Nursing Diagnosis

Ineffective Airway Clearance r/t tracheobronchial obstruction

Long Term Goal:

Patient will maintain a patent

airway

Short Term Goals / Outcomes:

Patients lungs sounds will be clear to auscultate

Patient will be free of dyspnea

Patient will demonstrate correct coughing and deep breathing techniques

Intervention Rationale Evaluation

Assess airway for

patency by asking the

patient to state his

name.

Maintaining an airway is always top priority

especially in patients who may have experienced

trauma to the airway. If a patient can articulate

an answer, their airway is patent.

Patient is able to state their name

without difficulty.

Inspect the mouth,

neck and position of

trachea for potential

obstruction.

Foreign materials or blood in the mouth,

hematoma of the neck or tracheal deviation can

all mean airway obstruction.

No foreign objects, blood in mouth

noted. Neck is free of

hematoma. Trachea is midline.

Auscultate lungs for

presence of normal

or adventitious lung

sounds.

Decreased or absent sounds may indicate the

presence of a mucous plug or airway

obstruction. Wheezing indicates airway

resistance. Stridor indicates emergent airway

obstruction.

Patient’s lungs sounds are clear to

auscultation throughout all lobes.

Assess respiratory

quality, rate, depth,

effort and pattern.

Flaring of the nostrils, dyspnea, use of accessory

muscles, tachypnea and /or apnea are all signs

of severe distress that require immediate

intervention.

Patient is free of signs of distress.

Assess for mental

status changes.

Increasing lethargy, confusion, restlessness and /

or irritability can be early signs of cerebral

hypoxia.

Patient is awake, alert and oriented

X3.

Assess changes in Tachycardia and hypertension occur with Patient is normotensive with heart

vital signs. increased work of breathing. rate 60 – 100 bpm.

Monitor arterial

blood gases (ABGs).

Increasing PaCO2 and decreasing PaO2 are signs

of respiratory failure.

ABGs show PaCO2 between 35-45

and PaO2 between 80 – 100.

Administer

supplemental

oxygen.

Early supplemental oxygen is essential in all

trauma patients since early mortality is

associated with inadequate delivery of

oxygenated blood to the brain and vital organs.

Patient is receiving oxygen. SaO2 via

pulse oximetry is 90 – 100%.

Position Patient with

head of bed 45

degrees (if tolerated).

Promotes better lung expansion and improved

gas exchange.

Patient’s rate and pattern are of

normal depth and rate at 45 degree

angle.

Assist Patient with

coughing and deep

breathing techniques

(positioning,

incentive spirometry,

frequent position

changes).

Assist patient to improve lung expansion, the

productivity of the cough and mobilize

secretions.

Patient is able to cough and deep

breathe effectively.

Prepare for

placement of

endotracheal or

surgical airway (i.e.

cricothyroidectomy,

tracheostomy).

If a patient is unable to maintain an adequate

airway, an artificial airway will be required to

promote oxygenation and ventilation; and

prevent aspiration.

Artificial airway is placed and

maintained without complications.

Confirm placement of

the artificial airway.

Complications such as esophageal and right

main stem intubations can occur during

insertion. Artificial airway placement should be

confirmed by CO2 detector, equal bilateral

breath sounds and a chest x-ray.

CO2 detector changes color, bilateral

breath sounds are audible equally

and artificial airway is at the tip of

the carina on x-ray.

If maxillofacial

trauma is present:

1. position the

patient for

The patient with maxillofacial trauma is usually

more comfortable sitting up. Any time there is

trauma to the maxillofacial area there is the

possibility of a compromised airway.

Patient exhibits normal respiratory

rate and depth in sitting

position. Patient is free of

wheezing, stridor and facial edema.

optimal

airway

clearance and

constant

assessment

of airway

patency

2. note the

degree of

swelling to

the face and

amount of

blood loss

3. prepare the

patient for

definitive

treatment

Noting swelling is important as a baseline for

comparison later.

If neck trauma is

present:

1. assess for

potential

hemorrhage

and

disruption of

the larynx or

trachea

2. prepare the

patient for CT

scan

Hemorrhage or disruption of the larynx and

trachea can be seen as hoarseness in speech,

palpable crepitus, pain with swallowing or

coughing, or hemoptysis. The neck should be

also assessed for ecchymosis, abrasions, or loss

of thyroid prominence.

Laryngeal injuries are most definitely diagnosed

by CT scans as soft tissue neck films are not

sensitive to these injuries.

Patient is free of signs of

hemorrhage or disruption. CT scan

reveals no injury to the larynx.

Teach patient correct coughing and Deep breathing techniques.

Weak, shallow breathing and coughing is ineffective in removing secretions.

Patient is able to demonstrate correct coughing and breathing techniques.

Nursing Diagnosis Long Term Goal

Patient will maintain optimal gas

Impaired Gas Exchange r/t altered oxygen supply exchange

Short Term Goals / Outcomes:

Patient will maintain normal arterial blood gas (ABGs).

Patient will be awake and alert.

Patient will demonstrate a normal depth, rate and pattern of respirations.

Interventions Rationale Evaluation

Assess respirations:

quality, rate, pattern,

depth and breathing

effort.

Rapid, shallow breathing and hypoventilation

affect gas exchange by affecting

CO2 levels. Flaring of the nostrils, dyspnea, use of

accessory muscles, tachypnea and /or apnea are

all signs of severe distress that require immediate

intervention.

Patient is free of signs of distress.

ABGs show PaCO2 between 35-45

Pts respirations are of a normal

rate and depth.

Assess for life-

threatening

problems. (i.e. resp

arrest, flail chest,

sucking chest

wound).

Absence of ventilation, asymmetric breath

sounds, dyspnea with accessory muscle use,

dullness on chest percussion and gross chest wall

instability (i.e. flail chest or sucking chest wound)

all require immediate attention.

Patient exhibits spontaneous

breathing, no dyspnea, use of

accessory muscles, resonance on

percussion and no chest wall

abnormalities.

Auscultate lung

sounds. Also assess

for the presence of

jugular vein

distention (JVD) or

tracheal deviation.

Absence of lung sounds, JVD and / or tracheal

deviation could signify a Pneumothorax or

Hemothorax.

Patient’s lungs sounds are clear to

auscultate throughout all lobes.

Assess for signs of

hypoxemia.

Tachycardia, restlessness, diaphoresis, headache,

lethargy and confusion are all signs of hypoxemia.

Patient is free of signs of hypoxia.

Monitor vital signs. Initially with hypoxia and hypercapnia blood

pressure (BP), heart rate and respiratory rate all

increase. As the condition becomes more severe

BP may drop, heart rate continues to be rapid

with arrhythmias and respiratory failure may

ensue.

Patient is normotensive with heart

rate 60 – 100 bpm and respiratory

rate 10-20.

Assess for changes in

orientation and

behavior.

Restlessness is an early sign of

hypoxia. Mentation gets worse as hypoxia

increases due to lack of blood supply to the brain.

Patient is awake, alert and

oriented X3.

Monitor ABGs. Increasing PaCO2 and decreasing PaO2 are signs of

respiratory failure.

ABGs show PaCO2 between 35-45

and PaO2 between 80 – 100.

Place the patient on

continuous pulse

oximetry.

Pulse oximetry is useful in detecting changes in

oxygenation. Oxygen saturation should be

maintained at 90% or greater.

SaO2 via pulse oximetry remains at

90 – 100%.

Assess skin color for

development of

cyanosis, especially

circumoral cyanosis.

Lack of oxygen delivery to the tissues will result in

cyanosis. Cyanosis needs treated immediately as

it is a late development in hypoxia.

Patient is free of cyanosis.

Provide supplemental

oxygen, via 100%

O2 non-rebreather

mask.

Early supplemental oxygen is essential in all

trauma patients since early mortality is associated

with inadequate delivery of oxygenated blood to

the brain and vital organs.

Patient is receiving 100%

oxygen. SaO2 via pulse oximetry is

90 – 100%.

Prepare the patient

for intubation.

Early intubation and mechanical ventilation are

necessary to maintain adequate oxygenation and

ventilation, prior to full decompensation of the

patient.

Artificial airway is placed and

maintained without complications.

Treat the underlying

injuries with

appropriate

interventions.

Treatment needs to focus on the underlying

problem that leads to the respiratory failure.

Appropriate injury specific

treatment has been started.

If rib fractures exist:

1. Assess for

paradoxical

chest

movements.

2. Provide

adequate

Paradoxical movements accompanied by dyspnea

and pain in the chest wall indicate flail chest. Flail

chest is a life-threatening complication of rib

fractures that requires mechanical ventilation and

aggressive pulmonary care.

Pain relief is essential to enhance coughing and

deep breathing.

No paradoxical movements are

noted.

Patient reports pain as <3 on 0-10

scale.

Bilateral breath sounds present in

all lobes.

pain

3. relief.

Assess breath

sounds.

Absence of bilateral breath sounds in the

presence of a flail chest, indicates a

pneumo/hemo thorax.

If Pneumothorax or

Hemothorax exist:

1. obtain chest

x-ray

2. prepare for

insertion of a

chest tube

If open

Pneumothorax exists

place a dressing that

is taped on three

sides for temporary

management.

A chest x-ray confirms the presence of a

Pneumothorax and / or Hemothorax.

A chest tube decreases the thoracic pressure and

re-inflates the lung tissue.

A three sided dressing gives the accumulated air a

way to escape, thereby decreasing thoracic

pressure and preventing a tension

Pneumothorax. A chest tube must then be

inserted.

Chest tube is placed and connected

to 20cm wall suction with good

tidaling and no air leak or SQ

emphysema noted.

Three-sided dressing

maintained. No further

cardiopulmonary decompensation

noted in patient.

Position patient with

head of bed 45

degrees (if tolerated).

Promotes better lung expansion and improved

gas exchange.

Patient’s rate and pattern are of

normal depth and rate at 45

degree angle.

Assist patient with

coughing and deep

breathing techniques

(positioning,

incentive spirometry,

frequent position

changes, splinting of

the chest).

Promotes alveolar expansion and prevents

alveolar collapse.

Splinting helps reduce pain and optimizes deep

breathing and coughing efforts.

Patient is able to cough and deep

breathe effectively.

Suction patient as

needed.

Suctioning aides to remove secretions from the

airway and optimizes gas exchange.

Patient suctioned for moderate

amount of thin yellow

secretion. Lung sounds clear after

suctioning.

Hyperoxygenate

patient with 100%

before and after

suctioning. Keep

suctioning to 10-15

seconds.

Prevents alteration in oxygenation during

suctioning.

Patient’s SaO2 remained >90%

during suctioning.

Pace activities and

provide rest periods

to prevent fatigue.

Even simple activities, such as bathing, can

increase oxygen consumption and cause fatigue.

No changes to cardiopulmonary

status noted during activity.

Patients SaO2 remains >90% during

activities.

Nursing Diagnosis

Deficient Fluid Volume r/t active fluid loss due to bleeding

Long Term Goal

Patient will maintain adequate

fluid and electrolyte balance.

Short Term Goals / Outcomes:

Patient will maintain urine output >30cc/hr.

Patient will be normotensive with heart rate 60 -100bpm.

Patient will demonstrate normal skin turgor.

Interventions Rationale Evaluation

Palpate pulses: carotid,

brachial, radial, femoral,

popliteal and pedal. Note

quality and rate.

If carotid and femoral pulses are palpable,

then the blood pressure is usually at least

60 – 80 mmHg systolic. If peripheral pulses

are present, the blood pressure is usually

higher than 80 mmHg systolic. Pulses may

be weak and irregular.

All pulses palpable, strong and

regular.

Assess skin color and

temperature.

Cool, pale, diaphoretic skin suggests

ineffective circulation due to hypovolemia.

Skin pink, warm and dry.

Monitor patient for active

blood loss from wounds,

tubes, etc. Control any

external bleeding.

Active fluid and/or blood loss adds to

Hypovolemic state and must be accounted

for when replacing fluids.

All external bleeding controlled.

Monitor vital signs.

(T,P,R,B/P)

Sinus tachycardia may occur with

hypovolemia to maintain cardiac

output. Hypotension is a hallmark of

hypovolemia. Febrile states decrease body

fluids through perspiration and increase

respiratory rate.

Vital signs within normal limits.

Monitor blood pressure for

orthostatic changes.

Greater than 10 mmHg drop signifies that

circulating volume is reduced by

20%. Greater that 20 – 30 mmHg drop

signifies blood volume is decreased by 40%.

No orthostatic changes noted

when patient placed from supine

to Fowlers position.

Auscultate heart tones and

inspect jugular veins.

Abnormally flattened jugular veins and

distant heart tones are signs of ineffective

circulation.

S1, S2 audible. No flattening or

distention of jugular vein noted.

Assess mental status. Loss of consciousness accompanies

ineffective circulating blood volume to the

brain.

Awake, alert and oriented X3.

Assess skin turgor over the

sternum or inner thigh; and

assess moisture and

condition of mucous

membranes.

Dry mucous membranes and tenting of the

skin are signs of hypovolemia. The sternum

and inner thigh should be used for skin

turgor due to loss of elasticity with aging.

Normal skin turgor. Mucous

membranes pink and moist.

Assess color and amount of

urine.

Concentrated urine and output <30cc for

two consecutive hours indicate insufficient

circulating volume.

Urine clear, yellow. Output at

least 30cc/hr.

Monitor serum electrolytes

and urine osmolality.

Elevated hemoglobin, Hematocrit and blood

urea nitrogen (BUN) accompany a fluid

deficit. Urine specific-gravity is also

increased.

All lab values within normal

ranges.

Monitor hemodynamic

pressures: central venous

pressure (CVP), pulmonary

artery pressure (PAP),

pulmonary capillary wedge

All values decrease with inadequate

circulating volume. Hemodynamic stability

is the goal of fluid

replacements. Monitoring of hemodynamic

All pressures within normal

ranges.

pressure (PCWP), if

available.

pressures can guide fluid replacements.

Initiate two large bore

intravenous catheters (IVs)

and start intravenous fluid

replacements as ordered.

14 -16 gauge catheters are preferred in case

fluids need to be given rapidly. Parenteral

fluids are necessary to restore

volume. Lactated Ringers is usually the fluid

of choice due to its isotonic properties and

close resemblance to the electrolyte

composition of plasma.

Two large bore IVs started,

lactated ringers infusing as per

physician orders without

complications.

Obtain a serum specimen

for type and cross

matCh Administer blood

and blood products as

ordered.

Blood and blood products will be necessary

for active blood loss. If there is no time to

wait for cross matching, Type O blood may

be transfused.

Type and cross sent. Type specific

blood infusing as per physician

orders.

During treatment monitor

for signs of fluid overload.

Due to large amounts of fluids administered

rapidly, circulatory overload can occur.

Headache, flushed skin, tachycardia, venous

distention, elevated hemodynamic

pressures (CVP, PCWP), increased blood

pressure, dyspnea, crackles, tachypnea and

cough are all signs of overload.

No signs of overload noted with

fluid replacements.

Assist the physician with

insertion of a central venous

line and arterial line if

indicated.

Provides for more effective fluid

replacements and accurate monitoring of

hemodynamic picture.

Central venous line and arterial

line inserted without difficulty.

Nursing Diagnosis

Acute Pain r/t trauma

Long Term Goal

Patient will be free of

pain

Short Term Goals / Outcomes:

Patient will report pain less than 3 on 0-10 scale.

Patient’s vital signs will be within normal limits.

Interventions Rationale Evaluation

Assess pain

characteristics: quality

(sharp, burning);

severity (0 -10 scale);

location; onset

(gradual, sudden);

duration (how long);

precipitating or

relieving factors.

A good assessment of pain will help in the treatment

and ongoing management of pain.

Patient reports pain as

3 or less on 0-10 scale;

intermittent and sharp

in incision area.

Monitor vital signs. Tachycardia, elevated blood pressure, tachypnea and

fever may accompany pain.

Vital signs within

normal limits.

Assess for non-verbal

signs of pain.

Some patients may verbally deny pain when it is still

present. Restlessness, inability to focus, frowning,

grimacing and guarding of the area may be non-

verbal signs of acute pain.

No non-verbal signs of

pain noted.

Give analgesics as

ordered and evaluate

the effectiveness.

Narcotics are indicated for severe pain. Pain

medications are absorbed and metabolized

differently in each patient, so their effectiveness

must be assessed after administration.

Analgesics given as

ordered. Patient

reports satisfactory

pain relief after

administration.

Assess the patient’s

expectations of pain

relief.

Some patients are content with reduction in pain,

others may expect complete elimination. This effects

the patient’s perception of the effectiveness of

treatment.

Patient states “I want

some relief. I know

some pain will still

exist.”

Assess for

complications to

analgesics, especially

respiratory depression.

Excessive sedation and respiratory depression are

severe side effects that need reported immediately

and may require discontinuation of

medication. Urinary retention, nausea/vomiting and

constipation can also occur with narcotic use and

need reported and treated.

No complications of

analgesia noted.

Anticipate the need for

pain relief and respond

The most effective way to deal with pain is to

prevent it. Early intervention can decrease the total

Patient reports pain as

immediately to

complaints of pain.

amount of analgesic required. Quick response

decreases the patient’s anxiety regarding having

their needs met and demonstrates caring.

soon as it starts.

Eliminate additional

stressors when

possible. Provide rest

periods, sleep and

relaxation.

Outside sources of stress, anxiety and lack of sleep all

may exaggerate the patient’s perception of pain.

Patient appears

relaxed, is sleeping

throughout the night.

Institute non-

pharmacological

approached to pain

(detraction, relaxation

exercises, music

therapy, etc.).

Non-pharmacological approaches help distract the

patient from the pain. The goal is to reduce tension

and thereby reduce pain.

Patient is relaxing by

use of non-

pharmacological

technique of choice.

If patient is on patient

controlled analgesia

(PCA):

1. Dedicate an IV

line for PCA

only.

2. Assess pain

relief and the

amount of pain

the patient is

requesting.

3. Educate

patient and

significant

others on

correct use of

PCA.

Drug interaction may occur, if dedicated line is not

possible consult pharmacist before mixing drugs.

If demands for the drug are frequent the basal or

lock-out dose may need to be increased to cover the

patient’s pain.

If demands for the drug are very low, the patient may

need further education of use of the PCA.

The patient and significant others must understand

that the patient is the only one who should control

the PCA.

PCA infusing without

complications. Patient

and family understand

purpose and use of

PCA. Patient is getting

adequate pain relief

with current dose.

If the patient is

receiving epidural

analgesia:

These symptoms indicate an allergic response, or

improper catheter placement.

Labeling of tubing is necessary to prevent

All tubing labeled. No

signs of allergic

reaction or catheter

1. Assess for

numbness,

tingling in

extremities;

and a metallic

taste in the

mouth.

2. Label all tubing

clearly.

inadvertent administration of fluids or drugs in the

epidural space.

Catheter migration or improper administration

through the catheter can result in life-threatening

complications.

migration noted.

For PCA and epidural

analgesia:

1. Keep Narcan

readily

available.

2. Place “No

additional

analgesia” sign

over head of

bed.

In event of respiratory depression reversal agent

must be available.

This prevents inadvertent analgesia overdosing.

Narcan on unit if

needed. Sign placed in

room for safety.

Nursing Diagnosis

Risk For Infection r/t inadequate primary defenses

Long Term Goal

Patient will be free of

infection

Short Term Goals / Outcomes:

Patient will maintain normal vital signs.

Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes.

Interventions Rationale Evaluation

Assess for presence of risk

factors: open wounds,

abrasions; indwelling catheters;

drains; artificial airways; and

venous access devices.

Represent a break in body’s first line of

defense.

Patient has midline

thoracic incision, Foley,

chest tube and

peripheral IV access.

Monitor white blood count Normal WBC is 4-11 mm3. Rising WBC Patient’s WBC are within

(WBC). indicates the body’s attempt to combat

pathogens.

the normal range.

Monitor incisions, injured sites

and exit sites of tubes, drains

and catheters for signs of

infection.

Redness, swelling, increased pain, or

purulent drainage is suspicious of infection

and should be cultured.

All areas are without

signs of infection.

Monitor temperature and the

presence of sweating and chills.

In the first 24-48 hours fever up to 38

degrees C (100.4F) is related to the stress of

surgery. After 48 hours fever above 37.7C

(99.8F) suggests infection. High fever with

sweating and chills suggests septicemia.

Temperature is less than

37.7C. No sweating or

chills present.

Monitor the color of respiratory

secretions.

Yellow or yellow-green sputum indicates a

respiratory infection.

Patient coughs up only

thin clear secretions.

Monitor the appearance of

urine.

Cloudy, foul-smelling urine, with sediments

indicates a urinary tract or bladder

infection.

Urine is clear yellow

with no sediments.

Maintain strict aseptic

technique with all dressing

changes; tubes, drains and

catheter care; and venous

access devices.

Strict asepsis is necessary to prevent cross-

contamination and nosocomial infections.

No further infections are

noted.

Wash hands and teach others to

wash hands before and after

patient care.

Hand washing reduces the risk of

transmitting pathogens from one area of

the body to another as well as from one

patient to another.

No further infections are

noted.

Encourage fluid intake of

2000ml – 3000ml of water per

day (unless contraindicated).

Fluids promote frequent emptying of the

bladder, reducing stasis of urine and risk of

urinary tract and bladder infections.

Patient drinks 2000 -

3000 ml of fluid. No

presence of urinary tract

or bladder infections.

Encourage intake of protein and

calorie rich foods. Provide

enteral feeding in patients who

Optimal nutritional status promotes wound

healing.

Wounds are well

approximated.

are NPO.

Encourage coughing and deep

breathing.

Reduces stasis of pulmonary secretions,

reducing the risk of pneumonia.

Patient coughs up thin

clear secretions.

Administer and teach the use of

antimicrobial drugs as ordered.

All agents are either toxic to the pathogens

or retard the pathogen’s growth. Ideally

medications should be selected based on a

culture from the infected area. A broad-

spectrum agent may be started until culture

reports are available.

WBC within normal

limits. No further

infections noted.

Nursing Diagnosis

Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary,

or central r/t hypovolemia, decreased arterial flow & cerebral edema

Long Term Goal

Patient will maintain

optimal tissue

perfusion to vital

organs

Short Term Goals / Outcomes:

Patient will maintain strong peripheral pulses.

Patient will report absence of chest pain.

Patient will be awake, alert and oriented.

Patient will maintain normal arterial blood gases (ABGs).

Patient will maintain normal urine output.

Patient will maintain normal bowel sounds.

Interventions Rationale Evaluation

Assess each area for

signs of decreased

tissue perfusion.

Early detection facilitates prompt, effective

treatment.

Signs may be:

Peripheral: weak, absent pulses; edema; numbness,

pain, aches; cool to touch; mottling; prolonged

capillary refill

Cardiopulmonary: tachycardia, arrhythmias,

hypotension, tachypnea, abnormal ABGs, angina

Renal: decreased output, hematuria, elevated

BUN/creatinine ratio

No signs of decreased

perfusion noted.

GI: decreased or absent bowel sounds; nausea;

abdominal pain / distention

Cerebral: restless, change in mentation seizure

activity, papillary changes and decrease reaction to

light

Monitor vital signs for

optimal cardiac output.

Adequate perfusion to vital organs is essential. A

mean arterial blood pressure of at least 60 mmHg is

essential to maintain perfusion.

All vital signs within

normal limits.

Administer fluids and

blood products as

ordered.

Aids in maintaining adequate circulating volume to

prevent irreversible ischemic damage.

Fluids infusing. Vital

signs, urine output and

mentation all within

normal limits.

Anticipate the need for

possible

antithrombolytic

therapy.

If an obstruction to the area has developed an

embolectomy, heparinzation, or thrombolytic

therapy may be necessary to restore flow and

prevent ischemia

Heparin infusing. PTT

within therapeutic

range.

Assess for

compartment

syndrome if peripheral

circulation is impaired

(pain, palor,

pulselessness,

paralysis, parathesia).

Compartment syndrome develops as the tissue

swells and the fascial covering over the muscles can

not yield to the pressure. Blood flow to the

extremity is drastically reduced. An emergent

fasciotomy may need to be performed to restore

flow.

No signs of

compartment

syndrome noted.

Administer oxygen as

prescribed. Titrate

oxygen based on

continuous pulse

oximetry levels.

Oxygen saturates circulating hemoglobin and

increases the effectiveness of blood that reached the

ischemic tissues. Thus improving tissue perfusion.

Patient receiving

oxygen. Pulse

Oximetry 90 – 100%.

Monitor ABGs,

especially for metabolic

acidosis and hypoxia.

Metabolic acidosis and hypoxia indicate that tissues

are not adequately being perfused.

ABGs within normal

limits.

If Patient complains of NTG causes vasodilation, decreases preload and

afterload and thus improves perfusion to the

NTG

administer. Patient

angina;

1. administer

nitroglycerin

(NTG)

sublingually.

myocardium. reports relief of angina.

If cerebral perfusion is

compromised:

1. Ensure proper

functioning of

intracranial

pressure (ICP)

catheter if

present.

2. Elevate head of

bed 30 -45

degrees.

3. Avoid

measures that

may trigger

increased ICP

4. Administer

anticonvulsants

as needed.

Promotes venous outflow from brain and helps

reduce pressure.

Straining, coughing, neck or hip flexion and lying

supine may increase ICP and further reduce blood

flow.

Reduces the risk of seizures, which may result from

cerebral edema or ischemia.

Patient awake and alert

with no change in

mentation.

No seizures noted

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTI

ON

RATIONALE EVALUATIO

N

SUBJECTIVE:

“Namamanas

ang paa

ko”(My feet

are swelling)

as verbalized

by the

patient.

OBJECTIVE:

Restlessn

ess

Fatigue

Edema on

lower

extremitie

s

V/S taken

as follows

T: 36.9˚C

Excess fluid

volume

related to

compromis

ed

regulatory

mechanism

Excessive

fluid

volume in

the blood.

This fluid

excess

usually

results

from

compromis

ed

regulatory

mechanism

s for

sodium and

water as

seen in

congestive

heart

failure

(CHF),

kidney

failure, and

liver failure.

It can also

be caused

by too

much

intake of

sodium

from foods,

intravenous

(IV)

solutions,

medication

s, or

After 4

hours of

nursing

interventio

ns, the

Patient will

demonstrat

e stabilized

fluid

volume as

evidenced

by balanced

intake and

output

(I&O) and

vital signs

within

client’s

normal

range.

INDEPENDEN

T

Monitor

vital

signs as

well as

central

venous

pressure.

Auscultat

e lung

and

heart

sounds.

Maintain

adequat

e I&O.

Note

decrease

d urinary

output

Tachycar

dia and

hyperten

sion are

common

manifest

ations.

Crackle

sounds

and extra

heart

sounds

are

indicative

of fluid

excess,

possibly

resulting

in rapid

develop

ment of

pulmonar

y edema.

Decrease

d renal

perfusion

, cardiac

insufficie

ncy, and

fluid

shifts

may

cause

After 4

hours of

nursing

interventio

ns, the

Patient was

able to

demonstrat

e stabilized

fluid

volume as

evidenced

by balanced

intake and

output

(I&O) and

vital signs

within

client’s

normal

range.

P: 102

R: 20

BP: 110/ 80

diagnostic

contrast

dyes. The

excess

fluid,

mainly salt

and water,

builds up in

different

body

locations

and can

lead to

swelling in

the legs

and arms

(peripheral

edema),

and/or fluid

in the

abdomen

(ascites).

and

positive

fluid

balance

on 24-

hour

calculati

ons.

Weigh as

indicated

. Be alert

for

sudden

weight

gain.

Encourag

e

coughing

and deep

breathin

g

exercises

.

Maintain

semi-

fowler’s

position.

decrease

urinary

output

and

edema

formatio

n.

One liter

of fluid

retention

equals a

weight

gain of 1

kilogram.

Pulmonar

y fluid

shifts

potentat

e

respirato

ry

complicat

ions.

Gravity

improves

lung

expansio

n.

Reduce

pressure

and

friction

on

edemato

us tissue.

Turn or

repositio

n, and

provide

skin care

at

regular

intervals.

Encourag

e bed

rest.

Limited

cardiac

reserves

results in

fatigue

and

activity

intoleran

ce.

Caregiver Role Strain - Evaluation, Interventions, Documentation

9:23 PM Posted by Pak Mantri

Desired Outcomes/Evaluation

Criteria—Client Will:

• Identify resources within self to deal with situation.

• Provide opportunity for care receiver to deal with situation in own way.

• Express more realistic understanding and expectations of the care receiver.

• Demonstrate behavior/lifestyle changes to cope with and/or resolve problematic factors.

• Report improved general well-being, ability to deal with situation.

Actions/Interventions

NURSING PRIORITY NO. 1. To assess degree of impaired function:

• Inquire about/observe physical condition of care receiver and surroundings as appropriate.

• Assess caregiver’s current state of functioning (e.g., hours of sleep, nutritional intake, personal

appearance, demeanor).

• Determine use of prescription/over-the-counter (OTC) drugs, alcohol to deal with situation.

• Identify safety issues concerning caregiver and receiver.

• Assess current actions of caregiver and how they are received by care receiver (e.g., caregiver may be

trying to be helpful but is not perceived as helpful; may be too protective or may have unrealistic

expectations of care receiver). May lead to misunderstanding and conflict.

• Note choice/frequency of social involvement and recreational activities.

• Determine use/effectiveness of resources and support systems.

NURSING PRIORITY NO. 2. To identify the causative/contributing factors relating to the impairment:

• Note presence of high-risk situations (e.g., elderly client with total self-care dependence, or family

with several small children with one child requiring extensive assistance due to physical

condition/developmental delays). May necessitate role reversal resulting in added stress or place

excessive demands on parenting skills.

• Determine current knowledge of the situation, noting misconceptions, lack of information.May

interfere with caregiver/ care receiver response to illness/condition.

• Identify relationship of caregiver to care receiver (e.g., spouse/lover, parent/child, sibling, friend).

• Ascertain proximity of caregiver to care receiver.

• Note physical/mental condition, complexity of therapeutic regimen of care receiver.

• Determine caregiver’s level of responsibility, involvement in and anticipated length of care.

• Ascertain developmental level/abilities and additional responsibilities of caregiver.

• Use assessment tool, such as Burden Interview, when appropriate, to further determine caregiver’s

abilities.

• Identify individual cultural factors and impact on caregiver. Helps clarify expectations of

caregiver/receiver, family, and community.

• Note co-dependency needs/enabling behaviors of caregiver.

• Determine availability/use of support systems and resources.

• Identify presence/degree of conflict between caregiver/care receiver/family.

• Determine preillness/current behaviors that may be interfering with the care/recovery of the care

receiver.

NURSING PRIORITY NO. 3. To assist caregiver in identifying feelings and in beginning to deal with

problems:

• Establish a therapeutic relationship, conveying empathy and unconditional positive regard.

• Acknowledge difficulty of the situation for the caregiver/ family.

• Discuss caregiver’s view of and concerns about situation.

• Encourage caregiver to acknowledge and express feelings. Discuss normalcy of the reactions without

using false reassurance.

• Discuss caregiver’s/family members’ life goals, perceptions and expectations of self to clarify

unrealistic thinking and identify potential areas of flexibility or compromise.

• Discuss impact of and ability to handle role changes necessitated by situation.

NURSING PRIORITY NO. 4. To enhance caregiver’s ability to deal with current situation:

• Identify strengths of caregiver and care receiver.

• Discuss strategies to coordinate caregiving tasks and other responsibilities (e.g., employment, care of

children/dependents, housekeeping activities).

• Facilitate family conference to share information and develop plan for involvement in care activities as

appropriate.

• Identify classes and/or needed specialists (e.g., first aid/CPR classes, enterostomal/physical therapist).

• Determine need for/sources of additional resources (e.g., financial, legal, respite care).

• Provide information and/or demonstrate techniques for dealing with acting out/violent or disoriented

behavior. Enhances safety of caregiver and receiver.

• Identify equipment needs/resources, adaptive aids to enhance the independence and safety of the

care receiver.

• Provide contact person/case manager to coordinate care, provide support, assist with problem-

solving.

NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):

• Assist caregiver to plan for changes that may be necessary (e.g., home care providers, eventual

placement in long-term care facility).

• Discuss/demonstrate stress management techniques and importance of self-nurturing (e.g., pursuing

self-development interests, personal needs, hobbies, and social activities).

• Encourage involvement in support group.

• Refer to classes/other therapies as indicated.

• Identify available 12-step program when indicated to provide tools to deal with enabling/co-

dependent behaviors that impair level of function.

• Refer to counseling or psychotherapy as needed.

• Provide bibliotherapy of appropriate references for self-paced learning and encourage discussion of

information.

Documentation Focus

ASSESSMENT/REASSESSMENT

• Assessment findings, functional level/degree of impairment, caregiver’s understanding/perception of

situation.

• Identified risk factors.

PLANNING

• Plan of care and individual responsibility for specific activities.

• Needed resources, including type and source of assistive devices/durable equipment.

• Teaching plan.

IMPLEMENTATION/EVALUATION

• Caregiver/receiver response to interventions/teaching and actions performed.

• Identification of inner resources, behavior/lifestyle changes to be made.

• Attainment/progress toward desired outcome(s).

• Modifications to plan of care.

DISCHARGE PLANNING

• Plan for continuation/follow-through of needed changes.

• Referrals for assist

ASSESSMENT DIAGNOSIS SCIENTIFICEXPLANATIONPLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

“eto nga at hianng hina siya, hindi naniya magalaw angright side niya”

As stated by the significant other

OBJECTIVE:-grade of 0 in the level of functioning-paraesthesia in the right side of thebody-0/5 muscle

strength in theRUE-1/5 muscle strength in the RLE-impaired coordination-inability to purposefully move

body part IMPAIREDPHYSICALMOBILITY r t neuromuscular involvement (right sided paraesthesia) abed

inability to purposefully move body parts. HPN, age, alcohol, smoking ↓Thrombus formation in the

blood vessel ↓Obstruction to the flow of blood↓ metabolic acidosis, an aerobic respiration

↓Destruction of neurons↓

DISCHARGEPLAN:

After 2 week of Nursing Intervention the client will be able to move and do minimal task such as:-go to

the toilet with minimal assistance- ambulate moderately-eat without assistance-do tooth brushing

without assistance

SHORT TERM: After 1 week of Nursing Intervention the Significant other will be able to verbalize

understanding of *Observe movement when client is unaware of observation*schedule activities with

adequate rest periods during the day* encourage energy conserving techniques for rising

ADLs*encourage adequate intake of fluids and nutritious foods like: fruits and vegetables.*Plan for

progressive increase of activity level/ participation in exercise, training as tolerated by the client, such

as:-performing ROM*to note any in congruencies w/reports or abilities*to reduce fatigue and increase

comfort.*limit fatigue and maximize participation*maximize energy production and aides in fast

recovery.*Helps to minimize frustrations and rechanneled energy .DISCHARGE PLAN: After 2 week of

Nursing Intervention the client had been able to move and do minimal task such as:-go to the toilet with

minimal assistance-ambulate moderately-eat without assistance-do tooth brushing without assistance

SHORT TERM: After 1 week of Nursing Intervention the Significant other had been able to verbalize

understanding of the situation and /evaluation.