intervention edwards

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.


2/19


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


3/19

For sleep difficulties


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


4/19

Urinary retention


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.


5/19

Feb. 11, 2013 risk for infection


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


6/19

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


1. Perform a comprehensive assessment of

pain to include location, characteristics,

onset, duration, frequency, quality,


factors of pain.

2. Teach the use of non pharmacologic



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






7/19



1. Encourage the patient to establish a



2. Determine the clients sleep and activity

pattern.

3. Encourage him to eliminate stressful


4. Instruct the patient and significant others


psychologic, lifestyle, frequent work shiftchanges, excessively long work hours, and



5. Encourage verbalization of feelings,


6. Monitor bedtime food and beverageintake for items that facilitate or interfere

with sleep









inhibit sleep





Milk and protein foods containtryptophan, a precursor of serotonin,





8/19

Feb. 12, 2013- anxiety


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.


9/19

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


10/19

excessive loss of bicarbonate fromduodenum.

7. Administer antiemetic as ordered by thephysician



Encourage the patient to establish a



Determine the clients sleep and activitypattern.

Encourage him to eliminate stressful


Instruct the patient and significant others


psychologic, lifestyle, frequent work shift




Encourage verbalization of feelings,


Monitor bedtime food and beverage


with sleep



The amount of sleep an individual needsvaries with lifestyle, health, and age





inhibit sleep








sleep. Stimulants should be avoidedbecause they inhibit sleep


11/19

Feb 13, 2013 pain


Perform a comprehensive assessment ofpain to include location, characteristics,

onset, duration, frequency, quality,


factors of pain.

Teach the use of non pharmacologic



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






12/19



Determine patient's perception of causes


Assess patient's level of mobility

Assess nutritional status.

Assess potential for physical injury with

activity

Assess need for ambulation aids: bracing,



Assess patient's cardiopulmonary status


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


activity


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.




13/19

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.


14/19

Impaired skin


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


15/19

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


16/19

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


17/19

Fatique


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



Determine patient's perception of causes


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


activity


Some aids may require more energy


18/19



Assess patient's cardiopulmonary status


measures

Heart rate



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.





Encourage the patient to establish abedtime routine to facilitate transition


Determine the clients sleep and activity

pattern.

Encourage him to eliminate stressful


Instruct the patient and significant others

about factors (e.g., physiologic,psychologic, lifestyle, frequent work shift




Encourage verbalization of feelings,


Rituals and routines induce comfort,relaxation, and sleep






the client to begin to control factors thatinhibit sleep




19/19

Monitor bedtime food and beverage


with sleep








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