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rencana keperawatan untuk merawat dan menolong nyawa pasien (In_English).

rencana keperawatan untuk merawat dan menolong nyawa pasien (In_English).

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    • Copyright © 2006 by F. A. Davis.
    • Copyright © 2006 by F. A. Davis. INDEX OF DISEASES/DISORDERS AIDS, 726 Heart failure: chronic, 47 Pneumonia, 128 Alcohol: acute withdrawal, 831 Hemodialysis, 581 Primary base bicarbonate deficiency, 492 Alzheimer’s disease, 945 Hemolytic anemia, 499 Primary base bicarbonate excess, 495 Amputation, 657 Hepatitis, 443 Primary carbonic acid deficit, 198 Anemias (iron deficiency, pernicious, Herniated nucleus pulposus (ruptured Primary carbonic acid excess, 194 aplastic, hemolytic), 499 intervertebral disc), 252 Prostatectomy, 604 Angina (coronary artery disease), 62 HIV-positive client, 712 Psychosocial aspects of care, 770 Anorexia nervosa, 376 Hospice care, 880 Pulmonary embolus, 108 Aplastic anemia, 499 Hypercalcemia (calcium excess), 938 Pulmonary tuberculosis, 184 Appendectomy, 350 Hyperkalemia (potassium excess), 933 Asthma, 117 Hypermagnesemia (magnesium excess), 943 Radical neck surgery: laryngectomy Hypernatremia (sodium excess), 928 (postoperative care), 157 Benign prostatic hyperplasia, 596 Hypertension: severe, 35 Regional enteritis, 324 Bulimia nervosa, 376 Hyperthyroidism (thyrotoxicosis, Graves’ Renal calculi, 613 Burns: thermal/chemical/electrical (acute disease), 426 Renal dialysis, 564 and convalescent phases), 680 Hypervolemia (extracellular fluid volume Renal dialysis: peritoneal, 575 excess), 919 Renal failure: acute, 541 Cancer, 857 Hypocalcemia (calcium deficit), 936 Renal failure: chronic, 553 Cardiac surgery: postoperative care, 96 Hypokalemia (potassium deficit), 931 Respiratory acid-base imbalances, 194 Cardiomyoplasty, 96 Hypomagnesemia (magnesium deficit), 941 Respiratory acidosis (primary carbonic acid Cerebrovascular accident/stroke, 236 Hyponatremia (sodium deficit), 925 excess), 194 Chemical burns, 680 Hypovolemia (extracellular fluid volume Respiratory alkalosis (primary carbonic acid Cholecystectomy, 371 deficit), 922 deficit), 194 Cholecystitis with cholelithiasis, 364 Hysterectomy, 621 Rheumatoid arthritis, 750 Cholelithiasis, 364 Ruptured intervertebral disc, 252 Chronic obstructive pulmonary disease, 117 Ileocolitis, 324 Cirrhosis of liver, 453 Ileostomy, 338 Seizure disorders, 208 Colostomy, 338 Inflammatory bowel disease: ulcerative Sepsis/septicemia, 701 Coronary artery bypass graft, 96 colitis, regional enteritis (Crohn’s disease, Septicemia, 701 Coronary artery disease, 62 ileocolitis), 324 Sickle cell crisis, 509 Craniocerebral trauma (acute rehabilitative Iron deficiency anemia, 499 Spinal cord injury (acute rehabilitative phase), 218 phase), 271 Crohn’s disease, 324 Laryngectomy (postoperative care), 157 Stroke, 236 Leukemias, 523 Substance dependence/abuse rehabilitation, Deep vein thrombosis, 108 Lung cancer (postoperative care), 141 843 Diabetes mellitus/diabetic ketoacidosis, 412 Lymphomas, 532 Subtotal gastrectomy/gastric resection, 320 Diabetic ketoacidosis, 412 Surgical interventions, 788 Disaster considerations, 890 Mastectomy, 630 Disc surgery, 260 Metabolic acid-base imbalances, 491 Thermal burns, 680 Dysrhythmias (including digitalis toxicity), Metabolic acidosis (primary base Thrombophlebitis: deep vein thrombosis 85 bicarbonate deficit), 492 (including pulmonary emboli Metabolic alkalosis (primary base considerations), 108 Eating disorders: anorexia nervosa/bulimia bicarbonate excess), 495 Thyroidectomy, 437 nervosa, 376 Minimally invasive direct coronary artery Thyrotoxicosis, 426 Eating disorders: obesity, 393 bypass, 96 Total joint replacement, 667 Electrical burns, 680 Multiple sclerosis, 291 Total nutritional support: parenteral/enteral End of life/hospice care, 880 Myocardial infarction, 72 feeding, 478 Enteral feeding, 478 Transplantation (postoperative and Esophageal bleeding, 309 Neurological/sensory disorders, 202 lifelong), 761 Extended care, 810 Obesity, 393 Ulcerative colitis, 324 Fecal diversions: postoperative care of Obesity: surgical interventions (gastric Upper gastrointestinal/esophageal ileostomy and colostomy, 338 partitioning/gastroplasty, gastric bleeding, 309 Fluid and electrolyte imbalances, 919 bypass), 402 Urinary diversions/urostomy Fluid balance, 919 (postoperative care), 585 Fractures, 642 Pancreatitis, 467 Urolithiasis (renal calculi), 613 Parenteral feeding, 478 Urostomy, 585 Gastric bypass, 402 Pediatric considerations, 905 Gastric partitioning, 402 Peritonitis, 355 Valve replacement, 96 Gastroplasty, 402 Pernicious anemia, 499 Ventilatory assistance (mechanical), 170 Glaucoma, 202 Graves’ disease, 426
    • Copyright © 2006 by F. A. Davis. KEY TO ESSENTIAL TERMINOLOGY CLIENT ASSESSMENT DATABASE Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical/sur- gical diagnosis as well as the signs/symptoms and corresponding diagnostic findings. NURSING PRIORITIES Establishes a general ranking of needs/concerns on which the Nursing Diagnoses are ordered in constructing the plan of care. This ranking would be altered according to the individual client situation. DISCHARGE GOALS Identifies generalized statements that could be developed into short-term and intermediate goals to be achieved by the client before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to work on after discharge. NURSING DIAGNOSIS The general problem/need (diagnosis) is stated without the distinct cause and signs/symptoms, which would be added to cre- ate a client diagnostic statement when specific client information is available. For example, when a client displays increased tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe Anxiety, re- lated to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observa- tions of quivering voice, focus on self. In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and new diagnoses added, depending entirely on the specific client information. MAY BE RELATED TO/POSSIBLY EVIDENCED BY These lists provide the usual/common reasons (etiology) why a particular problem may occur with probable signs/symptoms, which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statement when the specific situation is known. When a risk diagnosis has been identified, signs/symptoms have not yet developed and therefore are not included in the nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The exception to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status. DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL These give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms to permit the practitioner to modify/individualize them by adding time lines and individual client criteria so they become “measurable.” For example, “Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours.” Nursing Outcomes Classification (NOC) labels are also included. The outcome label is selected from a standardized nurs- ing language and serves as a general header for the outcome indicators that follow. ACTIONS/INTERVENTIONS NIC (Nursing Interventions Classification) intervention labels are drawn from a standardized nursing language and serve as a general header for the nursing actions that follow. Nursing actions are divided into independent (those actions that the nurse performs autonomously) and collaborative (those actions that the nurse performs in conjunction with others, such as implementing physician orders) and are ranked in this book from most to least common. When creating the individual plan of care, interventions would normally be ranked to reflect the client’s specific needs/situation. In addition, the division of independent/collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities and hospital/community standards. RATIONALE Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiologic ba- sis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation. CLINICAL PATHWAY This abbreviated plan of care or care map is event (task) oriented and provides outcome-based guidelines for goal achievement within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.
    • Copyright © 2006 by F. A. Davis. NURSING DIAGNOSES ACCEPTED FOR USE AND RESEARCH THROUGH 2006 Activity Intolerance [specify level] Gas Exchange, impaired Role Performance, ineffective Activity Intolerance, risk for Grieving, anticipatory Self-Care Deficit: bathing/hygiene Adjustment, impaired Grieving, dysfunctional Self-Care Deficit: dressing/grooming Airway Clearance, ineffective Grieving, risk for dysfunctional Self-Care Deficit: feeding Allergy Response, latex Growth & Development, delayed Self-Care Deficit: toileting Allergy response, risk for latex Growth, risk for disproportionate Self-Concept, readiness for enhanced Anxiety [specify level] Health Maintenance, ineffective Self-Esteem, chronic low Anxiety, death Health-Seeking Behaviors (specify) Self-Esteem, situational low Aspiration, risk for Home Maintenance, impaired Self-Esteem, risk for situational low Attachment, risk for impaired Hopelessness Self-Mutilation parent/infant/child Hyperthermia Self-Mutilation, risk for Autonomic Dysreflexia Hypothermia Sensory Perception, disturbed: (specify: visual, Autonomic Dysreflexia, risk for Identity, disturbed personal auditory, kinesthetic, gustatory, tactile, Body Image, disturbed Infant Behavior, disorganized olfactory) Body Temperature, risk for imbalanced Infant Behavior, readiness for enhanced Sexual Dysfunction Bowel Incontinence organized Sexuality Pattern, ineffective Breastfeeding, effective Infant Behavior, risk for disorganized Skin Integrity, impaired Breastfeeding, ineffective Infant Feeding Pattern, ineffective Skin Integrity, risk for impaired Breastfeeding, interrupted Infection, risk for Sleep Deprivation Breathing Pattern, ineffective Injury, risk for Sleep, readiness for enhanced Cardiac Output, decreased Injury, risk for perioperative positioning Sleep Pattern, disturbed Caregiver Role Strain Intracranial Adaptive Capacity, decreased Social Interaction, impaired Caregiver Role Strain, risk for Knowledge, deficient [Learning Need] Social Isolation Communication, impaired verbal [specify] Sorrow, chronic Communication, readiness for enhanced Knowledge [specify], readiness for enhanced Spiritual Distress Conflict, decisional (specify) Lifestyle, sedentary Spiritual Distress, risk for Conflict, parental role Loneliness, risk for Spiritual Well-Being, readiness for enhanced Confusion, acute Memory, impaired Suffocation, risk for Confusion, chronic Mobility, impaired bed Suicide, risk for Constipation Mobility, impaired physical Surgical Recovery, delayed Constipation, perceived Mobility, impaired wheelchair Swallowing, impaired Constipation, risk for Nausea Therapeutic Regimen Management, effective Coping, defensive Neglect, unilateral Therapeutic Regimen Management, ineffective Coping, ineffective Noncompliance, [Adherence, ineffective] Therapeutic Regimen Management, ineffective Coping, readiness for enhanced [specify] community Coping, ineffective community Nutrition: less than body requirements, Therapeutic Regimen Management, ineffective Coping, readiness for enhanced community imbalanced family Coping, compromised family Nutrition: more than body requirements, Therapeutic Regimen Management, readiness Coping, disabled family imbalanced for enhanced Coping, readiness for enhanced family Nutrition, readiness for enhanced Thermoregulation, ineffective Death syndrome, risk for sudden infant Nutrition: more than body requirements, Thought Processes, disturbed Denial, ineffective risk for imbalanced Tissue Integrity, impaired Dentition, impaired Oral Mucous Membrane, impaired Tissue Perfusion, ineffective (specify type: Development, risk for delayed Pain, acute cerebral, cardiopulmonary, renal, Diarrhea Pain, chronic gastrointestinal, peripheral) Disuse Syndrome, risk for Parenting, impaired Transfer Ability, impaired Diversional Activity, deficient Parenting, readiness for enhanced Trauma, risk for Energy Field disturbed Parenting, risk for impaired Urinary Elimination, impaired Environmental Interpretation Syndrome, Peripheral Neurovascular Dysfunction, risk for Urinary Elimination, readiness for enhanced impaired Poisoning, risk for Urinary Incontinence, functional Failure to Thrive, adult Post-Trauma Syndrome [specify stage] Urinary Incontinence, reflex Falls, risk for Post-Trauma Syndrome, risk for Urinary Incontinence, stress Family Processes: alcoholism, dysfunctional Powerlessness [specify level] Urinary Incontinence, total Family Processes, interrupted Powerlessness, risk for Urinary Incontinence, urge Family Processes, readiness for enhanced Protection, ineffective Urinary Incontinence, risk for urge Fatigue Rape-Trauma Syndrome Urinary Retention [acute/chronic] Fear Rape-Trauma Syndrome: compound reaction Ventilation, impaired spontaneous Fluid Balance, readiness for enhanced Rape-Trauma Syndrome: silent reaction Ventilatory Weaning Response, dysfunctional [Fluid Volume, deficient hyper/hypotonic] Religiosity, impaired Violence, [actual/] risk for other-directed Fluid Volume, deficient [isotonic] Religiosity, risk for impaired Violence, [actual/] risk for self-directed Fluid Volume, excess Religiosity, readiness for enhanced Walking, impaired Fluid Volume, risk for deficient Relocation Stress Syndrome Wandering [specify sporadic or continual] Fluid Volume risk for imbalanced Relocation Stress Syndrome, risk for [ ] author recommendations Used with permission from NANDA International: Definitions and Classification, 2005–-2006. NANDA, Philadelphia, 2005.
    • Copyright © 2006 by F. A. Davis. NURSING CARE PLANS GUIDELINES FOR INDIVIDUALIZING CLIENT CARE ACROSS THE LIFE SPAN EDITION 7 Marilynn E. Doenges, APRN, BC-Retired Clinical Specialist, Adult Psychiatric/Mental Health Nursing, Retired Adjunct Faculty Beth-El College of Nursing and Health Sciences, UCCS Colorado Springs, Colorado Mary Frances Moorhouse, RN, MSN, CRRN, LNC Adjunct Faculty/Clinical Instructor Pikes Peak Community College Nurse Consultant/TNT-RN Enterprises Colorado Springs, Colorado Alice C. Murr, RN, BSN, LNC Legal Nurse Consultant Telephone Triage Nurse Jackson, Mississippi F. A. DAVIS COMPANY • Philadelphia
    • Copyright © 2006 by F. A. Davis. NURSING CARE PLANS, 7th Edition… 7:25 PM Page 98 enges-04 12/9/05 Includes lab and diagnostic studies , and transportatio n, self-care needs NING ration, shopping, TEACHING/LEAR nce with food prepa Short-term assista The Guideline Approach Discharge plan maintenance tasks homemaker/home considerations: ions. ischarge considerat end of plan for postd Refer to section at cell VE) IES (POSTOPERATI ty and indicates need for red blood DIAGNOSTIC STUD s oxyge n-carrying capaci A low Hb reduce for fluid replacement . eutic ematocrit (Hct): to determine therap Hemoglobin (Hb)/h sts dehydration/need count, bleeding and clotting time) ion of Hct sugge to Individualized Care Planning replacement. Elevat platelet s may be done (e.g., affect cardiac s: Various studie hypocalcemia) can Coagulation studie t therapy when used. ponatremia, and level of anticoagulan hypernatremia/hy ia/hypokalemia, ances (hyperkalem Electrolytes: Imbal on, and acid-base balance. balance. function and fluid s of respiratory functi nation status, effectivenes at tissue level. ABGs: Verifies oxyge re of oxygenation ement. es noninvasive measu ion/function. going valve replac Pulse oximetry: Provid adequacy of renal and liver perfus heart failure under of Reflects ; e.g., those with an dysfunction, rate BUN/creatinine: in high-risk clients ce of diabetes/org is occasionally seen onal status, presen Amylase: Elevation preoperative nutriti occur because of Gluco se: Fluctuations may perioperativ e MI. s of acute, recent, or nary complication dextrose infusions. ed in the presence chang es indicative of pulmo r/cardiac enzymes: Elevat vasculature, and leads, intravascula Cardiac enzymes/iso position, pulmonary and sternal wires, position of pacing ls heart size and Chest x-ray: Revea of valve prosthesis Contains all the elements needed to make individualized patient care (e.g., atelectasis). lines. ECG: Identifies chang Verifies condition es in electrical, mecha nical function such nction, and/or perica as might occur in rditis. immediate postop erative phase, across valves, identi fies e MI, valve dysfu pressure gradients acute/perioperativ er pressures and es. choices, while teaching you how to critically analyze each component occlusions of arterie am/catheterizatio echocardiography: n: Measures chamb Cardiac echocardiogr s, impaired coronary perfusion, Usefu and possible wall l in diagnosing cardia motion abnormaliti c valve and chamb ach is not feasib le. er abnormalities, such as regurgitation coronary artery diseas e, heart , Transesophageal transthoracic appro scans demonstrate is in clients in whom m/Persantine): Heart and create the correct care plan for your patient. More than just a book shunting, or stenos Nuclear studies (e.g., chamber dimensions, thalliu m-201, DPY-thalliu and presurgical/ postsurgical functi onal capabilities. RITIES NURSING PRIO of Med-Surg care plans—this is an all-in-one resource that includes four 1. Support hemod 2. Promote relief ynamic stability/ve of pain/discomfort. ntilatory function. en. g. and treatment regim 3. Promote healin erative expectations new care plans, an introduction to Mind Mapping, and a bonus CD-ROM 4. Provide inform DISCHARGE GOA LS ation about postop nce adequate to meet self-care needs. Features diagnoses by priority covering all the care plans found in the book (plus 84 only available on 1. Activity tolera 2. Pain alleviated/m 3. Complications anaged. prevented/minimiz ed. understood. 4. Incisio ns healing. se, diet, therapy medications, exerci the disc) and the top 400 health conditions. 5. Postdischarge 6. Plan in place to meet needs after discharge. ut ased Cardiac Outp NOSIS: risk for decre NURSING DIAG Risk factors may include s (e.g., ventricular to temporary factor ctility secondary ) Loaded with care plans, including four new to this edition: Decreased myocardial contra wall surgery, recen Decreased t MI, response to preload (hypovolem tions in electrical ia) certain medications conduction (dysrh ythmias) /drug interactions Altera by osis.] Possibly evidenced ishes an actual diagn and symptoms establ Obesity Surgery – Complete coverage of gastric bypass surgery; [Not applicable; presence of signs ACTIONS/INTERVEN TIONS a procedure becoming more common across the country. 98 Investigate report leg, abdomen) or cially when accom s of pain in unusu vague complaints al areas (e.g., calf of discomfort, espe- of RATIONALE May be an early manifestation of panied by chang such as thrombophl developing compl es in mentation, ication Fluid and Electrolyte Imbalances – Clear and definitive care signs, respiratory Note reports of pain (fourth and fifth rate. and/or numbness digits) of the hand, in ulnar area vital function. ebitis, infection, Indicative of a stretch gastrointestinal dys- by pain/discomfort often accompanied injury of the brachi planning covering the role fluid and electrolyte imbalances that the problem Collaborative of the arms and should usually resolves with time. ers. Tell client result of the positio cific treatment is n of the arms during currently useful. al plexus as a surgery. No spe- play in many disorders. Administer medic and acetaminoph ations as indicated, en (Darvocet-N), e.g., propoxyphe ne Usually provides Highlights nursing diagnoses—now easier to find and use oxycodone (Tylox acetaminophen and ), and/or ketorolac (Toradol). for adequate contro mation, and reduce l of pain and inflam - More Life Span coverage – Extended Care and Pediatric comfort and promo s muscle tension, tes healing. which improves client care plans are also included. NURSING DIAG May be related to NOSIS: ineffective Role Performanc e Situational crisis (dependent role)/r Uncertainty about ecuperative proce future ss Possibly evidenced by Delay/alteration in physical capacity Change in usual to resume role role or Change in self/others’ responsibility perception of role DESIRED OUTCOMES /EVALUATION CRITE RIA—CLIENT WILL Here’s just a sample of what you’ll find PSYC HOSOCIAL ADJU Verbalize realistic Talk with SO about STMENT: perception and accep situation and chang : Life Chan ge (NOC) tance of self in chang ed role. Develop realistic es that have occur plans for adapting red. in the pages that follow… 7:25 PM Page 107 to perceived role changes. Doenges-04 12/9/05 ACTIONS/INTERVEN TIONS Role Enhancement RATIONALE Care plans you can adapt and customize to fit patient needs: CARDIOVAS (NIC) Independent RATIONALE ns depend on type of Asses NS s client role in family es and expectatio physical S/INTERVENTIO about role dysfuise pro- consteIndividual capa concerns ac function, and prior ital re- llation. Identify biliti • CD-ROM includes all 116 care plans from the book ACTION Review presc ribed cardiac exerc nction/inter ress to date. Assis health ion/ t client/SO to underlying cardi rehabilitat-illness transitrealistic set ions. Helps ruption; e.g., recupe surgery, conditioning. of hosp to know client’s is a predictor Note: Obesity affects this role. ons. responsibilities and how illness ration, tional interventi Dependent role may require addi concern Note: Strenuous of client provokes anxiet and CULAR: CAR gram and prog admission and verexhaustion. about how client plus 84 more—200 care plans! goals. Assess level of anxiet threat to self/life. Noteroutines; e y, client’s percep ents excessive fatigue/o role responsibilities. e.g., self-c cipation in hom cultural factors affecting are, activity and Prev of degree of undue stress on sternotom tion use of arms can place Information provid ing plan of care. y. will be able to manag es baseline for identi fying/individualiz y e usual Encourage parti nating rest perio ds with et- role changes. - Suggest alter y lifting, isom use of inter- - 115 Medical/Surgical care plans cooking. light tasks with heavy tasks. Avoi upper-body exerc d heav ise. res- Having a plan g up exercise forestalls givin determine can as weather. rent situation beca Cultural expectations regarding male/ how client/SO reacts female illness role DIAC SURGER ric/strenuous continue prog ferences such to and deals with Maintain to client/SO ways positive attitud and and may affect future cur- Prob lem-solve with erature extremes e toward client, provid changes. adaptation to percei ved ram during temp opportunities for etermined ing - 34 Psychiatric care plans sive activity prog n dayspossible. ing pred high wind/pol distance with lutio in own house ; e.g., walk or local indoor client to exercise shopping control as much Rest and sleep as enhance copin Helps client accept changes that g abilit control over self/situatio ote healing. ess realize thaties, reduce nervousn are occurring and begin n is possible. to mall/exercise track. 102 several times a day. phase), and prom pera- and short naps (common in this nt until after the first posto - 50 Maternal/Newborn care plans Schedule rest periods s are prese These restriction assessment of sternum heali ng. Y: lifting, driv- for ations about tive office visit ician’s time limit sexual activity, and exer- Postoperative Reinforce phys pressed, but to work, resum ing ity often go unex t sexual activ to expect. In - Pediatric Considerations ing, returning cising that invo Discuss issue lves upper extre s concerning mities. resumption of s of sexual inter sexual activity; cour se with other Concerns abou clients usually general, clien desire informati at which on about what ge in sex when activity level t can safely enga client can climb two flights n- e.g., comp arison of stres has adva nced to point same amou nt of energy expe ch is about the Prioritized nursing diagnoses to help students write activities: of stairs (whi diture). that restrict breat hing (sexual tion). Client Care avoid positions Client should nd and consump ases oxygen dema ort self or partner with measurable goal statements Position recom mendations; activity incre with sternotom arms (breast y should not bone healing, supp support musc ars to occur with les stretched) some regularity . in postop- is Impotence appe ugh etiology ry clients. Altho without spe- Focused on the patient, and applies the body system Expectatio ns of sexual perfo rmance; Loaded with rationales for every intervention erative cardiac unknown, cond cific interventi surge ition usually on. If situation resolves in time persists, may requ ire further evaluation. of complica- ce occurrence approach to care planning Appropriate sexual intercour timing; e.g., avoid ds of emotional dis- se fol- Timing of activ tions /angina. ity may redu use of antiangi- meal, during perio prophylactic lowing heavy exhausted; may benefit from ity. Some clients Guidelines covering total patient needs—physical, cultural, tress, when clien Pharmacologic t is fatigued/ considerations . nal medicatio Facilitates trans ns for sexual ition to home; ion of presc activ provides for ribed therapies, ongoing mon opportunity to i- discharge. toring, continuat available after anxiety. sexual, nutritional, and psychosocial Identify servi Provide telep ces/resources hone calls as appropria contact number/ te. Include refer schedule follo ral names for w-up hom e care discuss concerns and alleviate ated. services, as indic t’s age, physical Updated with the latest NANDA, NIC, and NOC content SIDERATIONS arge from care setting (dependes) following disch urces, and life responsib onal reso ilitie nt on clien POTENTIAL CON e of complications, pers senc condition/pre New emphasis on complementary therapies Activity Intol erance—genera ness, sede lized weak ntary lifestyle. surgical incis ions, puncture wounds. ms, reluctance to request assis tance. Tissue Integrity— support syste impaired Skin/ , inadequate to perform tasks New chapter on mind mapping impaired Hom e Maintenance—a broken skin, ltered ability traumatized tissu e, invasive proce dures, decreased hemo globin. risk for Infection— endurance, disco mfort. strength and future. it—decreased rtainty about Self-Care Defic ive process, unce ituational crisis/recuperat Performance—s 107 ineffective Role
    • Copyright © 2006 by F. A. Davis. Includes a Bonus CD-ROM—a Valuable Package of Resources You Can Use! Bonus CD-ROM You will find 200 Care Plans with an index of the top 400 Diseases/Disorders and their associated nursing diagnoses. To help make navigating the CD-ROM even easier, we’ve provided a complete Table of Contents to the CD in the book. The CD is a robust resource that will save valuable time and help you put all the pieces together quickly and accurately! 1 200 Care Plans The bonus CD-ROM contains 200 care plans that Cardiovascular students can adapt and customize to fit their needs. It also includes four NEW care plans covering obesity surgery, fluids and electrolytes, extended care, and pediatric considerations. A complete package including all 116 care plans featured in the 2 book plus 84 additional found only on the CD-ROM— that’s 200 care plans! Hypertension: Severe 400 Diseases/Disorders A complete index of 400 Disorders and Health 3 Conditions, with their associated nursing diagnoses, is also included. The menu screen features a user- friendly A to Z listing reflecting all specialty areas, with associated nursing diagnoses, that include "related to" and "evidenced by" statements. 2 AIDS 1 Includes 3+ books in 1, that feature: 3 115 Medical/Surgical care plans A 34 Psychiatric care plans 50 Maternal/Newborn care plans Pediatric Considerations
    • Copyright © 2006 by F. A. Davis. F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2006 by F. A. Davis Company Copyright © 1984, 1989, 1993, 1997, 2000, and 2002 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or other- wise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Joanne P. DaCunha, RN, MSN Developmental Editor: Alan Sorkowitz Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in ac- cordance with professional standards of care used in regard to the unique circumstances that may ap- ply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Doenges, Marilynn E., 1922- Nursing care plans : guidelines for individualizing client care/Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.—Ed. 7. p. ; cm. Includes bibliographical references and index. ISBN 0-8036-1294-X 1. Intensive nursing care—Handbooks, manuals, etc. 2. Nursing care plans—Handbooks, manuals, etc. [DNLM: 1. Patient Care Planning—Handbooks. 2. Nursing Process—Handbooks. WY 49 D651na 2006] I. Moorhouse, Mary Frances, 1947-II. Geissler-Murr, Alice, 1946-III. Title. RT49.D64 2006 610.73—dc22 2005036714 Authorization to photocopy items for internal or personal use, or the internal or personal use of spe- cific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1294/07 0 $.10.
    • Copyright © 2006 by F. A. Davis. DEDICATION To our spouses, children, parents, and friends, who much of the time have had to manage without us while we work as well as having to cope with our struggles and frustrations. The Doenges families: the late Dean, whose support and en- couragement is sorely missed; Jim; Barbara and Bob Lanza; David, Monita, Matthew, and Tyler; John, Holly, Nicole, and Kelsey; and the Daigle family, Nancy, Jim, Jennifer, Brandon, Anna, Will, and Henry Smith-Daigle, and Jonathan and Kim. The Moorhouse family: Jan, Paul, Jason, Thenderlyn, Alexa, and Mary. To Mary and Marilynn, couldn’t have done it without you. In loving memory of my parents, who were my biggest promoters in my early days of writing. To my children and grandchildren with love. You have expanded my horizons so wonderfully! Alice To our FAD family, especially Bob Martone and Bob Butler, whose support is so vital to the completion of a project of this magnitude. And to Alan Sorkowitz, the one who really kept us all together, our go-to-guy when the going got tough. We are fourtu- nate to have you working with us. To the nurses we are writing for, who daily face the challenge of caring for the acutely ill client and are looking for a practical way to organize and document this care. We believe that nursing diagnosis and these guides will help. To NANDA and to the international nurses who are develop- ing and using nursing diagnoses—here we come! Finally, to the late Mary Lisk Jeffries, who initiated the origi- nal project. The memory of our early friendship and struggles re- mains with us. We miss her and wish she were here to see the growth of the profession and how nursing diagnosis has con- tributed to the process. vii
    • Copyright © 2006 by F. A. Davis. REVIEWERS FOR THE BOOK JANE V. ARNDT, MS, RN, CWOCN Senior Instructor Nurse Clinician, Enterostomal Therapy University of Colorado Health Science Poudre Valley Hospital Center School of Nursing Ft. Collins, Colorado Denver, Colorado JENNIFER AVERY KIMBERLY TUCKER PFENNIGS, MA, Senior Nursing Student College of the Sequoias BAN, RN Visalia, California Pikes Peak Mental Health Program Manager, Lighthouse Assessment Center BETH HAMSTRA, RN, CNS, RCIS, PHD Adult Treatment Units Clinical Manager Invasive Cardiology Colorado Springs, Colorado Memorial Hospital Colorado Springs, Colorado GILDA ROLLS-DELLINGER, RN SANDRA HARPER, RN, CCRN Staff Nurse, Skin, Wound, and Burn Team Rehabilitation Care Specialist Penrose-St. Francis Health Services HealthSouth Rehabilitation Hospital Colorado Springs, Colorado Colorado Springs, Colorado ROCHELLE SALMORE, MSN, RN, CGRN, CHRISTIE A. HINDS, MSN, APRN-BC CAN, BC Primary Care Nurse Practitioner Clincal Manager Health Essentials Digestive Disease Center Chattanooga, Tennesse Penrose–St. Francis Health Services Colorado Springs, Colorado SUSAN JANTY, VN, ACRN SCD/HIV Medical Coordinator El Paso Department of Heath and TRACY STEINBERG, RN, MSN, CNS Environment Liver Transplant Coordinator Colorado Springs, Colorado Division of Transplant Surgery University of Colorado Health Sciences Center LAURA RUTH TEIGEN JOHNSON, RN, Denver, Colorado MNE, CNOR Perioperative Services Manager Colorado Springs, Colorado GERI L. TIERNEY, RN, BSN, ONC Nursing Simulation Lab Coordinator Pikes Peak Community College LENORA KRAFT, RN Past-President National Association of Surgical Clinical Manager Orthopaedic Nurses Penrose St-Francis Hospital Colorado Springs, Colorado Colorado Springs, Colorado KATHLEEN H. WINDER, RN, BSN SUZANNE LOGAN, MS, RD Clinical Manager, Pediatric Specialty Manager, Dietetic Internship Clinic Clinical Manager Memorial Hospital Penrose–St. Francis Health Services Colorado Springs, Colorado Colorado Springs, Colorado ANNE ZOBEC, MS, RN, CS, NP, MARY BETH FLYNN-MAKIC, RN, MS, AOCN CNS, CCRN Oncology Nurse Practitioner Clinical Nurse Specialist/Educator The Oncology Clinic, P. C. University of Colorado Hospital Colorado Springs, Colorado viii
    • Copyright © 2006 by F. A. Davis. REVIEWERS FOR THE CD-ROM CYNTHIA ASKVIG, RN, MS JILL MEIDER, APRN, BC Nursing Faculty Adjunct Instructor Pikes Peak Community College Pikes Peak Community College Colorado Springs, Colorado Colorado Springs, Colorado SUSAN JANTY, VN, ACRN SUSAN M. MOBERLY, RNC, BSN, ICCE Board Certified in HIV/AIDS Nursing Maternal/Newborn Nurse Consultant SCD/HIV Medical Coordinator ICEA Certified Childbirth Educator El Paso Department of Heath and Pikes Peak Choices in Childbirth Evironment Colorado Springs, Colorado Colorado Springs, Colorado LESLIE MURTAGH, MS, APRN, BC NOLA LANGE, MS, APRN, BC Board Certified Child and Adolescent Adjunct Psychiatric Instructor Clinical Nurse Specialist Pikes Peak Community College Casper, Wyoming Colorado Springs, Colorado ix
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    • Copyright © 2006 by F. A. Davis. ACKNOWLEDGEMENTS JOE RUSKIN, RPH THE LATE NANCY LEA CARTER, RN, Colorado Springs, Colorado MA Clinical Nurse, Orthopedics JAMES I. BURNS, BS Albuquerque, New Mexico Systems Analyst Disaster Science Coronado, California xi
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    • Copyright © 2006 by F. A. Davis. INTRODUCTION We are often asked how we came to write the Care Plan books. In the late 1970s we were involved with some publishing efforts that did not come to fruition. In this work we had included care plans, so ensuing discussions revolved around the need for a Care Plan book. We spent a year struggling to write care plans before we realized our major difficulty was the lack of standardized labels for client problems. At that time, we were given a list of nursing diagnoses from the Clearinghouse for Nursing Diagnosis, which became the North American Nursing Diagnosis Association (NANDA), and is now NANDA International. This work answered our need by providing concise titles that could be used in various care plans and followed across the spectrum of client care. We believed these nursing diagnosis labels would both define and focus nursing care. Because we had long been involved in direct client care in our nursing careers, we knew there was a need for guidelines to assist nurses in planning care. As we began to write, our focus was the nurse in a small rural community who at 2 AM needed the answer to a burning question for her client and had few resources available. We believed the book would give definition and direction to the development and use of individualized nursing care. Thus, in the first edition, the theory of nursing process, diagnosis, and intervention was brought to the clinical setting for implementation by the nurse. We also anticipated that nursing students would appreciate having access to these guidelines as they struggled to learn how to give nursing care. Therefore, we did not consider the book to be an end in itself, but rather a vehicle for the continuing growth and development of the profession. Obvi- ously we struck a chord and met a need because the first edition was an immediate success. In becoming involved with NANDA, we acknowledged that maintaining a strict adherence to their wording, while adding our own clearly identified recommendations, would help develop this neophyte standardized language and would promote the growth of nursing as a profession. We have continued our involvement with NANDA, promoting the use of the language by practicing nurses in the United States and around the world and encouraging them to participate in updating and refining the diagnoses. The wide use of our books within the student population has supported and fostered the acceptance of both the activity of diagnosing client problems/needs and the use of stan- dardized language. Nursing instructors initially expressed concern that students would simply copy the plans of care and thus limit their learning. However, as students used the plans to individualize care and to develop practice priorities and client care outcomes, the book met with more acceptance. Instructors began not only to recommend the book, but also to adopt it as an adjunct text. Today, it remains the best-selling nursing care plan book recognized as an important adjunct for student learning. In writing the second edition, we recognized the need for an assessment tool with a nursing focus instead of a medical focus. Not finding one that met our needs, we constructed our own. To facilitate problem identification, we categorized the nursing diagnosis labels and the information obtained in the client assessment database into a framework entitled “Diagnostic Divisions.” Our philosophy is to provide a way in which to gather information and to intervene beneficially, while thinking about the rationale for every action we take and the standardized language that best expresses it. When nurses do this they are defining their practice and are able to identify it with a code and charge for it. By doing this, we promote client protection (quality of care issue), provide for the definition and protection of nursing practice, and the protection of the individual (legal implica- tions). The latter is important because we live in a litigation-minded society and the nurse’s license and livelihood are at stake. One of the most significant achievements in the healthcare field over the past 20 or more years has been the emergence of the nurse as an active coordinator and initiator of client care. Although the transition from physician’s helpmate to healthcare professional has been painfully slow and is not yet complete, the importance of the nurse within the system can no longer be denied or ignored. Today’s nurse designs nursing care interventions that move the total client toward improved health and maximum independence. Professional care standards and healthcare providers and consumers will continue to increase the expectations for nurses’ performance. Each day brings new challenges in client care and the xiii
    • Copyright © 2006 by F. A. Davis. struggle to understand the human responses to actual and potential health problems. To meet these challenges competently, the nurse must have up-to-date assessment skills and a working knowledge of pathophysiologic concepts concerning the common diseases/conditions presented. We believe that this book is a tool, providing a means of attaining that competency. In the past, plans of care were viewed principally as learning tools for students and seemed to have little relevance after graduation. However, the need for a written format to communicate and document client care has been recognized in all care settings. In addition, healthcare policy, govern- mental regulations, and third-party payor requirements have created the need to validate many things, including appropriateness of care provided, staffing patterns, and monetary charges. Thus, although the student’s “case studies” were considered to be too cumbersome to be practical in the clinical setting, it has long been recognized that the client plan of care meets certain needs and there- fore its appropriate use was validated. The practicing nurse, as well as the nursing student, can welcome this text as a ready reference in clinical practice. It is designed for use in the acute care, community, and homecare settings. It is organized by systems for easy reference. Chapter 1 examines current issues and trends and their implications for the nursing profession. An overview of cultural, community, sociologic, and ethical concepts affecting the nurse is included. The importance of the nurse’s role in collaboration and coordination with other healthcare profes- sionals is integrated throughout the plans of care. Chapter 2 reviews the historical use of the nursing process in formulating plans of care and the nurse’s role in the delivery of that care. Nursing diagnoses, outcomes, and interventions are discussed to assist the nurse in understanding her or his role in the nursing process. In this book, we have also linked NANDA diagnoses with Nursing Intervention Classification (NIC) and Nursing Outcomes Classification (NOC) language. Chapter 3 discusses care plan construction and describes the use and adaptation of the guides presented in this book. A nursing-based assessment tool is provided to assist the nurse in identifying appropriate nursing diagnoses. A sample client situation (with individual database and a correspon- ding plan of care) is included to demonstrate how critical thinking is used to adapt nursing process theory to practice. Finally, a dynamic and creative approach for developing and documenting the planning of care is also included. Mind Mapping is a new technique or learning tool provided to assist you in achieving a holistic view of your client, enhance your critical thinking skills, and facili- tate the creative process of planning client care. Chapters 4 through 15 present plans of care that include information from multiple disciplines to assist the nurse in providing holistic care. Each plan includes a Client Assessment Database (presented in a nursing format) and associated Diagnostic Studies. After the database is collected, Nursing Priorities are sifted from the information to help focus and structure the care. Discharge Goals are created to identify what should be generally accomplished by the time of discharge from the care setting. Next, Desired Client Outcomes are stated in measurable behavioral terms to eval- uate both the client’s progress and the effectiveness of care provided. The nursing diagnoses listed in the plans of care are developed by identifying “may be related to” and “possibly evidenced by” factors that provide an explanation of client problems/needs. Corresponding actions/interventions are designed to promote resolution of the identified client needs. The nurse acting independently or collaboratively within the health team then uses a decision-making model to organize and prioritize nursing interventions. No attempt is made in this book to indicate whether independent or collaborative actions come first because this must be dictated by the individual situation. We do, however, believe that every collaborative action has a component that the nurse must identify and for which nursing has responsibility and accountability. Rationales for the nursing actions (which are not required in the customary plan of care) are included to assist the nurse in deciding whether the interventions are appropriate for an individual client. Additional information is provided to further assist the nurse in identifying and planning for rehabilitation as the client progresses toward discharge and across all care settings. A bibliography is provided as a reference and to allow further research as desired. This book is designed for students who will find the plans of care helpful as they learn and develop skills in applying the nursing process and using nursing diagnoses. It will complement their classroom work and support the critical thinking process. The book also provides a ready reference for the practicing nurse as a catalyst for thought in planning, evaluating, and documenting care. As a final note, this book is not intended to be a procedure manual, and efforts have been made to avoid detailed descriptions of techniques or protocols that might be viewed as individual or regional in nature. Instead the reader is referred to a procedure manual or text covering Standards of Care if detailed direction is desired. As we always say when we sign a book, “Use and enjoy.” MD, MM, and AM xiv
    • Copyright © 2006 by F. A. Davis. CONTENTS IN BRIEF INDEX OF NURSING DIAGNOSES APPEARS ON PAGES 983–988 INTRODUCTION vii 1 ISSUES AND TRENDS IN MEDICAL/SURGICAL NURSING 1 2 THE NURSING PROCESS: PLANNING CARE WITH NURSING DIAGNOSES 6 3 CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE 13 4 CARDIOVASCULAR 35 Hypertension: Severe 35 Heart Failure: Chronic 47 Angina (Coronary Artery Disease) 62 Myocardial Infarction 72 Dysrhythmias (Including Digitalis Toxicity) 85 Cardiac Surgery: Postoperative Care—Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), Cardiomyoplasty, Valve Replacement 96 Thrombophlebitis: Deep Vein Thrombosis (Including Pulmonary Emboli Considerations) 108 5 RESPIRATORY 117 Chronic Obstructive Pulmonary Disease (COPD) and Asthma 117 Pneumonia 128 Lung Cancer: Postoperative Care 141 Pneumothorax/Hemothorax 150 Radical Neck Surgery: Laryngectomy (Postoperative Care) 157 Ventilatory Assistance (Mechanical) 170 Pulmonary Tuberculosis (TB) 184 Respiratory Acid-Base Imbalances 194 Respiratory Acidosis (Primary Carbonic Acid Excess) 194 Respiratory Alkalosis (Primary Carbonic Acid Deficit) 198 6 NEUROLOGICAL/SENSORY DISORDERS 202 Glaucoma 202 Seizure Disorders 208 Craniocerebral Trauma (Acute Rehabilitative Phase) 218 Cerebrovascular Accident (CVA)/Stroke 236 Herniated Nucleus Pulposus (Ruptured Intervertebral Disc) 252 Disc Surgery 260 Spinal Cord Injury (Acute Rehabilitative Phase) 271 Multiple Sclerosis 291 7 GASTROINTESTINAL DISORDERS 309 Upper Gastrointestinal/Esophageal Bleeding 309 Subtotal Gastrectomy/Gastric Resection 320 Inflammatory Bowel Disease: Ulcerative Colitis, Regional Enteritis (Crohn’s Disease, Ileocolitis) 324 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 338 xv
    • Copyright © 2006 by F. A. Davis. Appendectomy 350 Peritonitis 355 Cholecystitis with Cholelithiasis 364 Cholecystectomy 371 8 METABOLIC AND ENDOCRINE DISORDERS 376 Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 376 Eating Disorders: Obesity 393 Obesity: Surgical Interventions (Gastric Partitioning/Gastroplasty, Gastric Bypass) 402 Diabetes Mellitus/Diabetic Ketoacidosis 412 Hyperthyroidism (Thyrotoxicosis, Graves’ Disease) 426 Thyroidectomy 437 Hepatitis 443 Cirrhosis of the Liver 453 Pancreatitis 467 Total Nutritional Support: Parenteral/Enteral Feeding 478 Metabolic Acid-Base Imbalances 491 Metabolic Acidosis (Primary Base Bicarbonate [HCO3] Deficit) 492 Metabolic Alkalosis (Primary Base Bicarbonate Excess) 495 9 DISEASES OF THE BLOOD/BLOOD-FORMING ORGANS 499 Anemias (Iron Deficiency, Pernicious, Aplastic, Hemolytic) 499 Sickle Cell Crisis 509 Leukemias 523 Lymphomas 532 10 RENAL AND URINARY TRACT 541 Renal Failure: Acute 541 Renal Failure: Chronic 553 Renal Dialysis 564 Renal Dialysis: Peritoneal 575 Hemodialysis 581 Urinary Diversions/Urostomy (Postoperative Care) 585 Benign Prostatic Hyperplasia (BPH) 596 Prostatectomy 604 Urolithiasis (Renal Calculi) 613 11 WOMEN’S REPRODUCTIVE 621 Hysterectomy 621 Mastectomy 630 12 ORTHOPEDIC 642 Fractures 642 Amputation 657 Total Joint Replacement 667 13 INTEGUMENTARY 680 Burns: Thermal/Chemical/Electrical (Acute and Convalescent Phases) 680 14 SYSTEMIC INFECTIONS AND IMMUNOLOGICAL DISORDERS 701 Sepsis/Septicemia 701 The HIV-Positive Client 712 AIDS 726 Rheumatoid Arthritis 750 Transplantation (Postoperative and lifelong) 761 15 GENERAL 770 Psychosocial Aspects of Care 770 Surgical Intervention 788 Extended Care 810 Alcohol: Acute Withdrawal 831 xvi
    • Copyright © 2006 by F. A. Davis. Substance Dependence/Abuse Rehabilitation 843 Cancer 857 End of Life/Hospice Care 880 Disaster Considerations 890 Pediatric Considerations 905 Fluid and Electrolyte lmbalances 919 Dementia of alzheimer’s Type/Vascular Dementia 945 BIBLIOGRAPHY 967 INDEX OF NURSING DIAGNOSES 983 A TABLE OF CONTENTS INCLUDING NURSING DIAGNOSES FOLLOWS. xvii
    • Copyright © 2006 by F. A. Davis. DETAILED CONTENTS INDEX OF NURSING DIAGNOSES APPEARS ON PAGES 983–988 INTRODUCTION vii 1 ISSUES AND TRENDS IN MEDICAL/SURGICAL NURSING 1 The Ever-Changing Healthcare Environment 1 Healthcare Costs and the Allocation of Resources 1 Managed Care: Restructuring Healthcare 1 Nursing Care Costs 3 Early Discharge 3 Aging Population 3 Technological Advances 4 Future of Nursing 4 Conclusion 5 2 THE NURSING PROCESS: PLANNING CARE WITH NURSING DIAGNOSES 6 Planning Care 9 Components of the Plan of Care 9 Client Database 9 Nursing Priorities 10 Discharge Goals 10 Nursing Diagnosis (Problem/Need Identification) 10 Desired Client Outcomes 11 Planning (Goals and Actions/Interventions) 11 Rationale 11 Conclusion 12 3 CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE 13 Client Situation: Diabetes Mellitus 22 Admitting Physician’s Orders 22 Client Assessment Database 22 Evaluation 26 Documentation 26 Plan of Care: Mr. R. S. 27 Mind Map 31 Sample Clinical Pathway 33 4 CARDIOVASCULAR 35 Hypertension: Severe 35 Cardiac Output, risk for decreased 38 Activity Intolerance 40 Pain, acute, headache 41 Nutrition: more than body requirements, imbalanced 42 Coping, ineffective 43 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care and discharge needs 44 Heart Failure: Chronic 47 Cardiac Output, decreased 50 xviii
    • Copyright © 2006 by F. A. Davis. Activity Intolerance 54 Fluid Volume, excess 55 Gas Exchange, risk for impaired 57 Skin Integrity, risk for impaired 58 Knowledge, deficient [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs 59 Sample Clinical Pathway 61 Angina (Coronary Artery Disease) 62 Pain, acute 65 Cardiac Output, risk for decreased 67 Anxiety [specify level] 69 Knowledge, deficient [Learning Need] regarding condition, treatment needs, self-care, and discharge needs 70 Myocardial Infarction 72 Pain, acute 75 Activity Intolerance 76 Anxiety [specify level]/Fear 77 Cardiac Output, risk for decreased 79 Tissue Perfusion, ineffective 81 Fluid Volume, risk for excess 83 Knowledge, deficient [Learning Need] regarding cause/treatment of condition, self-care, and discharge needs 83 Dysrhythmias (Including Digitalis Toxicity) 85 Cardiac Output, risk for decreased 88 Poisoning, risk for digitalis toxicity 92 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 93 Cardiac Surgery: Postoperative Care—Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), Cardiomyoplasty, Valve Replacement 96 Cardiac Output, risk for decreased 98 Pain, acute/[Discomfort] 100 Role Performance, ineffective 102 Breathing Pattern, risk for ineffective 103 Skin Integrity, impaired 105 Knowledge, deficient [Learning Need] regarding condition, treatment plan, postoperative care, self-care, and discharge needs 106 Thrombophlebitis: Deep Vein Thrombosis (Including Pulmonary Emboli Considerations) 108 Tissue Perfusion, ineffective 109 Pain, acute/[Discomfort] 112 Gas Exchange, impaired (in presence of pulmonary embolus) 113 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 115 5 RESPIRATORY Chronic Obstructive Pulmonary Disease (COPD) and Asthma 117 Airway Clearance, ineffective 120 Gas Exchange, impaired 123 Nutrition: less than body requirements, imbalanced 125 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 126 Pneumonia 128 Airway Clearance, ineffective 131 Gas Exchange, impaired 132 Infection, risk for [spread] 133 Activity Intolerance 134 Pain, acute 135 xix
    • Copyright © 2006 by F. A. Davis. Nutrition: risk for less than body requirements, imbalanced 136 Fluid Volume, risk for deficient 137 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 138 Sample Clinical Pathway 140 Lung Cancer: Postoperative Care 141 Gas Exchange, impaired 143 Airway Clearance, ineffective 145 Pain, acute 146 Fear/Anxiety [specify level] 147 Knowledge, deficient [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs 148 Pneumothorax/Hemothorax 150 Breathing Pattern, ineffective 152 Trauma/Suffocation 155 Knowledge, deficient [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs 156 Radical Neck Surgery: Laryngectomy (Postoperative Care) 157 Airway Clearance, ineffective/Aspiration, risk for 159 Communication, impaired verbal 160 Skin/Tissue Integrity, impaired 162 Oral Mucous Membrane, impaired 163 Pain, acute 164 Nutrition: less than body requirements, imbalanced 165 Body Image, disturbed/Role Performance, ineffective 167 Knowledge, deficient [Learning Need] regarding condition, treatment, self-care, and discharge needs 168 Ventilatory Assistance (Mechanical) 170 Breathing Pattern, ineffective/Spontaneous Ventilation, impaired 171 Airway Clearance, ineffective 174 Communication, impaired verbal 176 Fear/Anxiety [specify level] 177 Oral Mucous Membrane, impaired 178 Nutrition: less than body requirements, imbalanced 179 Infection, risk for 180 Ventilatory Weaning Response, risk for dysfunctional 181 Knowledge, deficient [Learning Need] regarding condition, prognosis and therapy, self-care, and discharge needs 183 Pulmonary Tuberculosis (TB) 184 Infection, risk for [spread/reactivation] 187 Airway Clearance, ineffective 189 Gas Exchange, risk for impaired 190 Nutrition: less than body requirements, imbalanced 191 Knowledge, deficient [Learning Need] regarding condition, treatment, prevention, self-care, and discharge needs 192 Respiratory Acid-Base Imbalances 194 Respiratory Acidosis (Primary Carbonic Acid Excess) 194 Gas Exchange, impaired 196 Respiratory Alkalosis (Primary Carbonic Acid Deficit) 198 Gas Exchange, impaired 200 6 NEUROLOGICAL/SENSORY DISORDERS 202 Glaucoma 202 Sensory Perception, disturbed visual 204 Anxiety [specify level] 206 Seizure Disorders 208 Trauma/Suffocation, risk for 211 xx
    • Copyright © 2006 by F. A. Davis. Airway Clearance/Breathing Pattern, risk for ineffective 214 Self-Esteem, [specify situational or chronic) low 215 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment regimen, self-care, and discharge needs 216 Craniocerebral Trauma (Acute Rehabilitative Phase) 218 Tissue Perfusion, ineffective cerebral 221 Breathing Pattern, risk for ineffective 224 Sensory Perception, disturbed (specify) 225 Thought Processes, disturbed 227 Mobility, impaired physical 229 Infection, risk for 231 Nutrition: risk for less than body requirements, imbalanced 232 Family Processes, interrupted 233 Knowledge, deficient [Learning Need] regarding condition, prognosis, potential complications, treatment, self-care, and discharge needs 234 Cerebrovascular Accident (CVA)/Stroke 236 Tissue Perfusion, ineffective cerebral 238 Mobility, impaired physical 241 Communication, impaired verbal [and/or written] 243 Sensory Perception, disturbed (specify) 244 Self-Care Deficit (specify) 246 Coping, ineffective 247 Swallowing, risk for impaired 248 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 250 Herniated Nucleus Pulposus (Ruptured Intervertebral Disc) 252 Pain, acute/chronic 254 Mobility, impaired physical 256 Anxiety [specify level]/Coping, ineffective 257 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 258 Disc Surgery 260 Tissue Perfusion, ineffective (specify) 261 Trauma, risk for (spinal) 262 Breathing Pattern/Airway Clearance, risk for ineffective 263 Pain, acute 264 Mobility, impaired physical 265 Constipation 266 Urinary Retention, risk for 267 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 268 Sample Clinical Pathway 270 Spinal Cord Injury (Acute Rehabilitative Phase) 271 Breathing Pattern, risk for ineffective 273 Trauma, risk for [additional spinal injury] 275 Mobility, impaired physical 276 Sensory Perception, disturbed 278 Pain, acute 279 Grieving, anticipatory 280 Self-Esteem, situational low 282 Bowel Incontinence/Constipation 283 Urinary Elimination, impaired 285 Autonomic Dysreflexia, risk for 286 Skin Integrity, risk for impaired 288 Knowledge, deficient [Learning Need] regarding condition, prognosis, potential complications, treatment, self-care, and discharge needs 289 xxi
    • Copyright © 2006 by F. A. Davis. Multiple Sclerosis 291 Fatigue 295 Self-Care Deficit (specify) 297 Self-Esteem, specify situational /chronic low 298 Powerlessness [specify degree]/Hopelessness 300 Coping, risk for ineffective 301 Coping, compromised/disabled family 302 Urinary Elimination, impaired 304 Caregiver Role Strain, risk for 305 Knowledge, deficient [Learning Need] regarding condition, prognosis, complications, treatment, self-care, and discharge needs 306 7 GASTROINTESTINAL DISORDERS 309 Upper Gastrointestinal/Esophageal Bleeding 309 Fluid Volume, deficient [isotonic] 312 Tissue Perfusion, risk for ineffective 315 Fear/Anxiety [specify level] 316 Pain, acute/chronic 317 Knowledge, deficient [Learning Need] regarding disease process, prognosis, treatment, self-care, and discharge needs 319 Subtotal Gastrectomy/Gastric Resection 320 Nutrition, imbalanced, risk for less than body requirements 321 Knowledge, deficient [Learning Need] regarding procedure, prognosis, treatment, self-care, and discharge needs 322 Inflammatory Bowel Disease: Ulcerative Colitis, Regional Enteritis (Crohn’s Disease, Ileocolitis) 324 Diarrhea 328 Fluid Volume, risk for deficient 330 Nutrition: less than body requirements, imbalanced 331 Anxiety [specify level] 333 Pain, acute 334 Coping, ineffective 335 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 336 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 338 Skin Integrity, risk for impaired 338 Body Image, disturbed 340 Pain, acute 341 Skin/Tissue Integrity, impaired 342 Fluid Volume, risk for deficient 343 Nutrition: risk for less than body requirements, imbalanced 344 Sleep Pattern, disturbed 345 Constipation/Diarrhea, risk for 346 Sexual Dysfunction, risk for 347 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 348 Appendectomy 350 Infection, risk for 352 Pain, acute 353 Knowledge, deficient Learning Need regarding condition, prognosis, treatment, self-care, and discharge needs 354 Peritonitis 355 Infection, risk for [septicemia] 357 Fluid Volume, deficient [mixed] 359 Pain, acute 360 Nutrition: risk for less than body requirements, imbalanced 361 xxii
    • Copyright © 2006 by F. A. Davis. Anxiety [specify level]/Fear 362 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 363 Cholecystitis with Cholelithiasis 364 Pain, acute 366 Fluid Volume, risk for deficient 367 Nutrition: risk for less than body requirements, imbalanced 368 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care and discharge needs 369 Cholecystectomy 371 Breathing Pattern, ineffective 371 Fluid Volume, risk for deficient 372 Skin/Tissue Integrity, impaired 373 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 374 8 METABOLIC AND ENDOCRINE DISORDERS 376 Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 376 Nutrition: less than body requirements, imbalanced 379 Fluid Volume, actual or risk for deficient 382 Thought Processes, disturbed 383 Body Image, disturbed/Self-Esteem, chronic low 383 Parenting, impaired 386 Skin Integrity, risk for impaired 387 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 388 Sample Clinical Pathway 390 Eating Disorders: Obesity 393 Nutrition: more than body requirements, imbalanced 394 Lifestyle, sedentary 397 Body Image, disturbed/Self-Esteem, chronic low 398 Social Interaction, impaired 400 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 401 Obesity: Surgical Interventions (Gastric Partitioning/Gastroplasty, Gastric Bypass) 402 Breathing Pattern, ineffective 404 Tissue Perfusion, risk for ineffective 405 Fluid Volume, risk for deficient 406 Nutrition, risk for less than body requirements, imbalanced 407 Skin Integrity, risk for impaired 408 Infection, risk for 409 Diarrhea 410 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 411 Diabetes Mellitus/Diabetic Ketoacidosis 412 Fluid Volume, deficient [specify] 415 Nutrition: less than body requirements, imbalanced 417 Infection, risk for [sepsis] 419 Sensory Perception, risk for disturbed (specify) 420 Fatigue 421 Powerlessness 422 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 423 Hyperthyroidism (Thyrotoxicosis, Graves’ Disease) 426 Cardiac Output, risk for decreased 428 Fatigue 431 xxiii
    • Copyright © 2006 by F. A. Davis. Nutrition: risk for less than body requirements, imbalanced 432 Anxiety [specify level] 433 Thought Processes, risk for disturbed 434 Tissue Integrity, risk for impaired 435 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 436 Thyroidectomy 437 Airway Clearance, risk for ineffective 438 Communication, impaired verbal 439 Injury, risk for [tetany] 440 Pain, acute 440 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 441 Hepatitis 443 Fatigue 445 Nutrition: less than body requirements, imbalanced 446 Fluid Volume, risk for deficient 447 Self-Esteem, situational low 449 Infection, risk for 450 Skin/Tissue Integrity, risk for impaired 451 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 452 Cirrhosis of the Liver 453 Nutrition: less than body requirements, imbalanced 456 Fluid Volume, excess 458 Skin Integrity, risk for impaired 460 Breathing Pattern, risk for ineffective 460 Injury, risk for [hemorrhage] 462 Confusion, risk for acute 463 Self-Esteem [specify] Body Image, disturbed 465 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 465 Pancreatitis 467 Pain, acute 470 Fluid Volume, risk for deficient 471 Nutrition: less than body requirements, imbalanced 473 Infection, risk for 474 Breathing Pattern, risk for ineffective 476 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 477 Total Nutritional Support: Parenteral/Enteral Feeding 478 Nutrition: less than body requirements, imbalanced 481 Infection, risk for 484 Injury, risk for [multifactor] 485 Aspiration, risk for 487 Fluid Volume, risk for imbalance 488 Fatigue 489 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 490 Metabolic Acid-Base Imbalances 491 Metabolic Acidosis (Primary Base Bicarbonate [HCO3] Deficit) 492 Metabolic Alkalosis (Primary Base Bicarbonate Excess) 495 9 DISEASES OF THE BLOOD/BLOOD-FORMING ORGANS 499 Anemias (Iron Deficiency, Pernicious, Aplastic, Hemolytic) 499 Activity intolerance 502 Nutrition: less than body requirements, imbalanced 504 Constipation/Diarrhea 505 xxiv
    • Copyright © 2006 by F. A. Davis. Infection, risk for 506 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 507 Sickle Cell Crisis 509 Gas Exchange, impaired 512 Pain, acute/chronic 514 Tissue Perfusion, ineffective (specify) 515 Fluid Volume, risk for deficient 517 Mobility, impaired physical 518 Skin Integrity, risk for impaired 519 Infection, risk for 520 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 520 Leukemias 523 Infection, risk for 525 Fluid Volume, risk for deficient 527 Pain, acute 529 Activity Intolerance 530 Knowledge, deficient [Learning Need] regarding disease, prognosis, treatment, self-care, and discharge needs 531 Lymphomas 532 Gas Exchange, risk for impaired 536 Sexual Dysfunction 537 Knowledge, deficient [Learning Need] regarding disease process, prognosis, treatment regimen, self-care, and discharge needs 538 10 RENAL AND URINARY TRACT 541 Renal Failure: Acute 541 Fluid Volume, excess 544 Cardiac Output, risk for decreased 546 Nutrition: risk for less than body requirements, imbalanced 548 Infection, risk for 549 Fluid Volume, risk for deficient 550 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 551 Renal Failure: Chronic 553 Cardiac Output, risk for decreased 556 Protection, risk for ineffective 557 Thought Processes, disturbed 558 Skin Integrity, risk for impaired 559 Oral Mucous Membrane, risk for impaired 560 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 561 Renal Dialysis 564 Nutrition: less than body requirements, imbalanced 565 Mobility, impaired physical 567 Self-Care Deficit (specify) 568 Constipation, risk for 568 Thought Processes, risk for disturbed 569 Anxiety [specify level]/Fear 570 Body Image, disturbed/Self-Esteem, situational low 571 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 573 Renal Dialysis: Peritoneal 575 Fluid Volume, risk for excess 576 Fluid Volume, risk for deficient 577 Trauma, risk for 578 Pain, acute 578 xxv
    • Copyright © 2006 by F. A. Davis. Infection, risk for [peritonitis] 579 Breathing Pattern, risk for ineffective 580 Hemodialysis 581 Injury, risk for [loss of vascular access] 582 Fluid Volume, risk for deficient 583 Fluid Volume, risk for excess 584 Urinary Diversions/Urostomy (Postoperative Care) 585 Skin Integrity, risk for impaired 586 Body Image, disturbed 588 Pain, acute 589 Infection, risk for 591 Urinary Elimination, impaired 592 Sexual Dysfunction, risk for 593 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 595 Benign Prostatic Hyperplasia (BPH) 596 Urinary Retention, acute/chronic 598 Pain, acute 600 Fluid Volume, risk for deficient 601 Fear/Anxiety [specify level] 602 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 603 Prostatectomy 604 Urinary Elimination, impaired 605 Fluid Volume, risk for deficient 606 Infection, risk for 607 Pain, acute 608 Sexual Dysfunction, risk for 609 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 610 Urolithiasis (Renal Calculi) 613 Pain, acute 615 Urinary Elimination, impaired 616 Fluid Volume, risk for deficient 617 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 618 11 WOMEN’S REPRODUCTIVE 621 Hysterectomy 621 Self-Esteem, situational low 622 Urinary Elimination, impaired/Urinary Retention [acute] 623 Constipation/Diarrhea, risk for 624 Tissue Perfusion, risk for ineffective (specify) 625 Sexual Dysfunction, risk for 626 Grieving, dysfunctional 627 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 628 Mastectomy 630 Fear/Anxiety [specify level] 632 Skin/Tissue Integrity, impaired 633 Pain, acute 635 Self-Esteem, situational low 636 Mobility, impaired physical 637 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 638 Sample Clinical Pathway 640 xxvi
    • Copyright © 2006 by F. A. Davis. 12 ORTHOPEDIC 642 Fractures 642 Trauma, risk for [additional] 644 Pain, acute 645 Peripheral Neurovascular Dysfunction, risk for 647 Gas Exchange, risk for impaired 649 Mobility, impaired physical 650 Skin/Tissue Integrity, actual/risk for impaired 652 Infection, risk for 654 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 655 Amputation 657 Self-Esteem, situational low 659 Pain, acute 660 Tissue Perfusion, risk for ineffective peripheral 662 Infection, risk for 663 Mobility, impaired physical 664 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 666 Total Joint Replacement 667 Infection, risk for 669 Mobility, impaired physical 670 Peripheral Neurovascular, Dysfunction risk for 671 Pain, acute 673 Constipation, risk for 674 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 675 Sample Clinical Pathway 677 13 INTEGUMENTARY 680 Burns: Thermal/Chemical/Electrical (Acute and Convalescent Phases) 680 Airway Clearance, risk for ineffective 683 Fluid Volume, risk for deficient 684 Pain, acute 686 Infection, risk for 688 Tissue Perfusion, ineffective/Peripheral Neurovascular dysfunction, risk for 690 Nutrition: less than body requirements, imbalanced 691 Mobility, impaired physical 693 Skin Integrity, impaired [grafts] 694 Fear/Anxiety 696 Body Image, disturbed/Role Performance, ineffective 697 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 698 14 SYSTEMIC INFECTIONS AND IMMUNOLOGICAL DISORDERS 701 Sepsis/Septicemia 701 Infection, risk for [progression of sepsis to septic shock, development of opportunistic infections] 704 Hyperthermia 706 Tissue Perfusion, risk for ineffective 707 Fluid Volume, risk for deficient 709 Gas Exchange, risk for impaired 710 Knowledge, deficient [Learning Need] regarding illness, prognosis, treatment, self-care, and discharge needs 711 xxvii
    • Copyright © 2006 by F. A. Davis. The HIV-Positive Client 712 Adjustment, impaired 714 Fatigue 715 Nutrition: risk for less than body requirements, imbalanced 716 Knowledge, deficient [Learning Need] regarding disease, prognosis, treatment self-care, and discharge needs 719 Social Isolation, risk for 722 Therapeutic Regimen Management, ineffective [Individual]/Family 723 AIDS 726 Infection, risk for [progression to sepsis/onset of new opportunistic infection] 730 Fluid Volume, risk for deficient 732 Breathing Pattern, ineffective/Gas Exchange, risk for impaired 733 Injury, risk for (hemorrhage) 735 Nutrition: less than body requirements, imbalanced 736 Pain, acute/chronic 738 Skin Integrity, actual and/or risk for impaired 739 Oral Mucous Membrane, impaired 740 Fatigue 742 Thought Processes, disturbed 743 Anxiety [specify level]/Fear 745 Social Isolation 746 Powerlessness 747 Knowledge, deficient [Learning Need] regarding disease, prognosis, current therapies, and self-care needs 748 Rheumatoid Arthritis 750 Pain, acute/chronic 752 Mobility, impaired physical/Walking, impaired 755 Body Image, disturbed/Role Performance, ineffective 756 Self-Care Deficit (specify) 757 Home Maintenance, risk for impaired 758 knowledge, deficient [Learning Need] regarding disease, prognosis, treatment, self-care, and discharge needs 759 Transplantation (Postoperative and Lifelong) 761 Infection, risk for 763 Anxiety [specify level]/Fear 764 Coping, risk for ineffective/compromised/disabled family 765 Knowledge, deficient [Learning Need] regarding prognosis, therapeutic regimen, self-care, and discharge needs 767 15 GENERAL 770 Psychosocial Aspects of Care 770 Coping, ineffective/decisional Conflict 771 Coping, risk for compromised family 773 Coping readiness for enhanced family 774 Anxiety [specify level]/Fear 775 Self-Esteem, situational low 778 Grieving [specify] 780 Religiosity, risk for impaired 782 Therapeutic Regimen: Management, risk for ineffective 783 Violence, risk for self-directed/other-directed 785 Post-Trauma Syndrome 787 Surgical Intervention 788 Knowledge, deficient [Learning Need] regarding condition, prognosis, self-care, and discharge needs 790 Fear/Anxiety [specify level] 792 Injury, risk for perioperative positioning 794 xxviii
    • Copyright © 2006 by F. A. Davis. Injury, risk for 795 Infection, risk for 797 Body Temperature, risk for imbalanced 799 Breathing Pattern, ineffective 800 Sensory Perception, disturbed: (specify)/Thought Processes, disturbed 801 Fluid Volume, risk for deficient 802 Pain, acute 804 Skin/Tissue Integrity, impaired 806 Tissue Perfusion, risk for ineffective 808 Knowledge, deficient [Learning Need] regarding condition/ situation, prognosis, treatment, self-care, and discharge needs 809 Extended Care 810 Relocation Stress Syndrome, risk for 811 Grieving, anticipatory 813 Memory/Thought Processes, disturbed 814 Coping, compromised family 815 Poisoning, risk for 817 Communication, impaired verbal 818 Sleep Pattern, disturbed 819 Nutrition, less/more than body requirements, imbalanced 820 Self-Care Deficit 822 Skin Integrity, risk for impaired 823 Urinary Elimination, risk for impaired 825 Constipation/Diarrhea, risk for 826 Mobility, impaired physical 827 Diversional Activity, deficient 828 Sexuality Pattern, risk for ineffective 829 Health Maintenance, ineffective 830 Alcohol: Acute Withdrawal 831 Breathing Pattern, risk for ineffective 834 Cardiac Output, risk for decreased 835 Injury, risk for [specify] 837 Sensory Perception, disturbed (specify) 838 Anxiety [severe/panic]/Fear 840 Sample Clinical Pathway 841 Substance Dependence/Abuse Rehabilitation 843 Denial, ineffective 844 Coping, ineffective 846 Powerlessness 848 Nutrition: less than body requirements, imbalanced 849 Self-Esteem, chronic low 850 Family Processes: alcoholic [substance abuse], dysfunctional 852 Sexual Dysfunction 854 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 855 Cancer 857 Fear/Anxiety [specify level] 859 Grieving, anticipatory 861 Self-Esteem, situational low 862 Pain, acute/chronic 864 Nutrition: less than body requirements, imbalanced 866 Fluid Volume, risk for deficient 868 Fatigue 869 Infection, risk for 871 Oral Mucous Membrane, risk for impaired 872 Skin/Tissue Integrity, risk for impaired 873 Constipation/Diarrhea, risk for 875 xxix
    • Copyright © 2006 by F. A. Davis. Sexuality Pattern, risk for ineffective 876 Family Processes, risk for interrupted 877 Knowledge, deficient [Learning Need] regarding illness, prognosis, treatment, self-care, and discharge needs 878 End of Life/Hospice Care 880 Pain, acute/chronic 881 Activity Intolerance/Fatigue 883 Grieving, anticipatory/Anxiety, death 884 Coping, compromised or disabled family Caregiver Role Strain, risk for 886 Spiritual Distress, risk for 888 Disaster Considerations 890 Injury, risk for/actual (trauma, suffocation, poisoning) 892 Infection, risk for 893 Anxiety [panic]/Fear 895 Spiritual Distress 896 Post-Trauma Syndrome, risk for 898 Coping, ineffective community 899 Coping, potential for enhanced community 900 Pediatric Considerations 905 Pain, acute 906 Anxiety/Fear: Coping, ineffective 907 Activity Intolerance/Fatigue 909 Growth and Development, risk for delayed 910 Nutrition, risk for less than body requirements, imbalanced 911 Injury, risk for 912 Family Processes Parenting impaired 915 Body Temperature, risk for imbalanced 916 Health Maintenance, risk for ineffective 917 Fluid and Electrolyte Imbalances 919 Fluid Balance 919 Hypervolemia (Extracellular Fluid Volume Excess) 919 Hypovolemia (Extracellular Fluid Volume Deficit) 922 Fluid Volume, deficient 923 Sodium 925 Hyponatremia (Sodium Deficit) 925 Hypernatremia (Sodium Excess) 928 Potassium 931 Hypokalemia (Potassium Deficit) 931 Hyperkalemia (Potassium Excess) 933 Calcium 936 Hypocalcemia (Calcium Deficit) 936 Hypercalcemia (Calcium Excess) 938 Magnesium 941 Hypomagnesemia (Magnesium Deficit) 941 Hypermagnesemia (Magnesium Excess) 943 Dementia of Alzheimer’ s Type/Vascular Dementia 945 Confusion, risk for 950 Sensory Perception, disturbed 953 Fear 954 Grieving, anticipatory 955 Sleep Pattern, disturbed 956 Self-Care deficit 957 Nutrition, risk for less than body requirements, imbalanced 959 Constipation/Bowel Incontinence, impaired 960 Sexual Dysfunction, risk for 961 xxx
    • Copyright © 2006 by F. A. Davis. Coping, compromised family 961 Home Maintenance/Health Maintenance, impaired 963 Caregiver Role Strain, risk for 965 Relocation Stress Syndrome, risk for 966 BIBLIOGRAPHY 967 INDEX OF NURSING DIAGNOSES 983 xxxi
    • Copyright © 2006 by F. A. Davis. CONTENTS OF THE CD-ROM MEDICAL/SURGICAL CARE PLANS (INCLUDES ALL CARE PLANS FROM THE BOOK) Cardiovascular Respiratory Neurologic/Sensory Disorders Gastrointestinal Disorders Metabolic and Endocrine Disorders Diseases of the Blood/Blood-Forming Organs Renal and Urinary Tract Women’s Reproductive Orthopedic Integumenatry Systemic Infections and Immunological Disorders General PSYCHIATRIC CARE PLANS Childhood and Adolescent Disorders Pervasive Developmental Disorders Attention-Deficit/Hyperactivity Disorder (ADHD) Conduct Disorder Oppositional Defiant Disorder Elimination Disorders: Enuresis/Encopresis Parenting: Growth-Promoting Relationship Dementia and Amnestic and Other Cognitive Disorders Dementia of Alzheimer’s Type/Vascular Dementia Dementia due to HIV Disease Substance-Related Disorders Alcohol-Related Disorders Stimulants (Amphetamines, Cocaine, Caffeine, and Nicotine) and Inhalant-Related Disorders Depressants (Barbiturates, Nonbarbiturates, Hypnotics and Anxiolytics, Opioids) Hallucinogen-, Phencyclidine-, and Cannabis-Related Disorders Substance Dependence/Abuse Rehabilatation Schizophrenia and Other Psychotic Disorders Schizophrenia Schizoaffective Disorder Delusional Disorder Mood Disorders Major Depressive/Dysthymic Disorder Bipolar Disorders Anxiety Disorders Generalized Anxiety Disorder Panic Disorders/Phobias Obsessive-Compulsive Disorder Posttrumatic Stress Disorder Somatofrom Disorders xxxii
    • Copyright © 2006 by F. A. Davis. Dissociative Disorders Sexual and Gender Identity Disorders Sexual Dysfunctions and Paraphilias Gender Identity Disorder Eating Disorders Anorexia Nervosa/Bulimia Nervosa Obesity Adjustment Disorders Personality Disorders Antisocial Personality Disorder Borderline Personality Disorder Passive-Aggressive Personality Disorder Other Conditions that May Be a Focus of Attention Psychologic Factors Affecting Medical Condition Problems Related to Abuse or Neglect Premenstrual Dysphoric Disorder (Premenstrual Syndrome) MATERNAL/NEWBORN CARE PLANS Prenatal Concepts Genetic Counseling First Trimester Second Trimester Third Trimester The High-Risk Pregnancy Prenatal Substance Dependence/Abuse The Pregnant Adolescent Cardiac Conditions Pregnancy-Induced Hypertension Diabetes Mellitus: Prepregnancy/Gestational Prenatal Hemorrhage Prenatal Infection Premature Dilation of the Cervix (Incompetent/Dysfunctional Cervix) Spontaneous Termination Elective Termination Preterm Labor/Prevention of Delivery Intrapartal Concepts Labor Stage I—Latent Phase Labor Stage I—Active Phase Labor Stage I—Transition Phase (Deceleration) Labor Stage II—Expulsion Labor Stage III—Placental Expulsion Dysfunctional Labor/Dystocia Labor: Induced/Augmented Cesarean Birth Precipitous Labor/Delivery or Unplanned/Out-of-Hospital Delivery Intrapartal Hypertension Intrapartal Diabetes Mellitus Maternal Postpartal Concepts Stage IV—First 4 Hours Following Delivery of the Placenta The Client at 4 Hours to 2 Days Postpartum Care Following Cesarean Birth (4 Hours to 3 Days Postpartum) The Client at 24–48 Hours Following Early Discharge The Client at 1 Week Following Discharge The Client at 4–6 Weeks Following Discharge Postpartal Hemorrhage Postpartal Diabetes Mellitus Puerperal Infection xxxiii
    • Copyright © 2006 by F. A. Davis. Postpartal Thrombophlebitis The Parents of a Child with Special Needs Perinatal Loss Newborn Concepts The First Hour of Life The Neonate at 2 Hours to 2 Days of Age The Neonate at 24–48 Hours Following Early Discharge The Neonate at 1 Week Following Discharge The Infant at 4 Weeks Following Birth The Preterm Infant Deviations in Growth Patterns Circumcision Hyperbilirubinemia The Infant of an Addicted Mother The Infant of an HIV-Positive Mother PEDIATRIC CONSIDERATIONS 400 HEALTH CONDITIONS AND CLIENT CONCERNS WITH ASSOCIATED NURSING DIAGNOSES xxxiv
    • Copyright © 2006 by F. A. Davis. 1 C H A P T E R Issues and Trends in Medical/Surgical Nursing THE EVER-CHANGING ices, preferring to provide payment for outpatient services, or in some cases, in-home care. Third-party payors are nego- HEALTHCARE ENVIRONMENT tiating contracts with healthcare providers, including physi- cians, provider agencies, and facilities, in order to reduce Understanding trends in client care and dealing with the cur- reimbursement rates or even to capitate fees (providing serv- rent issues in nursing require looking at the overall trends in ices for a preset fee regardless of actual cost). This method of healthcare practice and the ongoing restructuring of health- payment is based on both the number and specific demo- care delivery systems within the healthcare industry. graphics of the insured population. At the same time, third- Factors driving the changes in healthcare include the rising party payors continue to pay for extra care associated with cost of care, the ever-increasing numbers of uninsured/ medical errors, but seem reluctant to pay for best practices or underinsured healthcare consumers, and the need for alloca- increase reimbursement in ways that can reduce untoward tion of limited healthcare dollars and resources. In addition, outcomes. other factors, such as technologic advances, ever-enlarging Public Law 98–21 changed the method of payment for fed- populations with special needs; changing roles for, and short- erally subsidized (Medicare) inpatient healthcare services ages of, healthcare providers; ethical issues associated with from a cost-based retrospective payment system (payment living in a technologic age; the potential conflict of the client’s for services after care was provided) to a prospective pay- or family’s wishes and prudent medical care; and liability ment system based on 467 diagnoses or diagnosis-related concerns will continue to affect nursing practice in the future. groups, referred to as DRGs. Upgrades to this payment sys- Nurses must be aware of these influences and be actively tem have been made to better reflect the severity of client involved in the formulation of policies and legislation affect- condition/care needs (known as all-patient-related, or APR- ing practice. As the definers of nursing practice, nurses must DRGs). However, reimbursement remains below billed set the standards of practice so that quality nursing care is costs. Most states are considering or have developed options provided with a high degree of client satisfaction and within to similarly curb Medicaid reimbursement. the constraints of available resources. Finally, although the federal government has recently agreed to provide a measure of funding to states located along the southern U.S. border to reimburse facilities for HEALTHCARE COSTS AND THE services provided to undocumented aliens, the high cost of ALLOCATION OF RESOURCES emergent care has required some hospitals to engage in cost- shifting to insurance carriers and cash pay clients, or in some Healthcare expenditures continue to rise. Both government cases, to even close emgergency departments. Adults who and private payors of healthcare are pursuing various meth- lack health insurance coverage are more likely to rate their ods of cost containment. One of the most widespread solu- health status as poor or fair, and are less likely to often rely tions for cost containment has been the implementation of on emergent care, receive preventive services, cancer screen- managed care services, and health maintenance organiza- ings, or dental care than adults with insurance, increasing tions (HMOs) or physician provider organizations (PPOs). In their overall care costs (State Health, 2002). some cases, special incentives are provided for the consumer to promote wellness or manage disease risk factors (e.g., pro- viding health club memberships or smoking cessation pro- MANAGED CARE: RESTRUCTURING grams). There may also be provider incentives such as bonus HEALTHCARE checks when the cost of care is below projected costs for the program or the individual provider. In recent years, these changes in reimbursement and the Most insurance plans require preauthorization for many practice of managed healthcare delivery have required hos- services and/or procedures based on established protocols, pitals to restructure. They adopted methods used in industry and encourage early discharge from acute or hospital serv- (such as reengineering and work redesign) or used methods 1
    • Copyright © 2006 by F. A. Davis. developed specifically for the healthcare arena. The intent expected length of stay (ELOS). Their use provides a mecha- was to implement change aimed at reducing costs without nism for modifying care to reflect current clinical practice jeopardizing quality or consumer satisfaction. expectations based on clinical innovations and research Restructuring the workforce and the client care system findings. Clinical pathways may also be useful for timely was initially accomplished through mergers and consolida- identification of actual or potential outlyers, thus allowing tion of services, as well as downsizing professional staff by reallocation of resources to maximize client outcomes while means of normal attrition, early retirement programs, and controlling costs. However, although clinical pathways are layoffs. The responsibility for hands-on care in many settings useful for clients who fall within an expected course of ill- shifted away from registered nurses (RNs) to other providers ness, their lack of flexibility to accommodate preexisting such as licensed practical nurses (LPNs) and unlicensed multiple diagnoses (e.g., coronary bypass surgery for a client assistive personnel (UAPs). with diabetes mellitus and chronic renal insufficiency) or the Many healthcare professionals expressed great concern development of complications generally precludes their use regarding the effect of downsizing on the quality of care when greater individualization of care is required. In addi- provided, noting the decline in healthcare consumer satis- tion, because pathways generally address a specific episode faction reported on discharge surveys. Furthermore, a 1999 of care, they may not focus on care over a continuum. study by the Institute of Medicine conservatively projects Other structured care methodologies promoting standard- that 98,000 people a year die from medical errors. In contrast, ization of care processes include the use of algorithms, other studies (e.g., Blegen et al., 1998; Yang, 2003) have guidelines, or protocols (standing orders). In the field of shown that a higher ratio of professional nursing staff medicine, criteria have been developed such as the computer improves client outcomes and can lower medication errors program APACHE (Acute Physiology and Chronic Health and adverse events such as falls, and may even reduce mor- Evaluation) to assist providers in choosing appropriate treat- tality rates. However, facilities have been slow to improve ment options and to help allocate resources. This program staffing ratios (partly due to nursing shortages in some provides data on the likely outcomes of various treatments geographic areas and nursing specialties), resulting in in specific client populations. Thus, reimbursement could increased stress for staff and higher rates of errors and conceivably be tied to a scoring system reflecting the likeli- adverse incidents. hood of survival and corresponding treatment protocols. Responding to these concerns, many healthcare providers The advancement of knowledge continues with the work have formed collaborative practice teams whose goal is to of the U.S. Department of Health and Human Services’ revise the client care delivery system by reducing redun- Agency for Healthcare Research and Quality (formerly the dancy of services, eliminating nonproductive activities, and Agency for Health Care Policy and Research), whose pur- relocating ancillary services such as laboratory and radiog- pose is to enhance the quality, appropriateness, and effec- raphy to client care areas. The addition of a pharmacist as an tiveness of healthcare services. Multidisciplinary panels of active member of the healthcare team has been shown to clinicians (including nurses) created clinical practice and reduce preventable drug reactions by 78% (Leape and client teaching guidelines addressing specific client care sit- Berwick, 2005). Employers have implemented cross-training uations. These guidelines are intended not only to assist in of staff to enhance provider scope of services and qualifica- the prevention, diagnosis, and management of clinical con- tions. The reduction in the number of professional nurses ditions, but also to provide a resource by which client care providing direct client care has necessitated creative prob- can be evaluated, the provider is held accountable, and reim- lem solving to find ways to help nurses “work smarter” and bursement is justified. The agency now serves as a repository safer. for research resources and documents to provide a compre- The federal government has directed facilities to expand hensive database for the development of evidence-based computer capabilities to reduce errors and untoward out- clinical practice guidelines. comes by improving order entry, streamlining documenta- These processes tend to stabilize care practices and system tion, facilitating data retrieval, and developing structured processes and are designed to improve outcomes. By shifting care methodologies. Computerizing physician order entry some routine or nondirect care activities from the nurse to can reduce prescriptions errors by as much as 81% (Leape another provider, even the client or family, better use may be and Berwick, 2005). Access to computers, whether by central made of nursing time and efforts. In addition, promoting location, bedside terminal, or hand-held units, allows for the client self-care (through participation in the planning of care immediate entry and retrieval of client data by care and mutual goal setting as well as the self-administration of providers. Beepers, pagers, and cordless or cell phones have some therapies/medications) provides opportunities for the facilitated communication between the nurse and other client/family to maximize their control of/contribution to healthcare team members and clients, reducing response their health status, improve their acute care experience, and time for meeting client needs. Documentation time can be demonstrate newly learned skills. reduced through use of detailed flow sheets, charting by The need to provide services at lower costs has forced exception, standardized and computerized plans of care, providers to seek alternatives to inpatient care. Currently, and/or developing clinical pathways (care maps). the emphasis is on outpatient services and affiliations with Clinical pathways support the coordination and evalua- other provider groups to provide a wider continuum of tion of interdisciplinary care through the identification of client care. Healthcare networks have been created, some of specific outcomes (important in today’s focus of “outcomes- which encompass a major hub or tertiary hospital and based” client care) and corresponding activities for a given smaller affiliating hospitals, freestanding emergency clinics condition/procedure based on the DRG or the agency and surgical centers, subacute units, rehabilitation centers, 2
    • Copyright © 2006 by F. A. Davis. long-term care facilities, and home-care agencies. These net- billing of services rendered. In those facilities/agencies ISSUES AND TRENDS IN MEDICAL-SURGICAL NURSING works are designed to meet all the client’s healthcare needs already billing for nursing services, the client plan of care is while keeping all the revenue within the network. However, an integral part of the justification of nursing care costs. this practice has the potential of limiting competition, The “what” and “how” of the work of nursing have been thereby causing the decline of independent healthcare agen- explained in part in a number of existing publications that cies, especially when physicians, pharmacies, and equip- help operationalize the work of nursing. NANDA ment supply companies join one network. International (formerly The North American Nursing One innovation was the creation of Community Nursing Diagnosis Association) developed a taxonomy in 1989 that Organization (CNO) demonstration projects that offered began a classification scheme to categorize and classify nurs- direct access to professional nursing care and nursing coor- ing diagnostic labels, which was subsequently revised in dination of all services with community-based care delivery. 2000. In 1992, the Iowa Intervention Project: Nursing The Centers for Medicare and Medicaid Services (CMS), for- Interventions Classification (NIC) directed our focus to the merly the Health Care Financing Administration (HCFA), content and process of nursing care by identifying and stan- developed this nursing model to provide Medicare benefici- dardizing some of the direct care activities nurses perform. A aries with a specific package of services (including preven- second group, the Iowa Outcomes Project: Nursing tion and health promtion) plus case management to promote Outcomes Classification (NOC), addresses client outcomes health and manage acute or chronic illnesses under a capi- responsive to and associated with nursing interventions. tated payment methodology. At four demonstration sites, all members were seen a minimum of twice a year to evaluate their health and to develop or check on progress of a plan of EARLY DISCHARGE care. The final report to Congress (Abt Associates, 2003) Clients are discharged from acute care as soon as they are revealed that although an overwhelming majority of out of danger or their condition is stabilized, but they may enrollees in the CNOs were satisfied with the care received still require specialized care. Subacute or transitional units and believed that the services helped with health needs and provide routine services (such as monitoring), ongoing ther- problems, the CNOs actually significantly increased the apies, and complex care (such as intravenous therapy, pain average monthly Medicare spending per client instead of and wound management, airway care, and ventilator wean- decreasing costs. Further study is required to determine if ing), rehabilitation services, and postsurgical recovery care. decreasing the capitated rate can reduce costs without nega- Shorter hospital stays have also shifted recovery care to tively impacting client satisfaction. the home setting. Families are expected to be more involved Significant changes in client care management are taking in postdischarge care. Although the rate of nosocomial infec- place because of implementation of case management, tions may decline, clients could be “abandoned” or recovery disease-state management, and evidence-based care. Case delayed or prolonged if the family’s personal resources can- management services are now provided across all settings not meet the new challenges associated with the recovery from case managers employed by insurers to entrepreneur- process. ial individuals engaged in “continuum of care” specialty areas and alternate sites, including outpatient, subacute, and home care. AGING POPULATION Healthcare-delivery systems use managed care to keep clients out of acute care hospitals by providing early inter- Individuals are living longer and often more active lives. As vention treatment, and by using less costly services within a result they expect access to procedures such as coronary the network. Whether the case manager is a physician, artery bypass, total joint replacements, aggressive cancer nurse, or insurance adjuster, all individuals involved in care care, and other interventions that in the past were not rec- are responsible for evaluating both the therapeutic benefit ommended in the presence of advanced age. The increased and cost effectiveness of the services provided. This need is mean age of clients requiring hospitalization necessitates especially critical for end-of-life care, for which a high per- some changes in the way their healthcare is provided. A gen- centage of healthcare dollars are spent. eral lack of knowledge among healthcare providers regard- ing special needs of the elderly, along with limited resources to meet these needs and the high incidence of adverse events NURSING CARE COSTS (such as confusion, falls, and incontinence), can contribute to instances of suboptimal client care. At the least, these factors Nurses have always been mainstays of care for people can cause prolonged facility stays, and increase the number throughout the life span and especially at the end of their and complexity of treatments, readmissions, and adverse lives. They continue to play a vital role in promoting respon- outcomes. To this end, the nursing profession is working to sible, appropriate, and ethical healthcare. develop models that will improve the care provided to this Today, the nurse’s attention is focused on providing nurs- population (e.g., Nurses Improving Care to the Hospitalized ing care to clients within the guidelines of prospective reim- Elderly [NICHE] Project). The provision of primary nurse bursement and capitation, scarce dollars, limited time, case managers to follow chronically ill clients across the con- reduced beds and staff, and restricted numbers of therapy tinuum of care (and other projects such as the CNO) work to and home-care visits. Quantifying the contribution of nurs- ensure that elderly clients are not lost to follow-up and ing to client care requires identification of the level of nursing receive ongoing monitoring for timely, cost-effective inter- care necessary for each client and translating that into direct vention. 3
    • Copyright © 2006 by F. A. Davis. Healthcare decision making has changed dramatically in Additionally, point-of-care computer systems are being recent decades, with an explicit acknowledgment of the refined in an effort to cut documentation time, and to track client’s right to determine the course of care. In the nursing nursing time for the costing of care. Computers provid- profession, there has been a long-standing allegiance to the ing real-time updating of the client plan of care enable client’s role in decision making, but nurses, especially those the nurse to process data from monitoring activities and in elder care, fear that the interpretation and use of advance facilitate evaluation of the effectiveness of nursing actions directives are creating ethical conflicts regarding the with- and other therapies. drawal or withholding of treatment or care, especially when Telehealth is being used in the community to not only the client is concerned about being a “burden to others.” triage the needs of large populations, but also to provide Living wills and advance directives cannot be expected to direct client care to underserved areas via long-distance anticipate all situations that clients may encounter; however, communication lines. Video conferencing, the Internet, and they can provide information to a proxy (named in a medical interactive voice-response systems are being used to monitor durable power of attorney) to help in the decision-making chronically ill clients in their own homes. process. Even with advance directives in place, clients have Finally, work is progressing toward the creation of a com- a right to change their minds and redefine their wishes based puterized patient record (CPR) or electronic health record on changes in their health status/care options. (EHR) that will provide a composite “cradle to grave” record for each individual accessing healthcare in this country. However, many questions and concerns remain about on- TECHNOLOGIC ADVANCES line security and privacy. We are living in an age of escalating uncertainty and ten- Technology continues to evolve at an astounding rate in both sion. Scientific and technologic advances we so covet are the treatment and equipment. The purpose of technology is to same advances that strip life of its simplicity. In the future, improve clinical decision making and symptom manage- technologies can and will be created to support and, in some ment, facilitate early detection/prevention of illness, and cases, replace dependent and interdependent activities of enhance self-care and client outcomes. Robots are being used nursing. As a result of the efficiencies afforded by advances to dispense medications in pharmacies and to assist with in automation and information management, the focus of surgical procedures such as coronary artery bypass, mitral nursing practice could shift from primarily task-oriented valve repair, and prostate removal. Clients undergoing min- client interactions. Concrete activities, such as inserting an imally invasive surgery report less pain, have less blood loss intravenous line, assessing for respiratory sounds, and pro- and scarring, have shorter lengths of stay, and report faster viding client teaching, although vital, do not reflect what healing. nurses believe and value as the most important elements of The use of in-room cameras and computers combined practice. For even in a technologically driven healthcare sys- with video conferencing (eICU) to monitor the vital signs tem, clients will always feel the need to be comforted, lis- and status of multiple clients in intensive care units pro- tened to, and treated with dignity and respect. motes earlier recognition of changes and timely response by Nurses have long placed emphasis on the psychosocial, nurses and physicians, improving client outcomes and spiritual, and physical needs of their clients within the med- reducing mortality rates. Biventricular pacing for cardiac ical regimen. Today, individuals spend billions of dollars resynchronization is available, although underused, for the annually for therapies (ranging from guided imagery and treatment of clients with classes 3 and 4 heart failure. Brain meditation to homeopathy and acupuncture) not generally stimulators are being used to treat movement disorders such provided by their physicians or approved by their Health as Parkinson’s disease, dystonia, and essential tremors. And Maintenance Organizations. As technology changes and implantable insulin pumps are reducing or delaying the more people become knowledgeable partners in healthcare, complications associated with type 1 diabetus mellitus. many direct their therapies (challenging therapeutic plans In the near future, the expanded use of monoclonal anti- developed by healthcare providers or withdrawing from bodies to carry chemotherapy agents or radionuclides to established medical care), choosing alternative therapies and cancer cells will reduce adverse reactions and possibly the modalities. Nurses need to be knowledgeable and open need for acute care. Endotoxin antibodies (immune system minded regarding complementary/alternative therapies— molecules that can mediate sepsis) and gene therapies are supporting client choices and learning and evaluating new being developed that can manage or even eliminate heredi- techniques as appropriate. Although nurses and clients alike tary/degenerative diseases, thereby reducing high-cost ther- are turning to the Internet for medical information and ther- apy needs. Equipment developments that allow clients to apeutic options, this resource can be a double-edged sword leave acute care settings more quickly include user-friendly because data provided may or may not be accurate. ventilators, smaller implantable ventilator-assist devices, Therefore, nurses need to be aware and knowledgeable and artificial hearts. The cost of care and the incidence of regarding various sites in order to direct their clients to rep- complications or adverse outcomes have been reduced for utable and valid resources. many clients with the use of such procedures as noninvasive intracranial pressure monitoring, tube locators to verify placement of catheters or enteral tubes, and bedside moni- FUTURE OF NURSING toring of many laboratory studies (such as electrolytes, blood urea nitrogen, hematocrit, glucose, and coagulation Healthcare reform remains the focus of much writing and times). debate in this new century. Questions still abound about 4
    • Copyright © 2006 by F. A. Davis. what constitutes healthcare reform. Whether brought about fails to define its contribution, then, as far as the reimburser ISSUES AND TRENDS IN MEDICAL-SURGICAL NURSING by statute, insurance payors, or healthcare providers, the is concerned, the contribution does not exist. changes in healthcare delivery are continuing and far reach- A recent focus of growth in the profession has been ing. These changes are, and should be, of great concern to the effort to standardize nursing language to better demon- nurses. strate what nursing is and what nurses do. As of this edition, We, the authors, are nurses who still believe that a nursing more than 10 versions of standardized nursing languages perspective is essential if nurses are to position themselves have been recognized by the American Nurses Association for a role in future healthcare-delivery systems. As Virginia (ANA) and submitted to the National Library of Medicine Henderson said, “The beauty of nursing is the combination for inclusion in the Unified Medical Language System of the heart, head, and hands” (Buerhaus, 1998). We are Metathesaurus. These nursing languages (e.g., NANDA, opposed to any system that reduces or eliminates the role of NIC/NOC, Omaha System, Clinical Care Classification, the nursing. Clients depend on the nurse to advocate for the Perioperative Minimum Data Set, and Ozbolt Patient Care rights of the client and the quality of care provided. Data Set) can enhance the ability of nurses to communicate In general, the public’s image of nursing remains positive; and document the care they provide, and to charge for these however, we can fall short of meeting the public’s expecta- services. This facilitates the recognition of nursing’s contri- tions because people are sometimes unaware of nurses’ var- bution to client care and promotes the view that nursing is a ied capabilities or their advanced practice potential. revenue-generating center. Although the public expects nurses to demonstrate technical In the midst of this whirlwind of change, as we experi- competence and academic knowledge, it is also now ment with new ways to provide cost-effective care within a demanding better consumer service; that is, friendliness, specified time frame, it is imperative that we build on attention to the client’s personal or special needs, concern for the foundation of the profession; that is, nursing is a science privacy, information about tests and therapies, and inclusion as well as an art, and nursing practice is rooted in the scien- of the family in the information loop. As the number of RNs tific process. Whether or not we choose to rename the steps in acute care facilities declines, and as they are replaced with we engage in (assessing clients and determining their less knowledgeable client care providers, nurses need to del- needs, choosing actions to meet those needs, and evaluating egate and supervise appropriately, using team members the effectiveness of those actions), our purpose remains the effectively and safely. Nurses, who now have less time for same—the diagnosis and treatment of human responses to nonclinical activities, are nonetheless spending more time health and illness. It reinforces the importance of critical collaborating with a wide variety of healthcare professionals thinking and reasoning to professional nursing practice as to manage and coordinate care, as well as to communicate well as the differences between basic and advanced nursing data regarding effectiveness of therapies. Nurses are inter- practice. If we allow our nursing focus to be replaced by the acting more with families, providing them with the informa- medical model, our practice will be subsumed, and much tion they need to make treatment decisions that reflect the more will be lost than the essence of our profession. client’s goals and values, and incorporating them into the caregiving process in preparation for the client’s discharge. To ensure that clients are getting what they need without CONCLUSION wasting healthcare dollars, nurses must be knowledgeable about costs and reimbursement plans, as well as the relative Rapid and continuous changes in the healthcare environ- benefits of treatment options. Downsizing produced the ment have greatly increased the responsibilities facing stimulus to nurses to broaden their skill base through cross- today’s nurse. To fulfill these responsibilities, planning and training and certification in order to document their exper- documentation of care are essential to satisfy client needs tise in a given area. Staff cutting requires that nurses remain and meet legal obligations. Documentation of the impact of flexible and perhaps trained to work in more than one clini- nursing on desired client outcomes provides a basis for eval- cal area. Healthcare systems can no longer employ RNs in uating continuing care needs, dealing with legal concerns, roles that do not directly, critically, and clearly contribute to and determining payment. the outcomes of the organization. Today’s nurse must be Therefore, as nurses work collaboratively with other disci- technically competent, skilled at critical thinking and prob- plines to provide client care, we need to continue to identify lem solving, able to work with a variety of people, and fis- and document the nursing care needs of clients through the cally responsible. use of the nursing process and nursing diagnosis. Although This is not enough, however, because the outcomes of this journey into change is not optional, nursing does have nursing care are the true measurement of the ability to pro- the opportunity and responsibility to take an active role in vide care. Nurses are entering (and even creating) new prac- shaping that change. tice environments in which to use their skills. They are also What lies ahead for nursing and planning of client working to further define nursing practice and the special care? Definitely, a tremendously exciting and exacting chal- contribution that nursing will continue to offer because that lenge! is how services will be evaluated and reimbursed. If nursing 5
    • Copyright © 2006 by F. A. Davis. 2 C H A P T E R The Nursing Process: Planning Care Using Nursing Diagnoses Nurses and healthcare consumers agree that nursing care is tem. The process combines all the skills of critical thinking a key factor in achieving positive outcomes and enhancing and good nursing care because it creates a method of active client satisfaction. Nursing care is instrumental in all phases problem solving that is both dynamic and cyclic. Figure 2–1 of acute care as well as in the maintenance of general well- visualizes the way this cyclic process works. As we learn being (i.e., prevention of illness, rehabilitation, and maxi- more about diagnostic reasoning and critical thinking, some mization of health), or where a return to health is not scholars are proposing a new model of describing what possible, the relief of pain and discomfort and a peaceful nurses do. With the emphasis on outcomes (the most recent death. To this end, the nursing profession has identified a revision of the American Nurses Association [ANA] Social problem-solving process that “combines the most desirable Policy Statement [1995] focused on outcomes and deempha- elements of the art of nursing with the most relevant ele- sized problem-focused approaches to nursing care) and new ments of systems theory, using the scientific method” (Shore, research into the nature of thinking and reasoning, the nurs- 1988). ing process continues to be redefined (Pesut and Herman, The original concept of nursing process was introduced in 1999). the 1950s as a three-step process of assessment, planning, The “what” and “how” of the work of nursing have been and evaluation based on the scientific method of observing, explained in part in a number of existing publications that measuring, gathering data, and analyzing the findings. Over help operationalize the work of nursing. The ANA Social time, this process became part of the conceptual framework Policy Statement (1980) defined nursing as the “diagnosis of all nursing curricula and is included in the legal definition and treatment of human responses to actual and potential of nursing in the nurse practice acts of most states. After health problems.” It represents a framework for understand- years of study, use, and refinement, the three-step process ing nursing’s relationship with society and nursing’s obliga- was expanded. The five steps—(1) assessment (systematic tions to those who receive nursing care. In 1991, the ANA collection of data relating to clients and their Standards of Clinical Nursing Practice described the client care problems/needs), (2) problem identification (analysis and process and standards for professional performance, provid- interpretation of data), (3) planning (prioritizing needs, iden- ing impetus and support for the use of nursing diagnosis in tifying goals, and choosing solutions), (4) implementation the practice setting. The work of NANDA International (for- (putting the plan into action), and (5) evaluation (assessing merly North American Nursing Diagnosis Association) has the effectiveness of the plan and changing the plan as indi- been ongoing for more than 25 years, beginning with efforts cated by current needs)—are central to nursing actions and to identify client problems/needs for which nurses are the delivery of high-quality, individualized client care in any accountable. NANDA continues to develop nursing diag- setting. nostic labels (Table 2–1), which are now being comple- When a client enters the healthcare system, the nurse uses mented by the Iowa Intervention Project: Nursing the steps of the nursing process to work toward achieving Interventions Classification (NIC) and the Iowa Outcomes the desired outcomes and goals identified for the client. The Project: Nursing Outcomes Classification (NOC). NIC effectiveness of the plan of care is evaluated by ascertaining directs our focus to the content and process of nursing care whether or not the desired outcomes and goals have been by identifying and standardizing the care activities nurses attained (client’s problems/needs have been resolved) or perform while NIC describes client outcomes that are whether problems remain at the time of discharge. If prob- responsive to nursing intervention and developing corre- lems are unresolved, plans need to be made for further sponding measurement scales. follow-up including assessment, additional problem/need The implementation of prospective/capitated payment identification, alteration of desired outcomes and goals, plans has moved a greater portion of healthcare delivery and/or changes of interventions in the next care settings. away from acute care hospitals into the community, with an Although some nurses view the nursing process as sepa- emphasis on multifaceted free-standing care centers and rate, progressive steps; in reality, the elements are interre- home health services. Standards of care such as those pub- lated. Together, they form a continuous circle of thought and lished by the American Association of Critical-Care Nurses action throughout the client’s contact with the healthcare sys- (AACN) and the Joint Commission on Accreditation of 6
    • Copyright © 2006 by F. A. Davis. THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES on n Pl nti Pl tio t ion an n ve an en en ing ter ni rv rv In ng te te In In NURSE CLIENT Ev Eva alu is Dia rsing luat is sis Dia rsing ag g os atio os Ev Di rsin no gn ion gn alu Nu n Nu Nu ati on Assessment Assessment ment Assess Figure 2–1. Diagram of the nursing process. The steps of the nursing process are interrelated, forming a continuous circle of thought and action that is both dynamic and cyclic. Table 2–1 Nursing Diagnoses Accepted for Use and Research Through 2006 Activity Intolerance [specify level] Death Syndrome, risk for sudden infant Activity Intolerance, risk for Denial, ineffective Adjustment, impaired Dentition, impaired Airway Clearance, ineffective Development, risk for delayed Allergy Response, latex Diarrhea Allergy Response, risk for latex Disuse Syndrome, risk for Anxiety [specify level] Diversional Activity, deficient Anxiety, death Aspiration, risk for Energy Field, disturbed Attachment, risk for impaired parent/infant/child Environmental Interpretation Syndrome, impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Failure to Thrive, adult Falls, risk for Body Image, disturbed Family Processes: alcoholism, dysfunctional Body Temperature, risk for imbalanced Family Processes, interrupted Bowel Incontinence Family Processes, readiness for enhanced Breastfeeding, effective Fatigue Breastfeeding, ineffective Fear [specify focus] Breastfeeding, interrupted Fluid Balance, readiness for enhanced Breathing Pattern, ineffective [Fluid Volume, deficient hyper/hypotonic] Fluid Volume, deficient [isotonic] Cardiac Output, decreased Fluid Volume, excess Caregiver Role Strain Fluid Volume, risk for deficient Caregiver Role Strain, risk for Fluid Volume, risk for imbalanced Communication, impaired verbal Communication, readiness for enhanced Gas Exchange, impaired Conflict, decisional (specify) Grieving, anticipatory Conflict, parental role Grieving, dysfunctional Confusion, acute Grieving, risk for dysfunctional Confusion, chronic Growth, risk for disproportionate Constipation Growth & Development, delayed Constipation, perceived Constipation, risk for Health Maintenance, ineffective Coping, compromised family Health-Seeking Behaviors [specify] Coping, defensive Home Maintenance, impaired Coping, disabled family Hopelessness Coping, ineffective Hyperthermia Coping, readiness for enhanced Hypothermia Coping, ineffective community Coping, readiness for enhanced community Identity, disturbed personal Coping readiness for enhanced family Infant Behavior, disorganized (Continued on the following page) 7
    • Copyright © 2006 by F. A. Davis. Table 2–1 Nursing Diagnoses Accepted for Use and Research Through 2006 (Continued) Infant Behavior, readiness for enhanced organized Self-Concept, readiness for enhanced Infant Behavior, risk for disorganized Self-Esteem, chronic low Infant Feeding Pattern, ineffective Self Esteem, situational low Infection, risk for Self Esteem, risk for situational low Injury, risk for Self-Mutilation Injury, risk for perioperative positioning Self-Mutilation, risk for Intracranial Adaptive Capacity, decreased Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Knowledge, deficient [Learning Need] [specify] Sexual Dysfunction Knowledge [specify], readiness for enhanced Sexuality Pattern, ineffective Skin Integrity, impaired Lifestyle, sedentary Skin Integrity, risk for impaired Loneliness, risk for Sleep, readiness for enhanced Sleep Deprivation Memory, impaired Sleep Pattern, disturbed Mobility, impaired bed Social Interaction, impaired Mobility, impaired physical Social Isolation Mobility, impaired wheelchair Sorrow, chronic Spiritual Distress Nausea Spiritual Distress, risk for Neglect, unilateral Spiritual Well-Being, readiness for enhanced Noncompliance, [ineffective Adherence] [specify] Suffocation, risk for Nutrition: less than body requirements, imbalanced Suicide, risk for Nutrition: more than body requirements, imbalanced Surgical Recovery, delayed Nutrition: more than body requirements, risk for imbalanced Swallowing, impaired Nutrition, readiness for enhanced Therapeutic Regimen Management, effective Oral Mucous Membrane, impaired Therapeutic Regimen Management, ineffective Therapeutic Regimen Management, ineffective community Pain, acute Therapeutic Regimen Management, ineffective family Pain, chronic Therapeutic Regimen Management, readiness for enhanced Parenting, impaired Thermoregulation, ineffective Parenting, readiness for enhanced Thought Processes, disturbed Parenting, risk for impaired Tissue Integrity, impaired Peripheral Neurovascular Dysfunction, risk for Tissue Perfusion, ineffective (specify type: cerebral, car- Poisoning, risk for diopulmonary, renal, gastrointestinal, peripheral) Post-Trauma Syndrome [specify stage] Transfer Ability, impaired Post-Trauma Syndrome, risk for Trauma, risk for Powerlessness [specify level] Urinary Elimination, impaired Powerlessness, risk for Urinary Elimination, readiness for enhanced Protection, ineffective Urinary Incontinence, functional Urinary Incontinence, reflex Rape-Trauma Syndrome Urinary Incontinence, risk for urge Rape-Trauma Syndrome: compound reaction Urinary Incontinence, stress Rape-Trauma Syndrome: silent reaction Urinary Incontinence, total Religiosity, impaired Urinary Incontinence, urge Religiosity, risk for impaired Urinary Retention [acute/chronic] Religiosity, readiness for enhanced Relocation Stress Syndrome Ventilation, impaired spontaneous Relocation Stress Syndrome, risk for Ventilatory Weaning Response, dysfunctional Role Performance, ineffective Violence, [actual/] risk for other-directed Violence, [actual/] risk for self-directed Self-Care Deficit, bathing/hygiene Walking, impaired Self-Care Deficit, dressing/grooming Wandering [specify sporadic or continual] Self-Care Deficit, feeding Self-Care Deficit, toileting [ ] author recommendations Used with permission from NANDA International: Definitions and Classification, 2005–-2006. NANDA, Philadelphia, 2005. Healthcare Organizations (JCAHO) emphasize that, even in define itself in a way that will complement and facilitate the these environments, nursing must meet standards that fur- provision of appropriate, cost-effective evidenced-based care ther specify the parameters of client assessment and docu- to all persons. Nurses need a common framework of com- mentation of care. munication and documentation so their contribution to Changes in the healthcare system continue to occur at an healthcare is recognized as being essential and they are remu- ever-increasing rate, requiring the profession of nursing to nerated appropriately. At the very least, nursing requires a 8
    • Copyright © 2006 by F. A. Davis. commonality of words describing practice so it can be cap- lifestyle. These assessments, combined with the results of THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES tured and is visible in the healthcare databases. medical findings and diagnostic studies, are documented in The linkage of nursing diagnoses to specific nursing inter- the client database and form the foundation for development ventions and client outcomes has led to the development of of the client’s plan of care. For each plan of care presented in a number of standardized nursing languages (e.g., Omaha this book, a client assessment database is created from infor- System, Clinical Care Classification [formerly Home mation that would likely be obtained from the history, phys- Healthcare Classification], Ozbolt Patient Care Data Set, ical examination, and related diagnostic studies. Nursing Perioperative Minimum Data Set). The purpose of these lan- priorities are then determined and ranked. Priorities are sim- guages is to help ensure continuity of appropriate high- ply stated and represent a general ranking system for the quality nursing care for the client regardless of setting. This nursing diagnoses in the plan of care. They can be reworded is accomplished in part through enhanced communication, and/or reorganized along with their timelines to create standardization of the process evaluating the care provided, short- and long-term goals. Next, the nursing diagnosis and facilitation of documentation. statements, which include possible related factors (etiology) and corresponding signs and symptoms (cues) when appro- priate, are presented. Desired client outcomes are then iden- PLANNING CARE tified and followed by appropriate independent and collaborative interventions with accompanying rationales. Medicine and nursing as well as other healthcare disciplines are interrelated, and therefore the actions for each discipline have implications for the others. This interrelationship Client Database allows for exchange of information and ideas and for devel- opment of plans of care that include all data pertinent to the In this book, each selected medical condition has an accom- individual client and/or family. In this book, the plan of care panying client database that includes subjective (“may contains not only the actions initiated by medical and nurs- report”) and objective (“may exhibit”) data that would ing orders, but also the coordination of care provided by all likely be collected through the history-taking interview, related healthcare disciplines. The nurse is often the person physical assessment, diagnostic studies, and review of prior responsible for coordinating these various activities into a records. The client database is organized within the 13 cate- comprehensive functional plan, essential in providing holis- gories of the Diagnostic Divisions. A sample medical/surgi- tic care for the client. Although independent nursing actions cal assessment tool, definitions of the divisions, and a client are an integral part of this process, collaborative actions are situation are included in Chapter 3. As the nurse develops usually present based on the medical regimen or orders from the plan of care, it will also be individualized to the client’s other disciplines participating in the care of the client. We situation. believe that nursing is an essential part of collaborative prac- tice, and, as such, nursing has a responsibility and accounta- Interviewing bility in every collaborative problem in which the nurse Interviewing the client and/or significant other(s) provides interacts with the client. The educational background and data that the nurse obtains through conversation and obser- expertise of the nurse, standing protocols, delegation of vation. This information includes the individual’s percep- tasks, the use of care partners, and the area of practice (rural tions; that is, what the client perceives to be a problem and or urban, acute care or community care settings) influence typically what he or she wants to share. Data may be col- whether an intervention is actually an independent nursing lected during one or more contact periods and should function or requires collaboration. include all relevant information. All participants in the inter- The well-written plan of care communicates the client’s view process need to know that collected data are used in past and present health status and current needs to all mem- planning the client’s care. Organizing and updating the data bers of the healthcare team involved in providing care. It assists in the ongoing identification of client care needs and identifies problems solved and those yet to be solved, can nursing diagnoses. inform of approaches that have been successful, and notes patterns of client responses to interventions. In legal terms, Physical Assessment the plan of care documents client care in areas of liability, accountability, and quality improvement. It also provides a During information gathering, the nurse exercises percep- mechanism to help ensure continuity of care when the client tual and observational skills, assessing the client through the leaves a care setting while still needing services. senses of sight, hearing, touch, and smell. The duration and depth of any physical assessment depend on the current con- dition of the client and the urgency of the situation, but it COMPONENTS OF THE usually includes inspection, palpation, percussion, and aus- cultation. In this book, the physical assessment data are pre- PLAN OF CARE sented within the client database as objective data. The critical element for providing effective planned nursing care is its relevance as identified in client assessments. Diagnostic Studies According to ANA Standards of Clinical Nursing Practice Interpretation of diagnostic test results is integrated with the (ANA, 1991), client assessment is required in the following history and physical findings as part of objective findings. areas: physical, psychologic, sociocultural, spiritual, cogni- Some tests are used to diagnose disease, whereas others are tive, functional abilities, developmental, economic, and useful in following the course of a disease or in adjusting 9
    • Copyright © 2006 by F. A. Davis. therapies. The nurse needs to be aware of significant test BOX 2–1. NANDA DEFINITION results that require reporting to the physician and/or initia- OF NURSING DIAGNOSIS tion of specific nursing interventions. In many cases, the relationship of the test to the pathological physiology is clear, but in other cases it is not. This is the result of the inter- Nursing diagnosis is a clinical judgment about relationship between various organs and body systems. individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of Nursing Priorities nursing interventions to achieve outcomes for which the nurse is accountable. In this book, nursing priorities are listed in a certain order to facilitate the linking/ranking of selected associated nursing diagnoses that appear in the plan of care guidelines. In any There are several steps involved in the process of prob- given client situation, nursing priorities are based on the lem/need identification. Integrating these steps provides a client’s specific needs and can vary from minute to minute. systematic approach to accurately identifying nursing diag- A nursing diagnosis that is a priority today may be less of a noses using the process of critical thinking. priority tomorrow, depending on the fluctuating physical and psychosocial condition of the client or the client’s chang- 1. Collecting a client database (nursing interview, physical ing responses to the existing condition. assessment, and diagnostic studies) combined with infor- An example of nursing priorities for a client diagnosed mation collected by other healthcare providers with severe hypertension would include: 2. Reviewing and analyzing the client data 1. Maintain/enhance cardiovascular functioning. 3. Synthesizing the gathered client data as a whole and then 2. Prevent complications. labeling your clinical judgment about the client’s 3. Provide information about disease process, prognosis, responses to these actual or high-risk problems/life and treatment regimen. processes 4. Support active client control or management of condition. 4. Comparing and contrasting the relationships of your clin- ical judgments against related factors and defining char- acteristics for the selected nursing diagnosis. This step is crucial to choosing and validating the appropriate nurs- Discharge Goals ing diagnosis label that will be used to create a specific Once the nursing priorities are determined, the next step is client diagnostic statement. to establish goals of treatment. In this book, each medical 5. Combining the nursing diagnosis with the related factors condition has established discharge goals, which are broadly and defining characteristics to create the client diagnostic stated and reflect the desired general status of the client on statement. For example, the diagnostic statement for a discharge or transfer to another care setting. paraplegic client with a decubitus ulcer could read: Discharge goals for a client with severe hypertension impaired Skin Integrity related to pressure, circulatory would include: impairment, and decreased sensation evidenced by drain- ing wound, sacral area. 1. Blood pressure within acceptable limits for individual. 2. Cardiovascular and systemic complications prevented/ The nursing diagnosis is as correct as the present infor- minimized. mation allows because it is supported by the immediate 3. Disease process/prognosis and therapeutic regimen data collected. It documents the client’s situation at the pres- understood. ent time and should reflect changes as they occur in the 4. Necessary lifestyle/behavioral changes initiated. client’s condition. Accurate need identification and diag- nostic labeling provide the basis for selecting nursing inter- ventions. The nursing diagnosis may be a physical or a psychosocial Nursing Diagnosis (Problem/ response. Physical nursing diagnoses include those that per- Need Identification) tain to physical processes, such as circulation (ineffective renal Tissue Perfusion), ventilation (impaired Gas Nursing diagnoses are a uniform way of identifying, focus- Exchange), and elimination (Constipation). Psychosocial ing on, and dealing with specific client needs and responses nursing diagnoses include those that pertain to the mind to actual and high-risk problems. Nursing diagnosis labels (acute Confusion), emotions (Fear), or lifestyle/relationships (see Table 2–1) provide a format for expressing the problem (ineffective Role Performance). Unlike medical diagnoses, identification portion of the nursing process. In 1989, nursing diagnoses change as the client progresses through NANDA developed a taxonomy or classification scheme to various stages of illness/maladaptation to resolution of the categorize and classify nursing diagnostic labels. (This was problem or to the conclusion of the condition. Each decision replaced by a second taxonomy in 2000.) The NANDA defi- the nurse makes is time dependent, and, with additional nition of nursing diagnosis approved in 1990 further clari- information gathered at a later point in time, decisions may fied the second step of the nursing process (i.e., problem change. For example, the initial problems/needs for a client identification/diagnosis). The definition of nursing diagno- undergoing cardiac surgery may be acute Pain, decreased sis developed by NANDA is presented in Box 2–1. Cardiac Output, ineffective Airway Clearance, and Risk for 10
    • Copyright © 2006 by F. A. Davis. Infection. As the client progresses, problems/needs are more sensitive to nursing interventions. Other team mem- THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES likely to shift to Activity Intolerance, deficient Knowledge, bers can use the majority of NOC labels and identify differ- and ineffective Role Performance. ent indicators relative to their specialty focus to demonstrate Diagnostic reasoning is used to ensure the accuracy of the their contribution to client improvement or to track deterio- client diagnostic statement. The defining characteristics and ration. In this book, the identified outcomes in each plan of related factors associated with the chosen nursing diagnosis care are organized by using NOC labels (which are boxed to are reviewed and compared with the client data. If the diag- call attention to their introduction in this text). nosis is not consistent with a majority of the cues or is not supported by relevant cues, additional data may be required or another nursing diagnosis needs to be considered. Planning (Goals and Actions/Interventions) Desired Client Outcomes Nursing interventions are prescriptions for specific behav- A desired client outcome is defined as the result of achiev- iors expected from the client and actions to be carried able nursing interventions and client responses that is out/facilitated by nurses. These actions/interventions are desired by the client and/or caregiver and attainable within selected to assist the client in achieving the stated desired a defined time period, given the present situation and client outcomes and discharge goals. The expectation is that resources. These desired outcomes are the measurable steps the prescribed behavior will benefit the client/family in a toward achieving the previously established discharge goals predictable way related to the identified problem/need and and are used to evaluate the client’s response to nursing chosen outcomes. These interventions have the intent of interventions. (The fifth step of the nursing process, evalua- individualizing care by meeting a specific client need and tion, is addressed in the sample client situation provided in should incorporate identified client strengths when possible. Chapter 3.) Useful desired client outcomes must: Nursing interventions should be specific and clearly stated, beginning with an action verb. Qualifiers of how, 1. Be specific. when, where, time/frequency, and amount provide the con- 2. Be realistic. tent of the planned activity; for example, “Assist as needed 3. Be measurable. with self-care activities each morning,” “Record respiratory 4. Indicate a definite time frame for achievement. and pulse rates before, during, and after activity,” and 5. Consider client’s desires and resources. “Instruct family in postdischarge care.” The NIC project has identified 514 interventions (both Desired client outcomes are created by listing items direct and indirect) that are stated in general terms, such as and/or behaviors that can be observed or heard. They are Respiratory Monitoring. Each label has a varied number of monitored to determine whether an acceptable outcome has activities that may be chosen to accomplish the intervention. been achieved within a specified time frame. Action verbs The interventions encompass a broad range of nursing prac- and time frames are used; for example, “client will ambulate, tice, with some requiring specialized training/advanced cer- using cane, within 48 hours of surgery.” The action verbs tification. Others may be appropriate for delegation to other describe the client’s behavior to be evaluated. Time frames care providers (e.g., licensed practical nurses [LPNs], nurs- are dependent on the client’s projected or anticipated length ing assistants, unlicensed personnel) but still require plan- of stay, often determined by diagnosis-related group (DRG) ning and evaluation by registered nurses. In this text, these classification and considering the presence of complications NIC labels are boxed to help the user begin to identify how or extenuating circumstances (e.g., age, debilitating disease they can be used. process). The ongoing work of NOC in identifying 330 out- This book divides the nursing interventions/actions into comes now also addresses client groups or aggregates. independent (nurse initiated) and collaborative (initiated Although the NOC outcomes are listed in general terms such by/performed in conjunction with other care providers) as Ambulation: Walking, 12 indicators are included for this under the appropriate NIC labels. Examples of these two dif- outcome that can be measured by a five-point Likert-type ferent professionally initiated actions are: scale ranging from “dependent, does not participate” to “completely independent.” This facilitates tracking clients • Independent: Provide calm, restful surroundings, mini- across care settings and can demonstrate client progress mize environmental activity/noise, and limit numbers of even when outcomes are not met. visitors and length of stay. When outcomes are properly written, they provide direc- • Collaborative: Administer antianxiety medication as indi- tion for planning and validating the selected nursing inter- cated. ventions. Consider the two following client outcomes: “Client will identify individual nutritional needs within 36 hours” and “…formulate a dietary plan based on identified RATIONALE nutritional needs within 72 hours.” Based on the clarity of these outcomes, the nurse can select nursing interventions to Although rationales do not appear on regular plans of care, ensure that the client’s dietary knowledge is assessed, indi- they are included in this book to assist the student and prac- vidual needs identified, and nutritional education presented. ticing nurse in associating the pathophysiologic and/or psy- Often, the client outcomes identified are not unique to nurs- chologic principles with the selected nursing intervention. ing because we provide care in a team approach with other This will help the nurse determine whether an intervention disciplines. However, the NOC indicators for outcomes are is appropriate for a specific client. 11
    • Copyright © 2006 by F. A. Davis. CONCLUSION approved nursing diagnosis deficient Knowledge is one example where further clarification was added. The term This book is intended to facilitate the application of the nurs- Learning Need has been added to the nursing diagnosis label. ing process and the use of nursing diagnosis in medical/sur- Also, some diagnoses, such as Anxiety/Fear, have been com- gical clients. Each plan of care guideline was designed to bined for convenience; the combination indicates that two or provide generalized information on the associated medical more factors may be involved, and the nurse can then choose condition. The guidelines can be modified either by using the most appropriate diagnosis for a specific client. We rec- portions of the information provided or by adding more ognize that not all of the NANDA-approved nursing diag- client care information to the existing guides. The plan of care noses have been used in these plan of care guidelines, but we guidelines were developed according to the NANDA recom- hope that these guidelines will assist you in determining mendations except in a few examples where the authors your clients’ needs, outcomes, and nursing interventions. believed more clarification and enhancement were required. Next, Chapter 3 will assist you in applying and adapting The ongoing controversy on the validity of the NANDA- theory to practice. 12
    • Copyright © 2006 by F. A. Davis. 3 C H A P T E R Critical Thinking: Adaptation of Theory to Practice Critical thinking is defined as the “intellectually disciplined From the specific data recorded in the database, the process of actively and skillfully conceptualizing, applying, related/risk factors (etiology) and signs and symptoms can analyzing, synthesizing, and evaluating information gath- be identified, and an individualized client diagnostic state- ered from or generated by observation, experience, reflec- ment can be formulated according to the problem, etiology, tion, reasoning, or communication, as a guide to belief and and signs/symptoms (PES) format to accurately represent action” (National Council for Excellence in Critical Thinking, the client’s situation. For example, the diagnostic statement 1992). Critical thinking requires cognitive, psychomotor, and may read: ineffective peripheral Tissue Perfusion related to affective skills to use the tools of a comprehensive knowl- decreased arterial flow, evidenced by decreased pulses, edge base, the nursing process, and established standards of pale/cool feet, thick brittle nails, numbness/tingling of feet care, as well as nursing research, to analyze data and plan a when walks 1/4 mile. course of action based on new insights and conclusions. Outcomes are identified to facilitate choosing appro- Although critical thinking skills are used in all aspects of priate interventions and to serve as evaluators of both nursing practice, they are most evident when assessment nursing care and client response. In addition to being meas- data are analyzed to identify relevant information, make urable, outcomes must be achievable and desired by the decisions about client needs, and develop an individualized client. These outcomes also form the framework for docu- plan of care. Therefore, client assessment is the foundation mentation. on which identification of individual needs, responses, and Interventions are designed to specify the action of the problems is based. Nurses of the future will need to manage nurse, the client, and/or significant other(s). They are not all- and interpret data and evaluate nursing activities and inter- inclusive because such basic nursing actions as “bathe the ventions. They will also need competencies in case and client” or “notify the physician of changes” have been omit- financial management, healthcare policy and economics, leg- ted. It is expected that these actions are included in routine islative outcomes, and research methods. Additionally, they client care. Sometimes controversial issues or treatments are will need skills of delegation and the ability to think and rea- presented for the sake of information and/or because differ- son across a diversity of settings in which they will practice ent therapies may be used in different care settings or geo- (Pesut and Herman, 1999). graphic locations. To facilitate the steps of assessing and diagnosing in the Interventions need to promote the client’s movement nursing process and to aid in the critical thinking process, toward health and independence. This requires involvement assessment databases have been developed (Figure 3–1) that of the client in his or her own care, including participation in use a nursing focus instead of the traditional medical decisions about the care activities and projected outcomes. approach of review of systems. To achieve this nursing This promotes client responsibility, negating the idea that focus, we have grouped the NANDA International (formerly healthcare providers control clients’ lives. the North American Nursing Diagnosis Association) nursing To assist in visualizing this critical thinking process, a diagnoses into related categories titled Diagnostic Divisions prototype client situation (Figure 3–2) is provided as an (Box 3–1), which reflect a blending of theories, primarily example of data collection and construction of a plan of Maslow’s Hierarchy of Needs and a self-care philosophy. care. As the client assessment database is reviewed, the These divisions serve as the framework or outline for collec- nurse can identify the related/risk factors and defining tion of data and direct the nurse to the corresponding nurs- characteristics (signs/symptoms) that were used to formu- ing diagnosis labels. late the client diagnostic statements. The addition of time- Because these divisions are based on human responses/ lines to specific client outcomes and goals reflects the needs and are not specific “systems,” data may be recorded anticipated length of stay and individual client/nurse expec- in more than one area. For this reason, the nurse is encour- tations. Interventions are based on concerns/needs identi- aged to keep an open mind and to collect as much informa- fied by the client and nurse during data collection in tion as possible before choosing the nursing diagnosis label. addition to physician orders. Although not normally The results (synthesis) of the collected data are written con- included in a plan of care, rationales are included in this cisely (client diagnostic statements) to best reflect the client’s sample for the purpose of explaining or clarifying the choice situation. of interventions. (Text continues on p. 26) 13
    • Copyright © 2006 by F. A. Davis. ADULT MEDICAL/SURGICAL ASSESSMENT TOOL General Information Name: Age: DOB: Gender: Race: Admission Date: Time: From: Source of Information: Reliability (1–4 with 4 being very reliable): Activity/Rest Subjective (Reports) Objective (Exhibits) Occupation: Usual activities: Observed response to activity: Leisure time activities/hobbies: Cardiovascular: Respiratory: Limitations imposed by condition: Mental Status (e.g., withdrawn/lethargic): Sleep: Hours: Naps: Aids: Neuromuscular Assessment: Insomnia: Related to: Muscle mass/tone: Posture: Rested on awakening: ROM: Strength: Tremors: Excessive grogginess: Deformity: Feelings of boredom/dissatisfaction: Circulation Subjective (Reports) Objective (Exhibits) History of: Hypertension: Heart trouble: BP: R and L: Lying/sit/stand: Rheumatic fever: Ankle/leg edema: Pulse pressure: ______ Auscultatory gap: _________ Phlebitis: Slow healing: Pulses (palpation): Carotid: Claudication: Dysreflexia: Temporal: ______ Jugular: _______ Radial: _______ Bleeding tendencies/episodes: Femoral: ___________ Popliteal: Palpitations: Syncope: Posttibial: __________ Dorsalis pedis: ____________ Extremities: Numbness: ________Tingling: ___________ Cardiac (palpation): Thrill: _________ Heaves: _______ Cough/hemoptysis: Heart sounds: Rate: __________ Rhythm: ___________ Change in frequency/amount of urine: Quality: _____________ Friction rub: ____________ Murmur: ____________________________________ Vascular bruit: __________________________________ Jugular vein distention (JVD): Breath sounds: Extremities: Temperature: __________ Color: ________ Capillary refill: _________ Homans’ sign: ________ Varicosities: _______ Nail abnormalities: _________ Edema: Distribution/quality of hair: Trophic skin changes: Color: General: Mucous membranes: ___________ Lips: __________ Nailbeds: __________ Conjunctiva: Sclera: Diaphoresis: Figure 3–1. Adult medical-surgical assessment tool. This is a suggested guide and tool for creating a database reflecting a nursing focus. Although the diagnostic divisions are alphabetized here for ease of presentation, they can be prioritized or rearranged in any manner to meet individual needs. In addition, this assessment tool can be adapted to meet the needs of specific client populations. 14
    • Copyright © 2006 by F. A. Davis. Ego Integrity Subjective (Reports) Objective (Exhibits) Stress factors: Emotional status (check those that apply): Ways of handling stress: Calm: ________ Anxious: ________ Angry: ________ Financial concerns: Withdrawn/Fearful: __________ Irritable: _________ Relationship status: Restive: Euphoric: Cultural factors/ethnic ties: Observed physiological response(s): _______________ Religion: Practicing: Changes in energy field: Lifestyle: Recent changes: Temperature: Color: Sense of connectedness/harmony with self: Distribution: Movement: Feeling of: Helplessness: Sounds: Hopelessness: Powerlessness: Elimination Subjective (Reports) Objective (Exhibits) Usual bowel pattern: Abdomen: Tender: ___________ Soft/firm: Laxative use: Palpable mass: Size/girth: Character of stool: Last BM: __________ Bowel sounds: Location/type: Constipation: Diarrhea: _____________ Hemorrhoids: Stool guaiac: History of bleeding: Hemorrhoids: ________ Bladder palpable: Usual voiding pattern: Overflow voiding: Incontinence/when: Urgency: CVA tenderness: Frequency: Retention: Character of urine: Pain/burning/difficulty voiding: History of kidney/bladder disease: Diuretic use: Food/Fluid Subjective (Reports) Objective (Exhibits) Usual diet (type): Last meal/intake: Current weight: Height: Cultural/religious restrictions: Body build: Skin turgor: Dietary pattern/content: B: L: D: Mucous membranes: Moist/dry: Carbohydrate/protein/fat intake: g/d Breath sounds: Crackles: _________________________ Number of meals daily: Wheezes: ______________________________________ Vitamin/food supplement use: Edema: General: ____________ Dependent: _________ Last meal/intake: Periorbital: Ascites: Loss of appetite: Nausea/vomiting: Jugular vein distention (JVD): Heartburn/indigestion: Related to: Thyroid enlarged: Relieved by: Condition of teeth/gums: Food preferences: Food prohibitions: Appearance of tongue: Allergy/food intolerance: Mucous membranes: _________ Halitosis: ________ Figure 3–1. (Continued) 15
    • Copyright © 2006 by F. A. Davis. Mastication/swallowing problems: Bowel sounds: Dentures: Hernia/masses: Usual weight: Changes in weight: Urine S/A or Chemstix: Diuretic use: Serum glucose (Glucometer): Hygiene Subjective (Reports) Objective (Exhibits) Activities of daily living: Independent/ General appearance: dependent (level): Manner of dress: Mobility: Feeding: Hygiene: Personal habits: Dressing/grooming: Toileting: Body odor: Preferred time of personal care/bath: Condition of scalp: ____________________________ Equipment/prosthetic devices required: ______________ Presence of vermin: ___________________________ Assistance provided by: Neurosensory Subjective (Reports) Objective (Exhibits) Fainting spells/dizziness: Mental status (Note duration of change): Headaches: Location: _________ Frequency: _________ Oriented/disoriented: Person: ___________________ Tingling/numbness/weakness (location): _____________ Place: _________ Time: ________ Situation: _______ Stroke/brain injury (residual effects): ________________ Check all that apply: Seizures: _________ Type: __________ Aura: _________ Alert: _______ Drowsy: _______ Lethargic: _______ Frequency: ____________ Postictal state: __________ Stuporous: _______________ Comatose: __________ How controlled: _______________________________ Cooperative: ___________ Combative: ___________ Eyes: Vision loss: ___________ Last exam: ___________ Delusions: ___________ Hallucinations: __________ Glaucoma: _____________ Cataract: ______________ Affect (describe): Ears: Hearing loss: __________ Last exam: ___________ Memory: Recent: __________ Remote: ___________ Sense of smell: ____________ Epistaxis: Glasses: ______ Contacts: ______ Hearing aids: ______ Pupil: Shape: _________ Size/reaction: R/L: _________ Facial droop: _________ Swallowing: ______________ Handgrasp/release, R/L: Deep tendon reflexes: ___________________________ Posturing: Paralysis: _____________ Pain/Discomfort Subjective (Reports) Objective (Exhibits) Primary focus: _____________ Location: _____________ Facial grimacing: ________________________________ Intensity (0–10 with 10 being most severe): ________ Guarding affected area: __________________________ Frequency: ______________ Quality: ______________ Emotional response: _____________________________ Duration: _____________ Radiation: ______________ Narrowed focus: ________________________________ Precipitating/aggravating factors: Change in blood pressure: __________ Pulse: _______ How relieved: Associated symptoms: Effect on activities: _________ Relationships: _________ Additional focus: _________________________________ Figure 3–1. (Continued) 16
    • Copyright © 2006 by F. A. Davis. Respiration Subjective (Reports) Objective (Exhibits) Dyspnea/related to: Respiratory: Rate: ____________ Depth: ____________ Cough/sputum: Symmetry: ___________________________________ History of bronchitis: __________ Asthma: ___________ Use of accessory muscles: Emphysema: ____________ Tuberculosis: __________ Nasal flaring: _________________________________ Recurrent pneumonia: __________________________ Fremitus: _______________________________________ Exposure to noxious fumes: _____________________ Breath sounds: Egophony: _____________ Smoker: _________________ Pack/day: ______________ Cyanosis: No. of pack years: _____________________________ Clubbing of fingers: _____________________________ Use of respiratory aids: _________ Oxygen: __________ Sputum characteristics: Mentation/restlessness: ___________________________ Safety Subjective (Reports) Objective (Exhibits) Allergies/sensitivity: __________ Reaction: ___________ Temperature: ___________ Diaphoresis: ____________ Exposure to infectious diseases: ____________________ Skin integrity: Scars: ___________ Rashes: __________ Previous alteration of immune system: ______________ Lacerations: ____________ Ulcerations: __________ Cause: Ecchymosis: _________ Blisters: ___________ Burns History of sexually transmitted disease (degree/percent): __________ Drainage: __________ (date/type): _____________ Testing: _______________ Mark location of the above on diagram: High-risk behaviors: Blood transfusion/number: _________ When: _________ Reaction: _____________ Describe: Geographic areas lived in/visited: Seat belt/helmet use: ___________________________ ___ Workplace safety/health issues: History of accidental injuries: ______________________ Fractures/dislocations: __________________________ Arthritis/unstable joints: ___________________________ Back problems: __________________________________ Changes in moles: ________ Enlarged nodes: ________ Delayed healing: _________________________________ General strength: Cognitive limitations: _____________________________ Muscle tone: Impaired vision/hearing: __________________________ Gait: ROM: Prosthesis: _________ Ambulatory devices: __________ Paresthesia/paralysis: Results of cultures: Immune system testing: ________________________ Tuberculosis testing: ___________________________ Figure 3–1. (Continued) 17
    • Copyright © 2006 by F. A. Davis. Sexuality (Component of Ego Integrity and Social Interaction) Subjective (Reports) Objective (Exhibits) Sexually active: ________ Use of condoms: __________ Comfort level with subject matter: _________________ Birth control method: _____________________________ Sexual concerns/difficulties: _______________________ Recent change in frequency/interest: Female: Subjective (Reports) Objective (Exhibits) Age at menarche: _________ Length of cycle: ________ Breast exam: ___________________________________ Duration: ________ Number of pads used/d: _______ Genital warts/lesions: ____________________________ Last menstrual period: ______ Pregnant now: ______ Discharge: _____________________________________ Bleeding between periods: ________________________ Menopause: ___________ Vaginal lubrication: ________ Vaginal discharge: _______________________________ Surgeries: _______________________________________ Hormonal therapy/calcium use: ____________________ Practices breast self-exam: ________________________ Last mammogram: _________ PAP smear: _________ Male: Subjective (Reports) Objective (Exhibits) Penile discharge: ________ Prostate disorder: ________ Breast: __________________ Testicles: ______________ Circumcised: ____________ Vasectomy: _____________ Genital warts/lesions: ____________________________ Practice self-exam: Breast: ________ Testicles: ________ Discharge: _____________________________________ Last proctoscopic/prostate exam: Social Interactions Subjective (Reports) Objective (Exhibits) Marital status: ________ Years in relationship: ________ Speech: Clear: ____________ Slurred: ______________ Living with: _________ Concerns/stresses: _________ Unintelligible: ____________ Aphasic: ___________ Extended family: Usual speech pattern/impairment: _______________ Other support person(s): Use of speech/communication aids: _____________ Role within family structure: _______________________ Laryngectomy present: _________________________ Perception of relationships with family members: _____ Ethnic affiliation: _________________________________ Verbal/nonverbal communication with Strength of ethnic identity: ______________________ family/SO(s): Lives in ethnic community (y/n): _________________ Family interaction (behavioral) pattern: Feelings of: Mistrust: ___________ Rejection: _________ Unhappiness: _______ Loneliness/isolation: ________ Problems related to illness/condition: _______________ Problems with communication: ____________________ Figure 3–1. (Continued) 18
    • Copyright © 2006 by F. A. Davis. Teaching/Learning Subjective (Reports) Dominant language (specify): Prescribed medications: Second language: ______________________________ Drug: Dose: ________________ Literate: __________ Education level: _____________ Times (circle last dose): Learning disabilities: (specify): ___________________ Take regularly: ____________ Purpose: ___________ Cognitive limitations: ___________________________ Side effects/problems: Where born: ______________ If immigrant how long in Nonprescription drugs: OTC drugs: ________________ this country: __________________________________ Herbal supplements (specify): Health and illness beliefs/practices Street drugs: ____________ Tobacco: _____________ (e.g., complementary therapies)/customs: __________ Smokeless tobacco: Which family member makes healthcare decisions/ Alcohol (amount/frequency): is spokesperson: Admitting diagnosis per provider: Presence of Advance Directives/Durable Medical Reason for admission per client: Power of Attorney: _____________________________ History of current complaint: Special healthcare concerns (e.g., impact of Client expectations of care: religious/cultural practices): Previous illnesses and/or hospitalizations/ Health goals: surgeries: ____________________________________ Familial risk factors (indicate relationship): Evidence of failure to improve: Diabetes: __________ Thyroid (specify): ___________ Last complete physical exam: _____________________ Tuberculosis: ___________ Heart disease: __________ Strokes: _______ High BP: _______ Epilepsy: _______ Kidney disease: ____________ Cancer: ____________ Mental illness: ____________ Other: ______________ Discharge Plan Considerations DRG projected mean length of stay: ________________ Physical layout of home (specify): _______________ Date information obtained: ________________________ Anticipated changes in living situation Anticipated date of discharge: ______________________ after discharge: _______________________________ Resources available: Persons: ______________________ Living facility other than home (specify): Financial: __________ Community: __________ Support _______________________________________________ groups: ____________ Socialization: ______________ Referrals (date, source, services): Areas that may require alteration/assistance: Social Services: _______________________________ Food preparation: __________ Shopping: __________ Rehabilitation services: ________________________ Transportation: ____________ Ambulation: _________ Dietary: ____________ Home care: ______________ Medication/IV therapy: _________________________ Resp/O2: _____________ Equipment: ____________ Treatments: ___________ Wound care: ____________ Supplies: ____________________________________ Supplies: __________ Self-care (specify): ___________ Other: ______________________________________ Homemaker/maintenance (specify): _______________ 19
    • Copyright © 2006 by F. A. Davis. BOX 3–1. NURSING DIAGNOSES ORGANIZED ACCORDING TO DIAGNOSTIC DIVISIONS After data are collected and areas of concern/need identified, the nurse is directed to the Diagnostic Divisions to review the list of nursing diagnoses that fall within the individual categories. This will assist the nurse in choosing the specific diagnostic label to accurately describe the data. Then, with the addition of etiology or related/risk factors (when known) and signs and symp- toms, or cues (defining characteristics), the client diagnostic statement emerges. Activity/Rest—Ability to engage in necessary/desired activ- • Religiosity, readiness for enhanced ities of life (work and leisure) and to obtain adequate • Religiosity, impaired sleep/rest • Religiosity, risk for impaired • Activity Intolerance • Relocation Stress Syndrome • Activity Intolerance, risk for • Relocation Stress Syndrome, risk for • Disuse Syndrome, risk for • Self-Concept, readiness for enhanced • Diversional Activity, deficient • Self-Esteem, chronic low • Fatigue • Self-Esteem, situational low • Lifestyle, sedentary • Self-Esteem, risk for situational low • Mobility, impaired bed • Sorrow, chronic • Mobility, impaired physical • Spiritual Distress • Mobility, impaired wheelchair • Spiritual Distress, risk for • Sleep Deprivation • Spiritual Well-Being, readiness for enhanced • Sleep Pattern, disturbed Elimination—Ability to excrete waste products • Sleep, readiness for enhanced • Bowel Incontinence • Transfer Ability, impaired • Constipation • Walking, impaired • Constipation, perceived Circulation—Ability to transport oxygen and nutrients nec- • Constipation, risk for essary to meet cellular needs • Diarrhea • Autonomic Dysreflexia • Urinary Elimination, impaired • Autonomic Dysreflexia, risk for • Urinary Elimination, readiness for enhanced • Cardiac Output, decreased • Urinary Incontinence, functional • Intracranial Adaptive Capacity, decreased • Urinary Incontinence, reflex • Tissue Perfusion, ineffective (specify type: renal, cere- • Urinary Incontinence, stress bral, cardiopulmonary, gastrointestinal, peripheral) • Urinary Incontinence, total • Urinary Incontinence, urge Ego Integrity—Ability to develop and use skills and behav- • Urinary Incontinence, risk for urge iors to integrate and manage life experiences • Urinary Retention [acute/chronic] • Adjustment, impaired • Anxiety [specify level] Food/Fluid—Ability to maintain intake of and utilize nutri- • Anxiety, death ents and liquids to meet physiological needs • Body Image, disturbed • Breastfeeding, effective • Conflict, decisional (specify) • Breastfeeding, ineffective • Coping, defensive • Breastfeeding, interrupted • Coping, ineffective • Dentition, impaired • Coping, readiness for enhanced • Failure to Thrive, adult • Denial, ineffective • [Fluid Volume, deficient hyper/hypotonic] • Energy Field, disturbed • Fluid Volume, deficient [isotonic] • Fear • Fluid Volume excess • Grieving, anticipatory • Fluid Volume, risk for deficient • Grieving, dysfunctional • Fluid Volume, risk for imbalanced • Grieving, risk for dysfunctional • Infant Feeding Pattern, ineffective • Hopelessness • Nausea • Personal Identity, disturbed • Nutrition, less than body requirements, imbalanced • Post-Trauma Syndrome • Nutrition, more than body requirements, imbalanced • Post-Trauma Syndrome, risk for • Nutrition, risk for more than body requirements, imbal- • Powerlessness anced • Powerlessness, risk for • Nutrition, readiness for enhanced • Rape-Trauma Syndrome • Oral Mucous Membrane, impaired • Rape-Trauma Syndrome: compound reaction • Swallowing, impaired • Rape-Trauma Syndrome: silent reaction (Continued on the following page) 20
    • Copyright © 2006 by F. A. Davis. BOX 3–1. NURSING DIAGNOSES ORGANIZED ACCORDING TO DIAGNOSTIC DIVISIONS (Continued) Hygiene—Ability to perform activities of daily living • Suffocation, risk for • Self-Care Deficit: bathing/hygiene, dressing/grooming, • Suicide, risk for feeding, toileting • Surgical Recovery, delayed • Thermoregulation, ineffective Neurosensory—Ability to perceive, integrate, and respond • Tissue Integrity, impaired to internal and external cues • Trauma, risk for • Confusion, acute • Violence, [actual/]risk for other-directed • Confusion, chronic • Violence, [actual/]risk for self-directed • Infant Behavior, disorganized • Wandering [specify sporadic or continual] • Infant Behavior, risk for disorganized • Infant Behavior, readiness for enhanced organized Sexuality [Component of Ego Integrity and Social • Memory, impaired Interaction]—Ability to meet requirements/characteristics • Peripheral Neurovascular Dysfunction, risk for of male/female role • Sensory Perception, disturbed (specify: visual, auditory, • Sexual Dysfunction kinesthetic, gustatory, tactile, olfactory) • Sexuality Pattern, ineffective • Thought Processes, disturbed Social Interaction—Ability to establish and maintain rela- • Unilateral Neglect tionships Pain/Discomfort—Ability to control internal/external envi- • Attachment, risk for impaired parent/infant/child ronment to maintain comfort • Caregiver Role Strain • Pain, acute • Caregiver Role Strain, risk for • Pain, chronic • Communication, impaired verbal • Communication, readiness for enhanced Respiration—Ability to provide and use oxygen to meet • Coping, ineffective community physiological needs • Coping, readiness for enhanced community • Airway Clearance, ineffective • Coping, compromised family • Aspiration, risk for • Coping, disabled family • Breathing Pattern, ineffective • Coping, readiness for enhanced family • Gas Exchange, impaired • Family Processes, interrupted • Ventilation, impaired spontaneous • Family Processes, alcoholism, dysfunctional • Ventilatory Weaning Response, dysfunctional • Loneliness, risk for Safety—Ability to provide safe, growth-promoting environ- • Parental Role Conflict ment • Parenting, impaired • Allergy Response, latex • Parenting, risk for impaired • Allergy Response, risk for latex • Parenting, readiness for enhanced • Body Temperature, risk for imbalanced • Role Performance, ineffective • Environmental Interpretation Syndrome, impaired • Social Interaction, impaired • Falls, risk for • Social Isolation • Health Maintenance, ineffective Teaching/Learning—Ability to incorporate and use infor- • Home Maintenance, impaired mation to achieve healthy lifestyle/optimal wellness • Hyperthermia • Development, risk for delayed • Hypothermia • Growth and Development, delayed • Infection, risk for • Growth, risk for disproportionate • Injury, risk for • Health-Seeking Behaviors (specify) • Injury, risk for perioperative positioning • Knowledge, deficient (specify) • Mobility, impaired physical • Knowledge (specify), readiness for enhanced • Poisoning, risk for • Noncompliance [Adherence, ineffective] [specify] • Protection, ineffective • Therapeutic Regimen Management, effective • Self-Mutilation • Therapeutic Regimen Management, ineffective commu- • Self-Mutilation, risk for nity • Skin Integrity, impaired • Therapeutic Regimen Management, ineffective family • Skin Integrity, risk for impaired • Therapeutic Regimen Management, ineffective 21
    • Copyright © 2006 by F. A. Davis. Client Situation: Diabetes Mellitus Mr. R.S., a type 2 diabetic (formerly a non–insulin-dependent diabetic, or NIDDM) for 10 years, presented to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left foot. Screening studies done during the exam revealed blood glucose (BG) of 356/fingerstick and urine Chemstix of 2%. Because of distance from medical provider and lack of local community services, he is admitted to the hospital. Admitting Physician’s Orders Culture/sensitivity and Gram’s stain of foot ulcer Random blood glucose on admission and fingerstick BG qid CBC, electrolytes, serum lipid profile, glycosylated Hb in AM Chest x-ray and ECG in AM DiaBeta 10 mg, PO, bid Glucophage 500 mg, PO, daily to start—will increase gradually Humulin N 10 U SC q AM and hs. Begin insulin instruction for postdischarge self-care, if necessary Dicloxacillin 500 mg PO, q6h, start after culture obtained Darvocet-N 100 mg q4h PRN pain Diet—2400 calories/three meals with two snacks Up in chair ad lib with feet elevated Foot cradle for bed Irrigate lesion L foot with normal saline tid then apply wet to dry sterile dressing Vital signs qid Client Assessment Database Name: R.S. Informant: Client Reliability (scale 1–4): 3, Age: 73 DOB: 5/3/31 Race: White Gender: M Admission date: 6/28/2004 Time: 7 PM From: Home ACTIVITY/REST Reports (Subjective): Occupation: Farmer Usual activities/hobbies: Reading, playing cards. “Don’t have time to do much. Anyway I’m too tired most of the time to do anything after the chores.” Limitations imposed by illness: “Have to watch what I order if I eat out.” Sleep: Hours: 6–8 hr/night Naps: No Aids: No Insomnia: “Not unless I drink coffee after supper.” Usually feels rested when awakens at 4:30 AM Exhibits (Objective): Observed response to activity: Limps, favors L foot when walking Mental status: Alert/active Neuromuscular assessment: Muscle mass/tone: bilaterally equal/firm Posture: Erect ROM: normal all extremities Strength: Equal 3 extremities/favors L leg currently CIRCULATION Reports (Subjective): Slow healing: lesion L foot, 3 weeks’ duration Extremities: Numbness/tingling: “My feet feel cold and tingly like sharp pins poking the bottom of my feet when I walk the quarter mile to the mailbox.” Cough/character of sputum: Occasional/white Change in frequency/amount of urine: Yes, voiding more lately Exhibits (Objective): Peripheral pulses: Radials 3 ; popliteal, dorsalis, posttibial/pedal, all 1 BP: R: Lying: 146/90 Sitting: 140/86 Standing: 138/90 L: Lying: 142/88 Sitting: 138/88 Standing: 138/84 Pulse: Apical: 86 Radial: 86 Quality: Strong Rhythm: Regular Chest auscultation: Few wheezes clear with cough, no murmurs/rubs JVD: -0- Extremities: Temperature: Feet cool bilat/legs warm Color: Skin: Legs pale Capillary refill: Slow both feet (approx 5 sec) Figure 3–2. Client situation: Diabetes Mellitus. 22
    • Copyright © 2006 by F. A. Davis. Homans’ sign: -0- Varicosities: Few enlarged superficial veins both calves CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE Nails: Toenails thickened, yellow, brittle Distribution and quality of hair: Coarse hair to midcalf, none on ankles/toes Color: General: Ruddy face/arms Mucous membranes/lips: Pink Nail beds: Fingers blanch well Conjunctiva and sclera: White EGO INTEGRITY Reports (Subjective): Stress factors: “Normal farmer’s problems: weather, pests, bankers, and so on.” Ways of handling stress: “I get busy with the chores and talk things over with my livestock; they listen pretty good.” Financial concerns: No supplemental insurance; needs to hire someone to do chores while in hospital Relationship status: Married—45 years Cultural factors: Rural/agrarian, Eastern European descent, “American,” no ethnic ties Religion: Protestant/practicing Lifestyle: Middle class/self-sufficient farmer Recent changes: -0- Feelings: “I’m in control of most things, except the weather and this diabetes.” Concerned regarding possible therapy “change from pills to shots” Exhibits (Objective): Emotional status: Generally calm; appears frustrated at times Observed physiologic response(s): Occasionally sighs deeply/frowns, fidgeting with coin, shoulders tense, shrugs shoulders/throws up hands ELIMINATION Reports (Subjective): Usual bowel pattern: Almost every PM Last bowel movement: Last night Character of stool: Firm/brown Bleeding: -0- Hemorrhoids: -0- Constipation: Occasional Laxative used: Hot prune juice as needed Urinary: No problems Character of urine: Pale yellow Exhibits (Objective): Abdomen tender: No Soft/Firm: Soft Palpable mass: -0- Bowel sounds: Active all 4 quads FOOD/FLUID Reports (Subjective): Usual diet (type): 2400 calories (occasionally “cheats” with dessert; “My wife watches it pretty closely.”) Number of meals daily: 3/1 snack Dietary Pattern: Breakfast: Fruit juice, toast, ham, decaf coffee Lunch: Meat, potatoes, vegetables, fruit, milk Dinner: Meat sandwich, soup, fruit, decaf coffee Snack: Milk/crackers at hs. Usual beverage: Skim milk, 2–3 cups decaf coffee. Drinks “a lot of water”—several qt Last meal/intake: Dinner: Hot roast beef sandwich, vegetable soup, pear with cheese, decaf coffee Loss of appetite: “Never, but lately I don’t feel as hungry as usual.” Nausea/vomiting: -0- Food allergies: None Heartburn/food intolerance: Cabbage causes gas, coffee after supper causes heart- burn Mastication/swallowing problems: -0- Dentures: Partial upper plate fits OK Usual weight: 175 lb Recent changes: Has lost about 5 lb this month Diuretic therapy: No Exhibits (Objective): Wt: 171 lb Ht: 5 ft 10 in Build: Stocky Skin turgor: Good/leathery Appearance of tongue: Midline, pink Mucous membranes: Pink, intact Condition of teeth/gums: Good; no irritation/bleeding noted Breath sounds: Few wheezes cleared with cough Bowel sounds: Active all 4 quads Urine Chemstix: 2% Fingerstick: 356 (Dr. office) Random BG drawn on admission 450 HYGIENE Reports (Subjective): Activities of daily living: Independent in all areas Preferred time of bath: PM Figure 3–2. (Continued) 23
    • Copyright © 2006 by F. A. Davis. Exhibits (Objective): General appearance: Clean, shaven, short-cut hair, hands rough and dry, skin on feet dry, cracked, and scaly Scalp and eyebrows: Scaly white patches Body odor: -0- NEUROSENSORY Reports (Subjective): Headaches: “Occasionally behind my eyes when I worry too much.” Tingling/Numbness: Feet, once or twice a week (as noted) Eyes: Vision loss, farsighted, “seems a little blurry now.” Examination: 2 years ago Ears: Hearing loss: R: “Some.” L: No (has not been tested) Nose: Epistaxis: -0-. Sense of smell: “No problems” Exhibits (Objective): Mental status: Alert, oriented to time, place, person, situation Affect: Concerned Memory: Remote/recent: clear and intact Speech: Clear, coherent, appropriate Pupil reaction: PERLA/small Glasses: Reading Hearing aid: No Handgrip/release: Strong/equal PAIN/DISCOMFORT Reports (Subjective): Primary focus: L foot Location: Medial aspect, heel of L foot Intensity (0–10): 4–5/10 Quality: Dull ache with occasional sharp stabbing sensation Frequency/duration: “Seems like all the time” Radiation: No Precipitating factors: Shoes, walking How relieved: ASA, not helping Additional complaints: Sometimes has back pain following chores/heavy lifting Relieved by: ASA/liniment rubdown Exhibits (Objective): Facial grimacing: When lesion border palpated Guarding affected area: Pulls foot away Narrowed focus: -0- Emotional response: Tense, irritated RESPIRATORY Reports (Subjective): Dyspnea: -0- Cough: Occasional morning cough, white sputum Emphysema: -0- Bronchitis: -0- Asthma: -0- Tuberculosis: -0- Smoker: Filters Packs/day: 1/2 Number of pack years: 25 Use of respiratory aids: -0- Exhibits (Objective): Respiratory rate: 22 Depth: Good Symmetry: Equal, bilateral Auscultation: Few wheezes, clear with cough Cyanosis: -0- Clubbing of fingers: -0- Sputum characteristics: None to observe Mentation/restlessness: Alert/oriented/fairly relaxed SAFETY Reports (Subjective): Allergies: -0- Blood transfusions: -0- Sexually transmitted disease: -0- Fractures/dislocations: L clavicle, 1966, fell getting off tractor Arthritis/unstable joints: “Think I’ve got some arthritis in my knees.” Back problems: Occasional lower back pain Vision impaired: Requires glasses for reading Hearing impaired: Slightly (R), compensates by turning “good ear” toward speaker Exhibits (Objective): Temperature: 99.4 F (37.4 C) tympanic Skin integrity: Impaired L foot Scars: R Ing, surgical Rashes: -0- Bruises: -0- Lacerations: -0- Blisters: -0- Ulcerations: Medial aspect L heel, 2.5 cm diameter, approximately 3 mm deep, draining small amount cream colored/pink-tinged matter, no odor noted Strength (general): Equal 3 extremities/favors L leg Muscle tone: Firm ROM: Good. Gait: Favors L foot Paresthesia/Paralysis: -0- SEXUALITY: MALE Reports (Subjective): Sexually active: Yes Use of condoms: No (monogamous) Recent changes in frequency/interest: “I’ve been too tired lately.” Penile discharge: -0- Prostate disorder: -0- Vasectomy: -0- Last proctoscopic examination: 2 years ago Prostate examination: 1 year ago Practice self-examination: Breast/testicles: No Problems/complaints: “I don’t have any problems, but you’d have to ask my wife if there are any complaints.” Figure 3–2. (Continued) 24
    • Copyright © 2006 by F. A. Davis. Exhibits (Objective): CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE Examination: Breast: No masses Testicles: Deferred Prostate: Deferred SOCIAL INTERACTIONS Reports (Subjective): Marital status: Married, 48 years Living with: Wife Report of problems: -0- Extended family: 1 daughter lives in town (30 miles away); 1 daughter married/grandson, living out of state Other: Several couples; he and wife play cards/socialize 2 or 3 times a month Role: Works farm alone; husband/father/grandfather Report of problems related to illness/condition: None until now Coping behaviors: “My wife and I have always talked things out. You know the eleventh commandment is ‘Thou shalt not go to bed angry.”’ Exhibits (Objective): Speech: Clear, intelligible Verbal/nonverbal communication with family/SO(s): Speaks quietly with wife, look- ing her in the eye; relaxed posture Family interaction patterns: Wife sitting at bedside, relaxed, both reading paper, mak- ing occasional comments to each other TEACHING/LEARNING Reports (Subjective): Dominant language: English Second language: -0- Literate: Yes Education level: 2 years of college Health and illness beliefs/practices/customs: “I take care of the minor problems and only see the doctor when something’s broken.” Advance Directives: in chart Familial risk factors/relationship: Diabetes: Maternal uncle Tuberculosis: Brother died age 27 Heart Disease: Father died age 78, heart attack Strokes: Mother died age 81 High BP: Mother Prescribed medications: Drug Dose Schedule Last dose Purpose DiaBeta 10 mg bid 8 AM/6 PM 6 PM today Control diabetes Take medications regularly: Yes Home urine/glucose monitoring: “Stopped several months ago when I ran out of Tes- Tape. It was always negative anyway.” Nonprescription (OTC) drugs: Occasionally ASA Use of alcohol (amount/frequency): Socially, occasional beer Tobacco: Smokes 1/2 pack/day Admitting diagnosis (physician): Hyperglycemia with nonhealing lesion L foot Reason for hospitalization (client): “Sore on foot, and the doctor is concerned about my blood sugar and says I’m supposed to learn this fingerstick test now.” History of current complaint: “Three weeks ago, I got a blister on my foot from break- ing in my new boots. It got sore so I lanced it, but it isn’t getting any better.” Client’s expectations of this hospitalization: “Clear up this infection and control my diabetes.” Other relevant illness and/or previous hospitalizations/surgeries: 1969, R inguinal hernia repair Evidence of failure to improve: Lesion L foot, 3 weeks Last physical examination: Complete 1 year ago, office follow-up 3 months ago Discharge Anticipated discharge: 7/1/04 (3 days) Considerations Resources: Person: Self, wife Financial: “If this doesn’t take too long to heal, we got (as of 6/28): some savings to cover things.” Community supports: Diabetic support group (has not participated) Anticipated lifestyle changes: Become more involved in management of condition Assistance needed: May require farm help for several days Teaching: Learn new medication regimen, glucose monitoring, and wound care; review diet; encourage smoking cessation Referrals: Supplies: Downtown Pharmacy or AARP Equipment: Glucometer—AARP Follow-up: Primary care provider 1 wk after discharge to evaluate wound healing and potential need for additional changes in diabetic regimen 25
    • Copyright © 2006 by F. A. Davis. Another way to conceptualize the client’s care needs is to EVALUATION create a Mind Map (Figure 3–3). This new technique or learn- ing tool has been developed to help visualize the linkages or As nursing care is provided, ongoing assessment evaluates interconnections between various client symptoms, inter- the client’s response to therapy and progress toward accom- ventions, or problems as they impact each other. The parts plishing the desired outcomes. This activity serves as the that are great about traditional care plans (problem solving feedback and control part of the nursing process through and categorizing) are retained but the linear/columnar which the status of the individual client diagnostic statement nature of the plan is changed to a design that uses the whole is judged to be resolved, continuing, or requiring revision. brain—a design that brings left-brained, linear problem- This process is visualized in Figure 3–4. Observation of solving thinking together with the free-wheeling, intercon- Mr. R.S.’s wound reveals that edges are clean and pink and nected, creative right brain. Joining mind mapping and care drainage is scant. Therefore, he is progressing toward planning enables the nurse to create a holistic view of a achieving wound healing, and this problem will continue to client, strengthening critical thinking skills, and facilitating be addressed, although no revision in the treatment plan is the creative process of planning client care. required at this time. Mind mapping starts in the center of the page with a rep- resentation of the main concept—the client. (This helps keep in mind that the client is the focus of the plan, not the med- DOCUMENTATION ical diagnosis or condition.) From that central thought, other main ideas that relate to the client radiate out from the cen- To date, a number of charting formats are being used for doc- ter similar to spokes of a wheel (however, they do not have umentation. These include block notes, with a single entry to be added in a balanced manner; it does not have to be a covering an entire shift (e.g., 7–3 PM); narrative timed notes round “wheel”). Different concepts can be grouped together (e.g., 8:30 AM, ate all of breakfast); the problem-oriented by geometric shapes, color coding, or by placement on the medical record system (POMR or PORS) using the page. Connections and interconnections between groups of SOAP/SOAPIER approach; and the use of flow sheets with ideas are represented by the use of arrows or lines with charting by exception, to name a few. The POMR can pro- defining phrases added that explain how the interconnected vide thorough documentation, but it was designed by physi- thoughts relate to one another. In this manner, many differ- cians for episodic care and requires that the entries be tied to ent pieces of information about the client can be connected a problem identified from a problem list. directly to the client. A charting system format created by nurses for documen- tation of frequent/repetitive care is Focus Charting®. It was designed to encourage looking at the client from a positive INCREASES rather than a negative (or problem-oriented) perspective by using precise documentation to record the nursing process. Recording of assessment, interventions, and evaluation information in data, action, and response (DAR) categories facilitates tracking and following what is happening to the client at any given moment. Charting focuses on client and nursing concerns, with the focal point being client status and the associated nursing care. The focus is always stated in a way that reflects the client’s concern/need rather than a nursing task or medical diagnosis. Thus, the focus can be a client problem/concern or nursing diagnosis, signs/symp- Whichever piece is chosen becomes the first layer of con- toms of potential importance (e.g., fever, dysrhythmia, nections—clustered assessment data, nursing diagnoses, or edema), a significant event or change in status, or a specific outcomes. For example, a map could start with nursing diag- standard of care/hospital policy. An expansion of this for- noses featured as the first “branches,” each one being listed mat is DATRP—data, action, teaching, response, plan. separately in some way on the map. Next, the signs and A more recent way to evaluate and document the client’s symptoms or data supporting the diagnoses could be added. progress (response to care) is through the use of clinical Or the plan could begin with the client outcomes to be pathways. These were originally developed as tools for pro- achieved with connections then to nursing diagnoses. When viding care in case management systems and are now used the plan is completed, there should be a nursing diagnosis in many settings. A clinical pathway is a type of abbreviated (supported by subjective and objective assessment data), plan of care that is event oriented (task oriented) and pro- nursing interventions, desired client outcome(s), and any vides outcome-based guidelines for goal achievement within evaluation data, all connected in a manner that shows there a designated length of stay. The pathway incorporates is a relationship between them. It is critical to understand agency and professional standards of care and may be inter- that there is no preset order for the pieces because one clus- disciplinary, depending on the care setting. As a rule, how- ter is not more or less important than another (or one is not ever, the standardized clinical pathways address a specific “subsumed” under another). It is important, however, that diagnosis/condition or procedure (e.g., myocardial infarc- those pieces within a branch be in the same order in each tion, total hip replacement, chemotherapy) and do not branch. provide for inclusion of secondary diagnoses or complica- Finally, to complete the learning experience, we present tions (e.g., asthmatic client in alcohol withdrawal). In short, samples of the evaluation step based on the client situation. if the client does not achieve the daily outcomes or goals of 26
    • Copyright © 2006 by F. A. Davis. care, the variance is identified, and a separate plan of care for students who are working to practice the nursing CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE must be developed to meet the client’s individual needs. process, critical thinking, and a holistic approach to meeting Therefore, although clinical pathways are becoming more client needs. A sample clinical pathway (Figure 3–5) reflects common in the clinical setting, they have limited value (in Mr. R.S.’s primary diagnostic problem: nonhealing lesion, place of more individualized plans of care) as learning tools diabetic. PLAN OF CARE: Mr. R.S. CLIENT DIAGNOSTIC STATEMENT: impaired Skin Integrity related to pressure, altered metabolic state, circulatory impairment, and decreased sensation, as evidenced by draining wound L foot. Image/textBlood Glucose Control (NOC) Indicators: OUTCOME: rights unavailable. CLIENT WILL: Demonstrate correction of metabolic state as evidenced by FBS less than 120 mg/dL within 36 hours (6/30 0700). Image/textHealing: Secondary Intention (NOC) OUTCOME: Wound Indicators: rights unavailable. CLIENT WILL: Be free of purulent drainage within 48 hours (6/30 1900). Display signs of healing with wound edges clean/pink within 60 hours (7/1 0700). ACTIONS/INTERVENTIONS RATIONALE Image/text Care (NIC) Wound rights unavailable. Irrigate wound with room-temperature sterile NS tid. Cleans wound without harming delicate tissues. Assess wound with each dressing change. Provides information about effectiveness of therapy, and Obtain wound tracing on admission and at discharge. identifies additional needs. Apply wet to dry sterile dressing. Use paper tape. Keeps wound clean/minimizes cross-contamination. Adhesive tape may be abrasive to fragile tissues. Infection Control (NIC) Image/text rights unavailable. Follow wound precautions. Use of gloves and proper handling of contaminated dress- ings reduces likelihood of spread of infection. Obtain sterile specimen of wound drainage on admission Culture/sensitivity identifies pathogens and therapy of for laboratory analysis. choice. Administer dicloxacillin 500 mg PO q6h, starting 10 PM. Treatment of infection/prevention of complications. Food Observe for signs of hypersensitivity: pruritus, urticaria, interferes with drug absorption, requiring scheduling rash. around meals. Although no prior history of penicillin reaction, it may occur at any time. Administer antidiabetic medications: 10 U Humulin N Treats underlying metabolic dysfunction, reducing hyper- insulin SC q AM/hs after fingerstick BG; DiaBeta 10 mg glycemia and promoting healing. Glucophage lowers PO bid; Glucophage 500 mg PO daily. Note onset of side serum glucose levels by improving insulin sensitivity, effects. increasing glucose utilization in the muscles. By using in conjunction with DiaBeta, client may be able to discontinue insulin once target dosage is achieved (e.g., 2000 mg/day). Increase of 1 tablet per week is necessary to limit side effects of diarrhea, abdominal cramping, vomiting, possibly leading to dehydration and prerenal azotemia. (Continued on following page) 27
    • Copyright © 2006 by F. A. Davis. CLIENT DIAGNOSTIC STATEMENT: acute Pain related to physical agent (wound L foot) evidenced by verbal report of pain and guarding behavior. Image/textPain Self-Control (NOC) Indicators: OUTCOMES: rights unavailable. CLIENT WILL: Report pain is minimized/relieved within 1 hour of analgesic administration (ongoing). Report absence or control of pain by discharge (7/1). OUTCOME: Pain Disruptive Effects (NOC) Indicators: Image/text rights unavailable. Ambulate normally, full weight bearing by discharge (7/1). ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Image/text rights unavailable. Determine pain characteristics through client’s description. Establishes baseline for assessing improvement/changes. Place foot cradle on bed/encourage use of loose-fitting Avoids direct pressure to area of injury, which could slipper, when up. result in vasoconstriction/increased pain. Administer Darvocet-N 100 mg PO q4h as needed. Provides relief of persistent pain unrelieved by other Document effectiveness. measures. CLIENT DIAGNOSTIC STATEMENT: ineffective peripheral Tissue Perfusion related to decreased arterial flow as evidenced by decreased pulses, pale/cool feet, thick brittle nails, numbness/tingling of feet “when walks 1/4 mile.” Image/text rights unavailable. (NOC) Indicators: OUTCOMES: Knowledge: Diabetes Management CLIENT WILL: Verbalize understanding of relationship between chronic disease (diabetes mellitus) and circulatory changes within 48 hours (6/30 1900). Demonstrate awareness of safety factors/proper foot care within 48 hours (6/30 1900). Maintain adequate level of hydration to maximize perfusion (ongoing), as evidenced by balanced intake/output, moist skin/mucous membranes, capillary refill less than 4 sec (ongoing). ACTIONS/INTERVENTIONS RATIONALE Image/text rights unavailable. (NIC) CIRCULATORY CARE: Arterial Insufficiency Elevate feet when up in chair. Avoid long periods with Minimizes interruption of blood flow, reduces venous feet in dependent position. pooling. Assess for signs of dehydration. Monitor intake/output. Glycosuria may result in dehydration with consequent Encourage oral fluids. reduction of circulating volume and further impairment of peripheral circulation. Recommend cessation of smoking. Vascular constriction associated with smoking and dia- betes impairs peripheral circulation. (Continued on following page) 28
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE Instruct client to avoid constricting clothing/socks and ill- Compromised circulation and decreased pain sensation fitting shoes. may precipitate or aggravate tissue breakdown. Reinforce safety precautions regarding use of heating Heat increases metabolic demands on compromised tis- pads, hot water bottles/soaks. sues. Vascular insufficiency alters pain sensation, increas- ing risk of injury. Discuss complications of disease that result from vascular Although proper control of diabetes mellitus may not pre- changes: ulceration, gangrene, muscle or bony structure vent complications, severity of effects may be minimized. changes. Diabetic foot complications are the leading cause of non- traumatic lower extremity amputations. Note: Skin dry, cracked, scaly; feet cool, pain when walking a distance suggest mild to medium vascular disease (autonomic neu- ropathy) that can limit response to infection, impair wound healing, and increase risk of bony deformities. Review proper foot care as outlined in teaching plan. Altered perfusion of lower extremities may led to seri- ous/persistent complications at the cellular level. CLIENT DIAGNOSTIC STATEMENT: Learning Need regarding diabetic condition, related to misinterpretation of informa- tion and/or lack of recall as evidenced by inaccurate follow-through of instructions regarding home glucose monitoring and foot care and failure to recognize signs/ symptoms of hyperglycemia. Image/text rights unavailable. (NOC) Indicators: OUTCOMES: Knowledge: Diabetes Management CLIENT WILL: Perform procedure of home glucose monitoring correctly within 36 hours (6/30 0700). Verbalize basic understanding of disease process and treatment within 38 hours (6/30 0900). Explain reasons for actions within 38 hours (6/30 0900). Perform insulin administration correctly within 60 hours (7/1 0700). ACTIONS/INTERVENTIONS RATIONALE Image/text Disease Process (NIC) TEACHING: rights unavailable. Determine client’s level of knowledge, priorities of learn- Establishes baseline and direction for teaching/planning. ing needs, desire/need for including wife in instruction. Involvement of wife, if desired, will provide additional resource for recall/understanding and may enhance client’s follow-through. Provide teaching guide, Understanding Your Diabetes, 6/28 Provides different methods for accessing/reinforcing infor- PM. Show film Living with Diabetes, 6/29, 4 PM when wife mation, and enhances opportunity for learning/under- is visiting. Include in group teaching session 6/30 AM. standing. Review information and obtain feedback from client and wife. Discuss factors related to/altering diabetic control, such Drug therapy/diet may need to be altered in response to as stress, illness, exercise. both short- and long-term stressors, changes in activity level. Review signs/symptoms of hyperglycemia (e.g., fatigue, Recognition/understanding of these signs/symptoms and nausea/vomiting, polyuria/polydipsia). Discuss how to timely intervention will aid client in avoiding recurrences prevent and evaluate this situation and when to seek med- and preventing complications. ical care. Have client identify appropriate interventions. (Continued on following page) 29
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE Review and provide information about necessity for rou- Reduces risk of tissue injury, promotes understanding and tine examination of feet and proper foot care (e.g., daily prevention of stasis ulcer formation and wound healing inspection for injuries, pressure areas, corns, calluses; difficulties. proper nail cutting; daily washing, application of good moisturizing lotion such as Eucerin, Keri, or Nivea bid). Recommend loose-fitting socks, shoes that fit (break new shoes in gradually), and not going barefoot. If foot injury/skin break occurs, wash with soap/dermal cleanser and water, cover with sterile dressing, inspect wound, and change dressing daily; report redness, swelling, or presence of drainage. Image/text rights Medication (NIC) TEACHING: Prescribed unavailable. Instruct regarding prescribed insulin therapy: May be a temporary treatment of hyperglycemia with infection or may be permanent replacement of oral hypo- glycemic agent. Humulin N insulin, SC. Intermediate-acting insulin generally lasts 18–28 hr, with peak effect 6–12 hr. Keep vial in current use at room. temperature (if used Cold insulin is poorly absorbed. within 30 days). Store extra vials in refrigerator. Refrigeration prolongs the drug shelf life by prevent- ing wide fluctuations in temperature. Roll bottle and invert to mix, or shake gently, avoid- Vigorous shaking may create foam, which can inter- ing bubbles. fere with accurate dose withdrawal and damage the insulin molecule. Note: New research suggests that shaking the vial may be more effective in mixing suspension. Choice of injection sites (e.g., across lower abdomen Provides for steady absorption of medication. Site is in Z pattern). easily visualized and accessible by client; and Z pat- tern minimizes tissue damage. Demonstrate, then observe client in drawing insulin into May require several instruction sessions and practice syringe, reading syringe markings, and administering before client and wife feel comfortable drawing up and dose. Assess for accuracy. injecting medication. Instruct in signs/symptoms of insulin reaction/ hypo- Knowing what to watch for and appropriate treatment glycemia: fatigue, nausea, headache, hunger, sweating, (such as 12 cup grape juice for immediate response and / irritability, shakiness, anxiety, difficulty concentrating. snack within 1 2 hr; e.g., 1 slice bread with peanut butter or / cheese, fruit and slice of cheese for sustained effect) may prevent or minimize complications. Review “sick day rules,” e.g., call doctor if too sick to eat Understanding of necessary actions in the event of normally/stay active; take insulin as ordered. Keep record mild/severe illness promotes competent self-care and as noted in Sick Day Guide. reduces risk of hyperglycemia or hypoglycemia. Instruct client/wife in fingerstick glucose monitoring to Fingerstick monitoring provides accurate and timely be done 4 /day until stable, then bid at rotating times, information regarding diabetic status. Return demonstra- such as FBS and before dinner; before lunch, and hs. tion verifies correct learning. Observe return demonstrations of the procedure. Recommend client maintain record/log of fingerstick test- Provides accurate record for review by caregivers for ing, antidiabetic medication and insulin dosage/site, assessment of therapy effectiveness/needs. unusual physiological response, dietary intake. Outline desired goals; e.g., FBS 80–110, premeal 80–120. Schedule consultation with dietitian to restructure meal Calories are unchanged on new orders but have been plan and evaluate food choices. redistributed to three meals and two snacks. Dietary choices (e.g., increased vitamin C) may enhance healing. Discuss other healthcare issues, such as smoking habits, Encourages client involvement, awareness, and responsi- self-monitoring for cancer (breasts/testicles), and report- bility for own health; promotes wellness. Note: Smoking ing changes in general well-being. tends to increase client’s resistance to insulin. 30
    • Copyright © 2006 by F. A. Davis. CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE o airs healing ds t lea imp ND: deficient Knowledge of self-care Blood sugar 450 ND: impaired Skin Integrity -review disease process thirst/wt loss -wound care -BS monitoring -dressing change -insulin administration -infection precautions -s/s hyper/hypoglycemia -Dicloxacillin tion -dietary needs -Humulin N lica -foot care -Glucophage mp Co RS Perform Self-admin Understand FBS < 120 Wound No drainage/ DM RFS insulin DM & clean/pink erythema treatment Type 2 pulses ND: acute Pain numbness & tingling -foot cradle -Darvocet N es caus ND: impaired peripheral Tissue Perfusion -feet up in chair Pain free Full wt. bearing - fluids/I&O -safety precautions r isk -foot inspection for Pressure Maintain Understand Circulatory ulcer hydration DM changes Figure 3–3. Mind map for Mr. R.S. 31
    • Copyright © 2006 by F. A. Davis. Does R.S.display signs of wound healing (e.g., lesion has decreased in width NO YES and/or depth: lesion has decreased drainage: wound edges are clean/pink)? Record data, e.g., lesion has decreased in depth to 2 mm, and in width to 2 Reassess using initial cm. Has no drainage. assessment factors. Record RESOLVED (may wish to use CONTINUE until lesion has com- pletely healed). Is diagnonsis validated? NO Record new assessment data. Record REVISED. Did evaluation show Enter new diagnosis, objec- YES a new problem had tives, target date, and arisen? YES orders. Delete unvalidated diagnosis. NO Record data, e.g., lesion has increased in depth to 4 mm and in width to 3 cm. Drainage increased from Start new approximately the size of a evaluation dime to a 50-cent piece on process. dressing. Record CONTINUE and change target date. Alter FINISHED nursing orders as necessary. FIGURE 3–4. Outcome-based evaluation of the client’s response to therapy. (Adapted from Cox, HC, et al: Clinical Applications of Nursing Diagnosis, ed. 3. FA Davis, Philadelphia, 1996.) 32
    • Copyright © 2006 by F. A. Davis. CP: Non-healing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes ND and Categories of Care Adm Day 6/28 7pm Day 1 6/29 Day 2 6/30 Day 3 7/1 Discharge Impaired skin/ Actions: Goals: Actions: Goals: Actions: Goals: Actions: Goals: tissue integrity Verbalize under- Be free of signs of dehydration Wound edges show signs standing of Wound free of purulent drainage of healing process condition Verbalize understanding of treat- Perform self-care task: Display blood glu- ment need No. 2 correctly cose WNL (ongoing) Perform self-care tasks No. 1 & Explain reason for actions 3 correctly Plan in place to meet Referrals Dietician & determine need for: Explain reasons for actions discharge needs Home care Physical therapy Visiting nurse Diagnostic studies Wound culture/sensitivity CBC, electrolytes Gram’s stain Glycosylated Hb Serum lipid Random blood glucose profile Fingerstick BG hs → Fingerstick BG qid → Fingerstick BG bid if stable Chest x-ray (if indicated) ECG (if indicated) Additional VS qid → → VS each shift → assessments I&O/level of hydration qd → → →D/C Character of wound tid → → → Level of knowledge and prior- ities of learning needs Observe for signs of antibiotic Anticipated discharge needs hypersensitivity reaction Medications Antibiotic: Dicloxacillin Antibiotic: same Antibiotic: same Antibiotic: same 500 mg PO q6h Antidiabetic: Humulin N Antidiabetic: Humulin N insulin Antidiabetic: same Antidiabetic: same insulin 0 units 10 U SC q AM/hs SC hs DiaBeta 10 mg PO bid Glucophage 500 mg PO qd Client education Provide: Understanding Your Film Living with Diabetes Diabetes Demonstrate and practice self-care Group sessions: Practice self-care activities 2: insulin activities: Diabetic management administration 1. Fingerstick BG Review discharge instructions 2. Insulin administration 3. Wound care 4. Routine foot care Additional nursing Up ad lib → → → actions NS soaks/dressing change tid → → → Goals: Figure 3–5. Sample clinical pathway. 33 (Continued on following page) CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
    • Copyright © 2006 by F. A. Davis. 34 CP: Non-healing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes (Continued) ND and Categories of Care Adm Day 6/28 7pm Day 1 6/29 Day 2 6/30 Day 3 7/1 Discharge Acute Pain Actions: State pain relieved Actions: Goals: Actions: Goals: Actions: Goals: or minimized Verbalize under- Able to participate State pain-free/ with 1 hr of anal- standing of self- in usual level: controlled with gesic administra- care measure ambulate full medication tion (ongoing) No. 3 weight bearing Verbalize under- Verbalize under- Explain reason for standing of standing of when actions correct medica- to report pain and tion use rating scale used Verbalize under- standing of self- care measures No. 1–2 Explain reason for actions Additional Characteristics of pain → → → assessments Level of participation activities → → → Individual analgesic needs → → → Medications Analgesic: Darvocet-N 100 mg Analgesic: same Analgesic: same Analgesic: same Allergies: -0- PO q4h PRN Client education Orient to unit/room Safety/comfort measures 3 Review discharge medication Guidelines for self-report prevention of injury instructions: dosage, route, of pain and rating scale 0–10 frequency, side effects Safety/comfort measures: 1 elevation of feet 2 proper footwear Additional Bed cradle as indicated nursing actions
    • Copyright © 2006 by F. A. Davis. 4 C H A P T E R Cardiovascular HYPERTENSION: SEVERE Hypertension was previously defined as blood pressure greater than 140/90 mm Hg by the 1992 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure and was classified in stages, according the the degree of sever- ity. In 2003, new guidelines were issued by the National Heart, Lung, and Blood Institute (NHLBI) that include a lower “nor- mal blood pressure,” a “prehypertension” level, and a merging of staging categories. Normal blood pressure is now defined as measurements less than 120/80 mm Hg and prehypertension as 120–139/80–89 mm Hg. Hypertension is defined as pressure greater than 140/90 mm Hg; and is classified according to the degree of sever- ity. Stage I (mild) is 140/90–159/99. Stage II (moderate) is 160/100 or greater. Stage III (severe) is present when systolic pres- sure is greater than 180 and diastolic pressure is greater than 110. Stage IV (very severe) occurs when systolic pressure is 210 or greater with diastolic pressure greater than 120. Stages II and III hypertension have essentially been combined in the new guidelines, as their treatment is the same. Hypertension is also categorized according to etiology: as primary/essential (approximately 95% of all cases), when it has no identifiable cause; or secondary, which occurs as a result of an identifiable, sometimes correctable, pathologic condition (e.g., kidney disorders, use of medications, drugs or other chemicals, adrenal gland tumors, or primary aldosteronism). Hypertension increases with age and is one of the major risk factors in the development of cardiovascular disease. Current research has demonstrated that the systolic blood pressure is a more important determinant of cardiovascular risk in people over 50 years of age; however, in clients under 50 years old, the diastolic blood pressure is the major predictor. Blood pressure in the “prehypertension” range responds well to lifestyle changes (e.g., weight management and exer- cise), and is not usually treated with medications unless other risk factors are present, such as diabetes or heart disease. However, recent studies indicate that persons with prehypertension are at high risk for developing hypertension and death from heart diease and stroke. The goal of treatment is to prevent the long-term sequelae of the disease (i.e., target organ disease [TOD]). Although the elderly are most prone to this disorder and its sequelae, it is a growing health problem across many cultures, and is demon- strated in youger people in multiple populations. CARE SETTING Although hypertension is usually treated in a community setting, management of stages III and IV with symptoms of com- plications/compromise may require inpatient care, especially when TOD is present. The majority of interventions included here can be used in either setting. RELATED CONCERNS Cerebrovascular accident/stroke, page 236 Myocardial infarction, page 72 Psychosocial aspects of care, page 770 Renal failure: acute, page 541 Renal failure: chronic, page 553 Client Assessment Database ACTIVITY/REST May report: Weakness, fatigue, shortness of breath Sedentary lifestyle (major risk factor) May exhibit: Elevated heart rate Change in heart rhythm Tachypnea; shortness of breath with exertion 35
    • Copyright © 2006 by F. A. Davis. CIRCULATION May report: History of intermittent or sustained elevation of diastolic or systolic blood pressure; presence of atherosclerotic, valvular, or coronary artery heart disease (including myo- cardial infarction [MI], angina, heart failure [HF]) and cerebrovascular disease (reflecting TOD) Episodes of palpitations, diaphoresis May exhibit: Elevated blood pressure (BP) (serial elevated measurements are necessary to confirm diagno- sis) Note: Postural hypotension, when present, may be related to drug regimen or reflect dehydra- tion or reduced ventricular function. Pulse: Bounding carotid, jugular, radial pulsations; pulse disparities (e.g., femoral delay as compared with radial or brachial pulsation); absence of/diminished popliteal, posterior tibial, pedal pulses Apical pulse: Point of maximal impulse (PMI) possibly displaced and/or forceful Rate/rhythm: Tachycardia, various dysrhythmias Heart sounds: Accentuated S2 at base; S3 (early HF); S4 (rigid left ventricle/left ventricular hypertrophy) Murmurs of valvular stenosis Vascular bruits audible over carotid, femoral, or epigastrium (artery stenosis); jugular venous distension (JVD) (venous congestion) Extremities: discoloration of skin, cool temperature (peripheral vasoconstriction); capillary refill possibly slow/delayed (vasoconstriction) Skin: Pallor, cyanosis, and diaphoresis (congestion, hypoxemia); flushing (pheochromocytoma) EGO INTEGRITY May report: History of personality changes, anxiety, depression, euphoria, or chronic anger (may imdicate cerebral impairment) Multiple stress factors (relationship, financial, job related) May exhibit: Mood swings, restlessness, irritability, narrowed attention span, outbursts of crying Emphatic hand gestures, tense facial muscles (particularly around the eyes), quick physical movement, expiratory sighs, accelerated speech pattern ELIMINATION May report: Past or present renal insult (e.g., infection/obstruction or past history of kidney disease) FOOD/FLUID May report: Food preferences, which include high-salt, high-fat, high-cholesterol foods (e.g., fried foods, cheese, eggs); licorice; high caloric content; low dietary intake of potassium, calcium, and magnesium Nausea, vomiting Recent weight changes (gain/loss) Current/history of diuretic use May exhibit: Normal weight or obesity Presence of edema (may be generalized or dependent); venous congestion, JVD Glycosuria (almost 10% of hypertensive clients are diabetic, reflecting TOD) NEUROSENSORY May report: Fainting spells/dizziness Throbbing, suboccipital headaches (present on awakening and disappearing spontaneously after several hours) Episodes of numbness and/or weakness on one side of the body; brief periods of confusion or difficulty with speech (transient ischemic attack [TIA]); or history of cerebrovascular acci- dent (CVA) Visual disturbances (diplopia, blurred vision) Episodes of epistaxis May exhibit: Mental status: changes in alertness, orientation, speech pattern/content, affect, thought process, or memory Motor responses: decreased strength, hand grip, and/or deep tendon reflexes Optic retinal changes: from mild sclerosis/arterial narrowing to marked retinal and sclerotic changes with edema or papilledema, exudates, hemorrhages, and arterial nicking, dependent on severity/duration of hypertension (TOD) 36
    • Copyright © 2006 by F. A. Davis. PAIN/DISCOMFORT CARDIOVASCULAR: HYPERTENSION: Severe May report: Angina (coronary artery disease/cardiac involvement) Intermittent pain in legs/claudication (indicative of arteriosclerosis of lower extremity arteries) Severe occipital headaches as previously noted Abdominal pain/masses (pheochromocytoma) RESPIRATION (Generally associated with advanced cardiopulmonary effects of sustained/severe hyperten- sion) May report: Dyspnea associated with activity/exertion Tachypnea, orthopnea, paroxysmal nocturnal dyspnea Cough with/without sputum production Smoking history (major risk factor) May exhibit: Respiratory distress/use of accessory muscles Adventitious breath sounds (crackles/wheezes) Pallor or cyanosis SAFETY May report/exhibit: Impaired coordination/gait Transient episodes of numbness, unilateral paresthesias Light-headedness with position changes SEXUALITY May report: Postmenopausal (major risk factor) Erectile dysfunction (medication related) TEACHING/LEARNING May report: Familial risk factors: hypertension, atherosclerosis, heart disease, diabetes mellitus, cerebrovas- cular/kidney disease Ethnic/racial risk factors; e.g., more prevalent in African-American and southeast Asian popu- lations Use of birth control pills or other hormones; drug/alcohol use Use of herbal supplements to manage blood pressure (e.g. garlic, hawthorn, black cohash, cel- ery seed, coleus, evening primrose) Discharge plan Assistance with self-monitoring of blood pressure (BP) considerations: Periodic evaluation of and alterations in medication therapy Refer to section at end of plan for postdischarge considerations. DIAGNOSTIC STUDIES Hemoglobin/hematocrit: Not diagnostic but assesses relationship of cells to fluid volume (viscosity) and may indicate risk factors such as hypercoagulability, anemia. Blood urea nitrogen (BUN)/creatinine: Provides information about renal perfusion/function. Glucose: Hyperglycemia (diabetes mellitus is a precipitator of hypertension) may result from elevated catecholamine levels (increases hypertension), and/or use of thiazide diuretics. Serum potassium: Hypokalemia may indicate the presence of primary aldosteronism (cause) or be a side effect of diuretic therapy. Serum calcium and magnesium: Imbalances may contribute to hypertension. Lipid panel (total lipids, high-density lipoprotein [HDL], low-density lipoprotein [LDL], cholesterol, triglycerides, phos- pholipids [usually done by blood testing, however, a new test called PREVU measuring skin sterol may be used in some facilities]): Elevated level may indicate predisposition for/presence of atheromatous plaquing. Note: Diuretics and -blockers can also raise triglyceride and LDL levels. Thyroid studies: Hyperthyroidism may lead or contribute to vasoconstriction and hypertension. Serum/urine aldosterone level: May be done to assess for primary aldosteronism. Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal dysfunction and/or presence of dia- betes. Creatinine clearance: May be reduced, reflecting renal damage. Urine vanillylmandelic acid (VMA) (catecholamine metabolite): Elevation may indicate presence of pheochromocytoma (cause); 24-hour urine VMA may be done for assessment of pheochromocytoma if hypertension is intermittent. 37
    • Copyright © 2006 by F. A. Davis. Uric acid: Hyperuricemia has been implicated as a risk factor for the development of hypertension. Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders. Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary dysfunction, Cushing’s syndrome. Intravenous pyelogram (IVP): May identify cause of secondary hypertension; e.g., renal parenchymal disease, renal/ureteral calculi. Kidney and renography nuclear scan: Evaluates renal status (TOD). Excretory urography: May reveal renal atrophy, indicating chronic renal disease. Chest x-ray: May demonstrate obstructing calcification in valve areas; deposits in and/or notching of aorta; cardiac enlarge- ment. Computed tomography (CT) scan: Assesses for cerebral tumor, CVA, or encephalopathy or to rule out pheochromocytoma. Electrocardiogram (ECG): May demonstrate enlarged heart, strain patterns, conduction disturbances. Note: Broad, notched P wave is one of the earliest signs of hypertensive heart disease. NURSING PRIORITIES 1. Maintain/enhance cardiovascular functioning. 2. Prevent complications. 3. Provide information about disease process/prognosis and treatment regimen. 4. Support active client control of condition. DISCHARGE GOALS 1. BP within acceptable limits for individual. 2. Cardiovascular and systemic complications prevented/minimized. 3. Disease process/prognosis and therapeutic regimen understood. 4. Necessary lifestyle/behavioral changes initiated. 5. Plan in place to meet needs after discharge. NURSING DIAGNOSIS: risk for decreased Cardiac Output Risk factors may include Increased vascular resistance, vasoconstriction Myocardial ischemia Ventricular hypertrophy/rigidity Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Circulation Status (NOC) Image/text rights unavailable. Participate in activities that reduce BP/cardiac workload. Maintain BP within individually acceptable range. Demonstrate stable cardiac rhythm and rate within client’s normal range. ACTIONS/INTERVENTIONS RATIONALE Image/text rights unavailable. Hemodynamic Regulation (NIC) Independent Monitor BP. Measure in both arms/thighs three times, 3–5 Comparison of pressures provides a more complete picture min apart while client is at rest, then sitting, then standing of vascular involvement/scope of problem. Severe hyper- for initial evaluation. Use correct cuff size and accurate tension is classified in the adult as a diastolic pressure ele- technique. vation to 110 mm Hg; progressive diastolic readings above 120 mm Hg are considered first accelerated, then malignant 38
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE CARDIOVASCULAR: HYPERTENSION: Severe (very severe). Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease even when diastolic pressure is not elevated. In younger clients, diastolic with normal systolic readings, ele- vation of diastolic readings may indicate prehypertension. Note presence, quality of central and peripheral pulses. Bounding carotid, jugular, radial, and femoral pulses may be observed/palpated. Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion. Auscultate heart tones and breath sounds. S4 heart sound is common in severely hypertensive clients because of the presence of atrial hypertrophy (increased atrial volume/pressure). Development of S3 indicates ven- tricular hypertrophy and impaired functioning. Presence of crackles, wheezes may indicate pulmonary congestion sec- ondary to developing or chronic heart failure. Observe skin color, moisture, temperature, and capillary Presence of pallor; cool, moist skin; and delayed capillary refill time. refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/decreased output. Note dependent/general edema. May indicate heart failure, renal or vascular impairment. Provide calm, restful surroundings, minimize environ- Helps reduce sympathetic stimulation; promotes relaxation. mental activity/noise. Limit the number of visitors and length of stay. Maintain activity restrictions; e.g., bed rest/chair rest; Reduces physical stress and tension that affect blood pres- schedule periods of uninterrupted rest; assist client with sure and the course of hypertension. self-care activities as needed. Provide comfort measures; e.g., back and neck massage, Decreases discomfort and may reduce sympathetic stimula- elevation of head. tion. Instruct in relaxation techniques, guided imagery, distrac- Can reduce stressful stimuli, produce calming effect, tions. thereby reducing BP. Monitor response to medications to control blood pres- Response to drug therapy (usually consisting of several sure. drugs, including diuretics, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], vas- cular smooth muscle relaxants, and alpha, beta, and cal- cium channel blockers) is dependent on both the individual as well as the synergistic effects of the drugs. Because of side effects, drug interactions, and client’s motivation for taking antihypertensive medication, it is important to use the smallest number and lowest dosage of medications. Collaborative Administer medications as indicated: Thiazide diuretics; e.g., chlorothiazide (Diuril); Diuretics are considered first-line medications for uncom- hydrochlorothiazide (Esidrix/HydroDIURIL); plicated stage I or II hypertension and may be used alone hydrochlorothiazide with triamterene (Diazide, or in association with other drugs (such as -blockers) to Maxide) or amiloride (Modiuretic); bendroflumethi- reduce BP in clients with relatively normal renal function. azide (Naturetin); indapamide (Lozol), metolazone These diuretics potentiate the effects of other antihyperten- (Mykrox, Zaroxolyn); sive agents as well by limiting fluid retention, and may reduce the incidence of strokes and heart failure. Loop diuretics; e.g., furosemide (Lasix), bumetanide These drugs produce marked diuresis by inhibiting resorp- (Bumex), torsemide (Demadex); tion of sodium and chloride and are effective antihyperten- sives, especially in clients who are resistant to thiazides or have renal impairment. Potassium-sparing diuretics; e.g., spironolactone May be given in combination with a thiazide diuretic to (Aldactone); triamterene (Dyrenium); amiloride minimize potassium loss. (Midamor); 39
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE -adrenergic, -adrenergic, or centrally acting adren- -Blockers may be ordered instead of diuretics for clients ergic antagonists; e.g., doxazosin (Cardura); propra- with ischemic heart disease; obese clients with cardiogenic nolol (Inderal); acebutolol (Sectral); metoprolol hypertension; and clients with concurrent supraventricular (Lopressor), labetalol (Normodyne); atenolol arrhythmias, angina, or hypertensive cardiomyopathy. (Tenormin); nadolol (Corgard), carvedilol (Coreg); Specific actions of these drugs vary, but they generally methyldopa (Aldomet); clonidine (Catapres); pra- reduce BP through the combined effect of decreased total zosin (Minipress); terazosin (Hytrin); pindolol peripheral resistance, reduced cardiac output, inhibited (Visken); sympathetic activity, and suppression of renin release. Note: Clients with diabetes should use Corgard and Visken with caution because they can prolong and mask the hypo- glycemic effects of insulin. The elderly may require smaller doses because of the potential for bradycardia and hypoten- sion. African-American clients tend to be less responsive to -blockers in general and may require increased dosage or use of another drug; e.g., monotherapy with a diuretic. Calcium channel antagonists; e.g., nifedipine (Adalat, May be used to treat severe hypertension when a combina- Procardia); verapamil (Calan, Isoptin, Verelan); dilti- tion of a diuretic and a sympathetic inhibitor does not suffi- azem (Cardizem); amlodipine (Norvasc); isradipine ciently control BP. Vasodilation of healthy cardiac (DynaCirc); nicardipine (Cardene); vasculature and increased coronary blood flow are second- ary benefits of vasodilator therapy. Adrenergic neuron blockers: guanadrel (Hylorel); Reduce arterial and venous constriction activity at the sym- guanethidine (Ismelin); reserpine (Serpalan); pathetic nerve endings. Direct-acting oral vasodilators: hydralazine Action is to relax vascular smooth muscle, thereby reducing (Apresoline); minoxidil (Loniten); vascular resistance. Direct-acting parenteral vasodilators: diazoxide (Hyper- These are given intravenously for management of hyper- stat), nitroprusside (Nitropress); labetalol (Normodyne); tensive emergencies. Angiotensin-converting enzyme (ACE) inhibitors; The use of an additional sympathetic inhibitor may be e.g., captopril (Capoten); enalapril (Vasotec); required for its cumulative effect when other measures benazepril (Lotensin); lisinopril (Zestril); fosinopril have failed to control BP or when congestive heart failure (Monopril); ramipril (Altace) Angiotensin II blockers; (CHF) or diabetes is present. e.g., valsartan (Diovan), guanethidine (Ismelin). Implement dietary restrictions (e.g., calories, refined car- These restrictions can help manage fluid retention and, bohydrates, sodium, fat, and cholesterol) as indicated. with associated hypertensive response, decrease myocardial workload. Prepare for surgery when indicated. When hypertension is due to pheochromocytoma, removal of the tumor will correct condition. NURSING DIAGNOSIS: Activity Intolerance May be related to Generalized weakness Imbalance between oxygen supply and demand Possibly evidenced by Verbal report of fatigue or weakness Abnormal heart rate or BP response to activity Exertional discomfort or dyspnea Electrocardiogram (ECG) changes reflecting ischemia; dysrhythmias DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Endurance (NOC) Image/text rights unavailable. Participate in necessary/desired activities. Report a measurable increase in activity tolerance. Demonstrate a decrease in physiologic signs of intolerance. 40
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE CARDIOVASCULAR: HYPERTENSION: Severe Energy Management (NIC) Image/text rights unavailable. Independent Assess the client’s response to activity, noting pulse rate The stated parameters are helpful in assessing physiologic more than 20 beats/min faster than resting rate; marked responses to the stress of activity and, if present, are indica- increase in BP during/after activity (systolic pressure tors of overexertion. increase of 40 mm Hg or diastolic pressure increase of 20 mm Hg); dyspnea or chest pain; excessive fatigue and weakness; diaphoresis; dizziness or syncope. Instruct client in energy-conserving techniques; e.g., using Energy-saving techniques reduce the energy expenditure, chair when showering, sitting to brush teeth or comb hair, thereby assisting in equalization of oxygen supply and carrying out activities at a slower pace. demand. Encourage progressive activity/self-care when tolerated. Gradual activity progression prevents a sudden increase in Provide assistance as needed. cardiac workload. Providing assistance only as needed encourages independence in performing activities. NURSING DIAGNOSIS: acute headache Pain May be related to Increased cerebral vascular pressure Possibly evidenced by Reports of throbbing pain located in suboccipital region, present on awakening, and disappearing spontaneously after being up and about Reluctance to move head, rubbing head, avoidance of bright lights and noise, wrin- kled brow, clenched fists Reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Pain Control (NOC) Image/text rights unavailable. Report pain/discomfort is relieved/controlled. Verbalize methods that provide relief. Follow prescribed pharmacologic regimen. ACTIONS/INTERVENTIONS RATIONALE Image/text rights(NIC) Pain Management unavailable. Independent Determine specifics of pain; e.g., location, characteristics, Facilitates diagnosis of problem and initiation of appropri- intensity (0–10 scale), onset/duration. Note nonverbal cues. ate therapy. Helpful in evaluating effectiveness of therapy. Encourage/maintain bedrest during acute phase. Minimizes stimulation/promotes relaxation. Provide/recommend nonpharmacologic measures for Measures that reduce cerebral vascular pressure and that relief of headache; e.g., cool cloth to forehead; back and slow/block sympathetic response are effective in relieving neck rubs; quiet, dimly lit room; relaxation techniques headache and associated complications. (guided imagery, distraction); and diversional activities. Eliminate/minimize vasoconstricting activities that may Activities that increase vasoconstriction accentuate the aggravate headache; e.g., straining at stool, prolonged headache in the presence of increased cerebral vascular coughing, bending over. pressure. 41
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE Assist client with ambulation as needed. Dizziness and blurred vision frequently are associated with vascular headache. Client may also experience episodes of postural hypotension, causing weakness when ambulating. Provide liquids, soft foods, frequent mouth care if nose- Promotes general comfort. Nasal packing may interfere with bleeds occur or nasal packing has been done to stop swallowing or require mouth breathing, leading to stagna- bleeding. tion of oral secretions and drying of mucous membranes. Collaborative Administer medications as indicated: analgesics Reduce/control pain and decrease stimulation of the sympa- thetic nervous system. Antianxiety agents; e.g., lorazepam (Ativan), alprazolam May aid in the reduction of tension and discomfort that is (Xanax), diazepam (Valium) intensified by stress. NURSING DIAGNOSIS: imbalanced Nutrition: More than Body Requirements May be related to Excessive intake in relation to metabolic need Sedentary lifestyle Cultural preferences Possibly evidenced by Weight 10%–20% more than ideal for height and frame Triceps skinfold more than 15 mm in men and 25 mm in women (maximum for age and sex) Reported or observed dysfunctional eating patterns DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Image/text rights unavailable. KNOWLEDGE: Treatment Regimen (NOC) Identify correlation between hypertension and obesity. Image/text rights unavailable. NUTRITIONAL STATUS: Nutrient Intake (NOC) Demonstrate change in eating patterns (e.g., food choices, quantity) to attain desir- able body weight with optimal maintenance of health. Initiate/maintain individually appropriate exercise program. ACTIONS/INTERVENTIONS RATIONALE Weight Reduction Assistance (NIC) Image/text rights unavailable. Independent Assess client understanding of direct relationship between Obesity is an added risk with high blood pressure because hypertension and obesity. of the disproportion between fixed aortic capacity and increased cardiac output associated with increased body mass. Reduction in weight may obviate the need for drug therapy or decrease the amount of medication needed for control of BP. Note: Recent research suggests that bringing weight within 15% of ideal weight can result in a drop of 10 mm Hg in both systolic and diastolic BP. 42
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE CARDIOVASCULAR: HYPERTENSION: Severe Discuss necessity for decreased caloric intake and limited Faulty eating habits contribute to atherosclerosis and obesity, intake of fats, salt, and sugar as indicated. which predispose to hypertension and subsequent complica- tions; e.g., stroke, kidney disease, heart failure. Excessive salt intake expands the intravascular fluid volume and may dam- age kidneys, which can further aggravate hypertension. Note: One study showed that sodium reduction reduced the need for medication by 31%. Weight loss lowered the need for medication by 36% and the combination of the two by 53%. Determine client’s desire to lose weight. Motivation for weight reduction is internal. The individual must want to lose weight, or the program most likely will not succeed. Review usual daily caloric intake and dietary choices. Identifies current strengths/weaknesses in dietary program. Aids in determining individual need for adjustment/teach- ing. Establish a realistic weight reduction plan with the client; Reducing caloric intake by 500 calories daily theoretically e.g., 1-lb weight loss/wk. yields a weight loss of 1 lb/wk. Slow reduction in weight is therefore indicative of fat loss with muscle sparing and gener- ally reflects a change in eating habits. Encourage client to maintain a diary of food intake, includ- Provides a database for both the adequacy of nutrients eaten ing when and where eating takes place and the circum- and the emotional conditions of eating. Helps focus attention stances and feelings around which the food was eaten. on factors that client has control over/can change. Instruct and assist in appropriate food selections, such as Avoiding foods high in saturated fat and cholesterol is impor- a diet rich in fruits, vegetables, and low-fat dairy foods tant in preventing progressing atherogenesis. Moderation and referred to as the DASH (dietary approaches to stop use of low-fat products in place of total abstinence from cer- hypertension) diet and avoiding foods high in saturated tain food items may prevent sense of deprivation and fat (butter, cheese, eggs, ice cream, meat) and cholesterol enhance cooperation with dietary regimen. The DASH diet, (fatty meat, egg yolks, whole dairy products, shrimp, in conjunction with exercise, weight loss, and limits on salt organ meats). intake, may reduce or even eliminate the need for drug therapy. Collaborative Refer to dietitian as indicated. Can provide additional counseling and assistance with meet- ing individual dietary needs. NURSING DIAGNOSIS: ineffective Coping May be related to Situational/maturational crisis; multiple life changes Inadequate relaxation; little or no exercise, work overload Inadequate support systems Poor nutrition Unmet expectations; unrealistic perceptions Inadequate coping methods Possibly evidenced by Verbalization of inability to cope or ask for help Inability to meet role expectations/basic needs or problem-solve Destructive behavior toward self; overeating, lack of appetite; excessive smoking/drinking, proneness to alcohol abuse Chronic fatigue/insomnia; muscular tension; frequent head/neck aches; chronic worry, irritability, anxiety, emotional tension, depression 43
    • Copyright © 2006 by F. A. Davis. DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Coping (NOC) Image/text rights unavailable. Identify ineffective coping behaviors and consequences. Verbalize awareness of own coping abilities/strengths. Identify potential stressful situations and steps to avoid/modify them. Demonstrate the use of effective coping skills/methods. ACTIONS/INTERVENTIONS RATIONALE Image/text rights unavailable. Coping Enhancement (NIC) Independent Assess effectiveness of coping strategies by observing Adaptive mechanisms are necessary to appropriately alter behaviors; e.g., ability to verbalize feelings and concerns, one’s lifestyle, deal with the chronicity of hypertension, and willingness to participate in the treatment plan. integrate prescribed therapies into daily living. Note reports of sleep disturbances, increasing fatigue, Manifestations of maladaptive coping mechanisms may be impaired concentration, irritability, decreased tolerance of indicators of repressed anger and have been found to be headache, inability to cope/problem-solve. major determinants of diastolic BP. Assist client to identify specific stressors and possible Recognition of stressors is the first step in altering one’s strategies for coping with them. response to the stressor. Include client in planning of care, and encourage maxi- Involvement provides client with an ongoing sense of con- mum participation in treatment plan/interdisciplinary trol, improves coping skills, and can enhance cooperation team. with therapeutic regimen. Ongoing intensive assessment and management by an interdisciplinary team promotes timely adjustments to therapeutic regimen. Encourage client to evaluate life priorities/goals. Ask Focuses client’s attention on reality of present situation rel- questions such as, “Is what you are doing getting you ative to client’s view of what is wanted. Strong work ethic, what you want?” need for “control,” and outward focus may have led to lack of attention to personal needs. Assist client to identify and begin planning for necessary Necessary changes should be realistically prioritized so lifestyle changes. Assist to adjust, rather than abandon, client can avoid being overwhelmed and feeling powerless. personal/family goals. NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, treatment plan, self-care, and discharge needs May be related to Lack of knowledge/recall Information misinterpretation Cognitive limitation Denial of diagnosis Possibly evidenced by Verbalization of the problem Request for information Statement of misconception Inaccurate follow-through of instructions; inadequate performance of procedures Inappropriate or exaggerated behaviors; e.g., hostile, agitated, apathetic 44
    • Copyright © 2006 by F. A. Davis. CARDIOVASCULAR: HYPERTENSION: Severe DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Image/text rights unavailable. KNOWLEDGE: Disease Process (NOC) Verbalize understanding of disease process and treatment regimen. Identify drug side effects and possible complications that necessitate medical attention. Maintain BP within individually acceptable parameters. Image/text rights unavailable. KNOWLEDGE: Treatment Regimen (NOC) Describe reasons for therapeutic actions/treatment regimen. ACTIONS/INTERVENTIONS RATIONALE Image/textDisease Process (NIC) TEACHING: rights unavailable. Independent Assist client in identifying modifiable risk factors; e.g., These risk factors have been shown to contribute to hyper- obesity; diet high in sodium, saturated fats, and choles- tension and cardiovascular and renal disease. terol; sedentary lifestyle; smoking; alcohol intake (more than 2 oz/day on a regular basis); stressful lifestyle. Problem-solve with client to identify ways in which Changing “comfortable/usual” behavior patterns can be appropriate lifestyle changes can be made to reduce mod- very difficult and stressful. Support, guidance, and empa- ifiable risk factors. thy can enhance client’s success in accomplishing these tasks. Discuss importance of eliminating smoking, and assist Nicotine increases catecholamine discharge, resulting in client in formulating a plan to quit smoking. increased heart rate, BP, vasoconstriction, and myocardial workload, and reduces tissue oxygenation. Reinforce the importance of adhering to treatment regi- Lack of engagement in the treatment plan is a common rea- men and keeping follow-up appointments. son for failure of antihypertensive therapy. Therefore, ongo- ing evaluation for client cooperation is critical to successful treatment. Compliance usually improves when client understands causative factors and consequences of inade- quate intervention and health maintenance. Instruct and demonstrate technique of BP self-monitoring. Monitoring BP at home is reassuring to client because it Evaluate client’s hearing, visual acuity, manual dexterity, provides visual/positive reinforcement for efforts in follow- and coordination. ing the medical regimen and promotes early detection of deleterious changes. Help client develop a simple, convenient schedule for tak- Individualizing medication schedule to fit client’s personal ing medications. habits/needs may facilitate cooperation with long-term regimen. Explain prescribed medications along with their rationale, Adequate information and understanding that side effects dosage, expected and adverse side effects, and idiosyn- (e.g., mood changes, initial weight gain, dry mouth) are crasies; e.g.: common and often subside with time can enhance coopera- tion with treatment plan. Diuretics: Take daily doses (or larger dose) in the Scheduling minimizes nighttime urination. early morning; Weigh self on a regular schedule and record; Primary indicator of effectiveness of diuretic therapy. Avoid/limit alcohol intake; The combined vasodilating effect of alcohol and the volume-depleting effect of a diuretic greatly increase the risk of orthostatic hypotension. Notify physician if unable to tolerate food or fluid; Dehydration can develop rapidly if intake is poor and client continues to take a diuretic. 45
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE Antihypertensives: Take prescribed dose on a regular Because clients often cannot feel the difference the medica- schedule; avoid skipping, altering, or making up tion is making in blood pressure, it is critical that there be doses; and do not discontinue without notifying the understanding about the medication’s working and side healthcare provider. Review potential side effects effects. For example, abruptly discontinuing a drug may and/or drug interactions; cause rebound hypertension leading to severe complica- tions, or medication may need to be altered to reduce adverse effects. Rise slowly from a lying to standing position, sitting Measures reduce severity of orthostatic hypotension associ- for a few minutes before standing. Sleep with the ated with the use of vasodilators and diuretics. head slightly elevated. Suggest frequent position changes, leg exercises when Decreases peripheral venous pooling that may be potenti- lying down. ated by vasodilators and prolonged sitting/standing. Recommend avoiding hot baths, steam rooms, and saunas, Prevents vasodilation with potential for dangerous side especially with concomitant use of alcoholic beverages. effects of syncope and hypotension. Instruct client to consult healthcare provider before taking Precaution is important in preventing potentially danger- other prescription or over-the-counter (OTC) medications. ous drug interactions. Any drug that contains a sympa- thetic nervous stimulant may increase BP or counteract antihypertensive effects. Instruct client about increasing intake of foods/fluids Diuretics can deplete potassium levels. Dietary replacement high in potassium (e.g., oranges, bananas, figs, dates, is more palatable than drug supplements and may be all tomatoes, potatoes, raisins, apricots, Gatorade, and fruit that is needed to correct deficit. Some studies show that 400 juices) and foods/fluids high in calcium; e.g., low-fat mg of calcium/day can lower systolic and diastolic BP. milk, yogurt, or calcium supplements, as indicated. Correcting mineral deficiencies can also affect BP. Review signs/symptoms requiring notification of health- Early detection of developing complications/decreased care provider; e.g., headache present on awakening that effectiveness of drug regimen or adverse reactions to it does not abate, sudden and continued increase of BP, allows for timely intervention. chest pain/shortness of breath, irregular/increased pulse rate, significant weight gain (2 lb/day or 5 lb/wk) or peripheral/abdominal swelling, visual disturbances, fre- quent, uncontrollable nosebleeds, depression/emotional lability, severe dizziness or episodes of fainting, muscle weakness/cramping, nausea/vomiting; excessive thirst. Explain rationale for prescribed dietary regimen (usually Excess saturated fats, cholesterol, sodium, alcohol, and a diet low in sodium, saturated fat, and cholesterol). calories have been defined as nutritional risks in hyperten- sion. A diet low in fat and high in polyunsaturated fat reduces BP; possibly through prostaglandin balance in both normotensive and hypertensive people. Help client identify sources of sodium intake (e.g., table Two years on a moderate low-salt diet may be sufficient to salt, salty snacks, processed meats and cheeses, sauerkraut, control mild hypertension or reduce the amount of medica- sauces, canned soups and vegetables, baking soda, baking tion required. powder, monosodium glutamate). Stress the importance of reading ingredient labels of foods and OTC drugs. Encourage foods rich in essential fatty acids (e.g., salmon, Omega-3 fatty acids in fish tend to relax artery walls, cod, mackeral, tuna). reducing blood pressure. They also make blood thinner and less likely to clot. Encourage client to establish an individual exercise pro- Besides helping to lower BP, aerobic activity aids in toning gram incorporating aerobic exercise (walking, swimming) the cardiovascular system. Isometric exercise can increase within client’s capabilities. Stress the importance of avoid- serum catecholamine levels, further elevating BP. ing isometric activity. Demonstrate application of ice pack to the back of the Nasal capillaries may rupture as a result of excessive vascu- neck and pressure over the distal third of nose, and rec- lar pressure. Cold and pressure constrict capillaries to slow ommend that client lean the head forward if nosebleed or halt bleeding. Leaning forward reduces the amount of occurs. blood that is swallowed. Provide information regarding community resources, and Community resources such as the American Heart support client in making lifestyle changes. Initiate refer- Association, “coronary clubs,” stop smoking clinics, alcohol rals as indicated. (drug) rehabilitation, weight loss programs, stress manage- ment classes, and counseling services may be helpful in client’s efforts to initiate and maintain lifestyle changes. 46
    • Copyright © 2006 by F. A. Davis. POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical CARDIOVASCULAR: HEART FAILURE: Chronic condition/presence of complications, personal resources, and life responsibilities) Activity Intolerance—frequently occurs as a result of alterations in cardiac output and side effects of medication. imbalanced Nutrition: more than body requirements—obesity is often present and a factor in blood pressure control. ineffective Therapeutic Regimen Management—result of the complexity of the therapeutic regimen, required lifestyle changes, side effects of medication, and frequent feelings of general well-being (“I’m not really sick.”). ineffective Sexuality Pattern—interference in sexual functioning may occur because of activity intolerance and side effects of medication. readiness for enhanced family Coping—opportunity exists for family members to support client while reducing risk factors for themselves and improving quality of life for family as a whole. HEART FAILURE: CHRONIC Heart failure afflicts more than 22 million people worldwide, and in the United States, is the most costly heart-related disease because of its chronicity (Collins, 2003). Failure of the left and/or right chambers of the heart results in insufficient output to meet tissue needs and causes pulmonary and systemic vascular congestion. Remodeling of the myocardium as a structural response to injury is one of the pathophysiologic causes of heart failure (HF). During remodeling the heart changes from an efficient football shape to an inefficient basketball shape, making coordinated contractility difficult. Despite diagnostic and therapeutic advances, HF continues to be associated with high morbidity and mortality. (Agency for Health Care Policy and Research [AHCPR] guidelines [6/94] promote the term heart failure [HF] in place of congestive heart failure [CHF] because many clients with heart failure do not manifest pulmonary or systemic congestion.) The New York Heart Association Functional Classification System for HF includes classes I– IV. Common causes of HF include ventricular dysfunction, cardiomyopathies, hypertension, coronary artery disease, valvular disease, and dysrhythmias. CARE SETTING Although generally managed at the community level, inpatient stay may be required for periodic exacerbation of failure/development of complications. RELATED CONCERNS Myocardial infarction, page 72 Hypertension, page 35 Cardiac surgery, page 96 Dysrhythmias, page 85 Psychosocial aspects of care, page 770 Client Assessment Database ACTIVITY/REST May report: Fatigue/exhaustion progressing throughout the day; exercise intolerance Insomnia Chest pain/pressure with activity Dyspnea at rest or with exertion May exhibit: Restlessness, mental status changes; e.g., anxiety and lethargy Vital sign changes with activity CIRCULATION May report: History of hypertension, recent/acute multiple MIs, previous episodes of HF, valvular heart disease, cardiac surgery, endocarditis, systemic lupus erythematosus (SLE), anemia, septic shock Swelling of feet, legs, abdomen, “belt too tight” (right-sided heart failure) May exhibit: BP may be low (pump failure), normal (mild or chronic HF), or high (fluid overload/increased systemic vascular resistance [SVR]) Pulse pressure may be narrow, reflecting reduced stroke volume 47
    • Copyright © 2006 by F. A. Davis. Tachycardia (may be left- or right-sided heart failure) Dysrhythmias; e.g., atrial fibrillation, premature ventricular contractions/tachycardia, heart blocks Apical pulse: PMI may be diffuse and displaced inferiorly to the left Heart sounds: S3 (gallop) is diagnostic of congestive failure; S4 may occur; S1 and S2 may be softened Systolic and diastolic murmurs may indicate the presence of valvular stenosis or insuffi- ciency, both atrial and ventricular Pulses: Peripheral pulses diminished; central pulses may be bounding; e.g., visible jugular, carotid, abdominal pulsations; alteration in strength of beat may be noted Color ashen, pale, dusky, or even cyanotic Nailbeds pale or cyanotic, with slow capillary refill Liver may be enlarged/palpable, positive hepatojugular reflex Breath sounds: Crackles, rhonchi Edema may be dependent, generalized, or pitting, especially in extremities; JVD may be present EGO INTEGRITY May report: Anxiety, apprehension, fear Stress related to illness/financial concerns (job/cost of medical care) May exhibit: Various behavioral manifestations; e.g., anxiety, anger, fear, irritability ELIMINATION May report: Decreased voiding, dark urine Night voiding (nocturia) Diarrhea/constipation FOOD/FLUID May report: Loss of appetite/anorexia Nausea/vomiting Significant weight gain (may not respond to diuretic use) Lower extremity swelling Tight clothing/shoes Diet high in salt/processed foods, fat, sugar, and caffeine Use of diuretics May exhibit: Rapid/continuous weight gain Abdominal distention (ascites); edema (general, dependent, pitting, brawny) Abdominal tenderness (ascites, hepatic engorgement) HYGIENE May report: Fatigue/weakness, exhaustion during self-care activities May exhibit: Appearance indicative of neglect of personal care NEUROSENSORY May report: Weakness, dizziness, fainting episodes May exhibit: Lethargy, confusion, disorientation Behavior changes, irritability PAIN/DISCOMFORT May report: Chest pain, chronic or acute angina Right upper abdominal pain (right-sided heart failure [RHF]) Generalized muscle aches/pains May exhibit: Nervousness, restlessness Narrowed focus (withdrawal) Guarding behavior RESPIRATION May report: Dyspnea on exertion, sleeping sitting up or with several pillows Cough with/without sputum production, dry/hacking—especially when recumbent 48
    • Copyright © 2006 by F. A. Davis. History of chronic lung disease CARDIOVASCULAR: HEART FAILURE: Chronic Use of respiratory aids; e.g., oxygen and/or medications May exhibit: Tachypnea; shallow, labored breathing; use of accessory muscles, nasal flaring Cough: Dry/hacking/nonproductive or may be gurgling with/without sputum produc- tion Sputum may be blood-tinged, pink/frothy (pulmonary edema) Breath sounds may be diminished, with bibasilar crackles and wheezes Mentation may be diminished; lethargy, restlessness present Color: Pallor or cyanosis SAFETY May exhibit: Changes in mentation/confusion Loss of strength/muscle tone Skin excoriations, rashes SOCIAL INTERACTION May report: Decreased participation in usual social activities TEACHING/LEARNING May report: Family history of developing HF at young age (genetic form). Family hisotry of heart dis- ease, hypertension, diabetes (risk factors) Use/misuse of cardiac medications; e.g., -blockers, calcium channel blockers Use of vitamins, herbal supplements (e.g., niacin, coenzyme Q10, garlic, ginkgo, black helle- bore, dandelion), or aspirin Recent/recurrent hospitalizations Evidence of failure to improve Discharge plan Assistance with shopping, transportation, self-care needs, homemaker/maintenance considerations: tasks Alteration in medication use/therapy Changes in physical layout of home Refer to section at end of plan for postdischarge considerations. DIAGNOSTIC STUDIES ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias; e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs), may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present. Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilatation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour; e.g., bulging of left cardiac border, may suggest ventricular aneurysm. Sonograms (echocardiogram, Doppler and transesophageal echocardiogram): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction. Heart scans: Technetium-99m (99mTc) pyrophosphate scaning (also known as hot spot myocardial imaging and infarct avid imaging): Used to detect recent myocardial infaction and its extent. Multigated acquisition (MUGA): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion. Exercise or pharmacologic stress myocardial perfusion (e.g., dipyridamole [Persantine] or thallium scan): Evaluates blood flow, determines presence of myocardial ischemia and wall motion abnormalities. Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium. Cardiac magnetic resonance imaging (MRI): Helps detect congenital heart disease, valvular heart disease, and vascular dis- orders such as thoracic aneurysm. It also helps detect cardiac tumors and structural anomalies. Cardiac catheterization: Abnormal pressures are indicative of and help differentiate right-sided versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injec- ted into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyo- cardial biopsy may be useful in some clients to determine the underlying disorder, such as myocarditis or amylodosis. 49
    • Copyright © 2006 by F. A. Davis. BNP (Beta-type natruiretic peptide): Affects cardiac function and vascular tone and renal function. Low levels indicate worsening heart failure. Liver enzymes: Elevated in liver congestion/failure. Digoxin and other cardiac drug levels: Monitored to determine therapeutic range and correlate expected response with client response. Bleeding and clotting times: Determine therapeutic range for anticoagulant therapy and/or identify those at risk for exces- sive clot formation. Electrolytes: May be altered because of fluid shifts/decreased renal function and medications (e.g., diuretics, ACE inhibitors). Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased PCO2 (late). BUN/creatinine: Elevated BUN suggests decreased renal perfusion as may occur with HF and/or as a side effect of pre- scribed medications (e.g., diuretics and ACE inhibitors). Elevation of both BUN and creatinine is indicative of renal failure. Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in con- gested liver. Complete blood count (CBC): May reveal anemia (major contributor/exacerbating factor in HF), polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states. ESR: May be elevated, indicating acute inflammatory reaction (especially if viral infection is cause of HF). Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF. Hypothroydism can also cause or exacerbate HF. Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF. NURSING PRIORITIES 1. Improve myocardial contractility/systemic perfusion. 2. Reduce fluid volume overload. 3. Prevent complications. 4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences. DISCHARGE GOALS 1. Cardiac output adequate for individual needs. 2. Complications prevented/resolved. 3. Optimum level of activity/functioning attained. 4. Disease process/prognosis and therapeutic regimen understood. 5. Plan in place to meet needs after discharge. NURSING DIAGNOSIS: decreased Cardiac Output May be related to Altered myocardial contractility/inotropic changes Alterations in rate, rhythm, electrical conduction Structural changes (e.g., valvular defects, ventricular aneurysm) Possibly evidenced by Increased heart rate (tachycardia), dysrhythmias, ECG changes Changes in BP (hypotension/hypertension) Extra heart sounds (S3, S4) Decreased urine output Diminished peripheral pulses Cool, ashen skin; diaphoresis Orthopnea, crackles, JVD, liver engorgement, edema Chest pain 50
    • Copyright © 2006 by F. A. Davis. CARDIOVASCULAR: HEART FAILURE: Chronic DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Cardiac Pump Effectiveness (NOC) Image/text rights unavailable. Display vital signs within acceptable limits, dysrhythmias absent/controlled, and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, uri- nary output adequate). Report decreased episodes of dyspnea, angina. Image/text rights unavailable. Cardiac Disease Self-Management (NOC) Participate in activities that reduce cardiac workload. ACTIONS/INTERVENTIONS RATIONALE Image/text rights unavailable. Hemodynamic Regulation (NIC) Independent Auscultate apical pulse; assess heart rate, rhythm (docu- Tachycardia is usually present (even at rest) to compensate ment dysrhythmia if telemetry available). for decreased ventricular contractility. Premature atrial con- tractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibril- lation (AF) are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricu- lar dysrhythmias unresponsive to medication suggest ven- tricular aneurysm. Note heart sounds. S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant/distended chambers. Murmurs may reflect valvular incompetence/stenosis. Palpate peripheral pulses. Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and posttibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans (strong beat alternating with weak beat) may be present. Monitor BP. In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound/irreversible hypotension may occur. Inspect skin for pallor, cyanosis. Pallor is indicative of diminished peripheral perfusion sec- ondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases. Monitor urine output, noting decreasing output and Kidneys respond to reduced cardiac output by retaining dark/concentrated urine. water and sodium. Urine output is usually decreased dur- ing the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when client is recumbent. Note changes in sensorium; e.g., lethargy, confusion, dis- May indicate inadequate cerebral perfusion secondary to orientation, anxiety, and depression. decreased cardiac output. Encourage rest, semirecumbent in bed or chair. Assist Physical rest should be maintained during acute or refrac- with physical care as indicated. tory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen demand/consumption and workload. 51
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE Provide quiet environment; explain medical/nursing Psychologic rest helps reduce emotional stress, which can management; help client avoid stressful situations; lis- produce vasoconstriction, elevating BP and increasing heart ten/respond to expressions of feelings/fears. rate/work. Provide bedside commode. Have client avoid activities Commode use decreases work of getting to bathroom eliciting a vasovagal response; e.g., straining during defe- or struggling to use bedpan. Vasovagal maneuver cation, holding breath during position changes. causes vagal stimulation followed by rebound tachy- cardia, which further compromises cardiac function/ output. Elevate legs, avoiding pressure under knee. Encourage Decreases venous stasis, and may reduce incidence of active/passive exercises. Increase ambulation/activity as thrombus/embolus formation. tolerated. Check for calf tenderness; diminished pedal pulse; Reduced cardiac output, venous pooling/stasis, and swelling, local redness, or pallor of extremity. enforced bed rest increases risk of thrombophlebitis. Withhold digitalis preparation as indicated, and notify Incidence of toxicity is high (20%) because of narrow mar- physician if marked changes occur in cardiac rate or gin between therapeutic and toxic ranges. Digoxin may rhythm or signs of digitalis toxicity occur. have to be discontinued in the presence of toxic drug levels, a slow heart rate, or low potassium level. (Refer to CP: Dysrhythmias; ND: risk for Poisoning: digitalis toxicity.) Collaborative Administer supplemental oxygen as indicated. Increases available oxygen for myocardial uptake to combat effects of hypoxia/ischemia. Administer medications as indicated: A variety of medications may be used to increase stroke volume, improve contractility, and reduce congestion. Diuretics, e.g., furosemide (Lasix), ethacrynic acid Diuretics, in conjunction with restriction of dietary sodium (Edecrin), bumetanide (Bumex), spironolactone and fluids, often lead to clinical improvement in clients (Aldactone); with stages I and II HF. In general, type and dosage of diuretic depend on cause and degree of HF and state of renal function. Preload reduction is most useful in treating clients with a relatively normal cardiac output accompa- nied by congestive symptoms. Loop diuretics block chlo- ride reabsorption, thus interfering with the reabsorption of sodium and water. Vasodilators, e.g., nitrates (Nitro-Dur, Isordil); arterio- Vasodilators are the mainstay of treatment in HF and are dilators; e.g., hydralazine (Apresoline); combination used to increase cardiac and renal output, reducing circulat- drugs; e.g., prazosin (Minipress); nesiritide Natrecor); ing volume (preload and afterload) and decreasing SVR, thereby reducing ventricular workload. Note: Nesiritide is used in acutely decompensated CHF and has been used with digoxin, diuretics, and ACE inhibitors. Parenteral vasodilators are reserved for clients with severe HF or those unable to take oral medications. ACE inhibitors; e.g., benazepril (Lotensin), captopril ACE inhibitors represent first-line therapy to control heart (Capoten), lisinopril (Prinivil), enalapril (Vasotec), failure by decreasing venticular filling pressures and SVR quinapril (Accupril), ramipril (Altace), moexipril while increasing cardiac output with little or no change in (Univasc); BP and heart rate. Angiotensin II receptor antagonists, (also known as Antihypertensive and cardioprotective effects are attrib- angiotension receptor blockers [ARBs]); e.g., can- utable to selective blockade of AT1 (angiotensin II) receptors desartan (Atacand), losartan (Cozaar), eprosartan and angiotensin II synthesis. Note: ARBs used in combina- (Teveten), ibesartan (Avapro), valsartan (Diovan); tion with ACE inhibitors and -blockers are thought to have decreased hospitalizations for HF clients. Digoxin (Lanoxin); Increases force of myocardial contraction when diminished contractility is the cause of HF, and slows heart rate by decreasing conduction velocity and prolonging refractory period of the atrioventricular (AV) junction to increase car- diac efficiency/output. 52
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE CARDIOVASCULAR: HEART FAILURE: Chronic Inotropic agents; e.g., amrinone (Inocor), milrinone These medications are useful for short-term treatment of (Primacor), vesnarinone (Arkin-Z); HF unresponsive to cardiac glycosides, vasodilators, and diuretics in order to increase myocardial contractility and produce vasodilation. Positive inotropic properties have reduced mortality rates 50% and improved quality of life. -adrenergic receptor antagonists; e.g., carvedilol Useful in the treatment of HF by blocking the cardiac (Coreg), bisoprolol (Zebeta), metoprolol (Lopressor); effects of chronic adrenergic stimulation. Many clients experience improved activity tolerance and ejection frac- tion. Aldosterone antagonist; e.g. eplerenone (Inspra); Approved by the Food and Drug Administration (FDA) in 2003, eplerenone has been shown to improve survival in HF, especially following MI. Morphine sulfate; Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary conges- tion is present. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety. Antianxiety agents/sedatives; Promote rest/relaxation, reducing oxygen demand and myocardial workload. Anticoagulants; e.g., low-dose heparin, warfarin May be used prophylactically to prevent thrombus/embo- (Coumadin). lus formation in the presence of risk factors such as venous stasis, enforced bedrest, cardiac dysrhythmias, and history of previous thrombolic episodes. Administer IV solutions, restricting total amount as indi- Because of existing elevated left ventricular pressure, client cated. Avoid saline solutions. may not tolerate increased fluid volume (preload). Clients with HF also excrete less sodium, which causes fluid reten- tion and increases myocardial workload. Monitor/replace electrolytes. Fluid shifts and use of diuretics can alter electrolytes (espe- cially potassium and chloride), which affect cardiac rhythm and contractility. Monitor serial ECG and chest x-ray changes. ST segment depression and T wave flattening can develop because of increased myocardial oxygen demand, even if no coronary artery disease is present. Chest x-ray may show enlarged heart and changes of pulmonary congestion. Measure cardiac output and other functional parameters Cardiac index, preload/afterload, contractility, and cardiac as indicated. work can be measured noninvasively by using thoracic electrical bioimpedance (TEB) technique. Useful in deter- mining effectiveness of therapeutic interventions and response to activity. Monitor laboratory studies; e.g., BUN, creatinine: Elevation of BUN/creatinine reflects kidney hypoperfu- sion/failure. Liver function studies (AST, LDH); May be elevated because of liver congestion and indicate need for smaller dosages of medications that are detoxified by the liver. Prothrombin time (PT)/activated partial thrombo- Measures changes in coagulation processes or effectiveness plastin time (aPTT) coagulation studies. of anticoagulant therapy. Prepare for insertion/maintain pacemaker (or pace- May be necessary to correct bradydysrhythmias unrespon- maker/defibrillator), if indicated. sive to drug intervention, which can aggravate congestive failure/produce pulmonary edema. Note: Beiventricular pacemaker and cardiac defibirillators are designed to pro- vide resynchronization for the heart by simultaneous elec- trical activation of both the right and left sides of the heart, thereby creating a more effective and efficient pump. Prepare for surgery as indicated; e.g., valve replacement, Heart failure due to ventricular aneurysm or valvular dys- angioplasty, coronary artery bypass grafting (CABG); function may require aneurysmectomy or valve replace- ment to improve myocardial contractility/ function. Revascularization of cardiac muscle by CABG may be done to improve cardiac function. 53
    • Copyright © 2006 by F. A. Davis. ACTIONS/INTERVENTIONS RATIONALE Cardiomyoplasty; Cardiomyoplasty, an experimental procedure in which the latissimus dorsi muscle is wrapped around the heart and electrically stimulated to contract with each heartbeat, may be done to augment ventricular function while the client is awaiting cardiac transplantation or when transplantation is not an option. Transmyocardial revascularization. Other new surgical techniques include transmyocardial revascularization (percutaneous [PTMR]) using CO2 laser technology, in which a laser is used to create multiple 1-mm diameter channels in viable but underperfused cardiac muscle. Assist with/maintain mechanical circulatory support sys- An intra-aortic balloon pump (IABP) may be inserted as a tem, such as IABP or LVAD, when indicated. temporary support to the failing heart in the critically ill client with potentially reversible HF. A battery-powered left-ventricular assist device (LVAD) may also be used posi- tioned between the cardiac apex and the descending tho- racic or abdominal aorta. This device receives blood from the left ventricle (LV) and ejects it into the systemic circula- tion, often allowing client to resume a nearly normal lifestyle while awaiting heart transplantation, or in some instances, allows the heart to recover and regain its func- tion.. With end-stage HF, cardiac transplantation may be indicated. NURSING DIAGNOSIS: Activity Intolerance May be related to Imbalance between oxygen supply/demand Generalized weakness Prolonged bedrest/immobility Possibly evidenced by Weakness, fatigue Changes in vital signs, presence of dysrhythmias Dyspnea Pallor, diaphoresis DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL: Endurance (NOC) Image/text rights unavailable. Participate in desired activities; meet own self-care needs. Achieve measurable increase in activity tolerance, evidenced by re