General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Assist with moving slowly to a sitting position in bed and then standing at the bedside before attempting ambulation. For more information, see Risk for Ineffective Cerebral Tissue Perfusion, p. 67
Many anesthetic agents depress normal vasoconstrictor mechanisms and can result in sudden hypotension with quick changes in position.
Encourage frequent movement and ambulation by postoperative patients. Provide assistance as indicated.
These actions reduce the potential for postoperative complications, including atelectasis, pneumonia, thrombophlebitis, skin breakdown, muscle weakness, and decreased GI motility.
Teach exercises that can be performed in bed and explain their purpose. Exercises such as gluteal and quadriceps muscle sets (isometrics) and ankle circling and calf pumping promote muscle strength, increase venous return, and prevent stasis.
For additional information, see Chapter 4, “Prolonged Bedrest,” Risk for Activity Intolerance, p. 61, and Risk for Disuse Syndrome, p. 63.
Nursing Diagnosis:
Impaired Oral Mucous Membrane
related to NPO status and/or presence of NG or endotracheal tube
Desired Outcome:
At the time of hospital discharge, the patient’s oral mucosa is intact, without pain or evidence of bleeding.
ASSESSMENT/INTERVENTIONS RATIONALES
Provide oral care and oral hygiene q4h and prn. Arrange for patients to gargle, brush teeth, and cleanse mouth with sponge-tipped applicators as necessary.
Oral care provides comfort and prevents excoriation and excessive dryness of oral mucous membrane.
Use a moistened cotton-tipped applicator to remove encrustations. Carefully lubricate lips and nares with antimicrobial ointment or emollient cream.
These interventions provide comfort and decrease risk of tissue breakdown caused by dry tissues.
If indicated, obtain a prescription for lidocaine gargling solution. This solution provides comfort if the patient’s throat tissue is irritated from the presence of an NG tube.
Nursing Diagnoses:
Risk for Dysfunctional Gastrointestinal Motility/
Constipation
related to immobility, opioid analgesics and other medications, dehydration, lack of privacy, or disruption of abdominal musculature or manipulation of abdominal viscera during surgery
Desired Outcome:
The patient returns to his or her normal bowel elimination pattern as evidenced by return of active bowel sounds within 48-72 hr after most surgeries, absence of abdominal distention or sensation of fullness, and elimination of soft, formed stools.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess for and document elimination of flatus or stool. This signals return of intestinal motility.
Assess for abdominal distention, tenderness, absent or hypoactive bowel sounds, and sensation of fullness. Report gross distention, extreme tenderness, and prolonged absence of bowel sounds.
Gross distention, extreme tenderness, and prolonged absence of bowel sounds are signs of decreased GI motility and possible ileus.
High-pitched bowel sounds may indicate impending bowel obstruction.
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PART I: Medical-Surgical Nursing
Encourage in-bed position changes, exercises, and ambulation to the patient’s tolerance unless contraindicated.
These activities stimulate peristalsis, which promotes bowel elimination.
If an NG tube is in place, perform the following:
- Check placement of the tube after insertion, before any instillation, and q8h. For a larger bore tube, aspirate gastric contents and assess for pH less than 5.0 for gastric tube placement. If the tube is in the trachea, the patient may exhibit signs of respiratory distress or consistently low O2 saturation levels, or there may be absence of drainage. Reposition the tube immediately. Once assured of placement, mark tube to easily assess tube migration, and secure tubing in place. For smaller bore tubes, check recent x-ray film to confirm position before instilling anything.
A malpositioned NG tube will be ineffective in relieving gastric distention and pose a threat to the patient’s well-being.
- For patients with gastric, esophageal, or duodenal surgery, notify the health care provider before manipulating the tube.
Manipulation of NG tubes in these patients could result in disruption of the surgical anastomosis.
- Keep the tube securely taped to the patient’s nose, and reinforce placement by attaching the tube to the patient’s gown with a safety pin or tape.
Securing the tube prevents its migration into the patient’s airway.
- Measure and record quantity and quality of output, including color. Typically the color will be green. For patients who have undergone gastric surgery, output may be brownish initially because of small amounts of bloody drainage but should change to green after about 12 hr.
- Test reddish, brown, or black output for the presence of blood.
Reposition tube as necessary.
These colors may signal GI bleeding.
- Gently instill normal saline as prescribed. This action helps maintain patency of the GI tube.
- Ensure low, intermittent suction of gastric sump tubes by maintaining patency of the sump port (usually blue).
When the port is open and air is entering the stomach, continuous suction is safe.
- If the sump port becomes occluded by gastric contents, flush the sump port with air until a whoosh sound is heard over the epigastric area.
If the port becomes occluded, the tube essentially becomes a single lumen tube and the continuous suction could damage the lining of the stomach.
- Never clamp or otherwise occlude the sump port. For patients with gastric, esophageal, or duodenal surgery, notify the health care provider before irrigating the tube.
Excessive pressure may accumulate and damage gastric mucosa or disrupt the surgical anastomosis.
- When the tube is removed, monitor for abdominal distention, nausea, and vomiting.
These are signs that GI motility is still decreased and requires further intervention.
Monitor and document the patient’s response to diet advancement from clear liquids to a regular or other prescribed diet.
Poor response to diet advancement as evidenced by abdominal distention, nausea, and vomiting may signal continued decreased GI motility and should be reported for timely intervention. Postoperatively, decreased GI motility can result from stress (autonomic), surgical manipulation of the intestine, immobility, and effects of medications.
Encourage oral fluid intake (more than 2500 mL/day), especially intake of prune juice.
Increased hydration, including prune juice, helps promote soft stools that will minimize need to strain.
Administer stool softeners, mild laxatives, senna-based herbal teas, and enemas as prescribed. As appropriate, encourage a high-fiber diet (fresh vegetables and fruits). Monitor and record results.
These interventions promote bulk and softness in stools for easier evacuation.
Arrange periods of privacy during the patient’s attempts at bowel elimination. Privacy promotes relaxation and success with defecation.
ADDITIONAL NURSING DIAGNOSES/PROBLEMS:
“Pain” p. 39, Chapter 2
“Pneumonia” p. 116, Chapter 10
“Venous Thrombosis/Thromboembolism” p. 186, Chapter 24
“Managing Wound Care” p. 533, Chapter 73
“Providing Nutritional Support” p. 539, Chapter 74
61
Prolonged Bedrest 4
OVERVIEW/PATHOPHYSIOLOGY
Patients on prolonged bedrest face many potential physiologic and psychosocial problems. Complications may include respi- ratory, cardiac, and musculoskeletal disorders as well as other problems resulting in permanent disabilities. This section reviews the most common physiologic and psychosocial
problems that may occur. With patients being discharged from the hospital sooner, many health care problems are being treated in long-term care facilities or at home.
HEALTH CARE SETTING
Extended care, acute care, home care
Nursing Diagnosis:
Risk for Activity Intolerance
related to deconditioned status
Desired Outcomes:
Within 48 hr of discontinuing bedrest, the patient exhibits cardiac tolerance to activity or exercise as evidenced by heart rate (HR) 20 bpm or less over resting HR; systolic blood pressure (SBP) 20 mm Hg or less over or under resting SBP; respiratory rate (RR) 20 breaths/min or less with normal depth and pattern (eupnea); normal sinus rhythm; warm and dry skin; and absence of crackles (rales), new murmurs, new dys- rhythmias, gallop, or chest pain. The patient rates perceived exertion (RPE) at 3 or less on a scale of 0 (none) to 10 (maximum) and maintains muscle strength and joint range of motion (ROM).
ASSESSMENT/INTERVENTIONS RATIONALES
Assess for orthostatic hypotension: Prepare the patient for this change by increasing the amount of time spent in high Fowler’s position and moving the patient slowly in stages.
Orthostatic hypotension can occur as a result of decreased plasma volume and difficulty in adjusting immediately to postural change.
For more information about orthostatic hypotension, see Risk for Ineffective Cerebral Tissue Perfusion, p. 67.
Assess exercise tolerance: Be alert to signs and symptoms that the cardiovascular and respiratory systems are unable to meet the demands of the low-level ROM exercises.
Excessive shortness of breath may occur if (1) transient pulmonary congestion occurs secondary to ischemia or left ventricular dysfunction, (2) lung volumes are decreased, (3) oxygen-carrying capacity of the blood is reduced, or (4) there is shunting of blood from the right to the left side of the heart without adequate oxygenation. If cardiac output does not increase to meet the body’s needs during modest levels of exercise, SBP may fall; the skin may become cool, cyanotic, and diaphoretic; dysrhythmias may be noted; crackles (rales) may be auscultated; or a systolic murmur of mitral regurgitation may occur.
Perform ROM exercises 2-4 times/day on each extremity. Individualize the exercise plan.
These exercises build stamina by increasing muscle strength and endurance
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PART I: Medical-Surgical Nursing
Caution: Avoid isometric exercises in cardiac patients. These exercises can increase systemic arterial blood pressure.
Mode or type of exercise: Begin with passive exercises, moving the joints through the motions of abduction, adduction, flexion, and extension. Progress to active-assisted exercises in which you support the joints while the patient initiates muscle contraction. When the patient is able, supervise him or her in active isotonic exercises, during which the patient contracts a selected muscle group, moves the extremity at a slow pace, and then relaxes the muscle group.
Have the patient repeat each exercise 3-10 times.
Beginning with passive movement, progressing to active-assisted, and continuing with active isotonic takes patients from the least exerting to the most exerting exercises over a period of time, thus increasing gradual tolerance.
Caution: Stop the exercise if the patient becomes overly short of breath, has a rapid heart rate, passes out, or experiences severe pain, dizziness, or lightheadedness. Consult with the health care provider accordingly.
These exercises should be used with caution in any patient who has been recently ill or has unexplained weight gain or swelling of a joint because these may be signs of a serious health condition.
Caution: Stop any exercise that results in muscular or skeletal pain.
Consult a physical therapist (PT) about necessary modifications.
This action prevents injury in a joint too inflamed or diseased to tolerate this type of exercise intensity.
Intensity: Begin with 3-5 repetitions as tolerated by the patient. Starting with minimal intensity and progressing step-by-step to greater intensity enables gradual tolerance.
Measure HR and blood pressure (BP) at rest, peak exercise, and 5 min after exercise.
These assessments help determine tolerance to the exercise. If HR or SBP increases more than 20 bpm or more than 20 mm Hg over resting level, the number of repetitions should be decreased. If HR or SBP decreases more than 10 bpm or more than 10 mm Hg at peak exercise, this could be a sign of left ventricular failure, denoting that the heart cannot meet this workload. For other adverse signs and symptoms, see Assess exercise tolerance.
Duration: Begin with 5 min or less of exercise. Gradually increase the exercise to 15 min as tolerated.
Starting with minimal duration and progressing to greater duration enables gradual tolerance.
Frequency: Begin with exercises 2-4 times/day. As duration increases, the frequency can be reduced.
Ask patient to rate perceived exertion experienced during exercise, basing it on the following scale developed by Borg (1982).
0 = Nothing at all 1 = Very weak effort 2 = Weak (light) effort 3 = Moderate effort
4 = Somewhat stronger effort 5 = Strong effort
7 = Very strong effort 9 = Very, very strong effort 10 = Maximum effort
Borg’s Scale is a simple method of RPE that can be used to gauge a person’s level of exertion in training.
Exercises to prevent deconditioning should be performed at low levels of effort. Patients should not experience an RPE greater than 3 while performing ROM exercises.
If the patient tolerates the exercise, increase intensity or number of repetitions each day and increase activity as soon as possible to include sitting in a chair.
Tolerance is a sign that cardiovascular and respiratory systems are able to meet the demands of this low-level ROM exercise. To promote optimal conditioning, activity should be increased to correspond to the patient’s increased tolerance.
Monitor CBC and report any abnormal value. Disorders such as anemia can decrease the oxygen-carrying capacity of the blood and affect tolerance.
Progress activity in hospitalized patients as follows.