General Care Plans
PART I: Medical-Surgical Nursing
Nursing Diagnosis:
Ineffective Sexuality Patterns
related to actual or perceived physiologic limitations on sexual performance occurring with disease, therapy, or prolonged hospitalization
Desired Outcome:
Within 72 hr of this diagnosis, the patient relates satisfaction with sexual-ity and/or understanding of the abilsexual-ity to resume sexual activsexual-ity.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s normal sexual function, including importance placed on sex in the relationship, frequency of interaction, normal positions used, and the couple’s ability to adapt or change to meet
requirements of the patient’s limitations.
This assessment helps determine the patient’s normal sexual function and adaptations that will be necessary under current conditions.
Identify the patient’s problem diplomatically, and clarify it with the patient.
This assessment helps determine if the patient suffers from sexual dysfunction resulting from lack of privacy, current illness, or perceived limitations. Indicators of sexual dysfunction can include regression, acting-out with inappropriate behavior such as grabbing or pinching, sexual overtures toward staff members, self-enforced isolation, and similar behaviors.
Encourage the patient and significant other to verbalize feelings and anxieties about sexual abstinence, having sexual relations in the hospital, hurting the patient, or having to use new or alternative methods for sexual gratification.
Open communication is the foundation for maintaining a strong intimate relationship.
Develop strategies in collaboration with the patient and significant other. This information will promote understanding of ways to achieve sexual satisfaction.
Encourage acceptable expressions of sexuality by the patient. Examples of positive and acceptable behaviors may eliminate inappropriate behaviors. Examples for a woman could include wearing makeup and jewelry and for a man, shaving and wearing his own shirts and shorts.
Inform the patient and significant other that it is possible to have time alone together for intimacy. Provide that time accordingly by putting a Do not disturb sign on the door, enforcing privacy by restricting staff and visitors to the room, or arranging for temporary private quarters.
These actions facilitate intimacy by ensuring privacy.
Encourage the patient and significant other to seek alternative methods of sexual expression when necessary.
Accustomed methods of sexual expression may not work under current circumstances. Alternative methods may include mutual
masturbation, altered positions, vibrators, and identification of other erotic areas for each partner.
Refer the patient and significant other to professional sexual counseling as necessary.
Counseling may improve communication and acceptance of alternative therapies.
ADDITIONAL NURSING DIAGNOSES/PROBLEMS
“Psychosocial Support” for psychosocial nursing interventions p. 72
“Pneumonia” for interventions related to prevention of pneumonia p. 116
“Venous Thrombosis/Thrombophlebitis” for interventions related to DVT and pulmonary embolism p. 186
“Pressure Ulcers” in “Managing Wound Care” for Impaired Tissue Integrity (or risk for same) p. 536
5
Nursing Diagnosis:
Fatigue
related to disease process, treatment, medications, depression, or stress
Desired Outcome:
Before hospital discharge, the patient and caregivers describe interven-tions that conserve energy resources.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s patterns of fatigue and times of maximum energy. (Use of a visual analog scale may be helpful in monitoring the fatigue level.)
This information helps identify areas for teaching energy conservation, relaxation, and diversional activities to reduce fatigue.
Assess how fatigue affects the patient’s emotional status and ability to perform activities of daily living (ADLs). Suggest activity schedules to maximize energy expenditures (e.g., “After you eat lunch, take a 15-minute rest before you go to x-ray”).
Developing an activity plan (e.g., rescheduling activities, allowing rest periods, asking for assistance, exercise) will help conserve energy, reduce fatigue, and maintain ADLs.
Assess for signs and symptoms of anemia. Anemia can result from cancer or its treatments. Fatigue can occur because of decreased oxygen-carrying capacity of blood. Pharmacologic agents or transfusions may be needed to increase red blood cells.
Assess patterns of sleep. Disturbance in sleep pattern may influence level of fatigue.
Help the patient maintain a regular sleep pattern by allowing for uninterrupted periods of sleep. Encourage rest when fatigued rather than attempting to continue activity. Encourage naps during the day.
Lack of effective sleep can lead to psychosocial distress (e.g., inability to concentrate, anxiety, uncertainty, and depression).
Reduce environmental stimulation overload (e.g., noise level, visitors for long periods of time, lack of personal quiet time).
This action helps promote uninterrupted sleep patterns.
Discuss how to delegate chores to family and friends who are offering to assist.
This action helps conserve energy and enables family and friends to feel a part of patient’s care.
Encourage the patient to maintain a regular schedule once discharged, recognizing that attempting to continue previous activity levels may not be realistic.
This information helps patients engage in a realistic activity schedule to minimize fatigue and avoid frustration if physical functioning does not return to baseline levels.
Encourage mild exercise such as short walks and stretching, which may begin in the hospital if not contraindicated.
Such exercise will promote flexibility, muscle strength, and cardiac output and reduce stress.
Avoid exercise or use caution in patients with certain disease states.
Exercise should be used with caution and may be contraindicated in cases of - Bone metastases
- Immunosuppression or neutropenia - Thrombocytopenia
- Anemia
- Fever or active infection - Limitations due to other illnesses (Oncology Nursing Society, 2011b)
Anxiety
Psychosocial Support73
General Care Plans
PART I: Medical-Surgical Nursing
Nursing Diagnosis:
Disturbed Sleep Pattern
related to environmental changes, illness, therapeutic regimen, pain, immobil-ity, psychologic stress, altered mental status, or hypoxia
Desired Outcomes:
After discussion, the patient identifies factors that promote sleep. Within 8 hr of intervention, the patient attains 90-min periods of uninterrupted sleep and verbalizes satisfaction with the ability to rest.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s usual (before and after diagnosis) sleeping patterns (e.g., bedtime routine, hours of sleep per night, sleeping position, use of pillows and blankets, napping during the day, nocturia).
Some or all of the patient’s usual sleep pattern may be incorporated into the plan of care. A routine as similar to the patient’s normal routine as possible will help promote sleep.
Assess causative factors and activities that contribute to the patient’s insomnia, awaken the patient, or adversely affect sleep patterns.
Factors such as pain, anxiety, hypoxia, therapies, depression, hallucinations, medications, underlying illness, sleep apnea, respiratory disorder, caffeine, and fear may contribute to sleep pattern disturbance. Some may be ameliorated, and others may be modified.
Explore relaxation techniques that promote patient’s rest/sleep. Imagining relaxing scenes, listening to soothing music or taped stories, and using muscle relaxation exercises are relaxation techniques that are known to promote rest/sleep.
Administer sleep medicines at a time appropriate to induce sleep, taking into consideration time to onset and half-life.
Simulating the usual sleep/wake pattern aids in uninterrupted sleep.
As indicated, administer pain medications before sleep. This intervention decreases the likelihood that pain will interfere with sleep.
Promote physical comfort via such measures as massage, back rubs, bathing, and fresh linens before sleep.
These measures may help relieve stress and promote relaxation. More research is needed to establish their effectiveness (Margaretta, 2006; Oncology Nursing Society, 2011c).
Organize procedures and activities to allow for 90-min periods of uninterrupted rest/sleep. Limit visiting during these periods.
Ninety minutes of sleep enables complete progression through the normal phases of sleep.
Whenever possible, maintain a quiet environment. Excessive noise and light can cause sleep deprivation. Providing earplugs, reducing alarm volume, and using white noise (i.e., low-pitched, monotonous sounds: electric fan, soft music) may facilitate sleep. Dimming the lights for a period of time, drawing the drapes, and providing blindfolds are other ways of promoting sleep.
If appropriate, limit the patient’s daytime sleeping. Attempt to establish regularly scheduled daytime activity (e.g., ambulation, sitting in chair, active range of motion), which may promote nighttime sleep.
Napping less during the day will promote a more normal nighttime pattern. Physical activity causes fatigue and may facilitate nighttime sleeping.
Promote nonpharmacologic comfort measures that are known to promote the patient’s sleep.
Nonpharmacologic comfort measures such as earplugs, anxiety reduction, and use of the patient’s own bed clothing and pillows may promote sleep.
Nursing Diagnosis:
Anxiety
related to actual or perceived threat of death, change in health status, threat to self-concept or role, unfamiliar people and environment, medications, preexisting anxiety disorder, the unknown, or uncertainty
Desired Outcome:
Within 1-2 hr of intervention, the patient’s anxiety has resolved or
decreased as evidenced by the patient’s verbalization of same, stabilization of vital signs (VS)
if they were elevated due to anxiety (compared with the patient’s normal levels), and absence
of or decrease in irritability and restlessness.
PART I: Medical-Surgical Nursing
Assess the patient’s level of anxiety. Be alert to verbal and nonverbal cues. Assess for the following criteria that can contribute to anxiety: general medical condition, withdrawal from alcohol or narcotics, pain, generalized anxiety disorder, panic disorder, post-traumatic stress disorder, phobic disorder, or obsessive-compulsive disorder (Oncology Nursing Society, 2011a).
Being cognizant of a patient’s level of anxiety enables the nurse to provide appropriate interventions, as well as modify the plan of care
accordingly.
Levels of anxiety include:
- Mild: Restlessness, irritability, increased questions, focusing on the environment.
- Moderate: Inattentiveness, expressions of concern, narrowed perceptions, insomnia, increased heart rate (HR).
- Severe: Expressions of feelings of doom, rapid speech, tremors, poor eye contact. Patient may be preoccupied with the past; may be unable to understand the present; and may have tachycardia, nausea, and hyperventilation.
- Panic: Inability to concentrate or communicate, distortion of reality, increased motor activity, vomiting, tachypnea.
Validate assessment of the anxiety with the patient. Validating a patient’s anxiety level provides confirmation of nursing assessment, as well as openly acknowledges their emotional state. In so doing, patients are given permission to share feelings. For example,
“You seem distressed. Are you feeling uncomfortable now?”
Introduce self and other health care team members; explain each individual’s role as it relates to the patient’s care.
Familiarity with staff and their individual roles may increase the patient’s comfort level and decrease anxiety.
Engage in honest communication with the patient, providing empathetic understanding. Listen closely.
These actions help establish an atmosphere that enables free expression.
For patients with severe anxiety or panic state, refer to psychiatric clinical nurse specialist, case manager, or other health care team members as appropriate.
Patients in severe anxiety or panic state may require more sophisticated interventions or pharmacologic management.
Approach the patient with a calm, reassuring demeanor. Show concern and focused attention while listening to the patient’s concerns. Provide a safe environment and stay with the patient during periods of intense anxiety.
These actions reassure patients that you are concerned and will assist in meeting their needs.
Restrict the patient’s intake of caffeine, nicotine, and alcohol. Caffeine is a stimulant that may increase anxiety in persons who are sensitive to it. Cessation of caffeine, nicotine, and alcohol can lead to physiologic withdrawal symptoms including anxiety.
Avoid abrupt discontinuation of anxiolytics. Abrupt withdrawal can cause headaches, tiredness, and irritability.
If the patient is hyperventilating, have him or her concentrate on a focal point and mimic your deliberately slow and deep-breathing pattern.
Modeling provides patients with a focal point for learning effective breathing technique.
After an episode of anxiety, review and discuss the thoughts and feelings that led to the episode.
This action validates the cause of the anxiety and explores interventions that may avert another episode.
Identify the patient’s current coping behaviors. Review coping behaviors the patient has used in the past. Assist with using adaptive coping to manage anxiety.
Identifying maladaptive coping behaviors (e.g., denial, anger, repression, withdrawal, daydreaming, or dependence on narcotics, sedatives, or tranquilizers) helps establish a proactive plan of care to promote healthy coping skills. For example, “I understand that your wife reads to you to help you relax. Would you like to spend a part of each day alone with her?”
Encourage the patient to express fears, concerns, and questions. Encouraging questions gives patients an avenue in which to share concerns. For example, “I know this room looks like a maze of wires and tubes; please let me know when you have any questions.”
Provide an organized, quiet environment. Such an environment reduces sensory overload that may contribute to anxiety.
Encourage social support network to be in attendance whenever possible.
Many people benefit from support of others and find that it reduces their stress level.
Teach relaxation and imagery techniques. Relaxation and imagery skills empower individuals to manage anxiety-provoking episodes more skillfully and foster a sense of control.