Breastfeeding, readiness for improved breathing pattern, inefficient cardiac outcome, reduced caregiver role strain, caregiver role strain, risk to the childbearing process, ineffective. Sensory perception, impaired (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)]. retired 2012) Sexual dysfunction Sexual pattern, ineffective Shock, risk of.
CONTRIBUTORS TO THE 9TH EDITION
Cathryn Baack, PhD, RN, CPNP
Becky Craig, RN, MN, PhD
William H. Loughmiller, CRT
Maria Mackey, MSN, RN
Margaret (Peggy) Malone, MN, RN, CCRN
Laure Miller, MSN, RN
Lillian Ostrander, RN, MSN, MALS
Karen Reilly, ARNP
REVIEWERS FOR THE 9TH EDITION
ACKNOWLEDGMENTS
The late Nancy Lea Carter, RN, MA
Special thanks for many hours of research!
Kathe Lynn Ellis Case Manager
Linda R. Renberg, BA
INTRODUCTION
- examines current issues and trends and their implications for the nursing profession. An
- reviews the historical use of the nursing process in formulating plans of care and the nurse’s role
- discusses care plan construction and de- scribes the use and adaptation of the guides presented in
- through 15 present plans of care that include information from multiple disciplines to assist
The importance of the nurse's role in collaboration and coordination with other healthcare professionals is integrated into the care plans. This book is intended for students who will find the care plans useful in learning and developing skills in applying the nursing process and using nursing diagnoses.
CONTENTS IN BRIEF
INDEX OF NURSING DIAGNOSES APPEARS
INTRODUCTION CHAPTER 1
Cardiovascular 33
Hypertension: Severe 33 Heart Failure: Chronic 43
Acute Coronary Syndrome (ACS) 58 Angina: Chronic/Stable 67
Myocardial Infarction 75 Dysrhythmias 87
Cardiac Surgery: Postoperative Care—
Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery
Thrombophlebitis: Venous Thromboem- bolism (Including Pulmonary Emboli
Respiratory 118
Chronic Obstructive Pulmonary Disease (COPD) and Asthma 118
Pneumonia 129
Lung Cancer: Postoperative Care 141 Pneumothorax/Hemothorax 150
Ventilatory Assistance (Mechanical) 157 Pulmonary Tuberculosis (TB) 170
Respiratory Acid-Base Imbalances 179 Respiratory Acidosis (Primary Carbonic Acid
Excess) 179
Respiratory Alkalosis (Primary Carbonic Acid Deficit) 184
Craniocerebral Trauma—Acute Rehabilitative Phase 197
Cerebrovascular Accident (CVA)/Stroke 214 Brain Infections: Meningitis and
Encephalitis 229 Disc Surgery 237
Spinal Cord Injury (Acute Rehabilitative Phase) 248
Multiple Sclerosis (MS) 266 CHAPTER 7
Bleeding 281
Inflammatory Bowel Disease (IBD)
Ulcerative Colitis, Crohn’s Disease 291 Fecal Diversions: Postoperative Care of
Ileostomy and Colostomy 304 Appendectomy 315
Peritonitis 320
Cholecystitis with Cholelithiasis 329 Cholecystectomy 335
Nervosa 340
Eating Disorders: Obesity 358 Obesity: Bariatric Surgery 367
Diabetes Mellitus/Diabetic Ketoacidosis 377 Hyperthyroidism (Graves’ Disease,
Thyrotoxicosis) 391 Hepatitis 400
Cirrhosis of the Liver 412 Pancreatitis 426
Total Nutritional Support: Parenteral/
Enteral Feeding 437
Metabolic Acid-Base Imbalances 450 Metabolic Acidosis—Primary Base
Bicarbonate (HCO 3 ) Deficiency 450 Metabolic Alkalosis—Primary Base
Bicarbonate Excess 455
Anemias—Iron Deficiency, Anemia of Chronic Disease, Pernicious, Aplastic,
Sickle Cell Crisis 469 Adult Leukemias 484
Failure) 505
Renal Failure: Chronic (End-Stage Renal Disease) 517
Renal Dialysis—General Considerations 529 Peritoneal Dialysis (PD) 539
Hemodialysis (HD) 544 Urinary Diversions/Urostomy
Postoperative Care) 548
Benign Prostatic Hyperplasia (BPH) 559 Prostatectomy 566
Urolithiasis (Renal Calculi) 573 CHAPTER 11
Mastectomy 589 CHAPTER 12
Total Joint Replacement 625 CHAPTER 13
Burns: Thermal, Chemical, and Electrical—Acute and Convalescent
Wound Care: Complicated or Chronic 657
Sepsis/Septicemia 665 The HIV-Positive Client 677
Acquired Immunodeficiency Syndrome (AIDS) 689
Rheumatoid Arthritis (RA) 709 Transplantation Considerations—
Postoperative and Lifelong 719 CHAPTER 15
Psychosocial Aspects of Care 729 Dementia of the Alzheimer’s Type/
Vascular Dementia/Lewy Body Disease 743
Surgical Intervention 762 Extended Care 781
Alcohol: Acute Withdrawal 800 Substance Use Disorders (SUDs) 815
Disaster Considerations 858 Pediatric Considerations 872
Fluid and Electrolyte Imbalances 885
BIBLIOGRAPHY 918 INDEX OF NURSING
A table of contents including nursing diagnoses follows
DETAILED CONTENTS
INDEX OF NURSING
DIAGNOSES APPEARS ON PAGE V
INTRODUCTION XIX CHAPTER 1
The Ever-Changing Healthcare Environment 1
Challenges, Trends, and Opportunities 1
Planning Care 7
Components of the Plan of Care 7 Client Database 7
Conclusion 10 CHAPTER 3
Client Situation: Diabetes Mellitus 20 Admitting Physician’s Orders 20
Evaluation 24 Documentation 24
Cardiovascular 33
Hypertension: Severe 33
Acute Coronary Syndrome (ACS) 58 Pain, acute 62
Care—Coronary Artery Bypass Graft (CABG), Minimally Invasive
Thromboembolism (Including
Pulmonary Emboli Considerations) 109 Tissue Perfusion, ineffective peripheral 112
Lung Cancer: Postoperative Care 141 Gas Exchange, impaired 145
Craniocerebral Trauma—Acute Rehabilitative Phase 197
Encephalitis 229
Bleeding 281 Bleeding, risk for 284
Ulcerative Colitis, Crohn’s Disease 291 Diarrhea 296
Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 304
Eating Disorders: Obesity 358
Ketoacidosis 377
Thyrotoxicosis) 391
Feeding 437
Bicarbonate Excess 455 CHAPTER 9
Anemias—Iron Deficiency, Anemia of Chronic Disease, Pernicious,
Renal Disease) 517
Peritoneal Dialysis (PD) 539 Fluid Volume, risk for excess 540
Urinary Diversions/Urostomy (Postoperative Care) 548
Urolithiasis (Renal Calculi) 573 Pain, acute 576
Orthopedic 601
Integumentary 638
Sepsis/Septicemia 665 Infection, risk for [progression;
AIDS) 689
Transplantation Considerations—
Postoperative and Lifelong 719 Infection, risk for 723
General 729
Psychosocial Aspects of Care 729 Coping, ineffective 731
Alcohol: Acute Withdrawal 800
Substance Use Disorders (SUDs) 815 Denial, ineffective 817
Pediatric Considerations 872 Pain, acute/chronic 875
Hypervolemia (Extracellular Fluid Volume Excess) 886
Hypovolemia (Extracellular Fluid Volume Deficit) 890
Hyponatremia (Sodium Deficit) 893 Electrolyte Imbalance, risk for 896
Hypokalemia (Potassium Deficit) 900 Electrolyte Imbalance, risk for 902
Hypocalcemia (Calcium Deficit) 906 Electrolyte Imbalance, risk for 908
Hypomagnesemia (Magnesium Deficit) 912 Electrolyte Imbalance, risk for 913
Hypermagnesemia (Magnesium Excess) 915 Electrolyte Imbalance, risk for 916
Bibliography 918
Index of Nursing Diagnoses 949
CONTENTS ON DAVIS PLUS
Medical/Surgical Care Plans Respiratory
Neurological/Sensory Disorders Glaucoma
Gastrointestinal Disorders Gastrectomy/Gastric Resection
Psychiatric Care Plans
Neurodevelopmental Disorders Pervasive Developmental Disorder
Schizophrenic Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders Bipolar Disorder
Depressive Disorders Major Depressive Disorder
Obsessive-Compulsive and Related Disorders
Trauma and Stressor-Related Disorders Post-Traumatic Stress Disorder
Disorders
Elimination Disorders Enuresis/Encopresis
Disruptive, Impulse-Control, and Conduct Disorders
Neurocognitive Disorders
Maternal/Newborn Care Plans Prenatal Concepts
Client within 4 hours to 2 days postpartum after cesarean delivery (4 hours to 3 days postpartum).
Newborn Concepts First Hour of Life
550 Health Conditions and Client Concerns with Associated Nursing
Issues and Trends in Nursing and Healthcare Delivery
CHAPTER 1
The Ever-Changing Healthcare Environment
Challenges, Trends, and Opportunities
The increased power of the consumer in the client-provider relationship has created an increased demand for more sophisticated health education techniques for both client and provider. Numerous authors have recently discussed multigenerational conflict in the nursing workforce as one of the challenges facing nurses (Kupperschmidt, 2006; Lancaster, 2002).
The Nursing Process
Planning Care Using Nursing Diagnoses
CHAPTER 2
THE NURSING PR OCESS: PLANNING CARE USING NURSING DIA GNOSES
Religiosity, readiness for increased religiosity, risk of weakened relocation stress syndrome Relocation stress syndrome, risk of renal perfusion, risk of ineffective resistance, weakened individual resistance, readiness for increased resistance, risk of compromised role conflict, parental. Self-esteem, situational low self-esteem, risk of chronic low self-esteem, risk of situational low management of one's own health, ineffective management of one's own health, readiness to.
Planning Care
Components of the Plan of Care
Client Database
Interviewing
Physical Assessment
Diagnostic Studies
Nursing Priorities
Maintain or enhance cardiovascular functioning
Prevent complications
Provide information about disease process, prognosis, and treatment regimen
Support active client control or management of the condition
Discharge Goals
Blood pressure within acceptable limits for individual
Cardiovascular and systemic complications prevented or minimized
Disease process, prognosis, and therapeutic regimen understood
Necessary lifestyle and behavioral changes initiated
Plan in place to meet needs after discharge
Nursing Diagnosis (Problem and Need Identification)
- Collect a client database (nursing interview, physical as- sessment, and diagnostic studies) combined with informa-
- Review and analyze the client data
- Synthesize the gathered client data as a whole and then label the clinical judgment about the client’s responses to
- Compare and contrast the relationships of clinical judg- ments with related factors and defining characteristics for
- Combine the nursing diagnosis with the related factors and define characteristics, or risk factors, to create the client
- THE NURSING PR OCESS: PLANNING CARE USING NURSING DIA GNOSESIf the diagnosis is not consistent with at least two or more
CHAPTER 2 THE NURSING PROCESS: CARE PLANNING USING NURSING DIAGNOSES The diagnosis is inconsistent with at least two or more If the diagnosis is inconsistent with at least two or more.
Desired Client Outcomes
Be specific
Be realistic or achievable 3. Be measurable
Indicate a definite time frame for achievement or review 5. Consider client’s desires and resources
Planning (Goals and Actions/
Interventions)
Rationale
Conclusion
Critical Thinking: Adaptation of Theory to Practice
CHAPTER 3
ADULT MEDICAL/SURGICAL ASSESSMENT TOOL
Circulation
General Information
Ego Integrity
Elimination
Food/Fluid
Hygiene
Neurosensory
Pain/Discomfort
Respiration
Safety
Sexuality [Component of Social Interaction]
Sexuality [Component of Social Interaction] (continued)
Social Interactions
Teaching/Learning
Teaching/Learning (continued)
Discharge Plan Considerations
Teaching/learning – the ability to incorporate and use information to achieve a healthy lifestyle and optimal well-being. Interventions are based on concerns and needs identified by the client and nurse during data collection.
Client Situation: Diabetes Mellitus
Admitting Physician’s Orders
Client Assessment Database
CIRCULATION
ELIMINATION
FOOD/FLUID
HYGIENE
NEUROSENSORY
PAIN/DISCOMFORT
RESPIRATION
SAFETY
SEXUALITY: MALE
Subjective (Reports): Last proctoscopic examination: 2 years ago Prostate examination: 1 year ago Practice self-examination: Breast/testicles: No. Problems/Complaints: “I have no problems, but you will have to ask my wife if there are any complaints.”.
SOCIAL INTERACTIONS
TEACHING/LEARNING
DISCHARGE CONSIDERATIONS (AS OF 6/28)
Evaluation
Documentation
A more recent way to assess and document client progress (response to care) is by using clinical pathways. Analgesic: same actions/goals Pain-free/medicated state Verbalize understanding of correct medication use.
Client Diagnostic Statement
Outcome
Client Will
ACTIONS/INTERVENTIONS Wound Care
RATIONALE
ACTIONS/INTERVENTIONS Hyperglycemia Management
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Glucophage 500 mg PO daily. Note onset of side effects
ACTIONS/INTERVENTIONS Pain Management
Outcomes
Provides various methods for accessing and enhancing information and increases opportunities for learning and understanding. Recognition and understanding of these signs and symptoms and timely intervention will help the client prevent recurrences and prevent complications.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Review and provide information about necessity for routine ex-
Cardiovascular
CHAPTER 4
- Etiology
- Pathophysiology a. Multifactoral
- Classification—2003 Guidelines National Heart, Lung, and Blood Institute (NHLBI)
HYPERTENSION: SEVERE
Care Setting
Related Concerns
A CTIVITY /R EST
C IRCULATION
E GO I NTEGRITY
E LIMINATION
F OOD /F LUID
P AIN /D ISCOMFORT
T EACHING /L EARNING
Provide information about disease process, prognosis, and treatment regimen
Support active client control of condition
BP within acceptable limits for individual
Cardiovascular and systemic complications prevented or minimized
Necessary lifestyle or behavioral changes initiated
Desired Outcomes/Evaluation Criteria—Client Will Circulation Status
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Beta blockers, such as acebutolol (Sectral), atenolol
Desired Outcomes/Evaluation Criteria—Client Will Endurance
CARDIO V ASCULAR—HYPER TENSION
Desired Outcomes/Evaluation Criteria—Client Will Pain Control
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Treatment Regimen
Desired Outcomes/Evaluation Criteria—Client Will Coping
Desired Outcomes/Evaluation Criteria—Client Will Self-Management: Hypertension
ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process
CARDIO V ASCULAR—HEAR T F A ILUREACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
- Classification
Demonstrate application of ice pack to the back of the neck and pressure over the distal third of the nose, and advise the client to lean head forward if nosebleed occurs. Community resources, such as the American Heart Association, ..coronary clubs,” stop-smoking clinics, alcohol or drug rehabilitation, weight loss programs, stress management classes, and counseling services can be helpful in clients' efforts to initiate and maintain lifestyle changes. renal blood flow leads to sodium and water retention), and increasing pulmonary venous pressure leads to fluid accumulation in alveoli (left ventricular failure).
HEART FAILURE: CHRONIC
Etiology a. Multifactoral
Statistics
CARDIO V ASCULAR—HEAR T F A ILUREClient Assessment Database
H YGIENE
R ESPIRATION
S AFETY
S OCIAL I NTERACTION
Client Assessment Database (continued)
CARDIO V ASCULAR—HEAR T F A ILURE
- Improve myocardial contractility and systemic perfusion
- Reduce fluid volume overload
- Prevent complications
- Provide information about disease and prognosis, therapy needs, and prevention of recurrences
- Cardiac output adequate for individual needs
- Complications prevented or resolved
- Optimum level of activity and functioning attained
- Disease process, prognosis, and therapeutic regimen understood
A level of GDP greater than 100 pg/ml predicts HF and increased risk of sudden death and 1-year mortality (Kociol et al, 2011). May be elevated, indicating acute systemic inflammatory response, especially if viral infection is cause of HF.
Desired Outcomes/Evaluation Criteria—Client Will Cardiac Pump Effectiveness
Preload reduction is most helpful in treating clients with a relatively normal cardiac output accompanied by congestive symptoms. ACE inhibitors represent first-line therapy to control HF by lowering ventricular filling pressure and SVR while increasing cardiac output with little or no change in BP and heart rate.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Digoxin (Lanoxin)
Achieve a measurable increase in activity tolerance, evidenced by reduced fatigue and weakness, and by vital signs within acceptable limits during activity. Damaged myocardium and the inability to increase stroke volume during activity can cause an immediate increase in heart rate and oxygen demand, thus worsening weakness and fatigue.
Monitor vital signs before and immediately after activity during an acute episode or exacerbation of HF, especially if the client is receiving vasodilators, diuretics, or beta blockers. Orthostatic hypotension can occur with activity due to medication effects (vasodilation), fluid shifts (diuresis) or reduced pumping function of the heart.
Desired Outcomes/Evaluation Criteria—Client Will Fluid Overload Severity
Assess level of fatigue and assess for other precipitators and causes of fatigue, eg HF treatments, pain, cachexia, anemia and depression. Fatigue due to advanced HF can be profound and is related to hemodynamic, respiratory, and peripheral muscle abnormalities.
ACTIONS/INTERVENTIONS RATIONALE Fluid Management
It may be necessary to provide a diet acceptable to the client who is meeting caloric needs within sodium restriction. Although mechanical fluid removal is not commonly used, it rapidly reduces circulating volume, particularly in pulmonary edema that is refractory to other therapies.
Desired Outcomes/Evaluation Criteria—Client Will Respiratory Status: Gas Exchange
ACTIONS/INTERVENTIONS RATIONALE Pain Management
Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral
Report problems with prescribed regimen Failure to incorporate treatment regimen into daily life Failure to take action to reduce risk factors Unexpected acceleration of disease symptoms.
Desired Outcomes/Evaluation Criteria—Client Will Self-Management: Heart Failure
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Discharge
Pain may be associated with changes in vital signs, decreased oxygen saturation (SaO2), or cardiac dysrhythmias. Acute coronary syndrome' refers to a cluster of clinical symptoms consistent with myocardial ischemia and includes (1) unstable angina (UA), (2) ST-segment elevation myocardial infarction (NSTEMI), and (3) ST-segment elevation myocardial infarction (STEMI).
ACUTE CORONARY SYNDROME (ACS)
CARDIO V ASCULAR—A CUTE COR ON AR Y SYNDR OMEiii.Electrocardiographic (ECG) manifestations include
Myocardial infarction (MI): A blockage or blockage of the arteries that supply the heart muscle, resulting in injury or necrosis of the heart muscle (heart attack). ST-segment elevation myocardial infarction (STEMI): A transmural myocardial infarction in which the entire thickness of the myocardium has undergone necrosis.
Relieve or control pain
Prevent or minimize development of myocardial compli- cations
Provide information about disease process, prognosis, and treatment
Support client or significant other (SO) in initiating nec- essary lifestyle or behavioral changes
Desired activity level achieved, with return to activity baseline, and self-care needs met with minimal or no pain
Remains free of complications
Participates in treatment program and behavioral changes
Desired Outcomes/Evaluation Criteria—Client Will Pain Level
Diagnostic Studies (continued)
CARDIO V ASCULAR—A CUTE COR ON AR Y SYNDR OME
Pain and decreased cardiac output can stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation and the release of thromboxane A2. See NDs: risk of decreased cardiac tissue perfusion and risk of decreased cardiac output, subsequently for discussion of additional medications.).
CARDIO V ASCULAR—A CUTE COR ON AR Y SYNDR OMEACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
These agents prevent the binding of fibrinogen, thereby blocking platelet aggregation, and are considered, in combination with aspirin, as standard antiplatelet therapy for clients at high risk for unstable angina. Drug-eluting stents may be considered for clients at high risk for thrombosis or acute occlusion.
The use of low molecular weight heparin is increasing because it is more predictable and has fewer side effects. Note: One study found that unfractionated heparin was associated with a 33% reduction in the risk of myocardial infarction or death in individuals treated with aspirin and heparin compared with those treated with aspirin alone (Oler , 1996).
ACTIONS/INTERVENTIONS RATIONALE Cardiac Care: Acute
Desired Outcomes/Evaluation Criteria—Client Will Self-Management: Coronary Artery Disease
CARDIO V ASCULAR—ANGIN A
Encourage the identification and reduction of individual risk factors such as smoking, alcohol consumption and obesity. Some herbs can affect bleeding and clotting, especially if added to medications such as Plavix or Coumadin, which worsen bleeding.
ANGINA: CHRONIC/STABLE
Pathophysiology
Provides ongoing monitoring, continuation of prescribed therapies, and support for lifestyle changes. use, valvular diseases such as aortic stenosis and severe uncontrolled hypertension). History of dizziness, fainting spells, temporary numbness, tingling in the limbs (ischemia anywhere in the body can produce transient neurological symptoms).
- Prevent or minimize development of myocardial complications
- Disease process, prognosis, and therapeutic regimen un- derstood
Echocardiography (also called two-dimensional echocardiogram and Doppler ultrasound): evaluates structures and function of the heart. Visualizes changes in heart wall motion that occur during myocardial ischemia; identifies areas of reduced myocardial perfusion, such as might occur with coronary artery occlusion; reveals the function of structures of the heart (for example, valves and chambers); and measures cardiac output.
Stable angina usually lasts 3 to 15 minutes and is often relieved by rest and sublingual nitroglycerin (NTG); unstable angina is more intense, occurs unpredictably, may last longer, and is usually not relieved by NTG or rest. Refer to CP: Acute Coronary Syndromes for assessments and interventions related to unstable angina.) BP may initially rise due to sympathetic stimulation and. Three categories of drugs are commonly used to lower the oxygen demand of the heart muscle and to treat or prevent episodes of stable angina.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Prepare for/assist with additional diagnostic studies, proce-
CARDIO V ASCULAR—ANGIN AACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
These drugs are used in the prevention of cardiovascular events in clients with chronic stable angina and in those with CAD who also have diabetes, systolic dysfunction, or both. These drugs consist of four different classes of pharmaceutical drugs (eg, bile acid sequestrants, statins, fibric acid derivatives, and niacin) used in the treatment of hyperlipidemias.
Desired Outcomes/Evaluation Criteria—Client Will
These agents work in different ways to minimize the harmful effects of cholesterol on the cardiovascular system. Since lipids are critical in the progression of cardiovascular disease, these drugs have been shown to reduce fatal and nonfatal cardiovascular events in the general population (Pahan, 2006).
ACTIONS/INTERVENTIONS RATIONALE Cardiac Risk Management
CARDIO V ASCULAR—MY OCARDIAL INF ARCTION
- Etiology
MYOCARDIAL INFARCTION
There may be atypical locations, such as pain in the epigastric or abdominal area, elbow, jaw, back, neck, between the shoulders or throat.
S EXUALITY
CARDIO V ASCULAR—MY OCARDIAL INF ARCTIONT E S T
- Relieve pain and anxiety
- Reduce myocardial workload
- Prevent, detect, and assist in treatment of life-threatening dysrhythmias or complications
- Promote cardiac health and self-care
- Chest pain absent or controlled
- Heart rate and rhythm sufficient to sustain adequate car- diac output and tissue perfusion
- Achievement of activity level sufficient for basic self-care
- Anxiety reduced and managed
- Disease process, treatment plan, and prognosis understood
- Plan in place to meet needs after discharge, including follow-up appointments
Anti-anginal drugs, such as nitroglycerin (Nitro-Bid, Nitrostat, Nitro-Dur), isosorbide dinitrate (Isordil), and mononitrate (Imdur). The presence of rubbing with an infarction is also associated with inflammation, such as pericardial effusion and pericarditis.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Monitor laboratory data, such as cardiac enzymes, arterial
Desired Outcomes/Evaluation Criteria—Client Will Activity Tolerance
Desired Outcomes/Evaluation Criteria—Client Will Anxiety Self-Control
ACTIONS/INTERVENTIONS RATIONALE Anxiety Reduction
Investigate sudden changes or persistent changes in mental status, such as confusion, irritability, lethargy, and stupor. Monitor laboratory data, such as ABGs, blood urea nitrogen (BUN), creatinine, electrolytes, and coagulation studies (prothrombin time [PT], activated prothrombin time [aPTT], clotting times).
Abnormalities in coagulation can occur as a result of therapeutic measures, such as the use of heparin or Coumadin and some heart medications. Low-dose heparin is given during PTCA and may be given prophylactically to high-risk clients, such as those with atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis, to reduce the risk of thrombophlebitis or mural thrombus formation.
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Cardiac Disease Management
Limits venous stasis, improves venous return and reduces the risk of thrombophlebitis in clients with limited activity. IV antiplatelet agents such as ReoPro and Integrilin are used in addition to PTCA to reduce the complications of platelets clumping within the stent when it is placed.
ACTIONS/INTERVENTIONS RATIONALE Teaching: Individual
CARDIO V ASCULAR—D YSRHYTHMIASACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
DYSRHYTHMIAS
Atrial Fibrillation (AF)
Sinus Tachycardia
Atrial Flutter
COMMON DYSRHYTHMIAS
Tachycardias
Ventricular Tachycardia (VT)
Ventricular Fibrillation (VF)
Heart Blocks
Sinus Bradycardia
Sick Sinus Syndrome (SSS)
Bradycardias
Premature Atrial Complex (PAC)
Premature Ventricular Contraction (PVC)
Other Dysrhythmias
CARDIO V ASCULAR—D YSRHYTHMIAS
Care Settings
Evidence of failure to improve, such as recurrent or intractable arrhythmias that are life-threatening. Mental status or sensory changes such as disorientation, confusion, memory loss; changes in normal speech pattern and consciousness, stupor, coma.
- Prevent or treat life-threatening dysrhythmias
- Support client and significant other (SO) in dealing with anxiety and fear of potentially life-threatening situation
- Assist in identification of cause or precipitating factors
- Review information regarding condition, prognosis, and treatment regimen
- Free of life-threatening dysrhythmias and complications of impaired cardiac output and tissue perfusion
- Anxiety reduced and managed
- Disease process, therapy needs, and prevention of compli- cations understood
- Plan in place to meet needs after discharge
Atrial dysrhythmias, such as PAC, atrial flutter, AF, and supraventricular atrial tachycardia (SVT) (ie, paroxysmal atrial tachycardia [PAT], multifocal atrial tachycardia [MAT]). Ventricular dysrhythmias, such as PVCs and ventricular premature beats (VPBs), ventricular tachycardia (VT) and ventricular flutter and fibrillation (VF).
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Class Ic, such as flecainide (Tambocor), encainide (Enkaid),
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Medication
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Discuss necessity of periodic laboratory evaluations, as
Desired Outcomes/Evaluation Criteria—Client Will Self-Management: Dysrhythmias
Types
CARDIAC SURGERY: POSTOPERATIVE
CARE—CORONARY ARTERY BYPASS GRAFT (CABG), MINIMALLY INVASIVE DIRECT
CORONARY ARTERY BYPASS (MIDCAB),
CARDIOMYOPLASTY, VALVE REPLACEMENT
Current use of antithrombotic drugs, including those that inhibit the production of clotting factors in the liver, such as warfarin (Coumadin); those that interfere with blood clotting by blocking thrombin activity, such as heparin and lepirudin (Refludan); Coagulation studies: Various studies can be done, such as platelet count and bleeding and clotting time.
- Support hemodynamic stability and ventilatory function
- Promote relief of pain and discomfort
- Promote healing
- Provide information about postoperative expectations and treatment regimen
- Activity tolerance adequate to meet self-care needs
- Pain alleviated or managed
- Complications prevented or minimized
- Incisions healing
- Postdischarge medications, exercise, diet, and therapy understood
- Plan in place to meet needs after discharge
Provides good documentation of the filtering function of the kidneys and a measure of the degree of systemic hydration. Fluctuations may occur due to preoperative nutritional status, presence of organ dysfunction, and the effect of IV infusions.
Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Cardiac
Identify and encourage the use of behaviors such as guided imagery, distractions, visualizations and deep breathing. May be an early manifestation of developing complications, such as thrombophlebitis, infection and gastrointestinal dysfunction.
Note: IV narcotics will be used in the immediate postoperative period while the client is intubated.
Desired Outcomes/Evaluation Criteria—Client Will Respiratory Status: Ventilation
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Demonstrate and reinforce splinting chest with pillows during
Desired Outcomes/Evaluation Criteria—Client Will Wound Healing: Primary Intention
Desired Outcomes/Evaluation Criteria—Client Will Self-Management: Cardiac Disease
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) taking any drugs. Reinforce need for routine laboratory
CARDIO V ASCULAR—THR OMBOPHLEBITIS
- Statistics
- Etiology
It is mainly treated at the community level, with a short hospital stay, generally indicated in the presence of embolization. Pathophysiology: It is related to three factors known as the Virchow triad - stasis of blood flow, damage to the blood vessel wall and changes in the coagulation mechanism.
THROMBOPHLEBITIS: VENOUS
THROMBOEMBOLISM (INCLUDING
PULMONARY EMBOLI CONSIDERATIONS)
Presence of other predisposing factors, such as pregnancy-induced hypertension, diabetes mellitus, MI or valvular heart disease, thrombotic stroke or blood dyscrasias. Use of vitamins and herbal supplements, such as vitamin B6, vitamin E, niacin, magnesium, L-carnitine and bromelain, for heart or blood pressure health.
O THER D IAGNOSTIC S TUDIES
Maintain or enhance tissue perfusion and facilitate reso- lution of thrombus
Promote optimal comfort
Provide information about disease process, prognosis, and treatment regimen
Tissue perfusion improved in affected limb
Pain or discomfort relieved
Complications prevented or resolved
Disease process, prognosis, and therapeutic needs understood
CARDIO V ASCULAR—THR OMBOPHLEBITISACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
Note: Catheter-directed fibrinolysis can be used to inject a fibrinolytic agent directly into a thrombus in order to reduce the risks associated with systemic fibrinolytic therapy. Sequential compression devices can be used to improve blood flow velocity and empty vessels by providing artificial muscle pumping action.
Embolus)
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Monitor serial ABGs or pulse oximetry
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Thrombus Prevention
Promotes client safety by reducing the risk of inadequate therapeutic response and adverse side effects such as bleeding. In addition, the use of herbal products such as ginkgo, garlic and vitamin E also worsens clotting and should be avoided during anticoagulant therapy.
Respiratory
CHAPTER 5
- Spirometric Classification of Severity of COPD—2007 Global Initiative for Chronic Obstructive Lung Disease
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND ASTHMA
RESPIRA T OR Y—COPD AND ASTHMA
Forced expired volume in 1 second
History of recurrent pneumonia; long-term exposure to chemical pollution or respiratory irritants, such as cigarette smoke, or dust and occupational fumes, such as cotton, hemp, asbestos, coal dust, sawdust. Use of accessory muscles for breathing, such as raised shoulder girdle, retraction of supraclavicular fossae, flare of the nares.
- Maintain airway patency
- Assist with measures to facilitate gas exchange
- Enhance nutritional intake
- Prevent complications and slow progression of condition
- Provide information about disease process, prognosis, and treatment regimen
- Ventilation/oxygenation adequate to meet self-care needs
- Nutritional intake meeting caloric needs
- Infection treated or prevented
Desired Outcomes/Evaluation Criteria—Client Will Respiratory Status: Airway Patency
RESPIRA T OR Y—COPD AND ASTHMAACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
Beta agonists, such as epinephrine (Adrenaline, AsthmaNefrin, Primatene, Sus-Phrine), albuterol (Proventil, Velmax, Ventolin, AccuNeb, Airet), formoterol (Foradil), levalbuterol (Xopenex), metaproterenol (Alupent), piraxairbuterol (Maxairbuterol) ), terbutaline (Brethine), and salmeterol (Serevent), Indacterol (Arcapta). Methylxanthine derivatives, such as aminophylline, oxtriphylline (Choledyl) and theophylline (Bronkodyl, Theo-Dur, Elixophyllin, Slo-Bid, Slo-Phyllin).
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Analgesics, cough suppressants, or antitussives, such as
It may also be useful in the home setting to treat chronic respiratory failure or limit acute exacerbations in clients who are able to maintain spontaneous respiratory effort. A multidisciplinary approach, including education and exercise training, may be helpful in improving client function and quality of life.
Desired Outcomes/Evaluation Criteria—Client Will Nutritional Status
Encourage client to monitor own status using CAT score (evaluate cough, mucus production, chest rise, ability to rest, activity limitations, confidence and energy levels with a numerical value) and to communicate the information to health care providers. Regular use of the peak flow meter can reduce the severity of the attack due to earlier intervention.
RESPIRA T OR Y—PNEUMONIAACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
PNEUMONIA
History of altered immune system, such as systemic lupus erythematosus (SLE), AIDS, active malignancies, neurological disease, HF, diabetes, steroid or chemotherapy use; institutionalization, general impairment. Use of herbal supplements, such as garlic, ginkgo, licorice, onion, turmeric, horehound, marshmallow, mullein, wild cherry bark, astragalus, echinacea, elderberry, goldenseal, Oregon grape root.
A SSOCIATED T ESTS
RESPIRA T OR Y—PNEUMONIA
- Maintain or improve respiratory function
- Support recuperative process
- Provide information about disease process, prognosis, and treatment
- Ventilation and oxygenation adequate for individual needs
- Complications prevented or minimized
- Lifestyle changes identified and initiated to prevent recurrence
Listen to the lung fields, noting areas of decreased or absent airflow and occasional breath sounds, such as crackles and wheezes. Demonstrate and assist the customer, as needed; learn to perform activities such as chest expansion and effective coughing while upright.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Administer medications, as indicated, for example, mucolytics,
The goal of oxygen therapy is to maintain PaO2 above 60 mm Hg or greater than 90% O2 saturation.
Desired Outcomes/Evaluation Criteria—Client Will Infection Severity
Provide comfort measures, such as back massages, position changes and calming music or conversation. Chest pain, which is usually present to some degree with pneumonia, can also herald the onset of complications of pneumonia, such as pericarditis and endocarditis.
Changes in heart rate or blood pressure (BP) may indicate that the client is experiencing pain, especially when other reasons for changes in vital signs have been ruled out.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Provide covered container for sputum and replace at frequent
Desired Outcomes/Evaluation Criteria—Client Will Fluid Balance
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Pneumonia Management
ADM_____
Discharge____
- Statistics a. Morbidity
In the United States, lung cancer is the second most common cancer in women, behind prostate cancer in men. Although the number of lung cancer cases in men has decreased, the incidence in women has increased.
LUNG CANCER: POSTOPERATIVE CARE
Clubbing: Widening or thickening of the tips of the fingers (and toes) with increased longitudinal curvature of the nail and a decrease in the angle normally seen between the cuticle and the fingernail. The second part of the procedure - 24 to 72 hours later - involves introducing a laser light through a scope to the cancer cells.
Client Assessment Database (Preoperative)
Edema of the face or neck, chest, back, due to vena caval obstruction; facial or periorbital edema due to hormonal imbalance (SCLC). Biopsy: Can be done using forceps or needle or can be via open surgical incision.
RESPIRA T OR Y—LUNG CANCER
- Control or alleviate pain
- Support efforts to cope with diagnosis and situation
- Provide information about disease process, prognosis, and therapeutic regimen
- Oxygenation and ventilation adequate to meet individual activity needs
- Pain controlled
- Anxiety and fear decreased to manageable level
- Free of preventable complications
- Disease process, prognosis, and planned therapies understood
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Reposition frequently, placing client in sitting and supine to
RESPIRA T OR Y—LUNG CANCERACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
The use of the rating scale assists the client in assessing the level of pain and provides a tool for evaluating the effectiveness of analgesics, increasing the client's control of pain. The discrepancy between verbal and nonverbal cues can provide clues about the degree of pain and the need for and effectiveness of interventions.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Note possible psychological as well as pathophysiological
Desired Outcomes/Evaluation Criteria—Client Will Anxiety Level
Fear and anxiety will decrease as the client begins to accept reality and deal with it positively.
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Cancer Management
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued) Identify individually appropriate community resources, such as
PNEUMOTHORAX/HEMOTHORAX
RESPIRA T OR Y—PNEUMO THORAXoccurs in the absence of traumatic injury to the chest
Hemothorax: An accumulation of blood in the pleural space that can put pressure on the lungs and cause them to collapse. Pneumothorax: An accumulation of air in the pleural space that puts pressure on the lungs and causes them to collapse.
RESPIRA T OR Y—PNEUMO THORAX
- Promote or maintain lung reexpansion for adequate oxy- genation and ventilation
- Minimize or prevent complications
- Reduce discomfort and pain
- Provide information about disease process, treatment regimen, and prognosis
- Adequate ventilation and oxygenation maintained
- Pain absent or controlled
- Disease process, prognosis, and therapy needs understood
RESPIRA T OR Y—PNEUMO THORAXACTIONS/INTERVENTIONS (continued)RATIONALE (continued)
Note the character and amount of chest tube drainage, whether the tube is warm and full of blood, and whether the level of bloody fluid in the water seal bottle is rising. Assist and prepare for reinflation procedures; for example, simple aspiration, the Heimlich valve, and chest tube placement with the chest tube drainage unit (CDU).
Desired Outcomes/Evaluation Criteria—Client Will Risk Control
Caregiver Will
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Acute Illness Management
- Pathophysiology—impairment of respiratory function af- fecting O 2 uptake and CO 2 elimination, requiring mechanical
- Mechanical Ventilators
Certain underlying lung diseases, such as severe COPD and malignancies, may increase the incidence of recurrence. It prevents respiratory complications, such as fibrotic changes in lung tissue, and can prevent recurrence of lung collapse.
VENTILATORY ASSISTANCE (MECHANICAL)
- Promote adequate ventilation and oxygenation
- Provide emotional support for client and SO
- Provide information about disease process, prognosis, and treatment needs
- Respiratory function maximized and adequate to meet in- dividual needs
- Effective means of communication established
- Disease process, prognosis, and therapeutic regimen un- derstood, including home ventilatory support if indicated
Spontaneous breathing: initiated, controlled and ended by the client; however, the volume and pressure of exhaled air provided by the ventilator depends on the customer's requirement. Tidal Volume (VT): The specific volume of air drawn into and then exhaled from the lungs.
S TUDIES T HAT M ONITOR S TATUS , AND H ELP D ETERMINE R EADINESS FOR W EANING
Vital capacity (VC): The total amount of air that can be exhaled after a maximum inspiration; the sum of the inspiratory reserve volume, the tidal volume and the expiratory reserve volume. Forced Vital Capacity (FVC): Total amount of air that can be forcibly expelled after full inspiration.
Ventilation
Minute ventilation (ME): measures the volume of air inhaled and exhaled in 1 minute of normal breathing. Forced Expiratory Volume (FEV1): Measures the amount of air in liters that a person can forcefully blow out in 1 second.
NURSING DIAGNOSIS: ineffective Breathing Pattern/impaired spontaneous Ventilation (continued)
Respiratory rate of 10 to 15 per minute may be appropriate except for client with COPD and CO2 retention. Expiratory phase is usually twice the length of the inspiratory rate, but may be longer to compensate for air trapping to improve gas exchange in the client with COPD.
Suctioning should not be routine and the duration should be limited to reduce the risk of hypoxia. It promotes secretion drainage and ventilation of all lung segments, which reduces the risk of atelectasis.
Desired Outcomes/Evaluation Criteria—Client Will Communication: Expressive
Offer the client and the SO the opportunity to accept and begin to deal with what happened, thereby reducing anxiety. Additional assistance may be necessary if the client and SO are unable to control anxiety or if the client becomes “identified with the machine.”
Identify previous client and SO mastery strengths and current areas of mastery and ability. Provide and encourage sedentary vigorous activities within individual capabilities such as crafts, writing and television.
Desired Outcomes/Evaluation Criteria—Client Will Tissue Integrity: Skin and Mucous Membrane
Demonstrate and encourage the use of relaxation techniques such as focused breathing, guided imagery and progressive relaxation.
ACTIONS/INTERVENTIONS RATIONALE Nutrition Therapy
Desired Outcomes/Evaluation Criteria—Client Will Risk Control: Infectious Process