Download - Intervention Edwards
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7/29/2019 Intervention Edwards
1/19
DAY 1 (ASSESSMENT)
For pain
Intervention Rationale
1. Perform a comprehensive assessment of
pain to include location, characteristics,onset, duration, frequency, quality,
intensity or severity, and precipitating
factors of pain.
2. Teach the use of non pharmacologic
techniques (e.g., relaxation, guide
imagery, music therapy, distraction, and
massage) before, after, and if possible
during painful activities; before pain
occurs or increases; and along with other
pain relief measures.
3. Placed on moderate high back rest
4. Assisted upon ambulation
5. Encouraged diversional activities
6. Bed rest encouraged
7. Advised to avoid any strenuous activities
8. Advised to secure prescribed medications
Pain is a subjective experience and must
be described by the client in order to planeffective treatment
The use of noninvasive pain relief
measures can increase the release of
endorphins and enhance the therapeutic
effects of pain relief medications.
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Intervention Rationale
1. Provide accurate information about
the situation of the client andreasons for surgery.
2. Identify clients perception about theupcoming surgery
3. Promoted accurate informationabout the operation
4. Calm environment provided
5. Adequate rest period provided
6. Proper hygiene emphasized
To know his own perception about
the upcoming surgery
It can point to the clients levelof anxiety
To know more about her upcomingsurgery
To provide comfort
To
To prevent infection
For anxiety
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For sleep difficulties
Intervention Rationale
1. Encourage the patient to establish a
bedtime routine to facilitate transition
from wakefulness to sleep.
2. Determine the clients sleep and activity
pattern.
3. Encourage him to eliminate stressful
situations before bedtime
4. Instruct the patient and significant others
about factors (e.g., physiologic,
psychologic, lifestyle, frequent work shift
changes, excessively long work hours, and
other environmental factors) that
contribute to sleep pattern disturbances.
5. Encourage verbalization of feelings,
perceptions, and fears.
6. Monitor bedtime food and beverage
intake for items that facilitate or interfere
with sleep.
Rituals and routines induce comfort,
relaxation, and sleep
The amount of sleep an individual needs
varies with lifestyle, health, and age
Stress interferes with a persons ability to
relax, rest, and sleep
Knowledge of causative factors can enable
the client to begin to control factors that
inhibit sleep
Open expression of feelings facilitates
identification of specific emotions such as
anger or helplessness, distorted
perceptions, and unrealistic fears
Milk and protein foods contain
tryptophan, a precursor of serotonin,
which is thought to induce and maintain
sleep. Stimulants should be avoided
because they inhibit sleep
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Urinary retention
Intervention Rationale
1. Encourage patient to void every 24 hrand when urge is noted
2. Ask patient about stress incontinence
when moving, sneezing, coughing,
laughing, lifting objects.
3. Observe urinary stream, noting size and
force.
4. Have patient document time and amount
of each voiding. Note diminished urinary
output. Measure specific gravity as
indicated
5. Percuss/palpate suprapubic area.
6. Encourage oral fluids up to 3000 mL daily,
within cardiac tolerance, if indicated.
7. Monitor vital signs closely. Observe
for hypertension, peripheral/dependent
edema, changes in mentation. Weigh
daily. Maintain accurate I & O.
8. Provide/encourage meticulous catheterand perineal care.
9. Recommend sitz bath as indicated.
May minimize urinaryretention/overdistension of the bladder
High urethral pressure inhibits bladder
emptying or can inhibit voiding until
abdominal pressure increases enough for
urine to be involuntarily lost.
Useful in evaluating degree of obstruction
and choice of intervention
Urinary retention increases pressure
within the ureters and kidneys, which may
cause renal insufficiency. Any deficit in
blood flow to the kidney impairs its ability
to filter and concentrate substances.
A distended bladder can be felt in the
suprapubic area.
Increased circulating fluid maintains renal
perfusion and flushes kidneys, bladder,and ureters of sediment and bacteria.
Note: Initially, fluids may be restricted to
prevent bladder distension until adequate
urinary flow is reestablished.
Loss of kidney function results in
decreased fluid elimination and
accumulation of toxic wastes; may
progress to complete renal shutdown.
Reduces risk of ascending infection
Promotes muscle relaxation, decreases
edema, and may enhance voiding effort.
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Feb. 11, 2013 risk for infection
Intervention Rationale
1. Assess signs and symptomsof infection especially temperature.
2. Emphasize the importance of hand washingtechnique.
3. Maintain aseptic technique when changingdressing/ caring wound.
4. Keep area around wound clean and dry.
5. Emphasized necessity of taking
antibiotics as ordered
Fever may indicate infection.
It serves as a first line of defense against
infection.
Regular wound dressing promotes fast
healing and drying of wounds.
Wet area can be lodge area of bacteria
Pre matured is continuation of treatment
when client begins to feel well may resultin return of infection
Activity intolerance
Intervention Rationale1. Determine patient's perception of causes
of fatigue or activity
2. Assess patient's level of mobility
3. Assess nutritional status.
4. Assess potential for physical injury with
activity
5. Assess need for ambulation aids: bracing,
cane, walker, equipment modification for
activities of daily living (ADLs).
6. Assess patient's cardiopulmonary status
before activity using the following
measures
Heart rate
These may be temporary or permanent,physicalor psychological. Assessmentguides treatment
This aids in defining what patient iscapable of, which is necessary beforesetting realistic goals
Adequate energy reserves are required for
activity
injury may be related to falls oroverexertion
Some aids may require more energyexpenditurefor patients who have reduced upper armstrength(e.g., walking with crutches). Adequateassessment of energy requirements isindicated
Heart rate should not increase more than
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Osthortatic BP changes
Need for oxygen with increased activity
20 to 30 beats/min above resting withroutine activities.This number will change depending on theintensity of exercise the patient isattempting.
Elderly patients are more prone to drops inblood pressure with position changes
Portable pulse oximetry can be used toassess foroxygen desaturation. Supplemental oxygenmayhelp compensate for the increased oxygendemands.
Pain
Intervention Rationale
1. Perform a comprehensive assessment of
pain to include location, characteristics,
onset, duration, frequency, quality,
intensity or severity, and precipitating
factors of pain.
2. Teach the use of non pharmacologic
techniques (e.g., relaxation, guide
imagery, music therapy, distraction, and
massage) before, after, and if possibleduring painful activities; before pain
occurs or increases; and along with other
pain relief measures.
3. Placed on moderate high back rest
4. Assisted upon ambulation
5. Encouraged diversional activities
6. Bed rest encouraged
7. Advised to avoid any strenuous activities
8. Advised to secure prescribed medications
Pain is a subjective experience and must
be described by the client in order to plan
effective treatment
The use of noninvasive pain relief
measures can increase the release of
endorphins and enhance the therapeutic
effects of pain relief medications.
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For sleep difficulties
Intervention Rationale
1. Encourage the patient to establish a
bedtime routine to facilitate transition
from wakefulness to sleep.
2. Determine the clients sleep and activity
pattern.
3. Encourage him to eliminate stressful
situations before bedtime
4. Instruct the patient and significant others
about factors (e.g., physiologic,
psychologic, lifestyle, frequent work shiftchanges, excessively long work hours, and
other environmental factors) that
contribute to sleep pattern disturbances.
5. Encourage verbalization of feelings,
perceptions, and fears.
6. Monitor bedtime food and beverageintake for items that facilitate or interfere
with sleep
Rituals and routines induce comfort,
relaxation, and sleep
The amount of sleep an individual needs
varies with lifestyle, health, and age
Stress interferes with a persons ability to
relax, rest, and sleep
Knowledge of causative factors can enable
the client to begin to control factors that
inhibit sleep
Open expression of feelings facilitates
identification of specific emotions such as
anger or helplessness, distorted
perceptions, and unrealistic fears
Milk and protein foods containtryptophan, a precursor of serotonin,
which is thought to induce and maintain
sleep. Stimulants should be avoided
because they inhibit sleep
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Feb. 12, 2013- anxiety
Intervention Rationale
1. Provide accurate information aboutthe situation of the client andreasons for surgery.
2. Identify clients perception about theupcoming surgery
3. Promoted accurate informationabout the operation
4. Calm environment provided
5. Adequate rest period provided
6. Proper hygiene emphasized
7. Observe clients behavior
To know his own perception aboutthe upcoming surgery
It can point to the clients levelof anxiety
To more about her upcomingsurgery
Deficient fluid volume
Intervention Rationale1. Monitor for cardiac manifestations of
hypokalemia (e.g., hypotension,tachycardia, weak pulse, rhythmirregularities).
2. Obtain specimens for analysis of alteredsodium levels (e.g.,serum and urine
sodium, urine osmolality, and urine specificgravity) as indicated.
3. Monitor for neurologic and neuromuscularmanifestations of hypernatremia (e.g.,lethargy, irritability, seizures, andhyperreflexia).
Many cardiac rhythm disorders can resultfrom hypokalemia. It is critical to monitorcardiac function with hypokalemia.
Urine analysis provides information aboutretention or loss of sodium and the abilityof the kidneys to concentrate or dilute urine
in response to fluid changes.
Hypernatremia, as a result of low fluidvolume, creates a hypertonic vascularspace, which causes water to move out ofthe cells, including brain cells. Thisaccounts for neurologic symptoms.
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4. Monitor for cardiac manifestations ofhypernatremia (e.g., tachycardia,orthostatic hypotension).
5. Weigh daily and monitor trends.
6. Maintain accurate I & O record.
7. Monitor vital signs as appropriate.
8. Give fluids as appropriate.
The heart responds to a loss of fluid byincreasing the heart rate to compensatewith an increase in cardiac output. Lowfluid volume leads to a fall in blood
pressure.
Weight helps to assess fluid balance.
Accurate records are critical in assessingthe patients fluid balance.
Vital sign changes such as increased heartrate, decreased blood pressure, andincreased temperature indicatehypovolemia.
As her nausea decreases encourage heroral intake of fluids as tolerated, again toreplace lost volume.
Nausea and vomiting
Intervention Rationale1. Position the patient: To prevent aspiration
Conscious: semi fowlers,Unconscious:
lateral
2. Provide good oral care measures
3. Relieve sensation of nausea by providing
any of the following: Ice chips, Hot tea
with lemon, Hot ginger ale, Dry toast or
crackers, Cold cola beverage
4. Replace fluid-electrolyte loss (oralorintravenous fluid infusion) Observe forpotential complications as follows:Dehydration, Thirst (first sign), Dry
mouth and mucus membrane, Warm,flushed dry skin, Fever, tachycardia, lowBP, Weight loss, Sunken eyeballs
5. Acid-base balance Initially, metabolicalkalosis due to excessive loss of gastricacids
6. If vomiting is incessant /prolonged,metabolic acidosis occurs due to
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excessive loss of bicarbonate fromduodenum.
7. Administer antiemetic as ordered by thephysician
For sleep difficulties
Intervention Rationale
Encourage the patient to establish a
bedtime routine to facilitate transition
from wakefulness to sleep.
Determine the clients sleep and activitypattern.
Encourage him to eliminate stressful
situations before bedtime
Instruct the patient and significant others
about factors (e.g., physiologic,
psychologic, lifestyle, frequent work shift
changes, excessively long work hours, and
other environmental factors) that
contribute to sleep pattern disturbances.
Encourage verbalization of feelings,
perceptions, and fears.
Monitor bedtime food and beverage
intake for items that facilitate or interfere
with sleep
Rituals and routines induce comfort,
relaxation, and sleep
The amount of sleep an individual needsvaries with lifestyle, health, and age
Stress interferes with a persons ability to
relax, rest, and sleep
Knowledge of causative factors can enable
the client to begin to control factors that
inhibit sleep
Open expression of feelings facilitates
identification of specific emotions such as
anger or helplessness, distorted
perceptions, and unrealistic fears
Milk and protein foods contain
tryptophan, a precursor of serotonin,
which is thought to induce and maintain
sleep. Stimulants should be avoidedbecause they inhibit sleep
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7/29/2019 Intervention Edwards
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Feb 13, 2013 pain
Intervention Rationale
Perform a comprehensive assessment ofpain to include location, characteristics,
onset, duration, frequency, quality,
intensity or severity, and precipitating
factors of pain.
Teach the use of non pharmacologic
techniques (e.g., relaxation, guide
imagery, music therapy, distraction, and
massage) before, after, and if possible
during painful activities; before pain
occurs or increases; and along with otherpain relief measures.
Placed on moderate high back rest
Assisted upon ambulation
Encouraged diversional activities
Bed rest encouraged
Advised to avoid any strenuous activities
Advised to secure prescribed medications
Pain is a subjective experience and mustbe described by the client in order to plan
effective treatment
The use of noninvasive pain relief
measures can increase the release of
endorphins and enhance the therapeutic
effects of pain relief medications.
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7/29/2019 Intervention Edwards
12/19
Activity intolerance
Intervention Rationale
Determine patient's perception of causes
of fatigue or activity
Assess patient's level of mobility
Assess nutritional status.
Assess potential for physical injury with
activity
Assess need for ambulation aids: bracing,
cane, walker, equipment modification for
activities of daily living (ADLs).
Assess patient's cardiopulmonary status
before activity using the following
measures
Heart rate
Osthortatic BP changes
Need for oxygen with increased activity
These may be temporary or permanent,
physicalor psychological. Assessmentguides treatment
This aids in defining what patient iscapable of, which is necessary beforesetting realistic goals
Adequate energy reserves are required for
activity
injury may be related to falls oroverexertion
Some aids may require more energyexpenditurefor patients who have reduced upper armstrength(e.g., walking with crutches). Adequateassessment of energy requirements isindicated
Heart rate should not increase more than20 to 30 beats/min above resting withroutine activities.This number will change depending on theintensity of exercise the patient isattempting.
Elderly patients are more prone to drops inblood pressure with position changes
Portable pulse oximetry can be used toassess foroxygen desaturation. Supplemental oxygenmayhelp compensate for the increased oxygendemands.
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7/29/2019 Intervention Edwards
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Deficient fluid volume
Intervention Rationale Monitor for cardiac manifestations of
hypokalemia (e.g., hypotension,tachycardia, weak pulse, rhythmirregularities).
Obtain specimens for analysis of alteredsodium levels (e.g.,serum and urinesodium, urine osmolality, and urine specificgravity) as indicated.
Monitor for neurologic and neuromuscularmanifestations of hypernatremia (e.g.,lethargy, irritability, seizures, and
hyperreflexia).
Monitor for cardiac manifestations ofhypernatremia (e.g., tachycardia,orthostatic hypotension).
Weigh daily and monitor trends.
Maintain accurate I & O record.
Monitor vital signs as appropriate.
Give fluids as appropriate.
Many cardiac rhythm disorders can result
from hypokalemia. It is critical to monitorcardiac function with hypokalemia.
Urine analysis provides information aboutretention or loss of sodium and the abilityof the kidneys to concentrate or dilute urinein response to fluid changes.
Hypernatremia, as a result of low fluidvolume, creates a hypertonic vascularspace, which causes water to move out ofthe cells, including brain cells. Thisaccounts for neurologic symptoms.
The heart responds to a loss of fluid byincreasing the heart rate to compensatewith an increase in cardiac output. Lowfluid volume leads to a fall in bloodpressure.
Weight helps to assess fluid balance.
Accurate records are critical in assessingthe patients fluid balance.
Vital sign changes such as increased heartrate, decreased blood pressure, andincreased temperature indicatehypovolemia.
As her nausea decreases encourage heroral intake of fluids as tolerated, again toreplace lost volume.
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Impaired skin
Intervention Rationale
1. Assess noted skin turgos and sensation,described and measure wound andobserved changes
2. Demonstrated good skin hygiene: eg.Wash thoroughly and pat dry carefully.
3. Instructed family to clean dry clothes
preferably cotton fabric
4. Emphasized the importance of adequatenutrition and fluid intake
5. Demonstrated to the family member onhow a guava decoction to apply at thewound as alternative disinfectant.
6. Instructed family to clip and file nailsregularly.
7. Provided and applied wound dressingproperly
Establishes comparative baseline providingopportunity for timely intervention
Maintaining clean dry skin provides abarrier to infection. Patting skin dry insteadof rubbing reduces risk of dermal trauma tofragile skin.
Skin friction caused by stiff or rough
clothes leads to irritation of fragile skin andincreases risk for infection
Improved nutrition and hydration willimprove skin condition
Providing family with alternative solutionassists them in optimal healing with lessexpensive resources
Long and rough nails increase risk of skindamage
Wound dressings protect the wound andthe surrounding tissues
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headache
Intervention Rationale1. Make sure the duration / episode problems, who
have been consulted, and drug and / or whattherapy has been used
2. Thorough complaints of pain, record itensitasnya(on a scale 0-10), characteristics(eg, heavy,throbbing, constant) location, duration, factorsthat aggravate or relieve.
3. Note the possible pathophysiologicalcharacteristic, such as brain / meningeal /sinusinfection, cervical trauma, hypertension, ortrauma.
4. Observe for nonverbal signs of pain, are like:
facial expression, posture, restlessness, crying /grimacing, withdrawal, diaphoresis, changes inheart rate / breathing, blood pressure.
5. Assess the relationship of physical factors /emotional state of a person
6. Evaluation of pain behavior
7. Note the influence of pain such as: loss ofinterest in life, decreased activity, weight loss.
8. Assess the degree of making a false step inperson from the patient, such as isolatingthemselves.
9. Determine the issue of a second party to thepatient / significant others, such as insurance,spouse / family
10. Discuss the physiological dynamics of tension /anxiety with the patient / person nearest
11. Instruct patient to report pain immediately if thepain arises.
12. Place on a rather dark room according to theindication.
13. Suggest to rest in a quiet room.
14. Give cold compress on the head.15. Massage the head / neck / arm if the patient can
tolerate the touch.
16. Use the techniques of therapeutic touch,visualization, biofeedback, hypnosis itself, and
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stress reduction and relaxation techniques toanother.
17. Instruct the patient to use a positive statement "Iam cured, I'm relaxing, I love this life". Instruct thepatient to be aware of the external-internal
dialogue and say "stop" or "delay" if it comes upnegative thoughts.
18. Observe for nausea / vomiting. Give the ice,drinks containing carbonate as indicated.
Feb. 14, 2013
Intervention Rationale1. Assess the clients perception, level of
understanding and needs
2. Obtain clients baseline V/S includingpain scale
3. Encourage clients verbal report duringand after nursing interventions
4. Position the client to where she iscomfortable
5. Teach client deversional activities
6. Administer analgesic as prescribed
To identify and assess the different nursinginterventions to be done
To assess the effectiveness of nursinginterventions and obtain baseline for futurecomparison
Because pain is high subjective
To provide comfort
To divert attention from pain
Alleviate pain
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Fatique
Intervention Rationale
1. Monitor vital signs
2. Allow patient to have adequate restperiods, schedule activities for periodswhen client has the most energy
3. Encourage patient to do whateverpossible such as self care, walkingwithin war premises and interactingwith family
4. Instruct methods to conserve energy
such as sitting when doing daily care orother activities and taking frequentshort rest periods during activities.
5. Assist patient in self care needs andwith ambulation as needed
6. Provide supplemental oxygen
To evaluate fluid status and
cardiopulmonary response to activity To maximize patient participation
To manage patients limit of activity
To conserve and maximize patients
energy
To protect client from injury
Presence of hypoxemia/anemiareduces available oxygen for cellularuptake and contributes to fatique
Activity intolerance
Intervention Rationale
Determine patient's perception of causes
of fatigue or activity
Assess patient's level of mobility
Assess nutritional status.
Assess potential for physical injury with
activity
Assess need for ambulation aids: bracing,
These may be temporary or permanent,physicalor psychological. Assessmentguides treatment
This aids in defining what patient iscapable of, which is necessary before
setting realistic goals
Adequate energy reserves are required for
activity
injury may be related to falls oroverexertion
Some aids may require more energy
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cane, walker, equipment modification for
activities of daily living (ADLs).
Assess patient's cardiopulmonary status
before activity using the following
measures
Heart rate
Osthortatic BP changes
Need for oxygen with increased activity
expenditurefor patients who have reduced upper armstrength(e.g., walking with crutches). Adequateassessment of energy requirements isindicated
Heart rate should not increase more than20 to 30 beats/min above resting withroutine activities.This number will change depending on theintensity of exercise the patient isattempting.
Elderly patients are more prone to drops inblood pressure with position changes
Portable pulse oximetry can be used toassess foroxygen desaturation. Supplemental oxygenmayhelp compensate for the increased oxygendemands.
For sleep difficulties
Intervention Rationale
Encourage the patient to establish abedtime routine to facilitate transition
from wakefulness to sleep.
Determine the clients sleep and activity
pattern.
Encourage him to eliminate stressful
situations before bedtime
Instruct the patient and significant others
about factors (e.g., physiologic,psychologic, lifestyle, frequent work shift
changes, excessively long work hours, and
other environmental factors) that
contribute to sleep pattern disturbances.
Encourage verbalization of feelings,
perceptions, and fears.
Rituals and routines induce comfort,relaxation, and sleep
The amount of sleep an individual needs
varies with lifestyle, health, and age
Stress interferes with a persons ability to
relax, rest, and sleep
Knowledge of causative factors can enable
the client to begin to control factors thatinhibit sleep
Open expression of feelings facilitates
identification of specific emotions such as
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Monitor bedtime food and beverage
intake for items that facilitate or interfere
with sleep
anger or helplessness, distorted
perceptions, and unrealistic fears
Milk and protein foods contain
tryptophan, a precursor of serotonin,
which is thought to induce and maintain
sleep. Stimulants should be avoided
because they inhibit sleep