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The very best patient care begins with the very best
CARE PLANNING RESOURCES …now and throughout your career! Doenges, Moorhouse & Murr
NURSE’S POCKET GUIDE
Diagnoses, Prioritized Interventions and Rationales The perfect portable guide for practitioners and nursing students on the go! Here’s everything you need to select the appropriate diagnoses for your patients and develop safe and effective care plans.
Doenges & Moorhouse
APPLICATION OF NURSING PROCESS AND NURSING DIAGNOSIS
An Interactive Text for Diagnostic Reasoning Master the nursing process with this step-by-step approach to the whys and hows, while you develop the diagnostic reasoning and problem-solving skills you need to ‘think like a nurse.’
Doenges, Moorhouse & Murr
NURSING DIAGNOSIS MANUAL Planning, Individualizing, and Documenting Client Care
Rely on this complete reference to identify interventions commonly associated with specific nursing diagnoses across the lifespan, and to help plan, individualize, and document care for more than 800 diseases and disorders.
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A wealth of online tools help you learn to plan and implement safe, individualized care. Visit DavisPlus.FADavis.com today! § Concept Care Map Generator
§ Care Plan Case Studies
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§ Interactive Assessment Tool
§ Online Disorder Lookup
§ Care Plan Template
§ Nursing Diagnoses Arranged by Maslow Hierarchy
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INDEX OF DISEASES/DISORDERS This is 1 of 2 indexes in the book. It should be compiled by the indexer and only needs to contain the disorder/disease and the page number in which the care plan for that disorder/disease begins. Acid-base imbalances respiratory, 179 metabolic, 450 Acquired immunodeficiency syndrome (AIDS), 689 Acute coronary syndrome (ACS), 58 Acute kidney injury (acute renal failure), 505 Adult leukemias, 484 Alcohol: acute withdrawal, 800 Alzheimer’s disease, 743 Amputation, 616 Anemia–iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic, 459 Angina: chronic/stable, 67 Anorexia nervosa, 340 Aplastic anemia, 459 Appendectomy, 315 Asthma, 118 Bariatric surgery, 367 Benign prostatic hyperplasia, 559 Brain infections: meningitis and encephalitis, 229 Bulimia nervosa, 340 Burns: thermal, chemical, and electrical—acute and convalescent phases, 638 Cancer, 827 Cardiac dysrhythmias, 87 Cardiac surgery: postoperative care, 98 Cardiomyoplasty, 98 Cerebrovascular accident/stroke, 214 Chemical burns, 638 Cholecystectomy, 335 Cholecystitis with cholelithiasis, 329 Cholelithiasis, 329 Chronic obstructive pulmonary disease (COPD) and asthma, 118 Cirrhosis of the liver, 412 Colostomy, 304 Coronary artery bypass graft, 98 Craniocerebral trauma–acute rehabilitative phase, 197 Crohn’s disease, 291 Dementia (Alzheimer’s type or vascular), 743 Diabetes mellitus/diabetic ketoacidosis, 377 Diabetic ketoacidosis, 377 Disaster considerations, 858 Disc surgery, 237 Dysrthymias, 87 Eating disorders: anorexia nervosa/bulimia nervosa, 340 Eating disorders: obesity, 358 Electrical burns, 638 Encephalitis, 229 End-of-life care/hospice, 848 End stage renal disease, 517 Enteral feeding, 437 Esophageal bleeding, 281 Extended care, 781
Fecal diversions: postoperative care of ileostomy and colostomy, 304 Fluid and electrolyte imbalances, 886 Fractures, 601 Gastrectomy/gastroplasty, DavisPlus Gastric bypass, 367 Gastric partitioning, 367 Glaucoma, DavisPlus Graves’ disease, 391 Heart failure: chronic, 43 Hemodialysis, 544 Hemolytic anemia, 459 Hemothorax, 150 Hepatitis, 400 Herniated nucleus pulposus, DavisPlus HIV-positive client, 677 Hospice, 848 Hypercalcemia (calcium excess), 909 Hyperkalemia (potassium excess), 903 Hypermagnesemia (magnesium excess), 915 Hypernatremia (sodium excess), 897 Hypertension: severe, 33 Hyperthyroidism (Graves’ disease, thyrotoxicosis), 391 Hypervolemia (extracellular fluid volume excess), 886 Hypocalcemia (calcium deficit), 906 Hypokalemia (potassium deficit), 900 Hypomagnesemia (magnesium deficit), 912 Hyponatremia (sodium deficit), 893 Hypovolemia (extracellular fluid volume deficit), 890 Hysterectomy, 581 Ileostomy, 304 Inflammatory bowel disease: ulcerative colitis, Crohn’s disease, 291 Iron deficiency anemia, 459 Laminectomy, 237 Laryngectomy, DavisPlus Lewy body disease, 743 Leukemias, 484 Lung cancer: postoperative care, 141 Lymphomas, 494 Mastectomy, 589 Meningitis, 229 Metabolic acid-base imbalances, 450 Metabolic acidosis—primary base bicarbonate deficiency, 450 Metabolic alkalosis—primary base bicarbonate excess, 455 Minimally invasive direct coronary artery bypass, 98 Multiple sclerosis, 266 Myocardial infarction, 75 Obesity, 358 Obesity: bariatric surgery, 367
Pancreatitis, 426 Parenteral feeding, 437 Pediatric considerations, 872 Peritoneal dialysis, 539 Peritonitis, 320 Pernicious anemia, 459 Pneumonia, 129 Pneumothorax, 150 Primary base bicarbonate deficiency, 450 Primary base bicarbonate excess, 455 Primary carbonic acid deficit, 184 Primary carbonic acid excess, 179 Prostatectomy, 566 Psychosocial aspects of care, 729 Pulmonary emboli considerations, 109 Pulmonary tuberculosis (TB), 170 Radical neck surgery, DavisPlus Renal calculi, 573 Renal dialysis—general considerations, 529 Renal failure: acute, 505 Renal failure: chronic, 517 Respiratory acid-base imbalances, 179 Respiratory acidosis (primary carbonic acid excess), 179 Respiratory alkalosis (primary carbonic acid deficit), 184 Rheumatoid arthritis (RA), 709 Ruptured invertebral disc, DavisPlus Seizure disorders, 188 Sepsis/septicemia, 665 Sickle cell crisis, 469 Spinal cord injury (acute rehabilitative phase), 248 Stroke, 214 Substance use disorders (SUDs), 815 Surgical intervention, 762 Thermal burns, 638 Thrombophlebitis: venous thromboembolism, 109 Thyroidectomy, DavisPlus Thyrotoxicosis, 391 Total joint replacement, 625 Total nutritional support: parenteral/enteral feeding, 437 Transplantation considerations—postoperative and lifelong, 719 Tuberculosis (TB), pulmonary, 170 Ulcerative colitis, 291 Upper gastrointestinal/esophageal bleeding, 281 Urinary diversions/urostomy (postoperative care), 548 Urolithiasis (renal calculi), 573 Urostomy, 548 Valve replacement, 98 Vascular dementia, 743 Ventilatory assistance (mechanical), 157 Wound care: complicated or chronic, 657
Herdman, T.H. (Ed.). Nursing Diagnoses—Definitions and Classification 2012–2014. Copyright © 2012, 1994–2012 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
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KEY TO ESSENTIAL TERMINOLOGY Client Assessment Database Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical and/or surgical diagnosis or health condition as well as the signs and symptoms and corresponding diagnostic findings.
Nursing Priorities Establishes a general ranking of needs and 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 need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added to create 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 related to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observations of quivering voice, focus on self. In addition, diagnoses identified within these guides for planning care as actual, risk, or health-promotion can be changed or deleted and new diagnoses added, depending entirely on the specific client situation or available information.
May Be Related to/Possibly Evidenced by These lists provide the usual or common reasons (etiology) why a particular need or problem may occur with probable signs and 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 and 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. Furthermore, health-promotion diagnoses (readiness for enhanced) do not contain related factors, but do have defining characteristics for the “evidenced by” segment of the client diagnostic statement.
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 or individualize them by adding time lines and specific 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 nursing language and serves as a general header for the outcome indicators that follow.
Actions/Interventions Nursing Interventions Classification (NIC) labels are drawn from a third 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. The interventions in this book are generally ranked from most to least common. When creating the individual plan of care, interventions would normally be ranked to reflect the client’s specific needs and situation. In addition, the division of independent and collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities, agency protocols, and professional standards.
Rationale Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiological basis 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- or 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.
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NURSING DIAGNOSES ACCEPTED FOR USE AND RESEARCH FOR 2012–2014 Activity Intolerance [specify level] Activity Intolerance, risk for Activity Planning, ineffective Activity Planning, risk for ineffective Adverse Reaction to Iodinated Contrast Media, risk for Airway Clearance, ineffective Allergy Response, risk for Anxiety [specify level] Aspiration, risk for Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, disorganized infant Behavior, readiness for enhanced organized infant Behavior, risk for disorganized infant Bleeding, risk for Blood Glucose Level, risk for unstable Body Image, disturbed Body Temperature, risk for imbalanced Breast Milk, insufficient Breastfeeding, ineffective Breastfeeding, interrupted Breastfeeding, readiness for enhanced Breathing Pattern, ineffective Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Childbearing Process, ineffective Childbearing Process, readiness for enhanced Childbearing Process, risk for ineffective Comfort, impaired Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Confusion, acute Confusion, chronic Confusion, risk for acute Constipation Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, compromised family Coping, defensive Coping, disabled family Coping, ineffective Coping, ineffective community Coping, readiness for enhanced Coping, readiness for enhanced community Coping, readiness for enhanced family Death Anxiety Decision-Making, readiness for enhanced Decisional Conflict Denial, ineffective Dentition, impaired Development, risk for delayed Diarrhea Dignity, risk for compromised human Disuse Syndrome, risk for Diversional Activity, deficient Dry Eye, risk for Electrolyte Imbalance, risk for Energy Field, disturbed Environmental Interpretation Syndrome, impaired Failure to Thrive, adult Falls, risk for Family Processes, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Fatigue Fear Feeding Pattern, ineffective infant Fluid Balance, readiness for enhanced [Fluid Volume, deficient hyper/hypotonic] Fluid Volume, deficient [isotonic]
Fluid Volume, excess Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced Gas Exchange, impaired Gastrointestinal Motility, dysfunctional Gastrointestinal Motility, risk for dysfunctional Gastrointestinal Perfusion, risk for ineffective Grieving Grieving, complicated Grieving, risk for complicated Growth, risk for disproportionate Growth and Development, delayed Health, deficient community Health Behavior, risk-prone Health Maintenance, ineffective Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Human Dignity, risk for compromised Hyperthermia Hypothermia Immunization Status, readiness for enhanced Impulse Control, ineffective Incontinence, bowel Incontinence, functional urinary Incontinence, overflow urinary Incontinence, reflex urinary Incontinence, risk for urge urinary Incontinence, stress urinary Incontinence, urge urinary Infection, risk for Injury, risk for Insomnia Intracranial Adaptive Capacity, decreased Jaundice, neonatal Jaundice, risk for neonatal Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced Latex Allergy Response Latex Allergy Response, risk for Lifestyle, sedentary Liver Function, risk for impaired Loneliness, risk for Maternal-Fetal Dyad, risk for disturbed Memory, impaired Mobility, impaired bed Mobility, impaired physical Mobility, impaired wheelchair Moral Distress Nausea Noncompliance [Adherence, ineffective] [specify] Nutrition: less than body requirements, imbalanced Nutrition: more than body requirements, imbalanced Nutrition: more than body requirements, risk for imbalanced Nutrition, readiness for enhanced Oral Mucous Membrane, impaired Pain, acute Pain, chronic Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Perioperative Positioning Injury, risk for Peripheral Neurovascular Dysfunction, risk for Personal Identity, disturbed Personal Identity, risk for disturbed Poisoning, risk for Post-Trauma Syndrome [specify stage] Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness [specify level] Powerlessness, risk for Protection, ineffective Rape-Trauma Syndrome Relationship, ineffective
Relationship, readiness for enhanced Relationship, risk for ineffective Religiosity, impaired Religiosity, readiness for enhanced Religiosity, risk for impaired Relocation Stress Syndrome Relocation Stress Syndrome, risk for Renal Perfusion, risk for ineffective Resilience, impaired individual Resilience, readiness for enhanced Resilience, risk for compromised Role Conflict, parental Role Performance, ineffective Self-Care, readiness for enhanced Self-Care Deficit: bathing Self-Care Deficit: dressing Self-Care Deficit: feeding Self-Care Deficit: toileting Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, risk for chronic low Self-Esteem, risk for situational low Self-Esteem, situational low Self-Health Management, ineffective Self-Health Management, readiness for enhanced Self-Mutilation Self-Mutilation, risk for Self-Neglect [Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)] (retired 2012) Sexual Dysfunction Sexuality Pattern, ineffective Shock, risk for Skin Integrity, impaired Skin Integrity, risk for impaired Sleep, readiness for enhanced Sleep Deprivation Sleep Pattern, disturbed Social Interaction, impaired Social Isolation Sorrow, chronic Spiritual Distress Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced Stress Overload Sudden Infant Death Syndrome, risk for Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Swallowing, impaired Therapeutic Regimen Management, ineffective family Thermal Injury, risk for Thermoregulation, ineffective Tissue Integrity, impaired Tissue Perfusion, ineffective peripheral Tissue Perfusion, risk for decreased cardiac Tissue Perfusion, risk for ineffective cerebral Tissue Perfusion, risk for ineffective peripheral Transfer Ability, impaired Trauma, risk for Trauma, risk for vascular Unilateral Neglect Urinary Elimination, impaired Urinary Elimination, readiness for enhanced Urinary Retention [acute/chronic] Vascular Trauma, risk fo Ventilation, impaired spontaneous Ventilatory Weaning Response, dysfunctional Violence, risk for other-directed Violence, risk for self-directed Walking, impaired Wandering [specify sporadic or continual] [ ] author recommendations
Herdman, T.H. (Ed.). Nursing Diagnoses—Definitions and Classification 2012–2014. Copyright © 2012, 1994–2012 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
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Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span
EDITION 9
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Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span Marilynn E. Doenges, APRN, BC-Retired Clinical Specialist, Adult Psychiatric/Mental Health Nursing, Retired Retired Adjunct Faculty Beth-El College of Nursing and Health Sciences, UCCS Colorado Springs, Colorado
Mar y Frances Moorhouse, RN, MSN, CRRN Adjunct Faculty/Clinical Instructor Pikes Peak Community College Nurse Consultant/TNT-RN Enterprises Colorado Springs, Colorado
Alice C. Murr, BSN, RN-Retired Independence, Missouri
EDITION 9
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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2014 by F. A. Davis Company Copyright © 1984, 1989, 1993, 1997, 2000, 2002, 2006, and 2010 by F. A. Davis Company. All rights reserved. This book 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 otherwise, 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 Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN Director of Content Development: Darlene Pederson, MSN, APRN, BC Project Editor: Elizabeth Hart Art and Design Manager: Carolyn O’Brien Electronic Project Editor: Tyler Baber As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The authors 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 authors, 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 accordance with professional standards of care used in regard to the unique circ*mstances that may apply 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– author. Nursing care plans : guidelines for individualizing client care across the life span / Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.—Edition 9. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-3041-3 ISBN-10: 0-8036-3041-7 I. Moorhouse, Mary Frances, 1947– author. II. Murr, Alice C., 1946– author. III. Title. [DNLM: 1. Patient Care Planning—Handbooks. 2. Nursing Process—Handbooks. WY 49] RT49 610.73—dc23 2013041055 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific 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 $.25 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: 8036-1169-2/04 0 + $.25.
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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 encouragement is sorely missed; Jim; Barbara and Bob Lanza; David, Monita, and Tyler; Matthew, Trish, Sara, and Natilia; John, Holly, Nicole, and Kelsey; and the Daigle families: Nancy, Jim; Jennifer, Brandon, Annabelle, Will, and Henry Smith-Daigle, and Jonathan, Kim, and Mandalyn JoAn. The Moorhouse family: husband Jan, Paul Moorhouse; Jason and Thenderlyn Moorhouse; Alexa, Tanner, and Quinton Plant; and Mary Isabella Moorhouse. To my Kansas City family, Darin and Ck, Joe and Chelsea-Jane, Maxwell and Eisley: You have given me support, love and joy when I most needed it during this project. Thank you! -Alice Murr (aka Mom/Grammy) To our F. A. Davis family, especially Robert Allen and Sam Rondinelli, whose support is so vital to the completion of a project of this magnitude. And to Joanne DaCunha, who is not just our acquisitions editor but also a colleague and friend who has seen the project from both sides now. Last but not least, Elizabeth Hart, who supports us on a daily basis and keeps track of all the pieces. Thank you for your support and understanding. We are fortunate 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-I and to the international nurses who are developing and using nursing diagnoses—here we come! Finally, to the late Mary Lisk Jeffries, who initiated the original project. The memory of our early friendship and struggles remains with us. We miss her and wish she were here to see the growth of the profession and how nursing diagnosis has contributed to the process.
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CONTRIBUTORS TO THE 9TH EDITION Sharon A. Aronovitch, PhD, RN, ACNS-BC, CWOCN-AP Faculty, Graduate Nursing Program Excelsior College Albany, New York
Lillian Ostrander, RN, MSN, MALS Professor Bergen Community College Paramus, New Jersey
Cathryn Baack, PhD, RN, CPNP Assistant Professor; Online Faculty Manager Chamberlain College of Nursing Columbus, Ohio
Nancy E. Rogers, MA, BSN, RN Professor, Simulation Specialist Carroll Community College Westminster, Maryland
Becky Craig, RN, MN, PhD Georgia Perimeter College Clarkston, Georgia
Ruth A. Wittmann-Price, PhD, RN, CNS, CNE Chair, Department of Nursing Professor of Nursing Francis Marion University Florence, South Carolina
Catherine M. Gagnon, RNC-OB, MSN Nursing Faculty Pikes Peak Community College Colorado Springs, Colorado William H. Loughmiller, CRT Respiratory Therapist St. Francis Medical Center Colorado Springs, Colorado Maria Mackey, MSN, RN Instructor St. Luke’s School of Nursing Bethlehem, Pennsylvania Margaret (Peggy) Malone, MN, RN, CCRN Clinical Nurse Specialist St. John Medical Center Longview, Washington Laure Miller, MSN, RN Associate Professor Nursing Iowa Lakes Community College Emmetsburg, Iowa Ellen Odell, DNP, ACNS, CNE, RN Assistant Professor College of Education and Health Professions Eleanor Mann School of Nursing University of Arkansas Fayetteville, Arkansas
David W. Woodruff, MSN, RN-BC, CMSRN, CEN President Ed4Nurses, Inc. Macedonia, Ohio CONTRIBUTORS TO THE 9TH EDITION Mope T. Adeola, RN, MSN, CNS, OCN Jane V. Arndt, MS, RN, CWOCN Nancy Buttry, MSN, RN Kathleen A. Curtis, RN, MSN Rosemary Fliszar, PhD, RN, CNE Brenda Hicks, RN, OCN Christie A. Hinds, MSN, APRN-BC Jennifer Limongiello, MSN, ARNP Bill Loughmiller, CRT Larry Manalo, RN, MSN Julie Matheny, RRT Kathleen Molden, RN, MSN, CNE Kimberly Tucker Pfennigs, MA, BAN, RN Gilda Rolls-Dellinger, RN Rochelle Salmore, MSN, RN, CGRN, NE, BC April Sheker, RN, MSN(c), CMSRN Geri L. Tierney, RN, BSN, ONC Kathleen H. Winder, RN, BSN Anne Zobec, MS, RN, CS, NP, AOCN
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REVIEWERS FOR THE 9TH EDITION Mary Brune, RN, MS, CNE, EdD(c) Instructor Northwestern Oklahoma State University Woodward, Oklahoma
Karen Reilly, ARNP Nursing Professor Daytona State College Daytona Beach, Florida
Natalie Burkhalter, RN, MSN, CS, FNP-BC, ACNP-BC Associate Professor Texas A&M International University Laredo, Texas
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ACKNOWLEDGMENTS The late Nancy Lea Carter, RN, MA Clinical Nurse, Orthopedics Albuquerque, New Mexico Special thanks for many hours of research! Kathe Lynn Ellis Case Manager Colorado Springs, Colorado Statistical Research Linda R. Renberg, BA Instructor, Retired English, Music and Education Mitchell, South Dakota Statistical Research
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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 (NANDA-I). This work answered our need by providing concise titles that could be used in various plans of care 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 a.m. 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 provide 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. Obviously, 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 its 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-I, 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 or needs and the use of standardized 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) and provide for the definition and protection of nursing practice and the protection of the individual (legal implications). 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 25 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 struggle to understand the human responses to actual and potential health problems. To meet these challenges competently, the nurse must have up-todate assessment skills and a working knowledge of pathophysiological concepts concerning the common diseases and 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, governmental regulations, and third-party xix
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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” are too cumbersome to be practical in the clinical setting, it has long been recognized that the client plan of care meets certain needs and therefore 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 home-care 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 major factors driving changes in healthcare and the challenges and opportunities for nursing to participate and even lead some of the changes is presented. The importance of the nurse’s role in collaboration and coordination with other healthcare professionals 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-I diagnoses with Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) languages. 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 corresponding 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 another technique or learning tool provided to assist you in achieving a holistic view of your client, enhance your critical thinking skills, and facilitate 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. In addition to the care plans in the textbook, you will also find Psychiatric and Maternal/Newborn care plans on DavisPlus. (To access these, use the Plus Code found in front of your book.) 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
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should be generally accomplished by the time of discharge from the care setting. Nursing diagnosis labels are then chosen and combined with possible related factors designated by “may be related to,” and the signs and symptoms or defining characteristics as “possibly evidenced by,” if present, to create Client Diagnostic Statements that provide a clear picture of the client’s needs. Next, Desired Client Outcomes are stated in measurable behavioral terms to evaluate both the client’s progress and the effectiveness of care provided. 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. Continuing the life span, a plan of care for children (Pediatric Considerations) is included in Chapter 15, and Pediatric Pearls have been added to 11 plans of care common to this population. The Pediatric Pearls are noted by this icon . Lastly, 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, MFM, and AM
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CONTENTS IN BRIEF INDEX OF NURSING DIAGNOSES APPEARS ON PAGE V INTRODUCTION CHAPTER 1
Issues and Trends in Nursing and Healthcare Delivery 1 CHAPTER 2
The Nursing Process: Planning Care Using Nursing Diagnoses 4 CHAPTER 3
Critical Thinking: Adaptation of Theory to Practice 11 CHAPTER 4
Cardiovascular 33
Hypertension: Severe 33 Heart Failure: Chronic 43 Acute Coronary Syndrome (ACS) 58 Angina: Chronic/Stable 67 Myocardial Infarction 75 Dysrhythmias 87 Cardiac Surgery: Postoperative Care— Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), Cardiomyoplasty, Valve Replacement 98 Thrombophlebitis: Venous Thromboembolism (Including Pulmonary Emboli Considerations) 109
CHAPTER 5
Respiratory 118
Chronic Obstructive Pulmonary Disease (COPD) and Asthma 118 Pneumonia 129 Lung Cancer: Postoperative Care 141 Pneumothorax/Hemothorax 150 Ventilatory Assistance (Mechanical) 157 Pulmonary Tuberculosis (TB) 170 Respiratory Acid-Base Imbalances 179 Respiratory Acidosis (Primary Carbonic Acid Excess) 179 Respiratory Alkalosis (Primary Carbonic Acid Deficit) 184
CHAPTER 6
Neurological/Sensory Disorders 188
Seizure Disorders 188 Craniocerebral Trauma—Acute Rehabilitative Phase 197 Cerebrovascular Accident (CVA)/Stroke 214 Brain Infections: Meningitis and Encephalitis 229 Disc Surgery 237 Spinal Cord Injury (Acute Rehabilitative Phase) 248 Multiple Sclerosis (MS) 266
CHAPTER 7
Gastrointestinal Disorders 281
Upper Gastrointestinal/Esophageal Bleeding 281 Inflammatory Bowel Disease (IBD): Ulcerative Colitis, Crohn’s Disease 291 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 304 Appendectomy 315 Peritonitis 320 Cholecystitis with Cholelithiasis 329 Cholecystectomy 335
CHAPTER 8
Metabolic and Endocrine Disorders 340
Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 340 Eating Disorders: Obesity 358 Obesity: Bariatric Surgery 367 Diabetes Mellitus/Diabetic Ketoacidosis 377 Hyperthyroidism (Graves’ Disease, Thyrotoxicosis) 391 Hepatitis 400 Cirrhosis of the Liver 412 Pancreatitis 426 Total Nutritional Support: Parenteral/ Enteral Feeding 437 Metabolic Acid-Base Imbalances 450 Metabolic Acidosis—Primary Base Bicarbonate (HCO3) Deficiency 450 Metabolic Alkalosis—Primary Base Bicarbonate Excess 455
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CHAPTER 9
CHAPTER 14
Diseases of the Blood/Blood-Forming Organs 459
Systemic Infections and Immunological Disorders 665
Anemias—Iron Deficiency, Anemia of Chronic Disease, Pernicious, Aplastic, Hemolytic 459 Sickle Cell Crisis 469 Adult Leukemias 484 Lymphomas 494
Sepsis/Septicemia 665 The HIV-Positive Client 677 Acquired Immunodeficiency Syndrome (AIDS) 689 Rheumatoid Arthritis (RA) 709 Transplantation Considerations— Postoperative and Lifelong 719
CHAPTER 10
Renal and Urinary Tract 505
Acute Kidney Injury (Acute Renal Failure) 505 Renal Failure: Chronic (End-Stage Renal Disease) 517 Renal Dialysis—General Considerations 529 Peritoneal Dialysis (PD) 539 Hemodialysis (HD) 544 Urinary Diversions/Urostomy (Postoperative Care) 548 Benign Prostatic Hyperplasia (BPH) 559 Prostatectomy 566 Urolithiasis (Renal Calculi) 573
CHAPTER 11
Women’s Reproductive 581 Hysterectomy 581 Mastectomy 589
CHAPTER 12
Orthopedic 601
Fractures 601 Amputation 616 Total Joint Replacement 625
CHAPTER 13
Integumentary 638
Burns: Thermal, Chemical, and Electrical—Acute and Convalescent Phases 638 Wound Care: Complicated or Chronic 657
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CHAPTER 15
General 729
Psychosocial Aspects of Care 729 Dementia of the Alzheimer’s Type/ Vascular Dementia/Lewy Body Disease 743 Surgical Intervention 762 Extended Care 781 Alcohol: Acute Withdrawal 800 Substance Use Disorders (SUDs) 815 Cancer—General Considerations 827 End-of-Life Care/Hospice 848 Disaster Considerations 858 Pediatric Considerations 872 Fluid and Electrolyte Imbalances 885
BIBLIOGRAPHY 918 INDEX OF NURSING DIAGNOSES 949 A table of contents including nursing diagnoses follows.
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DETAILED CONTENTS INDEX OF NURSING DIAGNOSES APPEARS ON PAGE V INTRODUCTION XIX CHAPTER 1
Issues and Trends in Nursing and Healthcare Delivery 1 The Ever-Changing Healthcare Environment 1 Challenges, Trends, and Opportunities 1
CHAPTER 2
The Nursing Process: Planning Care Using Nursing Diagnoses 4 Planning Care 7 Components of the Plan of Care 7
Client Database 7 Interviewing 7 Physical Assessment 7 Diagnostic Studies 7 Nursing Priorities 8 Discharge Goals 8 Nursing Diagnosis (Problem and Need Identification) 8 Desired Client Outcomes 9 Planning (Goals and Actions/Interventions) 9
Rationale 10 Conclusion 10 CHAPTER 3
Critical Thinking: Adaptation of Theory to Practice 11
Client Situation: Diabetes Mellitus 20 Admitting Physician’s Orders 20 Client Assessment Database 20 Mind Map 24
Evaluation 24 Documentation 24
Sample Clinical Pathway 27 Plan of Care: Mr. R. S. 29
CHAPTER 4
Cardiovascular 33
Hypertension: Severe 33
Cardiac Output, risk for decreased 37 Activity Intolerance 38 Pain, acute 39
Nutrition: more than body requirements, imbalanced 40 Coping, ineffective 41 Self-Health Management, ineffective 41
Heart Failure: Chronic 43
Cardiac Output, decreased 48 Activity Intolerance 51 Fluid Volume, excess 51 Gas Exchange, risk for impaired 53 Pain, risk for chronic 53 Skin Integrity, risk for impaired 54 Self-Health Management, ineffective 55 Sample Clinical Pathway 57
Acute Coronary Syndrome (ACS) 58
Pain, acute 62 Tissue Perfusion, risk for decreased cardiac 64 Cardiac Output, risk for decreased 65 Knowledge, deficient [Learning Need] 66
Angina: Chronic/Stable 67
Pain, risk for acute 70 Cardiac Output, risk for decreased 72 Self-Health Management, ineffective 73
Myocardial Infarction 75
Pain, acute 79 Cardiac Output, risk for decreased 80 Activity Intolerance 83 Anxiety [moderate/severe] 83 Tissue Perfusion, risk for ineffective (specify) 84 Knowledge, deficient [Learning Need] 85
Dysrhythmias 87
Cardiac Output, risk for decreased 92 Poisoning, risk for [Digoxin Toxicity] 95 Self-Health Management, ineffective 96
Cardiac Surgery: Postoperative Care—Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), Cardiomyoplasty, Valve Replacement 98
Cardiac Output, risk for decreased 102 Pain, acute 104 Breathing Pattern, risk for ineffective 105 Skin/Tissue Integrity, impaired 106 Knowledge, deficient [Learning Need] 107
Thrombophlebitis: Venous Thromboembolism (Including Pulmonary Emboli Considerations) 109 Tissue Perfusion, ineffective peripheral 112 Pain, acute 114 Gas Exchange, impaired (in presence of pulmonary embolus) 115 Knowledge, deficient [Learning Need] 116
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CHAPTER 5
Respiratory 118
Chronic Obstructive Pulmonary Disease (COPD) and Asthma 118 Airway Clearance, ineffective 122 Gas Exchange, impaired 124 Nutrition: less than body requirements, imbalanced 126 Self-Health Management, ineffective 126
Pneumonia 129
Airway Clearance, ineffective 133 Gas Exchange, impaired 134 Infection, risk for [spread] 135 Activity Intolerance 136 Pain, acute 137 Nutrition: less than body requirements, risk for imbalanced 137 Fluid Volume, risk for deficient 138 Knowledge, deficient [Learning Need] 139 Sample Clinical Pathway 140
Lung Cancer: Postoperative Care 141
Gas Exchange, impaired 145 Airway Clearance, ineffective 146 Pain, acute 147 Anxiety [specify level] 148 Knowledge, deficient [Learning Need] 149
Pneumothorax/Hemothorax 150
Breathing Pattern, ineffective 153 Suffocation, risk for 156 Knowledge, deficient [Learning Need] 156
Ventilatory Assistance (Mechanical) 157
Breathing Pattern, ineffective/Spontaneous Ventilation, impaired 159 Airway Clearance, ineffective 162 Communication, impaired verbal 163 Anxiety [specify level] 164 Oral Mucous Membrane, impaired 165 Nutrition: less than body requirements, imbalanced 165 Infection, risk for 166 Ventilatory Weaning Response, risk for dysfunctional 168 Knowledge, deficient [Learning Need] 169
Pulmonary Tuberculosis (TB) 170
Infection, risk for [spread/reactivation] 173 Airway Clearance, ineffective 175 Gas Exchange, risk for impaired 176 Nutrition: less than body requirements, imbalanced 176 Self-Health Management, risk for ineffective 177
Respiratory Acid-Base Imbalances 179 Respiratory Acidosis (Primary Carbonic Acid Excess) 179 Gas Exchange, impaired 182
Respiratory Alkalosis (Primary Carbonic Acid Deficit) 184 Gas Exchange, impaired 186
CHAPTER 6
Neurological/Sensory Disorders 188 Seizure Disorders 188
Trauma/Suffocation, risk for 192 Airway Clearance, risk for ineffective 193 Self-Esteem, [specify situational or chronic low] 194 Self-Health Management, ineffective 195
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Craniocerebral Trauma—Acute Rehabilitative Phase 197
Tissue Perfusion, risk for ineffective cerebral 202 Breathing Pattern, risk for ineffective 205 Sensory Perception, disturbed (specify) 206 Confusion, risk for chronic 208 Mobility, impaired physical 209 Infection, risk for 210 Nutrition: less than body requirements, risk for imbalanced 211 Family Processes, interrupted 212 Knowledge, deficient [Learning Need] 213
Cerebrovascular Accident (CVA)/Stroke 214 Tissue Perfusion, ineffective cerebral 218 Mobility, impaired physical 220 Communication, impaired verbal [and/or written] 222 Sensory Perception, disturbed [specify] 223 Self-Care Deficit [specify] 224 Coping, ineffective 225 Swallowing, risk for impaired 226 Neglect, unilateral 227 Knowledge, deficient [Learning Need] 228
Brain Infections: Meningitis and Encephalitis 229
Infection, risk for [spread] 233 Intracranial Adaptive Capacity, risk for decreased 234 Comfort, impaired 235 Knowledge, deficient [Learning Need] 236
Disc Surgery 237
Peripheral Neurovascular Dysfunction, risk for 239 Injury, risk for [spinal] 240 Breathing Pattern, risk for ineffective 241 Pain, acute 242 Mobility, impaired physical 243 Constipation 243 Urinary Retention, risk for 244 Knowledge, deficient [Learning Need] 244 Sample Clinical Pathway 246
Spinal Cord Injury (Acute Rehabilitative Phase) 248
Breathing Pattern, risk for ineffective 252 Injury, risk for [additional spinal] 253 Mobility, impaired physical 254 Sensory Perception, disturbed tactile/ proprioception 255 Pain, acute 256 Grieving 257 Self-Esteem, situational low 258 Bowel Incontinence/Constipation 259 Urinary Elimination, impaired 260 Skin/Tissue Integrity, risk for impaired 262 Knowledge, deficient [Learning Need] 263 Autonomic Dysreflexia, risk for 265
Multiple Sclerosis (MS) 266
Fatigue 270 Self-Care Deficit [specify] 272 Self-Esteem, situational low 273 Powerlessness 274 Coping, risk for ineffective 275 Coping, risk for disabled family 276 Urinary Elimination, impaired 277 Caregiver Role Strain, risk for 278 Self-Health Management, ineffective 279
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Gastrointestinal Disorders 281
Upper Gastrointestinal/Esophageal Bleeding 281
Bleeding, risk for 284 Shock, risk for 287 Anxiety [specify level] 288 Pain, acute 289 Knowledge, deficient [Learning Need] 290
Inflammatory Bowel Disease (IBD): Ulcerative Colitis, Crohn’s Disease 291 Diarrhea 296 Fluid Volume, risk for deficient 298 Nutrition: less than body requirements, imbalanced 298 Anxiety [specify level] 300 Pain, acute 301 Coping, ineffective 301 Self-Health Management 303
Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 304
Skin Integrity, risk for impaired 306 Body Image, disturbed 307 Pain, acute 308 Skin/Tissue Integrity, impaired 309 Fluid Volume, risk for deficient 309 Nutrition: less than body requirements, risk for imbalanced 310 Insomnia 311 Constipation/Diarrhea, risk for 311 Sexual Dysfunction, risk for 312 Knowledge, deficient [Learning Need] 314
Appendectomy 315
Infection, risk for [spread] 318 Fluid Volume, risk for deficient 318 Pain, acute 319 Knowledge, deficient [Learning Need] 320
Peritonitis 320
Infection, risk for [septicemia] 324 Fluid Volume, deficient 325 Pain, acute 326 Nutrition: less than body requirements, risk for imbalanced 327 Anxiety [specify level] 327 Knowledge, deficient [Learning Need] 328
Cholecystitis with Cholelithiasis 329
Pain, acute 332 Fluid Volume, risk for deficient 333 Nutrition: less than body requirements, risk for imbalanced 333 Knowledge, deficient [Learning Need] 334
Cholecystectomy 335
Breathing Pattern, ineffective 336 Fluid Volume, risk for deficient 337 Skin/Tissue Integrity, impaired 338 Knowledge, deficient [Learning Need] 339
CHAPTER 8
Metabolic and Endocrine Disorders 340
Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 340 Nutrition: less than body requirements, imbalanced 345 Fluid Volume, risk for deficient 347 Body Image, disturbed 348 Self-Esteem, chronic low 348
Parenting, impaired 350 Skin Integrity, risk for impaired 351 Self-Health Management, ineffective 352 Sample Clinical Pathway 354
DETAILED CONTENTS
CHAPTER 7
Eating Disorders: Obesity 358
Nutrition: more than body requirements, imbalanced 361 Lifestyle, sedentary 363 Body Image, disturbed 364 Social Interaction, impaired 365 Self-Health Management, ineffective 366
Obesity: Bariatric Surgery 367
Breathing Pattern, ineffective 370 Tissue Perfusion, risk for ineffective [specify] 371 Fluid Volume, risk for deficient 372 Nutrition: less than body requirements, risk for imbalanced 372 Skin Integrity, impaired 373 Infection, risk for 374 Diarrhea 375 Knowledge, deficient [Learning Need] 376
Diabetes Mellitus/Diabetic Ketoacidosis 377
Fluid Volume, deficient [specify] 381 Blood Glucose Level, unstable 383 Infection, risk for 385 Sensory Perception, risk for disturbed (specify) 386 Fatigue 387 Coping, ineffective 387 Self-Health Management, ineffective 388
Hyperthyroidism (Graves’ Disease, Thyrotoxicosis) 391
Cardiac Output, risk for decreased 394 Fatigue 396 Nutrition: less than body requirements, risk for imbalanced 397 Anxiety [specify level] 398 Dry Eye, risk for 399 Knowledge, deficient [Learning Need] 400
Hepatitis 400
Liver Function, impaired 404 Fatigue 406 Nutrition: less than body requirements, imbalanced 406 Fluid Volume, risk for deficient/Bleeding 408 Self-Esteem, risk for situational low 409 Infection, risk for [secondary/spread] 409 Tissue Integrity, risk for impaired 410 Knowledge, deficient [Learning Need] 411
Cirrhosis of the Liver 412
Nutrition: less than body requirements, imbalanced 416 Fluid Volume, risk for excess 417 Infection, risk for 419 Skin Integrity, risk for impaired 420 Breathing Pattern, risk for ineffective 421 Bleeding, risk for 422 Confusion, risk for acute 423 Body Image, disturbed 424 Self-Health, ineffective 425
Pancreatitis 426
Pain, acute 430 Fluid Volume, risk for deficient 431 Nutrition: less than body requirements, imbalanced 433 xxv
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Blood Glucose Level, risk for unstable 433 Infection, risk for [sepsis] 434 Gas Exchange, impaired 435 Self-Health Management, ineffective 436
Total Nutritional Support: Enteral Feeding 437
Nutrition: less than body requirements, imbalanced 442 Infection, risk for 444 Injury, risk for 445 Aspiration, risk for 446 Fluid Volume, risk for deficient 447 Fatigue 448 Knowledge, deficient [Learning Need] 449
Metabolic Acid-Base Imbalances 450 Metabolic Acidosis—Primary Base Bicarbonate (HCO3) Deficiency 450 Metabolic Alkalosis—Primary Base Bicarbonate Excess 455 CHAPTER 9
Diseases of the Blood/Blood-Forming Organs 459 Anemias—Iron Deficiency, Anemia of Chronic Disease, Pernicious, Aplastic, Hemolytic 459
Activity Intolerance 464 Nutrition: less than body requirements, imbalanced 465 Constipation/Diarrhea 466 Infection, risk for 467 Knowledge, deficient [Learning Need] 468
Sickle Cell Crisis 469
Gas Exchange, impaired 475 Pain, acute/chronic 476 Tissue Perfusion, risk for ineffective [specify] 477 Fluid Volume, risk for deficient 479 Mobility, impaired physical 480 Skin Integrity, risk for impaired 480 Infection, risk for 481 Self-Health Management, ineffective 481
Adult Leukemias 484
Infection, risk for 488 Fluid Volume, risk for deficient 490 Pain, acute 491 Fatigue 492 Knowledge, deficient [Learning Need] 493
Lymphomas 494
Gas Exchange, risk for impaired 499 Nausea 500 Sexual Dysfunction 501 Knowledge, deficient [Learning Need] 502
CHAPTER 10
Renal and Urinary Tract 505
Acute Kidney Injury (Acute Renal Failure) 505
Fluid Volume, excess 510 Cardiac Output, risk for decreased 512 Nutrition: less than body requirements, risk for imbalanced 513
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Infection, risk for 514 Fluid Volume, risk for deficient 515 Knowledge, deficient [Learning Need] 516
Renal Failure: Chronic (End-Stage Renal Disease) 517
Cardiac Output, risk for decreased 522 Activity Intolerance 523 Bleeding, risk for 524 Confusion, risk for acute 525 Skin Integrity, risk for impaired 526 Oral Mucous Membrane, risk for impaired 526 Self-Health Management, ineffective 527
Renal Dialysis—General Considerations 529 Nutrition: less than body requirements, imbalanced 531 Skin Integrity, risk for impaired 533 Self-Care Deficit (specify) 533 Constipation, risk for 534 Confusion, risk for acute 534 Anxiety [specify level] 535 Body Image, disturbed 536 Self-Health Management, risk for ineffective 537
Peritoneal Dialysis (PD) 539
Fluid Volume, risk for excess 540 Fluid Volume, risk for deficient 541 Trauma, risk for 541 Pain, acute 542 Infection, risk for 543 Breathing Pattern, risk for ineffective 543
Hemodialysis (HD) 544
Injury, risk for [loss of vascular access] 545 Fluid Volume, risk for deficient 546 Fluid Volume, risk for excess 547
Urinary Diversions/Urostomy (Postoperative Care) 548 Skin Integrity, risk for impaired 550 Body Image, disturbed 552 Pain, acute 553 Infection, risk for 554 Urinary Elimination, impaired 555 Sexual Dysfunction, risk for 556 Knowledge, deficient [Learning Need] 557
Benign Prostatic Hyperplasia (BPH) 559
Urinary Retention, [acute/chronic] 561 Pain, acute 563 Fluid Volume, risk for deficient 563 Anxiety [specify level] 564 Knowledge, deficient [Learning Need] 564
Prostatectomy 566
Urinary Elimination, impaired 567 Bleeding, risk for 568 Infection, risk for 569 Pain, acute 569 Sexual Dysfunction, risk for 570 Knowledge, deficient [Learning Need] 571 Sample Clinical Pathway 572
Urolithiasis (Renal Calculi) 573
Pain, acute 576 Urinary Elimination, impaired 577 Fluid Volume, risk for deficient 579 Knowledge, deficient [Learning Need] 579
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Women’s Reproductive 581 Hysterectomy 581
Urinary Retention, risk for [acute] 583 Constipation, risk for 583 Tissue Perfusion, risk for ineffective (specify) 584 Sexual Dysfunction, risk for 585 Grieving 586 Knowledge, deficient [Learning Need] 587
Mastectomy 589
Anxiety 592 Tissue Integrity, impaired 593 Pain, acute 594 Self-Esteem, situational low 595 Mobility, impaired physical 596 Knowledge, deficient [Learning Need] 597 Sample Clinical Pathway 599
CHAPTER 12
Orthopedic 601 Fractures 601
Injury, risk for 605 Pain, acute 606 Peripheral Neurovascular Dysfunction, risk for 607 Gas Exchange, risk for impaired 609 Mobility, impaired physical 610 Tissue Integrity, impaired 611 Infection, risk for 613 Knowledge, deficient [Learning Need] 614 Self-Care, readiness for enhanced 615
Amputation 616
Pain, acute 618 Tissue Perfusion, risk for ineffective peripheral 619 Infection, risk for 620 Mobility, impaired physical 621 Grieving 623 Knowledge, deficient [Learning Need] 624
Total Joint Replacement 625
Pain, acute 627 Bleeding, risk for 629 Infection, risk for 629 Peripheral Neurovascular Dysfunction, risk for 630 Mobility, impaired physical 631 Constipation, risk for 632 Knowledge, deficient [Learning Need] 633 Sample Clinical Pathway 635
CHAPTER 13
Integumentary 638
Burns: Thermal, Chemical, and Electrical—Acute and Convalescent Phases 638
Airway Clearance, risk for ineffective 643 Fluid Volume, risk for deficient 644 Pain, acute 646 Infection, risk for 647 Peripheral Neurovascular Dysfunction, risk for 649 Nutrition: less than body requirements, imbalanced 650 Mobility, impaired physical 651
Skin Integrity, impaired [grafts] 652 Post-Trauma Syndrome, risk for 653 Body Image, disturbed 654 Knowledge, deficient [Learning Need] 655
DETAILED CONTENTS
CHAPTER 11
Wound Care: Complicated or Chronic 657 Skin/Tissue Integrity, impaired 659 Pain, acute/chronic 661 Infection, risk for 662 Nutrition: less than body requirements, imbalanced 663 Self-Health Management, risk for ineffective 663
CHAPTER 14
Systemic Infections and Immunological Disorders 665 Sepsis/Septicemia 665
Infection, risk for [progression; opportunistic/hospital acquired] 669 Hyperthermia 671 Shock, risk for 671 Fluid Volume, risk for deficient 673 Confusion, risk for acute 674 Gas Exchange, risk for impaired 675 Knowledge, deficient [Learning Need] 676
The HIV-Positive Client 677
Health Behavior, risk-prone 679 Fatigue 681 Nutrition: less than body requirements, imbalanced 682 Knowledge, deficient [Learning Need] 683 Social Isolation, risk for 686 Self-Health Management, ineffective 687
Acquired Immunodeficiency Syndrome (AIDS) 689
Infection, risk for [progression/onset of opportunistic infection] 694 Fluid Volume, risk for deficient 695 Breathing Pattern, ineffective 696 Bleeding, risk for 697 Nutrition: less than body requirements, imbalanced 698 Pain, acute/chronic 700 Skin Integrity, impaired 701 Oral Mucous Membrane, impaired 702 Fatigue 703 Confusion, risk for acute/chronic 703 Death Anxiety 705 Social Isolation 706 Powerlessness 707 Self-Health Management, ineffective 708
Rheumatoid Arthritis (RA) 709
Pain, acute/chronic 713 Mobility, impaired physical 715 Role Performance, ineffective 716 Self-Care Deficit (specify) 716 Home Maintenance, risk for impaired 717 Self-Health Management, risk for ineffective 718
Transplantation Considerations— Postoperative and Lifelong 719
Infection, risk for 723 Anxiety [specify level] 723 Coping, family compromised 725 Knowledge, deficient [Learning Need] 726
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CHAPTER 15
General 729
Psychosocial Aspects of Care 729
Coping, ineffective 731 Decisional Conflict (specify) 732 Coping, risk for compromised family 733 Coping, readiness for enhanced family 734 Anxiety [specify level] 734 Self-Esteem, risk for situational low 736 Grieving [specify] 738 Religiosity, risk for impaired 739 Self-Health Management, ineffective 740 Violence, risk for self- or other-directed 741
Dementia of the Alzheimer’s Type/ Vascular Dementia/Lewy Body Disease 743
Environmental Interpretation Syndrome, impaired 748 Confusion, chronic 749 Sensory Perception, disturbed (specify) 752 Anxiety 753 Grieving 753 Sleep Deprivation 754 Self-Care Deficit (specify type/level) 755 Nutrition: less/more than body requirements, risk for imbalanced 756 Bowel, Incontinence/Urinary Elimination, impaired 757 Sexual Dysfunction, risk for 758 Coping, compromised family 758 Health Maintenance, ineffective 760 Caregiver Role Strain, risk for 760 Relocation Stress Syndrome, risk for 761
Surgical Intervention 762
Knowledge, deficient [Learning Need] 765 Fear/Anxiety [specify level] 766 Perioperative Positioning Injury, risk for 768 Injury, risk for 769 Infection, risk for 771 Body Temperature, risk for imbalanced 772 Breathing Pattern, ineffective 773 [Sensory Perception, disturbed (specify)] 774 Fluid Volume, risk for deficient 775 Pain, acute 776 Tissue Integrity, impaired 778 Tissue Perfusion, risk for ineffective 779 Knowledge, deficient [Learning Need] 780
Extended/Long-Term Care 781
Relocation Stress Syndrome, risk for 783 Grieving 785 Memory, impaired 785 Coping, compromised family 787 Poisoning, risk for [drug toxicity] 788 Communication, impaired verbal 789 Sleep Pattern, disturbed 790 Nutrition: less [or] more than body requirements, imbalanced 790 Self-Care Deficit [specify] 792 Skin Integrity, risk for impaired 793 Urinary Elimination, risk for impaired 794 Constipation/Diarrhea, risk for 795 Mobility, impaired physical 796 Diversional Activity, deficient 798 Sexual Dysfunction, risk for 798 Self-Health Maintenance, ineffective 799
xxviii
Alcohol: Acute Withdrawal 800
Breathing Pattern, risk for ineffective 805 Cardiac Output, risk for decreased 806 Injury, risk for [specify] 807 [Sensory Perception, disturbed (specify)] 808 Anxiety [severe/panic] 809 Sample Clinical Pathway 811
Substance Use Disorders (SUDs) 815
Denial, ineffective 817 Coping, ineffective 818 Powerlessness 820 Nutrition: less than body requirements, imbalanced 821 Self-Esteem, chronic low 822 Family Processes, dysfunctional 823 Sexual Dysfunction 825 Knowledge, deficient [Learning Need] 826
Cancer—General Considerations 827
Fear/Anxiety [specify level] 832 Grieving 833 Self-Esteem, risk for situational low 834 Pain, acute/chronic 835 Nutrition: less than body requirements, imbalanced 837 Fluid Volume, risk for deficient 839 Fatigue 840 Infection, risk for 841 Oral Mucous Membrane, risk for impaired 842 Skin/Tissue Integrity, risk for impaired 843 Constipation/Diarrhea, risk for 844 Sexual Dysfunction, risk for 845 Family Processes, risk for interrupted 846 Knowledge, deficient [Learning Need] 847
End-of-Life Care/Hospice 848
Pain, acute/chronic 851 Fatigue 852 Grieving/Death Anxiety 853 Coping, compromised family 855 Spiritual Distress, risk for 856 Caregiver Role Strain, risk for 857
Disaster Considerations 858
Injury—Trauma, Suffocation, Poisoning, risk for 860 Infection, risk for 862 Anxiety [severe/panic] 863 Spiritual Distress 865 Post-Trauma Syndrome, risk for 866 Coping, ineffective community 867 Coping, readiness for enhanced community 867
Pediatric Considerations 872
Pain, acute/chronic 875 Anxiety/Fear 876 Activity Intolerance, [specify level] 877 Growth and Development, risk for delayed 878 Nutrition: less than body requirements, risk for imbalanced 879 Injury, risk for (specify: Trauma, Suffocation, Poisoning) 880 Fluid Volume, risk for imbalanced 881 Family Processes, interrupted 882 Body Temperature, risk for imbalanced 883 Health Maintenance, risk for ineffective 884
Fluid and Electrolyte Imbalances 885 Fluid Balance 885
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Hypocalcemia (Calcium Deficit) 906
Hypovolemia (Extracellular Fluid Volume Deficit) 890
Electrolyte Imbalance, risk for 911 Magnesium 912
Electrolyte Imbalance, risk for 908
Fluid Volume, excess 888
Hypercalcemia (Calcium Excess) 909
Fluid Volume, deficient 891 Sodium 893
Hypomagnesemia (Magnesium Deficit) 912 Electrolyte Imbalance, risk for 913
Hyponatremia (Sodium Deficit) 893
Hypermagnesemia (Magnesium Excess) 915
Hyponatremia (Sodium Excess) 897
Bibliography 918 Index of Nursing Diagnoses 949
Electrolyte Imbalance, risk for 896 Electrolyte Imbalance, risk for 899 Potassium 900
DETAILED CONTENTS
Hypervolemia (Extracellular Fluid Volume Excess) 886
Electrolyte Imbalance, risk for 916
Hypokalemia (Potassium Deficit) 900 Electrolyte Imbalance, risk for 902
Hyperkalemia (Potassium Excess) 903 Electrolyte Imbalance, risk for 905 Calcium 906
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CONTENTS ON DAVIS PLUS Medical/Surgical Care Plans Respiratory
Disruptive, Impulse-Control, and Conduct Disorders
Neurological/Sensory Disorders
Substance-Related and Addictive Disorders
Radical Neck Surgery: Laryngectomy Postoperative Care) Glaucoma Herniated Nucleus Pulposus (Ruptured Intervertebral Disc)
Gastrointestinal Disorders
Gastrectomy/Gastric Resection
Metabolic and Endocrine Disorders Thyroidectomy
Psychiatric Care Plans
Neurodevelopmental Disorders
Pervasive Developmental Disorder Attention-Deficit Disorder
Schizophrenic Spectrum and Other Psychotic Disorders Schizophrenia Schizoaffective Disorder Delusional Disorder
Bipolar and Related Disorders Bipolar Disorder
Depressive Disorders
Major Depressive Disorder Premenstrual Dysphoric Disorder
Anxiety Disorders
Generalized Anxiety Disorder Anxiety Disorder Panic Disorder (Phobias)
Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder
Trauma and Stressor-Related Disorders Post-Traumatic Stress Disorder Adjustment Disorder
Dissociative Disorders
Dissociative Identity Disorder
Somatic Symptom and Related Disorders Somatic Symptom Disorder
Feeding and Eating Disorders
Anorexia Nervosa/Bulimia Nervosa Obesity
Elimination Disorders Enuresis/Encopresis
Sexual Dysfunctions
Sexual Dysfunctions and Paraphilias
Gender Dysphoria
Gender Dysphoria
Oppositional Defiant Disorder Conduct Disorder
Alcohol-Related disorders Stimulant-Related Disorders (Amphetamines, Cocaine, Caffeine, and Nicotine) and Inhalant Disorders Depressants (Barbiturates, Nonbarbiturates, Hypnotics and Anxiolytics, Opioids) Hallucinogen, Phencyclidine, and Cannabis-related Disorders Substance Dependence/Abuse Rehabilitation
Dementia and Amnestic and Other Neurocognitive Disorders
Dementia of the Alzheimer’s Type/Vascular Dementia Dementia Due to HIV Disease
Personality Disorders
Antisocial Personality Disorder Borderline Personality Disorder Passive-Aggressive Personality Disorder
Other Mental Disorders
Psychological Factors Affecting Medical Conditions Parenting Growth-Promoting Relationship Problems related to Abuse and Neglect
Maternal/Newborn Care Plans Prenatal Concepts
Genetic Counseling First Trimester Second Trimester Third Trimester High-Risk Pregnancy Prenatal Substance Dependence/Abuse Pregnant Adolescent Cardiac Conditions Gestational 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
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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) 24–48 Hours Following Early Discharge 1 Week Following Discharge 4–6 Weeks Following Discharge Postpartal Hemorrhage Postpartal Diabetes Mellitus Puerperal Infection Postpartal Thrombophlebitis Parents of a Child with Special Needs Perinatal Loss
xxxii
Newborn Concepts
First Hour of Life Neonate at 2 Hours to 2 Days of Age Neonate at 24–48 Hours Following Early Discharge Neonate at 1 Week Following Discharge Infant at 4 Weeks Following Birth Preterm Infant Deviations in Growth Patterns Circumcision Hyperbilirubinemia Infant of an Addicted Mother Infant of an HIV-Positive Mother
550 Health Conditions and Client Concerns with Associated Nursing Diagnoses
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CHAPTER
1
Issues and Trends in Nursing and Healthcare Delivery The Ever-Changing Healthcare Environment One of the few guarantees in this new millennium is that how we provide and pay for healthcare is going to change. As experts struggle to predict the new face of healthcare, the nursing profession is poised to advance if nurses can navigate the turbulent waters of the impending changes. The leading change agent is the Affordable Care Act (ACA) of 2010. While increased access to care is a major driver, a primary focus of the ACA is preventive healthcare to help individuals stay healthy, avoid onset of disease, lead productive lives, and limit the need for more costly healthcare (Stokowski, 2011). In addition to mandating that third-party payors provide preventive screenings free of co-pays, billions of dollars will be invested in various programs across the life span. For example, Stokowski (2011) highlights the promotion of Maternal, Infant, and Early Child Home Visitation Programs providing counseling for at-risk prenatal clients and families along with interventions to improve health outcomes for infants, children, and adolescents. There also are initiatives expanding school-based health centers to reach children in disadvantaged neighborhoods and support for public health departments to address obesity and smoking cessation, promote physical activity, and improve nutrition. The expectation is that use of data-driven approaches and evidenced-based interventions and guidelines will reduce the occurrence of chronic disease and will help accomplish the goals of Healthy People 2020 (U.S. Department of Health & Human Services, no date): • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. • Achieve health equity, eliminate disparities, and improve the health of all groups. • Create social and physical environments that promote good health for all. • Promote quality of life, healthy development, and healthy behaviors across all life stages.
Challenges, Trends, and Opportunities To accomplish this move from acute illness care to a wellness and prevention model, a shift to increased delivery of primary
care is required. Nurses can and should play a fundamental role in this transformation of the healthcare system. The Institute of Medicine (IOM) 2010 report The Future of Nursing noted that the nursing profession is the largest segment of the healthcare workforce and can play a vital role in accomplishing the outcomes envisioned in the 2010 Affordable Care Act. To this end, the IOM has identified barriers limiting nursing’s ability to respond effectively to the coming changes and recommends the following: • Nurses should practice to the full extent of their education and training. • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. • Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States. • Effective workforce planning and policy making require better data collection and information infrastructure.
Strong clinical leadership will be required in order to take risks and innovate to improve the care provided and achieve the shift to a wellness focus. After a decade of research, Peter Buerhaus et al (2012) report that the latest survey results create a picture of nursing’s capacity to practice successfully in a care delivery environment that is expected to emphasize teams, care coordination, and become driven by payment incentives that reward quality, safety, and efficiency. New roles for nurses are being created and tested throughout the country. For example, at Massachusetts General Hospital the concept of the “Attending Nurse” has been introduced for the purpose of coordinating the work of the interdisciplinary team, which addresses overuse, underuse, and misuse of services to improve clinical outcomes, enhance client and staff satisfaction, reduce length of stay for inpatients, and lower costs. The Attending Nurse serves as a consistent contact for client/family and the healthcare team in support of the staff nurse and facilitates consistent use of a comprehensive client plan of care by all members of the healthcare team. The Attending Nurse also works to promote seamless communication between the healthcare team members to identify the next steps to ensure progression of the client’s plan of care (Erickson, 2012). 1
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Another role first introduced in oncology care 20 years ago is now expanding to other specialties—Nurse Navigator. The role, title, and description of Nurse Navigator (or Patient Navigator) vary with disease, practice setting, and gaps in care (Desimini, 2011). Various healthcare organizations are now utilizing Nurse Navigators to proactively address clients’ and families’ psychosocial, information, and care coordination needs (Horner, 2013). Nurse Navigators guide the client and family through healthcare experiences—answering healthcare questions, providing education, helping individuals understand their diagnoses and treatment options, communicating with insurance carriers, and facilitating timely access to appropriate healthcare resources, including appointments and diagnostic testing and support for follow-up care. Nurse Navigators also work in elder care with the goal of maintaining independence and quality of life for their aging clients. In addition to new roles, nursing is developing innovative care models, such as nurse-managed health clinics, home visitation programs for low-income mothers, and the Transitional Care Model (TCM). By emphasizing the use of master’s-prepared nurses to oversee care from the hospital to within the home, this model has reduced readmissions for elderly clients with multiple chronic conditions. In support of these new models and the IOM recommendations, advanced practice nurses (APNs) must be allowed to practice to the full extent of their education and licensure. Working independently or with physicians, they can provide costeffective care and help address the growing primary care shortage (Hassmiller, 2010). In the community setting, nurses working in collaboration with physicians can create a patient-centered medical home (PCMH), which is a model of care where individuals have a direct relationship with a provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the care provided, and arranges for appropriate care from other qualified providers when needed. This model encourages self-management support, electronic prescribing, test and referral tracking, and advanced electronic communication, resulting in a model that is dependent on information technology and exchange of health data (HIMS & NCQA, no date). In this new era, nurses must not only embrace technology but become super users. To date, nurses have not necessarily welcomed information technology for a number of reasons, such as complexity of user interface or difficulty of program navigation. More importantly, programs have often been developed for other departments, such as billing, or to promote physician order entry. As a result, nursing’s contribution to healthcare is often virtually invisible. In truth, nursing is a costly yet essential resource whose value is not adequately captured in the healthcare record. There have been no well-received and few successful software programs developed that accurately collect and generate data reflecting the true value of nursing, which is critical to assure adequate investment in the nursing profession (Rutherford, 2012). In fact, with a few exceptions, current billing practices subsume nursing in the room rate much like a hotel 2
includes housekeeping and maintenance services in their room rates. This practice essentially makes nursing invisible and implies that nursing care is static with all clients receiving the same level of care regardless of their diagnosis or individual needs. Harris (2007) further notes “the use of the DRG as the basis for payment suggests that nursing care is wholly linked to the medical diagnosis.” The growth of nursing informatics is leading the way in developing and implementing software programs using standardized nursing languages to demonstrate nursing’s contribution and provide data to support evidence-based practice. The rapid growth in information technology has already had a radical impact on healthcare. Advances in digital technology have increased the applications of telehealth and telemedicine, bringing together client and provider without physical proximity (Heller, 2011). Technological advances in the treatment of disease have led to the increased need for ethical, informed decision making by clients and families. The enhanced power of the consumer in the client-provider relationship has created a heightened demand for more sophisticated health education techniques for both the client and the provider. For example, “informational” sites have exploded on the Internet, providing the consumer with both factual resources and misinformation. For the nurse, distance learning modalities link students and faculty from different locales and expand the potential for continuing professional education. And technically sophisticated clinical simulation laboratories have been developed to sharpen critical thinking and client care skills in a safe and user-friendly environment (Hibbard, 2008). In 2011, an estimated 101.1million Americans were aged 50 years or over, representing more than 32% of the population. This number is predicted to rise to 111.3 million by 2016. Increased U.S. life expectancy has shifted the leading causes of death from infectious diseases and acute illnesses to chronic diseases and degenerative illnesses. Some 80% of older Americans live with at least one chronic condition (Economist Intelligence Unit, 2011). These statistics make two things clear to healthcare providers: (1) More people will receive their health and preventive care in community settings, and (2) people in need of hospital and other facility care will be sicker and in need of a higher level of care. Heller noted that the standard ratio of critical care/specialty beds to general-use beds in hospitals today is close to 1:1, up substantially from a decade ago. Furthermore, expanded life expectancy has led to increases in the number, severity, and duration of chronic conditions, thereby increasing the complexity of the care provided and managed by clinicians (Heller, 2011). Because of this escalating need for healthcare, there is legitimate concern in the healthcare world regarding the impact of potential mass retirements on the supply of nurses available to the workforce. The discussion of issues and challenges would be incomplete without consideration of the building and retention of the nurse workforce. Literature review confirms the everpresent issues of actual and perceived nursing shortages, financial constraints, and the promotion and funding of nursing education. But there is another issue that feels like
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3
ISSUES AND TRENDS IN NURSING AND HEALTHCARE DELIVERY
not necessarily welcomed information technology into their practice, but have been forced to learn and use technology. The next-generation nurses (often called Gen Xers) entered the workforce in a time of national recession and witnessed their parents losing pensions and job security. They experience more portability and options for the use of their practice skills and have little patience for hierarchical reverence in the workplace. The youngest nurses (and those who will be entering practice in the next few years) grew up enmeshed in digital technology, are not deeply invested in who does the work as long as the work gets done, and may view nursing more as an occupation than a profession. Finally, the patient population and the nursing workforce are becoming increasingly multicultural. Exactly how this is affecting (and will affect) healthcare in general is not known. What is clear is that there will be change and nursing needs to be an active participant in shaping this change. In closing, we take an optimistic view. Nursing is a rich and diverse profession practiced by people from many cultural and educational backgrounds and in varied settings, which creates a rich source for innovative thinking. Nurses are in a position—and have the opportunity and the challenge—to return to their earlier roots in communityfocused nursing as front-line advocates and supporters for improving the health and well-being of clients, families, or populations through cost-effective, culturally appropriate, evidence-based practice. The future of the profession is in our hands. It’s time to step up and demonstrate the real power, creativity, and caring of nursing.
CHAPTER 1
the proverbial elephant in the room . . . aging. The average age of nurses today is 46 years. Baby boomers now in their 50s comprise approximately 25% of today’s workforce (AACN, 2012). Research does support that, while young people are entering the field of nursing, aging is affecting the current workforce as a whole. Aging nurses are reported to have higher workload demands than other professions, as they struggle with the high demands of caring for an aging population with high-acuity needs. This increases the risk of stress reactions, including fatigue, poor health, injury, and chronic pain (Gabrielle, 2008). The Aging Nurse Project (2007) concluded that older nurses were most concerned about their physical health, particularly their backs, especially since many older nurses are working longer than they expected, reportedly because of changes in their retirement plans or other economic downturns (Restuccia, 2007). Numerous authors have recently discussed multigenerational conflict in the nursing workforce as one of the challenges nurses face (Kupperschmidt, 2006; Lancaster, 2002). When people born in the year 2000 begin working, the workforce will be composed of four generations, each bringing to the work setting the unique characteristics of their parentage, work ethic, and worldview. As might be expected, the oldest of the older nurses (so-called Traditionalists) have fewer technology skills, but a strong work ethic (almost a calling), and are dismayed by what they consider unprofessionalism in younger nurses. Baby boomers, who often rejected the conformity of their parents’ generation, are considered independent, critical thinkers who view their work as a career. These nurses have
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CHAPTER
2
The Nursing Process: Planning Care Using Nursing Diagnoses
N
urses and healthcare consumers agree that nursing care is a key factor in achieving positive outcomes and enhancing client satisfaction. Nursing care is instrumental in all phases of acute care as well as in the maintenance of general wellbeing, in such areas as prevention of illness, rehabilitation, and maximization of health, or, where a return to health is not possible, the relief of pain and discomfort and a peaceful death. To this end, the nursing profession has identified a problem-solving process that “combines the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method” (Shore, 1988). The original concept of the nursing process introduced in the 1950s involved three steps: assessment, planning, and evaluation, based on the scientific method of observing, measuring, gathering data, and analyzing the findings. Over time, this process became part of the conceptual framework of all nursing curricula and is included in the legal definition of nursing in the Nurse Practice Acts of most states. After years of study, use, and refinement, the three-step process was expanded to five steps: (1) assessment (systematic collection of data relating to clients and their problems and needs), (2) diagnosis (analysis and interpretation of data), (3) planning (prioritizing needs, identifying goals, and choosing solutions), (4) implementation (putting the plan into action), and (5) evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs). All five steps are central to nursing actions and the delivery of high-quality, individualized client care in any setting. When a client enters the healthcare system, the nurse uses the steps of the nursing process to work toward achieving desired outcomes and goals identified for the client. The effectiveness of the plan of care is evaluated by ascertaining whether or not the desired outcomes and goals have been attained (client’s problems and needs have been resolved) or whether problems remain at the time of discharge. If problems are unresolved, plans need to be made for further follow-up, including assessment, additional problem and need identification, alteration of desired outcomes and goals, and changes in interventions in the next care setting. Although some nurses view the nursing process as separate, progressive steps, the elements are actually interrelated. 4
Taken together, they form a continuous circle of thought and action throughout the client’s contact with the healthcare system. The process combines all the skills of critical thinking and good nursing care because it creates a method of active problem-solving that is both dynamic and cyclic. Figure 2.1 demonstrates the way this cyclic process works. As we learned more about diagnostic reasoning and critical thinking, some scholars proposed a new model to describe what nurses do, focusing more on consumer outcomes than nursing tasks. With this emphasis in mind, the 1995 Social Policy Statement of the American Nurses Association (ANA) increased the focus on nursing care outcomes. Through ongoing research into the nature of thinking and reasoning, the conception of the nursing process continues to be redefined (Pesut & Herman, 1999). A number of years ago, implementation of prospective and capitated payment plans moved a greater portion of healthcare delivery away from acute care hospitals into the community, with an emphasis on multifaceted free-standing care centers and home health services. Standards of care such as those published by the American Association of CriticalCare Nurses (AACN) and the Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) emphasized that in every healthcare environment, nursing must meet standards that specified parameters for client assessment, monitoring, and documentation of care. It had become apparent that nurses needed a common framework of communication and documentation so that their contribution to healthcare was recognized as essential and remunerated accordingly. At the very least, nursing required a commonality of terms describing practice so that it was visible in healthcare databases (Aquilino, 2000; Delany, 2000). Through the years, the “what” and “how” of the work of nursing had been partially explained in a number of publications that helped operationalize the work of nursing. The ANA Social Policy Statement (1980) defined nursing as the “diagnosis and treatment of human responses to actual and potential health problems,” providing a framework for understanding nursing’s relationship with society and nursing’s obligations to those receiving nursing care. In 1991, the ANA Standards of Clinical Nursing Practice described the client
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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.
care process and standards for professional performance, providing impetus and support for the development and use of nursing diagnosis in the practice setting. Finally, NANDA International (formerly North American Nursing Diagnosis Association) initiated research and intensified the work (ongoing for more than 30 years) of identifying client problems and needs for which nurses are accountable. The linkage of nursing diagnoses to specific nursing interventions and client outcomes led to the development of a number of standardized nursing languages, for instance, the Omaha System, Clinical Care Classification (formerly Home Healthcare Classification), Ozbolt Patient Care Data Set (now retired), and Perioperative Minimum Data Set. The purpose of these languages is to help ensure continuity of appropriate cost-effective nursing care for the client regardless of setting. TABLE 2.1
This is accomplished in part through enhanced communication, standardization of the process of evaluating the care provided, and facilitation of documentation. Today, NANDA-I continues the development of nursing diagnosis labels (Table 2.1), which are complemented by the Iowa Intervention Project: Nursing Interventions Classification (NIC) and the Iowa Outcomes Project: Nursing Outcomes Classification (NOC). NIC directs our focus to the content and process of nursing care by identifying and standardizing the care activities nurses perform, and NOC describes client outcomes that are responsive to nursing intervention and develops corresponding measurement scales. Combined, these three standardized languages (NNN) form a single language describing client problems or needs, nursing actions, and outcomes for evaluation of the care provided.
Nursing Diagnoses Accepted for Use and Research Through 2014
Activity Intolerance [specify level] Activity Intolerance, risk for Activity Planning, ineffective Activity Planning, risk for ineffective Adverse Reaction to Iodinated Contrast Media, risk for Airway Clearance, ineffective Allergy Response, risk for Anxiety [specify level] Aspiration, risk for Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, disorganized infant Behavior, readiness for enhanced organized infant Behavior, risk for disorganized infant Bleeding, risk for Blood Glucose Level, risk for unstable Body Image, disturbed Body Temperature, risk for imbalanced Breast Milk, insufficient Breastfeeding, ineffective Breastfeeding, interrupted
Breastfeeding, readiness for enhanced Breathing Pattern, ineffective Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Childbearing Process, ineffective Childbearing Process, readiness for enhanced Childbearing Process, risk for ineffective Comfort, impaired Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Confusion, acute Confusion, risk for acute Confusion, chronic Constipation Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, compromised family Coping, defensive Coping, disabled family Coping, ineffective
Coping, ineffective community Coping, readiness for enhanced Coping, readiness for enhanced community Coping, readiness for enhanced family Death Anxiety Decision Making, readiness for enhanced Decisional Conflict (specify) Denial, ineffective Dentition, impaired Development, risk for delayed Diarrhea Disuse Syndrome, risk for Diversional Activity, deficient Dry Eye, risk for Electrolyte Imbalance, risk for Energy Field, disturbed Environmental Interpretation Syndrome, impaired Failure to Thrive, adult Falls, risk for Family Processes, dysfunctional Family Processes, interrupted (continues on page 6)
5
THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES
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TABLE 2.1
Nursing Diagnoses Accepted for Use and Research Through 2014 (continued)
Family Processes, readiness for enhanced Fatigue Fear Feeding Pattern, ineffective infant Fluid Balance, readiness for enhanced [Fluid Volume, deficient hypertonic/ hypotonic] Fluid Volume, deficient [isotonic] Fluid Volume, excess Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced Gas Exchange, impaired Gastrointestinal Motility, dysfunctional Gastrointestinal Motility, risk for dysfunctional Gastrointestinal Perfusion, risk for ineffective Grieving Grieving, complicated Grieving, risk for complicated Growth, risk for disproportionate Growth and Development, delayed Health, deficient community Health Behavior, risk-prone Health Maintenance, ineffective Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Human Dignity, risk for compromised Hyperthermia Hypothermia Immunization Status, readiness for enhanced Impulse Control, ineffective Incontinence, bowel Incontinence, functional urinary Incontinence, overflow urinary Incontinence, reflex urinary Incontinence, stress urinary Incontinence, urge urinary Incontinence, risk for urge urinary Infection, risk for Injury, risk for Insomnia Intracranial Adaptive Capacity, decreased Jaundice, neonatal Jaundice, risk for neonatal Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced Latex Allergy Response Latex Allergy Response, risk for Lifestyle, sedentary
Liver Function, risk for impaired Loneliness, risk for Maternal-Fetal Dyad, risk for disturbed Memory, impaired Mobility, impaired bed Mobility, impaired physical Mobility, impaired wheelchair Moral Distress Nausea Noncompliance, [ineffective Adherence] [specify] Nutrition: less than body requirements, imbalanced Nutrition: more than body requirements, imbalanced Nutrition: more than body requirements, risk for imbalanced Nutrition, readiness for enhanced Oral Mucous Membrane, impaired Pain, acute Pain, chronic Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Perioperative Positioning Injury, risk for Peripheral Neurovascular Dysfunction, risk for Personal Identity, disturbed Personal Identity, risk for disturbed Poisoning, risk for Post-Trauma Syndrome [specify stage] Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness [specify level] Powerlessness, risk for Protection, ineffective Rape-Trauma Syndrome Relationship, ineffective Relationship, readiness for enhanced Relationship, risk for ineffective Religiosity, impaired Religiosity, readiness for enhanced Religiosity, risk for impaired Relocation Stress Syndrome Relocation Stress Syndrome, risk for Renal Perfusion, risk for ineffective Resilience, impaired individual Resilience, readiness for enhanced Resilience, risk for compromised Role Conflict, parental Role Performance, ineffective Self-Care, readiness for enhanced Self-Care Deficit, bathing Self-Care Deficit, dressing Self-Care Deficit, feeding Self-Care Deficit, toileting
Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, situational low Self-Esteem, risk for chronic low Self-Esteem, risk for situational low Self-Health Management, ineffective Self-Health Management, readiness for enhanced Self-Mutilation Self-Mutilation, risk for Self-Neglect [Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)] Sexual Dysfunction Sexuality Pattern, ineffective Shock, risk for Skin Integrity, impaired Skin Integrity, risk for impaired Sleep, readiness for enhanced Sleep Deprivation Sleep Pattern, disturbed Social Interaction, impaired Social Isolation Sorrow, chronic Spiritual Distress Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced Stress Overload Sudden Infant Death Syndrome, risk for Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Swallowing, impaired Therapeutic Regimen Management, ineffective family Thermal Injury, risk for Thermoregulation, ineffective Tissue Integrity, impaired Tissue Perfusion, ineffective peripheral Tissue Perfusion, risk for decreased cardiac Tissue Perfusion, risk for ineffective cerebral Tissue Perfusion, risk for ineffective peripheral Transfer Ability, impaired Trauma, risk for Unilateral Neglect Urinary Elimination, impaired Urinary Elimination, readiness for enhanced Urinary Retention [acute/chronic] Vascular Trauma, risk for Ventilation, impaired spontaneous Ventilatory Weaning Response, dysfunctional Violence, risk for other-directed Violence, risk for self-directed Walking, impaired Wandering [specify sporadic or continual]
[ ] author recommendations Herdman, T.H. (Ed.). Nursing Diagnoses—Definitions and Classification 2012–2014. Copyright © 2012, 1994–2012 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
6
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Client Database In this book, each selected medical condition has an accompanying client database that includes subjective (“may report”) and objective (“may exhibit”) data that would likely be collected through the history-taking interview, physical assessment, diagnostic studies, and review of prior records. The client database is organized within the 13 categories of the Diagnostic Divisions. A sample medical/surgical assessment tool, definitions of the Divisions, and a client situation are included in Chapter 3. As the plan of care is developed, the nurse will also individualize it to the client’s situation.
Interviewing Interviewing the client and significant other(s) provides data that the nurse obtains through conversation and observation. This information includes the individual’s perceptions, that is, what the client perceives to be a problem or need and typically what he or she wants to share. Data may be collected during one or more contact periods and should include all relevant information. All participants in the interview process need to know that collected data are used in planning the client’s care. Organizing and updating the data assists in the ongoing identification of client care needs and nursing diagnoses.
Physical Assessment
Components of the Plan of Care The critical element for providing effective planned nursing care is its relevance as identified in client assessments. ANA’s 2010 Nursing: Scope and Standards of Practice determined that client assessment is indicated in, but not limited to, the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. These assessments, combined with the results of medical findings and diagnostic studies, are documented in the client database and form the foundation for development of the client’s plan of care. For each plan of care presented in this book, pathophysiology, etiology, statistics, and a glossary are provided. A client assessment database is then created from information that would likely be obtained from the history and physical examination. A separate table defining diagnostic studies often associated with the condition provides information explaining usual findings. Next, nursing priorities and discharge
During information gathering, the nurse exercises perceptual and observational skills, assessing the client through the senses of sight, hearing, touch, and smell. The duration and depth of any physical assessment depend on the current condition of the client and the urgency of the situation, but it usually includes inspection, palpation, percussion, and auscultation. In this book, the physical assessment data are presented within the client database as objective data.
Diagnostic Studies A separate section for lab tests and other diagnostic studies describes the test and the usual findings. Some tests are used to diagnose disease, whereas others are useful in following the course of a disease or in adjusting therapies. The nurse needs to be aware of significant test results that require reporting to the physician and/or initiation 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 interrelationship between various organs and body systems. 7
THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES
Medicine and nursing, as well as other healthcare disciplines, are interrelated, and therefore the developments in each discipline have implications for the others. This interrelationship allows for exchange of information and ideas and for development of plans of care that include all data pertinent to the individual client and family. In this book, the plans of care contain not only the actions initiated by medical and nursing orders but also the coordination of care provided by all related healthcare disciplines. The nurse is often the person responsible for coordinating these various activities into a comprehensive functional plan, which is essential in providing holistic care for the client. Although independent nursing actions are an integral part of this process, collaborative actions are also present based on the medical regimen or orders from other disciplines participating in the care of the client. We believe that nursing is an essential part of collaborative practice, and as such, nursing has a responsibility and accountability in every collaborative problem in which the nurse interacts with the client. The educational background and expertise of the nurse, standing protocols, delegation of tasks, the use of care partners, and the area of practice—for example, rural or urban, acute care or community care settings—influence whether an intervention is actually an independent nursing function or requires collaboration. The well-developed plan of care communicates the client’s past and present health status and current needs to all members of the healthcare team involved in providing care. It identifies problems solved and those yet to be solved, can provide information about approaches that have been successful, and notes patterns of client responses to interventions. In legal terms, the plan of care documents client care in areas of liability, accountability, and quality improvement. It also provides a mechanism to help ensure continuity of care when the client leaves a care setting while still needing services.
goals are simply stated and represent a general ranking system for the nursing diagnoses in the plan of care. These can be reworded and reorganized, along with their timelines, to create short- and long-term goals. Nursing diagnosis statements are presented, which include possible related or risk factors (etiology) and corresponding defining characteristics (signs and symptoms or cues) as appropriate. Desired client outcomes are then identified and followed by appropriate independent and collaborative interventions with accompanying rationales.
CHAPTER 2
Planning Care
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Nursing Priorities In this book, nursing priorities are listed in a certain order to facilitate the linking and ranking of selected associated nursing diagnoses that appear in the plan of care guidelines. In any given client situation, nursing priorities are based on the client’s specific needs and can vary from minute to minute. A nursing diagnosis that is a priority today may be less of a priority tomorrow, depending on the fluctuating physical and psychosocial condition of the client or the client’s changing responses to the existing condition and/or treatment. An example of nursing priorities for a client diagnosed with severe hypertension would include the following: 1. Maintain or enhance cardiovascular functioning. 2. Prevent complications. 3. Provide information about disease process, prognosis, and treatment regimen. 4. Support active client control or management of the condition.
Discharge Goals Once the nursing priorities are determined, the next step is to establish goals of treatment. In this book, each medical condition has established discharge goals that are broadly stated and reflect the desired general status of the client on discharge or transfer to another care setting. Discharge goals for a client with severe hypertension would include the following: 1. Blood pressure within acceptable limits for individual. 2. Cardiovascular and systemic complications prevented or minimized. 3. Disease process, prognosis, and therapeutic regimen understood. 4. Necessary lifestyle and behavioral changes initiated. 5. Plan in place to meet needs after discharge.
Nursing Diagnosis (Problem and Need Identification) Nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual or high-risk problems and life processes. Nursing diagnosis labels (see Table 2.1) provide a format for expressing the problem-identification portion of the nursing process. In 1989, NANDA developed a taxonomy, or classification scheme, to categorize and classify nursing diagnostic labels. (This was replaced by a new taxonomy in 2000.) The NANDA definition of nursing diagnosis approved in 1990 further clarified the second step of the nursing process (i.e., diagnosis or problem and need identification). The definition of nursing diagnosis developed by NANDA is presented in Box 2.1. There are several steps involved in the process of problem and need identification. Integrating these steps provides a systematic approach to accurately identifying nursing diagnoses using the process of critical thinking. 1. Collect a client database (nursing interview, physical assessment, and diagnostic studies) combined with information collected by other healthcare providers. 8
Box 2.1 NANDA-I Definition of Nursing Diagnosis A nursing diagnosis is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
2. Review and analyze the client data. 3. Synthesize the gathered client data as a whole and then label the clinical judgment about the client’s responses to these actual or high-risk problems and life processes. 4. Compare and contrast the relationships of clinical judgments with related factors and defining characteristics for the selected nursing diagnosis. This step is crucial to choosing and validating the appropriate nursing diagnosis label that will be used to create a specific client diagnostic statement. 5. Combine the nursing diagnosis with the related factors and define characteristics, or risk factors, to create the client diagnostic statement. For example, the diagnostic statement for a paraplegic client with a pressure ulcer could read as follows: “impaired Skin Integrity related to mechanical factors (pressure, shearing forces), impaired circulation, and impaired sensation evidenced by destruction of skin layers—sacral area.” The nursing diagnosis is as correct as the present information allows because it is supported by the immediate data collected. It documents the client’s situation at the present time and should reflect changes as they occur in the client’s condition. Accurate need identification and diagnostic labeling provide the basis for selecting nursing interventions. The nursing diagnosis may be a physical or a psychosocial response. Physical nursing diagnoses include those that pertain to physical processes, such as “circulation (risk for ineffective Renal Perfusion), ventilation (impaired Gas Exchange), and elimination (Constipation).” Psychosocial nursing diagnoses include those that pertain to the mind (“acute Confusion”), emotions (“Fear”), or lifestyle and relationships (“ineffective Role Performance”). Unlike medical diagnoses, nursing diagnoses change as the client progresses through various stages of illness and/or maladaptation to resolution of the problem or to the conclusion of the condition. Each decision the nurse makes is time dependent, and with additional information gathered at a later time, decisions may change. For example, the initial problems and needs for a client undergoing cardiac surgery may be “acute Pain, decreased Cardiac Output, risk for ineffective Breathing Pattern, and risk for Infection.” As the client progresses, problems and needs are likely to shift to “Activity Intolerance, deficient Knowledge, and Self-Care Deficit.” Diagnostic reasoning is used to ensure the accuracy of the client diagnostic statement. The defining characteristics and related factors associated with the chosen nursing diagnosis are reviewed and compared with the client data.
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The nurse identifies expected outcomes for a plan of care individualized for a specific client (ANA, 2010). A desired client outcome is defined as the result of achievable nursing interventions and client responses that is desired by the client or caregiver and attainable within a defined time period, given the current situation and resources. These desired outcomes are the measurable steps toward achieving the previously established discharge goals and are used to evaluate the client’s response to nursing interventions. (The fifth step of the nursing process, evaluation, is addressed in the sample client situation provided in Chapter 3.) Useful desired client outcomes must have the following characteristics: 1. 2. 3. 4. 5.
Be specific Be realistic or achievable Be measurable Indicate a definite time frame for achievement or review Consider client’s desires and resources
Desired client outcomes are created by listing items and behaviors that can be observed or heard. They are monitored to determine whether an acceptable outcome has been achieved within a specified time frame. Action verbs and time frames are used, for example, “client will ambulate, using cane, within 24 hours of surgery.” The action verbs describe the client’s behavior to be evaluated. Time frames are dependent on the client’s projected or anticipated length of stay or period of care, often determined by diagnosis-related group (DRG) classification and considering the presence of complications or extenuating circ*mstances, such as age, debilitating disease process, and so on. The ongoing work of NOC in identifying 490 outcomes now also addresses client groups or aggregates. When using NOC, the outcomes are listed in general terms such as “Ambulation,” and 16 indicators have been identified for this outcome that can be measured by a five-point Likert-type scale, ranging from “severely compromised” to “not compromised.” This facilitates tracking clients across care settings and can demonstrate client progress even when outcomes are not met. When outcomes are properly written, they provide direction for planning and validating the selected nursing interventions. Consider the two following client outcomes: “Client will identify individual nutritional needs within 36 hours” and “. . . formulate a dietary plan based on identified nutritional needs within 72 hours.” Based on the clarity of these outcomes, the nurse can select nursing interventions to ensure that the client’s dietary knowledge is assessed, individual needs identified, and nutritional education presented. Often, the client outcomes identified are not unique to nursing because care is provided in a team approach with other disciplines. However, the NOC indicators for outcomes are generally more sensitive to nursing interventions. Other team members can use the majority of NOC labels and identify
Planning (Goals and Actions/ Interventions) Once the outcomes are identified, the nurse develops a plan that prescribes strategies and alternatives to achieve the expected outcomes (ANA, 2010). Nursing strategies are interventions and actions to be carried out or facilitated by nurses to achieve specific behaviors expected from the client. These actions and interventions are selected to assist the client in achieving the stated desired client outcomes and discharge goals. The expectation is that the prescribed behavior will benefit the client and family in a predictable way related to the identified problem or need and chosen outcomes. These interventions have the intent of individualizing care by meeting a specific client need and should incorporate identified client strengths when possible. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Qualifiers expressing how, when, where, time, frequency, and amount provide the content of the planned activity, for example, “Assist as needed with selfcare activities each morning”; “Record respiratory and pulse rates before, during, and after activity”; and “Instruct family in postdischarge care.” The NIC project has identified 554 interventions (both direct and indirect) that are stated in general terms, such as “Respiratory Monitoring.” Each label has a varied number of activities that may be chosen to accomplish the intervention. The interventions encompass a broad range of nursing practice, with some requiring specialized training or advanced certification. Others may be appropriate for delegation to other care providers (for example, licensed practical nurses [LPNs] or vocational nurses [LVNs], nursing assistants, and unlicensed personnel) but still require planning and evaluation by registered nurses. In this text, these sample NIC labels are boxed to help the user identify how they can be used. As with the NOC labels, the nurse is directed to the NIC work (Bulechek, 2013) when choosing to use the language in planning client care. This book divides the nursing interventions and actions into independent (nurse initiated) and collaborative (initiated by and/or performed in conjunction with other care providers) under the appropriate NIC labels. Examples of these two different professionally initiated actions are as follows: • Independent: Provide calm, restful surroundings, minimize environmental activity and noise, and limit numbers of visitors and length of stay. • Collaborative: Administer anti-anxiety medication as indicated. 9
THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES
Desired Client Outcomes
different indicators relative to their specialty focus to demonstrate their contribution to client improvement or to track deterioration. In this book, the identified outcomes in each plan of care are stated in more specific terms but are organized by using possible NOC labels (which are boxed to call attention to this language). The nurse is directed to the NOC work (Morehead, 2013) when choosing to use this specific language.
CHAPTER 2
If the diagnosis is not consistent with at least two or more cues, additional data may be required or another nursing diagnosis considered.
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Rationale Although rationales do not appear on regular plans of care, they are included in this book to assist the student and practicing nurse in associating the pathophysiological and psychological principles with the selected nursing intervention. This will help the nurse determine whether an intervention is appropriate for a specific client.
Conclusion This book is intended to facilitate the application of the nursing process and the use of nursing diagnosis in medical and surgical clients. (Plan of care guides for maternity, newborn, and psychiatric clients are available on a supporting Web site.) Each plan of care guideline was designed to provide generalized information on the associated medical condition. The guidelines can be modified either by using portions of the information provided or by adding more
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client care information to the existing guides. The plan of care guidelines were developed using the NANDA-I recommendations, except in a few bracketed examples where the authors believed more clarification and enhancement were required. The ongoing controversy over the validity of the nursing diagnosis of “deficient Knowledge” approved by NANDA-I is one example where further clarification was added. The term “Learning Need” has been added to the nursing diagnosis label. Also, on a few occasions, some diagnoses, such as “Anxiety/Fear,” have been combined for convenience; the combination indicates that two or more factors may be involved, and the nurse can then choose the most appropriate diagnosis for a specific client. We recognize that not all of the nursing diagnoses approved by NANDA-I have been used in the plan of care guidelines, but we hope that these guidelines will assist you in determining your clients’ needs, outcomes, and nursing interventions. Next, Chapter 3 will assist you in applying and adapting theory to practice.
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CHAPTER
3
Critical Thinking: Adaptation of Theory to Practice
C
ritical thinking is defined as the “intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information gathered from or generated by observation, experience, reflection, reasoning, or communication, as a guide to belief and action” (Scriven, 1987). In short, critical thinking is selfdirected, self-disciplined, self-monitored, and self-corrective thinking that also entails effective communication with others in figuring out solutions to complex problems (Paul, 2008). It requires cognitive, psychom*otor, and affective skills in order to use the tools of a comprehensive knowledge base, the nursing process, and established standards of care, as well as nursing research, to analyze data and plan a course of action based on new insights and conclusions. To this end, the nurse defines the problem, selects pertinent information for the solution, recognizes stated and unstated assumptions, formulates and selects relevant and promising hypotheses, draws conclusions, and judges the validity of the inferences (Hickman, 1993). Although critical thinking skills are used in all aspects of nursing practice, they are most evident when assessment data are analyzed to identify relevant information, make decisions about client needs, and develop an individualized plan of care. Therefore, client assessment is the foundation on which identification of individual needs, responses, and problems is based. Nurses of the future will still manage and interpret data and evaluate nursing activities and interventions. They will also need competencies in case and financial management, healthcare policy and economics, legislative outcomes, and research methods. Additionally, they will need delegation skills and the ability to think and reason across diverse settings in which they will practice (Pesut & Herman, 1999). To facilitate the steps of assessing and diagnosing in the nursing process and to aid in the critical thinking process, assessment databases have been developed (Fig. 3.1) that use a nursing focus instead of the traditional medical approach of a review of systems. To achieve this nursing focus, we have grouped NANDA International (NANDA-I) nursing diagnoses into related categories titled Diagnostic Divisions (Box 3.1). These categories reflect a blending of theories, primarily Maslow’s Hierarchy of Needs and a self-care phi-
losophy. These divisions serve as the framework or outline for data collection and direct the nurse to the corresponding nursing diagnosis labels. Because these divisions are based on human responses and needs and are not specific systems, data may be recorded in more than one area. For this reason, the nurse is encouraged to keep an open mind and to collect as much information as possible before choosing the nursing diagnosis label. The results (synthesis) of the collected data are written concisely (client diagnostic statements) to best reflect the client’s situation. From the specific data recorded in the database, the related or risk factors (etiology) and signs and symptoms can be identified, and an individualized client diagnostic statement can be formulated according to the problem, etiology, and signs and symptoms (PES) format to accurately represent the client’s situation. For example, the diagnostic statement may read as follows: “ineffective peripheral Tissue Perfusion related to smoking, hypertension, diabetes mellitus, evidenced by diminished pulses, pale and cool feet, paresthesia of feet when walks 1/4 mile.” Outcomes are identified to facilitate choosing appropriate interventions and to serve as evaluators of both nursing care and client response. In addition to being measurable, outcomes must be achievable and desired by the client. These outcomes also form the framework for documentation. Interventions are designed to specify the action of the nurse, the client, and significant other(s). They are not allinclusive because such basic nursing actions as “bathe the client” or “notify the physician of changes” have been omitted. It is expected that these actions are included in routine client care. On occasion, controversial issues or treatments are presented for the sake of information and because different therapies may be used in different care settings or geographic locations. Interventions need to promote the client’s movement toward health and independence. This requires involvement of the client in his or her own care, including participation in decisions about the care activities and projected outcomes. This promotes client responsibility, negating the idea that healthcare providers control clients’ lives. (text continues on page 19)
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ADULT MEDICAL/SURGICAL ASSESSMENT TOOL General Information Name: _________________________________________________________________________________________________________________ Age: _____________ DOB: ___________ Gender: ____________ Race: __________________________ Admission Date: ___________________ Time:_______________From: _________________________ Reason for this admission (primary concern): ____________________________________________________________________________ Cultural concerns (relating to healthcare decisions, religious concerns, pain, childbirth, family involvement, communication, etc): _______________________________________________________________________________________________________________________ Source of information: _________________________ Reliability (1–4 with 4 = very reliable):_____________________________________
Activity/Rest
Subjective (Reports) Occupation: _____________________________________________ Leisure time/diversional activities: ________________________ Able to participate in usual activities/hobbies:______________ Ambulatory: _____ Gait (describe): _______________ Activity level (sedentary to very active): ___________________ Daily exercise/type: ______________________________________ Muscle mass/tone/strength (e.g., normal, increased, decreased): ____________Change: _____________ History of problems/limitations imposed by condition (e.g., immobility, can’t transfer, weakness, breathlessness): _______________________________________ Feelings (e.g., exhaustion, restlessness, can’t concentrate, dissatisfaction): _______________________________________ Developmental factors (e.g., delayed/age): _________________ Sleep: Hours: ______ Naps: __________ Aids: _______________ Insomnia: _____ Related to: ____________________________ Difficulty falling asleep: ________________________________ Difficulty staying asleep: _______________________________ Rested on awakening: _________________________________ Excessive grogginess: _________________________________ Sleeps on more than one pillow: _______________________ Bedtime rituals: _______________________________________ Relaxation techniques: ___________________________________ Oxygen use (type): _______When used: ___________________ Medications or herbals for/affecting sleep: _________________ ________________________________________________________
Circulation
Objective (Exhibits) Observed response to activity: Heart rate: ____________________ Rhythm (reg/irreg): _______________________________________ Blood pressure: __________________________________________ Respiration rate: _________________________________________ Pulse oximetry: __________________________________________ Mental status (i.e., cognitive impairment, withdrawn/lethargic): _____________________________________ Neuromuscular assessment: Muscle mass/tone: _______________________________________ Posture (e.g., normal, stooped, curved spine): ______________ Tremors: ________________________________________________ (location): _____________________________________________ ROM: ____________________________________________________ Strength: ________________________________________________ Deformity: _______________________________________________ Uses mobility aid (list): _____________________________________
Subjective (Reports)
Objective (Exhibits)
History of/treatment for (date): High blood pressure: _______ Brain injury: _________ Stroke: _________ Heart problems/surgery: _________ Palpitations: _________ Syncope: _________________ Rheumatic fever: ___________ Cough/hemoptysis: ________ Blood clots: ________________ Bleeding tendencies/episodes: _______ (location): _______ Pain in legs w/activity __________ Extremities: Numbness: _______ (location): _______ Tingling: _______ (location): _______ Slow healing (describe): __________ Change in frequency/amount of urine:_____________________ History of spinal cord injury/dysreflexia episodes: _________ Medications/herbals: _____________________________________
Color (e.g., pale, cyanotic, jaundiced, mottled, ruddy): Skin: ______ Mucous membranes: _________ Lips: __________ Nail beds:__________ Conjunctiva: _________ Sclera: ________ Skin moisture (e.g., dry, diaphoretic): ________________________ BP: Lying: R________ L________ Sitting: R________ L________ Standing: R________ L________ Pulse pressure: ____________ Auscultatory gap: _____________ Pulses (palpated 1–4 strength): Carotid: _____ Temporal: ______ Jugular: _____ Radial: _____ Femoral: _____ Popliteal: ______ Post-tibial: _____________Dorsalis pedis: ___________________ Cardiac (palpation): Thrill: _________ Heaves: _________ Heart sounds (auscultation): Rate: _________ Rhythm: _________ Quality: _________ Friction rub: _________ Murmur (describe location/sounds): _______________________ Vascular bruit (location): ______ Jugular vein distention: _______ Breath sounds (location/describe): ___________________________ Extremities: Temperature: ___________ Color: _________________ Capillary refill (1–3 sec): _________ Homan’s sign: __________ Varicosities (location): ____________________________________ Distribution/quality of hair: _______________________________ Edema (location/severity +1– +4): ____________________________ Trophic skin changes: ________ Nail abnormalities: ________
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Subjective (Reports)
Elimination
Objective (Exhibits) Emotional status (check those that apply): Calm: __________________Anxious: ________________________ Angry: _________________Withdrawn: _____________________ Fearful: _________________Irritable: ________________________ Restive: ________________Euphoric: _______________________ Observed body language: ___________________________________ Observed physiological responses (e.g., palpitations, crying, change in voice quality/volume): __________________________ Changes in energy field: Temperature: ____________________________________________ Color: ___________________________________________________ Distribution: _____________________________________________ Movement: ______________________________________________ Sounds: _________________________________________________
Subjective (Reports)
Objective (Exhibits)
Usual bowel elimination pattern: _________________________ Character of stool (e.g., hard, soft, liquid): ______________ Stool color (e.g., brown, black, yellow, clay colored, tarry): ______________________________________________________ Date of last BM and character of stool: ____________________ History of bleeding: ________ Hemorrhoids/fistula: _________ Constipation: acute: _________ or chronic: _______________ Diarrhea: acute: _____________ or chronic: _______________ Bowel incontinence: _____________________________________ Laxative: _________ (how often): __________________________ Enema/suppository: _________ (how often): ______________ Usual voiding pattern and character of urine: ______________ Difficulty voiding: _______Urgency: _____________________ Frequency: _____________Retention: ____________________ Bladder spasms: ________Pain/Burning:_________________ Urinary incontinence (type/time of day usually occurs):___ ______________________________________________________ History of kidney/bladder disease: ________________________ Diuretic use: __________ Other medications: _______________ Herbals: _________________________________________________
Abdomen (auscultation): Bowel sounds (location/type): _______ Abdomen (palpation): Soft/firm: _____________________________ Tenderness/pain (quadrant location): ______________________ Distention: __________ Palpable mass/location: ____________ Size/girth: ___________ CVA tenderness: __________________ Bladder palpable: _______ Overflow voiding: _________________ Residual urine per scan: _____________________________________ Rectal sphincter tone (describe): _____________________________ Hemorrhoids/fistulas: _________ Stool in rectum: _____________ Impaction: __________ Occult blood (+ or –): ________________ Presence/use of catheter or continence devices: ______________ Ostomy appliances (describe appliance and location): ________ _________________________________________________________
Food/Fluid
Subjective (Reports)
Objective (Exhibits)
Usual diet (type): ________________________________________ Calorie, carbohydrate, protein, fat intake (g/day): ________ # of meals daily: ____ Snacks (number/time consumed): ____ Dietary pattern/content: B: ____________________________________________________ L:_____________________________________________________ D: ____________________________________________________ Snacks: _______________________________________________ Last meal consumed/content: ____________________________ Food preferences: _______________________________________ Food allergies/intolerances: ______________________________ Cultural or religious food preparation concerns/prohibitions: ________________________________________________________ Usual appetite: ________ Change in appetite: ______________ Usual weight: ________ Unexpected/undesired weight loss or gain: _____________ Nausea/vomiting: ____ (related to): _______________________ Heartburn/indigestion: ________________________________ (related to): ________ (relieved by): ______________________ Chewing/swallowing problems: ___________________________ Gag/swallow reflex present: ____________________________
Current weight: _____ Height: _______________________________ Body build: ________ Body fat %: __________________________ Skin turgor (e.g., firm, supple, dehydrated): __________________ Mucous membranes (moist/dry): ____________________________ Edema: Generalized: _______________________________________ Dependent: ______________________________________________ Feet/ankles: ______________________________________________ Periorbital: ______________________________________________ Abdominal/ascites: _______________________________________ Jugular vein distention: _____________________________________ Breath sounds (auscultate)/location: _________________________ Faint/distant: ________ Crackles: ________ Wheezes: _________ Condition of teeth/gums: _______ Appearance of tongue: ______ Mucous membranes: _____________________________________ Abdomen: Bowel sounds (quadrant location/type): ___________ Hernia/masses: ____________________________________________ Urine S/A or Chemstix: _____________________________________ Blood glucose (Glucometer): ______________________________
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CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Relationship status: _____________________________________ Expression of concerns (e.g., financial, lifestyle, relationship, or role changes): ______________________________________ Stress factors: __________________________________________ Usual ways of handling stress: ___________________________ Expression of feelings: Anger: _________ Anxiety: __________ Fear: ________ Grief: __________ Helplessness: ___________ Hopelessness: __________ Powerlessness: ______________ Cultural factors/ethnic ties: _______________________________ Religious affiliation: _________ Active/practicing: ___________ Practices prayer/meditation: ___________________________ Religious/spiritual concerns: ___________________________ Desires clergy visit: ___________________________________ Expression of sense of connectedness/harmony with self and others: __________________________________ Medications/herbals: ____________________________________
CHAPTER 3
Ego Integrity
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Food/Fluid (continued) Subjective (Reports) Facial injury/surgery: ____________________________________ Stroke/other neurological deficit: _______________________ Teeth: Normal: ____ Dentures (full/partial): _________________ Loose/absent teeth/poor dental care: ___________________ Sore mouth/gums:_____________________________________ Dental hygiene practices: ______________________________ Professional dental care/frequency: _____________________ Diabetes/type: ______ Controlled with diet/pills/insulin: _____ Vitamin/food supplements: _________________________________ Medications/herbals: _______________________________________
Hygiene Subjective (Reports)
Objective (Exhibits)
Ability to carry out activities of daily living: ________________ General appearance: Manner of dress: ____________________ Independent/dependent (level 1 = no assistance needed Grooming/personal habits: ____________________________ to level 4 = completely dependent): _____________________ Condition of hair/scalp: ________________________________ Mobility: ___ Assistance needed (describe): _______________ Body odor: ___________________________________________ Assistance provided by: _______________________________ Presence of vermin (e.g., lice, scabies): ___________________ Equipment/prosthetic devices required: _________________ Feeding: ___ Help with food preparation: __________________ Help with eating utensils: ______________________________ Hygiene: ____ Get supplies: ____ Wash body/body parts: ___ Regulate bath water temperature: ___ Get in/out alone: ___ Preferred time of personal care/bath: ___________________ Dressing: ___ Can select clothing: ____ Can dress self: ______ Needs assistance with(describe): _________________________ Toileting: ___ Can get to toilet/commode alone: ___________ Needs assistance with (describe): ________________________
Neurosensory Subjective (Reports)
Objective (Exhibits)
History of brain injury, trauma, stroke (residual effects): ____ Fainting spells/dizziness: _________________________________ Headaches (location/type/frequency): _____________________ Tingling/numbness/weakness (location): __________________ Seizures: ____ History or new onset:_______________________ Type (e.g., grand mal, partial): ______ Frequency: ________ Aura: _______ Postictal state: ______ How controlled: ____ Vision: Loss/changes in vision: ________ Date last exam: ____ Glaucoma: ____ Cataract: ____ Eye surgery (type/date): ___ Hearing loss: ____ Sudden or gradual: ____________________ Date last exam:________________________________________ Sense of smell (changes): ________________________________ Sense of taste (changes): ________________________________ Other: __________________________________________________
Mental status (note duration of change): Oriented/disoriented: Person: ____________ Time: ___________ Place:______________________ Situation: ____________________ Check all that apply: Alert: _____ Drowsy: _____ Lethargic: _____ Stupor: __ Comatose: __ Cooperative: __ Agitated/Restless: __ Combative: _____ Follows commands: _____________________ Delusions (describe): _______ Hallucinations (describe): ________ Affect (describe): ___________ Speech Pattern: ________________ Memory: Recent: ___________ Remote: _______________________ Pupil shape: _______________ Size/reaction: R/L: _______________ Facial droop: ______________ Swallowing: ____________________ Hand grasp/release: R: _______________ L: ____________________ Coordination: ________ Balance: ________ Walking: ____________ Deep tendon reflexes (present/absent/location): ______________ Tremors: ________ Paralysis (R/L): ________ Posturing: _________ Wears glasses: _______ Contacts: _______ Hearing aids: ________
Pain/Discomfort Subjective (Reports)
Objective (Exhibits)
Primary focus: ____________________ Location: _____________ Intensity (use pain scale or pictures): ______________________ Quality (e.g., stabbing, aching, burning): ________________ Radiation: ________ Duration: ________ Frequency: _______ Precipitating factors: _____________________________________ Relieving factors (including nonpharmaceuticals/therapies): ______________________________________________________ Associated symptoms (e.g., nausea, sleep problems): ______________________________________________________ Effect on daily activities: _______________________________ Relationships: ________________________________________ Enjoyment of life:______________________________________ Additional pain focus (describe): __________________________ Medications: _________________Herbals: ___________________
Facial grimacing: _______ Guarding affected area: _____________ Expressive behavior (e.g., crying, withdrawal, anger): ______ Narrowed focus: _________________________________________ Vital sign changes (acute pain): BP: ______________________________________________________ Pulse: ___________________________________________________ Respirations: ____________________________________________ Photosensitivity: _________________________________________ Employment: _______________________________________________
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CHAPTER 3
Respiration Objective (Exhibits)
Dyspnea/related to: ______________________________________ Precipitating factors: _________ Relieving factors: _________ Airway clearance (e.g., spontaneous/device): ______________ Cough (e.g., hard, persistent, croupy): ____________________ Produces sputum (describe color/character): ____________ Requires suctioning: __________________________________ History of (year): Bronchitis: _________ Asthma: ___________ Emphysema: _____________ Tuberculosis: _______________ Recurrent pneumonia: _________________________________ Exposure to noxious fumes/allergens, infectious agents/ diseases, poisons/pesticides: __________________________ Smoker: ______ packs/day: _________ # pack-years: ________ Cigars: _________ Smokeless tobacoo: _____________________ Use of respiratory aids: ____ Oxygen (type/frequency): _____ Medications/herbals: _____________________________________
Respirations (spontaneous/assisted): ________ Rate: ___________ Depth: _______ Chest excursion (e.g., equal/unequal): _______ Use of accessory muscles: ________________________________ Nasal flaring: ________________ Fremitus:___________________ Breath sounds (presence/absence; crackle, wheezes): _________ Egophony: ______________________________________________ Skin/mucous membrane color (e.g., pale, cyanotic): ___________ Clubbing of fingers: ________________________________________ Sputum characteristics: _____________________________________ Mentation (e.g., calm, anxious, restless): _____________________ Pulse oximetry: ____________________________________________
Safety
Subjective (Reports) Allergies/sensitivity (medications, foods, environment, latex, iodine): _________________________________________ Type of reaction: ______________________________________ Blood transfusion/number: ____ Date: _____________________ Reaction (describe): ___________________________________ Exposure to infectious diseases (e.g., measles, influenza, pink eye): _____________________________________________ Exposure to pollution, toxins, poisons/pesticides, radiation: ______________________________________________________ (describe reactions): ___________________________________ Geographic areas lived in/recent travel: ___________________ Immunization history: Tetanus:____ MMR: ____ Polio: ______ Influenza: ____ Pneumonia: ____ Hepatitis: ____ HPV: _____ Altered/suppressed immune system (infection cause): _____ History of sexually transmitted disease (date/type): ________ Testing: ______________________________________________ High risk behaviors: ______________________________________ Uses seat belt regularly: __________ Helmets: ______________ Other safety devices: __________________________________ Workplace safety/health issues (describe): _________________ Currently working: ____________________________________ Rate working conditions (e.g., safety, noise, heating, water, ventilation):_____________________________________ History of accidental injuries: _____________________________ Fractures/dislocations: ___________________________________ Arthritis/unstable joints: ________ Back problems: __________ Skin problems (e.g., rashes, lesions, moles, breast lumps, enlarged nodes) (describe): ____________________________ Delayed healing (describe): _______________________________ Cognitive limitations (e.g., disoriented, confusion): ________ Sensory limitations (e.g., impaired vision/hearing, detecting heat/cold, taste, smell, touch): __________________________ Prostheses: __________ Ambulatory devices: _______________ Violence (episodes or tendencies): _______________________
CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Subjective (Reports)
Objective (Exhibits) Body temperature/method: (e.g., oral, temporal, tympanic): ____ Skin integrity (mark location on diagram): Scars: ______________ Bruises:__________ Rashes:_________ Abrasions: ____________ Lacerations:_______Ulcerations: ________ Blisters: __________ Drainage: _____________ Burns [degree/%]: _________________
Musculoskeletal: General strength: ______ Muscle tone: _______ Gait: ________ ROM: ________ Paresthesia/paralysis: __________ Results of testing (e.g., cultures, immune function, TB, hepatitis): _________________________________________________________
Sexuality [Component of Social Interaction] Subjective (Reports)
Objective (Exhibits)
Sexually active: _________________Monogamous:__________ Birth control method: _________Use of condoms: _______ Sexual concerns/difficulties (e.g., pain, relationship, role performance):_____________________________________ Recent change in frequency/interest: ______________________
Comfort level with subject matter: ___________________________
Male: Subjective (Reports)
Objective (Exhibits)
Penis: Circumcised: ____ Vasectomy (date): _______________ Prostate disorder: _______________________________________ Practice self-exam: Breast: __________ testicl*s: ___________ Last proctoscopic/prostate exam: _____ Last PSA/date: _____ Medications/herbals: ____________________________________
Genitalia: Penis: Circumcised: _______ Warts/lesions: __________ Bleeding/discharge: ______testicl*s (e.g., lumps): ___________ Breasts examination: _______________________________________ Test results: PSA: ________________ STI: ______________________
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Sexuality [Component of Social Interaction] (continued) Female: Subjective (Reports) Menstruation: Age at menarche: ____ Length of cycle: ______ Duration: _____ Number of pads/tampons used/day: _____ Last menstrual period: ________________________________ Bleeding between periods: ____________________________ Reproductive: Infertility concerns: ________________________ Type of therapy: ____________ Pregnant now: ____________ Para: _________ Gravida: _________ Due date: ____________ Menopause: ____ Last period: ____________________________ Hysterectomy (type/date): _____________________________ Problem with: Hot flashes: _________ Night sweats: ______ vagin*l lubrication: ____ vagin*l discharge: _____________ Hormonal therapies: _____________________________________ Osteoporosis medications: ____________________________ Breasts: Practices breast self-exam: _______________________ Last mammogram: __________ Biopsy/surgery: __________ Last PAP smear: _________________________________________
Objective (Exhibits) Breasts examination: _______________________________________ Genitalia: Warts/lesions: ____________________________________ vagin*l bleeding/discharge: ______________________________ Test results: PAP ___________________________________________ Mammogram: ___________________________________________ STI: _____________________________________________________
Social Interactions Subjective (Reports) Relationship status (check): Single: ______ Married: ________ Living with partner: ____ Divorced: _____ Widowed: ______ Years in relationship: ____ Perception of relationship: ____ Concerns/stresses: ____________________________________ Role within family structure: _____________________________ Number/age of children: ________________________________ Perception of relationship with family members: ________ Extended family/availability: _____________________________ Other support person(s): ______________________________ Individuals living in home: _______________________________ Caregiver (to whom/how long): __________________________ Ethnic/cultural affiliations: _______________________________ Strength of ethnic identity: ____________________________ Lives in ethnic community: ____________________________ Feelings of (describe): Mistrust: ________ Rejection: ________ Unhappiness: __________ Loneliness/isolation: ___________ Problems related to illness/condition: _____________________ Difficulties with communication (e.g., speech, another language, brain injury): ________________________________ Use of speech/communication aids (list): _______________ Interpreter needed: ____ Primary language:______________ Genogram: Diagram on separate page
Objective (Exhibits) Communication/speech: Clear: ______________________________ Slurred:__________________________________________________ Unintelligible: ___________________________________________ Aphasic: _________________________________________________ Unusual speech pattern/impairment: ______________________ Laryngectomy present: ___________________________________ Verbal/nonverbal communication with family/SO(s): __________ _________________________________________________________ Family interaction (behavioral) pattern: ____________________
Teaching/Learning Subjective (Reports) Communication: Dominant language (specify): ____________ Second language: ______ Literate (reading/writing): ______ Education level: _______________________________________ Learning disabilities (specify): __________________________ Cognitive limitations: __________________________________ Culture/ethnicity: Where born: ___________________________ If immigrant, how long in this country: __________________ Health and illness beliefs/practices/customs: _______________ Which family member makes health care decisions/is spokesperson for client:________________________________ Presence of Advance Directives: ______ Code status: _______ Durable Medical Power of Attorney: ____________________ Designee: _____________________________________________ Health goals: ____________________________________________ Current health problem: __________________________________ Client understanding of problem: _________________________ Special health care concerns (e.g., impact of religious/cultural practices): ____________________________ Healthcare decisions: __________________________________ Family involvement: __________________________________
16
Familial risk factors (indicate relationship): Diabetes: ________ Thyroid (specify): ___________________ Tuberculosis: ______Heart disease: ________ Stroke: ______ Hypertension: _____Epilepsy/seizures:___________________ Kidney disease: ________ Cancer: _______________________ Mental illness/depression: ________ Other: ______________ Prescribed medications: Drug: ________________ Dose:_________ Times (circle last dose): ______Take regularly: ______________ Purpose: ________ Side effects/problems:___________________ Nonprescription drugs/frequency: OTC drugs: ________________ Vitamins: ______________________ Herbals: _________________ Street drugs: ________ Alcohol (amount/frequency): ___________ Tobacco: _____________ Smokeless tobacco: ________________ Admitting diagnosis per provider: ___________________________ Reason for hospitalization/visit per client: ____________________ History of current concern: __________________________________
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Teaching/Learning (continued) Subjective (Reports)
Discharge Plan Considerations Projected length of stay (days or hours): ___________________ Anticipated date of discharge: ____________________________ Date information obtained: ______________________________ Resources available: Persons: ____________________________ Financial: _____________________________________________ Groups: ______________________________________________ Community supports: ___________________________________ Areas that may require alteration/assistance Food preparation: ____ Shopping:_____Transportation: ___ Ambulation: ____Medication/IV therapy: ________________ Treatments: ________________________ Wound care: _____ Supplies: ___________ Durable medical equip: ___________ Self-care (specify): ____________________________________ Homemaker/maintenance (specify): ____Socialization:____ Physical layout of home (specify): ______________________
Anticipated changes in living situation after discharge: ________ Living facility other than home (specify): ___________________ Referrals (date/source/services): Social Services: _____________ Rehab services: _______ Dietary: ______ Home care: _________ Resp/O2: ______ Equipment: _______________________________ Supplies: ____________________ Other: _____________________ Hospice: _________________________________________________
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.
Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions After data are collected and areas of concern or 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 symptoms, or cues (defining characteristics), the client diagnostic statement emerges. Activity/Rest—ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest • • • • • • • • • • • • • •
Activity Intolerance Activity Intolerance, risk for Activity Planning, ineffective Activity Planning, risk for ineffective Disuse Syndrome, risk for Diversional Activity, deficient Fatigue Insomnia Lifestyle, sedentary Mobility, impaired bed Mobility, impaired wheelchair Sleep, readiness for enhanced Sleep Deprivation Sleep Pattern, disturbed
• Transfer Ability, impaired • Walking, impaired Circulation—ability to transport oxygen and nutrients necessary to meet cellular needs • • • • • • • • • • • •
Autonomic Dysreflexia Autonomic Dysreflexia, risk for Bleeding, risk for Cardiac Output, decreased Gastrointestinal Perfusion, risk for ineffective Intracranial Adaptive Capacity, decreased Renal Perfusion, risk for ineffective Shock, risk for Tissue Perfusion, ineffective peripheral Tissue Perfusion, risk for decreased cardiac Tissue Perfusion, risk for ineffective cerebral Tissue Perfusion, risk for ineffective peripheral
Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences • • • •
Anxiety [specify level] Body Image, disturbed Coping, defensive Coping, ineffective (continues on page 18)
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CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Expectations of this hospitalization/visit: _____________________ Will admission cause any lifestyle changes (describe): _________ _________________________________________________________ Previous illnesses and/or hospitalizations/surgeries: __________ _________________________________________________________ Evidence of failure to improve: ______________________________ Last complete physical exam: _______________________________
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Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions (continued) • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Coping, readiness for enhanced Death Anxiety Decision-Making, readiness for enhanced Decisional Conflict Denial, ineffective Energy Field, disturbed Fear Grieving Grieving, complicated Grieving, risk for complicated Health Behavior, risk-prone Hope, readiness for enhanced Hopelessness Human Dignity, risk for compromised Impulse Control, ineffective Moral Distress Personal Identity, disturbed Personal Identity, risk for disturbed Post-Trauma Syndrome Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness Powerlessness, risk for Rape-Trauma Syndrome Relationships, ineffective Relationships, readiness for enhanced Relationships, risk for ineffective Religiosity, impaired Religiosity, readiness for enhanced Religiosity, risk for impaired Relocation Stress Syndrome Relocation Stress Syndrome, risk for Resilience, impaired individual Resilience, readiness for enhanced Resilience, risk for compromised Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, risk for chronic low Self-Esteem, situational low Self-Esteem, risk for situational low Sorrow, chronic Spiritual Distress Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced
Elimination—ability to excrete waste products • • • • • • • • • • • • • • 18
Constipation Constipation, perceived Constipation, risk for Diarrhea Gastrointestinal Motility, dysfunctional Gastrointestinal Motility, risk for dysfunctional Incontinence, bowel Incontinence, functional urinary Incontinence, overflow urinary Incontinence, reflex urinary Incontinence, stress urinary Incontinence, urge urinary Incontinence, risk for urge urinary Urinary Elimination, impaired
• Urinary Elimination, readiness for enhanced • Urinary Retention, [acute/chronic] Food/Fluid—ability to maintain intake of and utilize nutrients and liquids to meet physiological needs • • • • • • • • • • • • • • • • • • • •
Blood Glucose Level, risk for unstable Breast Milk, insufficient Breastfeeding, ineffective Breastfeeding, interrupted Breastfeeding, readiness for enhanced Dentition, impaired Electrolyte Imbalance, risk for Failure to Thrive, adult Feeding Pattern, ineffective infant Fluid Balance, readiness for enhanced [Fluid Volume, deficient hypertonic or hypotonic] Fluid Volume, deficient [isotonic] Fluid Volume excess Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced Liver Function, risk for impaired Nausea Nutrition: less than body requirements, imbalanced Nutrition: more than body requirements, imbalanced Nutrition: more than body requirements, risk for imbalanced • Nutrition, readiness for enhanced • Oral Mucous Membrane, impaired • Swallowing, impaired Hygiene—ability to perform activities of daily living • • • • • •
Self-Care, readiness for enhanced Self-Care Deficit: bathing Self-Care Deficit: dressing Self-Care Deficit: feeding Self-Care Deficit: toileting Self-Neglect
Neurosensory—ability to perceive, integrate, and respond to internal and external cues • • • • • • • • •
Behavior, disorganized infant Behavior, risk for disorganized infant Behavior, readiness for enhanced organized infant Confusion, acute Confusion, risk for acute Confusion, chronic Memory, impaired Peripheral Neurovascular Dysfunction, risk for [Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)] • Stress Overload • Unilateral Neglect Pain/Discomfort—ability to control internal/external environment to maintain comfort • • • •
Comfort, impaired Comfort, readiness for enhanced Pain, acute Pain, chronic
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Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions (continued) Respiration—ability to provide and use oxygen to meet physiological needs Airway Clearance, ineffective Aspiration, risk for Breathing Pattern, ineffective Gas Exchange, impaired Ventilation, impaired spontaneous Ventilatory Weaning Response, dysfunctional
Safety—ability to provide safe, growth-promoting environment • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Adverse Reaction to Iodinated Contrast Media, risk for Allergy Response, risk for Body Temperature, risk for imbalanced Contamination Contamination, risk for Dry Eye, risk for Environmental Interpretation Syndrome, impaired Falls, risk for Health Maintenance, ineffective Home Maintenance, impaired Hyperthermia Hypothermia Immunization Status, readiness for enhanced Infection, risk for Injury, risk for Jaundice, neonatal Jaundice, risk for neonatal Latex Allergy Response Latex Allergy Response, risk for Maternal-Fetal Dyad, risk for disturbed Mobility, impaired physical Perioperative Positioning Injury, risk for Poisoning, risk for Protection, ineffective Self-Mutilation Self-Mutilation, risk for Skin Integrity, impaired Skin Integrity, risk for impaired Sudden Infant Death Syndrome, risk for Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Thermal Injury, risk for Thermoregulation, ineffective Tissue Integrity, impaired Trauma, risk for Vascular Trauma, risk for
To assist in visualizing this critical thinking process, a prototype client situation (Fig. 3.2) is provided as an example of data collection and construction of a plan of care. As the client assessment database is reviewed, the nurse can identify the related or risk factors, and defining characteristics (signs and symptoms) if present, that were used to formulate the client diagnostic statements. The addition of timelines to specific client outcomes and goals reflects
Sexuality [Component of Ego Integrity and Social Interaction]— ability to meet requirements/characteristics of male or female role • • • • •
Childbearing Process, ineffective Childbearing Process, readiness for enhanced Childbearing Process, risk for ineffective Sexual Dysfunction Sexuality Pattern, ineffective
Social Interaction—ability to establish and maintain relationships • • • • • • • • • • • • • • • • • • • •
Attachment, risk for impaired Caregiver Role Strain Caregiver Role Strain, risk for Communication, impaired verbal Communication, readiness for enhanced Coping, compromised family Coping, disabled family Coping, readiness for enhanced community Coping, readiness for enhanced family Family Processes, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Loneliness, risk for Parenting, impaired Parenting, risk for impaired Parenting, readiness for enhanced Role Conflict, parental Role Performance, ineffective Social Interaction, impaired Social Isolation
Teaching/Learning—ability to incorporate and use information to achieve healthy lifestyle and optimal wellness • • • • • • • • • •
Development, risk for delayed Growth, risk for disproportionate Growth and Development, delayed Health, deficient community Knowledge, deficient [Learning Need] (specify) Knowledge (specify), readiness for enhanced Noncompliance [Adherence, ineffective] [specify] Self-Health Management, ineffective Self-Health Management, readiness for enhanced Therapeutic Regimen Management, ineffective family
the anticipated length of stay and individual client-nurse expectations. Interventions are based on concerns and needs identified by the client and nurse during data collection. In addition, physician and other discipline orders are also considered when identifying interventions. Although not normally included in a plan of care, rationales are included in this sample for the purpose of explaining or clarifying the choice of interventions. (text continues on page 24)
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CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
• • • • • •
• Violence, risk for other-directed • Violence, risk for self-directed • Wandering [specify sporadic or continual]
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Client Situation: Diabetes Mellitus
Mr. R.S., a client with type 2 diabetes (non–insulin-dependent) for 8 years, presented to his physician’s office with a nonhealing ulcer of 3 weeks’ duration on his left foot. Screening studies done in the physician’s office 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—call for BG>250 CBC, electrolytes, serum lipid profile, glycosylated Hb in AM Chest x-ray and ECG in AM Humulin R 10 units SC on admission DiaBeta 10 mg, PO bid Glucophage 500 mg, PO daily to start—will increase gradually Humulin N 10 U SC q AM. Begin insulin instruction for post-discharge self-care if necessary Dicloxacillin 500 mg PO q6h, start after culture obtained Darvocet-N 100 mg PO q4h prn pain Diet—2400 calories, 3 meals with 2 snacks Arrange consult with dietician Up in chair ad lib with feet elevated Foot cradle for bed Irrigate lesion L foot with NS tid, then cover with sterile dressing Vital signs qid
Client Assessment Database Name: R.S. Gender: M
Informant: Client Reliability (Scale 1–4): 3 Age: 73 Adm. date: 6/28/2012 Time: 7 PM From: Home
DOB: 5/3/39
Race: Caucasian
ACTIVITY/REST Subjective (Reports):
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 to 8 hr/night Naps: No Aids: No Insomnia: “Not unless I drink coffee after supper.” Usually feels rested when awakens at 4:30 AM but feeling fatigued past several weeks
Objective (Exhibits):
Observed response to activity: limps, favors L foot when walking Mental status: Alert/active Neuro/muscular assessment: Muscle mass/tone: Bilaterally equal/firm Posture: Erect ROM: Full all extremities Strength: Equal 3 extremities/(favors L foot currently)
CIRCULATION Subjective (Reports):
History of 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: Occ./white Change in frequency/amount of urine: Yes/voiding more lately
Objective (Exhibits):
Peripheral pulses: Radials 3+; popliteal, dorsalis, post-tibial/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 Jugular vein distention: 0 Extremities: Temperature: Feet cool bilaterally/legs warm Color: Skin: Legs pale Capillary refill: Slow both feet (approx. 4 seconds) Homans’ sign: 0 Varicosities: Few enlarged superficial veins both calves 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 Nailbeds: Blanch well Conjunctiva and sclera: White
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EGO INTEGRITY Report of stress factors: “Normal farmer’s problems: weather, pests, bankers, etc.” 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 here Relationship status: Married Cultural factors: Rural/agrarian, eastern European descent, “American, no ethnic ties” Religion: Protestant/practicing Lifestyle: Middle class/self-sufficient farmer Recent changes: No Feelings: “I’m in control of most things, except the weather and this diabetes now.” Concerned re possible therapy change “from pills to shots.”
Objective (Exhibits):
Emotional status: generally calm, appears frustrated at times Observed physiological response(s): occasionally sighs deeply/ frowns, fidgeting with coin, shoulders tense/shrugs shoulders, throws up hands
CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Subjective (Reports):
ELIMINATION Subjective (Reports):
Usual bowel pattern: almost every PM Last BM: last night Character of stool: firm/brown Bleeding: 0 Hemorrhoids: 0 Constipation: occ. Laxative used: hot prune juice on occ. Urinary: Voiding more frequently, up 1 or 2 times nightly Character of urine: pale yellow
Objective (Exhibits):
Abdomen tender: no Soft/firm: soft Palpable mass: 0 Bowel sounds: active all 4 quads
FOOD/FLUID Subjective (Reports):
Usual diet (type): 2400 calorie (occ. “cheats” with dessert; “My wife watches it pretty closely.”) No. of meals daily: 3/1 snack Dietary pattern: B: Fruit juice/toast/ham/decaf coffee L: Meat/potatoes/veg/fruit/milk D: ½ meat sandwich/soup/fruit/decaf coffee Snack: Milk/crackers at HS. Usual beverage: Skim milk, 2 to 3 cups decaf coffee, drinks “lots of water— several quarts” Last meal/intake: Dinner: 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 heartburn Mastication/swallowing problems: 0 Dentures: Partial upper plate—fits well Usual weight: 175 lb Recent changes: Has lost about 6 lb this month Diuretic therapy: No
Objective (Exhibits):
Wt: 170 lb Ht: 5 ft 10 in Build: stocky Skin turgor: Good/leathery Condition of teeth/gums: Good, no irritation/bleeding noted Appearance of tongue: Midline, pink Mucous membranes: Pink, intact, moist Breath sounds: Few wheezes cleared with cough Bowel sounds: Active all 4 quads Urine Chemstix: 2% Fingerstick: 356 (Dr. office) 450 random BG on adm
HYGIENE Subjective (Reports):
Activities of daily living: Independent in all areas Preferred time of bath: PM
Objective (Exhibits):
General appearance: Clean, shaven, short-cut hair; hands rough and dry; skin on feet dry, cracked, and scaly Scalp and eyebrows: Scaly white patches No body odor
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NEUROSENSORY Subjective (Reports):
Headache: “Occasionally behind my eyes when I worry too much.” Tingling/numbness: Feet, 4 or 5 times/week (as noted) Eyes: Vision loss, farsighted, “Seems a little blurry now.” Examination: 2 yr ago Ears: Hearing loss R: “Some” L: No (has not been tested) Nose: Epistaxis: 0 Sense of smell: “No problem.”
Objective (Exhibits):
Mental status: Alert, oriented to person, place, time, situation Affect: Concerned Memory: Remote/recent: Clear and intact Speech: Clear/coherent, appropriate Pupil reaction: PERRLA/small Glasses: Reading Hearing aid: No Handgrip/release: Strong/equal
PAIN/DISCOMFORT Subjective (Reports):
Primary focus: L foot Location: Medial aspect, L heel Intensity (0–10): 4 to 5 Quality: Dull ache with occ. sharp stabbing sensation Frequency/duration: “Seems like all the time.” Radiation: No Precipitating factors: Shoes, walking How relieved: ASA, not helping Other concerns: Sometimes has back pain following chores/heavy lifting, relieved by ASA/liniment rubdown; knees ache—uses topical heat ointment
Objective (Exhibits):
Facial grimacing: When lesion border palpated Guarding affected area: Pulls foot away Narrowed focus: No Emotional response: Tense, irritated
RESPIRATION Subjective (Reports):
Dyspnea: 0 Cough: Occ. morning cough, white sputum Emphysema: 0 Bronchitis: 0 Asthma: 0 Tuberculosis: 0 Smoker: Filters pk/day: 1/2 No. yrs: 25+ Use of respiratory aids: 0
Objective (Exhibits):
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/relaxed
SAFETY Subjective (Reports):
Allergies: 0 Blood transfusions: 0 Sexually transmitted disease: 0 Risk behaviors: Wears seat belt Fractures/dislocations: L clavicle, 1960s, fell getting off tractor Arthritis/unstable joints: “Some in my knees.” Back problems: Lower back pain 2 or 3 times/month Vision impaired: Requires glasses for reading Hearing impaired: Slightly (R), compensates by turning “good ear” toward speaker Immunizations: Current flu/pneumonia 3 yrs ago/tetanus maybe 8 yrs ago
Objective (Exhibits):
Temperature: 99.4°F (37.4°C) tympanic Skin integrity: Impaired L foot Scars: R inguinal, surgical Rashes: 0 Bruises: 0 Lacerations: 0 Blisters: 0 Ulcerations: Medial aspect L heel, 2.5-cm diameter, approx. 3 mm deep, wound edges inflamed, draining small amount cream-color/pink-tinged matter, slight musty odor noted Strength (general): Equal all extremities Muscle tone: firm ROM: Good Gait: Favors L foot Paresthesia/paralysis: Tingling, prickly sensation in feet after walking ¼ mile
SEXUALITY: MALE Subjective (Reports):
22
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
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SEXUALITY: MALE (continued) Last proctoscopic examination: 2 yr ago Prostate examination: 1 yr ago Practice self-examination: Breast/testicl*s: No Problems/complaints: “I don’t have any problems, but you’d have to ask my wife if there are any complaints.”
Objective (Exhibits):
Examination: Breast: No masses
CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Subjective (Reports):
testicl*s: Deferred Prostate: Deferred
SOCIAL INTERACTIONS Subjective (Reports):
Marital status: Married 45 yr Living with: Wife Report of problems: None 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 with 2 to 3 times/mo 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 11th commandment is ‘Thou shalt not go to bed angry.’”
Objective (Exhibits):
Speech: Clear, intelligible Verbal/nonverbal communication with family/SO(s): Speaks quietly with wife, looking her in the eye; relaxed posture Family interaction patterns: Wife sitting at bedside, relaxed, both reading paper, making occasional comments to each other
TEACHING/LEARNING Subjective (Reports):
Dominant language: English Second language: 0 Literate: Yes Education level: 2-yr college Health and illness/beliefs/practices/customs: “I take care of the minor problems and see the doctor only when something’s broken.” Presence of Advance Directives: Yes—wife to bring in Durable Medical Power of Attorney: Wife 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: Diabeta Dose: 10 mg bid Schedule: 8 AM/6 PM, last dose 6 PM today Purpose: Control diabetes Takes medications regularly? Yes Home urine/glucose monitoring: “Only using TesTape, stopped some months ago when I ran out. It was always negative, anyway. Don’t like sticking my fingers.” Nonprescription (OTC) drugs: Occ. ASA Herbals/supplements: No Use of alcohol (amount/frequency): Socially, occ. beer Tobacco: 1/2 pk/day Smokeless: No 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 breaking 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: 1960s, R inguinal hernia repair, tonsils age 5 or 6 Evidence of failure to improve: Lesion L foot, 3 wk Last physical examination: Complete 1 yr ago, office follow-up 5 mo ago
DISCHARGE CONSIDERATIONS (AS OF 6/28) Anticipated discharge: 7/1/12 (3 days) Resources: Self, wife
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DISCHARGE CONSIDERATIONS (AS OF 6/28) (continued) Financial: “If this doesn’t take too long to heal, we got 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 and wound care; review diet; encourage smoking cessation Referral: 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 Figure 3.2 Client situation: Diabetes mellitus.
Another way to conceptualize the client’s care needs is to create a Mind Map, or Concept Map (Fig. 3.3). This technique and learning tool has been developed to help visualize the linkages or interconnections between various client symptoms, interventions, or problems as they impact each other. The best parts of the traditional care plans (problem-solving and categorizing) are retained, but the linear and columnar nature of the plan is changed to a design that uses the whole brain—a design that brings left-brained, linear problemsolving thinking together with the free-wheeling, interconnected, creative right brain. Joining mind mapping and care planning enables the nurse to create a holistic view of a client, strengthening critical thinking skills and facilitating the creative process of planning client care. Mind mapping starts in the center of the page with a representation of the main concept—the client. (This helps keep in mind that the client is the focus of the plan, not the medical diagnosis or condition.) From that central thought, other main ideas that relate to the client radiate out from the center similar to spokes of a wheel (however, they do not have to be added in a balanced manner; it does not have to be a round “wheel”). Different concepts can be grouped together by geometric shapes, color coding, or by placement on the page. Connections and interconnections between groups of ideas are represented by the use of arrows or lines, with defining phrases added that explain how the interconnected thoughts relate to one another. In this manner, many different pieces of information about the client can be connected directly to the client. INCREASES
Whichever piece is chosen becomes the first layer of connections—clustered assessment data, nursing diagnoses, or outcomes. For example, a map could start with nursing diagnoses featured as the first “branches,” each one being listed separately in some way on the map. Next, the signs and symptoms or data supporting the diagnoses could be added. Or, the plan could begin with the client outcomes to be achieved and then connecting them to nursing diagnoses. When the plan is completed, there should be a nursing diagnosis (supported by subjective and objective assessment data), nursing interventions, desired client outcome(s), and any evaluation data, all connected in a manner that shows there is a relationship between them. It is critical to understand that there is no preset order for the pieces because one cluster is not more or less important than another (or one is not subsumed under another). It is important, however, that those pieces within a branch be in the same order in each branch. Finally, to complete the learning experience, samples of the evaluation step based on the client situation are presented.
Evaluation As nursing care is provided, ongoing assessment evaluates the client’s response to therapy and progress toward accomplishing the desired outcomes. This activity serves as the feedback and control part of the nursing process through which the status of the individual client diagnostic statement is judged to be resolved, continuing, or requiring revision. This process is visualized in Figure 3.4. Observation of Mr. R.S.’s wound reveals that edges are clean and pink and drainage is scant. Therefore, he is progressing toward achieving wound healing; this problem will continue to be addressed, although no revision in the treatment plan is required at this time.
Documentation To date, a number of charting formats have been used for documentation. These include block notes, with a single entry covering an entire shift (e.g., 7 to 3 p.m.); narrative 24
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leads to
Perform Self-admin Understand RFS insulin DM and treatment
demonstrates ND: unstable Blood Glucose Level - fingerstick 4X day - 2400 cal diet 3 meals/2 snacks - Humulin N - Glucophage/DiaBeta
RS
impairs healing
DM Type 2
CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
complication
Blood sugar 450 thirst/wt loss
CHAPTER 3
ND: infective Self-Health Management - review disease process - BS monitoring - insulin administration - s/s hyper/hypoglycemia - dietary needs - foot care
FBS < 120 ND: impaired Skin Integrity - wound care - dressing change - infection precautions - Dicloxacillin
pulses numbness & tingling due to ND: impaired peripheral Tissue Perfusion - feet when in chair - increase fluids/l&O - safety precautions - foot inspection
Wound clean/pink
increases risk for
causes
No drainage/ erythema
ND: acute Pain - foot cradle - Darvocet N
Pressure ulcer Maintain hydration
Understand relationship of DM to circulatory changes
Pain free
Full wt. bearing
Figure 3.3 Mind map for Mr. R.S.
timed notes (e.g., 8:30 a.m., ate 100% of breakfast); the problem-oriented medical record system (POMR) to record the subjective and objective data, analysis of the data, and the resulting plan (SOAP); and flow sheets with charting by exception, to name a few. The POMR can provide thorough documentation, but it was designed by physicians for episodic care and requires that the entries be tied to a problem identified from a problem list. A charting system format created by nurses for documentation of frequent or repetitive care is Focus Charting®. It was designed to encourage looking at the client from a positive 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 concerns or needs rather than a nursing task or medical diagnosis. Thus, the focus can be a client’s problems or concerns or nursing diagnosis; signs and symptoms of potential importance, for instance, fever, dysrhythmia, and edema; a significant event or change in status; or a specific standard of care or hospital policy. An expansion of this format is DATRP: data, action, teaching, response, and plan.
A more recent way to evaluate and document the client’s progress (response to care) is by using clinical pathways. These pathways were originally developed as tools for providing care in case management systems and are now used in many settings. A clinical pathway is a type of abbreviated plan of care that is event oriented (task oriented) and provides outcome-based guidelines for goal achievement within a designated length of stay. The pathway incorporates agency and professional standards of care and may be interdisciplinary, depending on the care setting. As a rule, however, the standardized clinical pathways address a specific diagnosis, condition, or procedure, such as myocardial infarction, total hip replacement, or chemotherapy, and do not provide for inclusion of secondary diagnoses or complications, such as an asthmatic client in alcohol withdrawal. In short, if the client does not achieve the daily outcomes or goals of care, the variance is identified and a separate plan of care must be developed to meet the client’s individual needs. Therefore, although clinical pathways are becoming more common in the clinical setting, they have limited value (in place of more individualized plans of care) as learning tools for students who are working to practice the nursing process, critical thinking, and a holistic approach to meeting client needs. A sample clinical pathway (Fig. 3.5) reflects Mr. R.S.’s primary diagnostic problem: nonhealing wound, diabetic.
25
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Does R.S. display signs of wound healing (e.g., lesion has decreased in width and/or depth; lesion has decreased drainage; wound edges are clean/pink)?
NO
Record data, e.g., lesion has decreased in depth to 2 mm, and in width to 2 cm. Has no drainage. Record RESOLVED (may wish to use CONTINUE until lesion has completely healed).
Reassess using initial assessment factors.
Is diagnonsis validated?
YES
Record data, e.g., lesion has increased in depth to 4 mm and in width to 3 cm. Drainage increased from approximately the size of a dime to a 50-cent piece on dressing. Record CONTINUE and change target date. Alter nursing orders as necessary.
YES
NO
Record new assessment data. Record REVISED. Enter new diagnosis, objectives, target date, and orders. Delete unvalidated diagnosis.
YES
Did evaluation show a new problem had arisen?
NO
Start new evaluation process. FINISHED
Figure 3.4 Outcome-based evaluation of the client’s response to therapy. (Adapted from Newfield, SA, et al: Cox’s Clinical Applications of Nursing Diagnosis, ed 5. FA Davis, Philadelphia, 2007.)
26
Additional nursing actions
Client education
Medications
Up ad lib NS soaks/dressing change tid
→ →
VS qid I&O/level of hydration qd Character of wound tid Level of knowledge and priorities of learning needs Anticipated discharge needs Observe for signs of antibiotic hypersensitivity reaction Antibiotic: same Antibiotic: Dicloxacillin 500 mg PO q6h Antidiabetic: Humulin N insulin Antidiabetic: Humulin R 10 U SC q AM insulin 10 units DiaBeta 10 mg PO bid SC on adm Glucophage 500 mg PO daily Film Living with Diabetes Provide: Understanding Your Demonstrate and practice tasks: Diabetes 1. Fingerstick BG 2. Insulin administration 3. Wound care 4. Routine foot care
Additional assessments
Dietician & determine need for: Home care Physical therapy Visiting nurse CBC, electrolytes Glycosylated Hb, Serum lipid profile → Fingerstick BG qid/call>250 Chest x-ray (if indicated) ECG (if indicated) → → →
Actions/Goals: Verbalize understanding of condition Display blood glucose WNL (ongoing)
Wound culture/sensitivity Gram’s stain Random blood glucose Fingerstick BG hs
Actions/Goals:
Diagnostic studies
Referrals
impaired Skin/ Tissue Integrity
Day 2 6/29
→ →
→ →
Practice self-care task No. 2: insulin administration Review discharge instructions
Antidiabetic: same Antidiabetic: same
Group sessions: Diabetic management
Antibiotic: same
→ → D/C →
Fingerstick BG bid if stable
Actions/Goals: Wound edges show signs of healing process Perform self-care task No. 2 correctly Explain reason for actions Plan in place to meet discharge needs
Discharge 7/1
Antibiotic: same
→ VS each shift → →
→
Actions/Goals: Be free of signs of dehydration Wound free of purulent drainage Verbalize understanding of treatment needs Perform self-care tasks No. 1 and 3 correctly Explain reasons for actions
Day 3 6/30
CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Adm Day 1 6/28 7pm
CHAPTER 3
ND and Categories of Care
CP: Non-healing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes
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27
28 Characteristics of pain Level of participation activities Individual analgesic needs Analgesic: Darvocet-N 100 mg PO q4h PRN Orient to unit/room Guidelines for self-report of pain and rating scale 0–10 Safety/comfort measures: 1 elevation of feet 2 proper footwear Bed cradle as indicated
Additional assessments
Figure 3.5 Sample Clinical Pathway.
Additional nursing actions
Medications Allergies: -0Client education
Actions/Goals State pain relieved or minimized with 1 hr of analgesic administration (ongoing) Verbalize understanding of when to report pain and rating scale used Verbalize understanding of selfcare measures No. 1 and 2 Explain reason for actions
Adm Day 1 6/28 7pm
acute Pain
ND and Categories of Care
(Continued)
→ → → Analgesic:
→ → → Analgesic: Safety/comfort measures: 3 prevention of injury
same
Actions/Goals Able to participate in usual level: ambulate full weight bearing
Actions/Goals Verbalize understanding of selfcare test No. 3 Explain reason for actions
same
Day 3 6/30
Day 2 6/29
same Review discharge medication instructions: dosage, route, frequency, side effects
→ → → Analgesic:
Actions/Goals State pain-free/ controlled with medication Verbalize understanding of correct medication use
Discharge 7/1
CP: Non-healing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes
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CHAPTER 3
PLAN OF CARE:
Mr. R.S.
Client Diagnostic Statement
Outcome Wound Healing: Secondary Intention (NOC) Indicators:
Client Will Be free of purulent drainage within 48 hours (6/30, 7 p.m.). Display signs of healing with wound edges clean and pink within 60 hours (7/1, 7 a.m.).
ACTIONS/INTERVENTIONS
RATIONALE
Wound Care NIC Irrigate wound with room-temperature sterile normal saline (NS) tid. Assess wound with each dressing change. Obtain wound tracing on admission and at discharge. Apply sterile dressing using paper tape.
Cleans wound without harming delicate tissues. Provides information about effectiveness of therapy and identifies additional needs. Keeps wound clean, minimizes cross-contamination. Note: Adhesive tape may be abrasive to fragile tissues.
Infection Control NIC Follow wound precautions. Obtain sterile specimen of wound drainage on admission. Administer dicloxacillin 500 mg PO q6h, starting at 10 p.m.
Observe for signs of hypersensitivity: pruritus, urticaria, rash.
Use of gloves and proper handling of contaminated dressings reduces likelihood of spread of infection. Culture/sensitivity identifies pathogens and therapy of choice. Treatment of infection and prevention of complications. Food interferes with drug absorption, requiring scheduling around meals. Although no prior history of penicillin reaction, it may occur at any time.
PLAN OF CARE: Client Diagnostic Statement risk for unstable Blood Glucose Level related to lack of adherence to diabetes management and inadequate blood glucose monitoring with fingerstick 450/adm.
Outcome Blood Glucose Level (NOC) Indicators:
Client Will Demonstrate correction of metabolic state as evidenced by fasting blood sugar (FBS) less than 170 mg/dL within 36 hours (6/30, 7 a.m.).
ACTIONS/INTERVENTIONS
RATIONALE
Hyperglycemia Management NIC Perform fingerstick BG qid. Call for BG >250.
Administer antidiabetic medications: 10 units Humulin N insulin SC q AM after fingerstick BG
DiaBeta 10 mg PO bid
Bedside analysis of blood glucose levels is a more timely method for monitoring effectiveness of therapy and provides direction for alteration of medications such as additional regular insulin. Treats underlying metabolic dysfunction, reducing hyperglycemia and promoting healing. Intermediate-acting preparation with onset of 2 to 4 hr, peak 6 to 12 hr, with a duration of 18 to 24 hr. Increases transport of glucose into cells and promotes the conversion of glucose to glycogen. Lowers blood glucose by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at the receptor sites. (continues on page 30)
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CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
impaired Skin Integrity related to pressure, imbalanced nutritional state, impaired circulation, and impaired sensation, as evidenced by destruction of skin layers—draining wound L foot.
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ACTIONS/INTERVENTIONS (continued) Glucophage 500 mg PO daily. Note onset of side effects.
Provide diet 2400 cal—three meals/two snacks.
Schedule consultation with dietitian to restructure meal plan and evaluate food choices.
RATIONALE (continued) Glucophage lowers serum glucose levels by decreasing hepatic glucose production and intestinal glucose absorption and increasing sensitivity to insulin. By using in conjunction with DiaBeta, client may be able to discontinue insulin once target dosage is achieved (e.g., 2000 mg/d). An increase of 1 tablet per week is necessary to limit side effects of diarrhea, abdominal cramping, and vomiting, possibly leading to dehydration and prerenal azotemia. Proper diet decreases glucose levels and insulin needs, prevents hyperglycemic episodes, can reduce serum cholesterol levels, and promotes satiation. Calories are unchanged on new orders but have been redistributed to three meals and two snacks. Dietary choices (e.g., increased vitamin C) may enhance healing.
PLAN OF CARE: Client Diagnostic Statement acute Pain related to physical agent (open wound L foot) as evidenced by coded report of pain (4–5/10) and guarding behavior.
Outcome Pain Level (NOC) Indicators:
Client Will Report pain is minimized or relieved within 1 hr of analgesic administration (ongoing). Report absence or effective control of pain by discharge (7/1).
Outcome Pain: Disruptive Effects (NOC) Indicators:
Client Will Ambulate normally, full weight-bearing by discharge (7/1).
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Determine pain characteristics through client’s description. Place foot cradle on bed; encourage use of loose-fitting slipper when up. Administer Darvocet-N 100 mg PO every 4 hr as needed. Document effectiveness.
Establishes baseline for assessing improvement and changes. Avoids direct pressure to area of injury, which could result in vasoconstriction and increased pain. Provides relief of discomfort when unrelieved by other measures.
PLAN OF CARE: Client Diagnostic Statement ineffective peripheral Tissue Perfusion related to deficient knowledge of disease process and aggravating factors, diabetes mellitus as evidenced by diminished pulses, pale/cool feet, capillary refill 4 sec, paresthesia of feet “when walks 1/4 mile.”
Outcomes Knowledge: Diabetes Management (NOC) Indicators:
Client Will Verbalize understanding of relationship between chronic disease (diabetes mellitus) and circulatory changes within 48 hr (6/30, 7 p.m.). Demonstrate awareness of safety factors and proper foot care within 48 hr (6/30, 7 p.m.). Maintain adequate level of hydration to maximize perfusion (ongoing), as evidenced by balanced intake/output, moist skin and mucous membranes, and capillary refill less than 3 sec (daily; ongoing).
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Circulatory Care: Arterial Insufficiency NIC
Recommend cessation of smoking. Discuss complications of disease that result from vascular changes: ulceration, gangrene, and muscle or bony structure changes.
Review proper foot care as outlined in teaching plan.
Minimizes interruption of blood flow and reduces venous pooling. Glycosuria may result in dehydration with consequent reduction of circulating volume and further impairment of peripheral circulation. Compromised circulation and decreased pain sensation may precipitate or aggravate tissue breakdown. Heat increases metabolic demands on compromised tissues. Vascular insufficiency alters pain sensation, increasing risk of injury. Vascular constriction associated with smoking and diabetes impairs peripheral circulation. Although proper control of diabetes mellitus may not prevent complications, severity of effects may be minimized. Diabetic foot complications are the leading cause of nontraumatic lower-extremity amputations. Note: Skin dry, cracked, scaly; feet cool; and pain when walking a distance suggest mild to moderate vascular disease (autonomic neuropathy) that can limit response to infection, impair wound healing, and increase risk of bony deformities. Altered perfusion of lower extremities may lead to serious or persistent complications at the cellular level.
PLAN OF CARE: Client Diagnostic Statement deficient Knowledge/Learning Need regarding diabetic condition, related to misinterpretation of information 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 and symptoms of hyperglycemia.
Outcomes Knowledge: Diabetes Management (NOC) Indicators:
Client Will Perform procedure of home glucose monitoring correctly within 36 hr (6/30, 7 a.m.). Verbalize basic understanding of disease process and treatment within 38 hr (6/30, 9 a.m.). Explain reasons for actions within 38 hr (6/30, 9 a.m.). Perform insulin administration correctly within 60 hr (7/1, 7 a.m.).
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Determine client’s level of knowledge, priorities of learning needs, and desire/need for including wife in instruction.
Provide teaching guide, “Understanding Your Diabetes,” 6/28 p.m. Show film Living With Diabetes, 6/29, 4 p.m., when wife is visiting. Include in group teaching session, 6/30 a.m. Review information and obtain feedback from client and wife. Discuss factors related to and altering diabetic control, such as stress, illness, and exercise. Review signs and symptoms of hyperglycemia (e.g., fatigue, nausea, vomiting, polyuria, polydipsia). Discuss how to prevent and evaluate this situation and when to seek medical care. Have client identify appropriate interventions.
Establishes baseline and direction for teaching and planning. Involvement of wife, if desired, will provide additional resource for recall and understanding and may enhance client’s follow-through. Provides different methods for accessing and reinforcing information and enhances opportunity for learning and understanding.
Drug therapy and diet may need to be altered in response to both short- and long-term stressors and changes in activity level. Recognition and understanding of these signs and symptoms and timely intervention will aid client in avoiding recurrences and preventing complications.
(continues on page 32)
31
CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Elevate feet when up in chair. Avoid long periods with feet in dependent position. Assess for signs of dehydration. Monitor intake/output. Encourage oral fluids. Instruct client to avoid constricting clothing and socks and ill-fitting shoes. Reinforce safety precautions regarding use of heating pads, hot water bottles, or soaks.
RATIONALE
CHAPTER 3
ACTIONS/INTERVENTIONS
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Review and provide information about necessity for routine examination of feet and proper foot care (e.g., daily inspection for injuries, pressure areas, corns, calluses; proper nail care; daily washing; application of good moisturizing lotion such as Eucerin, Keri, or Nivea bid). Recommend loose-fitting socks and properly fitting shoes (break new shoes in gradually), and avoid going barefoot. If foot injury or skin break occurs, wash with soap or dermal cleanser and water, cover with sterile dressing, inspect wound and change dressing daily; report redness, swelling, or presence of drainage.
Reduces risk of tissue injury; promotes understanding and prevention of pressure ulcer formation and wound healing difficulties.
Teaching: Prescribed Medication NIC Instruct regarding prescribed insulin therapy:
Humulin N insulin, SC Keep vial in current use at room temperature (if used within 30 days). Store extra vials in refrigerator. Roll bottle and invert to mix, or shake gently, avoiding bubbles.
Choice of injection sites (e.g., across lower abdomen in Z pattern). Demonstrate, then observe client in drawing insulin into syringe, reading syringe markings, and administering dose. Assess for accuracy. Instruct in signs and symptoms of insulin reaction or hypoglycemia: fatigue, nausea, headache, hunger, sweating, irritability, shakiness, anxiety, or difficulty concentrating.
Review “sick day rules,” for example, call doctor if too sick to eat normally or stay active; take insulin as ordered. Keep record as noted in Sick Day Guide. Instruct client and wife in fingerstick glucose monitoring to be done four times per day until stable, then twice a day at rotating times, such as FBS and before dinner, or before lunch and at bedtime. Observe return demonstrations of the procedure. Recommend client maintain record or log of fingerstick testing, antidiabetic medication and insulin dosage/site, unusual physiological response, and dietary intake. Outline desired goals, for example, FBS 80 to 110, pre-meal 80 to 120. Discuss other healthcare issues, such as smoking habits, self-monitoring for cancer (breasts and testicl*s), and reporting changes in general well-being.
32
May be a temporary treatment of hyperglycemia with infection or may be permanent combination with oral hypoglycemic agent. Intermediate-acting insulin generally lasts 18 to 28 hr, with peak effect 6 to 12 hr. Cold insulin is poorly absorbed. Refrigeration prolongs the drug shelf-life by preventing wide fluctuations in temperature. Vigorous shaking may create foam, which can interfere with accurate dose withdrawal and damage the insulin molecule. Note: New research suggests that gently shaking the vial may be more effective in mixing suspension. (Refer to Procedure Manual.) Provides for steady absorption of medication. Site is easily visualized and accessible by client, and Z pattern minimizes tissue damage. May require several instruction sessions and practice before client and wife feel comfortable drawing up and injecting medication. Knowing what to watch for and appropriate treatment such as 1/ cup grape juice for immediate response and snack within 2 30 min (e.g., one slice bread with peanut butter or cheese, or fruit and slice of cheese for sustained effect) may prevent or minimize complications. Understanding of necessary actions in the event of mild-tosevere illness promotes competent self-care and reduces risk of hyperglycemia or hypoglycemia. Fingerstick monitoring provides accurate and timely information regarding diabetic control. Return demonstration verifies correct learning.
Provides accurate record for review by caregivers for assessment of therapy effectiveness and needs.
Encourages client involvement, awareness, and responsibility for own health; promotes wellness. Note: Smoking tends to increase client’s resistance to insulin.
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CHAPTER
4
Cardiovascular HYPERTENSION: SEVERE I. Pathophysiology a. Multifactoral i. Complex interactions between the vasculature, kidneys, sympathetic nervous system, baroreceptors, enninangiotensin-aldosterone system, and insulin resistance b. Mosaic theory i. Genetic disposition ii. Environmental: dietary Na+/fat intake, trace metals, stress, smoking iii. Anatomical: abnormalities of vascular system iv. Adaptive: e.g., regulation of intracellular Na+ and Ca++ by cell membrane ion pumps v. Neural: variety of complex nerve mechanisms vi. Endocrine: pheochromocytoma, primary aldosteronism vii. Humoral: varied agents that constrict and dilate blood vessels viii. Hemodynamic: blood volume or viscosity, intrarenal hemodynamics II. Classification—2003 Guidelines National Heart, Lung, and Blood Institute (NHLBI) a. Normal blood pressure (BP)—less than 120/80 mm Hg b. Prehypertension—120/80 to 139/89 mm Hg c. Hypertension—greater than 140/90 mm Hg III. Degree of Severity a. Stage I (mild)—140/90 to 159/99 mm Hg
b. Stage II (moderate)—160/100 mm Hg or greater c. Stage III (severe)—systolic pressure greater than 180 and diastolic pressure greater than 110 d. Stage IV (very severe)—systolic pressure 210 or greater with diastolic pressure greater than 120 IV. Etiology a. Primary (essential), which accounts for approximately 85% to 95% of all cases, has no identifiable cause b. Secondary, which occurs as a result of an identifiable, sometimes correctable, pathological condition, such as kidney disorders, adrenal gland tumors, or primary aldosteronism, medications, drugs, or other chemicals V. Statistics (MMWR, 2011; Roger, 2012) a. Morbidity: i. 68 million Americans are hypertensive (nearly 1 in 3). ii. More than 66% of men and 78% of women over age 75 are hypertensive. iii. Approximately 20% are undiagnosed. iv. Prevalence: African Americans 43%, Caucasians 34%, Hispanics 28%. b. Mortality (MMWR, 2011; Roger, 2012): High blood pressure was a primary or contributing cause of death for 348,000 Americans in 2008. c. Cost: Direct economic costs $47.5 billion in 2009 (NHLBI, 2012).
G L O S S A R Y Atrial hypertrophy: Increased atrial volume and pressure. Hyperglycemia: Increased serum glucose. Hypertension: Blood pressure (BP) greater than 140/90 mm Hg. Hypokalemia: Low serum potassium. Prehypertension: BP in range of 120/80 to 139/89 mm Hg. Stroke: Cellular death of cerebral tissue caused by obstruction of blood flow to sections of the brain, which results in neurological deficits.
Systemic vascular resistance (SVR): An index of arterial compliance or constriction throughout the body; equal to BP divided by cardiac output. Target organ disease or damage (TOD): Organ or system of organs that are primarily affected by hypertension, such as the heart, kidneys, and brain. Transient ischemic attack (TIA): Brief periods of confusion or difficulty with speech caused by an intermittent reduction in blood flow to the brain.
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Care Setting
Related Concerns
Although hypertension is usually treated in a community setting, management of stages III and IV with symptoms of complications or compromise may require inpatient care, especially when target organ disease (TOD) is present. The majority of interventions included here can be used in either setting.
Cerebrovascular accident (CVA)/stroke, page 214 Myocardial infarction, page 75 Psychosocial aspects of care, page 729 Kidney injury: acute, page 505 Renal failure: chronic, page 517
Client Assessment Database D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
ACTIVITY/REST • Sedentary lifestyle, which is a major risk factor for hypertension • Weakness, fatigue • Shortness of breath
• • • •
Elevated heart rate Change in heart rhythm Tachypnea Dyspnea with exertion
CIRCULATION • History of elevated BP over time • Presence of TOD, such as atherosclerotic, valvular, or coronary artery heart disease, including myocardial infarction (MI), angina, heart failure (HF), and cerebrovascular disease • Episodes of palpitations, diaphoresis
• Pulses: Bounding carotid, jugular, radial pulsations • Pulse disparities, particularly femoral delay as compared with radial or brachial pulsation and absence of or diminished popliteal, posterior tibial, pedal pulses • Apical pulse: Point of maximal impulse (PMI) possibly displaced or forceful • Heart rate and rhythm: Tachycardia, various dysrhythmias • Heart sounds: Accentuated S2 at base; S3 in early HF; S4, which reflects rigid left ventricle and left ventricular hypertrophy; murmurs of valvular stenosis; vascular bruits audible over carotid, femoral, or epigastrium • Jugular vein distension (JVD) • Extremities: Discoloration of skin; cool temperature, indicating peripheral vasoconstriction; and slow or delayed capillary refill, indicating vasoconstriction • Skin: Pallor, cyanosis, and diaphoresis, suggesting pulmonary congestion and hypoxemia, or flushing, suggesting pheochromocytoma
EGO INTEGRITY • History of personality changes, anxiety, depression, euphoria, or chronic anger that may indicate cerebral impairment • Multiple stress factors, such as relationship, financial, or job-related concerns
• Mood swings, restlessness, irritability • Narrowed focus
ELIMINATION • Past or present renal insult, such as kidney infection, renovascular obstruction, or past history of kidney disease
• May have decreased urinary output, if kidney failure is present, or increased output, if taking diuretics
FOOD/FLUID • Food preferences that are high-calorie, high-salt, high-fat, and high-cholesterol, such as fried foods, cheese, eggs, or licorice • Low dietary intake of potassium, calcium, and magnesium • Nausea, vomiting • Recent weight changes • Current or history of diuretic use
34
• • • •
Normal weight or obesity Presence of edema Venous congestion, JVD Glycosuria—almost 10% of hypertensive clients are diabetic, reflecting renal TOD
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M AY E X H I B I T
CHAPTER 4
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
(continued)
NEUROSENSORY • Mental status: Changes in alertness, orientation, speech pattern and content, affect, thought process, or memory • Motor responses: Decreased strength, hand grip, and deep tendon reflexes • Optic retinal changes: From mild sclerosis and arterial narrowing to marked retinal and sclerotic changes with edema or papilledema, exudates, hemorrhages, and arterial nicking, although dependent on severity and duration of hypertension and resulting TOD
PAIN/DISCOMFORT • Severe, throbbing occipital headaches located in suboccipital region, present on awakening, and disappearing spontaneously after several hours • Stiffness of neck, dizziness, and blurred vision • Abdominal pain or masses, suggesting pheochromocytoma
• Reluctance to move head, rubbing head, avoidance of bright lights and noise, wrinkled brow, clenched fists; grimacing and guarding behaviors
RESPIRATION • • • •
Dyspnea associated with activity or exertion Tachypnea, orthopnea, paroxysmal nocturnal dyspnea Cough with or without sputum production Smoking history, which is a major risk factor
• Respiratory distress or use of accessory muscles • Adventitious breath sounds, such as crackles or wheezes • Pallor or cyanosis generally associated with advanced cardiopulmonary effects of sustained or severe hypertension
SAFETY • Transient episodes of numbness, unilateral paresthesias • Light-headedness with position change
• Impaired coordination or gait
SEXUALITY • Postmenopausal, which is a major risk factor • Erectile dysfunction (ED), which may be associated with hypertension or antihypertensive medications
TEACHING/LEARNING • Familial risk factors, including hypertension, atherosclerosis, heart disease, diabetes mellitus, and cerebrovascular or kidney disease • Ethnic or racial risk factors, such as increased prevalence in African American and Southeast Asian populations • Use of birth control pills or other hormone replacement therapy • Drug and alcohol use • Use of herbal supplements to manage BP, such as garlic, hawthorn, black cohash, celery seed, coleus, and evening primrose
DISCHARGE PLAN CONSIDERATIONS • May require assistance with self-monitoring of BP as well as periodic evaluation of and alterations in medication therapy ➧ Refer to section at end of plan for postdischarge considerations.
35
CARDIOVASCULAR—HYPERTENSION
• History of numbness or weakness on one side of the body; TIA or stroke • Fainting spells or dizziness • Throbbing, suboccipital headaches, usually present on awakening and disappearing spontaneously after several hours • Visual disturbances, such as diplopia and blurred vision • Episodes of epistaxis
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Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
BLOOD TESTS • Blood urea nitrogen (BUN) and creatinine (Cr): BUN measures the amount of urea nitrogen in the blood. Cr measures the amount of creatinine in blood or urine. • Glucose: Measures the amount of glucose in the blood at the time of sample collection. • Serum potassium: Potassium is an electrolyte that helps regulate the amount of fluid in the body, stimulate muscle contraction, and maintain a stable acid-base balance. • Lipid panel, including total lipids, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol, triglycerides: The group of tests that make up a lipid profile have been shown to be good indicators of risk for heart attack or stroke. • Thyroid studies: Blood test and scan to evaluate thyroid function; most commonly used laboratory test is the measurement of thyroid-stimulating hormone (TSH). • Serum/urine aldosterone level: May be done to assess for primary aldosteronism as cause of hypertension. • Renin: An enzyme that activates the renin-angiotensin system and screens for essential, renal, or renovascular hypertension. • C-reactive protein (CRP): A member of the class of acute phase reactants. Serum levels rise dramatically during inflammatory processes occurring in the body. Monitoring serial CRP values can help determine disease progress or the effectiveness of treatment.
Provides information about renal perfusion and function and can reveal cause if hypertension is related to kidney dysfunction. Hyperglycemia may result from elevated catecholamine levels, which increases BP, and use of thiazide diuretics. Also, diabetes mellitus can be associated with hypertension. Hypokalemia may indicate the presence of primary aldosteronism as a possible cause of hypertension or it may be a side effect of diuretic therapy. A predisposition for or presence of atheromatous plaque is indicated by the following: HDL levels that are less than 40 mg/dL in men and less than 50 mg/dL in women, triglycerides that are more than 150 mg/dL, and an increase in small-particle LDL. Hypertension is present in approximately 3% of clients with hypothyroidism and 20% to 30% in those with thyrotoxicosis (Vidt, 2004). Elevated in primary aldosteronism. Elevated in renovascular and malignant hypertension and salt-wasting disorders. CRP is an indicator of vascular inflammation and can indicate athlerosclerotic disease that causes renal artery disease and hypertension.
OTHER DIAGNOSTIC STUDIES Electrocardiogram (ECG): Record of the electrical activity of the heart that can demonstrate conduction disturbances, enlarged heart, and chamber strain patterns. • Kidney and renography nuclear scan (also called renogram): Assists in diagnosing renal disorders. • Urine creatinine clearance: Determines extent of nephron damage in known kidney disease. • Uric acid: Measures end product of purine metabolism, providing one index of renal function.
Broad, notched P wave is one of the earliest signs of hypertensive heart disease. Determines if hypertension is due to kidney disease. Reduced in hypertensive patient with renal damage. Hyperuricemia has been implicated as a risk factor for the development of hypertension.
Nursing Priorities
Discharge Goals
1. Maintain or enhance cardiovascular functioning. 2. Prevent complications. 3. Provide information about disease process, prognosis, and treatment regimen. 4. Support active client control of condition.
1. BP within acceptable limits for individual. 2. Cardiovascular and systemic complications prevented or minimized. 3. Disease process, prognosis, and therapeutic regimen understood. 4. Necessary lifestyle or behavioral changes initiated. 5. Plan in place to meet needs after discharge.
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CHAPTER 4
NURSING DIAGNOSIS:
risk for decreased Cardiac Output
Risk Factors May Include Altered afterload [e.g., increased systemic vascular resistance, vasoconstriction] Altered contractility [e.g., ventricular hypertrophy or rigidity; myocardial ischemia] (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Circulation Status NOC Participate in activities that reduce BP and cardiac workload. Maintain BP within individually acceptable range. Demonstrate stable cardiac rhythm and rate within normal range.
ACTIONS/INTERVENTIONS
RATIONALE
Hemodynamic Regulation NIC Independent Measure BP in both arms or thighs. Take three readings, 3 to 5 minutes apart while client is at rest, then sitting, and then standing for initial evaluation. Use correct cuff size and accurate technique. Take note of elevations in systolic as well as diastolic readings.
Note presence and quality of central and peripheral pulses.
Auscultate heart tones and breath sounds.
Observe skin color, moisture, temperature, and capillary refill time. Note dependent and generalized edema. Provide calm, restful surroundings, minimize environmental activity and noise. Consider limiting the number of visitors or length of visitation. Maintain activity restrictions during crisis situation such as bedrest or chair rest and schedule periods of uninterrupted rest; assist client with self-care activities as needed. Provide comfort measures, such as back and neck massage or elevation of head. Instruct in relaxation techniques, guided imagery, and distractions. Monitor response to medications that control BP.
Serial measurements using correct equipment provide a more complete picture of vascular involvement and scope of problem. Progressive diastolic readings above 120 mm Hg are considered first accelerated, then malignant (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 client with normal systolic readings, elevated diastolic numbers may indicate prehypertension. Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be diminished, reflecting effects of vasoconstriction and venous congestion. S4 is commonly heard in severely hypertensive clients because of the presence of atrial hypertrophy. Development of S3 indicates ventricular hypertrophy and impaired cardiac functioning. Presence of crackles or wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure. Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation and decreased output. Indicates heart or kidney failure or vascular impairment. Helps reduce sympathetic stimulation and promotes relaxation.
Reduces physical stress and tension that affect BP and the course of hypertension. Decreases discomfort and may reduce sympathetic stimulation. Can reduce stressful stimuli and produce calming effect, thereby reducing BP. Response to drug therapy is dependent on both the individual drugs and their synergistic effects. Because of potential side effects and drug interactions, it is important to use the smallest number and lowest dosage of medications possible.
Collaborative Administer medications, as indicated: Diuretics, for example, thiazide, such as hydrochlorothiazide with triamterene (Maxide), metatolazone (Zaroxolyn), indapamide (Lozol); and loop diuretics, such as furosemide (Lasix), bumetanide (Bumex), and torsemide (Demadex).
Diuretics are considered first-line medications for uncomplicated hypertension and may be used alone or in association with other drugs, such as beta blockers, to reduce BP in clients with relatively normal renal function. These diuretics also potentiate the effects of other antihypertensive agents by limiting fluid retention and may reduce the incidence of stroke and heart failure. Note: Loop diuretics are less commonly used for treatment of hypertension. (continues on page 38)
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CARDIOVASCULAR—HYPERTENSION
Possibly Evidenced By
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ACTIONS/INTERVENTIONS (continued) Beta blockers, such as acebutolol (Sectral), atenolol (Tenormin), metoprolol (Lopressor), bisoprolol (Zibeta), nadolol (Corgard), carvedilol (Coreg), propranolol (Inderal), labatolol (Tandate), timolol (Blocarden)
Angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten), enalapril (Vasotec), benazepril (Lotensin), lisinopril (Zestril), fosinopril (Monopril), ramipril (Altace), moexipril (Univasc), and trandolapril (Mavik) Angiotensin II receptor blockers (ARBs), such as candesartan (Atacand), valsartan (Diovan), losartan (Cozaar), and irbesartan (Avapro) Calcium channel blockers, such as nifedipine (Adalat), diltiazem (Cardizem), amlodipine (Norvasc), nicardipine (Cardene) Combination drugs, such as amlodipine and benazepril (Lotrel), hydralazine and hydrochlorothiazide (Vaseretic), nadolol and bendroflumethiazide (Corzide), hydralazine and hydrochlothiazide (Apresazide)
Direct-acting parenteral vasodilators, such as diazoxide (Hyperstat), nitroprusside (Nitropress), and labetalol (Normodyne) Implement dietary restrictions, as indicated, such as reducing calories and avoiding refined carbohydrates, sodium, fat, and cholesterol. (Refer to ND: imbalanced Nutrition.) Prepare for surgery when indicated.
NURSING DIAGNOSIS:
RATIONALE (continued) Beta blockers are recommended for BP control in clients with heart failure and cardiovascular disease. Cardioselective beta blockers, such as acebutolol, atenolol, and metroprolol, primarily affect β-1 receptors in the heart, slowing heart rate and decreasing the heart’s workload. Nonselective beta blockers, such as propranolol and timolol, also decrease the heart’s workload and promote vasodilation, but they exert effects on the beta-2 receptors of the bronchioles as well, causing bronchoconstriction and potentially increasing symptoms of reactive airway disease and chronic obstructive pulmonary disease. Cardioselective beta blockers are safer choices for patients with pulmonary disorders (Woods & Moshang, 2006). ACE inhibitors are generally considered first-line drugs for clients with documented congestive heart failure (CHF), diabetes, and those at risk for renal failure.
ARBs block the action of angiotensin II. As a result, blood vessels dilate and BP is reduced. Calcium channel blockers primarily affect blood vessels and can be used to treat severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control BP. Combination antihypertensives include combined agents from the following pharmacologic classes: diuretics and potassium-sparing diuretics, beta blockers and diuretics, angiotensin-converting enzyme (ACE) inhibitors and diuretics, angiotensin-II antagonists and diuretics, and calcium channel blockers and ACE inhibitors. Note: Single-dose combination antihypertension therapy is an important option that combines efficacy of blood pressure reduction and a low side-effect profile with convenient once-daily dosing to enhance compliance (Skolnik, 2000). These are given intravenously (IV) for management of hypertensive emergencies. Limiting sodium and sodium-rich processed foods can help manage fluid retention and, with associated hypertensive response, decrease myocardial workload. A diet rich in calcium, potassium, and magnesium may help lower BP. When hypertension is due to pheochromocytoma, removing the tumor corrects the condition.
Activity Intolerance
May Be Related To Generalized weakness Imbalance between oxygen supply and demand
Possibly Evidenced By Reports fatigue; feeling weak Abnormal heart rate or BP response to activity Exertional discomfort or dyspnea ECG changes reflecting ischemia, arrhythmias
Desired Outcomes/Evaluation Criteria—Client Will Endurance NOC Participate in necessary and desired activities. Report a measurable increase in activity tolerance. Demonstrate a decrease in physiological signs of intolerance.
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RATIONALE
Energy Management NIC Independent
NURSING DIAGNOSIS:
Changes in baseline are helpful in assessing physiological responses to the stress of activity and, if present, are indicators of overexertion.
Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand. Gradual activity progression prevents a sudden increase in cardiac workload. Provide assistance only as needed, which encourages independence in performing activities.
acute Pain
May Be Related To Physical agent [increased cerebral vascular pressure]
Possibly Evidenced By Verbal/coded report Positioning to avoid pain Self-focus
Desired Outcomes/Evaluation Criteria—Client Will Pain Control NOC Report pain or discomfort is relieved or controlled. Verbalize methods that provide relief. Follow prescribed pharmacological regimen.
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Determine specifics of pain—location (e.g., suboccipital region), characteristics (e.g., throbbing, neck stiffness, blurred vision), intensity (0 to 10, or similar scale), onset (e.g., present on awakening), and duration (e.g., disappears spontaneously after being up and about). Note nonverbal cues (e.g., reluctance to move head, rubbing head, avoidance of bright lights/noise). Encourage and maintain bedrest during acute phase, if indicated. Provide or recommend nonpharmacological measures for relief of headache, such as placing a cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques, such as guided imagery and distraction; and diversional activities. Eliminate or minimize vasoconstricting activities that may aggravate headache, such as straining at stool, prolonged coughing, and bending over. Assist client with ambulation, as needed.
Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy.
Minimizes stimulation and promotes relaxation. Measures that reduce cerebral vascular pressure and that slow or block sympathetic response are effective in relieving headache and associated complications.
Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure. Dizziness and blurred vision frequently are associated with vascular headache. Client may also experience episodes of postural hypotension, causing weakness when ambulating.
Collaborative Administer analgesics, as indicated. Administer anti-anxiety agents, such as lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium).
Reduce or control pain and decrease stimulation of the sympathetic nervous system. May aid in the reduction of tension and discomfort that is intensified by stress.
39
CARDIOVASCULAR—HYPERTENSION
Assess the client’s response to activity, noting pulse rate more than 20 beats per minute faster than resting rate; marked increase in BP (systolic increases more than 40 mm Hg or diastolic increases more than 20 mm Hg) during and after activity, dyspnea or chest pain, excessive fatigue and weakness, and diaphoresis, dizziness, and syncope. Instruct client in energy-conserving techniques, such as using chair when showering, sitting to brush teeth or comb hair, and carrying out activities at a slower pace. Encourage progressive activity and self-care when tolerated. Provide assistance as needed.
CHAPTER 4
ACTIONS/INTERVENTIONS
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NURSING DIAGNOSIS:
imbalanced Nutrition: more than body requirements
May Be Related To Excessive intake in relation to metabolic need or physical activity (caloric expenditure)
Possibly Evidenced By Weight 20% over ideal for height and frame Triceps skinfold >15 mm in men or >25 mm in women Sedentary lifestyle Dysfunctional eating patterns
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Treatment Regimen NOC Identify correlation between hypertension and obesity.
Weight-Loss Behavior NOC Demonstrate change in eating patterns, such as food choices and quantity, to attain desirable body weight with optimal maintenance of health. Initiate and maintain individually appropriate exercise program.
ACTIONS/INTERVENTIONS
RATIONALE
Weight-Reduction Assistance NIC Independent Assess client’s understanding of direct relationship between hypertension and obesity.
Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar, as indicated.
Determine client’s desire to lose weight.
Review usual daily caloric intake and dietary choices.
Establish a realistic weight-reduction plan with the client, such as weight loss of 1 pound per week. Encourage client to maintain a diary of food intake, including when and where eating takes place and the circ*mstances and feelings around which the food was eaten. Instruct and assist client in appropriate food selections, such as implementing a diet rich in fruits, vegetables, and low-fat dairy foods referred to as the Dietary Approaches to Stop Hypertension (DASH) diet. Help the client identify—and thus avoid—foods high in saturated fat, such as butter, cheese, eggs, ice cream, and meat, and those that are high in cholesterol, such as whole dairy products, shrimp, and organ meats.
Obesity is an added risk with hypertension because of the disproportion between fixed aortic capacity and increased cardiac output associated with increased body mass. Reduction in weight may reduce or eliminate the need for drug therapy needed to control BP. Note: 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 (Khan et al, 2004). Faulty eating habits contribute to atherosclerosis and obesity that can predispose to hypertension and subsequent complications, such as stroke, kidney disease, and heart failure. Excessive salt intake expands the intravascular fluid volume and may damage kidneys, which can further aggravate hypertension. Motivation for weight reduction is internal. The individual must want to lose weight or the program most likely will not succeed. Identifies current strengths and weaknesses in dietary program. Aids in determining individual need for adjustment and teaching. Slow reduction in weight is associated with fat loss with muscle sparing and generally reflects a change in eating habits. Provides a database for both the adequacy of nutrients eaten and the relationship of emotion to eating. Helps focus attention on factors that client can control or change. Moderation and use of low-fat products in place of total abstinence from certain food items may prevent client’s sense of deprivation and enhance commitment to achieving health goals. Avoiding foods high in saturated fat and cholesterol is important in preventing progressing atherogenesis. The DASH diet, in conjunction with exercise, weight loss, and limits on salt intake, may reduce or even eliminate the need for drug therapy in early stages of hypertension (Elmer et al, 2006).
Collaborative Refer to dietitian or weight management programs, as indicated.
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Can provide additional counseling and assistance with meeting individual dietary needs.
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CHAPTER 4
NURSING DIAGNOSIS:
ineffective Coping
May Be Related To
CARDIOVASCULAR—HYPERTENSION
Situational crisis Inadequate level of perception of control Inadequate resources available Inadequate level of confidence in ability to cope
Possibly Evidenced By Reports inability to cope, or ask for help Inability to meet role expectations, basic needs, or Inadequate problem-solving Destructive behavior toward self [overeating], or use of forms of coping that impedes adaptive behavior
Desired Outcomes/Evaluation Criteria—Client Will Coping NOC Identify ineffective coping behaviors and consequences. Verbalize awareness of own coping abilities and strengths. Identify potential stressful situations and steps to avoid or modify them. Demonstrate the use of effective coping skills.
ACTIONS/INTERVENTIONS
RATIONALE
Coping Enhancement NIC Independent Assess effectiveness of coping strategies by observing behaviors, such as ability to verbalize feelings and concerns, and willingness to participate in the treatment plan. Note reports of sleep disturbances, increasing fatigue, impaired concentration, irritability, decreased tolerance of headache, and inability to cope or problem-solve. Assist client to identify specific stressors and possible strategies for coping with them. Include client in planning of care and encourage maximum participation in treatment plan and with the multidisciplinary team.
Encourage client to evaluate life priorities and personal goals. Ask questions such as, “Is what you are doing getting you what you want?” Assist client to identify and begin planning for necessary lifestyle changes. Assist to adjust, rather than abandon, personal and family goals.
NURSING DIAGNOSIS:
Adaptive mechanisms are necessary to appropriately alter one’s lifestyle, deal with the chronicity of hypertension, and integrate prescribed therapies into daily living. Manifestations of maladaptive coping mechanisms may be indicators of repressed anger and may contribute to hypertension. Recognition of stressors is often the first step in altering one’s response to the stressor. Involvement provides client with an ongoing sense of control, improves coping skills, and enhances commitment to achieving health goals. Ongoing intensive assessment and management by a team can promote timely adjustments to therapeutic regimen. Focuses client’s attention on reality of present situation relative to client’s goals. Strong work ethic, need for “control,” and outward focus may have led to lack of attention to personal needs. Necessary changes should be realistically prioritized so client can avoid being overwhelmed and feeling powerless.
ineffective Self-Health Management
May Be Related To Complexity of therapeutic regimen Economic difficulties Perceived seriousness Deficient knowledge
Possibly Evidenced By Failure to take action to reduce risk factors Failure to include treatment regimen in daily living Ineffective choices in daily living for meeting health goals
Desired Outcomes/Evaluation Criteria—Client Will Self-Management: Hypertension 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. Describe reasons for therapeutic actions and treatment regimen.
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ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Assist client in identifying modifiable risk factors, such as obesity; diet high in sodium, saturated fats, and cholesterol; sedentary lifestyle; smoking; alcohol intake of more than 2 ounces per day on a regular basis; and a stressful lifestyle. Problem-solve with client to identify ways in which appropriate lifestyle changes can be made to reduce modifiable risk factors. Discuss importance of eliminating smoking, and assist client in formulating a plan to quit smoking. Refer to smoking cessation program or healthcare provider for helpful medications. Reinforce the importance of adhering to treatment regimen and keeping follow-up appointments.
Instruct and demonstrate BP self-monitoring technique. Evaluate client’s hearing, visual acuity, manual dexterity, and coordination. Help client develop a simple, convenient schedule for taking medications. Explain prescribed medications along with their rationale, dosage, expected and adverse side effects, and particular traits, such as the following: Diuretics: Take daily or larger dose in the early morning. Weigh self on a regular schedule and record. Avoid or limit alcohol intake.
Notify physician if unable to tolerate food or fluid. Antihypertensives: Take prescribed dose on a regular schedule; avoid skipping, altering, or making up doses; and do not discontinue without notifying the healthcare provider. Review potential side effects and drug interactions, and discuss need for informing healthcare provider about onset of adverse effects such as erectile dysfunction (ED).
Rise slowly from a lying to standing position, sitting for a few minutes before standing. Sleep with the head slightly elevated. Suggest frequent position changes and leg exercises when lying down. Recommend avoiding hot baths, steam rooms, and saunas, especially with concomitant use of alcoholic beverages. Instruct client to consult healthcare provider before taking other prescription or over-the-counter (OTC) medications. Instruct client, as indicated, about increasing intake of foods and fluids high in potassium, such as oranges, bananas, figs, dates, tomatoes, potatoes, raisins, apricots, Gatorade, and fruit juices; and foods and fluids high in calcium, such as low-fat milk, yogurt, or calcium supplements. Review the signs and symptoms that require the client to notify the healthcare provider, such as headache present on awakening that does not abate; sudden and continued increase of BP; chest pain; shortness of breath; irregular or increased pulse rate; significant weight gain (2 lb/day or 5 lb/wk); peripheral or abdominal swelling; visual disturbances; frequent, uncontrollable nosebleeds; depression or emotional lability;
42
These risk factors contribute to hypertension and cardiovascular and renal disease.
Changing “comfortable or usual” behavior patterns can be very difficult and stressful. Support, guidance, and empathy can enhance client’s success in accomplishing his or her health goals. Nicotine increases catecholamine discharge, resulting in increased heart rate, BP, vasoconstriction, and myocardial workload, and reduces tissue oxygenation. Lack of engagement in the treatment plan is a common reason for failure of antihypertensive therapy. Therefore, ongoing evaluation for client participation is critical to successful treatment. When client understands causative factors and consequences of inadequate intervention and is motivated to achieve health, the client typically participates in treatment interventions. Monitoring BP at home is reassuring to client because it provides visual feedback to determine treatment outcomes and helps promote early detection of deleterious changes. Individualizing schedule to fit client’s personal habits may make it easier to get in the habit of including antihypertensives in healthcare management activities. Adequate information and understanding about side effects can enhance client’s commitment to the treatment plan. For instance, mood changes, initial weight gain, and dry mouth are common and often subside with time. Scheduling doses early in the day minimizes nighttime urination. Primary indicator of effectiveness of diuretic therapy. The combined vasodilating effect of alcohol and the volumedepleting effect of a diuretic greatly increase the risk of orthostatic hypotension. Dehydration can develop rapidly if intake is poor and client continues to take a diuretic. Because clients often cannot feel the difference the medication is making in BP, it is critical that there be understanding about the medication’s actions and side effects. For example, abruptly discontinuing a drug may cause rebound hypertension, leading to severe complications, or medication may need to be altered to reduce adverse effects. Note: Many drugs used to treat hypertension have been linked to ED. Drugs may need to be changed or dose adjusted. Measures reduce potential for orthostatic hypotension associated with the use of vasodilators and diuretics.
Prevents vasodilation with potential for dangerous side effects of syncope and hypotension. Any drug that contains a sympathetic nervous stimulant may increase BP or counteract effects of antihypertensive medications. Some diuretics can deplete potassium levels. Dietary potassium is desirable means of correcting deficits and may be more palatable to the client than drug supplements. Correcting mineral deficiencies can also affect BP. Early detection and reporting of developing complications, decreased effectiveness of drug regimen, or adverse reactions allow for timely intervention.
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Help client identify sources of sodium intake, such as table salt, salty snacks, processed meats and cheeses, sauerkraut, sauces, canned soups and vegetables, baking soda, baking powder, and monosodium glutamate. Emphasize the importance of reading ingredient labels of foods and OTC drugs. Encourage foods rich in essential fatty acids, such as salmon, cod, mackerel, and tuna. Encourage client to establish a regular exercise program, incorporating aerobic exercise within client’s capabilities. Stress the importance of avoiding isometric activity. Demonstrate application of ice pack to the back of the neck and pressure over the distal third of nose, and recommend that client lean head forward if nosebleed occurs. Provide information regarding community resources, and support client in making lifestyle changes. Initiate referrals, as indicated.
Excess saturated fats, cholesterol, sodium, alcohol, and calories have been defined as nutritional risks in hypertension. A diet low in fat and high in polyunsaturated fat reduces BP, possibly through prostaglandin balance in both normotensive and hypertensive people. A moderately low-salt diet may be sufficient to control mild hypertension or reduce or eliminate the need for drug therapy to control BP.
Omega-3 fatty acids in fish tend to relax artery walls, reducing blood pressure. They also make blood thinner and less likely to clot. Besides helping to lower BP, aerobic activity aids in toning the cardiovascular system. Isometric exercise can increase serum catecholamine levels, further elevating BP. Nasal capillaries may rupture as a result of excessive vascular pressure. Cold temperature and pressure constrict capillaries to slow or halt bleeding. Leaning forward reduces the amount of blood that is swallowed. Community resources, such as the American Heart Association, “coronary clubs,” stop smoking clinics, alcohol or drug rehabilitation, weight-loss programs, stress management classes, and counseling services may be helpful in client’s efforts to initiate and maintain lifestyle changes.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) • Activity Intolerance—imbalance between oxygen supply and demand • imbalanced Nutrition: more than body requirements—excessive intake in relation to metabolic needs/physical activity; sedentary lifestyle • ineffective Self-Health Management—complexity of therapeutic regimen, economic difficulties, perceived seriousness • Sexual Dysfunction—altered body function (activity intolerance, side effects of medication) • readiness for enhanced family Coping—SO(s) moves in direction of health promotion
HEART FAILURE: CHRONIC I. Pathophysiology a. Remodeling of the myocardium (as a structural response to injury) changes the heart from an efficient football shape to an inefficient basketball shape, making coordinated contractility difficult. i. Ventricular dilation (systolic dysfunction) results in poor contractility and inadequate emptying of chamber. ii. Ventricular stiffening (diastolic dysfunction) impairs ability of chamber to relax and receive and eject blood. b. Failure of the left and/or right chambers of the heart results in insufficient output to meet metabolic needs of organ and tissues. c. Cardiac-related elevation of pulmonary or systemic venous pressures leads to organ congestion. d. Backward heart failure (HF): passive engorgement of the veins caused by elevated systemic venous pressure or a “backward” rise in pressure proximal to the failing cardiac chambers (right ventricular failure) e. Forward HF: decreased cardiac output with reduced forward flow into the aorta, systemic circulation (inadequate
renal blood flow leads to sodium and water retention), and increasing pulmonary venous pressure results in fluid accumulation in alveoli (left ventricular failure) f. Myocardial muscle dysfunction associated with left ventricular hypertrophy (LVH) causes decreased cardiac output, activating neurohormones. g. Elevated circulating or tissue levels of neurohormones, norepinephrine, angiotensin II, aldosterone, endothelin, vasopressin, and cytokines causes sodium retention and peripheral vasoconstriction, increasing hemodynamic stresses on the ventricle. II. Classification a. Stages (American College of Cardiology/American Heart Association (ACC/AHA) 2009 Guidelines include specific recommendations for each stage [Jessup et al, 2009]). i. Stage A—high risk for HF associated with such conditions as hypertension, diabetes, and obesity. Treatment is focused on comorbidity. ii. Stage B—presence of structural heart disease, such as left ventricular remodeling (LVH, or previous myocardial (continues on page 44)
43
CARDIOVASCULAR—HEART FAILURE
severe dizziness or episodes of fainting; muscle weakness or cramping; nausea or vomiting; or excessive thirst. Explain rationale for prescribed dietary regimen—usually a diet low in sodium, saturated fat, and cholesterol.
RATIONALE (continued)
CHAPTER 4
ACTIONS/INTERVENTIONS (continued)
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infarction (MI) but is asymptomatic. Treatment is focused on retarding the progression of ventricular remodeling and delaying the onset of HF symptoms. iii. Stage C—clients with past or current HF symptoms associated with structural heart disease, such as advanced ventricular remodeling. Treatment is focused on modifying fluid and dietary intake and drug therapies as well as nonpharmacological measures, such as biventricular pacing and valvular or revascularization surgery. iv. Stage D—refractory advanced HF symptoms at rest or with minimal exertion and frequently requiring intervention in the acute setting. Treatment is focused on promoting clinical stability, including supportive therapy to sustain life, such as left ventricular assist device, continuous intravenous (IV) inotropic therapy, experimental surgery or drugs, a heart transplant, or end-oflife or hospice care. III. Etiology a. Multifactoral i. Complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood (ACC/AHA 2009 Guidelines; Jessup et al, 2009). ii. Risk factors and co-morbidities—hypertension; obesity; diabetes; coronary artery disease (CAD); peripheral and cerebrovascular disease; valvular heart disease with onset of atrial fibrillation (AF); sleep disorders such as sleep apnea; history of exposure to cardiotoxins, for example, chemotherapy, alcohol, and cocaine; family history of cardiomyopathy IV. Statistics a. High morbidity and mortality, particularly in stage D clients. (Jessup et al, 2009) b. Morbidity: 5.7 million Americans have HF. (Roger, 2012; Centers for Disease Control and Prevention [CDC], 2012) c. Mortality: Heart failure was listed as a contributing cause of 280,000 deaths in 2008 and was listed at number 4 in leading causes of death in 2009. (Roger, 2012; Kochanek, 2011). d. Cost: Direct costs projected to be $24.7 billion in 2010. (Heidenriech, 2011)
G L O S S A R Y Angiotensin converting enzyme inhibitor (ACEI) (also called ACE inhibitors): Medication that blocks the action of the angiotensin-converting enzyme in the lungs so that angiotensin I is not converted into angiotensin II. The production of this powerful blood vessel constrictor is thereby prevented and blood vessels remain dilated, which results in lower blood pressure. Angiotensin receptor blocker (ARB): Medication that blocks the chemical receptors for angiotensin II on the small arteries. Therefore, the angiotensin cannot cause these arteries to constrict, which lowers blood pressure. Ascites: Accumulation of fluid in the abdominal cavity can be associated with increased blood pressure in the veins draining the liver, with impaired drainage in the lymph system, and with low levels of albumin and other proteins in the blood. Cardiac remodeling: The left ventricular chamber dilates and becomes more spherical. This condition increases the stress on the myocardial walls and depresses cardiac performance. Remodeling often precedes symptoms and may contribute to worsening of symptoms despite treatment (Jessup et al, 2009).
Heart failure (HF): A clinical syndrome characterized by inadequate systemic perfusion to meet the body’s metabolic demands as a result of impaired cardiac pump function (McCance & Heuther, 2009). Heart sounds: S1 corresponds to the closure of mitral and tricuspid valves. S2 corresponds to closure of the aortic and pulmonary valves. S3, heard mid-diastolic at the apex, is a low-pitched gallop or blowing sound sometimes called a ventricular gallop and is a common sign of left ventricular failure or distension in adults (Karmath & Thornton, 2002). Positive hepatojugular reflex: An elevation of venous pressure, visible in the jugular veins and measurable in the veins of the arm, which is produced by firm pressure with the flat hand over the abdomen in active or impending congestive heart failure. Pulsas alternans: Alternating weak and strong beats of the pulse associated with weak left ventricular function. Pulse pressure: Difference between systolic and diastolic blood pressures.
Care Setting
Related Concerns
Although generally managed at the community level, an inclient stay may be required for periodic exacerbation of failure or development of complications.
Myocardial infarction, page 75 Hypertension: severe, page 33 Cardiac surgery, page 98 Dysrhythmias, page 87 Psychosocial aspects of care, page 729
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CHAPTER 4
Client Assessment Database D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
• Fatigue, exhaustion progressing throughout the day • Inability to perform normal daily activities, such as making bed, climbing stairs, and so on • Exercise intolerance • Dyspnea at rest or with exertion • Insomnia, inability to sleep flat
• Limited exercise tolerance • Fatigue • Restlessness, mental status changes, such as anxiety and lethargy • Vital sign changes with activity
CIRCULATION • History of hypertension, recent or past MIs, multiple MIs, previous episodes of HF, valvular heart disease, cardiac surgery, endocarditis, systemic lupus erythematosus, anemia, septic shock • Swelling of feet, legs, abdomen, or “belt too tight”
• Blood pressure (BP) may be low with cardiac pump failure; in normal range with mild or chronic HF; or high with fluid overload, left-sided HF, and increased systemic vascular resistance (SVR) • Pulse pressure narrow, reflecting reduced ventricular stroke volume • Heart rate and rhythm: Tachycardia; dysrhythmias such as atrial fibrillation, premature ventricular contractions, heart blocks • Apical pulse: Point of maximal intensity (PMI) diffuse and displaced to the left • Heart sounds: S1 and S2 possibly softened; S3 gallop rhythm diagnostic of congestive HF; S4 occurring with hypertension; systolic and diastolic murmurs indicating the presence of valvular stenosis or insufficiency, causing or exacerbating heart failure • Pulses: Peripheral pulses diminished; central pulses may be bounding, for example, visible jugular, carotid, abdominal pulsations • Pulsus alternans may be noted • Skin tissue color pale, ashen, dusky, or cyanotic • Nail beds pale or cyanotic, with slow capillary refill • Liver enlarged and palpable; positive hepatojugular reflex may be present in right-sided HF • Edema dependent, generalized, or pitting, especially in extremities • Bulging neck veins (jugular vein distention [JVD])
EGO INTEGRITY • Anxiety, apprehension, fear • Stress related to illness or financial concerns (job, cost of medical care)
• Various behavioral manifestations, for example, anxiety, anger, fear, irritability
ELIMINATION • Decreased voiding, dark urine • Night voiding
• Decreased daytime urination and increased nighttime urination (nocturia)
FOOD/FLUID • History of diet high in salt and processed foods, fat, sugar, and caffeine • Loss of appetite, anorexia • Nausea, vomiting • Significant weight gain (may not respond to diuretic use) • Tight clothing or shoes • Use of diuretics
• Rapid or continuous weight gain • Generalized edema, including whole body or lower extremity swelling—edema generalized, dependent, pitting, brawny • Abdominal distention, suggesting ascites or liver engorgement
HYGIENE • Fatigue, weakness, exhaustion during self-care activities
• Appearance indicative of neglect of personal care (continues on page 46)
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CARDIOVASCULAR—HEART FAILURE
ACTIVITY/REST
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Client Assessment Database
(continued)
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
M AY E X H I B I T
(continued)
NEUROSENSORY • Weakness • Dizziness • Fainting episodes
• Lethargy, confusion, disorientation • Behavior changes, irritability
PAIN/DISCOMFORT • • • •
Chest pain Chronic or acute angina Right upper abdominal pain (right-sided HF) Generalized muscle aches and pains
• Restlessness • Narrowed focus and withdrawal • Guarding behavior
RESPIRATION • • • •
Dyspnea with exertion or rest Nocturnal dyspnea that interrupts sleep Sleeping sitting up or with several pillows Cough with or without sputum production, especially when recumbent • Use of respiratory aids, for example, oxygen or medications
• • • • •
Tachypnea Shallow, labored breathing Use of accessory muscles, nasal flaring Moist cough with left-sided HF Sputum may be blood-tinged, pink, and frothy (pulmonary edema) • Breath sounds may be diminished, with bibasilar crackles and wheezes • Mentation may be diminished; lethargy, restlessness present • Pallor or cyanosis
SAFETY • • • •
SOCIAL INTERACTION • Decreased participation in usual social activities
TEACHING/LEARNING • Family history of developing HF at young age (genetic form) • Family risk factors, such as heart disease, hypertension, diabetes • Use or misuse of cardiac medications • Use of vitamins, herbal supplements, for example, niacin, coenzyme Q10, garlic, ginkgo, black hellebore, dandelion, or aspirin • Recent or recurrent hospitalizations • Evidence of failure to improve
DISCHARGE PLAN CONSIDERATIONS • Assistance with shopping, transportation, self-care needs, homemaker and maintenance tasks • Alteration in medication use or therapy • Changes in physical layout of home • May need oxygen at home ➧ Refer to section at end of plan for postdischarge considerations.
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Changes in mentation and confusion Loss of strength or muscle tone Increasing risk for falls Skin excoriations, rashes
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CHAPTER 4
Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
CARDIOVASCULAR—HEART FAILURE
BLOOD TESTS • Atrial natriuretic peptide (ANP): Hormone secreted from right atrial cells when pressure increases. • Beta-type natriuretic peptide (BNP): Neurohormone secreted from the cardiac ventricles as a response to ventricular volume and fluid overload.
• Liver enzyme tests, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) (formally referred to as SPGT and SGOT): To determine degree of end-organ involvement. • Erythrocyte sedimentation rate (ESR): Shows the alteration of blood proteins caused by inflammatory and necrotic processes. • Bleeding and clotting times: Clotting factors, prothrombin time (PT), partial thromboplastin time (PTT), platelets. • Electrolytes (sodium, potassium, chloride, magnesium, calcium): Elements or chemicals needed for the body and heart to work properly. • Arterial blood gas (ABG): Measures arterial pH, PCO2, and PO2. Evaluates respiratory function and provides a measure for determining acid-base balance. • Albumin and transferrin, total protein: Plasma proteins exert oncotic pressure needed to keep fluid in the capillaries. • Thyroid studies: Blood test and scan to evaluate thyroid function. The most commonly used laboratory screening test is the measurement of thyroid-stimulating hormone (TSH). • Blood urea nitrogen (BUN) and creatinine: BUN levels reflect the balance between production and excretion of urea. Creatine is end product of creatinine metabolism and must be cleared from blood via the kidneys.
Increased in congestive HF. The level of BNP in the blood increases when symptoms of HF worsen and decreases when symptoms of HF improve to stable condition. Elevation of BNP correlates with both the severity of symptoms and the prognosis in congestive HF. A level of BNP that is greater than 100 pg/mL is predictive of HF and increased risk of sudden death and 1-year mortality (Kociol et al, 2011). Elevated in liver congestion, which may be present in rightsided HF.
May be elevated, indicating acute systemic inflammatory reaction, especially if viral infection is cause of HF. Identifies those at risk for excessive clot formation and identifies therapeutic range for anticoagulant therapy. Electrolytes may be altered because of fluid shifts and decreased renal function associated with HF and medications (e.g., diuretics, ACE inhibitors) used in HF treatment. Left ventricular failure is characterized by mild respiratory alkalosis (early); respiratory acidosis, with hypoxemia; and increased PCO2, with decompensated HF. May be decreased as a result of reduced protein intake (nutritional) or reduced protein synthesis (congested liver associated with HF). Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF. Hypothyroidism can also cause or exacerbate HF. Elevated BUN suggests decreased renal perfusion as may occur with HF or as a side effect of prescribed medications (e.g., diuretics and ACE inhibitors). Elevation of both BUN and creatinine is typical in HF.
OTHER DIAGNOSTIC STUDIES • Chest x-ray: Evaluates organs and structures within the chest. • Electrocardiogram (ECG): Record of the electrical activity of the heart. • Echocardiography (also called two-dimensional echocardiogram or Doppler ultrasound): Evaluates the left ventricle, including size, valvular function, wall thickness, and pumping action as measured by the ejection fraction (EF). • Stress test (also called exercise treadmill or exercise ECG): Raises heart rate and BP by means of exercise; heart rate can also be raised pharmacologically through the use of such drugs as dobutamine or dipyridamol. • Cardiac angiography (also called cardiac catheterization): Assesses patency of coronary arteries, reveals abnormal heart and valve size or shape, and evaluates ventricular contractility. Pressures can be measured within each chamber of the heart and across the valves.
May demonstrate calcification in valve areas or aorta, causing blood flow obstruction, or cardiac enlargement, indicating HF. An abnormal ECG can point out the underlying cause of HF, such as ventricular hypertrophy, valvular dysfunction, ischemia, and myocardial damage patterns. May reveal enlarged chamber dimensions or alterations in valvular and ventricular function and structure. EF is reduced (less than 50%), indicating systolic dysfunction, or “preserved” (normal is 50% to 65%), indicating diastolic dysfunction (Cunningham, 2006). Helps detect valvular heart disease ventricular remodeling and structural anomalies and problems with coronary circulation affecting heart function. Abnormal pressures indicate problems with ventricular function, helping to identify valvular stenosis or insufficiency and differentiating right-sided versus left-sided HF.
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Nursing Priorities
Discharge Goals
1. 2. 3. 4.
1. 2. 3. 4.
Improve myocardial contractility and systemic perfusion. Reduce fluid volume overload. Prevent complications. Provide information about disease and prognosis, therapy needs, and prevention of recurrences.
NURSING DIAGNOSIS:
Cardiac output adequate for individual needs. Complications prevented or resolved. Optimum level of activity and functioning attained. Disease process, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge.
decreased Cardiac Output
May Be Related To Altered contractility (such as valvular defects and ventricular aneurysm) Altered heart rate, rhythm Altered afterload (vascular resistence)
Possibly Evidenced By Tachycardia, arrhythmias, ECG changes Variations in blood pressure readings (hypotension, hypertension) Decreased peripheral pulses S3, S4 heart sounds Orthopnea, crackles, jugular vein distension, edema, weight gain Skin color changes, clammy skin Oliguria
Desired Outcomes/Evaluation Criteria—Client Will Cardiac Pump Effectiveness NOC Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example, hemodynamic parameters within acceptable limits and urinary output adequate. Report decreased episodes of dyspnea and angina.
Cardiac Disease Self-Management NOC Participate in activities that reduce cardiac workload.
ACTIONS/INTERVENTIONS
RATIONALE
Hemodynamic Regulation NIC Independent Auscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available.
Note heart sounds.
Palpate peripheral pulses.
Monitor BP.
Inspect skin for pallor and cyanosis.
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Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive to medication suggest ventricular aneurysm. 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 and stenosis. Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans may be present. 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 or irreversible hypotension may occur. Note: Many clients with HF have consistently low systolic BP (80 to 100 mm Hg) due to their disease process and the medications they take. Most tolerate these BPs without incident (Wingate, 2007). Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases.
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Monitor urine output, noting decreasing output and dark or concentrated urine.
Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when client is recumbent. May indicate inadequate cerebral perfusion secondary to decreased cardiac output. Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen consumption and workload. Physical and psychological rest helps reduce stress, which can produce vasoconstriction, elevating BP and increasing heart rate and work. Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function and output. Decreases venous stasis and may reduce incidence of thrombus and embolus formation.
Note changes in sensorium, for example, lethargy, confusion, disorientation, anxiety, and depression. Encourage rest, semirecumbent in bed or chair. Assist with physical care, as indicated. Provide quiet environment, explain medical and nursing management, help client avoid stressful situations, listen and respond to expressions of feelings or fears. Provide bedside commode. Have client avoid activities eliciting a vasovagal response, for instance, straining during defecation and holding breath during position changes. Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase ambulation and activity as tolerated. Check for calf tenderness; diminished pedal pulse; and swelling, local redness, or pallor of extremity. Withhold digoxin, as indicated, and notify physician if marked changes occur in cardiac rate or rhythm or signs of digoxin toxicity occur.
Reduced cardiac output, venous pooling and stasis, and enforced bedrest increases risk of thrombophlebitis. Incidence of toxicity is high (20%) because of narrow margin between therapeutic and toxic ranges. Digoxin may 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 [Digoxin Toxicity].)
Collaborative Administer supplemental oxygen, as indicated. Administer medications, as indicated, for example:
Loop diuretics, such as furosemide (Lasix), ethacrynic acid (Edecrin), and bumetanide (Bumex); thiazide and thiazidelike diuretics, such as hydrochlorothiazide (HCTZ) and metolazone (Zaroxolyn)
ACE inhibitors, such as elanopril (Vasotec), captopril (Capoten), lisinopril (Prinivil), quinapril (Accupril), ramipril (Altace), and moexipril (Univasc) ARBs (also known as angiotensin II receptor antagonists), such as candesartan (Atacand), losartan (Cozaar), eprosartan (Teveten), ibesartan (Avapro), and valsartan (Diovan)
Vasodilators, such as nitrates (Nitro-Dur, Isordil); arteriodilators such as hydralazine (Apresoline); combination drugs, such as prazosin (Minipress) and nesiritide (Natrecor)
β-adrenergic receptor antagonists (also called beta blockers), such as carvedilol (Coreg), bisoprolol (Zebeta), and metoprolol (Lopressor) Inotropic agents, such as amrinone (Inocor), milrinone (Primacor), and vesnarinone (Arkin-Z)
Increases available oxygen for myocardial uptake to combat effects of hypoxia and ischemia. A variety of medications (usually a combination of a diuretic, an ACEI, or ARB and beta blocker) may be used to increase stroke volume, improve contractility, and reduce congestion. Diuretics, in conjunction with restriction of dietary sodium and fluids, often lead to clinical improvement in clients 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 accompanied by congestive symptoms. Loop diuretics block chloride reabsorption, thus interfering with the reabsorption of sodium and water. ACE inhibitors represent first-line therapy to control HF by decreasing ventricular filling pressures and SVR, while increasing cardiac output with little or no change in BP and heart rate. Antihypertensive and cardioprotective effects are attributable to selective blockade of AT1 (angiotensin II) receptors and angiotensin II synthesis. Note: ARBs used in combination with ACE inhibitors and beta blockers are thought to have decreased hospitalizations for HF clients. Vasodilators are used to increase cardiac and renal output, reducing circulating volume (preload and afterload), and decreasing SVR, thereby reducing ventricular workload. Note: Nesiritide is used in acutely decompensated congestive HF 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. Useful in the treatment of HF by blocking the cardiac effects of chronic adrenergic stimulation. Many clients experience improved activity tolerance and EF. These medications are useful for short-term treatment of HF unresponsive to cardiac glycosides, vasodilators, and diuretics in order to increase myocardial contractility and produce vasodilation. (continues on page 50)
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CARDIOVASCULAR—HEART FAILURE
RATIONALE (continued)
CHAPTER 4
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued) Digoxin (Lanoxin)
Anti-anxiety agents and sedatives
Anticoagulants, such as low-dose heparin, and warfarin (Coumadin); or antiplatelet agents, for example, low-dose aspirin, clopidogrel (Plavix), tirofiban (Aggrastat) Administer IV solutions, restricting total amount, as indicated. Avoid saline solutions.
Monitor and replace electrolytes, as indicated.
Monitor serial ECG and chest x-ray changes.
Measure cardiac output and other functional parameters, as indicated.
Prepare for insertion and maintain pacemaker or pacemaker/defibrillator, if indicated.
Prepare for surgery, such as valve replacement, angioplasty, coronary artery bypass grafting (CABG), as indicated:
Cardiomyoplasty
Assist with and maintain mechanical circulatory support system, such as intra-aortic balloon pump (IABP) or leftventricular assist device (LVAD), when indicated.
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RATIONALE (continued) Digoxin is no longer used routinely in HF but may be prescribed for symptomatic individuals with late-stage HF on maximal medication therapy (Suter, 2012). Digoxin may be added in low doses (0.125) to the client’s medication regimen to improve symptoms and is also used to treat atrial fibrillation. Allays anxiety and breaks the feedback cycle of anxiety to catecholamine release to anxiety. Promotes rest and relaxation, reducing oxygen demand and myocardial workload. May be used prophylactically to prevent thrombus and embolus formation in the presence of risk factors, such as venous stasis, enforced bedrest, cardiac dysrhythmias, and history of previous thrombolic episodes. Because of existing elevated left ventricular pressure, client may not tolerate increased fluid volume (preload). Clients with HF also excrete less sodium, which causes fluid retention and increases myocardial workload. Fluid shifts and use of diuretics can alter electrolytes (especially potassium and chloride), which affect cardiac rhythm and contractility. ST-segment depression and T-wave flattening can develop because of increased myocardial oxygen demand, even if no CAD is present. Chest x-ray may show enlarged heart and changes of pulmonary congestion. Cardiac index, preload and afterload, contractility, and cardiac work can be measured noninvasively by using thoracic electrical bioimpedance (TEB) technique. TEB is useful in determining effectiveness of therapeutic interventions and response to activity. May be necessary to correct bradydysrhythmias unresponsive to drug intervention, which can aggravate congestive failure and produce pulmonary edema. Note: Biventricular pacemaker and cardiac defibrillators are designed to provide resynchronization for the heart by simultaneous electrical activation of both the right and left sides of the heart, thereby creating a more effective and efficient pump. HF due to ventricular aneurysm or valvular dysfunction may require aneurysmectomy or valve replacement to improve myocardial contractility and function. Revascularization of cardiac muscle by CABG may be done to improve cardiac function. 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. Note: Despite all basic research and various clinical investigations, the role of cardiomyoplasty in the treatment of heart failure remains unclear (Bocchi, 2001). An IABP may be inserted into the aorta as a temporary support to the failing heart in the critically ill client with potentially reversible HF. A short (external) or long-term (implanted) LVAD may also be used, sometimes as a bridge to transplantation. A growing use of the LVAD is in so-called destination therapy (DT). The DT population typically includes individuals with end-stage heart failure and poor predictive survival in their current medical state. These people are also noneligible for transplantation, usually due to advanced age, significant comorbidities, or psychosocial issues contraindicating transplant. Clients who undergo LVAD implantation live the rest of their lives with the device permanently in place.
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CHAPTER 4
NURSING DIAGNOSIS:
Activity Intolerance
May Be Related To
Possibly Evidenced By Reports fatigue, feeling weak Abnormal blood pressure/heart rate in response to activity Exertional dyspnea
Desired Outcomes/Evaluation Criteria—Client Will Endurance NOC Participate in desired activities; meet own self-care needs. Achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity.
ACTIONS/INTERVENTIONS
RATIONALE
Energy Management NIC Independent Check vital signs before and immediately after activity during acute episode or exacerbation of HF, especially if client is receiving vasodilators, diuretics, or beta blockers. Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, and pallor.
Assess level of fatigue, and evaluate for other precipitators and causes of fatigue, for example, HF treatments, pain, cachexia, anemia, and depression.
Evaluate accelerating activity intolerance. Provide assistance with self-care activities, as indicated. Intersperse activity with rest periods.
Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function. Compromised myocardium and inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue. Fatigue because of advanced HF can be profound and is related to hemodynamic, respiratory, and peripheral muscle abnormalities. Fatigue is also a side effect of some medications (e.g., beta blockers). Other key causes of fatigue should be evaluated and treated as appropriate and desired. May denote increasing cardiac decompensation rather than overactivity. Meets client’s personal care needs without undue myocardial stress or excessive oxygen demand.
Collaborative Implement graded cardiac rehabilitation and activity program.
NURSING DIAGNOSIS:
Strengthens and improves cardiac function under stress if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption.
excess Fluid Volume
May Be Related To Compromised regulatory mechanism (reduced glomerular filtration rate, increased antidiuretic hormone [ADH] production, and sodium and water retention) Excess sodium intake
Possibly Evidenced By Orthopnea, S3 heart sound Oliguria, edema, JVD, positive hepatojugular reflex Weight gain over short period of time Blood pressure changes Pulmonary congestion, adventitious breath sounds
Desired Outcomes/Evaluation Criteria—Client Will Fluid Overload Severity NOC Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear or clearing, vital signs within acceptable range, stable weight, and absence of edema. Verbalize understanding of individual dietary and fluid restrictions.
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CARDIOVASCULAR—HEART FAILURE
Imbalance between oxygen supply and demand Generalized weakness Sedentary lifestyle
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ACTIONS/INTERVENTIONS
RATIONALE
Fluid Management NIC Independent Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.
Monitor 24-hour intake and output (I&O) balance.
Maintain chair rest or bedrest in semi-Fowler’s position during acute phase. Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care and ice chips as part of fluid allotment. Weigh daily.
Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema with and without pitting; note presence of generalized body edema (anasarca).
Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding, as indicated. (Refer to ND: risk for impaired Skin Integrity.) Auscultate breath sounds, noting decreased and adventitious sounds, for example, crackles and wheezes. Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, and persistent cough. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom. Monitor BP and central venous pressure (CVP) (if available).
Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distention, and constipation. Provide small, frequent, easily digestible meals.
Measure abdominal girth, as indicated. Palpate abdomen. Note reports of right upper-quadrant pain or tenderness.
Note increased lethargy, hypotension, and muscle cramping.
Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night or during bedrest. Diuretic therapy may result in sudden or excessive fluid loss, creating a circulating hypovolemia, even though edema and ascites remain in the client with advanced HF or CHF. Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis. Involving client in therapy regimen may enhance sense of control and cooperation with restrictions. Documents changes in or resolution of edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in rapid and excessive fluid shifts and weight loss. Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles, or dependent areas, and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion—associated with right-sided HF—eventually results in systemic tissue edema. Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility or bedrest are cumulative stressors that affect skin integrity and require close supervision and preventive interventions. Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left-sided HF. With right-sided HF, respiratory symptoms of dyspnea, cough, and orthopnea may have slower onset but are more difficult to reverse. May indicate development of complications, such as pulmonary edema or embolus, which differs from orthopnea or paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention. Hypertension and elevated CVP suggest fluid volume excess and may reflect developing or increasing pulmonary congestion, HF. Visceral congestion, occurring in progressive HF, can alter gastrointestinal function. Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion and prevent abdominal discomfort. In progressive right-sided HF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites). Advancing HF leads to venous congestion, resulting in abdominal distention, liver engorgement (hepatomegaly), and pain. This can alter liver function and impair or prolong drug metabolism. These are signs of potassium and sodium deficits that may occur because of fluid shifts and diuretic therapy.
Fluid/Electrolyte Management NIC Collaborative Administer medications, as indicated, for example: Diuretics, such as furosemide (Lasix) and bumetanide (Bumex), toresemide (Demadex) Potassium-sparing thiazides such as spironolactone (Aldactone), amiloride (Midamor), triamterene (Direnium) Potassium supplements, such as K-Dur, K-Lor, Micro-K Maintain fluid and sodium restrictions, as indicated.
52
Increases rate of urine flow and may inhibit reabsorption of sodium and chloride in the renal tubules. Promotes diuresis without excessive potassium losses. Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect cardiac function. Fluid restriction is not a general recommendation, but fluids should be restricted to less than 2 L/day in patients who have significant hyponatremia (25 in women Dysfunctional eating patterns, eating in response to external cues or internal cues other than hunger Sedentary lifestyle
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Diet NOC Identify inappropriate behaviors and consequences associated with overeating or weight gain. Demonstrate appropriate change in lifestyle and behaviors, including eating patterns and food quantity and quality, and involvement in individual exercise program.
Nutritional Status NOC Display weight loss with optimal maintenance of health.
ACTIONS/INTERVENTIONS
RATIONALE
Weight-Reduction Assistance NIC Independent Review individual cause for obesity, e.g., excess intake vs. metabolic or disease condition. Ascertain previous dieting history. Determine which diets and strategies have been used, results, and individual frustrations and factors interfering with success. Implement and review daily food diary, for example, total caloric intake, types and amounts of food, and eating habits and associated feelings. Determine client’s motivation for weight loss, for instance, health issues, own satisfaction, and to gain approval from others. Discuss client’s and SO’s view of self, including familial and cultural influences. Notice occurrence of negative feedback from SO(s). Formulate an eating plan with the overweight client, using knowledge of individual’s height, body build, age, gender, and individual patterns of eating, as well as energy and nutrient requirements.
Emphasize the importance of avoiding fad diets.
Discuss need to give self permission to include desired or craved food items in dietary plan.
Identifies and influences choice of some interventions Client may have tried multiple diets, with little lasting change in body weight and feel negatively about embarking on another plan. Provides the opportunity for the individual to focus on a realistic picture of the amount of food ingested and corresponding eating habits and feelings. Identifies patterns requiring change and a base on which to tailor the dietary program. Helps to clarify client’s motivation and potential for success in weight reduction. Client’s family and cultural practices greatly influence client’s self-view regarding food and body image. Feedback from family may reveal control issues impacting motivation for change. An important factor in the success of any weight-loss program is adherence to a sound nutritional plan. Although there is little basis for recommending one commercial diet plan over another, a good reducing diet should contain foods from all basic food groups, with a focus on low-fat intake and adequate protein intake to prevent loss of lean muscle mass. It is helpful to keep the plan as similar to client’s usual eating pattern as possible. A plan developed with and agreed to by the client is more likely to be successful. Elimination of needed components can lead to metabolic imbalances; for example, excessive reduction of carbohydrates can lead to fatigue, headache, instability, weakness, and metabolic acidosis (ketosis), thus interfering with effectiveness of weight-loss program. Denying self by always excluding favorite foods results in a sense of deprivation and feelings of guilt and failure when (continues on page 362)
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METABOLIC AND ENDOCRINE DISORDERS—OBESITY
Discharge Goals
CHAPTER 8
Nursing Priorities
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ACTIONS/INTERVENTIONS (continued)
Be alert to binge eating and develop strategies for dealing with these episodes, such as substituting other actions for eating. Identify realistic incremental goals for weekly weight loss.
Weigh periodically as individually indicated, and obtain appropriate body measurements.
Determine current activity level and exercise program.
Develop an appetite reeducation plan with client (e.g., avoiding sugary snacks, increasing protein foods, drinking water throughout day, brushing teeth or using mouthwash, eating something that takes up a lot of room in stomach but has few calories, such as soup). Emphasize the importance of avoiding tension at mealtimes and not eating too quickly.
Encourage client to eat only at a designated eating place and to avoid standing while eating. Discuss restriction of salt intake and diuretic drugs if used. Reassess caloric requirements every 2 to 4 weeks; provide additional support when plateaus occur.
RATIONALE (continued) individual “succumbs to temptation.” These feelings can sabotage weight loss. The client who binges experiences guilt about it, which is also counterproductive because negative feelings may sabotage further weight-loss efforts. Reasonable weight loss of 1 to 2 lb/wk results in longer-lasting effects. Excessive or rapid loss may result in fatigue and irritability and ultimately lead to failure in meeting goals for weight loss. Motivation is more easily sustained by meeting “stair-step” goals. Provides information about effectiveness of therapeutic regimen and visual evidence of success of client’s efforts. During hospitalization for controlled fasting, daily weighing may be required. Weekly weighing is more appropriate after discharge. Long-term exercise promotes weight loss by reducing appetite, burning fat while improving lean muscle mass and strength (Benton, 2011). Appetite is both a psychological and physical phenomenon, requiring thoughtful attention and preparedness.
Reducing tension provides a more relaxed eating atmosphere and encourages more leisurely eating patterns. This is important because a period of time is required for the appestat mechanism to know the stomach is full. Techniques that modify behavior may be helpful in avoiding diet failure. Water retention may be a problem because of increased fluid intake and fat metabolism. Changes in weight and exercise necessitate changes in plan. As weight is lost, changes in metabolism occur, resulting in plateaus when weight remains stable for periods of time. This can create distrust and lead to accusations of “cheating” on caloric intake, which are not helpful. Client may need additional support at this time.
Collaborative Perform comprehensive nutritional assessment to determine calorie, nutrient, and vitamin and supplement requirements for individual.
Provide medications, as indicated.
Appetite-suppressant drugs, such as: Diethylpropion (Tenuate), mazindol (Sanorex), and sibutramine (Meridia)
Lipase inhibitors, such as orlistat (Xenical, Alli)
CNS stimulants, such as phenteramine (Adipex-P), benzphetamine (Didrex)
362
Intake can be calculated by several different formulas, but weight reduction is based on the basal caloric requirement for 24 hours depending on client’s sex, age, current or desired weight, and length of time estimated to achieve desired weight. Note: Standard tables are subject to error when applied to individual situations, and circadian rhythms and lifestyle patterns need to be considered. Currently, there are three major groups of drugs used to manage obesity: (1) centrally acting medications that impair dietary intake (such as appetite suppressants); (2) medications that act peripherally to impair dietary absorption (such as lipase inhibitors); and (3) medications that increase energy expenditure (such as caffeine and other stimulants (Hamdy et al, 2013). May be used with caution and supervision at the beginning of a weight-loss program to support client during stress of behavioral changes. They are effective for only a few weeks and may cause problems of dependence in some people. These drugs induce weight loss by inhibiting fat absorption. Note: Use of lipase inhibitors may reduce absorption of some fat-soluble vitamins (A, D, E, K) and beta carotene. Vitamin supplement should be given at least 2 hours before or after Xenical. Adrenergic agonists that release tissue stores of epinephrine, causing subsequent alpha- and/or beta-adrenergic stimulation, have provided benefits to individuals with severe obesity who are under physician-supervised weight-loss programs. They are approved for short-term use (8 to 12 weeks) in adults.
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Hospitalize for fasting regimen or stabilization of medical problems, when indicated.
Aggressive therapy and support may be necessary to initiate weight loss, although fasting is not generally a treatment of choice. Client can be monitored more effectively in a controlled setting to minimize complications such as orthostatic hypotension, anemia, and cardiac irregularities. These interventions may be necessary to help the client lose weight when obesity is life-threatening. (Refer to CP: Obesity: Bariatric Surgery.)
Prepare for bariatric surgical interventions, such as gastric banding or bypass, as indicated.
NURSING DIAGNOSIS:
sedentary Lifestyle
May Be Related To Lack of interest, motivation, or resources Deficient knowledge of the health benefit of physical exercise
Possibly Evidenced By Demonstrates physical deconditioning Chooses daily routine lacking physical exercise
Desired Outcomes/Evaluation Criteria—Client Will Exercise Participation NOC Verbalize understanding of importance of regular exercise to weight loss and general well-being. Identify necessary precautions and safety concerns and self-monitoring techniques. Formulate realistic exercise program with gradual increase in activity.
ACTIONS/INTERVENTIONS
RATIONALE
Exercise Promotion NIC Independent Review necessity for and benefits of regular exercise.
Determine current activity level and plan progressive exercise program tailored to the individual’s physical condition, goals, and choice. Identify perceived and actual barriers to exercise.
Discuss appropriate warm-up exercises, cool-down activities, and specific techniques to avoid injury. Determine optimal exercise heart rate. Demonstrate proper technique to monitor pulse and discuss signs and symptoms requiring modification of activity. Identify alternatives to chosen activity program to accommodate weather, travel, and so forth. Discuss use of mechanical devices or equipment for weight reduction.
Recommend keeping a graph of activity as exercise program advances. Suggest client identify an exercise buddy. Encourage involvement in social activities that are not centered on food—bike ride or nature hike, attending musical event, and group sporting activities.
Exercise promotes weight loss by reducing appetite, increasing energy, toning muscles, and enhancing cardiac fitness and sense of well-being and accomplishment. Commitment on the part of the client enables the setting of more realistic goals and adherence to the plan. Lack of resources, including proper apparel such as supportive shoes and comfortable clothing, a safe place to walk, or facility membership for water aerobics, reduces the likelihood of individual adhering to specific program. In addition, fear of discrimination or ridicule by others may limit client’s willingness to exercise in public. Preventing muscle injuries allows client to stay active. Time spent recuperating from exercise-induced injuries may result in relapse to sedentary habits. Promotes safety as client exercises to tolerance, not peer pressure. Promotes continuation of program. Fat loss occurs on a generalized overall basis, and there is no evidence that spot reducing or mechanical devices aid in weight loss in specific areas; however, specific types of exercise or equipment may be useful in toning specific body parts. Provides visual record of progress and positive reinforcement for efforts. Provides support and companionship, increasing likelihood of adherence to program. Provides opportunity for pleasure and relaxation not associated with food. (continues on page 364)
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RATIONALE (continued)
CHAPTER 8
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Collaborative Involve physical therapist or exercise physiologist in developing progressive program.
NURSING DIAGNOSIS:
Facilitates development of an appropriate program of activities that are geared to obese individual and considers impact of client’s weight on ability to perform specific activities and safety concerns.
disturbed Body Image
May Be Related To Biophysical factor—changes in health status Psychosocial factors—client’s view of self; changes in body image, personal identity; control, sex, and love issues Culture, family, or subculture encouragement of overeating
Possibly Evidenced By Reports feelings/perceptions that reflect an altered view of one’s body in appearance Reports negative feelings about body (e.g., hopelessness, powerlessness) Change in social involvement; fear of reaction by others Preoccupation with change—attempts to lose weight
Desired Outcomes/Evaluation Criteria—Client Will Body Image NOC Verbalize a more realistic self-image. Demonstrate some acceptance of self as is rather than an idealized image.
Self-Esteem NOC Seek information and actively pursue appropriate weight loss. Acknowledge self as an individual who has responsibility for self.
ACTIONS/INTERVENTIONS
RATIONALE
Body Image Enhancement NIC Independent Determine client’s view of being fat and what it does for the individual.
Determine client perception of threat to self.
Identify basic sense of self-worth and image client has of existential, physical, and psychological self. Determine locus of control. Promote open communication, avoiding criticism or judgment about client’s behavior.
Assist client to identify feelings that lead to compulsive eating. Encourage journaling. Have client recall coping patterns related to food in family of origin and explore how these may affect current situation.
Develop strategies for doing something besides eating for dealing with dysfunctional eating, such as talking with a friend. Identify client’s motivation for weight loss and assist with goal setting.
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Mental image includes our ideal and is usually not up-to-date. Fat and compulsive eating behaviors may have deep-rooted psychological implications, such as compensation for lack of love and nurturing or a defense against intimacy. In addition, chronically obese client may report long-term discrimination in family, social, and professional settings. She or he may experience mixed feelings of fear and shame or compensate for psychological trauma by developing a strong or “big” personality. Client’s perception of what problem weight poses is more important than what the threat really is and needs to be dealt with before reality can be addressed. Provides insight into view of self as fat and own ability to control weight. Information necessary to determine individual needs and treatment plan. Supports client’s own responsibility for weight loss, enhances sense of control, and promotes willingness to discuss difficulties and setbacks and to problem-solve. Note: Distrust and accusations of “cheating” on caloric intake are not helpful. People often eat because of depression, anger, and guilt. Awareness of emotions that lead to overeating can be the first step in changing behavior. Parents act as role models for the child. Maladaptive coping patterns, such as overeating, are learned within the family system and are supported through positive reinforcement. Food may be substituted by the parent for affection and love, and eating is associated with a feeling of satisfaction, becoming the primary defense. Replacing eating with other activities helps retrain old patterns and establish new ways to deal with feelings. The individual may harbor repressed feeling of hostility, which may be expressed inward on the self. Because of a poor
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Graph weight on a weekly basis. Encourage client to use imagery to visualize self at desired weight and to practice handling of new behaviors.
Suggest client enhance current self through the application of makeup, current hairstyles, and dressing to maximize figure assets. Encourage buying clothes instead of food treats as a reward for weight loss and life successes.
Suggest the client dispose of “fat clothes” as weight loss occurs.
Be alert to myths the client and SO may have about weight and weight loss.
Determine relationship history and possibility of sexual abuse. Ensure availability of properly sized equipment, including gowns and other apparel; blood pressure cuff; wider and strong wheelchair, bed, commode, scales, and transfer devices, when providing inpatient care. Provide privacy during care activities. Assist with personal care, as needed. Help staff be aware of and deal with own feelings when caring for client.
self-concept, the person often has difficulty with relationships. Note: When losing weight for someone else, the client is less likely to be successful or maintain weight loss. It is helpful for each individual to understand area of own responsibility in the program so that misunderstandings do not arise. Provides ongoing visual evidence of weight changes, reinforcing reality. Mental rehearsal is very useful in helping the client plan for and deal with anticipated change in self-image or occasions that may arise, such as family gatherings or special dinners, where constant decisions about eating many foods will occur. Enhances feelings of self-esteem and promotes improved body image. Properly fitting clothes enhance the body image as small losses are made and the individual feels more positive. Waiting until the desired weight loss is reached can become discouraging. Removes the “safety valve” of having clothes available “in case” the weight is regained. Retaining fat clothes can convey the message that the weight loss will not occur or be maintained. Beliefs about what an ideal body looks like or unconscious motivations can sabotage efforts to lose weight. Some of these include the feminine thought of “If I become thin, men will view me as a sexual object”; the masculine counterpart, “I don’t trust myself to stay in control of my sexual feelings”; as well as issues of strength, power, or the “good cook” image. May contribute to current issues of self-esteem and patterns of coping. Healthcare providers have a moral and legal obligation to meet the client’s needs for dignity, comfort, and safety (Cheung et al, 2006). Individual knows size makes it hard to care for her or him and usually is sensitive and self-conscious about body. Judgmental attitudes, feelings of disgust, anger, and weariness can interfere with care and be transmitted to client, reinforcing negative self-concept and image.
Collaborative Refer to community support and/or therapy group.
NURSING DIAGNOSIS:
Weight-loss groups can provide companionship, enhance motivation, decrease loneliness and social ostracism, and give practical solutions to common problems. Group therapy can be helpful in dealing with underlying psychological concerns.
impaired Social Interaction
May Be Related To Self-concept disturbance Limited physical mobility
Possibly Evidenced By Discomfort in social settings Dysfunctional interaction with others
Desired Outcomes/Evaluation Criteria—Client Will Social Involvement NOC Verbalize awareness of feelings that lead to poor social interactions. Become involved in achieving positive changes in social behaviors and interpersonal relationships.
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Outline and clearly state responsibilities of client and nurse.
RATIONALE
CHAPTER 8
ACTIONS/INTERVENTIONS
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ACTIONS/INTERVENTIONS
RATIONALE
Socialization Enhancement NIC Independent Review family patterns of relating and social behaviors.
Encourage client to express feelings and perceptions of problems. Assess client’s use of coping skills and defense mechanisms.
Have client list behaviors that cause discomfort. Involve in role playing new ways to deal with identified behaviors or situations. Discuss negative self-concepts and self-talk, such as, “No one wants to be with a fat person,” “Who would be interested in talking to me?” Encourage use of positive self-talk such as telling oneself “I am OK” or “I can enjoy social activities and do not need to be controlled by what others think or say.”
Social interaction is primarily learned within the family of origin. When inadequate patterns are identified, actions for change can be instituted. Helps identify and clarify reasons for difficulties in interacting with others, such as feeling unloved or unlovable and insecure about sexuality. May have coping skills that will be useful in the process of weight loss. Defense mechanisms used to protect the individual may contribute to feelings of aloneness or isolation. Identifies specific concerns and suggests actions that can be taken to effect change. Practicing these new behaviors enables the individual to become comfortable with them in a safe situation. May be impeding positive social interactions.
Positive strategies enhance feelings of comfort and support efforts for change.
Collaborative Refer for ongoing family or individual therapy, as indicated.
NURSING DIAGNOSIS:
Client benefits from involvement of SO to provide support and encouragement.
ineffective Self-Health Management
May Be Related To Complexity of therapeutic regimen Family pattern of healthcare Perceived seriousness/barriers or benefits Deficient knowledge Social support deficit
Possibly Evidenced By Reports difficulty with prescribed regimen Ineffective choices in daily living for meeting health goals Failure to include treatment regimen in daily living or to take action to reduce risk factors
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Eating Disorder Management NOC Verbalize understanding of need for lifestyle changes to maintain or control weight. Establish individual goal and plan for attaining that goal. Begin to look for information about nutrition and ways to control weight.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Prescribed Diet NIC Independent Determine level of nutritional knowledge and what client believes is most urgent need. Identify individual long-term goals for health, such as lowering blood pressure, controlling serum lipid and glucose levels.
Provide information about ways to maintain satisfactory food intake in settings away from home. Identify other sources of information—Internet sites, books, community classes, and groups.
Necessary to know what additional information to provide. When client’s views are listened to, trust is enhanced. A high relapse rate at 5-year follow-up suggests obesity cannot be reliably reversed. Shifting the focus from initial weight loss and percentage of body fat to overall management of wellness may enhance rehabilitation. “Smart” eating when dining out or when traveling helps individual manage weight while still enjoying social outlets. Using different avenues of accessing information furthers client’s learning. Involvement with others who are also losing weight can provide support.
Teaching: Individual NIC Emphasize necessity of continued follow-up care or counseling, especially when plateaus occur.
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As weight is lost, changes in metabolism occur, interfering with further loss by creating a plateau as the body activates a
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Instruct client about risk of deep vein thrombosis (DVT) and self-care including ankle exercises, walking to limit of ability, and reporting any unusual discomfort in legs. Discuss necessity of good skin care, especially in skinfolds, such as pendulous abdomen, breasts, groin, perineal areas, during hot weather and times of immobility or following exercise. Identify alternative ways to “reward” self and family for accomplishments or to provide solace.
survival mechanism, attempting to prevent “starvation.” This requires new strategies and aggressive support to continue weight loss. Obesity can alter the pharmaco*kinetic properties of medications. Changes in dosages may be needed based on the degree to which drugs are absorbed, resulting in subtherapeutic or toxic drug levels or dangerous side effects and interactions that might occur. The very obese client is at higher risk for DVT and pulmonary embolism than the general population because of immobility, stasis, and polycythemia related to chronic respiratory insufficiency. Client is at risk for developing pressure ulcers and can be prone to yeast infections. Frequent skin care such as cleansing and drying the tissues and using antifungal creams in skinfolds, as appropriate, can prevent skin breakdown. Reduces likelihood of relying on food to deal with feelings.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities in addition to above nursing diagnoses) • ineffective Self-Health Management—complexity of therapeutic regimen, perceived seriousness and benefits, excessive demands made on individual; family conflict
OBESITY: BARIATRIC SURGERY I. Indications a. Weight and health of extremely obese persons can be favorably changed by bariatric surgery. b. Benefits are being reported in improvement in comorbid conditions associated with morbid obesity such as hypertension, hyperlipidemia, back pain, and sleep apnea. Studies are supporting that bariatric surgery is effective in remitting type 2 diabetes in 50% to 85% of indiviuals (Dixon, 2009; Levi et al, 2007). II. Procedures a. Open approaches with abdominal incisions or by laparoscopy b. Extremely obese individuals, or those with previous abdominal surgery or complicating medical problems, may require open approach. c. Two types of surgical procedures are offered (Gagnon, 2012). i. Restrictive 1. Small pouch with a restricted outlet is created across the stomach just distal to the gastroesophageal junction; a small opening remains through which food passes into lower stomach. 2. Reduces the amount of food the stomach can hold and slows passage of food through the stomach, resulting in a feeling of fullness 3. Most common procedures include stapling or banding of the stomach. a. Adjustable gastric banding (AGB, also may be called LAP-BAND): This reversible laparoscopic procedure is the second most common bariatric procedure (Demaria et al, 2010) and is considered by some to be the safest procedure (Favoretti et al, 2009; Salemeh, 2006). The tightness of the band can be adjusted depending on client’s tolerance.
Digestion is slowed by allowing smaller-thannormal amounts of food through to the remainder of the gastrointestinal tract. b. Vertical banded gastroplasty (VBG, or “stomach stapling): This procedure is restrictive and reversible. A line of staples is placed to section off a small portion of the upper stomach, creating a small pouch anchored distally by a prosthetic band. Digestion is slowed by allowing smallerthan-normal amounts of food through to the remainder of the gastrointestinal tract. ii. Combined restrictive and malabsorptive 1. Roux-en-Y gastric bypass (RYGB): Involves creating a small stomach pouch and attaching it directly to the small intestine using a Y-shaped limb of the small bowel; the larger stomach portion and the duodenum are bypassed. The procedure is irreversible, may be done by open abdomen or laparoscopy, works both by restricting intake and by slowing the digestion and absorption, and is the most common bariatric procedure performed (71% to 81%) (Gagnon, 2012; LABS, 2009). 2. Vertical sleeve gastrectomy (VSG, or simply sleeve gastrectomy): Performed in high-risk individuals with severe obesity (BMI of 50 kg/m2 or greater). This restrictive, irreversible procedure, usually performed laparoscopically, removes 80% to 90% of the stomach, leaving only a gastric “sleeve.” This operation is believed to be safer than the gastric bypass procedure, due to the fact that the natural anatomy of the gastrointestinal tract is not changed and therefore has no malabsorptive component (Moy et al, 2008). (continues on page 368)
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Discuss use of medications; advise client to discuss with physician and pharmacist any additions to regimen such as overthe-counter (OTC) medications, antibiotics, and herbal supplements.
RATIONALE (continued)
CHAPTER 8
ACTIONS/INTERVENTIONS (continued)
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3. Biliopancreatic diversion with duodenal switch (BPD-DS): Considered for individuals with severe obesity. The surgery involves removing 65% to 70% of the stomach, leaving the pyloric valve intact. The remaining portion of the stomach is then connected to the proximal portion of the ileum. The surgery restricts intake and slows digestion and absorption. Most people lose 75% to 80% of their excess weight and stay at their new weight (Colquitt et al, 2009). III. Complications (Gagnon, 2012; Thompson, 2011) a. Early complications include bleeding (0.6% to 4%), anastomotic leaks (1.5% to 6%) (Adair, 2013). b. Perioperative cardiovascular or pulmonary complications (e.g., heart failure, deep venous thrombosis, pulmonary embolism) appear to be related to comorbiditires in the morbidly obese but can sometimes be related to anastomotic leaks. c. Late complications: Cholelithiasis (common); stomal stenosis, gastric remnant distention, ulceration at margins, hernias (all relatively uncommon)
d. Wound infections: Open abdomen procedures have been associated with higher risk of infection (10% to 15%) than laparoscopic procedures (3% to 4%). e. Nutritional side effects: Malabsorptive effects include risk for deficiencies (e.g., iron, calcium, thiamine, folate, and vitamin B12); deficiencies can occur early or late and are long-term. IV. Statistics a. Morbidity: Recent numbers of bariatric surgeries vary, e.g., total procedures reported by the National Association for Weight Loss Surgery as 171,000 in 2005 (NAWLS, 2005–2012); Livingston reported a plateau of 113,000/year in 2006 (Livingston, 2010); but Agaba et al reported over 200,000 procedures performed in 2007 (Agaba et al, 2008). b. Mortality: Rates vary somewhat by procedures, but are generally low (e.g., 0.5% to 1.6%) (Demaria et al, 2010; Agaba et al, 2008). c. Cost: Annual direct care costs of bariatric surgery estimated at least $1.5 billion (Livingston, 2010).
G L O S S A R Y Bariatric surgery: Term is synonymous with “obesity surgery” or “weight-loss surgery.” Body mass index (BMI): Uses individual’s weight in kilograms divided by height in meters squared to produce a unit of measure for classifying body composition. Comorbidities: In the context of obesity, means medical conditions that a client may have that are either caused by, or exacerbated by, obesity. Examples include diabetes type 2, hypertension, cardiopulmonary disease, sleep apnea, gastroesophageal reflux disease (GERD), and musculoskeletal problems. Dumping syndrome: A group of symptoms that result from the quick “dumping” of food into the small intestine. The most typical forms may occur after gastric bypass, although not all individuals develop dumping syndrome. Early dumping occurs shortly after a meal and consists of any combination of light-headedness, flushing, diarrhea, and extreme weakness. Delayed dumping may occur an hour or later after a meal and is believed to be a result of hypoglycemia. Intertriginous dermatitis (ITD): An inflammatory condition of opposing skin surfaces caused by moisture. People with more skinfolds, especially the obese, often have ITD under the abdominal or pubic panniculi. Following weight-loss surgery, surplus skin remains and is also a site for the development of ITD.
Laparoscopic surgery: A way of performing various bariatric surgical procedures through multiple small holes or incisions in the abdomen. Malabsorptive surgery: A type of bariatric surgery that causes weight loss by bypassing a portion of the small intestine, where almost all of the absorption of nutrients takes place. Panniculus: Term used to describe an excess fold or layer (apron) of skin and tissue that hangs dependently. Abdominal panniculi can grow over and beyond the abdomen, eventually covering the genitals and potentially extending even further, passing the knees. This can cause considerable discomfort and disability. Other areas of the body that may develop panniculi include the neck, upper back, flank, upper-medial thigh, posterior legs and ankles. Restrictive surgery: A type of bariatric surgery that induces weight loss by making only a small portion of the stomach (the pouch or, in the case of sleeve gastrectomy, a tube) available to receive food from the esophagus. Skinfolds: Areas where one skin layer rests on or against another. These folds tend to be dark, moist, and warm, making them an ideal breeding ground for organisms like bacteria and fungi. Individuals can develop severe skin infections and may experience large ulcerations and lesions from unchecked growth of microorganisms.
Care Setting
Related Concerns
Care is provided in an inpatient acute surgical unit.
Eating disorders: obesity, page 358 Peritonitis, page 320 Psychosocial aspects of care, page 729 Surgical intervention, page 762 Thrombophlebitis: Venous Thromboembolism (Including Pulmonary Emboli Considerations), page 109
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CHAPTER 8
Client Assessment Database Refer to Endocrine Disorders: Obesity Database for additional assessment information.
M AY E X H I B I T
ACTIVITY/REST • Difficulty sleeping • Exertional discomfort, inability to participate in desired activity or sports
• Exertional dyspnea and/or chest discomfort • Slow to move, inability to participate in desired activity
EGO INTEGRITY • Motivated to lose weight for oneself (or for gratification of others) • Embarrassment that they’ve been unable to lose weight by other means • Worry that even after surgery will fail to lose weight • Hates body image, inability to be and do as others • Fear or anxiety about procedure and ability to deal with postoperative adjustments • Feels lonely, isolated, disconnected from others • History of psychiatric illness or treatment
• Anxiety, depression
ELIMINATION • Urinary stress incontinence
FOOD/FLUID • History of yo-yo dieting, years of failed dieting; weight fluctuations; dysfunctional eating patterns
• Weight exceeding ideal body weight by 100 lb, or BMI more than 40 (morbid obesity), or BMI of 25 to 40 with comorbid conditions, such as diabetes, sleep apnea, or heart disease
HYGIENE • Difficulty with dressing, bathing, toileting, perineal care, or other self-care activities
• Poor general hygiene, or constant attention to hygiene practices • Body odor
PAIN/DISCOMFORT • Incisional pain
• • • •
Guarding behavior Positioning to avoid pain Facial mask, grimacing Restlessness, moaning, irritability
RESPIRATION • History of chronic respiratory diseases; use of respiratory aids (including oxygen, medications) • Sleep apnea (may use CPAP) • History of/current smoking
• Shortness of breath with activity or rest • Breath sounds may be distant (chest depth and shallow respirations)
SAFETY • History of falls/other accidental injuries due to unstable gait, arthritis, joint problems • Use of ambulatory or other assistive devices for transportation (e.g., wheelchair) • Skin injuries, dermatitis, and other skin problems associated with skinfolds and hanging fat and tissue deposits (panniculi)
• Areas of skin breakdown including breast, abdominal, and other body skinfolds • Intertrigonous dermatitis, pressure ulcers, candidiasis, incontinence-associated dermatitis, lower leg ulcers (Blackett et al, 2011)
SEXUALITY/SOCIAL INTERACTIONS • Problems with menstruation, fertility, and/or childbearing • Problems with relationships that client perceives is related to condition • History of bullying, discrimination, and abuse
• May or may not have support people present
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D I AG N O S T I C D I V I S I O N M AY R E P O R T
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Client Assessment Database
(continued)
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
M AY E X H I B I T
(continued)
TEACHING/LEARNING • Presence of chronic conditions—hypertension, diabetes, heart failure, arthritis, sleep apnea, Pickwickian syndrome, infertility • Learning about lifelong healthy eating and physical activity habits, medical follow-up, and vitamin and mineral supplementation
DISCHARGE PLAN CONSIDERATIONS • May require support with therapeutic regimen and weight loss, assistance with self-care, homemaker and maintenance tasks ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies Studies depend on individual situation and are used to rule out underlying disease and provide a preoperative workup, including psychiatric evaluation.
Nursing Priorities
Discharge Goals
1. 2. 3. 4.
1. 2. 3. 4. 5.
Support respiratory function. Prevent or minimize complications. Provide appropriate nutritional intake. Provide information regarding surgical procedure, postoperative expectations, and treatment needs.
NURSING DIAGNOSIS:
Ventilation and oxygenation adequate for individual needs. Complications prevented or controlled. Nutritional intake modified for specific procedure. Procedure, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge.
ineffective Breathing Pattern
May Be Related To Obesity; body position Pain, anxiety Fatigue
Possibly Evidenced By Feeling breathless; dyspnea Tachypnea, alteration in depth of breathing; decreased vital capacity
Desired Outcomes/Evaluation Criteria—Client Will Respiratory Status: Ventilation NOC Maintain adequate ventilation. Experience no cyanosis or other signs of hypoxia, with ABGs within acceptable range.
ACTIONS/INTERVENTIONS
RATIONALE
Ventilation Assistance NIC Independent Monitor respiratory rate and depth. Auscultate breath sounds. Investigate presence of pallor and cyanosis, increased restlessness, or confusion.
Elevate head of bed 30 to 45 degrees.
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Respirations may be shallow because of incisional pain, analgesia, immobility, and obesity itself, causing hypoventilation and potentiating risk of atelectasis and hypoxia. Note: Many anesthetic agents are fat soluble, so risk of postoperative “resedation” and the potential for respiratory complications is increased. Encourages optimal diaphragmatic excursion and lung expansion and minimizes pressure of abdominal contents on the
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Turn periodically and ambulate as early as possible.
Pad side rails and teach client to use them as armrests. Use small pillow under head, when indicated.
thoracic cavity. Note: When kept recumbent, obese clients are at high risk for severe hypoventilation. Promotes maximal lung expansion and aids in clearing airways, thus reducing risk of atelectasis and pneumonia. Note: Use of abdominal binder—properly fitted and placed at least 2 inches below the xiphoid process—can encourage deep breathing. Promotes aeration of all segments of the lung, mobilizing and aiding movement of secretions. Note: If client was a good candidate for bariatric surgery, she or he was probably relatively healthy before operation and is usually able to turn self, walk, and transfer to chair within 8 hours of surgery. Using the side rail as an armrest allows for greater chest expansion. Many obese clients have large, thick necks, and use of large, fluffy pillows may obstruct the airway.
Collaborative Administer supplemental oxygen. Assist in use of blow bottle or incentive spirometer, as indicated. Monitor ABGs or pulse oximetry, as indicated.
Monitor patient-controlled analgesia (PCA) and administer analgesics, as appropriate.
NURSING DIAGNOSIS:
Maximizes available O2 for exchange and reduces work of breathing. Enhances lung expansion; reduces potential for atelectasis. Reflects ventilation, oxygenation, and acid-base status. Used as a basis for evaluating need for and effectiveness of respiratory therapies. Maintenance of comfort level enhances participation in respiratory therapy and promotes increased lung expansion. Note: For the first 48 hours after the procedure, intravenous (IV) PCA is the method of choice.
risk for ineffective Tissue Perfusion [specify]
Risk Factors May Include Deficient knowledge of disease process or aggravating factors Hypertension; diabetes mellitus Sedentary lifestyle
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Circulation Status NOC Maintain perfusion as individually appropriate—skin warm and dry, peripheral pulses present and strong, and vital signs within acceptable range.
Risk Control NOC Identify causative or risk factors. Demonstrate behaviors to improve or maintain circulation.
ACTIONS/INTERVENTIONS
RATIONALE
Surveillance NIC Independent Monitor vital signs, palpate peripheral pulses routinely, and evaluate capillary refill and changes in mentation. Note 24-hour fluid balance. Encourage frequent range-of-motion (ROM) exercises for legs and ankles. Maintain schedule of sequential compression devices (SCD) on lower extremities when used. Assess for redness, edema, and discomfort in calf. Encourage early ambulation; discourage sitting and dangling legs at the bedside.
Indicators of circulatory adequacy. (Refer to ND: risk for deficient Fluid Volume, below.) Stimulates circulation in the lower extremities, reduces highrisk complications associated with venous stasis, such as DVT and pulmonary embolus (PE). Indicators of thrombus formation, but warning signs may not always be present in obese individuals. Sitting constricts venous flow, whereas walking encourages venous return. (continues on page 372)
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Encourage deep-breathing exercises. Assist with coughing and splint incision.
RATIONALE (continued)
CHAPTER 8
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Evaluate for complications, such as rigid abdomen, nonincisional abdominal pain, fever, tachycardia, and low blood pressure.
Although rare, client can develop abdominal complications, such as abdominal compartment syndrome, sepsis or septic shock secondary to anastomotic leak or wound infection, requiring intensive interventions or return to surgery.
Collaborative Administer heparin therapy, as indicated. Monitor hemoglobin (Hgb), hematocrit (Hct), and coagulation studies, such as prothrombin time (PT) and International Normalized Ratio (INR).
NURSING DIAGNOSIS:
May be used prophylactically to reduce risk of thrombus formation or to treat thromboemboli. Provides information about circulatory volume and alterations in coagulation and indicates therapy needs and effectiveness.
risk for deficient Fluid Volume
Risk Factors May Include Extremes of weight Excessive gastric losses—nasogastric suction, diarrhea Deviations affecting intake—limited oral intake
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Hydration NOC Maintain adequate fluid volume with balanced intake and output (I&O) and be free of signs reflecting dehydration.
ACTIONS/INTERVENTIONS
RATIONALE
Fluid/Electrolyte Management NIC Independent Assess vital signs, noting changes in blood pressure (BP), such as orthostatic hypotension, tachycardia, and fever. Assess skin turgor, capillary refill, and moisture of mucous membranes. Monitor I&O, including nasogastric (NG) suction losses.
Evaluate muscle strength and tone. Observe for muscle tremors. Establish individual needs and replacement schedule. Encourage increased oral intake when able, beginning with clear liquids and advancing to full liquids. Encourage frequent small sips of fluids.
Indicators of dehydration and hypovolemia and adequacy of current fluid replacement. Note: Adequately sized cuff must be used to ensure factual measurement of BP. If cuff is too small, reading will be falsely elevated. Changes in gastric capacity and intestinal motility and nausea greatly influence intake and fluid needs, increasing risk of dehydration. Large gastric losses may result in decreased magnesium and calcium, leading to neuromuscular weakness and tetany. Determined by amount of measured losses and estimated insensible losses and dependent on gastric capacity. Intake capacity is drastically reduced (to as little as 15 to 30 mL), so client may need IV fluid support for a while, but once oral fluids are resumed, client must drink frequently in order to be hydrated. Small sips will reduce nausea.
Collaborative Administer IV fluids, as indicated.
Monitor electrolyte levels and replace, as indicated.
NURSING DIAGNOSIS:
Replaces fluid losses and restores fluid balance in immediate postoperative phase until client is able to take sufficient oral fluids. Use of NG tube, and changes in GI function can deplete electrolytes, affecting organ function.
risk for imbalanced Nutrition: less than body requirements
Risk Factors May Include Inability to ingest food—restricted intake, early satiety Inability to absorb nutrients—malabsorption of nutrients and impaired absorption of vitamins
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
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NURSING DIAGNOSIS:
risk for imbalanced Nutrition: less than body requirements (continued)
Desired Outcomes/Evaluation Criteria—Client Will Identify individual nutritional needs. Display behaviors to maintain adequate nutritional intake. Demonstrate appropriate weight loss with normalization of laboratory values.
ACTIONS/INTERVENTIONS
RATIONALE
Diet Staging: Weight-Loss Surgery NIC Independent Establish hourly intake schedule. Measure and provide food and fluids in amount specified. Instruct in how to eat slowly. Take small bites, using a baby spoon. Chew food thoroughly. Take 30 to 60 minutes to eat meal, then refrain from eating until next scheduled mealtime. Avoid taking fluids with meals and for 30 minutes before or after meals. Encourage almost constant sipping of fluids between scheduled eating times. Avoid high-calorie fluids—milkshakes, sodas, and alcoholic beverages. Emphasize importance of recognizing satiety and stopping intake. Require that client sit up to drink and eat. Determine foods that are gas forming and eliminate them from diet. Discuss food preferences with client and include those foods in puréed diet when possible. Weigh on regular schedule.
After gastric restriction procedures, stomach capacity is reduced to approximately 30 to 50 mL, necessitating frequent, small feedings. Increases satiety and reduces risk of overeating.
Although fluids are a necessary part of the client’s intake, the stomach is too small to hold food and fluids at the same time. These can sabotage weight loss. Overeating may cause nausea and vomiting, as well as having the potential to damage surgical anastomosis. Reduces possibility of aspiration. May cause nausea and bloating, interfering with digestion and causing client to restrict nutritional intake. May enhance intake and promote sense of participation and control. Monitors losses and aids in assessing nutritional needs and effectiveness of therapy.
Collaborative Refer to dietitian or multidisciplinary team.
Administer vitamin supplements (may use chewable vitamins) and vitamin B12 injections, folate, and calcium, as indicated.
NURSING DIAGNOSIS:
Provides assistance in planning a diet that meets client’s nutritional needs as well as offering individualized treatment and support. Note: Because quantity is strictly limited, foods should be nutrient dense, low in fat and sugars, and high in protein (Gagnon, 2012). When absorption is impaired, supplements will be needed for life to prevent complications associated with vitamin deficiencies. Increased intestinal motility following bypass procedure lowers calcium level and increases absorption of oxalates, which can lead to urinary stone formation.
impaired Skin Integrity
May Be Related To Mechanical factors (e.g., shearing forces, pressure, surgical procedure) Impaired circulation Imbalanced nutritional state—obesity
Possibly Evidenced By Disruption of skin surface/skin layers
Desired Outcomes/Evaluation Criteria—Client Will Wound Healing: Primary Intention NOC Display timely wound healing without complications. Demonstrate behaviors that reduce tension on suture line.
Tissue Integrity: Skin and Mucous Membranes NOC Display intact skin free of signs of pressure or breakdown.
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Eating Disorder Self-Control NOC
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ACTIONS/INTERVENTIONS
RATIONALE
Incision Site Care NIC Independent Support and instruct client in incisional support when turning, coughing, deep breathing, and ambulating. Observe incisions periodically, noting approximation of wound edges, hematoma formation and resolution, and presence of bleeding and drainage. Provide routine incisional care, being careful to keep dressing dry and sterile. Assess and maintain patency of drains.
Reduces possibility of dehiscence and incisional hernia. Verifies status of healing, provides for early detection of developing complications requiring prompt evaluation and influencing choice of interventions. Promotes healing. Accumulation of serosanguineous drainage in subcutaneous layers increases tension on suture line, may delay wound healing, and serves as a medium for bacterial growth.
Pressure Ulcer Prevention NIC Encourage frequent positional change, inspect pressure points, and massage gently, as indicated. Apply transparent skin barrier to elbows and heels, if indicated. Skinfold management (Black et al, 2011; Blackett et al, 2011): Inspect all skin surfaces, paying particular attention to multiple skinfolds common in the very obese client.
Bathe/cleanse skin carefully, using a mild skin cleanser instead of ordinary soap.
Apply skin moisturizers, as indicated. Use absorptive fabric/padding and loose fitting clothing, as indicated.
Utilize draw sheets to form sling to lift or shift large tissue areas (e.g., abdominal panniculus) when moving client in bed.
Reduces pressure on skin, promoting peripheral circulation and reducing risk of skin breakdown. Skin barrier reduces risk of shearing injury. Client may have intertriginous dermatitis (ITD), thought to arise from skin-on-skin friction that initially leads to mild erythema and may progress to more intense inflammation with erosion, oozing, exudation, maceration, and crusting. Moisture or excoriation enhances growth of yeast and bacteria that can lead to chronic skin infections and raise the risk of postoperative wound infection from local contamination (Black et al, 2011). Gentle mechanical actions should be used when cleansing the skin, and scrubbing should be avoided. The cleanser should be free of perfumes or potential irritants, and its pH should be similar to that of normal skin. One option is pH-balanced disposable cleansing cloths or soft baby washcloths, since regular washcloths can be abrasive. Note: The pH of ordinary soap is usually due to alkaline, which may increase skin irritation. May be needed to keep skin supple if at risk for cracking or fissuring from excessive dryness. Obese client tends to sweat profusely. The combination of increased perspiration and larger skinfolds increases the risk for maceration and for friction damage. Use of absorptive materials in skinfolds helps keep them dry and reduces risk of skin rashes and breakdown. Client should be encouraged to wear loose-fitting, lightweight clothing made from natural fibers to absorb moisture from skinfolds. Other options include athletic clothing specifically designed to draw moisture away from the skin. Reduces risk of friction and shear injuries and pain.
Collaborative Provide foam, water, or air mattress, as indicated. Refer to skin/wound specialist nurse if indicated.
NURSING DIAGNOSIS:
Reduces skin pressure and enhances circulation. May be desired/needed in client with severe skin and/or tissue conditions. Management strategies must focus on elimination of skin-to-skin contact without causing harm to friable tissue, as well as education of client/SO in skin care.
risk for Infection
Risk Factors May Include Inadequate primary defenses—broken skin, traumatized tissues, decreased ciliary action, stasis of body fluids Invasive procedures
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Infection Severity NOC Be free of healthcare-acquired infection. Achieve timely wound healing free of signs of local or generalized infectious process.
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RATIONALE
CHAPTER 8
ACTIONS/INTERVENTIONS Infection Protection NIC Independent
Observe for reports of abdominal pain, especially after third postoperative day, elevated temperature, and increased white blood cell (WBC) count.
Prevents spread of bacteria and cross-contamination. Reduces risk of healthcare-associated infection. Early detection of developing infection provides for prevention of more serious complications. Promotes mobilization of secretions, reducing risk of pneumonia.
Prevents ascending bladder infections. Maintains urine acidity and prevents bacteria from adhering to the bladder wall to retard bacterial growth. Suggests possibility of developing peritonitis.
Collaborative Apply topical antimicrobials or antibiotics, as indicated. Administer IV antibiotics, as indicated.
Obtain specimen of purulent drainage or sputum for culture and sensitivity.
NURSING DIAGNOSIS:
Reduces bacterial or fungal colonization on skin; prevents infection in the wound. A prophylactic antibiotic regimen is usually standard in these clients to reduce risk of perioperative contamination and peritonitis. Identifies infectious agent; aids in choice of appropriate therapy.
Diarrhea
May Be Related To Inflammation; irritation; malabsorption
Possibly Evidenced By Loose, liquid stools Hyperactive bowel sounds
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Treatment Regimen NOC Verbalize understanding of causative factors and rationale of treatment regimen. Follow through with treatment recommendations.
Gastrointestinal Function NOC Regain near-normal bowel function.
ACTIONS/INTERVENTIONS
RATIONALE
Diarrhea Management NIC Independent Observe and record stool frequency, characteristics, and amount.
Encourage diet high in fiber and bulk within dietary limitations, with moderate fluid intake as diet resumes. Restrict fat intake, as indicated. Observe for signs of dumping syndrome such as instant diarrhea, sweating, nausea, and weakness after eating. Assist with frequent perianal care, using ointments as indicated. Provide whirlpool bath.
Diarrhea often develops after resumption of diet because of shortened transit time through the GI tract and dumping syndrome. This condition is usually self-limiting but can cause discomfort and social difficulties when persistent. Increases consistency of the effluent. Although fluid is necessary for optimal body function, excessive amounts contribute to diarrhea. Low-fat diet reduces risk of steatorrhea and limits laxative effect of decreased fat absorption. Rapid emptying of food from the stomach may result in gastric distress and alter bowel function. Anal irritation, excoriation, and pruritus occur because of diarrhea. The client often cannot reach the area for proper cleansing and may be embarrassed to ask for help. (continues on page 376)
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Emphasize and model proper hand-washing technique. Maintain aseptic technique in dressing changes and invasive procedures. Inspect surgical incisions and invasive line sites for erythema and purulent drainage. Encourage frequent position changes, deep breathing, coughing, and use of respiratory adjuncts, such as incentive spirometer. Provide routine catheter care and provide or assist with good perineal care. Remove catheter as early as possible. Encourage client to drink acid-ash juices, such as cranberry.
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Collaborative Administer medications such as diphenoxylate with atropine (Lomotil), as indicated. Monitor serum electrolytes.
NURSING DIAGNOSIS:
Antidiarrheals may be necessary to control frequency of stools until body adjusts to changes in function brought about by surgery. Large gastric losses potentiate the risk of electrolyte imbalance, which can lead to more serious or life-threatening complications.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure, unfamiliarity with information resources Information misinterpretation Lack of recall
Possibly Evidenced By Reports the problem Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Disease Process NOC Verbalize understanding of surgical procedure, potential complications, and postoperative expectations.
Knowledge: Treatment Regimen NOC Verbalize understanding of therapeutic needs and rationale for actions. Initiate necessary lifestyle changes and participate in treatment regimen.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Individual NIC Independent Review specific surgical procedure and postoperative expectations.
Address concerns about altered body size and image.
Review medication regimen, dosage, and side effects.
Recommend avoidance of alcohol. Discuss responsibility for self-care with client and significant other (SO). Emphasize importance of regular medical follow-up, including laboratory studies, and discuss possible health problems.
Provides knowledge base from which informed choices can be made and goals formulated. Initial weight loss is rapid, with client often losing half of the total weight loss during the first 6 months. Weight loss then gradually stabilizes over a 2-year period. Anticipation of problems can be helpful in dealing with situations that arise. (Refer to CP: Eating Disorders: Obesity; ND: disturbed Body Image.) Knowledge may enhance client’s involvement with therapeutic regimen. Note: As client loses weight, the dosages of many medications may need to be recalculated because body fat alters the pharmaco*kinetics of many medications. High caloric count contributes to slowed weight loss as well as liver and pancreatic dysfunction. Full involvement in weight-loss program is important for successful outcome after procedure. Periodic assessment and evaluation, for example, over 3 to 12 months, promotes early recognition of such complications as liver dysfunction, malnutrition, electrolyte imbalances, and kidney stones, which may develop following bypass procedure.
Diet Staging: Weight Loss Surgery NIC Encourage progressive exercise and activity program balanced with adequate rest periods. Review proper eating habits; for example, eat small amounts of food slowly and chew well and sit at table in calm, relaxed environment; eat only at prescribed times, avoid betweenmeal snacking, and do not “make up” skipped feedings. Identify signs of hypokalemia, for example, diarrhea, muscle cramps, weakness of lower extremities, weak or irregular pulse, and dizziness with position changes.
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Promotes weight loss, enhances muscle tone, and minimizes postoperative complications while preventing undue fatigue. Focuses attention on eating, increasing awareness of intake and feelings of satiety.
Increasing dietary intake of potassium (e.g., milk, coffee, potatoes, carrots, bananas, oranges) may correct deficit, preventing serious respiratory or cardiac complications.
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Discuss symptoms that may indicate dumping syndrome: weakness, profuse perspiration, nausea, vomiting, faintness, flushing, and epigastric discomfort or palpitations occurring during or immediately following meals. Problem-solve solutions. Review symptoms requiring medical evaluation, including persistent nausea or vomiting, abdominal distention or tenderness, change in pattern of bowel elimination, fever, purulent wound drainage, excessive weight loss, plateauing, or weight gain.
Generally occurring in early postoperative period (1 to 3 weeks), syndrome is usually self-limiting but may become chronic and require medical intervention.
Early recognition of developing complications allows for prompt intervention, preventing serious outcome.
Collaborative Refer to bariatric postoperative program or community support groups.
Involvement with others who have dealt with same problems enhances coping; may promote cooperation with therapeutic regimen and long-term positive recovery.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) • risk for imbalanced Nutrition: more than body requirements—dysfunctional eating patterns, observed use of food as reward or comfort measure, history of morbid obesity • risk for delayed Surgical Recovery—obesity; pain; excessive surgical procedure • risk for ineffective Self-Health Management—complexity of therapeutic regimen; family patterns of healthcare; perceived benefit/barriers; social support deficit
Refer to Potential Considerations in Surgical Intervention plan of care.
DIABETES MELLITUS/DIABETIC KETOACIDOSIS I. Pathology a. Diabetes mellitus (DM) is a chronic metabolic disorder characterized by high blood glucose levels, in which the body cannot metabolize carbohydrates, fats, and proteins because of a lack of, or ineffective use of, the hormone insulin. b. Diabetic ketoacidosis (DKA) is a life-threatening emergency caused by a relative or absolute deficiency of insulin. c. Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness as well as a major cause of heart disease and stroke among adults in the United States (American Diabetes Association [ADA], 2013). II. Classification a. Three primary types that are different disease entities but share the symptoms and complications of hyperglycemia i. Type 1—formerly called juvenile or insulin dependent diabetes ii. Type 2—formerly known as adult onset or non-insulin dependent iii. Pre-diabetes, also sometimes known as impaired glucose tolerance and formerly known as borderline diabetes. This classification includes gestational diabetes (GD), which applies to women in whom glucose intolerance develops or is first discovered during pregnancy. GD develops in 2% to 18% of all pregnant women, but disappears after delivery (ADA, 2013).
III. Etiology a. Conditions or situations known to exacerbate glucose and insulin imbalance i. Previously undiagnosed or newly diagnosed type 1 diabetes ii. Food intake in excess of available insulin iii. Adolescence and puberty iv. Exercise in uncontrolled diabetes v. Stress associated with illness, infection, trauma, or emotional distress b. Type 1 diabetes i. An autoimmune disease possibly triggered by genetic and environmental factors, such as with virus, toxins, stress 1. Destroys beta-cells in the pancreas 2. When 80% to 90% of the beta cells are destroyed, overt symptoms occur. ii. Totally insulin-deficient; clients require exogenous insulin to survive. iii. Characteristics 1. Usually occurs before 30 years of age, but can occur at any age 2. Peak incidence occurs during puberty 3. Abrupt onset of signs and symptoms of hyperglycemia 4. Prone to ketoacidosis 5. Five percent of people with diabetes have this type (ADA, 2013).
(continues on page 378)
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RATIONALE (continued)
CHAPTER 8
ACTIONS/INTERVENTIONS (continued)
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c. Type 2 diabetes i. Involves a decreased ability to use the insulin produced in the pancreas 1. Decreased insulin secretion in response to glucose levels 2. Insulin resistance blocking cells from absorbing glucose 3. Excess production of glucose because of defective insulin secretory response ii. Accounts for approximately 90% to 95% of all diabetes in the United States iii. Characteristics 1. Usually occurs after 30 years of age, but is now occurring in children and adolescents 2. Increased prevalence in some ethnic groups—African Americans, Hispanic/Latino, Native Americans, Asian Americans, and Pacific Islanders 3. Strong genetic predisposition 4. Frequently obese 5. Not prone to ketoacidosis until late in course or with prolonged hyperglycemia d. Prediabetes (formerly called borderline diabetes) i. Blood glucose levels are higher than normal but not high enough for diagnosis of diabetes. Person is at risk
for developing type 2 diabetes as well as heart disease and strokes. Diagnosis of diabetes may be delayed or prevented with weight loss and increased exercise (CDC, 2011). ii. Accounts for 35% of 29 million Americans aged 20 years or older (CDC, 2013) iii. Based on fasting blood glucose or A1C levels IV. Statistics a. Morbidity: More than 25.8 million Americans have diabetes; affects 26% of people over the age of 65 years. Approximately 1.9 million people (age 20 and older) were newly diagnosed diabetics in 2010 (CDC, 2011). b. Mortality: Risk of death among people with diabetes is approximately twice that of those at a similar age, but without diabetes (CDC, 2011; Molinaro, 2011). In 2007, diabetes was reported to be the seventh leading cause of death. This ranking is based on the 71,382 death certificates in 2007 in which diabetes was the underlying cause of death (CDC, 2011). c. Cost: Direct medical care costs of $176 billion annually (ADA, 2013)
G L O S S A R Y A1C: Test (also known as HbA1c, glycated hemoglobin or glycosylated hemoglobin) is a blood test that correlates with a person’s average blood glucose level over a span of a few months. Acetone: Chemical formed in the blood when the body uses fat instead of glucose for energy. Acetone passes through the body into the urine. Someone with high levels of acetone can have breath that smells fruity and is called “acetone breath.” Beta cells: Cells that make insulin found in areas of the pancreas called the Islets of Langerhans. Blood glucose: The main sugar that the body makes from food. Glucose is carried through the bloodstream to provide energy to all of the body’s living cells. Dawn phenomenon: An abrupt increase in fasting levels of serum glucose concentrations between the hours of 5 a.m. and 9 a.m., without preceding hypoglycemia, especially in diabetic patients receiving insulin therapy. Diabetic neuropathy: Family of nerve disorders caused by diabetes, causing numbness, pain, and weakness in the hands, arms, feet, and legs. About half of all diabetics have some form of neuropathy. Gastroparesis: Delayed emptying of food and secretions from the stomach to the small bowel due to autonomic neuropathy. Gestational diabetes: A pregnant woman who is not diagnosed with diabetes but develops high blood glucose levels, usually at the 24th week of pregnancy. Affects approximately 18% of pregnancies. If not controlled, it places the baby and mother at risk with an increased chance of developing type 2 diabetes later in life. Hyperglycemia: High blood glucose. Hypoglycemia: Low blood glucose. Insulin: Hormone produced by the pancreas that helps the body use blood glucose for energy. A person lacking this hormone is dependent on supplemental, outside (exogenous) sources.
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Insulin resistance: Body is unable to use the insulin that it makes because of cell-receptor defect resulting in inability of cells to absorb glucose. Ketoacidosis: Condition in which very high blood sugar levels along with a very low level of insulin result in a dangerous accumulation of ketones in the blood and urine. Coma or death can result if condition is not treated. Ketones: Chemical substances produced when the body breaks down fat for energy. When ketones build up in the body over a long period of time, serious illness or coma can result. Kussmaul respirations: Abnormal respiratory pattern characterized by rapid, deep breathing, often seen in client with metabolic acidosis. Lactic acidosis: The buildup of lactic acid in the body. Cells make lactic acid when they use glucose for energy. If too much lactic acid stays in the body, the balance tips and the person begins to feel ill. Lactic acidosis may be caused by diabetic ketoacidosis or liver or kidney disease. Metabolic acidosis: A pH imbalance in which the body has accumulated too much acid and does not have enough bicarbonate to effectively neutralize the effects of the acid. It can be brought on by a lack of insulin, a starvation diet, a gastrointestinal (GI) disorder, or a major organ dysfunction. For a person with diabetes, this can lead to diabetic ketoacidosis. Paresthesias: Sensation of numbness or tingling, indicating nerve irritation, which may be due to diabetic neuropathy. Somogyi effect: A swing to a high level of glucose in the blood from an extremely low level; usually occurs after an untreated insulin reaction during the night. The swing is caused by the release of stress hormones to counter low glucose levels.
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DM is managed in the community setting. Diabetic ketoacidosis (DKA) may be encountered in any setting, with mild DKA managed at the community level; however, severe metabolic imbalance requires inpatient acute care on a medical unit.
Amputation, page 616 Fluid and electrolyte imbalances, page 885 Metabolic acidosis—primary base bicarbonate deficiency, page 450 Psychosocial aspects of care, page 729
Client Assessment Database Data depend on the severity and duration of metabolic imbalance, length and stage of diabetic process, and effects on other organ function.
D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
ACTIVITY/REST • Sleep and rest disturbances • Weakness, fatigue, difficulty walking and moving • Muscle cramps, decreased muscle strength
• Tachycardia and tachypnea at rest or with activity • Lethargy, disorientation, coma • Decreased muscle strength and tone
CIRCULATION • History of hypertension; acute myocardial infarction (MI), claudication, numbness, tingling of extremities (long-term effects) • Leg ulcers, slow healing
• • • • •
Tachycardia Postural blood pressure (BP) changes; hypertension Decreased and absent pulses Dysrhythmias Crackles; jugular vein distention (JVD)—if heart failure present • Hot, dry, flushed skin; sunken eyeballs—if dehydration is severe
EGO INTEGRITY • Life stressors, including financial concerns related to condition
• Anxiety, irritability
ELIMINATION • • • •
Change in usual voiding pattern Excessive urination (polyuria) Nocturia Pain and burning, difficulty voiding (infection neurogenic bladder) • Recent and recurrent urinary tract infections (UTIs) • Abdominal tenderness, bloating, diarrhea
• Pale, yellow, dilute urine • Polyuria may progress to oliguria and anuria if severe hypovolemia occurs • Cloudy, odorous urine (infection) • Abdomen firm, distended • Bowel sounds diminished or hyperactive (diarrhea)
FOOD/FLUID • Loss of appetite, nausea and vomiting • Not following prescribed diet, increased intake of glucose and carbohydrates • Weight loss over a period of days or weeks • Thirst • Use of medications exacerbating dehydration, such as diuretics
• Dry and cracked skin, poor skin turgor • Abdominal rigidity and distention • Halitosis and sweet, fruity breath odor
NEUROSENSORY • • • •
Fainting spells, dizziness Headaches Tingling, numbness, weakness in muscles Visual disturbances
• • • •
Confusion, disorientation Drowsiness, lethargy, stupor and coma (later stages) Deep tendon reflexes (DTRs) may be decreased Seizure activity (late stages of DKA or hypoglycemia)
PAIN/DISCOMFORT • Abdominal bloating and pain
• Facial grimacing with abdominal palpation, guarding (continues on page 380)
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Related Concerns
CHAPTER 8
Care Settings
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Client Assessment Database
(continued)
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
M AY E X H I B I T
(continued)
RESPIRATION • Air hunger (late stages of DKA) • Cough, with and without purulent sputum (infection)
• • • •
Tachypnea Kussmaul’s respiration (metabolic acidosis) Rhonchi, wheezes Yellow or green sputum (infection)
• • • •
Fever, diaphoresis Skin breakdown, lesions and ulcerations Decreased general strength and range of motion (ROM) Weakness and paralysis of muscles, including respiratory musculature—if potassium levels are markedly decreased
SAFETY • Dry, itching skin, skin ulcerations • Paresthesia (diabetic neuropathy)
SEXUALITY • vagin*l discharge (prone to infection) • Problems with impotence (men), org*smic difficulty (women)
TEACHING/LEARNING • Familial risk factors, such as diabetes mellitus, heart disease, stroke, hypertension • Slow and delayed healing • Use of drugs, such as steroids, thiazide diuretics, phenytoin (Dilantin), and phenobarbital (can increase glucose levels) • May or may not be taking diabetic medications as ordered
DISCHARGE PLAN CONSIDERATIONS • May need assistance with dietary regimen, glucose monitoring, medication administration, supplies, and self-care ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
BLOOD TESTS • Serum glucose: The gold standard for diagnosing diabetes is an elevated blood sugar level after an overnight fast. A value above 140 mg/dL on at least two occasions typically means a person has diabetes. Normal fasting sugar levels run between 70 and 110 mg/dL. • Total serum ketones: Types of naturally occurring and synthetic lipid compounds.
• Serum osmolality: Measures the concentration of particles found in the fluid part of blood to help evaluate the body’s water balance. Normal calculated values range from 280 to 303 mOsm/K.
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DKA is defined as glucose greater than 250 mg/dL in association with an arterial pH of less than 7.30 or serum bicarbonate of less than 15 mEq/L and ketonemia (serum ketones).
When insulin levels are too low or there is not enough glucose to use for energy, the body burns fatty acids for energy. The body then makes ketone bodies, waste products that cause the acid level in the blood to become too high. This in turn may lead to ketoacidosis. Ketones are positive at 1:2 dilution and may also be present in the urine as levels reach threshold and “spill” over into the urine. Osmolality increases with dehydration and decreases with overhydration. In DKA, osmolality is elevated.
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(continued)
• Glucogon: Hormone that raises the blood glucose level.
• Serum insulin: Peptide hormone that enables the body to metabolize and use glucose.
• Electrolytes: Substances that dissociate into ions in solution and acquire the capacity to conduct electricity. Common electrolytes include sodium, potassium, chloride, calcium, and phosphate.
• Arterial blood gases (ABGs): Assessment of ABG levels of oxygen (PaO2), carbon dioxide (PaCO2), bicarbonate (HCO3–), and pH. • Complete blood count (CBC): Battery of screening tests, which typically includes Hgb; hematocrit (Hct); red blood cell (RBC) count, morphology, indices, and distribution width index; platelet count and size; white blood cell (WBC) count and differential.
(continued)
Elevated level is associated with conditions that produce (1) actual hypoglycemia; (2) relative lack of glucose, such as trauma or infection; or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia. Currently, the gold standard for measuring glycemic control. Useful in differentiating inadequate control versus incident-related DKA. A result greater than 8% represents average blood glucose of 200 mg/dL or greater and signals a need for changes in treatment. May be decreased or absent (type 1) or normal to high (type 2), indicating insulin insufficiency or improper use (endogenous and exogenous). Insulin resistance may develop secondary to formation of antibodies. Sodium may be low, normal, or high (total body depletion). Initial potassium level may be high, normal, or low (total body depletion). Potassium may be falsely elevated, reflecting cellular shifts, then markedly decrease with treatment of the DKA. Phosphate may be normal or low; chloride may be high. Levels are determined by amount of solute and water loss, which is not always equal. Usually reflect low pH and decreased HCO3_ (metabolic acidosis) with compensatory respiratory alkalosis. Hct may be elevated reflecting dehydration; increased WBCs or leukocytosis suggests hemoconcentration, response to stress or infection.
OTHER DIAGNOSTIC STUDIES • Urine: Urine glucose correlates poorly with blood glucose, being dependent on renal glucose threshold (150 to 300 mg/dL) and should be used only if measuring of blood glucose is not possible or as a confirmatory test. Ketones should be self-monitored during febrile illness or when DKA symptoms are present. • Cultures and sensitivities: Specimens may include urine, sputum, or wound drainage.
In DKA, urine tests are positive for glucose and ketones. Specific gravity and osmolality may be elevated if dehydration is present.
May reveal source of infection and identify effective antimicrobial agent.
Nursing Priorities
Discharge Goals
1. Restore fluid, electrolyte, and acid-base balance. 2. Correct or reverse metabolic abnormalities. 3. Identify and assist with management of underlying cause or disease process. 4. Prevent complications. 5. Provide information about disease process, prognosis, selfcare, and treatment needs.
1. 2. 3. 4.
NURSING DIAGNOSIS:
Homeostasis achieved. Causative and precipitating factors corrected or controlled. Complications prevented or minimized. Disease process, prognosis, self-care needs, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge.
deficient Fluid Volume [specify]
May Be Related To Active fluid losses—diarrhea, vomiting, osmotic diuresis
Possibly Evidenced By Increased urine output (hyperglycemia); decreased urine output, increased urine concentration (dehydration) Weakness, thirst, sudden weight loss (continues on page 382)
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• Hemoglobin A1C (HgbA1C): Test that determines how much glucose has been sticking to part of the Hgb during the past 3 to 4 months, with the previous 2 weeks most heavily weighted. Target level is 90 mL/min/1.73 m2) . ii. Kidney dysfunction is present; however, it may be undiagnosed due to lack of symptoms—blood urea nitrogen/ creatinine (BUN/Cr) ratio is normal and nephron loss at less than 75%. b. Stage 2 i. GFR is mildly decreased (60 to 89 mL/min/1.73 m2), slight elevation in BUN/Cr ii. Client may be asymptomatic or have hypertension. iii. Polyuria and nocturia present—high output failure c. Stage 3 i. Moderate reduction in GFR (30 to 59 mL/min/1.73 m2) ii. Fluid and electrolyte abnormalities and other complications present iii. Client may be asymptomatic or have hypertension. d. Stage 4 i. Severe reduction in GFR (15 to 29 mL/min/1.73 m2) and/or very high albuminuria (>300 mg/24 hr) ii. Client has endocrine/metabolic derangements or disturbances in water or electrolyte balance, protein-energy malnutrition, loss of lean body mass, muscle weakness; peripheral and pulmonary edema iii. Timely referral to a nephrologist when glomerular filtration rate approaches 30 mL/min/1.73 m2 is believed to improve ESRD outcome and appropriate selection of dialysis modality. e. Stage 5 i. GRF 150. Individuals with cirrhosis or abnormal liver function tests are not able to metabolize ammonia properly and would experience an increased risk for liver failure following neobladder construction. Metabolic acidosis is another potential complication of neobladder construction, due to the potential for resorption of ammonium and chloride and excessive excretion of sodium and bicarbonate (Herdiman, 2013; Mills, 1999).
OTHER DIAGNOSTIC STUDIES • Imaging studies (e.g., ultrasound, CT, MRI) • Intravenous pyelogram (IVP) and retrograde pyelogram: X-ray examination and fluoroscopic visualization of the kidneys, ureters, and bladder using contrast material. Retrograde pyelogram requires cystoscopy and the placement of a small tube into the lower part of the ureter to inject contrast and opacify the ureter and renal pelvis. • Cystoscopy with biopsy: Diagnostic procedure that uses a cystoscope (endoscope), which is specially designed to examine the bladder, lower urinary tract, and prostate gland. It can also be used to perform biopsies. Ultraviolet cystoscopy outlines bladder lesions. Bladder washings can also be done during cystoscopy for cytological evaluation. • Pelvic magnetic resonance imaging (MRI) or computed tomography (CT) scans: Imaging techniques that use x-rays, or magnetic energy, and computer analysis to provide a complete picture of pelvic body tissues and structures.
Will have been done to determine the etiology for which urinary diversion is required (Costa, 2012). Shows size, shape, and location of urinary structures. Identifies filling defects caused by tumors or other obstructive disorders. Retrograde pyelogram may also be done to delineate urinary tract system anatomy in preparation for surgery.
Initially, may be done to evaluate painless hematuria. If bladder tumor is detected, biopsy will be done to stage the malignancy.
Defines size of tumor mass and degree of cancer spread into surrounding tissues.
Nursing Priorities
Discharge Goals
1. Prevent complications. 2. Assist client and significant other (SO) in physical and psychosocial adjustment. 3. Support independence in self-care. 4. Provide information about procedure, prognosis, treatment needs, potential complications, and resources.
1. 2. 3. 4.
Complications prevented or minimized. Adjusting to perceived or actual changes. Self-care needs met by self or with assistance, as necessary. Procedure, prognosis, therapeutic regimen, and potential complications understood and sources of support identified. 5. Plan in place to meet needs after discharge.
This plan of care primarily addresses the nursing care of the client with incontinent urinary diversion with a permanent stoma and urine-collecting device.
NURSING DIAGNOSIS:
risk for impaired Skin Integrity
Risk Factors May Include Excretions (e.g., continuous flow of urine, improper fitting of appliance) Chemical substance (e.g., reaction to skin product or chemicals) Mechanical factors (e.g., removal of adhesive)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
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risk for impaired Skin Integrity
CHAPTER 10
NURSING DIAGNOSIS:
(continued)
Desired Outcomes/Evaluation Criteria—Client Will Tissue Integrity: Skin and Mucous Membranes NOC Ostomy Self-Care NOC Identify individual risk factors. Demonstrate behaviors and techniques to promote healing and prevent skin breakdown.
ACTIONS/INTERVENTIONS
RATIONALE
Ostomy Care NIC Independent Inspect stoma and peristomal skin. Note irritation, bruises, rashes, and status of sutures.
Clean with water and pat dry, or use hair dryer on cool setting. Touch stoma gently to prevent irritation. Measure stoma periodically, for example, each appliance change for first 6 weeks, then monthly times six.
Apply effective sealant barrier, such as Skin Prep or similar product, as recommended by appliance manufacturer.
Ensure proper opening for adhesive backing of pouch. Using a stoma-measuring guide or ostomy sizer, find the smallest opening that fits over the stoma and does not allow any skin exposure. Cut the barrier to size with adequate adhesive area left to apply pouch. Use a transparent, odor-proof, drainable pouch. Keep gauze square over stoma while cleansing area, and have client cough or strain before applying skin barrier wafer.
Avoid use of karaya-type appliances. Apply waterproof tape around pouch edges, if desired. Connect collecting pouch to continuous bedside drainage system when necessary or desired.
Cleanse ostomy pouch on a routine basis, using vinegar solution or commercial solution designed for this purpose.
Change pouch every 3 to 7 days, or as needed for leakage. Remove appliance gently while supporting skin. Use adhesive removers as indicated and wash off completely. Investigate reports of burning or itching around stoma.
Evaluate adhesive product and appliance fit on an ongoing basis. Monitor for distention of lower abdomen in presence of ileal conduit; assess bowel sounds.
Stoma should be pink or reddish, similar to mucous membranes. Color changes may be temporary, but persistent changes may require surgical intervention. Early identification of stomal ischemia or fungal infection provides for timely interventions to prevent skin necrosis. Maintaining a clean and dry peristomal area helps prevent skin breakdown. Mucosa has good blood supply and bleeds easily with rubbing or trauma. As postoperative edema resolves, size of appliance must be altered to ensure proper fit so that urine is collected as it flows from the stoma and contact with the skin is prevented. Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary. Note: Some barriers are designed to be used without skin sealant. Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area is important to maintain a seal. Note: Too tight a fit may cause stomal edema or stenosis.
A transparent appliance during first 4 to 6 weeks allows easy observation of stoma and stents when used, without necessity of removing appliance and irritating skin. Covering stoma prevents urine from wetting the peristomal area during pouch changes. Coughing empties distal portion of conduit, followed by a brief pause in drainage to facilitate application of appliance. Will not protect skin because urine melts karaya. Reinforces anchoring to help maintain seal. May be needed during times when rate of urine formation is increased, such as while intravenous (IV) fluids are administered, or at night if client prefers. Weight of the urine can cause pouch to pull loose and leak when pouch becomes more than half full. Frequent pouch changes are irritating to the skin and should be avoided. Emptying and rinsing the pouch with vinegar or commercial solution not only removes bacteria but also deodorizes the pouch. Prevents tissue irritation or damage associated with pulling skin barrier wafer off. Suggests peristomal irritation or possibly Candida infection, both requiring intervention. Note: Continuous exposure of skin to urine can cause hyperplasia around stoma, affecting pouch fit and increasing risk of infection. Provides opportunity for problem-solving. Determines need for further intervention. Intestinal distention can cause tension on new suture lines with possibility of rupture. (continues on page 552)
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Maintain skin integrity.
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Collaborative Consult with ostomy nurse specialist.
Apply antifungal spray or powder, as indicated.
NURSING DIAGNOSIS:
Ostomy nurse specialist can help client and caregiver by providing support and education, helping with problem-solving and choosing products appropriate for client’s stoma characteristics, evaluating physical and mental status, and seeking financial resources. The client or caregiver should be capable of changing ostomy appliance prior to discharge or receive home care until such time as the client is competent (Colwell et al, 2001). Assists in healing if peristomal irritation is caused by fungal infection. Note: These products can have potent side effects and should be used sparingly. Creams and ointments are to be avoided because they interfere with adhesion of the appliance.
disturbed Body Image
May Be Related To Biophysical—surgery (e.g., presence of stoma, loss of control of urine elimination) Psychosocial—altered body structure Illness (e.g., cancer)
Possibly Evidenced By Reports feelings/perceptions that reflect an altered or negative view of one’s body (e.g., appearance, structure, function) Reports fear of reaction by others Actual change in structure and function (ostomy) Not looking at/not touching body part [stoma]
Desired Outcomes/Evaluation Criteria—Client Will Body Image NOC Demonstrate beginning acceptance by viewing and touching stoma and participating in self-care. Verbalize feelings about stoma and illness. Verbalize acceptance of self in situation, incorporating change into self-concept without negating self-esteem.
ACTIONS/INTERVENTIONS
RATIONALE
Body Image Enhancement NIC Independent Review reason for surgery and future expectations.
Ascertain whether counseling was initiated when the possibility or necessity of urinary diversion was first discussed.
Answer all questions concerning urostomy and its function. Encourage client and SO to verbalize feelings. Acknowledge normality of feelings of anger, depression, and grief over loss. Note behaviors of withdrawal, increased dependency, manipulation, or noninvolvement in care.
Provide opportunities for client and SO to view and touch stoma, using the moment to point out positive signs of healing, normal appearance, and so forth.
Provide opportunity for client to deal with ostomy through participation in self-care.
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Client may find it easier to accept and deal with an ostomy done for chronic or long-term disease, such as intractable incontinence or infections, than for traumatic injury or cancer. Provides information about client’s and SO’s levels of knowledge about individual situation and process of acceptance. Client with new ostomy is also often struggling to adjust to cancer or other devastating medical condition requiring the diversion. Establishes rapport and conveys interest and concern of caregiver. Provides additional information for client to consider. Provides opportunity to deal with issues and misconceptions. Helps client and SO to realize that feelings are not unusual and that feeling guilty for them is not helpful. Suggestive of problems in adjustment that may require further evaluation and more extensive therapy. May reflect grief response to loss of body part and function, worry over acceptance by others, and fear of further disability or loss of life from cancer. Although integration of stoma into body image can take months or even years, looking at the stoma and hearing comments made in a normal, matter-of-fact manner can help client with this process. Touching stoma reassures client and SO that it is not fragile and that slight movements of stoma actually reflect normal peristalsis. Independence in self-care helps improve self-esteem. In the case of a continent diversion, client needs the energy, ability, and time to intubate the stoma a minimum of four times a day.
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Maintain positive approach during care activities, avoiding expressions of disdain or revulsion. Do not take client’s angry expressions personally. Plan stoma care activities with client.
Assists client and SO to accept body changes and feel all right about self. Anger is most often directed at the situation and lack of control individual has over what has happened. Promotes client’s sense of control and gives message that client can handle this situation, enhancing self-esteem. Can provide a good support system. Shared experiences can facilitate acceptance of change as client realizes “life does go on” and can be relatively normal. Client may experience anticipatory anxiety and fear of failure in relation to sex after surgery, usually because of lack of knowledge. Surgery that removes the bladder and prostate (removed with the bladder) may disrupt parasympathetic nerve fibers that control erection in men, although newer techniques are available that may be used in individual cases to preserve nerve function.
Discuss contacting ostomy or urostomy visitor and make arrangements for visit if client desires. Discuss sexual functioning and potential physical changes that may occur or medications that effect sexual function, if applicable. (Refer to ND: risk for Sexual Dysfunction.)
NURSING DIAGNOSIS:
acute Pain
May Be Related To Physical factors—incisions, drains Biological factors—disease process (cancer), trauma Psychological factors—fear, anxiety
Possibly Evidenced By Verbalization/coded reports of pain Guarding behaviors Expressive behaviors—restlessness Self-focus Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Verbalize relief or control of pain. Appear relaxed and be able to sleep and rest appropriately.
Pain Control NOC Perform general comfort measures.
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Assess pain, noting location, characteristics, and intensity (0 to 10 or similar coded scale).
Auscultate bowel sounds; note passage of flatus.
Note urine flow and characteristics, and evaluate need for more intensive interventions.
Encourage client to verbalize concerns. Active-listen these concerns and provide support by acceptance, remaining with client and giving appropriate information. Provide comfort measures, such as back rub, repositioning, and ambulating. Assure client that position change will not injure stoma. Encourage use of relaxation techniques, such as guided imagery, visualization, and diversional activities.
Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Surgical causes for abdominal pain usually subside gradually as healing begins. Continued or increasing pain may be a sign of infection or intestinal obstruction. Indicates reestablishment of bowel function. Lack of return of bowel sounds and function within 72 hours may indicate presence of complication, such as peritonitis, hypokalemia, or mechanical obstruction. Decreased flow may reflect urinary retention due to edema with increased pressure in upper urinary tract organs or leakage into peritoneal cavity with failure of anastomosis. Cloudy urine may be normal because of mucus from intestinal tract or may indicate infectious process. Reduction of anxiety and fear can promote relaxation and comfort. Activity, movement, and comfort measures can reduce muscle tension, promote relaxation, and enhance coping abilities. Helps client rest more effectively and refocuses attention, which may enhance coping ability, reducing pain and discomfort. (continues on page 554)
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RATIONALE (continued)
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ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Assist with range-of-motion (ROM) exercises and encourage early ambulation.
Reduces muscle and joint stiffness. Ambulation returns organs to normal position, promotes return of gastrointestinal (GI) peristalsis, and enhances feelings of general well-being. Suggestive of peritoneal inflammation, requiring prompt medical intervention.
Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness.
Collaborative Administer medications as indicated, such as opioids, analgesics, and patient-controlled analgesia (PCA). Maintain patency of nasogastric (NG) tube.
NURSING DIAGNOSIS:
Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial than intermittent analgesia, especially following radical resection. Decompresses stomach and intestines; prevents abdominal distention when intestinal function is impaired.
risk for Infection
Risk Factors May Include Inadequate primary defenses—break in skin, stasis of body fluids (e.g., reflux of urine into urinary tract) Inadequate secondary defenses—immunosuppression
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Infection Severity NOC Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Risk Control: Infectious Process NOC Verbalize understanding of individual causative or risk factors. Demonstrate techniques or lifestyle changes to reduce risk.
ACTIONS/INTERVENTIONS
RATIONALE
Infection Protection NIC Independent Empty ostomy pouch when it becomes one-third to one-half full, once continuous pouch drainage is discontinued. Document urine characteristics and note whether changes are associated with reports of flank pain. Report sudden cessation of urethral drainage.
Note red rash around stoma. Inspect incision line around stoma. Observe and document wound drainage, signs of incisional inflammation, and systemic indicators of sepsis. Change dressings, as indicated, when used. Assess skinfold areas in groin, perineum, and under arms and breasts. Monitor vital signs.
Auscultate breath sounds.
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Reduces risk of urinary reflux and maintains integrity of appliance seal if pouch does not have an antireflux valve. Cloudy, odorous urine indicates infection, possibly pyelonephritis; however, urine normally contains mucus after a conduit procedure because of natural secretions of the intestine. Constant drainage usually subsides within 10 days; however, abrupt cessation may indicate plugging and lead to abscess formation. Rash is most commonly caused by yeast. Urine leakage or allergy to appliance or products may also cause red, irritated areas. Provides baseline and comparative reference. Complications may include interrupted anastomosis of intestine or ureteral conduit, with leakage of bowel contents into abdomen or urine into peritoneal cavity. Moist dressings act as a wick to the wound and provide media for bacterial growth. Use of antibiotics and trapping of moisture in skinfold areas increases risk of Candida infections. An elevated temperature suggests incisional infection, urinary tract infection (UTI), or respiratory complications. Note: Infection in a neobladder is most likely to occur in the early postoperative period; the infection may be afebrile and limited to the neobladder, or it may be associated with pyelonephritis or even urosepsis. Such infections of the neobladder are typically managed with antimicrobials (Thurairaja, 2008). Client is at high risk for development of respiratory complications because of length of time under anesthesia. Often this client is older and may already have a compromised immune system. Also, painful abdominal incisions cause client to breathe more shallowly than normal and to limit coughing effort. Accumulation of secretions in respiratory tract predisposes to atelectasis and infections.
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RATIONALE (continued)
Collaborative Use pouch with antireflux valve, if available. Obtain specimens of exudates, urine, sputum, and blood, as indicated.
NURSING DIAGNOSIS:
Given to treat identified infection or may be given prophylactically, especially with history of recurrent pyelonephritis. Used to treat yeast infections around stoma.
impaired Urinary Elimination
May Be Related To Surgical diversion, tissue trauma, postoperative edema
Possibly Evidenced By Incontinence (loss of continence) Changes in amount, character of urine; urinary retention
Desired Outcomes/Evaluation Criteria—Client Will Urinary Elimination NOC Display continuous flow of urine, with output adequate for individual situation.
ACTIONS/INTERVENTIONS
RATIONALE
Urinary Elimination Management NIC Independent Evaluate and maintain urinary catheters and drains in the immediate postoperative period.
Note presence of stents or ureteral catheters. Label “right” and “left” (or they may be color-coded), and observe urine flow through each. Record urinary output. Investigate sudden reduction or cessation of urine flow.
Observe and record color of urine. Note hematuria or bleeding from stoma.
Position tubing and drainage pouch so that it allows unimpeded flow of urine. Monitor and protect stents.
Demonstrate self-catheterization techniques and reservoir irrigations, as appropriate.
Most clients have Foley catheter, possibly a suprapubic catheter, and pelvic drains during perioperative phase, especially when neobladder has been constructed. Although pelvic drains and ureteral stents are usually removed within 7 to 10 days, the catheters will stay in place during the healing time (Costa, 2012). Stents and ureteral catheters are placed during surgery to facilitate healing of internal anastomosis by keeping it urine free. It is necessary to verify that both kidneys and ureters are functional. Sudden decrease in urine flow may indicate obstruction or dysfunction, such as blockage by edema or mucus, or dehydration. Note: Reduced urinary output not related to hypovolemia, associated with abdominal distention, fever, and clear, watery discharge from the incision; suggests urinary fistula, also requiring prompt intervention. Urine may be slightly pink, which should clear up in 2 to 3 days. Rubbing or washing stoma may cause temporary oozing because of vascular nature of mucosal tissues. Continued bleeding, frank blood in the pouch, or oozing around the base of stoma requires medical evaluation and intervention. Blocked drainage allows pressure to build within urinary tract, risking anastomosis leakage and damage to renal parenchyma. Note: Stents inserted to maintain patency of ureters during period of postoperative edema may be inadvertently dislodged, compromising urine flow. After a healing time of several weeks, catheters will be removed and new voiding techniques initiated. Some clients with neobladders can void spontaneously, whereas others void by sitting down and performing Valsalva’s maneuver. Clients should learn clean intermittent catheterization (CIC) in the event they cannot void spontaneously. Rarely, men will be unable to urinate by pelvic floor relaxation and Valsalva maneuver. In women, the incidence of urinary retention requiring CIC may be as high as 50% (Urology Care (continues on page 556)
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Administer medications, as indicated, for example: Cephalosporins, such as cefoxitin (Mefoxin) and cefazolin (Ancef) Antifungal powder
Prevents backflow of urine into stoma, reducing risk of infection. Identifies source of infection and most effective treatment. Infected urine may cause pyelonephritis. Note: Urine specimen must be obtained from the conduit because the pouch is considered contaminated.
CHAPTER 10
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Encourage increased fluids and maintain accurate intake. Monitor vital signs. Assess peripheral pulses, skin turgor, capillary refill, and oral mucosa. Weigh daily.
Foundation, 2011). Periodic irrigations with sterile water or saline are needed in the continent reservoir to remove accumulated mucus. Maintains hydration and good urine flow. Indicators of fluid balance. Reflects level of hydration and effectiveness of fluid replacement therapy.
Collaborative Administer fluids, as indicated. Monitor electrolytes and arterial blood gases (ABGs).
Prepare for diagnostic testing and procedures, as indicated.
NURSING DIAGNOSIS:
Assists in maintaining hydration and adequate circulating volume and urinary flow. Impaired renal function in client with intestinal conduit increases risk of severe electrolyte or acid-base problems, such as hyperchloremic acidosis. Retrograde ileogram may be done to evaluate patency of conduit; nephrostomy tube or stents may be inserted to maintain urine flow until edema or obstruction is resolved.
risk for Sexual Dysfunction
Risk Factors May Include Altered body structure and function Vulnerability (concern about response of SO)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Sexual Functioning NOC Verbalize understanding of relationship of physical condition to sexual difficulties. Identify satisfying, acceptable sexual practices and explore alternative methods. Resume sexual relationship, as appropriate.
ACTIONS/INTERVENTIONS
RATIONALE
Sexual Counseling NIC Independent Ascertain client and SO’s sexual relationship before surgery, if possible. Identify future expectations and desires.
Review with client and SO anatomy and physiology of sexual functioning in relation to own situation. Reinforce information given by the physician. Encourage questions. Provide additional information as needed.
Discuss resumption of sexual activities, beginning slowly and progressing, such as cuddling and caressing until both partners are comfortable with body image and function changes. Include alternative methods of stimulation, as appropriate. Encourage dialogue between client and SO. Suggest wearing pouch cover, T-shirt, or short nightgown. Stress awareness of factors that might be distracting— unpleasant odors and pouch leakage. Encourage use of sense of humor.
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Mutilation and loss of control of a bodily function can affect client’s view of personal sexuality. When coupled with the fear of rejection by a partner, the desired level of intimacy can be greatly impaired. Sexual needs are very basic, and client will be rehabilitated more successfully when a satisfying sexual relationship is continued or developed. Note: Even with nerve-sparing procedures, 15% to 50% of men will experience erectile dysfunction, and 30% to 40% of women will experience painful intercourse (Costa, 2012). Understanding normal physiology helps client and SO understand the mechanisms of nerve damage and need for exploring alternative methods of satisfaction. Reiteration of previously given information assists client and SO to hear and process the knowledge again, moving toward acceptance of individual limitations or restrictions and prognosis, for example, that it may take months to regain potency after a radical procedure or that a penile prosthesis may be necessary. Knowing what to expect in progress of recovery helps client avoid performance anxiety and reduce risk of “failure.” If the couple is willing to try new ideas, this can assist with adjustment and may help achieve sexual fulfillment. Disguising urostomy appliance may aid in reducing feelings of self-consciousness and embarrassment during sexual activity. Promotes resolution of solvable problems. Laughter can help individuals deal more effectively with difficult situation and promote a positive sexual experience.
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Problem-solve alternative positions for coitus.
Minimizing awkwardness of appliance and physical discomfort can enhance satisfaction. Rehearsal helps deal with actual situations when they arise, preventing self-consciousness about “different” body image. Confusion about impotency and sterility can lead to an unwanted pregnancy.
Discuss and role-play possible interactions or approaches when dealing with new sexual partners. Provide birth control information, as appropriate, and stress that impotence does not mean client is necessarily sterile.
Collaborative Arrange meeting with an ostomy visitor or support group, if appropriate. Refer for counseling or sex therapy, as indicated.
NURSING DIAGNOSIS:
Sharing of how these problems have been resolved by others can be helpful and reduce sense of isolation. If problems persist longer than several months after surgery, a trained therapist may be required to facilitate communication between client and partner.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall, information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instruction or performance of urostomy care Inappropriate or exaggerated behaviors—hostile, agitated, apathetic, withdrawn
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Chronic Disease Management NOC Verbalize understanding of condition, disease process, prognosis, and potential complications.
Ostomy Self-Care NOC Verbalize understanding of therapeutic needs. Correctly perform necessary procedures and explain reasons for the action. Initiate necessary lifestyle changes.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Evaluate client’s emotional and physical capabilities. Review anatomy, physiology, and implications of surgical intervention. Discuss future expectations. Include written and picture resources. Instruct client/SO in stomal care, as appropriate. Allow time for return demonstrations and provide positive feedback for efforts. Ensure that stoma and appliance are odorless and nonleaking. Demonstrate padding to absorb urethral drainage; ask client to report changes in amount, odor, and character. Recommend routine trimming of hair around stoma to edges of pouch adhesive. Encourage clients with Kock pouch to lengthen voiding interval each week unless discomfort noted. Review signs of reservoir overdistention and need for immediate medical intervention.
These factors affect client’s ability to master tasks and willingness to assume responsibility for ostomy care. Provides knowledge base from which client can make informed choices and an opportunity to clarify misconceptions regarding individual situation. Provides references after discharge to support client efforts for independence in self-care. Promotes positive management and reduces risk of improper ostomy care. When client feels confident about urostomy, energy and attention can be focused on other tasks. Small amount of leakage may continue for several weeks after prostate surgery with bladder left in place—a temporary diversion procedure. Hair can be pulled out when the pouch is changed, causing irritation of hair follicles and increasing risk of local infection. Increases capacity of reservoir to achieve a more normal voiding pattern. Presence of discomfort suggests reservoir is full, necessitating prompt emptying. Client and caregiver will need to recognize signs, such as lower abdominal pain accompanied by feelings of fullness, bloating, or nausea associated with reservoir overdistention. Severe overdistention can result in neobladder rupture, a life-threatening complication (Costa, 2012). (continues on page 558)
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RATIONALE (continued)
CHAPTER 10
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Instruct client in a progressive exercise program to include Kegel exercises that stop and start urinary stream. Encourage optimal nutrition.
Improves tone of pelvic muscles and the external sphincter to enhance continence when client voids through urethra. Promotes wound healing and increases utilization of energy to facilitate tissue repair. Anorexia may be present for several months postoperatively, requiring conscious effort to meet nutritional needs. May be useful in acidifying urine to decrease risk of infection and crystal or stone formation. Products containing bicarbonate or calcium potentiate risk of crystal and stone formation, affecting both urinary flow and tissue integrity. Note: Use of sulfa drugs requires alkaline urine for optimal absorption, necessitating acid-ash diet and vitamin C supplements withheld. Changes in weight can affect size of stoma and appliance fit. Note: Weight loss of 10 to 20 lb is not uncommon because of intestinal involvement and anorexia. Maintains urinary output and promotes acidic urine to reduce risk of infection and stone formation. Note: Oranges and citrus fruits make urine alkaline and are therefore contraindicated. Large doses of vitamin C can inhibit vitamin B12 absorption, requiring periodic monitoring of vitamin B12 levels. Client should be able to manage same degree of activity as previously enjoyed and in some cases increase activity level, except for contact sports. “Homecoming depression” may occur, lasting for up to 3 months after surgery, requiring patience, support, and ongoing evaluation. Immobility or inactivity increases urinary stasis and calcium shift out of bones, potentiating risk of stone formation and resultant urinary obstruction or infection. Smoking cessation is critical to the health of the new bladder, ureters, and kidneys because of the vasoconstrictive, acidic, and carcinogenic effects of smoking. Early detection and prompt intervention of developing problems such as UTI, stricture, and intestinal fistula, may prevent more serious complications. Urinary electrolytes, especially chloride, are reabsorbed in the intestinal conduit, which leads to compensatory bicarbonate loss, lowered serum pH or metabolic acidosis, and potassium deficit. Monitors healing and disease process and provides opportunity for discussion of appliance problems, general health, and adaptation to condition. Note: Bowel resection of the distal ileum creating ileal conduit can lead to vitamin B12 malabsorption. Therefore, long-term monitoring may be necessary as deficiency can lead to anemia, neurological problems, and anorexia (Clark, 2005; Pieper et al, 2006). Continued support after discharge is essential to facilitate the recovery process and client’s independence in care. Enterostomal nurse can be very helpful in solving appliance problems and identifying alternatives to meet individual client needs.
Discuss use of acid-ash diet: cranberries, prunes, plums, cereals, rice, peanuts, noodles, cheese, poultry, and fish; avoidance of salt substitutes, sodium bicarbonate, and antacids; and cautious use of products containing calcium.
Discuss importance of maintaining normal weight.
Stress necessity of increased fluid intake of at least 2 to 3 L/day and cranberry juice or ascorbic acid and vitamin C tablets. Explain to client that urine should be pale yellow to almost colorless.
Discuss resumption of presurgery level of activity and possibility of sleep disturbance, anorexia, and loss of interest in usual activities.
Encourage regular activity and exercise program.
Emphasize need for smoking cessation, if indicated. Refer for medication and smoking cessation assistance, if client is cooperative. Identify signs and symptoms requiring medical evaluation: changes in character, amount, and flow of urine; unusual drainage from wound; fatigue or muscle weakness; anorexia; abdominal distention; and confusion.
Stress importance of follow-up appointments.
Identify community resources, such as the United Ostomy Association, local ostomy support group, enterostomal therapist, visiting nurse, and pharmacy or medical supply house.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) In addition to postsurgical concerns: • impaired Urinary Elimination—anatomic diversion • situational low Self-Esteem—loss of or altered control of body function • risk for ineffective Self-Health Management—complexity of therapeutic regimen, perceived barriers
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III. Etiology a. Cause is unknown, although testosterone and other hormones may affect growth. b. Microscopically characterized as a hyperplastic process with the number of cells in the gland increasing with age c. Most commonly seen in men older than age 50 years IV. Statistics a. Morbidity: BPH is the most common disorder of the prostate gland and is the most common diagnosis by urologists for male patients age 45 to 74 (Prostatehealthcures .com, 2009). An estimated 14 million men in the United States have symptoms related to benign enlargement (Deters et al, 2013). b. Mortality: Generally related to renal failure, infection, and complications of surgery. c. Cost: In 2000, the direct cost of BPH treatment was estimated to be $1.1 billion exclusive of outpatient pharmaceuticals (Wei, 2008).
G L O S S A R Y Bladder outlet obstruction (BOO): Blockage at the base of the bladder causing compression of the urethra, thus reducing or preventing urine flow into the urethra. Bladder wall trabeculation: Characterized by thick wall and hypertrophied muscle bundles; typically seen in instances of long-standing obstruction.
Dysuria: Painful, difficult urination. LUTS: Lower urinary tract symptoms associated with BPH include urinary frequency, urgency, nocturia, decreased or intermittent force of stream, or a sensation of incomplete emptying. Prostatitis: Inflammation of the prostate gland.
Care Settings
Related Concerns
Client is treated at the community level, with more acute care provided during outpatient procedures.
Acute kidney injury, page 505 Prostatectomy, page 566 Psychosocial aspects of care, page 729
Client Assessment Database D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
CIRCULATION • Elevated blood pressure (BP)
ELIMINATION • Feeling need to urinate urgently, sensation of imminent loss of urine without control • Hesitancy or straining in initiating voiding, having to stand at or sit on the toilet for some time prior to producing a urinary stream • Decreased force or caliber of urinary stream, intermittent flow, dribbling • Usually voiding only small amounts of urine with each episode, sensation of incomplete emptying
• Firm mass in lower abdomen (distended bladder), bladder tenderness • Inguinal hernia, hemorrhoids—result of increased abdominal pressure required to empty bladder against resistance
(continues on page 560)
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RENAL AND URINARY TRACT—BENIGN PROSTATIC HYPERPLASIA
I. Pathophysiology a. Overgrowth of normal, nonmalignant cells that cause progressive enlargement of the prostate gland, resulting in bladder outlet obstruction with urinary retention, leakage, and frequency (Deters et al, 2013; Shiller, 2007) b. Additional complications: bladder wall trabeculation, detrusor muscle enlargement, narrowing of urethra, incontinence, and acute or chronic renal failure (Springhouse, 2005) II. Classification (American Urological Association [AUA], 2010) a. International scoring system has been adopted worldwide. b. Questions, and subsequent scoring, focus on degree of incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturia, as well as impact on quality of life. i. Score of 0 to 7: mildly symptomatic ii. Score of 8 to 19: moderately symptomatic iii. Score of 20 to 35: severely symptomatic
CHAPTER 10
BENIGN PROSTATIC HYPERPLASIA (BPH)
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Client Assessment Database
(continued)
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
M AY E X H I B I T
(continued)
• Need to urinate frequently during the day or night (nocturia), resulting in interrupted sleep • Dysuria, hematuria • Chronic constipation, resulting from protrusion of prostate into rectum
FOOD/FLUID • Anorexia, nausea, vomiting • Recent weight loss
PAIN/DISCOMFORT • Suprapubic, flank, or back pain; sharp, intense, with acute prostatitis • Low back pain
SAFETY • Fever
SEXUALITY • Concerns about effects of condition or therapy on sexual abilities • Fear of incontinence or dribbling during intimacy • Decrease in force of ejacul*tory contractions
• Enlarged, tender prostate
TEACHING/LEARNING • Family history of cancer, hypertension, kidney disease • Use of antihypertensive or antidepressant medications, overthe-counter (OTC) cold and allergy medications containing sympathomimetics, urinary antibiotics or antibacterial agents • Use of nutrients or herbal supplements for self-treatment of BPH and urinary flow—saw palmetto, pygeum, pumpkin seed oil, or soy products
DISCHARGE PLAN CONSIDERATIONS • May need assistance with management of therapy—catheter ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
BLOOD TESTS • Prostate-specific antigen (PSA): Substance manufactured solely by prostate gland cells. An elevated reading indicates an abnormal condition of the prostate gland, either benign or malignant.
560
In men without prostate cancer, serum PSA reflects the amount of glandular epithelium, which in turn reflects prostate size. As prostate size increases with increasing age, the PSA concentration also rises; it increases at a faster rate in elderly men. As a result, different normal reference ranges may be appropriate based upon a man’s age. Prostate cancer is only one of many potential causes of an elevated PSA; anything that irritates the prostate (including BPH) will cause the PSA to rise, at least temporarily (Schmidt, 2009).
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(continued)
W H AT I T T E L L S M E
(continued)
URINE TESTS
• Postvoid residual (PVR): Volume of urine remaining in bladder immediately after voiding.
Yellow, dark brown, dark or bright red (bloody) in color; appearance may be cloudy, pH of 7 or greater suggests infection; and bacteria, WBCs, and RBCs may be present microscopically. Determines the severity of urinary retention; may be done by catheterization or by transabdominal ultrasound.
OTHER DIAGNOSTIC STUDIES • Transrectal prostatic ultrasound (TRUS): Examination where a fingerlike probe is placed in the rectum and ultrasound pictures are made of the prostate. • Digital rectal exam (DRE): Test performed by inserting gloved finger into rectum to detect prostate abnormalities.
• Uroflowmetry: Measures urine amount and flow rate via a collection device and scale. The equipment creates a graph that shows changes in flow rate from second to second, measuring peak flow rate and how long it took to get there. • Urography: Series of x-rays of the kidney, ureters, and bladder after injection of a contrast dye into a vein. • Cystourethrography: Allows visualization of the bladder and urethra on x-ray, using radiopaque contrast material injected through the urethra. • Cystourethroscopy: Direct visualization of the bladder and urethra by means of a flexible fiber-optic scope.
Measures size of prostate and amount of residual urine, locates lesions unrelated to BPH. For client with elevated PSA levels, a TRUS-guided biopsy may be indicated. Prostate size and contour can be assessed, nodules evaluated, and areas of suspected malignancy detected; also helps determine pelvic floor tone and fluctuance, such as in prostate abscess, and pain and sensitivity of gland can be assessed. Results of this test will be abnormal if the bladder muscle is weak or urine flow is obstructed. Helps distinguish poor bladder contractibility (detrusor underactivity) from BOO caused by prostate hyperplasia. Shows any blockage in the urinary tract causing delayed emptying of bladder, urinary retention, or presence of prostatic enlargement. May be used instead of IVP to visualize bladder and urethra because it uses localized, rather than systemic, radiopaque contrast media. May be done in selected individuals. Shows degree of prostatic enlargement and bladder wall changes associated with bladder trabeculation.
Nursing Priorities
Discharge Goals
1. 2. 3. 4. 5.
1. 2. 3. 4. 5.
Relieve acute urinary retention. Promote comfort. Prevent complications. Help client deal with psychosocial concerns. Provide information about disease process, prognosis, and treatment needs.
NURSING DIAGNOSIS:
Voiding pattern normalized. Pain or discomfort relieved. Complications prevented or minimized. Situation being dealt with realistically. Disease process, prognosis, and therapeutic regimen understood. 6. Plan in place to meet needs after discharge.
[acute/chronic] Urinary Retention
May Be Related To Blockage [Decompensation of detrusor musculature] [Loss of bladder tone—inability of bladder to contract adequately]
Possibly Evidenced By Sensation of bladder fullness; dribbling Bladder distention; residual urine (150 mL or more)
Desired Outcomes/Evaluation Criteria—Client Will Urinary Elimination NIC Void in sufficient amounts with no palpable bladder distention. Demonstrate postvoid residuals of less than 50 mL, with absence of dribbling or overflow.
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• Urinalysis: Laboratory examination of urine for red blood cells (RBCs) and WBCs or presence of infection or excessive protein.
CHAPTER 10
TEST WHY IT IS DONE
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ACTIONS/INTERVENTIONS
RATIONALE
Urinary Retention Care NIC Independent Encourage client to void every 2 to 4 hours and when urge is noted. Ask client about stress incontinence when moving, sneezing, coughing, laughing, or lifting objects. Observe urinary stream, noting size and force. Have client document time and amount of each voiding. Note diminished urinary output. Measure specific gravity, as indicated. Percuss and palpate suprapubic area. Encourage oral fluids, if indicated.
Monitor vital signs closely. Observe for hypertension, peripheral or dependent edema, and changes in mentation. Weigh daily. Maintain accurate intake and output (I&O). Provide and encourage meticulous catheter and perineal care. Recommend sitz bath, as indicated.
May minimize urinary retention and overdistention 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: Fluids may be restricted to prevent bladder distention if severe obstruction is present or until adequate urinary flow is reestablished. Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes. Reduces risk of ascending infection. Promotes muscle relaxation, decreases edema, and may enhance voiding effort.
Collaborative Administer medications, as indicated, for example: 5-!-reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart)
Alpha-adrenergic antagonists, such as alfuzosin (UroXatral), terazosin (Hytrin), doxazosin (Cardura), and tamsulosin (Flomax) Antibiotics and antibacterials Catheterize for residual urine and leave indwelling catheter, as indicated.
Monitor laboratory studies, such as the following: Blood urea nitrogen (BUN), creatinine (Cr), and electrolytes
Urinalysis and culture Prepare for and assist with urinary drainage, such as emergency cystostomy. Prepare for minimally invasive therapies, such as: Heat therapies, such as laser, transurethral microwave thermotherapy (TUMT), Cortherm, Prostatron, and transurethral needle ablation (TUNA).
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Medications have long been used as a first-line therapy for clients with mild to moderate symptoms. Reduces the size of the prostate and decreases symptoms if taken long-term; however, side effects, such as decreased libido and ejacul*tory dysfunction, may influence client’s choice for long-term use. Studies indicate that combination therapy with 5-!-reductase inhibitor plus alpha blocker may be superior to taking either drug class alone for prevention of BPH progression (AUA, 2010; National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2003). These agents block effects of postganglionic synapses that affect smooth muscle and exocrine glands. This action can decrease adverse urinary tract symptoms and increase urinary flow. Given to combat infection. May be used prophylactically. Relieves and prevents urinary retention and rules out presence of ureteral stricture. Coudé catheter may be required because the curved tip eases passage of the tube around the enlarged prostate. Note: Bladder decompression should be done with caution to observe for signs of adverse reaction, such as hematuria due to rupture of blood vessels in the mucosa of the overdistended bladder and syncope due to excessive autonomic stimulation. Prostatic enlargement with obstruction eventually causes dilation of upper urinary tract, ureters, and kidneys, potentially impairing kidney function and leading to uremia. Urinary stasis potentiates bacterial growth, increasing risk of urinary tract infection (UTI). May be indicated to drain bladder during acute episode with azotemia or when surgery is contraindicated because of client’s health status. These therapies rely on heat to cause destruction of prostatic tissue. Treatment is often completed in a one-time procedure carried out in the physician’s office. Long-term outcomes are variable in terms of adequately treating urinary tract symptoms.
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CHAPTER 10
NURSING DIAGNOSIS:
acute Pain
May Be Related To Physical agents—mucosal irritation (e.g., bladder distention, renal colic, urinary infection, radiation therapy) Verbalized/coded reports of pain Self-focus Expressive behaviors (e.g., restlessness, irritability) Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain relieved or controlled. Appear relaxed. Be able to sleep and rest appropriately.
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Assess pain, noting location, intensity (0 to 10 or similar coded scale), characteristics, and duration. Tape drainage tube to thigh and catheter to the abdomen, if traction not required. Provide comfort measures, such as back rub, helping client assume position of comfort. Suggest use of relaxation and deep-breathing exercises and diversional activities. Encourage use of sitz baths and warm soaks to perineum.
Provides information to aid in determining choice and effectiveness of interventions. Prevents accidental dislodging of catheter with attendant urethral trauma. Promotes relaxation, refocuses attention, and may enhance coping abilities. Promotes muscle relaxation.
Collaborative Insert catheter and attach to straight drainage, as indicated. Administer medications, as indicated, for example: Opioids, such as meperidine (Demerol) Antibacterials, such as methenamine hippurate (Hiprex) Antispasmodics and bladder sedatives, such as flavoxate (Urispas) and oxybutynin (Ditropan).
NURSING DIAGNOSIS:
Draining bladder reduces bladder tension and irritability. Given to relieve severe pain; provide physical and mental relaxation. Reduces bacteria present in urinary tract and those introduced by drainage system. Relieves bladder irritability.
risk for deficient Fluid Volume
Risk Factors May Include Failure of regulatory mechanism (e.g., postobstructive diuresis from rapid drainage of a chronically overdistended bladder)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Fluid Balance NOC Maintain adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good capillary refill, and moist mucous membranes.
ACTIONS/INTERVENTIONS
RATIONALE
Fluid Management NIC Independent Monitor output carefully. Note outputs of 100 to 200 mL/hr.
Encourage increased oral intake based on individual needs.
Monitor BP and pulse. Evaluate capillary refill and oral mucous membranes.
Rapid or sustained diuresis could cause client’s total fluid volume to become depleted and limits sodium reabsorption in renal tubules. Client may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and increasing risk of dehydration and hypovolemia. Enables early detection of and intervention for systemic hypovolemia. (continues on page 564)
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Possibly Evidenced By
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Promote bedrest with head elevated.
Decreases cardiac workload, facilitating circulatory homeostasis.
Collaborative Monitor electrolyte levels, especially sodium. Administer intravenous (IV) fluids—hypertonic saline as needed.
NURSING DIAGNOSIS:
As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia. Replaces fluid and sodium losses to prevent or correct hypovolemia following outpatient procedures.
Anxiety [specify level]
May Be Related To Change in health status Threat to self-concept Threat to role function (e.g., concern about sexual ability)
Possibly Evidenced By Increased tension, apprehensive, worried Reports concerns due to change in life events
Desired Outcomes/Evaluation Criteria—Client Will Anxiety Self-Control NOC Appear relaxed. Verbalize accurate knowledge of the situation. Demonstrate appropriate range of feelings and lessened fear. Report anxiety is reduced to a manageable level.
ACTIONS/INTERVENTIONS
RATIONALE
Anxiety Reduction NIC Independent Be available to client. Establish trusting relationship with client and significant other (SO). Provide information about specific procedures and tests and what to expect afterward, such as catheter, bloody urine, and bladder irritation. Be aware of how much information client wants. Maintain matter-of-fact attitude in doing procedures and dealing with client. Protect client’s privacy. Encourage client and SO to verbalize concerns and feelings. Reinforce previous information client has been given.
NURSING DIAGNOSIS:
Demonstrates concern and willingness to help. Encourages discussion of sensitive subjects. Helps client understand purpose of what is being done and reduces concerns associated with the unknown, including fear of cancer. However, overload of information is not helpful and may increase anxiety. Communicates acceptance and eases client’s embarrassment. Defines the problem, providing opportunity to answer questions, clarify misconceptions, and problem-solve solutions. Allows client to deal with reality and strengthens trust in caregivers and information presented.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall, information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inappropriate behaviors—apathetic, withdrawn Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Disease Process NOC Verbalize understanding of disease process, prognosis, and potential complications. Identify relationship of signs and symptoms to the disease process. Initiate necessary lifestyle or behavior changes.
Knowledge: Treatment Regimen NOC Verbalize understanding of therapeutic needs. Participate in treatment regimen.
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RATIONALE
Teaching: Disease Process NIC Independent Review disease process and client expectations.
Review usual medication regimen.
Encourage reading of labels and discuss concerns with overthe-counter (OTC) drugs. Recommend avoiding spicy foods, coffee, alcohol, long automobile rides, and rapid intake of fluids.
Address sexual concerns—during acute episodes of prostatitis, intercourse should be avoided but may be helpful in treatment of chronic condition.
Provide information about sexual anatomy and function as it relates to prostatic enlargement. Encourage questions and promote a dialogue about concerns. Review signs and symptoms requiring medical evaluation— cloudy, odorous urine; diminished urinary output; inability to void; and presence of fever or chills. Discuss necessity of notifying other healthcare providers of diagnosis.
Reinforce importance of medical follow-up for at least 6 months to 1 year, including rectal examination and urinalysis. Discuss personal safety issues and potential environmental changes.
Reduces risk of inappropriate therapy, such as the use of decongestants, anticholinergics, and antidepressants, which can increase urinary retention and may precipitate an acute episode. Recurrence of hyperplasia and infection caused by same or different organisms is not uncommon and requires changes in therapeutic regimen to prevent serious complications. Recent research reports increased risk of falls in presence of moderate to severe BPH associated with urgency, nocturia, and straining to void, with fall risk increasing with age and symptom severity (Parsons et al, 2008).
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) • [acute/chronic] Urinary Retention—blockage, [loss of bladder tone, decompensation of detrusor musculature] • risk for Infection—urinary stasis, invasive procedure (periodic catheterization) • risk for ineffective Self-Health Management—perceived barriers
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Encourage verbalization of fears, feelings, and concerns. Give information that the condition is not sexually transmitted. Review drug therapy, use of herbal products, and diet, such as increasing intake of fruits and soybeans.
Provides knowledge base from which client can make informed therapy choices. Note: “Watchful waiting” is one of the options in client with early BPH with no symptoms of urinary retention. Client should understand that this includes ongoing periodic evaluation for change (Neal, 2009). Helping client work through feelings can be vital to rehabilitation. May be an unspoken fear. Some clients may prefer to treat with complementary therapy because of decreased occurrence and lessened severity of side effects, such as impotence. Note: Nutrients known to inhibit prostate enlargement include zinc, soy protein, essential fatty acids, flaxseed, and lycopene. Herbal supplements that client may use include saw palmetto, pygeum, stinging nettle, and pumpkin seed oil. However, a recent study found no difference in efficacy or side effects between saw palmetto and a placebo, indicating a need for further research as to benefit versus variability of potency or purity of botanical products (Bent, 2006). Medications known to be associated with urinary obstruction symptoms (e.g., tricyclic antidepressants, first generation antihistamines, anticholinergic agents, diuretics, narcotics, and decongestants) may require dose adjustment or change to a different drug (Neal, 2009). Many OTC medications for upper respiratory symptom relief can increase urinary retention. Client with BPH should avoid these medications. May cause prostatic irritation with resulting congestion. Sudden increase in urinary flow can cause bladder distention and loss of bladder tone, resulting in episodes of acute urinary retention. Sexual activity can increase pain during acute episodes but may serve as massaging agent in presence of chronic disease. Note: Medications, such as finasteride (Proscar), are known to interfere with libido and erections. Alternatives include terazosin (Hytrin), doxazosin mesylate (Cardura), and tamsulosin (Flomax), which do not affect testosterone levels. Having information about anatomy involved helps client understand the implications of proposed treatments because they might affect sexual performance. Prompt interventions may prevent more serious complications.
CHAPTER 10
ACTIONS/INTERVENTIONS
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PROSTATECTOMY I. Indications a. Benign prostatic hyperplasia (BPH)-related complications i. Urinary retention ii. Frequent urinary tract infections iii. Bladder stones iv. Recurrent gross hematuria v. Kidney damage from long-standing blockage vi. Failure to respond to medical or minimally invasive treatments b. Prostate cancer II. Procedures (Miles et al, 2011; American Urological Association, [AUA], 2010) a. Minimally invasive prostatectomy i. Transurethral microwave thermotherapy (TUMT) ii. Transurethral needle ablation (TUNA) using low-level frequency thermal energy iii. Laser ablation: includes transurethral holmium laser ablation of the prostate (HoLAP); transurethral laser enucleation of the prostate (HoLEP); holmium laser resection of the prostate (HoLRP) iv. Transurethral vaporization of the prostate (TUVP) v. Transurethral resection of the prostate (TURP) 1. Most common procedure for the long-term treatment of BPH, in client with moderate to severe lower urinary tract symptoms (LUTS) and/or where significantly bothered by these symptoms 2. Obstructive prostatic tissue of the medial lobe surrounding the urethra is removed by means of a cystoscope introduced through the urethra. b. Open surgical approaches performed when the prostate is overly enlarged (greater than 75 g), the bladder has been
damaged, or when there are complicating factors, such as cancer i. Robot assisted—nerve sparing, uses a laparoscope, and several incisions are made in the abdomen ii. Suprapubic prostatectomy 1. Obstructing prostatic tissue is removed through a low midline incision made through the bladder. 2. Preferred approach if bladder stones are present iii. Retropubic prostatectomy 1. Hypertrophied prostatic tissue mass located high in the pelvic region is removed through a low abdominal incision without opening the bladder. iv. Perineal prostatectomy 1. Laparoscopy removal of larger tumors or in presence of cancerous lymph nodes or nerve invasion 2. Large prostatic masses low in the pelvic area are removed through an incision between the scrotum and the rectum. III. Statistics a. Morbidity: In 2009, 158,000 prostatectomy procedures were performed in short-stay hospitals in the United States (Centers for Disease Control and Prevention [CDC], 2009); in 2011, 4 of 5 radical prostatectomies were robotic assisted (NCI National Cancer Bulletin, 2011). b. Mortality: Prostatectomy is a relatively low-risk procedure (generally stated as 0 or less than 1% and usually associated with cardiovascular disease) (AUA, 2010; Guilli et al, n.d.). c. Cost: In 2010, the direct costs for treatment of prostate cancer totaled $11.85 billion (NCI, 2011); most commonly performed procedures are prostatectomy and TURP (Milenkovic et al, 2007).
G L O S S A R Y Blood dyscrasias: General term used to describe any abnormality in the blood, such as low white blood cell (WBC) count, low red blood cell (RBC) count, or low platelet count. Continuous bladder irrigation (CBI): Constant flow of normal saline or another bladder irrigant through a three-way urinary catheter to keep the catheter patent. Hematuria: Blood in the urine. Kegel exercises: Pelvic muscle exercises intended to improve pelvic muscle tone and prevent urine leakage for sufferers of stress urinary incontinence.
Prostatic fossa: Cavity or depression where the prostate gland lies. Retropubic: Behind the pubic bone. Suprapubic: Above the pubic bone. Transurethral resection of the prostate (TURP) syndrome: Rare complication directly related to this procedure. During the surgery, excess fluid collects in the body, reducing the concentration of sodium in the bloodstream. Common symptoms include nausea, vomiting, and confusion. Urinary retention: Inability to empty bladder.
Care Setting
Related Concerns
Client is treated in inpatient acute surgical unit.
Benign prostatic hyperplasia (BPH), page 559 Cancer, page 827 Psychosocial aspects of care, page 729 Surgical intervention, page 762
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CHAPTER 10
Client Assessment Database Refer to CP: Benign Prostatic Hyperplasia (BPH) for assessment data.
M AY E X H I B I T
DISCHARGE PLAN CONSIDERATIONS • Dependent upon type of procedure, needs may be minimal or client may require assistance with self-care needs, transportation, medical supplies, and home maintenance ➧ Refer to section at end of plan for postdischarge.
Nursing Priorities
Discharge Goals
1. 2. 3. 4.
1. 2. 3. 4.
Maintain homeostasis and hemodynamic stability. Promote comfort. Prevent complications. Provide information about surgical procedure, prognosis, treatment, and rehabilitation needs.
NURSING DIAGNOSIS:
Urinary flow restored or enhanced. Pain relieved or controlled. Complications prevented or minimized. Procedure, prognosis, therapeutic regimen, and rehabilitation needs understood. 5. Plan in place to meet needs after discharge.
impaired Urinary Elimination
May Be Related To Anatomic obstruction (e.g., blood clots, edema, trauma, surgical procedure) [Loss of bladder tone—preoperative overdistention or continued decompression]
Possibly Evidenced By Frequency, urgency, hesitancy, dysuria Incontinence; retention
Desired Outcomes/Evaluation Criteria—Client Will Urinary Elimination NOC Void normal amounts without retention. Demonstrate behaviors to regain bladder and urinary control.
ACTIONS/INTERVENTIONS
RATIONALE
Urinary Elimination Management NIC Independent Assess urine output and catheter drainage system, especially during bladder irrigation. Assist client to assume normal position to void; for example, stand and walk to bathroom at frequent intervals after catheter is removed. Record time, amount of voiding, and size of stream after catheter is removed. Note reports of bladder fullness, inability to void, and urgency. Encourage client to void when urge is noted but not more than every 2 to 4 hours per protocol. Encourage fluid intake to 2000 to 2500 mL as tolerated. Limit fluids in the evening once catheter is removed. Instruct client in perineal exercises, such as tightening buttocks and stopping and starting urine stream. Advise client that “dribbling” is to be expected after catheter is removed and should resolve as recuperation progresses. Provide and instruct in use of continence pads when indicated.
Retention can occur because of edema of the surgical area, blood clots, and bladder spasms. Encourages passage of urine and promotes sense of normality.
The catheter is usually removed 2 to 5 days after surgery, but voiding may continue to be a problem for some time because of urethral edema and loss of bladder tone. Voiding with urge prevents urinary retention. Limiting voids to every 4 hours, if tolerated, increases bladder tone and aids in bladder retraining. Maintains adequate hydration and renal perfusion for urinary flow. “Scheduling” fluid intake reduces need to void during the night. Helps regain bladder sphincter control, minimizing incontinence. Information helps client deal with the problem. Postoperative incontinence is usually temporary, but stress incontinence— leaking urine when coughing, laughing, and lifting—can persist indefinitely. (continues on page 568)
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D I AG N O S T I C D I V I S I O N M AY R E P O R T
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Collaborative Maintain continuous bladder irrigation (CBI), as indicated, in early postoperative period. Measure residual volumes via suprapubic catheter, if present, or with Doppler ultrasound.
NURSING DIAGNOSIS:
Flushes bladder of blood clots and debris to maintain patency of the catheter and urinary flow. Monitors effectiveness of bladder emptying. Residuals of more than 50 mL suggest need for continuation of catheter until bladder tone improves.
risk for Bleeding
Risk Factors May Include Treatment-related side effects (e.g., surgery—vascular nature of surgical area)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Blood Loss Severity NOC Display no signs of active bleeding.
ACTIONS/INTERVENTIONS
RATIONALE
Bleeding Precautions NIC Independent Monitor intake and output (I&O).
Monitor vital signs, noting increased pulse and respiration, decreased blood pressure (BP), diaphoresis, pallor, delayed capillary refill, and dry mucous membranes. Investigate restlessness, confusion, and changes in behavior.
Inspect dressings and wound drains. Weigh dressings, if indicated. Note hematoma formation. Encourage increased fluid intake, preferably water, to 2000 to 2500 mL/day unless contraindicated by medical condition.
Indicator of fluid balance and replacement needs. With bladder irrigations, monitoring is essential for estimating blood loss and accurately assessing urine output. Note: Following release of urinary tract obstruction, marked diuresis may occur during initial recovery period. Hypovolemia requires prompt intervention to prevent impending shock. Note: Hypertension, bradycardia, and nausea or vomiting suggest TURP syndrome, requiring immediate medical intervention. May reflect decreased cerebral perfusion (hypovolemia) or indicate cerebral edema from excessive solution absorbed into the venous sinusoids during TUR procedure (TURP syndrome). Signs of persistent bleeding may be evident or sequestered within tissues of the perineum. Helps maintain fluid volume while flushing bladder of blood clots, debris, and bacteria (Wojcik & Dennison, 2006).
Bleeding Reduction NIC Anchor urethral catheter and avoid excessive manipulation.
Observe urethral and suprapubic catheter drainage, noting excessive or continued bleeding.
Evaluate color, consistency of urine, for example: Bright red with bright red clots Dark burgundy with dark clots and increased viscosity Bleeding with absence of clots. Avoid taking rectal temperatures and use of rectal tubes or enemas.
After TURP, the client will have special catheter in place that allows traction on the prostatic fossa to minimize bleeding. The catheter also allows irrigation of the bladder. Displacement of the catheter may cause bleeding. With bladder distention, clot formation may cause plugging of the catheter. Bleeding is not unusual during first 24 hours for all but the perineal approach. Continued or heavy bleeding or recurrence of active bleeding requires medical evaluation and intervention. Usually indicates arterial bleeding and requires aggressive therapy. Suggests venous source, which is the most common type of bleeding and usually subsides on its own. May indicate blood dyscrasias or systemic clotting problems. May result in referred irritation to prostatic bed and increased pressure on prostatic capsule with risk of bleeding.
Collaborative Monitor laboratory studies, as indicated, such as: Hemoglobin/hematocrit (Hgb/Hct) and RBCs Coagulation studies and platelet count
568
Useful in evaluating blood losses and replacement needs. May indicate developing complications that can potentiate bleeding or clotting.
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Administer intravenous (IV) therapy or blood products, as indicated. Maintain traction on indwelling catheter; tape catheter to inner thigh.
May need additional fluids, if oral intake inadequate, or blood products, if losses are excessive. Traction on the 30-mL balloon positioned in the prostatic urethral fossa creates pressure on the arterial supply of the prostatic capsule to help prevent or control bleeding. Prolonged traction may cause permanent trauma and problems with urinary control. Prevention of constipation and straining for stool reduces risk of rectal-perineal bleeding.
Release traction within 4 to 5 hours. Document period of application and release of traction, if used. Administer stool softeners or laxatives, as indicated.
NURSING DIAGNOSIS:
risk for Infection
Risk Factors May Include Inadequate primary defenses—traumatized tissue, surgical incision, invasive procedures (e.g., instrumentation during surgery, indwelling catheter, frequent bladder irrigation)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Wound Healing: Primary Intention NOC Experience no signs of infection. Achieve timely healing.
ACTIONS/INTERVENTIONS
RATIONALE
Infection Protection NIC Independent Maintain sterile catheter system; provide regular catheter and urinary meatus care with soap and water, applying antibiotic ointment around catheter site per protocol. Ambulate with drainage bag dependent. Monitor vital signs, noting low-grade fever, chills, rapid pulse and respiration, restlessness, irritability, and disorientation. Observe drainage from wounds around suprapubic catheter. Change suprapubic/retropubic and perineal incision dressings frequently, cleaning and drying skin thoroughly each time. Use ostomy-type skin barriers.
Prevents introduction of bacteria and resultant infection.
Avoids backward reflux of urine, which may introduce bacteria into the bladder. Client who has had cystoscopy or TURP is at increased risk for surgical and septic shock related to instrumentation. Presence of drains and suprapubic incision increases risk of infection, as indicated by erythema or purulent drainage. Wet dressings cause skin irritation and provide medium for bacterial growth, increasing risk of wound infection. Provides protection for surrounding skin, preventing excoriation and reducing risk of infection.
Collaborative Administer antibiotics, as indicated.
NURSING DIAGNOSIS:
May be given prophylactically because of increased risk of infection with prostatectomy.
acute Pain
May Be Related To Physical agents (e.g., irritation of bladder mucosa; reflex muscle spasm)
Possibly Evidenced By Verbalized/coded reports of pain Guarding behaviors Expressive behaviors—restlessness, irritability Self-focus Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain is relieved or controlled. Appear relaxed and sleep and rest appropriately.
Pain Control NOC Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.
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RATIONALE (continued)
CHAPTER 10
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Assess pain, noting location, intensity (0 to 10 or similar coded scale), and characteristics.
Maintain patency of catheter and drainage system. Keep tubing free of kinks and clots. Promote intake of up to 3000 mL/day, as tolerated. Give client accurate information about catheter, drainage, bladder spasms, and potential for voiding difficulties.
Provide comfort measures, such as position changes, back rub, Therapeutic Touch, and diversional activities. Encourage use of relaxation techniques, including deep-breathing exercises, visualization, and guided imagery.
Changes in pain reports may indicate developing complications requiring further evaluation and intervention. Note: Sharp, intermittent pain with urge to void and passage of urine around catheter suggests bladder spasms, which tend to be more severe with suprapubic or TUR approaches and usually decrease within 48 hours. Maintaining a properly functioning catheter and drainage system decreases risk of bladder distention and spasm. Decreases irritation by maintaining a constant flow of fluid over the bladder mucosa. Allays anxiety and promotes cooperation with necessary procedures. Note: Depending on the degree of preoperative urge incontinence, postoperative urge incontinence may be present for weeks or months (Mills, 2011). Reduces muscle tension, refocuses attention, and may enhance coping abilities.
Collaborative Provide sitz baths or heat lamp, if indicated. Administer antispasmodics, such as: Oxybutynin (Ditropan), flavoxate (Urispas), B & O suppositories Propantheline bromide (Pro-Banthine)
NURSING DIAGNOSIS:
Promotes tissue perfusion and resolution of edema and enhances healing in perineal approach. Relaxes smooth muscle to provide relief of spasms and associated pain. Relieves bladder spasms by anticholinergic action. Usually discontinued 24 to 48 hours before anticipated removal of catheter to promote normal bladder contraction.
risk for Sexual Dysfunction
Risk Factors May Include Situational crisis—incontinence/leakage of urine, involvement of genital area Vulnerability (e.g., change in health status, threat to self-concept)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Sexual Functioning NOC Report understanding of sexual function and alterations that may occur following surgery. Discuss concerns about possible changes in body image and sexual functioning with partner/significant other (SO). Demonstrate problem-solving skills regarding solutions to difficulties that occur.
ACTIONS/INTERVENTIONS
RATIONALE
Sexual Counseling NIC Independent Provide openings for client and SO to talk about concerns of incontinence and sexual functioning. Discuss basic anatomy. Be honest in answers to client’s questions.
Give accurate information about expectation of return of sexual function.
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May have anxieties about the effects of surgery and may be hesitant about asking necessary questions. Anxiety may have affected ability to access information given previously. The nerve plexus that controls erection runs posteriorly to the prostate through the capsule. In procedures that do not involve the prostatic capsule, impotence and sterility are usually not consequences. Surgical procedure may not provide a permanent cure, and hypertrophy may recur. Physiological impotence occurs when the perineal nerves are cut during radical procedures; with other approaches, sexual activity can usually be resumed within weeks. If erectile dysfunction persists after healing is complete, client may want to pursue options to restore function—use of medications such as sildenafil citrate (Viagra). Note: Coincident erectile dysfunction and bladder neck contracture have been
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Discuss retrograde ejacul*tion if transurethral or suprapubic approach is used.
reported postoperatively in approximately 2% to 3% of patients following suprapubic prostatectomy (Miles, 2011). Seminal fluid goes into the bladder and is excreted with the urine. This does not interfere with sexual functioning, but will decrease fertility and cause urine to be cloudy. Note: Retrograde ejacul*tion has been reported in up to 80% to 90% of patients after surgery (Miles et al, 2011). Tightening pelvic floor muscles prior to standing, coughing, and sneezing promotes regaining bladder and, perhaps, erectile function.
Collaborative Refer to sexual counselor as indicated.
NURSING DIAGNOSIS:
Persistent or unresolved problems may require professional intervention.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall, information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instruction
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Disease Process NOC Verbalize understanding of surgical procedure and potential complications. Initiate necessary lifestyle changes.
Knowledge: Treatment Regimen NOC Verbalize understanding of therapeutic needs. Correctly perform necessary procedures and explain reasons for actions. Participate in therapeutic regimen.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Review implications of procedure and future expectations. Stress necessity of good nutrition; encourage inclusion of fruits and increased fiber in diet. Advise client to avoid or limit intake of caffeine, citrus juices, carbonated beverages, and spicy foods for first few weeks after surgery. Discuss initial activity restrictions, such as avoidance of heavy lifting, strenuous exercise, prolonged sitting, long car trips, and climbing more than two flights of stairs at a time. Encourage continuation of perineal exercises. Instruct in urinary catheter care if present. Identify source for supplies and support. Instruct client to avoid tub baths after discharge. Review signs and symptoms requiring medical evaluation: erythema, purulent drainage from wound sites; inability to urinate, changes in character or amount of urine, presence of urgency or frequency; and heavy clots or bright red bleeding, fever, or chills. Provide written information to client and SO regarding recovery expectations and home management, as indicated, regarding pain, incision care, and catheter-related problems and care.
Provides knowledge base from which client can make informed choices. Promotes healing and prevents constipation, reducing risk of postoperative bleeding. Acidic substances can lower urine pH, thereby aggravating dysuria (Shiller, 2007). Increased abdominal pressure and straining places stress on the bladder and prostate, potentiating risk of bleeding. Facilitates urinary control and alleviation of incontinence. Promotes independence and competent self-care. Catheter may be in place only on day of surgery when laser procedure is done or for days to weeks with other procedures. Decreases the possibility of introduction of bacteria or undue tension on incision. Prompt intervention may prevent serious complications. Note: Urine may appear cloudy for several weeks until postoperative healing occurs and may appear cloudy after intercourse because of retrograde ejacul*tion. Anxiety related to hospitalization; procedure performed; and associated diagnosis, fatigue, and postoperative pain often makes it difficult for client to absorb necessary self-care information. (continues on page 572)
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RENAL AND URINARY TRACT—PROSTATECTOMY
Instruct in perineal and pelvic floor exercises and interruption of urinary stream exercises.
RATIONALE (continued)
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ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Stress importance of follow-up care—evaluation by primary healthcare provider, urologist or oncologist, and laboratory studies. Provide information on available community resources, such as home-health services, medical equipment supply company, housekeeping, and support persons.
Monitoring and follow-up can reduce incidence of unaddressed complications. Persistent incontinence and other postoperative issues will require additional evaluation and treatment. Can be helpful in assisting client and SO in coping with challenges they are faced with following prostatectomy, whatever the reason for procedure—BPH, cancer, incontinence, and so forth.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition, presence of complications, personal resources, and life responsibilities) In addition to surgical and cancer concerns: • impaired Urinary Elimination—loss of bladder tone, possible discharge with catheter in place • Sexual Dysfunction—situational crises (e.g., leakage of urine), altered body function (e.g., erectile dysfunction)
Sample clinical pathway follows in Table 10.1.
TABLE 10.1
TURP, Hospital. ELOS: 3 Days Urology or Surgical Unit
ND and Categories impaired Urinary Elimination R/T mechanical obstruction, loss of bladder tone, therapeutic intervention
Day 1 Day of Surgery_____ Display urine output individually appropriate, few clots and catheter free-flowing
Day 2 POD 1 _____ Verbalize understanding of homecare needs, S/S to report to healthcare provider
Referrals Additional assessments
Characteristics of urinary drainage
Home care →
Patient education
Urinary output q8h Presence of spontaneous voiding Foley catheter function, hygiene
Additional nursing actions
Foley catheter to straight drain, irrigate/CBI per protocol Bedrest if CBI Bed flat " 8 h if epidural anesthesia
acute Pain R/T physical agents: ureteral contractions, tissue trauma, edema Additional assessments
Report pain relieved/ controlled
Medications Allergies: ______ Patient education
Additional nursing actions
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Pain characteristics/ changes, presence of bladder spasms Response to interventions
→ → Perineal exercises Home-care needs, activity/dietary restrictions, sexual concerns S/S to report to healthcare provider → D/C Stand to void q2–4h Ambulate as tolerated Encourage fluids to 3 L/day as indicated →
→
Day 3 POD 2 Discharge ____ Void normal amounts w/o retention Demonstrate behaviors to regain bladder/ urinary control Plan in place to meet postdischarge needs Voiding frequency, character of urine Amount per void → Provide written instructions, schedule for follow-up visits
→ Per self q4h → Ad lib → → Verbalize understanding of pain management postdischarge →
→ Return of bowel function → PO analgesic → D/C Stool softener/laxative
→ → →
Reporting of pain/effects of intervention Relaxation techniques Routine comfort measures
→
→
Anchor catheter, avoid manipulation Maintain potency of catheter
→ Sitz bath as indicated
→ →
Analgesic of choice IM/PO q4h Antispasmotic prn
→
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TURP, Hospital. ELOS: 3 Days Urology or Surgical Unit (continued)
Diagnostic studies Additional assessments
Patient education Additional nursing actions
Day 1 Day of Surgery_____ Maintain adequate hydration with VS stable, palpable pulses, good capillary refill, adequate urinary output Free of active bleeding Characteristics of catheter drainage VS per postoperative protocol Peripheral pulses, capillary refill, status of skin q8h I&O q8h Mental status/restlessness q4h Temperature q8h IV therapy/blood products as indicated Fluid needs/restrictions Maintain catheter traction as indicated, release q4h per protocol Begin PO fluids as tolerated
Day 2 POD 1 _____ →
Day 3 POD 2 Discharge ____ →
→ Hb/Hct, RBC → Characteristics of urine → q8h →
→
→ → q8h → → D/C
→ D/C → D/C →
→ D/C → → D/C
→ D/C → D/C → Advance diet/fluids as tolerated
→
Key: ad lib, as desired; CBI, continuous bladder irrigation; D/C, discontinue; Hb/Hct, hemoglobin/hematocrit; IM, intramuscular; I&O, intake & output; PO, by mouth; prn, as needed; q2–4h, every 2 to 4 hours; q4h, every 4 hours; q8h, every 8 hours; RBC, red blood cell; R/T, related to; S/S, signs and symptoms; VS, vital signs.
UROLITHIASIS (RENAL CALCULI) I. Pathophysiology a. Presence of stones anywhere in the urinary tract i. Most commonly found in the renal pelvis and calyces 1. Stones forming in the kidney—nephrolithiasis 2. Stones formed in the ureters—ureterolithiasis ii. May be single or multiple calculi, ranging in size from a grain of salt to the size of a pebble or staghorn calculus b. Composition of calculi (Wolf, 2013; Miller, 2007) i. Formed of mineral deposits—predominantly calcium oxalate and calcium phosphate. Note: About 70% to 80% of renal calculi are calcium stones ii. Uric acid (5% to 10%), struvite (5% to 15%), and cystine (1%) are also calculus formers II. Etiology a. Slow urine flow allows accumulation of crystals—damaging the lining of the urinary tract and decreasing the number of inhibitor substances that would prevent crystal accumulation (Winkleman, 2006). b. May remain asymptomatic until passed into a ureter or urine flow is obstructed, at which time the potential for renal damage is acute and the level of pain is at its highest c. Causes: dehydration; heredity; excessive intake of vitamins A and D, grapefruit juice, and purines (gout); congenital renal abnormalities; and some medications, such as acetazolamide (Diamox), indinavir (Crixivan), dilantin, some antibiotics (e.g., ceftriazone [Rocephin], ciprofloxacin [Cipro]) (Wedro, 2010)
d. Risk factors: men aged 30 to 50, postmenopausal women; gender: male-to-female ratio 3:1; heredity may play a part in hypercalcuria; recurrent urinary tract infections; certain chronic conditions (e.g., cystic fibrosis, inflammatory bowel disease, hyperparathyroidism, hypertension); insulin resistance; prolonged bedrest; spinal cord injury; some geographic locations—southeastern United States; use of antacids or aspirin (Wedro, 2010) III. Statistics (Centers for Disease Control and Prevention [CDC], 2006) a. Morbidity: Each year in the United States more than 300,000 people go to emergency rooms for kidney stone problems (National Kidney and Urologic Diseases Information Clearinghouse [NKUDIC], 2012). Kidney stones affect approximately 1 in 11 people in the United States. These data represent a marked increase in stone disease compared with the National Health and Nutrition Examination Survey (NHANES) III cohort study of 2002 (Scales, 2012). b. Mortality: Rare and related to development of acute kidney injury or comorbidities. Note: Mortality and morbidity are not increased with uric acid stones compared with other stones; however, the process that leads to excess uric acid production (e.g., malignancy, Lesch-Nyhan syndrome) may cause death (Fathallah-Shaykh, 2013). c. Cost: In 2007, $10.3 billion expended for treatment of upper urinary tract stones, and almost $200 million for lower urinary tract stones (Litwin, 2012).
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RENAL AND URINARY TRACT—UROLITHIASIS
ND and Categories risk for deficient Fluid Volume, R/T nausea and vomiting, postobstructive diuresis
Medications
CHAPTER 10
TABLE 10.1
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G L O S S A R Y Calcium oxalate stones: Kidney stones formed by calcium and oxalate crystals, which usually develop in acidic urine. Calcium phosphate stones: Kidney stones formed by calcium and phosphate crystals, which usually develop in alkaline urine. Cystine stones: Kidney stones made of cystine crystals. Extracorporeal shock wave lithotripsy (ESWL): Procedure whereby a shock wave is transmitted through the body to target a stone, thus fragmenting it. Hematuria: Blood in the urine. Hypercalciuria: High calcium in the urine—an inherited condition. Hyperoxaluria: Excretion of excessive amounts of oxalate in the urine. Polycythemia: Too many red blood cells (RBCs) in the circulation. Pyuria: Pus in the urine. Renal calyces: The perimeter of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major
calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Renal colic: Flank (side) pain caused by obstruction to the flow of urine caused by kidney or ureteral stones. Renal pelvis: The area at the center of the kidney where urine collects and is funneled into the ureter. Renal tubular acidosis: Condition associated with dehydration, metabolic acidosis, low potassium, and high chloride. Often associated with renal stones due to hypercalciuria (high calcium in urine). Staghorn calculi: Develops in the center of the kidney or pelvis, filling the entire pelvis and extending out into the calyces. Stent: Tube inserted into the ureter to bypass a stone or to keep the ureter open so urine flows freely from the kidney to the bladder. Struvite stone: Also known as magnesium ammonium phosphate—stones that are often present with infection. Ureterovesical junction: Joining of the ureters and bladder. Uric acid stones: Kidney stones made of pure uric acid crystals. These stones develop in acidic urine.
Care Setting
Related Concerns
Treatment is often handled at the community level or as an outpatient; acute episodes occasionally require inpatient treatment on a medical or surgical unit. On occasion, surgery is necessary to remove the stone(s).
Acute kidney injury (acute renal failure), 505 Fluid and electrolyte imbalances, page 885 Metabolic acidosis—primary base bicarbonate deficiency, page 450 Metabolic alkalosis—primary base bicarbonate excess, page 455 Psychosocial aspects of care, page 729
Client Assessment Database Dependent on size, location, and etiology of calculi.
D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
ACTIVITY/REST • Sedentary occupation or occupation in which client is exposed to high environmental temperatures • Activity restrictions or immobility due to a preexisting condition—debilitating disease, spinal cord injury—causing bones to release more calcium
CIRCULATION • Elevated blood pressure (BP) and pulse associated with pain, anxiety, or kidney failure • Warm, flushed skin, pallor
ELIMINATION • • • • •
History of recent or chronic urinary tract infection (UTI) Previous kidney stones Decreased urinary output, bladder fullness Burning, urgency with urination Diarrhea
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• Oliguria (retention, scant urine), hematuria, pyuria • Alterations in voiding pattern
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M AY E X H I B I T
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D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
(continued)
FOOD/FLUID • Abdominal distention, decreased or absent bowel sounds
RENAL AND URINARY TRACT—UROLITHIASIS
• Nausea and vomiting (common) • A high-protein, high-sodium, low-calcium diet, which may increase risk of some types of stones • Insufficient fluid intake, does not drink fluids well (common)
PAIN/DISCOMFORT • Acute episode of excruciating, colicky pain, with location depending on stone location; in the flank in the region of the costovertebral angle, may radiate to back, abdomen, and down to the groin and genitalia; constant dull pain suggests calculi located in the renal pelvis or calyces • May be described as acute, severe, and not relieved by positioning or any other measures
• Guarding, distraction behaviors, self-focusing • Tenderness in renal areas on palpation
SAFETY • Use of alcohol can contribute to dehydration and to uric acid stone formation. • Fever (uncommon)
TEACHING/LEARNING • Family history of kidney stones, kidney disease, hypertension, gout, chronic UTI, or hereditary disease, such as renal tubular acidosis, cystinuria, hyperoxaluria • History of small bowel disease, previous abdominal surgery, hyperparathyroidism • Use of antibiotics, antihypertensives, sodium bicarbonate, allopurinol, phosphates, thiazides, excessive intake of calcium or vitamin D • Use of herbal remedies for kidney stones, such as valerian, skullcap, wild yam, khella, marshmallow, slippery elm
DISCHARGE PLAN CONSIDERATIONS • May require dietary modifications, exercise program, pain management plan ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
BLOOD TESTS • Serum and urine blood urea nitrogen/creatinine (BUN/Cr): Helpful in delineating obstructive uropathy due to urolithiasis.
• Complete blood count (CBC): Battery of screening tests, which typically includes hemoglobin (Hb); hematocrit (Hct); RBC count, morphology; and white blood cell (WBC) count and differential. • Blood chemistry: Measures levels of calcium, phosphate, uric acid, sodium, potassium, chloride, bicarbonate, and albumin. If serum calcium levels are elevated, then testing for hyperparathyroidism is performed.
Blockage of urine flow below the kidneys causes postrenal azotemia (ratio greater than 15:1) without intrinsic renal disease. Abnormal levels—high in serum and low in urine—are secondary to high obstructive stones with reduced urine output. Hgb/Hct—abnormal if client is severely dehydrated or client is anemic (hemorrhage, kidney dysfunction or failure) RBCs—usually normal WBCs—may be increased, indicating infection These tests are done if complications associated with kidney stones are suspected or present.
(continues on page 576)
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Diagnostic Studies TEST WHY IT IS DONE
(continued)
(continued)
W H AT I T T E L L S M E
(continued)
URINE TESTS • Urinalysis: Simple screening test may suggest type of stone and presence of infection.
• Urine (24-hour): Measures urine volume, pH, and levels of calcium, sodium, uric acid, oxalate, citrate, and creatinine. • Urine culture: Identifies presence of infection and causative agent.
Color may be yellow, dark brown, or bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, and pus. pH may be less than 5.0, which promotes cystine and uric acid stones, or higher than 7.5, which promotes magnesium, struvite, phosphate, or calcium phosphate stones. Helps identify degree of obstruction and type of stone—especially important for long-term management in client who is prone to stone formation. May reveal UTI and identify organism (e.g., Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas) as cause for stone development—struvite or infection stone.
OTHER DIAGNOSTIC STUDIES • Renal helical or spiral computerized tomography (CT) scan: Continuous motion image providing detailed views of the kidneys, ureters, and bladder in a shorter period of time. • Abdominal x-ray of kidneys-ureters-bladder (KUB): Usually ordered to evaluate hematuria flank pain. • Kidney ultrasound and intrarenal Doppler ultrasound: Determines obstructive changes and location of stone without the risk of kidney failure that can be induced by contrast medium.
• Intravenous urogram (IVU; also known as intravenous pyelogram [IVP]): Kidney x-ray performed by injecting radiopaque contrast into a vein. Multiple pictures of the kidneys are taken to follow the uptake and excretion of the contrast by the kidneys.
Identifies and delineates calculi and other masses, as well as kidney, ureteral, and bladder distention. Contrast is not used because it masks the stones. Note: This test has largely replaced IVP as the definitive diagnostic test for stones (Wolf et al, 2013). Shows presence of calculi and anatomic changes in the area of the kidneys or along the course of the ureter. May show small stones that can pass unnoticed. Ultrasound is used to show obstruction to the kidney. However, small kidney stones that are not obstructing may be missed. Renal Doppler ultrasound improves the detection of early obstruction by evaluating for elevated resistive index (RI) in kidney with nondilated collecting system. Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures, such as distended ureter, and outline of calculi.
Nursing Priorities
Discharge Goals
1. 2. 3. 4.
1. 2. 3. 4.
Alleviate pain. Maintain adequate renal functioning. Prevent complications. Provide information about disease process, prognosis, and treatment needs.
NURSING DIAGNOSIS:
Pain relieved or controlled. Fluid and electrolyte balance maintained. Complications prevented or minimized. Disease process, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge.
acute Pain
May Be Related To Physical agents (e.g., tissue trauma, ureteral contractions, edema formation, cellular ischemia)
Possibly Evidenced By Verbalized/coded reports of pain Expressive behaviors (e.g., restlessness, moaning) Self-focus; facial mask of pain (e.g., grimacing) Guarding behaviors
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain is relieved, with spasms controlled. Appear relaxed and able to sleep/rest appropriately.
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RATIONALE
Pain Management NIC Independent
Explain cause of pain and importance of notifying care providers of changes in pain occurrence or characteristics.
Provide such comfort measures as back rub and restful environment. Apply warm compresses to back. Assist with and encourage use of focused breathing, guided imagery, and diversional activities. Encourage frequent ambulation as indicated; increase fluid intake to at least 3 to 4 L/day within cardiac tolerance. Note reports of increased or persistent abdominal pain.
Helps evaluate site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, and genitalia because of proximity of nerve plexus and blood vessels supplying these areas. Sudden, severe pain may precipitate apprehension, restlessness, and severe anxiety. Provides opportunity for timely administration of analgesia and alerts care providers to possibility of passing of stone or developing complications. Sudden cessation of pain usually indicates stone passage. Promotes relaxation, reduces muscle tension, and enhances coping. Reduces muscle tension and may reduce reflex spasms. Redirects attention and aids in muscle relaxation. Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation. Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acuter surgical emergency.
Collaborative Administer medications, as indicated, for example: Analgesics, including narcotics (e.g., morphine sulfate [Astramorph], butorphenol [Stadol]; combination opiods such as oxycodone and acetaminophen [Percocet]; and NSAIDs such as ketorolac [Toradol], diclofenac [Voltaren], and ibuprophen
Antispasmodics, such as flavoxate (Urispas) and oxybutynin (Ditropan); calcium channel blockers, such as nifedipine (Adalat); and alpha-adrenergic blockers, such as tamsulosin (Flomax) Maintain patency of catheters when used.
NURSING DIAGNOSIS:
Acute renal colic may be the most painful event a person can endure. Striking without warning, the pain is often described as excruciating, and the client is unable to find a position of comfort. Parenteral narcotics have traditionally been prescribed for acute renal colic and are often required in the early phases of treatment, but NSAIDs are also effective for moderate to severe pain. Note: NSAIDs should be avoided in client with poor renal function or a history of gastrointestinal bleeding (Wolf, 2013; Miller, 2007). Decreases reflex spasm and relaxes ureteral smooth muscle, which facilitates stone passage. Note: Oral analgesics, NSAIDs, and alpha-adrenergic blockers help facilitate stone passage after acute attack. Prevents urinary stasis or retention, reduces risk of increased renal pressure and infection.
impaired Urinary Elimination
May Be Related To Anatomic obstruction
Possibly Evidenced By Dysuria Urgency; frequency Retention
Desired Outcomes/Evaluation Criteria—Client Will Urinary Elimination NOC Void in normal amounts of greater than or equal to 30 mL/hr and usual pattern. Experience no signs of retention
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RENAL AND URINARY TRACT—UROLITHIASIS
Document location, duration, intensity (0 to 10 or similar coded scale), and radiation. Note nonverbal signs—elevated BP, pulse and respirations, moaning and thrashing about.
CHAPTER 10
ACTIONS/INTERVENTIONS
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ACTIONS/INTERVENTIONS
RATIONALE
Urinary Elimination Enhancement NIC Independent Note urine output and characteristics of urine.
Determine client’s normal voiding pattern and note variations.
Encourage increased fluid intake, if nausea is not present.
Strain all urine. Document any stones expelled and send to laboratory for analysis. Investigate reports of bladder fullness; palpate for suprapubic distention. Note decreased urine output and presence of periorbital or dependent edema. Observe for changes in mental status, behavior, or level of consciousness (LOC).
Provides information about kidney function and presence of complications (such as infection and dehydration). Bleeding may also indicate increased obstruction or irritation of ureter. Calculi may cause urinary tract nerve excitability, which causes sensations of urgent need to void. Frequency and urgency usually increase as calculus nears the ureterovesical junction. Increased hydration dilutes urine and flushes bacteria, blood, and debris and may facilitate stone passage—especially small stones. Retrieval of calculi allows identification of type of stone and influences choice of therapy. Urinary retention may develop, causing bladder, ureteral, and kidney distention, exacerbating pain and potentiating risk of infection and renal failure. Accumulation of uremic wastes and electrolyte imbalances can be toxic to the central nervous system (CNS).
Collaborative Maintain patency of indwelling catheters—ureteral, urethral, or nephrostomy—when used.
Administer medications, as indicated, for example: Acetazolamide (Diamox) and allopurinol (Zyloprim)
Alpha-adrenergic blockers, e.g., tamsulosin (Flomax), terazosin (Hytrin)
Corticosteroids, such as prednisone (Deltasone) Penicillamine (Cuprimine), tiopronin (Thiola), and potassium citrate (Polycitra-K) Ammonium chloride and potassium or sodium phosphate Antibiotics Monitor laboratory studies, for example: Electrolytes, BUN, and Cr Urine culture and sensitivities
Prepare client for and assist with endoscopic procedures, such as the following: Basket procedure, percutaneous ultrasonic lithotripsy, and stent placement Extracorporeal shock wave lithotripsy (ESWL)
Percutaneous nephrolithotomy or open incision stone removal
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May be required to facilitate urine flow, preventing retention and corresponding complications. Catheters are positioned above the stone to promote urethral dilation and stone passage. Continuous or intermittent irrigation can be carried out to flush kidneys and ureters and adjust pH of urine to permit dissolution of stone fragments following lithotripsy. Increases urine pH (alkalinity) to reduce formation of acid stones. Antigout agents such as allopurinol also lower uric acid production and potential of uric acid stone formation. Although these drugs are designed specifically for prostatic hypertrophy, they have off-label use in treatment of kidney stones as smooth muscle relaxants, which facilitate passage of ureteral stones. May be used short-term to reduce tissue edema to facilitate movement of stones. Drugs may be prescribed to make urine more alkaline or bind cystine in the urine, when cystine stones cannot be controlled. Reduces phosphate stone formation. Antibiotics may be needed in presence of UTI or to keep urine bacteria-free to prevent struvite stone formation. Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction. Determines presence of UTI, which may be causing or complicating kidney stone symptoms; determines appropriate antibiotic therapy. For treatment of most kidney stones, shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy have largely replaced open surgery (Miller, 2007). Calculi in the distal and midureter may be removed by fiberoptic ureteroscope, which shatters the stone with a shock wave and captures it in a basket catheter. ESWL is the most frequently used outpatient procedure for treatment of stones that are not responsive to medical therapy, and has been found effective 80% to 85% of the time (Miller, 2007). Kidney stones are pulverized by shock waves delivered from outside the body while client reclines in water bath or on soft cushion. Note: ESWL is not ideal for large stones. Surgery may be necessary in about 15% to 20% of clients (Wolf, 2013) to remove a stone that is (1) too large to pass through ureters (e.g., >7 mm in diameter), (2) is caught in a difficult place, (3) blocks flow of urine, (4) causes or exacerbates ongoing urinary tract infection (UTI), (5) causes constant bleeding, or (6) is potentially damaging to kidney tissue. One advantage to the open procedure is that stone fragments are removed at surgery rather than relying on natural passage from the kidneys or urinary tract. Client may have a small drainage tube left in kidney or ureters during the healing process.
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NURSING DIAGNOSIS:
risk for deficient Fluid Volume
Risk Factors May Include Active fluid loss (e.g., nausea, vomiting) Failure of regulatory mechanisms (e.g., postobstructive diuresis) (Not applicable; presence of signs or symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Fluid Volume NOC Maintain adequate fluid balance as evidenced by vital signs and weight within client’s normal range, palpable peripheral pulses, moist mucous membranes, and good skin turgor.
ACTIONS/INTERVENTIONS
RATIONALE
Fluid/Electrolyte Management NIC Independent Monitor I&O.
Document incidence and note characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events. Increase fluid intake to 3 to 4 L/day within cardiac tolerance.
Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes. Weigh daily.
Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment. Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs and symptoms of heart failure (HF). Nausea or vomiting and diarrhea are commonly associated with renal colic because celiac ganglion serves both kidneys and stomach. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi. Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out. Note: Patients with recurrent kidney stones traditionally have been instructed to drink 8 glasses of fluid daily to maintain adequate hydration and decrease chance of urinary supersaturation with stoneforming salts. The goal is a total urine volume in 24 hours in excess of 2 liters (Wolf, 2013). Indicators of hydration and circulating volume and need for intervention. Rapid weight changes suggest water loss or retention.
Collaborative Monitor Hgb/Hct and electrolytes. Administer IV fluids. Provide appropriate diet, clear liquids, and bland foods, as tolerated. Administer medications, as indicated, for example, antiemetics, such as metoclopramide (Reglan), ondansetron (Zofran), promethazine (Phenergan), or droperidol (Inapsine).
NURSING DIAGNOSIS:
Assesses hydration and effectiveness of, or need for, interventions. Maintains circulating volume if oral intake is insufficient, promoting renal function. Easily digested foods decrease gastrointestinal (GI) activity or irritation and help maintain fluid and nutritional balance. Reduces nausea and vomiting.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall; information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Acute Illness Management NOC Verbalize understanding of disease process and potential complications. Correlate symptoms with causative factors. Verbalize understanding of therapeutic needs. Initiate necessary lifestyle changes and participate in treatment regimen.
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RENAL AND URINARY TRACT—UROLITHIASIS
Possibly Evidenced By
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ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Review disease process and future expectations. Stress importance of increased fluid intake, such as 3 to 4 L/day if not contraindicated. Encourage client to notice dry mouth and excessive diuresis or diaphoresis and to increase fluid intake whether or not feeling thirsty. Review dietary regimen, as individually appropriate, for example:
Low-purine diet, such as limited lean meat, turkey, legumes, whole grains, and alcohol Low-oxalate diet, such as limited chocolate, caffeine-containing beverages, beets, nuts, rhubarb, strawberries, spinach, and wheat bran
Limit calcium intake to about 800 mg/day when appropriate. Use calcium citrate when supplements are required.
Shorr regimen: low-calcium and phosphorus diet with aluminum carbonate gel 30 to 40 mL 30 minutes after meals and at bedtime Encourage foods rich in magnesium and vitamins B and K Discuss medication and herbal supplement regimen; avoidance of over-the-counter (OTC) drugs, and reading all product and food ingredient labels.
Encourage client to reveal all medications and herbals to physician or pharmacist. Emphasize need for smoking cessation, when indicated. Encourage regular activity and exercise program. Active-listen concerns about therapeutic regimen and lifestyle changes. Identify signs and symptoms requiring medical evaluation, such as recurrent pain, hematuria, and oliguria.
Demonstrate proper care of incisions or catheters if present.
Provides knowledge base from which client can make informed choices. Flushes renal system, decreasing opportunity for urinary stasis and stone formation. Increased fluid losses or dehydration require additional intake beyond usual daily needs. Diet depends on the type of stone. Understanding reason for modifications provides opportunity for client to make informed choices, increases cooperation with regimen, and may prevent recurrence. Decreases oral intake of uric acid precursors. Reduces calcium-oxalate stone formation. Note: Research suggests that daily inclusion of coffee, tea, beer, or wine decreases the risk of stone formation, whereas regular intake of apple or grapefruit juice increases the risk (Finkielstein & Goldfarb, 2006). Although not advocating high-calcium diets, researchers are urging that calcium limitation be reexamined. Research suggests that restricting dietary calcium is not helpful in reducing calcium stone formation and may actually increase oxalate formation. Use of citrate is helpful in binding oxalate and improving calcium absorption. Prevents phosphoric calculi by forming an insoluble precipitate in the GI tract, reducing the load to the kidney nephrons. Also effective against other forms of calcium calculi. Note: May cause constipation. These nutrients reduce stone formation. Drugs will be given to acidify or alkalize urine, depending on underlying cause of stone formation. Ingestion of products containing individually contraindicated ingredients, such as calcium and phosphorus, potentiates recurrence of stones. Note: Some herbal supplements—valerian, skullcap, wild yam, khella, and marshmallow—are known to have antispasmodic properties or are soothing to irritated urinary tissues. To reduce risk of dangerous interactions and side effects. Cigarette smoking may contribute to kidney stones because it increases urine levels of cadmium, a heavy metal. Inactivity contributes to stone formation through calcium shifts and urinary stasis. Helps client work through feelings and gain a sense of control over what is happening. With increased probability of stone recurrence, prompt interventions may prevent serious complications. Note: Rate of recurrence at 1 year is 14%; at 2 years, 35%; and at 10 years, 52% (Wolf, 2013). Promotes competent self-care and independence.
POTENTIAL CONSIDERATIONS following acute hospitalizations (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) • impaired Urinary Elimination—recurrence of calculi
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CHAPTER
11
Women’s Reproductive HYSTERECTOMY I. Indications—surgical removal of the uterus a. Malignancies: Cancer of the uterus, or endometrial cancer, is the most common gynecological cancer in the United States, and in 2000, 11% of hysterectomies were due to cancer (Greenlee, 2000; Encyclopedia of Surgery, n.d.). b. Nonmalignant conditions, such as endometriosis, fibroid tumors; pelvic relaxation with uterine prolapse that leads to disabling levels of pain, discomfort, uterine bleeding, emotional stress c. Life-threatening bleeding or hemorrhaging, such as obstetric or traumatic complication; irreparable rupture of the uterus d. Treatment of intractable pelvic infection II. Procedures a. Abdominal hysterectomy i. Subtotal or partial: removal of body of uterus; cervical stump remains ii. Total: removal of the uterus and cervix iii. Total with bilateral salpingo-oophorectomy: removal of uterus, cervix, fallopian tubes, and ovaries iv. Total pelvic exenteration (TPE): Complex, aggressive surgical procedure involving radical hysterectomy with dissection of pelvic lymph nodes, bilateral salpingooophorectomy, total cystectomy, and abdominoperineal resection of the rectum; colostomy and/or urinary conduit are created, and vagin*l reconstruction may or may not be performed. (Refer to additional care plans regarding fecal or urinary diversions, as appropriate.) b. vagin*l hysterectomy or laparoscopically assisted vagin*l hysterectomy (LAVH) i. Limited to certain conditions, such as uterine prolapse, cystocele or rectocele, carcinoma in situ, and high-risk obesity
ii. Requires removal of cervix iii. Advantages: less pain, no visible (or much smaller) scars, shorter hospital stay, and shorter recovery period of about 3 to 4 weeks (vagin*l) and 2 weeks (LAVH) versus approximately 6 weeks (abdominal) c. Laparoscopic-assisted abdominal supracervical hysterectomy (LASH) i. Can be performed in presence of mild to moderate adhesions or large uterus ii. A single abdominal incision is used instead of three iii. Removal of cervix not required iv. Usually done on outpatient basis, with a recovery period of about 1 week III. Statistics (Centers for Disease Control and Prevention [CDC], 2008) a. Morbidity: For 2000–2004 it was reported that 600,000 hysterectomies were performed annually, and during that four-year period an estimated 3.1 million women had a hysterectomy. The three conditions most often associated with hysterectomy during that four-year period were fibroid tumors, endometriosis, and uterine prolapse. b. Mortality: Death rate is reported as 1 per thousand (Encyclopedia of Surgery, n.d.; National Women’s Health Network [NWHN], 2005; Surgery.com, 2009). c. Cost: Direct care costs $3.7 billion for both abdominal and vagin*l hysterectomy in 2009 (Pfunter, 2012).
W H AT I T T E L L S M E
G L O S S A R Y Cervix: Lower end or neck of the uterus, which protrudes into the vagin*. DUB: Dysfunctional uterine bleeding (a common symptom in women undergoing hysterectomy when bleeding does not respond to other treatments). Endometriosis: Ectopic endometrial tissue found outside the uterine cavity, usually in the ovaries, fallopian tubes, and other pelvic structures. Endometriosis is the cause for about 20% of hysterectomies (Gor, 2012). Fibroids: Benign tumors that form in the uterine muscle; also called leiomyomas. Fibroids are the cause for about 33% of hysterectomies (Gor, 2012).
Laparoscopy: Use of a slender, light-transmitting tube to view abdominal organs or perform surgery. Leiomyoma: Benign soft tissue tumors that arise from smooth muscle, increase in size and frequency as a woman ages, but revert to size postmenopause; also called fibroids. Menopause: Permanent cessation of menstrual activity. Uterine prolapse: Displacement or sagging of the uterus into the vagin*. Prolapse accounts for about 5% of hysterectomies (Gor, 2012).
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Care Setting
Related Concerns
Procedure is performed in inpatient acute surgical unit or short-stay unit or outpatient, depending on type performed.
Cancer, page 827 Psychosocial aspects of care, page 729 Surgical intervention, page 762 Thrombophlebitis: venous thromboembolism, page 109
Client Assessment Database Data depend on the underlying disease process and the need for surgical intervention—cancer, prolapse, dysfunctional uterine bleeding, severe endometriosis, or pelvic infections unresponsive to medical management—and associated complications, such as anemia.
T E AC H I N G / L E A R N I N G
DISCHARGE PLAN CONSIDERATIONS • May need temporary help with transportation and homemaker and maintenance tasks ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies WHY IT IS DONE
W H AT I T T E L L S M E
• Pelvic examination: Identifies uterine and/or other pelvic organ irregularities. • Pap smear: Screening test for cervical cancer and certain vagin*l or uterine infections. • Pelvic ultrasound or computed tomography (CT) scan: Creates an electronic picture of the organs and structures within the pelvis. • Sonohysterogram: A saline-enhanced sonogram or ultrasound.
May reveal masses, tender nodules, visual changes of cervix, requiring further diagnostic evaluation. Cellular dysplasia reflects possibility of or actual presence of cancer, which may affect choice of procedure. Aids in identifying size and location of pelvic mass.
• Hysteroscopy: Uses fiberoptic viewing scope and a distending medium, such as carbon dioxide, to directly view the uterine cavity and/or biopsy growths. • Laparoscopy: Visualizes pathology, obtains biopsies, or performs laser treatment for endometriosis. • Endometrial sampling: Dilation and curettage (D&C) with biopsy of endometrial or cervical tissue for histopathological study of cells. • Schiller’s test (staining of cervix with iodine): Useful in identifying abnormal cells. • Complete blood count (CBC): Useful in determining general health status.
• Sexually transmitted disease (STD) screen: Determines presence of infection.
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Evaluates abnormal growths inside the uterus, lining of the uterus, and deeper tissue layers. Delineates polyps and submucosal fibroids. Viewed by some to be the “gold standard.” Determines cause of abnormal bleeding. May reveal source of bleeding, presence of tumors, and superficial peritoneal implants of endometriosis; determines cancer staging and assesses effects of chemotherapy. Determines presence and location of cancer.
Cervix turns dark brown in noncancerous areas and white or yellow in possible cancerous areas. Decreased hemoglobin (Hgb) may reflect chronic anemia; decreased hematocrit (Hct) suggests active blood loss; and elevated white blood cell (WBC) count may indicate inflammation and infectious process. Human papillomavirus (HPV) is present in 80% of clients with cervical cancer.
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1. Support adaptation to change. 2. Prevent complications. 3. Provide information about procedure, prognosis, and treatment needs.
1. 3. 4. 5.
Situation being dealt with realistically. Complications prevented or minimized. Procedure, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge.
In addition to these NDs, see nursing actions and interventions listed in CP: Surgical Intervention.
NURSING DIAGNOSIS:
risk for [acute] Urinary Retention
Risk Factors May Include Blockage (e.g., mechanical trauma, surgical manipulation, perineal swelling, hematoma) [Sensory and motor impairment—nerve paralysis]
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Urinary Elimination NOC Empty bladder regularly and completely.
ACTIONS/INTERVENTIONS
RATIONALE
Urinary Elimination Management NIC Independent Note voiding pattern and monitor urinary output, once surgical catheter is removed. Palpate bladder. Investigate reports of discomfort, fullness, and inability to void. Provide routine voiding measures, such as privacy, normal position, running water in sink, and pouring warm water over perineum. Provide and/or encourage good perineal cleansing and catheter care when present. Assess urine characteristics, noting color, clarity, and odor.
May indicate urinary retention if voiding frequently in small or insufficient amounts less than 100 mL. Perception of bladder fullness and distention of bladder above symphysis pubis indicates urinary retention. Promotes relaxation of perineal muscles and may facilitate voiding efforts. Promotes cleanliness, reducing risk of ascending urinary tract infection (UTI). Urinary retention, vagin*l drainage, and possible presence of intermittent or indwelling catheter increase risk of infection, especially if client has perineal sutures.
Collaborative Catheterize when indicated per protocol if client is unable to void or is uncomfortable.
Maintain patency of indwelling catheter; keep drainage tubing free of kinks. Check residual urine volume after voiding, as indicated.
NURSING DIAGNOSIS:
Edema or interference with nerve supply may cause bladder atony or urinary retention requiring decompression of the bladder. Note: Indwelling urethral or suprapubic catheter may be inserted intraoperatively if complications are anticipated. Promotes free drainage of urine, reducing risk of urinary stasis or retention and infection. May not be emptying bladder completely; retention of urine increases possibility for infection and is uncomfortable, even painful.
risk for Constipation
Risk Factors May Include Functional—abdominal muscle weakness Mechanical—pain or discomfort in abdomen or perineal area Physiological—decreased gastrointestinal motility, changes in dietary intake Pharmacological—use of opiates
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis) (continues on page 584)
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Discharge Goals
CHAPTER 11
Nursing Priorities
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NURSING DIAGNOSIS:
risk for Constipation
(continued)
Desired Outcomes/Evaluation Criteria—Client Will Bowel Elimination NOC Display active bowel sounds and peristaltic activity. Maintain usual pattern of elimination.
ACTIONS/INTERVENTIONS Bowel Management NIC Independent Auscultate bowel sounds. Note abdominal distention and presence of nausea or vomiting. Assist client with sitting on edge of bed and walking. Encourage adequate fluid intake, including fruit juices, when oral intake is resumed. Provide sitz baths.
RATIONALE
Indicators of presence or resolution of ileus, affecting choice of interventions. Early ambulation helps stimulate intestinal function and return of peristalsis. Promotes softer stool; may aid in stimulating peristalsis. Promotes muscle relaxation and minimizes discomfort.
Collaborative Restrict oral intake as indicated. Maintain nasogastric (NG) tube, if present. Provide clear or full liquids and advance to solid foods as tolerated. Administer medications, such as stool softeners, mineral oil, and laxatives, as indicated.
NURSING DIAGNOSIS:
Prevents nausea and vomiting until peristalsis returns in 1 to 2 days. May be inserted in surgery to decompress stomach. When peristalsis begins, food and fluid intake promote resumption of normal bowel elimination. Promotes formation and passage of softer stool.
risk for ineffective Tissue Perfusion (specify)
Risk Factors May Include Deficient knowledge of aggravating factors (e.g., dehydration, immobility, smoking) [Intraoperative pressure on pelvic or calf vessels; pelvic congestion, postoperative tissue inflammation, venous stasis]
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: (Specify) NOC Demonstrate adequate perfusion, as evidenced by stable vital signs, palpable pulses, good capillary refill, usual mentation, and individually adequate urinary output. Be free of edema and signs of thrombus formation.
ACTIONS/INTERVENTIONS
RATIONALE
Postanesthesia Care NIC Independent Monitor vital signs, palpate peripheral pulses and note capillary refill, assess urinary output and characteristics, and evaluate changes in mentation. Inspect dressings and perineal pads, noting color, amount, and odor of drainage. Weigh pads and compare with dry weight if client is bleeding heavily. Turn client and encourage frequent coughing and deep-breathing exercises. Assist with and/or encourage use of incentive spirometer.
Indicators of adequacy of systemic perfusion, fluid or blood needs, and developing complications. Proximity of large blood vessels to operative site and/or potential for alteration of clotting mechanism (e.g., cancer) increases risk of postoperative hemorrhage. Prevents stasis of secretions and respiratory complications. Promotes lung expansion and minimizes atelectasis.
Embolus Prevention NIC Avoid high Fowler’s position and pressure under the knees or crossing of legs. Assist with and instruct in foot and leg exercises and ambulate as soon as able. Note erythema, swelling of extremity, or reports of sudden chest pain with dyspnea.
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Creates vascular stasis by increasing pelvic congestion and pooling of blood in the extremities, potentiating risk of thrombus formation. Movement enhances circulation and prevents stasis complications. May be indicative of development of thrombophlebitis and pulmonary embolus.
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RATIONALE (continued)
Collaborative Apply sequential compression devices (SCDs): antiembolism stockings or pneumatic compression stocking and boots.
Aids in venous return; reduces stasis and risk of thrombosis.
Administer intravenous (IV) fluids and blood products, as indicated.
NURSING DIAGNOSIS:
Replacement of blood losses maintains circulating volume and tissue perfusion.
risk for Sexual Dysfunction
Risk Factors May Include Altered body structure (e.g., shortening of vagin*l canal) Altered body function (e.g., changes in hormone levels, possible change in sexual response pattern—absence of rhythmic uterine contractions during org*sm, vagin*l discomfort or pain) Biopsychosocial alteration of sexuality (e.g., decreased libido; sense of femininity)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Sexual Functioning NOC Verbalize understanding of changes in sexual anatomy or function. Discuss concerns about body image, sex role, and desirability as a sexual partner with SO. Identify satisfying and acceptable sexual practices and alternative ways of dealing with sexual expression.
ACTIONS/INTERVENTIONS
RATIONALE
Sexual Counseling NIC Independent Listen to comments of client and SO. Provide open environment for client to discuss concerns about sexuality.
Assess client’s and SO’s information regarding sexual anatomy, function, and effects of surgical procedure.
Identify cultural or value factors and conflicts present. Assist client to be aware of and deal with stage of grieving. Encourage client to share thoughts or concerns with partner. Problem-solve solutions to potential problems, such as postponing sexual intercourse when fatigued, substituting alternative means of expression, using positions that avoid pressure on abdominal incision, and using vagin*l lubricant or vagin*l estrogen product. Discuss expected physical sensations or discomforts and changes in response, as appropriate to the individual.
Sexual concerns are often disguised as humor and/or offhand remarks. An open environment promotes sharing of beliefs or values about sensitive subject and identifies misconceptions or myths that may interfere with adjustment to situation. May have misinformation or misconceptions that can affect adjustment. Negative expectations are associated with poor overall outcome. Changes in hormone levels can affect libido and decrease suppleness of the vagin*. Although a shortened vagin* can eventually stretch, intercourse initially may be uncomfortable or painful. May affect return to satisfying sexual relationship. Acknowledging normal process of grieving for actual or perceived changes may enhance coping and facilitate resolution. Open communication can identify areas of agreement and problems and promote discussion and resolution. Helps client return to desired and satisfying sexual activity. It may be of help to the client/partner to learn that there is abundant evidence in the medical literature supporting favorable sexual outcomes from hysterectomy (Katz, 2003) given time for recovery. vagin*l pain may be significant following vagin*l procedure, or sensory loss may occur because of surgical trauma. Research data show a trend toward more problems with lubrication, arousal, and altered genital sensation after total hysterectomy as compared to vagin*l hysterectomy. Altered hormone levels and loss of sensation of rhythmic contractions of the uterus during org*sm can impair sexual satisfaction for some women (American College of Obstetricians and Gynecologists [ACOG], 2011). Note: Many women experience few negative effects because fear of pregnancy is gone, and relief from symptoms often improves sexual pleasure.
Collaborative Refer to counselor or sex therapist as needed.
May need additional assistance to promote a satisfactory outcome.
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Postanesthesia Care NIC
CHAPTER 11
ACTIONS/INTERVENTIONS (continued)
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NURSING DIAGNOSIS:
Grieving
May Be Related To Loss of significant object (e.g., parts and processes of body/perceived sexual role or identity)
Possibly Evidenced By Making meaning of loss Experiencing relief
Desired Outcomes/Evaluation Criteria—Client Will Grief Resolution NOC Verbalize reality of perceived loss. Report sense of acceptance and hope for future.
ACTIONS/INTERVENTIONS
RATIONALE
Grief Work Facilitation NIC Independent Provide open environment in which client feels free to discuss realistic feelings and concerns without confrontation.
Discuss client’s perceptions of self, related to anticipated changes and her specific lifestyle.
Determine client’s perception and meaning of current and past losses. Note cultural factors and expectations. Assess emotional stress client is experiencing.
Encourage client to vent feelings appropriately, identifying meaning of loss.
Assist family/SO to cope with client’s responses. Identify and problem-solve solutions to existing physical responses—eating, sleeping, activity levels, and sexual desire. Note withdrawn behavior, negative self-talk, and overconcern with actual or perceived changes. Discuss healthy ways of dealing with difficult situation.
Therapeutic communication skills, such as active-listening, silence, being available, and acceptance, provide opportunity and encouragement for the client to talk freely and deal with the perceived loss. Provides opportunity for reflection aiding resolution and acceptance. Research supports the idea that hysterectomy is physiologically and psychologically stressful for a woman, even when she desires the procedure. The prospect of hysterectomy is said to engender more stress than other comparable surgeries. Cultural beliefs may result in delaying needed surgery, increasing risk of complications and negatively impacting recovery (Augustus, 2002). Although preoperative instruction and interaction are often performed at the community level, the postoperative care providers can convey interest and concern and make opportunities for support, teaching, and correction of misconceptions, such as loss of femininity and sexuality, weight gain, and menopausal body changes. Affects client’s response and needs to be acknowledged in planning care. Perceptions and way of expressing self may be result of cultural expectations. Being aware of what this operation means to client helps avoid inadvertent casualness or oversolicitude by care providers. Note: Women in their thirties who have hysterectomies are at risk for some degree of depression. Some of the feelings are part of the grieving process associated with never being able to bear children again. The degree of depression can be compounded by a trauma response and the significance attached to not being able to conceive. For others, depression can be the result of the abrupt hormonal changes that can accompany a hysterectomy in a woman who is not yet premenopausal (Bauers, 2010). Depending on the reason for the surgery (e.g., cancer or longterm, heavy bleeding), the client may be frightened or relieved. She may mourn the loss of ability to fulfill her reproductive role whether or not she has borne children. She may also worry about her wholeness as a woman or have heard stories about problems others have had with the procedure. Family may not share client’s perspective and be intolerant, not recognizing needs of client. May need additional assistance to deal with the physical aspects of the potential for grieving. May indicate difficulty in working through the grief process and need for additional interventions or support. Provides opportunity to look toward the future and incorporate perceived loss into lifestyle.
Collaborative Refer to other resources for counseling, spiritual or pastoral care, and psychotherapy, as indicated.
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May need additional help to prevent development of dysfunctional grieving and help client move toward a positive future.
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deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To
WOMEN’S REPRODUCTIVE—HYSTERECTOMY
Lack of exposure or recall Information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Disease Process NOC Verbalize understanding of condition and potential complications. Identify relationship of signs and symptoms related to surgical procedure and actions to deal with them.
Knowledge: Treatment Regimen NOC Verbalize understanding of therapeutic needs.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Review effects of surgical procedure and future expectations; for example, the client needs to know that she will no longer menstruate or bear children, whether surgical menopause will occur, and whether hormonal replacement will be necessary. Discuss complexity of problems anticipated during recovery, including emotional lability and expectation of feelings of depression or sadness, excessive fatigue, sleep disturbances, and urinary problems.
Discuss resumption of activity. Encourage light activities initially, with frequent rest periods, increasing activities and exercise as tolerated. Stress importance of individual response in recuperation. Identify individual restrictions, such as avoiding heavy lifting and strenuous activities (such as vacuuming, straining at stool) and prolonged sitting or driving. Avoid tub baths and douching until physician authorizes.
Encourage client to report bowel dysfunction—constipation, loss of urge to defecate, severe straining, incomplete evacuation, and digital evacuation—to healthcare providers if it occurs. Discuss dietary modifications, medicinal bulk agents, and stimulation by suppository, as indicated. Review recommendations of resumption of sexual intercourse. (Refer to ND: risk for Sexual Dysfunction.) Identify dietary needs, such as high-quality protein, complex carbohydrates, and additional iron. Provide information about foods to include and avoid in managing menopausal symptoms.
Review hormone replacement therapy (HRT) and route (oral, injection, patch) when used. Clarify distinction between long-term HRT use for preventive therapy and short-term use for symptom relief.
CHAPTER 11
NURSING DIAGNOSIS:
Provides knowledge base from which client can make informed choices.
Physical, emotional, and social factors can have a cumulative effect, which may delay recovery, especially if hysterectomy was performed because of cancer. Providing an opportunity for problem-solving may facilitate the process. Client and SO may benefit from the knowledge that a period of emotional lability is normal and expected during recovery. Client can expect to feel tired when she goes home and needs to plan a gradual resumption of activities, with return to work an individual matter. Prevents excessive fatigue; conserves energy for healing and tissue regeneration. Strenuous activity intensifies fatigue and may delay healing. Activities that increase intra-abdominal pressure can strain surgical repairs, and prolonged sitting potentiates risk of thrombus formation. Showers are permitted, but tub baths and douching may cause vagin*l or incisional infections and are a safety hazard. Constipation is a frequent symptom after hysterectomy and may be related to undiagnosed irritable bowel syndrome, which is often present preoperatively and/or associated with the particular procedure performed—vagin*l hysterectomy with posterior repair. Postsurgical bowel dysfunction may be short-term or longterm and may require simple home management measures or referral for medical intervention. When sexual activity is cleared by the physician, it is best to resume activity easily and gently, expressing sexual feelings in other ways or using alternative coital positions. Facilitates healing and tissue regeneration, helps correct anemia when present. Note: Certain vegetables, such as broccoli, cabbage, cauliflower, brussels sprouts, and turnips, may have protective action against excessive estrogen effects. Some foods and substances to avoid or limit include rich dairy products, sugar, fried foods, caffeine, alcohol, and nicotine. Total hysterectomy with bilateral salpingo-oophorectomy results in surgically induced menopause requiring replacement hormones. Benefits of HRT, particularly estrogen, include protection against osteoporosis and the (continues on page 588)
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ACTIONS/INTERVENTIONS (continued)
Encourage taking prescribed drug(s) routinely, for example, with meals or at bedtime. Determine when patch should be changed, wearing time altered. Discuss potential side effects, such as weight gain, increased skin pigmentation or acne, breast tenderness, headaches, and photosensitivity. Recommend cessation of smoking, especially when receiving estrogen therapy. Inquire if client is taking or planning to take vitamins and/or herbal supplements for menopause, such as vitamin C with bioflavonoids, calcium, magnesium, selenium, evening primrose oil, black cohosh, angelica, and wild yam.
Review incisional care, when appropriate. Emphasize importance of follow-up care.
Identify signs and symptoms requiring medical evaluation, such as fever or chills, change in character of vagin*l or wound drainage, and bright red bleeding. Identify support group and appropriate Web sites, as indicated.
RATIONALE (continued) amelioration of certain postmenopausal discomforts such as sleep disturbance, hot flashes, mood disorders, problems with memory and concentration, reduced libido, and urinary symptoms. Note: Regarding the media attention given in recent years to the risks of taking HRT, one author writes: “The risks of HRT—while real—are quite small for an individual person. For example, the 2002 Women’s Health Initiative study found that estrogen replacement therapy (ERT) increased the risk of strokes by 39%. That sounds frighteningly high. But the actual number of people affected is very small. Out of 10,000 women who are not taking ERT, 32 have strokes each year. Out of 10,000 who are taking ERT, 44 have strokes each year. That’s an increase of just 12 people out of 10,000” (Todd, 2012). This would seem to support the reason that most physicians continue to support the use of hormone replacement therapy, especially in younger women who have surgically induced menopause. Establishes routine for taking drug and reduces potential for discontinuing drug because of nausea that is often an early side effect. Development of some side effects is expected but may require problem-solving for the client to continue the hormones, such as change in dosage; change of delivery method; and use of analgesics, sunscreen, and sunglasses. Some studies suggest an increased risk of thrombophlebitis, myocardial infarction (MI), stroke, and pulmonary emboli associated with smoking and concurrent estrogen therapy. Client may express desire to use “natural hormones” and feel confused over choices. These substances are numerous and available and have been the object of media attention. They should be reviewed in terms of expected action, potential interaction, or adverse effects, depending on client’s particular situation and reason for the hysterectomy. Facilitates competent self-care, promoting independence. Provides opportunity to ask questions, clear up misunderstandings, and detect developing complications. Note: Client needs to discuss with the physician her particular requirements for follow-up pelvic exams with Pap smear, once surgical healing has occurred. The need and rationale for these exams depends upon the client’s reason for hysterectomy— benign fibroids versus cervical neoplasm. Early recognition and treatment of developing complications, such as infection or hemorrhage, may prevent life-threatening situations. May desire additional information or opportunity to discuss feelings or concerns with women with similar experiences. However, instruct client to exercise caution when choosing Internet resources and sharing personal information online (Bunde et al, 2007).
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition, and presence of complications, personal resources, and life responsibilities) In addition to surgical and cancer concerns (if appropriate): • Sexual Dysfunction—altered body structure and function, changes in hormone levels, decreased libido, possible change in sexual response pattern, vagin*l discomfort or pain (dyspareunia) • risk for situational low Self-Esteem—disturbed body image; loss (e.g., perceived changes in femininity, effect on sexual relationship, inability to have children); functional impairment (e.g., changes in sexual response pattern, decreased libido)
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4. Note: Invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) are the two most common types of invasive breast cancer. iii. Inflammatory breast cancer (IBC) (Cancer Treatment Centers of America [CTCA], 2012) 1. A rare (1% to 5%) and aggressive type of breast cancer 2. Starts within soft tissues of the breast and causes blocking of lymph vessels in the skin of the breast 3. Affects younger women more than other breast cancer types b. Clinical staging (National Comprehensive Cancer Network [NCCN], 2013) i. Classification: noninvasive, invasive (infiltrating) ii. Size and spread of tumor: T stage iii. Number of lymph nodes involved: N stage iv. Metastasis: M stage v. Grade measured from 0 to IV, with zero resembling normal breast tissue vi. Some stages further divided by letters of the alphabet (A, B, C, etc.) III. Statistics (National Cancer Institute [NCI], 2013; ACS, 2011) a. Morbidity: As of January 2012, approximately 2,477,847 American women had a history of breast cancer; in 2013, an estimated 232,340 new cases of breast cancer were diagnosed in women and 2,240 in men. b. Mortality: In 2009, breast cancer was the second leading cause of death in women in the United States; an estimated 39,520 women and 450 men died of breast cancer in 2011. c. Cost: $16.5 billion spent in United States in direct costs in 2010 (NCI, 2011), averaging $11,000 per Medicare client in first year following diagnosis and rising to just under $30,000 in the last year of life (Brown et al, 2002; Cancer Action Network, 2009).
G L O S S A R Y Adenocarcinoma: A carcinoma that originates in glandular tissue, or tissue responsible for the production and secretion of a substance. Breast ducts and lobules are examples of glandular tissues where adenocarcinomas may sometimes develop. Aromatase inhibitors (AIs): Newer drugs sometimes used in women who have already gone through menopause to treat breast cancer or reduce cancer recurrence after surgery. Instead of blocking estrogen receptors, they stop a key enzyme (called aromatase) from changing other hormones into estrogen, taking away the fuel that estrogen receptor-positive breast cancers need to grow. Breast-conserving therapy: Treatment of choice for most women with stage I or stage II breast cancer and usually followed with radiation therapy. Carcinoma: Cancer that originates in epithelial tissue cells, which are present both in the skin (epidermis) and in the lining of internal organs. The most common type of cancer. Grade: Determined by cellular differentiation; the lower the grade, the more it resembles normal breast tissue and the least likely it is to spread.
Infiltrating (invasive) breast cancer: Breast cancer that extends into the surrounding breast tissue and may metastasize. In situ (noninvasive) breast cancer: Breast cancer that is contained within a structure of the breast, such as a duct or lobe. Lumpectomy: Removes only the breast lump and a rim of normal surrounding breast tissue. Lymph node surgery: Removal of lymph node(s) to determine if breast cancer has spread to the lymph ducts or lymph nodes in the axilla. In tumors 2 cm or smaller in size, a sentinel procedure may be performed to remove only the node(s) deemed most likely to contain cancerous cells. In larger tumors, or if sentinel biopsy is positive, a traditional axillary lymph node dissection is performed. Metastasis: Cancer that has spread to other parts of the body. Modified radical mastectomy: Removal of entire breast and some axillary (underarm) lymph nodes. Partial or segmental mastectomy: Removes more breast tissue than a lumpectomy—up to one-quarter of the breast—which is then called a quadrantectomy. Radical mastectomy: All the muscle under the breast is removed; however, it is rarely used today because it is no more effective than the more limited forms of mastectomy. (continues on page 590)
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I. Purpose a. Removal of breast tissue due to presence of malignant or cancerous tumor changes b. Surgical procedures: dependent on tumor type, size, and location as well as clinical characteristics or staging i. Breast-conserving therapy ii. Lumpectomy iii. Partial or segmental mastectomy iv. Lymph node surgery v. Mastectomy (Mayo Clinic, 2011) 1. Simple or total 2. Modified radical 3. Radical 4. Skin-sparing mastectomy II. Pathology—Tumor growth originates in cells of the breast tissue occurring primarily in women, although men may also be affected. a. Types (National Comprehensive Cancer Network [NCCN], 2011) i. Ductal 1. Occurs in the ducts that connect the lobes and the nipple 2. May be in situ or invasive 3. Represents 83% of all breast cancers (invasive ductal carcinoma [IDC]) (American Cancer Society [ACS], 2011). 4. Note: Invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) are the two most common types of invasive breast cancer (Downs-Holmes, 2011). ii. Lobular 1. Occurs in the lobes where milk is produced 2. May be in situ or invasive 3. Represents 10% to 15% of all cancers
CHAPTER 11
MASTECTOMY
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G L O S S A R Y Simple or total mastectomy: Entire breast is removed, but no lymph nodes from under the arm or muscle tissue from beneath the breast are removed. Skin-sparing mastectomy: Removal of the entire breast, nipple, and areola, without removal of the breast skin for immediate or delayed breast reconstruction.
(continued)
Staging: Method to classify progression of cancer in order to select treatment options and predict a prognosis.
Care Setting
Related Concerns
Client is treated at inpatient acute surgical unit.
Cancer, page 827 Psychosocial aspects of care, page 729 Surgical intervention, page 762
Client Assessment Database D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
CIRCULATION • Unilateral engorgement in affected arm as a result of lymph node involvement
EGO INTEGRITY • Constant stressors in work or home life • Stress and fear involving diagnosis, prognosis, and future expectations
FOOD/FLUID • Loss of appetite, recent weight loss
PAIN/DISCOMFORT • Pain may be reported in advanced metastatic disease but rarely occurs in early malignancy • Discomfort or “funny feeling” in breast tissue occurs in some clients
SAFETY • Nodular axillary masses • Edema, erythema of involved skin
SEXUALITY • Changes in breast symmetry or size, pitting or dimpling of breast skin, color changes such as erythema or temperature, unusual nipple discharge, itching, burning, retracted nipple • History of early menarche younger than age 12, late menopause after age 50, late first pregnancy, such as after age 30 • Concerns about sexuality and intimacy
TEACHING/LEARNING • Family history of genetically transmitted breast cancer. Note: BRCA1 and BRCA2 genes that have mutated account for 80% to 90% of hereditary cancers and present a lifetime risk factor 10 times that of the population (NCI, 2008); however, most breast cancer clients have no relatives with the disease, with only 5% to 10% attributable to hereditary factors. 590
• Change in breast contour or symmetry • Retraction of nipple, discharge from nipple
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CHAPTER 11
Client Assessment Database
(continued)
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
M AY E X H I B I T (continued)
WOMEN’S REPRODUCTIVE—MASTECTOMY
• Previous unilateral breast cancer, endometrial cancer, or ovarian cancer • History of prolonged hormone replacement therapy, radiation, or multiple breast biopsies or procedures
DISCHARGE PLAN CONSIDERATIONS • May need assistance with treatments and rehabilitation, decisions, self-care activities, and homemaker or maintenance tasks. ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
BLOOD TESTS • Hormone receptor assay: Test to determine whether a breast cancer’s growth is influenced by hormones or if it can be treated with hormones.
• Human epidermal growth factor receptor 2 (HER2) tumor test: A growth-promoting protein.
• Breast cancer genes—BRCA1 and BRCA2: Normal genes that are associated with familial breast cancer when inherited in mutated state.
• Ploidy: Chromosome test that refers to the amount of DNA that cancer cells contain.
OTHER DIAGNOSTIC STUDIES • Mammography: Visualizes internal structure of the breast; capable of detecting nonpalpable cancers or tumors that are in early stages of development. • Digital mammography: Creates computer images, rather than images on film, which can be manipulated and transmitted for further review. • Ultrasound: Uses sound waves to produce images for both screening and diagnostic staging.
• Magnetic resonance imaging (MRI): Creates images that capture multiple cross-sectional pictures using a computer to generate detailed two- and three-dimensional images.
Reveals whether cells of excised tumor or biopsy specimens contain hormone receptors (estrogen and progesterone). In malignant cells, the estrogen-plus receptor complex stimulates cell growth and division. About two-thirds of all women with breast cancer are estrogen-receptor positive and tend to respond favorably to the addition of hormone blocking therapy, which extends the disease-free period and increases survival time. Cancer cells with too many copies of this gene tend to grow and spread more aggressively than do other breast cancers. Approximately 15% to 20% of women with breast cancer have HER2-positive tumors (NCCN, 2011). Associated with a high risk of female breast cancer and ovarian cancer, as well as male breast cancer (BRCA2), and other cancers. The tests may be performed on young women with more than one family member who has developed breast cancer at an early age. Note: Known BRCA1 or BRCA2 genetic mutations place women at 60% to 80% risk of breast cancer (Bland, 2009). Helps predict how aggressive a cancer is likely to be. If the amount is abnormal, the cells are aneuploid. Aneuploid breast cancers tend to be faster growing and more likely to recur than other forms of breast cancers. Women with dense breasts may benefit from digital, rather than a film, mammography. Complements findings of mammograms. Distinguishes fluidfilled cysts from solid tumors. Ongoing studies are evaluating whether whole-breast ultrasound should be used in conjunction with mammography to screen high-risk women with dense breast tissue (Mayo Clinic, 2011). Performed when more information is needed than a mammogram, ultrasound, or clinical breast exam can provide. Ductal cancer in situ is usually better detected with an MRI than with a mammography. (continues on page 592)
591
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Diagnostic Studies
(continued)
TEST W H Y I T I S D O N E (continued) • Biopsy: Removal of a sample of suspicious tissue for examination by a pathologist. • Fine-needle aspiration biopsy: A fine, hollow needle is inserted into a lump or lesion and cells are withdrawn for evaluation. • Core-needle biopsy: A hollow needle is used to take several rice- or grain-sized cores of tissue. • Stereotactic biopsy: Computer-guided procedure that uses a core needle to obtain a larger tissue sample (than the fineneedle procedure), or a vacuum-assisted device (VAD) that allows collection of multiple tissue samples during one needle insertion. • Ultrasound-guided core-needle biopsy: Core-needle biopsy that uses ultrasound to produce precise images of structures within the body. • Surgical biopsy: All or part of the suspicious tissues may be removed by surgery for cytological examination. • Sentinel node biopsy: The lymph ducts of the breast usually drain to one lymph node first before draining to the remaining axillary lymph nodes. Lymph node mapping helps to identify that specific lymph node to determine presence of cancerous cells. • 21 gene RT-PCR (reverse transcriptase-polymerase chain reaction) assay
W H AT I T T E L L S M E (continued) Biopsy may be done if a mammography, surgery, or other screening method reveals a mass or lesion to determine whether it is benign or cancerous. This is usually performed when a fluid-filled mass is seen on an ultrasound image or a lesion is detected during a clinical breast exam. With this type of biopsy, tissue structure and cells can be evaluated. When a solid mass has been detected, ultrasound may be used to guide the placement of the needle. When a suspicious area cannot be palpated or located by ultrasound—but is visible through mammography—the physician uses digital x-rays to guide the needle to the abnormality and perform the biopsy. May be used in place of fine-needle biopsy or surgical biopsy to verify diagnosis. Total removal of the tissue is called an excisional biopsy, whereas partial removal is called an incisional biopsy. If the first node is benign, it is likely that all other nodes are the same, thereby limiting removal of additional nodes, preventing damage to the ducts and the increased potential for lymphedema and avoiding an axillary node dissection (Mayo Clinic, 2011). May be done on excised breast tissue to help determine the risk of recurrence and the benefit of chemotherapy, assuming that 5 years of hormonal treatment is planned in early stage I or II, ER positive, HER-2 negative, and node-negative breast cancer of greater than 0.5 cm (a recent breakthrough in breast oncology care) (Lo et al, 2010; Mamounas et al, 2010).
Nursing Priorities
Discharge Goals
1. Assist client and significant other (SO) in dealing with stress of situation and prognosis. 2. Prevent complications. 3. Establish individualized rehabilitation program. 4. Provide information about disease process, procedure, prognosis, and treatment needs.
1. 2. 3. 4.
Situation being dealt with realistically. Complications prevented or minimized. Exercise regimen implemented. Disease process, surgical procedure, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge.
Preoperative NURSING DIAGNOSIS:
Anxiety
May Be Related To Situational crisis; threat to/change in health status Threat to self-concept (e.g., change of body image; scarring/loss of body part, change in sexual attractiveness) Threat of death (e.g., extent of disease, uncertainty of prognosis; denial of own mortality)
Possibly Evidenced By Behavioral—reports concerns due to change in life events, restlessness Affective—apprehensive; feelings of helplessness, inadequacy; focus on self Physiological—increased tension Sympathetic—changes in vital signs
592
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Anxiety
CHAPTER 11
NURSING DIAGNOSIS:
(continued)
Desired Outcomes/Evaluation Criteria—Client Will Anxiety Level NOC
Anxiety Self-Control NOC Communicate thoughts and feelings utilizing available support systems such as family, spiritual leaders, and other resources. Demonstrate coping behaviors that reduce anxiety.
ACTIONS/INTERVENTIONS
RATIONALE
Anxiety Reduction NIC Independent Ascertain what information client has about diagnosis, expected surgical intervention, and future therapies. Note presence of denial or extreme anxiety.
Explain purpose and preparation for diagnostic tests or procedures. Provide an atmosphere of concern and anticipatory guidance and privacy for client and family.
Encourage questions and provide time for expression of fears. Offer relaxation techniques such as back massage, guided imagery, and use of touch, if culturally acceptable. Explore previously used coping mechanisms as perceived by the client. Explore spiritual support as a resource. Discuss role of rehabilitation after surgery and use of community resources.
Provides knowledge base for the nurse to enable reinforcement of needed information, helps identify client with high anxiety or a low capacity for information processing, and need for special attention. Note: Denial may be useful as a coping method initially; however, extreme anxiety needs to be dealt with immediately. Promotes clear understanding of procedures and what is happening, increases feelings of control, and lessens anxiety and fear of the unknown. Facilitates therapeutic communication, active-listening, and expression of underlying unresolved issues. Privacy is needed to encourage open discussion related to feelings of anticipated loss and other concerns. Provides opportunity to identify and clarify misconceptions and offer emotional support. Relaxation may help in reducing anxiety and fear. Reinforces effective coping mechanisms previously used for coping in a new situation. Provides calmness and peace in times of uncertainty. Promotes support systems in place in the rehabilitation process as an essential component of therapy intended to meet physical, social, emotional, and vocational needs so that client can achieve the best possible level of physical and emotional functioning.
Postoperative NURSING DIAGNOSIS:
impaired Tissue Integrity
May Be Related To Altered circulation, sensation Mechanical factors (e.g., surgical removal of skin and tissue) Excess fluid volume (edema, changes in skin elasticity) Chemical irritants (e.g., drainage); radiation
Possibly Evidenced By Damaged/destroyed tissues
Desired Outcomes/Evaluation Criteria—Client Will Wound Healing: Primary Intention NOC Achieve timely wound healing free of purulent drainage or erythema.
Knowledge: Treatment Procedures NOC Verbalize understanding of treatment plan to promote wound healing. Demonstrate wound care techniques that facilitate increased tissue granulation at incision site. Demonstrate behaviors that prevent complications.
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Demonstrate appropriate range of feelings regarding possibility of death or increasing hope related to prognosis. Acknowledge acceptance of health status.
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ACTIONS/INTERVENTIONS Incision Site Care NIC Independent Assess dressings and wound for amount and characteristics of drainage.
Provide drain care, instructing client/family in the process, as indicated.
Monitor temperature. Place in semi-Fowler’s position on back or unaffected side; avoid letting the affected arm dangle. Prevent or minimize edema of involved arm. Elevate hand and arm with shoulder positioned at appropriate angles at no more than 65 degrees of flexion, 45 to 65 degrees of abduction, 45 to 60 degrees of internal rotation, and forearm resting on wedge or pillow, as indicated. Avoid measuring blood pressure (BP), injecting medications, or inserting intravenous (IV) lines in affected arm, where possible. Encourage wearing of loose-fitting, nonconstrictive clothing. Inform the client not to wear wristwatch or other jewelry on affected arm.
Collaborative Administer antibiotics, as indicated.
NURSING DIAGNOSIS:
RATIONALE
Use of dressings depends on the extent of surgery and the type of wound closure. Pressure dressings are usually applied initially and are reinforced, not changed. Drainage occurs because of the trauma of the procedure and manipulation of the numerous blood vessels and lymphatics in the area. The Jackson-Pratt drain is most commonly used for mastectomies to maintain negative pressure in the wound and is easily managed. Simple mastectomies use one drain, whereas more complex procedures, such as those involving removal of lymph nodes, may require several drains. Drains are usually removed around the third day or when drainage ceases, possibly after client is discharged. Teaching facilitates self-care, reducing a major concern of client. Early recognition of developing infection enables rapid institution of treatment. Assists with drainage of fluid through use of gravity. Reduces the discomfort and associated complications. Elevation of affected arm facilitates drainage and resolution of edema. Lymphedema is present in approximately 24% to 49% postmastectomy, depending on the malignancy and the surgical procedure performed (Warren et al, 2007). This may develop immediately after surgery or years later. Increases potential of constriction, infection, and lymphedema on affected side. Reduces pressure on compromised tissues, which may improve circulation and healing and minimize lymphedema.
Provides prophylaxis to treat specific infection and enhance healing.
acute Pain
May Be Related To Physical agents (e.g., surgical procedure; tissue trauma, interruption of nerves, dissection of muscles)
Possibly Evidenced By Verbalized/coded reports of pain Guarding behavior Self-focus
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Express reduction in pain or discomfort. Appear relaxed and able to sleep or rest appropriately.
Pain Control NOC Identify factors that aggravate or relieve pain.
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Assess reports of pain and sensory alterations, noting location, duration, and intensity (0 to 10 [or similar] scale). Note reports of stiffness, swelling, and numbness or burning in chest, shoulder, and affected arm. Identify verbal and nonverbal cues.
594
Examines the degree of discomfort and verifies the need for analgesia and evaluates its effectiveness. The amount of tissue, muscle, and lymphatic system removed can affect the amount of pain experienced. The need to elevate arm, the size of dressings, and the presence of drains all affect client’s ability to relax and rest or sleep effectively.
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Explain the causes of pain to the client.
Provides understanding of sensory alterations. Destruction of nerves in axillary region causes numbness in upper arm and scapular region, which may be more intolerable than surgical pain. Pain in chest wall can occur from muscle tension, be affected by extremes in heat and cold, and continue for several months. Provides reassurance that sensations are not imaginary and that relief can be obtained. Promotes relaxation, refocuses attention away from the discomfort, and may enhance coping abilities.
Acknowledge the presence of phantom breast sensations. Provide basic comfort and diversional activities. Encourage early ambulation and use of relaxation techniques, guided imagery, and Therapeutic Touch. Provide opportunities for uninterrupted sleep. Splint or support chest during coughing and deep-breathing exercises. Provide appropriate pain medication on a regular schedule before pain is severe and before activities are scheduled. Provide accurate information related to patient-controlled analgesia (PCA) or opioids to reduce fear of addiction. Describe the adverse effects of unrelieved pain. Discuss previous successful methods of coping with pain.
Relieves fatigue, increasing coping ability. Facilitates participation in activity without undue discomfort. Maintains comfort level and permits client to exercise arm and to ambulate without pain hindering efforts. Reduces fear, augmenting appropriate pain relief, to enhance mobility and coping abilities. Explains complications resulting from poor pain management both physiologically and emotionally (NCI, 2012). Provides pain-relieving methods to employ based on past experiences.
Collaborative Administer PCA, opioids, or nonopioids, as indicated.
NURSING DIAGNOSIS:
Provides relief from discomfort or pain and facilitates rest and participation in postoperative therapy.
situational low Self-Esteem
May Be Related To Physical illness; loss Disturbed body image (e.g., surgical change in structure or body contour) Behaviors inconsistent with values [Fear of rejection or reaction by others]
Possibly Evidenced By Reports current situational challenge to self-worth Self-negating verbalizations
Desired Outcomes/Evaluation Criteria—Client Will Self-Esteem NOC Distinguish between self-perceptions and societal stigmas. Identify strategies to cope with self-acceptance in present situation. Verbalize progress toward acceptance of self. Participate in setting realistic goals involving the postoperative therapy program.
ACTIONS/INTERVENTIONS
RATIONALE
Self-Esteem Enhancement NIC Independent Provide active-listening when surgical dressings are removed. Assess for grief, depression, and ineffective coping.
Validate client’s feelings and address any misinformation that is revealed. Encourage questions about current situation and future expectations.
Identify role concerns as woman, wife, mother, career woman, and so forth.
Provides emotional support and client safety. Common reactions that need to be recognized immediately for timely intervention, as indicated. Grief may resurface when subsequent procedures are done, such as fitting for prosthesis or reconstructive procedure if postponed. Encourages client to express feelings and provides opportunity to give or reinforce information. Loss of the breast causes many reactions, including feeling disfigured, fear of viewing scar, and fear of partner’s reaction to change in body. Loss of body part, disfigurement, and perceived loss of sexual desirability engender grieving process that needs to be dealt with so that client can make plans for the future. Explores possible alteration in client’s self-perception. (continues on page 596)
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RATIONALE (continued)
CHAPTER 11
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Provide positive reinforcement for gains and improvement and participation in self-care and treatment program. Review possibilities for reconstructive surgery and/or prosthetic augmentation.
Encourages continuation of healthy behaviors.
Identify concerns of client and SO regarding sexual dysfunction in order to provide acceptable practices for self and SO. Encourage communication of needs and fears of both partners. Discuss and refer to support groups, as appropriate.
If feasible, reconstruction may be performed to provide a less disfiguring or “near-normal” cosmetic result. Variations in skin flap may be done for facilitation of reconstructive procedure, which may be performed at the same time as mastectomy. The associated emotional boost may help the client through the more complex surgical recovery process and adjunctive therapies. Note: Sometimes, reconstruction is not done for 3 to 6 months. Negative responses actually reflect SO’s concern about hurting client, fear of cancer or death, or inability to look at operative area. Provides a place to exchange concerns and feelings with others who have had a similar experience and identifies ways SO can facilitate client’s recovery.
Collaborative Provide temporary soft prosthesis, if indicated.
NURSING DIAGNOSIS:
Prosthesis of nylon and Dacron fluff may be worn in bra indefinitely or until incision heals if reconstructive surgery is not performed at the time of mastectomy. This may promote social acceptance and allow client to feel more comfortable about body image at the time of discharge.
impaired physical Mobility
May Be Related To Neuromuscular impairment Pain, discomfort; reluctance to attempt movement Decreased muscle mass/strength; joint stiffness Difficulty turning
Possibly Evidenced By Limited range of motion (ROM); limited ability to perform gross motor skills
Desired Outcomes/Evaluation Criteria—Client Will Motivation NOC Display willingness to participate in therapy. Demonstrate techniques that enable resumption of activities.
Coordinated Movement NOC Demonstrate increased muscle strength of affected body parts.
ACTIONS/INTERVENTIONS
RATIONALE
Exercise Therapy: Muscle Control NIC Independent Elevate affected arm, as indicated. Perform passive ROM, such as flexion and extension of elbow, pronation and supination of wrist, and clenching and extending fingers, as soon as possible. Encourage client to move fingers, noting sensations and color of hand on affected side. Encourage client to use affected arm for personal hygiene: feeding, combing hair, and washing face.
Assist with self-care activities, as necessary. Assist with ambulation and encourage correct posture.
Advance exercise, as indicated, for example, active extension of arm and rotation of shoulder while lying in bed, pendulum swings, rope turning, and elevating arms to touch fingertips behind head.
596
Promotes venous return, lessening possibility of lymphedema. Early postoperative exercises are usually started in the first 24 hours to prevent joint stiffness that can further limit movement and mobility. Lack of movement may reflect problems with the intercostal brachial nerve. Discoloration can indicate impaired circulation. Increases circulation, minimizes edema, and maintains strength and function of the arm and hand. These activities use the arm without abduction, eliminating stress on the suture line in the early postoperative period. Conserves client’s energy and prevents undue fatigue. Client may feel unbalanced and need assistance until accustomed to change. Keeping back straight prevents shoulder from moving forward, avoiding permanent limitation in movement and posture. Prevents joint stiffness, increases circulation, and maintains muscle tone of the shoulders and arm.
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Progress to hand climbing or walking fingers up wall, clasping hands behind head, and full abduction exercises as soon as client can manage. Evaluate degree of exercise-related pain and changes in joint mobility. Measure upper arm and forearm if edema develops.
Because this group of exercises can cause excessive tension on the incision, they are usually delayed until healing process is well established. Monitors progression and resolution of complications. May need to postpone increasing exercises and wait until further healing occurs. Exercise program needs to be continued to regain optimal function of the affected side. Client is usually more willing to participate or finds it easier to maintain an exercise program that fits into her lifestyle and accomplishes tasks as well. Altered weight and support put tension on surrounding structures.
Discuss types of exercises to be done at home to regain strength and enhance circulation in the affected arm. Coordinate early exercise program into self-care and homemaker activities such as dressing self, washing, dusting, and mopping; and leisure activities, such as swimming. Assist client to identify signs/symptoms of shoulder tension, such as an inability to maintain posture or a burning sensation in the postscapular region. Instruct client to avoid sitting or holding arm in dependent position for extended periods.
Collaborative Administer medications, as indicated, for example: Analgesics Diuretics
Maintain integrity of elastic bandages or custom-fitted, pressure-gradient elastic sleeve. Refer to physical and occupational therapist and lymphedema clinic or specialist.
NURSING DIAGNOSIS:
Pain needs to be controlled before exercise or client may not participate optimally and incentive to exercise may be lost. May be useful in treating and preventing fluid accumulation or lymphedema. Promotes venous return and decreases risk or effects of edema formation. Provides an individualized exercise program. Assesses limitations or restrictions regarding employment requirements.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall Information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problems Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Acute Illness Care NOC Verbalize understanding of disease process and potential complications. Perform necessary procedures correctly and explain reasons for actions. Initiate necessary lifestyle changes and participate in treatment regimen.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Review disease process, surgical procedure, and future expectations. Review and have client demonstrate care of drains and wound sites. Encourage continuation of exercises, increasing program as healing progresses, for at least 1 year.
Discuss necessity for well-balanced, nutritious meals and adequate fluid intake.
Provides knowledge base from which client can make informed choices, including participation in radiation and/or chemotherapy programs. (Refer to CP: Cancer.) Shorter hospital stays may result in discharge with drains in place, requiring more complex care by client and caregivers. Drains may be removed 7 to 10 days after surgery. Good muscle tone enhances development of collateral lymphatic channels, reduces the tightening of scar tissue, and maintains muscle strength and function. Moderation is important because strenuous activity or exercise increases heart rate and body temperature, which can potentially increase edema. Some evidence suggests that exercise lowers the risk of recurrence of breast cancer (Ligibel, 2008). Provides optimal nutrition and maintains circulating volume to enhance tissue regeneration and the healing process. (continues on page 598)
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RATIONALE (continued)
CHAPTER 11
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Suggest alternating schedule of frequent rest and activity periods, especially in situations when sitting or standing is prolonged.
Prevents or limits fatigue, promotes healing, and enhances feelings of general well-being. Positions in which arm is dangling or extended intensify stress on suture lines, creating muscle tension and stiffness, and may interfere with healing. Lymphedema may or may not occur in the immediate postop period. An acute, temporary, and mild type of lymphedema occurs within a few days after surgery and usually lasts a short period of time. An acute and more painful type of lymphedema can occur about 4 to 6 weeks following surgery. However, the most common type of lymphedema is slow and painless and may occur 18 to 24 months after surgery (New York Presbyterian, 2008).
Discuss potential for lymphedema in affected arm and signs to watch for (e.g., feeling of fullness or tightness, aching or pain, weakness, swollen fingers)
Instruct client to protect hands and arms, for example: Wear long sleeves and gloves when gardening, use thimble when sewing, and do not carry purse or wear jewelry or wristwatch on affected side. Use potholders when handling hot items; use plastic gloves when doing dishes. Avoid lifting, moving heavy objects, or prolonged repetitive motions. Demonstrate holding affected arm appropriately, for example, not dangling the arm, swinging arms with elbows bent when walking, and placing arm above heart level when sitting or lying down. Warn against having blood withdrawn or receiving IV fluids and medications or BP measurements on the affected side.
Demonstrate use of intermittent sequential pumping or lowstretch, compression custom-made garments, as appropriate. Suggest gentle massage of healed incision with emollients. Recommend use of sexual positions that avoid pressure on chest wall. Encourage alternative forms of sexual expression such as cuddling or touching during initial healing process and while operative area is still tender. Encourage regular self-examination of remaining breast when mastectomy is unilateral. Determine recommended schedule for mammography. Emphasize importance of regular medical follow-up.
Identify signs and symptoms requiring medical evaluation: breast or arm red, warm, and swollen; edema and purulent wound drainage; and fever or chills. Address additional concerns as indicated—ongoing therapies and expected and/or adverse side effects.
Compromised lymphatic system causes tissues to be more susceptible to infection and/or injury, which may lead to lymphedema. Sensory alterations place client at risk for burns and infections. Prevents strain on tissues with potential for edema. Helps prevent or minimize lymphedema and “frozen shoulder.”
May restrict the circulation and increase risk of infection when the lymphatic system is compromised. Note: Following this guideline is not always possible (e.g., bilateral mastectomy, or loss of good sites for venipuncture in nonaffected arm), but should be adhered to as much as possible, especially in early postop period. Used in managing lymphedema by promoting circulation and venous return. Stimulates circulation, promotes elasticity of skin, and reduces discomfort associated with phantom breast sensations. Promotes feelings of femininity and sense of ability to resume sexual contact.
Identifies changes in breast tissue indicative of recurrent or new tumor development. Other treatment may be required as adjunctive therapy, such as radiation. Recurrence of breast cancer can be identified early and managed by an oncologist. Lymphangitis can occur as a result of infection, causing lymphedema. Depending on the type of cancer that required the mastectomy, the client may have ongoing cancer therapies (e.g., chemotherapy, radiotherapy), selective estrogen modulators (e.g., tamoxifen [Soltamox] and raloxifene [Evista]), or aromatase inhibitors (e.g., letrozole [Femara], anastrozole [Arimidex]) to treat cancer or prevent recurrence.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) In addition to surgical and cancer concerns: • impaired Tissue Integrity—altered circulation, sensation; tissue removal/destruction, radiation; drainage • situational low Self-Esteem—physical illness, loss, disturbed body image (e.g., disfiguring surgical procedure, concern about sexual attractiveness) • Self-Care Deficit (specify)—weakness, fatigue, neuromuscular impairment, pain, muscular impairment
Sample clinical pathway follows in Table 11.1. 598
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Sample CP: Mastectomy—Modified Radical, Hospital. ELOS: 2 Days
Referrals
Additional assessments
Postop Day 1 _____ Participate in self-care activities/beginning exercise program
Maintain usual color, sensation and motion in affected fingers/hand Physical Therapist Occupational Therapist Home Care Dressing/drainage q4h Presence/degree of edema q8h
Identify ways to maximize healing/minimize risk of injury to arm
Report plan in place to meet postdischarge needs
→ q8h Wound characteristics → qd & Measure upper arm/forearm if edema present → q8h → q8h →
→ →
Donor/graft site if used q4h VS q1h ! 4 → q4h I&O and wound drainage system q8h
Medications Client teaching
Additional nursing actions
acute Pain R/T physical agents (e.g., tissue trauma, muscle dissection, interruption of nerves)
Postop Day 2 _____ (Discharge) Display minimal erythema, absence of purulent drainage, edema resolving
Day of Surgery _____ Display wound drainage w/in established limits
Neurovascular check— UE q1h ! 4 → q4h ! 2 Diuretic if edema present Protection of affected arm: shaving, use of deodorant/creams, activity limitations, avoidance of heat/cold, proper posture/positioning of arm, sexual positions to prevent pressure on chest wall, wearing loose-fitting clothing Graduated exercise program incorporating ADLs/homemaking activities
Position per protocol; HOB elevated 30° or more BRP/chair w/assist Elevate affected arm Turn, cough, deep breath or incentive spirometry q2h Maintain elastic bandages/custom-fitted, pressure-gradient sleeve if used Reinforce dressing PRN Encourage progressive exercises & ambulate as tolerated Advance diet as tolerated Report pain reduced to manageable level
→ q8h
→ D/C → q12h → Discharge with drain in place/ remove when less than 30 mL/24 h →
→ Wound care
→ D/C Management of wound drain if not removed
Gentle massage of healed incision
S/S to report to healthcare provider
General healthcare needs to promote healing, dietary intake, fluids, rest/pacing self Breast self-examination
Use of medical alert device
→
Provide written instructions, schedule for follow-up visits/additional treatment modalities →
→ Ambulate/up ad lib → → DB/IS q2h WA
→ → →
→
→
→ Assist w/dressing chg →
→ D/C dressing →
→ →
→ Verbalize understanding of therapeutic regimen
(continues on page 600)
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WOMEN’S REPRODUCTIVE—MASTECTOMY
ND and Categories of Care impaired Tissue Integrity R/T tissue removal/ destruction; altered circulation, sensation; drainage, radiation
CHAPTER 11
TABLE 11.1
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TABLE 11.1
Sample CP: Mastectomy—Modified Radical, Hospital. ELOS: 2 Days (continued)
ND and Categories of Care
Additional assessments Medications Allergies:_______________ Client education
Additional nursing actions
situational low Self-Esteem R/T perceived disfigurement, psychosocial concerns
Referrals Additional assessments
Day of Surgery _____ Participate in activities to manage pain Pain characteristics/any changes Response to interventions Analgesic of choice IV/PO Orient to unit/room
Reporting of pain/effects of interventions Initial exercises of fingers/wrist of affected arm; ROM exercises of unaffected limbs Relaxation techniques Splinting of chest w/coughing, exercise Routine comfort measures Passive ROM/exercises per protocol Assist w/self-care Verbalize feelings, verbal/nonverbal communication congruents
Social services Reach to Recovery Response to surgical procedure by client and SO
Client education
Availability/effectiveness of support systems Postoperative routines
Additional nursing actions
Extent/outcome of surgical procedure Future treatment needs Use of/sources for temporary prosthesis Possibilities for reconstructive surgery/prosthetic augmentation Discuss normalcy of feelings
Encourage participation in self-care at level of ability Provide positive reinforcement for participation in therapeutic regimen
Postop Day 1 _____ →
Postop Day 2 _____ (Discharge) →
→
→
→ → PO analgesic
→ →
S/S of shoulder tension; possibility of phantom breast pain Progression of exercises as tolerated Home exercise program
Medication: dose, time/ frequency, purpose, side effects
→ → Advance exercises as tolerated → →
→ →
Participate in care/planning for future View incision
→ Plan in place to meet postdischarge needs
→ → Verbalize acceptance of self
Future expectations, role concerns, usual coping strategies, past coping successes Understanding of diagnosis Community resources for client and SO
S/S to report to healthcare provider (depression) Written information regarding diagnosis/treatment options
Role-play ways of handling responses of others
Identify options for managing home/work responsibilities; importance of taking time for self
Provide support/answer questions when dressing removed
Key: ADLs, activities of daily living; BRP, bathroom privileges; DB/IS, deep breath/incentive spirometry; D/C, discontinue; HOB, head of bed; I&O, intake and output; IV, intravenous; PO, per mouth; PRN, as needed; q1h × 4, every hour 4 times a day; q4h, every 4 hours; q8h, every 8 hours; q12h, every 12 hours; qd, every day; ROM, range of motion; R/T, related to; SO, significant other; S/S, signs and symptoms; UE, upper extremity; VS, vital signs; WA, while awake.
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CHAPTER
12
Orthopedic FRACTURES I. Pathophysiology a. Discontinuity or break in a bone b. May be associated with serious injury to nerves, blood vessels, muscles, and/or organs II. Etiology (Buckley, 2012; Smeltzer, 2010) a. Common causes: Trauma, such as falls, blunt force, and penetrating force. Note: 30% to 50% of children seen by orthopedic surgeons are the victims of nonaccidental injury (Budd, 2012). b. Osteoporosis, which leaves bones thinned and weakened c. Repetitive stress, which is associated with athletics d. Bone tumors e. Infections, such as osteomyelitis; may be acute or chronic III. Classifications (American Academy of Orthopedic Surgeons [AAOS], 2012; Walsh, 2011) a. Location in the bone (e.g., proximal, midshaft, distal, through a joint) b. Complete (through the entire bone); incomplete (the bone is not broken into two parts); comminuted (broken into three or more parts) c. Other fracture patterns: Stable (bone ends may touch and are in line); transverse (horizontal fracture line); oblique (angled fracture line); spiral (created by rotational force common in toddlers from relatively minor trauma, and in older children from skiing, contact sports); greenstick (common in children who fall onto arm while running); dislocated (fracture causes dislocation of part of joint, e.g., elbow, cervical vertebrae); impacted. d. Closed (also called simple) or open (also called compound). Open fractures are further classified as Type I (low-energy, simple fracture with wound opening less than 1 cm; Type II (higher energy with comminution and wound size greater than 1 cm; Type III (fractures are highenergy with moderate to large tissue loss and possible vascular injury). e. Velocity: Low-velocity injuries include falls from a standing height, athletic injuries, stab wounds, and shotgun injuries. High-velocity injuries are associated with motor vehicle crashes, pedestrian versus automobile injuries (most frequent fracture sites are tibia-fibula, and pelvis, followed by femur [Bradley, 1992]); falls from a height, and handgun injuries. f. Salter-Harris classification: Used for children and identifies where fracture is located relative to the growth plate: S = straight across; A = above growth plate; L = lower or below; T = through; ER = erasure of growth plate (crushed)
IV. Phases of healing (Buckley, 2012; Cho et al, 2002; Frost, 1989) a. Reactive phase i. Fracture and inflammatory phase: Bone fracture is an injury, and thus incites an inflammatory response, which peaks 24 hr following the injury and is complete by the first week. Soon after fracture (3 to 5 days), the blood vessels constrict, stopping any further bleeding. During this stage cellular signaling mechanisms work through chemotaxis and an inflammatory mechanism to attract the cells necessary to initiate the healing response. ii. Granulation tissue formation: Within 7 days, the body forms granulation tissue between the fracture fragments. This phase lasts about 2 weeks. b. Reparative phase i. Callus formation: Cell proliferation and differentiation begin to produce osteoblasts and chondroblasts in the granulation tissue, synthesizing the extracellular organic matrices of woven bone and cartilage. Then the newly formed bone is mineralized. This stage requires 4 to 16 weeks, depending on the type and location of the fracture. ii. Lamellar bone deposition: The mesh-like callus of woven bone is replaced by a hard, rigid form of connective tissue (lamellar bone). Eventually, the woven bone and cartilage is replaced by trabecular bone (dense, hard, and slightly elastic connective tissue in which the fibers are impregnated with a form of calcium phosphate), restoring most of the bone’s original strength. Note: Pediatric fractures heal more quickly than adult fractures due to children’s growth potential and a thicker, more active periosteum. c. Remodeling phase i. Trabecular bone is replaced by compact bone, remodeling to original bone contour. ii. The final two stages can take several years in adults. Younger children have greater and more rapid remodeling potential. V. Statistics a. Morbidity: In 2010, 671,000 Americans had open reduction for fractures listed on hospital discharge. 94,000 of those were under the age of 15 (Centers for Disease Control and Prevention [CDC], 2010). In 2007, discharge data from U.S. nonfederal hospitals listed 1.0 million with fractures as first diagnosis. About 12% of those were children (Mahar, 2011). More than one-half (531,000) were (text continues on page 602)
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aged 65 years and over. Almost one-half of the fracture hospitalizations for this age group were for hip fractures (fractures of neck of femur) (National Health Statistics Report, 2007). b. Mortality: Dependent upon multiple factors, including the specific bone affected, severity of fracture, associated soft tissue and organ involvement, age of individual, and presence of comorbidities. Note: Most currently available mortality studies are associated with hip fractures (estimated mortality rate within one year of a hip fracture ranges from 12% to 33 % (not the focus of this care plan) (Goel, 2013).
c. Cost: In 2012, osteoporosis-related fractures were responsible for an estimated $18 billion in medical treatment expenses while the cost of care and of lost work adds billions more (National Institute of Arthritis, and Musculoskeletal and Skin Diseases [NIAMSD], 2012). For the years 2004–2006, the sum of the direct expenditures in healthcare costs and the indirect expenditures in lost wages (for bone and joint health) has been estimated to be $950 billion dollars annually (The Burden of Musculoskeletal Diseases in the United States Project, 2011).
G L O S S A R Y Buckle fracture: Compression failure of bone that usually occurs at the junction of the metaphysis and the diaphysis. Commonly seen in distal radius Closed fracture: Fracture does not extend through the skin. Closed reduction: Nonsurgical method for reduction and stabilization of fracture through a wide range of interventions, such as simple braces or aluminum splints, plaster or fiberglass casts, metal braces, and/or traction devices. Comminuted fracture: Bone fragments into three or more pieces. Compartment syndrome: Excessive swelling in the tissues associated with a fracture or crush injury to a limb, which elevates tissue pressure, resulting in decreased arteriovascular pressure and impaired tissue perfusion. Complete fracture: Fracture line involves entire cross section of the bone, and bone fragments are usually displaced. Compression fracture: Collapsing of bone usually involves vertebra of the thoracic or lumbar spine and is often seen in elderly people as a result of osteoporosis, but may also occur traumatically. Crepitation: Grating sound heard with movement of ends of fractured bones. Fragility fracture: Fractures secondary to osteoporosis. Growth plate: Softer parts of child’s bones, where growth occurs. Located at each end of a bone, growth plates are the weakest sections of the skeleton. Incomplete or greenstick fracture: Involves only a portion of the cross section of the bone; one side breaks and the other usually just bends. Oblique fracture: Break occurs diagonally. Open fracture: Bone fragments extend through the muscle and skin and are potentially infected.
Open reduction: Surgical method for stabilization of a fracture using rods, pins, screws, and plates. Pathological fracture: Fracture occurs in diseased bone—such as in cancer and osteoporosis—with no (spontaneous) or only minimal trauma. Pediatric long bones: Three main regions: epiphysis (each end of a long bone with associated joint cartilage); physis ([growth plate]: cartilage cells that create solid bone with growth); and metaphysis (wide area below the physis, closest to the diaphysis/shaft). Periosteum: Membrane that lines the outer surface of all bones, except at the joints of long bones, and serves as the attachment mechanism for muscles and tendons. Physeal fractures: Fractures of the growth plate. May result in progressive angular deformity, limb-length discrepancy, or joint incongruity. The distal radial physis is the most frequently injured physis. Plastic deformation: The bone is angulated beyond its elastic limit, but the energy is insufficient to produce a fracture. No fracture line is visible radiographically. Unique to children. Most commonly seen in the ulna, occasionally in the fibula. Simple fracture: Bone breaks into two pieces. Spiral fracture: Break follows a helical line along and around the bone; commonly associated with a twisting motion. Stress fracture: Hairline fracture due to overuse or repeated microtrauma, such as those seen in gymnasts, runners, and tennis or basketball players, as well as those who participate in marching bands or drill teams. Transverse fracture: Break occurs in a straight line across the bone.
Care Setting
Related Concerns
Many fractures are managed at the community level. Although many of the interventions listed here are appropriate for this population, this plan of care addresses more complicated injuries encountered on an inpatient acute medical-surgical unit. Note: Definitive treatment of fractures may be delayed until life-threatening injuries, such as lung contusions, brain injury, or hemodynamic instability, have been stabilized (Weinstein, 2005).
Craniocerebral trauma—acute rehabilitative phase, page 197 Pneumonia, page 129 Psychosocial aspects of care, page 729 Renal failure: acute, page 505 Spinal cord injury (acute rehabilitative phase), page 248 Surgical intervention, page 762 Thrombophlebitis: venous thromboembolism, page 109
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Symptoms of fracture depend on the site, severity, type, and amount of damage to other structures.
D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
ACTIVITY/REST • • • •
Weakness Fatigue Gait and/or mobility problems Generalized weakness
CIRCULATION
ELIMINATION
• Restriction or loss of function of affected part—may be immediate, because of the fracture, or develop secondarily from tissue swelling, pain • Weakness of affected extremity • Range-of-motion (ROM) deficits • Hypertension—occasionally seen as a response to acute pain or anxiety, or hypotension from severe blood loss • Tachycardia—stress response, hypovolemia • Pulse diminished or absent distal to injury in extremity • Delayed capillary refill • Pallor of affected part • Tissue swelling • Bruising or hematoma mass at site of injury
• Hematuria • Sediment in urine • Changes in output—acute renal failure (ARF) with major skeletal muscle damage
NEUROSENSORY • Loss of or impaired motion or sensation • Muscle spasms worsening over time • Numbness or tingling (paresthesias)
• Local musculoskeletal deformities—abnormal angulation, posture changes, shortening of limbs, rotation, or crepitation • Muscle spasms • Visible weakness or loss of function • Giving way or collapse, locking of joints, dislocations • Agitation—may be related to pain, anxiety, or other trauma
PAIN/DISCOMFORT • Sudden severe pain at time of injury—may be localized to the area of tissue or skeletal damage and then become more diffuse; however, can diminish on immobilization • Absence of pain—suggests nerve damage • Muscle-aching pain • Muscle spasms or cramping following immobilization
• Guarding or distraction behaviors • Restlessness • Self-focus
SAFETY • Circ*mstances of incident may not support type of injury incurred—may be suggestive of abuse • Use of alcohol or other drugs
• • • • • • •
Skin lacerations Tissue avulsion Bleeding Color changes of skin Localized swelling—may increase gradually or suddenly Discrepancy in limb length Presence of risk factors for falling—age, osteoporosis, dementia, arthritis, other chronic conditions; preexisting unrecognized fracture (continues on page 604)
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CHAPTER 12 ORTHOPEDIC—FRACTURES
Client Assessment Database
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Client Assessment Database
(continued)
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
M AY E X H I B I T
(continued)
TEACHING/LEARNING • Use of multiple medications—prescribed and/or over-the-counter (OTC) with interactive effects
DISCHARGE PLAN CONSIDERATIONS • May require temporary assistance with transportation, self-care activities, and homemaker or maintenance tasks • May require additional therapy or rehabilitation postdischarge • Possible placement in assisted living or extended care facility for a period of time ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies TEST WHY IT IS DONE • Radiographic examinations: First-line tool to determine location and extent of fractures/trauma and bone alignment. • Bone scans, tomograms, computed tomography (CT), and magnetic resonance imaging (MRI) scans: Used to visualize changes of structure within the body and bone alignment. May be preferred diagnostic tool because of superior ability to image some types of injuries. • Bone densitometry: Photons from a single- or dual-emitting source are used to measure comparative density of the spine, femur, or distal radius. These are then compared with normal values for a large patient population based on sex and age. • Arteriograms: X-rays that use contrast media to evaluate arterial blood flow. • Complete blood count (CBC): Battery of screening tests, which typically includes hemoglobin (Hgb); hematocrit (Hct); red blood cell (RBC) count, morphology, indices, and distribution width index; platelet count and size; white blood cell (WBC) count and differential. • Urine creatinine (Cr) clearance: Measures filtering ability of the kidneys. • Coagulation profile: Tests that measure blood coagulation. There are many types of coagulation tests, some of which are general and tell only whether a person’s blood is clotting normally. Other tests can identify which element within the blood is causing abnormal clotting.
W H AT I T T E L L S M E May reveal preexisting and yet undiagnosed fracture(s). These are used to visualize fractures, bleeding, and soft tissue damage; they differentiate between stress or trauma fractures and bone neoplasms.
Procedure may be done if fracture is suspected or known to be associated with osteoporosis. Note: Osteoporosis is often underrecognized and undertreated, and clients with fragility fractures secondary to osteoporosis are at risk of recurrent fracture (Inderjeeth, 2006). May reveal vascular damage. Hct may be increased, reflecting hemoconcentration or dehydration; or Hct may be decreased, signifying hemorrhage at the fracture site or at distant organs in multiple trauma. Increased WBC count is a normal stress response after trauma. Muscle trauma increases Cr load for renal clearance; decreased renal perfusion or impaired renal function also elevates Cr. Alterations may occur because of blood loss, multiple transfusions, or liver injury.
Nursing Priorities
Discharge Goals
1. 2. 3. 4.
1. 2. 3. 4. 5.
Prevent further bone/tissue injury. Alleviate pain. Prevent complications. Provide information about condition, prognosis, and treatment needs.
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Fracture stabilized. Pain controlled. Complications prevented or minimized. Condition, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge.
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CHAPTER 12 ORTHOPEDIC—FRACTURES
NURSING DIAGNOSIS:
risk for Injury
Risk Factors May Include Physical (e.g., loss of skeletal integrity [fractures]; movement of bone fragments)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Bone Healing NOC Maintain stabilization and alignment of fracture(s). Display callus formation/beginning union at fracture site as appropriate.
Risk Control NOC Demonstrate body mechanics that promote stability at fracture site.
ACTIONS/INTERVENTIONS
RATIONALE
Positioning NIC Independent Ascertain type of fracture injury and medical treatment planned if surgery is not indicated.
Maintain bedrest or limb rest as indicated. Provide support of joints above and below fracture site, especially when moving and turning.
Nonoperative (closed) therapy consists of casting and traction (skin and skeletal traction). Closed reduction is performed initially for any fracture that is displaced, shortened, or angulated. This is achieved by applying force (traction) to the long axis of the injured bone (usually femur) and then reversing the mechanism of injury/fracture. This is followed by subsequent immobilization through casting/splinting or traction apparatus. Note: With the advancement of orthopedic implant technology and operative techniques, traction is rarely used for definitive fracture/dislocation management (Buckley, 2012). Provides stability, reducing possibility of disturbing alignment and aggravating muscle spasms, which enhances healing.
Cast Care: Wet (if cast is made of plaster of Paris) NIC Support fracture site with pillows or folded blankets. Maintain neutral position of affected part with sandbags, splints, trochanter roll, or footboard. Use the palms of the hands, not the fingertips, when touching the wet cast. Obtain sufficient personnel for turning. Avoid using abduction bar for turning client with spica cast.
Prevents unnecessary movement and disruption of alignment. Proper placement of pillows also can prevent pressure deformities in the drying cast. Fingertips can dent the cast before it is dry. Hip, body, or multiple casts can be extremely heavy and cumbersome. Failure to properly support limbs in casts may cause damage to cast or injury to client and staff.
Traction/Immobilization Care NIC Evaluate splinted extremity for edema resolution.
Maintain position and integrity of traction apparatus, when used.
Assess integrity of external fixator device.
Coaptation splint (e.g., Jones-Sugar tong) may be used to provide immobilization of fracture while excessive tissue swelling is present. As edema subsides, readjustment of splint or application of fiberglass or plaster cast may be required for continued alignment of stable fracture. Traction is a less frequently used modality than in times past. But it may still be used in some instances of femur fracture in children and older adults or client’s with multitrauma who are not current candidates for surgery. Traction permits pull on the long axis of the fractured bone and overcomes muscle tension and shortening to facilitate alignment and union. Skeletal traction using pins, wires, or tongs permits use of greater weight for traction pull than can be applied to skin tissues. External fixation has evolved from being used primarily as a last-resort fixation method to becoming a mainstream technique used to treat a great many bone and soft tissue pathologies in both adults and children. This device provides stabilization and rigid support for fractured bone without use of ropes, pulleys, (continues on page 606)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued) or weights, thus allowing for greater client mobility and comfort and facilitating wound care (Kidsfractures.com, 2011; Fragomen, 2007).
Collaborative Review follow-up or serial x-rays.
Prepare client for surgery where indicated.
Initiate and maintain bone rehabilitation—early ambulation, weight-bearing activities, soft tissue massage, or electrical stimulation if used.
NURSING DIAGNOSIS:
Provides visual evidence of proper alignment or beginning callus formation and healing process to determine level of activity and need for changes in, or additions to, the therapy plan. Surgical procedures may include open reduction and internal fixation (ORIF); flexible or rigid intramedullary nailing; insertion of plates, screws, and pins. Treatments are variable and dependent on the type, location, and severity of fracture and other internal injuries. Promotes bone growth and healing.
acute Pain
May Be Related To Physical agents (e.g., muscle spasms, movement of bone fragments, edema, soft tissue injury, traction/immobility device) Psychological (e.g., stress, anxiety)
Possibly Evidenced By Verbalized/coded reports of pain Self-focusing/narrowed focus; facial mask of pain Guarding behavior, protective gestures Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Verbalize relief of pain. Display relaxed manner, able to participate in activities, and sleep and rest appropriately.
Pain Control NOC Demonstrate use of relaxation skills and diversional activities, as indicated for individual situation.
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Maintain immobilization of affected part by means of bedrest, cast, splint, and traction. (Refer to ND: risk for Injury.) Elevate and support injured extremity. Avoid use of plastic sheets/pillows under limbs in cast. Elevate bed covers and keep linens off toes. Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (0 to 10, or similar coded scale), relieving, and aggravating factors. Note nonverbal pain cues, such as changes in vital signs and emotions or behavior. Listen to reports of family member/significant other (SO) regarding client’s pain. Encourage client to discuss problems related to injury. Explain procedures before beginning them. Medicate before care activities. Let client know it is important to request medication before pain becomes severe. Perform and supervise passive or active ROM exercises. Provide alternative comfort measures, for example, massage, back rub, or position changes.
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Relieves pain and prevents bone displacement/extension of tissue injury. Promotes venous return, decreases edema, and may reduce pain. Can increase discomfort by enhancing heat production in the drying cast. Maintains body warmth without discomfort due to pressure of bedclothes on affected parts. Influences choice of, and monitors effectiveness of, interventions. Many factors, including level of anxiety, may affect perception of and reaction to pain. Note: Absence of pain expression does not necessarily mean lack of pain.
Helps alleviate anxiety. Client may feel need to relive the accident experience. Allows client to prepare mentally for activity and to participate in controlling level of discomfort. Promotes muscle relaxation and enhances participation. Maintains strength and mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues. Improves general circulation; reduces areas of local pressure and muscle fatigue.
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RATIONALE (continued)
Provide emotional support and encourage use of stress management techniques—progressive relaxation, deep-breathing exercises, and visualization or guided imagery; provide Therapeutic Touch. Identify diversional activities appropriate for client’s age, physical abilities, and personal preferences. Investigate any reports of unusual or sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics.
Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period. Prevents boredom, reduces muscle tension, and can increase muscle strength; may also enhance coping abilities. May signal developing complications, such as infection, tissue ischemia, or compartment syndrome. (Refer to ND: risk for Peripheral Neurovascular Dysfunction, following.)
Collaborative Apply cold or ice pack first 24 to 72 hours and as necessary per facility policy or protocol. Administer medications, as indicated: opioid and nonopioid analgesics, such as morphine, meperidine (Demerol), or hydrocodone (Vicodin); injectable and oral NSAIDs, such as ketorolac (Toradol) or ibuprofen (Motrin); and/or muscle relaxants, such as cyclobenzaprine (Flexeril) or carisoprodol (Soma). Maintain continuous intravenous (IV) or patient-controlled analgesia (PCA) using peripheral, epidural, or intrathecal routes of administration. Maintain safe and effective infusions and equipment.
NURSING DIAGNOSIS:
Reduces edema and hematoma formation; decreases pain sensation. Note: Length of application depends on degree of client comfort and whether the skin is carefully protected. Given to reduce pain and/or muscle spasms. Studies of Toradol have shown it to be effective in alleviating bone pain, with longer action and fewer side effects than opioid agents.
Optimal pain management is essential to permit early mobilization and physical therapy and to maintain adequate blood level of analgesia, preventing fluctuations in pain relief with associated muscle tension or spasms.
risk for Peripheral Neurovascular Dysfunction
Risk Factors May Include Fractures; trauma; orthopedic surgery; immobilization Vascular obstruction Mechanical compression (e.g., cast, dressing)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral NOC Maintain tissue perfusion as evidenced by palpable pulses; warm, dry skin; normal sensation; usual sensorium; stable vital signs; and adequate urinary output for individual situation.
ACTIONS/INTERVENTIONS
RATIONALE
Circulatory Precautions NIC Independent Assess client’s risk for development of venous thromboembolism (VTE) and acute compartment syndrome (ACS).
Remove jewelry from affected limb immediately. Evaluate presence and quality of peripheral pulse distal to injury via palpation or Doppler. Compare with uninjured limb.
Any client with severe fractures or multiple fractures, especially of long bones (femur) is at risk for VTE (including deep vein thrombosis (DVT) and pulmonary embolus (PE) particularly if long-term bedrest is required. Clients with fractures of tibia or femur can be at risk for ACS if they have sustained severe tissue injury that resulted in significant bleeding into a closed compartment, compressed blood vessels such as might occur with a crush injury, or surgery to repair blood vessels with subsequent reperfusion to a compartment. ACS can also be a complication of circumferential dressings, splints, or casts that are applied too tightly (Walsh, 2011; Wedro, 2010). May restrict circulation when edema occurs. Decreased or absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Be aware that occasionally a pulse may be palpated even though circulation is blocked by a soft clot through which pulsations may be felt. In addition, perfusion through larger arteries may continue after increased compartment pressure has collapsed the arteriole and venule circulation in the muscle. (continues on page 608)
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ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Assess capillary return, skin color, and warmth distal to the fracture.
Return of color should be rapid (3–5 seconds). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. Note: Peripheral pulses, capillary refill, skin color, and sensation may be normal even in the presence of compartment syndrome because superficial circulation is usually not compromised.
Circulatory Care: Arterial [or] Venous Insufficiency NIC Maintain elevation of injured extremity(ies) unless contraindicated by confirmed presence of compartment syndrome.
Assess entire length of injured extremity for swelling and edema formation. Measure injured extremity and compare with uninjured extremity. Note appearance and spread of hematoma. Note reports of pain extreme for type of injury or increasing pain on passive movement of extremity, development of paresthesia, muscle tension or tenderness with erythema, and change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to physician at once. Investigate sudden signs of limb ischemia, such as decreased skin temperature, pallor, and increased pain. Encourage client to routinely exercise digits or joints distal to injury. Ambulate as soon as possible. Investigate tenderness, swelling, redness, or tissue pain on dorsiflexion of foot (positive Homans’ sign).
Monitor vital signs. Note signs of general pallor or cyanosis, cool skin, and changes in mentation. Test stools and gastric aspirant for occult blood. Note continued bleeding at trauma or injection site(s) and oozing from mucous membranes.
Promotes venous drainage and decreases edema. Note: In presence of increased compartment pressure, elevation of the extremity actually impedes arterial flow, decreasing perfusion. Casts or circumferential dressings can also cause arterial venous insufficiency. Increasing circumference of injured extremity may suggest general tissue swelling or edema but may also reflect hemorrhage. Note: A 1-inch increase in an adult thigh can equal approximately 1 unit of sequestered blood. Continued bleeding or edema formation within a muscle enclosed by tight fascia can result in impaired blood flow and ischemic myositis or compartment syndrome, necessitating emergency interventions to relieve pressure and restore circulation (Smeltzer, 2011). Note: This condition constitutes a medical emergency and requires immediate intervention. Fracture dislocations of joints, especially the knee, may cause damage to adjacent arteries, with resulting loss of distal blood flow. Enhances circulation and reduces pooling of blood, especially in the lower extremities. There is an increased potential for thrombophlebitis and pulmonary emboli in clients who have been immobile for several days. Note: The absence of a positive Homans’ sign is not a reliable indicator in many people. Refer to CP: Thrombophlebitis: Venous Thromboembolism—(Including Pulmonary Emboli Considerations), as indicated. Inadequate circulating volume compromises systemic tissue perfusion. Increased incidence of gastric bleeding accompanies fractures and trauma and may be related to stress or occasionally reflects a clotting disorder requiring further evaluation.
Pressure Management NIC Perform neurovascular assessments, noting changes in motor and sensory function. Ask client to localize pain or discomfort. Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between the first and second toe, and assess ability to dorsiflex toes, if indicated. Assess tissues around cast edges for rough places and pressure points. Investigate reports of “burning sensation” under cast. Monitor position and location of supporting ring of splints or sling.
Circulatory Care: Arterial [or] Venous Insufficiency NIC Collaborative Apply ice bags around fracture site for short periods of time on an intermittent basis for 24 to 72 hours. Monitor Hgb/Hct and coagulation studies, such as prothrombin time (PT).
Administer IV fluids and blood products as needed. Administer medications, as indicated: Low-molecular-weight heparin or heparinoids, such as enoxaparin (Lovenox), dalteparin (Fragmin), or fondaparinux (Arixtra), if indicated. Apply antiembolic hose or sequential pressure hose or compression boots, as indicated.
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Impaired feeling, numbness, tingling, and increased or diffuse pain occur when circulation to nerves is inadequate or nerves are damaged. Length and position of peroneal nerve increase risk of its injury in the presence of leg fracture, edema, or compartment syndrome, or because of malposition of traction apparatus. These factors may be the cause of or be indicative of tissue pressure or ischemia, leading to breakdown and necrosis. Traction apparatus can cause pressure on vessels and nerves, particularly in the axilla and groin, resulting in ischemia and possible permanent nerve damage.
Reduces edema and hematoma formation, which could impair circulation. Note: Length of application of cold therapy is usually 20 to 30 minutes at a time. Assists in calculation of blood loss and needs and effectiveness of replacement therapy. Coagulation deficits may occur secondary to major trauma, in presence of fat emboli, or during anticoagulant therapy. Maintains circulating volume, enhancing tissue perfusion. Anticoagulants may be given prophylactically to reduce threat of deep venous thrombus. Decreases venous pooling and may enhance venous return, thereby reducing risk of thrombus formation.
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Pressure Management NIC Split or bivalve cast as needed. Be sure to cut through wadding down to the skin.
Refer for and monitor intracompartmental pressures as appropriate.
Prepare for surgical intervention, such as fasciotomy, as indicated.
NURSING DIAGNOSIS:
RATIONALE (continued) May be done on an emergency basis to relieve restriction and improve impaired circulation resulting from compression and edema formation in injured extremity. The wadding under the cast may also be restrictive. Diagnosis of compartment syndrome is typically performed with client under light or local anesthesia and measured by means of slit catheter or side-ported catheter. Values of 30 mm Hg or greater indicate a probable compartment problem, requiring prompt medical attention (Jagminas, 2011). Failure to relieve pressure or correct compartment syndrome within 4 to 6 hours of onset can result in severe contractures, loss of function, and disfigurement of extremity distal to injury, possibly necessitating amputation.
risk for impaired Gas Exchange
Risk Factors May Include Ventilation-perfusion imbalance (e.g., altered blood flow, blood or fat emboli) Alveolar and capillary membrane changes (e.g., interstitial congestion, pulmonary edema)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Respiratory Status: Gas Exchange NOC Maintain adequate respiratory function, as evidenced by absence of dyspnea or cyanosis; respiratory rate and arterial blood gases (ABGs) are within client’s normal range.
ACTIONS/INTERVENTIONS
RATIONALE
Respiratory Monitoring NIC Independent Monitor respiratory rate and effort. Note stridor, use of accessory muscles, retractions, and development of central cyanosis.
Auscultate breath sounds, noting development of unequal, hyperresonant sounds; also note presence of crackles, rhonchi, or wheezes and inspiratory crowing or croupy sounds.
Instruct and assist with deep-breathing and coughing exercises. Reposition frequently. Note increasing restlessness, confusion, lethargy, or stupor.
Observe sputum for signs of blood. Inspect skin for petechiae above nipple line, in axilla, spreading to abdomen or trunk, buccal mucosa and hard palate, and conjunctival sacs and retina.
Tachypnea, dyspnea, and changes in mentation are early signs of respiratory insufficiency and may be the only indicator of developing pulmonary emboli in the early stage. Remaining signs and symptoms reflect advanced respiratory distress and impending failure. Changes in or presence of adventitious breath sounds reflects developing respiratory complications—atelectasis, pneumonia, emboli, or acute respiratory distress syndrome (ARDS). Note: Early fixation of long-bone fractures (within 24 hours of injury) can reduce client’s risk of developing ARDS (Kirkland, 2013; Walsh, 2011). Inspiratory crowing reflects upper airway edema and is suggestive of fat emboli as a reason for ARDS. Note: Fat embolus syndrome (FES) should be suspected in client with long-bone fractures who develops hypoxia, fever, bilateral pulmonary infiltrates, and a rash (Kirkland, 2013; Smeltzer, 2011). Promotes alveolar ventilation and perfusion. Repositioning promotes drainage of secretions and decreases congestion in dependent lung areas. Impaired gas exchange or presence of pulmonary emboli can cause deterioration in client’s level of consciousness as hypoxemia and acidosis develop. Hemoptysis may occur with pulmonary emboli. This is the most characteristic sign of fat emboli, which may appear within 2 to 3 days after injury.
Collaborative Instruct in, and encourage regular use of, incentive spirometry. Administer supplemental oxygen, if indicated.
Maximizes ventilation and minimizes atelectasis. Increases available O2 for optimal tissue oxygenation. (continues on page 610)
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ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued) Monitor laboratory studies, such as the following: Pulse oximetry or serial ABGs
Hgb, calcium, erythrocyte sedimentation rate (ESR), serum lipase, fat screen, and platelets, as appropriate Administer medications, as indicated, for example: Low-molecular-weight heparin or heparinoids, such as enoxaparin (Lovenox), dalteparin (Fragmin), or fondaparinux (Arixtra) Corticosteroids
NURSING DIAGNOSIS:
RATIONALE (continued) Identifies situations in which oxygen desaturation is occurring and reveals complications such as impaired gas exchange and developing respiratory failure. Anemia, hypocalcemia, elevated ESR and lipase levels; fat globules in blood, urine, or sputum; and decreased platelet count (thrombocytopenia) are often associated with fat emboli. Used for prevention of thromboembolic phenomena, including deep vein thrombosis and pulmonary emboli. Steroids have been used with some success to prevent and treat fat embolus.
impaired physical Mobility
May Be Related To Loss of integrity of bone structures; decreased muscle strength or control Pain or discomfort; reluctance to initiate movement Prescribed movement restrictions—limb immobilization
Possibly Evidenced By Limited range of motion; slowed movement Difficulty turning
Desired Outcomes/Evaluation Criteria—Client Will Skeletal Function NOC Maintain position of function. Increase strength and function of affected and compensatory body parts.
Mobility NOC Regain and maintain mobility at the highest possible level. Demonstrate techniques that enable resumption of activities, especially activities of daily living (ADLs).
ACTIONS/INTERVENTIONS
RATIONALE
Bedrest Care NIC Independent Assess degree of immobility produced by injury and/or treatment and note client’s perception of immobility. Encourage participation in diversional or recreational activities. Maintain stimulating environment—radio, TV, newspapers, personal possessions, pictures, clock, calendar, and visits from family and friends. Instruct client in active, or assist with passive, ROM exercises of affected and unaffected extremities. Encourage use of isometric exercises, starting with the unaffected limb.
Provide footboard, wrist splints, and trochanter or hand rolls, as appropriate. Instruct in, and encourage use of, trapeze and “post position” for lower limb fractures.
Assist with and encourage self-care activities such as bathing, shaving, and oral hygiene. Assist with mobility by means of wheelchair, walker, crutches, and/or canes as soon as possible. Instruct in safe use of mobility aids.
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Client may be restricted by self-view or self-perception out of proportion with actual physical limitations, requiring information and interventions to promote progress toward wellness. Provides opportunity for release of energy, refocuses attention, enhances client’s sense of self-control and self-worth, and aids in reducing social isolation. Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding or edema is present. Useful in maintaining functional position of extremities, hands or feet, and preventing complications such as contractures or footdrop. Facilitates movement during hygiene, skin care, and linen changes; reduces discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed. Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness. Early mobility reduces complications of bedrest, such as phlebitis, and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and client safety.
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RATIONALE (continued)
Monitor blood pressure (BP) with resumption of activity. Note reports of dizziness.
Postural hypotension is a common problem following prolonged bedrest and may require specific interventions, such as tilt table with gradual elevation to upright position. Prevents or reduces incidence of skin and respiratory complications—decubitus ulcer, atelectasis, or pneumonia. Bedrest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent or limit complications. Provides baseline for comparison with postsurgical concerns. The long-term use of opioids for pain and limited mobility causes constipation in orthopedic clients. Constipation is a major issue and needs immediate and ongoing attention. Keeps the body well hydrated, decreasing risk of urinary infection and stone formation, and helps to prevent constipation.
Reposition periodically and encourage coughing and deepbreathing exercises. Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible. Provide privacy. Evaluate client’s prior bowel habits.
Encourage increased fluid intake of 2000 to 3000 mL/day within cardiac tolerance, including acid ash juices such as cranberry. Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.
Increase the amount of roughage and fiber in the diet. Limit gas-forming foods.
In the presence of musculoskeletal injuries, early good feeding is needed as nutrients required for healing are rapidly depleted. This can have a profound effect on muscle mass, tone, and strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are increased. Adding bulk to stool helps prevent constipation. Gas-forming foods may cause abdominal distention, especially in presence of decreased intestinal motility.
Collaborative Consult with physical or occupational therapist and/or rehabilitation specialist.
Refer to dietitian or nutrition team, as indicated.
Initiate bowel program—stool softeners, enemas, or laxatives, as indicated. Refer to psychiatric clinical nurse specialist or therapist, as indicated.
NURSING DIAGNOSIS:
Useful in creating aggressive individualized activity or exercise program. Client may require long-term assistance with movement, strengthening, and weight-bearing activities as well as use of adjuncts, for example, walkers, crutches, canes; elevated toilet seats; pickup sticks or reachers; special eating utensils; and help for women with actions such as hooking a brassiere. The client with fractures, especially when associated with trauma, may have special nutritional considerations; for example, he or she may need enteral or parenteral feedings to maximize healing of tissues and bones. Important to promote regular bowel evacuation and prevent constipation. Client/SO may require more intensive treatment to deal with reality of current condition, prognosis, prolonged immobility, and perceived loss of control.
impaired Tissue Integrity
May Be Related To Mechanical factors (e.g., compound fracture; surgical repair; insertion of traction pins, wires, screws) Altered sensation, circulation Chemical irritants (e.g., accumulation of excretions or secretions) Impaired physical mobility
Possibly Evidenced By (actual) Damaged/destroyed tissue (e.g., abrasions, lacerations, puncture wounds, surgical incisions)
Desired Outcomes/Evaluation Criteria—Client Will Tissue Integrity: Skin & Mucous Membranes NOC Verbalize relief of discomfort. Demonstrate behaviors or techniques to prevent skin breakdown and facilitate healing, as indicated. Achieve timely wound or lesion healing, if present.
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ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS
RATIONALE
Skin Surveillance NIC Independent Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, and/or blanching.
Provide specialty beds and Geomatts as indicated. Massage skin and bony prominences. Keep bed linens dry and free of wrinkles. Place water pads or other padding under elbows and heels, as indicated. Reposition frequently. Encourage use of trapeze, if possible. If not able to turn independently, a turning schedule must be maintained by the nurse.
Provides information regarding skin circulation and problems that may be caused by application and/or restriction of cast, splint, or traction apparatus, or edema formation that may require further medical intervention. Used for clients with a high risk of skin breakdown or in whom long-term immobility is expected. Reduces pressure on susceptible areas and risk of abrasions or skin breakdown. Lessens constant pressure on same areas and minimizes risk of skin breakdown. Use of trapeze may reduce risk of abrasions to elbows and heels.
Cast Care: Wet NIC Plaster cast application and skin care: Cleanse skin with soap and water, rubbing gently with alcohol and/or dust with small amount of a zinc or stearate powder. Cut a length of stockinette to cover the area and extend several inches beyond the cast. Use palm of hand to apply, hold, or move cast and support on pillows after application; avoid using fingertips to hold cast.
Trim excess plaster from edges of cast as soon as casting is completed. Promote cast drying by removing bed linen, exposing to circulating air. Observe for potential pressure areas, especially at the edges of and under the splint/cast. Pad or petal tape the edges of the cast with waterproof tape or moleskin. Cleanse excess plaster from skin while still wet, if possible. Protect cast and skin in perineal area, providing frequent perineal care. Instruct client/SO to avoid inserting objects inside casts. Massage the skin around the cast edges with alcohol.
Provides a dry, clean area for cast application. Note: Excess powder may cake when it comes in contact with water or perspiration. Useful for padding bony prominences, finishing cast edges, and protecting the skin. Prevents indentations or flattening over bony prominences, such as back of heels, and weight-bearing areas, which would cause abrasions or tissue trauma. An improperly shaped or dried cast is irritating to the underlying skin and may lead to circulatory impairment. Fingertips may dent the cast when it is wet. Uneven plaster is irritating to the skin and may result in abrasions. Prevents skin breakdown caused by prolonged moisture trapped under cast. Pressure can cause ulcerations, necrosis, and/or nerve palsies. These problems may be painless when nerve damage is present. Provides an effective barrier to cast flaking and moisture. Helps prevent breakdown of cast material at edges and reduces skin irritation and excoriation. Dry plaster may flake into completed cast and cause skin damage. Prevents tissue breakdown and infection by fecal contamination. “Scratching an itch” may cause tissue injury. Has a drying effect, which toughens the skin. Creams and lotions are not recommended because excessive oils can seal cast perimeter, not allowing the cast to “breathe.” Powders are not recommended because of potential for excessive accumulation inside the cast.
Pressure Management NIC Collaborative Provide foam mattress, sheepskins, flotation pads, or air mattress, as indicated. Monovalve, bivalve, or cut a window in the cast, per protocol.
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Because of immobilization of body parts, bony prominences other than those affected by the casting may suffer from decreased circulation. Cutting or hinging the cast allows the release of pressure and provides access for wound and skin care.
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CHAPTER 12 ORTHOPEDIC—FRACTURES
NURSING DIAGNOSIS:
risk for Infection
Risk Factors May Include Inadequate primary defenses—broken skin, traumatized tissues, invasive procedures, skeletal traction Increased environmental exposure
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Infection Severity NOC Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
ACTIONS/INTERVENTIONS
RATIONALE
Infection Protection NIC Independent Inspect the skin for preexisting irritation or breaks in continuity. Assess pin sites and skin areas, noting reports of increased pain or burning sensation, or presence of edema, erythema, foul odor, or drainage. Provide sterile pin and wound care according to protocol, and exercise meticulous hand washing. Instruct client not to touch the insertion sites. Line perineal cast edges with plastic wrap. Observe wounds for formation of bullae, crepitation, bronze discoloration of skin, and frothy or fruity-smelling drainage. Assess muscle tone, reflexes, and ability to speak. Monitor vital signs. Note presence of chills, fever, and malaise and any changes in mentation. Investigate abrupt onset of pain or limitation of movement with localized edema and erythema in injured extremity. Institute prescribed isolation procedures.
Pins or wires should not be inserted through skin infections, rashes, or abrasions—may lead to bone infection. May indicate onset of local infection or tissue necrosis, which can lead to osteomyelitis. May prevent cross-contamination and possibility of infection. Minimizes risk of contamination. Damp, soiled casts can promote growth of bacteria. Signs suggestive of gas gangrene infection. Muscle rigidity, tonic spasms of jaw muscles, and dysphagia reflect development of tetanus. Hypotension and confusion may be seen with gas gangrene; tachycardia, chills, and fever reflect developing sepsis. May indicate development of osteomyelitis. Presence of purulent drainage requires wound and linen precautions to prevent cross-contamination.
Collaborative Monitor laboratory/diagnostic studies, for example: CBC ESR Cultures and sensitivity of wound, serum, and/or bone Radioisotope scans Administer medications, as indicated, for example: IV/topical antibiotics Tetanus toxoid
Provide wound or bone irrigations, and apply warm, moist soaks, as indicated.
Assist with procedures such as incision and drainage, placement of drains, and hyperbaric oxygen therapy. Prepare for surgery, as indicated.
Anemia may be noted with osteomyelitis; leukocytosis is usually present with infective processes. Elevated in osteomyelitis. Identifies infective organism and effective antimicrobial agent(s). Hot spots signify increased areas of vascularity, indicative of osteomyelitis. Wide-spectrum antibiotics may be used prophylactically or may be geared toward a specific microorganism. Given prophylactically because the possibility of tetanus exists with any open wound. Note: Risk increases when injury or wound(s) occur in “field conditions”—outdoors, rural areas, or the work environment. Local debridement and cleansing of wounds reduces microorganisms and incidence of systemic infection. Continuous antimicrobial drip into bone may be necessary to treat osteomyelitis, especially if blood supply to bone is compromised. Numerous procedures may be carried out in treatment of local infections, osteomyelitis, and gas gangrene. Sequestrectomy, removal of necrotic bone, is necessary to facilitate healing and prevent extension of infectious process.
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NURSING DIAGNOSIS:
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall Misinterpretation of information Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Treatment Regimen NOC Verbalize understanding of condition, prognosis, and potential complications. Correctly perform necessary procedures and explain reasons for actions.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Review pathology, prognosis, and future expectations.
Discuss prophylactic antibiotic use.
Discuss dietary needs. Discuss individual drug regimen, as appropriate. Reinforce methods of mobility and ambulation as instructed by physical therapist when indicated. Suggest use of a backpack.
List activities that the client can perform independently and those that require assistance. Identify available community services, such as a rehabilitation team, home nursing care, or homemaker services. Encourage client to continue active exercises for the joints above and below the fracture. Discuss importance of clinical and therapy follow-up appointments.
Review proper pin or wound care. Recommend cleaning external fixator device regularly. Identify signs and symptoms requiring medical evaluation, for example, severe pain, fever or chills, or foul odors; changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, or white/cool toes or fingertips; and warm spots, soft areas, or cracks in the cast. Discuss care of “green” or wet cast.
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Provides knowledge base from which client can make informed choices. Note: Internal fixation devices can ultimately compromise the bone’s strength, and intramedullary nails or rods, and plates may be removed at a future date. When hardware, such as pins, screws, and plates, is implanted, it provides a place for infection to develop. If there are procedures that open the GI tract to the bloodstream, such as dental procedures or a colonoscopy, antibiotics should be given. A low-fat diet adequate in quality protein and rich in calcium promotes healing and general well-being. Proper use of pain medication and antiplatelet agents can reduce risk of complications. Most fractures require casts, splints, or braces during the healing process. Further damage and delay in healing could occur secondary to improper use of ambulatory devices. Provides place to carry necessary articles and leaves hands free to manipulate crutches; may prevent undue muscle fatigue when one arm is casted. Organizes activities around need and who is available to provide help. Provides assistance to facilitate self-care and support independence. Promotes optimal self-care and recovery. Prevents joint stiffness, contractures, and muscle wasting, promoting earlier return to independence in ADLs. Fracture healing may take as long as a year for completion, and client cooperation with the medical regimen facilitates proper union of bone. Physical therapy and occupational therapy may be indicated for exercises to maintain or strengthen muscles and improve function. Additional modalities such as low-intensity ultrasound may be used to stimulate healing of lower-forearm or lower-leg fractures. Reduces risk of bone and tissue trauma and infection, which can progress to osteomyelitis. Keeping device free of dust or contaminants reduces risk of infection. Prompt intervention may reduce severity of complications such as infection or impaired circulation. Note: Some darkening of the skin reflecting vascular congestion may occur normally when walking on the casted extremity or using casted arm; however, this should resolve with rest and elevation. Promotes proper curing to prevent cast deformities and associated misalignment or skin irritation. Note: Placing a “cooling” cast directly on rubber or plastic pillows traps heat and increases drying time.
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RATIONALE (continued)
Suggest the use of a blow-dryer to dry small areas of dampened cast. Demonstrate use of plastic bags to cover plaster cast during wet weather or while bathing. Clean soiled cast with a slightly dampened cloth and some scouring powder.
Cautious use can hasten drying.
Emphasize the importance of not adjusting clamps or nuts of an external fixator device. Recommend use of loose-fitting or adaptive clothing. Suggest ways to cover toes if appropriate, for example, using stockinette or soft socks. Discuss postcast removal instructions: Instruct client to continue exercises as permitted. Inform client that the skin under the cast is commonly mottled and covered with scales or crusts of dead skin. Wash the skin gently with soap and water and lubricate with a protective emollient. Inform client that muscles may appear flabby and atrophied (less muscle mass); recommend supporting the joint above and below the affected part and the use of mobility aids—elastic bandages, splints, braces, crutches, walkers, or canes. Elevate the extremity, as needed.
NURSING DIAGNOSIS:
Protects from moisture, which softens the plaster and weakens the cast. Note: Fiberglass casts are being used more frequently. They also need to be thoroughly dried if they get wet to avoid developing mold. Tampering may alter compression and misalign fracture. Facilitates dressing and grooming activities. Helps maintain warmth and protect from injury.
Reduces stiffness and improves strength and function of affected extremity. It will be several weeks before normal appearance returns. New skin is extremely tender because it has been protected beneath a cast. Muscle strength will be reduced and new or different aches and pains may occur secondary to loss of support.
Swelling and edema tend to occur after cast removal.
readiness for enhanced Self-Care
May Be Related To (Not applicable; readiness diagnoses do not have related factors)
Possibly Evidenced By Expression of desire to enhance self-care, knowledge for strategies for self-care, or responsibility for self-care
Desired Outcomes/Evaluation Criteria—Client Will Discharge Readiness: Independent Living NOC Demonstrate proactive management of chronic condition, potential complications. Identify and use resources appropriately. Remain free of preventable complications.
ACTIONS/INTERVENTIONS
RATIONALE
Self-Efficacy Enhancement NIC Independent Note age, developmental level, and presence of comorbidities. Discuss client’s understanding of current situation. Determine individual strengths and skills of the client, using functional status instrument if indicated. Review coping skills (e.g., assertiveness, interpersonal relations, decision making, problem-solving). Provide accurate and relevant information regarding current and future needs. Active-listen client’s/SO’s concerns. Note availability and use of resources, and supportive persons and assistive devices. Identify reliable reference sources and strategies for self-care. Review safety concerns and potential for modification of therapies, activities, or environment. Refer to home-care provider, social services, physical or occupational therapy, durable medical equipment, rehabilitation and counseling resources as indicated or requested. Identify additional community resources (e.g., handicap transportation van for appointments, accessible and safe locations for social or sports activities).
These factors impact ability of client to meet own needs. Helps determine areas that can be clarified or strengthened. Establishes comparative baseline for potential for growth or modifications in current strategies. Useful for managing a wide range of stressful conditions. Client can incorporate information into self-care plans, while minimizing difficulties associated with change. Exhibits regard for their values and beliefs and encourages open discussion about concerns. Makes sure that client has means for sharing concerns, needs, and wishes, as well as has access to support and approval (family members, professionals). Reinforces learning and promotes self-paced review. May be needed to prevent complications or enhance successful functioning. May be helpful for education, assistance, adaptive devices, and modifications that may be desired.
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CHAPTER 12 ORTHOPEDIC—FRACTURES
ACTIONS/INTERVENTIONS (continued)
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POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) In addition to surgical considerations: • risk for Trauma—balancing difficulties, weakness, reduced muscle coordination, history of previous trauma • impaired physical Mobility —neuromuscular skeletal impairment, pain/discomfort, prescribed movement restrictions (limb immobilization) • Self-Care Deficit—musculoskeletal impairment, decreased strength/endurance, pain • risk for Infection—inadequate primary defenses: broken skin, traumatized tissues, environmental exposure, invasive procedures, skeletal traction
AMPUTATION I. Pathophysiology—Partial or complete detachment of body part with residual extremity covered with well-vascularized muscle and skin, although reattachment surgery may be possible for fingers, hands, and arms a. Primarily two types of amputations i. Open or provisional: Requires subsequent revisions ii. Closed or flap: All surgical revision is performed and the wound closed in one procedure. b. Amputation levels (Amputation Coalition, 2012): i. Lower-extremity: Partial foot or toe, below knee (BKA), above knee (AKA), hip disarticulation or hemipelvectomy, and bilateral lower-limb loss ii. Upper-extremity amputation: Partial hand or finger, below elbow, above elbow, shoulder disarticulation or forequarter, and bilateral upper-limb loss c. Two basic types of prosthetic designs are used: exoskeletal and endoskeletal. II. Etiology a. Varied causes ( Ertl, 2012; Kalapatapu, 2012; Kirshner, 2011) i. Peripheral vascular disease (causing critical limb ischemia, often associated with diabetes (45% to 50%), usually involves lower extremity; most common in the United States, accounting for 65% of cases ii. Trauma: Examples include direct limb transection or a severe open fracture with an associated unreconstructable neurovascular injury (often associated with motor vehicle crashes or industrial accidents), battlefield wounds. Note: U.S. wounded in current war theaters include more than 1500 amputations to date (Huffington Post, October 2012).
iii. Malignant bone tumors iv. Infections: osteomyelitis, gangrene v. Congenital disorders: approximately 5% of cases b. Lower-extremity amputations are performed much more frequently than upper-extremity amputations. c. Upper-extremity amputations generally result from trauma caused by industrial accidents. III. Statistics a. Morbidity: In the year 2005, 1.6 million persons were living with the loss of a limb (Ziegler-Graham, 2008). In 2008, the incidence of amputation for those with a previous incident amputation was 17.1% (Margolis et al, 2011). b. Mortality: One review of a series of studies showed 30-day mortality rates for major amputation range from 3% to 18% (Kalapatapu, 2012). A higher level of amputation correlates with increased mortality and may reflect the severity of systemic cardiovascular disease or differences in the incidence of thromboembolism rather than the magnitude of the procedure (Dillingham, 2005). One study indicated that while there is a high prevalence of preexisting neurological disorders among lower-extremity amputees affecting the risk of mortality, age is a stronger predictor of mortality (Prvu-Bettger, 2009). c. Costs: The average total charge equals $32,129 per amputation and cumulative inpatient hospitalization equaled $56.5 million in 2008 (Peaco*ck, 2011).
G L O S S A R Y Complete amputation: Total detachment of appendage or limb from the body. Endoskeletal prosthetic: Aluminum, titanium, and other tubular materials form the inner structure, providing strength; external shape is removable, usually composed of foam or skinsimulating material. Exoskeletal prosthetic: Outer plastic laminated skin with wood or urethane foam interiors where the strength is provided by the outer layer.
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Neuromas: Painful proliferation of nerve fibers at the proximal end of a severed nerve. Partial amputation: Some soft tissue remains attached to the body. Residual limb: Remaining portion of the amputated limb (once referred to as the stump).
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Related Concerns
Client is treated in inpatient acute surgical unit and subacute or rehabilitation unit.
Cancer, page 827 Diabetes mellitus/diabetic ketoacidosis, page 377 Psychosocial aspects of care, page 729 Surgical intervention, page 762
CHAPTER 12 ORTHOPEDIC—AMPUTATION
Care Setting
Client Assessment Database Data depend on underlying reason for surgical procedure, for example, severe trauma, peripheral vascular/arterial occlusive disease, diabetic neuropathy, osteomyelitis, and cancer.
D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
ACTIVITY/REST • Actual or anticipated limitations imposed by condition or amputation
CIRCULATION • Presence of edema • Absent or diminished pulses in affected limb or digits
EGO INTEGRITY • Concern about negative effects or anticipated changes in lifestyle, financial situation, reactions of others • Feelings of helplessness, powerlessness
• • • • •
Anxiety, apprehension Irritability Anger, frustration Withdrawal, grief False cheerfulness
• • • •
Necrotic or gangrenous area Nonhealing wound Local infection Altered gait; increased risk for falls
NEUROSENSORY • Loss of sensation in affected area • Phantom pain
SAFETY • History of falls, traumatic injuries, risky behavior, or work environment resulting in injury • Loss of ability to walk; altered gait
SEXUALITY • Concern about intimate relationships
SOCIAL INTERACTION • Problems related to illness or condition • Concern about role function • Concern about reaction of others
TEACHING/LEARNING DISCHARGE PLAN CONSIDERATIONS • May require assistance with wound care and supplies, adaptation to prosthesis or other ambulatory devices, transportation, homemaker or maintenance tasks, and possibly self-care activities and vocational retraining ➧ Refer to section at end of plan for postdischarge considerations.
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Diagnostic Studies Studies depend on the underlying condition necessitating amputation and are used to determine the appropriate level for amputation.
TEST WHY IT IS DONE
W H AT I T T E L L S M E
• X-rays: Used to visualize pathology and the extent of involvement. • Computed tomography (CT) scan: Used to visualize changes of structure within the body and bone alignment. • Angiography and blood flow studies: Evaluates circulation and tissue perfusion. • Doppler ultrasound, laser Doppler flowmetry: Performed to assess and measure blood flow. • Transcutaneous oxygen pressure: Maps out areas of greater and lesser perfusion in the involved extremity. • Thermography: Measures temperature differences in an ischemic limb at two sites—the skin and the center of the bone. • C-reactive protein (CPR): Inflammatory marker as indicator of infection. • White blood cell (WBC) count/differential: Assess body’s ability to respond to and eliminate infection. • Biopsy: Determines presence of pathology and treatment needs or options.
Identify skeletal abnormalities, trauma, or mass or tumor. Identifies soft tissue and bone destruction, neoplastic lesions, osteomyelitis, and hematoma formation. Helps predict potential for tissue healing after amputation. Determines adequacy of skin microcirculation and helps predict tissue or muscle viability and primary wound healing. Helps determine lowest level at which to perform amputation for maximum preservation of limb length and successful healing. The lower that the difference is between the two readings, the greater the chances will be for healing. Important if osteomyelitis or sepsis is a suspected or known factor in considering amputation. A level greater than 8 mg/L indicates significant infection. Elevation and “shift to left” suggest infectious process. Confirms diagnosis of benign or malignant mass.
Nursing Priorities
Discharge Goals
1. 2. 3. 4. 5.
1. 2. 3. 4. 5.
Alleviate pain. Prevent complications. Promote mobility and functional abilities. Support psychological and physiological adjustment. Provide information about surgical procedure, prognosis, and treatment needs.
NURSING DIAGNOSIS:
Pain relieved or controlled. Complications prevented or minimized. Mobility and function regained or compensated for. Dealing with current situation realistically. Surgical procedure, prognosis, and therapeutic regimen understood. 6. Plan in place to meet needs after discharge.
acute Pain
May Be Related To Physical injury (e.g., tissue and nerve trauma) Psychological (e.g., impact of loss of body part, stress, anxiety)
Possibly Evidenced By Verbalized/coded reports of pain Guarding behavior, protective gestures Narrowed focus Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain is relieved or controlled. Appear relaxed and able to rest and sleep appropriately. Verbalize understanding of phantom pain and methods to provide relief.
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RATIONALE
Pain Management NIC Independent Document location and intensity of pain (0 to 10, or similar coded scale) as well as quality and aggravating factors. Investigate changes in pain characteristics—numbness and tingling. Elevate affected part by raising foot of bed slightly or using a pillow or sling for upper-limb amputation.
Provide or promote general comfort measures (e.g., frequent turning, back rub) and diversional activities. Encourage use of stress management techniques, such as deep-breathing exercises, visualization and guided imagery, and Therapeutic Touch. Investigate reports of progressive or poorly localized pain unrelieved by analgesics. Acknowledge reality of residual limb pain and phantom pain and that various modalities will be tried for pain relief.
Aids in evaluating need for and effectiveness of interventions. Changes may indicate developing complications, such as necrosis or infection. Lessens edema formation by enhancing venous return; reduces muscle fatigue and skin or tissue pressure. Note: After initial 24 hours and in absence of edema, residual limb may be extended and kept flat. Refocuses attention, promotes relaxation, may enhance coping abilities, and may decrease occurrence of phantom-limb pain.
May indicate developing compartment syndrome, especially following traumatic injury. (Refer to CP: Fractures; ND: risk for Peripheral Neurovascular Dysfunction.) Residual limb pain is believed to come from injuries to bone, muscle, nerve, and skin at the amputation site (Ertl, 2012). At the ends of injured nerve fibers, neuromas send out pain impulses in a random fashion, or when trapped, as in excessive compression by other tissues such as muscle, or in the development of the infectious process. In contrast, phantom pain is thought to originate in the part of the brain that controlled the limb before it was amputated. So the client experiences pain and sensation as if the limb were still in place. Phantom pain is often described as crushing, grinding, or burning. It can occur immediately or may not start for several weeks. Note: Phantom pain is not well relieved by traditional pain medications.
Collaborative Administer medications, as indicated, such as the following: Opioid analgesics, for example, morphine sulfate (Astramorph, MS Contin), Fentanyl patch; combination agents: oxycodone with acetaminophen (Percocet); and anti-inflammatory agents, for example, acetaminophen (Tylenol) and ibuprofen (Motrin) Antidepressants, for example, amitriptyline (Elavil), nortriptyline (Pamelor), and duloxetine (Cymbalta); antiseizure drugs, for example, carbamazepine (Tegretol), gabapentin (Neurontin), and pregabalin (Lyrica); sedatives/anti-anxiety agents, for example, diazepam (Valium) and alprazolam (Xanax); and local/regional anesthetics, for example, novocaine (Marcaine) and ropivacaine (Naropin) Instruct in, and monitor use of, patient-controlled analgesia (PCA). Refer to interdisciplinary providers as appropriate—pain management specialist, physical therapist, prosthetist, orthopedic surgeon, and neurosurgeon. Discuss and monitor use of transcutaneous electrical nerve stimulation (TENS) of the residual limb.
NURSING DIAGNOSIS:
Many medications and routes of administration may be used. In acute post-amputation pain, opioid analgesics are the mainstay of pain management to reduce pain and muscle spasms. As surgical pain subsides, other medications will be added to manage more long-term conditions; for example, antidepressants and antiseizure medications appear to help with neuritic pain associated with phantom pain and sensations.
PCA provides for continuous and timely drug administration, preventing fluctuations in pain level and muscle tension and spasms associated with surgical procedures. A multidisciplinary approach is required, and many therapy modalities may be needed both in the acute and the longterm management of pain. For some individuals, a TENS unit may help to treat retractable phantom-limb pain, especially in combination with medications for neuropathic pain. Note: Stimulation of the intact (opposite) limb is often more effective. Indeed, an increase in phantom pain has occasionally been reported when TENS unit has been applied to residual limb.
risk for ineffective peripheral Tissue Perfusion
Risk Factors May Include Hypovolemia; tissue edema, hematoma formation
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral NOC Maintain adequate tissue perfusion as evidenced by palpable peripheral pulses; warm, dry skin; and timely wound healing.
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ACTIONS/INTERVENTIONS
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ACTIONS/INTERVENTIONS
RATIONALE
Circulatory Precautions NIC Independent Monitor vital signs. Palpate peripheral pulses, noting strength and equality. Perform periodic neurovascular assessments—sensation, movement, pulse, skin color, and temperature.
Note type of dressing used—soft, soft with pressure wrap, semirigid, or rigid.
Inspect dressings and drainage device, noting amount and characteristics of drainage, especially in client receiving antithrombotic therapy, including DVT prophylaxis. Apply direct pressure to bleeding site if hemorrhage occurs. Contact physician immediately. Investigate reports of persistent or unusual pain in operative site. Evaluate nonoperated lower limb and residual limb for redness, unexplained fever, or tenderness.
Encourage and assist with early ambulation.
General indicators of circulatory status and adequacy of perfusion. Amputation wound healing is a concern because most are performed for compromised circulation, for example, with peripheral vascular disease (PVD) or damaged soft tissue resulting from trauma (Ertl, 2012). Postoperative tissue edema, hematoma formation, or restrictive dressings may impair circulation to residual limb, resulting in tissue necrosis. Postoperative dressing varies, each with its advantages and disadvantages. For example, a soft dressing does not control edema. Adding a pressure wrap distributes pressure, but requires measures to avoid possible limb strangulation. Semirigid dressings (e.g., plaster splint, Unna paste bandage) or rigid dressings allow for decreased edema and immediate postoperative prosthesis with early ambulation but limit access to the wound, and possible excessive pressure may lead to compromised healing (Ertl, 2012). Continued blood loss may indicate need for additional fluid replacement and evaluation for coagulation defect or surgical intervention to ligate bleeder, hematoma evacuation, or revision of stump (Nowygrod et al, 2006). Direct pressure to bleeding site may be followed by application of a bulk dressing secured with an elastic wrap once bleeding is controlled. Hematoma can form in muscle pocket under the flap, compromising circulation and intensifying pain. Increased incidence of thrombus formation in clients with preexisting peripheral vascular disease or diabetic changes. Note: Research reveals that the incidence of deep vein thrombosis (DVT) is higher for above-knee amputation compared with below-knee amputation (37.5% versus 21.2%, respectively) (Matielo et al, 2008). Enhances circulation and helps prevent stasis and associated complications. Promotes sense of general well-being.
Collaborative Administer intravenous (IV) fluids and blood products as indicated. Apply anti-embolic or sequential compression hose to nonoperated leg, as appropriate. Administer low-dose anticoagulant, as indicated.
Monitor laboratory studies, for example: Hemoglobin/hematocrit (Hgb/Hct) Prothrombin time (PT)/activated partial thromboplastin time (aPTT).
NURSING DIAGNOSIS:
Maintains circulating volume to maximize tissue perfusion. Enhances venous return, reducing venous pooling and risk of thrombophlebitis. May be useful in preventing thrombus formation without increasing risk of postoperative bleeding or hematoma formation. Indicators of hypovolemia, or dehydration, which can impair tissue perfusion. Evaluates need for, and effectiveness of, anticoagulant therapy and identifies developing complication such as posttraumatic disseminated intravascular coagulation (DIC).
risk for Infection
Risk Factors May Include Inadequate primary defenses—broken skin, traumatized tissue, invasive procedures Chronic disease
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Wound Healing: Primary Intention NOC Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
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RATIONALE
Wound Care NIC Independent Evaluate client’s risk for infection.
Maintain strict hand hygiene measures, using soap and water or antibacterial soaps, before and after client care and after glove removal. Maintain aseptic technique when changing dressings and caring for wound. Inspect wound (noting redness and excess warmth) and dressings daily or per prescription; note characteristics of drainage, particularly in client with unexplained fever or reporting excessive stump pain. Maintain patency and routinely empty drainage device.
Cover dressing with plastic when using the bedpan or if incontinent Expose residual limb to air and wash with mild soap and water after dressings are discontinued. Monitor vital signs.
Every client is at risk for postoperative infection; however, lower-extremity amputation is often associated with open, infected wounds and, thus, surgical wounds are classified as contaminated and associated with a high risk for surgical site infection (Kalapatapu, 2012). Hand hygiene remains the cornerstone of infection prevention and control in healthcare and community settings. Minimizes opportunity for introduction of bacteria. Early detection of developing infection provides opportunity for timely intervention and prevention of more serious complications such as osteomyelitis. Hemovac and Jackson-Pratt drains facilitate removal of drainage, promoting wound healing and reducing risk of infection. Reduces risk of contamination in high-level, lower-limb amputation. Maintains cleanliness, minimizes skin contaminants, and promotes healing of tender, fragile skin. Temperature elevation and tachycardia may reflect developing sepsis.
Collaborative Obtain wound and drainage cultures and sensitivities, as appropriate. Administer antibiotics, as indicated.
NURSING DIAGNOSIS:
Identifies presence of infection, specific organisms, and appropriate therapy. Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.
impaired physical Mobility
May Be Related To Pain or discomfort Decreased muscle mass/strength Musculoskeletal impairment (e.g., loss of a limb—particularly a lower extremity) Deconditioning; decreased endurance
Possibly Evidenced By Limited range of motion; difficulty turning Postural instability; gait changes
Desired Outcomes/Evaluation Criteria—Client Will Coordinated Movement NOC Increase strength and function of affected and compensatory body parts. Move about environment safely.
Knowledge: Body Mechanics NOC Verbalize understanding of individual situation and safety measures. Demonstrate techniques and behaviors that enable resumption of activities. Maintain position of function as evidenced by absence of contractures.
ACTIONS/INTERVENTIONS
RATIONALE
Amputation Care NIC Independent Provide residual limb care on a routine basis; for example, inspect the area, clean and dry it thoroughly, and rewrap the residual limb with elastic bandage or air splint. Conversely, apply a “stump shrinker” or heavy stockinette sock for “delayed” prosthesis.
Provides opportunity to evaluate healing and note complications unless covered by immediate prosthesis. Wrapping residual limb controls edema and helps form residual limb into conical shape to facilitate fitting of prosthesis. Note: Air splint may be preferred because it permits visual inspection of the wound. (continues on page 622)
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ACTIONS/INTERVENTIONS
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Measure circumference periodically.
Measurement is done to estimate shrinkage to ensure proper fit of sock and prosthesis. Edema will occur rapidly, thus delaying rehabilitation.
Rewrap residual limb immediately with an elastic bandage; elevate if “immediate or early” cast is accidentally dislodged. Prepare for reapplication of cast. Assist with specified range-of-motion (ROM) exercises for both the affected and unaffected limbs, beginning early in postoperative stage. Encourage active and isometric exercises for upper torso and unaffected limbs. Provide trochanter rolls, as indicated. Instruct client to lie in prone position, as tolerated, at least twice a day with pillow under abdomen and lower-extremity residual limb. Caution against keeping pillow under lower-extremity residual limb or allowing BKA limb to hang dependently over side of bed or chair. Demonstrate/assist with transfer techniques and use of mobility aids such as a trapeze, crutches, or a walker. Assist with ambulation based on specific prosthesis used, for example: Immediate postoperative fitting Early postoperative fitting
Delayed fitting
Help client continue preoperative muscle exercises as able or when allowed out of bed; for example, the client should perform abdomen-tightening exercises and knee bends; hop on foot; and stand on toes while holding on to chair for balance. Instruct client in residual limb-conditioning exercises, for example, pushing the residual limb against a pillow initially, then progressing to harder surface.
Prevents contracture deformities, which can develop rapidly and could delay prosthesis usage. Increases muscle strength to facilitate transfers and ambulation and promotes mobility and more normal lifestyle. Prevents external rotation of lower-limb residual limb. Strengthens extensor muscles and prevents flexion contracture of the hip, which can begin to develop within 24 hours of sustained malpositioning. Use of pillows can cause permanent flexion contracture of hip; a dependent position of residual limb impairs venous return and may increase edema formation. Facilitates self-care and client’s independence. Proper transfer techniques prevent shearing abrasions/dermal injury related to “scooting.”
Reduces potential for injury. Ambulation after lower-limb amputation depends on timing of prosthesis placement. A rigid dressing is applied to the residual limb and a pylon and artificial foot are attached. Weight-bearing begins within 24 to 48 hours. Weight-bearing normally does not occur until 10 to 30 days postoperatively. More common in areas that do not have facilities available for immediate or early application of prosthesis or when the condition of the residual limb and/or client precludes these choices. Note: With the advent of new medical techniques at the trauma scene, new surgical techniques, new occupational therapy techniques, and new component and prosthetic technology, such as the C-leg prosthesis that uses computer sensors and hydraulics (enabling client to move around nearly effortlessly), the initial steps for fitting begin when the stitches are removed. Client is fitted with prosthetic 2 weeks after final amputation (Schuch, 2008). Contributes to gaining improved sense of balance and strengthens compensatory body parts.
Hardens the residual limb by toughening the skin and altering feedback of resected nerves to facilitate use of prosthesis.
Collaborative Refer to rehabilitation team, for example, physical and occupational therapy and prosthetic specialists.
Provide foam or flotation mattress.
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Provides for creation of exercise and activity program to meet individual needs and strengths and identifies mobility functional aids to promote independence. Early use of a temporary prosthesis promotes activity and enhances general well-being and a positive outlook. Note: Vocational counseling and/or retraining also may be indicated. Reduces pressure on skin and tissues that can impair circulation, potentiating risk of tissue ischemia and breakdown.
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CHAPTER 12 ORTHOPEDIC—AMPUTATION
NURSING DIAGNOSIS:
Grieving
May Be Related To Significant loss (e.g., body part, change in functional abilities, professional/family role, perception of self)
Possibly Evidenced By Anger; suffering; psychological distress; detachment Making meaning of loss; personal growth
Desired Outcomes/Evaluation Criteria—Client Will Grief Resolution NOC Begin to show adaptation and verbalize acceptance of self in situation (amputee). Recognize and incorporate changes into self-concept in accurate manner without negating self-esteem. Develop realistic plans for adapting to new role or role modifications.
ACTIONS/INTERVENTIONS
RATIONALE
Grief Work Facilitation NIC Independent Assess and consider client’s preparation for and view of amputation.
Encourage expression of fears, negative feelings, and grief over loss of body part. Reinforce preoperative information, including type and location of amputation, type of prosthetic fitting if appropriate (i.e., immediate, delayed), and expected postoperative course, including pain control and rehabilitation. Assess degree of support available to client. Discuss client’s perceptions of self, related to change, and how client sees self in usual lifestyle and role functioning.
Ascertain individual strengths and identify previous positive coping behaviors. Encourage participation in activities of daily living (ADLs). Provide opportunities to view and care for residual limb, using the moment to point out positive signs of healing.
Encourage or provide for a visit by another amputee, especially one who is successfully rehabilitating. Provide open environment for client to discuss concerns about sexuality. Note withdrawn behavior, negative self-talk, use of denial, depression, or overconcern with actual or perceived changes.
Research shows that amputation poses serious threats to client’s psychological and psychosocial adjustment. Client who views amputation as life-saving or reconstructive may be able to accept the new self more quickly. Client with sudden traumatic amputation or who considers amputation to be the result of failure in other treatments is at greater risk for disturbances in self-concept and complicated grieving. Venting emotions helps client begin to deal with the fact and reality of life without a limb. Provides opportunity for client to question and assimilate information and begin to deal with changes in body image and function, which can facilitate postoperative recovery. Sufficient support by significant other (SO) and friends can facilitate rehabilitation process and grief resolution. Aids in defining concerns in relation to previous lifestyle and facilitates problem-solving. For example, client likely fears loss of independence, ability to work or express sexuality, and may experience role and/or relationship changes. Helpful to build on strengths that are already available for client to use in dealing with current situation. Promotes independence and enhances feelings of self-worth. Although integration of residual limb into body image can take months or even years, looking at the residual limb and hearing positive comments made in a normal, matter-of-fact manner can help client with this acceptance. A peer who has been through a similar experience serves as a role model and can provide validity to comments and hope for recovery and a positive future. Promotes sharing of beliefs and values about sensitive subject, and identifies misconceptions or myths that may interfere with adjustment to situation. Identifies stage of grief and may indicate need for more intensive interventions. Note: Studies show that post-traumatic stress disorder (PTSD) develops in 20% to 22% of people who have amputations associated with combat or accidental injury (Kalapatapu, 2012).
Collaborative Discuss availability of various resources, for example, psychiatric or sexual counseling, a prosthetist, or a physical or occupational therapist.
May need assistance and long-term support to facilitate optimal adaptation and establish a “new” normal for future.
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NURSING DIAGNOSIS:
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May Be Related To Lack of exposure or recall Information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Disease Process NOC Verbalize understanding of condition, disease process, and potential complications.
Knowledge: Treatment Regimen NOC Verbalize understanding of therapeutic needs. Correctly perform necessary procedures and explain reasons for the actions. Initiate necessary lifestyle changes and participate in treatment regimen.
ACTIONS/INTERVENTIONS
RATIONALE
Amputation Care NIC Independent Review disease process, surgical procedure, and future expectations. Instruct in dressing and wound care, inspection of residual limb using mirror to visualize all areas, skin massage, and appropriate wrapping of the residual limb. Discuss general residual limb care, for example: Wash daily with mild soap and water; rinse and pat dry. Do this daily, or more often if client sweats a lot or in treating a rash or infection. Massage the residual limb after dressings are discontinued and suture line is healed. Avoid the use of alcohol-based lotions or use of powders.
Wear only properly fitted, clean, wrinkle-free limb sock.
Use clean cotton T-shirt under harness for upper-limb prosthesis. Review common problems and appropriate actions.
Discuss need to report changes in pain characteristics, range of motion restrictions, warmth, and socket fitting in residual limb.
Emphasize importance of well-balanced diet and adequate fluid intake.
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Provides knowledge base from which client can make informed choices. Promotes competent self-care, facilitates healing and fitting of prosthesis, and reduces potential for complications.
Hygiene of residual limb is critical because most of the time it is enclosed in the socket or liner of the prosthesis, rendering it more prone to skin breakdown and infection. Massage softens the scar and prevents adherence to the bone, decreases tenderness, and stimulates circulation. Although a small amount of lotion may be indicated if skin is dry, emollients and creams soften skin and may cause maceration when prosthesis is worn. Powder may cake, potentiating skin irritation. Residual limb may continue to shrink for up to 2 years, and an improperly fitting sock or one that is mended or dirty can cause skin irritation or breakdown. Absorbs perspiration; prevents skin irritation from harness. Problems can occur even when client is taking precautions, for example, the development of a red, sore area that does not resolve when prosthesis is off, or a blister caused by pressure between socket liner and skin. These problems need early medical follow-up if home interventions are not effective. Among recent military amputees returning from combat, a high rate of heterotopic ossification (HO) has been seen in amputated residual. This complication of bone formation in soft tissue presents numerous rehabilitation challenges. For example, bone formed in soft tissues of a weight-bearing limb can result in high-pressure areas, creating a risk for skin breakdown. Skin breakdown can have devastating effects on rehabilitation because it often requires prolonged periods of non-weight-bearing and presents a risk for infection. HO can also result in complex residual limb shapes and multiple pressure-sensitive areas that can make prosthesis fitting difficult or impossible (Goff, et al, 2009). Provides needed nutrients for tissue regeneration and healing, aids in maintaining circulating volume and normal organ function, and aids in maintenance of proper weight. Note: Weight changes affect fit of prosthesis.
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RATIONALE (continued)
Recommend cessation of smoking. Offer referral resources for cessation programs. Review and demonstrate care of prosthetic device. Stress importance of routine maintenance and periodic refitting. Encourage continuation of postoperative exercise program.
Smoking potentiates peripheral vasoconstriction, impairing circulation and tissue oxygenation. Ensures proper fit and alignment, reduces risk of complications, and prolongs life of prosthesis. Enhances circulation, healing, and function of affected part, facilitating adaptation to prosthetic device. Persistent and/or recurring pain requires long-term management, with multiple strategies and modalities, including desensitization therapy, intermittent compression, medications, TENS, and nerve blocks. Note: Electrical stimulation offers a short-term rerouting or stimulation of different nerve pathways, thus reducing the activity of the usual pain patterns. Various techniques may be implemented, such as relaxation breathing, exercises, visualization, or biofeedback to reduce muscle tension and enhance client’s control of situation and coping abilities. Prompt intervention may prevent serious complications and/or loss of function. Note: Chronic phantom-limb pain may indicate neuroma, requiring surgical resection.
Identify techniques to manage phantom sensation and phantom pain. (Refer to ND: acute Pain.)
Encourage taking care of whole self: body, mind, and spirit. Emphasize socialization, stress management, relaxation training, or counseling. Identify signs and symptoms requiring medical evaluation— edema, erythema, increased or odorous drainage from incision, changes in sensation, movement, skin color, and persistent phantom pain. Identify community and rehabilitation support, such as a certified prosthetist-orthotist, amputee groups, home-care service, and homemaker services, as needed.
Facilitates transfer to home, supports independence, and enhances coping.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) In addition to considerations in Surgical Intervention plan of care: • impaired physical Mobility—decreased muscle mass/strength; musculoskeletal impairment; deconditioning; decreased endurance • risk for Trauma—balancing difficulties, muscle weakness, reduced muscle coordination, lack of safety precautions, hazards associated with use of assistive devices • disturbed Body Image—loss of body part, change in functional abilities • Self-Care Deficit/impaired Home Maintenance (dependent on location of amputation)—musculoskeletal impairment, decreased strength/endurance, pain, depression
TOTAL JOINT REPLACEMENT I. Purpose a. Definitive treatment for advanced, irreversibly damaged joints with loss of function and unremitting pain b. Common conditions: degenerative and rheumatoid arthritis (RA); selected fractures, such as with hip and femoral neck; joint instability; congenital hip disorders; avascular necrosis II. Procedures a. Performed on any joint except the spine, with hip and knee replacements the most common procedures b. Prosthesis may be metallic, polyethylene, or ceramic, or a combination c. Implanted with methylmethacrylate cement or may be a porous, coated implant that encourages bony ingrowth III. Statistics a. Morbidity: In 2006, hip and knee replacements, including revision procedures, accounted for 96% of the nearly one million inpatient arthroplasty procedures performed.
Women accounted for 62% of all procedures, with a mean age (at time of procedure) of 66 to 68 years (U.S. Bone and Joint Decade, 2011). b. Mortality: Rate is low, 0.29% in 2004, related to advanced age and comorbidities (Liu et al, 2008). c. Cost: In 2004, annual hospital cost estimated at over $44 billion (U.S. Bone and Joint Decade, 2008). At approximately $15,000 per knee joint replacement, and with an estimated 600,000 total knee replacements performed annually in the United States, the aggregate annual cost for total knee replacement (also known as total knee arthroplasty, or TKA) is $9 billion (Cram et al, 2012). An additional estimated $15 billion is spent on hip replacement surgeries.
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ACTIONS/INTERVENTIONS (continued)
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G L O S S A R Y Arthroplasty: Reconstruction or replacement of a diseased or damaged joint. Cemented joint replacement (cemented joint arthroplasty): Procedure in which bone cement or polymethylmethacrylate (PMMA) is used to fix the prosthesis in place in the joint. Hemiarthroplasty: Replacement of only the femoral head. Ingrowth, or cementless, joint replacement (ingrowth, or cementless, arthroplasty): Procedure that does not involve bone cement to fix the prosthesis in place; an anatomic or press fit with bone ingrowth into the surface of the prosthesis leads to a stable fixation.
Primary joint replacement: Initial surgical procedure. Revision: Second or succeeding procedures to correct loose, unstable hardware or address return of pain in the joint. THA: Total hip arthroplasty, also called total hip replacement (THR). TJR: Total joint replacement. TKA: Total knee arthroplasty, also called total knee replacement (TKR).
Care Setting
Related Concerns
Client is treated in inpatient acute surgical unit and subacute or rehabilitation unit.
Fractures, page 601 Psychosocial aspects of care, page 729 Rheumatoid arthritis (RA), page 709 Sepsis/septicemia, page 665 Surgical intervention, page 762 Thrombophlebitis: venous thromboembolism, page 109
Client Assessment Database D I AG N O S T I C D I V I S I O N M AY R E P O R T
M AY E X H I B I T
ACTIVITY/REST • History of occupation or participation in sports activities that wear on a particular joint • Difficulty walking • Stiffness in joints, which is worse in the morning or after a period of inactivity • Fatigue • Generalized muscle weakness • Inability to participate in occupational and/or recreational activities at desired level • Interruption of sleep, delayed falling asleep or awakened by pain • Does not feel well rested
• Decreased range of motion (ROM) of affected joints • Decreased muscle strength and tone • Gait disturbances—effort to compensate for joint pain
HYGIENE • Difficulty performing activities of daily living (ADLs) • Use of special equipment and/or mobility devices • Need for assistance with some or all activities
NEUROSENSORY • Soft tissue swelling, nodules • Muscle spasm, stiffness • Deformity
PAIN/DISCOMFORT • Pain—dull, aching, persistent in affected joint(s) • Pain worsened by movement
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SAFETY • Traumatic injury and/or fractures affecting the joint • Congenital deformities • History of inflammatory, debilitating arthritis—RA or osteoarthritis • Aseptic necrosis of the joint head
M AY E X H I B I T • • • •
CHAPTER 12 ORTHOPEDIC—TOTAL JOINT REPLACEMENT
D I AG N O S T I C D I V I S I O N M AY R E P O R T (continued)
(continued)
Distorted joints Joint or tissue swelling Decreased ROM Changes in gait
TEACHING/LEARNING • Current medication use—anti-inflammatories, analgesics, opioids, steroids, hormone replacement therapy (HRT), bone resorption inhibitor (e.g., donosumab [Prolia]), calcium supplements
DISCHARGE PLAN CONSIDERATIONS • May need assistance with transportation, self-care activities, and homemaker or maintenance tasks • Possible placement in rehabilitation or extended care facility for continued therapy and assistance ➧ Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies TEST WHY IT IS DONE
W H AT I T T E L L S M E
• Radiographs: Visualize and evaluate skeletal changes or damage, determine treatment options, and guide orthopedic surgery. • Bone scan, computed tomography (CT) scans, magnetic resonance imaging (MRI): Assess bone loss and determine presence of comorbidities.
May reveal destruction of articular cartilage, bony demineralization, fractures, soft tissue swelling, narrowing of joint space, joint subluxations, or deformity. Determine extent of degeneration and rule out malignancy or infectious process.
Nursing Priorities
Discharge Goals
1. 2. 3. 4.
1. 2. 3. 4. 5.
Alleviate pain. Prevent complications. Promote optimal mobility. Provide information about diagnosis, prognosis, and treatment needs.
NURSING DIAGNOSIS:
Mobility increased. Complications prevented or minimized. Pain relieved or controlled. Diagnosis, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge.
acute Pain
May Be Related To Physical agents (e.g., surgical procedure, muscle spasms, preexisting chronic joint diseases) Psychological (e.g., anxiety)
Possibly Evidenced By Verbalized/coded reports of pain distraction Expressive behavior (e.g., restlessness, irritability) Guarding behaviors; protective behaviors Narrowed focus, self-focusing Changes in vital signs (continues on page 628)
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NURSING DIAGNOSIS:
acute Pain
(continued)
Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain relieved or controlled. Appear relaxed, able to rest or sleep appropriately.
Pain Control NOC Demonstrate use of relaxation skills and diversional activities, as indicated by individual situation.
ACTIONS/INTERVENTIONS
RATIONALE
Pain Management NIC Independent Perform comprehensive assessment of pain, noting intensity (0 to 10, or similar coded scale), duration, and location. Determine if pain is at operative or different site, associated with ROM or weight-bearing, associated with vascular compromise or fever. Maintain prescribed position of operated extremity. Provide comfort measures—frequent repositioning, back rub— and diversional activities. Encourage stress management techniques, such as progressive relaxation, guided imagery, visualization, and meditation. Provide Therapeutic Touch, as appropriate. Medicate on a round-the-clock schedule initially and well before activities or therapies if getting prn dosing.
Investigate reports of sudden, severe joint pain with muscle spasms and changes in joint mobility, or sudden, severe chest pain with dyspnea and restlessness.
Provides information on which to base and monitor effectiveness of interventions.
Reduces muscle spasm and undue tension on new prosthesis and surrounding tissues. Reduces muscle tension, refocuses attention, promotes sense of control, and may enhance coping abilities in the management of discomfort or pain, which can persist for an extended period. Total joint replacement (TJR) surgeries are known to be accompanied by moderate to severe pain from the reconstruction. Pain management is often complicated by client’s age, comorbidities, and general deconditioned status before surgery. Effectively managing postoperative pain is essential for helping client achieve the best possible functional outcome (Rasul, 2012; D’Arcy, 2007). Early recognition of developing problems, such as dislocation of prosthesis or blood or fat pulmonary emboli, provides opportunity for prompt intervention and prevention of more serious complications.
Collaborative Administer medications as indicated, around the clock, such as: Opioids—instruct in and monitor use of patient-controlled analgesia (PCA); and/or targeted analgesia, such as epidural infusion or continuous femoral blockade
Oral analgesics (both extended release and shorter-acting formulations) such as oxycodone (OxyContin) or morphine sulfate extended release capsules (Kadian, Avinza); oxycodone and acetaminophen (Percocet), hydrocodone and acetaminophen (Vicodin, Lortab); and muscle relaxants Apply ice packs, as indicated. Refer for/assist mobilization, such as early ambulation, transfers, gait training and other physical therapy modalities, or continuous passive motion (CPM) device (for knee joint) when used.
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Relieves surgical pain and reduces muscle tension and spasm, which contribute to overall discomfort. Opioid infusion (including epidural) may be given during the first 24 to 48 hours. The ON-Q PainBuster® ball provides continuous infusion of local anesthetic directly into surgical site for up to 5 days, decreasing need for other opioids and allowing for earlier ambulation than epidural administration (D’Arcy, 2007). Oral analgesics are added to pain management program as the client progresses. Note: Use of ketorolac (Toradol) or other NSAID is contraindicated when client is receiving enoxaparin (Lovenox) therapy. Promotes vasoconstriction to reduce bleeding and tissue edema in surgical area and lessens perception of discomfort. Improves circulation and range of motion of affected joint and muscles and can relieve muscle spasms related to disuse.
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risk for Bleeding
Risk Factors May Include Trauma Treatment-related side effects (e.g., surgery, medication)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Blood Loss Severity NOC Be free of active bleeding or excessive blood loss as evidenced by stable vital signs, usual mentation, absence of skin pallor, and adequate urinary output
ACTIONS/INTERVENTIONS
RATIONALE
Bleeding Precautions NIC Independent Monitor vital signs, including pulse and blood pressure and urinary output. Assess skin color and moisture. Note changes in mentation, or delay in return of usual mentation after recovery from anesthesia. Monitor amount and characteristics of drainage on dressings and from suction device (e.g., hemovac, Jackson-Pratt drain) when used. Note swelling in operative area.
Tachycardia, falling blood pressure (BP), and low urinary output may reflect hypovolemia due to blood loss. May reflect effects of anemia and hypoxemia from blood loss. May indicate excessive bleeding or hematoma formation, which can potentiate neurovascular compromise. Note: Suction device is often discontinued the second or third day postop (Shiel, 2012).
Collaborative Monitor laboratory studies, such as: Hemaglobin (Hgb), hematocrit (Hct)
Administer IV fluids, and donor or autologous blood transfusions, as needed.
NURSING DIAGNOSIS:
Most clients display some anemia following primary joint replacement, and many older clients are anemic prior to surgery. A Hgb drop of 4 (for hips) and 3.8 (for knees) can be expected due to intraoperative blood loss. Note: Studies show that clients who undergo a single total knee replacement consistently lose two or more units of blood. This includes the measured blood loss during surgery and that which is lost into the soft tissues from exposed bone and into the joint after wound closure (Jackson, 2010). Restores circulating volume to maintain perfusion. Note: Current management of postoperative anemia in elective TJR (when preoperative anemia is diagnosed) includes infusion of client’s own red blood cells (autologous donation) if donated and banked at least a month out from the procedure); or use of the hormone erythropoietin (EPO) to increase red blood count. When an anemic client has considerable perioperative blood loss, salvaged blood collected from operative site during first 6 hours following procedure may be reinfused per protocol. Research continues on this practice to determine benefit vs risk. For example, a recent prospective study showed that autotransfusion with a large volume of unwashed shed blood results in an increase of postoperative drainage due to the activation of fibrinolysis (Jackson, 2010; Matsuda et al, 2010).
risk for Infection
Risk Factors May Include Inadequate primary defenses (e.g., broken skin, traumatized tissues, invasive procedures, exposure of joint, implantation of foreign body) Inadequate secondary defenses (e.g., decreased hemoglobin, immunosuppression—long-term corticosteroid use)
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Infection Severity NOC Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
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NURSING DIAGNOSIS:
3041_Ch12_601-637 28/01/14 11:10 AM Page 630
ACTIONS/INTERVENTIONS
RATIONALE
Infection Protection NIC Independent Promote good hand washing by staff and client. Use strict aseptic or clean technique, as indicated, to reinforce or change dressings and when handling drains. Instruct client not to touch or scratch incision. Maintain patency of drainage devices (e.g., Hemovac, JacksonPratt) when present. Note characteristics of wound drainage.
Assess skin and incision color, temperature, and integrity; note presence of erythema, inflammation, and loss of wound approximation. Investigate reports of increased incisional pain and changes in characteristics of pain.
Monitor temperature. Note presence of chills.
Encourage fluid intake coupled with a high-protein diet.
Reduces risk of cross-contamination. Prevents contamination and risk of wound infection, which could require removal of prosthesis. Reduces risk of infection by preventing accumulation of blood and secretions in the joint space, which is a medium for bacterial growth. Purulent, nonserous, odorous drainage is indicative of infection, and continuous drainage from incision may reflect developing skin tract, which can potentiate infectious process. Provides information about status of healing process and alerts staff to early signs of infection. Deep, dull, aching pain in operative area may indicate developing infection in joint. Note: Infection can be devastating because once infection sets in, joint may not be salvageable and prosthetic loss may occur. Although temperature elevations are common in early postoperative phase, elevations occurring 5 or more days postoperatively and/or presence of chills usually require intervention to prevent more serious complications, such as sepsis, osteomyelitis, tissue necrosis, and prosthetic failure. Maintains fluid and nutritional balance to support tissue perfusion and provide nutrients necessary for cellular regeneration and tissue healing.
Collaborative Maintain reverse or protective isolation, if appropriate.
Administer antibiotics, as indicated.
NURSING DIAGNOSIS:
May be done initially to reduce contact with sources of possible infection, especially in an elderly, immunosuppressed, or diabetic client. Used prophylactically in the operating room and for the first 24 hours to prevent infection. Late infections may require intravenous (IV) antibiotic treatments for several weeks, in an effort to save the prosthetic joint.
risk for Peripheral Neurovascular Dysfunction
Risk Factors May Include Orthopedic surgery, immobilization, mechanical compression (e.g., dressing, brace) Vascular obstruction
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral NOC Maintain function as evidenced by sensation and movement within normal limits for individual situation. Demonstrate adequate tissue perfusion as evidenced by palpable pulses, brisk capillary refill, warm or dry skin, and normal color.
ACTIONS/INTERVENTIONS
RATIONALE
Circulatory Care: Arterial [or] Venous Insufficiency NIC Independent Palpate pulses. Evaluate capillary refill and skin color and temperature. Compare with unoperated limb.
Assess motion and sensation of operated extremity.
630
Diminished or absent pulses, delayed capillary refill time, pallor, blanching, cyanosis, and coldness of skin reflect diminished circulation or perfusion. Comparison with unoperated limb provides clues as to whether neurovascular problem is localized or generalized. Increasing pain, numbness or tingling, and/or inability to perform expected movements (such as flexing foot) suggest nerve injury, compromised circulation, or dislocation of prosthesis, requiring immediate intervention.
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RATIONALE (continued)
Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between first and second toe, and assess ability to dorsiflex toes after hip or knee replacement. Ensure that stabilizing devices (such as abduction pillow or splint device) are in correct position and are not exerting undue pressure on skin and underlying tissue. Avoid use of pillow or bed knee gatch under knees. Evaluate for calf tenderness, tension, and redness.
Position and length of peroneal nerve increase risk of direct injury or compression by tissue edema or hematoma.
Encourage regular “foot pumps” throughout day.
Reduces risk of pressure on underlying nerves or compromised circulation to extremities.
Although clinical signs are often not reliable in this population, surveillance should be carried out. Early identification of thrombus development and intervention may prevent embolus formation. Pushing the foot down, pointing toes, and pulling toes up toward the ceiling causes the calf to tighten and assists venous return to prevent blood pooling and reduce risk of deep vein thrombosis (DVT). Note: Blood clots (above or below the knee) following knee surgery most often occur immediately after surgery (Shiel, 2012).
Collaborative Monitor laboratory studies, such as: Coagulation studies
Administer medications, as indicated, for example, lowmolecular-weight heparins, enoxaparin (Lovenox), or fondaparinux (Arixtra).
Maintain intermittent compression stocking or foot/ankle compression boots (e.g., PlexiPulse) when used.
NURSING DIAGNOSIS:
Evaluates presence and degree of alteration in clotting mechanisms and effects of anticoagulant or antiplatelet agents when used. Anticoagulants or antiplatelet agents may be used routinely to reduce risk of thrombophlebitis and pulmonary emboli. Note: Without prophylaxis, the incidence of DVT after total knee replacement (TKR) is 50% to 84%, and after total hip replacement (THR), 47% to 64%. With prophylaxis, the incidence is reduced 22% to 57% after TKR and 6% to 24% after THR (Rasul, 2012). Promotes venous return and prevents venous stasis, reducing risk of thrombus formation.
impaired physical Mobility
May Be Related To Pain/discomfort; pharmaceutical agents Musculoskeletal impairment; joint stiffness Decreased endurance, deconditioning Prescribed movement restrictions
Possibly Evidenced By Limited range of motion; difficulty turning Slowed movement; gait changes
Desired Outcomes/Evaluation Criteria—Client Will Mobility NOC Display increased strength, ROM, and function of affected joint and limb.
Ambulation NOC Ambulate with assist/assistive device as needed.
ACTIONS/INTERVENTIONS
RATIONALE
Positioning NIC Independent Maintain affected joint in prescribed position and body in alignment when in bed. Medicate around the clock, or sufficient time before procedures and activities, so that client is able to participate. Turn on unoperated side using adequate number of personnel and maintaining operated extremity in prescribed alignment. Support position with pillows and wedges. Demonstrate and assist with transfer techniques and use of mobility aids, such as a trapeze, walker, crutches, or canes.
Provides for stabilization of prosthesis and reduces risk of injury during recovery from effects of anesthesia. Adequate analgesia is a priority to decrease pain, reduce muscle tension and spasm, and facilitate participation in therapy. Prevents dislocation of hip prosthesis and prolonged skin and tissue pressure, reducing risk of tissue ischemia and breakdown. Facilitates self-care and client’s independence. Proper transfer techniques prevent shearing abrasions of skin and falls. (continues on page 632)
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CHAPTER 12 ORTHOPEDIC—TOTAL JOINT REPLACEMENT
ACTIONS/INTERVENTIONS (continued)
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Determine upper body strength and need for equipment to assist with ADLs, as appropriate. Involve in exercise program.
Replacement of lower-extremity joint requires increased use of upper extremities for transfer, ADLs, and desired activities as well as use of ambulation devices. Prevents skin irritation or breakdown.
Inspect skin; observe for reddened areas. Keep linens dry and wrinkle-free. Massage skin and bony prominences routinely. Protect operative heel, elevating whole length of leg with pillow and placing heel on water glove if burning sensation reported or area reddened.
Exercise Therapy: Joint Mobility NIC Perform or assist with ROM to unoperated joints.
Promote participation in rehabilitative exercise program, such as the following: Total hip: Quadriceps and gluteal muscle setting, isometrics, leg lifts, dorsiflexion, and plantar flexion (ankle pumps) of the foot Total knee: Quadriceps setting, gluteal contraction, flexion and extension exercises, and isometrics
Observe appropriate limitations based on specific joint; for example, avoid marked flexion or rotation of hip and flexion or hyperextension of leg; adhere to weight-bearing restrictions; and wear knee immobilizer, as indicated. Investigate sudden increase in pain and shortening of limb as well as changes in skin color, temperature, and sensation. Encourage participation in ADLs. Provide positive reinforcement for efforts.
Client with degenerative joint disease can quickly lose function in unoperated joints during periods of restricted activity. Contralateral joint may be nearly as painful as the surgical joint and may require careful and consistent treatment to maximize mobility.
Strengthens muscle groups, increasing muscle tone and mass; stimulates circulation; and prevents decubitus ulcers. Active use of the joint may be painful but will not injure the joint. Continuous passive motion exercise may be initiated on the knee joint postoperatively, although its use is dependent on the particular surgeon and on the individual’s needs. Joint stress is to be avoided at all times during stabilization period to prevent dislocation of new prosthesis.
May be indicative of slippage of prosthesis or other complication, requiring medical evaluation and intervention. Enhances self-esteem and promotes sense of control and independence. Promotes a positive attitude and encourages involvement in therapy.
Collaborative Collaborate with physical and occupational therapists and rehabilitation specialist.
Provide foam or flotation mattress.
NURSING DIAGNOSIS:
Client will require individualized activity and exercise program, ongoing assistance with movement, strengthening, and weight-bearing activities for an extended period of time, as well as use of adjuncts, such as walkers, crutches, canes, elevated toilet seat, pickup sticks, and so on. Reduces skin and tissue pressure; limits feelings of fatigue and general discomfort.
risk for Constipation
Risk Factors May Include Insufficient physical activity Insufficient fiber or fluid intake Decreased gastrointestinal (GI) motility, effects of medications—anesthesia, opiate analgesics Recent environmental changes
Possibly Evidenced By (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Bowel Elimination NOC Maintain usual pattern of bowel functioning. Demonstrate behaviors to prevent problem.
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RATIONALE
Bowel Management NIC Independent Identify individual risk factors. Determine current situation and possible impact on bowel function—surgery, new and chronic use of medications affecting intestinal functioning, age, or weakness. Auscultate abdomen for presence, location, and characteristics of bowel sounds. Determine usual elimination pattern or frequency, characteristics of stool—color, consistency, amount—manner of constipation, and use of laxatives. Evaluate usual dietary and fluid intake; compare with current intake. Promote increased fluid intake, including water and high-fiber fruit juices; offer warm stimulating fluids, such as coffee, tea, and hot water. Encourage early ambulation and exercise within client’s limitation of activity. Assist with early mobility. Provide privacy and routinely scheduled time for defecation based on usual pattern, as appropriate (e.g., bedside commode or toilet with elevated seat, after breakfast).
Constipation is one of the most frequent complaints following surgery and during rehabilitation. If left untreated, constipation can lead to nausea and vomiting, bowel obstruction, or even sepsis, especially in the elderly. Reflects activity of GI tract. Provides baseline for comparison, promotes recognition of changes, and helps to establish a preventative plan. Client’s usual diet and fluid intake may be marginal at best in promoting healthy bowel functioning, especially when combined with current postsurgical status. Prevents dehydration and decreases reabsorption of water from the bowel, promoting softer stool and facilitating passage of stool. To stimulate and optimize GI function. To facilitate return of normalcy in toileting routine.
Collaborative Consult with dietitian or nutritionist, as indicated.
Implement bowel program: administer routine stool softeners (e.g., docusate [Colace]); stool stimulants (e.g., bisacodyl [Dulcolax]), polyethylene glycol (Miralax); sennosides (e.g., Senokot, Ex-lax); bulk-forming agents (e.g., polycarbophil [FiberCon]), psyllium (Metamucil); saline laxatives (e.g., magnesium citrate), and enemas, as indicated.
NURSING DIAGNOSIS:
Helpful in providing a diet with balanced fiber and bulk that client can continue after discharge to improve consistency of stool and facilitate its passage. Used to prevent or treat constipation.
deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
Risk Factors May Include Lack of exposure or recall Information misinterpretation Unfamiliarity with information resources
Possibly Evidenced By Reports the problem Inaccurate follow-through of instructions
Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Treatment Regimen NOC Verbalize understanding of surgical procedure and prognosis. Correctly perform necessary procedures and explain reasons for the actions.
ACTIONS/INTERVENTIONS
RATIONALE
Teaching: Disease Process NIC Independent Review disease process, surgical procedure, and future expectations.
Encourage alternating rest periods with activity.
Provides knowledge base from which client can make informed choices. The majority of total joint surgeries are elective, and preoperative education is done in some form in the surgeon’s office or in the admitting facility. Postsurgical review of process and expectations may be needed or desired. Conserves energy for healing and prevents undue fatigue, which can increase risk of injury or fall. (continues on page 634)
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ACTIONS/INTERVENTIONS
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ACTIONS/INTERVENTIONS (continued)
RATIONALE (continued)
Stress importance of continuing prescribed exercise and rehabilitation program within client’s tolerance—crutch or cane walking, weight-bearing exercises, stationary bicycling, or hydrotherapy and swimming.
Increases muscle strength and joint mobility. Most clients will be involved in formal outpatient rehabilitation, home-care programs, or be followed in extended care facilities by physical therapists. Note: Client with cemented joint replacement can weight-bear as tolerated (WBAT) unless the operative procedure involved a soft tissue repair or internal fixation of bone (following fracture). Client with cementless joint replacement is put on partial weight-bearing (PWB) or toe-touch weight-bearing (TTWB) for several weeks to allow maximum bony ingrowth to take place. A knee immobilizer sometimes is worn after total knee replacement until quadriceps strength is regained. All programs will add specific range of motion and strengthening therapies as time passes after surgery (Iverson, 2012; Rasul, 2012). Prevents undue stress on implant. Long-term restrictions depend on individual situation and physician protocol.
Review activity limitations, depending on joint replaced: for hip or knee—sitting for long periods or in low chair or toilet seat, recliner; jogging, jumping, excessive bending, lifting, twisting, or crossing legs. Discuss need for safe environment in home, including removing scatter rugs and unnecessary furniture, and use of assistive devices, such as hand rails in tub and toilet, raised toilet seat, and cane for long walks. Review and have client or caregiver demonstrate incisional or wound care. Identify signs and symptoms requiring medical evaluation: fever or chills, incisional inflammation, unusual wound drainage, pain in calf or upper thigh, or development of sore throat or dental infections. Review procedure for removal of painball catheter if not discontinued before discharge. Review drug regimen, for example, anticoagulants or antibiotics prior to invasive procedures (e.g., tooth extraction).
Identify bleeding precautions—for example, use of soft toothbrush, electric razor, avoidance of trauma, or forceful blowing of nose—and necessity of routine laboratory follow-up. Encourage intake of balanced diet, including roughage and adequate fluids. Discuss continuation of supplemental calcium and vitamin D, hormone replacement, bisphosphonates, and the like as indicated.
Reduces risk of falls and excessive stress on joints.
Promotes independence in self-care, reducing risk of complications. Bacterial infections require prompt treatment to prevent progression to osteomyelitis in the operative area and prosthesis failure, which could occur at any time, even years later. Medication may infuse for up to 5 days and if client removes catheter after discharge it is important to check for black marking on tip to ensure tubing is removed intact. Prophylactic therapy may be necessary for a prolonged period after discharge to limit risk of thromboemboli and infection. Procedures known to release bacteria into the bloodstream can lead to infection, osteomyelitis, and prosthesis failure. Reduces risk of therapy-induced bleeding or hemorrhage.
Enhances healing and feeling of general well-being. Promotes bowel and bladder function during period of altered activity. Promotes bone health in clients with decreased bone density or who are at risk for osteoporosis.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) In addition to considerations in Surgical Intervention plan of care: • risk for Falls—postoperative conditions, impaired physical mobility, decreased lower extremity strength, impaired balance, use of assistive devices • risk for Constipation—insufficient physical activity, decreased motility of gastrointestinal tract, insufficient fiber/fluid intake, side effects of medications • Self-Care Deficit—musculoskeletal impairment, weakness, fatigue, pain • impaired Home Maintenance—impaired functioning, inadequate support systems, unfamiliarity with neighborhood resources
Sample clinical pathway follows in Table 12.1.
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CHAPTER 12 ORTHOPEDIC—TOTAL JOINT REPLACEMENT
TABLE 12.1
Sample CP: Total Hip Replacement, Hospital. ELOS: 3 Days Orthopedic or Surgical Unit
ND and Categories of Care risk for Infection R/T broken skin, exposure of joint, longterm steroid use, decreased mobility
Day of Surgery _____ Goals: Participate in activities to reduce risk of postoperative infection
Day 2 _____
Day 3 _____
D/C _____
→
→
→
Free of purulent drainage Be afebrile
→
→ Free of erythema
→ Verbalize understanding of healthcare needs to enhance healing, promote wellness Electrolytes if indicated
→ Plan in place to meet postdischarge needs, self-care
→ q8h
→ bid/ D/C
Hgb/Hct Pulse oximetry VS/Temp per postoperative protocol Breath sounds q8h Amount/characteristic of Hemovac drainage q8hr
→ → D/C if stable → q4h → →
→ → D/C Characteristics of wound/drainage qd and prn
→ bid/ D/C
→ D/C →
→ NS lock or D/C →
→ D/C lock → D/C
→ S/S to report of healthcare provider
Dietary needs Balancing rest/activity
Wound care Provide written instructions for home care
Additional nursing actions
IV antibiotics IV fluids/blood products Tylenol—Temp ≥101°F Disease process/ surgical procedure Hand-washing technique, avoid touching of dressing/ wound Respiratory exercises, incentive spirometry Aseptic/clean technique Reinforce dressing
→ →
→ → Change dressing qd and prn
→
→
→ → q2h WA
Per self → q4h WA
→ →
→ D/C if stable →
High-calorie/protein diet →
→
impaired physical Mobility R/T musculoskeletal impairment/ discomfort, therapeutic restrictions
Encourage PO fluids as tolerated T, C, DB, q2h Incentive spirometry q2h Supplemental O2 as indicated Maintain proper alignment and position of function Participate in rehabilitation/ exercise program
→ → D/C if incision dry Clean incision bid →
→
→
Free of DVT/ thromboembolic complications
→
→ Ambulate per self w/ assistive device → Display increased strength/function of operated limb Establish regular bladder/bowel elimination
Diagnostics Additional assessments
Medications Allergies: _______
Client education
→
Independent in transfers
(continues on page 636)
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TABLE 12.1
Sample CP: Total Hip Replacement, Hospital. ELOS: 3 Days Orthopedic or Surgical Unit (continued)
ND and Categories of Care Referrals
Day of Surgery _____
Diagnostic studies
Additional assessments
Medications Allergies: __________
Client education
Additional nursing actions
acute Pain R/T therapeutic interventions, preexisting chronic joint disease
636
Day 2 _____ PT-assistive devices if not done preop
Coumadin (if Lovenox not ordered) Stool softener/bowel program Hip precautions Use of trapeze Initial exercises—ankle pumps, quad/gluteal sets
D/C _____ OT/rehabilitation specialist Home care
→ q4h
→ q8h
→ CBC w/platelets (if Lovenox used) → bid/ D/C
→
→
→ qd
→
→
→ D/C
→ Stool characteristics → Daily order or Lovenox q12h →
→ bid → →
→ qd → →
→
→
Transfer techniques
Use of mobility aids
S/S to report to healthcare provider
Ambulation/weightbearing exercises Self-administer Lovenox Home exercise program Sexual concerns
Activity level/ restrictions postdischarge
Protime (coumadin use) Neurovascular status/alignment of operated leg per postoperative protocol Skin (especially heels) q8h or per protocol Voiding/urinary output q8h Bowel sounds q8h
Day 3 _____ PT-exercises/ ambulation Social Services if placement indicated →
→ Provide written instructions Coumadin dose, time, purpose, side effects, precautions, monitoring (if used) → Ambulate with assist as needed prn → → →
Bedrest/HOB elevated 30° Pillow between knees Turn per protocol q2h ROM to nonoperated side q2h Initial exercises q1h WA
→ Chair/commode elevate operated leg → → →
→ Chair × 3 ambulate with assistance → → → Per self
CPM to tolerance
→
SCDs to calves while in bed Total care Fracture pan Straight catheter if no void q8h × 2 Foam/special mattress Verbalize pain within manageable level
→
→
→ Knee exercise × 5 q1h WA/Leg strengthening →
→ Assist w/care Elevated toilet seat → Insert Foley on #3 if no void → →
→ Self-care → → D/C Foley-male
→ Shower as indicated → → D/C Foley-female
→ → Participate in action to decrease pain Demonstrate proper use of adjunct comfort measures
→ → → Verbalize understanding of medications/ modalities for pain management
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Sample CP: Total Hip Replacement, Hospital. ELOS: 3 Days Orthopedic or Surgical Unit (continued)
ND and Categories of Care Additional assessments
Medications Allergies: ____________ ____________
Client education
Additional nursing actions
Day of Surgery _____ Pain characteristics/ changes Response to interventions PCA—narcotic of choice Painball Anti-emetic prn
Day 2 _____ →
Day 3 _____ →
D/C _____ →
→
→
→
→ D/C, begin PO if tolerated → → D/C
→
→ → →
Muscle relaxant Orient to unit/room Proper use of PCA Reporting of pain/ effects of interventions
→ Relaxation techniques, guided imagery, breathing exercises
→ Acetaminophen prn for breakthrough pain → Medications: dose, time, route, purpose, side effects
Maintain position/ alignment of leg per protocol Ice pack to operated site Routine comfort measures prn
→
→
→ prn
→D/C
→
→
→
→ Written instructions for home-care needs, equipment resources, removal of pain ball if still in place →
→
Key: bid, twice a day; C, cough; CBC, complete blood count; CPM, continuous passive motion; DB, deep breath; D/C, discontinue; DVT, deep vein thrombosis; Hct, hematocrit; Hgb, hemoglobin; HOB, head of bed; IV, intravenous; NS, normal saline; OT, occupational therapist; PCA, patient-controlled analgesia; PO, by mouth; prn, as needed; PT, physical therapist; q1h, every 1 hour; q2h, every 2 hours; q4h, every 4 hours; q8h, every 8 hours; q12h, every 12 hours; qd, every day; ROM, range of motion; R/T, related to; SCD, sequential compression device; S/S, signs and symptoms; T, temp; VS, vital signs; WA, while awake.
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CHAPTER 12 ORTHOPEDIC—TOTAL JOINT REPLACEMENT
TABLE 12.1
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CHAPTER
13
Integumentary BURNS: THERMAL, CHEMICAL, AND ELECTRICAL—ACUTE AND CONVALESCENT PHASES I. Pathophysiology —Local and systemic response affecting skin and/or other tissues depending on cause of burn injury and physiological response (Hettiaratchy, 2004) a. Local responses i. Coagulation: Occurs at the point of maximum damage, causing irreversible tissue loss due to coagulation of the constituent proteins ii. Stasis: Area characterized by decreased tissue perfusion that is potentially salvageable unless additional insults, such as prolonged hypotension, infection, or edema, occur, converting this zone into an area of complete tissue loss. iii. Hyperemia: Outermost area has increased tissue perfusion, and tissue will recover unless severe sepsis or prolonged hypoperfusion occurs. b. Systemic response—Cytokines and other inflammatory mediators are released at the site of burn injuries with total body surface area (TBSA) of 30% or greater. i. Cardiovascular: Increased capillary permeability leads to shift of intravascular proteins and fluids into the interstitial space, followed by vasoconstriction and decreased myocardial contractility; combined with fluid loss from the burn wound, systemic hypotension and organ hypoperfusion occur. ii. Respiratory: Bronchoconstriction occurs in response to inflammatory mediators, which, in severe inhalation injury, can cause acute respiratory distress syndrome (ARDS). iii. Metabolic—Rate increases up to three times the baseline rate, resulting in breakdown of muscle tissue. iv. Immunological—Immune suppression response occurs. II. Classification by burn wound and depth a. Superficial partial-thickness (first-degree) burns: affect only the epidermis; skin is often warm and dry; and wounds appear bright pink to red with minimal edema and fine blisters, if present b. Moderate partial-thickness (second-degree) burns: include the epidermis and dermis; wounds appear red to pink with moderate edema and blisters that may be intact or draining c. Deep partial-thickness (second-degree) burns: extend into the deep dermis; wounds are dryer than moderate partialthickness burns and appear pale pink to pale ivory, with moderate edema and blisters d. Full-thickness (third-degree) burns: include all layers of skin and subcutaneous fat and may involve the muscle, nerves, and blood supply; wounds have a dry, leathery 638
texture and appearance varies from white to cherry-red to brown or black, with blistering uncommon; absence of pain in the center, but the edges of the burn wound may have heightened sensation e. Full-thickness, subdermal (fourth-degree) burns: involve all skin layers as well as muscle, organ tissue, and bone, with charring III. Etiology a. Thermal burns: flame, hot fluids or gases, friction, or exposure to extremely cold objects (e.g., snow, nitrogen, dry ice); flame burns are often associated with smoke/inhalation injury. Note: It is reported that 5% to 20% of all combat injuries include burns, often of the hands and head (Hedman et al, 2008). The majority of burn injuries in children are scald injuries resulting from hot liquids, occurring most commonly in children aged 0–4 years (Toon et al, 2011). Burns in older children and teenagers, especially boys, are often associated with risk-taking behavior, such as careless use of flammable substances and experimentation with fireworks (Reed, 2009). b. Chemical burns: contact with a caustic substance (acid or alkaline); degree of injury dependent on type and content as well as concentration and temperature of injuring agent c. Electrical burns: current travels through the body along the pathway of least resistance (i.e., nerves offer the least resistance and bones the greatest resistance), generating heat in proportion to resistance offered; degree of injury dependent on type/voltage of current with underlying injury more severe than visible injury. High-voltage injuries are a serious problem in adolescent boys engaging in high-risk behavior around power lines or from lightning strikes (Tomkins, 2008). d. Radiation burns: exposure to ionizing radiation, most commonly protracted and overexposure to ultraviolet rays—UVA and UVG (e.g., the sun, sunlamps, tanning booths), or high exposure to x-rays including radiotherapy (e.g., cancer therapy) e. Risk factors: substance abuse, careless smoking, cultural practices, socioeconomic status (e.g., overcrowded living conditions, insufficient parental supervision of children, lack of safety precautions), and violence, including abuse and neglect, such as with those aged 4 years and under or those aged 65 years and older. Note: Burn injuries account for approximately 6% to 20% of all child abuse cases (Peck, 2002), and severe burns are reported in an estimated 10% of all children suffering physical abuse (Maguire et al, 2008).
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G L O S S A R Y Catabolism: Breaking down of muscle tissue. Dermis: Inner layer of skin, which contains blood and lymph vessels, hair follicles, and glands. Epidermis: Outermost layer of skin, made up of flat, scale-like cells called squamous cells. Total body surface area (TBSA): The “rule of nines” estimates the extent of TBSA involved in a burn injury to guide treatment.
Major anatomic areas of the body are divided into percentages: in adults, 9% for the head and neck, 9% for each upper extremity, 18% to each of the anterior and posterior portions of the trunk, 18% to each lower extremity, and 1% to the perineum and genitalia. The client’s palm area represents approximately 1% of TBSA and can be helpful in calculating scattered areas of involvement.
Care Setting
Related Concerns
The following adult clients are admitted for acute care and, during the rehabilitation phase, may be cared for in a subacute or rehabilitation unit: The American Burn Association criteria for burn center care includes any full thickness burn greater than 5%; partial thickness burn greater than 20% in people between ages 10–50; any partial thickness burn greater than 10% in children younger than 10 years and adults older than 50 years of age; any significant burns to the ears, eyes, hands, feet, or genitals (ABA, 2012; Cunha, 2007). Inhalation injury is cited by some as the single most important predictor of mortality in burn victims and occurs in 50% of children less than 9 years old involved in home fires (Cunha, 2007).
Disaster considerations, page 858 Fluid and electrolyte imbalances, page 885 Metabolic acidosis—primary base bicarbonate deficiency, page 450 Pediatric considerations, page 872 Psychosocial aspects of care, page 729 Respiratory acidosis (primary carbonic acid excess), page 179 Sepsis/septicemia, page 665 Surgical intervention, page 762 Total nutritional support: parenteral and enteral feeding, page 437 Upper gastrointestinal/esophageal bleeding, page 281
Client Assessment Database Data depend on type, severity, and body surface area involved. D I AG N O S T I C D I V I S I O N M AY R E P O R T
ACTIVITY/REST
M AY E X H I B I T • Decreased strength, endurance • Limited range of motion (ROM) of involved areas • Altered muscle mass and tone (continues on page 640)
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of injury resulting in death, behind motor vehicle accidents and drowning (Benjamin, 2002). A direct but inverse relationship exists between age and survival for any burn size. While the mortality of a 40% TBSA burn in a 20-year-old is approximately 8%, the mortality of this same injury in someone older than 70 years is 94% (Edlich et al, 2010). Respiratory failure and sepsis are the leading causes of death in severely burned children, with acute lung injury and respiratory distress syndrome (ARDS) accounting for 40% to 50% of all deaths (Williams et al, 2009). c. Cost: In 2007, the Centers for Disease Control and Prevention (CDC) reported that $7.5 billion is spent annually for burn care in hospitals, with another $3.3 billion spent in nonhospitalized burn care (CDC, 2011).
CHAPTER 13
IV. Statistics (American Burn Association, 2012) a. Morbidity: 450,000 burn injuries require medical attention in the United States annually, with approximately 40,000 requiring hospitalization, including 30,000 at hospital burn centers. Burns account for the greatest length of stay of all pediatric hospital admissions for injuries (Benjamin, 2002). b. Mortality: In 2012, the ABA reported a 96.1% survival rate in clients discharged from burn care centers but approximately 3400 deaths annually. The Federal Emergency Management Association (FEMA) report in 2011 listed approximately 4000 deaths from fires in the United States annually (Burn Injury online.com, 2011). Although mortality rate is low (40%, who is unconsciousness, has other neurologic findings, or has severe metabolic acidosis (pH 10 mEq/L) result in respiratory depression, coma, and cardiac arrest (Angus, 2012).
OTHER DIAGNOSTIC STUDIES • ECG: Record of the electrical activity of the heart.
NURSING DIAGNOSIS:
Changes associated with hypermagnesemia include prolonged PR and QT intervals, widened QRS, elevated T waves, development of heart block, and cardiac arrest.
risk for Electrolyte Imbalance
Risk Factors May Include Chronic diarrhea Renal dysfunction Treatment-related side effects (e.g., medications containing magnesium, diuretic abuse, dialysis with hard water) Endocrine dysfunction (diabetic ketoacidosis)
Possibly Evidenced By (Not applicable, presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will Electrolyte & Acid/Base Balance NOC Display heart rhythm, muscular strength, cognitive status, and laboratory results WNL for client and absence of respiratory impairment.
ACTIONS/INTERVENTIONS
RATIONALE
Electrolyte Management: Hypermagnesemia NIC Independent Monitor cardiac rate and rhythm.
Monitor BP. Assess LOC and neuromuscular status, including reflexes, muscle tone, movement, and strength. Monitor respiratory rate, depth, and rhythm. Encourage coughing and deep-breathing exercises. Elevate head of bed, as indicated. Check patellar reflexes periodically.
Encourage increased fluid intake, if appropriate. Monitor urinary output and 24-hour fluid balance. Promote bedrest; assist with personal care activities, as needed. Recommend avoidance of magnesium-containing antacids, such as Maalox, Mylanta, Gelusil, and Riopan, in client with renal disease. Caution clients with renal disease to avoid over-the-counter (OTC) drug use without discussing with healthcare provider.
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Bradycardia and heart block may develop, progressing to cardiac arrest as a direct result of hypermagnesemia on cardiac muscle. Hypotension unexplained by other causes is an early sign of toxicity. CNS and neuromuscular depression can cause decreasing level of alertness, progressing to coma, and depressed muscular responses, progressing to flaccid paralysis. Neuromuscular transmissions are blocked by magnesium excess, resulting in respiratory muscular weakness and hypoventilation, which may progress to apnea. Absence of these reflexes suggests magnesium levels about 7 mEq/L or greater. If untreated, cardiac and respiratory arrest can occur. Increased hydration enhances magnesium excretion, but fluid intake must be cautious in event of renal or cardiac failure. Renal failure is the primary contributing factor in hypermagnesemia, and, if it is present, fluid excess can easily occur. Flaccid paralysis, lethargy, and decreased mentation can reduce activity tolerance and ability. Limits oral intake to help prevent hypermagnesemia.
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RATIONALE (continued)
Collaborative Assist with treatment of underlying cause.
Administer 10% calcium chloride or gluconate IV. Assist with dialysis, as needed.
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Monitor laboratory studies, as indicated. Administer IV fluids (e.g., Normal Saline, Lactated Ringer’s) and thiazide diuretics, as indicated.
Refer to listing of predisposing and contributing factors to determine treatment needs. Note: Most frequently occurs in clients with advanced renal failure. Evaluates therapy needs and effectiveness. Intravenous fluids work by dilution of the extracellular magnesium. Fluids are used with diuretics to promote increased excretion of magnesium by the kidney (Novello, 2012). Antagonizes action and reverses symptoms of magnesium toxicity to improve neuromuscular function. In the presence of renal disease or failure, dialysis may be needed to lower serum levels.
CHAPTER 15
ACTIONS/INTERVENTIONS (continued)
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BIBLIOGRAPHY CHAPTER 1 Books American Nurses Association: Code of ethics for nurses. American Nurses Association, Silver Spring, MD, 2001. American Nurses Association: Nursing scope and standards of practice. American Nurses Association, Silver Spring, MD, 2004. Jacob, SR: The evolution of professional nursing. In Cheery, B, and Jacob, SR: Contemporary nursing: Issues, trends, and management, ed 6. Elsevier Mosby, St. Louis, 2014. Lancaster L, and Stillman, D: When generations collide: Who they are. Why they clash. How to solve the generational puzzle at work. Harper Business, New York, 2002. National Center for Health Statistics. (2007). Health, United States, 2007, with chartbook on trends in the health of Americans. National Center for Health Statistics, Hyattsville, MD, 2007.
Articles Blegen, MA, Goode, CJ, and Reed, L: Nursing staffing and patient outcomes. Nurs Res 47(1):43–50, 1998. Buerhaus, PJ: Is a nursing shortage on the way? Nursing98 28(8):34–35, 1998. Buerhaus, PI, DesRoches, C, Applebaum, S, et al: Are nurses ready for health care reform? A decade of survey research. Nurs Econ 30(6):318–329, 2012. Desimini, EM, Kennedy, JA, Helsley, MF, et al: Making the case for nurse navigators—. Benefits, outcomes, and return on investment. Oncology Issues 26(5):26–33, 2011. Dunton, N, Gajewski, B, Taunton, RL, et al: Nurse staffing and patient falls on acute care hospital units. Nurs Outlook 52(1):53–59, 2004. Erickson, JI, Ditomassi, M, and Adams, JM: Attending registered nurse—An innovative role to manage between the spaces. Nurse Econ 30(5):282–287, 2012. Gabrielle, S, Jackson, D, and Mannix, J: Older women nurses: Health, ageing concerns, and self care strategies. J Adv Nurs 61(3):316–25, 2008. Hassmiller, S: Nursing’s role in healthcare reform. Am Nurs Today 5(9):68–69, 2010. Harris, K, and Welton, JM: Guest editorial: Hospital billing and reimbursem*nt: Charging for inpatient nursing care. J Nurs Admin 37(4):164–166, 2007. Horner, K, Ludman, EJ, McCorkle, R, et al: An oncology nurse program designed to eliminate gaps in early cancer care. Clin J Oncol Nurs 17(1):43–48, 2013. Keenan, G, Tschannen, D, and Wesley, M: Standardized nursing terminologies can transform practice. JONA 38(3):103–106, 2008. Keenan, GM, Stocker, JR, Geo-Thomas, AT, et al: The HANDS project: Studying and refining the automated collection of a cross-setting clinical data set. Comp Inform Nurs 20(3):89–100, 2002. Kohl, BA, Fortino-Mullen, M, Praestgaard, A, et al: Effect of telemedicine on mortality and length of stay in a university ICU. Crit Care Med 35(12):A22, 2007. Kupperschmidt, BR: Addressing multigenerational conflict: Mutual respect and care fronting a strategy. Online J Issues Nurs 11(2):4, 2006. Leape, LL, and Berwick, DM: Five years after to err is human: What have we learned? JAMA 293(19):2384–2390, 2005. Mark, BA, Harless, D, and Berman, WF: Nurse staffing and adverse events in hospitalized children. Policy Polit Nurs Pract 8(2):83–92, 2007. Matthews, JT: The nursebot project: Developing a personal robotic assistant for frail older adults in the community. Home Health Care Management & Practice 14(5):403–405, 2002. Needleman, J, Buerhaus, P, Mattke, S, et al: Nurse staffing levels and the quality of care in hospitals. New Eng J Med 346(22):1715–1722, 2002.
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Pineau, J, Montemerlo, M, Pollak, M, et al: Towards robotic assistants in nursing homes: Challenges and results. Rob Auton Syst 42(3–4): 271–281, 2003. Rivera, D, and Halvorson, G: We’re in it together. Modern Healthcare 38(11):22, 2008. Rutherford, MM: Nursing is the room rate. Nurs Econ 30(4):193–199, 206, 2012. Solovy, A, Hoppszallern, S, and Brown, S: Ten lessons from the top 100; Healthcare most wired. Hosp Health Network 81(7):40–53, 2007. Yang, KP: Relationships between nurse staffing and client outcomes. J Nurs Res 11(3):149–158, 2003.
Electronic Resources American Association of Colleges of Nursing (AACN), updated 2012. Nursing shortage. Retrieved July 2013 from http://www .aacn.nche.edu/media-relations/fact-sheets/nursing-shortage American Nurses’ Association Health Care Agenda 2005. Retrieved March 2008 from http://nursingworld.org/MainMenuCategories/ HealthcareandPolicyIssues/Reports/HealthCareAgenda.aspx Center for American Nurses: Restructuring and redesigning nurses’ work environments, 2007 revised. Retrieved March 2008 from http://www.centerforamericannurses.org/positions/ finalworkenviron.pdf Economist Intelligence Unit, 2011: Preventive care and health aging: A global perspective. Retrieved June 2013 from http://digitalresearch.eiu.com/healthyageing/country-profiles/ united-states Health Information and Management Systems Society (HIMS) and National Committee for Quality Assurance (NCQA): Leveraging health IT to achieve ambulatory quality: The patient-centered medical home (PCMH). Retrieved June 2013 from http://www.ncqa.org/ Portals/0/Public%20Policy/HIMSS_NCQA_PCMH_Factsheet.pdf Healthy People 2020—U.S. Department of Health and Human Services Healthy People 2020 Framework, n.d. Retrieved June 2013 from http://www.healthypeople.gov/2020/Consortium/ HP2020Framework.pdf Heller, BR, Oros, MT, and Durney-Crowley, J: The future of nursing education: Ten trends to watch, 2011. Retrieved June 2013 from http://www.nln.org/nlnjournal/infotrends.htm#2 HHS Secretary Leavitt: 500-Day Plan for improving the health, safety, and well-being of America. Retrieved March 2008 from www.hhs.gov/500DayPlan Hibbard, JH, and Cunningham: How engaged are consumers in their health and health care, and why does it matter? 2008. Research Brief No. 8. Retrieved June 2013 from http://ualr.edu/seniorjustice/ uploads/2008/12/How%20Engaged%20Are%20Consumers%20in %20Their%20Health%20and%20Health%20Care.pdf Institute of Medicine (IOM) report: The future of nursing: Leading change, advancing health, 2010. Retrieved June 2013 from http://www.iom.edu/Reports/2010/The-future-of-nursing-leadingchange-advancing-health.aspx Park, HK, Hong, HS, Kwon, HJ, et al: A nursing robot system for the elderly and the disabled. Int J of Human-friendly Welfare Robotic Systems 2(4):11–16, 2001. Retrieved April 2008 from http://web.cecs.pdx. edu/~mperkows/Rehabilitation_Robots/nursing-robot.pdf Pollack, ME, Brown, L, Colbry, D, et al: Pearl: A mobile robotic assistant for the elderly, 2002. Retrieved May 2008 from http://www.eecs.umich.edu/~pollackm/distrib/aaai02wkshp.pdf Restuccia, P: The aging nurse project, 2007. Retrieved June 2013 from http://www.truthaboutnursing.org/news/2007/aug/15_boston_ herald.html
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CHAPTER 2 Books American Nurses Association: Nursing: Scope and standards of practice. American Nurses Association, Silver Spring, MD, 2004. American Nurses Association: Nursing: Scope and standards of practice, ed 2. American Nurses Association, Silver Spring, MD, 2010. American Nurses Association: Nursing’s social policy statement. American Nurses Association, Kansas City, MO, 1980. American Nurses Association: Nursing’s social policy statement. American Nurses Association, Washington, DC, 1995. American Nurses Association: Standards of clinical nursing practice. American Nurses Association, Kansas City, MO, 1991. Bulechek, GM, Butcher, HK, Dochterman, JM, et al (eds): Nursing Interventions Classification (NIC). Elsevier, St Louis, MO, 2013. Morehead, S, Johnson, M, Maas, ML, et al (eds): Nursing Outcomes Classification (NOC) Measurement of Health Outcomes. Elsevier, St Louis, MO, 2013. NANDA-I: Nursing diagnoses: Definitions and classification. NANDA International, Philadelphia, 2007. Pesut, DJ, and Herman, J: Clinical reasoning, the art and science of critical and creative thinking. Delmar, Albany, NY, 1999. Shore, LS: Nursing diagnosis: What it is and how to do it: A programmed text. Medical College of Virginia Hospitals, Redmond, VA, 1988.
Articles Aquilino, ML, and Keenan, G: Having our say: Nursing’s standardized nomenclature. Am J Nurs 100(7):33–38, 2000. Delaney, C, and Maas, M: Reliability of nursing diagnoses documented in a computerized nursing information system. Nurs Diagn 11(3): 121–134, 2000.
CHAPTER 3 Books Newfield, SA, Hinz, MD, Tilley, DS, et al: Cox’s clinical applications of nursing diagnosis. FA Davis, Philadelphia, 2007. Pesut, DJ, and Herman, J: Clinical reasoning, the art and science of critical and creative thinking. Delmar, Albany, NY, 1999.
Articles Hickman, JS: A critical assessment of critical thinking in nursing education. Holistic Nurse Practitioner 7(3):36–47, 1993.
Electronic Resources Paul, R, and Elder, L: The miniature guide to critical thinking concepts and tools. Foundation for Critical Thinking Press, 2008. Retrieved May 2013 from http://www.criticalthinking.org/pages/ defining-critical-thinking/766 Scriven, M, and Paul, R: Critical thinking as defined by the National Council for Excellence in Critical Thinking. Presented at the 8th Annual International Conference on Critical Thinking and Education Reform, Summer 1987. Retrieved February 2009 from http://www.criticalthinking.org/aboutCT/define_critical_ thinking.cfm
CHAPTER 4 Books Deglin, JH, and Vallerand, AH: Davis’s drug guide for nurses, ed 13. FA Davis, Philadelphia, 2010. LeFever Kee, J: Laboratory and diagnostic tests with nursing implications, ed 8. Pearson Prentice Hall, Upper Saddle River, NJ, 2009. McCance, KL, and Heuther, SE: Pathophysiology: The biologic basis for disease in adults and children, ed 6. Elsevier, New York, 2009. Smeltzer, S, Bare, BG, Hinkle, JL, et al: Brunner and Suddarth’s textbook of medical-surgical nursing, ed 11. Lippincott, Williams & Wilkins, Philadelphia, 2010. Van Leeuwen, AM, Poelhuis-Leth, D, and Bladh, M: Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications, ed 5. FA Davis, Philadelphia, 2013. Williams, SE: Chapter 4: The fourth heart sound. In Walker HK, Hall WD, and Hurst, JW (eds). Clinical methods: The history, physical, and laboratory examinations, ed 3. Boston, Butterworths, 1990. Wilson, BA, Shannon, MT, Shields, KM, et al: Prentice Hall nurse’s drug guide 2009. Pearson Prentice Hall, Upper Saddle River, NJ, 2009.
Articles Aldrich, D, and Hunt, DP: When can the patient with deep venous thrombosis begin to ambulate? Phys Ther 84(3):268–273, 2004. Antman, EM, Cohen, M, Bernink, PJ, et al: The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 284(7):835–842, 2000. Balser, JR: Managing arrhythmias after cardiac surgery. AACN News 17(2):10–11, 2000. Barron, HV, Every, NR, Parsons, LS, et al: The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: Data from the National Registry of Myocardial Infarction 2. Am Heart J 141(9):933–939, 2001. Berger, R, et al: B-type natriuretic peptide predicts sudden death in clients with chronic heart failure. Circulation (105):2328–2331, 2002. Bocchi, EA: Cardiomyoplasty for treatment of heart failure. Eur J Heart Fail 3(4):403–406, 2001. Bond, EA, et al: The left ventricular assist device. Am J Nurs 103(1): 33–41, 2003. Braun, LT: Cardiovascular disease: Strategies for risk assessment and modification. J Cardiovas Nurs 21(6)(suppl):S20–S42, 2006. Braun, LT, and Davidson, MH: Cholesterol-lowering drugs bring benefits to high-risk populations even when LDL is normal. J Cardiovas Nurs 18(1):44–49, 2003. Cheek, D, and Cesan, A: What’s different about heart disease in women? Nursing(8):36–42, 2003. Cheek, DJ, Grauity, R, Hawkins, J, et al: Oral heart failure medications: An update for home health clinicians. Home Healthcare Nurse 26(10):600–611, 2008. Chobanian, AV, Bakris, GL, Black, HR, et al: Seventh report of Joint National Committee (JNC) on detection, evaluation, and treatment of high blood pressure. Hypertension 42(6):1206–1252, 2003. Colwell, CW, and Hardwick, ME: Natural history of venous thromboembolism. Tech Orthop 19:236–239, 2004. Coughlin, RM: Recognizing ventricular arrhythmias and preventing sudden cardiac death: Be prepared to stop these dangerous arrhythmias. Am Nurse Today 2(5):38–43, 2007. Coviello, JS, and Nystrom, KV: Obesity and heart failure. J Cardiovasc Nurs 18(5):360–368, 2003. Craft, J: Eplerenone (Inspra), a new aldosterone antagonist for the treatment of systemic hypertension and heart failure. Proc (Bayl Univ Med Cent) 17(2):217–220, 2004. Crowther, M, and McCourt, K: Get the edge on deep vein thrombosis. Nurs Manage 35(1):21–29, 2004. Crowther, M, and McCourt, K: Venous thromboembolism: A guide to prevention and treatment. Nurse Pract 30(8):26–43, 2005. Cucinelli, C: Minimally invasive coronary artery bypass surgery. Crit Care Nurse 23(1):54, 2000.
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Articles Albert, HB, Kjaer, P, and Jensen, TS: Modic changes, possible causes and relation to low back pain. Med Hypotheses 70(2):361–368, 2008. Aref, AA, and Schmitt, BP: Open-angle glaucoma: Tips for earlier detection and treatment selection. J Fam Pract 54(2):117–125, 2005. Aschenbrenner, DS: Drug watch: New drug treats partial seizures. Am J Nurs 111(10):23, 2011. Balague, F, and Dudler, J: An overview of conservative treatment for lower back pain. Int J Clin Rheumatol 6(3):281–290, 2011. Bay, E, and McLean, SA: Mild traumatic brain injury: An update for advanced practice nurses. J Neurosci Nurs 39(1):43–51, 2007. Bazarian, J, McClung, J, Shah, M, et al: Mild traumatic brain injury in the United States, 1998–2000. Brain Injury 19(2):85–91, 2005. Berg, PJ, Smallfield, S, and Svien, L: An investigation of depression and fatigue post West Nile virus infection. S D Med, 63(4):127–129, 2010. Bonner, SM: My aching back: Relieving the pain of herniated disk. Nursing Made Incredibly Easy! 6(1):19–30, 2008. Brandt, JD, Gordon, MO, and Kass, MA: Central corneal thickness in the ocular hypertension treatment study (OHTS). Opthalmology 108(10): 1779–1788, 2001. Brethour, MK, Nystrom, KV, Broughton, S, et al: Controversies in acute stroke treatment. AACN Advanced Crit Care 23(2):158–172, 2012. Brodkey, MB, Ben-Zacharia, AB, and Reardon, JD: Living well with multiple sclerosis. Am J Nurs 111(7):40–48, 2011.
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Pamphlets American Autoimmune Related Disease Association (AARDA): The cost of autoimmune disease: The latest front in the war on healthcare spending. Author, Eastpoint, MI, 2011. Everhart, JE (ed): The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Washington, DC, US Government Printing Office, 2008; NIH Publication No. 09-6443. Rooney, D: Colostomy irrigation: A personal account of managing a colostomy. The Phoenix, pp 1–5, A publication of the United States Ostomy Association (USOA), 2007. Washuta, L: Basic colostomy care. Colostomy new patient guide. In The Phoenix, pp 26–33, A publication of the United States Ostomy Associaten (USOA), 2010.
Articles Alloo, J, Gerstle, T, Shiliansky, J, et al: Appendicitis in children less than 3 years of age, a 28-year review. Pediatr Surg Int 17(2):777–779, 2004. Bae, J, Park, J, Yang, H, et al: Nutritional status of gastric cancer patients after total gastrectomy. World J Surg 22(3):254–261, 1998. Bildozola, M, Kravetz, D, Argonz, J, et al: Efficacy of octreotide and sclerotherapy in the treatment of acute variceal bleeding in cirrhotic patients. A prospective, multicentric, and randomized clinical trial. Scand J Gastroenterol 35(4):419–425, 2000. Borwell, B: Stoma management and palliative care. JCN 25(4):4–10, 2011. Bosshardt, TL: Outcomes of ostomy procedures in patients aged 70 years and older. Arch Surg 138(10):1077–1082, 2003. Boyer, TD, and Haskal, ZJ: The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: Update 2009. Hepatology 51(1):306, 2010. Bozetti, F, Ravera, E, Cozzaglio, L, et al: Comparison of nutritional status after total or subtotal gastrectomy. Nutrition 6(5):371–375, 1990. Butler, DL: Early postoperative complications following ostomy surgery: A review. J Wound Ostomy Continence Nurs 38(5):513–519, 2009. Chen, GZ, and Freeman, ML: Management of upper gastrointestinal bleeding emergencies: Evidence-based medicine and practical considerations. World J Emerg Med 2(1):5–12, 2011.
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National Heart, Lung and Blood Institute: What are overweight and obesity? Diseases and conditions index, 2012. Retrieved March 2013 from http://www.nhlbi.nih.gov/health/health-topics/topics/obe/ National Institute of Diabetes and Digestive and Kidney Disorders (NIDDK): What I need to know about Hepatitis C. NIH publication 074230, n.d. Retrieved March 2013 from http://digestive.niddk.nih.gov/ ddiseases/pubs/hepc_ez/hepc_508.pdf Nazario, B: Oral diabetes medications, 2011. Retrieved March 2013 from http://diabetes.webmd.com/guide/oral-medicine-pills-treat-diabetes No author listed: Pathophysiology of obesity, 2012. Retrieved March 2013 from http://www.obesityeducationnetwork.com/pathophysiology No author listed: What are eating disorders? The alliance for eating disorder awareness, 2013. Retrieved February 2013 from http://www. allianceforeatingdisorders.com/what-are-eating-disorders Ogunyemi, DA: Autoimmune thyroid disease and pregnancy, 2012. Retrieved March 2013 from http://emedicine.medscape.com/ article/261913-overview#showall OPTN/SRTR Annual data report 2011. Liver. Retrieved March 2013 from http://srtr.transplant.hrsa.gov/annual_reports/2011/pdf/03_ %20liver_12.pdf Polin, BS: Ketoacidosis: A diabetes complication, 2012. Retrieved March 2013 from http://www.diabeticlifestyle.com/type-1diabetes/ketoacidosis-diabetes-complication Pyrsopoulos, NT, and Reddy, KR: Primary biliary cirrhosis, 2013. Retrieved April 2013 from http://emedicine.medscape.com/article/171117-overview Quigley, P, and Moreno, MA: Pediatric bulimia, 2011. Retrieved March 2013 from http://emedicine.medscape.com/article/913721-overview Radar, J: Eating disorders and men, 2011. Retrieved February 2013 from http://eatingdisorderstreatment.com/eating-disorders-and-men/ Raghavan, RA, Bensson, HA, Hamdy, O, et al: Diabetic ketoacidosis treatment & management, 2012. Retrieved March 2013 from http://emedicine.medscape.com/article/118361-treatment#showall Ross, DS: Iodine in the treatment of hyperthyroidism, 2012. Retrieved March 2013 from http://www.uptodate.com/contents/radioiodinein-the-treatment-of-hyperthyroidism Schraga, ED: Hyperthyroidism, thyroid storm, and Graves’ disease in emergency medicine, 2008, 2012. Retrieved March 2013 from http://emedicine.medscape.com/article/767130-overview Shah, R, and Fields, JM: Ascites treatment & management, 2012. Retrieved March 2013 from http://emedicine.medscape.com/ article/170907-treatment#showall Stevens, T, and Conwell, D: Chronic pancreatitis. Cleveland Clinic Disease Management Project, 2010. Retrieved March 2013 from http://www.clevelandclinicmeded.com/medicalpubs/ diseasemanagement/gastroenterology/acute-pancreatitis/ Sun, GH, DeMonner, S, and Davis, MM: Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996–2006. Thyroid, 2012. Retrieved March 2013 from http://online.liebertpub.com/doi/abs/10.1089/thy.2012.0218? journalCode=thy Thomas, CP, and Hamawi, K: Metabolic acidosis, 2013. Retrieved April 2013 from http://emedicine.medscape.com/article/242975overview#showall Thompson, EG, and Tavakkolizadeh, A: Biliopancreatic diversion and biliopancreatic diversion with duodenal switch, 2011. Retrieved March 2013 from http://www.webmd.com/diet/weight-loss-surgery/ biliopancreatic-diversion-1920 Tortorice, J: Total parenteral nutrition, 2007. Retrieved April 2013 from http://www.ceufast.com/courses/viewcourse.asp?id=180 Waldrop, R, and Brenner, BE: Emergent management of anorexia nervosa, 2011. Retrieved February 2013 from http://emedicine.medscape.com/article/805152-overview Wolf, DC: Cirrhosis, 2012. Retrieved March 2013 from http://emedicine.medscape.com/article/185856-overview World Health Organization (WHO): Fact sheet. Obesity and overweight, 2013. Retrieved March 2013 from http://www.who.int/mediacentre/factsheets/fs311/en/ Yaseen, S, and Thomas, C: Metabolic alkalosis, 2011. Retrieved April 2013 from http://emedicine.medscape.com/article/243160-overview
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CHAPTER 9 Books American Academy of Pediatrics: Scheduling immunizations. In Red Book for PDA: Report of the Committee on Infectious Diseases. American Academy of Pediatrics, Committee on Infectious Diseases, ed 26. Elk Grove Village, IL, 2003. Beers, MK (ed): The Merck manual of diagnosis and therapy, ed 11. Merck Research Laboratories, West Point, PA, 2006. Evens, A, and Tallman, M: Acute leukemias. In Skeel, RT (ed): Handbook of cancer chemotherapy, ed 6. Lippincott, Williams & Wilkins, Philadelphia, 2003. Foster, J, and Prevost, S: Advanced practice nursing of adults in acute care. FA Davis, Philadelphia, 2012. Iltano, JK, and Taoka, KN: ONS core curriculum for oncology nursing, ed 4. Elsevier Saunders, Philadelphia, 2005. Johnston, L: Sexuality. In Johnson, L (ed): Non-Hodgkin’s lymphomas: Making sense of diagnosis, treatment, and options. O’Reilly Media (no location given), 1999. Katz, A: Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Oncology Nursing Society, Philadelphia, 2006. Lippincott, Williams & Wilkins (contributors): Professional guide to pathophysiology, ed 3. Lippincott, Williams & Wilkins, Philadelphia, 2010. Stein, R, Morgan, D, and Greer, J: Hodgkin’s disease and non-Hodgkin’s lymphoma. In Skeel, RT (ed): Handbook of cancer chemotherapy, ed 6. Lippincott, Williams & Wilkins, Philadelphia, 2003. Visovsky, C: Interventions for clients with hematologic problems. In Ignatavicius, DD, and Workman, ML (eds): Medical-surgical nursing: Critical thinking for collaborative care, ed 5. Elsevier Saunders, St. Louis, MO, 2006.
Articles American Academy of Pediatrics, Committee on Infectious Diseases: Policy statement: Recommendations for the prevention of pneumococcal infections, including the use of pneumococcal conjugate vaccine (Prevnar), pneumococcal polysaccharide vaccine, and antibiotic prophylaxis. Pediatrics 2000;106(2 Pt 1):362–366. Basile, J: Clinical considerations and practical recommendations for the primary care practitioner in the management of anemia of chronic kidney disease. South Med J 100(12):1200–1207, 2007. Bernard, AW, Yasin, Z, and Venkat, A: Acute chest syndrome of sickle cell disease. Hosp Physician 43(1):13–18, 2007. Brousseau, DC, Panepinto, JA, Minner, M, et al: The number of people with sickle-cell disease in the United States: National and state estimates. Am J Hematol 85(1):77–78, 2009. Cerrato, PL: Complementary therapies: Diet and herbs for BPH? RN 63(2):63–64, 2000. Corwin, H, and Krantz, S: Anemia of the critically ill: Acute anemia of chronic disease. Crit Care Med 29(9):S199–S200, 2001. Creary, M, Williamson, D, and Kulkarni, R: Sickle cell disease: Current activities, public health implications, and future directions. J Women’s Health 16(5):575–582, 2007. Cushman, M, Cantrell, RA, McClure, LA, et al: Estimated 10-year stroke risk by region and race in the United States: Geographic and racial differences in stroke risk. Ann Neurol 64(5):507–513, 2008. Dahoui, HA, Hayek, MN, Nietert, PJ, et al: Pulmonary hypertension in children and young adults with sickle cell disease: Evidence for familial clustering. Pediatr Blood Cancer 54(3):398–402, 2010. Druker, BJ, Guilhot, F, O’Brien, SG: Five-year follow-up of patients receiving imatinib for chronic myeloid leukemia. N Engl J Med 355(23):2408–2417, 2006. Ellison, AM: Sickle cell disease advice on handling emergencies. Contemporary Pediatrics 29(9):18–27, 2012. Harel, S, Ferme, C, and Poirot, C: Management of fertility in patients treated for Hodgkin’s lymphoma. Haematol 96(11):1692–1699, 2010.
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Hebbar, AK, and Gibson, MV: Recognizing and managing anemia of chronic disease. Patient Care 40(11):36–40, 2006. Held-Warmkessel, J: How to prevent and manage tumor-lysis syndrome. Nursing 40(2):26–31, 2010. Jordan, K, Sippel, C, and Schmoll, H-J: Guidelines for antiemetic treatment of chemotherapy-induced nausea and vomiting: Past, present, and future recommendations. Oncologist 12(9):1143–1150, 2007. Klepin, HD, and Balducci, L: Acute myelogenous leukemia in older adults. Oncologist 14(3):222–232, 2009. Knight, K, Wade, S, and Balducci, L: Prevalence and outcomes of anemia in cancer: A systematic review of the literature. Am J Med 116 (Suppl 7A):11S–26S, 2004. Kosits, C, and Callaghan, M: Rituximab: A new monoclonal antibody therapy for non-Hodgkin’s lymphoma. Oncol Nurs Forum 27(1):51, 2000. Maples, BL, and Hagemann, TM: Treatment of priapism in pediatric patients with sickle cell disease. Am J Health Syst Pharm 61(4):355–363, 2004. Meier, ER, and Miller, JL: Sickle cell disease in children. Drugs 72(7): 895–906, 2012. Mohanty, D, Mukherjee, MB, and Colah, RB: Iron deficiency anaemia in sickle cell disorders in India. Indian J Med Res 127:366–369, 2008. Mullen, E: Hodgkin lymphoma: An update. J Nurse Pract 3(6):393–403, 2007. Pack-Mabien, A, and Haynes, J: A primary care provider’s guide to preventive and acute care management of adults and children with sickle cell disease. J Am Acad Nurse Pract 21(5):250–257, 2009. Phillips, RM: The mystery of leukemia in older adults. Nursing Made Incredibly Easy! 10(1):39–45, 2012. Rogers, B: Looking at lymphoma and leukemia. Nursing 35(7):56–63, 2005. Rogers, GM, Becker, PS, Blinder M, et al: Cancer- and chemotherapyinduced anemia. J Natl Compr Canc Netw 10(5):628–653, 2012. Roy, C, Weinstein, D, and Andrews, N: 2002 E. Mead Johnson award for research in pediatrics lecture: The molecular biology of the anemia of chronic disease: A hypothesis. Pediat Res 53(3):507–512, 2003. Sherbenou, D, and Druker, B: Applying the discovery of the Philadelphia chromosome. J Clin Invest 117(8):2067–2074, 2007. Steinberg, MH, Barton, F, Castro, O, et al: Effect of hydroxyurea on mortality and morbidity in adult sickle cell anemia: Risks and benefits up to 9 years of treatment. JAMA 289(13):1645–1651, 2003. Stremick, K, and Gallagher, E: Malignant lymphomas. Am J Nurs 4(Suppl):18–22, 2000. Verduzco, LA, and Nathan, DG: Sickle cell disease and stroke. Am Fam Physician 61(5):1349–1356, 2000. Vichinsky, EP, Neumayr, LD, Earles, AN, et al: Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group. N Engl J Med 342(25):1855–1865, 2000. Yale, SH, Nagib, N, and Guthrie, T: Approach to the vaso-occlusive crisis in adults with sickle cell disease. Am Fam Physician 61(5):1349–1356, 2000. Yusuf, HR, Lloyd-Puryear, MA, Grant, AM, et al: Sickle cell disease. The need for a public health agenda. Am J Prev Med 41(6S4):S376–S383, 2011.
Electronic Resources American Cancer Society (ACS): Cancer facts and figures, 2013. Retrieved March 2013 from http://www.cancer.org/acs/groups/ content/@epidemiologysurveilance/documents/document/ acspc-036845.pdf American Cancer Society (ACS): What happens after treatment for Hodgkin Disease?, 2012. Retrieved April 2013 from http://www .cancer.org/cancer/hodgkindisease/detailedguide/hodgkindisease-after-follow-up Cancer Treatment Centers of America (CTCA): Cancers we treat: Various pages, 2012. Retrieved April 2013 from http://www.cancercenter.com/cancer-type.cfm Dunleavy, KM, Kass, E, and Wilson, W: Lymphoma of the head and neck, 2012. Retrieved April 2012 from http://emedicine.medscape.com/article/854110-overview Ellison, AM: Sickle cell disease. Advice on handling emergencies. Contemporary Pediatrics 29(9):18–27, 2012. Retrieved January 2013 from www.ebscohost.com
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CHAPTER 10 Books Bernhard, JD: Itch: Mechanisms and management of pruritus. McGraw-Hill, New York, 1994. Caputi, LJ: Interventions for male clients with reproductive problems. In Ignatavicius, DD, and Workman, ML (eds): Medical-surgical nursing: Critical thinking for collaborative care, ed 5. Elsevier Saunders, St. Louis, MO, 2006. Choka, KP: Renal failure. In Copstead, LEC, and Banasik, JL (eds): Pathophysiology, ed 3. Elsevier Saunders, St. Louis, MO, 2005. Doenges, ME, Moorhouse, MF, and Murr, AC: Nurse’s pocket guide diagnoses, prioritized interventions and rationales, ed 13. FA Davis, Philadelphia, 2013. Fulgham, PF, and Bishoff, JT: Urinary tract imaging: Basic principles. In Wein, AJ (ed): Campbell-Walsh urology, ed 10. Saunders Elsevier, Philadelphia, 2011. Karch, AM: Lippincott’s nursing drug guide. Lippincott, Williams & Wilkins, Ambler, PA, 2008. Lacharity, LA: Interventions for clients with acute and chronic renal failure. In Ignatavicius, DD, and Workman, ML (eds): Medicalsurgical nursing: Critical thinking for collaborative care, ed 5. Elsevier Saunders, St. Louis, MO, 2006. National Institutes of Health (NIH): Urostomy and continent urinary diversion. Publication no. 06–5629. Washington, DC, May 2006. Porth, CM: Essentials of pathophysiology: Concepts of altered health states, ed 2. Lippincott, Williams & Wilkins, Philadelphia, 2007. Springhouse (ed): Emergency nursing made incredibly easy! Lippincott, Williams & Wilkins, Ambler, PA, 2007. Springhouse (ed): Pathophysiology made incredibly easy! Lippincott, Williams & Wilkins, Philadelphia, 2005. Wei, JT, Calhoun, EA, and Jacobsen, SJ: Benign prostatic hyperplasia. In Litwin, MS, and Saigal, CS (eds): Urologic diseases in America. National Institutes for Health. NIH publication 07-5512:43–67, Washington, DC, 2007. Winkleman, C: Interventions for clients with urinary problems. In Ignatavicius, DD, and Workman, ML (eds): Medical-surgical nursing: Critical thinking for collaborative care, ed 5. Elsevier Saunders, St. Louis, MO, 2006. Wolfson, AB, et al: Clinical practice of emergency medicine, ed 4. Lippincott, Williams & Wilkins, Philadelphia, 2005.
Articles Ali, B, and Gray-Vickery, P: Limiting the damage from acute kidney injury. Nursing 41(3):22–31, 2011. Bak, GP: Teaching ostomy patients to regain their independence. Am Nurse Today 3(3):30–34, 2008. Bent, S, Kane, C, Shinohara, K, et al: Saw palmetto for benign prostatic hyperplasia. N Engl J Med 354(6):557–566, 2006. Burrows-Hudson, S: Chronic kidney disease: An overview. Am J Nurs 105(2):40–49, 2005. Calabrese, DA: Prostate cancer in older men. Urol Nurs 24(4):258–264, 2004. Cartin-Ceba, R, Kashiouris, M, Plataki, M, et al: Risk factors of development of acute kidney injury in critically ill patients: A systematic review and meta-analysis of observational studies. Crit Care Res Pract, vol. 2012, Article ID 691013, 15 pages, 2012, 10.1155/2012/691013 Centers for Disease Control and Prevention (CDC): Acute kidney injury associated with synthetic cannabinoid use—multiple states, 2012. MMWR 62(6):93–98, 2013. Cheung, CM, Ponnusamy, A, and Anderton, JG: Management of acute renal failure in the elderly: A clinician’s guide. Drugs Aging 25(6):455–476, 2008. Chung, SH, Lindholm, B, and Lee, HB: Influence of initial nutritional status on continuous ambulatory peritoneal dialysis patient survival. Perit Dial Int 20(1):19–26, 2000.
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Colwell, JC, Goldberg, M, and Carmel, J: The state of the standard diversion. J Wound Ostomy Continence Nurs 28(1):6–17, 2001. Corbello, J, and Rosner, MH: Intradialytic total parenteral nutrition (IDPN): Evidence-based recommendations. Practical Gastroenterol April:14–28, 2009. Davison, BJ, Moore, KN, MacMillian, H, et al: Client evaluation of a discharge program following a radical prostatectomy. Urol Nurs 24(6):483–489, 2004. Finkelstein, VA, and Goldfarb, DS: Strategies for preventing calcium oxalate stones. CMAJ 174(10):1407–1409, 2006. Gilchrist, K: Benign prostatic hyperplasia: Is it a precursor to prostatic cancer? Nurse Pract 29(6):30–37, 2004. Goldberg, R, and Dennen, P. Long-term outcomes of acute kidney injury. Adv Chronic Kidney Dis 15(3):297–307, 2008. Goodman, ED, and Ballou, MB: Perceived barriers and motivators to exercise in hemodialysis patients. Nephrol Nurs J 31(1):23–29, 2004. Herdiman, O, Johnson, L, Lawrentschuk, N, et al: Orthotopic bladder substitution (neobladder) indications, patient selection, preoperative education, and counseling. J Wound Ostomy Continence Nurs 40(1):73–82, 2013. Holcomb, SS: Evaluating chronic kidney disease risk. Nurse Pract 30(4):12–25, 2005. How, PP, and Lau, AH: Malnutrition in patients undergoing hemodialysis: Is intradialytic parenteral nutrition the answer? Pharmacotherapy 24(12);1748–1758, 2004. Litwin, MS, and Saigal, CS (eds): Urologic diseases in America. U.S. Department of Health and Human Service, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 12-7865. U.S. Government Printing Office, Washington, DC, 2012. McGlynn, B, Al-Saffar, N, Begg, H, et al: Management of urinary incontinence following radical prostatectomy. Urol Nurs 24(6):475–482, 2004. Mehta, RL, Kellam, JA, Shah, SV, et al: Acute Kidney Injury Network: Report of an initiative to improve outcomes in acute kidney injury. Crit Care 11(2):R31, 2007. Miller, NL, and Lingeman, JE: Management of kidney stones. BMJ 334(7591):468–472, 2007. Mills, RD, and Studer, UE: Metabolic consequences of continent urinary diversion. J Urol 161:1057–1066, 1999. Mountokalakis, TD: Magnesium metabolism in chronic renal failure. Magnes Res 3(2):121–127, 1990. National Kidney Foundation: Clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 35(6 Suppl 2):S1–S140, 2000. Neal, RH, and Keister, D: What’s best for your patient with BPH? J Fam Pract 58(5):241–247, 2009. Nikken, JJ, and Krestin, GP: MRI of the kidney—state of the art. Eur Radiol November, 17(11): 2780–2793, 2007. Parsons, JK, Mougey, J, Lambert, L, et al: Lower urinary tract symptoms and the risk of falls in older men. J Urol 179(suppl):140; Abstract 394, 2008. Paton, M: CRRT: Help for acute renal failure. Nursing Made Incredibly Easy! 5(5):28–38, 2007. Pieper, B, et al: Discharge information needs of patients after surgery. J Wound, Ostomy, Continence Nurs 33(3):281–290, 2006. Perl, J, and Chan, CT: Sleep apnea in peritoneal dialysis: Nocturnal versus continuous ambulatory treatment. Nat Clin Pract Nephrol 3(2):72–73, 2007. Polzien, G: Chronic kidney disease and kidney failure important numbers to know. Home Health Nurs 25(10):655–660, 2007. Pupim, LB, Flakoll, PJ, and Brouillette, JR: Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 110(4):483–492, 2002. Rosner, MH: Acute kidney injury in the elderly: Pathogenesis, diagnosis and therapy. Aging Health 5(5):635–646, 2009. Scales, SC, Smith, AC, Hanley, JM, et al: Prevalence of kidney stones in the United States. Eur Urol 62(1):160–165, 2012. Sexena, R, and West, C: Peritoneal dialysis: A primary care perspective. Am Board Fam Med 19(4):380–389, 2006. Silverman, SG, Leyendecker, JR, and Amis, ES: What is the current role of CT urography and MR urography in the evaluation of the urinary tract? Radiology 250(2):209–223, 2009.
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Thurairaja, R, Burkhard, FC, and Studer UE: The orthotopic neobladder. BJU Int 102(9 Pt B):1307–1313, 2008. Wei, JT, Calhoun, E, and Jacobson, SJ: Urologic diseases in America project: Benign prostatic hyperplasia. J Urology 179(5 Suppl):S75–S80, 2008. Wojcik, M, and Dennison, D: Photoselective vaporization of the prostate in ambulatory surgery. AORN J 83(2):330, 2006. Xue, JL, Daniels, F, Star, RA, et al: Incidence and mortality of acute renal failure in Medicare beneficiaries, 1992 to 2001. J Am Soc Nephrol 17(4):1135–1142, 2006.
Electronic Resources Advanced Renal Education Program: Mortality trends in peritoneal dialysis and hemodialysis, 2011. Retrieved April 2013 from http://www.advancedrenaleducation.com/peritonealdialysis/ clinicaloutcomes/clinicaloutcomesofpdandhd Alper, AB, Senava, RG, and Young, BA: Uremia, 2012. Retrieved April 2012 from http://emedicine.medscape.com/article/245296overview#showall American Cancer Society (ACS): Cancer facts & figures 2013. Bladder cancer: Statistics. Retrieved April 2013 from http://www.cancer.net/cancer-types/bladder-cancer/statistics American Cancer Society (ACS): Urostomy: A guide, revised 2011. Retrieved April 2013 from http://www.cancer.org/acs/groups/ cid/documents/webcontent/002931-pdf.pdf American Urological Association Education and Research, Inc.: AUA guideline on the management of benign prostatic hyperplasia: Diagnosis and treatment recommendations, updated 2010. Retrieved April 2013 from http://www.auanet.org/content/guidelines-and-qualitycare/clinical-guidelines/main-reports/bph-management/ chap_1_GuidelineManagementof(BPH).pdf Centers for Disease Control and Prevention (CDC): FastStats2009: National hospital discharge survey: 2009 table, procedures by selected patient characteristics—number by procedure category and age. Retrieved March 2013 from http://www.cdc.gov/nchs/fastats/prostate.htm Costa, JA, and Kreder, K: Urinary diversions and neobladders, 2012. Retrieved April 2013 from http://emedicine.medscape.com/article/ 451882-overview#showall Deters, LA, Costabile, RA, and Leveille, RJ: Benign prostatic hypertrophy, 2013. Retrieved April 2013 from http://emedicine.medscape.com/article/437359-overview#showall Fathallah-Shaykh, S, and Neiberger, R: Uric acid stones, 2013. Retrieved April 2013 from http://emedicine.medscape.com/article/983759overview#showall Gonzalez-Parra, E, Gracia-Iguacel, C, Egido, J, et al: Phosphorus and nutrition in chronic kidney disease, 2012. Retrieved April 2013 from http://www.hindawi.com/journals/ijn/2012/597605/#B12 Guilli, LF, Mori, A, Ettaher, AF, et al: Open prostatectomy. Surgery encyclopedia: A guide for patients and caregivers, n.d. Retrieved April 2013 from http://www.surgeryencyclopedia.com/La-Pa/Open-Prostatectomy.html Hoyert, D, and Xu, J: Deaths: Preliminary data for 2011. National Vital Statistics Report (NVSR) 6(1):18, 2012. Retrieved March 2013 from http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf Hudson, K: Acute renal failure. Nursing CE course, n.d. Retrieved April 2013 from http://dynamicnursingeducation.com/class.php?class_id=131&pid=18 Kontamwar, A: Complications of peritoneal dialysis. Slide presentation for Renal Consultants, Inc., 2011. Retrieved April 2013 from http://www.slideshare.net/kenar78/complications-of-peritonealdialysis Lewington, A, and Kanagasundaram, S: Acute kidney injury (guidelines), 2011. Retrieved April 2013 from http://www.renal.org/clinical/ guidelinessection/AcuteKidneyInjury.aspx Mailloux, LU, and Henrich, WL: Patient survival and maintenance dialysis, 2013. Retrieved April 2013 from paid site: http://www .uptodate.com/contents/patient-survival-and-maintenancedialysis#H1
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Sofocleous, CT, Cerveira, J, Cooper, SG, et al: Dialysis fistulas, 2011. Retrieved April 2013 from http://emedicine.medscape.com/ article/419393-overview#showall Suracusano, S, Ciciliato, S, and Visalli, F: Current trends in urinary diversion in men, 2012. Retrieved April 2013 from http://cdn .intechopen.com/pdfs/27330/InTech-Current_trends_ in_urinary_diversion_in_men.pdf Urology Care Foundation: Continent urinary diversion, 2011. Retrieved April 2013 from http://www.urologyhealth.org/urology/index.cfm?article=106 U.S. Renal Data System (USRDS): 2012 Annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2012. Retrieved March 2013 from http://www.usrds.org/reference.aspx Wedro, BC: Kidney stones, 2010. Retrieved April 2013 from http://www.emedicinehealth.com/kidney_stones/ article_em.htm Wolf, JS, Howes, DS, Craig, S, et al: Nephrolithiasis, 2013. Retrieved April 2013 from http://emedicine.medscape.com/article/ 437096-overview#showall Workeneh, BT, Agraharkar, M, and Gupta, R: Acute kidney injury, 2013. Retrieved April 2013 from http://emedicine.medscape.com/ article/243492-overview
CHAPTER 11 Books American Cancer Society (ACS): Breast cancer facts and figures 2011– 2012. American Cancer Society, Atlanta, GA, 2011. Bland, KI, and Copeland, EM: The breast: Comprehensive management of benign and malignant disease. Vols 1 and 2, ed 4. Saunders Elsevier, Philadelphia, 2009. Mohamed, I, and Skeel, RT: Carcinoma of the breast. In Skeel, RT (ed): Handbook for cancer chemotherapy, ed 6. Lippincott, Williams & Wilkins, Philadelphia, 2003. Winer, EP, Morrow, M, Osborne, CK, et al: Malignant tumors of the breast. In DeVita, VT, Hellman, S, and Rosenberg, SA (eds): Cancer: Principles and practice of oncology. Lippincott, Williams & Wilkins, Philadelphia, 2001.
Articles Augustus, CE: Beliefs and perspectives of African American women who have had hysterectomies. J Transcul Nurs 13(4):296–302, 2002. Bunde, M, et al: On-line hysterectomy support: Characteristics of website experience. Cyberpsychol Behav 10(1):80–85, 2007. Buren, JM, and Linton, C: The role of exercise in treating lymphedema. Rehab Manage 13(6):26–31, 2000. Downs-Holmes, C, and Silverman, P: Breast cancer: Overview & updates. Nurse Pract 36(12):20–26, 2011. Ely, S, and Vioral, AN: Breast cancer overview. Plast Surg Nurs 27(3):128–133, 2007. Greenlee, RT, Murray, T, Bolden, S, et al: Cancer statistics, 2000. CA Cancer J Clin 50(1):7–33, 2000. Katz, A: Sexuality after hysterectomy: A review of the literature and discussion of nursing roles. J Adv Nurs 42(3):297–303, 2003. Ligibel, JA, Giobbe-Hurder, A, Olenzcuk, D, et al: Impact of a mixed strength and endurance exercise intervention on insulin levels in breast cancer survivors. J Clin Oncol 26(6):907–912, 2008. Lo, SS, Mumby, PB, Norton, J, et al: Prospective multicenter study of the impact of the 21-gene recurrence score assay on medical oncologist and patient adjuvant breast cancer treatment selection. J Clin Oncol 28(10):1671–1676, 2010. Mamounas, EP, Tang, G, Fisher, B, et al: Association between the 21-gene recurrence score assay and risk of locoregional recurrence in nodenegative, estrogen receptor-positive breast cancer: Results from NSABP B-14 and NSABP B-20. J Clin Oncol 28(10):1677–1683, 2010. Moreria, V: Hysterectomy: Nursing the physical and emotional wounds. Nurs Times 96(20):41–42, 2000. Risser, N, and Murphy, M: Literature review: Women’s health care: Sexual function after hysterectomy. Nurs Pract 29(2):49, 2004.
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Milenkovic, M, Russo, A, and Elixhauser, A: Hospital stays for prostate cancer, 2004. AHRQ Healthcare cost and utilization project. Statistical brief #30, 2007. Retrieved April 2013 from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb30.jsp Miles, BJ, Khera, M, Colen, JS, et al: Simple prostatectomy, 2011. Retrieved April 2013 from http://emedicine.medscape.com/article/445996-overview National Cancer Institute (NCI): The cost of cancer, 2011. Retrieved April 2013 from http://www.cancer.gov/aboutnci/servingpeople/ cancer-statistics/costofcancer National Cancer Institute (NCI): Surveillance Epidemiology and End Results (SEER) 2012: SEER stat fact sheets: Bladder. Retrieved March 2013 from http://seer.cancer.gov/statfacts/html/urinb.html National Cancer Institute (NCI): Tracking the rise of robotic surgery for prostate cancer. National Cancer Bulletin 8(16):2011. Retrieved March 2013 from http://www.cancer.gov/ncicancerbulletin/080911/page4 National Institutes of Health: Fact sheet: Chronic kidney disease and kidney failure, 2013. Retrieved April 2013 from http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=34 National Institutes of Health: Kidney failure: Choosing a treatment that’s right for you, 2010. Retrieved April 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/choosingtreatment/ National Kidney Foundation: Kidney Disease Outcome Quality Initiative (KDOQI). KDOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification, 2002. Retrieved April 2013 from http://www.kidney.org/professionals/kdoqi/ guidelines_ckd/p1_exec.htm National Kidney Foundation: Fact sheets 2013. Retrieved March 2013 from http://www.kidney.org/news/newsroom/factsheets/CKD-AGrowing-Problem.cfm National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): Eat right to feel right on hemodialysis, update 2012. Retrieved April 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/eatright/ National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): Hemodialysis dose and adequacy, 2009. Retrieved April 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/hemodialysisdose/ index.aspx National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): Kidney disease statistics for the United States, 2012. Retrieved April 2013 from http://kidney.niddk.nih.gov/KUDiseases/pubs/ kustats/index.aspx National Kidney And Urologic Diseases Information Clearinghouse (NKUDIC): Kidney disease statistics for the United States, 2012. Retrieved March 2013 from http://kidney.niddk.nih.gov/ kudiseases/pubs/kustats/ku_diseases_stats_508.pdf National Kidney and Urologic Diseases Information Clearing House (NKUDIC): Kidney stones in adults, 2013. Retrieved April 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/ National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): Treatment methods for kidney failure: Hemodialysis, 2010. Retrieved April 2013 from http://kidney.niddk.nih.gov/ kudiseases/pubs/hemodialysis/index.aspx National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): Treatment methods for kidney failure: Peritoneal dialysis, 2010. Retrieved April 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/ Peaco*ck, PR, and Sinert, RH: Management of acute complications of acute renal failure, 2011. Retrieved April 2013 from http://emedicine.medscape.com/article/777845-overview Pradeep, A, and Batuman, V: Chronic kidney disease, 2013. Retrieved April 2013 from http://emedicine.medscape.com/article/238798-overview Prostatehealthcures.com: Prostate disease statistics, 2006–2013. Retrieved April 2013 from http://www.prostatehealthcures.com/prostate-cat/prostate-statistics Schmidt, M: Non-cancerous causes of elevated PSA, 2009. Retrieved April 2013 from http://prostatecancer.about.com/od/symptomsanddiagnosis/a/ psacauses.htm
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Thomas, S, and Greifzu, SP: Oncology today: Breast cancer. RN 63(4):40–45, 2000a. Thomas, S, and Greifzu, SP: Oncology today: Breast reconstruction. RN 63(4):45–47, 2000b. Walling, AD: Laparoscopic vs. abdominal hysterectomy: A comparison. Am Family Phys 70(8):1570–1575, 2004. Warren, A, Brorson, H, Barud, SJ, et al: Lymphedema: A comprehensive review. Ann Plast Surg 59(4):464–472, 2007.
Electronic Resources American College of Obstetricians and Gynecologists: Hysterectomy, 2011. Retrieved April 2013 from http://www.acog.org/~/media/ For%20Patients/faq008.pdf?dmc=1&ts=20130424T1346545747 Bauers, D: Emotional effects of having a hysterectomy in your 30’s, 2010. Retrieved April 2013 from http://www.helium.com/items/1874487how-can-having-a-hysterectomy-women-in-their-thirties Cancer Action Network: Cancer and Medicare—A chartbook, 2009. Retrieved April 2013 from http://www.allhealth.org/briefingmaterials/ CancerandMedicareChartbookFinalfulldocumentMarch111412.pdf Cancer Treatment Centers of America (CTCA): Types of breast cancer, 2012. Retrieved April 2013 from http://www.cancercenter.com/breast-cancer/types.cfm Centers for Disease Control and Prevention (CDC): Hysterectomy in the United States, 2000–2004, 2008. Retrieved April 2013 from http://www.cdc.gov/reproductivehealth/womensrh/00-04-FS_ Hysterectomy.htm Encyclopedia of Surgery: Hysterectomy, n.d. Retrieved April 2013 from http://www.surgeryencyclopedia.com/Fi-La/Hysterectomy.html Gor, HB: Hysterectomy, 2012 Retrieved April 2013 from http://emedicine.medscape.com/article/267273-overview Mayo Clinic: Mastectomy, 2011. Retrieved April 2013 from http://www.mayoclinic.com/health/mastectomy/MY00943 National Cancer Institute (NCI): Breast cancer, 2013: Retrieved March 2013 from http://www.cancer.gov/cancertopics/types/breast National Cancer Institute (NCI): Breast cancer. Various articles, including statistics, 2012. Retrieved April 2013 from http://www.cancer.gov/cancertopics/wyntk/breast/page6 National Cancer Institute (NCI): The cost of cancer, 2011. Retrieved April 2013 from http://www.cancer.gov/aboutnci/servingpeople/ cancer-statistics/costofcancer National Comprehensive Cancer Network (NCCN): Breast cancer treatment guidelines for patients, 2011. Retrieved April 2013 from http://www.nccn.com/cancer-guidelines.html National Guideline Clearinghouse: Breast cancer screening: A national clinical guideline, 2011. Retrieved April 2013 from http://guideline.gov/content.aspx?id=34275 National Women’s Health Network (NWHN): Hysterectomy: Fact sheets, 2005. Retrieved April 2013 from http://nwhn.org/hysterectomy New York Presbyterian: Lymphedema following mastectomy, 2008. Retrieved April 2013 from http://nyp.org/health/breast-lymph.html Pfunter, A, Levit, K, and Elixhauser, A: Healthcare Cost and Utilization Project (H_CUP); Statistical brief #133: Components of cost increases for inpatient hospital procedures, 1997–2009, 2012. Retrieved April 2012 from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb133.pdf Surgery.com: Hysterectomy: Morbidity and mortality, 2009. http://www.surgery.com/procedure/hysterectomy/morbiditymortality Todd, N: Surgical menopause: Should you take estrogen after your hysterectomy? 2012. Retrieved April 2013 from http:// women.webmd.com/surgical-menopause-estrogen-afterhysterectomy
Weinstein, SL, and Buckwalter, JA: Turek’s orthopaedics principles and their applications, ed 6. Philadelphia, Lippincott, Williams, & Wilkins. 2005.
Articles Aulivola, B, Hile, CN, Hamdan, AD, et al: Major lower extremity amputation: Outcome of a modern series. Arch Surg 139(4):395–399, 2004. Bailey, J: Getting a fix on orthopedic care. Nursing 33(6):58–63, 2003. Bradley, JB, Slauterbeck, J, and Benjamin, JB: Fracture patterns and mechanisms in pedestrian motor vehicle trauma: The ipsilateral dyad. J OrthopTrauma 6(3):279–282, 1992. Cho, TJ, Gerstenfeld, C, and Einhorn, TA: Differential temporal expression of members of the transforming growth factor β superfamily during murine fracture healing. J Bone Miner Res 17(3):513–520, 2002. D’Arcy, Y, and Tovornik, M: How to control pain and improve functionality after total joint replacement surgery. Nursing 6(Suppl Therapy Insider):2–5, 2007. Dillingham, TR, Pezzin, LE, and Shore, AD: Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil 86(3):480–486, 2005. Frost, HM: The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res (248):283–293, 1989. Frakes, M, and Evans, T: Major pelvic fractures. Crit Care Nurse 24(2):24–30, 2004. Inderjeeth, CA, Glennon, D, and Petta, A: Study of osteoporosis awareness, investigation and treatment of patients discharged from a tertiary public teaching hospital. Intern Med 36(9):547–555, 2006. Iverson, MD: Rehabilitation interventions for pain and disability in osteoarthritis: A review of interventions including exercise, manual techniques, and assistive devices. Orthop Nurs 31(2):103–108, 2012. Matielo, MF, Presti, C, Casella, IB, et al: Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease. J Vasc Surg 48(6):1514–1519, 2008. Matsuda, K, Nozawa, M, Katsube, S, et al: Activation of fibrinolysis by reinfusion of unwashed salvaged blood after total knee arthroplasty. Transfus Apher Sci 42:33–37, 2010. Nowygrod, R, Egorova, N, Greco, G, et al: Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg 43(2):205–216, 2006. Peaco*ck, JM, Keo, HH, Duval, S, et al: The incidence and health economic burden of ischemic amputation in Minnesota, 2005–2008. Preventing Chronic Disease: Public Health Research, Practice, and Policy 8(6):1–8, 2011. Prvu-Bettger, J, Bates, B, Bidelspach, D, et al: Short- and long-term prognosis among veterans with neurological disorders and subsequent lower-extremity amputation. Neuroepidemiology 32(1):4–10, 2009. Smeltzer, MD: Making a point about open fractures. Nursing 40(4):24–30, 2010. Walsh, C: Breaking bad: What you need to know about femur fractures. OR Nurse 5(1):30–38, 2011. Wilson, T: Advanced prosthetic devices aid amputees. Disabled Am Veterans (DAV) Magazine (November/December), 2004. Ziegler-Graham, K, Mackenzie, EJ, Ephraim, PL, et al: Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 89(3):422–429, 2008.
Pamphlet Margolis, DJ, Malay, DS, Hoffstad, OJ, et al: Incidence of diabetic foot ulcer and lower extremity amputation among medicare beneficiaries, 2006–2008. In Data Points Publication Series [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US), 2011.
CHAPTER 12
Electronic Resources
Books
American Academy of Orthopedic Surgeons (AAOS): Fractures (broken bones), 2012. Retrieved May 2013 from http://orthoinfo.aaos.org/ topic.cfm?topic=A00139 Amputation Coalition. Limb Loss Resource Center: Resources by amputation level, 2012. Retrieved 2012 from http://amputee-coalition.org/ limb-loss-resource-center/resources-by-amputation-level/
Margolis, DJ, Malay, DS, Hoffstad, OJ, et al: Incidence of diabetic foot ulcer and lower extremity amputation among medicare beneficiaries, 2006–2008. In Data Points Publication Series [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US), 2011.
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National Limb Loss Information Center (NLLIC): Fact Sheet: Pain management and the amputee, updated 2008. Retrieved May 2013 from http://www.amputee-coalition.org/easyread/fact_sheets/ painmgmt-ez.html National Limb Loss Information Center (NLLIC) Staff: Wound care: Preventing infection. Amputee Coalition of America Fact Sheet revised 2009. Retrieved May 2013 from http://www.amputee-coalition.org/fact_sheets/woundcare.pdf Rasul, AT, and Wright, J: Total joint replacement rehabilitation, 2012. Retrieved May 2013 from http://emedicine.medscape.com/article/320061-overview Schuch, CM: Consumer guide for amputees: A guide to lower limb prosthetics: Part 1—Prosthetic designs: Basic concepts. inMotion: a Publication of the Amputee Coalition of America, updated 2008. Retrieved May 2013 from http://www.amputee-coalition.org/inmotion/ mar_apr_98/pros_primer/page1.html Shiel, WC: Total hip replacement, 2012. Retrieved May 2013 from http://www.emedicinehealth.com/total_hip_replacement/article_ em.htm Wedro, B: Compartment syndrome, 2010. Retrieved May 2012 from http://www.medicinenet.com/compartment_syndrome/article.htm
CHAPTER 13 Books Benjamin, D, and Herndon, DN: Special considerations of age: The pediatric burned patient. In Herndon, DN (ed): Total burn care, ed 2. Saunders, London, 2002. Green, TL: Principles and practices of rehabilitation. In Smeltzer, SC, Bare, BG, Hinkle, JL, et al (eds): Brunner & Suddarth’s textbook of medical-surgical nursing, ed 12. Wolters Kluwer/Lippincott, Williams & Wilkins, Philadelphia, 2010. Hartford, CE, and Kealey, GP: Care of outpatient burns. In Herndon, DN, and Jones, JH (eds): Total burn care, ed 3. WB Saunders, Philadelphia, 2007. Stotts, NA: Nutritional assessment and support. In Bryant, RA, and Nix, DP (eds): Acute & chronic wounds: Current management concepts, ed 4. Elsevier, St. Louis, MO, 2012.
Articles Abbade, LP, and Lastória, S: Venous ulcer: Epidemiology, physiopathology, diagnosis and treatment. Int J Dermatol 44(6):449–456, 2005. Alexander, G, Saldanha, J, Ebrahim, MK, et al: Is routine admission chest radiograph of any clinical value in non-intensive care burn patients without inhalation injury? Burns 29(5):499–500, 2003. Ayello, AE, Burrell, RE, Goodman, L, et al: Special considerations in wound bed preparation 2011: An update. Adv Skn Wound Care 24(9):415–436, 2011. Brem, H, Sheehan, P, Rosenberg, H, et al: Evidence-based protocol for diabetic foot ulcers. J Plast Reconstr Surg 117:193S–209S, 2006. Connor-Ballard, PA: Understanding and managing burn pain: Part 2. Am J Nurs 109(5):54–62, 2009. Dale, BA, and Wright, DH: Say goodbye to wet-to-dry wound care dressings: Changing the culture of wound care management within your agency. Home Healthc Nurse 29(7):429–440, 2011. Demling, RH, and DeSanti, L: Closure of partial-thickness facial burns with a bioactive skin substitute in the major burn population decreases the cost of care and improves outcome. Wounds 14(6):230–234, 2002. DeSanti, L: Pathophysiology and current management of burn injury. Adv Skin Wound Care 18(6):323–332, 2005. Fogg, E: Best treatment of non-healing and problematic wounds. JAAPA 22(8):46–48, 2009. Fong, J, Wood, F, and Fowler, B: A silver coated dressing reduces the incidence of early burn wound cellulitis and associated costs of inpatient treatment: Comparative patient care audits. Burns 31(15):562–567, 2005. Hedman, TL, Evans, EM, Richard, RL, et al: Incidence and severity of combat hand burns after all army activity message. J Trauma 64(2Suppl):S169–172, 2008. Hettiaratchy, S, and Dziewulski, P: Pathophysiology and types of burns. BMJ 328:1427–1429, 2004.
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INDEX OF NURSING DIAGNOSES A Activity intolerance: anemias—iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic and, 464; end-of-life care/hospice and, 848; heart failure: chronic and, 51; hypertension: severe and, 38; myocardial infarction and, 83; pediatric considerations and, 872; pneumonia and, 136; renal failure: chronic and, 523 Airway clearance, ineffective: burns: thermal, chemical, electrical and, risk for, 643; COPD and asthma, 118; lung cancer: postoperative care and, 146; pneumonia and, 133; pulmonary tuberculosis (TB) and, 175; seizure disorders and, risk for, 193; ventilatory assistance (mechanical) and, 162 Anxiety: alcohol: acute withdrawal and, 809; benign prostatic hyperplasia and, 564; cancer and, 832; disaster considerations and, 863; hyperthyroidism: Graves’ disease, thyrotoxicosis and, 398; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, 300; lung cancer: postoperative care and, 148; mastectomy and, 592; myocardial infarction and, 83; pediatric considerations and, 894; peritonitis and, 327; psychosocial aspects of care and, 734; renal dialysis and, 535; surgical intervention and, 766; transplantation considerations and, 723; upper gastrointestinal/esophageal bleeding and, 288; ventilatory assistance (mechanical) and, 164 Anxiety, death: end-of-life care/hospice and, 853; mastectomy and, 592 Aspiration, risk for: total nutritional support: parenteral/enteral feeding and, 446 Autonomic dysreflexia, risk for: spinal cord injury (acute rehabilitative phase) and, 265
B Bleeding, risk for: acquired immunodeficiency syndrome (AIDS) and, 697; cirrhosis of the liver and, 422; prostatectomy and, 568; renal failure: chronic and, 524; total joint replacement and, 629; upper gastrointestinal/esophageal bleeding and, 284 Blood glucose level, risk for unstable blood: diabetes mellitus/diabetic ketoacidosis and, 383; pancreatitis and, 433 Body image, disturbed: burns: thermal/chemical/electrical and, 654; cirrhosis of the liver and, 424; eating disorders: anorexia nervosa/bulimia nervosa and, 348; eating disorders: obesity and, 364; fecal diversions: postoperative care of ileostomy and colostomy and, 307; renal dialysis and, 536; urinary diversions/urostomy (postoperative care) and, 552 Body temperature, risk for imbalanced: pediatric considerations and, 883; surgical intervention and, 772 Bowel incontinence: dementia of the Alzheimer’s type/vascular dementia and, 757; spinal cord injury (acute rehabilitative phase) and, 259 Breathing pattern, ineffective: acquired immunodeficiency syndrome (AIDS) and, 696; alcohol: acute withdrawal and, 805; cardiac surgery: postoperative care and, 105; cholecystectomy and, 336; cirrhosis of the liver and, 421; craniocerebral trauma and, risk for, 205; disc surgery and, 241; obesity: bariatric surgery and, 370; peritoneal dialysis and, risk for, 543; pneumothorax/hemothorax and, 153; spinal cord injury (acute rehabilitative phase) and, 252; surgical intervention and, 773; ventilatory assistance (mechanical) and, 159
C Cardiac output, risk for decreased: acute kidney injury (acute renal failure), 512; alcohol: acute withdrawal and, 806; angina: chronic/stable and, 72; acute coronary syndrome (ACS) and, risk for, 65; cardiac surgery: postoperative care and, 102; dysrhythmias and, 92; heart failure: chronic and, 48; hypertension: severe and, 37; hyperthyroidism (Graves’ disease, thyrotoxicosis) and, 394; myocardial infarction and, 80; renal failure: chronic and, 522 Caregiver role strain, risk for: dementia of the Alzheimer’s type/vascular dementia and, 760; end-of-life care/hospice and, 857; multiple sclerosis and, 278 Comfort, impaired: brain infections: meningitis and encephalitis and, 235 Communication, impaired verbal: cerebrovascular accident (CVA)/stroke and, 222; extended/long-term care and, 789; ventilatory assistance (mechanical) and, 163 Confusion, acute: acquired immunodeficiency syndrome (AIDS) and, 703; cirrhosis of the liver and, risk for, 423; renal dialysis and, risk for, 534; renal failure: chronic and risk for, 525 Confusion, chronic: craniocerebral trauma and, risk for, 208; dementia of the Alzheimer’s type/vascular dementia and, 749 Constipation: anemias—iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic and, 466; cancer and, 844; disc surgery and, 243; fecal diversions: postoperative care of ileostomy and colostomy and, 311; spinal cord injury (acute rehabilitative phase) and, 259 Constipation, risk for: hysterectomy and, 583; extended/long-term care and, 795; fecal diversions: postoperative care of ileostomy and colostomy and, 311; renal dialysis and, 534; total joint replacement and, 632 Coping, ineffective: cerebrovascular accident/stroke and, 225; diabetes mellitus/diabetic ketoacidosis and, 387; hypertension: severe and, 41; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, 301; multiple sclerosis and, risk for, 275; psychosocial aspects of care and, 731; substance use disorders and, 818 Coping, ineffective community: disaster considerations and, 867 Coping, readiness for enhanced community: disaster considerations and, 867 Coping, compromised family: dementia of the Alzheimer’s type/vascular dementia and, 758; end-of-life care/hospice and, 855; extended/long-term care and, 787; psychosocial aspects of care and, risk for, 733; transplantation considerations—postoperative and lifelong and, 725 Coping, readiness for enhanced family: psychosocial aspects of care and, risk for, 734 Coping, risk for disabled family: multiple sclerosis and, 276
D Death anxiety: acquired immunodeficiency syndrome (AIDS) and, 705 Decisional conflict: psychosocial aspects of care and, 732 Denial, ineffective: substance use disorders and, 817 Development, risk for delayed: pediatric considerations and, 878
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E Electrolyte imbalance, risk for: hypercalcemia (calcium excess) and, 909; hyperkalemia (potassium excess) and, 903; hypermagnesemia (magnesium excess) and, 915; hypernatremia (sodium excess) and, 897; hypocalcemia (calcium deficit) and, 906; hypokalemia (potassium deficit) and, 900; hypomagnesemia (magnesium deficit) and, 912; hyponatremia (sodium deficit) and, 893 Environmental interpretation syndrome, impaired: dementia of the Alzheimer's type/vascular dementia and, 748
F Family processes, dysfunctional: substance use disorders and, 823 Family processes, interrupted: cancer and, risk for, 846; craniocerebral trauma (acute rehabilitative phase) and, 212; pediatric consideration and, 882 Fatigue: acquired immunodeficiency syndrome (AIDS) and, 492; adult leukemias and, 703; diabetes mellitus/diabetic ketoacidosis and, 387; hepatitis and, 406; HIV-positive client and, 681; hyperthyroidism (Graves’ disease, thyrotoxicosis) and, 396; multiple sclerosis and, 270; total nutritional support: parenteral/enteral feeding and, 448 Fear: cancer and, 832; pediatric considerations, 876; surgical intervention and, 766 Fluid volume, deficient: diabetes mellitus/diabetic ketoacidosis and, 381; hypovolemia and, 891; peritonitis and, 325 Fluid volume, excess: acute kidney injury (acute renal failure) and, 510; cirrhosis of the liver and, 417; heart failure: chronic and, 51; hemodialysis and, risk for, 547; hypervolemia and, 886; peritoneal dialysis and, risk for, 540; renal failure: acute and, 510 Fluid volume, risk for deficient: acute kidney injury (acute renal failure) and, 515; adult leukemias and, 490; acquired immunodeficiency syndrome (AIDS) and, 695; appendectomy and, 318; benign prostatic hyperplasia and, 563; burns: thermal, chemical, electrical and, 644; cancer, 839; cholecystectomy and, 337; cholecystitis with cholelithiasis and, 333; eating disorders: anorexia nervosa/bulimia nervosa and, 347; fecal diversions: postoperative care of ileostomy and colostomy and, 309; hemodialysis and, 546; hepatitis and, 408; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, 298; obesity: bariatric surgery and, 372; pancreatitis and, 431; peritoneal dialysis and, 541; peritonitis and, 325; pneumonia and, 138; sepsis/septicemia and, 673; sickle cell crisis and, 479; surgical intervention and, 775; total nutritional support: parenteral/enteral feeding and, 447; urolithiasis (renal calculi) and, 579 Fluid volume, risk for imbalanced: pediatric considerations and, 881
G Gas exchange, impaired: COPD and asthma and, 124; fractures and, risk for, 609; heart failure: chronic and, risk for, 53; lung cancer: postoperative care and, 145; lymphomas and, risk for, 499; pancreatitis and, 435; pneumonia and, 134; pulmonary tuberculosis and, risk for, 176; respiratory acidosis (primary carbonic acid excess) and, 182; respiratory alkalosis (primary carbonic acid deficit) and, 186; sepsis/septicemia and, risk for, 675; sickle cell crisis and, 475; thrombophlebitis: venous thromboembolism and, 115 Glucose level, risk for unstable blood: diabetes mellitus/diabetic ketoacidosis and, 383; pancreatitis and, 433 Grieving: amputation and, 623; cancer and, 833; dementia of the Alzheimer’s type/vascular dementia and, 753; end-of-life care/hospice and, 853; extended/ long-term care and, 781; hysterectomy and, risk for, 586; psychosocial aspects of care and, 738; spinal cord injury (acute rehabilitative phase) and, 257 Growth and development, delayed: pediatric considerations and, risk for, 878
H Health behavior, risk-prone: HIV-positive client and, 679 Health maintenance, ineffective: dementia of the Alzheimer’s type/vascular dementia and, 760; extended/long-term care and, 799; pediatric considerations and, risk for, 884 Home maintenance, risk for impaired: rheumatoid arthritis and, 717 Hyperthermia: sepsis/septicemia and, 671
I Incontinence, bowel: spinal cord injury (acute rehabilitative phase) and, 259 Infection, risk for: acute kidney injury (acute renal failure) and, 514; adult leukemias and, 488; amputation and, 620; anemias—iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic and, 467; appendectomy and, 318; brain infections: meningitis and encephalitis and, 233; burns: thermal, chemical, and electrical—acute and convalescent phases and, 638; cirrhosis of the liver and, 419; craniocerebral trauma (acute rehabilitative phase) and, 210; diabetes mellitus/diabetic ketoacidosis and, 385; fractures and, 613; hepatitis and, 409; obesity: bariatric surgery and, 374; pancreatitis and, 434; peritoneal dialysis and, 543; peritonitis and, 324; pneumonia and, 135; prostatectomy and, 569; pulmonary tuberculosis and, 173; renal failure: acute and, 514; sickle cell crisis and, 481; total nutritional support: parenteral/enteral feeding and, 444; transplantation considerations—postoperative and lifelong and, 723; urinary diversions/urostomy (postoperative care) and, 554; ventilatory assistance (mechanical) and, 166 Injury, risk for: alcohol: acute withdrawal and, 807; disaster considerations and, risk for, 860; disc surgery and, 240; fractures and, 605; hemodialysis and, 545; pediatric considerations and, 880; spinal cord injury (acute rehabilitative phase) and, 253; surgical intervention and, 769; total nutritional support: parenteral/enteral feeding and, 445 Insomnia: fecal diversions: postoperative care of ileostomy and colostomy and, 311 Intracranial adaptive capacity, risk for decreased: brain infections: meningitis and encephalitis and, 234
K Knowledge, deficient: acute kidney injury (acute renal failure) and, 516; adult leukemias and, 493; amputation and, 624; anemias–iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic and, 468; acute coronary syndrome and, 66; appendectomy and, 320; benign prostatic hyperplasia and, 564; brain infections: meningitis and encephalitis and, 236; burns: thermal/chemical/electric and, 655; cancer and, 847; cardiac surgery: postoperative care and, 107; cerebrovascular accident (CVA)/stroke and, 228; cholecystectomy and, 339; cholecystitis with cholelithiasis and, 334; craniocerebral trauma (acute rehabilitative phase) and, 213; disc surgery and, 244; fecal diversions: postoperative care of ileostomy and colostomy and, 314; fractures and, 614; hepatitis and, 411; HIV-positive client and, 683; hyperthyroidism (Graves’ disease, thyrotoxicosis) and, 399; hysterectomy and, 587; lymphomas and, 502; lung cancer: postoperative care and, 149; mastectomy and, 597; myocardial infarction and, 85; obesity: bariatric surgery and, 376; peritonitis and, 328; pneumonia and, 139; pneumothorax/hemothorax and, 156; prostatectomy and, 571; renal failure: acute and, 516; sepsis/septicemia and, 676; spinal cord injury (acute rehabilitative phase) and, 263; substance use disorder and, 826; surgical intervention and, 765, 780; total nutritional support: parenteral/enteral feeding
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Diarrhea: anemias—iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic and, 466; cancer and, risk for, 844; extended/long-term care and, risk for, 795; fecal diversions: postoperative care of ileostomy and colostomy and, risk for, 311; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, 291; obesity: bariatric surgery and, 375 Diversional activity, deficient: extended/long-term care and, 798 Dry eye, risk for: hyperthyroidism (Graves’ disease, thyrotoxicosis) and, 399
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and, 449; thrombophlebitis: venous thromboembolism and, 116; total joint replacement and, 633; transplantation considerations—postoperative and lifelong and, 726; upper gastrointestinal/esophageal bleeding and, 290; urinary diversions/urostomy (postoperative care) and, 557; urolithiasis (renal calculi) and, 579; ventilatory assistance (mechanical) and, 169
L Lifestyle, sedentary: eating disorders: obesity and, 363 Liver function, risk for impaired: hepatitis and, 404
M Memory, impaired: extended/long-term care and, 785 Mobility, impaired physical: amputation and, 621; burns: thermal, chemical, electric and, 651; cerebrovascular accident (CVA)/stroke and, 220; craniocerebral trauma (acute rehabilitative phase) and, 209; disc surgery and, 243; extended/long-term care and, 796; fractures and, 610; mastectomy and, 596; rheumatoid arthritis and, 715; sickle cell crisis and, 480; spinal cord injury (acute rehabilitative phase) and, 254; total joint replacement and, 631
N Nausea: lymphomas and, 500 Neglect, unilateral: cerebrovascular accident (CVA)/stroke and, 227 Nutrition: less than body requirements, imbalanced: acute kidney injury (acute renal failure) and, 513; acquired immunodeficiency syndrome (AIDS) and, 698; anemias—iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic and, 465; burns: thermal, chemical, electric and, 650; cancer and, 837; cholecystitis with cholelithiasis and, risk for, 333; cirrhosis of the liver and, 416; COPD and asthma and, 126; craniocerebral trauma (acute rehabilitative phase) and, risk for, 211; dementia of the Alzheimer’s type/vascular dementia and, risk for, 756; eating disorders: anorexia nervosa/bulimia nervosa, 345; eating disorders: obesity and, 361; extended/long-term care and, 790; fecal diversions: postoperative care of ileostomy and colostomy and, risk for, 310; hepatitis and, 406; HIV-positive client and, 682; hyperthyroidism (Graves’ disease, thyrotoxicosis) and, risk for, 397; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, risk for, 298; obesity: bariatric surgery and, risk for, 372; pancreatitis and, 433; pediatric considerations and, risk for, 879; peritonitis and, risk for, 327; pneumonia and, risk for, 137; pulmonary tuberculosis and, 176; renal dialysis and, 531; renal failure: acute and, risk for, 513; substance use disorders and, 821; total nutritional support: parenteral/enteral feeding and, 437; ventilatory assistance (mechanical) and, 165; wound care: complicated or chronic and, 663 Nutrition: more than body requirements, imbalanced: dementia of the Alzheimer’s type/vascular dementia and, risk for, 756; extended/long-term care and, 781; hypertension: severe and, 40
O Oral mucous membrane, impaired: acquired immunodeficiency syndrome (AIDS) and, 702; cancer and, risk for, 842; renal failure: chronic and, risk for, 526; ventilatory assistance (mechanical) and, 165
P Pain, acute: acute coronary syndrome (ACS) and, 62; adult leukemias and, 491; acquired immunodeficiency syndrome (AIDS) and, 700; amputation and, 618; angina: chronic/stable and, risk for, 70; appendectomy and, 319; benign prostatic hyperplasia and, 563; burns: thermal, chemical, electrical and, 646; cancer and, 835; cardiac surgery: postoperative care and, 104; cholecystitis with cholelithiasis and, 332; disc surgery and, 242; end-of-life care/hospice and, 851; fecal diversions: postoperative care of ileostomy and colostomy and, 308; fractures and, 606; hypertension: severe and, 39; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, 301; lung cancer: postoperative care and, 147; mastectomy and, 594; myocardial infarction and, 79; pancreatitis and, 430; peritoneal dialysis and, 542; pediatric considerations and, 875; peritonitis and, 326; pneumonia and, 137; prostatectomy and, 569; rheumatoid arthritis and, 713; sickle cell crisis and, 476; spinal cord injury (acute rehabilitative phase) and, 256; surgical intervention and, 776; total joint replacement and, 627; thrombophlebitis: venous thromboembolism and, 114; upper gastrointestinal/esophageal bleeding and, 289; urinary diversions/urostomy (postoperative care) and, 553; urolithiasis (renal calculi) and, 576; wound care: complicated or chronic, 661 Pain, chronic: acquired immunodeficiency syndrome (AIDS) and, 700; cancer and, 835; end-of-life care/hospice and, 851; heart failure: chronic and, risk for, 53; pediatric considerations and, 875; rheumatoid arthritis and, 713; sickle cell crisis and, 476; wound care: complicated or chronic and, 661 Parenting, impaired: eating disorders: anorexia nervosa/bulimia nervosa and, 350 Perioperative positioning injury, risk for: surgical intervention and, 768 Peripheral neurovascular dysfunction, risk for: burns: thermal, chemical, and electrical and, 649; disc surgery and, 239; fractures and, 607; total joint replacement and, 630 Poisoning, risk for: dysrhythmias (digoxin toxicity) and, 95; extended/long-term care and, 788 Post-trauma syndrome, risk for: burns: thermal, chemical, and electrical and, 653; disaster considerations and, 866 Powerlessness: acquired immunodeficiency syndrome (AIDS) and, 707; multiple sclerosis and, 274; substance use disorders and, 820
R Religiosity, risk for impaired: psychosocial aspects of care and, 739 Relocation stress syndrome, risk for: dementia of the Alzheimer’s type/vascular dementia and, 761; extended/long-term care and, 783 Role performance, ineffective: rheumatoid arthritis and, 716
S Self-care deficit: cerebrovascular accident (CVA)/stroke and, 224; dementia of the Alzheimer’s type/vascular dementia and, 755; extended/long-term care and, 792; multiple sclerosis and, 272; renal dialysis and, 533; rheumatoid arthritis and, 716 Self-care, readiness for enhanced: fractures and, 615 Self-esteem, chronic low: eating disorders: anorexia nervosa/bulimia nervosa and, 349; seizure disorders and, 194; substance use disorder and, 822 Self-esteem, situational low: cancer and, 834; hepatitis and, 409; mastectomy and, 595; multiple sclerosis and, 273; psychosocial aspects of care and, 736; seizure disorders and, 194; spinal cord injury (acute rehabilitative phase) and, 258 Self-health management, ineffective: acquired immunodeficiency syndrome (AIDS) and, 708; angina: chronic/stable and, 73; cirrhosis of the liver, 425; dysrhythmias and, 96; COPD and asthma and, 126; diabetes mellitus/diabetic ketoacidosis and, 388; eating disorders: anorexia nervosa/bulimia nervosa and, 352; eating disorders: obesity and, 366; heart failure: chronic and, 55; HIV-positive client and, 687; hypertension: severe and, 41; inflammatory bowel disease: ulcerative colitis, Crohn’s disease and, 303; multiple sclerosis and, 279; pancreatitis and, 436; psychosocial aspects of care and, 740; pulmonary tuberculosis and, risk for, 177; renal dialysis and, risk for, 537; renal failure: chronic and, 527; rheumatoid arthritis and, 718; seizure disorders and, 195; sickle cell crisis and, 481; wound care: complicated or chronic and, 663
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T Tissue integrity, impaired: cancer and, risk for, 843; cardiac surgery: postoperative care and, 106; cholecystectomy and, 338; fecal diversions: postoperative care of ileostomy and colostomy and, 309; fractures and, risk for, 611; hepatitis and, risk for, 410; mastectomy and, 593; spinal cord injury (acute rehabilitative phase) and, risk for, 262; surgical intervention and, 778; wound care: complicated or chronic and, 659 Tissue perfusion, ineffective cerebral: cerebrovascular accident (CVA)/stroke and, 218; craniocerebral trauma (acute rehabilitative phase) and, risk for, 202 Tissue perfusion, ineffective peripheral: amputation and, risk for, 619; thrombophlebitis: venous thromboembolism and, 112 Tissue perfusion, risk for decreased cardiac: acute coronary syndrome (ACS) and, 64 Tissue perfusion, risk for ineffective: hysterectomy and, 584; myocardial infarction and, 84; obesity: bariatric surgery and, 371; sickle cell crisis and, 477; surgical intervention and, 779 Trauma, risk for: peritoneal dialysis and, 541; seizure disorders and, 192
U Unilateral neglect: cerebrovascular accident (CVA)/stroke and, 227 Urinary elimination, impaired: dementia of the Alzheimer’s type/vascular dementia and, 757; extended/long-term care and, risk for, 794; multiple sclerosis and, 277; prostatectomy and, 567; spinal cord injury (acute rehabilitative phase) and, 260; urinary diversions/urostomy (postoperative care) and, 555; urolithiasis (renal calculi) and, 577 Urinary retention: benign prostatic hyperplasia and, 561; disc surgery and, risk for, 244; hysterectomy and, risk for (acute), 583
V Ventilation, impaired spontaneous: ventilatory assistance (mechanical) and, 159 Ventilatory weaning response, dysfunctional: ventilatory assistance (mechanical) and, risk for, 168 Violence, risk for other-directed: psychosocial aspects of care and, 741 Violence, risk for self-directed: psychosocial aspects of care and, 741
VQMPBEFECZ
951
INDEX OF NURSING DIAGNOSES
Sensory perception, disturbed: alcohol: acute withdrawal and, 808; cerebrovascular accident (CVA)/stroke and, 223; craniocerebral trauma (acute rehabilitative phase) and, 206; dementia of the Alzheimer’s type/vascular dementia and, 752; diabetes mellitus/diabetic ketoacidosis and, risk for, 386; spinal cord injury (acute rehabilitative phase) and, 255; surgical intervention and, 774 Sexual dysfunction: cancer and, risk for, 845; dementia of the Alzheimer’s type/vascular dementia and, risk for, 758; extended/long-term care and, risk for, 386; fecal diversions: postoperative care of ileostomy and colostomy and, risk for, 312; hysterectomy and, risk for, 585; lymphomas and, 501; prostatectomy and, risk for, 570; substance use disorders and, 825; urinary diversions/urostomy (postoperative care) and, risk for, 556 Shock, risk for: sepsis/septicemia and, 671; upper gastrointestinal/esophageal bleeding and, 287 Skin integrity, impaired: acquired immunodeficiency syndrome (AIDS) and, 701; burns: thermal, chemical, electrical and, 652; cardiac surgery: postoperative care and, 106; cholecystectomy and, 338; fecal diversions: postoperative care of ileostomy and colostomy and, 309; obesity: bariatric surgery and, 373 Skin integrity, risk for impaired: cancer and, 843; cirrhosis of the liver and, 420; heart failure: chronic and, 54; eating disorders: anorexia nervosa/bulimia nervosa and, 351; extended/long-term care and, 793; fecal diversions: postoperative care of ileostomy and colostomy and, 306; renal dialysis and, 533; renal failure: chronic and, 526; sickle cell crisis and, 480; spinal cord injury (acute rehabilitative phase) and, 262; urinary diversions/urostomy (postoperative care) and, 550 Sleep deprivation: dementia of the Alzheimer’s type/vascular dementia and, 754 Sleep pattern, disturbed: extended/long-term care and, 790 Social interaction, impaired: eating disorders: obesity and, 365 Social isolation: acquired immunodeficiency syndrome (AIDS) and, 706; HIV-positive client and, risk for, 686 Spiritual distress: disaster considerations and, 865; end-of-life care/hospice and, risk for, 856 Suffocation, risk for: pneumothorax/hemothorax and, 156; seizure disorders and, 192 Swallowing, impaired: cerebrovascular accident (CVA)/stroke and, risk for, 226
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GORDON’S FUNCTIONAL HEALTH PATTERNS Modified by Marjory Gordon, 2012, with permission. HEALTH PERCEPTION–HEALTH MANAGEMENT PATTERN • Contamination • Deficient community health • Disturbed energy field • Ineffective family therapeutic regimen management • Ineffective health maintenance • Ineffective protection • Ineffective self-health management • Noncompliance (specify area) • Readiness for enhanced immunization status • Readiness for enhanced self-health management • Risk for contamination • Risk for bleeding • Risk for falls • Risk for infection • Risk for injury • Risk for perioperative positioning injury • Risk for poisoning • Risk for suffocation • Risk for thermal injury • Risk for trauma • Risk for vascular trauma • Risk-prone health behavior NUTRITIONAL–METABOLIC PATTERN • Adult failure to thrive • [Deficient fluid volume: hyper/hypotonic] • Deficient fluid volume [isotonic] • Excess fluid volume • Hyperthermia • Hypothermia • Imbalanced nutrition: less than body requirements • Imbalanced nutrition: more than body requirements • Imbalanced nutrition: risk for more than body requirements • Impaired dentition • Impaired oral mucous membrane • Impaired skin integrity • Impaired swallowing • Impaired tissue integrity • Ineffective breastfeeding • Ineffective infant feeding pattern • Ineffective thermoregulation • Interrupted breastfeeding • Insufficient breast milk • Latex allergy response • Nausea • Neonatal jaundice • Readiness for enhanced breastfeeding • Readiness for enhanced fluid balance • Readiness for enhanced nutrition • Risk for adverse reaction to iodinated contrast media • Risk for allergy response • Risk for aspiration • Risk for deficient fluid volume • Risk for dry eye • Risk for electrolyte imbalance • Risk for imbalanced fluid volume • Risk for imbalanced body temperature • Risk for impaired liver function • Risk for impaired skin integrity • Risk for latex allergy response • Risk for neonatal jaundice • Risk for unstable blood glucose level ELIMINATION PATTERN • Bowel incontinence • Constipation • Diarrhea • Dysfunctional gastrointestinal motility • Functional urinary incontinence • Impaired urinary elimination • Overflow urinary incontinence • Perceived constipation • Readiness for enhanced urinary elimination • Reflex urinary incontinence • Risk for constipation • Risk for dysfunctional gastrointestinal motility • Risk for urge urinary incontinence
• Stress urinary incontinence • Urge urinary incontinence • Urinary retention [acute/chronic] ACTIVITY–EXERCISE PATTERN • Activity intolerance • Autonomic dysreflexia • Decreased cardiac output • Decreased intracranial adaptive capacity • Deficient diversional activity • Delayed growth and development • Delayed surgical recovery • Disorganized infant behavior • Dysfunctional ventilatory weaning response • Fatigue • Impaired spontaneous ventilation • Impaired bed mobility • Impaired gas exchange • Impaired home maintenance • Impaired physical mobility • Impaired transfer ability • Impaired walking • Impaired wheelchair mobility • Ineffective airway clearance • Ineffective breathing pattern • Ineffective peripheral tissue perfusion • Readiness for enhanced organized infant behavior • Readiness for enhanced self-care • Risk for decreased cardiac tissue perfusion • Risk for delayed development • Risk for disorganized infant behavior • Risk for disproportionate growth • Risk for activity intolerance • Risk for autonomic dysreflexia • Risk for disuse syndrome • Risk for ineffective cerebral tissue perfusion • Risk for ineffective gastrointestinal perfusion • Risk for ineffective peripheral tissue perfusion • Risk for ineffective renal perfusion • Risk for peripheral neurovascular dysfunction • Risk for shock • Risk for sudden infant death syndrome • Sedentary lifestyle • Self-care deficit: bathing, dressing, feeding, toileting • Self neglect • Wandering SLEEP–REST PATTERN • Disturbed sleep pattern • Insomnia • Readiness for enhanced sleep • Sleep deprivation COGNITIVE–PERCEPTUAL PATTERN • Acute confusion • Acute pain • Chronic confusion • Chronic pain • Decisional conflict (specify) • Deficient knowledge (specify level) • [Disturbed sensory perceptual] • Impaired comfort • Impaired environmental interpretation syndrome • Impaired memory • Ineffective activity planning • Readiness for enhanced comfort • Readiness for enhanced decision-making • Readiness for enhanced knowledge • Risk for ineffective activity planning • Risk for acute confusion • Unilateral neglect SELF-PERCEPTION–SELF-CONCEPT PATTERN • Anxiety • Chronic low self-esteem • Death anxiety • Disturbed body image • Disturbed personal identity • Fear • Hopelessness
• • • • • • • • • • • • •
Ineffective impulse control Powerlessness Readiness for enhanced hope Readiness for enhanced power Readiness for enhanced self-concept Risk for chronic low self-esteem Risk for compromised human dignity Risk for disturbed personal identity Risk for loneliness Risk for powerlessness Risk for situational low self-esteem Risk for self-directed violence Situational low self-esteem
ROLE–RELATIONSHIP PATTERN • Caregiver role strain • Chronic sorrow • Complicated grieving • Dysfunctional family processes • Grieving • Impaired parenting • Impaired social interaction • Impaired verbal communication • Ineffective relationship • Ineffective role performance • Interrupted family processes • Parental role conflict • Readiness for enhanced communication • Readiness for enhanced family processes • Readiness for enhanced parenting • Readiness for enhanced relationship • Relocation stress syndrome • Risk for caregiver role strain • Risk for complicated grieving • Risk for impaired attachment • Risk for impaired parenting • Risk for ineffective relationship • Risk for other-directed violence • Risk for relocation stress syndrome • Social isolation SEXUALITY–REPRODUCTIVE • Ineffective childbearing process • Ineffective sexuality pattern • Rape-trauma syndrome • Readiness for enhanced childbearing process • Risk for disturbed maternal-fetal dyad • Risk for ineffective childbearing process • Sexual dysfunction COPING–STRESS TOLERANCE PATTERN • Compromised family coping • Defensive coping • Disabled family coping • Impaired individual resilience • Ineffective community coping • Ineffective coping • Ineffective denial • Post-trauma syndrome • Readiness for enhanced community coping • Readiness for enhanced coping • Readiness for enhanced family coping • Readiness for enhanced resilience • Risk for compromised resilience • Risk for self-mutilation • Risk for suicide • Risk for post-trauma syndrome • Self-mutilation • Stress overload VALUE–BELIEF PATTERN • Impaired religiosity • Moral distress • Readiness for enhanced religiosity • Readiness for enhanced spiritual well-being • Risk for impaired religiosity • Risk for spiritual distress • Spiritual distress
