigs, Foods that stimulate the colon and may cause diarrhea lead to loss
coffee, alcohol, foods made with synthetic sugars). of fluid and electrolytes.
e Administer vitamins and minerals if ordered. D + Supplements may be required to maintain adequate intake.
e Perform a calorie count if ordered. Report information to Helps to determine if client is eating adequate about of calories.
dietitian and physician.
° Consult physician about an alternative method of provid- Notification of the appropriate health care provider allows for
ing nutrition (e.g., parenteral nutrition, tube feedings) if modification of the treatment plan.
client does not consume enough food or fluids to meet
nutritional needs.

|Nursing >.
Diagnosis |IMPAIRED SWALLOWING nox |
Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal
structure or function.

Related to:
e Oral, pharyngeal, or esophageal pain associated with inflammation and/or ulceration of the mucosa if the treatment field
includes the head, neck, or mediastinum
e Dry mouth and viscous oral secretions associated with destruction of the salivary glands (particularly the parotids) if the
treatment field includes the head and neck
e Decreased oral intake

CLINICAL MANIFESTATIONS

Subjective Objective
Statements of difficulty swallowing; stasis of food in oral Coughing or choking when eating or drinking
cavity

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784 Chapter 15 = The Client Receiving Treatment for Neoplastic Disorders

RISK FACTORS DESIRED OUTCOMES

e Upper airway abnormalities
The client will experience an improvement in swallowing
e Oropharyngeal abnormalities as evidenced by
e Esophageal defects a. Verbalization of same
b. Absence of food in oral cavity after swallowing
c. Absence of coughing and chocking when eating and
drinking

NOC OUTCOMES NIC INTERVENTIONS

ee eee

Swallowing status Swallowing therapy; pain management; oral health

restoration

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired swallowing. Early recognition of signs and symptoms of impaired swallowing
e Statements of difficulty swallowing allows for implementation of the appropriate interventions.
e Stasis of food in oral cavity
e Coughing or choking when eating or drinking

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Perform actions to reduce oral, pharyngeal, and esophageal Measures that act to reduce oral, pharyngeal, and esophageal pain
pain: help to improve the ability to swallow. Oral and pharyngeal
e Offer cool, soothing liquids. discomfort can interfere with the client’s ability and willingness
to swallow effectively.
e Instruct client to gargle with saline solution every 2 hrs to Decreases irritation of the mouth and throat that may decrease
sooth mucous membranes. pain or discomfort upon swallowing.
e Perform frequent oral hygiene. A moist mouth helps to lubricate food, making it easier to chew
form into a bolus, and manipulate it toward the back of the
mouth. A formed, moist bolus triggers the swallowing reflex
more effectively and moves more easily through the esophagus.
e Help client to select foods that require little or no chewing Improves client nutrition without additional irritation to the oral
and are easily swallowed (e.g., custard, eggs, canned fruit, and throat mucosa.
mashed potatoes).
e Avoid serving foods that are sticky (e.g., peanut butter, soft Sticky foods are difficult to move through the mouth because they
bread, honey). adhere to various structures, especially the hard palate.
e Perform actions to stimulate salivation at mealtime. A moist mouth helps to lubricate food, making it easier to chew
and swallow.
e Provide oral hygiene before meals. Removes residue in the mouth that may decrease appetite.
e Provide a piece of hard candy for client to suck on just Improves salivation that decreases oral irritation and enhances
before meals unless contraindicated. swallowing of food.
e Serve foods that are visually pleasing. Involves more senses than taste and smell that may improve appetite.

Dependent/Collaborative Actions
Implement measures to improve client’s ability to swallow.
Perform actions to reduce oral, pharyngeal, and esophageal Thick oral secretions interfere with movement of food in the
pain: mouth. Liquefying these secretions makes it easier for a bolus of
food to be formed and moved to the back of the mouth.
e Administer oral protective agents and topical anesthetics Prevents ongoing oral irritation.
or analgesics if ordered.
e Perform actions to reduce and/or liquefy viscous oral se- Removes excess secretions from the oral cavity.
cretions.
e Encourage a fluid intake of 2500 mL/day unless contra- Enhances moisture of the oral cavity and throat.
indicated.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 785

THERAPEUTIC INTERVENTIONS
RATIONALE
e Encourage client to avoid milk, milk products, and
choco- Prevents thick secretions which may be difficult to swallow.
late (when combined with saliva, they produce very
thick
secretions).
Consult appropriate health care provider (e.g., oncolog
y Notification of the appropriate health care provider allows for
nurse specialist, physician) if swallowing difficulties persist
modification of the treatment plan.
or worsen.

|Nursing poe’
Diagnosis |IMPAIRED COMFORT nox PRURITUS
_ Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmenta
l, cultural, and/or social
dimensions.

Related to: Decreased function of skin sebaceous and sweat glands within the treatment field

CLINICAL MANIFESTATIONS

Subjective Objective
-Verbal self-report of itchiness Persistent scratching or rubbing of skin; dryness and
redness or excoriation of skin within the treatment field

RISK FACTORS DESIRED OUTCOMES

e Prescribed treatment regimen
The client will experience relief of pruritus as evidenced
by:
a. Verbalization of same
b. No scratching and rubbing skin

NOC OUTCOMES NIC INTERVENTIONS

eee

Comfort level; symptom control Pruritus management

NURSING ASSESSMENT RATIONALE

Assess the client for signs and symptoms of pruritus: Early recognition of signs and symptoms of pruritus allows for
implementation of the appropriate interventions.
e Reports of itchiness
e Persistent scratching or rubbing of skin; dryness and red-
ness or excoriation of skin within the treatment field

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to help relieve pruritus in the treatment The client experiencing pruritus is likely to scratch the affected
area: areas, which irritates the skin and can cause excoriation.
e Apply cool, moist compresses to pruritic areas. Implementing measures to reduce the itching sensation helps
prevent scratching and reduces trauma to the skin.
e Maintain a cool environment.
e Perform actions to reduce skin dryness. Dry skin is more prone to crack and has decreased elasticity, which
makes it susceptible to damage.
e Use tepid water and mild soaps for bathing, being careful
not to remove temporary skin markings.
e Apply water-based lubricant lotions (e.g., Lubriderm, Eu- Avoid lotions that contain lanolin or petrolatum because they must
cerin) two to three times daily and after bath. D@ + be removed before treatments
e Limit bathing to once every other day. D@ + Prevents skin from becoming dry.
e Usearoom humidifier to increase moisture in the air. D @+
e Add emollients, cornstarch, baking soda, or colloid-based Moisturizing lotions and emollients provide a source of moisture to
bath products to bath water. D @+ the skin.

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786 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders

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THERAPEUTIC INTERVENTIONS RATIONALE

e Apply a light dusting of cornstarch to areas of dry desqua- Absorbs excessive moisture on skin and decreases itching.
mation (cornstarch should not be used if moist desquama-
tion is present). D @ +
e Make an oatmeal paste, apply to pruritic areas, let dry for Oatmeal binds to the skin and provides a protective barrier against
3 to 5 minutes, and then rinse with cool water. D@ > irritants. It can also help to normalize skin pH.
e Pat skin dry after bathing, making sure to dry it thor- Rubbing of the skin after bathing can irritate the skin and stimu-
oughly. D @ + late itching.
e Encourage participation in diversional activities and use of Diversional activities, such as guided imagery, have a calming
relaxation techniques (e.g., music, imagery, watching TV). effect on the body and have been used to improve comfort.
De+
e Use cutaneous stimulation techniques (e.g., stroking with Skin within the treatment field should never be rubbed or deeply
a soft brush, light massage, pressure) at sites of itching or massaged.
acupressure points.
e Encourage client to wear loose cotton garments. Cotton is a natural fiber that is less irritating to the skin. Loose
garments allow air to circulate over the skin and decrease the
sensation to itch.

Dependent/Collaborative Actions
Implement measures to help relieve pruritus in the treatment
area.
e Perform actions to reduce skin dryness:
e Encourage a fluid intake of 2500 mL/day unless contra- Adequate fluid intake helps to keep the skin well hydrated.
indicated. D @+
e Administer antihistamines and/or apply topical anes- Antihistamines block the release of histamine which can increase
thetic cream (e.g., Lanacane) if ordered. D > skin irritaton.
Consult appropriate health care provider (e.g., oncology Notification of the appropriate health care provider allows for
nurse specialist, physician) if above measures fail to relieve modification of the treatment plan.
pruritus or if the skin becomes more excoriated.

|Nursing »-
Diagnosis |RISK FOR IMPAIRED SKIN INTEGRITY nox
Definition: Susceptibility to alteration in epidermis and/or dermis, which may compromise health.

Related to:
e Dry desquamation of irradiated site associated with increased sensitivity of skin in certain areas (e.g., opposing skin surfaces,
face, perineum) and destruction of rapidly dividing epithelial cells of the skin
¢ Moist desquamation of irradiated area associated with damage to the basal cells of the skin
Increased skin fragility is associated with:
e Tissue edema resulting from vascular changes in irradiated area
e Malnutrition
e Excessive scratching associated with pruritus
e Frequent contact of the skin with irritants associated with diarrhea if present

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of painful dermal areas Pallor; redness; change in skin temperature; firm or boggy
tissue; pruritus; abrasions; blisters

RISK FACTORS DESIRED OUTCOMES

e Prescribed treatment regimen
The client will maintain or regain skin integrity as evi-
e Imbalanced nutritional state
denced by:
e Impaired sensation
a. Minimal redness and irritation within the treatment field.
b. Absence of redness and irritation in body areas not in
treatment field.
c. No skin breakdown
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 787

NOC OUTCOMES NIC INTERVENTIONS

Tissue integrity; skin and mucous membranes, wound
Skin surveillance, skin care, topical treatments, wound care
healing, secondary intention

NURSING ASSESSMENT RATIONALE

Assess the client for signs and symptoms of actual or impaired
Early recognition of signs and symptoms of impaired skin integrity
skin integrity: allows for implementation of the appropriate interventions.
e Verbal reports of painful dermal areas
* Pallor, redness, change in skin temperature
e Firm or boggy tissue
e Pruritus
_ ¢ Abrasions
e Blisters
e Inspect the following anatomic fields:
e Treatment field and area on the body surface opposite to it
(should be assessed before treatment, every week during
treatment, and on every subsequent visit)
¢ Opposing skin surfaces
e- Bony prominences
¢ Dependent, pruritic, and edematous areas
e Perineum

THERAPEUTIC INTERVENTIONS RATIONALE

SS.

Independent Actions
Implement measures to maintain or regain skin integrity: These actions help to prevent or treat skin irritation or breakdown
within the treatment field.
e Cleanse irradiated area gently each shift with tepid water May be contraindicated initially when temporary skin markings
and mild soap. rather than tattoos are used.
° Pat skin dry using soft materials, paying particular atten- Decreases irritation and potential for scratching.
tion to opposing skin surfaces within the treatment field.
¢ Expose irradiated area to the air as much as possible,
avoiding extremes of temperature.
e Avoid use of tape within irradiated area. Prevents skin irritation and potential breakdown.
Instruct client to:
e Wear loose cotton clothing. Cotton is a natural fabric that is less irritating to the skin.
e Avoid use of perfumed lotions or soaps, cosmetics, and Avoiding the use of perfumed soaps, cosmetics, and deodorants
deodorants. helps to prevent chemical irritation (many of these products
contain heavy metals that will augment effects of radiation on
the skin).
e Apply a light dusting of cornstarch to areas of dry desqua- Cornstarch helps to reduce friction.
mation.
e Apply a mild, water-based lubricant lotion (e.g., Lubri- Lubricants help to reduce skin dryness and subsequent cracking.
derm, Eucerin). D ® +
e Avoid use of hydrophobic products (e.g., Vaseline). D @ > Hydrophobic products are difficult to remove.
e Use an electric rather than a straight-edge razor if it is Use of an electric razor decreases irritation and potential for skin
absolutely necessary to shave in the irradiated area. injury.
¢ Avoid applications of heat and cold to irradiated area. D @ + Heat and cold may be drying to the skin.
Implement measures to prevent skin breakdown associated
with scratching:
e Perform actions to relieve pruritus (e.g., apply water-based Water-based lubricants decrease itching without drying the skin as
lubricant lotion). D@ do lotions with alcohol.
° Keep nails trimmed and/or apply mittens if necessary. Prevents further skin irritation with scratching.
e Instruct client to apply firm pressure to pruritic areas Prevents further irritation and decreases stimulus to scratch area.
rather than scratching.
¢ Implement measures to treat a moist desquamation reac-
tion if it has occurred.
¢ Keep involved area exposed to the air as much as possible.
De+¢+

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788 Chapter 157 = The Client Receiving Treatment for Neoplastic Disorders

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THERAPEUTIC INTERVENTIONS RATIONALE

Perform actions to decrease skin irritation and prevent break- These actions help to reduce the risk of breaks in the integrity of
down associated with diarrhea: skin, which increases the client’s exposure to pathogens.
e Avoid extremely hot or cold foods; encourage foods high Foods that are very hot or cold and that are high in pectin can
in pectin, such as bananas and apple juice). cause diarrhea.
e Help client to thoroughly cleanse and dry perineal area Reduces itching and potential for infection.
with soft tissue or cloth after each bowel movement; apply
a protective ointment or cream, being sure to remove it
before treatments if rectal area is within treatment field.
De+
e If use of absorbent products such as pads or undergar- Prevents skin irritation and potential for itching.
ments is necessary, select those that effectively absorb
moisture and keep it away from the skin. D@ +
Perform actions to reduce fluid accumulation in dependent Fluid accumulation in dependent areas increases pressure and
areas: increases the risk of disruption in normal skin integrity.
e Instruct client in and assist with range-of-motion exercises. Improves circulation and decrease potential for edema.
e Elevate affected extremities whenever possible. D @ + Promotes lymph drainage of extremities.
e Handle edematous areas carefully. Prevents skin damage.
e Perform actions to promote an adequate nutritional status.

Dependent/Collaborative Actions
Implement measures to maintain or regain skin integrity:
e Perform actions to prevent or treat skin irritation or break
down within the treatment field.
e Apply a skin sealant to the area to be irradiated if ordered. Prevents skin breakdown or improves healing if breakdown has
occurred.
Implement measures to treat a moist desquamation reaction
if it has occurred.
e Cleanse area well with a saline solution, water, or a dilute Decreases itch sensation and decreases potential for scratching of
solution of chlorhexidine three times a day; apply an the skin.
astringent soak if ordered.
e Apply a metal-free gel (e.g., RadiaCare) to involved area if Helps to maintain skin integrity.
ordered.
e Apply a topical antimicrobial agent as ordered if signs and Helps to prevent infection.
symptoms of a localized infection occur.
If unexpected skin irritation or breakdown occurs:
e Notify appropriate health care provider (e.g., oncology Notification of the appropriate health care provider allows for
nurse specialist, wound care specialist, physician). modification of the treatment plan.
e Perform care of involved areas as ordered or per standard
hospital procedure.

|Nursing »Diagnosis
~~ RISK FOR IMPAIRED ORAL MUCOUS
MEMBRANE INTEGRITY nox
Definition: Susceptibility to injury to the lips, soft tissues, buccal cavity, and/or oropharynx, which may compromise health.

Related to: '

e Dryness associated with decreased oral intake and destruction of salivary glands if the treatment field includes the head and
neck
e Stomatitis associated with malnutrition, inadequate oral hygiene, and disruption in the renewal process of mucosal epithelial
cells if the oral cavity is irradiated
 Chapter 15 = The Client Receiving Treatment for Neoplastic Disorders 789

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of burning pain in mouth; difficulty Dryness of the oral mucosa; thick, ropey saliva; inflamed
swallowing, taste changes and/or ulcerated oral mucosa; positive results of cultured
specimens from oral lesions

RISK FACTORS DESIRED OUTCOMES

e Radiation therapy
e Chemical irritants The client maintains a healthy oral cavity as evidenced by
e Ineffective oral hygiene a. No reports of oral dryness and burning
¢ Malnutrition b. Pink, moist, intact mucosa
c. Absence of inflammation
d . Ability to swallow without discomfort

NIC OUTCOMES NIC INTERVENTIONS

SSS nee
ee eee eee ee eee

Oral hygiene Oral health maintenance; oral health restoration

NURSING ASSESSMENT RATIONALE

Assess the client for signs and symptoms of impaired oral Early recognition of signs and symptoms of impaired oral mucous
mucous membranes: membranes allows for implementation of the appropriate inter-
e Reports of burning pain in mouth ventions.
e Difficulty swallowing or taste changes
e Dryness of the oral mucosa
e Thick, ropey saliva
e Inflamed and/or ulcerated oral mucosa
¢ Positive results of cultured specimens from oral lesions

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent or reduce the severity of stoma-
titis and/or relieve dryness of the oral mucous membrane:
e Instruct and assist client to perform oral hygiene after eating Lemon/glycerin and alcohol-based products have a drying and
and as often as needed; avoid use of products that contain irritating effect on the oral mucous membrane.
lemon and glycerin and mouthwashes containing alcohol.
e Instruct and help client to perform oral hygiene using a Helps to maintain health gums and removes debris.
soft-bristle toothbrush or a sponge-tipped swab and to
floss teeth gently.
e Have client rinse mouth frequently with warm saline solution, Provides additional moisture to the oral cavity.
baking soda and warm water, or chlorhexidene gluconate
(Peridex) or mist oral cavity frequently using a spray bottle.
e Lubricate client’s lips frequently. Prevents cracking of lips.
e Encourage client not to smoke or chew tobacco. Smoking dries the mucosa; tobacco acts as an irritant to the oral
mucosa.
Perform actions to stimulate salivation:
e Encourage client to suck on sugarless candy or chew sugar- Stimulates salivation decrease irritation of the oral mucosa and
less gum. enhance appetite.
e Instruct client to avoid substances that might further irri- Decreases irritation of the oral cavity and oral pharynx.
tate the oral mucosa (e.g., hot, spicy, or acidic foods/fluids).
_e Perform actions to promote an adequate nutritional status Enhance appetite and removes debris from the mouth.
(e.g., provide oral hygiene before meals).
e Encourage client to use a saliva substitute such as Salivart Provides additional moisture to the mouth and throat.
if indicated.
If stomatitis is not controlled:
e Increase frequency of oral hygiene. Helps to maintain moisture and removal debris.
e If client has dentures, remove them and replace only for Helps to prevent breakdown of oral mucosa.
meals.

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790 Ghapter Sie The Client Receiving Treatment for Neoplastic Disorders

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THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent or reduce the severity of
stomatitis and/or relieve dryness of the oral mucous
membrane:
e Administer amifostine 15 to 30 minutes before radiation Amifostine is used as a protectant agent to reduce the incidence of
treatment that includes the parotid glands in client with xerostomia.
head and neck cancer.
e Administer sialagogues (e.g., oral pilocarpine [Salagen]) if This drug increases the natural production of saliva.
ordered.
e Encourage a fluid intake of 2500 mL/day unless contra- Maintains overall hydration and provides ongoing moisture to the
indicated. alimentary canal.
e Provide client with a prophylactic antifungal oral suspen- Helps to prevent suprainfections.
sion or lozenge (e.g., nystatin) if ordered.
Consult appropriate health care provider (e.g., oncology Notification of the appropriate health care provider allows for
nurse specialist, physician) if oral dryness and signs and modification of the treatment plan.
symptoms of stomatitis persist or worsen.

|Nursing ~Diagnosis
- RISK FOR BLEEDING nox
Definition: Susceptible to a decrease in blood volume, which may compromise health.

Related to: Thrombocytopenia associated with bone marrow suppression if large amounts of active bone marrow are included
in the treatment field

CLINICAL MANIFESTATIONS

Subjective Objective
N/A Petechiae, purpura, or ecchymoses; gingival bleeding;
prolonged bleeding from puncture sites; epistaxis,
hemoptysis; unusual joint pain; frank or occult blood in
stool, urine, or vomitus; increase in abdominal girth;
menorrhagia; restlessness, confusion; decreasing blood
pressure (BP) and increased pulse rate; decrease in hemato-
crit (Hct) and hemoglobin (Hgb) levels; platelet levels

RISK FACTORS DESIRED OUTCOMES

e Treatment regimen
The client will not experience unusual bleeding, as evi-
e Impaired liver function
denced by:
a. Skin and mucous membranes free of petechiae, pur-
pura, ecchymoses, and active bleeding
b. Absence of unusual joint pain
c. Absence of frank and occult blood in stool, urine, and
vomitus
d. No increase in abdominal girth
e. Usual menstrual flow
f. Usual mental status }
g. Vital signs within normal range for client
h. Stable or improved Hct and Hgb levels
i. Stable or improve platelet levels

NOC OUTCOMES NIC INTERVENTIONS

ee

Blood coagulation; blood loss severity Bleeding precautions; administration of blood products
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 791

NURSING ASSESSMENT RATIONALE

Assess the client for signs and symptoms of bleeding: Early recognition of signs and symptoms of bleeding allows for
e Unusual joint pain implementation of the appropriate interventions.
° Petechiae, purpura, or ecchymoses
°* Gingival bleeding; prolonged bleeding from puncture sites
e Epistaxis, hemoptysis
e Increase in abdominal girth
e Frank or occult blood in stool, urine, or vomitus; menorrhagia
e Restlessness, confusion
e Decreasing BP and increased pulse rate
e Decrease in Hct and Hgb levels
° Monitor platelet count and coagulation test results (e.g.,
bleeding time). Report significant worsening of values.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If platelet count is low, coagulation test results are abnormal,
or Hct and Hgb levels decrease, test all stools, urine, and
- vomitus for occult blood. Report positive results.
Implement measures to prevent bleeding:
° Avoid giving injections whenever possible; consult physi- Intramuscular injections in a client that is thrombocytopenic may
cian about prescribing an alternative route for medications lead to the formation of hematomas.
ordered to be given intramuscularly or subcutaneously.
e When giving injections or performing venous or arterial Providing pressure to the site helps facilitate hemostasis.
punctures, use the smallest gauge needle possible and
apply gentle, prolonged pressure to the site after the
needle is removed. D @+
e Take BP only when necessary and avoid overinflating the BP cuff inflation in a client that is thrombocytopenic may lead to
cuff. D @ + petechiae in the affected extremity.
¢ Caution client to avoid activities that increase the risk for Potential for injury and increase bleeding.
trauma (e.g., shaving with a straight-edge razor, using stiff-
bristle toothbrush or dental floss).
e Whenever possible, avoid intubations (e.g., nasogastric) Prevents injury to mucosa and decrease the potential for bleeding.
and procedures that can cause injury to rectal mucosa
(e.g., taking temperature rectally, inserting a rectal sup-
pository, administering an enema).
e Pad side rails if client is confused or restless. Precaution to prevent client injury.
Perform actions to reduce the risk for falls (e.g., keep bed in Decreases risk for potential injury.
low position with side rails up when client is in bed, avoid
unnecessary clutter in room, instruct client to wear
slippers/shoes with nonslip soles when ambulating).
Instruct client to avoid blowing nose forcefully or straining to
have a bowel movement; consult physician regarding an
order for a decongestant and/or laxative if indicated.
Administer the following if ordered:
e Platelet-stimulating factor (romiplostim) Platelet stimulation factors help the bone marrow increase produc-
tion of platelets.
e Estrogen-progestin preparations. Estrogen-progesterone preparations help suppress menses.
*~ Platelets. Administration of platelets replaces components necessary for
optimum clot formation.
If bleeding occurs and does not subside spontaneously:
e Apply firm, prolonged pressure to bleeding area(s) if possible. Application of pressure helps facilitate hemostasis.
e If epistaxis occurs, place client in a high-Fowler’s position Application of ice helps to facilitate hemostasis through vasocon-
and apply pressure and ice pack to nasal area. striction of vessels.
e Maintain oxygen therapy as ordered. Supplemental oxygen is necessary in Clients with reduced
hemoglobin.
e Administer whole blood or blood products (e.g., platelets) Actions help to replace deficit of components necessary to achieve
as ordered. hemostasis.

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|Collaborative =Diagnosis
os |RADIATION CYSTITIS

Definition: Inflammation of cells lining the bladder.

Related to: Irritation of the bladder mucosa if the bladder is in the treatment field

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dysuria; urinary frequency and/or Frank or occult blood in the urine
urgency; suprapubic discomfort

RISK FACTORS DESIRED OUTCOMES

e Localized radiation therapy The client will experience resolution of radiation cystitis if
it occurs as evidenced by:
a. Reports of decreasing dysuria, urinary frequency and
urgency, and suprapubic discomfort
b. Absence of hematuria

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of radiation cystitis: Early recognition of signs and symptoms of radiation cystitis
e Reports of dysuria, urinary frequency and/or urgency, or allows for implementation of the appropriate interventions.
suprapubic discomfort
e Frank or occult blood in the urine

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to reduce discomfort associated with
cystitis:
Encourage a minimum fluid intake of 2500 mL/day unless Adequate fluid intake helps to keep urine dilute and thereby reduce
contraindicated. further irritation of the bladder lining.
Instruct client to avoid substances that can cause bladder Avoidance ofstimulants can decrease bladder irritation.
irritation (e.g., caffeinated beverages, alcohol, tobacco,
spicy foods).
Administer urinary tract analgesic/anesthetic agents and Analgesia can prevent pain and improve urination.
bladder smooth muscle relaxants if ordered. D +
Assist with measures to control bleeding (e.g., continuous Preparation of client for procedures decreases anxiety.
bladder irrigation with silver nitrate, cystoscopy to cauter-
ize bleeding vessels, instillation of formalin into the
bladder) if bleeding occurs and is persistent or severe.

Collaborative »Diagnosis
65 RADIATION PNEUMONITIS

Definition: Localized inflammation of the lung.

Related to: Inflammation of lung tissue resulting from radiation to the chest

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal reports of shortness of breath Cough; fever; night sweats; finding of infiltrates on chest
radiograph; dyspnea
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RISK FACTORS DESIRED OUTCOMES

° Localized radiation therapy
The client will have improvement of radiation pneumoni-
tis if it occurs as evidenced by:
a. Decreased dyspnea and coughing
b. Temperature declining toward normal

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of radiation pneu- Early recognition of signs and symptoms of radiation pneumonitis
monitis: allows for implementation of the appropriate interventions.
e Dyspnea
¢ Cough
e Fever
e Night sweats
Assess chest radiograph and report abnormal findings.
Assess pulse oximetry and arterial blood gas values, and
report abnormal findings.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to improve respiratory function: These actions help to reexpand alveoli, improving oxygenation.
e Instruct and assist client to turn, cough, and breathe
deeply every 1 to 2 hrs.
e Reinforce correct use of incentive spirometer every 1 to Improves lung expansion and increases oxygenation.
2 hrs. D +
e Maintain oxygen therapy if ordered. D+ Supplemental oxygen increases the partial pressure of oxygen in the
blood.
Administer the following medications if ordered:
e Corticosteroids. Corticosteroids help to reduce inflammation.
e Bronchodilators. ronchodilators dilate larger airways, improving ventilation.
Consult physician if signs and symptoms of pneumonitis worsen Notifying the appropriate health care provider allows for modifica-
or signs and symptoms of impaired gas exchange (e.g., restless- tion of the treatment plan.
ness, irritability, confusion, decreased partial pressure of oxy-
gen in arterial blood [PaO.], and increased partial pressure of
carbon dioxide in arterial blood [PaCO,]) develop.

Collaborative >
Diagnosis |~LYMPHEDEMA |

Definition: Accumulation of lymph fluid in soft tissue.

Related to: Damage to and subsequent obstruction of lymphatic vessels in the area being irradiated (seen most frequently in persons
having radiation for breast cancer, melanoma in an upper or lower extremity, gynecologic cancer, or prostate cancer)

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain or feeling of heaviness, fullness, Increase in size of extremity; sensory or motor deficits in
or tightness in extremity extremity

RISK FACTORS DESIRED OUTCOMES

e Surgical excision of lymph nodes
The client will have decreasing signs and symptoms of
e Radiation of lymph nodes
lymphedema if it occurs as evidenced by:
a. Decreased pain and feeling of heaviness and tightness
in involved extremity
b. Reduction in size of involved extremity
c. Improved motor and sensory function in involved
extremity

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NURSING ASSESSMENT RATIONALE

Assess extremities in or near the treatment field for signs and Early recognition of signs and symptoms of lymphedema allows for
symptoms of lymphedema: implementation of the appropriate interventions.
e Verbal reports of pain or feeling of heaviness, fullness, or
tightness in extremity
e Increase in size of extremity
e Sensory or motor deficits in extremity
e Assess daily measurement of limb circumference.

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
If signs and symptoms of lymphedema occur:
e Elevate the involved extremity. D@ + Elevation of an edematous extremity helps promote excess fluid
drainage, promoting reabsorption.
e Avoid use of involved extremity for BP measurements, in- Clients must protect the integrity of the skin as the first barrier to
jections, and venipunctures. D @ + the prevention of infection.
e Apply a graded-pressure or sequential compression device Helps to promote drainage of lymphatic fluid.
to involved extremity if ordered. D @ +
Administer the following medications if ordered:
e Antimicrobial agents. D+ Agents help to prevent or treat cellulitis and lymphangitis.
e Analgesics. D + Agents help to alleviate pain associated with soft tissue swelling.
Consult physician if signs and symptoms of lymphedema per- Notification of the appropriate health care provider allows for
sist or worsen or if signs and symptoms of infection (e.g., modification of the treatment plan and reduces the risk of
redness or unusual warmth in extremity, fever) develop. complications.

Nursing Diagnosis DISTURBED SELF-CONCEPT*

Definition: Disturbed Body Image NDx: confusion in mental picture of one’s physical self; Risk for Situational Low
Self-Esteem NDx: Susceptibility to developing a negative perception of self-worth in response to current situation,
which may compromise health.

Related to:
e Changes in appearance (e.g., temporary or permanent hair loss within the treatment field; skin changes such as erythema,
uneven skin texture, or hyperpigmentation within the treatment field; excessive weight loss)
e Possible alteration in usual sexual activities associated with:
° Fatigue, decreased levels of testosterone (if testes are in the treatment field), psychologic factors, and vaginal and/or
urethral discomfort (if the lower abdomen, pelvis, or perineal area is irradiated)
e Temporary or permanent impotence resulting from psychologic factors, decreased levels of testosterone (if testes are in
the treatment field), and/or injury to pelvic nerves and blood vessels if included within the treatment field
e Altered reproductive function:
e Sterility associated with exposure of testes or ovaries to radiation
* Potential for genetic mutations associated with sperm or ova chromosomal damage resulting from irradiation of the
gonads
e Increased dependence on others to meet self-care needs
e Changes in lifestyle and roles associated with the effects of the disease process and its treatment

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of negative feelings about self; with- Lack of participation in activities of daily living
drawal from significant others; lack of planning to adapt
to necessary changes in lifestyle

= las diagnostic label includes the nursing diagnoses of Disturbed Body Image and Situational Low Self-Esteem. —
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 795

RISK FACTORS DESIRED OUTCOMES

Illness treatment
Disturbed body image The client will demonstrate beginning adaptation to
Social role change changes in appearance, body functioning, lifestyle, and
roles as evidenced by:
a. Verbalization of feelings of self-worth and sexual adequacy
b. Maintenance of relationships with significant others
c. Active participation in activities of daily living
d. Verbalization of a beginning plan for adapting lifestyle
to changes resulting from the disease process and the
residual effects of radiation therapy

NOC OUTCOMES NIC INTERVENTIONS

Self-esteem; psychosocial adjustment: life change; personal Body image enhancement; self-esteem enhancement; role en-
autonomy; body image hancement; emotional support; support system enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of a disturbed self-concept: Early recognition of signs and symptoms of disturbed self-concept
allows for implementation of the appropriate interventions.
Verbalization of negative feelings about self
Withdrawal from significant others
Lack of planning to adapt to necessary changes in lifestyle
Lack of participation in activities of daily living

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to assist client to adapt to the following Measures that help to minimize changes in appearance reduce the
changes in appearance and body functioning if appropriate: impact of these changes on self-concept.
Alopecia. Instructing the client about hair loss associated with radiation
therapy may reduce anxiety and allow for implementation of
temporary measures that help improve self-esteem.
Inform client that hair loss in the treatment field usually
begins 2 to 3 weeks after initiation of therapy.
Reassure client that regrowth of hair within the treatment
field will occur within 2 to 3 months after cessation of
therapy if the loss is temporary (temporary or patchy loss
will usually occur with a radiation dose of 2000-3000 cGy;
delayed hair growth or complete, permanent hair loss
within the treatment field may result from a radiation
exposure >4000 cGy); explain that regrowth may be a
different color, texture, and thickness.
Instruct the client in ways to minimize scalp hair loss if Provides client methods to help in controlling hair loss.
thinning or partial hair loss is anticipated.
Brush and comb hair gently.
Wash hair only when necessary and avoid harsh shampoo,
cream rinse, and other hair care products.
Do not use hair dryer, curling iron, curlers, or constrictive
decorations (e.g., clips, rubber bands) on hair.
Avoid hairstyles that create tension on hair (e.g., ponytails,
braids).
Encourage the client to wear a wig, scarf, hat, or turban if de- Provides client with choices concerning what to do when hair loss
sired to conceal hair loss; contact the American Cancer Society occurs. Use of these help to improve client’s self-esteem.
for a wig if client is unable to obtain one but desires to do so.
Encourage use of the wig before hair loss. Use of the wig before hair loss facilitates adjustment to the wig and
its integration into body image.
Caution client to remove wig several times a day to allow Protects scalp from ongoing irritation.
for exposure of treatment area to the air.
Skin changes within the treatment field.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Reinforce physician’s explanation about skin changes that Explain what skin changes may occur and help client be ready for
will occur and when they can be expected. when they occur.
e Suggest possible clothing styles that will make changes in Natural fabrics such as cotton are less irritation to the skin.
skin texture and pigmentation less obvious.
e Sterility or chromosomal damage. Inform client of potential reproductive changes that impact one’s
ability to have children.
e Clarify physician’s explanation about probable effects of radia- Allows client time to ask question concerning potential changes.
tion therapy on the gonads if they are in the treatment field.
e Discuss alternative methods of becoming a parent (e.g., Allows client to prepare for changes and determine methods that
artificial insemination, adoption) if of concern to client. may be used for reproduction prior to treatment, when possible.
e Impotence. Sexual functioning is an important component of one’s sense of self.
Assistance may be necessary to help the client adjust to changes
experienced and/or to identify alternative ways of sexual expression.
e Reinforce physician’s explanation about the temporary or Allows client time to ask question concerning treatment options to
permanent nature of impotence; if it will be permanent, maintain as much sexual functioning as possible.
encourage client to discuss various treatment options (e.g.,
vacuum erection aids, penile prosthesis) with physician.
e Suggest alternative methods of sexual gratification if
appropriate.
e Discuss ways to be creative in expressing sexuality (e.g., Allows client to ask questions in a supportive environment.
massage, fantasies, cuddling).
e Assist client with usual grooming and makeup habits if Appearance is an essential component of self-esteem and one’s
necessary. concept of self.
Support behaviors suggesting positive adaptation to changes Maintaining an appearance the client is comfortable with has a
that have occurred (e.g., interest in personal appearance positive effect on self-concept.
maintenance of relationships with significant others).
Encourage significant others to allow client to do what Allowing the client to do as much as he/she is able facilitates the
he/she is able so that independence can be reestablished reestablishment of independence, which enhances feelings of
and/or self-esteem redeveloped. self-esteem.
Assist client’s and significant others’ adjustment by listening, Listening, facilitating communication, and providing information
facilitating communication, and providing information. assist the client and significant others to cope with the present
situation.
Encourage visits and support from significant others.
Provide information about and encourage use of community Community agencies and support groups provide the opportunity
agencies and support groups (e.g., vocational rehabilita- for the client to see that he/she is not experiencing a unique
tion; sexual, family, individual, and/or financial counsel- problem, to share feelings and concerns, to profit from the expe-
ing). rience ofothers with similar difficulties, and to learn new skills
necessary to rebuild self-esteem.
Consult appropriate health care provider (e.g., psychiatric Additional counseling may be necessary to facilitate positive adap-
nurse clinician, oncology nurse specialist, physician) if tation to the changes in appearance and/or body functioning
client seems unwilling or unable to adapt to changes that have occurred.
resulting from cancer and radiation therapy.

|Nursing »-)
Diagnosis |6DEFICIENT KNOWLEDGE? nox INEFFECTIVE HEALTH
MANAGEMENT?* nox INEFFECTIVE FAMILY HEALTH
MANAGEMENT?® nox ‘

Definition: Deficient Knowledge NDx: Absence of cognitive information related to a specific topic, or its acquisition;
Ineffective Health Management NDx: Pattern of regulating and integrating into daily living a therapeutic
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals;
Ineffective Family Health Management NDx: A pattern of regulating and integrating into family processes a program
for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals of the family unit.

Related to: Lack of understand of illness and long-term impact on life and family.

*The nurse should select the nursing diagnostic label that is most appropriate for the client's discharge teaching needs.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders PDI

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of the problem Exaggerated behaviors; inaccurate follow-through of
instructions; lack of attention to illness; lack of interest in
improving health behaviors

RISK FACTORS
e Lack of exposure
e Unfamiliarity with information resources
e Economically disadvantaged patient

NOC OUTCOMES NIC INTERVENTIONS

ee ee eee
Knowledge: disease process; treatment regimen; energy Health system guidance; teaching: disease process; teaching:
conservation; treatment procedure(s) prescribed activity/exercise; teaching: procedure/treatment;
nutrition management

THERAPEUTIC INTERVENTIONS RATIONALE

-

Desired Outcome: The client will verbalize an understand-

ing of appropriate skin care for site of irradiation.

Independent Actions
e Reinforce teaching about the expected skin reaction at Skin contains rapidly proliferating cells that are readily damaged
the site of irradiation (e.g., redness, tanned appearance, by radiation.
peeling, itching, loss of hair, decreased perspiration). Interventions should be directed at maintaining the integrity of the
skin and preventing wound development and infection.
e Instruct the client to:
e Clean irradiated area gently using a mild soap and tepid Helps to prevent skin breakdown and potential for infection.
water, being careful not to wash off temporary skin
markings.
e Pat skin dry with a soft cotton towel.
e Avoid rubbing, scratching, and massaging irradiated skin.
Relieve itching by:
e Applying a light dusting of cornstarch to area of dry des- Moisturizing lotions and emollients provide a source of moisture to
quamation. the skin.
e Adding emollients, colloidal-based bath products, corn
starch, or baking soda to bath water.
e Relieve dryness by applying a water-based lubricant Prevents skin drying as seen with alcohol-based products.
lotion (e.g., Lubriderm, Eucerin).
e Avoiding use of deodorant if treatment field includes Prevents skin irritation.
axillae.
e Check with physician before using cosmetics or Chemicals contained in perfumes and lotions may exacerbate
perfumed lotions or creams in treatment area. imitated skin.
e Protect irradiated skin from exposure to temperature ex-
tremes and wind.
e Avoid exposure of treated area to direct sunlight or tan- Burns can occur easily because melanin production in new epider-
ning beds during treatment period and for at least mal cells is slowed.
1 month after therapy is complete and always use
sunscreen with sun protection factor of 15 or greater.
e Wear soft cotton garments next to treatment area; use a Decreases irritation and potential for itching which can lead to
gentle detergent to launder clothing. breakdown.
e Avoid wearing tight or constrictive clothing over irradi- Action helps to reduce mechanical irritation.
ated area.
e Avoid shaving and using tape within treatment field; use Prevents injury.
an electric razor if shaving is absolutely necessary.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Care for a moist desquamation reaction by:
e Performing wound care and applying sterile dressings Moist desquamation produces pain and drainage, and increases the
as prescribed (stretchable netting should be used risk of infection. Actions help to maintain or prevent increased
instead of tape to hold dressings in place). irritation to irradiated skin areas.
e Exposing area to the air as much as possible. Helps to decrease skin irritation.
e Demonstrate care of treatment site. Allows health care provider to correct any actions by the client or
family.
e Allow time for questions, clarification, and return dem- Allows the health care provider to assess the client’s understanding
onstration of skin and wound care. of information and allow reinforcement if needed.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify techniques to

control nausea and vomiting.

Independent Actions
Instruct client in the following techniques to control nausea Interventions aimed at controlling nausea and vomiting can assist
and vomiting: with improving appetite.
e Clean mouth frequently.
e Avoid offensive odors and sights. Decrease potential nausea and vomiting and can improve appetite.
e Eat several small meals each day instead of three large Prevents excessive stomach expansion which can lead to nausea
ones. and vomiting.
e Eat the largest meal 3 to 4 hrs before treatments and eat Nausea and vomiting commonly occur after chemotherapy and/or
lightly for at least 3 to 4 hrs after a treatment. radiation.
e Eat foods that are cool or at room temperature (hot foods Prevention and control of nausea and vomiting are necessary to
frequently have a strong aroma that stimulates nausea). ensure adequate nutrition.
e Eat dry foods (e.g., toast, crackers) or sip cold carbonated
beverages if nausea is present.
e Select bland foods (e.g., mashed potatoes, cottage cheese) Decreases irritation to the oral mucosa and decreases potential for
rather than fatty, spicy foods. nausea.
e If feasible, have someone else prepare the food.
e Avoid drinking liquids with meals. Drinking at meals increases feeling of fullness.
e Rest after eating.
e Take deep, slow breaths when nauseated. Decreases sensation of nausea.
e Follow prescribed antiemetic regimen.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to im-

prove appetite and nutritional status

Independent Actions
Instruct client in ways to improve appetite and maintain an The stress of illness increases the metabolic needs of clients.
adequate nutritional status: Caloric requirements are greatly increased during illness.
Maintaining an optimal nutritional status helps support the
client during hypermetabolic periods and prevents complica-
tions associated with malnutrition, which may include sepsis.
e Try chicken, fish, cheese, and eggs as protein sources Assures adequate intake of protein.
instead of beef and pork if taste distortion is a problem.
e Increase the amount of sweeteners and seasonings usually May improve appetite. '
used in foods or beverages.
e Use plastic eating utensils and cook foods in glass or Decreases potential for metallic taste when eating.
plastic containers rather than metal ones.
e Moisten dry foods with sauces, salad dressing, or sour Improves client’s ability to swallow food.
cream if mouth is dry or sore.
e Eat in a pleasant environment with company if possible. May increase caloric intake.
e Perform frequent oral hygiene to eliminate unpleasant Removes unpleasant taste in the mouth and helps maintains oral
tastes in mouth. health.
e Try recommended methods of controlling nausea.
 Chapter 15 » The Client Receiving Treatment for Neoplastic Disorders 799

THERAPEUTIC INTERVENTIONS RATIONALE

e Eat several high-calorie, high-protein, nutritious small Prevents oral distention of the stomach while improving caloric
meals each day rather than three large ones; use nutri- intake.
tional supplements if needed to maintain an adequate
calorie intake.
e Plan ahead for low-energy days (e.g., have some prepared When foods are readily available, it helps client to maintain
meals available; maintain an ample supply of nutritious, adequate nutritional intake.
minimal preparation foods such as eggs, tuna fish, cheese,
peanut butter, and yogurt; keep nutritious snacks and
beverages within easy reach).
e Take vitamins and minerals as prescribed. Supplements may be required to maintain nutritional status.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to reduce

the risk of dental caries and periodontal disease and manage
stomatitis if present.

Independent Actions
Inform client that dental caries and periodontal disease can Frequent oral hygiene is necessary in the neutropenic client to keep
occur months to years after irradiation of the jaw, neck, or the oral cavity clean, moist, and free of bacterial infection so
oral cavity. Emphasize that a meticulous daily oral hygiene adequate nutritional intake can occur.
program is essential, particularly if salivary flow is perma-
nently reduced.
Instruct client in ways to reduce the risk of dental caries and
periodontal disease:
e Use appropriate technique for cleansing teeth. These techniques help to prevent oral injury and support dental
e Brush teeth with a fluoride toothpaste several times a day, health.
particularly after eating.
e Use a small, soft, flexible toothbrush to brush teeth.
e Rinse mouth with a fluoride solution after brushing.
e If stomatitis is present, instruct client to:
e Rinse mouth with the following solutions as prescribed:
e Salt or baking soda and warm water. Removes debris from the oral cavity and is soothing to the mucus
membranes.
e Chlorhexidine gluconate (Peridex). Prevents gingivitis.
e Consult physician about use of preparations to Decrease oral pain and irritation.
soothe the oral mucous membrane (e.g., diphen-
hydramine and water mixture) if mouth is painful.
e Wear dentures only at mealtime. Prevents ongoing irritation.
e Eat soft, bland foods and avoid substances that might These types of foods are irritants to the oral cavity and may cause
further irritate the mouth (e.g., extremely hot, spicy, or diarrhea, which can lead to loss of fluid and electrolytes.
acidic foods/fluids).
e Allow time for questions, clarification, and practice of oral Actions allow the health care provider to assess client’s understand-
hygiene techniques. ing of information and provide reinforcement as needed.
e Instruct client to discuss any planned dental care with
the radiologist and to inform the dentist that he/she is
receiving or has had radiation to the oral cavity.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

bleeding if platelet counts are low.

Independent Actions
Instruct client in ways to minimize the risk of bleeding: A client who is thrombocytopenic is at risk for increased bleeding
and should be instructed on actions to prevent and/or control
bleeding.
° Avoid taking aspirin and other nonsteroidal antiinflamma- Aspirin and NSAIDS decrease the platelets ability to participate in
tory agents (e.g., ibuprofen). the clotting process.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Consult health care provider before routinely taking herbs Several herbal products may increase the risk of bleeding and
that can increase the risk of bleeding (e.g., ginkgo, arnica, should be avoided.
chamomile).
e Brush teeth gently using a soft-bristle toothbrush; do not Decrease the risk of gingival injury.
use dental floss or put sharp objects (e.g., toothpicks) in
mouth.
e Be attentive when using scissors, knives, and tools to These actions decrease the potential for injury, bleeding, and
reduce the risk of cuts. possible infection.
e Use an electric rather than a straight-edge razor.
e Cut nails and cuticles carefully.
e Use caution when ambulating to prevent falls or bumps
and do not walk barefoot.
e Avoid blowing nose forcefully.
e Avoid contact sports and other activities that could result
in injury.
e Avoid straining to have a bowel movement.
e Avoid wearing constrictive clothing (e.g., garters, knee Decreases circulation to the extremities.
high stockings).
e Use an ample amount of water-soluble lubricant before
sexual intercourse and avoid anal sexual activity, douch-
ing, use of rectal suppositories, and enemas in order to
prevent trauma to the vaginal and rectal mucosa.
e Avoid heavy lifting.
e Instruct client to control any bleeding by applying firm, Helps to promote clotting.
prolonged pressure to the site.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify ways to prevent

infection if WBC counts are low.

Independent Actions
Explain to client that his/her resistance to infection is
reduced when WBC counts are low. Emphasize the need
to adhere closely to recommended techniques to prevent
infection.
Instruct client in ways to prevent infection:
e Avoid crowds, persons with any sign of infection, and Prevents exposure to infection.
persons who have recently been vaccinated.
e Use good hand hygiene (e.g., wash hands using an anti- Good hand hygiene is paramount in preventing infection.
bacterial soap, use an alcohol-based hand rub).
e Wear gloves to protect hands during activities such as Animal feces are often present in garden soil and if ingested, can
cleaning and gardening. lead to infection in an immunocompromised client.
e Take an axillary rather than an oral temperature if stoma- Axillary temperature assessment is more comfortable for a client
titis is present. with stomatitis.
e Lubricate the skin outside irradiated area frequently to Dry, cracked skin provides an avenue for bacteria to enter the body.
prevent dryness and subsequent cracking.
e Cleanse and care for skin within treatment field as recom- Helps to maintain skin intetrity.
mended.
e Avoid unnecessary rectal invasion (e.g., temperature Decreases potential for injury and_ potential intrbduction of
taking, enemas, suppositories, sexual activity) to prevent infectious organisms.
trauma to the rectal mucosa.
e Avoid constipation to prevent trauma to the bowel Damage or perforation of the bowel can lead to sepsis in an
mucosa from hard or impacted stool. immunocompromised client.
e Wash perianal area thoroughly with soap and water after Prevents irritation and exposure to infectious bacteria.
each bowel movement; inform female client to always
wipe from front to back after defecating and urinating.
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 801

THERAPEUTIC INTERVENTIONS RATIONALE

e Avoid douching unless ordered. Douching disturbs normal vaginal flora and may cause trauma to
the vaginal mucosa.
Drink at least 10 glasses of liquid per day unless contra- Adequate hydration prevents constipation.
indicated.
Cough and deep breathe or use incentive spirometer every Coughing and deep breathing keep alveoli expanded, improve gas
2 hrs until usual activity level is resumed. exchange, and facilitate expectoration of secretions, preventing
pneumonia.
Stop smoking. Smoking damages the mucociliary system, which helps facilitate
the expectoration of secretions.
Perform meticulous oral hygiene after meals and at Proper oral hygiene reduces oral bacteria and helps to keep oral
bedtime or more often if directed, change denture care mucosa intact.
solution daily, and replace toothbrush routinely.
Maintain an optimal nutritional status (e.g., diet high in Helps body to maintain adequate immune system.
protein, calories, vitamins, and minerals).
e Avoid sharing eating utensils. Decreases exposure to infectious organisms.
Maintain an adequate balance between activity and rest. Prevents fatigue.
Cleanse respiratory equipment as instructed; change water Prevents growth of and subsequent exposure to infectious
in humidifiers daily. organisms.
e Decrease risk of food-borne illness. Inadequate preparation of foods may predispose the client with
a weakened immune system to food-borne pathogens that
precipitate illness.
Avoid intake of foods with a high microorganism content Decreases exposure to infectious organisms.
(e.g., unwashed fruits and vegetables; under-cooked eggs,
meat, poultry, and seafood).
Be sure that juices and ciders are pasteurized or processed Prevents exposure to unpasteurized products which decrease poten-
and that milk and cheese are pasteurized. tial for infection.
Thoroughly wash hands and food preparation items and Handwashing and cleaning food preparation surfaces are critical in
surfaces (e.g., knives, cutting boards, countertop) before decreasing exposure to infectious organisms.
and after cooking, especially when working with raw
meat, poultry, and fish.
Thaw food items in the refrigerator rather than on kitchen Prevents bacteria growth during food thawing.
counter.
Avoid picking up animal waste or cleaning animal litter Animal feces contain pathogens that can be harmful in a client
boxes and bird cages. with a compromised immune system.
Avoid elective surgery and dental work. Prevents injury and potential exposure to infection.
Reinforce the importance of taking prescribed medications Improves body’s ability to fight infections.
such as colony-stimulating factors and prophylactic anti-
microbial agents.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize an understand-

ing of and ways to manage the effects of radiation therapy on
sexual and reproductive functioning.

Independent Actions
Clarify physician’s explanation about the possible effects of Reproductive and sexual dysfunction will vary according to radia-
irradiation on the gonads if included in the treatment tion treatment protocols. Reproductive effects may be enhanced
field. when area is included in the radiation treatment field.
Explain that a temporary decrease in libido may occur as a
result of radiation treatment.
Encourage client to rest before sexual activity if fatigue is a
problem.
Instruct client in measures to reduce discomfort associated Radiation therapy can result in tenderness, irritation, and loss of
with decreased vaginal secretions and mucositis. lubrication. These actions help client minimize discomfort
encountered as a result of these side effects.
e Use an ample amount of water-soluble lubricant. Improves conform and decreases potential for trauma to the
vaginal mucosa.

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802 @haprerslome The Client Receiving Treatment for Neoplastic Disorders

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Use a vaginal steroid cream, if prescribed. Decreases vaginal dryness and inflammation.
e Avoid intercourse until mucositis of the vaginal canal and/or Prevents injury and potential spread of infectious organisms.
urethra resolves.
e Have male partner use a condom during intercourse to Semen can cause a burning sensation in the early months after
prevent contact of vaginal area with semen. vaginal irradiation.
e Emphasize the need for frequent intercourse or vaginal Stenosis may develop several weeks or months after cessation of
dilatation once mucositis has resolved to prevent stenosis treatment that includes the vaginal area.
of the vaginal canal.
e Explain to the female client that ovarian failure during Allows client to mentally prepare for changes and speak to health
therapy may result in decreased libido, irritability, hot care provided about ways to decrease impact of changes.
flashes, and other symptoms of premature menopause.
e Inform the female client that her usual menstrual cycle Reproductive function may be temporarily altered and as such
will resume within 6 months to 1 year after treatment if appropriate precautions should be taken.
sterility is temporary.
e Emphasize the need for both male and female clients to practice
birth control during treatment and for at least 2 years after it.
e Encourage both male and female clients to seek genetic Allows for continuum of care and information sharing prior to
counseling before attempting conception to ascertain the pregnancy.
risk of chromosomal anomalies.
e Instruct client to take hormone replacements (e.g., estro- Hormone replacement therapy may reduce symptoms associated
gen, testosterone) as prescribed. with ovarian failure.

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will verbalize ways to manage

and cope with persistent fatigue.

Independent Actions
Instruct client in ways to manage and cope with persistent fatigue: Fatigue affects most all clients undergoing chemotherapy and/or
e View fatigue as a protective mechanism rather than a radiation. Fatigue may be related to anemia or side effects from
problematic limitation. therapy.
e Determine ways that daily patterns of activity can be modi-
fied to conserve energy and prevent excessive fatigue (e.g.,
spread light and heavy tasks throughout the day, take short
rests during an activity whenever possible, take several
short rest periods during the day instead of one long one).
e Determine whether life demands are realistic in light of physi-
cal state and adjust short- and long-term goals accordingly.
e Avoid situations that are particularly fatiguing such as Ignoring fatigue or participating in activities that increase stress or
those that are boring, frustrating, or require prolonged or fatigue may exacerbate symptoms.
strenuous physical activity.
e Participate in a moderate exercise program (e.g., walking Walking is an effective way for a client to be active without
or bicycling 20-30 minutes three to four times a week). overtaxing the body.
e Participate in “attention-restoring” activities (e.g., walking Improves clients muscle tone and self-esteem.
outdoors, gardening).

THERAPEUTIC INTERVENTIONS RATIONALE

—_——

Desired Outcome: The client will verbalize an understand-

ing of the signs and symptoms of lymphedema and ways to
manage it if it occurs.

Independent Actions
Instruct the client at risk for lymphedema (e.g., person receiv- Lymphedema occurs as a result of excision or radiation of lymph
ing radiation for breast cancer, melanoma in an extremity, nodes. Fluid accumulates in the soft tissues as lymph nodes are
gynecologic cancer, or prostate cancer) to: unable to return fluid to the circulation fluid accumulation can
result in impaired motor function in the affected area.
e Monitor for and report signs and symptoms of lymph Allows for early identification of problem and appropriate treat-
edema (e.g., pain or a feeling of heaviness or tightness in ment to be prescribed.
involved extremity).
 Chapter 15 * The Client Receiving Treatment for Neoplastic Disorders 803

THERAPEUTIC INTERVENTIONS RATIONALE

° Measure the circumference of involved arm or leg daily if
the extremity appears swollen and report a sudden
increase in size to the physician.
° Provide the following instructions about ways to manage
and prevent complications associated with lymphedema if
it occurs:
° Keep pressure off the involved extremity (e.g., avoid Clients must protect the integrity of the skin as the first barrier to
wearing tight jewelry, clothes with constricting bands, the prevention of infection.
and elastic stockings with constricting bands; carry
bags on unaffected arm; do not cross legs).
° Keep involved extremity elevated as much as possible. Elevation of an edematous extremity helps promote excess fluid
drainage, promoting reabsorption.
e Perform prescribed exercises. This helps to promote drainage of lymphatic fluid.
e Gently clean and apply oil or skin cream to involved Presents skin injury and helps to maintain intact skin.
extremity daily.
¢ Avoid injury to the involved extremity (e.g., do not allow Prevents further complications from decreasing circulation and
finger sticks or venipunctures in involved extremity, use lymphatic drainage.
an electric rather than straight-edge razor when shaving
os involved extremity, wear gardening and cooking gloves
and use a thimble for sewing if upper extremity is
affected, do not walk barefoot if lower extremity is affected,
avoid extreme hot or cold on affected extremity, do not
cut cuticles on hand or foot of involved extremity).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will state signs and symp-

toms to report to the health care provider.

Independent Actions
Instruct the client to observe for and report the following: Prompt reporting of adverse signs and symptoms allows for
e Signs and symptoms of infection (stress that the usual modification of the treatment plan and may reduce the risk of
signs of infection are diminished in people with a sup- complications.
pressed immune system and that it is necessary to monitor
closely for the following signs and symptoms).
Temperature above 38°C (100.4°F).
e Changes in odor, color, or consistency or urine.
Signs and symptoms of bleeding.
e Signs and symptoms of radiation cystitis.
e Signs and symptoms of radiation pneumonitis.
e Signs and symptoms of tissue fibrosis within treatment
field.
e Excessive tooth decay.
e Persistent nausea, vomiting, or decreased oral intake.
¢ Significant weight loss (weight loss of 1-2 Ib/week during
radiation therapy is not unusual).
e Persistent diarrhea.
e Excessive depression or difficulty coping with the effects of
the diagnosis and treatment.
e Instruct client to keep a record of signs and symptoms,
activities at the time the symptoms occur, measures to
achieve relief, and the effect of the measures taken. In-
struct client to take the information to each appointment
with the health care provider.

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804 Chapter dom The Client Receiving Treatment for Neoplastic Disorders

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client will identify community

resources that can assist with home management and adjust-
ment to the diagnosis of cancer and radiation therapy and its
effects.

Independent Actions
Provide information about and encourage use of community Knowledge of community resources can aid client in identification
resources that can assist the client and significant others of services that may facilitate adherence to the treatment plan
with home management and adjustment to cancer and and provide the social support necessary during the treatment
the effects of radiation therapy (e.g., local support groups, process.
American Cancer Society, home health agencies, counsel-
ors, social service agencies, Meals on Wheels, Make Today
Count, hospice).

THERAPEUTIC INTERVENTIONS RATIONALE

Desired Outcome: The client, in collaboration with the

nurse, will develop a plan for adhering to recommended
follow-up care including medications prescribed and future
appointments with health care provider, radiation depart-
ment, and laboratory.

Independent Actions
Explain the rationale for, side effects of, and importance of These actions help client adhere to the prescribed treatment
taking medications prescribed. Inform client of pertinent regimen.
food and drug interactions:
e Reinforce physician’s explanation of planned radiation Allows client to ask questions and to determine actions necessary
therapy schedule. to meet appointments.
e Discuss with client any difficulties he/she might have
adhering to the schedule and assist in planning ways to
overcome these.
e Reinforce the importance of keeping appointments for
radiation treatments and follow-up laboratory studies.
e Reinforce the importance of keeping follow-up appoint-
ments with health care provider.
Implement measures to improve client compliance:
e Include significant others in teaching sessions.
e Encourage questions and allow time for reinforcement and
clarification of information provided.
e Provide written instructions regarding future appoint-
ments with health care provider, radiation department,
and laboratory; medications prescribed; and signs and
symptoms to report.

ADDITIONAL NURSING DIAGNOSIS

FEAR NDx/ANXIETY NDx ACUTE PAIN NDx

Related to: Related to: '
e Unfamiliar environment Inflammation and/or moist desquamation (if it occurs) in
e Lack of knowledge about radiation therapy if admitted to irradiated area
initiate therapy
e Need for hospitalization to manage existing side effects of NAUSEA NDx
radiation therapy and concern that additional untoward Related to:
effects will occur with subsequent radiation treatments Stimulation of the vomiting center associated with:
e Financial concerns * Presence of byproducts of cellular destruction if client is
e Diagnosis of cancer with potential for premature death receiving a large daily fraction of radiation or daily treat-
ments over a period of several weeks
 Chapter 15 The Client Receiving Treatment for Neoplastic Disorders 805

Stimulation of the visceral afferent pathways resulting from Related to:

inflammation of the gastrointestinal mucosa (occurs when
Increased peristalsis and disorders of intestinal secretion and
areas of the chest, back, abdomen, or pelvis are irradiated)
absorption associated with damage to the intestinal mucosa if
Stimulation of the cerebral cortex resulting from cerebral the treatment field includes the pelvis, abdomen, or lower
inflammation (if client is receiving whole-brain irradia- back
tion) and stress
RISK FOR INFECTION NDx
FATIGUE NDx Related to:
Related to: Break in the integrity of the skin associated with dry or
A buildup of cellular waste products associated with rapid moist desquamation
lysis of cancerous and normal cells exposed to radiation Lowered natural resistance associated with
Tissue hypoxia associated with anemia (can result from Malnutrition
malnutrition or depression of bone marrow activity if large Neutropenia resulting from bone marrow suppression if
amounts of active bone marrow are included in the treat- large amounts of active bone marrow are included in the
ment field) treatment field
Difficulty resting and sleeping associated with fear, anxi- Impaired immune system functioning resulting from
ety, and discomfort certain malignancies (e.g., Hodgkin disease, lymphoma)
Overwhelming emotional demands associated with the Stasis of respiratory secretions and urinary stasis if mobil-
diagnosis of cancer and treatment with radiation ity is decreased
Increased energy expenditure associated with an increase
in the metabolic rate resulting from continuous active GRIEVING NDx
tumor growth and increased levels of certain cytokines Related to:
(e.g., tumor necrosis factor, interleukin-1) Changes in body image and usual lifestyle and roles
Malnutrition Diagnosis of cancer with potential for premature death
Side effects of medications client may be receiving (e.g.,
narcotic [opioid] analgesics, antiemetics, antianxiety agents)

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 CHAPTER

1 6 Nursing Care of the Elderly Client

|Feethares 65 years of age and older are the fastest-growing be addressed, particularly when the client requires health care
segment of the population, making the elderly a major por- interventions.
tion of the health care consumer population. Older persons This care plan focuses on the elderly client requiring
experience many physiologic changes that occur with aging. health care intervention. It includes the nursing diagnoses
The extent or degree of the changes that take place depends that reflect the biopsychosocial changes that commonly
on genetic and environmental factors as well as on the occur with old age and are intensified with the stressors of
client’s previous attention to health maintenance. As clients illness. This care plan can be used in conjunction with the
reach old age, there may also be many changes in roles, care plans in this text that are appropriate to the client’s
relationships, and the ability to maintain their usual life- specific medical diagnosis or surgery and is intended for use
styles. These factors create psychosocial concerns that must in an acute or extended care facility or in a home setting.

:Nursing Diagnosis INEFFECTIVE PERIPHERAL TISSUE PERFUSION npx/RISK FOR

DECREASED CARDIAC OUTPUT nox
Definition: Ineffective Peripheral Tissue Perfusion NDx: Decreased in blood circulation to the periphery, which may
compromise health; Risk For Decreased Cardiac Output NDx: Susceptible to inadequate blood pumped by the
heart to meet the metabolic demands of the body, which may compromise health.

Related to:
Ineffective tissue perfusion NDx:
e Increased vascular resistance associated with decreased elasticity and increased rigidity of the arterial vessels, associated with
changes in the proportion of elastin and collagen in the vessel walls and accumulation of substances such as calcium and
lipids
e Decrease in baroreceptor sensitivity
e Peripheral pooling of blood associated with loss of muscle tone in extremities, decreased competence of venous valves, and
venous dilation (resulting from loss of vascular elasticity)

Decreased cardiac output NDx Related to:

e Impaired relaxation and contractility of the heart associated with stiffening of the ventricular walls
e Increased cardiac workload resulting from an increase in vascular resistance, thickened and rigid cardiac valves, and stress
of current illness

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of increased fatigue and weakness; Variations in blood pressure (BP); irregular, rapid, or slow
confusion; dizziness or lightheadedness, and syncopal pulse; dyspnea; increased crackles; edema; jugular vein
episodes distention (JVD); changes in electrocardiogram (ECG);
restlessness; cool, pale skin; decreased or absent peripheral
pulses; capillary refill greater than 2 to 3 seconds; elevated
levels of blood urea nitrogen (BUN) and serum creatinine;
oliguria; claudication; angina

806
 Chapter 16 = Nursing Care of the Elderly Client 807

RISK FACTORS
DESIRED OUTCOMES
e Immobility
e Inadequate fluid intake The client will maintain adequate cardiac output and tissue
e Cardiovascular changes peripheral perfusion as evidenced by:
e Aging process . BP and heart rate within normal range for client
. Usual mental status
. Absence of dizziness or light-headedness and syncope
. Extremities warm with absence of pallor or cyanosis
. Palpable peripheral pulses
. Capillary refill time less than 2 to 3 seconds
. Absence of edema
2
@
pos
5S
ao . BUN and serum creatinine levels within normal limits
for an elderly client
. Urine output = 30 mL/h
ieake
fern
j. Absence of exercise-induced pain

NOC OUTCOMES NIC INTERVENTIONS

Tissue perfusion: peripheral circulation status, effectiveness Circulatory care for arterial/venous insufficiency; cardiac
of cardiac pump monitoring.
-

NURSING ASSESSMENT RATIONALE

ee Se OE ae a ea a a a

Assess for and report signs and symptoms of: Early recognition of signs and symptoms of decreased cardiac output
e Decreased cardiac output (can lead to diminished tissue and decreased tissue perfusion allows for prompt intervention.
perfusion)
e Variations in BP BP may be increased because of compensatory vasoconstriction and
may be decreased when compensatory mechanisms and pump
fail.
e Irregular, rapid, or slow pulse The incidence of dysrhythmias increases with age and is of concern
because of the coexisting decrease in cardiac reserve.
e Increase in loudness of existing systolic murmurs or Soft systolic murmurs are often present in elderly clients because of
presence of diastolic murmur sclerosed valves.
e Development of or an increase in loudness of $3 and/or An S4 can be present in healthy adult clients.
Sz gallop rhythm
e Development of or increase in fatigue and weakness Muscles do not receive adequate oxygenation.
e Development of or increase in dyspnea Crackles in the morning are a common finding in an elderly adult
e New finding of or increased crackles client.
e Edema Expected age-related changes include left axis deviation and some
e JVD prolongation of the PR and QT intervals.
e Changes in ECG readings
e Chest radiograph showing pleural effusion or pulmo- Pleural effusion or pulmonary edema can occur with increased
nary edema afterload and decreased cardiac output.
e Diminished peripheral tissue perfusion:
e Significant decrease in BP Elevated systolic BP is often present in elderly clients because of the
age-related stiffening of the arteries and impaired baroreceptor
function.
e Decline in systolic BP of more than 20 mm Hg when client In an elderly client, there is often a decline in systolic BP of 12 to
changes from a lying to a sitting or standing position 20 mm Hg with this positional change because of a decrease in
e Restlessness, confusion, or other change in mental status baroreceptor sensitivity and vasomotor responsiveness. Can
e Reports of dizziness or light-headedness or occurrence indicate decreased cardiac output and decreased cerebral
of syncopal episodes perfusion pressures.
e Cool, pale, or cyanotic skin Indicates decreased peripheral tissues perfusion potentially caused
e Diminished or absent peripheral pulses by decreased cardiac output.
e Capillary refill time greater than 2 to 3 seconds
e Peripheral edema Indicated decrease blood return to the heart.
e Elevated BUN and serum creatinine levels The BUN and serum creatinine levels tend to be slightly elevated
because of the age-related decline in renal function.

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808 Chapter 16 * Nursing Care of the Elderly Client

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate tissue perfusion:
e Perform actions to reduce cardiac workload and help
maintain an adequate cardiac output:
e Place client in a semi- to high-Fowler’s position when- Prevents slumping and decreases pressure on abdominal organs.
ever possible. D @+
e Instruct client to avoid activities that create a Valsalva These activities decrease the heart rate and subsequently cardiac
response (e.g., straining to have a bowel movement, output.
holding breath while moving up in bed).
e Implement measures to promote rest and conserve Decreases stress on the heart and body’s oxygenation demands.
energy (e.g., maintain activity restrictions, minimize
environmental noise, limit number of visitors and
length of stay). D @+
Implement measures to maintain an adequate respira- Promotes adequate tissue oxygenation by allowing full expansion
tory status (place in high-Fowler’s positions, change of the lungs.
position every 2 hrs, instruct client in deep breathing
exercises, to be done every 2 hrs). D @ +
e Discourage smoking. Nicotine has a cardiostimulatory effect and causes vasoconstriction
which can decrease cardiac ouptut; the carbon monoxide in
smoke reduces the availability of oxygen (O2).
e Discourage excessive intake of
beverages high in Caffeine is a myocardial stimulant that can increase myocardial
caffeine, such as coffee, tea, and colas.D Oz consumption and can decrease cardiac output.
e Provide small meals rather than large ones. D + Large meals can increase cardiac workload because they require an
increase in blood supply to the gastrointestinal tract to aid
digestion.
e Increase activity gradually as allowed and tolerated. D + This will improve stamina and cardiac function.
e Perform actions to reduce peripheral pooling of blood and
increase venous return:
e Instruct client in active foot and leg exercises every 1 to Improve venous return to the heart through the muscle pump
2 hrs during periods of decreased activity and assist system.
with these.
e Encourage and assist client with ambulation as allowed Increases muscle strength, improves the ability to extract oxygen
and tolerated. D @+ from the blood, reducing the heart to pump more frequently and
decreases stress hormones impact on the heart. It also provides
the nurse a chance to assess exercise tolerance.
e Instruct and assist client to change from a supine to an Allows time for autoregulatory mechanisms to adjust to the
upright position slowly. D@ + change in the distribution of blood associated with an upright
position.
e Discourage positions that compromise blood flow in lower These positions increase pooling of blood in the feet and legs, thus
extremities (e.g., crossing legs, use of knee gatch, sitting decreasing venous return to the heart.
for long periods, prolonged standing). D @ +
e Maintain a comfortable room temperature and provide Exposure to cold causes generalized vasoconstriction.
client with adequate clothing and blankets. D @ +

Dependent/Collaborative Actions
Implement measures to maintain adequate tissue perfusion:
e Maintain a fluid intake of 1500 to 2000 mL/day unless There is a greater risk for fluid overload in the elderly client
contraindicated; if oral intake is inadequate or contraindi- because of the age-related decline in the kidneys’ ability to
cated, maintain intravenous and/or enteral fluid therapy excrete a large volume of water in response to sudden volume
as ordered. excess.

Consult appropriate health care provider if signs and symp- Allows for prompt alterations in the treatment plan.
toms of diminished tissue perfusion persist or worsen.
 Chapter 16 = Nursing Care of the Elderly Client 809

|Nursing ~--
Diagnosis IMPAIRED RESPIRATORY FUNCTION* |
Definitions: Ineffective Breathing Pattern NDx: Inspiration/expiration that does
not provide adequate ventilation;
Ineffective Airway Clearance NDx: Inability to clear secretions or obstructions from the respirator
y tract to
maintain a clear airway; Impaired Gas Exchange NDx: Excess or deficit in oxygenation
and/or carbon
dioxide elimination at the alveolar-capillary membrane.
Related to:
Ineffective breathing pattern NDx
° Loss of alveolar elasticity (results in reduced efficiency of air expulsion)
° Decreased chest expansion associated with calcification of costal cartilage and weakened respiratory
muscles
e Decreased responsiveness of chemoreceptors to hypoxia and hypercapnia

Ineffective airway clearance NDx

° Stasis of secretions associated with decreased activity during illness and an age-related decrease in ciliary
activity and cough
effectiveness
e Weakening of respiratory muscles

Impaired gas exchange NDx

° Loss of effective lung surface associated with a reduced number of alveoli, changes in the alveolar walls, and accumulation
of secretions in the bronchioles and alveoli (can result from ineffective airway clearance)
» Reduced airflow associated with loss of alveolar elasticity, restricted chest expansion, and premature closure of small airways
Decreased pulmonary blood flow associated with a decrease in the number of capillaries surrounding the alveoli, fibrosis of
the pulmonary vessels, and a generalized decrease in tissue perfusion

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of shortness of breath; Self-report of Irritability, confusion, somnolence, dyspnea, orthopnea,
inability to cough up secretions use of accessory muscles when breathing, asymmetric
chest excursion, adventitious breath sounds, diminished
or absent breath sounds, abnormal breath sounds,
decreased oximetry results, abnormal chest radiograph

RISK FACTORS DESIRED OUTCOMES

e Sedentary lifestyle
The client will experience adequate respiratory function as
e Chronic illness
evidenced by:
e Respiratory system changes
. Normal rate and depth of respirations
. Absence of dyspnea
. Symmetrical chest excursion
. Usual or improved breath sounds
. Usual mental status
Oo
&
OO
ee. Oximetry results within normal range for an elderly
client
g. Arterial blood gas values within normal range for an
elderly client

NOC OUTCOMES NIC INTERVENTIONS

Respiratory status: ventilation; airway patency; gas exchange Respiratory monitoring; airway management; chest
physiotherapy; oxygen therapy; cough enhancement

*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern, ineffective airway clearance, and
impaired gas exchange.

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810 Chapter 16 = Nursing Care of the Elderly Client

NURSING ASSESSMENT ee
RATIONALE
e
Pama
Assess for and report signs and symptoms of impaired respira- Early recognition of signs and symptoms of impaired respiratory
tory function: function allows for prompt intervention.
e Rapid, shallow, or slow respirations Decreased oxygenation to the tissues.
e Dyspnea, orthopnea Results from alveolar collapse associated with age-related hypoven-
e Use of accessory muscles when breathing tilation and decreased activity.
e Asymmetric chest excursion
e Adventitious breath sounds (e.g., crackles [rales], rhon- Diminished sounds are often present in the elderly client because
chi; crackles may be heard especially on initial morning of reduced airflow.
assessment)
e Diminished or absent breath sounds
e Cough Will have decreased cough effort due to decreased muscle tone.
e Restlessness, irritability
e Confusion, somnolence Decreased cerebral oxygenation leads to restlessness, irritability,
confusion, and somnolence.
e Abnormal arterial blood gas values (partial pressure of Oz in Changes in ABG’s provide the best indication of oxygen in the blood.
arterial blood [PaO] is normally lower in the elderly client)
e Decrease in oximetry results O> saturation is normally lower in the elderly client.
e Abnormal chest radiograph results

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain an adequate respiratory
status:
e Place client in a semi- to high-Fowler’s position unless This will prevent slumping and improve lung expansion.
contraindicated; position with pillows. D @ +
e If client must remain flat in bed, assist with position This will improve lung expansion and decrease stasis of lung
change at least every 2 hrs. D @ + secretions.
e Instruct client to breathe deeply or use incentive spirom- These actions improve lung expansion and mobilization of
eter every 1 to 2 hrs. secretions.
e Perform actions to decrease pain if present (e.g., splint/ Client will be hesitant to take deep breaths if pain is present.
protect painful area during movement, administer pre- Splinting helps to support painful area when coughing.
scribed analgesics before planned activity). D @ +
e Perform actions to decrease fear and anxiety (e.g., explain Fear and anxiety can cause the client to breathe in shallow and/or
procedures, provide a calm environment). D @ + rapid breaths.
e Instruct client in and assist with diaphragmatic and These techniques improve oxygenation.
pursed-lip breathing techniques if indicated.
e Instruct and assist client to cough or “huff” every 1 to This improves lung expansion and oxygenation.
2 hrs. D >
e Discourage smoking. Irritants in smoke increase the production of mucus, further impair
ciliary function, and can damage the bronchial and alveolar
walls; the carbon monoxide also decreases O> availability.
e Instruct client to avoid intake of gas-forming foods (e.g., These measures will help to reduce gastric distention and pressure
beans, cabbage, cauliflower, onions), carbonated bever- on the diaphragm.
ages, and large meals.
e Maintain activity restrictions as ordered; increase activity This will improve cardiac output and exercise stamina.
gradually as allowed and tolerated. D @ +

Dependent/Collaborative Actions
Implement measures to thin tenacious secretions and reduce
dryness of the respiratory mucous membrane:
e Maintain a fluid intake of 1500 to 2000 mL/day unless Maintains adequate vascular fluid volume and increased hydration
contraindicated. D@ +
° Humidify inspired air if ordered. D + Moisturizes air and helps to thin secretions.
If client has difficulty mobilizing secretions:
e Assist with or perform postural drainage therapy if ordered. Helps to mobilize and excrete secretions.
e Consult physician about use of a mucolytic (e.g., acet- These medications improve client’s ability to expectorate secretions.
ylcysteine) or diluent or hydrating agent (e.g., water,
saline) via nebulizer.
e Suction as needed. Manually removes secretions.
 Chapter 16 = Nursing Care of the Elderly Client 811

THERAPEUTIC INTERVENTIONS
RATIONALE
° Assist with positive airway pressure techniques (e.g.,
con- Improves oxygenation by helping to expand alveoli and force air
tinuous positive airway pressure [CPAP], bilevel positive
into the lungs.
airway pressure [BiPAP], flutter/positive expiratory pres-
sure [PEP] device) if ordered.
° Maintain O, therapy if ordered. D+ Provides supplemental oxygenation to support tissue requirements.
e Administer central nervous system depressants judiciously
The possibility of respiratory depression is increased in the elderly
because of their respiratory depressant effect; hold medica-
because of their altered metabolism, distribution and excretion
tion and consult physician if respiratory rate is below
of drugs, and decreased responsiveness of chemoreceptors to
12 breaths/min. hypoxia and hypercapnia.
Consult appropriate health care provider (e.g., physician,
Allows for prompt alteration in treatment plan.
respiratory therapist) if signs and symptoms of impaired
respiratory function persist or worsen.

Nursing Diagnosis RISK FOR DEFICIENT FLUID VOLUME nox

Definition: Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which
may
compromise health.
Related to:
e Age-related decrease in total body water
e Decreased fluid intake associated with:
° Restrictions imposed by current illness and/or treatment plan
e Diminished thirst sensation
e Desire to avoid nocturia and/or urinary incontinence
¢ Age-related decline in the kidney’s ability to conserve water when a deficit is caused by disease or environmental factors

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of dry mouth, self-report of confusion Decreased skin turgor; dry skin and mucous membranes;
weight loss of 2% or greater over a short period; hypoten-
sion; weak, rapid pulse; capillary refill time greater than
2 to 3 seconds; flat neck veins when lying flat; elevated
BUN, serum creatinine, and hematocrit (Hct) levels;
oliguria; change in mental status; decreased urine output

RISK FACTORS DESIRED OUTCOMES

e Changes in regulatory systems
The client will not experience deficient fluid volume as
e Inadequate fluid intake
evidenced by:
e Medication regimen
a. Normal skin and tongue turgor for client
b. Moist mucous membranes
c. Stable weight
d. BP and pulse within normal range for client with no
further increase in postural hypotension
e. Capillary refill time below 2 to 3 seconds
f. BUN and Het levels within normal range for age
g. Usual mental status
h. Balanced intake and output

NOC OUTCOMES NIC INTERVENTIONS

Fluid balance Fluid monitoring; fluid management; hypovolemia

management; intravenous therapy

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812 Chapter 16 = Nursing Care of the Elderly Client

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of deficient fluid Early recognition of signs and symptoms of deficient fluid volume
volume: allows for prompt intervention.
e Decreased skin turgor This is not always a reliable indicator because decreased skin
turgor is a normal age-related change; turgor is best assessed
over the forehead or sternum in an elderly client.
e Decreased tongue turgor The tongue may be smaller than usual and have more than one
longitudinal furrow.
e Dry mucous membranes, thirst Thirst may not be a reliable indicator because saliva production
and sensation of thirst are diminished in elderly clients.
e Weight loss of 2% or greater over a short period May indicate fluid loss.
e Low BP and/or decline in systolic BP of more than 20 mm A drop of 15 to 20 mm Hg is not unusual in elderly clients because of
Hg when client sits up decreased baroreceptor sensitivity and vasomotor responsiveness.
e Weak, rapid pulse These clinical manifestations indicate decreased vascular fluid
e Capillary refill time greater than 2 to 3 seconds volume.
e Neck veins flat when client is supine
e Elevated BUN and Het levels
e Change in mental status (e.g., confusion) Indicates decreased volume below the level required to maintain
cerebral perfusion pressure.
e Decreased urine output Indicates an actual rather than potential fluid volume deficit.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent deficient fluid volume:
e Maintain a fluid intake of 1200 to 2500 mL/day and instruct Maintains adequate vascular volume. Adequate fluid intake is
client to continue this regimen after discharge unless con- required to maintain vascular status.
traindicated. D @ +
e Monitor intake and output D@ + Aging decreases kidney function and decreased fluid volume and
further decrease output.

Dependent/Collaborative Actions
Implement measures to prevent deficient fluid volume:
e Maintain intravenous and/or enteral fluid therapy if Administer intravenous fluids cautiously because the elderly client
ordered. is also at risk for fluid overload.
e¢ Monitor laboratory values: These values indicate fluid volume deficit, and dehydration that
e BUN, creatinine, Hct can cause increased levels.

|Nursing >)
Diagnosis | IMBALANCED NUTRITION: LESS THAN BODY
REQUIREMENTS nox
Definition: Intake of nutrients insufficient to meet metabolic needs.

Related to:
e Decreased oral intake associated with:
e Anorexia resulting from factors such as depression, loneliness, diminished sense of smell and/or taste, early satiety, and
dyspepsia
¢ Difficulty chewing and swallowing food resulting from poor dentition, a decreased amount of saliva, and weakened
chewing and swallowing muscles
e Decreased ability to purchase and/or prepare healthy foods
e Decreased utilization of nutrients associated with impaired digestion resulting from:
e Decreased ability to chew foods thoroughly
e Reduced secretion of digestive enzymes (e.g., salivary ptyalin, hydrochloric acid, pepsin, lipase)
e Reduced absorption of nutrients associated with hypochlorhydria, decreased intestinal blood flow, and atrophy of the
absorptive surface of the intestine
 Chapter 16 = Nursing Care of the Elderly Client 813

CLINICAL MANIFESTATIONS

Subjective
Objective
Verbal self-report of abdominal pain and cramping; sore
Aversion to eating; body weight 20% or more under ideal;
buccal cavity capillary fragility; hair loss; lack of food; lack of interest in food;
pale mucous membranes; low serum albumin, prealbumin, Hct,
and hemoglobin (Hgb) levels, and low lymphocyte count

RISK FACTORS DESIRED OUTCOMES

e Living on a fixed income
e Changes in taste sensation The client will maintain an adequate nutritional status as
° Medication regimen evidenced by:
° Mental status changes—dementia, anxiety, depression a. Weight within normal range for client
b. Normal serum albumin, prealbumin, Hct, and Hgb
levels and normal lymphocyte count for client’s age
c. Usual strength and activity tolerance
d. Healthy oral mucous membrane

NOC OUTCOMES NIC INTERVENTIONS

ae qn ggg
Nutritional status Nutritional monitoring; appetite; nutrition management;
nutrition therapy; nutritional counseling

NURSING ASSESSMENT RATIONALE

a ee a ee ee eee
Assess for and report signs and symptoms of malnutrition: Early recognition of signs and symptoms of malnutrition allows for
prompt intervention.
° Weight significantly below client’s usual weight or below Indicates that client has not maintained a proper diet. When using
normal for client’s age, height, and body frame height and weight charts, be aware that weight is expected to
decline gradually with age.
e Low serum albumin, prealbumin, Hct, and Hgb levels and These indicate protein depletion. Low Hct and Hgb levels and low
low lymphocyte count white blood cell (WBC) counts lead to anemia and potential
Weakness and fatigue infections. Clinical manifestations of decreased intake and
Sore, inflamed oral mucous membrane potential anemia, and weight loss.
e Pale conjunctiva
e Lower-than-normal anthropometric measurements such
as skinfold thickness, body circumferences (e.g., hip, waist,
mid- and upper arm), and bioelectric impedance analysis

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain an adequate nutritional
status:
e Perform actions to improve oral intake:
e Implement measures to relieve dyspepsia, gastric Decreases pressure in the abdomen, which helps to improve appetite.
fullness, and gas pain. D @ +
e Increase activity as allowed and tolerated. D @ + Activity usually promotes a sense of well-being, which can improve
appetite; it also promotes gastric emptying, which reduces the
feeling of gastric fullness.
¢ Maintain a clean environment and a relaxed, pleasant These help to improve appetite.
atmosphere. D@ +
* Implement measures to decrease the sense of isolation These promote a sense of well-being, which can improve appetite.
and aloneness (e.g., use touch to demonstrate accep-
tance, encourage significant others to visit, schedule
time to sit and speak with the client each day).
e Encourage a rest period before meals if client is weak or Fatigue can reduce the client’s desire and ability to eat.
fatigues easily. D @>
e Provide frequent, small meals rather than large ones This may help to improve intake and decrease fatigue associated
if client is weak, fatigues easily, and/or has a poor with eating a large meal.
appetite. D @+
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THERAPEUTIC INTERVENTIONS RATIONALE

° Provide oral hygiene before eating. D @+ Oral hygiene moistens the mouth, which may make it easier to
chew and swallow; it also removes unpleasant tastes, which
often improves the taste of foods/fluids.
° Serve foods/fluids that are appealing to the client. D@ + Visual appeal is especially important if client’s sense of smell is
diminished.
e Encourage significant others to bring in client’s favor- Clients may be more inclined to eat food they like. When family
ite foods unless contraindicated and eat with client members eat with client, it helps to increase intake.
to make eating more of a familiar social experience.
D+
e Provide a soft, ground, or pureed diet if client has Easier for client to chew and swallow.
difficulty chewing.
e Implement measures to compensate for taste altera-
tions and/or dislike of prescribed diet.
(1) Serve foods warm to stimulate sense of smell. D @ + Improves taste of foods that should be served warm and can
improve intake.
(2) Encourage client to experiment with different Adds different flavors, which may stimulate appetite.
flavorings and seasonings. D@ +
(3) Instruct client to use salt substitutes and salt-free Decreases salt intake and subsequent fluid retention. Use with
herbs and spices if receiving a low-sodium diet. caution as they may increase intake of potassium.
(4) Encourage client to add extra sweeteners to foods Helps improve taste of foods.
unless contraindicated.
(5) Provide alternative sources of protein if meats such Improves nutritional status and assure adequate protein intake.
as beef or pork taste bitter or rancid.
e Limit fluid intake with meals. D+ Unless the fluid has high nutritional value, the fluid should be
avoided as it may cause early satiety and subsequent decreased
food intake.
e Allow adequate time for meals; reheat foods/fluids if Improves intake of nutrients.
necessary. D@ >
e Ensure that meals are well balanced and high in essen- Ensures adequate nutrition is maintained.
tial nutrients; offer high-protein supplements if client
is having difficulty maintaining an adequate caloric
intake.

Dependent/Collaborative Actions
Implement measures to maintain an adequate nutritional
status:
e Administer vitamins and minerals if ordered. D Supplements regular diet and increases importance for clients with
poor or those not eating a-nutritional diet.
¢ Perform a calorie count if ordered. Report this information It is important to know how many calories and what type client is
to dietitian and physician. eating.
¢ Consult physician regarding an alternative method of pro- Allows for alteration in treatment plan to provide adequate nutrition.
viding nutrition (e.g., parenteral nutrition, tube feedings)
if client does not consume enough food or fluids to meet
nutritional needs.
e If indicated, obtain a social service consult to assist client Provides for continuum of care and provides support for client
in arranging for services such as Meals on Wheels and following discharge from the health care facility.
home health aides for feeding assistance at home.
e Obtain a dietary consult, if necessary, to assist client Provides a multidisciplinary approach to care.
in selecting foods/fluids that meet nutritional needs
as well as personal and cultural preferences whenever
possible.
e If client has dentures, assist with putting them in before Improves client’s ability to macerate foods and decreases pain and
meals; if dentures do not fit properly, obtain a dental trauma associated with loose fitting dentures.
consult.
 Chapter 16 = Nursing Care of the Elderly Client 815

|Nursing "RI
Diagnosis.SK FOR IMPAIRED SKIN INTEGRITY no. | |
Definition: Susceptibility to alteration in epidermis and/or dermis,
which may compromise health.
Related to:
° Increased fragility of the skin associated with decreased nutritional status
and age-related dryness, loss of elasticity, and
thinning of skin
e Frequent contact with irritants if urinary incontinence is present
Accumulation of waste products and decreased Oz and nutrient supply to the skin
and subcutaneous tissue associated with
decreased blood flow to the skin due to:
e An age-related decrease in dermal vascularity
° Prolonged pressure on the tissues if mobility is decreased

NOC OUTCOMES NIC INTERVENTIONS

Tissue integrity: skin and mucous membranes Skin surveillance; positioning, skin care, topical, pressure
ulcer prevention

RISK FACTORS
DESIRED OUTCOMES
e Poor nutritional status
* Chronic illness The client will maintain skin integrity as evidenced by:
° Sedentary lifestyle a. Absence of redness and irritation
e Inadequate fluid intake b. No skin breakdown

NURSING ASSESSMENT RATIONALE

Determine client’s risk for skin breakdown using a risk- Early recognition of signs and symptoms of skin breakdown allows
assessment tool (e.g., Norton Scale, Braden Scale, Gosnell for prompt intervention.
Scale). Use of a scale provides for standardized assessment.
Inspect the skin (especially bony prominences, dependent
areas, perineum, and areas of decreased sensation and/or
edema) for pallor, redness, and breakdown.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent skin breakdown:
e Assist client to turn at least every 2 hrs. D @ > Elderly clients may require more frequent position changes because
of decreased blood flow to the skin, reduced amounts of protec-
tive subcutaneous fat, and a decreased ability to sense pressure
and discomfort.
e Position client properly; use pressure-reducing or pressure- Decreases the amount of pressure placed on the skin.
relieving devices (e.g., pillows, gel or foam cushions, alter-
nating pressure mattress, air-fluidized bed) if indicated.
De+
e Gently massage around reddened areas at least every Improves circulation, which increases supply of O2 and nutrients.
2hrs.D @®
e Apply a thin layer of a dry lubricant such as powder or Reduces friction between client’s skin and the bed linens.
cornstarch to bottom sheet or skin and to opposing skin
surfaces (e.g., axillae, beneath breasts) if indicated. D@ >
e Lift and move client carefully, using a turn sheet and ade- Prevents accidental skin tears.
quate assistance. D@ +
e Perform actions to keep client from sliding down in bed Reduces the risk ofskin surface abrasion and shearing.
(e.g., gatch knees slightly when head of bed is elevated
30 degrees or higher, limit length of time client is in a
semi-Fowler’s positions to 30-minute intervals). D @ +
e Instruct or assist client to shift weight at least every Changes area of pressure on the skin and decreases incidence of
30 minutes. D@ + skin breakdown.
° Keep client’s skin clean. D@ + Removes surface microorganisms which, if allowed to accumulate,
increase the risk of irritation and infection.

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THERAPEUTIC INTERVENTIONS RATIONALE

° Keep bed linens dry and wrinkle-free. D@ + Moisture harbors microorganisms that can cause irritation and/or infec-
tion. Keeping linens wrinkle free decreases the possibility of friction.
e Thoroughly dry skin after bathing and as often as needed, Excessive moisture or prolonged skin exposure softens the
paying special attention to skinfolds and opposing skin epidermal cells and makes them less resistant to damage.
surfaces (e.g., axillae, perineum, beneath breasts); pat skin
dry rather than rub. D@ +
e Make sure that external devices such as braces, casts, and Prevents accidental skin tears and allows for adequate circulation.
restraints are applied properly.
e Provide elbow and heel protectors if indicated. D @ + Reduces pressure on these areas.
e Encourage client to wear socks while in bed. D @ + Helps reduce friction on heels and decreases incidence of skin
breakdown.
e Increase activity as allowed and tolerated. Improves circulation and improves muscle strength.
e Avoid use of harsh soaps and hot water; use a mild soap Reduces dryness of the skin and potential for breakdown.
and tepid water for bathing. D @+
e Apply moisturizing lotion and/or emollient to skin at least Reduces friction and helps prevent skin surface irritation and
once a day. abrasion.
e Assist client with total bath or shower every other day Reduces drying of the skin.
rather than daily. D@ +
e Encourage a fluid intake of 1500 to 2000 mL/day unless Ensures skin is well hydrated.
contraindicated.
e Protect skin from wound drainage and urinary inconti- Prevents skin irritation resulting from exposure to wound drainage
nence (e.g., change dressing when damp, apply drainage or urine.
collection device; take client regularly to the bathroom,
encourage client to urinate when urge is felt, allow client
to assume normal position for voiding). D+
e Assist client to thoroughly clean and dry perineal area Excessive exposure of skin to urine increases the potential for skin
with soft tissue or cloth after each episode of inconti- breakdown.
nence; apply a protective ointment or cream. D @ +
e If use of absorbent products such as pads or undergar- Decreases skin exposure to moisture and potential for irritation and
ments is necessary, select those that effectively absorb breakdown.
moisture and keep it away from the skin. D @ +
e Apply a protective covering such as a hydrocolloid or Decreases friction between skin and bed linens or clothing and
transparent membrane dressing to areas of the skin suscep- decreases incidence of tears and/or breakdown.
tible to breakdown (e.g., coccyx, elbows, heels).
e Use caution with application of heat or cold to areas of Aging process decreases sensation and the client may not realize
decreased sensation or circulatory impairment. D + that skin is being affected. Prevents potential burn to the skin.
° Maintain optimal nutritional status. D + Proper nutrition is required to maintain the appropriate amount of
subcutaneous tissue and prevent skin from becoming thin and
losing its elasticity.

Dependent/Collaborative Actions
If skin breakdown occurs:
e Notify appropriate health care provider (e.g., physician, Allows for alteration in treatment plan.
wound care specialist).
e Perform care of involved areas as ordered or per standard Provides standardized care for skin breakdown.
hospital procedure. D+

|Nursing oo)
Diagnosis | 6IMPAIRED ORAL MUCOUS MEMBRANE INTEGRITY nox}
Definition: Injury to the lips, soft tissues, buccal cavity, and/or oropharynx.

Related to:
e Dryness due to decreased saliva production associated with a gradual decline in salivary gland activity
e Irritation and breakdown related to dryness and thinning of the oral mucosa

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of oral dryness, irritation Breakdown of oral mucosa
 Chapter 16 = Nursing Care of the Elderly Client 817

RISK FACTORS
DESIRED OUTCOMES
e Chronic changes
e Inadequate fluid intake The client will maintain a moist, intact oral mucous
° Medication regimen membrane.

NOC OUTCOMES NIC INTERVENTIONS

Oral health, tissue integrity, skin and mucous membranes
Oral health maintenance, oral health restoration, oral health
promotion.

NURSING ASSESSMENT RATIONALE

- Assess client for dryness, irritation, and breakdown of the oral
Early recognition of signs and symptoms of impaired mucous
mucosa.
membranes allows for prompt intervention.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to decrease dryness and irritation of the
oral mucous membrane:
e Instruct and assist client in performing oral hygiene as These products have a drying and irritating effect on the oral mu-
often as needed; avoid products that contain lemon and cous membrane. Commercial mouthwashes should be avoided
glycerin and mouthwashes containing alcohol. D + as they contain alcohol. Teach client to read labels.
° Instruct and assist client to perform oral hygiene using a A soft-bristle toothbrush or sponge-tipped swab decreases potential
soft-bristle toothbrush or sponge-tipped swab and to floss for mucous membrane irritation. Gentle flossing will clean
teeth gently. D+ between teeth while not traumatizing the gums.
e Encourage client to rinse mouth frequently with water. Helps to keep mucous membranes moist and remove debris from
De+ the mouth.
e Lubricate client's lips frequently. D@ + Helps prevents lips from chafing.
e Encourage client to breathe through nose rather than Breathing through the nose prevents air from drying out the oral
mouth. mucous membranes.
e Encourage client not to smoke or chew tobacco. D + Smoking dries the mucosa; tobacco acts as an irritant to the oral
mucosa.
e Encourage a fluid intake of 1500 to 2000 mL/day unless Maintains adequate vascular fluid volume and oral hydration.
contraindicated. D+
e Encourage client to chew sugarless gum or suck on sugar- Stimulates salivation and helps to maintain moist mucous
less hard candy. D+ membranes.
e Encourage client to use artificial saliva. D> Lubricates the mucous membranes and prevents dryness or
irritation.
If mucosa is irritated or cracked,
e Assist client to select soft, bland foods. Spicy foods can cause irritation to the oral mucosa. Client may
e Instruct client to avoid foods/fluids that are extremely hot. not realize how hot food is due to decreased sensation in the
mouth.
e If client has dentures, remove and replace only for meals. Relieves discomfort, prevents further irritation, decreases incidence
D+ of breakdown, and promotes healing.

Dependent/Collaborative Actions
Implement measures to decrease dryness and irritation of the
oral mucous membrane:
e Inspect client’s dentures; obtain a dental consult if den- Improves client’s ability to eat without discomfort.
tures are rough, cracked, or ill-fitting.
If mucosa is irritated or cracked:
e Administer topical anesthetics, oral protective agents, and These medications protect oral mucosa from further breakdown,
analgesics as ordered. decrease pain, and promote healing.
Consult appropriate health care provider (i.e., dentist) if dry- Allows for multidisciplinary care.
ness, irritation, breakdown, or discomfort persists.

NDx = NANDA Diagnosis D = Delegatable Action @=UAP ¢ =LVN/LPN © = Goto ©volve for animation
818 Chapter 16 * Nursing Care of the Elderly Client

Diagnosis | RISK FOR ACTIVITY

|Nursing > INTOLERANCE nox

Definition: Susceptible to experiencing insufficient physiological or psychological energy to endure or complete

required or desired daily activities, which may compromise health.

Related to:
e Decreased tissue oxygenation associated with diminished functional reserve capacity of the respiratory and cardiac systems
during stress/illness
e Decrease in strength and endurance associated with the loss of muscle mass that occurs with aging
e Inadequate nutritional status
e Inadequate rest and sleep associated with age-related changes in sleep pattern and effects of current illness and hospitaliza-
tion on sleep pattern

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of weakness or fatigue; report of Exertional dyspnea; exertional changes in heart rate
exertional chest pain and/or dizziness and BP

RISK FACTORS DESIRED OUTCOMES

e Medication regimen The client will not experience activity intolerance, as evi-
e Poor dietary intake
denced by:
e Changes in the musculoskeletal system
a. No reports of fatigue and weakness
e Sedentary lifestyle b. Ability to perform activities of daily living (ADLs) with-
out exertional dyspnea, chest pain, diaphoresis, dizzi-
ness, and a significant change in vital signs

NOC OUTCOMES NIC INTERVENTIONS

Activity tolerance, energy status Activity therapy, energy management, nutrition manage-
ment, nutrition therapy, sleep enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of activity intolerance: Early recognition of activity intolerance allows for prompt
e Statements of fatigue or weakness intervention.
e Exertional dyspnea, chest pain, diaphoresis, or dizziness
e Abnormal heart rate response to activity (e.g., increase in
rate of 20 beats/min above resting rate, rate not returning
to preactivity level within 10 minutes after stopping activ-
ity, change from regular to irregular rate); be aware that
the pulse rate increases only slightly with activity and
returns to preactivity level slowly in an elderly client.
e A significant change (15-20 mm Hg) in BP with activity

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain adequate activity tolerance:
° Maintain activity restrictions as ordered. D @ Promotes rest and/or conserves energy.
e Minimize environmental activity and noise. D @ + A quiet environment supports sleep and rest.
* Implement group nursing interventions. D @ + Allows for periods of uninterrupted rest.
e Limit the number of visitors and their length of stay. D @ Reduces client fatigue.
Assist client with self-care activities as needed. D @ Conserves client energy.
Keep supplies and personal articles within easy reach. Prevents client from having to get up to obtain supplies and
De+ personal articles.
Assist client in using energy-saving techniques (e.g., using Conserves energy.
shower chair when showering, sitting to brush teeth or
comb hair). D @
 Chapter 16 = Nursing Care of the Elderly Client 819

THERAPEUTIC INTERVENTIONS RATIONALE

° Slow pace of providing care.
Client may need extra time to complete activities. Hurrying the
client may increase the risk for falls and cause anxiety related
to ability to care for self.
e Discourage smoking and excessive intake of beverages Both nicotine and excessive caffeine intake can increase cardiac
high in caffeine such as coffee, tea, and colas. D> workload and myocardial Op utilization.
¢ Perform actions to maintain an adequate respiratory status
Maintaining or improving respiratory status increases the amount
(e.g., encourage use of incentive spirometer; elevate head
of O2 available for energy production.
of bed; assist with turning, coughing, and deep breathing).
D+
e Maintain adequate nutritional status. Provides energy for activities.
° Increase client’s activity gradually as allowed and toler- Improves stamina for increasing activity.
ated; periods of activity should be short, frequent, and
interspersed with rest periods.
° Instruct client to report a decreased tolerance for activity; This is due to age-related changes in thermoregulatory mechanisms
caution client that tolerance for vigorous activity may be and sympathetic nervous system response.
diminished.
° Instruct client to stop any activity that causes chest pain, These symptoms indicate that insufficient Oz is reaching the tissues
shortness of breath, dizziness, or extreme fatigue or weakness. and that activity has been increased beyond a therapeutic level.

Dependent/Collaborative Actions
Implement measures to maintain adequate activity tolerance:
e Implement measures to increase cardiac output (e.g., Sufficient cardiac output is necessary to maintain an adequate
administer positive inotropic agents, vasodilators, or anti- blood flow and Oz supply to the tissues. Adequate tissue oxy-
dysrhythmics as ordered; elevate the head of the bed) if genation promotes more efficient energy production, which
decreased cardiac output is contributing to the client’s subsequently improves client’s activity tolerance.
activity intolerance.
Consult physician if signs and symptoms of activity intoler- Allows for prompt alteration in treatment plan.
ance develop and persist or worsen.

Nursing Diagnosis IMPAIRED PHYSICAL MOBILITY nox

Definition: Limitation in independent, purposeful movement of the body or of one or more extremities.
Related to:
e Decreased muscle strength associated with the loss of muscle mass that occurs with aging
e Weakness and fatigue associated with decreased functional reserve capacity of the respiratory and cardiac systems during
stress and illness, inadequate nutritional status, and difficulty resting and sleeping
e Joint aching and stiffness that may be present as a result of degenerative changes in the joints
e Fear of falling
e Physical limitations/activity restrictions associated with current diagnosis and/or treatment plan
e Polypharmacy

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain, discomfort, or fatigue with Decreased reaction time; difficulty moving; engages in
activities substitution for movement; supporting the affected limb;
exertional dyspnea; contractures; limited ability to perform
gross and fine motor skills; limited range of motion;
intentional movement-induced tremor; postural instability;
uncoordinated movements

RISK FACTORS DESIRED OUTCOME

e Pain
The client will maintain an optimal level of physical
e Chronic illness
mobility within prescribed activity restrictions.
e Decreased muscle mass
e Sedentary lifestyle

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820 Chapter 16 = Nursing Care of the Elderly Client

NOC OUTCOMES NIC INTERVENTIONS

Mobility; ambulation: balance Exercise therapy and promotion: joint mobility, ambulation,
strength training, stretching, balance, muscle control

NURSING ASSESSMENT RATIONALE

Assess client’s movement ability and activity tolerance. Use Assessment of mobility is used to best determine how to facilitate
a tool such as the Assessment Tool for Safe Patient movement. Assessment of activity tolerance provides a baseline
Handling and Movement or the Functional Independence for patient strength and endurance with movement.
Measures (FIM).
Assess for cause of immobility. It is important to determine whether the cause of immobility is
physical or psychologic and to plan interventions to improve
mobility.
Assess circulation, motion, and feeling in digits. Circulation may be compromised by edema of extremities, which
can lead to tissue necrosis and/or contractures.
Assess skin integrity. Routine examination of the skin provides for early detection and
intervention of pressure sores. Pressure sores develop quickly in
patients who are immobile.
Assess need for assist devices. Determine client’s need for assistive devices as well as proper use of
wheelchairs, walkers, canes, etc., to reduce incidence of falls.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Encourage and implement strength training activities:
° Active and/or passive range of motion D @ + Inactivity contributes to muscle weakening. Contractures can develop
e Ambulation D @ + as early as 8 hrs after a client becomes immobile. These activities
e Use of trapeze for pull-ups maintain and increase client’s strength and ability to move.
e Allow client to perform as many ADLs as they are able D @ + Allowing client to perform self-care increases confidence in ability
to maintain ADLs.
Use assistive devices to help client with movement: Use of assistive devices helps the caregivers decrease the potential
e Crutches for client falls and/or injuries.
° Gait belt D@® +
¢ Walker D @
Encourage patient with positive reinforcement during activi- A positive approach to activities supports the client’s accomplish-
ties. D@ + ment and engagement in new activities, and improves self-
esteem.
If client complains of joint aching or stiffness:
e Encourage client to perform mild exercise of affected joint Reduces stiffness, improves mobility and muscle strength.
or joints upon awakening in the morning. D +
Encourage activity and participation in self-care as allowed Client should be as active as possible to prevent potential loss of
and tolerated. D@ + mobility.
Encourage client to continue a regular exercise program after Improves strength and stamina for activities. Client must
discharge. understand the importance of continuing an exercise program
postdischarge to maintain mobility.
Encourage the support of significant others. Involves significant others in client care.
Allow them to assist with range-of-motion exercises, position- Exercises improve stamina for activities and improve muscle
ing, and activity unless contraindicated. D + strength. Allowing significant others to engage in care of the
client helps them to understand what is required to assist the
client in maintaining mobility.
'
Dependent/Collaborative Actions
If client complains of joint aching or stiffness:
e Consult physician regarding application of heat to affected Application of heat helps to relax joints and relieve stiffness.
joint or joints.
e Administer analgesics (e.g., nonsteroidal anti-inflammatories) Analgesics reduce joint pain and stiffness.
if ordered.
Consult appropriate health care provider if client is unable to Allows for prompt alteration in treatment plan.
achieve expected level of mobility or if range of motion
becomes more restricted.
 Chapter 16 = Nursing Care of the Elderly Client 821

|Nursing Diagnosis
=>) | IMPAIRED URINARY ELIMINATION® np.
Definitions: Risk for Urge Urinary Incontinence NDx: Susceptible to involuntar
y passage of urine occurring soon after
a strong sensation or urgency to void, which may compromise health; Stress Urinary
Incontinence NDx: Sudden
leakage of urine with activities that increase intra-abdominal pressure; Reflex Urinary Incontine
nce NDx: Involuntary
loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Overflow
Urinary
Incontinence NDx: Involuntary loss of urine associated with overdistention of the bladder.
Functional
Urinary Incontinence NDx: Inability of usually continent person to reach toilet in time to
avoid unintentional
loss of urine.
Related to:
Frequency and urgency:
e Incomplete bladder emptying, decrease in bladder capacity, and uninhibited bladder contractions
in response to small vol-
umes of urine (bladder detrusor muscle hyperactivity or instability)

Urinary retention:
e Decreased tone of bladder muscle
° Obstruction of the bladder outlet by an enlarged prostate or fecal impaction
e Decreased attention to the urge to urinate
° Difficulty urinating associated with anxiety about a lack of privacy and possibly having to use a bedpan or urinal
e The effect of some medications (e.g., sedatives, narcotic [opioid] analgesics, anticholinergics)

Incontinence (urge, stress, reflex, overflow, functional):

° Decreased tone of the external urinary sphincter and an incompetent bladder outlet (a result of lessening of the urethro-
vesical junction angle in women) associated with degenerative changes in the urethra and pelvic floor muscles and structural
supports of the bladder (occurs more in women as a result of childbearing and estrogen deficiency)
e Decreased bladder capacity and an increase in uninhibited bladder contractions in response to small volumes of urine
(bladder detrusor muscle hyperactivity or instability)
° Overflow of urine associated with overdistention of the bladder if urinary retention is present
e Delays in toileting associated with:
° Inability to get to the toilet in time to urinate resulting from unfamiliar environment and impaired physical mobility
* Difficulty removing clothing in a timely manner when needing to urinate resulting from reduced manual dexterity

CLINICAL MANIFESTATIONS

Subjective Objective
Urge incontinence: Self-reports of involuntary loss of Urge incontinence: Observed inability to reach commode
urine in time to avoid urine loss
Stress incontinence: Self-reports of leakage of small Stress incontinence: Observe leakage of urine during
amounts of urine on exertion, with coughing, sneezing, exertion, coughing, sneezing, and/or laughing
and/or laughing
Reflex incontinence: Self-reports of inability to inhibit or Reflex incontinence: N/A
initiate voiding or sensation of bladder fullness
Overflow urinary incontinence: Self-report of leaking urine Overflow urinary incontinence: Observed leakage of
due to overdistention of the bladder urine following intake of fluids.
Functional incontinence: Self-reports of loss of urine Functional incontinence: N/A
prior to getting to the commode; amount of time to reach
commode exceeds length of time between sensing the
urge to void and uncontrolled voiding; report of being
incontinent only in the morning

* The nurse should select the appropriate nursing diagnosis that is most appropriate based on the nursing assessment.

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822 Chapter 16 * Nursing Care of the Elderly Client

RISK FACTORS DESIRED OUTCOMES

i et Se ae eee eee ee
e Medication regimen
The client will maintain or regain optimal urinary elimina-
e Changes in urinary system functioning
tion as evidenced by:
e Childbearing a. Voiding at normal intervals
b. No reports of urgency, frequency, bladder fullness, and
suprapubic discomfort
c. Absence of bladder distention
d. Absence of incontinence
e. Balanced intake and output

NOC OUTCOMES NIC INTERVENTIONS

a a a a Se SS ee SS SS

Urinary continence; urinary elimination Urinary incontinence care; urinary retention Care; urinary
elimination management; urinary habit training; urinary
bladder training

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of impaired urinary elimination: Early recognition of signs and symptoms of impaired urinary
e Frequent voiding of small amounts (25-60 mL) of urine elimination allows for prompt intervention.
° Nocturia
e Reports of urgency, frequency, bladder fullness, or supra-
pubic discomfort
e Bladder distention
e Incontinence
e Output less than intake

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Monitor client’s pattern of fluid intake and urination (e.g., Knowledge of the client’s fluid intake and urination pattern assists
times and amounts of fluid intake, types of fluids con- in the identification of factors that may be causing urinary
sumed, times and amounts of voluntary and involuntary incontinence. This information helps the nurse plan individual-
voiding, reports of sensation of the need to void, activities ized interventions that promote urinary continence.
preceding incontinence).
Implement measures to promote optimal urinary elimination:
¢ Offer bedpan or urinal or assist client to bedside commode Urinary incontinence occurs when the pressure in the bladder be-
or bathroom every 2 to 4 hrs if indicated. D @ + comes greater than the pressure exerted by the urinary sphincters.
e Instruct client to urinate when the urge is first felt. D Emptying the bladder before the pressure becomes too great reduces
the risk ofincontinence.
¢ Implement measures to promote relaxation during void- Improves the client’s ability to completely empty the bladder.
ing attempts (e.g., provide privacy, encourage client to
read). D @
e¢ Implement measures involving use of water and warmth Triggers the micturition reflex and promotes relaxation, which
to promote voiding (e.g., run water, place client’s hands in improves client’s ability to empty the bladder.
warm water, pour warm water over perineum). D @ +
e Allow client to assume a normal position for voiding un- A sitting or standing position uses gravity to facilitate bladder
less contraindicated. D @ + emptying. The more completely the bladder is emptied, the less
risk there is ofincontinence.
e Instruct client to lean upper body forward and/or gently This puts pressure on the bladder, which helps create a sensation
press downward on lower abdomen during voiding at- of bladder fullness, which stimulates the micturitiort reflex.
tempts unless contraindicated.
° Maintain normal bowel function measures. Constipation increases pressure on the bladder outlet causing
increased urinary retention.
e Implement measures to reduce delays in toileting (e.g., have Delays in toileting or the distance needed to get to the bathroom
call signal within client’s reach and respond promptly to increase the chance of urinary incontinence.
requests for assistance; have bedpan, urinal, or bedside com-
mode readily available to client; provide easy access to
bathroom; provide client with easy-to-remove clothing
such as pajamas with Velcro closures or an elastic waist-
band). D @ +
 Chapter 16 = Nursing Care of
the Elderly Client 823

THERAPEUTIC INTERVENTIONS RATIONALE

° Instruct client to perform pelvic floor muscle exercises
Strengthens pelvic floor muscles and improves tone of the external
(e.g., stopping and starting stream during voiding; squeez-
urinary sphincter.
ing buttocks together, then relaxing the muscles) several
times a day if appropriate.
° Instruct client to continue these exercises after discharge,
Provides for continuum of care once discharged from the acute care
emphasizing that it will take several weeks of exercise facility.
before improvement may be noted. Decreases frustration in knowing that improvement will not be
seen for several weeks.
* Instruct client to space fluids evenly throughout the day Rapid filling of the bladder can result in incontinence if client has
rather than drinking a large quantity at one time. decreased urinary sphincter control.
° Limit oral fluid intake in the evening. D@ + Decreases the possibility of nighttime incontinence.
* Instruct client to avoid drinking alcohol and beverages Alcohol and caffeine have a mild diuretic effect and act as irritants
containing caffeine. to the bladder; both factors may make urinary control more
difficult.

Dependent/Collaborative Actions
Implement measures to promote optimal urinary elimination.
° Administer the following medications if ordered:
- © Cholinergic (parasympathomimetic) agents (e.g., Cholinergics stimulate bladder contractions and promote complete
bethanechol). D bladder emptying if incontinence is associated with overflow
resulting from urinary retention.
° Estrogen preparations. D + May be used to treat stress incontinence in postmenopausal
women.
° Anticholinergics (e.g., oxybutynin, tolterodine) D + Anticholinergics decrease bladder detrusor muscle hyperactivity
and reduce episodes of urge incontinence.
° Sympathomimetic agents (e.g., ephedrine) D + Sympathomimetics increase urethral sphincter tone.
* Catheterize client if ordered. D+ Determination of the amount of residual urine.
e Assist with urodynamic studies (e.g., urethral pressure These can help to determine the cause of altered urinary elimination.
profile, uroflowmetry, cystometrogram) if ordered.
e If urinary incontinence persists:
e Use biofeedback techniques if appropriate. Assists client in regaining control over the pelvic floor muscles and
external urinary sphincter.
¢ Instruct and assist client with bladder retraining Establishes a schedule of when client should empty his or her
program if appropriate. bladder with the goal of decreasing urinary elimination problems.
* Consult physician regarding intermittent catheteriza- Allows for alteration in treatment plan.
tion, insertion of an indwelling catheter, or use of an
external collection device (e.g., condom catheter).

= RISK FOR CONSTIPATION nox ah

Definition: Susceptible to a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of
stool, which may compromise health.

Related to:
° Decreased gastrointestinal motility associated with age and exacerbated by decreased activity and anxiety during illness
e Failure to respond to the urge to defecate associated with dulling of the impulses that sense the signal to defecate, inability
to get to the toilet independently, and/or reluctance to use a bedpan or bedside commode
° Difficulty evacuating stool associated with weakened abdominal muscles and decreased lubrication of stools (a result of
diminished intestinal production of mucus)
© Decreased intake of fiber and fluids
e Possible chronic laxative use

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain on defecation Infrequent bowel movements; hard, dry stool; chronic
laxative use

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824 Chapter 16 * Nursing Care of the Elderly Client

RISK FACTORS DESIRED OUTCOMES

Ee
ee
e Poor muscle tone
The client will not experience constipation, as evi-
Inadequate fluid/fiber intake
denced by:
Medication regimen
a. Usual frequency of bowel movements
Sedentary lifestyle
b. Passage of soft, formed stool
c. Absence of abdominal distention and pain, feeling
of rectal fullness or pressure, and straining during
defecation

NOC OUTCOMES NIC INTERVENTIONS

Bowel elimination; status Bowel incontinence care; bowel management; bowel

training

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of constipation (e.g., decrease in Early recognition of signs and symptoms of constipation allows for
frequency of bowel movements; passage of hard, formed prompt intervention.
stools; anorexia; abdominal distention and pain; feeling of
fullness or pressure in rectum; straining during defecation).
Assess bowel sounds. Report a pattern of decreasing bowel
sounds.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Determine if the client regularly uses laxatives. Laxative abuse decreases the colon’s musculature and decreases the
urge to defecate.
Implement measures to prevent constipation:
e Encourage client to defecate whenever the urge is Prevents stool from remaining too long in the bowel and becoming
felt. D + hard.
e Encourage client to relax, provide privacy, and have call Measures that promote relaxation enable the client to relax the
signal within reach during attempts to defecate. D @ + levator ani muscle and external anal sphincter, which facili-
tates evacuation ofstool.
e Encourage client to establish a regular time for defecation, Promotes routine defecation.
preferably within an hour after a meal.
e Instruct client to increase intake of foods high in fiber Fiber adds bulk to the intestinal contents.
(e.g., bran, whole-grain breads and cereals, fresh fruits and
vegetables) unless contraindicated.
e Determine if client has irregular mealtimes. Changes in or irregular meal times can lead to constipation.
e Instruct client to maintain a minimum fluid intake of Adequate hydration is important in having a soft stool.
1500 to 2000 mL/day unless contraindicated.
Encourage client to drink hot liquids (e.g., tea) upon Stimulates peristalsis which promotes passage of stool through the
arising in the morning. D @ colon.
Increase activity as allowed and tolerated. D @ + Activity improves peristalsis and strengthens the abdominal
muscles.
Encourage client to perform isometric abdominal strength- This type of exercise strengthens the abdominal muscles and
ening exercises unless contraindicated. stimulates peristalsis.
e Perform actions to reduce fear and anxiety (e.g., explain Promotes relaxation.
procedures, provide care in a confident manner). D +
e If client is taking analgesics for pain management, encour- Analgesics decrease peristalsis and promote constipation.
age the use of nonopioid rather than opioid analgesics
when appropriate. D+
Instruct client to continue with actions to promote regular Provides for continuum of care postdischarge from the acute care
bowel function after discharge (e.g., maintain a fluid intake facility.
of at least six to eight glasses per day, increase intake of
foods high in fiber, participate in regular exercise program).
 Chapter 16 = Nursing Care of the Elderly Client 825

THERAPEUTIC INTERVENTIONS
RATIONALE
Dependent/Collaborative Actions
Implement measures to prevent constipation:
e Administer laxatives, stool softeners, and/or enemas if These medications promote evacuation of the bowel.
ordered. D @> Stool softeners decrease hardness of the stool that allows for easier
passage.
Consult physician about checking for an impaction and Minimizes risk for bowel obstruction.
digitally removing stool if client has not had a bowel
movement in 3 days, if client is passing liquid stool, or if
other signs and symptoms of constipation are present.
Consult appropriate health care provider if signs and symp- Allows for prompt alterations in treatment plan.
toms of constipation persist and appear to be an ongoing
problem.

|Nursing ="
Diagnosis DISTURBED SLEEP PATTERN nox
Definition: Time-limited awakenings due to external factors.

“Related to:
° Fear, anxiety, change in environment if in hospital or extended care facility, and discomfort associated with present illness
e Age-related nocturia
° Age-related changes in the stages of sleep resulting in frequent awakenings and less deep restorative sleep

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty falling asleep; statements of Frequent awakenings
not feeling well rested

RISK FACTORS DESIRED OUTCOMES

e Sedentary lifestyle
The client will attain optimal amount of sleep as evi-
¢ Chronic illness
denced by statements of feeling well rested.
e Medication regimen
e Daytime napping
e Decrease in exercise

NOC OUTCOMES NIC INTERVENTIONS

Sleep; status Sleep enhancement

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of a disturbed sleep pattern Early recognition of signs and symptoms of disrupted sleep patterns
(e.g., statements of difficulty falling asleep, frequent awak- allows for prompt intervention.
enings, or not feeling well rested).
Assess client’s regular sleep patterns (e.g., hour of bedtime,
frequency and length of naps).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote sleep:
e Discourage excessive napping during the day unless signs Clients will have more hours ofsleep if they do not nap during the
and symptoms of sleep deprivation exist. D + day. Elderly clients may have short naps during the day because
ofshorter sleep time at night.
e Perform actions to reduce fear and anxiety (e.g., explain Promotes relaxation and rest.
procedures, provide care in a confident manner). D @ +

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826 Chapter 16 * Nursing Care of the Elderly Client

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to reduce dyspepsia, gastric fullness, and Causes discomfort and interferes with sleep.
gas pain if present (tell client not to eat foods that promote
gas and to avoid sodas) and discomfort associated with
client’s diagnosis and treatment.
e Inform client of normal changes in sleep pattern that Reduces concerns about quality and amount of sleep necessary to
occur with aging. maintain health.
e Encourage participation in relaxing diversional activities Decreases stress and promotes relaxation.
during the evening. D@ +
e Discourage intake of foods and fluids high in caffeine (e.g., Caffeine is a stimulant and will make it difficult for the client to
chocolate, coffee, tea, colas) in the evening. D @ + rest.
e Offer client an evening snack that includes milk unless Milk contains L-tryptophan, which is believed to help induce and
contraindicated. D@ > maintain sleep.
e Allow client to continue usual sleep practices (e.g., position; Allowing client normal sleep practices will decrease disruption of
time; presleep routines such as reading, watching television, sleep patterns while in the acute care facility.
and listening to music) whenever possible. D @ +
e Satisfy basic needs such as comfort and warmth before Promotes relaxation.
sleep. D @ +
e Encourage client to limit intake of fluids in the evening Reduces nocturia.
and urinate just before bedtime. D+
e Encourage client to avoid drinking alcohol in the evening. Alcohol interferes with rapid eye movement (REM) sleep.
e Encourage client to avoid smoking before bedtime. D @ Nicotine is a stimulant.
e Reduce environmental distractions (e.g., close door to Most individuals sleep in a dark, quiet environment.
client’s room; use night-light rather than overhead light
whenever possible; lower volume of paging system; keep
staff conversations at a low level and away from client’s
room; close curtains between clients in a semiprivate room
or ward; keep beepers and alarms on low volume; have
earplugs available for client if needed). D +
e Perform actions to reduce interruptions during sleep Interruptions decrease REM sleep, causing disruption of sleep
(70-100 minutes of uninterrupted sleep is usually needed patterns.
to complete one sleep cycle).
e Restrict visitors.
e Group care (e.g., medications, treatments, physical
care, assessments) whenever possible.
e Encourage client to use relaxation techniques. These measures help to promote relaxation and increase potential
for adequate sleep.

Dependent/Collaborative Actions
Implement measures to promote sleep:
e Review medications that client takes with pharmacist or Medications that may interfere with sleep should be given as early
physician and identify those that can interfere with in the day as possible.
sleep (e.g., nicotine transdermal systems, theophylline,
corticosteroids, diuretics, diphenhydramine or other over-
the-counter sleep aids, some antidepressants); if possible,
administer medications such as corticosteroids and diuret-
ics early in the day rather than late afternoon or evening
and encourage client to continue this schedule for these
medications at home.
Administer a prescribed sedative-hypnotic only if indicated; The metabolism, distribution, and excretion of drugsyare often
administer these agents cautiously; inform client that altered in the elderly client.
over-the-counter sleep aids (e.g., diphenhydramine) can
interfere with the quality of sleep and daytime functioning
and should not be taken on a regular basis. D +
Consult appropriate health care provider if signs and symp- Allows for prompt alterations in treatment plan.
toms of sleep deprivation (e.g., irritability, lethargy, agita-
tion, inability to concentrate) occur and persist or worsen.
 Chapter 16 = Nursing Care ofthe Elderly Client 827

Nursing Diagnosis RISK FOR INFECTIOnox

N
Definition: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise
health.
Related to:
*° Stasis of respiratory secretions associated with decreased activity during illness and age-related decrease in
ciliary activity and
cough effectiveness
e Decrease in immunity associated with:
° An age-related decline in T-cell and B-cell function and the number of functional macrophages in the skin and alveoli
° An inadequate nutritional status if present
Decrease in effectiveness of the body’s physical barriers associated with changes in the skin and mucous membranes
Urinary stasis associated with decreased activity during illness and the urinary retention that can result from a decrease in
bladder muscle tone, the effect of certain medications, an enlarged prostate, and difficulty urinating in a new environment
e Favorable environment for growth of pathogens in vagina associated with an increase in the pH of vaginal secretions

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of fatigue and lack of appetite Elevated temperature; chills; increased pulse rate;
Reports of frequency, urgency, or burning when malaise, lethargy, acute confusion; abnormal breath
urinating sounds; productive cough of purulent, green, or rust-colored
sputum; cloudy urine; urinalysis showing a WBC count
greater than S, positive leukocyte esterase or nitrites, or
presence of bacteria; heat, pain, redness, swelling, or
unusual drainage in any area; elevated WBC count
and/or significant change in differential

RISK FACTORS DESIRED OUTCOMES

e Chronic illness
The client will remain free of infection, as evidenced by:
e Injury
a. Absence of fever and chills
e Inadequate immune system response
b. Pulse rate within normal limits
e Increased susceptibility to pathogens
c. Normal breath sounds
e Decrease in exercise
. Cough productive of clear mucus only
oa. Voiding clear urine without reports of burning and
increased frequency and urgency
aad. Absence of heat, pain, redness, swelling, and unusual
drainage in any area
g. Usual mental status
h. WBC and differential counts within normal range for
elderly client
i. Negative results of cultured specimens

NOC OUTCOMES NIC INTERVENTIONS

Immune status Infection control; infection protection; immunization/

vaccination management

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of infection. Early recognition of signs and symptoms of infection allows for
prompt intervention.
e Increase in temperature above client’s usual level (be aware Be aware that some signs and symptoms vary because of an
that normal temperature in the elderly client may be age-related decline in thermoregulatory, immune, and sympa-
<3 ©) thetic nervous system responses.

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828 Chapter 16 = Nursing Care of the Elderly Client

Continued...

NURSING ASSESSMENT RATIONALE

Chills The elderly individual may have a diminished shivering reflex.
Increased pulse rate The elderly client may not demonstrate the classic elevation in
Abnormal breath sounds pulse rate that occurs with infection because of a decreased
Cough productive of purulent, green, or rust-colored sputum sympathetic nervous system response.
Loss of appetite
Cloudy urine
Reports of burning when urinating
Reports of increased urinary frequency or urgency
Urinalysis showing a WBC count >S per high-power field,
positive leukocyte esterase or nitrites, or the presence of
bacteria
Heat, pain, redness, swelling, or unusual drainage in any area
Malaise, lethargy, acute confusion
Increase in WBC count and/or significant change in
differential
Positive results of cultured specimens (e.g., urine, vaginal
drainage, wound drainage, sputum, blood)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent infection:
Maintain a fluid intake of =1500 to 2000 mL/day unless Maintains adequate hydration and vascular fluid volume.
contraindicated.
Use good hand hygiene and encourage client to do the Hand hygiene removes transient flora, which reduces the risk of
same. D@ > transmission of pathogens.
Adhere to the appropriate precautions established to Helps prevent the transmission of microorganisms and reduces the
prevent transmission of infection to the client (standard client’s risk of infection.
precautions, transmission-based precautions on other
clients, neutropenic precautions). D @
Use sterile technique during invasive procedures (e.g., uri- Reduces the possibility of introducing pathogens into the body
nary catheterizations, venous and arterial punctures,
injections, wound care) and dressing changes. D
Anchor catheters/tubings (e.g., urinary, intravenous, Reduces the risk for trauma to the tissues and the risk for introduc-
wound drainage) securely. D@ + tion of pathogens associated with in-and-out movement of the
tubing.
Change equipment, tubings, and solutions used for treat- The longer that equipment, tubings, and solutions are in use, the
ments such as intravenous infusions, respiratory care, irriga- greater the chance of colonization of microorganisms, which
tions, and enteral feedings according to hospital policy. can then be introduced into the body.
Change peripheral intravenous line sites according to Peripheral intravenous line sites are changed routinely to reduce
hospital policy. persistent irritation of one area of a vein wall and the resultant
colonization of microorganisms at that site.
Maintain a closed system for drains (e.g., wound, chest Prevents introduction of pathogens into the body.
tube, urinary catheter) and intravenous infusions when-
ever possible.
Protect client from others with infections and instruct Protecting the client from others with infections reduces the client’s
client to continue this after discharge. D @ + risk of exposure to pathogens.
Maintain adequate nutritional status. D + Adequate nutrition is needed to maintain normal function of the
immune system. '
Perform actions to prevent and treat irritation and break- Frequent oral hygiene helps prevent infection by removing most of
down of the oral mucous membrane (e.g., maintain the food, debris, and many of the microorganisms that are pres-
oral hydration, use a soft-bristle toothbrush, do not use ent in the mouth. It also helps maintain the integrity of the oral
glycerin swabs for mouth care). D@ + mucosa, which provides a physical and chemical barrier to
pathogens.
Instruct and assist client to perform good perineal care The perineal area contains a large number of organisms. Routine
routinely and after each bowel movement. D @ + cleaning of the area reduces the risk of colonization of organ-
isms and subsequent perineal, urinary tract, and/or vaginal
infection.
 Chapter 16 = Nursing Care of the Elderly Client 829

THERAPEUTIC INTERVENTIONS RATIONALE

e Perform actions to maintain an adequate respiratory status
Reduces stasis of respiratory secretions and the risk of a respiratory
(e.g., use incentive spirometry every 2 hrs, change position tract infection.
every 2 hrs, ambulating as able).
e Perform actions to prevent or treat urinary retention (e.g., Prevents urine accumulation in the bladder, which creates an
encourage clients to void when they experience the urge, environment conducive to the growth and colonization of
maintain adequate fluid volume). D @ microorganisms, and reduces the risk of urinary tract infection.
e Perform actions to prevent skin breakdown (promote am- Skin breakdown removes one of the physical barriers to the body.
bulation, change positions of bedridden clients every
2 hrs, maintain adequate hydration). D@ +
° If client has a wound, provide appropriate wound care Facilitates wound healing and reduces the number of pathogens
(e.g., use dressing materials that maintain a moist wound that enter or are present in the wound.
surface, assist with debridement of necrotic tissue, use
dressing materials that absorb excess exudate, maintain
patency of wound drains). D
e Perform actions to reduce stress (e.g., reduce fear, anxiety, Prevents an increase in cortisol secretion, which is important
and pain; help client identify and use effective coping because cortisol interferes with some immune responses.
mechanisms). D@

-Dependent/Collaborative Actions
Implement measures to prevent infection.
e Instruct client to receive immunizations and vaccinations Immunizations are often recommended to reduce the possibility of
(e.g., pneumococcal pneumonia, tetanus, influenza) at some infections in high-risk clients (e.g., those clients who are
recommended intervals if appropriate. immunosuppressed, elderly, or have a chronic disease).
e Consult appropriate health care provider regarding the
following:
e Initiation of antimicrobial therapy if indicated. D + Prevents and/or treats infection.
e Antimicrobial orders that do not seem appropriate (e.g., Reduces the risk of elimination of the client’s natural flora and/or
prolonged use of antimicrobials, excessively high doses the development of drug-resistant microorganisms.
of an antimicrobial, unnecessary use of broad-spectrum or
multiple antimicrobials). D +

|Nursing ~~
Diagnosis RISK FOR FALLS nox
Definition: Susceptible to increased susceptibility to falling, which may cause physical harm and compromise health.

Related to:
e Dizziness or syncope associated with decreased cerebral tissue perfusion that can result from certain medications (e.g.,
antihypertensive agents) and from age-related vascular changes, decrease in cardiac output, and postural hypotension
e Loss of balance associated with the effect of certain medications (e.g., sedatives, narcotic [opioid] analgesics) and the changes
in posture, reduced coordination, delayed reaction time, and impaired proprioception that can occur with aging
e Tripping associated with age-related gait abnormalities (e.g., decreased step height and length) and impaired vision
e Weakness associated with an age-related decrease in muscle strength and the general deconditioning that can occur with
reduced physical activity

CLINICAL MANIFESTATIONS

Subjective Objective
Self-expressed concern for safety during ambulation; stated Unsteadiness when ambulating, use of ambulation aids,
history of previous falls visual field deficits, confusion, orthostatic hypotension,
medication therapy (e.g., antihypertensives, diuretics,
hypnotics, antianxiety agents, narcotics, tranquilizers,
antidepressants), anemias, arthritis

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830 Chapter 16 = Nursing Care of the Elderly Client

RISK FACTORS DESIRED OUTCOMES

e Medication
The client will not experience falls.
e Sedentary lifestyle
e Safety hazards in the home
e Weakness

NOC OUTCOMES NIC INTERVENTIONS

Fall Prevention Behavior; Falls Occurrence Fall Prevention; Environmental Management

NURSING ASSESSMENT RATIONALE

Assess Client’s risk for falls using standardized assessment tool A client’s risk for falls increases with the number of risk factors.
(e.g., Fall Risk Assessment). Determining the client’s risk for falls allows implementation of
the appropriate preventive measures.
Assess client’s balance and mobility skills. Determining the client’s baseline status allows for the implementa-
tion of the appropriate preventive measures.
Evaluate client’s medications to determine whether they Some medications may cause excessive drowsiness, altered mental
place the client at increased risk for falls. states, or physiologic changes such as orthostatic hypotension
that can increase the risk offalls in clients. Early identification
of such medications allows for implementation of appropriate
preventive measures.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for falls:
e Keep bed in low position with side rails up when client is Prevents client from falling when getting out of bed.
in bed. D@ >
Keep needed items within easy reach and help client to Prevents client from stretching to obtain items, losing balance, and
identify their location. D@ + falling.
Encourage client to request assistance whenever needed; Provides assurance to client that someone will assist him or her as
have call signal within easy reach. D @ needed and that he or she can remain in bed until assistance
arrives.
Use lap belt when client is in chair if indicated. D@ Prevents client from sliding out of a chair.
Instruct client to wear well-fitting slippers/shoes with Decreases potential for falls and improves ambulation.
nonslip soles and low heels when ambulating.
Keep floor free of clutter and wipe up spills promptly. Prevents client from tripping over clutter or slipping on wet floors.
De+
Instruct and assist client to get out of bed slowly. Reduces dizziness associated with postural hypotension.
e Carefully position tubings and equipment. D ® + Prevents client from tripping over equipment.
Accompany client during ambulation and use a transfer Provides stability when ambulating and helps prevent falls.
safety belt if client is weak or dizzy. D @ +
Provide ambulatory aids (e.g., walker, cane) if client is Provides stability when ambulating.
weak or unsteady on feet. D @
Reinforce instructions from physical therapist on correct Improves client adherence and improves safety.
ambulation and transfer techniques.
If vision is impaired, orient client to surroundings, room, Ensures that client will be able to see obstacles in his or her path
and arrangement of furniture and identify obstacles when ambulating.
during ambulation.
Instruct client to move slowly, use wider stance when Prevents loss of balance when ambulating.
ambulating, and avoid turning head or body rapidly. '
Instruct client to ambulate in well-lit areas and to use Allows client to see obstacles that may be in his or her path when
handrails if needed. ambulating.
Do not rush client; allow adequate time for ambulation to Elderly clients may move more slowly; allowing them adequate time
the bathroom and in hallway. D@ + for ambulation decreases their frustration and risk for falls.
Make sure that shower has a nonslip bottom surface and Decreases risk for slipping and falling while on wet surfaces.
that shower chair; make sure that bath mat, call signal,
grab bars, and adequate lighting are present.
 Chapter 16 = Nursing Care of the Elderly Client 831

THERAPEUTIC INTERVENTIONS RATIONALE

e Maintain adequate strength and activity tolerance and an Provides for client stamina while performing ADLs.
optimal level of physical mobility.
e If client is at high risk for falls and gets up without Institute facility’s fall protocol.
assistance despite reminders to request assistance,
e Attach an alarm device to bed or chair. D@ a Notifies health care personnel if client leaves the chair or bed.
Include client and significant others in planning and imple- Helps family understand what they can do to assist client and
menting measures to prevent falls. D@ + reduce risk for falls.
Discuss with client and significant other:
e The need to evaluate living environment for hazards (Giga Improves safety.
thick or loose carpets, inadequate or loose railings, insuf-
ficient lighting) and make necessary modifications.
° The importance of participating in a regular exercise pro- Provides conditioning and muscle strengthening and improves
gram for conditioning and muscle strengthening and balance.
continuing with therapy for gait and balance training if
needed.
e Stress the importance of continuing appropriate safety Prevents falls.
precautions after discharge.
If falls occur, initiate appropriate first aid and notify physician. Allows for prompt intervention.

Dependent/Collaborative Actions
Implement measures to reduce the risk for falls:
e Tf client is at high risk for falls and gets up without assis-
tance despite reminders to request assistance:
e Consult physician about the temporary use of jacket or Helps prevent falls of clients who won’t remain in the bed or chair
wrist restraints. to protect them from falling.
e Administer central nervous system depressants judiciously. Central nervous system depressants decrease client’s level of
D+ consciousness and increase risk for falls.

Nursing Diagnosis RISK FOR ASPIRATION nox

Definition: Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheobron-
chial passages, which may compromise health.

Related to: Diminished gag reflex and the gastroesophageal reflux that can occur as a result of decreased tone of the lower
esophageal sphincter

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty swallowing and choking on Choking on food or liquids. Cough presence of tube feeding
food or liquids in tracheal aspirate, chest radiograph showing pulmonary
infiltrate

RISK FACTORS DESIRED OUTCOMES

e Changes in esophageal sphincter tone
The client will not aspirate secretions or foods/fluids as
e Medication regimen evidenced by:
a. Clear breath sounds
b. Resonant percussion note over lungs
c. Absence of cough, tachypnea, and dyspnea

NOC OUTCOMES NIC INTERVENTIONS

Aspiration prevention Aspiration precautions

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NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of aspiration of Early recognition of signs and symptoms of aspiration of secretions
secretions or foods/fluids (e.g., rhonchi, dull percussion or foods/fluids allows for prompt intervention.
note over affected lung area, cough, tachypnea, dyspnea,
tachycardia, presence of tube feeding in tracheal aspirate,
chest radiograph showing pulmonary infiltrate).
Assess Client’s gag reflex. Aging individuals have a decreased rate of swallowing. Silent
aspirations may occur in an elderly client.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for aspiration:
e Perform actions to reduce gastroesophageal reflux (e.g., Prevents stomach from becoming too full and incidence gastric
provide small frequent meals rather than three large ones; fluid reflux into the oropharynx. Reflux is decreased when the
instruct client to ingest food slowly; maintain client in head of the bed is elevated at least a 35- to 45-degree angle.
high Fowler’s positions during ingestion of foods and Maintaining a sitting position after eating decreases the incidence
fluids and for =30 minutes thereafter). D @ + of aspiration in the elderly.
e Instruct client to avoid laughing and talking while eating Prevents food/fluids from moving into the trachea rather than the
and drinking. esophagus.
e Encourage client to concentrate on eating and drinking Allows client to fully chew foods, which makes them easier to swal-
and allow ample time for meals and snack. D @ + low and reduces the risk of aspiration. Eating slowly assures the
client does not feel rushed and tries to swallow food too quickly
which may lead to aspiration.
e Instruct and assist client to perform oral hygiene after Ensures that food particles do not remain in the mouth.
meals. D@ >
e If client is receiving tube feedings, check tube placement be- Prevents overdistention of the stomach and subsequent increased
fore each feeding or on a routine basis if tube feeding is pressure, which can force gastric contents into the oropharynx
continuous, and do not administer tube feeding if the resid- and increase the risk for aspiration.
ual exceeds a specified amount (usually 75-100 mL). D +

Dependent/Collaborative Actions
If signs and symptoms of aspiration occur:
e Perform tracheal suctioning. Manually removes contents from the trachea.
e Withhold oral intake. Prevents further aspiration.
e Prepare client for chest radiograph. Helps to determine degree of aspiration and treatment required.

|Nursing 2
Diagnosis |
6s
RISK FOR INJURY nox

Definition: Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and
defensive resources, which may compromise health.
Related to:
Visual: The lens becoming more opaque, losing elasticity, and yellowing; loss of ciliary muscle tone; decreased pupil size; and
changes in the cornea, retina, macula, and vitreous humor
Gustatory: A diminished sense of smell and atrophy of the taste buds (there usually only a modest, quality-specific loss of taste
in elderly clients)
Kinesthetic: A decrease in vestibular sensitivity and ability to perceive movement '
Tactile: A decreased number of sensory receptors in the skin
Age-related: Decrease in tactile sensation; changes in vision and incidence of cataracts; hearing loss
 Chapter 16 = Nursing Care of the Elderly Client 833

RISK FACTORS
DESIRED OUTCOMES
e Changes in sensations
e Visual disturbances The client will not experience an injury related to declines
e Polypharmacy in his or her senses.

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of difficulty with vision, hearing, taste, Visible injury on client’s body
and difficulty moving.

NOC OUTCOMES NIC INTERVENTIONS

Se a a a a ee ek ee er ee ee ee ee ae
Knowledge personal safety and medication Environmental management, safety, medication
management

NURSING ASSESSMENT RATIONALE

Le nnn a aa eee eee ee ee

Assess Client for the following: Early recognition of changes in sensory functioning allows for
e Vision changes (e.g., statements of decreased visual acuity, prompt intervention.
altered depth perception, inability to adjust to changes in
+
lighting, increased sensitivity to glare, or altered color
perception; overreaching or underreaching for objects
which may lead to injury)
e Diminished kinesthetic sense (e.g., unsteadiness on feet,
swaying, lack of coordination which may lead to falls
e Diminished tactile sensation (e.g., statements of dimin-
ished feeling in extremities, holding or touching very hot
objects, use of heating pad at higher-than-expected
temperatures; increases potential for burns)

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
If client’s vision is impaired:
e Ensure that lighting is adequate but not too bright. D @ + Elderly individuals have increased sensitivity to glare.
e Avoid sudden changes in light intensity. D @ + Elderly clients often adjust more slowly to changes in lighting.
e Reduce the glare from windows by partially closing blinds Increased sensitivity to glare makes it more difficult to see.
or curtains. D @ +
° Provide a night-light. D@ > Facilitates adaptation to a darkened environment and improves
night vision. Decreases potential for falls.
e Provide large-print reading material if available. D @ > Easier for client to read with reading glasses. Decreases potential
for medication errors.
¢ Keep frequently used items within the visual range. The visual field narrows with aging and keeping things within the
bDe+ visual range decreases risk of falls.
e Encourage client to wear his/her glasses; make sure glasses Improves visual acuity and ability to see through lenses.
are clean. D@ +
e Provide auditory rather than visual diversionary activities Relieves boredom.
if indicated. D@ +
e Inform client of resources available if additional informa- Provides for continuum of care once discharged from the acute care
tion about visual aids is desired (e.g., American Foundation facility.
for the Blind).
e Assist with activities such as filling out menus and reading Assists the client in making decisions and decreases potential for
mail and legal documents as needed. being abused.
Implement measures to prevent burns if client has decreased These safety measures help prevent injury from burns.
tactile sensation:
° Let hot foods and fluids cool slightly before serving. D @ +
e Supervise client while smoking if indicated. D @ +
° Assess temperature of bath water and direct heat applica-
tion (e.g., heating pad, warm compress) before and during
use. D © >

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834 Chapter 16 * Nursing Care of the Elderly Client

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Implement measures to reduce the risk for falls if client’s
vision and/or sense of position or balance seems impaired:
° Keep bed in low position. D® + Prevents potential for client falling when getting out of bed.
e Keep needed items within easy reach and assist client to Prevents stretching to reach objects and possible loss of balance or
identify their location. D@ + falling out of bed.
e Encourage client to request assistance whenever needed; Assures client that someone is available to help them.
have call signal within easy reach. D@ +
e Use lap belt when client is in chair if indicated. D @ Prevents client from sliding out of the chair.
e Keep floor free of clutter and wipe up spills. D @ + Improves client safety.
e Instruct and assist client to get out of bed slowly and Reduces dizziness associated with postural hypotension.
change position slowly.
e Provide ambulatory aids (e.g., walker, cane) if appropriate. Improves balance when walking.
De+
Instruct client and significant others in above methods of Provides for continuum of care.
adapting to disturbed sensory perceptions.

Dependent/Collaborative Actions
Consult appropriate health care provider if disturbed sensory Allows prompt alteration in intervention.
perceptions worsen.

RISK FOR INJURY nox (PATHOLOGIC FRACTURES)

Definition: Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and
defensive resources, which may compromise health.
Related to:
° Pathologic fractures osteoporosis associated with an imbalance between bone resorption and bone formation resulting
from decreased estrogen levels in women
° Calcium deficiency (results from decreased dietary intake and decreased absorption due to vitamin D deficiency), and
e Decreased activity

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain in joints and/or bones Decrease in mobility and range of motion of extremities,
abnormal joint positioning; swelling over skeletal
structures, radiographs showing pathologic fractures

RISK FACTORS DESIRED OUTCOMES

e Decreased calcium absorption
e Sedentary lifestyle The client will not experience pathologic fractures, as evi-
e Medication regimen denced by:
e Chronic illness a. Usual mobility and range of motion
¢ Poor diet b. Absence of unusual motion, abnormal joint position,
and obvious deformity of any body part
c. Absence of pain and swelling over skeletal strugtures
d. Radiographs showing absence of fractures

NOC OUTCOMES NIC INTERVENTIONS

Knowledge of personal safety and medication Environmental management, safety, medication
management
 Chapter 16 * Nursing Care of the Elderly Client 835

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of pathologic frac- Early recognition of signs and symptoms of fractures allows for
tures (e.g., decrease in mobility or range of motion, motion prompt interventions.
at site where motion does not usually occur, abnormal joint
position or obvious deformity, pain or swelling over skeletal
structures, radiographs showing pathologic fracture).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent pathologic fractures:
e Move client carefully; obtain adequate assistance as Prevents falls and fractures.
needed. D@
e When turning client, logroll and support all extremities. Prevents dangling of extremities during turning and decreases the
De+ potential for injury.
e Use smooth movements when moving client; avoid Prevents sharp, jerking movements, which may cause fractures.
pulling or pushing on body parts. D@ +
e Initiate and follow facility safety protocol. D @ + Provides standardized care to prevent accidental falls and bone injury.
° Help client to maintain maximum mobility. D @ Weight-bearing exercises reduce bone breakdown.
e Discourage smoking and excessive caffeine and alcohol Nicotine and caffeine increase cardiac workload and may increase
intake. D+ shortness of breath. Alcohol will increase diuresis requirement
and increase activity and the potential for falls.
e Encourage client to consume a diet that includes adequate Ensures an adequate amount of nutrients required for healthy
amounts of protein, vitamins, and calcium. bones.
e Emphasize need for client to follow a regular exercise pro- Provides for continuum of care once client is discharged from the
gram after discharge. acute care facility.

Dependent/Collaborative Actions
Implement measures to prevent pathologic fractures:
e Consult physician about use of a tilt table if client is immobile. Facilitates weight bearing.
e Administer calcium preparations, vitamin D, and medica- These preparations improve potential for bone health and decrease
tions that inhibit bone resorption (e.g., calcitonin, in pathologic fractures.
alendronate) if ordered. D @ +
If fractures occur:
e Maintain activity restrictions if ordered. D @ + Prevents further bone injury.
« Apply external stabilization device (e.g., cervical collar, Stabilizes bone for healing.
brace, splint, sling) if ordered.
e Prepare client for surgery (e.g., internal fixation) if planned. Decreases client’s fear and anxiety.
e Administer analgesics and/or muscle relaxants if ordered. Controls pain associated with pathologic fractures.
D+

Collaborative »Diagnosis.
- DRUG TOXICITY |

Definition: An accumulation drug or drugs in the bloodstream that may lead to severe side effects.

Related to:
e An increase in cell receptor sensitivity to some drugs
° Changes in the usual distribution of drugs associated with factors such as a decrease in total body water, a decrease in
lean body mass, an increase in total body fat, and a decrease in serum albumin
° Impaired metabolism and excretion of drugs associated with diminished liver and kidney function
e Synergistic effect that occurs with some combinations of medications (elderly clients are often taking a number of
medications)

CLINICAL MANIFESTATIONS

Subjective | Objective
Verbal self-report of confusion, blurred vision, anorexia, Ataxia; vomiting; diarrhea; dysrhythmias; postural
nausea, dizziness, itchy skin hypotension; stridor; rash; urticaria; agitation; elevated
BUN, serum creatinine, and serum transaminase levels

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836 Chapter 16 * Nursing Care of the Elderly Client

RISK FACTORS DESIRED OUTCOMES

e Polypharmacy
The client will not develop drug toxicity as evidenced by
e Changes in distribution
absence of signs and symptoms commonly associated with
e Inadequate fluid intake
drug toxicity, such as:
e Poor diet
Ataxia, agitation, confusion, and blurred vision
e Changes in mental status: dementia, anxiety, depression
Anorexia, nausea, vomiting, and diarrhea
Dizziness, dysrhythmias, and postural hypotension
Dyspnea and stridor
Rash and urticaria
Elevated BUN, serum creatinine, and serum transami-
moan
nase levels

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms that might be indicative Early recognition of signs and symptoms of drug toxicity allows for
of drug toxicity (e.g., ataxia, agitation, confusion, blurred prompt intervention.
vision, anorexia, nausea, vomiting, diarrhea, dizziness, Signs and symptoms will vary depending on drugs being taken.
dysrhythmias, postural hypotension, dyspnea, stridor,
rash, urticaria, elevated BUN, serum creatinine, and serum
transaminase levels).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent drug toxicity:
e Educate client about common adverse effects of drugs Informs client of what to observe for and what to do should adverse
being taken and ways to avoid toxicity; encourage client effects occur. Also improves adherence to medication regimen.
to report adverse effects or any other unusual symptoms
immediately.
e Obtain baseline vital signs and results of laboratory studies Facilitates assessment of the effects of medications on these
indicative of renal and hepatic function. systems.
e Monitor blood levels (e.g., peak, trough) of drugs as Helps to appropriately determine amount of medication client
ordered and report results to physician; be aware that the should receive and prevents drug toxicity.
elderly client may experience toxic effects when drug
levels are within the “normal” therapeutic range.
e Before discharge:
e Provide client and family members with clear, simple, Provides an ongoing source of information about client’s
written instructions for taking medications prescribed; medications.
include drug name, dose, schedule, route of administra-
tion, special precautions such as incompatible foods or
drugs, and adverse reactions to observe for.
e Assist client to set up a system for remembering to take Facilitates appropriate administration of client’s medications.
medications as prescribed (e.g., divided pill container, use
of timer).
e Emphasize the importance of taking only those medica- Prevents interaction between medications that may decrease or in-
tions that are prescribed, following the directions carefully, crease the potency of the client’s medications.
and keeping the physician informed of adverse effects
experienced.
e Provide client with a written schedule for any laboratory Facilitates client taking mediations at the appropriate times and
tests that are to be done to monitor the therapeutic effect what should be monitored. '
or side effects of medications being taken.
e Encourage client to get all of medications from one phar- Prevents potential drug interactions if client received multiple
macy and to provide that pharmacy with a complete prescriptions from multiple pharmacies.
medical history and list of medications being taken.
If signs and symptoms of drug toxicity occur, withhold dose Prevents further buildup of drug toxicity and allows for prompt
and notify appropriate health care provider (e.g., physi- intervention.
cian, practitioner, pharmacist).
 Chapter 16 = Nursing Care of the Elderly Client 837

THERAPEUTIC INTERVENTIONS RATIONALE

Dependent/Collaborative Actions
Implement measures to prevent drug toxicity:
° Consult appropriate resource (e.g., pharmacist, physician,
Provides multidisciplinary approach to medication administration.
drug book, geriatrician) for the following:
e Information about possible drug interactions of the Facilitates monitoring of drug toxicity effects.
medications client is taking
e Appropriate dosages of medications for elderly clients The smallest effective dose of a medication should be ordered for
elderly persons to reduce the risk of adverse effects.
e Schedule for and order of administration of medications The absorption, distribution, metabolism, and excretion of many
medications may be altered by other medications as well as the
age-related changes in body function and the client’s current
illness.
Administer central nervous system depressants judiciously. Central nervous system depressants decrease client’s level of con-
sciousness so that drug toxicity may be difficult to recognize.

|Nursing =.
Diagnosis INEFFECTIVE SEXUALITY PATTERN nox
+

Definition: Expressions of concern regarding own sexuality.

Related to:
e Fear of rejection associated with feelings of loss of physical attractiveness
e Inadequate opportunities for sexual expression associated with lack of available partner
e Misconceptions about sexual functioning in old age
e Fear of urinary incontinence
e Dyspareunia associated with vaginal changes (e.g., decreased vaginal lubrication, thinning and loss of elasticity of the vaginal
wall, shortening and narrowing of the vagina) resulting from decreased estrogen levels
e Embarrassment associated with possible impotence (erections are usually less intense and slower in the elderly male; may be
further affected by certain disease processes [e.g., diabetes, vascular disorders, chronic renal failure] and medications [e.g.,
thiazide diuretics, tricyclic antidepressants, certain antihypertensive agents])

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of sexual concerns; report of difficulties N/A
in performing sexual activities

RISK FACTORS DESIRED OUTCOMES

e Lack of interest and/or partner
The client will demonstrate beginning adaptation to
e Medication regimen
changes in sexuality patterns as evidenced by:
e Chronic illness a. Verbalization of a perception of self as sexually accept-
e Changes in sexual response
able and adequate
e Absence of significant other b. Statements reflecting ways to adjust to effects of aging
on sexual functioning

NOC OUTCOMES NIC INTERVENTIONS

ee

Sexual identity Body image enhancement, sexual counseling

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NURSING ASSESSMENT RATIONALE

Assess for symptoms of altered sexuality patterns (e.g., verbal- Early recognition of signs and symptoms of altered sexuality
ization of sexual concerns, limitations, or difficulties; patterns allows for prompt intervention.
reports of changes in sexual activities or behaviors).
Determine client’s perception of desired sexuality, usual Be aware that the client may be reluctant to express concerns
pattern of sexual expression, recent changes in sexuality because of the common stereotype that the elderly are not
patterns, and knowledge of age-related changes in sexual sexually active.
functioning.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote an optimal sexuality pattern:
e Educate client on the age-related changes in sexual func- Gives client factual information about changes in sexual perfor-
tioning (e.g., sexual responses are slower and less intense, mance that client may not have known.
vaginal secretions are diminished, erections take longer to
achieve, seminal fluid volume is reduced, erection is rap-
idly lost after orgasm, refractory time between orgasms is
longer); encourage questions and clarify misconceptions.
e Facilitate communication between client and partner; Allows client and significant other to discuss and make changes in
focus on feelings shared by the couple and assist them to a safe environment.
identify changes that may affect their sexual relationship.
e Discuss ways to be creative in expressing sexuality (e.g., Client may not be aware of alternative methods of expressing
massage, fantasies, cuddling). sexuality.
e Arrange for uninterrupted privacy if desired by couple. Allows client and significant other to explore identified changes.
e Perform actions to improve client’s self-concept (e.g., limit Positive self-esteem should have a positive effect on client’s
negative self-reflection, assist client in identification of sexuality.
effective coping mechanisms).
e If dyspareunia is a problem:
e Encourage female client to use a water-soluble lubricant Reduces vaginal dryness.
before sexual intercourse.
e Suggest experimentation with different positions Reduces the depth of penetration.
during intercourse.
e If impotence is a problem: Impotence may be due to reversible factors such as medication
e Encourage client to discuss it with physician. therapy, alcohol, and poorly controlled chronic disease
conditions.
e Assure client that occasional episodes of impotence are Assures client of normalcy.
normal.
e Suggest alternative methods of sexual gratification if May improve sexual gratification.
appropriate.
e Encourage client to discuss various treatment options Allows client to know there are options available to treat impotence
(e.g., penile prosthesis, sildenafil, vardenafil, intraure- and the appropriateness of discussing this with his physician.
thral alprostadil pellet placement, external vacuum
device) with physician if appropriate.
e Reinforce the importance of rest before sexual activity. Improves ability to perform sexually.
e If incontinence of urine is a problem, encourage client to Decreases incidence of incontinence during sexual activity.
void just before intercourse and other sexual activity.
e Include partner in above discussions and encourage Demonstrates support for client and partner and allows them to
continued support of the client. receive factual information.

Dependent/Collaborative Actions
Implement measures to promote an optimal sexuality pattern:
e If dyspareunia is a problem:
e Administer estrogen if ordered or provide client with Reduces vaginal dryness and thinning of vaginal epithelium.
information about estrogen therapy.
Consult appropriate health care provider (counselor, sex Allows for a multidisciplinary treatment plan.
therapist, physician) if counseling appears indicated.
 Chapter 16 = Nursing Care of the Elderly Client 839

| RISK FOR FRAIL ELDERLY SYNDROME no

Definition: Susceptible to a dynamic state of unstable equilibrium that affects the older individual
experiencing deterioration
in one or more domains of health (physical, functional, psychological, or social) and leads
to increased
susceptibility to adverse health effects, in particular disability.

Related to:
e Reduced opportunities for socialization associated with inadequate financial resources,
death or disability of friends and
family members, reluctance of others to include the elderly in activities, reluctance to establish new
relationships and try
new activities, and/or a move to a different location (e.g., family member’s home, foster home, extended care
facility)
° Decreased desire to communicate with others associated with an imbalance between the effort required
to interact with
others and the anticipated rewards of the interaction
e Decreased participation in usual activities associated with changes in sensory and motor function and fear of falls
e Withdrawal from others associated with fear of embarrassment resulting from functional changes such as incontinence or
hearing loss

CLINICAL MANIFESTATIONS

Subjective Objective
Expression of feelings of rejection; being different from Sad, dull affect; hostility; uncommunicative and
others or being lonely withdrawn; absence of supportive significant others

RISK FACTORS DESIRED OUTCOMES

e Chronic illness
e Sedentary lifestyle The client will not experience a sense of isolation and
e Loss of friends and/or family loneliness, as evidenced by:
e Lack of interest in interacting with others a. Maintenance of relationships with significant others
b. No expression of feelings of isolation and loneliness

NOC OUTCOMES NIC INTERVENTIONS

Social support, quality of life Enhancement of socialization, facilitation of visits

NURSING ASSESSMENT RATIONALE

Assess for indications of isolation and loneliness (e.g., absence Early recognition of signs and symptoms of loneliness allows for
of supportive significant others; uncommunicative and prompt intervention.
withdrawn; expressing feelings of rejection, being different
from others, or being lonely; hostility; sadness; dull affect).

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to decrease isolation and reduce the risk
for loneliness:
e Help client to identify reasons for feeling isolated and Helps clients to realize they have to be actively involved in chang-
alone; aid client in developing a plan of action to reduce ing feelings of loneliness.
these feelings.
e Use touch to demonstrate acceptance of client. D @ + Decreases loneliness and connects client with others.
e Encourage significant others to visit. D @ > Helps client to understand that he or she is not alone.
e Encourage client to maintain telephone contact with Helps client become actively engaged in decreasing feelings of
others. D @®+ loneliness.
e Schedule time each day to sit and talk with client. D @ + Demonstrates acceptance of client and shows client that having
positive interactions with others is possible.
° Help client to identify a few persons they she feels com- Help client role play with interactions to provide self-esteem in
fortable with and encourage interactions with them. ability to relate others in social interactions.
° Make objects such as telephone, television, radio, newspa- Allows client to interact with others, and electronics may provide
pers, and greeting cards accessible to client. D @ + distractions.

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840 Chapter 16 * Nursing Care of the Elderly Client

Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Have significant others bring client’s favorite objects from Makes client feel more at home in the health care environment.
home and place in room. D @ +
e Change room assignments if necessary. Provide the client with a roommate with similar interests.
e Encourage interaction between client and roommate. Demonstrates to client that others find client interesting and are
willing to spend time with him or her.
e Emphasize the importance of maintaining active friend- Encourages client to engage in interactions with others.
ships and seeking out new relationships; encourage
participation in support groups if appropriate.
e Encourage client to participate in structured activity Provides for continuum of care after discharge from the acute care
programs after discharge; provide information about facility.
community senior centers and the programs they offer.

DEFICIENT KNOWLEDGE nox

Definition: Absence of cognitive information related to a specific topic, or its acquisition.

Related to:
e Lack of motivation, inadequate support and supervision, and insufficient financial resources
e Confusion about appropriate health care practices and a decreased level of trust associated with conflicting advice from
multiple health care providers
e Conflicting values between client and health care providers
e Knowledge deficit regarding current diagnosis, medications and treatments prescribed, and consequences of failure to
comply with treatment plan

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of inability to care for self at home; Nonadherence to diet; refusal to be involved in treatment
statements reflecting lack of understanding of self-care; regimen.
statements reflect understanding of disease progression
with or without treatment; statements of unwillingness
to engage in required treatment regimen

RISK FACTORS DESIRED OUTCOMES

e Chronic illness
The client will demonstrate the probability of effective
e Medication regimen
management of therapeutic regimen as evidenced by:
e Lack of resources both social and financial
a. Willingness to learn about and participate in treat-
ments and care
b. Statements reflecting ways to modify personal habits
and integrate treatments into lifestyle
c. Statements reflecting an understanding of the implica-
tions of not following the prescribed treatment plan

‘
NOC OUTCOMES NIC INTERVENTIONS

Knowledge: treatment regimen; disease process; Discharge planning; health system guidance; teaching:
participation in health care decisions; compliance disease process; teaching: treatment; financial resource
behavior; health beliefs. assistance
 Chapter 16 = Nursing Care of the Elderly Client 841

NURSING ASSESSMENT RATIONALE

Assess for indications that the client may be unable to effec-
Early recognition of signs and symptoms of ineffective therapeutic
tively manage the therapeutic regimen:
management allows for prompt intervention.
° Statements reflecting inability to manage care at home.
° Failure to adhere to treatment plan (e.g., not adhering to
dietary modifications, refusing medications, refusing to
ambulate).
° Statements reflecting a lack of understanding of the factors
that will cause further progression of current illness and/or
accelerate aging process.
° Statements reflecting an unwillingness or inability to
modify personal habits and integrate necessary treatments
into lifestyle.
° Statements reflecting view that situation is hopeless and
that efforts to comply are useless.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to promote effective management of the
therapeutic regimen:
e Discuss with client the specific factors that may interfere Helps client identify underlying cause of ineffective treatment
with management of care (e.g., inadequate financial management.
resources, religious or cultural conflicts, lack of support
systems).
e Explain the aging process and current diagnosis in terms Helps client understand that some physiologic changes are part of
the client can understand; stress the fact that adherence to the aging process, but others require adherence to a treatment
the treatment plan is necessary in order to delay and/or regimen.
prevent complications associated with the diagnosis and
minimize some of the changes that occur with aging.
¢ Help client to clarify values and identify ways to incorpo- Values clarification and lifestyle changes.
rate the therapeutic goals and priorities into his or her
value system.
e Encourage questions and clarify misconceptions the client Ensures client’s understanding of physiologic changes and impact
may have about aging and his or her diagnosis and effects on his or her ability to maintain earlier lifestyle.
of each.
e Perform actions to promote trust in caregivers (e.g., validate Helps improve adherence.
conflicting advice, explain reasons for treatment plan).
e Encourage client to participate in treatment plan (e.g., Helps to improve client’s self-confidence in ability to care for self.
take medications as prescribed, perform recommended
exercises).
e Provide instruction regarding medications and treatments Knowledge of medications and how they impact the system
prescribed; allow time for return demonstration of proce- improves client adherence to treatment regimen and under-
dures; determine areas of difficulty and misunderstanding standing of the importance of adhering to the prescribed medi-
and reinforce teaching as necessary. cation regimen. The client must be able to recognize alterations
in functioning related to medication administration and what
clinical manifestations that should be reported to the health
care provider.
e Provide client with written instructions about medications Provides a reference once discharged from the acute care facility.
and treatments.
¢ Help client to identify ways to incorporate treatments into Clients will adhere more closely to lifestyle modifications that they
his or her lifestyle; focus on modifications of lifestyle identify.
rather than complete change, if possible.
e Encourage client to discuss his or her financial concerns; Provides for ongoing support post discharge from the acute care
obtain a social service consult to help client with financial facility,
planning and to obtain financial aid if indicated.
e Provide information about and encourage use of commu- Provides ongoing support and continuum of care post discharge
nity resources that can assist client to make necessary from the acute care facility.
lifestyle changes if appropriate.

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

e Encourage client to attend follow-up educational classes if Increases client’s understanding of disease process and ongoing
appropriate. self-care.
e Reinforce behaviors suggesting future compliance with the Improves client’s self-confidence in abilities to adhere to treatment
therapeutic regimen (e.g., statements reflecting plans for regimen and to care for self.
integrating treatments into lifestyle, active participation in
exercise program, changes in personal habits).
e Include significant others in explanations and teaching Provides ongoing support once the client is discharged from the
sessions and encourage their support; reinforce the need acute care facility.
for client to assume responsibility for managing as much
of his or her care as possible.

Dependent/Collaborative Actions
Consult appropriate health care provider about referrals to Allows for multidisciplinary client care and for continuum of care
community health agencies if continued instruction, once in the community.
support, or supervision is needed.

| Nursing Diagnosis ‘INTERRUPTED FAMILY PROCESSES nox

Definition: Break in the continuity of family functioning which fails to support the well-being of its members.

Related to:
¢ Financial, physical, and psychologic stresses associated with family member’s illness and/or progressive disability
e Inadequate knowledge about the normal aging process, client’s current diagnosis, and necessary care
e Inadequate support services
e Decreased ability of client to fulfill usual family roles
e Guilt associated with the need to change client’s living situation, resulting from family’s inability to provide necessary care

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-reports of increased stress related to financial, Change in financial situations; change in psychologic
physical, and/or psychologic associated with disability stress; change in communication patterns; changes in inti-
macy; changes in participation in problem solving; changes
in rituals; changes in satisfaction with family; changes in
somatic behavior; changes in stress-reduction behavior

RISK FACTORS DESIRED OUTCOMES

e Chronic illness
Client’s significant others will demonstrate beginning ad-
e Sedentary lifestyle
justment to changes in functioning of family member and
e Changes in roles and responsibilities
family roles and structure as evidenced by:
e Poor self-esteem
a. Meeting client’s needs
e Poor social support system
b. Verbalization of ways to adapt to required role and
e Loss of family members
lifestyle changes
e Changes in mental status: dementia, anxiety, depression
c. Active participation in decision making and client’s
rehabilitation
d. Positive interactions among one another

NOC OUTCOMES NIC INTERVENTIONS

Family integrity; family support Promotion of family integrity; maintenance of family

process; family support
 Chapter 16 = Nursing Care of
the Elderly Client 843

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of interrupted family processe
s Early recognition of signs and symptoms of interrupted family
(e.g., inability to meet client's needs, statements of not processes allows for prompt intervention.
being able to accept client’s disabilities or make necessary
role and lifestyle changes, inability to make decisions,
inability or refusal to participate in client’s care and/or
rehabilitation, negative family interactions).
Identify components of the family and their patterns of
communication and role expectations.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to facilitate family members’ adjust- Helps them work through their issues and concern related to
ment to age- or diagnosis-related changes in client and changes in the family structure. Family members must be open
resultant changes in family roles and structure: and honest and focused on working through changes in family
° Encourage family members to verbalize feelings about structure and support.
changes in client and the effect of these changes on family
structure; actively listen to each family member and main-
- tain a nonjudgmental attitude about feelings shared.
° Instruct client and family about normal aging processes Provides client and family with factual information related to
(e.g., sensory deficits, decreased muscle strength, reduced changes being experienced.
coordination).
e Reinforce physician’s explanation of the effects of the cur- Reinforcing important information allows the nurse to both
rent diagnosis and planned treatment and rehabilitation. summarize key concepts and further assess client’s understand-
ing of instructions.
° Help family members to gain a realistic perspective of Improves family members’ support and understanding of client’s
client’s situation, conveying as much hope as appropriate. situation and the importance of their support.
e Provide privacy so that family members and client can Allows for open communication between family members and
share their feelings; stress the importance of good client.
communication techniques and facilitate their use.
¢ Help family members to progress through their grieving pro- Helps family members understand that a significant change has
cesses; explain that they may encounter times when they must occurred and it is OK to grieve about the changes.
focus on meeting their own rather than the client’s needs.
* Emphasize the need for family members to obtain ade- Helps them to deal emotionally and physically with the changes
quate rest and nutrition and to identify and use stress experienced.
management techniques.
e Encourage and assist family members to identify coping Helps them learn what mechanisms work best for them in dealing
strategies for dealing with client’s age-related changes and with client and family changes.
changes in health status and their effect on the family.
e Help family members to identify realistic goals and ways Helps to decrease disappointment when unrealistic goals are not
of reaching these goals. met.
e Include family members in decision making about client’s Helps family have some sense of control over the situation.
care; convey appreciation for their input and continued
support of the client.
e Encourage and allow family members to participate in cli- Improves family’s understanding of treatment regimen and their
ent’s care and rehabilitation; instruct family in any special ability to support client.
procedures and allow them to practice with supervision
before discharge of the client.
¢ Help family members to identify resources that could assist Provides for continuum of care once client is discharged from the
them in coping with their feelings and meeting their im- acute care facility.
mediate and long-term needs (e.g., counseling and social
services; pastoral care; service, church, and support
groups); initiate a referral if indicated.

Dependent/Collaborative Actions
Consult appropriate health care provider if family members Allows for multidisciplinary input into continuum ofcare.
continue to demonstrate difficulty adapting to changes in
client’s functioning, roles, and family structure.

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844 Chapter 16 * Nursing Care of the Elderly Client

ADDITIONAL NURSING DIAGNOSES

DISTURBED BODY IMAGE NDx RISK FOR POWERLESSNESS NDx

Related to: Related to:
e Changes in appearance and body functioning (e.g., gray- e Increased dependence on others to meet basic needs
ing and thinning of hair; sagginess of eyelids, earlobes, e Inability to pursue usual life activities and roles associated
and breasts; dry, wrinkled skin; reduced height; increase in with age-related changes in body functioning, current
and change in distribution of body fat; reduction in lean diagnosis and its treatment, and inadequate financial
body mass; decreased bladder control; diminished visual resources
acuity and hearing) Inability to control many of the changes that occur with
Increased dependence on others to meet basic needs aging
Feelings of powerlessness
Change in usual lifestyle and roles associated with decreased
strength and endurance and disturbed sensory perception
 CHAPTER

: End-of-Life Nursing Care

his care plan focuses on care of the adult client who is

physical and emotional needs, and adjust to their loss of the
expected to die soon. The information included is ap- client.
propriate for clients in acute or extended care settings or in
This care plan does not deal with any specific medical
the home. The major goals of nursing care are to prevent or diagnosis. The nursing diagnoses included are those that
control physiological problems that could reduce the quality are common to all persons facing death. Care plans that
of the client’s remaining life; facilitate the client’s psycho- pertain to the client’s specific medical diagnosis will provide
logical adjustment to his/her imminent death; and assist the additional guidelines for nursing care during the terminal
client to experience a peaceful, dignified death. The nurse stages of that illness.
also assists the significant others (SO) to understand the Use in conjunction with the Care Plan on Immobility and
dying process, support the dying person, meet their own care plans that pertain to the client’s medical diagnosis.

Nursing Diagnosis RISK FOR ASPIRATION nox

Definition: Susceptible to entry of gastrointestinal secretions, oropharynx secretions, solids, or fluids to the tracheobronchial
passages, which may compromise health.
Related to:
e Decreased level of consciousness
e Absent or diminished gag reflex associated with the underlying disease process and/or the depressant effect of some medica-
tions (e.g., narcotic [opioid] analgesics, some antiemetics and antianxiety agents)
e Supine positioning
e Increased risk for gastroesophageal reflux associated with increased gastric pressure resulting from decreased GI motility
e Impaired swallowing associated with dry mouth and absent or diminished swallowing reflex (can occur as a result of the
underlying disease process)

CLINICAL MANIFESTATIONS

Subjective Objective
Not applicable Rhonchi; dull percussion note over affected lung area;
cough; tachypnea; tachycardia; development of or increase
in dyspnea; presence of tube feeding in tracheal aspirate;
chest radiograph showing pulmonary infiltrate

RISK FACTORS DESIRED OUTCOMES

e Delayed gastric emptying The client will not aspirate secretions or foods/fluids as
e Impaired swallowing evidenced by:
e Decreased level of consciousness a. Clear or usual breath sounds
e Tube feeding b. Resonant percussion note over lungs
e Immobility and positioning c. Absence of cough and tachypnea
d. Absence of or no increase in dyspnea

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846 Chapter 17. * End-of-Life Nursing Care

NOC OUTCOMES NIC INTERVENTIONS

a a SSS SS SS

Aspiration prevention; respiratory status: gas exchange Respiratory monitoring; aspiration precautions, airway
precautions

NURSING ASSESSMENT RATIONALE

Assess for and report signs and symptoms of aspiration of Early recognition of signs and symptoms of aspiration allows for
secretions, vomitus, or foods/fluids: prompt intervention.
e Rhonchi
e Dull percussion note over affected lung area
¢ Cough, tachypnea, tachycardia
¢ Development of or increase in dyspnea
e Presence of tube feeding in tracheal aspirate
Assess chest radiograph for evidence of pulmonary infiltrates.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce the risk for aspiration:
¢ Position client in side-lying or semi- to high-Fowler’s posi- These positions decrease the incidence of aspiration by decreasing
tions at all times. D @+ the direct access to the trachea of fluids and/or food.
e Perform actions to prevent nausea and vomiting:
e Eliminate noxious sights/odors. Noxious sights/odors can cause nausea and vomiting. Eliminating
these reduces the risk for aspiration.
e Perform actions to reduce the accumulation of GI gas and Reducing gastric distention and gastroesophageal reflux reduces the
fluid (e.g., expel flatus, eructate). movement of fluids/foods into the upper esophagus.
e Withhold oral food/fluids if gag reflex is depressed or absent, Risk for aspiration is high when mechanisms to protect the client’s
client is not alert, or client is experiencing severe dysphagia. airway (e.g., gag reflex) are impaired.
e If client is taking foods/fluids orally: Thin fluids rapidly pass through the mouth and can pour over the
e Offer foods/fluids that promote an effective swallow (e.g., back of the tongue without triggering an effective swallow,
thick rather than thin fluids, moist rather than dry foods). D increasing the risk for aspiration.
Maintain client in a high-Fowler’s position during and for at least Head-of-bed elevation facilitates movement of foods and fluid
30 minutes after client eats unless contraindicated. D @ + through the pharynx into the esophagus, where the risk for
aspiration is greatly reduced.
e Encourage client to concentrate on eating and drinking Ifaclient becomes distracted during meals or is rushed, swallowing
and allow ample time for meals. D + and breathing attempts can become uncoordinated, increasing
the risk for aspiration.
e Instruct client to avoid talking or laughing when swal- Laughing or talking results in the larynx remaining open during
lowing. eating and increases the risk of aspiration.
A high-Fowler’s position uses gravity to aid in the flow of fluids/
foods through the esophagus.
* Assist client with oral hygiene after eating. D@ + Good oral hygiene after meals results in the removal of remaining
If signs and symptoms of aspiration occur: food particles that could enter the larynx and be aspirated into
e Perform tracheal suctioning. the lungs.
e Withhold oral intake.
e Prepare client for chest radiograph if ordered.

Dependent/Collaborative Actions
Implement measures to reduce the risk for aspiration:
e Perform oropharyngeal suctioning and oral hygiene as Oropharyngeal suctioning helps to remove excess secrefions, vomi-
often as needed. tus, and food particles.
e If client is receiving tube feedings:
e Check tube placement before each feeding or on a rou- Validation of appropriate location of feeding tube ensures that tube
tine basis if continuous feeding. D + feeding solution goes into the alimentary tract and not the lungs.
Do not increase rate of continuous tube feeding unless High residual volumes can lead to upward pressure placed on the
allowed and tolerated; administer intermittent tube feed- lower esophagus, increasing the risk for regurgitation.
ings slowly.
Stop tube feeding and notify physician if residuals exceed Allows for prompt changes in treatment regimen.
established parameters.
 Chapter 17 = End-of-Life Nursing Care 847

ie Tarek BIEYelatekyry ACUTE/CHRONIC PAIN no»

Definition: Acute pain NDx: Unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage (International Associat
ion for the Study of Pain); sudden or slow
onset of any intensity from mild to severe with anticipated or predictab
le end, and with a duration of less than
3 months; Chronic Pain NDx: Unpleasant sensory and emotional experien
ce associated with actual or potential
tissue damage, or described in terms of such damage (International Associat
ion for the Study of Pain); sudden or
slow onset of any intensity from mild to severe, constant or recurring without
an anticipated or predictable end,
and with a duration of greater than 3 months.
Related to:
° The underlying disease process
° Muscle spasms or stiff joints associated with decreased mobility
Reluctance to take pain medication associated with fear of loss of control and/or
oversedation, feeling that taking
medication is a sign of weakness, or that pain has redemptive qualities and/or
need to be stoic

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of pain Grimacing; reluctance to move; restlessness; diaphoresis;
+
increased blood pressure; tachycardia

RISK FACTORS DESIRED OUTCOMES

e Injury agents
The client will experience diminished pain as evi-
¢ Immobility/positioning
denced by:
° Chronic disability
a. Verbalization of decrease in or absence of pain
b. Relaxed facial expression and body positioning
c. Stable vital signs

NOC OUTCOMES NIC INTERVENTIONS

———————————————

Comfort level; pain control Analgesic administration; pain management; patient-

controlled analgesia (PCA) assistance; environmental
management: comfort; dying care

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of pain: Early recognition of signs and symptoms of pain allows for prompt
¢ Grimacing intervention.
e Reluctance to move
e Restlessness
e Diaphoresis
e Increased BP
e Tachycardia
e Verbalization of pain
Assess client’s perception of the severity of pain using a pain Use of a pain intensity rating scale gives the nurse a clearer under-
intensity rating scale. standing of the client’s pain being experienced, changes in pain
Assess the client’s pain pattern (e.g., location, quality, onset, over time, and promotes consistency when communicating with
duration, precipitating factors, aggravating factors, allevi- others.
ating factors).
_ Ask the client to describe previous pain experiences and Provides comparison to determine ifpain and associated factors are
methods used to manage pain effectively. changing.

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848 Chapter 17 * End-of-Life Nursing Care

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to reduce pain:
e Perform actions to reduce fear and anxiety about the pain Actions help promote relaxation and subsequently increase the
experience (e.g., assure client that the need for pain relief client’s threshold and tolerance for pain.
is understood; plan methods for achieving pain control
with client).
e Perform actions to promote rest: Actions help reduce fatigue and subsequently increase the client’s
° Cluster nursing care. D® + threshold and tolerance for pain.
e Plan methods for achieving pain control with client. Actions help assist client to maintain a sense of control over the
pain experience.
e Provide or assist with nonpharmacological methods for Nonpharmacological pain management includes a variety of inter-
pain relief (e.g., massage; position change; progressive relax- ventions. These interventions are believed to be effective
ation exercise; restful environment; diversional activities because they stimulate closure of the gating mechanism in the
such as watching television, reading, or conversing). D+ spinal cord.

Dependent/Collaborative Actions
Implement measures to reduce pain:
e If client has a PCA device, encourage client to use it as
instructed.
Maintain integrity of analgesia delivery system (e.g., epidural, Provides the client a sense of control over care and experience of
intravenous, subcutaneous, transdermal). pain.
e Administer analgesics before activities and procedures that Prevents or decreases the experience of pain and allows the client
can cause pain and before pain becomes severe. to engage in activities as able.
e Administer the following medications as ordered to pro- Medications help to decrease pain experience. Client may need
vide maximum pain relief with minimal side effects: D + medications on a regular schedule to remain pain free. Be sure
e Opioid analgesics to address issues such as constipation when client is regularly
e Nonopioid analgesics taking opioids.
¢ Local anesthetics
e Muscle relaxants
Consult appropriate health care provider (e.g., hospice nurse, Consulting the appropriate health care provider allows for modifi-
palliative care nurse, pharmacist, physician, pain manage- cation of the treatment plan.
ment specialist) if above measures fail to provide adequate
pain relief.

|Nursing Diagnosis
Diagnosis |RISK FOR IMPAIRED SKIN INTEGRITY nox
Definition: Susceptible to alteration in epidermis and/or dermis, which may compromise health.

Related to:
e Accumulation of waste products and decreased oxygen and nutrient supply to the skin and subcutaneous tissue associated
with reduced blood flow from prolonged pressure on the tissues resulting from decreased mobility
e Damage to the skin and/or subcutaneous tissue associated with friction or shearing
e Frequent contact with irritants associated with incontinence of urine or stool
e Increased fragility of skin associated with inadequate nutritional status, dryness, and dependent edema

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of problem Pallor; redness; obvious areas of skin breakdown

RISK FACTORS DESIRED OUTCOMES

e Immobility
The client will maintain tissue integrity as evidenced by:
e Shearing/pressure forces
a. Absence of redness and irritation
e Impaired circulation b. No skin breakdown
e Changes in fluid status
 Chapter 17 = End-of-Life Nursing Care 849

NOC OUTCOMES
NIC INTERVENTIONS
Tissue integrity: skin and mucous membrane
Skin surveillance; skin care: topical treatments; pressure
ulcer prevention; positioning

_ NURSING ASSESSMENT RATIONALE

Determine client’s risk for skin breakdown using a risk
assess- Early recognition of signs and symptoms of skin breakdown allows
ment tool (e.g., Norton Scale, Braden Scale, Gosnell
Scale). for prompt intervention.
Inspect the skin (especially bony prominences; dependent,
edematous, and pruritic areas; and perianal area) for pallor,
redness, and breakdown.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to prevent skin irritation resulting from
incontinence of urine or stool in order to help prevent
tissue breakdown:
e Perform actions to reduce the episodes of urinary and
Helps to avoid skin irritation from exposure to fecal material and
bowel incontinence: urine.
° Offer assistance to defecate at regular intervals during Helps to prevent incontinence and subsequent exposure to fecal
the day. D @ material and urine
° Assist client to thoroughly cleanse and dry perineal area Keeping skin dry and protected prevents breakdown.
with soft tissue or cloth after each episode of inconti-
nence; apply a protective ointment or cream. D @
° Apply a fecal incontinence pouch if bowel incontinence is Protects skin from exposure to irritating substances.
a persistent problem. D+
e If use of absorbent products such as pads or undergar- Constant exposure to moisture will increase the potential for skin
ments is necessary, select those that effectively absorb breakdown.
moisture and keep it away from the skin.

Dependent/Collaborative Actions
If tissue breakdown occurs:
° Notify appropriate health care provider (e.g., wound care Consulting the appropriate health care provider allows for modifi-
specialist, physician). cation of the treatment plan.
e Perform pressure ulcer care as ordered or per standard
hospital procedure (extensiveness of treatment is usually
limited to that necessary to maintain comfort).

|Nursing 2)
Diagnosis |FUNCTIONAL URINARY INCONTINENCE/BOWEL
INCONTINENCE nox
Definition: Functional Urinary Incontinence NDx: Inability of a usually continent person to reach toilet in time to avoid
unintentional loss of urine. Bowel Incontinence NDx: Involuntary passage of stool.

Functional urinary incontinence NDx

Related to:
e Decreased ability to respond to the urge to urinate associated with decreased level of consciousness and impaired physical
mobility
e Decreased awareness of full bladder and poor urinary sphincter control associated with decreased level of consciousness
and/or the underlying disease process

. Bowel incontinence NDx

Related to:
¢ Decreased ability to respond to the urge to defecate associated with decreased level of consciousness and impaired physical
mobility
e Decreased awareness of urge to defecate and poor anal sphincter control associated with decreased level of consciousness
¢ Fecal impaction if present (continuous stimulation of the defecation reflex by the fecal mass that inhibits the internal anal
sphincter and results in loss of ability to retain the mucus and fluid that collects proximal to and leaks around the fecal mass)

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850 Chapter 17 * End-of-Life Nursing Care

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal report of urgency Leakage of urine during body movements
Leakage of fecal material

RISK FACTORS DESIRED OUTCOME

¢ Immobility functional urinary and
The client will not experience
e Impaired cognition
bowel incontinence
e Toileting self-care deficit

NOC OUTCOMES NIC INTERVENTIONS

Seen
ea

Urinary continence; bowel continence Urinary incontinence care; self-care assistance: toileting;
urinary catheterization
Bowel incontinence care

NURSING ASSESSMENT RATIONALE

Assess for urinary incontinence: Early recognition of signs and symptoms of urinary and bowel
e Leakage of urine during body movements incontinence allows for prompt intervention.
e Verbal report of urgency with post-void residuals
e Assess for bowel incontinence:
e Leakage of fecal material from the body
e Assess the number of incontinence events.

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to maintain or regain urinary and bowel
continence:
e Offer bedpan or urinal or assist client to bedside commode Bladder and bowel training programs help to reduce the incidence
or bathroom every 2 to 4 hrs if indicated. D@ + of incontinence.

e Allow client to assume a normal position for voiding and Promotes evacuation of the bladder and bowel.
a bowel movement unless contraindicated.
e Perform actions to reduce delays in toileting (e.g., have call Actions help to promote complete bladder emptying.
signal within client’s reach and respond promptly to
requests for assistance; have bedpan, urinal, or bedside
commode readily available to client; provide client with
easy-to-remove clothing such as pajamas with Velcro
closures or an elastic waistband). D @ +
e If client has a good fluid intake, encourage him/her Rapid filling of bladder can result in incontinence if client has
to space fluids evenly throughout the day rather than decreased urinary sphincter control.
drinking a large quantity at one time.
e Encourage client to avoid drinking alcohol and beverages Alcohol and caffeine have a mild diuretic effect and act as
containing caffeine. irritants; these factors may make urinary control more difficult.
If urinary and/or bowel incontinence persists:
e Provide client with or apply disposable undergarments Helps prevent exposure of skin to urine, preventing skin breakdown.
(e.g., Depends, Attends) if indicated. D @ + Be sure to check client regularly to prevent thetskin being
exposed for a long period of time to urine or fecal material.

Dependent/Collaborative Actions
If urinary and/or bowel incontinence persists:
e For urinary incontinence: Consulting the appropriate health care provider allows for modifi-
¢ Consult appropriate health care provider about inter- cation of the treatment plan.
mittent catheterization, insertion of indwelling cathe-
ter, or use of external collection device (e.g., condom
catheter).
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THERAPEUTIC INTERVENTIONS
RATIONALE
e For bowel incontinence:
° Consult appropriate health care provider (e.g., Hospic
e
nurse, palliative care nurse, physician) about the use
of
a fecal incontinence pouch.

|Nursing *Diagno
=)sis |DEATH ANXIETY nox
Definition: Vague, uneasy feeling of discomfort or dread generated by perception
s of a real or imagined threat to one’s
existence.
Related to:
° Concern about the well-being of caregivers and the impact of death on SO
° Fear of loss of physical and mental capabilities during dying process
e Anticipated discomfort (e.g., pain, nausea, difficulty breathing) during dying
process
° Feeling of powerlessness over issues related to death
e Feeling of doubt about existence of a God or higher being
¢ Unfinished business and unresolved conflicts
“e Fear of abandonment and dying alone

CLINICAL MANIFESTATIONS

Subjective Objective
Verbal self-report of concerns about death and dying Acting out with anger or aggression; mood swings

RISK FACTORS DESIRED OUTCOMES

e Uncertainty about a higher power
e Pain/suffering The client will experience a reduction in death anxiety as
evidenced by:
e Terminal illness
a. Verbalization of feeling less anxious
e Loss of control
b. Usual sleep pattern
c. Relaxed facial expression and body movements
d. Stable vital signs
e. Statements reflecting resolution of unfinished business,
conflicts, and concerns

NOC OUTCOMES NIC INTERVENTIONS

Anxiety self-control; fear self-control; dignified life closure; Anxiety reduction; presence; emotional support; spiritual
spiritual health support; decision-making support; self-esteem enhancement

NURSING ASSESSMENT RATIONALE

Assess client for concerns related to death and the dying process: Early recognition of signs and symptoms of death anxiety allows
e Increased anxiety for prompt intervention.
e Acting out with anger and aggression
e Mood swings

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement additional measures to reduce fear and anxiety
about death and dying: . tes .
Establish a trusting relationship with the client and SO. Establishing a trusting relationship is the first step in the process
Spend quality time with client and SO. of supporting the patient and SO through this difficult time.
Spend time with the patient and make sure that they don’t feel
rushed or unimportant due to other responsibilities.

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Continued...

THERAPEUTIC INTERVENTIONS RATIONALE

Provide a supportive environment in which the client and SO Allow client and SO time to determine what they would like to
can explore concerns about death: happen and how they can maintain control of what happens to
e Advance directives, living will, and durable power of them if they are unable to communicate their wishes for care.
attorney.
e Planning funeral/burial arrangements.
e Organ/tissue donation.
e How to spend remaining time.
e Spend quality time with client.
e Assist client to formulate plans for completing unfinished Provides an opportunity for client and SO to consider these things
business and providing for care of SO if appropriate. and what needs to be put in place to care for others if the client
was a part of the support system.
e If appropriate, encourage and assist client to record (e.g., Gives client and family lasting memories and a way for the SO
write, audiotape, videotape) information he/she would like to retain memories and ability to introduce the client to new
others to know at the present time and after his/her death. members of the family after his/her death.
e Encourage SO to stay with client and participate in care if This provides a time for the client to spend time with his/her
their presence seems to relieve the client’s fear and anxiety. family members and for the family to feel involved in their SO’s
care. It also helps the client not to feel alone in this journey and
can decrease fear and anxiety.
Gives the client a sense of control over their belongings, ability to
support their family and pets, and to provide for them once they
are deceased.
Consult appropriate individuals (e.g., attorneys, social ser- Provides for interprofessional client focused care.
vices, Hospice nursing) to help meets client’s need to put
systems in place for remaining friends, family, and pets.
e Consult with patient regarding potential spiritual or
religious needs.

|Nursing »Diagnosis
6 GRIEVING nox

Definition: A normal, complex process that includes emotional, physical, spiritual, social, and intellectual responses and
behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss
into their daily lives.

Related to: Loss of control over life and body functioning, changes in body image, loss of SO, and imminent death

CLINICAL MANIFESTATIONS

Subjective Objective
Expression of distress about terminal illness and dying; Change in eating habits; inability to concentrate;
denial of impending death insomnia; anger; sadness; withdrawal from SO

RISK FACTOR DESIRED OUTCOMES

e Anticipatory loss of body processes
The client will demonstrate progression through the griev-
ing process as evidenced by:
a. Verbalization of feelings about dying '
b. Usual sleep pattern
c. Use of available support systems

NOC OUTCOMES NIC INTERVENTIONS

Grief resolution Grief work facilitation; emotional support; presence; support

system enhancement; dying care
 Chapter 17. = End-of-Life Nursing Care 853

NURSING ASSESSMENT RATIONALE

Assess for signs and symptoms of grieving:
Early recognition of signs and symptoms of grieving allows for
e Expression of distress about terminal illness and
dying prompt intervention.
e Denial of impending death
e Change in eating habits
¢ Inability to concentrate
e Insomnia
e Anger
e Sadness
e¢ Withdrawal from SO

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to facilitate the grieving process:
° Assist client to acknowledge that death is imminent.
Acknowledgment of imminent death allows grief work to progress.
e Assess for factors that may hinder and facilitate acknowl-
edgment.
e Discuss the grieving process and assist client to accept the Phases of grieving vary among theorists, but progress from shock
- phases of grieving as an expected response to anticipated and alarm to acceptance.
losses and impending death.
° Allow time for client to progress through the phases of
grieving. Be aware that not every phase is expressed by all
individuals, that phases do not necessarily occur in se-
quential order, and that recurrence of phases is common
during the course of an illness and the dying process.
e Provide an atmosphere of care and concern (e.g., provide Action helps client to feel free to express feelings.
privacy, be available and nonjudgmental, display empathy
and respect).
e Perform actions to promote trust (e.g., answer questions
honestly, provide requested information).
e Encourage the verbal expression of anger and sadness about Allows client time to express concerns and fears and feel that they
anticipated losses; recognize displacement of anger and assist are heard. Helps client work through issues associated with
client to see the actual cause of angry feelings and resent- imminent death.
ment; establish limits on abusive behavior if demonstrated.
e Encourage client to express feelings in whatever ways are
comfortable (e.g., writing, drawing, conversation).
e Assist client to identify and use techniques that have
helped him/her cope in previous situations of loss.
e If desired by client, assist with after-death arrangements Allows client a measure of control over future events when they are
(e.g., funeral, religious service, who should be called). no longer here.
e Perform actions to assist the client to maintain a positive self- Use of personal clothing helps client to maintain his/her identity.
concept and feel good about the life he/she has experienced:
e Visit frequently and encourage verbalization about past
events, life accomplishments, interests, and feelings.
e Help client to focus on positive rather than negative Provides closure for client in relation to their life and life experi-
aspects of his/her life experience. ences. The more involved the client is in self-care, the more they
e Maintain a nonjudgmental attitude about the kind of feel they have control of care.
life client has led and his/her beliefs.
e Encourage participation in decisions about care.
e Encourage and assist client with good physical hygiene
and grooming; suggest use of personal rather than
hospital clothing.
¢ Support behaviors suggesting successful grief work (e.g., The nurse should be available to spend time with client and
verbalizing feelings about dying, statements reflecting that encourage family and friends to be involved in celebrating
dying is difficult but a part of life, comfortable and realistic client’s life with them.
remembrances about significant relationships, use of avail-
able support systems).
e Explain the phases of the grieving process to SO; encour-
age their support and understanding.

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THERAPEUTIC INTERVENTIONS RATIONALE

e Facilitate communication between the client and SO; be aware Helps family and others to understand what the client is going
that they may be in different phases of the grieving process. through and what their role can be in the process.
e Provide information about counseling services and sup- The client and family members may require counseling to work
port groups that might assist client and SO in working through the grief and loss processes.
through grief.
Consult spiritual advisor or pastor. Allows client to obtain spiritual support and work to get “right”
with God if they are interested in this aspect of life.
Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., hospice nurse, Consulting the appropriate health care provider allows for modifi-
palliative care nurse, psychiatric nurse clinician, physi- cation of the treatment plan.
cian) regarding a referral for counseling if signs of dysfunc-
tional grieving (e.g., persistent denial of terminal state,
excessive anger or sadness, emotional lability) occur.

|Nursing "RISK
Diagnosis | FOR SPIRITUAL DISTRESS nox
Definition: Susceptible to an impaired ability to experience and integrate meaning and purpose in life through connectedness
with self, literature, nature, and/or a power greater than oneself, which may compromise health.

Related to:
¢ Challenged belief and value system as a result of intense or prolonged suffering and imminent death
e Separation from religious/cultural ties
e Overwhelming grief and sense of hopelessness

CLINICAL MANIFESTATIONS

Subjective Objective
Verbalization of conflict about beliefs and relationship with Refusal to participate in usual religious practices or to
deity; reports of anger toward God; questioning the purpose have visits from clergy; apathy; hostility; withdrawal
for suffering; verbalizing that illness and imminent death
are a punishment

RISK FACTORS DESIRED OUTCOMES

° Active dying The client will not experience spiritual distress as evi-
e Chronic illness
denced by:
e Pain
a. Expression of a sense of spiritual well-being
e Social alienation
b. Participation in usual religious/spiritual practices when
possible
c. Maintaining connectedness with SO

NOC OUTCOMES NIC INTERVENTIONS

Hope; spiritual health Hope; inspiration; spiritual support; grief work facilitation;
coping enhancement; dying care

NURSING ASSESSMENT RATIONALE '

Assess client’s religious/spiritual beliefs and practices: Provides baseline understanding of client's beliefs.
e Verbalization of conflict about beliefs and relationship
with deity
e Reports of anger toward God
° Questioning the purpose for suffering
e Verbalizing that illness and imminent death are a punishment
e Refusal to participate in usual religious practices or to have
visits from clergy
e Apathy, hostility, withdrawal
 Chapter 17 * End-of-Life Nursing Care 855

NURSING ASSESSMENT
RATIONALE
Assess for signs and symptoms of spiritual distress.
Early recognition of signs and symptoms of spiritual distress allows
for prompt intervention.

THERAPEUTIC INTERVENTIONS
RATIONALE
Independent Actions
Implement measures to promote a sense of Spiritual well-
Spirituality, whether it is religion or other beliefs, has been associ-
being: ated with decreased despair in patients at the end of life.
° Give client permission to express feelings and concerns
about his/her religious/spiritual beliefs.
° Maintain a nonjudgmental attitude about client’s beliefs
and any inner conflicts client is experiencing.
e Encourage client to use available spiritual resources (e.g.,
Provide support based on client’s specific beliefs
clergy, prayer, religious rituals) for support.
° Perform actions to facilitate the grieving process. Encour-
This gives the client time to work through the grieving process and
age verbalization of anger (e.g., allow time for client to may reduce experience of anxiety.
progress through phases of grief).
° Perform actions to reduce feelings of hopelessness (e.g., allow
+
client to exert control over activities as much as possible).

Dependent/Collaborative Actions
Consult appropriate resource (e.g., clergy, psychiatric nurse Consulting the appropriate health care provider allows for modifi-
clinician, physician, palliative care nurse, hospice nurse) if cation of the treatment plan.
signs and symptoms of spiritual distress occur and client’s
response is inappropriate and/or destructive.

Nursing Diagnosis HOPELESSNESS nox

Definition: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable
to mobilize energy on own behalf.
Related to: Deteriorating physical condition, feelings of abandonment, loss of belief in religious/cultural values, and inability
to reach self-fulfillment associated with terminal state

CLINICAL MANIFESTATIONS

Subjective Objective
Statements of feeling hopeless Decreased response to SO; decreased participation in self-
care and decision-making; decreased verbalization; flat
affect

RISK FACTORS DESIRED OUTCOMES

e Long-term stress
The client will maintain hope as evidenced by:
¢ Deteriorating physical condition
a. Verbal expression of same
e Terminal illness
b. Maintenance of satisfying relationships with others
c. Participation in self-care and decision-making as able
d. Identification of realistic goals

NOC OUTCOMES NIC INTERVENTIONS

Hope; decision-making; quality of life; spiritual well-being Decision-making support; presence; grief work facilitation;
hope instillation

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856 Chapter 17. = End-of-Life Nursing Care

NURSING ASSESSMENT RATIONALE

Assess client for signs and symptoms of hopelessness: Early recognition of signs and symptoms of hopelessness allows for
e Decreased response to SO prompt intervention.
e Decreased participation in self-care and decision-making
e Decreased verbalization
e Flat affect
e Statements of feeling hopeless

THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to assist client to reduce feelings of
hopelessness:
e Perform actions to facilitate the grieving process: Grieving occurs in phases or stages over time.
e Provide an atmosphere of care and concern. Stages must be allowed to occur in order to reduce the risk for
dysfunctional grieving.
e Perform actions to promote a sense of spiritual well-being Spiritual support can be a great source of strength and solace to the
(e.g., encourage client to use available spiritual resources). client and can facilitate resolution of grief.
e Allow client to retain as much control as possible over Provides clienta sense of control over life and care.
activities of daily living; involve client in as much self-care
and decision-making as feasible.
e Assist client to identify goals that are achievable in the Helps client to see purpose in their end-of-life journey and ability
time that client has left, ways to continue working toward to impact others.
goals previously set even if not possible to achieve them
totally, and the purpose remaining in client’s life such as
role model or advisor to SO.

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., palliative Consulting the appropriate health care provider allows for modifi-
care nurse, hospice nurse, psychiatric nurse clinician, cation of the treatment plan.
physician) if client demonstrates increased feelings of
hopelessness.

|Nursing ©
Diagnosis |INTERRUPTED FAMILY PROCESSES nox
Definition: Break in the continuity of family functioning which fails to support the well-being of its members.

Related to: Excessive anxiety, grief, disorganization, and current and future role changes within the family unit, inadequate
support systems, and fatigue

CLINICAL MANIFESTATIONS

Subjective Objective
Statements of not being able to accept client’s imminent Inability to make decisions; infrequent visits; inappropriate
death or to make necessary role and lifestyle changes, response to client’s situation; preoccupation with other
verbalization of guilt aspects of life; negative family interactions

RISK FACTORS DESIRED OUTCOMES

e Situational crisis The family members will demonstrate beginning adjust-
e Shift in health status of family member ment to loss of client and changes in family roles and
e Terminal illness structure as evidenced by:
a. Verbalization of ways to adapt to required role and life-
style changes
b. Active participation in decision-making and client’s
care
c. Positive interactions with one another
 Chapter 17 = End-of-Life Nursing Care 857

NOC OUTCOMES NIC INTERVENTIONS

Family coping; family functioning; family resiliency; family Family involvement promotion; family process mainte-
normalization nance; family support; caregiver support; support system
enhancement

aNURSING ASSESSMENT RATIONALE

a eee A ee es Pei ae vy Cee
Assess for signs and symptoms of interrupted family processes: Early recognition of signs and symptoms of interrupted family
e Statements of not being able to accept client’s imminent processes allows for prompt intervention.
death or to make necessary role and lifestyle changes
e Verbalization of guilt
e Inability to make decisions
e Infrequent visits
e Inappropriate response to client’s situation
e Preoccupation with other aspects of life
e Negative family interactions
Identify components of the family and their patterns of com-
munication and role expectations.

- THERAPEUTIC INTERVENTIONS RATIONALE

Independent Actions
Implement measures to facilitate family members’ adjust-
ment to imminent loss of client and altered family roles
and structure:
e Encourage and assist family members to verbalize feelings Client and family member must be given time to openly and
about the death of the client and the effect of it on their honestly express feelings to facilitate the grieving process.
lifestyle and family structure; actively listen to each family
member and maintain a nonjudgmental attitude about
feelings shared.
e Assist family members to confront the reality of the Discussion of feelings helps the client and family work through the
client’s imminent death when they are ready; encourage grieving process.
them to imagine life after death of the client and to set
some personal goals if appropriate.
e Provide privacy so that family members can share their Assistance with funeral planning may be needed, based on the
feelings and grief with one another; stress the importance coping abilities of the family.
of and facilitate the use of good communication tech-
niques.
e Explain the phases of grieving and assist family members
to progress through their own grieving process; explain
that they may encounter times when they need to focus
on meeting their own rather than the client’s needs.
e Emphasize the need for family members to obtain Work with family to assure that they are able to deal with the
adequate rest and nutrition and to identify and use stress stress of loss and ability to support client until that time.
management techniques so that they are better able to
emotionally and physically deal with the death of the
client; assure them that the client will be well cared for in
their absence.
e Encourage and assist family members to identify coping Helps the family members determine what works best for them and
strategies for dealing with the client’s death and its effect to implement those processes.
on those left behind.
e Include family members in decision-making about client
and his/her care; convey appreciation of their input and
continued support of the client.
e Encourage and allow family members to participate in
client’s care if desired by both client and family members.
e Assist family members to make necessary postmortem Allows family and client to be involved in client care.
arrangements for or with the client (e.g., funeral home,
burial place, clergy visitation).

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THERAPEUTIC INTERVENTIONS RATIONALE

e Provide information to family members about:
e The current status of client. Keeps family members informed on client's condition and what
e Behaviors to expect as the client progresses through they can expect in the dying process.
terminal stages of disease and his/her own grieving.
e Physical signs and symptoms of approaching death
(e.g., decrease in appetite and thirst; lack of interest in
environment; withdrawal from relationships; disorien-
tation; restlessness; agitation; vision-like experiences;
“out-of-character” statements or requests; increased
sleeping; incontinence; decreased level of conscious-
ness; reduced urine output; cool, mottled extremities;
respiratory sounds such as gurgling or rattling, labored
breathing, or periods of no breathing).
e Ways they can best assist in meeting client’s needs.
e When appropriate, help and encourage family members to Family members must be given time to acknowledge sadness,
“let go” of client and say goodbye. forgive one another, and say goodbye.
e Assist family members to identify resources that can assist Provides for continuum of care for family members.
them in coping with their feelings and in meeting their
immediate and long-term needs (e.g., counseling and so-
cial services; pastoral care; service, bereavement, and
church groups; hospice); initiate a referral if indicated.
e Assist family members to contact appropriate persons (e.g.,
funeral home director, clergy) when death occurs.

Dependent/Collaborative Actions
Consult appropriate health care provider (e.g., hospice nurse, Consulting the appropriate health care provider allows for
palliative care nurse, physician) if family members con- modification of the treatment plan.
tinue to demonstrate difficulty adjusting to the loss of the
client and role changes within the family unit.

ADDITIONAL NURSING DIAGNOSES

NAUSEA NDx/IMPAIRED COMFORT NDx IMPAIRED ORAL MUCOUS MEMBRANE NDx

Related to: (DRYNESS AND IRRITATION) START
e An accumulation of gas and fluid in the gastrointestinal GI Related to:
tract associated with decreased gastrointestinal GI motility e Decreased salivation associated with decreased oral intake
resulting from depressant effect of some medications (e.g., and some medications (e.g., tricyclic antidepressants, anti-
narcotic [opioid] analgesics) and decreased activity and cholinergics, narcotic [opioid] analgesics, phenothiazines)
nausea e Deficient fluid volume associated with decreased fluid in-
take and increased fluid loss
RISK FOR DEFICIENT FLUID VOLUME NDx e Prolonged oxygen therapy (especially if administered by
Related to: mask)
e Decreased oral intake and increased fluid loss associated ¢ Mouth breathing
with vomiting and/or diaphoresis if client has a fever e Inadequate nutritional status

IMPAIRED PHYSICAL MOBILITY NDx SELF-CARE DEFICIT (BATHING, DRESSING i

Related to: FEEDING AND TOILETING) NDx
e Weakness and fatigue Related to:
e Dyspnea and/or sensory and motor deficits (can occur as a e Weakness and fatigue
result of the underlying disease process) * Activity limitations associated with the underlying disease
e Reluctance to move associated with pain and nausea if process
present * Pain, nausea, dyspnea, and/or disturbed thought processes
e Decreased level of consciousness if present
e Decreased level of consciousness
 Chapter 17 = End-of-Life Nursing Care 859

DISTURBED SLEEP PATTERN NDx the urge to defecate because of reluctance to use bedpan,
Related to:
and decreased gravity filling of lower rectum resulting
e Decreased physical activity, fear, anxiety, unfamiliar envi-
from horizontal positioning
ronment, discomfort, and inability to assume usual sleep
Decreased ability to respond to the urge to defecate associ-
position associated with orthopnea if present
ated with weakened abdominal muscles, impaired physical
mobility, and decreased level of consciousness
RISK FOR FALLS NDx
Decreased GI motility associated with decreased activity,
Related to:
increased sympathetic nervous system activity that occurs
° Weakness, fatigue, and attempting activity unassisted be-
with anxiety, and use of some medications (e.g., narcotic
cause of agitation or confusion lopioid] analgesics, antacids containing aluminum or
calcium)
RISK FOR CONSTIPATION NDx Decreased intake of fluids and foods high in fiber
Related to:
e Diminished defecation reflex associated with decreased
nervous system responses in terminal state, suppression of

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4) rien per AGHMAM @
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A Abdominal trauma (Continued) Acquired immune deficiency syndrome
Abdominal aortic aneurysm, 217 risk for electrolyte imbalance with, (Continued)
anxiety/fear with, 217-218 468-470 impaired comfort with, 433
discharge teaching/continued desired outcomes for, 469-470 impaired oral mucous membrane
care for, 225 NIC interventions for, 469 with, 433
postoperative nursing/collaborative NOC outcomes for, 469 impaired respiratory function with,
diagnosis for, 218 nursing assessment for, 469 423-425
preoperative care for, 217 risk factors for, 469 ineffective coping with, 433
related care plans for, 227 therapeutic interventions for, 469 ineffective family health management
surgical repair of, 217 tisk for imbalanced fluid volume with, with, 428
tisk for cardiac dysrhythmias 468-470 ineffective health management with,
after, 225 desired outcomes for, 469-470 414-415, 428-434 ’
risk for imbalanced fluid and NIC interventions for, 469 ineffective sexuality pattern with, 434
electrolytes after, 218-220 NOC outcomes for, 469 interrupted family process with, 434
risk for lower extremity arterial nursing assessment for, 469 powerlessness with, 434
embolization after, 222 risk factors for, 469 pruritus with, 433
risk for shock after, 220-222 therapeutic interventions for, 469 risk for deficient fluid volume with,
sexual dysfunction after, 227 risk for organ ischemia/dysfunction 421-423
Abdominal distention with, 474-476 risk for electrolyte imbalance, 421-423
with pancreatitis, 630 desired outcomes for, 475 risk for impaired skin integrity with,
postoperative, nausea due to, 103 nursing assessment for, 475 433
Abdominal pain risk factors for, 475 risk for infection with, 418-420
with chemotherapy, 756 therapeutic interventions for, 475 risk for loneliness with, 434
with human immunodeficiency virus risk for peritonitis with, 472-473 spiritual distress with, 427-428
infection and acquired immune desired outcomes for, 472-473 transmission of, 412
deficiency syndrome, 425 nursing assessment for, 473 treatment of, 412
with inflammatory bowel disease, 531 risk factors for, 472 Activity intolerance, 25-26
with intestinal obstruction, 547 therapeutic interventions for, 473 with acute GI bleed, 523-524
desired outcomes for, 547-548 risk for septic shock with, 473-474 desired outcomes for, 523-524
NIC interventions for, 547-548 desired outcomes for, 474 NIC interventions for, 523
NOC outcomes for, 547 nursing assessment for, 474 NOC outcomes for, 523
nursing assessment for, 547 risk factors for, 474 nursing assessment for, 524
risk factors for, 547 therapeutic interventions for, 474 risk factors for, 523
therapeutic interventions for, 548 Abscess formation therapeutic interventions for, 524
Abdominal trauma, 466 after cholecystectomy, risk for, 574-575 in asthma, 116, 118-120
acute pain with, 471-472 clinical manifestations of, 574 clinical manifestations of, 118
desired outcomes for, 471-472 desired outcomes for, 574-575 desired outcomes for, 119-120
NIC interventions for, 471 nursing assessment of, 573 NIC interventions for, 119
NOC outcomes for, 471 risk factors of, 574 NOC outcomes for, 117, 119
nursing assessment for, 472 therapeutic interventions for, 574 nursing assessment for, 119
risk factors for, 471 with inflammatory bowel disease, risk factors of, 119
therapeutic interventions for, 472 537-539 therapeutic interventions for, 119
discharge teaching/continued desired outcomes for, 538 in chronic obstructive pulmonary
care for, 476 nursing assessment, 538 disease, 128-129
emergency assessment of, 466 risk factors for, 538 clinical manifestations of, 128
ineffective breathing pattern with, therapeutic interventions for, 538 desired outcomes for, 128-129
466-468 Accessory nerve damage, after carotid NIC interventions for, 128
desired outcomes for, 467-468 endarterectomy, 242-244 NOC outcomes for, 128
NIC interventions for, 467 Acidosis, metabolic, with inflammatory nursing assessment for, 128
NOC outcomes for, 467 bowel disease, 529 risk factors of, 128
nursing assessment for, 467 Acquired immune deficiency syndrome, therapeutic interventions for, 128
risk factors for, 467 412-413 with cirrhosis, 585-587
therapeutic interventions for, 467 acute/chronic pain with, 425-427 clinical manifestations of, 586
ineffective peripheral perfusion with, chills and diaphoresis with, 418 desired outcomes of, 586-587
470-471 diarrhea with, 433 NIC interventions of, 586
desired outcomes for, 470-471 discharge teaching/continued care, 428 NOC outcomes of, 586
NIC interventions for, 470 disturbed body image with, 420-421 nursing assessment of, 586
NOC outcomes for, 470 disturbed sleep pattern with, 434 risk factors of, 586
nursing assessment for, 471 fatigue with, 434 therapeutic interventions for, 586
risk factors for, 470 fear/anxiety with, 433 clinical manifestations of, 25
therapeutic interventions for, 471 grieving with, 434 desired outcomes for, 25
outcome/discharge criteria, 466 hyperthermia with, 439-440 documentation for, 25-26
postoperative infection after, 476 imbalanced nutrition with, 415-417 due to pneumonia, 159-160

871
872 Index

Activity intolerance (Continued) Acute pain (Continued) Acute pain (Continued)

due to tuberculosis, 207-209 clinical manifestations of, 66 NIC interventions for, 67
clinical manifestations of, 207 with deep vein thrombosis, 248-249 NOC outcomes for, 67
desired outcomes for, 208-209 desired outcomes for, 67 nursing assessment for, 67
NIC interventions for, 208 documentation for, 67-68 with pancreatitis, 613-615
NOC outcomes for, 208 due to angina pectoris, 230 postoperative, 85-86, 95-97
nursing assessment for, 208 due to pneumonia, 156-158 clinical manifestations of, 95
risk factors of, 208 due to pneumothorax, 170-171 desired outcomes for, 96-97
therapeutic interventions for, due to pulmonary embolism, NIC interventions for, 96
208-209t 180-182 NOC outcomes for, 96
in elderly client, risk for, 818-819 end-of-life nursing care for, 847-848 nursing assessment for, 96
with heart failure, 281 in fractured hip with internal fixation risk factors for, 96
after heart surgery, 301 or prosthesis insertion, 686-688 therapeutic interventions for, 96
with hepatitis, 612 clinical manifestations of, 686 preoperative, prior to femoropopliteal
with hyperthyroidism, 465.e4—e6 desired outcomes for, 686-688 bypass, 257-259
clinical manifestations of, 465.e5 NIC interventions for, 686 with procedural sedation, 85-86
desired outcomes for, 465.e5-e6 NOC outcomes for, 686 clinical manifestations of, 85
NIC interventions in, 465.e5t nursing assessment for, 687 desired outcomes for, 85-86
NOC outcomes in, 465.e5t risk factors for, 686 NIC interventions for, 85
nursing assessment, 465.eSt therapeutic interventions for, 687 NOC outcomes for, 85-86
risk factors for, 465.e5 with hepatitis, 612 nursing assessment for, 85
therapeutic interventions for, 465.e5—-e6t with human immunodeficiency virus risk factors for, 85
with hypothyroidism, 465.e17-e18 infection and acquired immune therapeutic interventions for, 85
with inflammatory bowel disease, 544 deficiency syndrome, 425-427 risk factors for, 67
with myocardial infarction, 327-328 clinical manifestations of, 426, 426t with spinal cord injury, 397
NIC interventions for, 25 desired outcomes in, 426-427 therapeutic interventions for, 67
NOC outcomes for, 25 NIC interventions in, 426t with total joint replacement (hip/
nursing assessment for, 25 NOC outcomes in, 426t knee), 690-691
with Parkinson disease, 411 nursing assessment, 426t clinical manifestations of, 690
postoperative, due to anemia, 207-209 risk factors for, 426 desired outcomes for, 690-691
with renal failure, 669 therapeutic interventions for, 427t NIC interventions for, 691
risk factors for, 25 in hypertension, 304-305 NOC outcomes for, 691
therapeutic interventions for, 26 with inflammatory bowel disease, nursing assessment for, 691
Acute confusion, 38-40 531-533 tisk factors for, 690
clinical manifestations of, 39 desired outcomes for, 532-533 therapeutic interventions
desired outcomes for, 39 NIC interventions for, 532 for, 691
documentation for, 36-38 NOC outcomes for, 532 with traumatic brain injury/
NIC interventions for, 39 nursing assessment for, 532 craniotomy, 362-363
NOC outcomes for, 39 risk factors for, 532 with tuberculosis, 216
nursing assessment for, 39 therapeutic interventions for, 532 after TURP, 744-745
risk factors for, 39 with intestinal obstruction, 547 clinical manifestations, 744
therapeutic interventions for, 39 desired outcomes for, 547-548 desired outcomes, 745
Acute pain, 66-68 NIC interventions for, 547-548 NIC interventions, 745
with abdominal trauma, 471-472 NOC outcomes for, 547 NOC outcomes, 745
desired outcomes for, 471-472 nursing assessment for, 547 nursing assessment, 745
NIC interventions for, 471 risk factors for, 547 risk factors, 745
NOC outcomes for, 471 therapeutic interventions for, 548 therapeutic interventions, 745
nursing assessment for, 472 after laminectomy/discectomy with or urolithiasis in, 632-633
risk factors for, 471 without fusion, 704—705 clinical manifestations of, 632
therapeutic interventions for, 472 clinical manifestations of, 704 desired outcomes for, 632-633
in amputation, 673-674 desired outcomes for, 704-705 NIC interventions for, 632
chemotherapy, 756-758 NIC interventions for, 704 NOC outcomes for, 632
desired outcomes for, 757-758 NOC outcomes for, 704 nursing assessment for, 632
NIC interventions for, 757 nursing assessment for, 704 tisk factors for, 632
NOC outcomes for, 757 risk factors for, 704 therapeutic interventions
nursing assessment for, 757 therapeutic interventions for, 704 for, 632
risk factors for, 757 with myocardial infarction, 325-327 Acute pulmonary edema, risk fbr,
therapeutic interventions for, 757 clinical manifestation of, 326 thoracic surgery, 198-199
chest and arm on operative side, after desired outcomes for, 326-327 clinical manifestations of, 198
mastectomy, 722-723 nursing assessment for, 326 desired outcomes for, 198-199
clinical manifestations, 722 nursing interventions classifications nursing assessment for, 198
desired outcomes, 722-723 (NIC) for, 326 risk factors of, 198
NIC interventions, 722 nursing outcomes interventions therapeutic interventions for, 199
NOC outcomes, 722 (NOC) for, 326 Adventitious breath sounds, in elderly
nursing assessment, 722 risk factors for, 326 client, with impaired respiratory
risk factors for, 722 therapeutic interventions for, 326 function, 810
therapeutic interventions, 722, 723 with neoplastic disorders, 804 Atterload, cardiac output and, 37
 Index 873

Airway clearance, ineffective, 27-28,

Analgesia, patient-controlled Anxiety (Continued)
94-95 for acute/chronic pain, 68 with cirrhosis, 601
in asthma, 117 with abdominal trauma, 471 clinical manifestations of, 29
after bowel resection, 555-556 with inflammatory bowel disease, 533 desired outcomes for, 29
desired outcomes for, 555-556 after thoracic surgery, 195 disturbed sleep pattern due to, 73
NIC interventions for, 555 Anemia documentation for, 29-31
NOC outcomes for, 555 and activity intolerance, 585 in fractured hip with internal fixation
nursing assessment for, 555 with acute GI bleed, 524 or prosthesis insertion, 687
risk factors for, 555 activity intolerance due to, 25, 26 with heart failure, 282
therapeutic interventions due to tuberculosis, 209 with hepatitis, 612
for, 555 Aneurysm, abdominal aortic, 217-227 impaired gas exchange due to, 52
with cerebrovascular accident, 346 anxiety/fear with, 217-218 with implantable cardiac devices, 323
in chronic obstructive pulmonary discharge teaching/continued care ineffective breathing pattern due to, 34
disease, 123 for, 225 postoperative, 93
clinical manifestations of, 94 postoperative nursing/collaborative with inflammatory bowel disease, 543
desired outcomes for, 27, 94-95 diagnosis for, 218 with intestinal obstruction and bowel
documentation for, 27-28 preoperative care for, 217 resection, 565
due to pneumonia, 151 related care plans for, 227 with mechanical ventilation, 150
due to tuberculosis, 203 surgical repair of, 217 with myocardial infarction, 339
in elderly client, 809 tisk for cardiac dysrhythmias with neoplastic disorders, 804
with heart failure, 268 after, 225 NIC interventions for, 29
after heart surgery, 285 risk for imbalanced fluid and NOC outcomes for, 29
_ with human immunodeficiency virus electrolytes after, 218-220 nursing assessment for, 30
infection and acquired immune risk for lower extremity arterial pain and, 67
deficiency syndrome, 423 embolization after, 222 in pneumonia, 166
with mechanical ventilation, 142 risk for shock after, 220-222 postoperative, 96
NIC interventions for, 27, 94 sexual dysfunction after, 227 with procedural sedation, 85
NOC outcomes for, 27, 94 Angina pectoris, 227-228 with pancreatitis, 630
nursing assessment for, 27, 94 acute pain with, 230 with pneumonia, 166
postoperative, 94-95 discharge teaching/continued care for, 233 with pneumothorax, 173-174, 175-176
risk factors for, 27, 94 fear/anxiety with, 237 clinical manifestations of, 173
therapeutic interventions for, 27, 94 risk for cardiac dysrhythmias with, desired outcomes for, 173-174
after thoracic surgery, 191 231-232 ineffective breathing pattern due
with traumatic brain injury/ risk for decreased cardiac output with, to, 167
craniotomy, 374 228-231 NIC interventions for, 173
Airway obstruction, with procedural risk for myocardial infarction with, NOC outcomes for, 173
sedation, 82 232-233 nursing assessment for, 173
Airway patency, with mechanical treatment of, 227 risk factors of, 173
ventilation, 143 types of, 227 therapeutic interventions for, 173-174t
Alzheimer disease, 340-341 unstable, 227 postoperative, 115
chronic confusion with, 342-343 Anticholinergics, for impaired urinary ineffective breathing pattern due to, 93
disturbed sensory perception elimination, in elderly client, 823 pain and, 96
with, 346 Antihistamine block histamine, with preoperative, 87-90
grieving with, 346 cirrhosis, 585 clinical manifestations of, 87
impaired social interactions Anxiety, 29-31 desired outcomes for, 88-90
with, 346 with abdominal aortic aneurysm, NIC interventions for, 88
outcome/discharge criteria for, 341 217-218 NOC outcomes for, 88
risk factors for, 340 with acute GI bleed, 527 nursing assessment for, 88
risk for injury with, 346 with acute pain, in urolithiasis, 632 prior to femoropopliteal bypass, 258
self-care deficit with, 341-342 with angina pectoris, 237 prior to heart surgery, 283
treatment of, 341 in asthma prior to thoracic surgery, 191
wandering with, 344-346 discharge teaching on, 120 risk factors for, 88
Amputation, 670 due to impaired respiratory therapeutic interventions for, 88
acute/chronic pain in, 673-674 function, 117 with procedural sedation
closed, 670 with cardiac dysrhythmias, 237.e10 impaired respiratory function and, 82
deficient knowledge in, 670 with chemotherapy, 779 pain and, 85
disturbed body image, 679-681 in chronic obstructive pulmonary, with pulmonary embolism, 180-182,
grieving with, 685 132-133 186-187
impaired physical mobility in, clinical manifestations of, 132 clinical manifestations of, 186
676-677 desired outcomes for, 132-133 desired outcomes for, 186-187
impaired tissue integrity in, 675-676 due to impaired respiratory function, and ineffective breathing pattern, 178
ineffective family health management 123-125 NIC interventions for, 186-187
in, 681-685 NIC interventions for, 128, 132 NOC outcomes for, 186
open, 670 NOC outcomes for, 132 nursing assessment for, 186
risk for falls with, 685 nursing assessment for, 132t risk factors of, 186
risk for surgical site infection after, risk factors of, 132 therapeutic interventions for, 186
678-679 therapeutic interventions for, 133 with renal failure, 669
874 Index

Anxiety (Continued) Aspiration, 31-33 B

risk factors for, 29 clinical manifestations of, 31 Bacteremia, 434
with sepsis, 446 desired outcomes for, 31 with pneumonia, 160-162
with spinal cord injury, 397 documentation for, 31-33 Bariatric surgery, 507
therapeutic interventions for, 30 NIC interventions for, 32 actual/risk for impaired tissue integrity
with traumatic brain injury/ NOC outcomes for, 32 with, 518-519
craniotomy, 374 nursing assessment for, 32 discharge teaching/continued after
with tuberculosis, 216 risk factors for, 31 for, 515
Aortic aneurysm, abdominal, 217-227 risk for on community resources, 518
anxiety/fear with, 217-218 with cerebrovascular accident, on follow-up care, 518
discharge teaching/continued care 349-350 on lifestyle changes, 515
for, 225 in elderly client, 831-832 on maintaining adequate nutritional
postoperative nursing/collaborative with Parkinson disease, 403-404 status, 516
diagnosis for, 218 with spinal cord injury, 397 on prevention of excessive stretching
preoperative care for, 217 therapeutic interventions for, 32 of gastric pouch, 516
related care plans for, 227 Assistive devices, for elderly client, 820 on reducing risk of consuming
surgical repair of, 217 Asthma, 116 excessive amounts of food, 517
risk for cardiac dysrhythmias after, 225 activity intolerance in, 118-120 on reporting of signs and symptoms,
risk for imbalanced fluid and clinical manifestations of, 117 Sly
electrolytes after, 218-220 deficient knowledge, ineffective disturbed self-concept prior to,
risk for lower extremity arterial on adherence to medication 508-509
embolization after, 222 regimen, 120 desired outcomes for, 508-509
risk for shock after, 220-222 on follow-up care, 120 NIC interventions for, 508
sexual dysfunction after, 227 management in, 120-122 NOC outcomes for, 508
Aortic dissection, due to hypertension, on reporting of signs and nursing assessment for, 508
307-308 symptoms, 121 risk factors for, 508
Aphasia, expressive, with chemotherapy, on side effects and drug therapeutic interventions for, 508
768 interactions, 121 imbalanced nutrition with, 518
Apnea, with procedural sedation, 83 desired outcomes for, 117 outcome/discharge criteria, 507
Appendectomy, 478 disturbed sleep pattern in, 122 risk for deep vein thrombosis and
outcome/discharge criteria, 478 fear and anxiety in, 122 thromboembolism with,
Appendicitis, 478 impaired respiratory function in, 513-515
outcome/discharge criteria, 478 116-118 desired outcomes for, 513-514
Arterial embolism, systemic, with cardiac NIC interventions for, 117 NIC interventions for, 513
dysrhythmias, 237.e5—-e7 NOC outcomes for, 117 NOC outcomes for, 513
clinical manifestations of, 237.e5 nursing assessment for, 117 nursing assessment for, 514
desired outcomes for, 237.e6—e7 outcome/discharge criteria of, 116 risk factors for, 513
nursing assessment for, 237.e6 risk factors of, 117 therapeutic interventions for, 514
risk factors for, 237.e6 tisk for powerless in, 122 tisk for overdistention of gastric pouch
therapeutic interventions for, 237.e6 therapeutic interventions for, 118t with, 510-511
Arterial embolization, lower extremity, Atelectasis, risk for desired outcomes for, 511
after abdominal aortic aneurysm after bowel resection, 558-559 nursing assessment for, 511
repair, 222 desired outcomes for, 559 risk factors for, 511
Arterial embolus, with cardiac nursing assessment for, 559 therapeutic interventions for, $11
dysrhythmias, 237.e6 risk factors for, 559 tisk for peritonitis with, 511-513
Arthritis, septic, with pneumonia, 160-162 therapeutic interventions desired outcomes for, 512-513
Arthroplasty (hip/knee), 689-690 for, 559 nursing assessment for, 512
activity intolerance with, 701 with pneumonia, 163-164 risk factors for, 512
actual/risk for impaired tissue integrity clinical manifestations of, 163 therapeutic interventions for, 512
with, 695-697 desired outcomes for, 163-164 Barotrauma, risk for, with mechanical
acute pain with, 690-691 nursing assessment for, 163 ventilation, 150
discharge teaching/continued care risk factors of, 163 Bile flow obstruction, risk for continued,
after, 697 therapeutic interventions for, 164 after cholecystectomy, 578
impaired physical mobility with, 691-693 with pulmonary embolism, 185-186 Biliary tract, nursing care of client with,
preoperative care for, 690 clinical manifestations of, 185 572-630
prosthetic devices for, 690 desired outcomes for, 185-186 Biofeedback, for impaired urinary
related care plans for, 701 nursing assessment for, 185 elimination, in elderly client, 823
risk for falls with, 701 risk factors of, 185 Bladder irrigation, for hemorrhagic
risk for infection with, 701 therapeutic interventions for, 185 cystitis, with chemotherapy, 763
risk for peripheral neurovascular with tuberculosis, 212-213 Bleeding, risk for
dysfunction after, 693-695 clinical manifestations of, 212 with cirrhosis, 589-591
Ascending spinal cord injury, 389-390 desired outcomes for, 212-213 clinical manifestations of, 589
Ascites, risk for, with cirrhosis, 591-592 nursing assessment for, 212 desired outcomes of, 589-591
clinical manifestations of, 591 risk factors of, 212 NIC interventions of, 589
desired outcomes of, 591-592 therapeutic interventions for, 213 NOC outcomes of, 589
nursing assessment of, 591 Autonomic dysreflexia, with spinal cord nursing assessment of, 590
risk factors of, 591 injury, 380-382 risk factors of, 589
therapeutic interventions for, 591 Axillary node dissection, 720 therapeutic interventions for, 590
 Index 875

Bleeding, risk for (Continued) Bowel diversion (Continued) Bowel obstruction, 544
after heart surgery, 292-294 risk factors for, 492 acute abdominal pain with, 547
clinical manifestation of, 292 therapeutic interventions for, 493 desired outcomes for, 547-548
desired outcomes for, 293 emptying or changing of pouch with NIC interventions for, 547-548
nursing assessment for, 293 discharge teaching/continued care NOC outcomes for, 547
nursing interventions classifications on, 496 nursing assessment for, 547
(NIC) for, 293 and impaired tissue integrity, 485 risk factors for, 547
nursing outcomes interventions and risk for peritonitis, 487 therapeutic interventions for, 548
(NOC) for, 293 fluid and electrolyte imbalance with discharge information for
therapeutic interventions for, 293 with discharge teaching on, 495 after surgery, 563
with hepatitis, 606-607 risk for, 480-482 without surgery, 551
desired outcomes of, 606-607 grieving with, 500 disturbed sleep pattern with, 565
nursing assessment of, 606 imbalanced nutrition with, 499 fear/anxiety with, 565
therapeutic interventions for, 607 impaired tissue integrity with, 482-486 imbalanced fluid and electrolytes with,
in hyperthyroidism, 465.e8-e10 desired outcomes for, 483-486 545-548
pulmonary embolism and, 182-183 NIC interventions for, 483 desired outcomes for, 545-546
clinical manifestations of, 182 NOC outcomes for, 483 NIC interventions for, 545
desired outcomes for, 182-183 nursing assessment for, 483 NOC outcomes for, 545
NIC interventions for, 182-183 risk factors for, 483 nursing assessment for, 546
NOC outcomes for, 182 therapeutic interventions for, 483 risk factors for, 545
nursing assessment for, 182 ineffective coping with, 499-500 therapeutic interventions for, 546
risk factors of, 182 ineffective sexuality patterns with, impaired oral mucous membrane
_ therapeutic interventions for, 183 490-492 with, 565
after TURP, 746-747 desired outcomes for, 491-492 nausea with, 548-549
clinical manifestations, 746 NIC interventions for, 491 desired outcomes for, 549
desired outcomes, 746-747 NOC outcomes for, 491 NIC interventions for, 549
NIC interventions, 746 nursing assessment for, 491 NOC outcomes for, 549
NOC outcomes, 746 risk factors for, 491 nursing assessment for, 549
nursing assessment, 746 therapeutic interventions for, 491 risk factors for, 549
risk factors, 746 odor and sound control with therapeutic interventions for, 549
therapeutic interventions, 746, 747 discharge teaching on, 496 outcome/discharge criteria, 544
Blunt abdominal trauma, 466 and disturbed self-concept, 493 postoperative, 544
Body image, disturbed and ineffective sexuality patterns, 491 postoperative interventions for, 553
in elderly client, 844 outcome/discharge criteria, 478-479 for imbalanced nutrition, 556-558
with human immunodeficiency virus preoperative knowledge deficit with, for ineffective airway clearance,
infection and acquired immune 479-480 555-556
deficiency syndrome, 420-421 NIC interventions for, 479 for ineffective breathing pattern,
Body temperature, imbalanced, with NOC outcomes for, 479 553-554
traumatic brain injury/craniotomy, nursing assessment for, 479 potential complications after surgery
374 risk factors for, 479-480 with, 558
Bone pain, with chemotherapy, 756 therapeutic interventions for, 479 risk for aspiration with, 565
Bowel diversion, 478-479 with proctocolectomy, 478, 479 tisk for atelectasis as, potential
continent, 478, 479 risk for peritonitis with, 486-488 complications after surgery with,
discharge teaching on, 497 desired outcomes for, 486-488 558-559
conventional (Brooke), 478 nursing assessment for, 486 desired outcomes for, 559
discharge teaching/continued care risk factors for, 486 nursing assessment for, 559
after, 494 therapeutic interventions for, 487 risk factors for, 559
on community resources, 499 risk for stomal changes with, 488-489 therapeutic interventions for, 559
on drainage and irrigation, 497 desired outcomes for, 488-489 risk for constipation with, 565
on emptying and changing pouch, nursing assessment for, 488 risk for dehiscence as, potential
496 risk factors for, 488 complications after surgery with,
on follow-up care, 499 therapeutic interventions for, 489 562-563
on maintaining fluid and electrolyte risk for stomal obstruction with, 489-490 desired outcome for, 562
balance, 495 desired outcomes for, 489-490 nursing assessment for, 562
on maintaining optimal nutritional nursing assessment for, 489 risk factors for, 562
status, 496 risk factors for, 489 therapeutic interventions for, 562
on odor and sound control, 496 therapeutic interventions for, 489 risk for falls with, 565
on prevention and treatment of stomal obstruction with, discharge risk for infection with, 565
blockage of stoma, 497 teaching on prevention of, 497 risk for intestinal necrosis with,
on reporting on signs and symptoms, Bowel incontinence, end-of-life nursing 550-551
498 care for, 849 desired outcomes for, 551
on use, cleaning, and storage of clinical manifestations of, 850, 850t nursing assessment for, 551
ostomy products, 497 desired outcomes in, 850-851 risk factors for, 551
disturbed self-concept with, 492-494 NIC interventions in, 850t therapeutic interventions for, 551
desired outcomes for, 492-494 NOC outcomes in, 850t tisk for paralytic ileus as, potential
NIC interventions for, 492-494 nursing assessment, 850t complications after surgery with,
NOC outcomes for, 492 risk factors for, 850 561-562
nursing assessment for, 492 therapeutic interventions for, 850t desired outcomes for, 561-562
876 Index

Bowel obstruction (Continued) Breathing pattern, ineffective (Continued) Bronchitis, chronic. see Chronic obstructive
nursing assessment for, 561 in chronic obstructive pulmonary pulmonary disease (COPD)
risk factors for, 561 disease, 123 Bronchopleural fistula, after thoracic
therapeutic interventions for, 561 with cirrhosis, 579-580 surgery, 199
risk for peritonitis with, 549-550 clinical manifestations of, 579
desired outcomes for, 550 desired outcomes of, 579-580 G
nursing assessment for, 550 NIC interventions of, 579 CABG. see Coronary artery bypass
risk factors for, 550 NOC outcomes of, 579 grafting
therapeutic interventions for, 550 nursing assessment of, 579 Caffeine, in elderly client, with tissue
thromboembolism as, potential risk factors of, 579 perfusion, 808
complications after surgery with, therapeutic interventions for, 579 Candidiasis, with pneumonia, 160-162
559-561 clinical manifestations of, 33 CAP. see Community-acquired pneumonia;
desired outcomes for, 560-561 desired outcomes for, 34 community-acquired pneumonia
NIC interventions for, 560 documentation for, 34-35 Cardiac dysrhythmias, 237.e1-e10
NOC outcomes for, 560 due to pneumonia, 151 with angina pectoris, 231-232
nursing assessment for, 560 due to pneumothorax, 167-168 with chemotherapy, 765-766
risk factors for, 560 due to pulmonary embolism, 177-179 desired outcomes for, 765-766
therapeutic interventions for, 560 due to tuberculosis, 203 NIC interventions for, 765
Bowel resection, 544 in elderly client, 809 NOC outcomes for, 765
discharge teaching after, 563 after gastric reduction surgery, nursing assessment for, 765
disturbed sleep pattern with, 565 postoperative, 509-510 risk factors for, 765
fear/anxiety with, 565 desired outcomes for, 509-510 discharge teaching/continued care for,
imbalanced nutrition after, 556-558 NIC interventions for, 510 237.e8
impaired oral mucous membrane NOC outcomes for, 510 fear/anxiety with, 237.e10
with, 565 nursing assessment for, 510 with heart failure, 274-275
for ineffective airway clearance, risk factors for, 509 risk for, 237.e10
555-556 therapeutic interventions for, 510 after heart surgery, 290-291
ineffective breathing pattern after, with heart failure, 268 from impulse conduction defects, 237.e1
553-554 with human immunodeficiency virus with myocardial infarction, 328-329
potential complications after, 558 infection and acquired immune risk for activity intolerance with, 237.e3-e4
risk for atelectasis as, 558-559 deficiency syndrome, 423 risk for decreased cardiac output with,
risk for dehiscence as, 562-563 with mechanical ventilation, 142 237.e1-e3
risk for paralytic ileus as, 561-562 after nephrectomy, postoperative, risk for falls with, 237.e4-e5
thromboembolism as, 559-561 641-642 risk for sudden cardiac death with,
risk for aspiration with, 565 clinical manifestations of, 641 237.e7-e8
risk for constipation with, 565 desired outcomes for, 641-642 risk for systemic arterial embolism
risk for falls with, 565 NIC interventions for, 641 with, 237.e5-e7
risk for infection with, 565 NOC outcomes for, 641 supraventricular, 237.e1
Brain attack. see Cerebrovascular accident nursing assessment for, 641 after thoracic surgery, 197-198
Brain infection, risk for, with tuberculosis, risk factors for, 641 ventricular, 237.e1
209-211 therapeutic interventions for, 641 Cardiac output (CO), decreased, 35-38
Breast, client with alterations in, 713-752 NIC interventions for, 34 after abdominal aortic aneurysm
mastectomy, 720 NOC outcomes for, 34 repair, 223-225
additional care plans, 733 nursing assessment for, 34 clinical manifestation of, 223
discharge teaching/continued care, with pancreatitis, 621-622 desired outcomes for, 223-225
729 clinical manifestations of, 621 nursing assessment for, 224
outcome/discharge criteria, 720 desired outcomes of, 621-622 nursing interventions classifications
postoperative, 722 NIC interventions of, 621 (NIC) for, 224
preoperative, 720 NOC outcomes of, 621 nursing outcomes interventions
Breast-conserving surgery, 720 nursing assessment of, 621 (NOC) for, 224
Breathing pattern, ineffective, 33-35 risk factors of, 621 risk factors for, 223
with abdominal trauma, 466-468 therapeutic interventions for, 622 therapeutic interventions for, 224
desired outcomes for, 467-468 postoperative, 92-93 activity intolerance due to, 26
NIC interventions for, 467 after cholecystectomy, 572-574 in tuberculosis, 209
NOC outcomes for, 467 clinical manifestations of, 92 with angina pectoris, 228-231
nursing assessment for, 467 desired outcomes for, 92-93 clinical manifestation of, 228
risk factors for, 467 after heart surgery, 285 desired outcomes for, 228-230
therapeutic interventions for, 467 NIC interventions for, 92 nursing assessment for, 229
in asthma, 117 NOC outcomes for, 92 nursing interventions classifications
after bowel resection, postoperative, nursing assessment for, 92 (NIC) for, 228
553-554 risk factors for, 92 nursing outcomes interventions
desired outcomes for, 553-554 therapeutic interventions for, 93 (NOC) for, 228
NIC interventions for, 553 with procedural sedation of, 82 risk factors for, 228
NOC outcomes for, 553 risk factors for, 33 therapeutic interventions for, 229
nursing assessment for, 554 with spinal cord injury, 376-377 with cardiac dysrhythmias, 237.e1-e3
risk factors for, 553 therapeutic interventions for, 34 clinical manifestations of, 237.e1
therapeutic interventions for, 554 after thoracic surgery, 191 desired outcomes for, 237.e1-e3
 Index 877

Cardiac output (CO), decreased

Cardiotoxicity, of chemotherapy, 766 Cerebrovascular accident (Continued)
(Continued) Cardiovascular function alterations, with impaired urinary elimination,
nursing assessment for, 237.e2 217-339 Bog
nursing interventions classifications Cardioversion, with cardiac dysrhythmias with impaired verbal communication,
(NIC) for, 237.e2 for activity intolerance, 237.e4 552)
nursing outcomes interventions with decreased cardiac output, 237.e2 ineffective coping with, 359
(NOC) for, 237.e2 Care plan, creation of individualized, ischemic, 346
tisk factors for, 237.e1 prioritized, 4-7 outcome/discharge criteria
therapeutic interventions for, 237.e2 Carotid endarterectomy, 238 for, 346-347
clinical manifestations of, 35 cranial nerve damage after, 242-244, 245 potential complications for, 358-359
desired outcomes for, 36 discharge teaching/continued risk for aspiration with, 349-350
documentation for, 36-38 care for, 244 risk for constipation with, 358
in elderly client, 806 related care plans for, 246 risk for ineffective cerebral tissue
clinical manifestations of, 806 risk for cerebral ischemia after, 240 perfusion, 348-349
desired outcomes in, 807-808 tisk for respiratory distress after, self-care deficit with, 352-354
NIC interventions, 807 241-242 sexual dysfunction with, 358
NOC outcomes, 807 tisk of ineffective cerebral tissue with unilateral neglect, 350-351
risk factors for, 807 perfusion after, 239-241 Chemotherapy, 753-754
signs and symptoms of, 807 risk of ineffective cerebral tissue acute/chronic pain with, 756-758
therapeutic interventions for, 808 perfusion prior to, 238-239 desired outcomes for, 757-758
with heart failure, 266-268 Central venous catheter, with NIC interventions for, 757
clinical manifestations of, 266 chemotherapy, 776 NOC outcomes for, 757
desired outcomes for, 266-268 Cerebral blood flow, inadequate, after nursing assessment for, 757
nursing assessment for, 267 heart surgery, 294, 295 risk factors for, 757
nursing interventions classifications Cerebral edema, after heart surgery, 294 therapeutic interventions for, 757
(NIC) for, 267 Cerebral embolism, with cardiac bleeding with, 760-761, 774, 777
nursing outcomes interventions dysrhythmias, 237.e6 desired outcomes for, 760-761
(NOC) for, 267 Cerebral tissue perfusion, ineffective NIC interventions for, 760
therapeutic interventions for, 267 after carotid endarterectomy, 239-241 NOC outcomes for, 760
after heart surgery, 283-285 clinical manifestations of, 240 nursing assessment for, 760
clinical manifestation of, 283 desired outcomes for, 240-241 risk factors for, 760
desired outcomes for, 284-285 nursing assessment for, 240 therapeutic interventions for, 761
nursing assessment for, 284 nursing interventions classifications cardiac dysrhythmias with, 765-766
nursing interventions classifications (NIC) for, 240 desired outcomes for, 765-766
(NIC) for, 284 nursing outcomes interventions NIC interventions for, 765
nursing outcomes interventions (NOC) for, 240 NOC outcomes for, 765
(NOC) for, 284 risk factors for, 240. nursing assessment for, 765
therapeutic interventions for, 284 therapeutic interventions for, 240 risk factors for, 765
with hyperthyroidism, 237.e1-e2 prior to carotid endarterectomy, classification of agents for, 753
with implantable cardiac devices, 238-239 combination, 753
313-315 risk for, with cerebrovascular accident, diarrhea with, 779
clinical manifestation of, 313 348-349 discharge teaching/continued care
desired outcomes for, 314-315 Cerebrospinal fluid leak with, 771, 796
nursing assessment for, 314 after laminectomy/discectomy with or on alterations in reproductive and
nursing interventions classifications without fusion, 707—708 sexual functioning, 770, 775
(NIC) for, 314 clinical manifestations of, 707 on central venous catheter or
nursing outcomes interventions desired outcomes for, 708 peritoneal catheter, 776
(NOC) for, 314 nursing assessment for, 708 on community resources, 778
therapeutic interventions for, 314 risk factors for, 708 on diet, 773
with mechanical ventilation, 149 therapeutic interventions for, 708 on fatigue, 774
risk for, 149 with traumatic brain injury/ on follow-up plan, 778
with myocardial infarction, 323-325 craniotomy, 365 on implanted infusion pump, 776
clinical manifestation of, 324 Cerebrovascular accident, 346-347 on neuropathy, 775
desired outcomes for, 324-325 with acute confusion, and chronic on oral hygiene, 773
nursing assessment for, 324 confusion, 354-355 on prevention of bleeding, 774
nursing interventions classifications with decreased intracranial adaptive on prevention of infection, 771
(NIC) for, 324 capacity, 347-348 on reporting on signs and symptoms,
nursing outcomes interventions discharge teaching/continued care VIE
(NOC) for, 324 with, 355 disturbed self-concept with,
therapeutic interventions for, 325t with disturbed self-concept, 359 768-771
NIC interventions for, 36 family process, interrupted, 359 desired outcomes for, 769-771
NOC outcomes for, 36 fear/anxiety with, 358 NIC interventions for, 769
nursing assessment for, 36 with grieving, 359 NOC outcomes for, 769
risk factors for, 35 hemorrhagic, 346 nursing assessment for, 769
therapeutic interventions for, 37 imbalanced nutrition with, 358 risk factors for, 769
Cardiopulmonary bypass (CPB), during with impaired physical mobility, 359 therapeutic interventions for, 769
heart surgery, 282 with impaired swallowing, 359 disturbed sleep pattern with, 779
878 Index

Chemotherapy (Continued) Chest pain (Continued) Chronic bronchitis. see Chronic

drug extravasation with, 764-765, 777 ineffective breathing pattern with, obstructive pulmonary disease
desired outcomes for, 764-765 167 (COPD)
nursing assessment for, 764 NIC interventions for, 170 Chronic obstructive pulmonary disease
risk factors for, 764 NOC outcomes for, 170 (COPD), 123
therapeutic interventions for, 764 nursing assessment for, 170 activity intolerance in, 128-129
fatigue with, 774, 779 risk factors of, 170 causative factors of, 123
fear/anxiety with, 779 therapeutic interventions for, 171 discharge teaching/continued care
grieving with, 779 due to pulmonary embolism, 180-182 for, 135
hemorrhagic cystitis with, 763, 777 clinical manifestations of, 180 on chest physiotherapy and use of
desired outcomes for, 763 desired outcomes for, 181-182 respiratory equipment, 138
nursing assessment for, 763 NIC interventions for, 181-182 on energy conservation, 136
risk factors for, 763 NOC outcomes for, 181 on follow-up care, 141
therapeutic interventions for, 763 nursing assessment for, 181 on medications, 136
imbalanced nutrition with, 754-756 risk factors of, 181 on precautions with oxygen usage, 140
desired outcomes for, 754-756 therapeutic interventions for, 181 on prevention or minimization of
NIC interventions for, 754 with human immunodeficiency virus further respiratory problems, 135
NOC outcomes for, 754 infection and acquired immune on reporting of signs and
nursing assessment for, 754 deficiency syndrome, 426 symptoms, 140
risk factors for, 754 and ineffective breathing pattern, on resource identification, 141
therapeutic interventions for, 755 193-195 disturbed body image with, 141
impaired oral mucous membrane with, with myocardial infarction, 325-327 disturbed sleep pattern with, 141
758-759 clinical manifestation of, 326 fear/anxiety in, 132-133
desired outcomes for, 758-759 desired outcomes for, 326-327 imbalanced nutrition in, 126-127
NIC interventions for, 758 nursing assessment for, 326 impaired respiratory function in, 123
NOC outcomes for, 758 nursing interventions classifications ineffective health management in,
nursing assessment for, 759 (NIC) for, 326 134-135
risk factors for, 758 nursing outcomes interventions on chest physiotherapy and use of
therapeutic interventions for, 759 (NOC) for, 326 respiratory equipment, 138
impaired renal function with, 761-762 risk factors for, 326 chest physiotherapy and use of
desired outcomes for, 762 therapeutic interventions for, 326 respiratory equipment for, 136
nursing assessment for, 762 with thoracic surgery on energy conservation, 136
risk factors for, 762 clinical manifestations of, 193 on follow-up care, 141
therapeutic interventions for, 762 desired outcomes for, 194-195 maintaining optimal nutritional
indications for, 753 NIC interventions for, 194 status for, 135-141
inflammation and fibrosis of lung NOC outcomes for, 194 on medications, 136
tissue with, 766-767 nursing assessment for, 194 on precautions with oxygen usage, 140
desired outcomes for, 766-767 postoperative, 193-195 on prevention or minimization of
nursing assessment for, 766 preoperative, 193-195 further respiratory problems, 135
risk factors for, 766 risk factors of, 194 on reporting of signs and
therapeutic interventions for, 767 therapeutic interventions for, 194 symptoms, 140
mechanism of action of, 753 with tuberculosis, 216 on resource identification, 141
nausea with, 773, 779 Chlorhexidine, for infections, 22 infection, 129-130
neurotoxicity of, 767-768, 775, 778 Cholecystectomy, 572 clinical manifestations of, 129-130
desired outcomes for, 767-768 clinical manifestations of, 573 desired outcomes for, 130
nursing assessment for, 767 desired outcomes for, 573-574 NIC interventions for, 130
risk factors for, 767 discharge teaching/continued care NOC outcomes for, 130
therapeutic interventions for, 768 after, 596 nursing assessment for, 130
outcome/discharge criteria, 753-754 indications of, 572 risk factors of, 130
resistance to, 753 ineffective breathing pattern with, therapeutic interventions for, 130
risk for constipation with, 768, 779 572-574 on maintaining optimal nutritional
risk for impaired skin integrity with, laparoscopic, 572 status, 137
779 NIC interventions for, 573 outcome/discharge criteria of, 123
risk for infection with, 771, 777, 779 NOC outcomes for, 573 risk for infection (pneumonia) in,
risk for powerlessness with, 779 nursing assessment of, 573 129-130
routes of administration of, 753 open, 572 risk for powerlessness with, 441
side effects of, 753 outcome/discharge criteria for, 572 risk for respiratory failure in, 140
Chest drainage system, and risk for risk factors of, 573 risk for right-sided heart failure in,
ineffective lung expansion, after risk for abscess formation with, 131-132
thoracic surgery, 195 574-575 self-care deficit with, 141
Chest pain therapeutic interventions for, 573 Chronic pain
due to angina pectoris, 230 Cholecystitis, 572 in amputation, 673-674
due to pneumothorax, 170-171 Choledocholithotomy, 572 chemotherapy, 756-758
clinical manifestations of, 170 Cholelithiasis, 572 desired outcomes for, 757-758
desired outcomes for, 170-171 Cholinergic agents, for impaired urinary NIC interventions for, 757
discharge teaching/continued elimination, in elderly client, 823 NOC outcomes for, 757
care on, 174 Chronic active hepatitis, 608-609 nursing assessment for, 757
 Index 879

Chronic pain (Continued) Colitis, ulcerative (Continued) Compartment syndrome, after

risk factors for, 757 nursing assessment for, 532 femoropopliteal bypass, 261
therapeutic interventions for, 757 risk factors for, 532 Confusion
end-of-life nursing care for, 847-848
therapeutic interventions for, 532 acute, 38-40
with human immunodeficiency virus discharge teaching/continued care for, clinical manifestations of, 39
infection and acquired immune 541-544 desired outcomes for, 39
deficiency syndrome, 425-427 disturbed self-concept with, 543 documentation for, 36-38
clinical manifestations, 426, 426t disturbed sleep pattern with, 543 NIC interventions for, 39
desired outcomes in, 426-427 fear/anxiety with, 543 NOC outcomes for, 39
NIC interventions in, 426t imbalanced nutrition with, 529-531 nursing assessment for, 39
NOC outcomes in, 426t desired outcomes for, 530-531 risk factors for, 39
nursing assessment, 426t NIC interventions for, 530 therapeutic interventions for, 39
risk factors for, 426 NOC outcomes for, 530 acute, with procedural sedation, 86-87
therapeutic interventions for, 427t nursing assessment for, 530 clinical manifestations of, 86
with inflammatory bowel disease, risk factors for, 530 desired outcomes for, 86-87
531-533 therapeutic interventions for, 530 NIC interventions for, 86
desired outcomes for, 532-533 tisk for abscesses and fistulas with, NOC outcomes for, 86
NIC interventions for, 532 537-539 nursing assessment for, 86
NOC outcomes for, 532 desired outcomes for, 538 risk factors for, 86
nursing assessment for, 532 nursing assessment, 538 therapeutic interventions for, 86
risk factors for, 532 risk factors for, 538 with Alzheimer disease, 342-343
therapeutic interventions for, 532 therapeutic interventions for, 538 clinical manifestations of, 342, 342t
_ with spinal cord injury, 397 tisk for imbalanced fluid and electrolytes desired outcomes in, 342-343
Chronic renal failure (CRF), 667 with, 527-529 NIC interventions in, 342t
Cirrhosis, 578 desired outcomes for, 528-529 NOC outcomes in, 342t
activity intolerance with, 585-587 NIC interventions for, 528-529 nursing assessment, 343t
acute and chronic confusion with, NOC outcomes for, 528 risk factors for, 342
587-589 nursing assessment for, 528 therapeutic interventions for, 343t
alcohol-related, 578 risk factors for, 528 with cerebrovascular accident, 354-355
discharge teaching/continued care therapeutic interventions with chemotherapy, 768
with, 609 for, 529 with cirrhosis, 587-589
disturbed sleep pattern with, 601 risk for impaired tissue integrity with, clinical manifestations of, 587
fear and anxiety with, 601 543-544 desired outcomes of, 588-589
imbalanced nutrition with, 603-605 risk for infection with, 534-536 NIC interventions of, 588
less than body requirements, desired outcomes for, 534-536 NOC outcomes of, 588
582-584 NIC interventions for, 534 nursing assessment of, 588
impaired comfort with NOC outcomes for, 534 risk factors of, 588
due to dyspepsia, 583 nursing assessment for, 534 therapeutic interventions for, 588
due to pruritus, 584-585 risk factors for, 534 with traumatic brain injury/craniotomy,
ineffective breathing pattern with, therapeutic interventions for, 535 363-365
579-580 risk for peritonitis with, 540 Constipation, 40-42
ineffective coping with, 601 desired outcomes for, 540 after abdominal aortic aneurysm
ineffective family therapeutic regimen nursing assessment for, 540 repair, 227
management with, 595-596 risk factors for, 540. with cerebrovascular accident, 358
outcome/discharge criteria for, 578 therapeutic interventions for, 540 with chemotherapy, 768, 779
risk for ascites with, 591-592 risk for renal calculi with, 536-537 clinical manifestations of, 40
risk for bleeding esophageal varices desired outcomes for, 537 desired outcomes for, 41
with, 592 nursing assessment for, 537 with diabetes mellitus, 465
risk for bleeding with, 589-591 risk factors for, 537 documentation for, 41-42
risk for excess fluid volume and therapeutic interventions for, 537 with enteral nutrition, 506
third-spacing with, 580-582 risk for toxic megacolon with, 538 with hypothyroidism, 465.e17-e18
risk for hepatic (portal-systemic) desired outcomes for, 539 with intestinal obstruction and bowel
encephalopathy (hepatic coma) nursing assessment for, 539 resection, 565
with, 592-594 risk factors for, 539 NIC interventions for, 41
risk for hypokalemia with, 593 therapeutic interventions for, 539 NOC outcomes for, 41
risk for infection with, 588, 601 Comfort, impaired nursing assessment for, 41
risk for injury with, 601 end-of-life nursing care for, 858 with Parkinson disease, 382-383,
risk for spiritual distress, 594-595 after TURP, 744-745 404-406
CO. see Cardiac output clinical manifestations, 744 clinical manifestations for, 404, 404t
Cold cardioplegia, during heart desired outcomes, 745 desired outcomes in, 405-406
surgery, 282 NIC interventions, 745 NIC interventions in, 405St
Colitis, ulcerative, 527 NOC outcomes, 745 NOC outcomes in, 405t
activity intolerance with, 543 nursing assessment, 745 nursing assessment, 405t
acute/chronic pain with, 531-533 risk factors, 745 therapeutic interventions for,
desired outcomes for, 532-533 therapeutic interventions, 745 405—406t
NIC interventions for, 532 Community-acquired pneumonia postoperative, 114
NOC outcomes for, 532 (CAL) ast with renal failure, 669
880 Index

Constipation (Continued) Craniotomy (Continued) Crohn disease (Continued)

risk factors for, 41 with ineffective coping, 375 risk factors for, 537
risk for, in elderly client, 823-825 with interrupted family processes, 375 therapeutic interventions for, $37
clinical manifestations of, 823 risk for acute confusion with, 363-365 risk for toxic megacolon with, 538
desired outcomes, 824-825 tisk for diabetes insipidus, 368 desired outcomes for, 539
NIC interventions, 824 risk for gastrointestinal bleeding, nursing assessment for, 539
NOC outcomes, 824 370-371 risk factors for, 539
nursing assessment, 824 risk for imbalanced body temperature, therapeutic interventions for, 539
risk factors for, 824 374 Crutches, 820
therapeutic interventions, 824 risk for ineffective airway clearance, CVA. see Cerebrovascular accident
with spinal cord injury, 398 374 Cystectomy with urinary diversion,
therapeutic interventions for, 41 risk for injury, 374 639-640
Contamination, 43-45 risk for meningitis with, 365-366 Cystitis
clinical manifestations of, 43 risk for post-trauma syndrome, 374 hemorrhagic, with hemotherapy,
desired outcomes for, 43 risk for seizures with, 367-368 cra IT
documentation for, 43-45 risk for syndrome of inappropriate desired outcomes for, 763
NIC interventions for, 43 antidiuretic hormone, 368-370 nursing assessment for, 763
NOC outcomes for, 43 with self-care deficit, 374 risk factors for, 763
nursing assessment for, 43 CRF. see Chronic renal failure therapeutic interventions for, 763
tisk factors for, 43 Critical thinking, 3-7 radiation, as neoplastic disorders, 792
therapeutic interventions for, 44 Crohn disease, 527 desired outcomes for, 792
Continent ileostomy, 478, 479 activity intolerance with, 543 nursing assessment for, 792
discharge teaching on, 497 acute/chronic pain with, 531-533 risk factors for, 792
Continuous bladder irrigation, for desired outcomes for, 532-533 therapeutic interventions for, 792
hemorrhagic cystitis, with NIC interventions for, 532
chemotherapy, 763 NOC outcomes for, 532
COPD. see Chronic obstructive nursing assessment for, 532 Death anxiety, end-of-life nursing care
pulmonary disease risk factor for, 532 for, 851-852
Coping therapeutic interventions for, 532 Decision-making, readiness for
with cerebrovascular accident, 359 discharge teaching/continued care for, enhanced, 45
ineffective, 45 541-544 Deep vein thrombosis (DVT), 246
with cirrhosis, 601 disturbed self-concept with, 543 acute pain with, 248-249
with diabetes mellitus, 465 disturbed sleep pattern with, 543 discharge teaching/continued care for,
with heart failure, 282 fear/anxiety with, 543 253-255
with ileostomy, 499-500 imbalanced nutrition with, 529-531 ineffective peripheral tissue perfusion
with spinal cord injury, 398 desired outcomes for, 530-531 with, 247-248
with traumatic brain injury/ NIC interventions for, 530 postoperative, after bowel resection,
craniotomy, 375 NOC outcomes for, 530 559-561
Coronary artery bypass grafting nursing assessment for, 530 postoperative, after gastric reduction
(CABG), 282 risk factors for, 530 surgery, 513-515
activity intolerance after, 301 therapeutic interventions for, 530 desired outcomes for, 513-514
decreased cardiac output after, 283-285 risk for abscesses and fistulas with, NIC interventions for, $13
fear/anxiety prior to, 283 537-539 NOC outcomes for, 513
potential complications desired outcomes for, 538 nursing assessment for, 514
bleeding as, 292-294 nursing assessment, 538 risk factors for, 513
cardiac dysrhythmias as, 290-291 risk factors for, 538 therapeutic interventions for, 514
cardiac tamponade as, 291-292 therapeutic interventions for, 538 risk for bleeding with, 251-253
heart failure as, 301 risk for imbalanced fluid and electrolytes risk for impaired tissue integrity with,
impaired renal function as, 295-296 with, 527-529 249-250
myocardial infarction as, 301-302 desired outcomes for, 528-529 risk for pulmonary embolism with,
neurological dysfunction as, 294-295 NIC interventions for, 528-529 250-251
pneumothorax as, 296-297 NOC outcomes for, 528 Defecation reflex, constipation and, 41
procedures for, 282 nursing assessment for, 528 Deficient knowledge
related care plans for, 301 risk factors for, 528 in amputation, 670
risk for imbalanced fluid and electrolytes therapeutic interventions for, 529 clinical manifestations of, 671
after, 287-289 risk for impaired tissue integrity with, NIC interventions for, 671
risk for impaired respiratory function 543-544 NOC outcomes for, 671
after, 285-287 risk for infection with, 534-536 nursing assessment for, 671
risk for infection after, 289-290 desired outcomes for, 534-536 nursing interventions for, 671
CPB. see Cardiopulmonary bypass NIC interventions for, 534 risk factors for, 671
Craniotomy, 359-360 NOC outcomes for, 534 hysterectomy and, 717-720
acute pain (headache), 362-363 nursing assessment for, 534 clinical manifestations, 717
decreased intracranial adaptive risk factors for, 534 NIC interventions, 717
capacity with, 360-362 therapeutic interventions for, 535 NOC outcomes, 717
with disturbed self-concept, 375 risk for renal calculi with, 536-537 nursing assessment, 718
fear/anxiety with, 374 desired outcomes for, 537 risk factors, 717-719
with impaired physical mobility, 374 nursing assessment for, 537 therapeutic interventions, 718, 719
 Index 881

Deficient knowledge (Continued)

Deficient knowledge (Continued) Diabetes mellitus (Continued)
after mastectomy, 729-733 risk factors for, 665-669 risk for infection with, 465
clinical manifestations, 729 therapeutic interventions for, 665, risk for unstable blood glucose level
NIC interventions, 729 666, 667, 668, 669 with, 448-449
NOC outcomes, 729 TURP and, 749-752 sexual dysfunction with, 465
nursing assessment, 729 clinical manifestations, 749 type 1 and type 2, 447
risk factors, 729-733 NIC interventions, 749 urinary retention with, 465
therapeutic interventions, 730, 73 ily, NOC outcomes, 749 Diabetic ketoacidosis, 448
V3, HSS) nursing assessment, 750 Diabetic neuropathy, 447
before mastectomy, 720-722 risk factors, 749-752 Diarrhea, 45-47
clinical manifestations, 720 therapeutic interventions, 750, with chemotherapy, 779
desired outcomes, 721 US, SVE clinical manifestations of, 45
NIC interventions, 721 after urolithiasis, 637-640 desired outcomes for, 46
NOC outcomes, 721 clinical manifestations of, 637 with diabetes mellitus, 465
nursing assessment, 721 NIC interventions for, 637 documentation for, 46-47
risk factors, 721 NOC outcomes for, 637 fluid deficit due to, 48
therapeutic interventions, 721 nursing assessment for, 637 in pneumonia, 154
nurse-sensitive indicators, 11-13, risk factors for, 637-639 impaired nutrition due to, 63
17-19, 23-24 therapeutic interventions for, 637, NIC interventions for, 46
additional nursing diagnoses of, 638, 639 NOC outcomes for, 46
12-13, 18-19 Delayed surgical recovery, postoperative, nursing assessment for, 46
clinical manifestations of, 11, 17, 23 105-107 risk factors for, 46
desired outcomes for, 11-12, 17-18, clinical manifestations of, 105 therapeutic interventions for, 46
23-24 desired outcomes for, 105-107 DIC. see Disseminated intravascular
NIC interventions for, 12, 17-18, NIC interventions for, 105 coagulation
23-24 NOC outcomes for, 105 Discectomy, with or without fusion,
NOC outcomes for, 12, 17, 23 nursing assessment for, 105 701-702
nursing assessment for, 12, 18, 23 risk factors for, 105 actual/risk for impaired skin integrity
risk factors for, 11, 17, 23 therapeutic interventions for, 106 with, 705-706
therapeutic interventions for, 12, Delegation, 1-8 acute pain after, 704-705
18, 24 Dementia, 340-341 discharge teaching/continued care
postoperative, 112-115 AIDS and, 433 after, 710
clinical manifestations of, 112 chronic confusion with, 342-343 knowledge deficit prior to, 702
desired outcomes of, 112-114 disturbed sensory perception, 346 procedure for, 701
NIC interventions for, 112 grieving with, 346 related care plans for, 712
NOC outcomes for, 112 impaired social interaction with, 346 tisk for cerebrospinal fluid leak with,
nursing assessment for, 112 risk for injury with, 346 707-708
risk factors for, 112 self-care deficits with, 341-342 tisk for laryngeal nerve damage with,
therapeutic interventions for, 112 wandering with, 344-346 708-709
postoperative, after nephrectomy, 647 Dentures, impaired oral mucous risk for paralytic ileus with, 709-710
clinical manifestations of, 647 membrane due to, 66 tisk for peripheral neurovascular
NIC interventions for, 647 Desmopressin, for diabetes insipidus, dysfunction after, 702-703
NOC outcomes for, 647 with traumatic brain injury/ risk for respiratory distress with,
nursing assessment for, 647 craniotomy, 368 706-707
risk factors for, 647-649 Diabetes insipidus, with traumatic brain Discharge teaching
therapeutic interventions for, 647, injury/craniotomy, 368 after abdominal aortic aneurysm
648, 649 Diabetes mellitus, 447-448 repair, 225
preoperative, 90 complications of, 447 with abdominal trauma, 476
clinical manifestations of, 90 constipation with, 465 with acute GI bleed, 525
NIC interventions for, 90 diarrhea with, 465 for angina pectoris, 233
NOC outcomes for, 90 hypertension in, 447 after bowel resection, 563
nursing assessment for, 90 imbalanced nutrition with, 465 for cardiac dysrhythmias, 237.e8
risk factors for, 90-91 ineffective coping, 465 for carotid endarterectomy, 244
therapeutic interventions for, 90 ineffective family health management, with cerebrovascular accident, 355
radical prostatectomy and, 738-741 456-458 with chemotherapy, 771
clinical manifestations, 739 ineffective peripheral tissue perfusion on alterations in reproductive and
NIC interventions, 739 with, 453-455 sexual functioning, 775
NOC outcomes, 739 knowledge, deficit, of ineffective on central venous catheter or
nursing assessment, 739 health management with, 458-465 peritoneal catheter, 776
risk factors, 739-741 outcome/ discharge criteria in, 447-448 on community resources, 778
therapeutic interventions, 739, pathophysiological events in, 447 on diet, 773
740, 741 risk for dysfunctional gastrointestinal on fatigue, 774
with renal failure, 664-669 motility, 455-456 on follow-up plan, 778
clinical manifestations of, 7, 664 risk for electrolyte imbalance, 451-453 on implanted infusion pump, 776
NIC interventions for, 665 risk for falls with, 465 on neuropathy, 775
NOC outcomes for, 665 risk for imbalanced fluid volume, on oral hygiene, 773
nursing assessment for, 665 450-451 on prevention of bleeding, 774
882 Index

Discharge teaching (Continued) Discharge teaching (Continued) Dyspnea

on prevention of infection, 771 on measuring fluid intake and in elderly client
on reporting on signs and output and monitoring blood with impaired respiratory function, 810
symptoms, 777 pressure, 666 with tissue perfusion, 807
after cholecystectomy, 596 on reducing risk of infection, 666 imbalanced nutrition and, 63
for chronic obstructive pulmonary on reporting signs and symptoms, in chronic obstructive pulmonary
disease, 135 667 disease, 126, 136, 140
on chest physiotherapy and use of on slowing progression of kidney due to tuberculosis, 203
respiratory equipment, 135 damage, 665 in pneumonia, 156
on follow-up care, 141 with spinal cord injury, 393 Dysrhythmias, in elderly client, with
on maintaining optimal nutritional after thoracic surgery, 200 tissue perfusion, 807
status, 137 after total joint replacement (hip/
on prevention or minimization of knee), 697 E
further respiratory problems, 135 for tuberculosis, 213 ECG. see Electrocardiogram
on reporting of signs and symptoms, Disseminated intravascular coagulation Edema, in elderly client, with tissue
140 (DIC), 444 perfusion, 807
with cirrhosis, 609 and pancreatitis, 626 Elderly client, 806-844
for deep vein thrombosis, 253-255 Disturbed body image, after amputation, deficient knowledge in, 840-842
with enteral nutrition, 505 679-681 disturbed body image in, 844
after femoropopliteal bypass, 262 clinical manifestations of, 679 disturbed sleep pattern in, 825-826
after gastric reduction surgery, 515 desired outcomes for, 679-681 drug toxicity in, 835-837
with heart failure, 278-281 NIC interventions for, 679 clinical manifestations, 835
on hepatitis, 609 NOC outcomes for, 679 desired outcomes, 836-837
with human immunodeficiency virus nursing assessment for, 680 nursing assessment, 836
infection and acquired immune risk factors for, 679 risk factors for, 836
deficiency syndrome, 428 therapeutic interventions for, 680 therapeutic interventions for, 836
with ileostomy, 494 Disturbed self-concept imbalanced nutrition in, 812-814
on community resources, 499 after mastectomy, 727-729 clinical manifestations, 813
on drainage and irrigation, 497 clinical manifestations, 727 desired outcomes in, 813-814
on emptying and changing pouch, 496 desired outcomes, 727-729 NIC interventions in, 813
on follow-up care, 499 NIC interventions, 728 NOC outcomes in, 813
on maintaining fluid and electrolyte NOC outcomes, 728 nursing assessment, 813
balance, 495 nursing assessment, 728 risk factors for, 813
on maintaining optimal nutritional risk factors, 727 signs and symptoms of, 813
status, 496 therapeutic interventions, 728 therapeutic interventions for, 813
on odor and sound control, 496 after radical prostatectomy, 737-738 impaired oral mucous membrane
on prevention and treatment of clinical manifestations, 737 integrity in, 816-817
blockage of stoma, 497 desired outcomes, 737-738 impaired physical mobility in, 819-820
on reporting on signs and symptoms, NIC interventions, 737 impaired respiratory function in,
498 NOC outcomes, 737 809-811
on use, cleaning, and storage of nursing assessment, 737 clinical manifestations of, 809
ostomy products, 497 risk factors, 737 desired outcomes, 809-811
with implantable cardiac devices, 319 therapeutic interventions, 737 NIC interventions, 809
with inflammatory bowel disease, Disturbed sleep pattern, 72-74 NOC outcomes, 809
541-544 clinical manifestations of, 72 nursing assessment, 810
with intestinal obstruction, 551 desired outcomes for, 72 risk factors for, 809
NIC interventions for, 552 documentation for, 72—74 signs and symptoms of, 810
NOC outcomes for, 552 NIC interventions for, 73 therapeutic interventions for, 810
nursing assessment for, 552 NOC outcomes for, 73 impaired urinary elimination in,
risk factors for, 552-553 nursing assessment for, 73 821-823
therapeutic interventions for, 552 risk factors for, 72 clinical manifestations of, 821
after myocardial infarction, 334 therapeutic interventions for, 73 desired outcomes in, 822-823
with neoplastic disorders, 796 Documentation, 25—80 NIC interventions, 822
after nephrectomy, 647 Drug extravasation, with chemotherapy, NOC outcomes, 822
with pancreatitis, 628 764-765, 777 nursing assessment for, 822
with parenteral nutrition, 569 desired outcomes for, 764—765 risk factors for, 822
for pneumonia, 164 nursing assessment for, 764 signs and symptoms of, g32
for pneumothorax, 174 risk factors for, 764 therapeutic interventions, 822
for postoperative patient, 112 therapeutic interventions for, 764 ineffective peripheral tissue perfusion
for pulmonary embolism, 187 Drug toxicity, in elderly client, in, 806
with renal failure, 664 835-837 clinical manifestations of, 806
community resources, 668 clinical manifestations, 835 desired outcomes in, 807-808
on fluid restrictions and dietary desired outcomes, 836-837 NIC interventions, 807
modifications, 666 nursing assessment, 836 NOC outcomes, 807
on follow-up care, 668 risk factors for, 836 risk factors for, 807
on managing signs and symptoms, therapeutic interventions for, 836 signs and symptoms of, 807
667 DVT. see Deep vein thrombosis therapeutic interventions for, 808
 Index 883

Elderly client (Continued) Electrolyte imbalance (Continued) Electrolyte imbalance (Continued)

ineffective sexuality pattern in, with acute GI bleed, 521-522 nursing assessment for, 546
837-838 : desired outcomes for, 521-522 risk factors for, 545
interrupted family processes in, NIC interventions for, 521 therapeutic interventions for, 546
842-844 NOC outcomes for, 521 with pancreatitis, 617-619
risk for activity intolerance in, 818-819 nursing assessment for, 522 clinical manifestations of, 617
risk for aspiration in, 831-832 risk factors for, 521 desired outcomes of, 618-619
tisk for constipation in, 823-825 therapeutic interventions for, 522 NIC interventions of, 618
clinical manifestations of, 823 with cirrhosis, 580-582 NOC outcomes of, 618
desired outcomes, 824-825 clinical manifestations of, 581 nursing assessment of, 618
NIC interventions, 824 desired outcomes of, 581-582 risk factors of, 618
NOC outcomes, 824 NIC interventions of, 581 therapeutic interventions for, 618
nursing assessment, 824 NOC outcomes of, 581 postoperative, 98-101
risk factors for, 824 nursing assessment of, 581 clinical manifestations of, 99
therapeutic interventions, 824 risk factors of, 581 desired outcomes for, 99-101
risk for deficient fluid volume in , therapeutic interventions for, 582 NIC interventions for, 99
811-812 with diabetes mellitus, 451-453 NOC outcomes for, 99
clinical manifestations of, 811 with heart failure, 270-272 nursing assessment for, 99
desired outcomes in, 811-812 clinical manifestation of, 271 risk factors for, 99
NIC interventions, 811 desired outcomes for, 271-272 therapeutic interventions for, 100
NOC outcomes, 811 nursing assessment for, 271-272t Electrophysiological study (EPS), for
nursing assessment, 812 NIC interventions for, 271 decreased cardiac output, with
risk factors for, 811 NOC outcomes for, 271 cardiac dysrhythmias, 237.e3
signs and symptoms of, 812 therapeutic interventions for, 272 Embolism, pulmonary, 177
therapeutic interventions for, 812 after heart surgery, 287-289 acute pain (chest) in, 180-182
risk for falls in, 829-831 clinical manifestation of, 288 with cardiac dysrhythmias, 237.e6
clinical manifestations, 829 desired outcomes for, 288-289 with deep vein thrombosis, 250-251
desired outcomes, 830-831 nursing assessment for, 289t discharge teaching/continued care
NIC interventions, 830 NIC interventions for, 288 for, 187
NOC outcomes, 830 NOC outcomes for, 288 fear/anxiety in, 186-187
nursing assessment, 830 therapeutic interventions for, 289t impaired gas exchange, 179-180
risk factors for, 830 with human immunodeficiency virus ineffective breathing pattern in,
therapeutic interventions for, 830 infection and acquired immune 177-179
risk for frail elderly syndrome in, deficiency syndrome, risk for, ineffective health maintenance,
839-840 421-423 187-190
risk for impaired skin integrity in, clinical manifestations of, risk for atelectasis in, 185-186
815-816 421, 421t risk for right-sided heart failure in,
risk for infection in, 827-829 desired outcomes in, 422—423 184-185
clinical manifestations of, 827 NIC interventions in, 422t treatment of, 177
desired outcomes, 827-829 NOC outcomes in, 422t Emphysema, 123
NIC interventions, 827 nursing assessment in, 422t Endocarditis, with pneumonia,
NOC outcomes, 827 risk factors for, 422 160-162
nursing assessment, 827 therapeutic interventions in, End-of-life nursing care, 845-860
risk factors for, 827 422-423t for acute/chronic pain, 847-848
therapeutic interventions for, 828 with ileostomy, 480-482 for aspiration, 845-846
risk for injury in, 832-834 desired outcomes for, 481-482 for bowel incontinence, 849
due to pathologic fractures, 834-835 discharge teaching on, 495 for constipation, 859
risk for powerlessness in, 844 NIC interventions for, 481 for death anxiety, 851-852
Electrocardiogram (ECG), for decreased NOC outcomes for, 481 for deficient fluid volume, 858
cardiac output, 36 nursing assessment for, 481 for disturbed sleep pattern, 859
Electrolyte imbalance risk factors for, 481 for falls, 859
after abdominal aortic aneurysm therapeutic interventions for functional urinary incontinence,
repair, 218-220 for, 482 849
clinical manifestations of, 218 with inflammatory bowel disease, for grieving, 852-854
desired outcomes for, 219-220 527-529 for hopeless, 855-856
nursing assessment for, 219 desired outcomes for, 528-529 for impaired comfort, 858
NIC interventions for, 219 NIC interventions for, 528-529 for impaired oral mucous membrane,
NOC outcomes for, 219 NOC outcomes for, 528 858-859
risk factors for, 219 nursing assessment for, 528 for impaired physical mobility, 858
therapeutic interventions for, 219 risk factors for, 528 for impaired skin integrity, 848-849
with abdominal trauma, 468-470 therapeutic interventions for interrupted family processes,
desired outcomes for, 469-470 for, 529 856-858
NIC interventions for, 469 with intestinal obstruction, for nausea, 858
NOC outcomes for, 469 545-548 for self-care deficit, 858
nursing assessment for, 469 desired outcomes for, 545-546 for spiritual distress, 854-855
risk factors for, 469 NIC interventions for, 545 Endotracheal suctioning, for
therapeutic interventions for, 469 NOC outcomes for, 545 infections, 22
884 Index

Energy conservation Epigastric pain, with pancreatitis Family health management, ineffective
for activity intolerance (Continued) (Continued)
with acute GI bleed, 524 NIC interventions for, 614 risk factors for, 457
in chronic obstructive pulmonary NOC outcomes for, 614 therapeutic interventions for,
disease, 128 nursing assessment of, 614 457—-458t
with myocardial infarction, 327 risk factors for, 613 with hepatitis, 609-613
with chronic obstructive pulmonary therapeutic interventions for, 614 clinical manifestations of, 609
disease, for risk of respiratory EPS. see Electrophysiological study NIC interventions for, 609
failure, 136 Erythema, pressure ulcer due to, 15 NOC outcomes for, 609
with cirrhosis, 586 Esophageal bleeding, with hepatitis, 607 nursing assessment of, 609
due to pneumonia, 159 Esophageal phase impairment, impaired risk factors for, 609-612
due to tuberculosis, 208 swallowing due to, 74 therapeutic interventions
for impaired respiratory function, in Esophageal varices, bleeding, with for, 610
asthma, 118 cirrhosis, 592 with human immunodeficiency virus
for ineffective breathing pattern Estrogen, for impaired urinary elimination, infection and acquired immune
after cholecystectomy, 573 in elderly client, 823 deficiency syndrome, 428-434
due to pulmonary embolism, 208 Expressive aphasia, with chemotherapy, for hypertension, 308-309
after nephrectomy, 642 768 with implantable cardiac devices,
Enhanced comfort, readiness for, 38 Extrapulmonary infection, with 319-323
Enteral nutrition, 500 pneumonia, 160-162 clinical manifestations of, 320
assessment for, 500 Extravasation, of drugs, with nursing assessment for, 320t
delivery of, 500 chemotherapy, 764-765, 777 NIC interventions for, 320
discharge teaching/continued care desired outcomes for, 764-765 NOC outcomes for, 320
for, 505 nursing assessment for, 764 risk factors for, 320-322
imbalanced nutrition with, 502-503 risk factors for, 764 therapeutic interventions
desired outcomes for, 502-503 therapeutic interventions for, 764 for, 320
NIC interventions for, 502 after laminectomy/discectomy with or
NOC outcomes for, 502 F without fusion, 710-712
nursing assessment for, 502 Factor Xa inhibitors, for ineffective clinical manifestations of, 710
risk factors for, 502 peripheral tissue perfusion, due to NIC interventions for, 710
therapeutic interventions for, 503 deep vein thrombosis, 247 NOC outcomes for, 710
with mechanical ventilation, 145 Falls, 9 nursing assessment for, 711
and risk of GI bleeding, 150 amputation with, 685 risk factors for, 710-712
outcome/discharge criteria, 500 with diabetes mellitus, risk for, 465 therapeutic interventions for, 711
risk for aspiration with, 500-502 in elderly client, risk for, 829-831 with pancreatitis, 628-630
desired outcomes for, 501-502 clinical manifestations, 829 clinical manifestations of, 628
NIC interventions for, 501 desired outcomes, 830-831 desired outcomes for, 628-630
NOC outcomes for, 501 NIC interventions, 830 nursing assessment of, 629
nursing assessment for, 501 NOC outcomes, 830 risk factors of, 628
risk factors for, 501 nursing assessment, 830 therapeutic interventions for, 629
therapeutic interventions for, 501 risk factors for, 830 with Parkinson disease, 409-411
risk for constipation with, 506 therapeutic interventions for, 830 clinical manifestations of, 409, 409t
risk for deficient fluid volume with, risk for, 10-11 NIC interventions for, 409
503-505 clinical manifestations of, 10 NOC outcomes for, 409
desired outcomes for, 504-505 desired outcomes for, 10 nursing assessment, 409t
NIC interventions for, 504 documentation for, 10-11 risk factors for, 409
NOC outcomes for, 504 NIC interventions for, 10-11 therapeutic interventions for, 409t,
nursing assessment for, 504 NOC outcomes for, 10 410-411t, 410t, 411t
risk factors for, 504 nursing assessment for, 10 postoperative, after nephrectomy, 647
therapeutic interventions for, 504 risk factors for, 10 clinical manifestations of, 647
risk for infection with, 506 therapeutic interventions for, 10 NIC interventions for, 647
Enteroenteric fistulas, with inflammatory Family health management, ineffective NOC outcomes for, 647
bowel disease, 537-539 after amputation, 681-685 nursing assessment for, 647
desired outcomes for, 538 clinical manifestations of, 681 risk factors for, 647-649
nursing assessment for, 538 desired outcomes for, 681-682 therapeutic interventions for, 647,
risk factors for, 538 NIC interventions for, 681 648, 649 '
therapeutic interventions for, 538 NOC outcomes for, 681 radical prostatectomy and, 738-741
Enterovesical fistulas, with inflammatory nursing assessment for, 681 clinical manifestations, 739
bowel disease, 537-539 risk factors for, 681 NIC interventions, 739
desired outcomes for, 538 therapeutic interventions for, 682 NOC outcomes, 739
nursing assessment for, 538 with cerebrovascular accident, 355-359 nursing assessment, 739
risk factors for, 538 with diabetes mellitus, 456-458 risk factors, 739-741
therapeutic interventions for, 538 clinical manifestations of, 456, 456t therapeutic interventions, 739,
Epigastric pain, with pancreatitis, desired outcomes in, 457-458 740, 741
613-615 NIC interventions in, 457t after total joint replacement (hip/knee)
clinical manifestations of, 613 NOC outcomes in, 457t clinical manifestations of, 698
desired outcomes of, 613-615 nursing assessment, 457t NIC interventions for, 698
 Index 885

Family health management, ineffective

Family therapeutic regimen management, Family therapeutic regimen management,
(Continued) ineffective (Continued) ineffective (Continued)
NOC outcomes for, 698 after carotid endarterectomy, therapeutic interventions for,
nursing assessment for, 698 244-246 298-299t
risk factors for, 698-701 clinical manifestations of, 244 with inflammatory bowel disease,
therapeutic interventions for, 698 nursing assessment for, 244 541-544
TURP and, 749-752 nursing interventions Classifications NIC interventions for, 541
clinical manifestations, 749 (NIC) for, 244 NOC outcomes for, 541
NIC interventions, 749 nursing outcomes interventions nursing assessment for, 541
NOC outcomes, 749 (NOC) for, 244 risk factors for, 541-543
nursing assessment, 750 risk factors for, 244-246 therapeutic interventions for, 541
tisk factors, 749-752 therapeutic interventions for, 244 with intestinal obstruction,
therapeutic interventions, 750, 751, with cirrhosis, 595-596 551-553
WS clinical manifestations of, 595 NIC interventions for, 552
after urolithiasis, 637-640 desired outcomes for, 595-596 NOC outcomes for, 552
clinical manifestations of, 637 NIC interventions for, 595 nursing assessment for, 552
NIC interventions for, 637 NOC outcomes for, 595 risk factors for, 552-553
NOC outcomes for, 637 nursing assessment of, 595 therapeutic interventions for, 552
nursing assessment for, 637 risk factors of, 595 with neoplastic disorders, 796-805
risk factors for, 637-639 therapeutic interventions for, 596 NIC interventions for, 797
therapeutic interventions for, 637, for deep vein thrombosis, 253-255 NOC outcomes for, 797
638, 639 clinical manifestations of, 253 risk factors for, 797-804
Family processes, interrupted nursing assessment for, 253 therapeutic interventions for, 797
with cerebrovascular accident, 359 nursing interventions classifications with parenteral nutrition, 569-571
in elderly client, 842-844 (NIC) for, 253t NIC outcomes for, 570
end-of-life nursing care for, 856-858 nursing outcomes interventions NOC interventions for, 570
clinical manifestations of, 856, 856t (NOC) for, 253t nursing assessment for, 570
desired outcomes in, 856-858 risk factors for, 253-255 risk factors for, 570
NIC interventions in, 857t therapeutic interventions for, 254 therapeutic interventions for, 570
NOC outcomes in, 857t with enteral nutrition, 505-508 Fatigue
nursing assessment, 857t NIC interventions for, 505 with acute pain, in urolithiasis, 632
risk factors for, 856 NOC outcomes for, 505 with chemotherapy, 774, 779
therapeutic interventions for, nursing assessment for, 505 with human immunodeficiency virus
857-858 risk factors for, 505-506 infection and acquired immune
spinal cord injury, 388-389 therapeutic interventions for, 505 deficiency syndrome, 434
with traumatic brain injury/ after femoropopliteal bypass, 262-264 with neoplastic disorders, 805
craniotomy, 375 clinical manifestations of, 262-263 Fear
Family therapeutic regimen management, nursing assessment for, 263 with abdominal aortic aneurysm,
ineffective nursing interventions classifications 217-218
with abdominal trauma, 476-479 (NIC) for, 263 with acute GI bleed, 527
NIC interventions for, 476 nursing outcomes interventions with acute pain, in urolithiasis, 632
NOC outcomes for, 476 (NOC) for, 263 with angina pectoris, 237
nursing assessment for, 476 risk factors for, 263-264 in asthma, 122
risk factors for, 476-477 therapeutic interventions for, 263 due to impaired respiratory function,
therapeutic interventions for, 476 after gastric reduction surgery, 515-521 117
with acute GI bleed, 525-527 NIC interventions for, 515 with cardiac dysrhythmias, 237.e10
NIC interventions for, 525 NOC outcomes for, 515 with cerebrovascular accident, 358
NOC outcomes for, 525 nursing assessment for, 515 with chemotherapy, 779
nursing assessment for, 525 risk factors for, 515 in chronic obstructive pulmonary,
risk factors for, 525-526 therapeutic interventions for, 515 132-133
therapeutic interventions with heart failure, 278-281 clinical manifestations of, 132
for, 525 clinical manifestations of, 278 desired outcomes for, 132-133
with angina pectoris, 233-237 nursing assessment for, 278 due to impaired respiratory function,
clinical manifestations of, 233 nursing interventions classifications 123-125
nursing assessment for, 234 (NIC) for, 278 NIC interventions for, 132
NIC interventions for, 234 nursing outcomes interventions NOC outcomes for, 132
NOC outcomes for, 234 (NOC) for, 278 nursing assessment for, 132t
risk factors for, 234-237 risk factors for, 278-281 risk factors of, 132
therapeutic interventions therapeutic interventions for, 278 therapeutic interventions for, 133
for, 234 after heart surgery, 297-301 with cirrhosis, 601
after bowel resection, 563-566 clinical manifestations of, 297 disturbed sleep pattern due to, 73
NIC interventions for, 563 nursing assessment for, 298 in fractured hip with internal fixation
NOC outcomes for, 563 nursing interventions classifications or prosthesis insertion, 687
nursing assessment for, 563 (NIC) for, 298 with heart failure, 282
risk factors for, 563-565 nursing outcomes interventions with hepatitis, 612
therapeutic interventions for, 563 (NOC) for, 298 impaired gas exchange due to, 52
for cardiac dysrhythmias, 237.e8-e10 risk factors for, 297-301 with implantable cardiac devices, 323
886 Index

Fear (Continued) Femoropopliteal bypass (Continued) Fluid imbalance (Continued)

ineffective breathing pattern due to, 34 saphenous nerve damage as, NIC interventions for, 528-529
postoperative, 93 261-262 NOC outcomes for, 528
with inflammatory bowel disease, 543 ineffective peripheral tissue perfusion nursing assessment for, 528
with intestinal obstruction and bowel with risk factors for, 528
resection, 565 postoperative, 259-260 therapeutic interventions for, 529
with mechanical ventilation, 150 preoperative, 256-257 with intestinal obstruction, 545-548
with myocardial infarction, 339 postoperative care with, 259 desired outcomes for, 545-546
with neoplastic disorders, 804 related care plans for, 265 NIC interventions for, 545
pain and, 67 Fever, with renal failure, 668 NOC outcomes for, 545
in pneumonia, 166 Fluid imbalance nursing assessment for, 546
postoperative, 96 after abdominal aortic aneurysm risk factors for, 545
with procedural sedation, 85 repair, postoperative, 218-220 therapeutic interventions for, 546
with pancreatitis, 630 clinical manifestations of, 218 with pancreatitis, 617-619
with pneumonia, 166 desired outcomes for, 219-220 clinical manifestations of, 617
with pneumothorax, 173-174, nursing assessment for, 219 desired outcomes of, 618-619
175-176 nursing interventions classifications NIC interventions of, 618
clinical manifestations of, 173 (NIC) for, 219 NOC outcomes of, 618
desired outcomes for, 173-174 nursing outcomes interventions nursing assessment of, 618
ineffective breathing pattern due (NOC) for, 219 risk factors of, 618
(tO, O7/ risk factors for, 219 therapeutic interventions for, 618
NIC interventions for, 173 therapeutic interventions for, 219 Fluid volume
NOC outcomes for, 173 with abdominal trauma, 468-470 with abdominal trauma, deficient,
nursing assessment for, 173 desired outcomes for, 469-470 468-470
risk factors of, 173 NIC interventions for, 469 desired outcomes for, 469-470
therapeutic interventions for, NOC outcomes for, 469 NIC interventions for, 469
173-174t nursing assessment for, 469 NOC outcomes for, 469
postoperative, 115 risk factors for, 469 nursing assessment for, 469
ineffective breathing pattern due therapeutic interventions for, 469 risk factors for, 469
to, 93 with acute GI bleed, 521-522 therapeutic interventions for, 469
pain and, 96 desired outcomes for, 521-522 with acute GI bleed, deficient, 521-522
preoperative, 87-90 NIC interventions for, 521 desired outcomes for, 521-522
clinical manifestations of, 87 NOC outcomes for, 521 NIC interventions for, 521
desired outcomes for, 88-90 nursing assessment for, 522 NOC outcomes for, 521
NIC interventions for, 88 risk factors for, 521 nursing assessment for, 522
NOC outcomes for, 88 therapeutic interventions for, 522 tisk factors for, 521
nursing assessment for, 88 with cirrhosis, 580-582 therapeutic interventions for, 522
prior to femoropopliteal with heart failure, 270-272 with cirrhosis, imbalance, 580-582
bypass, 258 clinical manifestation of, 271 clinical manifestations of, 581
prior to heart surgery, 283 desired outcomes for, 271-272 desired outcomes of, 581-582
prior to thoracic surgery, 191 nursing assessment for, 271-272t NIC interventions of, 581
risk factors for, 88 nursing interventions Classifications NOC outcomes of, 581
therapeutic interventions for, 88 (NIC) for, 271 nursing assessment of, 581
with procedural sedation, 83 nursing outcomes interventions risk factors of, 581
with pulmonary embolism, 180-182, (NOC) for, 271 therapeutic interventions for, 582
186-187 therapeutic interventions for, 272 deficient, 47-49
clinical manifestations of, 186 after heart surgery, postoperative, clinical manifestations of, 47
desired outcomes for, 186-187 287-289 desired outcomes for, 48
NIC interventions for, 186-187 clinical manifestation of, 288 documentation for, 48-49
NOC outcomes for, 186 desired outcomes for, 288-289 end-of-life nursing care for, 858
nursing assessment for, 186 nursing assessment for, 289t NIC interventions for, 48
risk factors of, 186 nursing interventions classifications NOC outcomes for, 48
therapeutic interventions for, 186 (NIC) for, 288 nursing assessment for, 48
with renal failure, 669 nursing outcomes interventions risk factors for, 48
with sepsis, 446 (NOC) for, 288 therapeutic interventions for, 48
with spinal cord injury, 397 therapeutic interventions for, 289t with diabetes mellitus, imbalance,
with traumatic brain injury/ after ileostomy, postoperative, 480-482 450-451
craniotomy, 374 desired outcomes for, 481-482 due to pneumonia, deficient, 153-155
with tuberculosis, 216 discharge teaching on, 494 clinical manifestations of, 153
Fecal impaction, 42 NIC interventions for, 481 desired outcomes for, 154-155
diarrhea due to, 47 NOC outcomes for, 481 NIC interventions for, 154
Feedback, in delegation, 2, 2f nursing assessment for, 481 NOC outcomes for, 154
Femoropopliteal bypass, 255-256 risk factors for, 481 nursing assessment for, 154
acute/chronic pain with, 257-259 therapeutic interventions for, 482 risk factors of, 154
complications with inflammatory bowel disease, therapeutic interventions for, 154
compartment syndrome as, 261 527-529 in elderly client, deficient, 811-812
graft occlusion as, 260 desired outcomes for, 528-529 clinical manifestations of, 811
 Index 887

Fluid volume (Continued) Fluid volume (Continued) Fractured hip with internal fixation or
desired outcomes in, 811-812 with intestinal obstruction, deficient, prosthesis insertion, 685-686
NIC interventions, 811 545-548 preoperative care for, 686
NOC outcomes, 811 desired outcomes for, 545-546 acute pain in, 686-688
nursing assessment, 812 NIC interventions for, 545 fear/anxiety in, 687
risk factors for, 811 NOC outcomes for, 545 risk for peripheral neurovascular
signs and symptoms of, 812 nursing assessment for, 546 dysfunction in, 688-689
therapeutic interventions for, 812 risk factors for, 545 Fractures, pathologic, in elderly client,
with enteral nutrition, deficient, therapeutic interventions for, 546 834-835
503-505 with pancreatitis, 623 Frail elderly syndrome, risk for, 839-840
desired outcomes for, 504-505 postoperative, deficient Friction massage, pressure ulcer due to, 15
NIC interventions for, 504 after abdominal aortic aneurysm Functional urinary incontinence, 76
NOC outcomes for, 504 repair, 218-220 in elderly client, 821
nursing assessment for, 504 after heart surgery, 287-289 end-of-life nursing care for, 849
risk factors for, 504 postoperative, imbalance, 98-101 clinical manifestations of, 850, 850t
therapeutic interventions for, 504 clinical manifestations of, 99 desired outcomes in, 850-851
excess, 49-50 desired outcomes for, 99-101 NIC interventions in, 850t
after abdominal aortic aneurysm NIC interventions for, 99 NOC outcomes in, 850t
repair, postoperative, 218-220 NOC outcomes for, 99 nursing assessment, 850t
clinical manifestations of, 49 nursing assessment for, 99 risk factors for, 850
desired outcomes for, 49 risk factors for, 99 therapeutic interventions for, 850t
documentation for, 49-50 therapeutic interventions for, 100
with heart failure, 270 with renal failure, deficient, G
after heart surgery, postoperative, 656-657 Gait belt, 820
287-289 clinical manifestations of, 657 Gallbladder, surgical removal of, 572
NIC interventions for, 49 desired outcomes for, 657 discharge teaching/continued care
NOC outcomes for, 49 NIC interventions for, 657 after, 596
nursing assessment for, 50 NOC outcomes for, 657 ineffective breathing pattern with,
risk factors for, 49 nursing assessment for, 657 572-574
therapeutic interventions for, 50 risk factors for, 657 laparoscopic, 572
with hepatitis, deficient, 602-603 therapeutic interventions for, 657 OpEenira 7/2
clinical manifestations of, 602 with renal failure, excess, 650-653 risk for abscess formation with,
desired outcomes of, 602-603 clinical manifestations of, 650-652 574-575
NIC interventions of, 602 desired outcomes for, 650-653 Gallstones, 613
NOC outcomes of, 602 NIC interventions for, 632, 652 Gas exchange, impaired, 51-53
nursing assessment of, 602 NOC outcomes for, 651, 652 in asthma, 117, 124
risk factors of, 602 nursing assessment for, 651, 653 clinical manifestations of, 51
therapeutic interventions for, 603 nursing interventions for, 653 desired outcomes for, 51
with human immunodeficiency virus risk factors for, 650, 652 documentation for, 51-53
infection and acquired immune therapeutic interventions for, 651 due to pneumonia, 151
deficiency syndrome, deficient, with sepsis, imbalance, 436-438 due to pneumothorax, 168-170
421-423 clinical manifestations of, 436, 436t clinical manifestations of, 168
clinical manifestations of, 421, 421t desired outcomes in, 437-438 desired outcomes for, 168-170
desired outcomes in, 422-423 NIC interventions in, 437t NIC interventions for, 168
NIC interventions in, 422t NOC outcomes in, 437t NOC outcomes for, 168
NOC outcomes in, 422t nursing assessment, 437t nursing assessment for, 169
nursing assessment in, 422t therapeutic interventions for, risk factors of, 168
risk factors for, 422 437-438t therapeutic interventions for, 169
therapeutic interventions in, with tuberculosis, 216 due to pulmonary embolism, 179-180
422-423t after TURP, risk for imbalanced, clinical manifestations of, 179
after ileostomy, postoperative, 747-749 desired outcomes for, 179-180
480-482 clinical manifestations, 747 NIC interventions for, 179
desired outcomes for, 481-482 NIC interventions, 748-749 NOC outcomes for, 179t
NIC interventions for, 481 NOC outcomes, 748 nursing assessment for, 180
NOC outcomes for, 481 nursing assessment, 748 risk factors of, 179
nursing assessment for, 481 risk factors, 748 therapeutic interventions for, 180t
risk factors for, 481 therapeutic interventions, 748 due to tuberculosis, 203
therapeutic interventions urolithiasis in, deficient, 636-637 in elderly client, 809
for, 482 clinical manifestations of, 636 with heart failure, 268
with inflammatory bowel disease, desired outcomes for, 636-637 after heart surgery, 286
deficient, 527-529 NIC interventions for, 636 with human immunodeficiency virus
desired outcomes for, 528-529 NOC outcomes for, 636 infection and acquired immune
NIC interventions for, 528-529 nursing assessment for, 636 deficiency syndrome, 423
NOC outcomes for, 528 risk factors for, 636 with mechanical ventilation, 142
nursing assessment for, 528 therapeutic interventions for, NIC interventions for, 51
risk factors for, 528 636 NOC outcomes for, 51
therapeutic interventions for, 529 Foot drop, with chemotherapy, 768 nursing assessment for, 51
 888 Index

Gas exchange, impaired (Continued) Gastrointestinal (GI) bleed, acute, 519 Glucose level, blood, risk for unstable,
with procedural sedation, 82 discharge teaching/continued care 53-55
risk factors for, 51 for, 525 clinical manifestations of, 53
with sepsis, 438-439 fear/anxiety with, 527 desired outcomes for, 53
therapeutic interventions for, 51 outcome/discharge criteria, 519 in diabetes, 448-449
after thoracic surgery, 192 risk for activity intolerance with, documentation for, 53-55
Gas formation, with ileostomy, 493 523-524 NIC interventions for, 54
Gastrectomy, 506-507 desired outcomes for, 523-524 NOC outcomes for, 54
outcome/discharge criteria, 507 NIC interventions for, 523 nursing assessment for, 54
Gastric bypass, 507 NOC outcomes for, 523 risk factors for, 53
Gastric pouch, 507 nursing assessment for, 524 Glycosylated hemoglobin, 53
overdistention of risk factors for, 523 Graft occlusion, after femoropopliteal
discharge teaching on prevention therapeutic interventions for, 524 bypass, 260
of, 516 risk for aspiration with, 522-523 Grieving, 5S—S7
risk for, 510-511 desired outcomes for, 522-523 with Alzheimer disease/dementia, 346
Gastric reduction surgery, 507 NIC interventions for, 522 with amputation, 685
actual/risk for impaired tissue integrity NOC outcomes for, 522 with cerebrovascular accident, 359
with, 518-519 nursing assessment for, 523 with chemotherapy, 779
discharge teaching/continued after risk factors for, 522 clinical manifestations of, 55
for, 515 therapeutic interventions for, 523 desired outcomes for, 55
on community resources, 518 tisk for electrolyte imbalance with, documentation for, 55-57
on follow-up care, 518 521-522 end-of-life nursing care for, 852-854
on lifestyle changes, 515 desired outcomes for, 521-522 clinical manifestations of, 852, 852t
on maintaining adequate nutritional NIC interventions for, 521 desired outcomes in, 852-854
status, 516 NOC outcomes for, 521 NIC interventions in, 852t
on prevention of excessive stretching nursing assessment for, 522 NOC outcomes in, 852t
of gastric pouch, 516 risk factors for, 521 nursing assessment, 853t
on reducing risk of consuming therapeutic interventions for, 522 risk factors for, 852
excessive amounts of food, 517 tisk for imbalanced fluid volume with, therapeutic interventions for,
on reporting of signs and symptoms, 521-522 853-854
517 desired outcomes for, 521-522 with ileostomy, 500
disturbed self-concept prior to, 508-509 NIC interventions for, 521 with myocardial infarction, 339
desired outcomes for, 508-509 NOC outcomes for, 521 with neoplastic disorders, 805
NIC interventions for, 508 nursing assessment for, 522 NIC interventions for, 55
NOC outcomes for, 508 risk factors for, 521 NOC outcomes for, 55
nursing assessment for, 508 therapeutic interventions for, 522 nursing assessment for, 56
risk factors for, 508 risk for shock, 519-521 with renal failure, 669
therapeutic interventions for, 508 desired outcomes for, 520-521 risk factors for, 5S
imbalanced nutrition with NIC interventions for, 520 with spinal cord injury, 397
discharge teaching on, 516 NOC outcomes for, 520 therapeutic interventions for, 56
risk for, 518 nursing assessment for, 520
ineffective breathing pattern after, risk factors for, 520 H
509-510 therapeutic interventions Hand hygiene, for risk of infection, 21, 58
desired outcomes for, 509-510 for, 520 with inflammatory bowel disease, 535
NIC interventions for, 510 Gastrointestinal bleeding, risk for with pneumonia, 161
NOC outcomes for, 510 with mechanical ventilation, 150-151 HAP. see Hospital-acquired pneumonia
nursing assessment for, 510 with spinal cord injury, 391-393 HDL. see High-density lipoprotein
risk factors for, 509 with traumatic brain injury/ Headache, in hypertension, 304-305
therapeutic interventions for, 510 craniotomy, 370-371 Health behavior, risk-prone, 57
outcome/discharge criteria, 507 Gastrointestinal (GI) distention, impaired with human immunodeficiency virus
overdistention of gastric pouch with nutrition due to, 63 infection and acquired immune
discharge teaching on, 516 Gastrointestinal motility, dysfunctional, deficiency syndrome, 413-414
risk for, 510-511 with diabetes mellitus, 455-456 Health care—associated infections, 18-19
risk for deep vein thrombosis and Gastrointestinal tract, alterations in, Health maintenance, ineffective
thromboembolism with, 513-515 466-571 after abdominal aortic aneurysm
desired outcomes for, 513-514 abdominal trauma, 466 repair, 225-228
NIC interventions for, 513 appendicitis/appendectomy, 478 clinical manifestations of, 225
NOC outcomes for, 513 bariatric surgery, 507 nursing assessment for, 226
nursing assessment for, 514 bowel diversion: ileostomy, 478-479 nursing interventions classifications
risk factors for, 513 enteral nutrition, 500 (NIC) for, 225
therapeutic interventions for, 514 gastrectomy, 506-507 nursing Outcomes interventions
risk for peritonitis with, 511-513 gastrointestinal bleed, acute, 519 (NOC) for, 225
desired outcomes for, 512-513 inflammatory bowel disease, 527 risk factors for, 225-227
nursing assessment for, 512 intestinal obstruction and bowel therapeutic interventions for, 226
risk factors for, 512 resection, 544 with abdominal trauma, 476-479
therapeutic interventions for, 512 peptic ulcer, 571 NIC interventions for, 476
Gastroesophageal balloon tube, 592 Gastrostomy tube, proper care of, 506 NOC outcomes for, 476
 Index 889

Health maintenance, ineffective (Continued)

Health maintenance, ineffective (Continued) Health maintenance, ineffective (Continued)
nursing assessment for, 476 risk factors for, 253-255 with pneumonia, 164-166
risk factors for, 476-477 ~ therapeutic interventions for, 254 with pneumothorax, 174-177
therapeutic interventions for, 476 after femoropopliteal bypass, 262-264 for pulmonary embolism, 187-190
with angina pectoris, 233-237 clinical manifestations of, 262-263 after thoracic surgery, 200-202
clinical manifestations of, 233 nursing assessment for, 263 clinical manifestations of, 201
nursing assessment for, 234 nursing interventions classifications NIC interventions for, 201
nursing interventions classifications (NIC) for, 263 NOC outcomes for, 201
(NIC) for, 234 nursing outcomes interventions nursing assessment for, 201
nursing outcomes interventions (NOC) for, 263 risk factors of, 201-202
(NOC) for, 234 risk factors for, 263-264 therapeutic interventions for, 201t
risk factors for, 234-237 therapeutic interventions for, 263 with tuberculosis, 213-216
therapeutic interventions for, 234 with heart failure, 278-281 clinical manifestations of, 213
for cardiac dysrhythmias, 237.e8-e10 clinical manifestations of, 278 NIC interventions for, 213
clinical manifestations of, 237.e8 nursing assessment for, 278 NOC outcomes for, 213
nursing assessment for, 237.e8 nursing interventions Classifications nursing assessment for, 213
nursing interventions classifications (NIC) for, 278 risk factors of, 213-216
(NIC) for, 237.e8 nursing outcomes interventions therapeutic interventions for, 214
nursing outcomes interventions (NOC) for, 278 Health management, ineffective
(NOC) for, 237.e8 risk factors for, 278-281 after abdominal aortic aneurysm
risk factors for, 237.e8-e10 therapeutic interventions for, 278 repair, 225-228
therapeutic interventions for, 237.e8 after heart surgery, 297-301 clinical manifestations of, 225
_ after carotid endarterectomy, 244—246 clinical manifestations of, 297 nursing assessment for, 226
clinical manifestations of, 244 nursing assessment for, 298 nursing interventions classifications
nursing assessment for, 244 nursing interventions classifications (NIC) for, 225
nursing interventions classifications (NIC) for, 298 nursing outcomes interventions
(NIC) for, 244 nursing outcomes interventions (NOC) for, 225
nursing outcomes interventions (NOC) for, 298 risk factors for, 225-227
(NOC) for, 244 risk factors for, 297-301 therapeutic interventions for, 226
risk factors for, 244-246 therapeutic interventions for, 298-299t after amputation, 681-686
therapeutic interventions for, 244 for hypertension, 310-312 clinical manifestations of, 681
with cerebrovascular accident, 355-359 clinical manifestations of, 310-311 desired outcomes for, 681-682
clinical manifestations of, 355, 355t nursing assessment for, 310 NIC interventions for, 681
NIC interventions for, 356t nursing interventions classifications NOC outcomes for, 681
NOC outcomes for, 356t (NIC) for, 310 nursing assessment for, 681
nursing assessment, 356t nursing outcomes interventions risk factors for, 681
risk factors for, 356-358 (NOC) for, 310 therapeutic interventions for, 682
therapeutic interventions for, 356t, therapeutic interventions for, 310 with angina pectoris, 233-237
357t, 358t with hyperthyroidism, discharge clinical manifestations of, 233
with chronic obstructive pulmonary teaching, 465.e14-e16 nursing assessment for, 234
disease clinical manifestations of, 465.e14, nursing interventions classifications
on chest physiotherapy and use of 465.e14t (NIC) for, 234
respiratory equipment, 136, 138 NIC interventions in, 465.e14t nursing outcomes interventions
clinical manifestations of, 135 NOC outcomes in, 465.e14t (NOC) for, 234
on energy conservation, 136 nursing assessment, 465.e14t risk factors for, 234-237
on follow-up care, 141 risk factors for, 465.e14—-e15 therapeutic interventions for, 234
maintaining optimal nutritional therapeutic interventions for, for cardiac dysrhythmias, 237.e8-e10
status for, 135-141 465.e14-e15St, 465.e14t, clinical manifestations of, 237.e8
on medications, 136 465.e15t nursing assessment for, 237.e8
NIC interventions for, 136 with hypothyroidism, discharge nursing interventions classifications
NOC outcomes for, 136 teaching, 465.e20-e21 (NIC) for, 237.e8
nursing assessment for, 136 after laminectomy/discectomy with or nursing outcomes interventions
on precautions with oxygen usage, 140 without fusion, 710-712 (NOC) for, 237.e8
on prevention or minimization of clinical manifestations of, 710 risk factors for, 237.e8-e10
further respiratory problems, 135 NIC interventions for, 710 therapeutic interventions for, 237.e8
on reporting of signs and symptoms, NOC outcomes for, 710 after carotid endarterectomy, 244-246
140 nursing assessment for, 711 clinical manifestations of, 244
on resource identification, 141 risk factors for, 710-712 nursing assessment for, 244
risk factors of, 136-141 therapeutic interventions for, 711 nursing interventions classifications
therapeutic interventions for, 136 with Parkinson disease, 409-411 (NIC) for, 244
for deep vein thrombosis, 253-255 clinical manifestations of, 409, 409t nursing outcomes interventions
clinical manifestations of, 253 NIC interventions for, 409 (NOC) for, 244
nursing assessment for, 253 NOC outcomes for, 409 risk factors for, 244-246
nursing interventions classifications nursing assessment, 409t therapeutic interventions for, 244
(NIC) for, 253t risk factors for, 409 with cerebrovascular accident, 355-359
nursing outcomes interventions therapeutic interventions for, 409t, clinical manifestations of, 355, 355t
(NOC) for, 253t 410-411t, 410t, 411t NIC interventions for, 356t
890 Index

Health management, ineffective (Continued) Health management, ineffective (Continued) Health management, ineffective (Continued)
NOC outcomes for, 356t with human immunodeficiency virus NOC outcomes for, 698
nursing assessment, 356t infection and acquired immune nursing assessment for, 698
risk factors for, 356-358 deficiency syndrome, 428-434 risk factors for, 698-701
therapeutic interventions for, 356t, clinical manifestations of, 428, 428t therapeutic interventions for, 698
357t, 358t NIC interventions in, 429t with tuberculosis, 213-216
after cholecystectomy, 575-578 NOC outcomes in, 429t clinical manifestations of, 213
clinical manifestations of, 575 nursing assessment, 429t NIC interventions for, 213
nursing assessment of, 576 risk factors for, 429-433 NOC outcomes for, 213
risk factors of, 576-578 therapeutic interventions, 429t, nursing assessment for, 213
therapeutic interventions for, 576 430-431t, 431t, 432-433t, 432t risk factors of, 213-216
in chronic obstructive pulmonary with hyperthyroidism, discharge therapeutic interventions for, 214
disease, 134-135 teaching, 465.e14-e16 TURP and, 749-752
with cirrhosis, 596-602 clinical manifestations of, 465.e14, clinical manifestations, 749
clinical manifestations of, 597 465.e14t NIC interventions, 749
NIC interventions of, 594 NIC interventions in, 465.e14t NOC outcomes, 749
NOC outcomes of, 597 NOC outcomes in, 465.e14t nursing assessment, 750
nursing assessment of, 597 nursing assessment, 465.e14t risk factors, 749-752
risk factors of, 597-600 risk factors for, 465.e14-e15 therapeutic interventions, 750,
therapeutic interventions for, 597 therapeutic interventions for, Tole
for deep vein thrombosis, 253-255 465.e14-e1St, 465.e14t, 465.e15t after urolithiasis, 637-640
clinical manifestations of, 253 with hypothyroidism, discharge clinical manifestations of, 637
nursing assessment for, 253 teaching, 465.e20-e21 NIC interventions for, 637
nursing interventions classifications with implantable cardiac devices, NOC outcomes for, 637
(NIC) for, 253t 319-323 nursing assessment for, 637
nursing outcomes interventions clinical manifestations of, 320 risk factors for, 637-639
(NOC) for, 253t nursing assessment for, 320t therapeutic interventions for, 637,
risk factors for, 253-255 nursing interventions classifications 638, 639
therapeutic interventions for, 254 (NIC) for, 320 Hearing impairment, with chemotherapy,
with diabetes mellitus, 458-465 nursing Outcomes interventions 768
clinical manifestations of, 458, 458t (NOC) for, 320 Heart, rupture of portion of, with
NIC interventions in, 458t risk factors for, 320-322 myocardial infarction, 331-332
NOC outcomes in, 458t therapeutic interventions for, 320 Heart failure, 265-266
nursing assessment, 458t after nephrectomy, postoperative, 647 activity intolerance with, 281
risk factors for, 458-465 clinical manifestations of, 647 cardiac dysrhythmias with, 237.e10-e238
therapeutic interventions for, NIC interventions for, 647 decreased cardiac output in, 266-268
459-460t, 459t, 460t, 461t, NOC outcomes for, 647 discharge teaching/continued care
462-463t, 463-464t, 464t, 465t nursing assessment for, 647 after, 278-281
after femoropopliteal bypass, 262-264 risk factors for, 647-649 disturbed sleep pattern with, 281
clinical manifestations of, 262-263 therapeutic interventions for, 647, disturbed thought processes in, 282
nursing assessment for, 263 648, 649 fear/anxiety in, 282
nursing interventions classifications with pancreatitis, 628-630 after heart surgery, 301
(NIC) for, 263 clinical manifestations of, 628 imbalanced nutrition in, 281
nursing outcomes interventions desired outcomes for, 628-630 impaired respiratory function in,
(NOC) for, 263 nursing assessment of, 629 268-270
risk factors for, 263-264 tisk factors of, 628 ineffective coping in, 282
therapeutic interventions for, 263 therapeutic interventions for, 629 with myocardial infarction, 331-332
with heart failure, 278-281 with pneumonia, 164-166 nausea in, 282
clinical manifestations of, 278 with pneumothorax, 174-177 renal insufficiency, 273
nursing assessment for, 278 for pulmonary embolism, 187-190 right-sided
nursing interventions classifications clinical manifestations of, 188 in chronic obstructive pulmonary
(NIC) for, 278 NIC interventions for, 188 disease, 131-132
nursing outcomes interventions NOC outcomes for, 188 with pulmonary embolism, 184-185
(NOC) for, 278 nursing assessment for, 188 risk for acute pulmonary edema in, 275
risk factors for, 278-281 risk factors of, 188-190 tisk for cardiac dysrhythmias in,
therapeutic interventions for, 278 therapeutic interventions for, 188 274-275
after heart surgery, 297-301 radical prostatectomy and, 738-741 risk for cardiogenic shock in, 27-278
clinical manifestations of, 297 clinical manifestations, 739 risk for falls with, 281
nursing assessment for, 298 NIC interventions, 739 tisk for imbalanced fluid and electrolytes
nursing interventions classifications NOC outcomes, 739 in, 270-272
(NIC) for, 298 nursing assessment, 739 risk for impaired tissue integrity
nursing outcomes interventions risk factors, 739-741 with, 281
(NOC) for, 298 therapeutic interventions, 739, 740, 741 risk for thromboembolism in, 276-277
risk factors for, 297-301 after thoracic surgery, 200-202 signs and symptoms of, 265
therapeutic interventions for, after total joint replacement (hip/knee) treatment of, 265
298-299t clinical manifestations of, 698 Heart rate, cardiac output and, 36
with hepatitis, 609-613 NIC interventions for, 698 Heart rhythm, cardiac output and, 36
 Index 891

Heart surgery, 282 Hematologic function, alterations in Home maintenance, impaired, with
activity intolerance after, 301 (Continued) Alzheimer disease/dementia
decreased cardiac output after, 283-285 risk for infection, 440-442 (Continued)
fear/anxiety prior to, 283 septic shock as, potential NOC outcomes in, 344t
potential complications complication of, 442-443 nursing assessment, 344t
bleeding as, 292-294 splenectomy for, 446 risk factors for, 344
cardiac dysrhythmias as, 290-291 Hemodynamic monitoring, for shock, therapeutic interventions for, 344t
cardiac tamponade as, 291-292 after nephrectomy, 644 Hopeless, end-of-life nursing care for,
heart failure as, 301 Hemoglobin A,., 53 855-856
impaired renal function as, 295-296 Hemorrhagic cerebrovascular Hospital-acquired pneumonia (HAP), 151
myocardial infarction as, 301-302 accident, 346 Hospital-acquired pressure ulcers/
neurological dysfunction as, 294-295 Hemorrhagic cystitis, with chemotherapy, injuries, 12-13
pneumothorax as, 296-297 763, 777 Human immunodeficiency virus
procedures for, 282 desired outcomes for, 763 infection, 412-413
related care plans for, 301 nursing assessment for, 763 acute/chronic pain with, 425-427
risk for imbalanced fluid and risk factors for, 763 chills and diaphoresis with, 418
electrolytes after, 287-289 therapeutic interventions for, 763 diarrhea with, 433
tisk for impaired respiratory function Hemothorax, after thoracic surgery, 195 discharge teaching/continued care, 428
after, 285-287 Hepatic coma, with cirrhosis, 592-594 disturbed body image with, 420-421
risk for infection after, 289-290 clinical manifestations of, 592 disturbed sleep pattern with, 434
Heart valve replacement, 282 desired outcomes of, 593-594 fatigue with, 434
activity intolerance after, 301 nursing assessment of, 593 fear/anxiety with, 433
<
decreased cardiac output after, 283-285 risk factors of, 593 grieving with, 434
fear/anxiety prior to, 283 therapeutic interventions for, 593 hyperthermia with, 439-440
potential complications Hepatic encephalopathy, with cirrhosis, imbalanced nutrition with, 415-417
bleeding as, 292-294 593 impaired comfort with, 433
cardiac dysrhythmias as, 290-291 Hepatitis, 601-602 impaired oral mucous membrane
cardiac tamponade as, 291-292 acute pain with, 612 with, 433
heart failure as, 301 chronic active, 608-609 impaired respiratory function with,
impaired renal function as, 295-296 and cirrhosis, 597 423-425
myocardial infarction as, 301-302 discharge teaching/continued care ineffective coping with, 433
neurological dysfunction as, 294-295 with, 609 ineffective family health management
pneumothorax as, 296-297 fear and anxiety with, 612 with, 428
procedures for, 282 fulminant, 608-609 ineffective health management with,
related care plans for, 301 imbalanced nutrition with, 603-605 414-415, 428-434
risk for imbalanced fluid and impaired comfort due to pruritus with, ineffective sexuality pattern with, 434
electrolytes after, 287-289 584-585 interrupted family process with, 434
risk for impaired respiratory function ineffective health management with, powerlessness with, 434
after, 285-287 609-613 pruritus with, 433
risk for infection after, 289-290 knowledge deficit with, 609-613 risk for deficient fluid volume with,
Helicobacter pylori, peptic ulcer due nausea with, 605-606 421-423
to, 571 outcome/discharge criteria for, 602 risk for electrolyte imbalance, 421-423
Helium/oxygen mixture (Heliox), for prevention of further liver damage risk for impaired skin integrity with,
asthma, 118 with, 610 433
Hematemesis, 519 risk for activity intolerance with, 612 risk for infection with, 418-420
Hematologic function, alterations in, risk for bleeding, 606-607 risk for loneliness with, 434
412-446 risk for deficient fluid volume with, spiritual distress with, 427-428
due to sepsis, 434-435 602-603 spread, prevention of, 429
decreased cardiac tissue perfusion, risk for progressive liver degeneration transmission of, 412
435-436 with, 608-609 treatment of, 412
disseminated intravascular Hepatotoxic agents, and cirrhosis, 597 Hyperesthesia, with diabetes, 447
coagulation as, potential High-density lipoprotein (HDL), with Hyperglycemia hyperosmolar nonketotic,
complication of, 444 angina pectoris, 235 with diabetes, 448
fear, and anxiety with, 446 Histamine (Hz) receptor antagonists Hypertension, 301-302
hyperthermia with, 434 for fluid and electrolyte imbalance acute pain/headache in, 304-305
impaired gas exchange with, 438-439 with pancreatitis, 614 deficient knowledge or ineffective
ineffective cerebral tissue perfusion, for GI bleeding, acute, 521 health maintenance in, 310-312
435-436 with mechanical ventilation, 150 in diabetes, 447
ineffective peripheral tissue perfusion, HIV. see Human immunodeficiency virus essential (primary, idiopathic), 301-302
435-436 Homans’ sign, with deep vein thrombosis, fear/anxiety with, 312
organ ischemia/dysfunction and risk for pulmonary embolism, 251 ineffective family health management
(multiple organ dysfunction Home maintenance, impaired, with in, 308-309
syndrome) as, potential Alzheimer disease/dementia, ineffective peripheral tissue perfusion
complication of, 445-446 343-344 in, 302-303
potential complication of, 442 clinical manifestations of, 343, 343t pathological hallmark of, 302
risk for imbalanced fluid volume, desired outcomes in, 344 potential complications of
436-438 NIC interventions in, 344t aortic dissection as, 307-308
 892 Index

Hypertension (Continued) Ileostomy, 478 Ileostomy (Continued)

cerebrovascular accident/hypertensive actual/risk for impaired tissue integrity NOC outcomes for, 479
encephalopathy as, 305-306 with, 482-486 nursing assessment for, 479
impaired renal function as, desired outcomes for, 483-486 risk factors for, 479-480
306-307 NIC interventions for, 483 therapeutic interventions for, 479
secondary, 301-302 NOC outcomes for, 483 with proctocolectomy, 478, 479
stage 1, 301 nursing assessment for, 483 reduction of gas formation with, 493
stage 2, 301 risk factors for, 483 risk for peritonitis with, 486-488
systolic, 301 therapeutic interventions for, 483 desired outcomes for, 486-488
treatment of, 302 continent, 478, 479 nursing assessment for, 486
Hypertensive crisis, 301 discharge teaching on, 497 risk factors for, 486
Hypertensive emergency, 301 conventional (Brooke), 478 therapeutic interventions for, 487
Hypertensive encephalopathy, 305-306 discharge teaching/continued care risk for stomal changes with, 488-489
Hyperthermia after, 494 desired outcomes for, 488-489
with human immunodeficiency virus on community resources, 499 nursing assessment for, 488
infection and acquired immune on drainage and irrigation, 497 risk factors for, 488
deficiency syndrome, 439-440 on emptying and changing pouch, therapeutic interventions for, 489
with sepsis, 434 496 risk for stomal obstruction with,
Hyperthyroidism, 465.e1 on follow-up care, 499 489-490
activity intolerance with, 465.e4-e6 on maintaining fluid and electrolyte desired outcomes for, 489-490
deficient knowledge with, 465.e8 balance, 495 nursing assessment for, 489
disturbed sleep pattern with, 465.e6-e8 on maintaining optimal nutritional risk factors for, 489
imbalanced nutrition with, 465.e3-e4 status, 496 therapeutic interventions for, 489
outcome/discharge criteria for, 465.e1 on odor and sound control, 496 stomal obstruction with, discharge
risk for bleeding, 465.e8-e10 on prevention and treatment of teaching on prevention of, 497
risk for decreased cardiac output, blockage of stoma, 497 temporary, 478
465.e1-e2 on reporting on signs and Ileostomy pouch, emptying or
tisk for hypocalcemia with, 465.e11 symptoms, 498 changing of
risk for laryngeal nerve damage with, on use, cleaning, and storage of discharge teaching/continued care on,
465.e13-e14 ostomy products, 497 496
risk for respiratory distress, 465.e10-e11 disturbed self-concept with, 492-494 and impaired tissue integrity, 485
subtotal, 465.e1 desired outcomes for, 492-494 and risk for peritonitis, 487
and thyrotoxicosis, 465.e1 NIC interventions for, 492-494 Immobility, in elderly client, 820
Hyperventilation, 34 NOC outcomes for, 492 Immune function, alterations in, 412-446
after bowel resection, 554 nursing assessment for, 492 due to human immunodeficiency virus
after cholecystectomy, 573 risk factors for, 492 infection and acquired immune
due to pneumothorax, 168 therapeutic interventions for, 493 deficiency syndrome, 412-413
after gastric reduction, 510 emptying or changing of pouch with acute/chronic pain with, 425-427
after nephrectomy, 642 discharge teaching/continued care diarrhea with, 433
postoperative, 93 on, 496 discharge teaching/continued care, 428
Hypocalcemia, with hyperthyroidism, and impaired tissue integrity, 485 disturbed body image with, 420-421
465.e11 and risk for peritonitis, 487 disturbed sleep pattern with, 434
Hypoglycemia, 55 fluid or electrolyte imbalance with fatigue with, 434
Hyponatremia, with heart failure, 270 discharge teaching on, 495 fear/anxiety with, 433
Hypotension, and decreased cardiac grieving with, 500 grieving with, 434
output, after abdominal aortic imbalanced nutrition with hyperthermia with, 439-440
aneurysm repair, 225 discharge teaching on, 496 imbalanced nutrition with, 415-417
Hypothyroidism, 465.e16 less than body requirements, 499 impaired comfort with, 433
activity tolerance with, 465.e16-e17 ineffective coping with, 499-500 impaired oral mucous membrane
constipation with, 465.e17-e18 ineffective sexuality patterns with, with, 433
discharge teaching/continued care 490-492 impaired respiratory function with,
with, 465.e20 desired outcomes for, 491-492 423-425
outcome/discharge criteria, 465.e16 NIC interventions for, 491 ineffective coping with, 433
risk for myxedema coma with, NOC outcomes for, 491 ineffective family health management
465.e19-e20 nursing assessment for, 491 with, 428
Hypovolemia, cardiac output and, 37 risk factors for, 491 ineffective health management with,
Hysterectomy, 713 therapeutic interventions for, 491 414-415, 428-434
additional care plans, 719 odor and sound control with ineffective sexuality pattern with, 434
discharge teaching/continued care, 717 discharge teaching on, 496 interrupted family process with, 434
outcome/discharge criteria, 713 and disturbed self-concept, 493 powerlessness with, 434
postoperative, 713 and ineffective sexuality patterns, pruritus with, 433
49] tisk for deficient fluid volume with,
I outcome/discharge criteria, 478-479 421-423
Ibuprofen, with acute GI bleed, 526 permanent, 478 tisk for electrolyte imbalance, 421-423
ICDs. see Implantable cardiac devices preoperative knowledge deficit with, tisk for impaired skin integrity
IgE antagonists, for asthma, 121 479-480 with, 433
Ileoanal reservoir, 478 NIC interventions for, 479 risk for infection with, 418-420
 Index 893

Immune function, alterations in Infection, risk for (Continued) Infection, risk for (Continued)
(Continued) with human immunodeficiency virus NIC interventions for, 635
risk for loneliness with, 434 infection and acquired immune NOC outcomes for, 635
spiritual distress with, 427-428 deficiency syndrome, 418-420 nursing assessment for, 635
spread, prevention of, 429 clinical manifestations of, 418, 418t risk factors for, 635
transmission of, 412 desired outcomes in, 418-420 therapeutic interventions for, 635
treatment of, 412 NIC interventions in, 418t Infertility, with chemotherapy, 770, 775
splenectomy for, 446 NOC outcomes in, 418t Inflammation, of lung tissue, with
Immunizations, and risk for infection, nursing assessment, 418t chemotherapy, 766-767
with inflammatory bowel disease, therapeutic interventions for, desired outcomes for, 766-767
536 419-420t nursing assessment for, 766
Immunomodulator agents, for risk of with inflammatory bowel disease, risk factors for, 766
abscesses and fistulas, with 534-536 therapeutic interventions for, 767
inflammatory bowel disease, 538 desired outcomes for, 534-536 Inflammatory bowel disease, 527
Impaired skin integrity, end-of-life NIC interventions for, 534 activity intolerance with, 543
nursing care for, 848-849 NOC outcomes for, 534 acute/chronic pain with, 531-533
Implantable cardiac devices (ICDs), nursing assessment for, 534 desired outcomes for, 532-533
312-313 risk factors for, 534 NIC interventions for, 532
discharge teaching/continued care therapeutic interventions for, 535 NOC outcomes for, 532
with, 319 with intestinal obstruction and bowel nursing assessment for, 532
fear/anxiety with, 323 resection, 563, 565 risk factors for, 532
potential complications of with mechanical ventilation, 146-147 therapeutic interventions for, 532
cardiac tamponade as, 317 with neoplastic disorders, 805 discharge teaching/continued care for,
malfunction as, 315-316 NIC interventions for, 20, 58 541-544
pneumothorax as, 318 NOC outcomes for, 20, 58 disturbed self-concept with, 543
undesired stimulation of heart and/ nursing assessment for, 20, 58 disturbed sleep pattern with, 543
or certain nerves and muscles with parenteral nutrition, 568-569, 571 fear/anxiety with, 543
as, 319 desired outcomes for, 568-569 imbalanced nutrition with, 529-531
related care plans for, 323 NIC interventions for, 568 desired outcomes for, 530-531
risk for/actual decreased cardiac output NOC outcomes for, 568 NIC interventions for, 530
prior to, 313-315 nursing assessment for, 569 NOC outcomes for, 530
Implanted infusion device (MediPort, risk factors for, 568 nursing assessment for, 530
Port-a-Cath), with chemotherapy, 776 therapeutic interventions for, 569 risk factors for, 530
Impulse conduction defects, 237.e1 postoperative, 114 therapeutic interventions for, 530
Individualized care plan after heart surgery, 289-290 risk for abscesses and fistulas with,
creation of, 4-7 after radical prostatectomy, 735-736 537-539
sample, 7t clinical manifestations, 735 desired outcomes for, 538
Indwelling catheter, patency of, 79 desired outcomes, 735-736 nursing assessment, 538
Infection, risk for, 19-23, 57 NIC interventions, 736 risk factors for, 538
after abdominal trauma, 476 NOC outcomes, 736 therapeutic interventions for, 538
with chemotherapy, 771, 777, 779 nursing assessment, 736 risk for imbalanced fluid and
in chronic obstructive pulmonary risk factors, 735 electrolytes with, 527-529
disease, 129-130 therapeutic interventions, 736 desired outcomes for, 528-529
clinical manifestations of, 129-130 with renal failure, 655-656 NIC interventions for, 528-529
desired outcomes for, 130 clinical manifestations of, 655 NOC outcomes for, 528
NIC interventions for, 130 desired outcomes for, 656 nursing assessment tor, 528
NOC outcomes for, 130 NIC interventions for, 656 risk factors for, 528
nursing assessment for, 130 NOC outcomes for, 656 therapeutic interventions for, 529
risk factors of, 130 nursing assessment for, 656 risk for impaired tissue integrity with,
therapeutic interventions for, 130 risk factors for, 656 543-544
with cirrhosis, 578, 601 therapeutic interventions for, 656 risk for infection with, 534-536
clinical manifestations of, 19, 57 risk factors for, 19-20, 57 desired outcomes for, 534-536
desired outcomes for, 20, 58 with sepsis, 440-442 NIC interventions for, 534
with diabetes mellitus, 465 with spinal cord injury, 398 NOC outcomes for, 534
documentation for, 20-23, 58-60 surgical site, after amputation nursing assessment for, 534
in elderly client, 827-829 clinical manifestations of, 678 risk factors for, 534
clinical manifestations of, 827 NIC interventions for, 678 therapeutic interventions for, 535
desired outcomes, 827-829 NOC outcomes for, 678 tisk for peritonitis with, 540
NIC interventions, 827 nursing assessment for, 678 desired outcomes for, 540
NOC outcomes, 827 risk factors for, 678 nursing assessment for, 540
nursing assessment, 827 therapeutic interventions for, 678 risk factors for, 540
risk factors for, 827 therapeutic interventions for, 21, 58 therapeutic interventions for, 540
therapeutic interventions for, 828 with total joint replacement (hip/ risk for renal calculi with, 536-537
with enteral nutrition, 506 knee), 701 desired outcomes for, 537
extrapulmonary urolithiasis in, 634-635 nursing assessment for, 537
with pneumonia, 160-162 clinical manifestations of, 635 risk factors for, 537
with tuberculosis, 209-211 desired outcomes for, 635 therapeutic interventions for, 537
894 Index

Inflammatory bowel disease (Continued) Intestinal obstruction (Continued) Intracranial adaptive capacity, decreased
risk for toxic megacolon with, 538 impaired oral mucous membrane with cerebrovascular accident, 347-348
desired outcomes for, 539 with, 565 clinical manifestations of, 347, 347t
nursing assessment for, 539 nausea with, 548-549 desired outcomes in, 347-348
risk factors for, 539 desired outcomes for, 549 NIC interventions in, 347t
therapeutic interventions for, 539 NIC interventions for, 549 NOC outcomes in, 347t
Injury, risk for NOC outcomes for, 549 nursing assessment, 347t
with Alzheimer disease/dementia, 346 nursing assessment for, 549 risk factors for, 347
with cirrhosis, 601 risk factors for, 549 therapeutic interventions for, 348t
with diabetes mellitus, 465 therapeutic interventions for, 549 with traumatic brain injury, 347-348,
in elderly client, 832-834 outcome/discharge criteria, 544 360-362
with Parkinson disease, 411 postoperative, 544 clinical manifestations of, 360, 360t
with procedural sedation, 84-85 postoperative interventions for, 553 desired outcomes in, 361
clinical manifestations of, 84 for imbalanced nutrition, 556-558 NIC interventions in, 361t
desired outcomes for, 84-85 for ineffective airway clearance, NOC outcomes in, 361t
NIC interventions for, 84 555-556 nursing assessment, 361t
NOC outcomes for, 84 for ineffective breathing pattern, risk factors for, 361
nursing assessment for, 84 553-554 therapeutic interventions for,
risk factors for, 84 potential complications after surgery 361-362t
therapeutic interventions for, 84 with, 558 Intrarenal AKI, 649
with spinal cord injury, 383-385 risk for aspiration with, 565 Ischemic cerebrovascular accident, 346
with traumatic brain injury/ tisk for atelectasis as potential compli-
craniotomy, 374 cation after surgery with, 558-559 J
Insulin deficiency, in diabetes, 447 desired outcomes for, 559 Jejunostomy tube, proper care of, 506
Insulin resistance, with parenteral nursing assessment for, 559 Joint infection, with tuberculosis,
nutrition, 566 risk factors for, 559 209-211
Intermittent catheterization, for impaired therapeutic interventions for, 559 Joint pain, with inflammatory bowel
urinary elimination, in elderly risk for constipation with, 565 disease, 531
client, 823 risk for dehiscence as potential
Internal fixation or prosthesis insertion, complication after surgery with, K
fractured hip with, 685-686 562-563 Kernig sign, meningitis and, due to
preoperative care for, 686 desired outcome for, 562 traumatic brain injury/craniotomy,
acute pain in, 686-688 nursing assessment for, 562 365
fear/anxiety in, 687 risk factors for, 562 Ketogenesis, 447
tisk for peripheral neurovascular therapeutic interventions for, 562 Ketones, in diabetes, 447
dysfunction in, 688-689 risk for falls with, 565 Kidney, client with alterations in,
Interventions, 25-80 risk for infection with, 565 631-669
Interventricular septum, rupture of, risk for intestinal necrosis with, cystectomy with urinary diversion,
with myocardial infarction, 550-551 639-640
331-332 desired outcomes for, 551 outcome/discharge criteria of, 640
Intestinal necrosis, with intestinal nursing assessment for, 551 nephrectomy, 640
obstruction, 550-551 risk factors for, 551 outcome/discharge criteria of, 640
desired outcomes for, 551 therapeutic interventions for, 551 urolithiasis, 631
nursing assessment for, 551 tisk for paralytic ileus as potential outcome/discharge criteria of, 631
risk factors for, 551 complication after surgery with, Kidney injury/disease
therapeutic interventions for, 551 561-562 activity intolerance with, 669
Intestinal obstruction, 544 desired outcomes for, 561-562 acute, 649-650
acute abdominal pain with, 547 nursing assessment for, 561 causes of, 649
desired outcomes for, 547-548 risk factors for, 561 chronic, 649-650
NIC interventions for, 547-548 therapeutic interventions for, 561 diagnosis and treatment of, 649
NOC outcomes for, 547 risk for peritonitis with, 549-550 discharge teaching/continued care
nursing assessment for, 547 desired outcomes for, 550 with, 664
risk factors for, 547 nursing assessment for, 550 community resources, 668
therapeutic interventions for, 548 risk factors for, 550 on fluid restrictions and dietary
discharge information for therapeutic interventions for, 550 modifications, 666
after surgery, 563 thromboembolism as potential on follow-up care, 668
without surgery, 551 complication after surgery with, on managing signs and symptoms, 667
disturbed sleep pattern with, 565 559-561 on measuring fluid intake and
fear/anxiety with, 565 desired outcomes for, 560-561 output and monitoring blood
imbalanced fluid and electrolytes with, NIC interventions for, 560 pressure, 666
545-548 NOC outcomes for, 560 on reducing risk of infection, 666
desired outcomes for, 545-546 nursing assessment for, 560 on reporting signs and symptoms, 667
NIC interventions for, 545 risk factors for, 560 on slowing progression of kidney
NOC outcomes for, 545 therapeutic interventions for, 560 damage, 665
nursing assessment for, 546 Intolerance, with cardiac dysrhythmias, diuretic phase of, 649
risk factors for, 545 237.e3-e4 fear and anxiety with, 669
therapeutic interventions for, 546 Intra—abdominal reservoir, 478 grieving with, 669
 Index 895

Kidney injury/disease (Continued) Knowledge, deficient (Continued) Knowledge, deficient (Continued)

imbalanced nutrition with, 654 desired outcomes for, 120-122 for deep vein thrombosis, 253-255
impaired oral mucous membrane on follow-up care, 120 clinical manifestations of, 253
with, 669 management in, 120-122 nursing assessment for, 253
initiation phase of, 649 NIC interventions for, 120 nursing interventions classifications
intrarenal, 649 NOC outcomes for, 120 (NIC) for, 253t
oliguric phase of, 649 nursing assessment for, 120 nursing outcomes interventions
outcome/discharge criteria of, 650 on reporting of signs and (NOC) for, 253t
postrenal, 649 symptoms, 121 risk factors for, 253-255
prerenal, 649 risk factors of, 120 therapeutic interventions for, 254
recovery phase of, 649 on side effects and drug with diabetes mellitus, 458-465
risk for constipation with, 669 interactions, 121 clinical manifestations of, 458, 458t
tisk for decreased cardiac output with, therapeutic interventions for, 121 NIC interventions in, 458t
652-653 after bowel resection, postoperative, NOC outcomes in, 458t
risk for deficient fluid volume with, 563-566 nursing assessment, 458t
656-657 for cardiac dysrhythmias, 237.e8-e10 risk factors for, 458-465
risk for excess fluid volume with, clinical manifestations of, 237.e8 therapeutic interventions for,
650-652 nursing assessment for, 237.e8 459-460t, 459t, 460t, 461t,
risk for infection with, 655-656 nursing interventions Classifications 462-463t, 463-464t, 464t, 465t
risk for metabolic acidosis with, (NIC) for, 237.e8 with enteral nutrition, 505-508
654-655 nursing outcomes interventions NIC interventions for, 505
risk for uremia syndrome with, (NOC) for, 237.e8 NOC outcomes for, 505
658-664 risk factors for, 237.e8-e10 nursing assessment for, 505
Knowledge, deficient therapeutic interventions for, 237.e8 risk factors for, 505-506
after abdominal aortic aneurysm after carotid endarterectomy, 244-246 therapeutic interventions for, 505
repair, 225-228 clinical manifestations of, 244 after femoropopliteal bypass, 262-264
clinical manifestations of, 225 nursing assessment for, 244 clinical manifestations of, 262-263
nursing assessment for, 226 nursing interventions classifications nursing assessment for, 263
nursing interventions classifications (NIC) for, 244 nursing interventions classifications
(NIC) for, 225 nursing outcomes interventions (NIC) for, 263
nursing Outcomes interventions (NOC) for, 244 nursing outcomes interventions
(NOC) for, 225 risk factors for, 244-246 (NOC) for, 263
risk factors for, 225-227 therapeutic interventions for, 244 risk factors for, 263-264
therapeutic interventions for, 226 with cerebrovascular accident, 355-359 therapeutic interventions for, 263
with abdominal trauma, 476-479 clinical manifestations of, 355, 355t after gastric reduction surgery,
NIC interventions for, 476 NIC interventions for, 356t postoperative, 515-521
NOC outcomes for, 476 NOC outcomes for, 356t NIC interventions for, 515
nursing assessment for, 476 nursing assessment, 356t NOC outcomes for, 515
risk factors for, 476-477 risk factors for, 356-358 nursing assessment for, 515
therapeutic interventions for, 476 therapeutic interventions for, 356t, risk factors for, 515
with acute GI bleed, 525-527 357t, 358t therapeutic interventions for, 515
NIC interventions for, 525 after cholecystectomy, 575-578 with heart failure, 278-281
NOC outcomes for, 525 clinical manifestations of, 575 clinical manifestations of, 278
nursing assessment for, 525 nursing assessment of, 576 nursing assessment for, 278
risk factors for, 525-526 risk factors of, 576-578 nursing interventions classifications
therapeutic interventions for, 525 therapeutic interventions for, 576 (NIC) for, 278
after amputation, 681-686 with chronic obstructive pulmonary nursing outcomes interventions
clinical manifestations of, 681 disease, 135-141 (NOC) for, 278
desired outcomes for, 681-682 on chest physiotherapy and use of risk factors for, 278-281
NIC interventions for, 681 respiratory equipment, 138 therapeutic interventions for, 278
NOC outcomes for, 681 clinical manifestations of, 135 after heart surgery, 297-301
nursing assessment for, 681 on energy conservation, 136 clinical manifestations of, 297
risk factors for, 681 on follow-up care, 141 nursing assessment for, 298
therapeutic interventions for, 682 on maintaining optimal nutritional nursing interventions classifications
with angina pectoris, 233-237 status, 137 (NIC) for, 298
clinical manifestations of, 233 on medications, 136 nursing outcomes interventions
nursing assessment for, 234 NIC interventions for, 136 (NOC) for, 298
nursing interventions classifications NOC outcomes for, 136 risk factors for, 297-301
(NIC) for, 234 nursing assessment for, 136 therapeutic interventions for,
nursing outcomes interventions on precautions with oxygen usage, 140 298-299t
(NOC) for, 234 on prevention or minimization of with hepatitis, 609-613
risk factors for, 234-237 further respiratory problems, 135 clinical manifestations of, 609
therapeutic interventions for, 234 on reporting of signs and symptoms, NIC interventions of, 609
in asthma, 120-122 140 NOC outcomes of, 609
on adherence to medication on resource identification, 141 nursing assessment of, 609
regimen, 120 risk factors of, 136-141 risk factors of, 609-612
clinical manifestations of, 120 therapeutic interventions for, 136 therapeutic interventions for, 610
896 Index

Knowledge, deficient (Continued) Knowledge, deficient (Continued) Knowledge, deficient (Continued)

for hypertension, 310-312 therapeutic interventions for, NIC interventions for, 213
clinical manifestations of, 310-311 780, 797 NOC outcomes for, 213
nursing assessment for, 310 with pancreatitis, 628-630 nursing assessment for, 213
nursing interventions classifications clinical manifestations of, 628 risk factors of, 213-216
(NIC) for, 310 desired outcomes for, 628-630 therapeutic interventions for, 214
nursing outcomes interventions nursing assessment of, 629 Kock pouch, 478
(NOC) for, 310 risk factors of, 628 Kwashiorkor, 500
therapeutic interventions for, 310 therapeutic interventions for, 629
with hyperthyroidism with parenteral nutrition, 569-571 ib
discharge teaching for, 465.e14 NIC outcomes for, 570 Lactose, diarrhea due to, 46
preoperative, 465.e8 NOC interventions for, 570 Laminectomy, with or without fusion,
with hypothyroidism, discharge nursing assessment for, 570 701-702
teaching, 465.e20-e21 risk factors for, 570 actual/risk for impaired skin integrity
clinical manifestation for, 465.e20 therapeutic interventions for, 570 with, 705-706
NIC interventions in, 465.e20t with Parkinson disease, 409-411 acute pain after, 704-705
NOC outcomes in, 465.e20t clinical manifestations of, 409, 409t discharge teaching/continued care
nursing assessment, 465.e20t NIC interventions for, 409 after, 710
risk factors for, 465.e20-e21 NOC outcomes for, 409 knowledge deficit prior to, 702
therapeutic interventions for, nursing assessment, 409t procedure for, 701
465.e20-e21t, 465.e21t risk factors for, 409 related care plans for, 712
with implantable cardiac devices, therapeutic interventions for, 409t, risk for cerebrospinal fluid leak with,
319-323 410-411t, 410t, 411t 707-708
clinical manifestations of, 320 with pneumonia, 164-166 risk for laryngeal nerve damage with,
nursing assessment for, 320t with pneumothorax, 174-177 708-709
nursing interventions classifications preoperative, prior to ileostomy, risk for paralytic ileus with, 709-710
(NIC) for, 320 479-480 risk for peripheral neurovascular
nursing outcomes interventions NIC interventions for, 479 dysfunction after, 702-703
(NOC) for, 320 NOC outcomes for, 479 risk for respiratory distress with,
tisk factors for, 320-322 nursing assessment for, 479 706-707
therapeutic interventions for, 320 risk factors for, 479-480 Laryngeal infection, with tuberculosis,
with inflammatory bowel disease, therapeutic interventions for, 479 209-211
541-544 with pulmonary embolism, 187-190 clinical manifestations of, 209
NIC interventions for, 541 clinical manifestations of, 188 desired outcomes for, 210-211
NOC outcomes for, 541 NIC interventions for, 188 NIC interventions for, 210
nursing assessment for, 541 NOC outcomes for, 188 NOC outcomes for, 210
risk factors for, 541-543 nursing assessment for, 188 nursing assessment for, 210
therapeutic interventions for, 541 risk factors of, 188-190 risk factors of, 210
with intestinal obstruction, 551-553 therapeutic interventions for, 188 therapeutic interventions for, 210
NIC interventions for, 552 with spinal cord injury, 393-398 Laryngeal nerve damage, after
NOC outcomes for, 552 clinical manifestations of, 393, 393t laminectomy/discectomy with or
nursing assessment for, 552 NIC interventions for, 393t without fusion, 708-709
risk factors for, 552-553 NOC outcomes for, 393t clinical manifestations of, 708
therapeutic interventions for, 552 nursing assessment, 393t desired outcomes for, 708-709
after laminectomy/discectomy with or risk factors for, 393-397 nursing assessment for, 709
without fusion, 710-712 therapeutic interventions for, 393t, risk factors for, 708
clinical manifestations of, 710 395t, 396-397t, 396t therapeutic interventions for, 709
NIC interventions for, 710 after thoracic surgery, 200-202 Laxatives, for constipation, 42
NOC outcomes for, 710 after total joint replacement (hip/ in elderly client, 824
nursing assessment for, 711 knee), 697-702 LDLs. see Low-density lipoproteins
risk factors for, 710-712 clinical manifestations of, 698 Leucovorin calcium, for impaired renal
therapeutic interventions for, 711 NIC interventions for, 698 function, with chemotherapy, 762
after myocardial infarction, 334-339 NOC outcomes for, 698 Liver disturbances, nursing care of client
clinical manifestations of, 334 nursing assessment for, 698 with, 572-630
nursing assessment for, 335 risk factors for, 698-701 cholecystectomy, 572
nursing interventions classifications therapeutic interventions for, 698 clinical manifestations of, 573
(NIC) for, 335 with traumatic brain injury/ desired outcomes for, 573-594
nursing outcomes interventions craniotomy, 371-375 discharge teaching/continued care
(NOC) for, 335 clinical manifestations of, 371, 371t after, 596
risk factors for, 335-338 NIC interventions for, 371t indications of, 572
therapeutic interventions for, 335 NOC outcomes for, 371t ineffective breathing pattern with,
after neoplastic disorders, 780-781, nursing assessment, 371t 572-574
796-805 risk factors for, 371-374 laparoscopic, 572
NIC interventions for, 780, 797 therapeutic interventions for, 358t, NIC interventions for, 573
NOC outcomes for, 780, 797 SAINT St OVAL NOC outcomes for, 573
nursing assessment for, 780 with tuberculosis, 213-216 nursing assessment of, 573
risk factors for, 780-781, 797-804 clinical manifestations of, 213 open, 572
 Index 897

Liver disturbances, nursing care of client Liver disturbances, nursing care of client Malnutrition (Continued)
with (Continued) with (Continued) in elderly client, 812-814
outcome/discharge criteria for, 572 fear and anxiety with, 630 clinical manifestations, 813
risk factors of, 573 imbalanced fluid and electrolytes desired outcomes in, 813-814
risk for abscess formation with, with, 580-582 NIC interventions in, 813
574-575 imbalanced nutrition with, 615-617 NOC outcomes in, 813
therapeutic interventions for, 573 impaired oral mucous membrane nursing assessment, 813
cirrhosis, 578 with, 630 risk factors for, 813
activity intolerance with, 585-587 ineffective breathing pattern with, signs and symptoms of, 813
acute and chronic confusion with, 621-622 therapeutic interventions for, 813
587-589 nausea with, 630 with enteral nutrition, 502-503
alcohol-related, 578 outcome/discharge criteria for, 613 after gastric reduction surgery, 518
discharge teaching/continued care risk for infection (sepsis) with, with hepatitis, 604
with, 609 619-621 with ileostomy, 500
disturbed sleep pattern with, 601 tisk for organ ischemia/dysfunction, with inflammatory bowel disease,
due to dyspepsia, impaired comfort 626-628 529-531
with, 583 tisk for peritonitis with, 624-625 kwashiorkor as, 500
due to pruritus, impaired comfort tisk for unstable blood glucose level, marasmus as, 500
with, 584-585 625-626 with mechanical ventilation, 145
fear and anxiety with, 601 risk of shock, 623-624 with neoplastic disorders, 781-783
imbalanced nutrition with, 603-605 Low-density lipoproteins (LDLs), with desired outcomes for, 782-783
ineffective breathing pattern with, angina pectoris, 235 NIC interventions for, 782
579-580 Lower extremity arterial embolization, NOC outcomes for, 782
ineffective coping with, 601 after abdominal aortic aneurysm nursing assessment for, 782
ineffective family therapeutic regimen repair, 222 risk factors for, 782
management with, 595-596 Lung expansion, ineffective risk for, therapeutic interventions for, 782
less than body requirements, thoracic surgery, 195-197 with pancreatitis, 616
imbalanced nutrition with, clinical manifestations of, 195 in pneumonia, 126
582-584 desired outcomes for, 195-197 primary, 500
outcome/discharge criteria for, 578 nursing assessment for, 196 protein-calorie, 500
risk for ascites with, 591-592 risk factors of, 195 with renal failure, 654
risk for bleeding esophageal varices therapeutic interventions for, 196 secondary, 500
with, 592 Lung tissue, inflammation and fibrosis Marasmus, 500
tisk for bleeding with, 589-591 of, with chemotherapy, 766-767 Maslow’s hierarchy of needs, in
risk for excess fluid volume and desired outcomes for, 766-767 prioritization, 1
third-spacing with, 580-582 nursing assessment for, 766 Massage, for risk of impaired skin
risk for hepatic (portal-systemic) risk factors for, 766 integrity, 70
encephalopathy (hepatic coma) therapeutic interventions for, 767 Mast cell stabilizers, for asthma, 121
with, 592-594 Lymphatic infection, with tuberculosis, Mastectomy, 720
risk for hypokalemia with, 593 209-211 additional care plans, 733
risk for infection with, 588, 601 clinical manifestations of, 209 discharge teaching/continued care, 729
risk for injury with, 601 desired outcomes for, 210-211 outcome/discharge criteria, 720
risk for spiritual distress, 594-595 NIC interventions for, 210 postoperative, 722
hepatitis as, 601-602 NOC outcomes for, 210 preoperative, 720
acute pain with, 612 nursing assessment for, 210 Mechanical ventilation, 141-142
discharge teaching/continued care risk factors of, 210 actual/risk for dysfunctional ventilatory
with, 609 therapeutic interventions for, 210 weaning response with, 147-149
fear and anxiety with, 612 Lymphedema, as neoplastic disorders, alarms with, 144
imbalanced nutrition with, 603-605 793-794 fear/anxiety with, 150
impaired comfort due to pruritus desired outcomes for, 793-794 imbalanced nutrition with, 145
with, 584-585 nursing assessment for, 794 impaired oral mucous membrane
ineffective family health management risk factors for, 793 with, 150
with, 609-613 therapeutic interventions for, 794 impaired physical mobility with, 150
ineffective health management with, and impaired respiratory function,
609-613 M 142-145
knowledge deficit with, 609-613 Magnesium (Mg+) replacement, for risk after heart surgery, 287
nausea with, 605-606 of cardiac dysrhythmias, with heart impaired verbal communication
risk for activity intolerance with, 612 failure, 274 with, 150
risk for bleeding, 606-607 Malnutrition, 62 outcome/discharge criteria of, 142
risk for deficient fluid volume with, assessment of, 500 potential complications of, 143
602-603 after bowel resection, 556-558 powerlessness with, 150
risk for progressive liver degeneration categories of, SOO risk for aspiration with, 150
with, 608-609 with chemotherapy, 754-756 risk for barotrauma with, 150
pancreatitis, acute, 613 in chronic obstructive pulmonary risk for decreased cardiac output
acute pain with, 613-615 disease, 126 with, 149
discharge teaching/continued care with cirrhosis, 583 tisk for fluid retention/fluid volume
due to tuberculosis, 203 overload with, 151
with, 628
898 Index

Mechanical ventilation (Continued) Metabolic function, alterations with Mucous membrane, oral, impaired
tisk for infection (ventilator-acquired (Continued) (Continued)
pneumonia) with, 146-147 risk for hypocalcemia with, 465.e11 NIC interventions for, 789
risk for injury with, 151 risk for laryngeal nerve damage with, NIC outcomes for, 789
ventilator settings for, 144 465.e13-e14 nursing assessment for, 789
Mediastinal shift, 195 risk for respiratory distress, 465.e10-e11 risk factors for, 789
Mediastinitis, after heart surgery, 289 subtotal, 465.e1 therapeutic interventions for, 789
MediPort (implanted infusion device), and thyrotoxicosis, 465.e1 NIC interventions for, 65
with chemotherapy, 776 due to hypothyroidism/myxedema, NOC outcomes for, 65
Megacolon, toxic, with inflammatory 465.e16 nursing assessment for, 65
bowel disease, 538 activity tolerance with, 465.e16-e17 with pancreatitis, 630
desired outcomes for, 539 constipation with, 465.e17-e18 postoperative, 107-108
nursing assessment for, 539 discharge teaching/continued care clinical manifestations of, 107
risk factors for, 539 with, 465.e20 desired outcomes for, 107-108
therapeutic interventions for, 539 outcome/discharge criteria, 465.e16 NIC interventions for, 107
Melena, 519 tisk for myxedema coma with, NOC outcomes for, 107
Memory loss, with chemotherapy, 768 465.e19-e20 nursing assessment for, 108
Meningitis, with pneumonia, 160-162 Metabolism, defined, 26 risk factors for, 107
Mesna (Mesnex), for hemorrhagic MI. see Myocardial infarction therapeutic interventions for, 108
cystitis, with chemotherapy, 763 Minimally invasive direct coronary artery with renal failure, 669
Metabolic acidosis, with renal failure, bypass (MIDCAB), 282 risk factors for, 65
654-655 Mobility, impaired therapeutic interventions for, 65
clinical manifestations of, 658 with cerebrovascular accident, 359 Multiple organ dysfunction syndrome
desired outcomes for, 654 in elderly client, 819-820 (MODS), 445-446
nursing assessment for, 658 with mechanical ventilation, 150 with abdominal trauma, 474-476
risk factors for, 658 with Parkinson disease, 399-400 desired outcomes for, 475
therapeutic interventions for, 658 physical, 60-62 nursing assessment for, 475
Metabolic function, alterations with, clinical manifestations of, 60 risk factors for, 475
447-21 desired outcomes for, 60 therapeutic interventions for, 475
due to diabetes mellitus, 447-448 documentation for, 60-62 with pancreatitis, 628
complications of, 447 NIC interventions for, 61 Musculoskeletal function alterations,
constipation with, 465 NOC outcomes for, 61 670-716
diarrhea with, 465 nursing assessment for, 61 due to amputation, 670
hypertension in, 447 risk factors for, 60 acute/chronic pain in, 673-674
imbalanced nutrition with, 465 therapeutic interventions for, 61 deficient knowledge in, 670
ineffective coping, 465 with spinal cord injury, 377-379 disturbed body image, 679-681
ineffective family health management, clinical manifestations for, 377, 377t grieving with, 685
456-458 desired outcomes in, 377-379 impaired physical mobility in, 676-677
ineffective peripheral tissue NIC interventions in, 378t impaired tissue integrity in, 675-676
perfusion with, 453-455 NOC outcomes in, 378t ineffective family health management
knowledge, deficit, of ineffective health nursing assessment, 378t in, 681-685
Management with, 458-465 risk factors for, 377 risk for falls with, 685
outcome/discharge criteria in, therapeutic interventions for, 378-379t tisk for surgical site infection after,
447-448 with traumatic brain injury/ 678-679
pathophysiological events in, 447 craniotomy, 374 due to fractured hip with internal
risk for dysfunctional gastrointestinal Modified radical mastectomy, 720 fixation or prosthesis insertion,
motility, 455-456 MODS. see Multiple organ dysfunction 685-686
risk for electrolyte imbalance, 451-453 syndrome acute pain in, preoperative care for,
risk for falls with, 465 Mucokinetic substances, for ineffective 686-688
tisk for imbalanced fluid volume, postoperative airway clearance, 95 fear/anxiety in, preoperative
450-451 Mucous membrane, oral, impaired, 64-66 care for, 687
risk for infection with, 465 with chemotherapy, 758-759 preoperative care for, 686
risk for unstable blood glucose level desired outcomes for, 758-759 risk for peripheral neurovascular
with, 448-449 NIC interventions for, 758 dysfunction in, preoperative care
sexual dysfunction with, 465 NOC outcomes for, 758 for, 688-689
type 1 and type 2, 447 nursing assessment for, 759 laminectomy/discectomy with or
urinary retention with, 465 risk factors for, 758 without fusion for, 701-708
due to hyperthyroidism/ therapeutic interventions for, 759 actual/risk for impaired skin integrity
thyroidectomy, 465.e1 clinical manifestations of, 64 with, 705-706
activity intolerance with, 465.e4—-e6 desired outcomes for, 65 acute pain after, 704-705
deficient knowledge with, 465.e8 documentation for, 65-66 discharge teaching/continued care
disturbed sleep pattern with, 465.e6-e8 in elderly client, 816-817 after, 710
imbalanced nutrition with, 465.e3-e4 with intestinal obstruction and bowel knowledge deficit prior to, 702
outcome/discharge criteria for, 465.e1 resection, 565 procedure for, 701
risk for bleeding, 465.e8-e10 with mechanical ventilation, 150 related care plans for, 712
risk for decreased cardiac output, with neoplastic disorder, 788-790 risk for cerebrospinal fluid leak with,
465.e1-e2 desired outcomes for, 789-790 707-708
 Index 899

Musculoskeletal function alterations Nausea (Continued) Neoplastic disorders (Continued)

(Continued) end-of-life nursing care for, 858 inflammation and fibrosis of lung
tisk for laryngeal nerve damage with, fluid deficit due to, 48 tissue with, 766-767
708-709 in pneumonia, 154 mechanism of action of, 753
tisk for paralytic ileus with, 709-710 postoperative, 100, 101 nausea with, 773, 779
risk for peripheral neurovascular with heart failure, 282 neurotoxicity of, 767-768, 775, 778
dysfunction after, 702-703 with hepatitis, 605-606 outcome/discharge criteria, 753-754
tisk for respiratory distress with, clinical manifestations of, 605 resistance to, 753
706-707 desired outcomes of, 605-606 risk for constipation with, 779
total joint replacement/arthroplasty NIC interventions of, 605 risk for impaired skin integrity
(hip/knee) for, 689-690 NOC outcomes of, 605 with, 779
activity intolerance with, 701 nursing assessment of, 605 risk for infection with, 771, 777, 779
actual/risk for impaired tissue risk factors of, 605 risk for powerlessness with, 779
integrity with, 695-697 therapeutic interventions for, 605 routes of administration of, 753
acute pain with, 690-691 with intestinal obstruction, 548-549 side effects of, 753
discharge teaching/continued care desired outcomes for, 549 client teaching, 780
after, 697 NIC interventions for, 549 fatigue with, 805
impaired physical mobility with, NOC outcomes for, 549 fear/anxiety with, 779, 804
691-693 nursing assessment for, 549 grieving with, 805
preoperative care for, 690 risk factors for, 549 imbalanced nutrition with, 781-783
prosthetic devices for, 690 therapeutic interventions for, 549 desired outcomes for, 782-783
related care plans for, 701 with neoplastic disorders, 804-805 NIC interventions for, 782
risk for falls with, 701 with pancreatitis, 630 NOC outcomes for, 782
risk for infection with, 701 with pneumonia, 166 nursing assessment for, 782
risk for peripheral neurovascular with pneumothorax, 177 risk factors for, 782
dysfunction after, 693-695 postoperative, 103-104 therapeutic interventions for, 782
Myalgias, with hepatitis, 612 clinical manifestations of, 103 impaired comfort with, due to pruritus,
Myocardial infarction (MI), 323 desired outcomes for, 103-104 785-786
acute pain with, 325-327 fluid deficit due to, 100, 101 desired outcomes for, 785-786
with angina pectoris, 232-233 imbalanced nutrition due to, 102, 103 NIC interventions for, 785
cardiac dysrhythmias with, 328-329 NIC interventions for, 104 NOC outcomes for, 785
cardiogenic shock with, 333-334 NOC outcomes for, 104 nursing assessment for, 785
discharge teaching/continued care nursing assessment for, 104 risk factors for, 785
for, 334 risk factors for, 103 therapeutic interventions for, 785
disturbed sleep pattern with, 339 therapeutic interventions for, 104 with impaired swallowing, 783-785
extension or recurrence of, 333 Neglect, unilateral, with cerebrovascular desired outcomes for, 784-785
fear/anxiety with, 339 accident, 350-351 NIC interventions for, 784
grieving with, 339 Neoplastic disorders, 753-805 NOC outcomes for, 784
after heart surgery, 301-302 acute pain with, 804 nursing assessment for, 784
pericarditis with, 332 bleeding, risk for, 790-791 risk factors for, 784
risk for activity intolerance with, 327-328 desired outcomes for, 790-791 therapeutic interventions for, 784
risk for decreased cardiac output with, NIC interventions for, 790 ineffective family therapeutic regimen
323-325 NOC outcomes for, 790 management with, 796-805
rupture of portion of heart with, nursing assessment for, 791 ineffective self-health management
331-332 risk factors for, 790. with, 796-805
ST-elevation vs. non-ST-elevation, 323 therapeutic interventions for, 791 knowledge deficit with, 796-805
symptoms of, 323 chemotherapy for, 753-754 lymphedema as, 793-794
thromboembolism with, 329-330 acute/chronic pain with, 756-758 desired outcomes for, 793-794
transmural, 323 bleeding with, 760-761, 774, 777 nursing assessment for, 794
Myxedema, 465.e16 cardiac dysrhythmias with, 765-766 risk factors for, 793
activity tolerance with, 465.e16-e17 classification of agents for, 753 therapeutic interventions for, 794
constipation with, 465.e17-e18 combination, 753 nausea with, 804-805
discharge teaching/continued care diarrhea with, 779 radiation cystitis as, 792
with, 465.e20 discharge teaching/continued care desired outcomes for, 792
outcome/discharge criteria, 465.e16 with, 771, 796 nursing assessment for, 792
risk for myxedema coma with, disturbed self-concept with, 768-771 risk factors for, 792
465.e19-e20 disturbed sleep pattern with, 779 therapeutic interventions for, 792
Myxedema coma, with hypothyroidism, drug extravasation with, 764-765, 777 radiation pneumonitis as, 792-793
465.e19-e20 fatigue with, 774, 779 desired outcomes for, 793
fear/anxiety with, 779 nursing assessment for, 793
N grieving with, 779 risk factors for, 793
Nail changes, with chemotherapy, 770 hemorrhagic cystitis with, 763, 777 therapeutic interventions for, 793
NAP. see Nursing assistive personnel imbalanced nutrition with, 754-756 risk for infection with, 805
Nausea impaired oral mucous membrane self-concept, disturbed with, 794-796
with chemotherapy, 773, 779 with, 758-759 desired outcomes for, 795-796
in chronic obstructive pulmonary impaired renal function with, NIC interventions for, 795
disease, 126 761-762 NOC outcomes for, 795
900 Index

Neoplastic disorders (Continued) Neurological function, client with Neurological function, client with
nursing assessment for, 795 alterations (Continued) alterations (Continued)
risk factors for, 795 risk for ineffective cerebral tissue with disturbed self-concept, 375
therapeutic interventions for, 795 perfusion, 348-349 fear/anxiety with, 374
with skin integrity, impaired, 786-788 self-care deficit, 352-354 with impaired physical mobility, 374
desired outcomes for, 786-788 self-care deficit with, 352-354 with ineffective coping, 375
NIC interventions for, 787 sexual dysfunction with, 358 with interrupted family processes, 375
NOC outcomes for, 787 with unilateral neglect, 350-351 risk for acute confusion with, 363-365
nursing assessment for, 787 due to Parkinson disease, 398-399 risk for diabetes insipidus, 368
risk factors for, 786 with activity intolerance, 411 risk for gastrointestinal bleeding,
therapeutic interventions for, 787 with caregiver role strain, 411 370-371
Nephrectomy, 640 for constipation, 404-406 risk for imbalanced body temperature,
discharge teaching/continued with deficient knowledge, 409-411 374
care for, 647 with disturbed self-concept, 407-408 risk for ineffective airway clearance,
ineffective breathing pattern with, with imbalanced nutrition, 400-403 374
641-642 with impaired physical mobility, risk for injury, 374
partial, 640 399-400 risk for meningitis with, 365-366
radical, 640 with impaired verbal communication, risk for post-trauma syndrome, 374
risk for paralytic ileus with, 644-645 406-407 risk for seizures with, 367-368
risk for pneumothorax with, outcome/discharge criteria, 399 risk for syndrome of inappropriate
645-647 risk for aspiration, 403-404 antidiuretic hormone, 368-370
risk for shock with, 643-644 with risk for aspiration, 403-404 with self-care deficit, 374
surgical approach for, 640 with risk for injury, 411 Neuromuscular blocking agents, with
Nerve agent poisoning, 45 with self-care deficit, 411 mechanical ventilation, 144
Neurological dysfunction, after heart due to spinal cord injury, 375 Neuropathic pain, with human
surgery, 294-295 acute/chronic pain with, 397 immunodeficiency virus infection
Neurological function, client with anxiety with, 397 and acquired immune deficiency
alterations in, 340-411 discharge teaching/continued syndrome, 425
Alzheimer disease/dementia causing, care, 393 Neurotoxicity, of chemotherapy,
340-341 with disturbed self-concept, 398 767-768, 775, 778
chronic confusion with, 342-343 fear with, 397 desired outcomes for, 767-768
disturbed sensory perception with, grieving with, 397 nursing assessment for, 767
346 imbalanced nutrition with, 397 risk factors for, 767
grieving, 346 impaired physical mobility with, therapeutic interventions for, 768
impaired home maintenance with, 377-379 N-methyl-D-aspartate (NMDA) receptor
343-344 impaired urinary elimination antagonists, for pain, with
impaired social interactions with, 397 chemotherapy, 758
with, 346 ineffective breathing pattern with, Non-ST-elevation myocardial infarction
risk for injury with, 346 376-377 (NSTEMI), 323
self-care deficits with, 341-342 with ineffective coping, 398 Nonsteroidal anti-inflammatory drugs
wandering with, 344-346 ineffective thermoregulation with, (NSAIDs), discharge teaching on,
cerebrovascular accident causing, 379-380 with acute GI bleed, 526
346-347 with interrupted family process, NSAIDs. see Nonsteroidal anti-
with acute confusion, and chronic 388-389 inflammatory drugs
confusion, 354-355 outcome/discharge criteria, 375 NSTEMI. see Non-ST-elevation myocardial
with decreased intracranial adaptive tisk for ascending spinal cord injury, infarction
capacity, 347-348 389-390 Numbness, with diabetes, 447
discharge teaching/continued care risk for aspiration with, 397 Nurse-sensitive indicators, 9-24
with, 355 risk for autonomic dysreflexia, additional nursing diagnoses, 12-13,
with disturbed self-concept, 359 380-382 18-19
family process, interrupted, 359 tisk for constipation, 398 falls, 9
fear/anxiety with, 358 risk for gastrointestinal bleeding, health care—associated infections,
with grieving, 359 391-393 18-19
hemorrhagic, 346 risk for infection, 398 hospital-acquired pressure ulcers/
imbalanced nutrition with, 358 risk for injury, 383-385 injuries, 12-13
with impaired physical mobility, 359 risk for loneliness with, 397 outcome/discharge criteria, 9
with impaired swallowing, 359 risk for paralytic ileus, 391 Nursing assistive personnel (NAP),
with impaired urinary elimination, 359 risk for powerlessness, 397 delegation to, 2, 2f
with impaired verbal communication, risk for venous thromboembolism, Nursing care plan, creation of
SoZ 385-386 individualized, prioritized, 4-7
ineffective coping with, 359 with self-care deficit, 382-383 Nursing process, 4
ischemic, 346 sexual dysfunction with, 386-388 Nutrition
outcome/discharge criteria for, traumatic brain injury/craniotomy in chronic obstructive pulmonary
346-347 causing, 359-360 disease, imbalanced, 126-127
potential complications for, 358-359 acute pain (headache), 362-363 clinical manifestations of, 126
risk for aspiration with, 349-350 decreased intracranial adaptive desired outcomes for, 126-127
tisk for constipation with, 358 capacity with, 360-362 NIC interventions for, 126
 Index 901

Nutrition (Continued) Nutrition (Continued) Oral hygiene (Continued)

NOC outcomes for, 126 with enteral nutrition, 502-503 for chronic obstructive pulmonary
nursing assessment for, 126 after gastric reduction surgery, 518 disease
risk factors of, 126 with heart failure, 281 with nutritional imbalance, 127, 137
therapeutic interventions for, 126 with hepatitis, 603-605 with pneumonia, 129
cirrhosis and, imbalanced, 582-584 with hyperthyroidism, 465.e3-e4 in end-of-life nursing care, with risk
clinical manifestations of, 582 with ileostomy, 499 for aspiration, 846
desired outcomes of, 583-584 with inflammatory bowel disease, for imbalanced nutrition, 63
NIC interventions of, 583 529-531 after bowel resection, 557
NOC outcomes of, 583 kwashiorkor as, 500 with chemotherapy, 755
nursing assessment of, 583 marasmus as, 500 due to tuberculosis, 206
risk factors of, 583 with mechanical ventilation, 145 with hepatitis, 604
therapeutic interventions for, 583 with neoplastic disorder, 781-783 with hyperthyroidism, 465.e4
in elderly client, imbalanced, 812-814 with pancreatitis, 615-617 with inflammatory bowel disease, 531
clinical manifestations, 813 Parkinson disease, 400-403 in pneumonia, 156
desired outcomes in, 813-814 in pneumonia, 155-156 postoperative, 102
NIC interventions in, 813 secondary, 500 with renal failure, 655
NOC outcomes in, 813 spinal cord injury, 397 for impaired oral mucous membrane, 65
nursing assessment, 813 parenteral, 566 with chemotherapy, 759
risk factors for, 813 administration of, 566 postoperative, 108
signs and symptoms of, 813 composition of, 566 with inflammatory bowel disease
therapeutic interventions for, 813 discharge teaching/continued care for imbalanced nutrition, 531
enteral, 500 with, 569 for risk of infection, 536
+
assessment for, 500 outcome/discharge criteria, 566 for pneumonia
delivery of, 500 recommendations on, 566 discharge teaching on, 165
discharge teaching/continued care risk for infection, 568-569, 571 with risk of extrapulmonary
for, 505 tisk for unstable blood glucose level infection, 162
imbalanced nutrition with, 502-503 with, 566-568 postoperative
outcome/discharge criteria, 500 postoperative, imbalance, less than for imbalanced nutrition, 102
risk for aspiration with, 500-502 body requirements, 101-103 for nausea, 104, 108
risk for constipation with, 506 clinical manifestations of, 101 for risk of infection, 59
risk for deficient fluid volume with, desired outcomes for, 102-103 with inflammatory bowel disease,
503-505 NIC interventions for, 102 536
risk for infection with, 506 NOC outcomes for, 102 Oral hypoglycemic agents, for
with human immunodeficiency virus nursing assessment for, 102 hyperglycemia, with pancreatitis, 626
infection and acquired immune risk factors for, 102 Oral mucous membrane, impaired, 64-66
deficiency syndrome, imbalanced, therapeutic interventions for, 102 with chemotherapy, 758-759
less than body requirements, with renal failure, imbalanced, less desired outcomes for, 758-759
415-417 than body requirements, 654 NIC interventions for, 758
clinical manifestations, 416, 416t clinical manifestations of, 654 NOC outcomes for, 758
desired outcomes in, 416-417 desired outcomes for, 654-655 nursing assessment for, 759
NIC interventions in, 416t NIC interventions for, 654 risk factors for, 758
NOC outcomes in, 416t NOC outcomes for, 654 therapeutic interventions for, 759
nursing assessment, 416t nursing assessment for, 654 clinical manifestations of, 64
risk factors for, 416 risk factors for, 654 desired outcomes for, 65
therapeutic interventions for, therapeutic interventions for, 654 documentation for, 65-66
416-417t Nutritional status, assessment of, 500 end-of-life nursing care for, 858-859
imbalanced, less than body requirements, with intestinal obstruction and bowel
62-64 O resection, 565
clinical manifestations of, 62 Omega-3 fatty acids, for angina pectoris, with mechanical ventilation, 150
desired outcomes for, 62 255 with neoplastic disorder, 788-790
documentation for, 62-64 Opportunistic infection, with human desired outcomes for, 789-790
NIC interventions for, 62 immunodeficiency virus infection NIC interventions for, 789
NOC outcomes for, 62 and acquired immune deficiency NIC outcomes for, 789
nursing assessment for, 62 syndrome, 418-420, 430 nursing assessment for, 789
risk factors for, 62 clinical manifestations of, 418, 418t risk factors for, 789
therapeutic interventions for, 63 desired outcomes in, 418-420 therapeutic interventions for, 789
less than body requirements NIC interventions in, 418t NIC interventions for, 65
assessment of, 500 NOC outcomes in, 418t NOC outcomes for, 65
after bowel resection, 556-558 nursing assessment, 418t nursing assessment for, 65
categories of, 500 therapeutic interventions for, 419—420t with pancreatitis, 630
with cerebrovascular accident, 358 Oral care, for infections, 22 postoperative, 107-108
with chemotherapy, 754-756 Oral hygiene clinical manifestations of, 107
in chronic obstructive pulmonary with chemotherapy, 773 desired outcomes for, 107-108
disease, 126-127 for imbalanced nutrition, 755 NIC interventions for, 107
with diabetes mellitus, 465 for impaired oral mucous membrane, NOC outcomes for, 107
due to tuberculosis, 205-207 759 nursing assessment for, 108
 902 Index

Oral mucous membrane, impaired Pain (Continued) Pain management, for fear/anxiety, in
(Continued) desired outcomes for, 67 chronic obstructive pulmonary
risk factors for, 107 documentation for, 67-68 disease, 132
therapeutic interventions for, 108 due to angina pectoris, 230 Pancreas, nursing care of client with,
with renal failure, 669 due to pneumonia, 156-158 572-630
risk factors for, 65 due to pneumothorax, 170-171 Pancreatitis, acute, 613
therapeutic interventions for, 65 due to pulmonary embolism, 180-182 acute pain with, 613-615
Oral pain, with human immunodefi- end-of-life nursing care for, 847-848 discharge teaching/continued care
ciency virus infection and acquired in fractured hip with internal with, 628
immune deficiency syndrome, 425 fixation or prosthesis insertion, fear and anxiety with, 630
Oral phase impairment, impaired swal- 686-688 imbalanced fluid and electrolytes
lowing due to, 74 with hepatitis, 612 with, 580-582
Organ ischemia/dysfunction with human immunodeficiency virus imbalanced nutrition with, 615-617
with abdominal trauma, 474-476 infection and acquired immune impaired oral mucous membrane
desired outcomes for, 475 deficiency syndrome, 425-427 with, 630
nursing assessment for, 475 in hypertension, 304-305 ineffective breathing pattern with,
risk factors for, 475 with inflammatory bowel disease, 621-622
therapeutic interventions for, 475 531-533 nausea with, 630
with pancreatitis, 626-628 with intestinal obstruction, 547 outcome/discharge criteria for, 613
clinical manifestations of, 627 after laminectomy/discectomy with risk for infection (sepsis) with, 619-621
desired outcomes of, 627-628 or without fusion, 704-705 risk for organ ischemia/dysfunction,
nursing assessment of, 627 with myocardial infarction, 325-327 626-628
risk factors of, 627 with neoplastic disorders, 804 risk for peritonitis with, 624-625
therapeutic interventions for, 627 NIC interventions for, 67 risk for unstable blood glucose level,
with sepsis, 445-446 NOC outcomes for, 67 625-626
Ostomy products, discharge teaching on, nursing assessment for, 67 risk of shock, 623-624
497 with pancreatitis, 613-615 Papillary muscle rupture, with myocardial
Overflow urinary incontinence, 76 postoperative, 85-86, 95-97 infarction, 331-332
in elderly client, 821 preoperative, prior to femoropopliteal Paralytic ileus
Oxygen deficiency, activity intolerance bypass, 257-259 after laminectomy/discectomy with or
due to, 26 with procedural sedation, 85-86 without fusion, 709-710
Oxygen/carbon dioxide (O2/CO>) risk factors for, 67 clinical manifestations of, 709
in asthma, 116 therapeutic interventions for, 67 desired outcomes for, 709-710
in chronic obstructive pulmonary with total joint replacement (hip/ nursing assessment for, 710
disease, 123 knee), 690-691 risk factors for, 709
due to pneumonia, 151 with traumatic brain injury/ therapeutic interventions for, 710
due to pneumothorax, 168 craniotomy, 362-363 after nephrectomy, 644-645
exchange, impaired, 51 with tuberculosis, 216 clinical manifestations of, 644
with mechanical ventilation, 142 urolithiasis in, 632-633 desired outcomes for, 644-645
with procedural sedation, 82 chronic nursing assessment for, 645
in amputation, 673-674 risk factors for, 644
P chemotherapy, 756-758 therapeutic interventions for, 645
Pacemakers, 312-313 end-of-life nursing care for, 847-848 postoperative, 111-112
discharge teaching/continued care with human immunodeficiency virus clinical manifestations of, 111-112
with, 319 infection and acquired immune desired outcomes for, 111-112
dual-chamber, 312-313 deficiency syndrome, 425-427 NIC interventions for, 110-111
fear/anxiety with, 323 with inflammatory bowel disease, NOC outcomes for, 110
indications for, 312 531-533 nursing assessment for, 111
potential complications of prior to femoropopliteal bypass, risk factors for, 111
cardiac tamponade as, 317 257-259 therapeutic interventions for, 111
malfunction as, 315-316 due to pulmonary embolism, and with spinal cord injury, risk for, 391
pneumothorax as, 318 ineffective breathing pattern, Parenteral nutrition
undesired stimulation of heart and/ 180-182 administration of, 566
or certain nerves and muscles fear and anxiety and, 30 discharge teaching/continued care
as, 319 postoperative, 96 with, 569
related care plans for, 323 ineffective airway clearance due to, with mechanical ventilation, 145
risk for/actual decreased cardiac output 27, 28 risk for infection with, 568-560, Oil
prior to, 313-315 postoperative, 94 desired outcomes for, 568-569
temporary vs. permanent, 312 ineffective breathing pattern due to, 34 NIC interventions for, 568
types of, 312 postoperative, 93 NOC outcomes for, 568
Pain postoperative nursing assessment for, 569
acute, 66-68 fear and anxiety, 96 risk factors for, 568
with abdominal trauma, 471-472 for imbalanced nutrition, 102, 103 therapeutic interventions for, 569
in amputation, 673-674 ineffective airway clearance due to, 94 risk for unstable blood glucose level
chemotherapy, 756-758 ineffective breathing pattern due to, 93 with, 566-568
clinical manifestations of, 66 pressure ulcer due to, 14, 16 desired outcome for, 567-568
with deep vein thrombosis, 248-249 urinary retention due to, 79 NIC interventions for, 567
 Index 903

Parenteral nutrition (Continued) Peripheral neurovascular dysfunction Physical mobility, impaired (Continued)
NOC outcomes for, 567 (Continued) after mastectomy, 725-726
nursing assessment for, 567 after mastectomy, risk for, 723-725 clinical manifestations, 725
risk factors for, 567 clinical manifestations, 723 desired outcomes, 725-726
therapeutic interventions for, 567 desired outcomes, 724-725 NIC interventions, 725
Parkinson disease, 398-399 NIC interventions, 724 NOC outcomes, 725
with activity intolerance, 411 NOC outcomes, 724 nursing assessment, 725
with caregiver role strain, 411 nursing assessment, 724 risk factors, 725
for constipation, 404-406 risk factors, 724 therapeutic interventions, 725
with deficient knowledge, 409-411 therapeutic interventions, 724, 725 with mechanical ventilation, 150
with disturbed self-concept, 407-408 after total joint replacement NIC interventions for, 61
with imbalanced nutrition, 400-403 (hip/knee), 693-695 NOC outcomes for, 61
with impaired physical mobility, clinical manifestations of, 693 nursing assessment for, 61
399-400 desired outcomes for, 694-695 risk factors for, 60
with impaired verbal communication , NIC interventions for, 694 therapeutic interventions for, 61
406-407 NOC outcomes for, 694 with total joint replacement (hip/
outcome/discharge criteria, 399 nursing assessment for, 694 knee), 691-693
risk for aspiration, 403-404 risk factors for, 694 clinical manifestations of, 692
with risk for aspiration, 403-404 therapeutic interventions for, 694 desired outcomes for, 692-693
with risk for injury, 411 Peripheral polyneuropathy, in diabetes, NIC interventions for, 692
with self-care deficit, 411 453 NOC outcomes for, 692
Pathologic fractures, in elderly client, Peripheral tissue perfusion, risk for nursing assessment for, 692
834-835 ineffective, after hysterectomy, risk factors for, 692
PCM. see Protein-calorie malnutrition 715-716 therapeutic interventions for, 692
PEEP. see Positive end-expiratory pressure clinical manifestations, 715 Planning, in delegation, 1, 2f
Pelvic floor muscle exercises, for elderly desired outcomes, 715-716 Platelet count, for risk of unusual
client, 823 NIC interventions, 715 bleeding, with pulmonary
Penetrating abdominal trauma, 466 NOC outcomes, 715 embolism, 183
Peptic ulcer, 571 nursing assessment, 716 Pneumonia, 151
outcome/discharge criteria, 571 risk factors, 715 activity intolerance in, 159-160
Perianal pain, with inflammatory bowel therapeutic interventions, 716 acute pain in, 156-158
disease, 531 Peripheral vascular insufficiency, with bacterial, 151
Perianal skin care, with inflammatory diabetes mellitus, 453 after bowel resection, 565
bowel disease, 542 Perirectal abscesses, with inflammatory in chronic obstructive pulmonary
Pericardial infection, with tuberculosis, bowel disease, 537-539 disease, 129-130
209-211 desired outcomes for, 538 community-acquired, 151
clinical manifestations of, 209 nursing assessment for, 538 discharge teaching/continued care
desired outcomes for, 210-211 risk factors for, 538 for, 164
NIC interventions for, 210 therapeutic interventions for, 538 disturbed sleep pattern in, 166
NOC outcomes for, 210 Peritoneal catheter, with chemotherapy, fear/anxiety in, 166
nursing assessment for, 210 776 after heart surgery, 289
risk factors of, 210 Peritoneal lavage, for peritonitis, with hospital-acquired, 151
therapeutic interventions for, 210 pancreatitis, 625 hyperthermia in, 158
Pericarditis, with pneumonia, 160-162 Peritonitis, risk for, pancreatitis, acute, imbalanced nutrition in, 155-156
Perineal care, for risk of infection, 59 624-625 impaired respiratory function in,
with inflammatory bowel disease, 536 clinical manifestations of, 624 151-153
Perineal hygiene, for risk of extrapulmo- desired outcomes of, 625 nausea in, 166
nary infection, with pneumonia, 162 nursing assessment of, 625 outcome/discharge criteria for, 151
Peripheral neurovascular dysfunction risk factors of, 625 postoperative, 114
in fractured hip with internal fixation therapeutic interventions for, 625 risk for atelectasis in, 163-164
or prosthesis insertion, 688-689 Pesticides, contamination due to, 43 risk for deficient fluid volume in,
clinical manifestations of, 688 Pharyngeal phase impairment, impaired 153-155
desired outcomes for, 688-689 swallowing due to, 74 risk for extrapulmonary infection and/
NIC interventions for, 688 Physical mobility, impaired, 60-62 or superinfection in, 160-162
NOC outcomes for, 688 in amputation, 676-677 risk for pleural effusion in, 162-163
nursing assessment for, 688 clinical manifestations of, 677 ventilator-acquired, 146-147
risk factors for, 688 desired outcomes for, 677 Pneumonitis, radiation, as neoplastic
therapeutic interventions for, 689 NIC interventions for, 677 disorders, 792-793
after laminectomy/discectomy with or NOC outcomes for, 677 desired outcomes for, 793
without fusion, 702-703 nursing assessment for, 677 nursing assessment for, 793
clinical manifestations of, 702 risk factors for, 677 risk factors for, 793
desired outcomes for, 702-703 therapeutic interventions for, 677 therapeutic interventions for, 793
NIC interventions for, 703 with cerebrovascular accident, 359 Pneumothorax, 166
NOC outcomes for, 703 clinical manifestations of, 60 acute chest pain in, 170-171
nursing assessment for, 703 desired outcomes for, 60 closed, 166
risk factors for, 702 documentation for, 60-62 discharge teaching/continued care
therapeutic interventions for, 703 in elderly client, 819-820 for, 174
 904 Index

Pneumothorax (Continued) Post-trauma syndrome, with traumatic Prophylactic dressings, for pressure ulcer, 17
disturbed sleep pattern in, 177 brain injury/craniotomy, 374 Prosthesis insertion, internal fixation or,
extended, 172, 195 Powerlessness fractured hip with, 685-686
after thoracic surgery, 195 with chemotherapy, 779 preoperative care for, 686
fear/anxiety in, 173-174, 175-176 risk for acute pain in, 686-688
after heart surgery, 296-297 with asthma, 122 fear/anxiety in, 687
impaired gas exchange in, 168-170 with chronic obstructive pulmonary risk for peripheral neurovascular
with implantable cardiac devices, 318 disease, 141 dysfunction in, 688-689
ineffective breathing pattern in, with mechanical ventilation, 150 Protamine sulfate, for risk of bleeding
177-179 with spinal cord injury, 397 after heart surgery, 294
nausea in, 177 Preload, cardiac output and, 37 with pulmonary embolism, 183
after nephrectomy, 645-647 Preoperative care, 87 Protectants, for diarrhea, 47
clinical manifestations of, 645 client teaching in, 90 Protective measures, for confusion, with
desired outcomes for, 645-647 deficient knowledge, 90 procedural sedation, 87
nursing assessment for, 646 for fear/anxiety, 87-90 Protein-calorie malnutrition (PCM), 500
risk factors for, 645 goals of, 87 Pruritus, impaired comfort with, cirrho-
therapeutic interventions for, 646 Prerenal AKI, 649 sis, 584-585
open, 166 Prerenal failure, 649 clinical manifestations of, 584
outcome/discharge criteria for, 166 Pressure ulcer, 13-17 desired outcomes of, 584-585
primary spontaneous, 166 clinical manifestations of, 13 NIC interventions of, 584
tension, with mediastinal shift, 171-172 desired outcomes for, 13 NOC outcomes of, 584
with implantable cardiac devices, documentation for, 13-17 nursing assessment of, 585
318 NIC interventions for, 14 risk factors of, 584
treatment of, 166 NOC outcomes for, 14 therapeutic interventions for, 585
Pollution, contamination due to, 43 nursing assessment for, 14 Pulmonary embolism, 177
Polyuria, due to diabetes insipidus, with risk factors for, 13 acute pain (chest) in, 180-182
traumatic brain injury/craniotomy, therapeutic interventions for, 14 with cardiac dysrhythmias, 237.e6
368 Prinzmetal variant angina, 227 with deep vein thrombosis, 250-251
PONV. see Postoperative nausea and Prioritization, 1-8 discharge teaching/continued care
vomiting Procedural sedation, 81 for, 187
Port-a-Cath (implanted infusion device), actual/risk for impaired respiratory fear/anxiety in, 180-182
with chemotherapy, 776 function with, 82-83 impaired gas exchange, 179-180
Portal-systemic encephalopathy, with cir- clinical manifestations of, 82 ineffective breathing pattern in, 177-179
rhosis, 592-594 desired outcomes for, 82-83 outcome/discharge criteria of, 177
clinical manifestations of, 592 NIC interventions for, 82 tisk for atelectasis in, 185-186
desired outcomes of, 593-594 NOC outcomes for, 82 risk for bleeding, 182-183
nursing assessment of, 593 nursing assessment for, 82 risk for right-sided heart failure in,
risk factors of, 593 risk factors for, 82 184-185
therapeutic interventions for, 593 therapeutic interventions for, 83 treatment of, 177
Positive end-expiratory pressure (PEEP), acute confusion with, 86-87 Pulmonary fibrosis, with chemotherapy,
for risk of decreased cardiac output, clinical manifestations of, 86 766-767
with mechanical ventilation, 144 desired outcomes for, 86-87 desired outcomes for, 766-767
Positive-pressure ventilation, invasive, 142 NIC interventions for, 86 nursing assessment for, 766
Postoperative care, 91-92 NOC outcomes for, 86 risk factors for, 766
for acute pain, 95-97 nursing assessment for, 86 therapeutic interventions for, 767
additional care plans for, 114 risk factors for, 86 Pulmonary inflammation, with chemo-
for bathing, dressing, feeding, and therapeutic interventions for, 86 therapy, 766-767
toileting self-care deficit, 108-109 acute pain with, 85-86 desired outcomes for, 766-767
for deficient knowledge, 112-115 clinical manifestations of, 85 nursing assessment for, 766
for delayed surgical recovery, 105-107 desired outcomes for, 85-86 risk factors for, 766
for electrolyte imbalance, 98-101 NIC interventions for, 85 therapeutic interventions for, 767
for imbalanced fluid volume, 98-101 NOC outcomes for, 85-86 Pulseless ventricular tachycardia, with
for imbalanced nutrition, 101-103 nursing assessment for, 85 malfunction of implantable cardiac
for impaired oral mucous membrane, risk factors for, 85 devices, 316
107-108 therapeutic interventions for, 85
for ineffective airway clearance, 94-95 additional care plans for, 87 Q
for ineffective breathing pattern, 92-93 risk for injury with, 84-85 Quinine sulfate, with diabetes niellitus,
for nausea, 103-104 clinical manifestations of, 84 455
outcome/discharge criteria of, 92 desired outcomes for, 84-85
for risk of paralytic ileus, 111-112 NIC interventions for, 84 R
for risk of urinary retention, 109-111 NOC outcomes for, 84 Radiation, contamination due to, 43
for risk of venous thromboembolism, nursing assessment for, 84 Radiation cystitis, as neoplastic disorders,
97-98 risk factors for, 84 792
Postoperative nausea and vomiting therapeutic interventions for, 84 desired outcomes for, 792
(PONV), 104 Proctocolectomy, with ileostomy, nursing assessment for, 792
Postrenal AKI, 649 478, 479 risk factors for, 792
Postrenal failure, 649 Prokinetic agents, with enteral nutrition, 503 therapeutic interventions for, 792
 Index 905

Radiation pneumonitis, as neoplastic Respiratory depression, due to procedural Respiratory function (Continued)
disorders, 792-793 sedation, 86 pneumonia, 151
desired outcomes for, 793 Respiratory distress activity intolerance in, 159-160
nursing assessment for, 793 with hyperthyroidism, 465.e10-e11 acute pain in, 156-158
risk factors for, 793 with laminectomy/discectomy with or bacterial, 151
therapeutic interventions for, 793 without fusion, 706-707 in chronic obstructive pulmonary
Radical prostatectomy, 733-734 clinical manifestations of, 706 disease, 129-130
discharge teaching/continued care, 738 desired outcomes for, 707 community-acquired, 151
outcome/discharge criteria, 733 nursing assessment for, 707 discharge teaching/continued care
postoperative, 734 risk factors for, 707 for, 164
preoperative, 734 therapeutic interventions for, 707 disturbed sleep pattern in, 166
Rationales, 25-80 tisk for, after carotid endarterectomy, fear/anxiety in, 166
Recombinant activated protein C 241-242 hospital-acquired, 151
(drotrecogin alfa), for multiple Respiratory function hyperthermia in, 158
organ dysfunction syndrome, with client with alterations in, 116-216 imbalanced nutrition in, 155-156
abdominal trauma, 475 asthma, 116 impaired respiratory function in,
Rectovaginal fistulas, with inflammatory activity intolerance in, 118-120 151-153
bowel disease, 537-539 clinical manifestations of, 117 nausea in, 166
desired outcomes for, 538 desired outcomes for, 117 outcome/discharge criteria for, 151
nursing assessment for, 538 disturbed sleep pattern in, 122 risk for atelectasis in, 163-164
risk factors for, 538 fear and anxiety in, 122 risk for deficient fluid volume in,
therapeutic interventions for, 538 impaired respiratory function in, 153-155
Reflex urinary incontinence, 76 116-118 risk for extrapulmonary infection
in elderly client, 821 NIC interventions for, 117 and/ or superinfection in,
Regurgitation, aspiration risk and, 33 NOC outcomes for, 117 160-162
Renal calculi, with inflammatory bowel nursing assessment for, 117 risk for pleural effusion in, 162-163
disease, 536-537 outcome/discharge criteria of, 116 ventilator-acquired, 146-147
desired outcomes for, 537 risk factors of, 117 pneumothorax, 166
nursing assessment for, 537 risk for powerless in, 122 acute chest pain in, 170-171
risk factors for, 537 therapeutic interventions for, 118t closed, 166
therapeutic interventions for, 537 imbalanced nutrition in pneumonia discharge teaching/continued care
Renal function, impaired clinical manifestations of, 155 for, 174
with chemotherapy, 761-762 desired outcomes for, 155-156 disturbed sleep pattern in, 177
desired outcomes for, 762 NIC interventions for, 155 extended, 172, 195
nursing assessment for, 762 NOC outcomes for, 155 fear/anxiety in, 173-174, 175-176
risk factors for, 762 nursing assessment for, 155 impaired gas exchange in, 168-170
therapeutic interventions for, 762 risk factors of, 155 ineffective breathing pattern in,
due to hypertension, 306-307 therapeutic interventions for, 155 177-179
after heart surgery, 295-296 mechanical ventilation, 141-142 nausea in, 177
Renal infection, with tuberculosis, actual/risk for dysfunctional open, 166
209-211 ventilatory weaning response outcome/discharge criteria for, 166
clinical manifestations of, 209 with, 147-149 primary spontaneous, 166
desired outcomes for, 210-211 alarms with, 144 treatment of, 166
NIC interventions for, 210 fear/anxiety with, 150 pulmonary embolism, 177
NOC outcomes for, 210 imbalanced nutrition with, 145 acute pain (chest) in, 180-182
nursing assessment for, 210 impaired oral mucous membrane discharge teaching/continued care
risk factors of, 210 with, 150 for, 187
therapeutic interventions for, 210 impaired physical mobility with, fear/anxiety in, 180-182
Renal insufficiency, with heart failure, 273 150 impaired gas exchange, 179-180
Renal stones. see Urolithiasis and impaired respiratory function, ineffective breathing pattern in,
Reproductive system, client with 142-145 177-179
alterations in, 713-752 impaired verbal communication outcome/discharge criteria of, 177
hysterectomy, 713 with, 150 risk for atelectasis in, 185-186
additional care plans, 719 outcome/discharge criteria of, 142 tisk for bleeding, 182-183
discharge teaching/continued care, 717 potential complications of, 143 risk for right-sided heart failure in,
outcome/discharge criteria, 713 powerlessness with, 150 184-185
postoperative, 713 risk for aspiration with, 150 treatment of, 177
radical prostatectomy, 733-734 risk for barotrauma with, 150 thoracic surgery, 191
discharge teaching/continued care, 738 risk for decreased cardiac output acute pain (chest) in, 193-195
outcome/discharge criteria, 733 with, 149 discharge teaching/continued care
postoperative, 734 risk for fluid retention/fluid for, 200
preoperative, 734 volume overload with, 151 fear and anxiety prior to, 191
transurethral resection of the prostate, 742 risk for infection (ventilator- impaired respiratory function in,
additional nursing diagnoses, 752 acquired pneumonia) with, 191-193
discharge teaching/continued care, 749 146-147 outcome/discharge criteria for, 191
outcome/discharge criteria, 742 risk for injury with, 151 restricted arm and shoulder
postoperative, 742 ventilator settings for, 144 movement in, 200
 Index

Respiratory function (Continued) Respiratory function (Continued) Sedation, procedural (Continued)

risk for acute pulmonary edema, therapeutic interventions for, 287 NIC interventions for, 82
198-199 with human immunodeficiency virus NOC outcomes for, 82
risk for bronchopleural fistula in, infection and acquired immune nursing assessment for, 82
19S deficiency syndrome, 423-425 risk factors for, 82
risk for cardiac dysrhythmias in, clinical manifestations of, 424, 424t therapeutic interventions for, 83
197-198 desired outcomes in, 424-425 acute confusion with, 86-87
risk for ineffective lung expansion NIC interventions in, 424t clinical manifestations of, 86
in, 195-197 NOC outcomes in, 424t desired outcomes for, 86-87
tuberculosis, 203 nursing assessment in, 424t NIC interventions for, 86
activity intolerance in, 207-209 risk factors for, 424 NOC outcomes for, 86
acute pain in, 216 therapeutic interventions for, nursing assessment for, 86
disturbed sleep pattern in, 216 424-425t risk factors for, 86
fear/anxiety in, 216 in mechanical ventilation, 142-145 therapeutic interventions for, 86
imbalanced nutrition in, 205—207 clinical manifestations of, 143 acute pain with, 85-86
impaired respiratory function in, desired outcomes for, 143-145 clinical manifestations of, 85
203-205 NIC interventions for, 143 desired outcomes for, 85-86
multidrug-resistant, 203 NOC outcomes for, 143 NIC interventions for, 85
outcome/discharge criteria for, 203 nursing assessment for, 143 NOC outcomes for, 85-86
patient discharge/continued care risk factors of, 143 nursing assessment for, 85
for, 213 therapeutic interventions for, 143 risk factors for, 85
precautions with, 203 in pneumonia, 151-153 therapeutic interventions for, 85
risk for atelectasis, 212-213 clinical manifestations of, 152 additional care plans for, 87
risk for deficient fluid volume in, desired outcomes for, 152-153 risk for injury with, 84-85
216 NIC interventions for, 152 clinical manifestations of, 84
risk for extrapulmonary infection NOC outcomes for, 152 desired outcomes for, 84-85
and/or superinfection in, 210 nursing assessment for, 152 NIC interventions for, 84
risk for pleural effusion, 211-212 risk factors of, 152 NOC outcomes for, 84
signs and symptoms of, 203 therapeutic interventions for, 152 nursing assessment for, 84
impaired Respiratory secretions, and risk of infec- risk factors for, 84
in chronic obstructive pulmonary, tion therapeutic interventions for, 84
123-125 with inflammatory bowel disease, 536 Sedative-hypnotics, for disturbed sleep
clinical manifestations of, 124 with stasis, 59 pattern, in elderly client, 826
desired outcomes for, 124-125 Rest pain, prior to femoropopliteal Seizures, with traumatic brain injury/
NIC interventions for, 124 bypass, 257-259 craniotomy, 367-368
NOC outcomes for, 124 clinical manifestations of, 257 Selected nursing diagnoses, 25-80
nursing assessment for, 124 desired outcomes for, 258-259 Self-care, readiness for enhanced, 68-69
risk factors of, 124 nursing assessment for, 258 clinical manifestations of, 68
therapeutic interventions for, 125 nursing interventions Classifications desired outcomes for, 68
in elderly client, 809-811 (NIC) for, 258 documentation for, 68-69
clinical manifestations of, 809 nursing Outcomes interventions (NOC) NIC interventions for, 69
desired outcomes, 809-811 for, 258 NOC outcomes for, 69
NIC interventions, 809 risk factors for, 258 nursing assessment for, 69
NOC outcomes, 809 therapeutic interventions for, 258 therapeutic interventions for, 69
nursing assessment, 810 Right-sided heart failure, risk for Self-care deficits
risk factors for, 809 in chronic obstructive pulmonary with Alzheimer disease/dementia, 341-
signs and symptoms of, 810 disease, 131-132 342
therapeutic interventions for, 810 clinical manifestations of, 131 clinical manifestations of, 341, 341t
with heart failure, 268-270 desired outcomes for, 131-132 desired outcomes in, 341-342
clinical manifestation of, 268 nursing assessment for, 131t NIC interventions in, 341t
desired outcomes for, 269-270 risk factors of, 131 NOC outcomes in, 341t
nursing assessment for, 269 therapeutic interventions for, 131 nursing assessment, 342t
nursing interventions classifica- with pulmonary embolism, 184-185 risk factors for, 341
tions (NIC) for, 269 Right upper quadrant pain, with therapeutic interventions for, 342t
nursing outcomes interventions hepatitis, 612 bathing, dressing, feeding, and
(NOC) for, 269 Risk-prone health behavior, 57 toileting, postoperative, 108-109
risk factors for, 269 Role performance, ineffective, with clinical manifestations of, 108
therapeutic interventions for, 269 ileostomy, 492 desired outcomes for, 108
after heart surgery, 285-287 NIC interventions for, 110
clinical manifestation of, 286 S NOC outcomes for, 109
desired outcomes for, 286-287 Saphenous vein damage, after nursing assessment for, 109
nursing assessment for, 286 femoropopliteal bypass, 261-262 risk factors for, 108
nursing interventions classifications Sedation, procedural, 81 therapeutic interventions for, 109
(NIC) for, 286 actual/risk for impaired respiratory with cerebrovascular accident, 352-354
nursing outcomes interventions function with, 82-83 clinical manifestations of, 353, 353t
(NOC) for, 286 clinical manifestations of, 82 desired outcomes in, 353-354
risk factors for, 286 desired outcomes for, 82-83 NIC interventions in, 353t
 Index 907

Self-care deficits (Continued) Self-health management, ineffective Sepsis (Continued)

NOC outcomes in, 353t (Continued) desired outcomes of, 620-621
nursing assessment, 353t after bowel resection, 563-566 NIC interventions of, 623
risk factors for, 353 NIC interventions for, 563 NOC outcomes of, 620
therapeutic interventions for, 353-354t NOC outcomes for, 563 nursing assessment of, 620
with chronic obstructive pulmonary nursing assessment for, 563 risk factors of, 620
disease, 141 risk factors for, 563-565 therapeutic interventions for, 620
end-of-life nursing care for, 858 therapeutic interventions for, 563 potential complication of, 442
with Parkinson disease, 411 with enteral nutrition, 505-508 disseminated intravascular
with spinal cord injury, 382-383 NIC interventions for, 505 coagulation, 444
clinical manifestations for, 382, 382t NOC outcomes for, 505 organ ischemia/ dysfunction
desired outcomes in, 382-383 nursing assessment for, 505 (multiple organ dysfunction
NIC interventions in, 382t risk factors for, 505-506 syndrome), 445-446
NOC outcomes in, 382t therapeutic interventions for, 505 septic shock, 442-443
nursing assessment, 383t after gastric reduction surgery, 515-521 risk for imbalanced fluid volume,
therapeutic interventions for, 383t NIC interventions for, 515 436-438
with traumatic brain injury/ NOC outcomes for, 515 risk for infection, 440-442
craniotomy, 374 nursing assessment for, 515 Septic arthritis, with pneumonia, 160-162
Self-concept risk factors for, 515 Septic shock, 442
disturbed therapeutic interventions for, 515 with abdominal trauma, 473-474
with cerebrovascular accident, 359 with inflammatory bowel disease, desired outcomes for, 474
with chemotherapy, 768-771 541-544 nursing assessment for, 474
desired outcomes for, 769-771 NIC interventions for, 541 risk factors for, 474
NIC interventions for, 769 NOC outcomes for, 541 therapeutic interventions for, 474
NOC outcomes for, 769 nursing assessment for, 541 Septicemia, 434
nursing assessment for, 769 risk factors for, 541-543 Sexual dysfunction
risk factors for, 769 therapeutic interventions for, 541 with cerebrovascular accident, 358
therapeutic interventions for, 769 with intestinal obstruction, 551-553 with diabetes mellitus, 465
with ileostomy, 492-494 NIC interventions for, 552 with spinal cord injury, 386-388
desired outcomes for, 492-494 NOC outcomes for, 552 clinical manifestations of, 386,
NIC interventions for, 492-494 nursing assessment for, 552 386t
NOC outcomes for, 492 risk factors for, 552-553 NIC interventions for, 387t
nursing assessment for, 492 therapeutic interventions for, 552 NOC outcomes for, 387t
risk factors for, 492 after myocardial infarction, 334-339 nursing assessment, 387t
therapeutic interventions for, 493 clinical manifestations of, 334 risk factors for, 386
with inflammatory bowel disease, 543 nursing assessment for, 335 therapeutic interventions for,
with neoplastic disorders, 794-796 nursing interventions classifications 387-388t
desired outcomes for, 795-796 (NIC) for, 335 TURP and, 752
NIC interventions for, 795 nursing outcomes interventions Sexuality patterns, ineffective
NOC outcomes for, 795 (NOC) for, 335 in elderly client, 837-838
nursing assessment for, 795 risk factors for, 335-338 ileostomy, 490-492
risk factors for, 795 therapeutic interventions for, 335 desired outcomes for, 491-492
therapeutic interventions for, 795 with neoplastic disorders, 796-805 NIC interventions for, 491
Parkinson disease with, 407-408 NIC interventions for, 797 NOC outcomes for, 491
prior to gastric reduction surgery, NOC outcomes for, 797 nursing assessment for, 491
507, 508-509 risk factors for, 797-804 risk factors for, 491
desired outcomes for, 508-509 therapeutic interventions for, 797 therapeutic interventions for, 491
NIC interventions for, 508 with parenteral nutrition, 569-571 Shock
NOC outcomes for, 508 NIC outcomes for, 570 after abdominal aortic aneurysm
nursing assessment for, 508 NOC interventions for, 570 repair, 220-222
risk factors for, 508 nursing assessment for, 570 clinical manifestations of, 220
therapeutic interventions for, 508 risk factors for, 570 desired outcome for, 220-222
spinal cord injury, 398 therapeutic interventions for, 570 nursing assessment for, 220
with traumatic brain injury/ Sensory perception, disturbed, with nursing interventions classifications
craniotomy, 375 Alzheimer disease/dementia, 346 (NIC) for, 220
readiness for enhanced, 69 Sepsis, 434-435 nursing outcomes interventions
Self-esteem, situational low decreased cardiac tissue perfusion, (NOC) for, 220
with chemotherapy, 768 435-436 risk factors for, 220
with ileostomy, 492 fear, and anxiety with, 446 therapeutic intervention for, 221
prior to gastric reduction, 508 hyperthermia with, 434 after nephrectomy, 643-644
Self-health management, ineffective impaired gas exchange with, 438-439 clinical manifestations of, 643
with acute GI bleed, 525-527 ineffective cerebral tissue perfusion, desired outcomes for, 643-644
NIC interventions for, 525 435-436 NIC interventions for, 643
NOC outcomes for, 525 ineffective peripheral tissue perfusion, NOC outcomes for, 643
nursing assessment for, 525 435-436 nursing assessment for, 643
risk factors for, 525-526 with pancreatitis, 619-621 risk factors for, 643
therapeutic interventions for, 525 clinical manifestations of, 620 therapeutic interventions for, 643
908 Index

Shock (Continued) Skin integrity, impaired (Continued) Spinal cord injury (Continued)
pancreatitis and, 623-624 nursing assessment for, 70 with interrupted family process,
clinical manifestations of, 623 tisk factors for, 70 388-389
desired outcomes of, 623-624 therapeutic interventions for, 70 outcome/discharge criteria, 375
NIC interventions of, 623 Skin pain, with human immunodeficiency with risk for ascending spinal cord
NOC outcomes of, 623 virus infection and acquired immune injury, 389-390
nursing assessment of, 623 deficiency syndrome, 426 risk for aspiration with, 397
risk factors of, 623 Skin turgor, in elderly client, 812 risk for autonomic dysreflexia, 380-382
therapeutic interventions for, 624 Skin wounds, pressure ulcer due to, 14 risk for constipation, 398
risk for, gastrointestinal bleed, acute, Sleep cycle, 73 risk for gastrointestinal bleeding,
519-521 Sleep pattern 391-393
desired outcomes for, 520-521 with chemotherapy, 779 risk for infection, 398
NIC interventions for, 520 disturbed, 72-74 risk for injury, 383-385
NOC outcomes for, 520 in asthma, 122 risk for loneliness with, 397
nursing assessment for, 520 with chronic obstructive pulmonary risk for paralytic ileus, 391
risk factors for, 520 disease, 141 risk for powerlessness, 397
therapeutic interventions for, 520 with cirrhosis, 601 risk for venous thromboembolism,
Shoulder movement, restricted, after clinical manifestations of, 72 385-386
thoracic surgery, 200 desired outcomes for, 72 with self-care deficit, 382-383
Side effects, of drugs, in asthma, 121 documentation for, 72-74 sexual dysfunction with, 386-388
Situational low self-esteem in elderly client, 825-826 Spiritual distress
with chemotherapy, 768 end-of-life nursing care for, 859 end-of-life nursing care for, 854-855
with ileostomy, 492 with heart failure, 281 with human immunodeficiency virus
prior to gastric reduction, 508 with hyperthyroidism, 465.e6—e8 infection and acquired immune
risk for, after hysterectomy, 716-717 with inflammatory bowel disease, deficiency syndrome, 427-428
clinical manifestations, 716 543 tisk for, with cirrhosis, 594-595
NIC interventions, 717 with intestinal obstruction and clinical manifestations of, 594
NOC outcomes, 717 bowel resection, 565 NIC interventions of, 594
nursing assessment, 717 with myocardial infarction, 339 NOC outcomes of, 594
risk factors, 717 NIC interventions for, 73 nursing assessment of, 594
therapeutic interventions, 717 NOC outcomes for, 73 tisk factors of, 594-595
Skeletal infection, with tuberculosis, nursing assessment for, 73 therapeutic interventions for, 594
209-211 with pneumonia, 166 Splenectomy, 446
clinical manifestations of, 209 with pneumothorax, 177 Spontaneous breathing trial, for ventilator
desired outcomes for, 210-211 postoperative, 114 weaning, 148
NIC interventions for, 210 risk factors for, 72 Spontaneous ventilation, impaired, with
NOC outcomes for, 210 therapeutic interventions for, 73 mechanical ventilation, 142
nursing assessment for, 210 with tuberculosis, 216 Standardized nursing care plan, creation
risk factors of, 210 Sleep promotion, for activity intolerance of individualized, prioritized care
therapeutic interventions for, 210 in asthma, 118 plan from, 4
Skin changes, with chemotherapy, 770 in chronic obstructive pulmonary ST-elevation myocardial infarction, 323
Skin damage, pressure ulcer due to, 14 disease, 128 Stomal changes, risk for, 488-489
Skin integrity, impaired, 69-72 Smoking, in elderly client desired outcomes for, 488-489
with chemotherapy, 779 with impaired respiratory function, nursing assessment for, 488
clinical manifestations of, 69 810 risk factors for, 488
desired outcomes for, 70 with tissue perfusion, 808 therapeutic interventions for, 489
documentation for, 70-72 Social interactions, impaired, with Stomatitis, with chemotherapy, 758
in elderly client, 815-816 Alzheimer disease/dementia, 346 Stool softeners, for constipation, in
end-of-life nursing care for, 848-849 Sodium nitrite, for cyanide poisoning, 45 elderly client, 825
with laminectomy/discectomy with or Sodium thiosulfate, for cyanide Stress reduction, for risk of infection, with
without fusion, 705-706 poisoning, 45 inflammatory bowel disease, 536
clinical manifestations of, 705 Spinal cord injury, 375 Stress urinary incontinence, 76
desired outcomes for, 705-706 acute/chronic pain with, 397 in elderly client, 821
NIC interventions for, 705 anxiety with, 397 Subclavian venous thrombosis, 246
NOC outcomes for, 705 discharge teaching/continued care, 393 Suctioning
nursing assessment for, 706 with disturbed self-concept, 398 for impaired gas exchange, du¢ to
risk factors for, 705 fear with, 397 pneumothorax, 169
therapeutic interventions for, 706 grieving with, 397 for impaired respiratory function, due
with neoplastic disorders, 786-788 imbalanced nutrition with, 397 to pneumonia, 153
desired outcomes for, 786-788 impaired physical mobility with, for ineffective airway clearance after
NIC interventions for, 787 377-379 bowel resection, 556
NOC outcomes for, 787 impaired urinary elimination with, 397 for ineffective airway clearance due to,
nursing assessment for, 787 ineffective breathing pattern with, postoperative, 95
risk factors for, 786 376-377 for risk for aspiration, in end-of-life
therapeutic interventions for, 787 with ineffective coping, 398 nursing care, 846
NIC interventions for, 70 ineffective thermoregulation with, Sudden cardiac death, with cardiac
NOC outcomes for, 70 379-380 dysrhythmias, 237.e7-e8
 Index 909

Sulfasalazine, for acute/chronic pain, with Swallowing, impaired (Continued) T

inflammatory bowel disease, 533 risk for aspiration due to, 33 T tube care, after cholecystectomy, 572
Superinfection, with tuberculosis, and risk for imbalanced nutrition, with T3 (triiodothyronine), in hyperthyroidism,
209-211 chemotherapy, 755 465.e1
Supervision, in delegation, 1-2, 2f therapeutic interventions for, 75 T4 (thyroxine), in hyperthyroidism, 465.e1
Supraventricular dysrhythmias, 237.e1 Sympathetic stimulation, and decreased TB. see Tuberculosis
Surgical patient, 81-115 cardiac output, after abdominal Thermoregulation, ineffective, with
outcome/discharge criteria of, 81 aortic aneurysm repair, 224 spinal cord injury, 379-380
postoperative care, 91-92 Sympathomimetics Thiamine, for confusion, with cirrhosis, 587
for acute pain, 95-97 for cardiogenic shock, with heart Third-spacing of fluid, with heart failure,
additional care plans for, 114 failure, 277 270
for bathing, dressing, feeding, and for decreased cardiac output, after Thoracic surgery, 191
toileting self-care deficit, heart surgery, 285 acute pain (chest) in, 193-195
108-109 for decreased intracranial adaptive discharge teaching/continued care
for deficient knowledge, 112-115 capacity, due to traumatic brain for, 200
for delayed surgical recovery, 105-107 injury/craniotomy, 362 fear and anxiety prior to, 191
for electrolyte imbalance, 98-101 for impaired urinary elimination, in impaired respiratory function in,
for imbalanced fluid volume, 98-101 elderly client, 823 191-193
for imbalanced nutrition, 101-103 for ineffective airway clearance, 28 clinical manifestations of, 192
for impaired oral mucous membrane, Symptoms, reporting on desired outcomes for, 192-193
107-108 after abdominal aortic aneurysm NIC interventions for, 192
for ineffective airway clearance, repair, 226 NOC outcomes for, 192
94-95 with abdominal trauma, 477 nursing assessment for, 192
for ineffective breathing pattern, with acute GI bleed, 526 risk factors of, 192
92-93 with angina pectoris, 236 therapeutic interventions for, 192
for nausea, 103-104 with asthma, 121 outcome/discharge criteria for, 191
outcome/discharge criteria of, 92 after bowel resection, 564 restricted arm and shoulder movement
for risk of paralytic ileus, 111-112 with cardiac dysrhythmias, 237.e9 in, 200
for risk of urinary retention, 109-111 after carotid endarterectomy, 245 tisk for acute pulmonary edema,
for risk of venous thromboembolism, with chemotherapy, 777 198-199
97-98 after cholecystectomy, 572 risk for bronchopleural fistula in, 199
preoperative, 87 with chronic obstructive pulmonary risk for cardiac dysrhythmias in,
client teaching in, 90 disease, 140 197-198
deficient knowledge, 90 with deep venous thrombosis, 255 risk for ineffective lung expansion in,
for fear/anxiety, 87-90 after femoropopliteal bypass, 264 195-197
procedural sedation of, 81 after gastric reduction surgery, 517 Thought processes, disturbed end-of-life
actual/risk for impaired respiratory with heart failure, 280 nursing care for, with heart failure, 282
function with, 82-83 after heart surgery, 300 Thrombin inhibitors, for ineffective
acute confusion with, 86-87 with hepatitis, 611 peripheral tissue perfusion, due to
acute pain with, 85-86 with human immunodeficiency virus deep vein thrombosis, 247
additional care plans for, 87 infection and acquired immune Thrombophlebitis, 246
risk for injury with, 84-85 deficiency syndrome, 431 Thyroid storm, 465.e1
Surgical site infection, after amputation, with hypertension, 311 after thyroidectomy, 465.e12
678-679 with ileostomy, 498 Thyroidectomy
clinical manifestations of, 678 with implantable cardiac devices, 322 postoperative care plan for, 465.e8
NIC interventions for, 678 with inflammatory bowel disease, 542 preoperative care plan for, 465.e8
NOC outcomes for, 678 with intestinal obstruction, 552 Thyroidism, 465.e1
nursing assessment for, 678 with myocardial infarction, 337 activity intolerance with, 465.e4-e6
risk factors for, 678 with nephrectomy, 648 deficient knowledge with, 465.e8
therapeutic interventions for, 678 with parenteral nutrition, 569 disturbed sleep pattern with, 465.e6-e8
Surveillance, in delegation, 2, 2f with pneumonia, 165 imbalanced nutrition with, 465.e3-e4
Swallowing, impaired, 74—76 with pneumothorax, 176 outcome/discharge criteria for, 465.e1
with cerebrovascular accident, 359 with pulmonary embolism, 190 risk for bleeding, 465.e8-e10
clinical manifestations of, 74 after thoracic surgery, 200 risk for decreased cardiac output,
desired outcomes for, 7, 75 with tuberculosis, 212 465.e1-e2
documentation for, 75-76 Syndrome of inappropriate antidiuretic risk for hypocalcemia with, 465.e11
with neoplastic disorders, 783-785 hormone, with traumatic brain risk for laryngeal nerve damage with,
desired outcomes for, 784-785 injury/craniotomy, 368-370 465.e13-e14
NIC interventions for, 784 Systemic arterial embolism, with cardiac risk for respiratory distress, 465.e10-el1
NOC outcomes for, 784 dysrhythmias, 237.e5—e7 subtotal, 465.e1
nursing assessment for, 784 clinical manifestations of, 237.e5 and thyrotoxicosis, 465.e1
risk factors for, 784 desired outcomes for, 237.e6-e7 Thyroid-stimulating hormone, in
therapeutic interventions for, 784 nursing assessment for, 237.e6 hyperthyroidism, 465.e1
NIC interventions for, 75 risk factors for, 237.e6 Thyrotoxic crisis, 465.e1
NOC outcomes for, 75 therapeutic interventions for, 237.e6 after thyroidectomy, 465.e12
nursing assessment for, 75 Systemic inflammatory response Thyrotoxicosis, 465.e1
risk factors for, 74 syndrome, 434 Tingling, with diabetes, 447
910 Index

Tissue integrity, impaired Tissue perfusion (Continued) Traumatic brain injury, 359-360
in amputation, 675-676 risk factors for, 240 acute pain (headache), 362-363
clinical manifestations of, 675 therapeutic interventions for, 240 decreased intracranial adaptive
desired outcomes for, 675-676 prior to carotid endarterectomy, capacity with, 360-362
NIC interventions for, 675 238-239 with disturbed self-concept, 375
NOC outcomes for, 675 ineffective, with sepsis, 435-436 fear/anxiety with, 374
nursing assessment for, 675 peripheral, ineffective with impaired physical mobility, 374
risk factors for, 675 with abdominal trauma, 470-471 with ineffective coping, 375
therapeutic interventions for, 675 desired outcomes for, 470-471 with interrupted family processes, 375
with deep vein thrombosis, 249-250 NIC interventions for, 470 risk for acute confusion with,
after gastric reduction surgery, 518-519 NOC outcomes for, 470 363-365
with heart failure, 281 nursing assessment for, 471 risk for diabetes insipidus, 368
with ileostomy, 478, 482-486 risk factors for, 470 risk for gastrointestinal bleeding,
desired outcomes for, 483-486 therapeutic interventions for, 471 370-371
NIC interventions for, 483 with deep vein thrombosis, 247-248 risk for imbalanced body temperature,
NOC outcomes for, 483 with diabetes mellitus, 453-455 374
nursing assessment for, 483 clinical manifestations for, 453, 453t risk for ineffective airway clearance,
risk factors for, 483 desired outcomes in, 453-455 374
therapeutic interventions for, 483 NIC interventions in, 453t risk for injury, 374
with inflammatory bowel disease, NOC outcomes in, 453t risk for meningitis with, 365-366
543-544 nursing assessment, 454t risk for post-trauma syndrome, 374
after mastectomy, 726-727 risk factors for, 453 risk for seizures with, 367-368
clinical manifestations, 726 therapeutic regimen, 454—-455t risk for syndrome of inappropriate
desired outcomes, 726-727 after femoropopliteal bypass, antidiuretic hormone, 368-370
NIC interventions, 726 256-257 with self-care deficit, 374
NOC outcomes, 726 in hypertension, 302-303 Tuberculosis (TB), 203
nursing assessment, 726 prior to femoropopliteal bypass, activity intolerance in, 207-209
risk factors, 726 256-257 acute pain in, 216
therapeutic interventions, 726 Tongue turgor, in elderly client, 812 disturbed sleep pattern in, 216
with total joint replacement (hip/ Total joint replacement (hip/knee), fear/anxiety in, 216
knee), 695-697 689-690 imbalanced nutrition in, 205-207
clinical manifestations of, 695 activity intolerance with, 701 clinical manifestations of, 206
desired outcomes for, 696-697 actual/risk for impaired tissue integrity desired outcomes for, 206-207
NIC interventions for, 696 with, 695-697 NIC interventions for, 207
NOC outcomes for, 696 acute pain with, 690-691 NOC outcomes for, 206
nursing assessment for, 696 discharge teaching/continued care nursing assessment for, 206
risk factors for, 696 after, 697 risk factors of, 206
therapeutic interventions for, 696 impaired physical mobility with, therapeutic interventions for, 206
Tissue perfusion 691-693 impaired respiratory function in,
cerebral, with cerebrovascular accident, preoperative care for, 690 203-205
348-349 prosthetic devices for, 690 multidrug-resistant, 203
clinical manifestations of, 347t, 348, related care plans for, 701 outcome/discharge criteria for, 203
348t risk for falls with, 701 patient discharge/continued care for,
desired outcomes in, 348-349 risk for infection with, 701 213
NIC interventions in, 348t risk for peripheral neurovascular precautions with, 203
NOC outcomes in, 348t dysfunction after, 693-695 risk for atelectasis, 212-213
nursing assessment, 349t Toxic megacolon, with inflammatory risk for deficient fluid volume in, 216
risk factors for, 348 bowel disease, 538 risk for extrapulmonary infection and/
therapeutic interventions for, 349t desired outcomes for, 539 or superinfection in, 210
in elderly client, 806 nursing assessment for, 539 risk for pleural effusion, 211-212
clinical manifestations of, 806 risk factors for, 539 signs and symptoms of, 203
desired outcomes in, 807-808 therapeutic interventions for, 539 Tubes, for risk of infection with, 59
NIC interventions, 807 Toxicity, drug, in elderly client, 835-837 TURP. see Transurethral resection of the
NOC outcomes, 807 clinical manifestations, 835 prostate
risk factors for, 807 desired outcomes, 836-837
signs and symptoms of, 807 nursing assessment, 836 U
therapeutic interventions for, 808 risk factors for, 836 Ulcer
ineffective, cerebral therapeutic interventions for, 836 peptic, 571
after carotid endarterectomy, Tracheostomy, after carotid endarterectomy, pressure, 13-17
239-241 242 clinical manifestations of, 13
clinical manifestations of, 240 Transmural myocardial infarction, 323 desired outcomes for, 13
desired outcomes for, 240-241 Transurethral resection of the prostate documentation for, 13-17
nursing assessment for, 240 (TURP), 742 NIC interventions for, 14
nursing interventions Classifications additional nursing diagnoses, 752 NOC outcomes for, 14
(NIC) for, 240 discharge teaching/continued care, 749 nursing assessment for, 14
nursing outcomes interventions outcome/discharge criteria, 742 tisk factors for, 13
(NOC) for, 240 postoperative, 742 therapeutic interventions for, 14
 Index 911

Ulcerative colitis, 527 Unstable blood glucose level (Continued) Urinary retention, 78-80
activity intolerance with, 543 NOC outcomes for, 54 clinical manifestations of, 78
acute/chronic pain with, 531-533 nursing assessment for, 54 desired outcomes for, 79
desired outcomes for, 532-533 risk factors for, 53 with diabetes mellitus, 465
NIC interventions for, 532 therapeutic interventions for, 54 documentation for, 79-80
NOC outcomes for, 532 Uremic syndrome, with renal failure, in elderly client, 821
nursing assessment for, 532 658-664 after hysterectomy, 713-715
risk factor for, 532 clinical manifestations of, 658 clinical manifestations, 714
therapeutic interventions for, 532 desired outcomes for, 663-664 desired outcomes, 714-715
discharge teaching/continued care for, nursing assessment for, 663 NIC interventions, 714
541-544 risk factors for, 663 NOC outcomes, 714
disturbed self-concept with, 543 therapeutic interventions for, 663 nursing assessment, 714
disturbed sleep pattern with, 543 Urge incontinence, 78 risk factors, 714
fear/anxiety with, 543 Urge urinary incontinence, 76 therapeutic interventions, 714, 715
imbalanced nutrition with, 529-531 in elderly client, 821 NIC interventions for, 79
desired outcomes for, 530-531 Urinary diversion, cystectomy with, NOC outcomes for, 79
NIC interventions for, 530 639-640 nursing assessment for, 79
NOC outcomes for, 530 Urinary elimination, impaired, postoperative, 109-111
nursing assessment for, 530 76-78 clinical manifestations of, 109
risk factors for, 530 with cerebrovascular accident, 359 desired outcomes for, 110-111
therapeutic interventions for, 530 clinical manifestations of, 77 NIC interventions for, 110-111
outcome/discharge criteria for, 527 desired outcomes for, 77 NOC outcomes for, 110
- tisk for abscesses and fistulas with, documentation for, 77-78 nursing assessment for, 110
537-539 in elderly client, 821-823 risk factors for, 110
desired outcomes for, 538 clinical manifestations of, 821 therapeutic interventions for, 110
nursing assessment, 538 desired outcomes in, 822-823 after radical prostatectomy, 734-735
risk factors for, 538 NIC interventions, 822 clinical manifestations, 734
therapeutic interventions for, 538 NOC outcomes, 822 desired outcomes, 734-735
risk for imbalanced fluid and nursing assessment for, 822 NIC interventions, 734
electrolytes with, 527-529 risk factors for, 822 NOC outcomes, 734
desired outcomes for, 528-529 signs and symptoms of, 822 nursing assessment, 734
NIC interventions for, 528-529 therapeutic interventions, 822 risk factors, 734
NOC outcomes for, 528 NIC interventions for, 77 therapeutic intervention, 734, 735
nursing assessment for, 528 NOC outcomes for, 77 risk factors for, 79
risk factors for, 528 nursing assessment for, 77 and risk for infection
therapeutic interventions for, 529 risk factors for, 77 with inflammatory bowel disease, 536
risk for impaired tissue integrity with, with spinal cord injury, 397 with sepsis, 419
543-544 therapeutic interventions for, 78 therapeutic interventions for, 79
risk for infection with, 534-536 after TURP, 742-744 Urinary tract, client with alterations in,
desired outcomes for, 534-536 clinical manifestations, 743 631-669
NIC interventions for, 534 desired outcomes, 743-744 cystectomy with urinary diversion,
NOC outcomes for, 534 NIC interventions, 743 639-640
nursing assessment for, 534 NOC outcomes, 743 outcome/discharge criteria of, 640
risk factors for, 534 nursing assessment, 743 nephrectomy, 640
therapeutic interventions for, 535 risk factors, 743 outcome/discharge criteria of, 640
risk for peritonitis with, 540 therapeutic interventions, 743 urolithiasis, 631
desired outcomes for, 540 urolithiasis in, 633-634 outcome/discharge criteria of, 631
nursing assessment for, 540 clinical manifestations of, 633 Urinary tract infection
risk factors for, 540 desired outcomes for, 633-634 after bowel resection, 565
therapeutic interventions for, 540 NIC interventions for, 635 postoperative, 114
risk for renal calculi with, 536-537 NOC outcomes for, 635 TURP and, 752
desired outcomes for, 537 nursing assessment for, 634 Urinary urgency, in elderly client, 821
nursing assessment for, 537 risk factors for, 633 Urolithiasis (renal stones), 631
risk factors for, 537 therapeutic interventions for, 634
therapeutic interventions for, 537 Urinary frequency, in elderly client, 821 V
risk for toxic megacolon with, 538 Urinary incontinence Vagal maneuvers, with cardiac
desired outcomes for, 539 with cerebrovascular accident, 359 dysrhythmias
nursing assessment for, 539 in elderly client, 821, 822 for activity intolerance, 237.e4
risk factors for, 539 end-of-life nursing care for, 849 for decreased cardiac output, 237.e2
therapeutic interventions for, 539 clinical manifestations of, Valve replacement, 282
Unilateral neglect, with cerebrovascular 850, 850t activity intolerance after, 301
accident, 350-351 desired outcomes in, 850-851 decreased cardiac output after, 283-285
Unstable blood glucose level, 53-55 NIC interventions in, 850t fear/anxiety prior to, 283
clinical manifestations of, 53 NOC outcomes in, 850t potential complications
desired outcomes for, 53 nursing assessment, 850t bleeding as, 292-294
documentation for, 53-55 risk factors for, 850 cardiac dysrhythmias as, 290-291
NIC interventions for, 54 therapeutic interventions for, 850t cardiac tamponade as, 291-292
912 Index

Valve replacement (Continued) Venous thromboembolization, after Vitamin K, for risk of bleeding, after
heart failure as, 301 abdominal aortic aneurysm repair heart surgery, 294
impaired renal function as, (Continued) Vitamin K antagonists, for ineffective
295-296 risk factors for, 222 peripheral tissue perfusion, due to
myocardial infarction as, 301-302 therapeutic interventions for, 222 deep vein thrombosis, 248
neurological dysfunction as, Ventilator-acquired pneumonia (VAP),
294-295 risk for, 146-147 W
pneumothorax as, 296-297 Ventilatory weaning response, Walker, 820
procedures for, 282 dysfunctional, 147-149 Wandering, with Alzheimer disease/
related care plans for, 301 clinical manifestations of, 147 dementia, 344-346
risk for imbalanced fluid and desired outcomes for, 147-149 clinical manifestations of,
electrolytes after, 287-289 NIC interventions for, 148 344, 344t
risk for impaired respiratory function NOC outcomes for, 148 desired outcomes in, 345-346
after, 285-287 nursing assessment for, 148 NIC interventions in, 345t
risk for infection after, 289-290 risk factors of, 147 NOC outcomes in, 345t
VAP. see Ventilator-acquired pneumonia therapeutic interventions for, 148, 148t nursing assessment, 345t
Venous thromboembolism Ventricular dysrhythmias, 237.e1 risk factors for, 345
postoperative, 97-98 Ventricular fibrillation, with malfunction therapeutic interventions for, 345t
clinical manifestations of, 97 of implantable cardiac devices, 316 Waste, contamination due to, 43
desired outcomes for, 97-98 Ventricular free wall, rupture of, with Weaning, from ventilator, dysfunctional,
NIC interventions for, 98 myocardial infarction, 331-332 147-149
NOC outcomes for, 98 Verbal communication, impaired Wound infection, after heart surgery,
nursing assessment for, 98 with cerebrovascular accident, 352 289
risk factors for, 97 with mechanical ventilation, 150 Wrist drop, with chemotherapy, 768
therapeutic interventions for, 98 with Parkinson disease, 406-407
with spinal cord injury, 385-386 Vesicant drugs, extravasation of, 764, 777 X
Venous thromboembolization, after Vitamin(s) Xanthine oxidase inhibitor, for impaired
abdominal aortic aneurysm repair, in chronic obstructive pulmonary renal function, with chemotherapy,
222-223 disease, 137 762
clinical manifestations of, 222 for imbalanced nutrition
desired outcomes for, 222-223 after bowel resection, 558 Z
nursing assessment for, 222 in chronic obstructive pulmonary Zinc supplements, for risk for hepatic
nursing interventions classifications disease, 127 encephalopathy, with cirrhosis, 594
(NIC) for, 222 with cirrhosis, 578
nursing outcomes interventions (NOC) with pancreatitis, 616
for, 222 in pneumonia, 183
 LL_—<—<_.- SStCS
Chapter 4
Nervous System Overview
Vertebral Column and Spinal Nerves
Neurobiology of Alzheimer’s
Airway Positioning 3D
Nasopharyngeal Airway Insertion Chapter 8
Oral Airway Insertions Platelets and blood clotting
Blood cell formation
Chapter 5 Blood Cell Types — coagulation
Pulse Oximetry
Respiratory System Overview Chapter 9
Respiratory Cycle Overview of the Endocrine System
Endotracheal Tube Closed Suctioning Skills Procedure Insulin Function
Nasotracheal Intubation Thyroid and Parathyroid Glands
Nasotracheal Suctioning Thyroid Secretion
~ Open Suction Tracheosteomy Tube 3D Chapter 10
Medication Administration via small volume nebulizer 3D Mechanism of Action of Proton Pump Inhibitors
Aerrosol breathing respiratory bronchodilator Digestive System Overview
Oral Endotracheal Tube Intubation Bariatric Surgery
Gas Exchange
Oxygenation Chapter 11
Chest Tube Insertion 3D Cholecystectomy (Gall Bladder Removal)
Emergent Sternotomy Pancreatitis
Cardiac Tampondate Hemorrhage Chapter 12
Pericardiocentesis 3D The kidney
Thoracentesis 3D Bladder and Kidney Function Urine Passing
Asthma Dialysis
Fine and Coarse Crackles Lithotripsy
Wheezing The Kidney, Part 2
Stridor Creatinine and Renal Function
Pneumonia Peritoneal Dialysis 3D
Pulmonary Systemic Circulation Renal and Urinary Disorders
Respiratory Acidosis Nephrons
Metabolic Acidosis
Chapter 6
Cardiopulmonary System Chapter 13
Overview of the Cardiovascular System Total Knee Replacement
Interior Anatomy of the Heart Open Reduction, Internal Fixation (ORIF)
Internal Anatomy of the Heart Diskectomy
Electrical Conduction of the Heart Osteoporosis
Coronary Artery Bypass Graft (CABG)
Chapter 14
Physiology of blood pressure
Prostatectomy
Coronary artery disease
Nitrates Chapter 15
Diuretics Chemotherapy
Pericardiocentesis 3D Radiation Therapy
Benign and Malignant Neoplasms
Chapter 7
Cranial Nerves
Brain ventricles

@volve Find these animations on Evolve at

http://evolve.elsevier.com/Haugen/careplanning/
 Ulrich & Canale’'s
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Sin

NURSING CARE
Edition

PLANNING UIDES
irlon, Delegarfion, and Clini easoning

Write better care plans with this in-depth guide!

A practical guide to care planning, this practical reference helps you confidently plan individualized
care for clients in acute care, extended care, and home care settings. It reflects the latest evidence-
based interventions and includes a companion Evolve website with animations, skills videos,
and an online care planner for customized care planning.

OUTSTANDING FEATURES:
© NEW! Up-to-date nursing taxonomies include the most recent NANDA-I® nursing diagnoses,
NIC® interventions, and NOC® outcomes.
© NEW and UNIQUE! Nurse-Sensitive Indicators chapter covers three elements of patient
care that are directly affected by nursing practice: structure, process, and outcomes.
© UNIQUE! Care plan format focuses on prioritized nursing interventions, interventions
that can be delegated, and documentation criteria.
® More than 60 comprehensive disorder care plans delineate nursing care for common
health problems.
® More than 30 nursing diagnosis care plans include detailed interventions with rationales
and documentation guidelines for the most common NANDA-I® nursing diagnoses.

Recommended
Shelving Classification
Nursing Care Planning

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