Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span [10 ed.] 0803660863, 9780803660861

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DOENGES MOORHOUSE MURR

Guidelines for Individualizing Client Care Across the Life Span lOTH EDITION

INDEX OF DISEASES/DISORDERS Acid-base imbalances DavisPlus Acquired immunodeficiency syndrome (AIDS), 800 Acute coronary syndrome (ACS), 54 Acute kidney injury (acute renal failure), 595 Adult leukemias, 569 Alcohol: acute withdrawal, 919 Alzheimer’s disease, 851 Amputation, 718 Anemia—iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic, 541 Angina: chronic/stable, 64 Anorexia nervosa, 413 Aplastic anemia, 541 Appendectomy, 382 Asthma, 132 Bariatric surgery, 442 Benign prostatic hyperplasia (BPH), 686 Brain infections: meningitis and encephalitis, 267 Bulimia nervosa, 413 Burns: thermal, chemical, and electrical—acute and convalescent phases, 740 Cancer, general considerations, 945 Cardiac dysrhythmias, 85, 86 Cardiac surgery: postoperative care, 98 Cardiomyoplasty, 46 Cerebrovascular accident/stroke, 247 Chemical burns, 741 Cholecystectomy DavisPlus Cholecystitis with cholelithiasis, 399 Cholelithiasis, 399 Chronic obstructive pulmonary disease (COPD) and asthma, 132 Cirrhosis of the liver, 494 Colostomy, 368 Coronary artery bypass graft (CABG), 98 Craniocerebral trauma—acute rehabilitative phase, 226 Crohn’s disease, 352 Dementia: Alzheimer’s type/vascular dementia/, Lewy body disease, frontotemporal dementia, 851 Deep vein thrombosis (DVT), 120 Diabetes mellitus, 454 Diabetic ketoacidosis, 454 Dialysis: hemodialysis (HD), 641 Dialysis: peritoneal (PD), 635 Disaster considerations, 980 Disc surgery (now called Spinal Surgery), 276 Dysrhythmias, 85, 86

Gastrectomy/gastroplasty (see DavisPlus) Gastric bypass, 442 Glaucoma DavisPlus Graves’ disease, 471 Heart failure: chronic, 38 Hemodialysis, 641 Hemolytic anemia, 541 Hemothorax, 169 Hepatitis, 482 Herniated nucleus pulposus (see DavisPlus) HIV-positive client, 785 Hospice, 970 Hypercalcemia (calcium excess) (see DavisPlus) Hyperkalemia (potassium excess) (see DavisPlus) Hypermagnesemia (magnesium excess) (see DavisPlus) Hypernatremia (sodium excess) (see DavisPlus) Hypertension: severe, 26 Hyperthyroidism (Graves’ disease, thyrotoxicosis, thyroid storm), 471 Hypervolemia (extracellular fluid volume excess) (see DavisPlus) Hypocalcemia (calcium deficit) (see DavisPlus) Hypokalemia (potassium deficit) (see DavisPlus) Hypomagnesemia (magnesium deficit) (see DavisPlus) Hyponatremia (sodium deficit) (see DavisPlus) Hypovolemia (extracellular fluid volume deficit) (see DavisPlus) Hysterectomy, 666 Ileostomy, 368 Inflammatory bowel disease: ulcerative colitis, Crohn’s disease, 352 Iron-deficiency anemia, 541 Laminectomy (see Spinal Surgery), 276 Laryngectomy (see DavisPlus) Lewy body disease, 851 Leukemias, 569 Lung cancer: postoperative care, 159 Lymphomas, 582 Mastectomy, 675 Meningitis, 267 Metabolic acid-base imbalances (see DavisPlus) Metabolic acidosis—primary base bicarbonate deficiency (see DavisPlus) Metabolic alkalosis—primary base bicarbonate excess (see DavisPlus) Minimally invasive direct coronary artery bypass (MIDCAB), 98 Multiple sclerosis, 311 Myocardial infarction, 72 Obesity, 430

Eating disorders: anorexia nervosa/bulimia nervosa, 413 Electrolyte imbalances DavisPlus Electrical burns, 740 Encephalitis, 267 End-stage renal disease, 607 Enteral feeding, 525 Esophageal bleeding, 347 Extended care, 896 Fecal diversions: postoperative care of ileostomy and colostomy, 368 Fluid and electrolyte imbalances, DavisPlus Fractures, 702

Bariatric surgery, 442 Pancreatitis, 511 Parkinson’s disease, 330 Parenteral feeding, 525 Pediatric considerations, 993 Peritoneal dialysis, 635 Peritonitis, 389 Pernicious anemia, 541 Pneumonia, 147 Pneumothorax, 169

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Primary base bicarbonate deficiency (see DavisPlus) Primary base bicarbonate excess (see DavisPlus) Primary carbonic acid deficit (see DavisPlus) Primary carbonic acid excess (see DavisPlus) Prostatectomy, 694 Psychosocial aspects of care, 835 Pulmonary emboli (PE), 120 Pulmonary tuberculosis (TB), 204 Radical neck surgery (see DavisPlus) Renal calculi, 656 Renal dialysis—general considerations, 623 Renal failure: acute, 595 Renal failure: chronic, 607 Respiratory acid-base imbalances (see DavisPlus) Respiratory acidosis (see DavisPlus) Respiratory alkalosis (see DavisPlus) Rheumatoid arthritis (RA), 824 Respiratory failure/ventilatory assistance, 187 Ruptured intervertebral disc (see DavisPlus) Seizure disorders, 216 Sepsis/Septic Shock, 772 Sickle cell crisis, 552 Spinal cord injury (acute rehabilitative phase), 288

Stroke, 247 Substance use disorders (SUDs), 929 Surgical interventions, 873 Thermal burns, 740 Thrombophlebitis: venous thromboembolism, 120 Thyroidectomy (see DavisPlus) Thyrotoxicosis, 471 Total joint replacement, 729 Total nutritional support: parenteral/enteral feeding, 525 Tuberculosis (TB), pulmonary, 204 Ulcerative colitis, 352 Upper gastrointestinal bleeding, 340 Urinary diversions/urostomy (postoperative care) Urinary stones (calculi), 656 Urostomy, 645 Valve replacement, 98 Vascular dementia, 851 Venous thromboembolism (VTE) disease, 120 Ventilatory assistance (mechanical), 187 Wound care: complicated or chronic, 762

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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. The Database contains the information used to identify Nursing Diagnoses for planning client care.

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 value conflict, threat to current status as evidenced by increase in tension, apprehensiveness; voice quivering, self-focused. In addition, diagnoses identified within these guides for planning care as actual, risk, health promotion, or syndrome 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 par ticular 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 is used, the identified risk factors serve as the “evidenced by” segment of the nursing diagnosis statement, and interventions are provided to prevent progression to a problem-focused diagnosis. 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 timelines 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.

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NURSING DIAGNOSES ACCEPTED FOR USE AND RESEARCH FOR 2018–2020 Activity Intolerance [specify level] Activity Intolerance, risk for Activity Planning, ineffective Activity Planning, risk for ineffective Acute Substance Withdrawal Syndrome Acute Substance Withdrawal Syndrome, risk for Adaptive Capacity, decreased intracranial Adverse Reaction to Iodinated Contrast Media, risk for Airway Clearance, ineffective Allergy Reaction, risk for Anxiety Aspiration, risk for Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, disorganized infant Behavior, risk for disorganized infant Behavior, readiness for enhanced organized infant Bleeding, risk for Blood Glucose Level, risk for unstable Blood Pressure, risk for unstable Body Image, disturbed Breast Milk Production, insufficient Breastfeeding, ineffective Breastfeeding, interrupted Breastfeeding, readiness for enhanced Breathing Pattern, ineffective Cardiac Output, decreased Cardiac Output, decreased, risk for Childbearing Process, ineffective Childbearing Process, readiness for enhanced Childbearing Process, risk for ineffective Chronic Pain Syndrome Comfort, impaired Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Confusion, acute Confusion, risk for acute Confusion, chronic Constipation Constipation, chronic functional Constipation, perceived Constipation, risk for Constipation, risk for chronic functional 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 Disuse Syndrome, risk for

Diversional Activity Engagement, deficient Dry Eye, risk for Dry Mouth, risk for Eating Dynamics, ineffective adolescent Eating Dynamics, ineffective child Eating Dynamics, ineffective infant Electrolyte Imbalance, risk for Elimination, impaired urinary Emancipated Decision-Making, impaired Emancipated Decision-Making, readiness for enhanced Emancipated Decision-Making, risk for impaired Emotional Control, labile Energy Field, imbalanced Falls, risk for Family Processes, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Fatigue Fear Feeding Pattern, ineffective infant Female Genital Mutilation, risk for 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 Frail Elderly Syndrome Frail Elderly Syndrome, risk for Gas Exchange, impaired Gastrointestinal Motility, dysfunctional Gastrointestinal Motility, risk for dysfunctional Grieving Grieving, complicated Grieving, risk for complicated [Growth, risk for disproportionate] (retired 2018) Health, deficient community Health Behavior, risk-prone Health Literacy, readiness for enhanced Health Maintenance, ineffective Health Management, ineffective Health Management, ineffective family Health Management, readiness for enhanced Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Human Dignity, risk for compromised Hyperthermia Hyperbilirubinemia, neonatal Hyperbilirubinemia, risk for neonatal Hypothermia Hypothermia, risk for Hypothermia, risk for perioperative Immigration Transition, risk for complicated 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

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Injury, risk for Injury, risk for corneal Injury, risk for urinary tract Insomnia Knowledge, deficient Knowledge, readiness for enhanced Latex Allergy Reaction Latex Allergy Reaction, 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 Mood Regulation, impaired Moral Distress Mucous Membrane Integrity, impaired oral Mucous Membrane Integrity, risk for impaired oral Nausea Neonatal Abstinence Syndrome Neurovascular Dysfunction, risk for peripheral Nutrition: less than body requirements, imbalanced Nutrition, readiness for enhanced Obesity Occupational Injury, risk for Overweight Overweight, risk for Pain, acute Pain, chronic Pain, labor Palliative/end-of-life care—hospice, Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Perioperative Positioning Injury, risk for Personal Identity, disturbed Personal Identity, risk for disturbed Physical Trauma, risk for Poisoning, risk for Post-Trauma Syndrome Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness Powerlessness, risk for Pressure Ulcer, 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 Resilience, impaired Resilience, readiness for enhanced Resilience, risk for impaired Retention, urinary Role Conflict, parental Role Per for mance, ineffective

Role Strain, caregiver Role Strain, risk for caregiver 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-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 Sitting, impaired 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 Standing, impaired Stress Overload Substance Withdrawal Syndrome, acute Substance Withdrawal Syndrome, risk for acute Sudden infant Death, risk for Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Surgical Recovery, risk for delayed Surgical Site Infection, risk for Swallowing, impaired Thermal Injury, risk for Thermoregulation, ineffective Thermoregulation, risk for ineffective Thromboembolism, risk for venous Tissue Integrity, impaired Tissue Integrity, risk for 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 vascular Unilateral Neglect 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, TH, and Kamitsuru, S (eds): Nursing Diagnoses— Defi nitions and Classification 2018–2020. Copyright © 2018, 1994–2018 NANDA International. Used by arrangement with Thieme. 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 10th EDITION

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

Mary 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 Retired Legal Nurse Consultant, certified Rehabilitation Case Manager, and certified practitioner in Critical Care Nursing Parkville, Missouri

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2019 by F. A. Davis Company Copyright © 1984, 1989, 1993, 1997, 2000, 2002, 2006, 2010, 2019 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 other wise, without written permission from the publisher. Printed in the United States of Amer ica Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Jacalyn Sharp Senior Content Project Manager: Amy M. Romano Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The 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 circumstances 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 Names: Doenges, Marilynn E., 1922– author. | Moorhouse, Mary Frances, 1947– author. | Murr, Alice C., 1946– author. Title: Nursing care plans : guidelines for individualizing client care across the life span / Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr. Description: Edition 10. | Philadelphia : F.A. Davis Company, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018041708 (print) | LCCN 2018042523 (ebook) | ISBN 9780803694958 | ISBN 9780803660861 (pbk. : alk. paper) Subjects: | MESH: Patient Care Planning | Nursing Process | Handbooks Classification: LCC RT49 (ebook) | LCC RT49 (print) | NLM WY 49 | DDC 610.73—dc23 LC record available at https://lccn.loc.gov/2018041708 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 Ser vice, 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 Ser vice is: 978-0-8036-6086-1/19 0 + $.25.

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To our families, friends, and colleagues, 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 (MED). The Moorhouse family: the late and ever present Jan; Paul Moorhouse and Jessica Kantorski; Jason and Thenderlyn Moorhouse; Alexa, Tanner, and Quinton Plant; and Mary Isabella Moorhouse and Richard Ortiz Vega (MFM). To the memory of my long-time dear friend Peggy French, who lost her battle with heart failure last year. I miss her laughter and jokes that carried me through many a day in my “writing cave” over the last 32 years (ACM). To our F. A. Davis family, especially Robert Allen whose support is so vital to the completion of a project of this magnitude. We are happy to welcome Jacalyn Sharp, who is the Acquisitions Editor for this project. And last but not least, Amy Romano, 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 10TH EDITION Lisa L. Doremus, MSN, RN, CMSRN Hospice Nurse Abode Hospice & Home Health Adjunct Faculty Pikes Peak Community College Colorado Springs, Colorado Linda R. Renberg, BA Instructor, Retired English, Music and Education Mitchell, South Dakota Statistical Research

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CONTRIBUTORS TO PREVIOUS EDITIONS Mope T. Adeola, RN, MSN, CNS, OCN

Julie Matheny, RRT

Jane V. Arndt, MS, RN, CWOCN

Laure Miller, MSN, RN

Sharon A. Aronovitch, PhD, RN, ACNS-BC, CWOCN-AP

Kathleen Molden, RN, MSN, CNE

Cathryn Baack, PhD, RN, CPNP

Ellen Odell, DNP, ACNS, CNE, RN

Nancy Buttry, MSN, RN

Lillian Ostrander, RN, MSN, MALS

Kathleen A. Curtis, RN, MSN

Kimberly Tucker Pfennigs, MA, BAN, RN

Rosemary Fliszar, PhD, RN, CNE

Nancy E. Rogers, MA, BSN, RN

Catherine M. Gagnon, RNC-OB, MSN

Gilda Rolls-Dellinger, RN

Brenda Hicks, RN, OCN

Rochelle Salmore, MSN, RN, CGRN, NE, BC

Christie A. Hinds, MSN, APRN-BC

April Sheker, RN, MSN(c), CMSRN

Jennifer Limongiello, MSN, ARNP

Geri L. Tierney, RN, BSN, ONC

William H. Loughmiller, CRT

Kathleen H. Winder, RN, BSN

Maria Mackey, MSN, RN

Ruth A. Wittmann-Price, PhD, RN, CNS, CNE

Margaret (Peggy) Malone, MN, RN, CCRN

David W. Woodruff, MSN, RN-BC, CMSRN, CEN

Larry Manalo, RN, MSN

Anne Zobec, MS, RN, CS, NP, AOCN

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REVIEWERS FOR THE 10TH EDITION Catherine D. Hall, MSN, RN, OCN, CNE Assistant Professor Albany State University Albany, Georgia

Tammie McCoy, PhD, RN Professor and Chair, BSN Department Mississippi University for Women Columbus, Mississippi

Norma Katz, MS, PMHNP, BC, RN Assistant Professor Westchester Community College Valhalla, New York

Roxann Sparks, RN, MSN, MICN, LNC, ENPC Assistant Director, Vocational Nursing Merced College Merced, California

Laurel Lalicker, MSN, RN, CNN, CNE Professor Aims Community College Greeley, Colorado

Annette Stacy Emeritus Associate Professor of Nursing Arkansas State University Jonesboro, Arkansas

Margaret Mackowick, MR, RN Assistant Professor North Dakota State University Fargo, North Dakota

Heather Vitko, RN, MSN, CCRN, CNL Assistant Professor Saint Francis University Loretto, Pennsylvania

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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

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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 the original 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 NANDAI, 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 a 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-to-date 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 payer 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.

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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 14, and Pediatric Pearls have been added to 14 plans of care common to this population. The Pediatric Pearls are noted by this icon . Finally, 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.” MED, MFM, and ACM

INTRODUCTION

The practicing nurse, as well as the nursing student, can welcome this text as a ready reference in clinical practice. It is designed for use in the acute care, community, and homecare settings. It is organized by systems for easy reference. Chapter 1 reviews the 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 two other standardized nursing languages—Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC). A nursing-based assessment tool and NANDA-I diagnosis labels organized in Diagnostic Divisions are provided to assist the nurse in employing critical thinking and identifying appropriate nursing diagnoses. A sample client situation with an individual database and a corresponding plan of care is included to further demonstrate how critical thinking is used to adapt nursing process theory to practice. Finally, several creative approaches for developing and documenting the planning of care are also included. Mind mapping is one 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  2 through 14 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 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/or the signs and symptoms or defining characteristics as “possibly evidenced by,” to create Client Diagnostic

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CONTENTS IN BRIEF INDEX OF NURSING DIAGNOSES APPEARS ON PAGE v INTRODUCTION xiv CHAPTER 1 The Nursing Process: Planning Care Using Critical Thinking 1 CHAPTER 2 Cardiovascular Disorders 26 Hypertension: Severe 26 Heart Failure: Chronic 38 Acute Coronary Syndromes (ACS) 54 Angina: Chronic/Stable 64 Myocardial Infarction 72 Dysrhythmias 85 Cardiac Surgery: Coronary Artery Bypass Graft (CABG) and Valve Replacement: Postoperative Care 98 Aortic Aneurysms (Abdominal and Thoracic) 110 Venous Thromboembolism (VTE) Disease Including Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) 120

CHAPTER 3 Respiratory Disorders 132 Chronic Obstructive Pulmonary Disease (COPD) and Asthma 132 Pneumonia 147 Lung Cancer: Postoperative Care 159 Pneumothorax/Hemothorax 169 Acute Lung Injury/Acute Respiratory Distress Syndrome 177 Respiratory Failure/Ventilatory Assistance 187 Pulmonary Tuberculosis (TB) 204

CHAPTER 4 Neurological/Sensory Disorders 216 Seizure Disorders 216 Craniocerebral Trauma—(Acute Care Phase) 226 Cerebrovascular Accident (CVA/Stroke) 247 Brain Infections: Meningitis and Encephalitis 267 Spinal Surgery 276 Spinal Cord Injury (Acute and Rehabilitative Phases) 288 Multiple Sclerosis (MS) 311 Parkinson’s Disease (PD) 330 Glaucoma (see DavisPlus) Herniated Nucleus Pulposus (Ruptured Intervertebral Disc) (see DavisPlus)

CHAPTER 5 Gastrointestinal Disorders 340 Upper Gastrointestinal Bleeding 340 Inflammatory Bowel Disease (IBD): Ulcerative Colitis, Crohn’s Disease 352 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 368 Appendectomy 382 Peritonitis 389 Cholecystitis with Cholelithiasis 399 Cholecystectomy (see DavisPlus) 407 Gastrectomy/Gastric Resection (see DavisPlus)

CHAPTER 6 Metabolic and Endocrine Disorders 413 Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 413 Obesity 430 Bariatric Surgery 442

Diabetes Mellitus and Diabetic Ketoacidosis 454 Hyperthyroidism, Thyrotoxicosis, and Thyroid Storm 471 Hepatitis 482 Cirrhosis of the Liver 494 Pancreatitis 511 Total Nutritional Support: Parenteral/Enteral Feeding 525 Metabolic Acid-Base Imbalances (see DavisPlus) Metabolic Acidosis: Primary Base Bicarbonate Deficiency Metabolic Alkalosis: Primary Base Bicarbonate Excess Thyroidectomy (see DavisPlus)

CHAPTER 7 Diseases of the Blood/Blood-Forming Organs 541 Anemias: Iron Deficiency, Anemia of Chronic Disease, Pernicious, Aplastic, Hemolytic 541 Sickle Cell Crisis 552 Adult Leukemias 569 Adult Lymphomas 582

CHAPTER 8 Renal and Urinary Tract Disorders 595 Acute Kidney Injury (Acute Renal Failure) 595 Renal Failure: Chronic Kidney Disease and End-Stage Renal Disease 607 Renal Dialysis: General Considerations 623 Peritoneal Dialysis (PD) 635 Hemodialysis (HD) 641 Urinary Diversions: Urostomy (Postoperative Care) 645 Urinary Stones (Calculi) 656

CHAPTER 9 Women’s Health 666 Hysterectomy 666 Mastectomy 675

CHAPTER 10 Men’s Health 686 Benign Prostatic Hyperplasia (BPH) 686 Prostatectomy 694

CHAPTER 11 Orthopedic Disorders 702 Fractures 702 Amputation 718 Total Joint Replacement 729

CHAPTER 12 Integumentary Disorders 740 Burns: Thermal, Chemical, and Electrical (Acute and Convalescent Phases) 740 Wound Care: Complicated or Chronic 762

CHAPTER 13 Systemic Infections and Immunological Disorders 772 Sepsis/Septic Shock 772 The HIV-Positive Client 785 Acquired Immunodeficiency Syndrome (AIDS) 800 Rheumatoid Arthritis (RA) 824

CHAPTER 14 General 835 Psychosocial Aspects of Care 835 Dementias: Alzheimer’s Type/Vascular Dementia/Lewy Body Disease/ Frontotemporal Dementia 851

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CONTENTS IN BRIEF

Surgical Interventions 873 Extended/Long-Term Care 896 Alcohol: Acute Withdrawal 919 Substance Use Disorders (SUDs) 929 Cancer: General Considerations 945 Palliative/End-of-Life Care—Hospice 970 Disaster Considerations 980

Pediatric Considerations 993 Fluid and Electrolyte Imbalances (See DavisPlus) Definitions for NANDA-I Nursing Diagnoses Used in This Text 1009 Index of Nursing Diagnoses 1013

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DETAILED CONTENTS INDEX OF NURSING DIAGNOSES APPEARS ON PAGE v INTRODUCTION xiv CHAPTER 1 The Nursing Process: Planning Care Using Critical Thinking 1 Defining Nursing 1 Critical Thinking 1 Where Does Nursing Diagnosis Fit? 1 How the Nursing Process Works with Nursing Diagnosis 2 The Plan of Care 11 Doing It 11 Step 1: Assessment 11 Step 2: Diagnosis 11 Step 3: Planning 11 Step 4: Implementation 17 Step 5: Evaluation and Documentation of Plans of Care 18

CHAPTER 2 Cardiovascular Disorders 26 Hypertension: Severe 26 Cardiac Output, risk for decreased 30 Activity Intolerance 32 Pain, acute 32 Overweight 33 Coping, ineffective 33 Health Management, ineffective 35 Heart Failure: Chronic 38 Cardiac Output, decreased 43 Activity Intolerance 46 Fluid Volume, excess 47 Gas Exchange, risk for impaired 49 Pain, risk for chronic 50 Skin Integrity, risk for impaired 50 Health Management, ineffective 51 Acute Coronary Syndrome (ACS) 54 Pain, acute 58 Tissue Perfusion, risk for decreased cardiac 60 Cardiac Output, risk for decreased 61 Knowledge, deficient 63 Angina: Chronic/Stable 64 Pain, risk for acute 67 Cardiac Output, risk for decreased 69 Health Management, ineffective 70 Myocardial Infarction 72 Pain, acute 77 risk for decreased cardiac Tissue Perfusion 78 Cardiac Output, risk for decreased 79 Activity Intolerance 82 Anxiety [moderate/severe] 82 Knowledge, deficient 83 Dysrhythmias 85 Cardiac Output, risk for decreased 90 Poisoning, risk for [Digoxin Toxicity] 94 Health Management, ineffective 96 Cardiac Surgery: Coronary Artery Bypass Graft (CABG) and Valve Replacement: Postoperative Care 98 Cardiac Output, risk for decreased 102 Pain, acute 104 Breathing Pattern, risk for ineffective 106

Skin/Tissue Integrity, impaired 107 Knowledge, deficient 108

Aortic Aneurysms: (Abdominal and Thoracic) 110 Venous Thromboembolism (VTE) Disease Including Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) 120 Tissue Perfusion, ineffective peripheral 125 Pain, acute 127 Gas Exchange, impaired (in presence of pulmonary embolus) 128 Knowledge, deficient 130

CHAPTER 3 Respiratory Disorders 132 Chronic Obstructive Pulmonary Disease (COPD) and Asthma 132 Airway Clearance, ineffective 137 Gas Exchange, impaired 140 Nutrition: less than body requirements, imbalanced 142 Health Management, ineffective 143 Pneumonia 147 Airway Clearance, ineffective 151 Gas Exchange, impaired 153 Infection, risk for [spread] 154 Activity Intolerance 155 Pain, acute 156 Fluid Volume, risk for deficient 157 Knowledge, deficient 158 Lung Cancer: Postoperative Care 159 Gas Exchange, impaired 163 Airway Clearance, ineffective 165 Pain, acute 166 Anxiety [specify level] 167 Knowledge, deficient 167 Pneumothorax/Hemothorax 169 Breathing Pattern, ineffective 173 Knowledge, deficient 177 Acute Lung Injury/Acute Respiratory Distress Syndrome 177 Respiratory Failure/Ventilatory Assistance 187 Breathing Pattern, ineffective/Spontaneous Ventilation, impaired 192 Airway Clearance, ineffective 195 Communication, impaired verbal 196 Anxiety [specify level] 197 Oral Mucous Membrane, impaired 198 Nutrition: less than body requirements, imbalanced 198 Infection, risk for 199 Ventilatory Weaning Response, risk for dysfunctional 201 Knowledge, deficient 203 Pulmonary Tuberculosis (TB) 204 Infection, risk for [spread/reactivation] 208 Airway Clearance, ineffective 210 Gas Exchange, risk for impaired 211 Nutrition: less than body requirements, imbalanced 212 Health Management, risk for ineffective 214 Respiratory Acid-Base Imbalances (See DavisPlus) Respiratory Acidosis (Primary Carbonic Acid Excess) (See DavisPlus) Gas Exchange, impaired Respiratory Alkalosis (Primary Carbonic Acid Deficit) (See DavisPlus) Gas Exchange, impaired

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Seizure Disorders 216 Trauma/Suffocation, risk for 220 Airway Clearance, risk for ineffective 220 Self-Esteem, [specify situational or chronic low] 223 Health Management, ineffective 224 Craniocerebral Trauma—Acute Rehabilitative Phase 226 risk for decreased intracranial Adaptive Capacity 233 Breathing Pattern, risk for ineffective 237 Confusion, risk for acute 238 [Sensory Perception, disturbed (specify)] 239 Infection, risk for 240 Nutrition: less than body requirements, risk for imbalanced 241 Mobility, impaired physical 242 Trauma, risk for physical 243 Family Processes, interrupted 244 Knowledge, deficient 245 Cerebrovascular Accident (CVA)/Stroke 247 Tissue Perfusion, ineffective cerebral 252 Mobility, impaired physical 255 Communication, impaired verbal [and/or written] 257 [Sensory Perception, disturbed [specify] 258 Self- Care deficit [specify] 259 Coping, ineffective 261 Swallowing, risk for impaired 262 Neglect, unilateral 264 Knowledge, deficient 265 Brain Infections: Meningitis and Encephalitis 267 Infection, risk for [spread] 270 Intracranial Adaptive Capacity, risk for decreased 272 Comfort, impaired 273 Knowledge, deficient 275 Spinal Surgery 276 Peripheral Neurovascular Dysfunction, risk for 279 Injury, risk for [spinal] 280 Breathing Pattern, risk for ineffective 281 Pain, acute 281 Mobility, impaired physical 283 Infection, risk for 283 Urinary Retention, risk for acute 285 Knowledge, deficient 286 Spinal Cord Injury (Acute Care and Rehabilitative Phase) 288 Breathing Pattern, risk for ineffective 292 Trauma, risk for [additional spinal] 294 Mobility, impaired physical 295 [Sensory Perception, disturbed tactile/proprioception] 297 Pain, acute 298 Grieving 299 Self-Esteem, risk for situational low 301 Bowel Incontinence/Constipation 302 Elimination, impaired urinary 303 Pressure Ulcer/Tissue Integrity, risk for impaired 305 Knowledge, deficient 306 Autonomic Dysreflexia, risk for 309 Multiple Sclerosis (MS) 311 Fatigue 315 Self- Care deficit [specify] 318 Elimination, impaired urinary 320 Constipation/bowel Incontinence, risk for 322 Self-Esteem, risk for chronic 324 Powerlessness 324 Coping, risk for ineffective 323 Coping, risk for compromised family 326 Urinary Elimination, impaired 320 Caregiver Role Strain, risk for 327 Health Management, readiness for enhanced 328 Parkinson’s Disease (PD) 330 Mobility, impaired physical/Walking, impaired 333

Swallowing, impaired 336 Confusion, risk for chronic 338

DETAILED CONTENTS

CHAPTER 4 Neurological/Sensory Disorders 216

CHAPTER 5 Gastrointestinal Disorders 340 Upper Gastrointestinal Bleed 340 Fluid Volume, deficient 340 Shock, risk for 344 Anxiety [specify level] 349 Pain, acute 350 Knowledge, deficient 350 Inflammatory Bowel Disease (IBD): Ulcerative Colitis, Crohn’s Disease 352 Diarrhea 359 Fluid Volume, risk for deficient 361 Nutrition: less than body requirements, imbalanced 361 Anxiety [specify level] 363 Pain, acute 364 Coping, ineffective 365 Health Management, ineffective 366 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy Body Image, disturbed 370 Pain, acute 371 Skin Integrity, risk for impaired 372 Skin Integrity, risk for impaired 374 Fluid Volume, risk for deficient 375 Nutrition: less than body requirements, risk for imbalanced Constipation/Diarrhea, risk for 377 Sleep Pattern, disturbed 378 Sexual Dysfunction, risk for 378 Knowledge, deficient 380 Appendectomy 382 Infection, risk for/Surgical Site Infection, risk for 385 Fluid Volume, risk for deficient 386 Pain, acute 387 Knowledge, deficient 388 Peritonitis 389 Infection, risk for [spread] 392 Shock, risk for 395 Pain, acute 396 Nutrition: less than body requirements, risk for imbalanced Anxiety [specify level] 398 Knowledge, deficient 398 Cholecystitis With Cholelithiasis 399 Pain, acute 403 Fluid Volume, risk for deficient 404 Nutrition: less than body requirements, risk for imbalanced Knowledge, deficient 406 Cholecystectomy 407 (See DavisPlus)

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CHAPTER 6 Metabolic and Endocrine Disorders 413 Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 413 Eating Dynamics, ineffective child/adolescent 419 Nutrition: less than body requirements, imbalanced 419 Fluid Volume, risk for deficient 423 Body Image, disturbed 424 Self-Esteem, chronic low 425 Coping, readiness for enhanced family 427 Skin Integrity, risk for impaired 428 Health Management, ineffective 429 Eating Disorders: Obesity 430 Obesity: more than body requirements, imbalanced 340 Lifestyle, sedentary 437 Body Image, risk for disturbed 438 Social Isolation, impaired 440 Health Management, ineffective 441 Bariatric Surgery 442 Breathing Pattern, ineffective 445

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Tissue Perfusion, risk for ineffective [specify] 447 Fluid Volume, risk for deficient 447 Nutrition: less than body requirements, risk for imbalanced 448 Skin/Tissue Integrity, impaired 449 Infection, risk for 450 Diarrhea 451 Knowledge, deficient 452 Diabetes Mellitus and Diabetic Ketoacidosis 454 Fluid Volume, deficient [specify] 459 Blood Glucose Level, unstable 461 Infection, risk for 464 [Sensory Perception, risk for disturbed (specify)] 465 Coping, ineffective 466 Health Management, ineffective 467 Hyperthyroidism, Thyrotoxicosis and Thyroid Storm 471 Cardiac Output, risk for decreased 475 Fatigue 477 Nutrition: less than body requirements, risk for imbalanced 478 Anxiety [specify level] 478 Dry Eye, risk for 480 Knowledge, deficient 481 Hepatitis 482 Liver Function, impaired 486 Fatigue 487 Nutrition: less than body requirements, imbalanced 489 Fluid Volume, risk for deficient/Bleeding 490 Self-Esteem, risk for situational low 491 Infection, risk for [secondary/spread] 492 Knowledge, deficient 493 Cirrhosis of the Liver 494 Nutrition: less than body requirements, imbalanced 498 Fluid Volume, risk for excess 500 Infection, risk for 502 Skin Integrity, risk for impaired 503 Breathing Pattern, risk for ineffective 504 Bleeding, risk for 505 Venous Thromboembolism 505 Confusion, risk for acute 507 Body Image, disturbed 509 Health Management, ineffective 509 Pancreatitis 511 Pain, acute 516 Fluid Volume, risk for deficient 517 Nutrition: less than body requirements, imbalanced 519 Blood Glucose Level, risk for unstable 521 Infection, risk for [sepsis] 522 Gas Exchange, risk for impaired 523 Health Management, ineffective 523 Total Nutritional Support: Parenteral/Enteral Feeding 525 Nutrition: less than body requirements, imbalanced 530 Infection, risk for 534 Injury, risk for 535 Aspiration, risk for 536 Fluid Volume, risk for imbalanced 537 Knowledge, deficient 538 Metabolic Acid-Base Imbalances DavisPlus Metabolic Acidosis— Primary Base Bicarbonate Deficiency DavisPlus Metabolic Alkalosis— Primary Base Bicarbonate Excess DavisPlus

CHAPTER 7 Diseases of the Blood/Blood-Forming Organs 541 Anemias—Iron Deficiency, Anemia of Chronic Disease, Pernicious, Aplastic, Hemolytic 547 Activity Intolerance 547 Nutrition: less than body requirements, imbalanced 549 Infection, risk for 550 Knowledge, deficient 551

Sickle Cell Crisis 552 Gas Exchange, impaired 558 Pain, acute/chronic 560 Tissue Perfusion, risk for ineffective [specify] 562 Fluid Volume, risk for deficient 564 Mobility, impaired physical 564 Skin Integrity, risk for impaired 565 Infection, risk for 566 Health Management, ineffective 566 Adult Leukemias 569 Infection, risk for 574 Fluid Volume, risk for deficient 575 Pain, acute 577 Fatigue 578 Knowledge, deficient 579 Adult Lymphomas 582 Gas Exchange, risk for impaired 587 Nausea 590 Sexual Dysfunction 591 Knowledge, deficient 592

CHAPTER 8 Renal and Urinary Tract Disorders 595 Acute Kidney Injury (Acute Renal Failure) 595 Fluid Volume, excess 601 Cardiac Output, risk for decreased 603 Fluid Volume, risk for deficient 604 Infection, risk for 605 Knowledge, deficient] 606 Renal Failure: Chronic Kidney Disease and End-Stage Renal Disease 607 Electrolyte Imbalance, risk for 613 Cardiac Output, risk for decreased 614 Activity Intolerance, risk for 616 Bleeding, risk for 617 Confusion, risk for acute 618 Skin Integrity, risk for impaired 619 Oral Mucous Membrane, risk for impaired 620 Health Management, ineffective 620 Renal Dialysis—General Considerations 623 Nutrition: less than body requirements, imbalanced 625 Skin Integrity, risk for impaired 627 Self- Care deficit (specify) 628 Constipation, risk for 629 Confusion, risk for acute 630 Anxiety [specify level] 631 Body Image, disturbed 631 Health Management, risk for ineffective 633 Peritoneal Dialysis (PD) 635 Fluid Volume, risk for excess 635 Fluid Volume, risk for deficient 636 Trauma, risk for physical 637 Pain, acute 638 Infection, risk for 639 Breathing Pattern, risk for ineffective 640 Hemodialysis (HD) 641 Injury, risk for 642 Fluid Volume, risk for deficient 643 Fluid Volume, risk for excess 644 Urinary Diversions: Urostomy (Postoperative Care) 645 Skin Integrity, risk for impaired 647 Body Image, disturbed 648 Pain, acute 650 Infection, risk for 651 Sexual Dysfunction, risk for 653 Knowledge, deficient 654 Urinary Stones (Calculi) 656 Pain, acute 660 Elimination, impaired urinary 661

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CHAPTER 9 Women’s Health 666 Hysterectomy 666 Urinary Retention, risk for [acute] 668 Constipation, risk for 669 Tissue Perfusion, risk for ineffective (specify) 670 Sexual Dysfunction, risk for 671 Grieving 672 Knowledge, deficient 673 Mastectomy 675 Anxiety 679 Tissue Integrity, impaired 680 Pain, acute 681 Self-Esteem, situational low 682 Mobility, impaired physical 683 Knowledge, deficient 684

CHAPTER 10 Men’s Health 686 Benign Prostatic Hyperplasia (BPH) 686 Urinary Retention, [acute/chronic] 689 Pain, acute 691 Fluid Volume, risk for deficient 692 Anxiety [specify level] 692 Knowledge, deficient 693 Prostatectomy 694 Elimination, impaired urinary 696 Bleeding, risk for 697 Infection, risk for 698 Pain, acute 699 Sexual Dysfunction, risk for 700 Knowledge, deficient 700

CHAPTER 11 Orthopedic Disorders 702 Fractures 702 Injury, risk for 706 Pain, acute 707 Peripheral Neurovascular Dysfunction, risk for 709 Gas Exchange, risk for impaired 711 Mobility, impaired physical 712 Tissue Integrity, risk for impaired/Pressure Ulcer 714 Infection, risk for 715 Knowledge, deficient 716 Amputation 718 Pain, acute 721 Tissue Perfusion, risk for ineffective peripheral 723 Infection, risk for 724 Mobility, impaired physical 725 Grieving 726 Knowledge, deficient 728 Total Joint Replacement 729 Pain, acute 731 Bleeding, risk for 733 Infection, risk for 734 Peripheral Neurovascular Dysfunction, risk for 735 Mobility, impaired physical 736 Constipation, risk for 737 Knowledge, deficient 738

CHAPTER 12 Integumentary Disorders 740 Burns: Thermal, Chemical, and Electrical—Acute and Convalescent Phases 746 Airway Clearance, risk for ineffective 747 Fluid Volume, risk for deficient 749

Pain, acute 749 Infection, risk for 751 Peripheral Neurovascular Dysfunction, risk for 754 Nutrition: less than body requirements, imbalanced 755 Mobility, impaired physical 756 Skin Integrity, impaired [grafts/donor site] 757 Post-Trauma Syndrome, risk for 759 Knowledge, deficient 760 Wound Care: Complicated or Chronic 762 Skin/Tissue Integrity, impaired 765 Pain, acute/chronic 767 Infection, risk for 769 Nutrition: less than body requirements, imbalanced 769 Health Management, risk for ineffective 770

DETAILED CONTENTS

Fluid Volume, risk for deficient 663 Knowledge, deficient 664

CHAPTER 13 Systemic Infections and Immunological Disorders 772 Sepsis/Septic Shock 772 Infection, risk for [progression; opportunistic/ hospital acquired] 776 Hyperthermia 778 Shock, risk for 779 Fluid Volume, risk for deficient 781 Confusion, risk for acute 783 Gas Exchange, risk for impaired 783 Knowledge, deficient 784 The HIV-Positive Client 785 Health Behavior, risk-prone 788 Fatigue 790 Nutrition: less than body requirements, imbalanced 791 Knowledge, deficient 793 Social Isolation, risk for 797 Health Management, ineffective 798 Acquired Immunodeficiency Syndrome (AIDS) 800 Infection, risk for [progression/onset of opportunistic infection] 805 Fluid Volume, risk for deficient 807 Breathing Pattern, ineffective 808 Bleeding, risk for 810 Nutrition: less than body requirements, imbalanced 811 Pain, acute/chronic 813 Skin Integrity, impaired 814 Oral Mucous Membrane, impaired 815 Fatigue 816 Confusion, risk for acute/chronic 817 Death Anxiety 819 Social Isolation 820 Health Management, ineffective 822 Rheumatoid Arthritis (RA) 824 Pain, acute/chronic 827 Mobility, impaired physical 829 Role Per for mance, ineffective 830 Self- Care deficit (specify) 831 Home Maintenance, risk for impaired 831 Health Management, risk for ineffective 832

CHAPTER 14 General 835 Psychosocial Aspects of Care 835 Coping, ineffective 837 Decisional Conflict (specify) 838 Coping, compromised family 839 Coping, readiness for enhanced family 840 Anxiety [specify level] 841 Self-Esteem, risk for situational low 843 Grieving [specify] 845 Religiosity, risk for impaired 847 Health Management, ineffective 848 Violence, risk for self- or other- directed 849

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Dementias: Alzheimer’s Type/Vascular Dementia/Lewy Body Disease/ Frontotemporal Dementia 851 Injury, risk for 857 Confusion, chronic 858 [Sensory Perception, disturbed (specify)] 861 Anxiety 862 Grieving 863 Sleep Deprivation 864 Self- Care deficit (specify type/level) 865 Nutrition: less/more than body requirements, risk for imbalanced 866 Bowel Incontinence/Elimination, impaired urinary 867 Sexual Dysfunction, risk for 868 Coping, compromised family 869 Health Maintenance, ineffective 870 Role Strain, risk for caregiver 871 Relocation Stress Syndrome, risk for 872 Surgical Interventions 873 Knowledge, readiness for enhanced 877 Anxiety [specify level] 878 Perioperative Positioning Injury, risk for 880 Injury, risk for 881 Infection, risk for 883 Hypothermia/Hypethermia, risk for [perioperative] 885 Breathing Pattern, ineffective 886 [Sensory Perception, disturbed (specify)] 887 Fluid Volume, risk for deficient 889 Pain, acute 890 Tissue Integrity, impaired 892 Tissue Perfusion, risk for ineffective 894 Health Management, readiness for enhanced 895 Extended/Long-Term Care 896 Relocation Stress Syndrome, risk for 898 Grieving 900 Memory, impaired 901 Coping, compromised family 903 Poisoning, risk for [drug toxicity] 904 Communication, impaired verbal 905 Sleep Pattern, disturbed 906 Nutrition: risk for less than body requirements/Overweight 907 Self- Care deficit [specify] 909 Skin Integrity, risk for impaired 910 Elimination, risk for impaired urinary 911 Constipation/Diarrhea, risk for 912 Mobility, impaired physical 914 Pain, chronic 915 Sexual Dysfunction, risk for 916 Health Management, readiness for enhanced 917 Alcohol: Acute Withdrawal 919 Acute Substance Withdrawal Syndrome Breathing Pattern, risk for ineffective 927 Cardiac Output, risk for decreased 928 Substance Use Disorders (SUDs) 929 Denial, ineffective 932 Acute Substance Withdrawal Syndrome, risk for Coping, ineffective 933 Powerlessness 937 Nutrition: less than body requirements, imbalanced 938 Self-Esteem, chronic low 828

Family Processes, dysfunctional 941 Sexual Dysfunction 943 Knowledge, deficient 944 Cancer—General Considerations 945 Fear/Anxiety [specify level] 950 Grieving 952 Self-Esteem, risk for situational low 953 Pain, acute/chronic 954 Nutrition: less than body requirements, imbalanced 957 Fluid Volume, risk for deficient 959 Fatigue 960 Infection, risk for 961 Oral Mucous Membrane, risk for impaired 962 Skin/Tissue Integrity, risk for impaired 964 Constipation/Diarrhea, risk for 965 Sexual Dysfunction, risk for 966 Family Processes, risk for interrupted 967 Health Management, readiness for enhanced 968 Palliative/End-of-Life Care—Hospice 970 Pain, acute/chronic 972 Fatigue 974 Grieving/Death Anxiety 975 Coping, compromised family 977 Spiritual Distress, risk for 978 Role Strain, risk for caregiver 979 Disaster Considerations 980 Injury, risk for/Trauma, physical 983 Infection, risk for 985 Anxiety [severe/panic] 986 Spiritual Distress risk 989 Post-Trauma Syndrome, risk for 990 Coping, ineffective community 991 Coping, readiness for enhanced community 992 Pediatric Considerations 993 Pain, acute/chronic 996 Anxiety/Fear 997 Activity Intolerance 998 Development, risk for delayed [Growth] 999 Nutrition: less than body requirements, risk for imbalanced 1001 Injury, risk for (specify: Trauma, Suffocation, Poisoning) 1002 Fluid Volume, risk for imbalanced 1003 Family Processes, interrupted 1004 Thermoregulation, risk for ineffective 1005 Health Maintenance, risk for ineffective 1006 Fluid and Electrolyte Imbalances (see DavisPlus) Hypervolemia (Extracellular Fluid Volume Excess) Hypovolemia (Extracellular Fluid Volume Deficit) Hyponatremia (Sodium Deficit) Hyponatremia (Sodium Excess) Hypokalemia (Potassium Deficit) Hyperkalemia (Potassium Excess) Hypocalcemia (Calcium Deficit) Hypercalcemia (Calcium Excess) Hypomagnesemia (Magnesium Deficit) Hypermagnesemia (Magnesium Excess) Definitions for NANDA-I Nursing Diagnoses Used in This Text 1009 Index of Nursing Diagnoses 1013

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CONTENTS ON DAVIS PLUS 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 Posttraumatic 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 Disruptive, Impulse-Control, and Conduct Disorders Oppositional Defi ant Disorder Conduct Disorder Substance-Related and Addictive Disorders 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 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 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

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Medical Surgical Care Plans Fluid and Electrolyte Imbalances Hypervolemia (Extracellular Fluid Volume Excess) Hypovolemia (Extracellular Fluid Volume Deficit) Hyponatremia (Sodium Deficit) Hyponatremia (Sodium Excess) Hypokalemia (Potassium Deficit) Hyperkalemia (Potassium Excess) Hypocalcemia (Calcium Deficit) Hypercalcemia (Calcium Excess) Hypomagnesemia (Magnesium Deficit) Hypermagnesemia (Magnesium Excess) Gastrectomy/gastroplasty Herniated nucleus pulposus Hypercalcemia (calcium excess) Hyperkalemia (potassium excess) Hypermagnesemia (magnesium excess) Hypernatremia (sodium excess) Hypervolemia (extracellular fluid volume excess)

Hypocalcemia (calcium deficit) Hypokalemia (potassium deficit) Hypomagnesemia (magnesium deficit) Hyponatremia (sodium deficit) Hypovolemia (extracellular fluid volume deficit) Laryngectomy Metabolic Acid-Base Imbalances Metabolic Acidosis: Primary Base Bicarbonate Deficiency Metabolic Alkalosis: Primary Base Bicarbonate Excess Primary base bicarbonate deficiency Primary base bicarbonate excess Primary carbonic acid deficit Primary carbonic acid excess Radical neck surgery Respiratory Acid-Base Imbalances Respiratory Acidosis (Primary Carbonic Acid Excess) Respiratory Alkalosis (Primary Carbonic Acid Deficit) Ruptured intervertebral disc Thyroidectomy

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CHAPTER

1

The Nursing Process: Planning Care Using Critical Thinking

DEFINING NURSING Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Nursing care is a key factor in achieving positive outcomes for the client with illness, as well as in the enhancement of client satisfaction in all phases of healthcare. The goals of nursing care include the prevention of illness, the provision of rehabilitation for compromising conditions, and the maximization of health. Where a return to health is not possible, nurses are also instrumental in helping the individual to achieve relief of pain and other discomforts, as well as to potentially experience a more peaceful death. So do these things define nursing? Through the years, the “what” and “how” of the work of nursing have been explained by numerous nursing organizations in a number of publications to help define the work of nursing. Nursing interventions are based on needs identified by the client and the nurse during data collection. The 1980 Nursing: A Social Policy Statement by the American Nurses Association (ANA) 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 (Neuman, n.d.). In the 2003 Nursing: A Social Policy Statement, the ANA definition was expanded: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” Human responses that are the phenomena of concern to nurses include “any observable need, concern, event, or fact of interest to nurses that may be the target of evidenced-based nursing practice” (ANA, 2010). The nursing profession had already implemented (in the 1950s) 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). This “nursing process” evolved into five steps central to nursing actions and the delivery of high-quality, individualized client care in any setting. These are the following:

(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). The nursing process combines the skills of critical thinking with the skills of hands-on care and creates a method of active problem-solving that is both dynamic and cyclic. Although some view the nursing process as separate and progressive steps, the elements are actually interrelated. Taken together, they form a continuous circle of thought and action throughout the client’s contact with the healthcare system. Figure 1.1 demonstrates the way this cyclic process works.

CRITICAL THINKING The ability to think critically is vital to the success of effectively using the nursing process. Critical thinking in general has been defined as the “intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information gathered from or by observation, experience, reflection, reasoning, or communication, as a guide to belief and action” (Scriven & Paul, 1987). In nursing, critical thinking for clinical decision making has been defined as “the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care” (Heaslip, 1993, revised 2008). Nursing critical thinking requires a comprehensive knowledge base; use of one’s cognitive, psychomotor, and affective skills; established standards of care for best practice; and ongoing nursing research. The final product of this effort is effective nursing action, which is carried out and documented in the plan of care for a specific client.

WHERE DOES NURSING DIAGNOSIS FIT? In 1991, the ANA Standards of Clinical Nursing Practice described the client care process and standards for professional performance, providing impetus and support for the development and use of nursing diagnosis in the practice setting. Nursing diagnoses are useful in providing a uniform 1

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Figure 1.1 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.

way of identifying, focusing on, and dealing with specific client needs and responses to actual or high-risk problems and life processes. While a number of standardized nursing languages have been developed using nursing diagnosis terminology, we have supported and operationalized the NANDAInternational’s (NANDA-I’s) research and ongoing work of identifying client problems and needs for which nurses are accountable. NANDA-I defines nursing diagnosis as “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community . . . and provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (Herdman & Kamitsuru, 2018). NANDA-I nursing diagnosis labels (see page 1049) provide a format for expressing the problem identification portion of the nursing process. There are four forms of nursing diagnoses: “1) problem-focused—a clinical judgement concerning an undesirable human response to health conditions/life processes that exists in an individual, family, group, or community; 2) health promotion—a clinical judgement concerning motivation and desire to increase well-being and to actualize health potential; 3) risk—a clinical judgement concerning the susceptibility of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes; 4) syndrome—a clinical judgement concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions” (Herdman & Kamitsuru, 2018).

HOW THE NURSING PROCESS WORKS WITH NURSING DIAGNOSIS 1. Collect a client database (nursing interview, physical assessment, and diagnostic studies) combined with information collected by other healthcare providers. 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 or risk factors and defining characteristics for possible NANDA nursing diagnosis labels. This step is crucial to choosing and validating the appropriate nursing diagnosis label that will be used to create a specific client diagnostic statement. The defining characteristics and related factors associated with the chosen NANDA nursing diagnosis are reviewed and compared with the client data. If the diagnosis is not consistent with at least two or more cues, additional data may be required or another nursing diagnosis considered. 5. The results of the synthesis of the collected data are written concisely to create the client diagnostic statement by combining the nursing diagnosis with the identified NANDA related factors, defining characteristics, or risk factors to best reflect the client’s situation. In this text, to facilitate the steps needed to arrive at a nursing diagnosis and to aid in the critical thinking process, we developed an assessment database that uses a nursing focus instead of the traditional medical approach of a review of systems (Fig. 1.2). To achieve this nursing focus, we have grouped NANDA-I nursing diagnoses into related categories titled Diagnostic Divisions (Box 1.1). These categories reflect a blending of theories, primarily Maslow’s hierarchy of needs and a self-care philosophy. And because diagnostic divisions are based on human responses and needs rather than specific body systems, assessment data may be recorded in more than one area. These divisions serve as the framework for data collection and direct the nurse to the corresponding nursing diagnosis labels in the second step of the nursing process. For this reason, the nurse is encouraged to keep an open mind during the assessment phase and to collect as much information as possible before choosing the nursing diagnosis label.

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CHAPTER 1

ADULT MEDICAL/SURGICAL ASSESSMENT TOOL General Information

The Nursing Pro cess: Planning Care Using Critical Thinking

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): ___________________ Regular 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: _________________ ________________________________________________________

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): _____________________________________

Circulation 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): _________ Homans’ sign: __________ Varicosities (location): ____________________________________ Distribution/quality of hair: _______________________________ Edema (location/severity: mild, moderate, severe): ___________ Trophic skin changes: ________ Nail abnormalities: ________

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Ego Integrity Subjective (Reports) 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: ____________________________________

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: _________________________________________________

Elimination 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/fistula: _________ 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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CHAPTER 1

Food/Fluid (continued) Subjective (Reports)

The Nursing Pro cess: Planning Care Using Critical Thinking

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., tonic-clonic, 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: ____________ Place: ___________ Time: ______________________ 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: _________________________________________ Effect on lifestyle/employment: ______________________________

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Respiration Subjective (Reports)

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 tobacco: _________ Vapes: ________ 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): _______________________

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: _______________________________________ Practices self-exam: Breast: __________ Testicles: __________ Last proctoscopic/prostate exam: _____ Last PSA/date: _____ Medications/herbals: ____________________________________

Genitalia: Penis: Circumcised: _______ Warts/lesions: __________ Bleeding/discharge: ______Testicles (e.g., lumps): ___________ Breast examination: ________________________________________ Test results: PSA: ________________ STI: ______________________

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CHAPTER 1

Sexuality [Component of Social Interaction] (continued) Female: Subjective (Reports)

Objective (Exhibits) Breast examination: ________________________________________ Genitalia: Warts/lesions: ____________________________________ Vaginal bleeding/discharge: ______________________________ Test results: PAP smear: ____________________________________ Mammogram: ___________________________________________ STI: _____________________________________________________

The Nursing Pro cess: Planning Care Using Critical Thinking

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: ______ Vaginal lubrication: ____ Vaginal discharge: _____________ Hormonal therapies: _____________________________________ Osteoporosis medications: ____________________________ Breasts: Practices breast self-exam: _______________________ Last mammogram: __________ Biopsy/surgery: __________ Last PAP smear: _________________________________________

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 challenges (specify): __________________________ Cognitive limitations: __________________________________ Culture/ethnicity: Where born: ___________________________ If immigrant, how long in this country: __________________ Health and illness beliefs/practices/customs: _______________ Which family member makes healthcare 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 healthcare concerns (e.g., impact of religious/cultural practices): ____________________________ Healthcare decisions: __________________________________ Family involvement: __________________________________

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: ______________Vapes: ______ Admitting diagnosis per provider: ___________________________ Reason for hospitalization/visit per client: ____________________ History of current concern: __________________________________

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Teaching/Learning (continued) Subjective (Reports) 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: _______________________________

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 1.2 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 1.1 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, as well as 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

• • • • • • • • • • •

• • • • • • • • • • • • •

Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences

Activity Intolerance Activity Intolerance, risk for Disuse Syndrome, risk for Diversional Activity Engagement, deficient Fatigue Insomnia Lifestyle, sedentary 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 • Adaptive Capacity, decreased intracranial • Autonomic Dysreflexia

• • • • • • • • • • • • • • •

Autonomic Dysreflexia, risk for Bleeding, risk for Blood Pressure, risk for unstable Cardiac Output, decreased and risk for Metabolic Imbalance Syndrome, risk for Shock, risk for Thromboembolism, risk for venous Tissue Perfusion, ineffective peripheral Tissue Perfusion, risk for decreased cardiac Tissue Perfusion, risk for ineffective cerebral Tissue Perfusion, risk for ineffective peripheral

Activity Planning, ineffective Activity Planning, risk for ineffective Anxiety [mild, moderate, severe panic level] Body Image, disturbed Coping, defensive Coping, ineffective Coping, readiness for enhanced Death Anxiety Decision-Making, readiness for enhanced Decisional Conflict Denial, ineffective Emancipated Decision-Making, readiness for enhanced Emancipated Decision-Making, impaired Emancipated Decision-Making, risk for impaired Emotional Control, labile

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CHAPTER 1

Box 1.1 Nursing Diagnoses Organized According to Diagnostic Divisions (continued) 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 Mood Regulation, impaired 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 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 Resilience, impaired Resilience, readiness for enhanced Resilience, risk for impaired 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 Sorrow, chronic Spiritual Distress Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced

Elimination—ability to excrete waste products • • • • • • • • • • • • • • • • •

Constipation Constipation, chronic functional Constipation, perceived Constipation, risk for Constipation, risk for chronic functional Diarrhea Elimination, impaired urinary Gastrointestinal Motility, dysfunctional Gastrointestinal Motility, risk for dysfunctional Incontinence, bowel Incontinence, functional urinary Incontinence, overflow urinary Incontinence, reflex urinary Incontinence, risk for urge urinary Incontinence, stress urinary Incontinence, urge urinary Retention, [acute/chronic] urinary

Food/Fluid—ability to maintain intake of and utilize nutrients and liquids to meet physiological needs • • • • • • • • • • • • • • • • • • • • • • • • • •

Blood Glucose Level, risk for unstable Breast Milk Production, insufficient Breastfeeding, ineffective Breastfeeding, interrupted Breastfeeding, readiness for enhanced Dentition, impaired Eating Dynamics, ineffective adolescent Eating Dynamics, ineffective child Eating Dynamics, ineffective infant Electrolyte Imbalance, risk for Failure to Thrive, adult Feeding Pattern, ineffective infant [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 Mucous Membrane Integrity, impaired oral Nausea Nutrition: less than body requirements, imbalanced Nutrition, readiness for enhanced Obesity Overweight Overweight, risk for Swallowing, impaired

The Nursing Pro cess: Planning Care Using Critical Thinking

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

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 Neurovascular Dysfunction, risk for peripheral [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 • • • •

Chronic Pain Syndrome Comfort, impaired Comfort, readiness for enhanced Pain, acute (continues on page 10)

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Box 1.1 Nursing Diagnoses Organized According to Diagnostic Divisions (continued) • Pain, chronic • Pain, labor 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 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Acute Substance Withdrawal Syndrome Acute Substance Withdrawal Syndrome, risk for Adverse Reaction to Iodinated Contrast Media, risk for Allergy Reaction, risk for Contamination Contamination, risk for Dry Eye, risk for Dry Mouth, risk for Falls, risk for Frail Elderly Syndrome Health Maintenance, ineffective Home Maintenance, impaired Hyperthermia Hyperbilirubinemia, neonatal Hyperbilirubinemia, risk for neonatal Hypothermia Hypothermia, risk for perioperative Infection, risk for Injury, risk for Injury, risk for corneal Injury, risk for urinary tract Latex Allergy Reaction Latex Allergy Reaction, risk for Maternal-Fetal Dyad, risk for disturbed Mobility, impaired bed Mobility, impaired physical Neonatal Abstinence Syndrome Occupational Injury, risk for Perioperative Positioning Injury, risk for Poisoning, risk for Pressure Ulcer, risk for Protection, ineffective Self-Mutilation Self-Mutilation, risk for Sitting, impaired Skin Integrity, impaired Skin Integrity, risk for impaired Standing, impaired Sudden infant Death, risk for Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Surgical Recovery, risk for delayed Surgical Site Infection, risk for

• • • • • • • • • •

Thermal Injury, risk for Thermoregulation, ineffective Thermoregulation, risk for ineffective Tissue Integrity, impaired Tissue Integrity, risk for impaired Trauma, risk for physical Trauma, risk for vascular Violence, risk for other-directed Violence, risk for self-directed Wandering [specify sporadic or continual]

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 Female Genital Mutilation, risk for Sexual Dysfunction Sexuality Pattern, ineffective

Social Interaction—ability to establish and maintain relationships • • • • • • • • • • • • • • • • • • • • • •

Attachment, risk for impaired Communication, impaired verbal Communication, readiness for enhanced Coping, compromised family Coping, disabled family Coping, ineffective community Coping, readiness for enhanced community Coping, readiness for enhanced family Family Processes, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Immigration Transition, risk for complicated Loneliness, risk for Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Role Conflict, parental Role Perfor mance, ineffective Role Strain, caregiver Role Strain, risk for caregiver Social Interaction, impaired Social Isolation

Teaching/Learning— ability to incorporate and use information to achieve healthy lifestyle and optimal wellness • • • • • • • •

Development, risk for delayed Health, deficient community Health Literacy, readiness for enhanced Health Maintenance, ineffective Health Management, ineffective Health Management, ineffective family Knowledge, deficient Knowledge, readiness for enhanced

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DOING IT Step 1—Assessment (Gathering Data) The critical element for providing effectively planned nursing care is its relevance to concerns identified in client assessments. ANA’s 2010 Nursing: Scope and Standards of Practice determined that client assessment is indicated in the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic, and environmental. Nursing 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. Interviewing the client and significant other(s) provides data through conversation and observation. This information includes the client’s perceptions, that is, what the individual 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. During information gathering, the nurse also 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 session de-

Step 2—Diagnosis (Analyzing the Data) The nursing diagnosis is only as correct as current assessment allows because it is supported by currently collected data. It documents the client’s situation in real time and must be updated periodically (sometimes frequently) to reflect changes as they occur in the client’s condition. The combination of accurate need identification and accurate diagnostic labeling provides the basis for selecting nursing interventions. From the specific data recorded in the database, signs and symptoms can be identified, the related or risk factors (etiology) determined, and an individualized client diagnostic statement formulated. The nurse may use one of several formats such as a “problem, etiology, and signs and symptoms (PES)” format to accurately represent the client’s situation for a problem-focused diagnosis. For example, the diagnostic statement may read as follows: “ineffective peripheral Tissue Perfusion related to smoking, sedentary lifestyle, evidenced by decrease in peripheral pulses, capillary refill >3 seconds, paresthesia.” For a risk or health promotion diagnosis that does not have related factors, the diagnostic statement might read “risk for ineffective peripheral Tissue Perfusion as evidenced by insufficient knowledge of disease process, sedentary lifestyle, smoking” or “readiness for enhanced Health Management as evidenced by expressed desire to enhance management of risk factors and choices of daily living for meeting goals.” To use a syndrome diagnosis, at least two or more nursing diagnoses must be present from the identified defining characteristics for the diagnosis— for example, “Chronic Pain Syndrome as evidenced by impaired physical mobility, insomnia, fatigue.” Unlike medical diagnoses (which describe disease conditions), 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.”

The Nursing Pro cess: Planning Care Using Critical Thinking

A well-developed plan of care communicates the client’s status to all members of the healthcare team involved in providing care. The plan of care (1) documents the client’s past and present health status and current needs, (2) identifies problems solved and those yet to be solved, (3) notes patterns of client responses to interventions, and (4) may be personalized to provide information about successful approaches to problem-solving. In legal terms, the plan of care documents nurse intervention and client response in areas of liability, accountability, and quality improvement. Finally, the plan of care provides a mechanism to help ensure continuity of care when the client leaves one healthcare setting for another while still needing services. The client plan of care contains 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 the comprehensive functional plan, essential in providing holistic care for the client. Although independent nursing actions are an integral part of this process, collaborative actions are also implemented based on orders from all other disciplines participating in the care of the client. We believe that because nursing is an essential part of collaborative practice, we have responsibility and accountability in every collaborative problem in which the nurse interacts with the client. Many factors influence whether an intervention is independent or requires collaboration. These factors include the educational preparation and expertise of the nurse, facility standing protocols, delegation of tasks, and the geographic area of care provision—for example, rural or urban, acute care, or community care settings.

pends on the current condition of the client and the urgency of the situation, but it usually includes inspection, palpation, percussion, and auscultation. Additionally, the nurse needs to be aware of medically determined diagnoses, results of diagnostic tests, and significant problems that require immediate physician intervention and/or initiation of specific nursing interventions.

CHAPTER 1

THE PLAN OF CARE

Step 3—Planning (Choosing Outcomes and Interventions) Desired Client Outcomes The nurse identifies expected outcomes for a plan of care individualized for a specific client (ANA, 2010). These desired outcomes (sometimes called goals) are identified to facilitate 11

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choosing appropriate interventions and to serve as evaluators of both nursing care and client response. 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 the client’s desires and resources

Desired client outcomes are created by listing items and behaviors that can be measured (i.e., observed, reported, or documented). They are monitored to determine whether an acceptable outcome or goal has been achieved within a specified time frame. Action verbs describe the client’s behavior to be evaluated and time frames are used, for example, “client will ambulate, using cane, within 24 hours of surgery.” Time frames are dependent on the client’s projected or anticipated length of stay (or period of care) and consider the presence of complications or extenuating circumstances, such as age or debilitating disease process. 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. Continuing the work on naming what nursing does (as discussed in opening paragraphs of this chapter), a standardized nursing language that focused on outcomes was developed—Nursing Outcomes Classification (NOC), containing more than 540 outcomes (Morehead et  al, ed. 6, 2018). NOC outcomes take a more standardized approach, with an outcome label such as Ambulation having 16 indicators identified and measured on a five-point Likert-type scale ranging from “severely compromised” to “not compromised.” NOC outcomes have been linked with NANDA nursing diagnoses, and we operationalize NOC labels to a limited extent in this textbook.

Interventions/Actions 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 to assist the client in achieving the stated desired client outcomes (e.g., movement toward health and independence). 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. 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.” Continuing the work on naming what nursing does (as discussed in opening paragraphs of this chapter), another standardized nursing language—Nursing Interventions Classification (NIC)—has been linked to NANDA-I nursing diagnoses. NIC has identified more than 550 (Butcher et al, 2018) direct and indirect interventions 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. These three languages—NANDA, NOC, and NIC—have been combined in some computerized clinical decision support programs. We have used NIC labels to a limited extent in this textbook to demonstrate a more complete blending of nursing diagnoses, outcomes, and interventions and operationalize them, especially for use in electronic health records. To assist in visualizing this critical thinking process, a prototype client situation (Fig. 1.3) is provided as an example of data collection and construction of a plan of care. In the sample situation, we can see that as the client assessment database is reviewed, the nurse can identify the related or risk factors and defining characteristics for formulating the client diagnostic statements. Nursing interventions are based on needs identified by the client and the nurse during data collection. Timelines for outcomes reflect the anticipated length of stay for the client (thus potential discharge planning needs) and individual client-nurse expectations. 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 by assisting the student and practicing nurse in associating the pathophysiology and psychological principles with the selected nursing interventions. Another way to conceptualize the client’s care needs is to create a mind map, or concept map (Fig. 1.4). This learning tool was developed to help visualize the interconnectedness between various client symptoms, interventions, or problems as they impact each other. This design brings leftbrained, linear problem-solving thinking together with the freewheeling, interconnected, creative right brain. Thus, the best parts of the traditional care plan (problem-solving and categorizing) are retained, but the linear and columnar nature of the traditional care plan is expressed in a design that uses the whole brain. Joining mind mapping and care planning enables the nurse to visualize a holistic view of a client, strengthening critical thinking skills and facilitating the creative process of planning client care. Mind mapping starts with a figure drawn in the center of the page labeled with 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 major ideas that relate to the client radiate out from the center like spokes of a wheel. Different concepts can be grouped together by geometric shapes, color coding, or placement on the page. Connections and interconnections

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CHAPTER 1

Client Situation: Diabetes Mellitus

The Nursing Pro cess: Planning Care Using Critical Thinking

Mr. R.S., a client with type 2 diabetes 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. Review Database for clues to possible Nursing Diagnosis choices.

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 a.m. Chest x-ray and ECG in a.m. 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 units SC q a.m. Begin insulin instruction for post-discharge self-care if necessary Dicloxacillin 500 mg PO q6h, start after culture obtained Percocet 2.5/325 mg 1 or 2 tabs every 6 hrs PRN pain Diet—2400 calories, 3 meals with 2 snacks Arrange consult with dietitian 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: 6/28/2018 Time: 7 p.m. From: Home

DOB: 5/3/45

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 a.m. but feeling fatigued past several weeks

Objective (Exhibits):

Observed response to activity: limps, favors L foot when walking Mental status: Alert/active Neuromuscular assessment: Muscle mass/tone: Bilaterally equal/firm Posture: Erect ROM: 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 Subjective (Reports):

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

ELIMINATION Subjective (Reports):

Usual bowel pattern: almost every p.m. 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 calories (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: p.m.

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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CHAPTER 1

NEUROSENSORY 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

The Nursing Pro cess: Planning Care Using Critical Thinking

Subjective (Reports):

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 unlabored Depth: Good Auscultation: Few wheezes, clear with cough Cyanosis: 0 Clubbing of fingers: 0 Sputum characteristics: None to observe Mentation/restlessness: Alert/oriented/relaxed

Symmetry: Equal, bilateral

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):

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) Subjective (Reports):

Last proctoscopic examination: 2 yr ago Prostate examination: 1 yr ago Practice self-examination: Breast/testicles: No Problems/complaints: “I don’t have any problems, but you’d have to ask my wife if there are any complaints.”

Objective (Exhibits):

Examination: Breast: No masses

Testicles: Deferred Prostate: Deferred

SOCIAL INTERACTIONS Subjective (Reports):

Marital status: Married 45 yr Living with: Wife Report of problems: None Extended family: One daughter lives in town (30 miles away); one 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 a.m./6 p.m., last dose 6 p.m. today Purpose: Control diabetes Takes medications regularly? Yes Home urine/glucose monitoring: “Only using Tes-Tape, 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: 1986, 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: 7/1/18 (3 days) Resources: Self, wife

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CHAPTER 1

DISCHARGE CONSIDERATIONS (AS OF 6/28) (continued)

The Nursing Pro cess: Planning Care Using Critical Thinking

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 1.3 Client situation: Diabetes mellitus. leads to

ND: infective Health Management - review disease process - BS monitoring - insulin administration - s/s hyper/hypoglycemia - dietary needs - foot care 6/30

6/30

7/1

demonstrates Blood sugar (BS) 450 thirst/wt loss

complications

RS

Perform Understand Self-admin RFS DM and insulin treatment

ND: risk for unstable Blood Glucose Level - fingerstick 4X day - 2400 cal diet 3 meals/2 snacks - Humulin N - Glucophage/DiaBeta

impairs healing

6/30 FBS < 120

DM Type 2

ND: impaired Skin Integrity - wound care - dressing change - infection precautions - Dicloxacillin

pulses numbness & tingling legs

6/30

7/1

due to ND: impaired peripheral Tissue Perfusion - feet when in chair - increase fluids/l&O - safety precautions - foot inspection

ongoing Maintain hydration

No drainage/ erythema pain 4-5/10 increases risk for

6/30 Understand relationship of DM to circulatory changes

Wound clean/pink

ND: acute Pain - foot cradle - Percocet

causes Pressure ulcer

7/1 Pain free

7/1 Full wt. bearing

Figure 1.4 Mind map for Mr. R.S.

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. When the plan is completed, there should be a clear nursing diagnosis (supported by subjective and objective evaluation assessment data), nursing interventions, and desired client outcome(s) 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 assembling the pieces because one cluster is not more or less important than another (and one is not subsumed under another). However, it is impor tant that the pieces are in the same order in each spoke. For example, if the first piece is assessment data, followed by the nursing diagnosis, then outcomes, and finally interventions, that order should be maintained throughout the map.

Step 4—Implementation To operationalize step 4 and implement the plan in a timely and cost-effective manner, first identify the priorities for providing client care. Review the plan for outcomes that are to be evaluated during your time of providing care (e.g., shift or day), followed by planned interventions that are sequential or time related, as well as those that can be combined to maximize nursing time and client effort. This is also the time to review the plan of care with the client/significant other to schedule activities and verify the client’s responsibilities. In addition, legal and ethical concerns related to the interventions need to be considered. For example, the wishes of the client and family/significant others regarding what is being done need to be discussed and respected, as well as differences resolved where possible. Finally, it is important to provide an environment conducive to carrying out the planned interventions. 17

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Step 5—Evaluation and Documentation of Plans of Care As nursing care is provided, ongoing assessment evaluates the client’s response to therapy and progress toward accomplishing the desired outcomes. As care is provided, the nurse monitors and documents the client’s response to the interventions and communicates this information to other healthcare providers as appropriate. 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. Then the data are used to document nursing interventions and client response, as well as to reevaluate and revise the plan of care as needed. This process is visualized in Figure 1.5. 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. Another 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 pro-

viding 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.  1.6) reflects Mr. R.S.’s primary diagnostic problem: nonhealing diabetic wound.

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 diagnosis validated?

YES

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 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.

Start new evaluation process. FINISHED

Figure 1.5 Outcome-based evaluation of the client’s response to therapy (adapted from Newfield et al, 2016). 18

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Additional nursing actions

Client education

Medications

Up ad lib NS soaks/dressing change tid

→ →

VS qid I&O/level of hydration daily Character of wound tid Level of knowledge and priorities of learning needs Observe for signs of antibiotic Anticipated discharge needs hypersensitivity reaction Antibiotic: Dicloxacillin Antibiotic: same 500 mg PO q6h Antidiabetic: Humulin R Antidiabetic: Humulin N insulin insulin 10 units 10 U SC q a.m. SC on adm DiaBeta 10 mg PO bid Glucophage 500 mg PO daily Provide: Understanding Your Film Living with Diabetes Diabetes Demonstrate and practice tasks: 1. Fingerstick BG 2. Insulin administration 3. Wound care 4. Routine foot care

Additional assessments

Dietitian & 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)

Day 2 6/29

Wound culture/sensitivity Gram’s stain Random blood glucose Fingerstick BG hs

Actions/Goals:

Adm Day 1 6/28 7 p.m.

Diagnostic studies

Referrals

Impaired Skin/ Tissue Integrity

ND and Categories of Care

→ →

→ →

Practice self-care task No. 2: insulin administration Review discharge instructions

Antidiabetic: same

Antidiabetic: same

Group sessions: Diabetic management

Antibiotic: same

→ → D/C →

→ VS each shift → →

Antibiotic: same

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

→

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

CP: Nonhealing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes

The Nursing Pro cess: Planning Care Using Critical Thinking

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Characteristics of pain Level of participation activities Individual analgesic needs Analgesic: Percocet 2.5/325 mg PO 1 or 2 tabs q6h 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 1.6 Sample Clinical Pathway: Nonhealing diabetic wound.

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 7 p.m.

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: Nonhealing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes

CHAPTER 1

PL A N O F C A R E:

Mr. R.S.

The Nursing Pro cess: Planning Care Using Critical Thinking

Client Diagnostic Statement impaired Skin Integrity related to pressure over a bony prominence, as evidenced by acute pain, alteration in skin integrity— draining wound L foot. 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 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. Infection Control NIC Follow wound precautions. Obtain sterile specimen of wound drainage on admission. Administer dicloxacillin 500 mg per os (PO) q6h, starting at 10 p.m. Observe for signs of hypersensitivity: pruritus, urticaria, rash.

RATIONALE 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. 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 history of penicillin reaction, it may occur at any time.

PL A N O F C A R E: Client Diagnostic Statement risk for unstable Blood Glucose Level as evidenced by insufficient diabetes management and inadequate blood glucose monitoring (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 Hyperglycemia Management NIC Perform fingerstick blood glucose (BG) qid. Call for BG >250.

RATIONALE 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. (continues on page 22)

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ACTIONS/INTERVENTIONS (continued) Administer antidiabetic medications: 10 units Humulin N insulin subcutaneous (SC) every a.m. after fingerstick BG

DiaBeta 10 mg PO bid

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) 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. 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.

PL A N O F C A R E: Client Diagnostic Statement acute Pain related to physical injury agent (open wound L foot) as evidenced by self-report of intensity using standardized pain scale (4 to 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 with ease, full weight-bearing by discharge (7/1).

ACTIONS/INTERVENTIONS Pain Management: Acute 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.

RATIONALE 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.

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CHAPTER 1

PL A N O F C A R E:

The Nursing Pro cess: Planning Care Using Critical Thinking

Client Diagnostic Statement ineffective peripheral Tissue Perfusion related to insufficient knowledge of disease process and modifiable factors, as evidenced by decrease in peripheral pulses, alteration in skin characteristics [pale/cool feet], capillary refill 4 sec, paresthesia [of feet]. 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 4 sec (daily; ongoing).

ACTIONS/INTERVENTIONS Circulatory Care: Arterial Insufficiency NIC 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. 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.

RATIONALE 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.

PL A N O F C A R E: Client Diagnostic Statement ineffective Health Management related to insufficient knowledge of therapeutic regimen, perceived benefit/susceptibility or seriousness of condition as evidenced by failure to include treatment regimen in daily living [home glucose monitoring, foot care] and failure to take action to reduce risk factors. 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.). 23

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ACTIONS/INTERVENTIONS 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. 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. 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 and 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.

RATIONALE 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 dif ferent 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.

Reduces risk of tissue injury; promotes understanding and prevention of pressure ulcer formation and woundhealing difficulties.

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 facility 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 ½ cup grape juice for immediate response and snack within 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.

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CHAPTER 1

RATIONALE (continued) Understanding of necessary actions in the event of mild to severe illness promotes competent self-care and reduces risk of hyperglycemia or hypoglycemia. Fingerstick monitoring provides accurate and timely information regarding diabetic control.

The Nursing Pro cess: Planning Care Using Critical Thinking

ACTIONS/INTERVENTIONS (continued) 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, premeal 80 to 120. Discuss other healthcare issues, such as smoking habits, self-monitoring for cancer (breasts and testicles), and reporting changes in general well-being.

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.

25

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CHAPTER

2

Cardiovascular

HYPERTENSION: SEVERE I. Pathophysiology a. Multifactorial i. Complex interactions between the vasculature, kidneys, sympathetic ner vous system, baroreceptors, renin-angiotensin-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 and Severity— (Scordo, 2015; American Heart Association ([AHA], 2014; Scordo & Pickett, 2015; Weber et al, 2014) (American College of Cardiology/American Heart Association [ACC/AHA], 2017)

a. Normal adult blood pressure (BP)—less than 120/100/min • Accentuated second heart sound (53% with PE) • Peripheral pulse may be diminished in the affected extremity • Varicosities or dilated veins • Skin color and temperature in affected extremity: variable discoloration, may be pinkish red, warm along the superficial vein (over area of thrombosis in DVT) (Patel et al, 2016) • Pallor or cyanosis (PE) • Differences in leg circumferences: affected leg may be larger than the unaffected leg when measured 10 cm (4 inches) below the kneecap (tibial tuberosity) • Syncope

Ego Integrity • Sense of impending doom (PE)

• Apprehension

Food/Fluid • Poor skin turgor, dry mucous membranes (dehydration predisposes to hypercoagulability) • Obesity (predisposes to stasis and pelvic vein pressure)

Pain/Discomfort • Throbbing, tenderness, aching pain aggravated by standing or movement of affected extremity (DVT) • Severe crushing chest pain (during onset of PE) • Pleuritic chest pain (sharp pain on inhalation or exhalation) may be present (84%) • Pain may radiate through to back or into jaws and/or ears (PE)

• Guarding of affected extremity

Respiratory • Sudden-onset shortness of breath • Cough, with or without sputum production

• Dyspnea (73% with PE) • Tachypnea (rate over 18 breaths/min) (96%) (Ouellette et al, 2016) • Normal lung sounds can be present (PE), although crackles (rales) are common (53%) • Sputum may be pink tinged

Safety • History of direct or indirect injury to extremity or vein, such as major trauma or fractures, orthopedic or pelvic surgery, surgical procedures longer than 2 hours, urologic surgery, pregnancy, prolonged labor with fetal head pressure on pelvic veins, heart failure, venous cannulation or catheterization, or IV therapy

• Fever, chills

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(continued)

M AY E X H I B I T

CHAPTER 2

M AY R E P O R T

(continued)

• Presence of malignancy, particularly neoplasms of the pancreas, lung, gastrointestinal system, prostate • Sepsis

Cardiovascular: Thromboembolism: Venous & Pulmonary

Teaching/Learning • Use of oral contraceptives and estrogens; recent anticoagulant therapy predisposes to hypercoagulability • Use of vitamins and herbal supplements, such as vitamin B6, vitamin E, niacin, magnesium, l-carnitine, and bromelain, for heart or blood pressure health • Recurrence and lack of resolution of previous thrombophlebotic episode

Discharge Plan Considerations • Temporary assistance with shopping, transportation, and homemaker and maintenance tasks • Properly fitted antiembolic hose ➧ 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 • 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; and white blood cell (WBC) count and differential. • Coagulation profile: (e.g., prothrombin time and activated partial thromboplastin time) to evaluate for a hypercoagulable state.

• D- dimer assay: Measures fibrin degradation fragments generated by fibrinolysis.

• Troponins: Protein molecules that are part of cardiac and skeletal muscle.

Hemoconcentration (elevated Hct) potentiates risk of thrombus formation. WBC count may be normal or elevated in patients with pulmonary embolism.

Identifies clotting problems that may increase one’s risk of VTE. For example, antithrombin is useful in determining cause of hypercoagulation; inherited biochemical conditions; and deficits in certain other coagulation modulators, such as antithrombin III, protein S, or protein C, that can predispose client to thrombus formation. An elevated D-dimer level indicates a thrombotic process but is not specific to DVT. Combining D-dimer results with measurement of the exhaled end-tidal ratio of carbon dioxide to oxygen (etCO2/O2) can be useful for diagnosis of pulmonary embolism (Ouellette et al, 2016). Cardiac troponins (cTnT and CTnI) may be elevated in patients with confirmed PE. Elevated cTnTs and cTnIs also correlate with the severity of right ventricular (RV) dysfunction, most likely because of acute right ventricular myocardial stretch (Glatter, 2008; Konstantinides, 2008). (continues on page 124)

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D I A G N O S T I C S T U D I E S (contd.) WHY IT IS DONE

(continued)

W H AT I T T E L L S M E

(continued)

Other Diagnostic Studies (Wilber & Shian, 2012) • Noninvasive flow studies (Doppler ultrasound; compression ultrasonography duplex venous ultrasound): Detect and measure blood flow.

• Contrast venography: A special x-ray of the veins that is performed by first injecting a radiopaque contrast into the vein in question and then taking a conventional x-ray.

• CT scan with or without contrast: A series of x-ray images taken from different angles using computer processing to create cross-sectional images of body. • Computed tomography angiography (CTA): Uses an injection of iodine-rich contrast material and CT scanning to help diagnose and evaluate blood vessel disease or blockages. • Ventilation-perfusion (V/Q) scanning: Imaging test that uses special x-ray scanners to create pictures of air and blood flow patterns in the lungs. • Magnetic resonance imaging (MRI): Technique that uses the properties of magnetic fields to provide images of the body.

Ultrasound imagery can reveal a thrombus in a deep vein, especially above the knee. The Doppler ultrasound measures the blood flow velocity in veins and can detect flow abnormalities. Note: In most circumstances, compression ultrasonography is the test of choice for patients with suspected DVT. When a blood clot is present in a vein, it is relatively difficult to collapse, making compression ultrasound a reliable indicator of DVT, especially in veins of the groin and thigh (Fogoros, 2016; Pai & Douketis, 2016). Duplex venous ultrasonography appears to be the most accurate noninvasive method for diagnosing multiple proximal VTE in iliac, femoral, and popliteal veins but is less reliable in detecting isolated calf vein thrombi. Used to demonstrate a vein blockage. Radiographically confirms diagnosis through changes in blood flow and size of channels. Note: Although considered the gold standard for diagnosing DVT, this study carries a risk of inducing VTE and therefore is reserved for the client with negative or difficult to interpret noninvasive studies. Contrast-enhanced CT scanning is increasingly used as the initial radiologic study in the diagnosis of PE, especially in patient with abnormal chest x-ray. Considered by the American College of Radiology to be standard of care for detection of PE. May be used to establish PE when CT scanning not available or contraindicated. May be done for diagnosis of both proximal and distal VTE and is believed to be superior to other diagnostic tests for detection of pelvic VTE or suspected VTE of the inferior vena cava or pelvic veins. MRI is highly sensitive for detection of central, lobar, or segmental PE.

NURSING PRIORITIES

DISCHARGE GOALS

1. Maintain or enhance tissue perfusion and facilitate resolution of thrombus. 2. Maintain adequate oxygenation. 3. Promote optimal comfort. 4. Prevent complications. 5. Provide information about disease process, prognosis, and treatment regimen.

1. 2. 3. 4. 5.

Tissue perfusion improved in affected limb. Pain or discomfort relieved. Absence of symptoms of respiratory distress. Complications prevented or resolved. Disease process, prognosis, and therapeutic needs understood. 6. Plan in place to meet needs after discharge.

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CHAPTER 2

N U R S I N G D I AG N OS I S:

ineffective peripheral tissue Perfusion

May Be Related To Deficient knowledge of disease process or aggravating factors (e.g., sedentary lifestyle/immobility, trauma, smoking, obesity)

Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral NOC Demonstrate improved perfusion as evidenced by peripheral pulses present, equal skin color, and temperature normal and absence of edema. Engage in behaviors or actions to enhance tissue perfusion (e.g., engage in regular exercise, cessation of smoking, disease management). Display increasing tolerance to activity. ACTIONS/INTERVENTIONS

RATIONALE

Embolus Care: Peripheral NIC Independent

Inspect legs from groin to foot for skin color and temperature changes as well as edema. Note symmetry of calves; measure and record calf circumference. Report proximal progression of inflammatory process and traveling pain.

Examine extremity for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along the course of the vein. Evaluate client for Homans’ sign (pain in the calf of the leg upon dorsiflexion of the foot with the leg extended) per protocol.

Promote early ambulation.

Elevate legs when in bed or chair, as indicated.

Initiate active or passive exercises while in bed or chair; for example, flex, extend, and rotate feet periodically. Assist with ambulation as needed as soon as client is out of bed. Caution client to avoid crossing legs or hyperflexion at knee, such as seated position with legs dangling or lying in jackknife position. Instruct client to avoid rubbing or massaging the affected extremity.

Symptoms help distinguish between thrombophlebitis and VTE. Redness, heat, tenderness, and localized edema are characteristic of superficial involvement. Calf vein involvement is associated with the absence of edema; femoral vein involvement is associated with mild to moderate edema, and iliofemoral vein thrombosis is characterized by severe edema. Note: Unilateral edema is one of the most reliable physical findings in DVT. Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebitis in superficial veins may be visible or palpable. Homans’ sign is easily applied at point of care and is an assessment that clinicians often perform. However, its use is considered unreliable because Homans’ sign is absent in many clients with VTE and can be positive in several other conditions beside DVT. A negative Homans’ sign, on the other hand, doesn’t automatically exclude DVT (Patel et al, 2016). Short, frequent walks are better for extremities and prevention of pulmonary complications than one long walk. If client is confined to bed, engage in range-of-motion exercises. Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistention and thereby increasing venous return. Note: Some physicians believe that elevation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity. These measures are designed to increase venous return from lower extremities and reduce venous stasis as well as improve general muscle tone and strength. Physical restriction of circulation impairs blood flow and increases venous stasis in pelvic, popliteal, and leg vessels, thus increasing swelling and discomfort. This activity potentiates risk of fragmenting and dislodging thrombus, causing embolization and increasing risk of complications.

Cardiovascular: Thromboembolism: Venous & Pulmonary

Possibly Evidenced By Edema, extremity pain Diminished pulses, capillary refill >3 seconds Alteration in skin characteristics (e.g., color, temperature, sensation)

(continues on page 126)

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ACTIONS/INTERVENTIONS (continued) Encourage deep-breathing exercises. Increase fluid intake to at least 1500 to 2000 mL/d, within cardiac tolerance.

RATIONALE (continued) Increases negative pressure in thorax, which assists in emptying large veins. Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.

Collaborative

Administer pharmacological measures, as indicated: Heparin sodium via continuous or intermittent IV and intermittent subcutaneous (SC) injections

Low-molecular-weight heparin (LMWH) preparations, such as enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep), and fondaparinux (Arixtra) via SC injections Oral anticlotting agents; vitamin K antagonists, e.g., warfarin (Coumadin, Jantoven)

Factor Xa inhibitors, e.g., rivaroxaban (Xarelto), apixaban (Eliquis), and fondaparinux (Arixtra)

Direct thrombin inhibitors, e.g., dabigatran (Pradaxa) and bivalirudin (Angiomax) Thrombolytic agents, such as tenecteplase (TNKase), activase (Alteplase), and reteplase (Retavase)

Monitor laboratory studies, as indicated: Platelet counts (if on heparin); prothrombin time (PT), partial thromboplastin time (PTT), activated prothrombin time (aPTT), international normalized ratio (INR) (if on warfarin), hemoglobin/hematocrit (Hgb/ Hct), as indicated Apply and regulate graduated compression stockings and intermittent pneumatic compression if indicated. Apply elastic support hose following acute phase. Take care to avoid tourniquet effect.

Pharmacological measures involve various types of anticoagulation to reduce blood coagulability. Heparin prevents extension of the thrombus by preventing the conversion of prothrombin to prothrombin at low doses and preventing the conversion of fibrinogen to fibrin in higher does. It has been shown to significantly reduce (but may not eliminate) the incidence of fatal and nonfatal pulmonary embolism and recurrent thrombosis. The efficacy and safety of LMWH for the initial treatment of deep venous thrombosis have been well established in several trials. May be used as “bridging” drugs while client starts oral anticoagulant therapy. Coumadin has a potent depressant effect on liver formation of prothrombin from vitamin K and impairs formation of factors VII, IX, and X (extrinsic pathway). Coumadin is generally used for long-term postdischarge therapy to keep international normalized ratio (INR) at 2 to 3. However, it does have a narrow therapeutic window and requires frequent monitoring. Many foods, drugs, and disease processes alter Coumadin’s effectiveness, sometimes making it difficult to regulate. These drugs have been approved for treating DVT and PE and for prevention of recurrences. Benefits of these agents include no need for heparin bridging, and drugs can be given in fixed doses without routine coagulation monitoring. Note: Fondaparinux is administered SC, whereas other drugs listed here are given orally (“Antiarrhythmic Agents,” 2017; Patel et al, 2016). Inhibits free and clot-bound thrombin and thrombininduced platelet aggregation. Used in both treatment and prevention of VTE (Patel et al, 2016). May be used in hemodynamically unstable client with PE or massive VTE. Note: Currently accepted indications for thrombolytic therapy include hemodynamic instability (systolic BP 40 • Age 5 years: >20 • Dyspnea • Retractions (suprasternal, intercostal, or subcostal); nasal flaring • Grunting • Apnea • Altered mental status • Sputum: Scanty or copious; pink, rusty, or purulent (green, yellow, or white)

(continues on page 150)

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C L I E N T A S S E S S M E N T D ATA B A S E (contd.) M AY R E P O R T

(continued)

M AY E X H I B I T

(continued)

Safety • Recurrent chills • History of altered immune system, such as systemic lupus erythematosus (SLE), AIDS, active malignancies, neurological disease, HF, diabetes, steroid or chemotherapy use; institutionalization, general debilitation

• Diaphoresis • Shaking • Fever

Teaching/Learning • Recent surgery, chronic alcohol use or long history of alcoholism, intravenous (IV) drug therapy or abuse, chemotherapy or other immunosuppressive therapy • Use of herbal supplements, such as garlic, ginkgo, licorice, onion, turmeric, horehound, marshmallow, mullein, wild cherry bark, astragalus, echinacea, elderberry, goldenseal, Oregon grape root

Discharge Plan Considerations • Assistance with self-care, homemaker tasks • Supplemental oxygen, especially if recovery is prolonged or other predisposing condition exists ➧ 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

Diagnostic Tests • Chest x-ray: Evaluates organs and structures within the chest. Confirms the diagnosis of pneumonia. • Chest x-rays are not routinely done for children but should be obtained in child with suspected or documented hypoxemia or significant respiratory distress. • Ultrasonography: Uses ultrasonic waves to visualize internal organs for possible pathology.

Confirms diagnosis of pneumonia. Identifies structural distribution of pneumonia, such as lobar or bronchial. May show scattered or localized infiltration (bacterial) or diffuse and extensive nodular infiltrates (more often viral). In Mycoplasma pneumoniae, chest x-ray may be clear. Recent studies have found that point-of-care ultrasound imaging can diagnose pneumonia in children and young adults with higher specificity than x-ray (Shah et al, 2013).

Blood tests • Complete blood count (CBC): Battery of screening tests that 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. Provides baseline data about the hematologic system and yields information related to oxygencarrying capacity and infection. • Blood cultures: Determines presence of infection.

Leukocytosis with a left shift is usually present in bacterial pneumonia, although a low WBC count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia.

Identification of specific organism useful in choice of therapy for child requiring hospitalization for presumed bacterial pneumonia or in outpatient setting for children receiving antibiotic therapy who demonstrate progressive deterioration.

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(continued)

W H AT I T T E L L S M E

CHAPTER 3

WHY IT IS DONE

(continued)

Associated Tests

RSV washing: Detects virus that is being shed in the respiratory/nasal secretions of an infected child usually between age 6 months to 2 years. • Serologic studies (viral or Legionella titers, cold agglutinins): Assist in differential diagnosis of specific organism. • Arterial blood gases (ABGs): Measure oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia. • Pulse oximetry: Noninvasive measure of arterial blood oxygen diffusion and saturation. • Bronchoscopy: Insertion of a flexible scope into the airways allows direct visualization of tracheobronchial tree for abnormalities and to obtain sputum for cytological examination.

More than one type of organism may be present. Fifty percent of pneumonia cases are believed to be caused by viruses and tend to result in less severe illness than pneumonias triggered by bacteria. Mycoplasma pneumonia is one of the most common causes of atypical pneumonia. Opportunistic pneumonias (organisms causing disease in a host whose resistance to fight infection is diminished) consist of Pneumocystis carinii, cytomegalovirus, and tuberculosis (TB) (Benito et al, 2012). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia. Rapid results help guide treatment options and possible need for further testing if results are negative in a symptomatic child. Provide information on the specific organism causing the pneumonia or can rule out other diseases. Abnormalities may be present, depending on extent of lung involvement and underlying lung disease. The percentage expressed is the ratio of oxygen to Hgb. Pulse oximetry less than 90% indicates hypoxia. Abnormally low levels (30 mg/g [>3 mg/mmol]) iii. Fluid and electrolyte abnormalities may be present but are not clinically significant. iv. 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, proteinenergy 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. End-stage renal disease/kidney failure (GRF 8 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.

CHAPTER 8

ACTIONS/INTERVENTIONS (continued) Percutaneous nephrolithotomy (PNL) or open incision stone removal

risk for deficient Fluid Volume

Possibly Evidenced By Active fluid volume loss (e.g., nausea, vomiting) Failure of regulatory mechanisms (e.g., postobstructive diuresis) 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 and document I&O, noting 24-hour fluid balance.

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/d 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 impairment. Note: Impaired kidney functioning and decreased urinary output can actually 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 enough fluid to decrease chance of urinary supersaturation with stone-forming salts. The goal is a total urine volume in 24 hours in excess of 2 liters (Chirag et al, 2016). Indicators of hydration and circulating volume and need for intervention. Rapid weight changes suggest water loss or retention.

Collaborative

Monitor Hgb/Hct and electrolytes.

Assesses hydration and effectiveness of, or need for, interventions. (continues on page 664)

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ACTIONS/INTERVENTIONS (continued) 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).

N U R S I N G D I AG N OS I S:

RATIONALE (continued) Maintains circulating volume if oral intake is insufficient, promoting renal function. Easily digested foods decrease gastrointestinal (GI) activity or irritation and help improve fluid and nutritional balance. Reduces nausea and vomiting.

deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs

May Be Related To Insufficient information or interest in learning Insufficient knowledge of resources Possibly Evidenced By Insufficient knowledge Inaccurate follow-through of instructions or per formance of a procedure 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. ACTIONS/INTERVENTIONS

RATIONALE

Teaching: Disease Process NIC Independent

Review disease process and future expectations. Emphasize importance of increased fluid intake (including water, coffee, milk), roughly 3 to 4 L/d 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:

Avoid excess salt and protein. Advise that client discuss with physician or nutritionist specific recommendations for protein and animal fat.

Provides knowledge base from which client can make informed choices. Water is essential for stone formers as it significantly reduces calcium oxalate and calcium phosphate saturation, and uric acid production. Water also flushes renal system, decreasing opportunity for urinary stasis and stone formation. Research has shown that other fluids taken in sufficient volume (such as coffee [diuretic effect] and milk [raises urinary volume, meets calcium dietary reference intake (DRI), and chelates oxalate in foods and beverages]) are also beneficial in reducing stone formation (Goldfarb et al, 2005). Increased fluid losses or dehydration require additional intake beyond usual daily needs. Diet may or may not be an issue. However, understanding reason for modifications provides opportunity for client to make informed choices, increases cooperation with regimen, and may prevent recurrence. If a person is susceptible to forming stones, then foods high in animal proteins and salt may increase the risk; however, if a person isn’t susceptible to forming stones, diet probably will not change that risk. There is lack of consensus among clinicians concerning how little or how much protein affects stone formation, because studies have not produced sufficient evidence one way or another. Some clinicians have concluded that eating amounts of protein near the DRI does not increase risk of

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Avoid very high (>2500 mg/d) or very low (75 g) or with concomitant bladder stones or who cannot be positioned for transurethral surgery (Deters et al, 2017).

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CHAPTER 10

N U R S I N G D I AG N OS I S:

acute Pain

Men’s Health: Benign Prostatic Hyperplasia

May Be Related To Physical injury agents—[mucosal irritation (e.g., bladder distention/urinary retention; urinary infection)] Possibly Evidenced By Self-report of pain intensity and characteristics using a standardized rating scale Guarding and protective behavior Expressive behaviors (e.g., restlessness, irritability) Self-focus/narrowed focus 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: Acute NIC Independent

Assess pain, noting location, intensity (0 to 10 or similar coded scale), characteristics, and duration. 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.

Ascertain that client is taking medications for BPH as prescribed. Document and discuss with physician if medication changes may be needed in medication regimen.

Provides information to aid in determining choice and effectiveness of interventions. Promotes relaxation, refocuses attention, and may enhance coping abilities. Helps relax the smooth muscle in the prostate, easing the constriction of the urethra and bladder neck and increasing blood circulation to the pelvic region. Client should be constant in taking prostate medications as prescribed to reduce swelling, improve urine flow, and prevent or treat urinary retention. The client should also avoid medications known to be associated with urinary retention (e.g., those that contain decongestants).

Collaborative

Insert catheter and attach to straight drainage, as indicated. Maintain indwelling catheter when needed.

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)

N U R S I N G D I AG N OS I S:

Draining bladder reduces acute bladder tension and irritability. Indwelling catheter may be needed in the short term for acute urinary retention or may be required long term for chronic retention. 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

Possibly Evidenced By Failure of regulatory mechanism (e.g., postobstructive diuresis from rapid drainage of a chronically overdistended bladder) Desired Outcomes/Evaluation Criteria—Client Will Fluid Balance NOC Maintain adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, adequate capillary refill, and moist mucous membranes.

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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. Promote bedrest with head elevated.

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. Decreases cardiac workload, facilitating circulatory homeostasis.

Collaborative

Monitor electrolyte levels, especially sodium. Administer intravenous (IV) fluids—hypertonic saline as needed.

N U R S I N G D I AG N OS I S:

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 Stressors/threat to current status (change in health status; threat to self-concept; threat to role function [e.g., concern about sexual ability]) Possibly Evidenced By Increase in tension, apprehensiveness, uncertainty Worried about change in life event Desired Outcomes/Evaluation Criteria—Client Will Anxiety Self-Control NOC Appear relaxed and report anxiety is reduced to a manageable level. Verbalize accurate knowledge of the situation. Demonstrate problem-solving skills. Uses resources/support systems effectively. 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.

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.

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CHAPTER 10

N U R S I N G D I AG N OS I S:

deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs

Men’s Health: Benign Prostatic Hyperplasia

May Be Related To Insufficient information; insufficient interest in leaning; misinformation presented by others Insufficient knowledge of resources Possibly Evidenced By Insufficient knowledge Inappropriate behaviors—apathetic, withdrawn Inaccurate follow-through of instruction or per formance on a test or procedure Development of preventable complications 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. Perform necessary procedures correctly.

ACTIONS/INTERVENTIONS

RATIONALE

Teaching: Disease Process NIC Independent

Review disease process and client expectations.

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.

Review usual medication regimen.

Encourage reading of labels and discuss concerns with over-the-counter (OTC) drugs. Recommend avoiding spicy foods, coffee, alcohol, long automobile rides, and rapid intake of fluids.

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. 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. Note: 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 (Martin, 2016). 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 dif ferent drug. 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. (continues on page 694)

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ACTIONS/INTERVENTIONS (continued) 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.

RATIONALE (continued) 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 per formance. Prompt interventions may prevent more serious complications.

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 dif ferent organisms is not uncommon and requires changes in therapeutic regimen to prevent serious complications. Recent research reports increased risk of falls in the presence of moderate to severe BPH associated with urgency, nocturia, and straining to void, with fall risk increasing with age and symptom severity (Parsons, 2010).

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 Health Management—perceived barriers

PROSTATECTOMY Prostatectomy includes a number of surgical procedures to remove part or all of the prostate gland and can be performed in several ways depending on the condition involved and the recommended treatment approach. When medical and minimally invasive options for benign prostatic hyperplasia (BPH) have been unsuccessful, more invasive treatment options may be considered, such as transurethral resection of the prostate (TURP) or open prostatectomy. Simple prostatectomy removes part of the prostate and is generally recommended for men with severe urinary symptoms and very enlarged prostate gland (BPH) rather than cancer and can be performed open or robotically. Prostatectomy for localized prostate cancer is often a radical procedure, removing not only the prostate but also surrounding lymph nodes and/or other structures. Prostatectomy may be used alone or in conjunction with chemotherapy, radiation, and hormone therapy. Transurethral procedures may be performed before open prostatectomy when urinary retention is occurring because of obstruction.

I. Indications a. Benign prostatic hyperplasia (BPH)–related complications i. Urinary retention ii. Frequent urinary tract infections iii. Bladder stones secondary to bladder outlet obstruction iv. Recurrent gross hematuria v. Kidney damage from longstanding blockage vi. Failure to respond to medical or minimally invasive treatments b. Prostate cancer II. Procedures (AUA, 2014; Khera et al, 2015; Mayo Clinic Staff, 2017)

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), and holmium laser resection of the prostate (HoLRP)

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CHAPTER 10

III. Statistics a. Morbidity: In 2010, 138,000 prostatectomy (for any diagnosis) procedures were performed in short-stay hospitals in the United States (Centers for Disease Control and Prevention [CDC], 2016). The most commonly performed procedures are prostatectomy and TURP, although numerous other less invasive procedures are on the rise (El-Hakim, 2010). b. Mortality: Prostatectomy is a relatively low-risk procedure (mortality stated as 0% or less than 1% and usually associated with cardiovascular disease) (Guilli et al, n.d.). The current 5-year survival rate for prostate cancer (stage dependent) is 98.6%, despite the fact that it was estimated that 26,730 would die of it in 2017 (National Cancer Institute, Surveillance, Epidemiology, and End Results Program [SEER], 2014). c. Cost: In 2017, the direct costs for treatment of prostate cancer totaled $14.3 billion (NCI, 2018). A study of 1499 men who underwent robotic prostatectomy and 2565 men who had retropubic prostatectomy between 2008 and 2011 in Maryland reported that during that study period, the cost of a robotic prostatectomy averaged $14,000 compared with $10,100 for retropubic prostatectomy (Bankhead, 2012).

Men’s Health: Prostatectomy

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— Obstructing prostatic tissue is removed through a low midline incision made through the bladder. iii. Retropubic prostatectomy—Hypertrophied prostatic tissue mass located high in the pelvic region is removed through a low abdominal incision without opening the bladder. iv. Perineal prostatectomy—Large prostatic masses low in the pelvic area are removed through an incision between the scrotum and the rectum.

G L O S S A R Y 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. 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 short-stay inpatient acute surgical unit.

Benign prostatic hyperplasia (BPH), page 686 Cancer, page 945 Psychosocial aspects of care, page 835 Surgical intervention, page 873

C L I E N T A S S E S S M E N T D ATA B A S E Refer to CP: Benign Prostatic Hyperplasia (BPH) for assessment data.

DIAGNOSTIC DIVISION M AY R E P O R T

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.

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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.

N U R S I N G D I AG N OS I S:

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) 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 after TURP. 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 incontinence.

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 and if not contraindicated by cardiac or kidney disease. Limit evening fluids once catheter is removed. Instruct client in perineal exercises, trying to repeatedly stop and start urine stream several times a day.

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. Urinary incontinence (associated with sphincter insufficiency and bladder dysfunction) is a common complication following prostate surgery and persists for varying lengths of time. Note: A review of two randomized trials of incontinent men postsurgery compared one-to-one sessions with a physical therapist to standard care and lifestyle advice only. High rates of incontinence persisted in both groups after 12 months. Pelvic floor muscle training after prostate surgery is unlikely to be effective (Glazner et al, 2011). Voiding with urge can reduce risk of urinary retention. However, limiting voids to every 4 hours, if tolerated, can increase 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. Although not always successful in men after prostatectomy, exercise should be initiated to regain bladder sphincter control, in effort to minimize incontinence over time (Robinson, 2016; Sobol, 2016). Information can help client deal with and manage the problem.

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CHAPTER 10

ACTIONS/INTERVENTIONS (continued)

RATIONALE (continued)

Collaborative

N U R S I N G D I AG N OS I S:

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.

Men’s Health: Benign Prostatic Hyperplasia

Maintain continuous bladder irrigation (CBI), as indicated, in early postoperative period. Measure residual volumes via suprapubic catheter, if present, or with Doppler ultrasound.

risk for Bleeding

Possibly Evidenced By Treatment-related side effects (e.g., surgery—vascular nature of surgical area) 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/d unless contraindicated by medical condition. Bleeding Reduction NIC Anchor urethral catheter and avoid excessive manipulation.

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. If these symptoms are present, client may be hypovolemic due to overt or hidden hemorrhage. Hypovolemia requires prompt intervention to prevent impending shock. Note: Hypertension, bradycardia, and nausea or vomiting suggest TURP syndrome, requiring immediate medical intervention. TURP syndrome occurs because of fluid overload and hyponatremia associated with the use of large amounts of irrigation fluids flushing the bladder during surgery. If this solution is low in sodium, and the body absorbs too much of the fluid, the sodium level in the entire body can fall rapidly. Symptoms can occur within minutes to around 24 hours after surgery and can range from mild to life-threatening (Whitlock, 2017). May reflect decreased cerebral perfusion (hypovolemia) or indicate cerebral edema from excessive solution absorbed into the venous sinusoids during TURP procedure (TURP syndrome). Signs of persistent bleeding may be evident or sequestered within tissues of the perineum. Helps maintain circulating fluid volume.

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. (continues on page 698)

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ACTIONS/INTERVENTIONS (continued) 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.

RATIONALE (continued) 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 Serum sodium Administer intravenous (IV) therapy or blood products, as indicated. Maintain traction on indwelling catheter; tape catheter to inner thigh. Release traction within 4 to 5 hours. Document period of application and release of traction, if used. Administer stool softeners or laxatives, as indicated.

N U R S I N G D I AG N OS I S:

Useful in evaluating blood losses and replacement needs. May indicate developing complications that can potentiate bleeding or clotting. Monitors for presence of hyponatremia. 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.

risk for Infection

Possibly Evidenced By Alteration in skin/tissue integrity—traumatized tissue, surgical incision, drains Invasive procedures (e.g., instrumentation during surgery, indwelling catheter, frequent bladder irrigation) 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.

Prevents introduction of bacteria and resultant infection.

Avoids backward reflux of urine, which may introduce bacteria into the bladder. Client who has had 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.

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CHAPTER 10

ACTIONS/INTERVENTIONS (continued) Change suprapubic/retropubic and perineal incision dressings frequently, cleaning and drying skin thoroughly each time. Use ostomy-type skin barriers.

Men’s Health: Benign Prostatic Hyperplasia

RATIONALE (continued) 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.

N U R S I N G D I AG N OS I S:

May be given prophylactically because of increased risk of infection with prostatectomy.

acute Pain

May Be Related To Physical injury agents (e.g., operative procedure; irritation of bladder mucosa; reflex muscle spasm) Possibly Evidenced By Self-report of pain intensity and characteristics using a standardized rating scale Guarding and protective 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. ACTIONS/INTERVENTIONS

RATIONALE

Pain Management: Acute 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/d, 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 TURP 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. Reduces muscle tension, refocuses attention, and may enhance coping abilities.

Collaborative

Administer antispasmodics, such as: Oxybutynin (Ditropan), flavoxate (Urispas), B&O suppositories Propantheline bromide (Pro-Banthine)

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. 699

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N U R S I N G D I AG N OS I S:

risk for Sexual Dysfunction

Possibly Evidenced By Perceived sexual limitation; undesired change in sexual function Situational crisis—incontinence/leakage of urine, involvement of genital area Vulnerability (e.g., change in health status, threat to self-concept) 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.

Discuss retrograde ejaculation if transurethral or suprapubic approach is used.

Instruct in perineal and pelvic floor exercises and interruption of urinary stream exercises.

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 reported postoperatively in approximately 2% to 3% of patients following suprapubic prostatectomy (Khera et al, 2015). 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 ejaculation has been reported in up to 80% to 90% of patients after surgery (Khera et al, 2015). Tightening pelvic floor muscles prior to standing, coughing, and sneezing promotes regaining bladder and, perhaps, erectile function.

Collaborative

Refer to sexual counselor as indicated.

N U R S I N G D I AG N OS I S:

Persistent or unresolved problems may require professional intervention.

deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs

May Be Related To Insufficient information or knowledge of resources; insufficient interests in learning; misinformation presented by others Possibly Evidenced By Insufficient knowledge Inaccurate follow-through of instruction; development of preventable complications

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N U R S I N G D I AG N OS I S:

deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs (continued)

ACTIONS/INTERVENTIONS

Men’s Health: Benign Prostatic Hyperplasia

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. RATIONALE

Teaching: Disease Process NIC Independent

Review implications of procedure and future expectations. Emphasize 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 catheterrelated problems and care. Emphasize 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 ser vices, medical equipment supply company, housekeeping, and support persons.

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. 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 ejaculation. 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. 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) 701

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CHAPTER

11

Orthopedic Disorders

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 & Page, 2016) a. Common causes: Trauma, such as car crashes, falls, natural disasters, blunt force, and penetrating force. Fractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries (Flaherty et al, 2014; Rennie et al, 2007). Common mechanisms of injury in children with growth plate fractures include motor vehicle crashes (including pedestrians and cyclists), sports-related injuries, and falls. b. Osteoporosis, which leaves bones thinned and weakened. Fractures of the spine, hip, or wrist are the most common types in persons with osteoporosis. c. Repetitive stress, often associated with athletics (e.g., result of increasing amount or intensity of an activity too rapidly, improper equipment; increased physical stress, such as substantial increase in exercise time) d. Bone tumors, can be malignant or benign e. Infections, such as osteomyelitis; may be acute or chronic f. The energy (high vs low) and velocity (speed) and direction of injury dictate the type and severity of fractures. 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. Types: (1) closed (also called simple) or open (formerly called compound), (2) complete (through the entire bone), (3) incomplete (the fracture does not go all the way through the bone), and (4) comminuted (broken into three or more parts [multifragmentary], where there is no contact between proximal and distal bone fragments). c. Fracture patterns: (1) spiral (from rotational force), (2) greenstick (one side of bone is broken and the other only bent), (3) oblique (angled fracture line), (4) transverse (horizontal fracture line), and (5) dislocated (fracture causes dislocation of part of joint, e.g., elbow, cervical vertebrae). Note: Spiral fractures are common in toddlers from relatively minor trauma and can occur in older children from skiing and contact sports; greenstick

fractures occur most often during infancy and childhood when bones are soft. d. Open fractures are further classified as (Gustilo et al, 1990) i) Type I (low-energy, simple fracture with wound opening less than 1 cm) ii) Type II (also considered a low- energy injury, minimally contaminated, and without major softtissue damage or defect; with wound size greater than 1 cm) iii) Type III (wound is longer than 1 cm; the mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation and significant soft tissue disruption). Type III is further divided into subtypes: (a) IIIA: Wound has enough healthy soft tissue to cover bone without need for skin graft coverage. (b) IIIB: Disruption of soft tissues is extensive enough that skin grafting is necessary to cover bone; wound may be contaminated; multiple debridement procedures may be needed. (c) IIIC: Open fracture is associated with vascular and neurologic injuries and requires vascular and plastic surgery. e. The types of fractures typically occurring to children are Salter-Harris fractures, distal radius fractures (torus fractures and greenstick fractures), clavicular fractures, tibial shaft fractures, and radial head subluxation or nursemaid elbow. 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 & Page, 2016; 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 fi rst 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.

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CHAPTER 11

V. Statistics a. Morbidity: In 2010, 671,000 Americans had open reduction for fractures listed on hospital discharge. Of those, 94,000 were under the age of 15 (Centers for Disease Control and Prevention [CDC], 2010). The National Hospital Ambulatory Medical Care Survey for 2013 reported that fractures accounted for 3,300,831 visits to the emergency department in 2013. 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: Currently available mortality studies are associated with hip fractures (many related to the aging population and rising incidence of osteoporosis). Kim et al reported overall mortality rate of hip fractures as 15% to 20%, yet in older persons, this can increase to 36% over the year following hip fracture (Davenport, 2016; Kim et al, 2008). c. Cost: Because of the wide variety of fractures and treatment types and healthcare settings, no general figures are available about fractures. Figures are available regarding some very specific conditions and associated direct costs. For example, the estimated annual cost of hip fractures in 2009 in the United States ranged from $10.3 to $15.2 billion (LaBlanc et al, 2014). For a client without health insurance, surgical treatment of a broken leg typically costs $17,000 to $35,000, not including the surgeon’s fee.

Orthopedic Disorders: Fractures

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 meshlike callus of woven bone is replaced by a hard, rigid form of connective tissue (lamellar bone). Eventually, the woven bone and cartilage are 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. 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.

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. 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: Growth plate (physeal) fractures are defined as disruptions in the cartilaginous physis of long bones that may or may not involve epiphyseal or metaphyseal bone (Jones et al, 2017). There are two growth plates in immature long bones: the horizontal growth plate (physis) and the spherical growth plate (enables epiphyseal growth) (Rabin, 2017). 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. Remodeling: Stage in which fracture healing is completed (i.e., bone is restored to its original shape, structure, and mechanical strength). Remodeling of the bone occurs slowly over months to years. (continues on page 704)

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G L O S S A R Y

(continued)

Salter-Harris fracture: Common fracture that occurs in growth plate in children. There are five types of SalterHarris growth plate fractures. Note: An estimated 75% of all physeal fractures are type 2 and the most common physeal fracture in children (Rabin, 2017; Wound Care Society, 2016). 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 medicalsurgical 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

Craniocerebral trauma—acute care and rehabilitation, page 226 Pediatric considerations, page 993 Pneumonia, page 147 Psychosocial aspects of care, page 835 Acute kidney injury (acute renal failure), page 595 Spinal cord injury (acute care and rehabilitative phase), page 288 Surgical intervention, page 873 Venous thromboembolism (VTE) disease including deep vein thrombosis (DVT) and pulmonary embolism (PE), page 120

C L I E N T A S S E S S M E N T D ATA B A S E Symptoms of fracture depend on the site, severity, type, and amount of damage to other structures.

DIAGNOSTIC DIVISION 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

• 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 • Discrepancy in limb length

Circulation • 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 • Pallor of affected part • Tissue swelling • Bruising or hematoma mass at site of injury

Elimination • Hematuria • Changes in output—acute renal failure (ARF) with major skeletal muscle damage

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(continued)

M AY E X H I B I T

CHAPTER 11

M AY R E P O R T

(continued)

Neurosensory • Local musculoskeletal deformities—abnormal angulation, posture changes, shortening of limbs, rotation, or crepitation • Giving way or collapse, locking of joints, dislocations • Muscle spasms • Visible weakness or loss of function

Orthopedic Disorders: Fractures

• Loss of or impaired motion or sensation • Muscle spasms worsening over time • Numbness or tingling (paresthesias)

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, irritability, moaning, crying • Self-focus

Safety • Use of alcohol or other drugs • Circumstances of incident may not support type of injury incurred—may be suggestive of abuse

• Skin lacerations • Tissue avulsion • Bleeding • Color changes of skin • Presence of risk factors for falling—age, osteoporosis, dementia, arthritis, other chronic conditions; preexisting unrecognized fracture

Teaching/Learning • Use of multiple medications—prescribed and/or over-thecounter (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.

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 et al, 2006). (continues on page 706)

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D I A G N O S T I C S T U D I E S (contd.) WHY IT IS DONE

(continued)

• 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 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.

N U R S I N G D I AG N OS I S:

(continued)

Fracture stabilized. Pain controlled. Complications prevented or minimized. Condition, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge.

risk for Injury [additional]

Possibly Evidenced By Physical (e.g., loss of skeletal integrity [fractures]; movement of bone fragments) 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 immobilization through splinting, casting (fiberglass or plaster of Paris), or traction apparatus (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. Note: With the advancement of orthopedic implant technology and operative techniques, traction is rarely used for definitive fracture/dislocation management (Buckley & Page, 2016). Provides stability, reducing possibility of disturbing alignment and aggravating muscle spasms, which enhances healing.

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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.

RATIONALE (continued) 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.

Orthopedic Disorders: Fractures

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.

CHAPTER 11

ACTIONS/INTERVENTIONS (continued)

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.

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 may still be used in some instances of femur fracture in children and older adults or clients 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, or weights, thus allowing for greater client mobility and comfort and facilitating wound care.

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. N U R S I N G D I AG N OS I S:

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 injury agents [e.g., muscle spasms, movement of bone fragments, soft tissue injury, traction/immobility device] Possibly Evidenced By Self-report of intensity and characterizes of pain using standardized pain scale/instrument Self-focused/narrowed focus; facial expression of pain Guarding/protective behavior Changes in vital signs (continues on page 708)

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N U R S I N G D I AG N OS I S:

acute Pain (continued)

Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain is relieved or controlled. 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: Acute NIC Independent

Maintain immobilization of affected part by means of bedrest, cast, splint, and traction. (Refer to ND: risk for Injury [additional].) 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 age appropriate 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 impor tant 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. 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.

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. 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.

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.

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RATIONALE (continued) Given to reduce pain and/or muscle spasms.

Orthopedic Disorders: Fractures

N U R S I N G D I AG N OS I S:

CHAPTER 11

ACTIONS/INTERVENTIONS (continued) Administer medications, as indicated: opioid and nonopioid analgesics, such as morphine, meperidine (Demerol), or hydrocodone (Vicodin); injectable and oral nonsteroidal anti-inflammatory drugs (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.

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

Possibly Evidenced By Fractures; trauma; orthopedic surgery; immobilization Vascular obstruction Mechanical compression (e.g., cast, dressing) Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral NOC Maintain function as evidenced by absence of pallor and palpable pulses, movement, and sensation (CMS) within normal range for individual. 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.

Assess capillary return, skin color, and warmth distal to the fracture.

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, 2016). 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. Return of color should be rapid (3–5 seconds in adults—time 25%, who is unconsciousness or has other neurologic findings, cardiovascular dysfunction, pulmonary edema, or severe metabolic acidosis (Lafferty et al, 2017). Changes reflecting atelectasis or pulmonary edema may not occur for 2 to 3 days after burn injury. Chest physiotherapy drains dependent areas of the lung, and incentive spirometry may be done to improve lung expansion, thereby promoting respiratory function and reducing atelectasis. Note: Bronchoscopy may be done to remove endotracheal debris. Intubation and mechanical support is required when airway edema or circumferential burn injury interferes with respiratory function and oxygenation. If client develops signs of respiratory failure or ARDS, mechanical ventilation and intensive respiratory care are required. (Refer to CP: Respiratory Failure/Ventilatory Assistance.)

Integumentary Disorders: Burns

Monitor carboxyhemoglobin (COHgb) levels, if indicated.

CHAPTER 12

ACTIONS/INTERVENTIONS (continued) Monitor serial ABGs.

risk for deficient Fluid Volume

Possibly Evidenced By Fluid loss through abnormal routes—burn wounds; hemorrhagic losses Factors influencing fluid needs—hypermetabolic state Deviations affecting fluid intake Desired Outcomes/Evaluation Criteria—Client Will Fluid Balance NOC Demonstrate adequate fluid balance as evidenced by appropriate urinary output with normal specific gravity, stable vital signs, and moist mucous membranes. ACTIONS/INTERVENTIONS

RATIONALE

Shock Prevention NIC Independent

Monitor vital signs and central venous pressure (CVP). Note capillary refill and strength of peripheral pulses.

Serves as a guide to fluid replacement needs and assesses cardiovascular response to fluid loss and fluid shifts. Note: The metabolic rate increases proportionally with burn size. A 15% to 20% TBSA burn injury initiates a catabolic response, including impaired immunity and accentuating fluid shifts. The burned client will initially have a low cardiac index and be extremely vasodilated (causing drop in blood pressure), then will go into a hyperdynamic state with tachycardia and increased cardiac output (Gauglitz & Williams, 2017). (continues on page 748)

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ACTIONS/INTERVENTIONS (continued) Monitor urinary output and specific gravity. Observe urine color and Hematest, as indicated.

Estimate wound drainage and insensible losses.

Maintain cumulative record of amount and types of fluid intake. Weigh daily.

Measure circumference of burned extremities, as indicated. Investigate changes in mentation.

Observe for gastric distention, hematemesis, and tarry stools. Hematest nasogastric (NG) drainage and stools periodically.

RATIONALE (continued) Generally, fluid replacement should be titrated to ensure average urinary output of 30 to 50 mL/hr in the adult. Urine can appear red to black due to muscle destruction causing release of myoglobin. Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24 to 72 hours after burn injury. During fluid resuscitation, there is fine line between adequate resuscitation and one that is associated with the deleterious effects of fluid overload. Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15% to 20% weight gain can be anticipated in the first 72 hours during fluid replacement, with return to preburn weight approximately 10 days after burn. May be helpful in estimating extent of edema and fluid shifts affecting circulating volume and urinary output. Deterioration in the level of consciousness may indicate inadequate circulating volume and reduced cerebral perfusion. Stress (Curling’s) ulcer occurs in up to half of all severely burned clients and can occur as early as the first week. Clients with burns more than 20% of TBSA are at risk for mucosal bleeding in the gastrointestinal (GI) tract during the acute phase because of decreased splanchnic blood flow and reflex paralytic ileus.

Collaborative

Insert and maintain indwelling urinary catheter.

Insert/maintain large-bore intravenous (IV) catheter(s). Administer calculated IV replacement of fluids, electrolytes, plasma, and albumin.

Monitor laboratory studies, such as Hgb/Hct, electrolytes, and urine sodium.

Administer medications, as indicated, such as the following: Diuretics, for example, mannitol (Osmitrol)

Allows for close observation of renal function and prevents urinary retention. Retention of urine with its by-products of tissue cell destruction can lead to renal dysfunction and infection. Accommodates rapid infusion of fluids. Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications, such as shock and acute tubular necrosis (ATN). Replacement formulas vary, such as Brooke, Evans, or Parkland, but all are based on extent of burn injury, body weight, and amount of urinary output. Note: Once initial fluid resuscitation has been accomplished (usually with lactated Ringer’s solution), a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion. The rate of fluid administration should be titrated to maintain a urine output of 0.5 mL/kg/h in older children (>50 kg). In small children, fluid should be maintained to produce urine output of approximately 1 mL/kg/h (Oliver, 2017). Identifies blood loss, RBC destruction, and fluid and electrolyte replacement needs. Urine sodium less than 10 mEq/L suggests inadequate fluid resuscitation. Note: During first 24 hours after burn, hemoconcentration is common because of fluid shifts into the interstitial space. May be indicated to enhance urinary output and clear tubules of debris to prevent necrosis if acute renal failure (ARF) is present.

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N U R S I N G D I AG N OS I S:

acute Pain

May Be Related To Physical injury agents (e.g., destruction of skin and tissues, edema formation, wound debridement) Possibly Evidenced By Self-report of intensity and characteristics of pain using standardized pain scale/instrument Expressive behavior (e.g., irritability, restlessness, crying) Narrowed focus; facial expression of pain—grimacing Guarding behavior Changes in vital signs

Integumentary Disorders: Burns

Antacids, for example, calcium carbonate (Titralac) and magaldrate (Riopan) and histamine inhibitors, for example, cimetidine (Tagamet) and ranitidine (Zantac) Add electrolytes to water used for wound debridement, as indicated.

RATIONALE (continued) Although hyperkalemia often occurs during first 24 to 48 hours due to tissue destruction, subsequent replacement may be necessary because of large urinary losses. Antacids may reduce gastric acidity; histamine inhibitors decrease production of hydrochloric acid to reduce risk of gastric irritation or bleeding. Washing solution that approximates tissue fluids may minimize osmotic fluid shifts.

CHAPTER 12

ACTIONS/INTERVENTIONS (continued) Potassium

Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Report pain reduced or controlled. Display relaxed facial expressions and body posture. Pain Control NOC Participate in activities and sleep and rest appropriately. ACTIONS/INTERVENTIONS

RATIONALE

Pain Management: Acute NIC Independent

Be aware of types of pain that can occur with burns during the acute phase and with burn injury treatment: (1) Acute pain short-term intense pain that typically happens during a procedure like dressing changes or physical therapy; (2) breakthrough pain comes and goes despite pain medications, often due to wound healing, contractures, or repositioning; (3) background pain is burn-associated pain that is almost always present but is of lower intensity than the acute pain experienced during wound procedures; (4) neuropathic pain is caused by damage to and/or regeneration of nerve endings in the skin (Connor-Ballard, 2009; Drug Therapy Perspectives, 2001; Wiechman & Mason, 2016). Assess client’s pain, ongoing, noting location/character and intensity (using a standardized coding scale [e.g., numbers, pictures; pain thermometer]).

Identifying what client is experiencing at the moment helps in anticipating type of pain management needed at any given time. For example: Following the initial burn injury, there is a massive stimulation of nerve endings in the damaged skin, which is painful regardless of burn depth (inflammatory reactions causing extreme sensitivity to painful stimuli [hyperalgesia]). Manipulation of the hyperalgesic areas in the course of wound care exacerbates pain.

Pain is the common experience of all clients with burns— regardless of the cause, size, or depth of the burn—and the pain they experience can be among the worst known. Changes in location, character, and intensity of pain may indicate developing complications (e.g., limb ischemia) or herald improvement and return of nerve function and Children with burn injuries, regardless of sensation. the severity of the burn, are often anxious and fearful in addition to being in physical pain, and each of these factors can exacerbate the other (Granger et al, 2009). Concerning analgesia needs in the burned child, Stafford and Curran stated “pediatric burns often require more (continues on page 750)

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ACTIONS/INTERVENTIONS (continued)

Note nonverbal indicators of pain (e.g., changes in vital signs, grimacing, inconsolable crying, restlessness, trembling, or withdrawal from verbal communication or touch), especially in client who is unable to verbalize. Cover wounds as soon as possible unless open-air exposure burn care method required. Elevate burned extremities periodically.

Wrap digits and extremities in position of function, avoiding flexed position of affected joints, using splints and footboards as necessary. Change position frequently and assist with active and passive range-of-motion (ROM) exercises, as indicated. Maintain comfortable environmental temperature; provide heat lamps and heat-retaining body coverings. Provide adequate pain medication and adjunctive medications, such as antianxiety drugs, before, during, or after a procedure, such as dressing changes and debridement.

Encourage expression of feelings about pain. Involve client in determining schedule for activities, treatments, and drug administration. Explain procedures and provide frequent information as appropriate, especially during wound debridement.

Provide basic comfort measures—being present, gentle touch or massage, and frequent position changes.

Instruct in and encourage use of stress management techniques, such as progressive relaxation, deep breathing, guided imagery, and visualization. Provide diversional activities appropriate for age and condition. Promote uninterrupted sleep periods.

RATIONALE (continued) frequent and larger doses than typically recommended. It is not uncommon to repeat full doses until adequate pain control is achieved” (Stafford & Curran, 2010). Client (adult or child) may not be able to verbalize pain or pain characteristics due to age, developmental level, loss of consciousness or other cognitive issues, and/or type and severity of injuries. Temperature changes and air movement can cause great pain to exposed nerve endings. Elevation may be required initially to reduce edema formation; thereafter, changes in position and elevation reduce discomfort and risk of joint contractures. Position of function reduces deformities and contractures and promotes comfort. Although flexed position of injured joints may feel more comfortable, it can lead to flexion contractures. Movement and exercise reduce joint stiffness and muscle fatigue, but type of exercise depends on location and extent of injury. Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling. The procedure may stimulate remaining nerve fibers, resulting in greater pain than was evident during the procedure. In some cases, conscious sedation for procedural pain may be needed to reduce severe physical and emotional distress associated with painful procedures. Verbalization allows outlet for emotions and may enhance coping mechanisms. Enhances client’s sense of control and strengthens coping mechanisms. Knowing what to expect provides opportunity for client to prepare self and enhances sense of control. Showing empathy and support can help alleviate pain and promote relaxation. Note: Burn injury and wound care often induces acute stress disorder, which heightens the pain Studies have shown that about 90% of experience. both adults and children with burn injuries report at least one symptom of acute stress disorder right after the traumatic event, but only about 30% develop posttraumatic stress disorder (PTSD) (Gianoni-Pastor et al, 2016). Promotes relaxation and reduces muscle tension and general fatigue. Note: Studies on both adults and adolescents found that massaging burn injuries during the remodeling stage (after the acute stage of wound debridement) significantly reduced itching, as well as pain and anxiety (Field et al, 2000; Parlak Gurol et al, 2010). Refocuses attention, promotes relaxation, and enhances sense of control, which may enhance analgesia and/or reduce pharmacological dependency. Helps refocus attention, lessening concentration on pain experience. Sleep deprivation can increase perception of pain and reduce coping abilities.

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CHAPTER 12

ACTIONS/INTERVENTIONS (continued)

RATIONALE (continued)

Collaborative

Provide and instruct in use of patient-controlled analgesia (PCA).

N U R S I N G D I AG N OS I S:

The burned client may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of client addiction or doubts regarding degree of pain experienced are not valid during emergent and acute phases of care, but opioids should be decreased as soon as feasible and alternative methods for pain relief initiated. Note: Research is ongoing in search of new technologies for the nonpharmacologic management of severe pain, which may positively impact burn-related pain. For example, in a recent small investigational study, the use of virtual reality (VR) technology was found to be superior to standard controlled distraction therapy for the management of pain in hospitalized individuals (Tashijan et al, 2017). PCA provides for timely drug administration, preventing fluctuations in intensity of pain, often at lower total dosage than would be given by conventional methods.

Integumentary Disorders: Burns

Administer analgesics (opioid and nonopioid) as indicated, such as morphine, fentanyl (Sublimaze, Ultiva), alfentanil (Alfenta), ketamine (Ketalar), hydrocodone (Vicodin, Hycodan), or oxycodone (OxyContin, Percocet)

risk for Infection

Possibly Evidenced By Alteration in skin integrity [destruction of skin barrier, traumatized tissues] Environmental exposure; invasive procedures Decreased in hemoglobin, leukopenia; suppressed inflammatory response Desired Outcomes/Evaluation Criteria—Client Will Burn Healing NOC Achieve timely wound healing free of purulent exudate and be afebrile. ACTIONS/INTERVENTIONS

RATIONALE

Infection Protection NIC Independent

Be aware of client at high risk for development of infection.

Examine wounds daily; document and report changes in appearance, odor, or quantity of drainage.

Emphasize and model good handwashing technique for all individuals coming in contact with client. Implement appropriate isolation techniques, as indicated.

Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens and gowns.

Infection is the most common cause of morbidity and mortality in the burn-injured population, with almost 61% of deaths being caused by infection (Fonseca & Hospenthal, 2016). Identifies presence of granulation tissue indicating healing and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: Early signs may not be obvious (changes are primarily in numbers of bacteria colonization in the wound). Cellulitis manifests as erythema, induration, warmth, and tenderness in the tissue surrounding the burn wound and, occasionally, the development of sepsis (Fonseca & Hospenthal, 2016). Prevents cross-contamination from one wound area to another and reduces risk of healthcare-acquired infection. Dependent on type and extent of wounds and the choice of wound treatment (e.g., open versus closed); isolation may range from simple wound and skin to complete or reverse to reduce risk of cross-contamination and exposure to multiple bacterial flora. Prevents exposure to infectious organisms.

(continues on page 752)

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ACTIONS/INTERVENTIONS (continued) Monitor and limit visitors, if necessary. Explain isolation procedure to visitors, if used. Supervise visitor adherence to protocol as indicated. Wound Care: Burns NIC Shave/clip all hair from around burned areas, (where indicated) to include a 1-inch border (excluding eyebrows). Shave facial hair (men) and shampoo head daily. Examine unburned areas, such as groin, neck creases, and mucous membranes, and note onset of vaginal discharge in women. Provide special care for eyes, for example, use eye covers and tear formulas as appropriate. Prevent skin-to-skin surface contact—wrap each burned finger or toe separately; do not allow burned ear to touch scalp. Monitor vital signs for fever and increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.

RATIONALE (continued) Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against client’s need for family support and socialization.

Hair is a good medium for bacterial growth; however, eyebrows act as a protective barrier for the eyes. Regular shampooing decreases bacterial fallout into burned areas. Opportunistic infections (e.g., yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy. Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage. Prevents adherence to the surface that it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis. Indicators of sepsis—often occurring with full-thickness burn—requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.

Collaborative

Remove dressings and cleanse burned areas in a hydrotherapy or whirlpool tub or in a shower stall with handheld showerhead. Maintain temperature of water at 100°F (37.8°C). Wash areas with a mild cleansing agent or surgical soap.

Excise and cover burn wounds quickly. Debride necrotic and loose tissue, including ruptured blisters, with scissors and forceps. Do not disturb intact blisters if they are smaller than 1 to 2 cm, do not interfere with joint function, and do not appear infected. Photograph wound initially and at periodic intervals. Infection Protection NIC Maintain aseptic technique when inserting invasive lines and tubes (e.g., Foley catheter). Remove invasive devises as early as possible.

Administer topical antimicrobial agents, as indicated, for example:

Water softens and aids in removal of dressings, slough layer of dead skin or tissue, and dry scabs or eschar. Sources vary as to whether bath or shower is best. Bath has advantage of water providing support for exercising extremities but may promote cross-contamination of wounds. Showering enhances wound inspection and prevents contamination from floating debris. Early excision is known to reduce scarring and risk of infection, thereby facilitating healing. Promotes healing and prevents autocontamination. Small, intact blisters help protect skin and increase rate of reepithelialization unless the burn injury is the result of chemicals, in which case fluid contained in blisters may continue to cause tissue destruction. Provides baseline and documentation of healing process.

Reduces access for healthcare-acquired infections related to invasive procedures and devices. Note: The clinical signs of sepsis in the burned client are subtle and are easily missed until septic shock is present. Client with burns has lost the primary barrier to infectious invasion (skin). In addition, the client with extensive burns develops a profound hypermetabolic response that heightens the risk for sepsis and multiple-organ dysfunction syndrome (MODS) as long as the wounds are open (Greenhalgh, 2017). The following agents help control bacterial growth and prevent drying of wound, which can cause further tissue destruction (Fonsesca & Hospenthal, 2016).

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Mafenide (Sulfamylon) solution or mafenide HCl cream

Silver-coated dressings (e.g., Acticoat, Aquacel Ag)

Silver nitrate

Poloxamer 188 (Primaderm)

Hydrogels, such as Aquasite sheet dressings

Administer other medications, as appropriate, for example: Subeschar clysis or systemic antibiotics

Tetanus toxoid or clostridial antitoxin, as appropriate.

Place IV and invasive lines in nonburned area. Obtain routine cultures and sensitivities of wounds and drainage. Assist with excisional biopsies when infection is suspected.

RATIONALE (continued) Effective, safe, and reliable against gram-positive and gram-negative organisms, facultative anaerobes (grows with or without oxygen), aerobes (requires oxygen for growth), and yeast. Still the most common topical antibiotic used in burn care, Silvadene is useful in the prevention of infections from second- or third-degree burns. It has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast. Antibiotic of choice with confirmed invasive burn wound infection that does not respond to Silvadene. Useful against gram-negative and gram-positive organisms and some fungal species. The solution is painless; however, the cream causes burning or pain on application and for 30 minutes thereafter. Can cause rash and is contraindicated in metabolic acidosis. Nonadherent antimicrobial dressings that stay on the wound for up to 7 days, delivering a low concentration of nanocrystalline silver, with the added benefit of reduced pain with application or removal. Available in knitted flexible fabric useful for circumferential burn care (Fong et al, 2005). Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa but has poor eschar penetration, is painful, and may cause electrolyte imbalance. Dressings must be constantly saturated. Product stains skin and other surfaces black. This gel is effective against gram-positive organisms, does not interfere with reepithelialization, and is generally used for tar and asphalt-based residues, other imbedded materials, and for superficial and facial burns. Useful for partial- and full-thickness burns, in rehydrating dry wound beds, and promoting autolytic debridement. Because of the moisture provided to the wound from the hydrogel dressing, healing phases (e.g., removal of dead tissue, granulation, and epidermis repair) are simplified. In addition, the cool sensation provided by the hydrogel to the wound offers relief from pain.

Integumentary Disorders: Burns

Silver sulfadiazine (Silvadene, Flammazine)

CHAPTER 12

ACTIONS/INTERVENTIONS (continued) Chlorhexidine (Hibiclens) topical wash

Systemic antibiotics are given to control general infections identified by culture and sensitivity. Subeschar clysis has been found effective against pathogens in granulated tissues at the line of demarcation between viable and nonviable tissue, reducing risk of sepsis. Tissue destruction and altered defense mechanisms increase risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity. Decreased risk of infection at insertion site with possibility of progression to septicemia. Allows early recognition and specific treatment of wound infection. Bacteria can colonize the wound surface without invading the underlying tissue; therefore, biopsies may be obtained for diagnosing infection.

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N U R S I N G D I AG N OS I S:

risk for peripheral Neurovascular Dysfunction

Possibly Evidenced By Burn injury; immobilization Trauma; fractures Mechanical compression (e.g., circumferential burns/edema of extremities) Desired Outcomes/Evaluation Criteria—Client Will Tissue Perfusion: Peripheral NOC Maintain palpable peripheral pulses of equal quality and strength; good capillary refill, free of numbness or paresthesia. ACTIONS/INTERVENTIONS

RATIONALE

Circulatory Care: Venous [or] Arterial NIC Independent

Assess color, sensation, movement, capillary refill, and peripheral pulses via Doppler on extremities with circumferential burns. Compare findings between limbs if burn is unilateral.

Elevate affected extremities, as appropriate. Remove jewelry or arm band. Avoid taping around a burned extremity or digit.

Obtain BP in unburned extremity when possible. Remove BP cuff after each reading, as indicated.

Investigate reports of deep, throbbing ache and numbness.

Encourage active ROM exercises of unaffected body parts. Investigate irregular pulses.

Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis and edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems (e.g., hypovolemia and decreased cardiac output). Promotes systemic circulation and venous return and may reduce edema or other deleterious effects of constriction of edematous tissues. Note: Prolonged elevation can impair arterial perfusion if BP falls or tissue pressures rise excessively. If BP readings must be obtained on an injured extremity, leaving the cuff in place may increase edema formation, reduce perfusion, and convert partial-thickness burn to a more serious injury. Indicators of decreased perfusion and/or increased pressure within enclosed space, such as may occur with a circumferential burn of an extremity (compartment syndrome). Promotes local and systemic circulation. Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output and tissue perfusion.

Collaborative

Maintain fluid replacement per protocol. (Refer to ND: risk for deficient Fluid Volume.) Monitor electrolytes, especially sodium, potassium, and calcium. Administer replacement therapy, as indicated.

Avoid use of intramuscular (IM) and subcutaneous (SC) injections.

Measure intracompartmental pressures as indicated. (Refer to CP: Fractures; ND: risk for peripheral Neurovascular Dysfunction.) Assist with or prepare for escharotomy or fasciotomy, as indicated.

Maximizes circulating volume and tissue perfusion. Losses or shifts of these electrolytes affect cellular membrane potential and excitability, thereby altering myocardial conductivity, potentiating risk of dysrhythmias, and reducing cardiac output and tissue perfusion. Altered tissue perfusion and edema formation impair drug absorption. Injections into potential donor sites may render them unusable because of hematoma formation. Ischemic myositis may develop because of decreased perfusion. Enhances circulation by relieving constriction caused by rigid, nonviable tissue (eschar) or edema formation.

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CHAPTER 12

N U R S I N G D I AG N OS I S:

imbalanced Nutrition: less than body requirements

Integumentary Disorders: Burns

May Be Related To Inability to ingest food [to meet needs] (e.g., hypermetabolic state; protein catabolism) Possibly Evidenced By Bodyweight 20% or more below ideal weight range; insufficient muscle tone Food intake less than recommended daily allowance; insufficient interest in food; food aversion; satiety immediately after ingesting food [Development of negative nitrogen balance] Desired Outcomes/Evaluation Criteria—Client Will Nutritional Status NOC Demonstrate nutritional intake adequate to meet metabolic needs as evidenced by stable weight and muscle mass measurements, positive nitrogen balance, and tissue regeneration. ACTIONS/INTERVENTIONS

RATIONALE

Nutrition Therapy NIC Independent

Auscultate bowel sounds, noting hypoactive or absent sounds. Determine food and calorie count. Weigh daily. Reassess percentage of open body surface area and wounds weekly.

Monitor muscle mass and subcutaneous fat, as indicated.

Provide small, frequent meals and snacks. Encourage client to view diet as a treatment and to make food and beverage choices high in calories and protein. Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. Encourage client to sit up for meals and visit with others.

Provide oral hygiene before meals. Perform fingerstick glucose and urine testing, as indicated.

Ileus is often associated with postburn period but usually subsides within 36 to 48 hours, at which time oral or intragastric feedings can be initiated. Appropriate guides to proper caloric intake include 25 kcal/ kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As burn wound heals, energy needs are reevaluated to calculate prescribed dietary formulas and appropriate adjustments are made. Indirect calorimetry, if available, may be useful in more accurately estimating body reserves and losses and effectiveness of therapy. Helps prevent gastric distention or discomfort and may enhance intake. Calories and proteins are needed to meet metabolic needs and promote wound healing. Provides client/SO sense of control; enhances participation in care and may improve intake. Sitting helps prevent aspiration and aids in proper digestion of food. Socialization promotes relaxation and may enhance intake. Clean mouth and clear palate enhances taste and helps promote a good appetite. Monitors for development of hyperglycemia related to hormonal changes and demands or use of hyperalimentation to meet caloric needs.

Collaborative

Refer to dietitian or nutritional support team.

Provide diet high in calories and protein with trace elements and vitamin supplements.

Useful in establishing individual nutritional needs based on weight and body surface area of injury and identifying appropriate routes. Note: Hypermetabolic state can increase caloric needs as much as 50% to 60% higher than normal proportional to the severity of injury (Rousseau et al, 2013). Calories approximating 25 kcal/kg/d, protein up to 2 g/kg/d, and vitamins are needed to meet increased metabolic needs, maintain weight, and encourage tissue regeneration. Energy from fat should be 50 years (continues on page 916)

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N U R S I N G D I AG N OS I S: chronic Pain (continued) Possibly Evidenced By Self-report of intensity/pain characteristics using standardized pain scale/instrument; self-focused Alteration in sleep pattern, ability to continue previous activities Desired Outcomes/Evaluation Criteria—Client Will Pain Level NOC Verbalize/demonstrate relief or reduction of pain to manageable level. Pain Control NOC Engage in behavioral modifications and appropriate use of therapeutic interventions. Verbalize enhanced enjoyment of life. ACTIONS/INTERVENTIONS

RATIONALE

Pain Management: Chronic NIC Independent

Evaluate client’s pattern of coping and locus of control.

Determine relevant cultural and spirituality factors affecting pain response.

Evaluate pain behavior, noting past and current pain experience, using pain rating scale (e.g., 0–10 scale or similar tool) or standardized behavior checklist for nonverbal clients, and including functional effects and psychological factors. Provide nonpharmacological methods of pain control considering techniques that may or not been successful in the past. Encourage participation in mix of activities and stimuli, such as music, news program, educational presentations, crafts, and social interactions, as appropriate. Provide change of scenery when possible, alter personal environment, encourage participation in facility activities, off-site outings, and family events.

Passive/avoidant behavioral pattern or lack of active engagement in self-management of activities can contribute to diminished activity and perpetuation of chronic pain. Individuals with external locus of control may take little or no responsibility for pain management. Pain is accepted and expressed in dif ferent ways. Some may magnify symptoms to convince others of reality of pain or believe that suffering in silence helps atone for past wrongdoing. Pathophysiology of chronic pain is multifactorial. Effects on lifestyle can include depressed mood, fatigue, weight changes, sleep disturbances, decreased activity, withdrawal. Engaging in techniques such as progressive muscle relaxation, chair yoga, meditation, visualization or guided imagery, biofeedback, heat or cold application can enhance comfort and decrease need for analgesia. Offering dif ferent activities helps client to try out new ideas and develop new interests providing diversion from focus on pain. Stimulates energy and provides new outlook for client.

Collaborative

Assist in treatment for underlying cause of pain. (Refer to specific care plan.) Administer medications as indicated such as NSAIDs, opioids, tranquilizers. Refer to physical/occupational therapist.

N U R S I N G D I AG N OS I S:

Pain management options can vary based on specific condition such as arthritis, multiple sclerosis, herniated disc, peripheral neuropathy of diabetes mellitus, cancer. Medications may need to be scheduled around the clock, doses titrated up or down, and dose maximized to optimize pain control while managing side effects. Can design exercise programs, identify assistive devices to enhance mobility.

risk for Sexual Dysfunction

Possibly Evidenced By Alteration in body function (e.g., disease process, medications, surgery) Absence of privacy and/or significant other

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CHAPTER 14

N U R S I N G D I AG N OS I S:

risk for Sexual Dysfunction (continued)

ACTIONS/INTERVENTIONS

General: Extended Care/Long-Term Care

Desired Outcomes/Evaluation Criteria—Client Will Sexual Functioning NOC Verbalize knowledge and understanding of sexual limitations, difficulties, or changes that have occurred. Demonstrate improved communication and relationship skills. Identify appropriate options to meet needs. RATIONALE

Sexual Counseling NIC Independent

Note client’s and SO’s cues regarding sexuality.

Determine cultural and religious values and conflicts or other factors that may be present. Assess developmental and lifestyle issues.

Provide atmosphere in which discussion of sexuality is permitted and encouraged. Provide privacy for client and SO.

May be concerned that condition or environmental restrictions may interfere with sexual function or ability but is afraid to ask directly. Affects client’s perception of existing problems and response of others—family, staff, and other residents. Provides starting point for discussion and problem-solving. Factors such as menopause and aging, adolescence, and young adulthood need to be taken into consideration with regard to sexual concerns about illness and long-term care. When concerns are identified and discussed, problem-solving can begin. Demonstrates acceptance of need for intimacy and provides opportunity to continue previous patterns of interaction as much as possible.

Collaborative

Refer to sex counselor or therapist and family therapy when indicated.

N U R S I N G D I AG N OS I S:

May require additional assistance for resolution of issues.

readiness for enhanced Health Management

Possibly Evidenced By Expresses desire to enhance management of illness/symptoms, risk factors Expresses desire to enhance management of prescribed regimen Expresses desire to enhance choices of daily living for meeting goals Desired Outcomes/Evaluation Criteria—Client/Caregiver Will Participation in Health Care Decisions NOC Verbalize understanding of factors contributing to current situation. Adopt lifestyle changes supporting individual healthcare goals. Assume responsibility for own healthcare needs when possible. ACTIONS/INTERVENTIONS

RATIONALE

Health Coaching NIC Independent

Assess level of adaptive behavior, knowledge, and skills about health maintenance, environment, and safety. Provide information about individual healthcare needs. Develop plan with client and SO for self-care incorporating existing disabilities and adapting and organizing care. Maintain adequate hydration and balanced diet with sufficient protein intake.

Identifies areas of concern or need and aids in choice of interventions. Provides knowledge base and encourages participation in decision making. Assists client and caregiver to maintain and manage desired level of independence when possible. Promotes general well-being and aids in disease prevention. (continues on page 918)

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ACTIONS/INTERVENTIONS (continued) Schedule adequate rest with progressive activity program. Promote good handwashing and personal hygiene. Use aseptic techniques as necessary. Protect from exposure to infections and avoid extremes of temperature. Recommend the wearing of masks, monitor staff and visitors, and provide other interventions, as indicated.

Encourage cessation of smoking. Encourage reporting of signs and symptoms as they occur.

Health System Guidance NIC Note client’s previous use of professional ser vices, and continue as appropriate. Include in choice of new healthcare providers as able. Observe for and monitor changes in vital signs such as temperature elevation.

RATIONALE (continued) Prevents fatigue and enhances general well-being. Prevents contamination or cross-contamination, reducing risk of illness or infection. With age, immune-protective responses slow down and physiological reactions to temperature extremes may be impaired. As organ function decreases, especially the thymus gland, and natural antibodies decline, clients are at increased risk for infection. Staff and/or visitors with colds or other infections may expose client to these illnesses. Note: Nursing home–acquired pneumonia (NHAP) is a common cause of infection in chronic care facilities and is a significant cause of mortality (Cunha, 2013). Smokers are prone to bronchitis and ineffective clearing of secretions. Provides opportunity for early recognition of developing complications and timely intervention to prevent serious illness.

Preserves continuity and promotes independence in meeting own healthcare needs. Early identification of onset of illness allows for timely intervention and may prevent serious complications. Note: Elderly persons often display subnormal temperatures, so presence of a low-grade fever may be of serious concern.

Collaborative

Identify resources for, or administer medications, as indicated, for example: Immunizations, such as Haemophilus influenzae (flu) and pneumonia Antibiotics Schedule preventive and routine healthcare appointments based on individual needs with cardiologist, podiatrist, ophthalmologist, or dentist, etc. Prepare for discharge or transfer to independent care setting as appropriate.

Refer to support ser vices as indicated, such as home health care agency, durable medical equipment company, Senior Resources, social ser vices, national hospice organization, Alzheimer’s Disease and Related Disorders Association, American Association of Retired Persons (AARP), Center for Health Care Ethics, Choice in Dying, American Bar Association, Commission on Legal Problems of the Elderly, Internet resources, and Adult Protective Ser vices.

Reduces risk of acquiring contagious, potentially lifethreatening diseases. May be used prophylactically, depending on individual disease process or risk factors, and to treat infections. Promotes optimal recovery and maintenance of health.

For some clients, stabilization of chronic conditions, improved nutrition, and medication management may allow movement to lower level of care with adequate family/ community support. Many community resources are available, and often untapped, to make life and care of the individual easier at a lower level of care.

POTENTIAL CONSIDERATIONS following discharge from care facility. Refer to plan of care for diagnosis that required admission.

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CHAPTER 14

ALCOHOL: ACUTE WITHDRAWAL (National Institutes of Health [NIH], n.d.). In 2007, approximately 463,000 hospital discharge episodes in the United States for persons age 15 and older had a principal (fi rst-listed) alcohol-related diagnosis (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2010); approximately 5% of individuals who have alcohol withdrawal progress to DTs (McKeown & West, 2012). b. Mortality: There are approximately 88,000 deaths related to health consequences of alcohol abuse annually (CDC, 2015). This figure includes every type of alcohol-attributable condition or event, including acute causes (e.g., alcohol poisoning, vehicle crashes, fall injuries, hom icide) and chronic causes (e.g., alcoholic liver disease, alcoholism, various cancers, pancreatitis, fetal alcohol syndrome). In 2013, over 32,000 liver disease deaths among individuals ages 12 and older involved alcohol (NIH, 2017). Review of death certificates from 2010 to 2012 revealed alcohol poisoning resulted in approximately 22,000 deaths annually (Kanny et al, 2015). Despite appropriate treatment, DTs are reported to have a 5% to 15% mortality rate (McKeown & West, 2012). c. Cost: In 2010, the estimated cost of excessive alcohol consumption reached $249 billion (NIH, 2017). The costs largely resulted from losses in workplace productivity, healthcare expenses for problems caused by excessive drinking, law enforcement and other criminal justice expenses related to excessive alcohol consumption, and motor vehicle crash costs from impaired driving. In 2014, the number of emergency department visits involving alcohol consumption was almost 5 million, resulting in a cost of $15.3 billion (White, 2018).

General: Alcohol: Acute Withdrawal

I. Pathophysiology (McKeown & West, 2017) a. Alcohol intoxication and withdrawal— complex mechanism b. Most clinical effects explained by the interaction of ethanol with various neurotransmitters and neuroreceptors in the brain c. Resulting changes in the inhibitory and excitatory neurotransmitters disrupt the neurochemical balance in the brain, causing symptoms of withdrawal if alcohol is suddenly stopped or decreased after extended usage (Burton, 2010; Donnelly et al, 2012). II. Stages of Alcohol Withdrawal (McKeown & West, 2017) a. Stage I: autonomic hyperactivity b. Stage II: hallucinations c. Stage III: neuronal excitation d. Stage IV: delirium tremens (DTs) III. Etiology a. Individual’s desire to repeatedly reach a state of feeling high; numb, negative feelings b. Associated with serious mental health disorders—anxiety, mood disorders, or major depression c. Personality traits— dependency more common in isolation, loneliness, shyness, depression, dependency, hostile and self-destructive impulsivity, and sexual immaturity (Ali et al, 2013) d. Environment—frequently come from a broken home and have a disturbed relationship with their parents e. Genetics—Incidence of alcoholism is higher in biological children of alcoholics, and some people who become alcoholics are less easily intoxicated, having a higher threshold for central ner vous system (CNS) effects. IV. Statistics a. Morbidity: Approximately 15.1 million adults in the U.S. ages 18 and older had alcohol use disorder (AUD) in 2015

G L O S S A R Y Addiction: Dependence on a substance (such as alcohol or other drugs) or an activity to the point that stopping is very difficult and causes severe physical and mental reactions. Alcohol withdrawal syndrome (AWS): The neurological, psychiatric, and cardiovascular manifestations that result when a person accustomed to consuming large quantities of alcohol suddenly becomes abstinent or reduces usual amount of alcohol intake (Burton, 2010). Arcus senilis: White or gray ring-like opacity of the cornea. Ataxia: Gross incoordination of voluntary muscle movement, reflecting loss of proprioception in chronic alcohol abuse. Autonomic hyperactivity stage: Usually occurs within 24 hours of the last drink. Symptoms may be mild, characterized by tremulousness, insomnia, anxiety, diaphoresis, mild tachycardia, and gastrointestinal (GI) upset. Binge: Uninterrupted consumption of a drug for several hours or days. Blackout: Amnesia for events occurring during the period of alcoholic intoxication, even though consciousness is still maintained during that time.

Delirium tremens (DTs): Potentially fatal form of alcohol withdrawal characterized by disorientation, confusion, impaired attention, pronounced autonomic hyperactivity, and visual and auditory hallucinations. Usually begins at 48 to 72 hours but can be delayed up to 4 to 5 days. Death is usually due to cardiovascular or respiratory collapse. Detoxification: Process of removing alcohol or other drugs from the body. This is the initial period addicts must go through to become drug-free. Withdrawal symptoms appear early during this process. Depending on the drug, detoxification lasts for a few days to a week or more. Gluconeogenesis: Conversion of glycogen to glucose in the liver. Hallucination stage: Development of false visual (most common), olfactory, or auditory perceptions that have no relation to reality, usually occurring 24 to 36 hours after the cessation of alcohol intake. Hepatic encephalopathy: Condition used to describe the deleterious effects of liver failure on the central nervous system (CNS). Features include confusion ranging to (continues on page 920)

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G L O S S A R Y

(continued)

coma, with alcoholic cirrhosis being the most common cause. Myelosuppression: Decrease in the production by the bone marrow of red blood cells (RBCs), platelets, and some white blood cells (WBCs). Neuronal excitation stage: Development of autonomic hyperactivity or seizures occurring within 48 hours after cessation of alcohol consumption.

Nystagmus: Unintentional jittery movement of the eyes. Nystagmus usually involves both eyes and is often exaggerated by looking in a par ticular direction. Thrombocytopenia: Low platelet count, which can lead to impaired blood clotting and spontaneous bleeding. Wernicke’s syndrome or Wernicke encephalopathy: Neurological disease characterized by the clinical triad of confusion, inability to coordinate voluntary movement, and eye abnormalities.

CARE SETTING

RELATED CONCERNS

Client may be inpatient on a behavioral unit, at a substance abuse rehabilitation facility, or outpatient in community programs. Although clients are not generally admitted to the acute care setting with this diagnosis, withdrawal from alcohol may occur secondarily during hospitalization for other illnesses or conditions (Riddle et al, 2010). An alcohol screening should be done for all hospitalized clients (Burton, 2010; Daly et al, 2009). A short hospital stay may be required during the acute phase because of severity of general condition or comorbidities, or a delayed discharge from acute care can be the result of alcohol withdrawal beginning within 6 to 48 hours of admission.

Cirrhosis of the liver, page 494 Heart failure: chronic, page 38 Psychosocial aspects of care, page 835 Respiratory failure/ventilatory assistance, page 187 Substance use disorders (SUDs), page 929 Upper gastrointestinal bleeding, page 340

C L I E N T A S S E S S M E N T D ATA B A S E Data depend on the duration and extent of use of alcohol, concurrent use of other drugs, degree of organ involvement, and presence of other pathology.

DIAGNOSTIC DIVISION M AY R E P O R T

M AY E X H I B I T

Activity/Rest • Insomnia, difficulty sleeping, not feeling well rested • Fatigue or weakness

• Abnormal heart rate or blood pressure (BP) in response to activity

Circulation • Tachycardia common during acute withdrawal • Numerous dysrhythmias may be identified, especially atrial fibrillation • Hypertension common in early withdrawal stage; may become labile or progress to hypotension • Peripheral pulses weak, irregular, or rapid

Ego Integrity • Feelings of guilt, shame; defensiveness about drinking • Denial, rationalization • Multiple stressors or losses—relationships, employment, finances • Use of alcohol to deal with life stressors, boredom

• Anxiety, fear • Irritability • Antisocial behavior

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(continued)

M AY E X H I B I T

CHAPTER 14

M AY R E P O R T

(continued)

Elimination • Diarrhea

General: Alcohol: Acute Withdrawal

• Bowel sounds varied (may reflect gastric complications such as hemorrhage)

Food/Fluid • Nausea, vomiting; food intolerance • Anorexia

• Gastric distention, ascites, liver and spleen enlargement (seen in cirrhosis) • Muscle wasting; dry, dull hair; swollen salivary glands; inflamed buccal cavity; capillary fragility (malnutrition) • Bowel sounds varied (reflecting malnutrition, electrolyte imbalances, general bowel dysfunction)

Neurosensory • “Internal shakes” • Headache, dizziness, blurred vision • Blackouts

• Psychopathology—paranoia, schizophrenia, major depression, neurosis (may indicate dual diagnosis) • Level of consciousness (LOC) and orientation varied— confusion, stupor, hyperactivity, distorted thought processes, slurred, incoherent speech • Memory loss, confabulation • Affect/mood/behavior—fearful, anxious, easily startled, inappropriate, silly, euphoric, irritable, physically or verbally abusive, depressed, and/or paranoid • Hallucinations may be visual, tactile, olfactory, or auditory; for example, client may be picking items out of the air or responding verbally to unseen person or voices • Eye examination: • Nystagmus—associated with cranial nerve palsy • Pupil constriction (may indicate CNS depression) • Arcus senilis (normal in aging populations, suggests alcohol-related changes in younger individuals) • Fine-motor tremors of face, tongue, and hands • Seizure—grand mal or partial that is usually brief, generalized, tonic-clonic in nature, and without an aura, occurs in a cluster of one to three seizures with a short postictal period; in 20% to 50% of individuals, the seizures progress to DTs (McKeown & West, 2012; Riddle et al, 2010). • Gait unsteady (ataxia), which may be due to thiamine deficiency or cerebellar degeneration associated with Wernicke’s encephalopathy (Riddle et al, 2010).

Pain/Discomfort • Constant upper abdominal pain and tenderness radiating to the back (pancreatic inflammation) • Headache (may be “pulsating”)

• Guarding affected area • Narrowed focus

Respiration • History of smoking • Chronic respiratory problems

• Tachypnea, hyperventilation • Breath sounds diminished, adventitious sounds (suggests pulmonary complications such as respiratory depression or pneumonia)

Safety • History of recurrent trauma—falls, fractures, lacerations, burns, or motor vehicle crashes • Violence toward self or others

• Skin—flushed face and palms of hands; scars, ecchymotic areas; fissures at corners of mouth (vitamin deficiency) • Fractures healed or new—signs of recent or recurrent trauma • Temperature elevation, flushing, diaphoresis • Suicidal ideation; alcohol is a major risk factor in suicide (Ali et al, 2013; Davies, 2012). (continues on page 922)

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C L I E N T A S S E S S M E N T D ATA B A S E (contd.) M AY R E P O R T

(continued)

M AY E X H I B I T

(continued)

Sexuality • Loss of sexual desire • Not achieving sexual satisfaction, or needing alcohol for satisfying sex • Actual or perceived limitation imposed by disease

• Alteration in relationship with partner

Social Interaction • Frequent sick days off from work or school, fighting with others, arrests for disorderly conduct, or motor vehicle violations such as driving under the influence (DUI) • Denial that alcohol intake has any significant effect on present condition • Dysfunctional family system of origin (generational involvement), problems in current relationships, often alienated from family when problem is chronic • Mood changes affecting interactions with others

• Speech unintelligible or slurred • Family interactions and communications strained and difficult. Alcohol is often the cause of social decline, which includes failed marriages, loss of employment, and severed family ties (Ali et al, 2013).

Teaching/Learning • Family history of alcoholism • History of alcohol and/or other drug use or abuse, tobacco use • Ignorance and/or denial of addiction to alcohol, or inability to cut down or stop drinking despite repeated efforts, previous periods of abstinence or withdrawal • History of daily alcohol use for at least 3 months • Large amount of alcohol consumed in last 24 to 48 hours (“bingeing”) • Previous hospitalizations for alcoholism or alcohol-related diseases such as cirrhosis and esophageal varices

• Acting annoyed when people ask client about drinking (McPeake, 2013)

Discharge Plan Considerations • May require assistance to maintain abstinence and begin to participate in rehabilitation program ➧ 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 • Blood alcohol level (BAL): Measures level of alcohol in the blood.

BAL may or may not be severely elevated, depending on amount consumed, time between consumption and testing, and the degree of tolerance, which varies widely. In the absence of elevated alcohol tolerance, blood levels of 100 mg/dL are associated with loss of control of fine motor movements and confusion when faced with tasks requiring thinking; at 200 mg/dL, very slurred speech, ataxia, and lethargy; at 400 mg/dL, coma and respiratory depression; at 500 mg/dL, death is possible due to respiratory arrest, severe hypotension, and aspiration (Balentine, 2018).

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(continued)

• Glucose and ketones: Determines ability of liver to manage simple sugars and end products of sugar metabolism.

• Electrolytes: Substances that dissociate into ions in solution and acquire the capacity to conduct electricity. Common electrolytes include sodium, potassium, chloride, calcium, and phosphate.

• Liver function tests— lactate dehydrogenase (LDH), alanine aminotransferase (ALT), lipase, and amylase: Determine level of liver and pancreatic dysfunction. • Blood ammonia: Helps evaluate the cause of the change in consciousness. • Nutritional tests— albumin or prealbumin, total protein, carbohydrate- deficient transferrin (CDT), iron, vitamins D and B12 , and folate: Evaluates nutritional status, identifies deficiencies and treatment needs. • Drug screens— serum, urine

(continued)

Blood loss from the GI tract and nutritional deficiencies producing anemia are common in alcohol withdrawal. In addition, alcohol ingestion leads to myelosuppression with a slight reduction in all cell lines. Thrombocytopenia is common. Increased mean corpuscular volume (MCV) suggests anemia based on deficiencies in vitamin B12 and folate. WBC count may be increased with infection or decreased if client is immunosuppressed. Clients with liver disease due to alcoholism have reduced glycogen stores, and alcohol impairs gluconeogenesis. As a consequence, these clients are susceptible to hypoglycemia (McKeown & West, 2012). Ketoacidosis may be present with or without metabolic acidosis. Alcoholic ketoacidosis (AKA) can occur in chronic alcohol abuse with history of recent binge drinking, decreased food intake, and persistent vomiting (Ansstas et al, 2017). Alcoholics with liver disease frequently have abnormal sodium serum concentrations, with hyponatremia (low plasma sodium concentration) as the most common alteration. Decreased serum potassium concentration may be associated with respiratory alkalosis, elevated insulin levels, and elevated epinephrine levels resulting from alcohol withdrawal. Client with chronic alcoholism usually has dietary magnesium deficiency and possibly concurrent alcoholic hepatitis. Alcoholic pancreatitis may cause hypocalcemia. May be elevated, reflecting liver or pancreatic damage.

General: Alcohol: Acute Withdrawal

• Complete blood count (CBC): Battery of screening tests, which typically includes hemoglobin (Hgb); hematocrit (Hct); RBC count, morphology, indices, and distribution width index; platelet count and size; WBC count and differential.

W H AT I T T E L L S M E

CHAPTER 14

WHY IT IS DONE

Level is elevated if hepatic encephalopathy is present. Albumin and total protein may be decreased. CDT, a protein molecule involved in iron transport, is a relatively new test that is sometimes used to help identify chronic, heavy drinking. Vitamin deficiencies are usually present, reflecting malnutrition or malabsorption. Identifies drugs being used in conjunction with alcohol that may complicate withdrawal, impact therapy choices.

Other Diagnostic Studies • Urinalysis: Detects and measures various compounds that pass through the urine. • Chest x-ray: Procedure used to evaluate organs and structures within the chest for symptoms of disease.

• Electrocardiogram (ECG): Record of the electrical activity of the heart.

• Computed tomography (CT) scan of the head: X-ray procedure that uses a computer to produce a detailed picture of a cross section of the body.

Increased WBCs and/or protein may indicate infection; ketones may be related to breakdown of fatty acids in malnutrition (pseudodiabetic condition). May reveal right lower lobe pneumonia, a common manifestation that may be related to malnutrition, depressed immune system, and aspiration. X-ray may also reveal evidence of chronic lung disorders associated with heavy tobacco use, also common in alcoholics. Dysrhythmias, cardiomyopathies, and/or ischemia may be present because of direct effect of alcohol on the cardiac muscle and/or conduction system, as well as effects of electrolyte imbalance. The adrenergic storm produced by alcohol withdrawal increases cardiac demand, which may precipitate infarction in susceptible individuals. Atrial fibrillation is the most common cardiac symptom seen in the alcoholic (Burton, 2010). May be obtained in clients with depressed LOC, in those with multiple seizures or signs of head trauma, and in those with failure to respond to treatment. Note: Client with AWS is at risk for intracranial bleeding because of frequent falls, cortical atrophy, and coagulopathy. (continues on page 924)

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WHY IT IS DONE

(continued)

• Clinical Institute Withdrawal Assessment of Alcohol, Revised (CIWA-Ar): Clinical rating tool that provides a numerical rating for 10 factors, including nausea and vomiting, tactile disturbances, tremor, auditory and visual disturbances, sweating, anxiety, headache agitation, and orientation (Donnelly et al, 2012; Hoffman & Weinhouse, 2017). • Addiction severity index (ASI): A 161-item multidimensional clinical and research tool that produces a “problem severity profile” of the client, including chemical, medical, psychological, legal, family and social, and employment and support aspects, indicating areas of treatment needs.

W H AT I T T E L L S M E

(continued)

Provides a clinical quantification of the severity of the alcohol withdrawal syndrome and can be rapidly administered at the bedside. Scores of 9 to 15 points correspond with moderate withdrawal, and scores greater than 15 correspond to severe withdrawal symptoms and increased risk of DTs and seizures. Provides basic diagnostic information on a client prior to, during, and after treatment for substance use–related problems as well as for the assessment of change in client status and treatment outcome.

NURSING PRIORITIES

DISCHARGE GOALS

1. Maintain physiological stability during acute withdrawal phase. 2. Promote client safety. 3. Provide appropriate referral and follow-up. 4. Encourage and support significant other (SO) involvement in “intervention” or confrontation process. 5. Provide information about condition, prognosis, and treatment needs.

1. 2. 3. 4.

Homeostasis achieved. Complications prevented or resolved. Sobriety maintained on a day-to-day basis. Ongoing participation in rehabilitation program or group therapy, such as Alcoholics Anonymous (AA). 5. Condition, prognosis, and therapeutic regimen understood. 6. Plan in place to meet needs after discharge.

***This plan of care is to be used in conjunction with CP: Substance Use Disorders.

N U R S I N G D I AG N OS I S:

Acute Substance Withdrawal Syndrome

May Be Related To Developed dependence to alcohol; heavy use of an addictive substance over time Sudden cessation of an addictive substance Possibly Evidenced By Anxiety; acute confusion Risk for electrolyte imbalance Risk for injury Desired Outcomes/Evaluation Criteria—Client Will Substance Withdrawal Severity NOC Demonstrate absence of untoward effects of withdrawal (e.g., seizures, dysrhythmias). Experience no physical injury. Report absence or reduced frequency of hallucinations. Verbalize reduction of fear and anxiety to a manageable level free of emotional outbursts. Alcohol Abuse Cessation Behaviors NOC Commit to cease alcohol use. Engage in counseling/support group. ACTIONS/INTERVENTIONS

RATIONALE

Substance Use Treatment: Alcohol Withdrawal NIC Independent

Develop a trusting relationship through frequent contact and being honest and nonjudgmental. Project an accepting attitude about alcoholism.

Provides client with a sense of humanness, helping to decrease paranoia and distrust. Client will be able to detect biased or condescending attitude of caregivers.

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Determine stage of AWS using CIWA-Ar. Stage I is associated with signs and symptoms of hyperactivity, such as tremors, sleeplessness, nausea, vomiting, diaphoresis, tachycardia, and hypertension; stage II is manifested by increased hyperactivity plus hallucinations and/or seizure activity; stage III symptoms include DTs and extreme autonomic hyperactivity with profound confusion, anxiety, insomnia, and fever. Assist client to identify cause of anxiety. Explain that alcohol withdrawal increases anxiety and uneasiness. Reassess level of anxiety on an ongoing basis.

Encourage SO to stay with client whenever possible. Note onset of hallucinations and document as auditory, visual, and/or tactile.

Reorient frequently to person, place, time, and surrounding environment, as indicated.

Provide quiet environment. Speak in calm, quiet voice. Regulate lighting, as indicated. Turn off radio or TV during sleep. Avoid bedside discussion about client or topics unrelated to the client that do not include the client. Provide environmental safety as indicated; for example, place bed in low position, leave doors in full open or closed position, observe frequently, place call light/bell within reach, and remove articles that can harm client. Assist with ambulation and self-care activities, as needed.

RATIONALE (continued) Enhances sense of trust, and explanation may increase cooperation and reduce anxiety. Provides sense of control over self in circumstance where loss of control is a significant factor. Note: Feelings of self-worth are intensified when one is treated as a worthwhile person. Speech may be garbled, confused, or slurred. Response to commands may reveal inability to concentrate, impaired judgment, or muscle coordination deficits. Hyperactivity related to CNS disturbances may escalate rapidly. Sleeplessness is common due to loss of sedative effect gained from alcohol usually consumed before bedtime. Sleep deprivation may aggravate disorientation or confusion. Progression of symptoms may indicate impending hallucinations (stage II) or DTs (stage IV). AWS usually begins 3 to 36 hours after the last drink. Prompt recognition and intervention may halt progression of symptoms and enhance recovery, improving prognosis. In addition, progression of symptoms indicates need for changes in drug therapy and more intense treatment to prevent death. DTs may not present until 2 to 3 days after last alcohol intake, usually lasting 1 to 5 days.

General: Alcohol: Acute Withdrawal

Assess LOC, ability to speak, and response to stimuli and commands. Observe for behavioral responses such as hyperactivity, disorientation, confusion, sleeplessness, and irritability.

CHAPTER 14

ACTIONS/INTERVENTIONS (continued) Inform client about what you plan to do and why. Include client in planning process and provide choices when possible.

Persons in acute phase of withdrawal may be unable to identify and/or accept what is happening. Anxiety may be physiologically or environmentally caused. Note: Individuals with alcohol use disorders often also have posttraumatic stress disorder (PTSD) (U.S. Department of Veterans Affairs, 2011). Promotes recognition of caregivers and a sense of consistency, which may reduce fear. Auditory hallucinations are reported to be more frightening and threatening to client. Visual hallucinations occur more at night and often include insects, animals, or faces of friends or enemies. Clients are frequently observed “picking the air.” Yelling may occur if client is calling for help from perceived threat, which is usually seen in stage III of AWS. Client may experience periods of confusion, resulting in increased anxiety. May have a calming effect and reduce confusion, prevent or limit misinterpretation of external stimuli. Reduces external stimuli during hyperactive stage. Client may become more delirious when surroundings cannot be seen, but some respond better to quiet, darkened room. Client may hear and misinterpret conversation, which can aggravate hallucinations. Client may have distorted sense of reality or be fearful or suicidal, requiring protection from self.

Prevents falls, reducing possible injury. May be required when equilibrium and hand-eye coordination problems exist, impacting per formance of ADLs. (continues on page 926)

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ACTIONS/INTERVENTIONS (continued) Observe for and document seizure activity. Maintain patent airway. Provide environmental safety such as padded side rails and bed in low position.

Check deep-tendon reflexes (DTRs). Assess gait, if possible. Palpate upper arm to discern actual withdrawal versus medication-seeking behavior.

RATIONALE (continued) Generalized tonic-clonic convulsions are most common and may be related to decreased magnesium levels, hypoglycemia, and elevated blood alcohol and usually occur within 12 to 48 hours of last drink. Note: In absence of history of seizures or other pathology causing them (e.g., head trauma), they usually stop spontaneously or with magnesium replacement (Burns et al, 2017; Hoffman & Weinhouse, 2017). Reflexes may be depressed, absent, or hyperactive. Peripheral neuropathies are common, especially in malnourished client. Ataxia is associated with Wernicke’s syndrome (thiamine deficiency) and cerebellar degeneration. Three ways to assess whether the client is having actual withdrawal tremors are (1) have the client stick out his or her tongue—it will be tremulous; (2) feel the client’s upper arm—withdrawal tremors can be felt bone deep; and (3) have the client visually track a pencil—there will be observable nystagmus.

Collaborative

Monitor laboratory studies such as electrolytes, magnesium levels, liver function studies, ammonia, BUN, glucose, and ABGs.

Administer medications, as indicated, for example: Benzodiazepines (BZDs), such as chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan), oxazepam (Serax), or clonidine (Catapess)

Barbiturates, such as phenobarbital, or possibly secobarbital (Seconal) or pentobarbital (Nembutal)

Haloperidol (Haldol)

Changes in organ function may precipitate or potentiate sensory-perceptual deficits. Electrolyte imbalance is common. Liver function is often impaired in the chronic alcoholic, and ammonia intoxication can occur if the liver is unable to convert ammonia to urea. Ketoacidosis is sometimes present without glycosuria; however, hyperglycemia or hypoglycemia may occur, suggesting pancreatitis or impaired gluconeogenesis in the liver. Hypoxemia and hypercarbia are common manifestations in chronic alcoholics who are also heavy smokers. BZDs are commonly used to control neuronal hyperactivity and promote relaxation and sleep because of their minimal respiratory and cardiac depression and anticonvulsant properties. In addition, drugs that have little effect on dreaming may be desired to allow dream recovery or rapid eye movement (REM) rebound to occur, which has previously been suppressed by alcohol use. Studies have also shown that these drugs can prevent progression to more severe states of withdrawal. Intravenous (IV) or oral (PO) administration is preferred route because intramuscular (IM) absorption is unpredictable. Muscle-relaxant qualities are particularly helpful to client in controlling “the shakes,” trembling, and ataxic quality of movements. Note: Lorazepam and oxazepam may be preferred in clients with advanced cirrhosis or acute alcoholic hepatitis due to shorter drug half-life and a decrease in effects if oversedation occurs (Hoffman & Weinhouse, 2017). These drugs are sometimes used with benzodiazepines to treat or prevent alcohol withdrawal seizures but need to be used with caution because they are respiratory depressants and REM sleep cycle inhibitors and may mask hemodynamic signs of withdrawal, which can precede seizures (Hoffman & Weinhouse, 2017). Occasionally may be used in conjunction with BZDs for clients experiencing agitation and hallucinations, although should be used with caution as it can lower seizure threshold and interfere with heat dissipation (Hoffman & Weinhouse, 2017).

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Magnesium sulfate

Provide seclusion and restraints as necessary, adhering to facility policy regarding restraints.

Arrange “intervention” or confrontation in controlled setting when client has recovered sufficiently from withdrawal to address addiction issues.

Provide consultation or referral to detoxification or crisis center for ongoing treatment program as soon as medically stable (e.g., oriented to reality).

N U R S I N G D I AG N OS I S:

RATIONALE (continued) Thiamine deficiency may lead to neuritis, Wernicke’s syndrome (abnormal gait and paralysis of eye muscles as well as cognitive deficits), and/or Korsakoff’s psychosis (Riddle et al, 2010). Vitamins may be depleted because of insufficient intake and malabsorption. Vitamin deficiency, especially thiamine, is associated with ataxia, loss of eye movement and pupillary response, palpitations, postural hypotension, and exertional dyspnea. Reduces tremors and seizure activity by decreasing neuromuscular excitability. Process wherein SO and family members, supported by staff, provide information about how client’s drinking and behavior have affected each one of them; helps client acknowledge that drinking is a problem and has resulted in current situational crisis. Clients with excessive psychomotor activity, severe hallucinations, violent behavior, and/or suicidal gestures may respond better to seclusion. Physical restraints are usually ineffective and add to client’s agitation and increase risk of rhabdomyolysis but occasionally may be required to prevent harm to self/others until adequate chemical sedation is achieved (Hoffman & Weinhouse, 2017). Client is more likely to contract for treatment while still hurting and experiencing fear and anxiety from last drinking episode. Motivation decreases as well-being increases and person again feels able to control the problem. Direct contact with available treatment resources provides realistic picture of help. Decreases time for client to “think about it,” change mind, or restructure and strengthen denial systems.

General: Alcohol: Acute Withdrawal

Vitamins C and B complex, multivitamins, and Stresstabs

CHAPTER 14

ACTIONS/INTERVENTIONS (continued) Thiamine, glucose

risk for ineffective Breathing Pattern

Possibly Evidenced By Neuromuscular impairment (e.g., direct effect of alcohol toxicity on respiratory center and/or sedative drugs given to decrease alcohol withdrawal symptoms) Fatigue [Tracheobronchial obstruction] Desired Outcomes/Evaluation Criteria—Client Will Respiratory Status: Ventilation NOC Maintain effective breathing pattern with respiratory rate within normal range, lungs clear, and free of cyanosis or other signs and symptoms of hypoxia. ACTIONS/INTERVENTIONS

RATIONALE

Respiratory Monitoring NIC Independent

Monitor respiratory rate, depth, and pattern as indicated. Note periods of apnea and Cheyne-Stokes respirations.

Frequent assessment is impor tant because toxicity levels may change rapidly. Hyperventilation is common during acute withdrawal phase. Kussmaul’s respirations are sometimes present because of acidotic state associated with vomiting and malnutrition. However, marked respiratory depression can occur because of CNS depressant effects of alcohol if acute intoxication is present. This may be compounded by drugs used to control AWS. (continues on page 928)

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ACTIONS/INTERVENTIONS (continued) Auscultate breath sounds. Note presence of adventitious sounds such as rhonchi, wheezes. Airway Management NIC Elevate head of bed. Encourage coughing, deep-breathing exercises, and frequent position changes. Have suction equipment and airway adjuncts available.

RATIONALE (continued) Client is at risk for atelectasis related to hypoventilation and pneumonia.

Decreases potential for aspiration; lowers diaphragm, enhancing lung inflation. Facilitates lung expansion and mobilization of secretions to reduce complications from atelectasis or pneumonia. Sedative effects of alcohol potentiate risk of aspiration, relaxation of oropharyngeal muscles, and respiratory depression, requiring intervention to prevent respiratory arrest.

Collaborative

Administer supplemental oxygen, if necessary. Review serial chest x-rays, arterial blood gases (ABGs), or pulse oximetry, as indicated.

Transfer to higher level of care/critical care unit as indicated. (Refer to CP: Respiratory Failure/Ventilatory Assistance.)

N U R S I N G D I AG N OS I S:

Hypoxia may occur with respiratory depression and chronic anemia. Monitors presence of secondary complications, evaluates effectiveness of respiratory effort, and identifies therapy needs. Note: Right lower lobe pneumonia is common in alcohol-debilitated clients and is often due to chronic aspiration. Chronic lung diseases, such as emphysema or bronchitis, are also common. May require more aggressive pulmonary therapy/mechanical ventilation if unable to maintain adequate oxygenation.

risk for decreased Cardiac Output

Possibly Evidenced By Altered contractility (e.g., direct effect of alcohol on the heart muscle) Altered afterload—systemic vascular resistance Alteration in heart rate/rhythm Desired Outcomes/Evaluation Criteria—Client Will Circulation Status NOC Display vital signs within client’s normal range; absence, or reduced frequency, of dysrhythmias. Demonstrate an increase in activity tolerance. ACTIONS/INTERVENTIONS

RATIONALE

Hemodynamic Regulation NIC Independent

Monitor vital signs frequently during acute withdrawal.

Monitor cardiac rate and rhythm. Document irregularities and dysrhythmias.

Monitor body temperature.

Hypertension frequently occurs in acute withdrawal phase. Extreme hyperexcitability, accompanied by catecholamine release and increased peripheral vascular resistance, raises BP and heart rate; however, BP may become labile and progress to hypotension. Note: Client may have underlying cardiovascular disease, which is compounded by alcohol withdrawal. Long-term alcohol abuse may result in cardiomyopathy and heart failure (HF). Tachycardia is common because of sympathetic response to increased circulating catecholamines. Dysrhythmias may develop with electrolyte imbalance. All of these may have an adverse effect on cardiac output. Elevation may occur because of sympathetic stimulation, dehydration, and/or infections, causing vasodilation and compromising venous return and cardiac output.

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Collaborative

Monitor laboratory studies, such as serum electrolyte levels, RBCs, Hgb and Hct, and platelets.

Administer fluids and electrolytes, as indicated, especially potassium (Riddle et al, 2010).

Administer medications, as indicated, for example: Clonidine (Catapres) or atenolol (Tenormin)

Consult with medical toxicologist or regional poison control center as needed.

Potassium and magnesium imbalances potentiate risk of cardiac dysrhythmias. Anemia may be present and platelets can be decreased in late-stage alcoholism due to liver dysfunction. Severe alcohol withdrawal causes the client to be susceptible to excessive fluid losses associated with diuresis, fever, diaphoresis, and vomiting; electrolyte imbalances, especially potassium and magnesium that can result in life-threatening dysrhythmias (Hoffman & Weinhouse, 2017).

General: Substance Use Disorders

Be prepared for and assist in cardiopulmonary resuscitation.

RATIONALE (continued) Preexisting dehydration, vomiting, fever, and diaphoresis may result in decreased circulating volume that can compromise cardiovascular function. Note: Hydration is difficult to assess in the alcoholic client because the usual indicators are not reliable, and overhydration is a risk in the presence of compromised cardiac function. Causes of death during acute withdrawal stages include cardiac dysrhythmias, respiratory depression and arrest, oversedation, excessive psychomotor activity, severe dehydration or overhydration, and massive infections. Mortality for DTs ranges from 5% to 15% (Burns et al, 2017).

CHAPTER 14

ACTIONS/INTERVENTIONS (continued) Monitor intake and output (I&O). Note 24-hour fluid balance.

Although the use of benzodiazepines is often sufficient to control hypertension during initial withdrawal from alcohol, some clients may require more specific therapy. Note: Atenolol and other beta-adrenergic blockers may speed up the withdrawal process and eliminate tremors as well as lower the heart rate, BP, and body temperature but are not useful in preventing seizures or DTs (Burns et al, 2017; Hoffman & Weinhouse, 2017). Useful resources for diagnosis and management of acute/ critically ill clients (Hoffman & Weinhouse, 2017).

POTENTIAL CONSIDERATIONS following acute care (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) Refer to: Substance Use Disorders (SUDs) plan of care and plans of care for any specific underlying medical condition(s).

SUBSTANCE USE DISORDERS (SUDs) I. Pathophysiology a. Considered a continuum of phases incorporating a cluster of cognitive, behavioral, and physiological symptoms, including loss of control over use of the substance and a continued use of the substance to reach a state of feeling high despite adverse consequences— effects on all body systems, relationship problems, financial difficulties, self- or other-directed violence, exposure to criminal element and activities, legal consequences. b. All commonly abused drugs stimulate the brain’s limbic system, elevating dopamine levels and affecting level of alertness, perceptions, emotions, judgment, attention, movement, and sleep (Ali et al, 2013; Crews, 2011).

c. Prescription drug abuse is the fastest-growing type of drug abuse in the United States, and deaths from prescription drugs are reaching epidemic proportions (Garcia, 2013; Phillips, 2013). d. The following is a recently compiled list of commonly misused substances in descending order according to the number of people affected (National Institute on Drug Abuse [NIDA], 2016): i. Alcohol: An estimated 20 million adults in the United States abuse alcohol. More than half of these alcoholics started drinking heavily when they were teenagers (American Academy of Child and Adolescent Psychiatry, 2012). (continues on page 930)

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ii. Bath salts (synthetic cathinones): new family of drugs containing one or more manmade chemicals related to cathinone, an amphetamine-like stimulant found naturally in the khat plant. Teens and young adults are gravitating to these easy-to-access drugs, as they incorrectly believe them to be legal and harmless (Lohmann, 2012). iii. Club drugs: includes methamphetamines (e.g., “speed, crystal, meth, crank”), methamphetaminederivative methylenedioxymethamphetamine (MDMA, Ecstasy), and other stimulant drugs such as methylphenidate (Ritalin), phencyclidine (PCP), and ketamine (Special K). Club drugs are not only popular in raves (all-night dance parties with loud, pounding music and flashing lights stimulating vigorous dancing) but are often used in other social settings frequented by adolescents and young adults (Dryden-Edwards, 2017). iv. Cocaine: The National Survey on Drug Use and Health (NIDA, 2017a and NSDUH, 2015) report that cocaine use has gone down in the last few years. In 2013, the number of current users aged 12 or older was 1.5 million, down from 1.9 million in 2008. v. Heroin: In 2011, 4.2 million Americans aged 12 or older had used heroin at least once in their lives. Although heroin abuse has trended downward during the past several years, its prevalence is still higher than in the early 1990s, especially among school-age youth (NIDA, 2013). vi. Inhalants: includes volatile solvents (e.g., paint thinner, nail-polish remover), aerosols (e.g., spray paint, hair or deodorant spray), gases (e.g., butane lighters, nitrous oxide [laughing gas]), and hydrocarbons (e.g., fluorinated hydrocarbons, found in whipped cream dispensers called “whippits”). Data from national and state surveys suggest that inhalant abuse is most common among seventh through ninth graders (NIDA for Teens, 2017). vii. K2/Spice (also called synthetic marijuana, fake weed, Yucatan Fire, Skunk, Moon Rocks): wide variety of herbal mixtures that produce experiences similar to marijuana. Of the illicit drugs most used by high school seniors, K2 is secondary only to marijuana (NIDA, 2016). viii. LSD (acid) and other hallucinogens such as psilocybin (mushrooms, “shrooms”), phencyclidine (PCP): In 2013, the National Survey on Drug Use and Health (NSDUH) stated that approximately 1.3 million persons aged 12 or older reported using hallucinogens (NSDUH, 2014). ix. Marijuana (e.g., pot, grass, weed, reefer, mary jane): In 2012, 6.5% of 12th graders reported using marijuana daily, compared to 5.1% in 2007 (NIDA, 2017). x. Tobacco (street names for tobacco delivery methods include “smokes, cigs, chew, dip, snuff”): In 2012, smoking was at historically low levels among young people, according to NIDA’s Monitoring the Future study (reported as 4.9% for 8th graders and 17.1% for 12th graders) (NIDA, 2017). xi. Prescription drugs: In 2010, the National Institute on Drug Abuse reported that an estimated 52 million people (20% of those aged 12 and older) have used prescription drugs for nonmedical reasons at least once

in their lifetimes. In 2015, it was reported that in the 12 to 17 age group, data on “past-year” of any prescription psychotherapeutic drug, dependence or abuse is higher than in adults. In this age group, females exceed males in the nonmedical use of all psychotherapeutics, including pain relievers, tranquilizers, and stimulants, and are more likely to be dependent on stimulants (National Institutes of Health [NIH], 2015). These include: 1. Opioids, such as fentanyl (Duragesic), hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), oxymorphone (Opana), propoxyphene (Darvon), hydromorphone (Dilaudid), meperidine (Demerol), morphine (Kadian, Avenza), diphenoxylate (Lomotil) 2. Central nervous system (CNS) depressants, such as pentobarbital sodium (Nembutal), diazepam (Valium), alprazolam (Xanax) 3. Stimulants such as dextroamphetamine (Dexedrine), methylphenidate (Ritalin and Concerta), amphetamines (Adderall) II. Etiology a. No single theory developed to date explains condition. b. Multiple predisposing factors implicated in abuse of substances (Claros & Sharma, 2012): i. Biological—genetic predisposition, chronic pain, illness, trauma ii. Biochemical—properties of psychoactive drugs, individual’s higher threshold for central nervous system (CNS) effects iii. Psychological— depression; psychosis (Charles & Weaver, 2010); personality traits including isolation, low selfesteem, passivity, impulsivity, sexual immaturity, lack of emotional intelligence (Claros & Sharma, 2012); comorbidity with schizophrenia in 50% of cases (Bridgman, 2013) iv. Sociocultural—unstable home environment, disturbed relationship with parental figures, peer or group pressure, conditioning, availability of substance, childhood sexual abuse (Sartor et al, 2013) v. Cultural and ethnic influences—attitudes toward alcohol or drug use, expectation that substance can safely relieve distress III. Statistics a. Morbidity: Excessive alcohol use, either in the form of heavy drinking or binge drinking, occurred in approximately 17% of the U.S. population in 2013, and 6% reported heavy drinking (CDC, 2015). In the 2014 survey by the Substance Abuse and Mental Health Services Administration (SAMHA) published in 2015, illicit drugs with the highest levels of past-year dependence or abuse were marijuana (an estimated 4.2 million people ages 20 or older), pain relievers (1.9 million), and cocaine (1 million). In 2011, there were 5.1 million drug-related emergency department (ED) visits; about one-half (49%) were attributed to drug misuse or abuse. Among visits involving drug misuse or abuse, 1.4 million visits involved phar maceuticals and 1.3 million involved illicit drugs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). Only 11.2% of people who were found to need substance use treatment received such treatment in a specialty facility (Center for Behavioral Health Statistics and Quality [CBHSQ], 2011).

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CHAPTER 14

for healthcare and more than $193 billion overall, with the majority share attributable to lost productivity (U.S. Department of Justice [DOJ], 2011). The National Institute on Drug Abuse (NIDA, 2016) report did not have updated data with one exception: that report estimates in 2013 prescription opioid health care costs of $26 billion with $78.5 in overall costs.

General: Substance Use Disorders

b. Mortality: More than 64,000 Americans died from drug overdoses in 2016, including illicit drugs and opioids, almost double in a decade, according to a report published by the National Institute on Drug Abuse (NIDA, 2017). c. Cost: According to a survey published in 2011 by the U.S. Department of Justice, use of illicit drugs in 2007 (the most recent year for which data were available) cost $11 billion

G L O S S A R Y Addiction: Chronic relapsing brain disorder characterized by compulsive drug seeking and use and by long-lasting chemical changes in the brain. ATOD: Stands for alcohol, tobacco, and other drug— acronym used for addressing substance use in interviews. CAGE Screening tool: A questionnaire focusing on individual’s attempts to Cut down on drinking (or drug use), and Annoyance with criticism from others regarding use, and Guilt about substance use, and using alcohol (or drug) as an Eye opener or to counter negative effects of withdrawal. Cognitive-behavioral therapy: Assists clients to recognize, avoid, and cope with situations in which they are most likely to use substance. Compulsive: Type of behavior a person exhibits that is overpowering, repeated, and, often, irrational. Craving: Powerful desire for a substance that cannot be ignored. Detoxification: Medically supervised treatment for alcohol or drug addiction designed to purge the body of intoxicating or addictive substances. Dual diagnosis: Co-occurring mental illness and substance abuse. Enabling: Doing for the client what he or she needs to do for self—rescuing. Due to shame and fear, significant others (SOs) and family member(s) often allow the drug or alcohol user to continue disruptive, irrational behavior patterns.

Harm reduction: Program that accepts the reality of drug use while attempting to reduce its harmful consequences to individuals and society. An example could be a “clean-needle program” for intravenous (IV) drug users. Medication-assisted treatment (MAT): The use of FDA-approved medications with counseling and behavioral therapies to treat SUDs. Motivational incentives/contingency management: Uses positive reinforcement/tangible rewards to encourage abstinence from substance(s). Motivational interviewing: Nonconfrontational approach assisting client to explore internal motivations for client’s behavior and feelings of ambivalence and fear of change in an effort to find motivation to make changes and accomplish treatment goals. Multidimensional family therapy: Developed for adolescents and their families to address a range of influences on the client’s substance use patterns and which is designed to improve overall family functioning. Peer support: Structured relationship in which people meet to provide or exchange emotional support with others facing similar challenges. Peer-to-peer groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Smart Recovery, and online forums. Substance use disorder (SUD): Condition that is used to describe a person dependent on or abusing alcohol and/or drugs, including the nonmedical use of prescription drugs.

CARE SETTING

RELATED CONCERNS

Client is treated inpatient on behavioral unit/residential facility or outpatient in a day program or community agency.

Alcohol: acute withdrawal, page 919 Psychosocial aspects of care, page 835

C L I E N T A S S E S S M E N T D ATA B A S E Data depend on substances involved, duration of use, and organs affected.

M AY R E P O R T

M AY E X H I B I T

Additional Data Requirements • Family issues— discipline, conflict, attitudes • Peer and individual—the individual’s delinquency, perception of risk, friends’ attitudes and use of substances • History of substances used—type used, length of use; method of use (e.g., snorting, smoking, injecting, or swallowing); amount taken each time • Family history and genetic makeup

• Family issues— communication • Community—availability of substances, attitudes regarding use • Work or school—attendance, perfor mance or grades • Risk-taking behaviors • Medical and mental health comorbidities

(continues on page 932)

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C L I E N T A S S E S S M E N T D ATA B A S E (contd.) M AY R E P O R T

M AY E X H I B I T

(continued)

(continued)

Teaching/Learning • Discharge plan considerations: May need assistance with long-range plan for recovery ➧ 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

Drug Screens • Drug screens: Serum, urine, saliva, sweat, and/or hair may be tested. • Screening for use or relapse: Variety of tools may be used, such as Alcohol Use Disorders Identification Test (AUDIT), CAGE survey, Drug Abuse Screening Test (DAST), and brief Michigan Alcoholism Screening Test (BMAST). • Addiction Severity Index (ASI) assessment tool: Produces a “problem severity profile” of the client, including chemical, medical, psychological, legal, family and social, and employment and support aspects. • Other screening studies (e.g., hepatitis, HIV, tuberculosis [TB], venereal diseases): Depends on general condition, individual risk factors, and care setting.

Identifies drug(s) being used, including usual drugs of abuse— alcohol, heroin, marijuana, cocaine, and inhalants. Useful in determining patterns reflecting social, vocational, or family problems associated with alcohol intake or abuse of other drugs. MAST has a geriatric version and DAST has an adolescent version. Reveals treatment needs and areas to be addressed.

Reveals organ involvement and presence of comorbidities.

NURSING PRIORITIES

DISCHARGE GOALS

1. Provide support for decision to stop substance use and adopt a harm reduction program. 2. Strengthen individual coping skills. 3. Facilitate learning of new ways to reduce anxiety. 4. Promote family involvement in rehabilitation program. 5. Facilitate family growth and development. 6. Provide information about condition, prognosis, and treatment needs.

1. 2. 3. 4. 5. 6.

N U R S I N G D I AG N OS I S:

Responsibility for own life and behavior assumed. Plan to maintain substance-free life formulated. Family relationships and enabling issues being addressed. Treatment program successfully begun. Condition, prognosis, and therapeutic regimen understood. Plan in place to meet needs after discharge.

ineffective Denial

May Be Related To Anxiety; threat of unpleasant reality Excessive stress Ineffective coping strategies Threat of unpleasant reality Possibly Evidenced By Delay in seeking or refusal of healthcare; minimizes symptoms Does not admit impact of condition on life

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CHAPTER 14

N U R S I N G D I AG N OS I S:

ineffective Denial (continued)

Use of dismissive comments or gestures when speaking of distressing events Does not perceive personal relevance of danger

ACTIONS/INTERVENTIONS

RATIONALE

Behavior Modification NIC Independent

Ask client (including pediatric client) about alcohol, tobacco, and other drug (ATOD) use at each contact.

Convey attitude of acceptance, separating individual from unacceptable behavior. Ascertain reason for beginning abstinence and involvement in therapy.

Review definition of drug dependence and use with categories of symptoms, including risk factors, patterns of use, impairment caused by use, tolerance to substance.

Answer questions honestly and provide factual information. Keep your word when agreements are made. Provide information about addictive use versus experimental, occasional use; biochemical and genetic disorder theory—genetic predisposition, use activated by environment; and compulsive desire. Discuss current life situation and impact of substance use.

Confront and examine denial and rationalization in peer group. Use confrontation with caring attitude.

Provide information regarding effects of addiction on mood and personality.

Although client may deny or minimize actions, healthcare provider can open the door to obtaining help and treatment for client by asking broad questions in initial and subsequent interviews. In 2014, an estimated 14.5 million adults aged 26 or older had SUDs. Note: An estimated 1.3 million adolescents aged 12 to 17 and 5.7 million young adults aged 18 to 25 also had SUDs in 2014 (Substance Abuse and Mental Health Ser vices Administration [SAMHSA], 2015). Promotes feelings of dignity and self-worth. Demonstrates caring attitude. Provides insight into client’s willingness to commit to long-term behavioral change and whether client even believes that he or she can change. Note: Denial is one of the strongest and most resistant manifestations of SUD. The decision to quit is an impor tant step to success in therapy. This information helps client make decisions regarding acceptance of problem and treatment choices. Note: The risk of becoming a drug abuser involves the relationship among the number and type of risk factors (e.g., deviant attitudes and behaviors) and protective factors (e.g., parental support). Early intervention with risk factors (e.g., aggressive behavior and poor self-control) often has a greater impact than later intervention by changing a child’s life path (trajectory) away from problems and toward positive behaviors (Hawkins et al, 2008). Creates trust, which is the basis of the therapeutic relationship. Progression of use continuum ranges from experimental or recreational to addictive use. Comprehending this process is impor tant in combating denial. Education may relieve client’s guilt and blame and may help awareness of recurring addictive characteristics. First step in decreasing use of denial is for client to see the relationship between substance use and personal problems. Because denial is the major defense mechanism in addictive disease, confrontation by peers can help the client accept the reality of adverse consequences of behaviors and that drug use is a major problem. Caring attitude preserves self-concept and helps decrease defensive response. Individuals often mistake effects of addiction and use this to justify or excuse drug use.

General: Substance Use Disorders

Desired Outcomes/Evaluation Criteria—Client Will Acceptance: Health Status NOC Verbalize awareness of relationship of substance use to current situation. Engage in therapeutic program. Verbalize acceptance of responsibility for own behavior.

(continues on page 934)

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ACTIONS/INTERVENTIONS (continued) Remain nonjudgmental. Be alert to changes in behavior such as restlessness and increased tension. Provide positive feedback for expressing awareness of denial in self and others. Maintain firm expectation that client attends recovery support and therapy groups regularly. Encourage and support client’s taking responsibility for own recovery, such as development of alternative behaviors to drug urge and use. Assist client to learn own responsibility for recovering. Be aware of own enabling behaviors. Understand professional boundaries needed to be therapeutic with client experiencing a SUD (Tsai et al, 2010).

N U R S I N G D I AG N OS I S:

RATIONALE (continued) Confrontation can lead to increased agitation, which may compromise safety of client and staff. Necessary to enhance self-esteem and to reinforce insight into behavior. Attendance is related to admitting need for help, to working with denial, and for maintaining long-term, substancefree existence. Denial can be replaced with positive action when client accepts the reality of own responsibility.

Caregiving lends itself to “taking care” of clients that can backfire in substance abuse treatment.

risk for Acute Substance Withdrawal Syndrome

Possibly Evidenced By Developed dependence to alcohol or other addictive substance Heavy use of an addictive substance over time Sudden cessation of an addictive substance Desired Outcomes/Evaluation Criteria—Client Will Substance Withdrawal Severity NOC Display stable vital signs and usual orientation, absence of hallucinations and seizure activity. Free of agitation or emotional outbursts. ACTIONS/INTERVENTIONS

RATIONALE

Substance Use Treatment NIC Independent

Note presence of comorbidities—medical conditions/ psychiatric disorders and currently prescribed medications. Assess vital signs (VS) and level of consciousness (LOS) as indicated. Identify stage of alcohol withdrawal syndrome (AWS) using CIWA-Ar. Stage I is associated with signs and symptoms of hyperactivity, such as tremors, sleeplessness, nausea, vomiting, diaphoresis, tachycardia, and hypertension; stage II is manifested by increased hyperactivity plus hallucinations and/or seizure activity; stage III symptoms include DTs and extreme autonomic hyperactivity with profound confusion, anxiety, insomnia, and fever. Monitor for signs of withdrawal relative to other substance(s) used.

Suggests additional monitoring and potential treatment needs. VS and LOC can be labile, based on specific substance(s) and length of time since last used, requiring more in-depth evaluation and medical intervention. AWS usually begins 3 to 36 hours after the last drink. Prompt recognition and intervention may halt progression of symptoms and enhance recovery, improving prognosis. In addition, progression of symptoms indicates need for changes in drug therapy and more intense treatment with possible transfer to higher level of care (refer to CP: Alcohol: Acute Withdrawal). Not all clients will have completed the withdrawal process prior to admission, and symptoms and timing of occurrence depend on type of substance(s) used and last dose. For example: Heroin flu-like symptoms begin within 12 hours of last dose, peaks 24 to 48 hours and lasting a week to up to a few months. Prescription painkillers—opiate flu-like symptoms begin within 8 to 12 hours, peak 12 to 48 hours, and last 5 to 10 days. Cocaine depression and restlessness start within hours of last dose, peak in 7 to 10 days, and last 1 to 10 weeks.

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CHAPTER 14

ACTIONS/INTERVENTIONS (continued)

General: Substance Use Disorders

RATIONALE (continued) Benzodiazepines anxiety and/or seizures begin within 1 to 4 days, peaking in a few days and lasting weeks or (in some cases) months (American Addiction Centers, n.d., 2017). Presence and degree of symptoms may require medical evaluation and support.

Collaborative

Administer medications, as indicated, for example:

Disulfiram (Antabuse)

Acamprosate (Campral EC)

Buprenorphine (Buprex, Subutex, Suboxone)

Methadone (Dolophine) and levo-acetylmethadol (LAAM)

Naltrexone (Narcan) and nalmefene (Revex)

Monitor results of periodic drug testing as appropriate.

Medications can be used to manage withdrawal symptoms, prevent relapse, and treat co-occurring conditions (NIDA, 2016; SAMHSA, 2015). Note: There are no FDA-approved medications for treating cannabis, cocaine, or methamphetamine SUDs and medication-assisted treatments (MAT) are rarely used to treat adolescent alcohol use (NIDA, 2016). This drug can be helpful in maintaining abstinence from alcohol while other therapy is undertaken. By inhibiting alcohol oxidation, the drug leads to an accumulation of acetaldehyde with a highly unpleasant reaction if alcohol is consumed. Helps prevent relapses in alcoholism by lowering receptors for the excitatory neurotransmitter glutamate. This agent may become drug of choice because it does not make the user sick if alcohol is consumed; it has no sedative, antianxiety, muscle-relaxant, or antidepressant properties and produces no withdrawal symptoms. Used in the treatment of opioid addiction. At low doses, it produces sufficient agonist effect to enable opioidaddicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. This drug carries a lower risk of abuse, dependence, and side effects compared to full opioid agonists (Liberto & Fornili, 2013). Note: FDA does not recommend Subutrex and Suboxone for use in pediatric clients (NIDA, 2016). Methadone is thought to blunt the craving for or diminish the effects of opioids and is used to assist in withdrawal and long-term maintenance programs. It can allow the individual to maintain daily activities and ultimately withdraw from drug use. LAAM, a long-acting synthetic μ agonist, is an effective alternative to methadone maintenance and only has to be taken three times a week. Harm reduction needs to be considered versus the possibility of exchanging one addiction for another (Tetrault & Fiellin, 2012). Used to suppress craving for opioids and may help prevent relapse in the client abusing alcohol. Current research suggests that naltrexone suppresses urge to continue drinking by interfering with alcohol-induced release of endorphins (Tetrault & Fiellin, 2012). Used in emergency situations to prevent death from overdose. Note: Genetic differences may affect how well the drug works in certain clients (NIDA, 2016). Impor tant to identify that return to substance use or change to another drug results in serious consequences.

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N U R S I N G D I AG N OS I S:

ineffective Coping

May Be Related To Situational/maturational crisis; uncertainty Inadequate confidence in ability to deal with a situation Ineffective tension release strategies Inadequate resources; insufficient social support (created by characteristics of relationships) Possibly evidenced by Substance abuse; risk taking; destructive behavior toward self Insufficient problem-solving or problem resolution Ineffective coping strategies Inability to deal with a situation, ask for help Desired Outcomes/Evaluation Criteria—Client Will Substance Addiction Consequences NOC Identify consequences of using substance as a method of coping. Coping NOC Identify other ineffective coping behaviors. Engage in problem-solving using effective coping skills. Initiate necessary lifestyle changes. ACTIONS/INTERVENTIONS

RATIONALE

Substance Use Treatment NIC Independent

Review program rules, philosophy, and expectations.

Determine understanding of current situation and previous or other methods of coping with life’s problems.

Set limits and confront efforts to get caregiver to grant special privileges, making excuses for not following through on agreed-upon behaviors and attempting to continue drug use. Avoid use of labels, such as lying.

Be aware of staff attitudes, feelings, and enabling behaviors.

Encourage verbalization of feelings, fears, and anxiety. Explore alternative coping strategies.

Assist client to learn and encourage use of relaxation skills, guided imagery, and visualizations. Structure diversional activity that relates to recovery such as social activity within support group, wherein issues of being chemically free are examined. Use peer support to examine ways of coping with drug hunger.

Having information provides opportunity for client to cooperate and function as a member of the group or milieu, enhancing sense of control and sense of success. Provides information about degree of denial, acceptance of personal responsibility, and commitment to change; identifies coping skills that may be used in present situation. Note: Adolescents are at high risk for drug abuse due to incomplete brain development, which may lead to poor decision making and risk taking (Winters & Arria, 2011). Client has learned manipulative behavior throughout life and needs to learn a new way of getting needs met. Following through on consequences of failure to maintain limits can help the client to change ineffective behaviors. Use of labels promotes negative attitudes that can impede therapeutic relationships. Lack of understanding and judgmental or enabling behaviors can result in inaccurate data collection and nontherapeutic approaches. May help client begin to come to terms with long-unresolved issues. Client may have little or no knowledge of adaptive responses to stress and needs to learn other options for managing time, feelings, and relationships without drugs. Helps client relax and develop new ways to deal with stress and to problem-solve. Discovery of alternative methods of coping with drug hunger can remind client that addiction is a lifelong process and opportunity for changing patterns is available. Self-help groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Crystal Methamphetamine Anonymous (CMA), are valuable for learning and promoting abstinence in each member by using understanding and support as well as peer pressure.

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Discuss client’s plans for living without drugs.

RATIONALE (continued) Employment and financial stressors, isolation, unhealthy relationships, being around substance-using friends, hearing certain songs, premenstrual syndrome—the list of possibilities depends on the individual. Being aware of the triggers provides an opportunity to plan for ways to avoid and deal with them. Therapeutic writing or journaling can enhance participation in treatment; serves as a release for grief, anger, and stress; provides a useful tool for monitoring client’s safety; and can be used to evaluate client’s progress. Autobiographical activity provides an opportunity for client to remember and identify sequence of events in his or her life that relate to current situation. Provides opportunity to develop and refine plans. Devising a comprehensive strategy for avoiding relapses helps client into maintenance phase of behavioral change.

General: Substance Use Disorders

Encourage involvement in therapeutic writing. Have client begin journaling or writing autobiography.

CHAPTER 14

ACTIONS/INTERVENTIONS (continued) Identify possible and actual triggers for relapse. Encourage client to use the acronym HALT—“Am I hungry, angry, lonely, or tired?”

Collaborative

Collaborate with counselors and provide consistency in treatment approach.

Encourage involvement with self-help associations such as AA, NA, or CMA. Facilitate visit by a group member/ possible sponsor as appropriate. Refer to community or social resources such as housing assistance, employment agencies, childcare, food stamps, or alternative schooling.

N U R S I N G D I AG N OS I S:

Individual counseling can promote skill building and adherence to a recovery plan through techniques such as cognitive-behavioral therapy, contingency management, and motivational interviewing/incentives therapies (NIDA, 2016). Puts client in direct contact with support system necessary for managing sobriety and drug-free life. Dealing with life problems in a proactive way enhances coping abilities, reduces sense of isolation and hopelessness, and decreases risk of relapse.

Powerlessness

May Be Related To Unsatisfactory interpersonal interactions; insufficient social support; social marginalization Ineffective coping strategies; low self-esteem Complex treatment regimen Possibly Evidenced By Insufficient sense of control; shame; depression; alienation Dependency (substance use) Inadequate participation in care Desired Outcomes/Evaluation Criteria—Client Will Health Beliefs: Perceived Threat NOC Admit inability to control drug habit and surrender to powerlessness over addiction. Verbalize acceptance of need for treatment and awareness that willpower alone cannot control abstinence. Acceptance: Health Status NOC Demonstrate active participation in care and treatment program. Regain and maintain healthy state with a drug-free lifestyle. ACTIONS/INTERVENTIONS

RATIONALE

Self-Responsibility Facilitation NIC Independent

Use crisis intervention techniques to initiate behavior changes:

May need to use emergency commitments or other legal holds for the client’s safety. Client may be more amenable to acceptance of need for treatment at this time. (continues on page 938)

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ACTIONS/INTERVENTIONS (continued) Assist client to recognize problem exists. Discuss in a caring, nonjudgmental manner how drug has interfered with life. Involve client in development of treatment plan, using problem-solving process in which client identifies goals for change and agrees to desired outcomes.

Discuss alternative solutions.

Assist in selecting most appropriate alternative. Support decision and implementation of selected alternative(s).

Explore support in peer group. Encourage sharing about drug hunger, situations that increase the desire to indulge, and ways that substance has influenced life. Assist client to learn ways to enhance health and structure healthy diversion from drug use, including maintaining a balanced diet, getting adequate rest, exercise such as walking, slow or long-distance running, and acupuncture, biofeedback, or deep meditative techniques.

Provide information regarding understanding of human behavior and interactions with others, such as transactional analysis. Assist client in self-examination of spirituality and faith.

Instruct in and role-play assertive communication skills.

Provide treatment information on an ongoing basis.

RATIONALE (continued) In the precontemplation phase, the client has not yet identified that drug use is problematic. While client is hurting, it is easier to admit substance use has created negative consequences. During the contemplation phase, the client realizes a problem exists and is thinking about a change of behavior. The client is committed to the outcomes when the decision-making process involves solutions that are promulgated by the individual. Brainstorming helps creatively identify possibilities and provides sense of control. During the preparation phase, minor action may be taken as individual organizes resources for definitive change. As possibilities are discussed, the most useful solution becomes clear. Helps the client persevere in process of change. During the action phase, the client engages in a sustained effort to maintain sobriety and mechanisms are put in place to support abstinence. Client may need assistance in expressing self, speaking about powerlessness, and admitting need for help in order to face up to problem and begin resolution. Learning to empower self in constructive ways can strengthen ability to continue recovery. These activities help restore natural biochemical balance, aid detoxification, and manage stress, anxiety, and use of free time. These diversions can increase self-confidence, thereby improving self-esteem. Note: Exercise promotes release of endorphins, creating a feeling of well-being. Understanding these concepts can help the client to begin to deal with past problems and losses and prevent repeating ineffective coping behaviors and self-fulfilling prophecies. Although not mandatory for recovery, surrendering to and faith in a power greater than oneself has been found to be effective for many individuals in substance recovery; may decrease sense of powerlessness. Effective in helping refrain from use, to stop contact with users and dealers, to build healthy relationships, and to regain control of own life. Helps client know what to expect and creates opportunity for client to be a part of what is happening and make informed choices about participation and outcomes.

Collaborative

Refer to, or assist with making contact with, programs for ongoing treatment needs—partial hospitalization drug treatment programs; NA, AA, CMA, or peer support groups.

N U R S I N G D I AG N OS I S:

Continuing treatment is essential to positive outcome. Follow-through may be easier once initial contact has been made.

imbalanced Nutrition: less than body requirements

May Be Related To Insufficient dietary intake—psychological, physiological, or insufficient finances Possibly Evidenced By Weight loss; body weight below norm for height and body build Alteration in taste sensation; food intake less than recommended daily allowance; insufficient interest in food Insufficient muscle tone; sore buccal cavity [Laboratory evidence of protein and vitamin deficiencies] 938

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CHAPTER 14

N U R S I N G D I AG N OS I S:

imbalanced Nutrition: less than body requirements (continued)

ACTIONS/INTERVENTIONS

General: Substance Use Disorders

Desired Outcomes/Evaluation Criteria—Client Will Nutritional Status NOC Demonstrate progressive weight gain toward goal with normalization of laboratory values and absence of signs of malnutrition. Knowledge: Treatment Regimen NOC Verbalize understanding of effects of substance abuse and reduced dietary intake on nutritional status. Demonstrate behaviors or lifestyle changes to regain and maintain appropriate weight. RATIONALE

Nutrition Therapy NIC Independent

Assess height, weight, age, body build, strength, and activity and rest levels. Note condition of oral cavity. Take anthropometric measurements, such as midarm muscle circumference, triceps skinfold, and percentage of body fat, when available. Note total daily calorie intake. Recommend client maintain a diary of intake, as well as times and patterns of eating. Evaluate energy expenditure (e.g., pacing or sedentary), and establish an individualized exercise program. Provide opportunity to choose foods and snacks to meet dietary plan. Recommend monitoring weight weekly.

Provides information on which to base individual caloric needs and dietary plan. Type of foods may be affected by condition of mucous membranes and teeth. Calculates subcutaneous fat and muscle mass to aid in determining dietary needs. Information will help identify nutritional deficiencies. Activity level affects nutritional needs. Exercise enhances muscle tone and may stimulate appetite. Enhances sense of control, may promote resolution of nutritional deficiencies, and helps evaluate client’s understanding of dietary teaching. Provides information regarding effectiveness of dietary plan.

Collaborative

Consult with dietitian. Review laboratory studies as indicated, such as glucose, serum albumin or prealbumin, and electrolytes. Refer for dental consultation as necessary.

N U R S I N G D I AG N OS I S:

Useful in establishing individual dietary needs and plan and provides additional resource for learning. Identifies anemias, electrolyte imbalances, and other abnormalities that may be present, requiring specific therapy. Teeth are essential to good nutritional intake, and oral hygiene and dental care are often a neglected area in this population.

chronic low Self-Esteem

May Be Related To Repeated failures, negative reinforcement Receiving insufficient affection; inadequate respect from others Psychiatric disorder Cultural incongruencies Possibly Evidenced By Underestimation of ability to deal with situation Repeatedly unsuccessful in life events Rejection of positive feedback; exaggerates negative feedback about self Overly conforming; passivity Desired Outcomes/Evaluation Criteria—Client Will Self-Esteem NOC Identify feelings and underlying dynamics for negative perception of self. Verbalize acceptance of self as is and an increased sense of self-worth. Set goals and participate in realistic planning for lifestyle changes necessary to live without drugs.

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ACTIONS/INTERVENTIONS

RATIONALE

Self-Esteem Enhancement NIC Independent

Provide opportunity for and encourage verbalization and discussion of individual situation.

Assess mental status. Note presence of other psychiatric disorders.

Spend time with client. Discuss client’s behavior and use of substance in a nonjudgmental way. Note cultural, racial/ ethnic, religious, gender issues.

Provide grief counseling, as indicated.

Provide reinforcement for positive actions and encourage client to accept this input. Observe family interactions and SO dynamics and level of support.

Encourage expression of feelings of guilt, shame, and anger.

Help client acknowledge that substance use is the problem and that problems can be dealt with without the use of drugs. Confront the use of defenses—denial, projection, and rationalization. Ask client to list and review past accomplishments and positive happenings. Use techniques of role rehearsal.

Client often has difficulty expressing self, even more difficulty accepting the degree of importance substance has assumed in life and its relationship to present situation. Many clients use substances in an attempt to obtain relief from depression or anxiety, which may predate use and/or be the result of substance use. Approximately 60% of substance-dependent clients have underlying psychological problems or a dual diagnosis, and treatment for both is imperative to achieve and maintain abstinence. The nurse’s presence conveys acceptance of the individual as a worthwhile person. Based on personal issues, client may be dealing with stigma of condition, discrimination, and scarcity of community resources necessitating additional support. Discussion provides opportunity for insight into the problems substance abuse has created for the client. Life losses secondary to alcohol or other drug use problems need to be addressed to enable client to move forward with rehabilitation. Failure and lack of self-esteem have been problems for this client, who needs to learn to accept self as an individual with positive attributes. Substance abuse is a family disease, and how the members act and react to the client’s behavior affects the course of the disease and how client sees self. Many unconsciously become “enablers,” helping the individual to cover up the consequences of the abuse. (Refer to ND: dysfunctional Family Processes, following.) The client often has lost respect for self and believes that the situation is hopeless. Expression of these feelings helps client begin to accept responsibility for self and take steps to make changes. When drugs can no longer be blamed for the problems that exist, client can begin to deal with the problems and live without substance use. Confrontation helps client accept the reality of the problems as they exist. There are things in everyone’s life that have been successful. Often when self-esteem is low, it is difficult to remember these successes or to view them as successes. Assists client to practice developing skills to cope with new role as a person who no longer uses or needs drugs to handle life’s problems.

Collaborative

Involve client in group therapy.

Engage in motivational enhancement therapy.

Group sharing helps encourage verbalization because other members of the group are in various stages of abstinence from drugs and can address the client’s concerns or denial. The client can gain new skills, hope, and a sense of family or community from group participation. Assists individuals with SUDs to build motivation and commit to specific treatment plans and seek recovery.

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Monitor for diabetes, weight gain, and dyslipidemia.

N U R S I N G D I AG N OS I S:

RATIONALE (continued) Clients who seek relief for other mental health problems through drugs will continue to do so once discharged. Both the substance use and the mental health problems need to be treated together to maximize abstinence potential. Treatment may be difficult because of difficulty of taking initiative, thinking realistically, and problemsolving. Behavioral methods seem to be most helpful. Prolonged or profound psychosis following lysergic acid diethylamide (LSD) or phencyclidine (PCP) use can be treated with these drugs because it is probably the result of an underlying functional psychosis that has now emerged. Methamphetamine psychosis often does not reverse. Note: Avoid the use of phenothiazines because they may decrease seizure threshold and cause hypotension in the presence of LSD or PCP use. Atypical antipsychotics (e.g., Zyprexa) are associated with these effects and should be monitored closely for changes in glucose control. Measurement of fasting blood glucose at the beginning of therapy and periodical monitoring during therapy are recommended.

General: Substance Use Disorders

Administer antipsychotic medications, such as quetiapine (Seroquel) or olanzapine (Zyprexa or Zydis), as necessary.

CHAPTER 14

ACTIONS/INTERVENTIONS (continued) Formulate plan to treat other mental illness problems.

dysfunctional Family Processes

May Be Related To Substance misuse; addictive personality Ineffective coping strategies; insufficient problem-solving skills Family history of substance misuse, resistance to treatment Genetic predisposition to substance misuse Possibly Evidenced By Feelings: anxiety, anger, shame, embarrassment, emotional isolation, loneliness, vulnerability, repressed emotions Roles and responsibilities: disturbance in family dynamics, closed communication system, ineffective communication with partner, change in role function, disruption in family roles, inconsistent parenting Behaviors: manipulation, dependency, criticizing, rationalization, denial of problems, enabling maintenance of substance use pattern, refusal to get help, inability to receive help appropriately Desired Outcomes/Evaluation Criteria—Family Will Family Coping NOC Verbalize understanding of dynamics of enabling behaviors. Participate in individual family programs. Identify ineffective coping behaviors and consequences. Initiate and plan for necessary lifestyle changes. Take action to change self-destructive behaviors and alter behaviors that contribute to partner’s/SO’s addiction. ACTIONS/INTERVENTIONS

RATIONALE

Substance Use Treatment NIC Independent

Review family history and explore roles of family members, circumstances involving drug use, strengths, and areas for growth. Explore how the SO has coped with the client’s habit—use of denial, repression, rationalization, projection, feelings of hurt, and loneliness. Determine understanding of current situation and previous methods of coping with life’s problems.

Determines areas for focus and potential for change.

The person who enables also suffers from the same feelings as the client and uses ineffective methods for dealing with the situation, necessitating help in learning new, more effective coping skills. Provides information on which to base present plan of care. (continues on page 942)

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ACTIONS/INTERVENTIONS (continued) Assess current level of functioning of family members. Determine extent of enabling behaviors being evidenced by family members and explore with each individual and client.

Provide information about enabling behavior, addictive disease characteristics for both user and nonuser.

Identify and discuss sabotage behaviors of family members.

Encourage participation in therapeutic writing, such as journaling (narrative) or guided or focused writing. Provide factual information to client and family about the effects of addictive behaviors on the family and what to expect after discharge. Encourage family members to be aware of their own feelings and look at the situation with perspective and objectivity. They can ask themselves, “Am I being conned? Am I acting out of fear, shame, guilt, or anger? Do I have a need to control?” Provide support for enabling partner(s). Encourage group work. Assist the client’s partner to become aware that client’s abstinence and drug use are not the partner’s responsibility. Help the recovering partner who is enabling to distinguish between destructive aspects of behavior and genuine motivation to aid the user. Note how partner relates to the treatment team.

Explore conflicting feelings the enabling partner may have about treatment, such as feelings similar to those of abuser—blend of anger, guilt, fear, exhaustion, embarrassment, loneliness, distrust, grief, and possibly relief. Involve family in discharge referral plans.

Be aware of staff’s enabling behaviors and feelings about client and enabling partners.

RATIONALE (continued) Affects individual’s ability to cope with situation. People want to be helpful and do not want to feel powerless to help their loved one stop substance use and change the behavior that is so destructive. However, the substance user often relies on others to rescue them by covering up own inability to cope with daily responsibilities. Awareness and knowledge of behaviors such as avoiding and shielding, taking over responsibilities, rationalizing, and subservience provide opportunity for individuals to begin the process of change. Even though family member(s) may verbalize a desire for the individual to become substance-free, the reality of interactive dynamics is that they may unconsciously not want the individual to recover because this would affect their own role in the relationship. Additionally, they may receive sympathy and attention from others—secondary gain. Serves as a release for feelings such as anger, grief, and stress and helps move individuals forward in treatment process. Many clients and SOs are not aware of the nature of addiction. If client is using legally obtained drugs, he or she may believe this does not constitute abuse. When the enabling family members become aware of their own actions that perpetuate the addict’s problems, they need to decide to change themselves. If they change, the client can then face the consequences of his or her own actions and may choose to get well. Families and SOs need support to produce change as much as the person who is addicted. Partners need to learn that user’s habit may or may not change despite partner’s involvement in treatment. Enabling behavior can be partner’s attempts at personal survival. Determines enabling style. A parallel exists between how partner relates to user and to staff, based on partner’s feelings about self and situation. Useful in establishing the need for therapy for the partner. This individual’s own identity may have been lost; she or he may fear self-disclosure to staff and may have difficulty giving up the dependent relationship. Drug abuse is a family illness. Because the family has been so involved in dealing with the substance use behavior, family members need help adjusting to the new behavior of sobriety and abstinence. Incidence of recovery is almost doubled when the family is treated along with the client. Lack of understanding of enabling can result in nontherapeutic approaches to clients and their families.

Collaborative

Involve in substance abuse prevention or treatment plan, as indicated.

Can be voluntary, court ordered, or via the Department of Human Ser vices (DHS) involvement. Prevention programs should address all forms of drug use, alone or in combination, including the underage use of legal drugs (e.g., tobacco or alcohol), the use of illegal drugs (e.g., marijuana [real and counterfeit] such as 9K2, Spice), meth, cocaine, other designer drugs, including Ecstasy, and the

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Encourage involvement with self-help associations, AA or NA, Al-Anon, Alateen, and professional family therapy.

N U R S I N G D I AG N OS I S:

RATIONALE (continued) inappropriate use of legally obtained substances (e.g., inhalants), prescription medications, or over-the-counter drugs (Johnston et al, 2002). Program developed for adolescents with SUDs and their families to address the various influences on client’s drug abuse patterns, which is designed to improve overall family functioning by fostering family competency and collaboration with other systems such as school and juvenile justice (SAMHSA, 2015). Puts client and family in direct contact with support systems necessary for continued sobriety and to assist with problem resolution.

General: Substance Use Disorders

Promote involvement of all members in multidimensional family therapy.

CHAPTER 14

ACTIONS/INTERVENTIONS (continued)

Sexual Dysfunction

May Be Related To Alteration in body function (e.g., neurological damage, debilitating effects of drug use—particularly alcohol and opiates) Vulnerability; presence of abuse Value conflict (gender identity, sexual preferences) Insufficient knowledge, misinformation Possibly Evidenced By Decrease in sexual desire Alteration in sexual activity, satisfaction Undesired change in sexual function Desired Outcomes/Evaluation Criteria—Client Will Substance Addiction Consequences NOC Verbally acknowledge effects of drug use on sexual functioning and reproduction. Sexual Functioning NOC Identify interventions to correct and overcome individual situation. ACTIONS/INTERVENTIONS

RATIONALE

Sexual Counseling NIC Independent

Ascertain client’s beliefs and expectations. Have client describe problem in own words. Encourage and accept individual expressions of concern. Provide educational opportunities such as pamphlets or consultation with appropriate persons regarding effects of drug on sexual functioning. Provide information about individual’s condition.

Assess drinking and drug history of pregnant client. Provide information about effects of substance abuse on the reproductive system and fetus, including increased risk of premature birth, brain damage, and fetal malformation. Discuss prognosis for sexual dysfunction, such as impotence or low sexual desire.

Determines level of knowledge, identifies misperceptions, level of concern regarding sexually transmitted infections (STIs), level of risk reduction, and specific learning needs. Most people find it difficult to talk about this sensitive subject and may not ask directly for information. Much of denial and hesitancy to seek treatment may be reduced as a result of sufficient and appropriate information. Sexual functioning may have been affected by the drug itself and/or by psychological factors, such as stress or depression. Information can assist client to understand own situation and identify actions to be taken. Awareness of the negative effects of alcohol and other drugs on reproduction may motivate client to stop using substance. When client is pregnant, identification of potential problems aids in identifying concerns and planning for future fetal needs. Impotence may be reversed with abstinence from drug(s) for many individuals; however, for some, erectile dysfunction will be permanent. (continues on page 944)

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ACTIONS/INTERVENTIONS (continued)

RATIONALE (continued)

Collaborative

Refer for sexual counseling, if indicated.

Review results of sonogram if pregnant.

N U R S I N G D I AG N OS I S:

Couple may need additional assistance to resolve more severe problems or situations. Client may have difficulty adjusting if drug has improved sexual experience, such as heroin, which decreases dyspareunia in women and premature ejaculation in men. Furthermore, the client may have engaged enjoyably in bizarre, erotic sexual behavior under influence of the stimulant drug; client may have found no substitute for the drug, may have driven a partner away, and may have no motivation to adjust to sexual experience without drugs. Assesses fetal growth and development to identify possibility of fetal alcohol syndrome or other harmful drug effects and future needs. There are concerns about placental abruption with the use of methamphetamine and cocaine.

deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs

May Be Related To Insufficient information, insufficient knowledge of resources Alteration in cognitive functioning Possibly Evidenced By Insufficient knowledge; insufficient interest in learning Inaccurate follow-through of instructions Inappropriate behavior Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Substance Abuse Control NOC Verbalize understanding of own condition or disease process, prognosis, and potential complications. Verbalize understanding of therapeutic needs. Identify and initiate necessary lifestyle changes to remain drug-free. Participate in treatment program including plan for follow-up and long-term care. ACTIONS/INTERVENTIONS

RATIONALE

Learning Facilitation NIC Independent

Be aware of and deal with anxiety of client and family members. Provide an active role for the client and SO in the learning process using discussions, group participation, and role-playing. Provide written and verbal information as indicated. Include list of articles, books, Internet resources, and special TV programs related to client and family needs and encourage reading and discussing what they learn. Assess client’s knowledge of own situation, including disease process (including comorbidities), prognosis, complications, and needed changes in lifestyle. Pace learning activities to individual needs.

Anxiety can interfere with ability to hear and assimilate information. Learning is enhanced when persons are actively involved.

Helps client and SO make informed choices about future and can be a useful addition to other therapeutic approaches.

Assists in planning for long-range changes necessary for maintaining sobriety and drug-free status. Client may have street knowledge of the drug but be ignorant of medical facts. Facilitates learning because information is more readily assimilated when timing is considered.

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Teaching: Disease Process NIC Review condition, prognosis, and future expectations.

Educate about effects of specific drug(s) used; for example, PCP is deposited in body fat and may reactivate, causing flashbacks even after long interval of abstinence; alcohol use may result in mental deterioration and liver involvement or damage; cocaine can damage postcapillary vessels and increase platelet aggregation, promoting thromboses and infarction of skin or internal organs, causing localized atrophie blanche or sclerodermatous lesions. Discuss potential for reemergence of withdrawal symptoms in stimulant abuse as early as 3 months or as late as 9 to 12 months after discontinuing use.

Inform client of effects of disulfiram (Antabuse) in combination with alcohol intake and importance of avoiding use of alcohol-containing products such as cough syrups, foods, candy, mouthwash, aftershave, and cologne.

Review specific aftercare needs; for example, PCP user should drink cranberry juice and continue use of ascorbic acid; alcohol abuser with liver damage should refrain from drugs, anesthetics, or use of household cleaning products that are detoxified in the liver. Discuss variety of helpful organizations and programs that are available for assistance or referral such as AA, Dual Recovery Anonymous (DRA), or NA.

RATIONALE (continued) Provides knowledge base from which client can make informed choices. Often client has misperception or denial of real reason for admission to the medical or psychiatric care setting. Information will help client understand possible long-term effects of drug use.

General: Cancer: General Considerations

Discuss relationship of drug use to current situation.

CHAPTER 14

ACTIONS/INTERVENTIONS (continued)

Even though intoxication may have passed, client may manifest denial, drug hunger, and periods of “flare-up,” wherein there is a delayed recurrence of withdrawal symptoms such as anxiety, depression, irritability, sleep disturbance, or compulsiveness with food, especially sugars. Interaction of alcohol and Antabuse results in nausea and hypotension, which may produce fatal shock. Individuals on Antabuse are sensitive to alcohol on a continuum, with some being able to drink while taking the drug and others having a reaction with only slight exposure. Reactions also appear to be dose related. Promotes individualized care related to specific situation. Cranberry juice and ascorbic acid enhance clearance of PCP from the system. Substances that have the potential for liver damage are more dangerous in the presence of an already damaged liver. Long-term support is necessary to maintain optimal recovery. Psychosocial needs and other issues may need to be addressed.

POTENTIAL CONSIDERATIONS following acute care (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities) • ineffective Health Management/ineffective family Health Management—decisional conflicts, excessive demands made on individual or family, family conflict, perceived seriousness/benefits

• ineffective Coping—situational crises, inadequate level of confidence in ability to cope, inadequate level of perception of control • readiness for enhanced family Coping—significant person moves in direction of health promotion, chooses experiences that optimize wellness Physical needs depend on substance effect on organ systems—refer to appropriate medical plans of care for additional considerations.

CANCER—GENERAL CONSIDERATIONS I. Pathophysiology a. General term describing a disturbance of cellular growth and referring to a group of 150 different known diseases or types b. Genetic and genomic factors underlie the etiology of all cancer. The alteration of genes manifests in abnormal

cellular proliferation. Genes and genomic alterations often occur due to multifactorial genetic, infectious, radiation, environmental, hormonal, or lifestyle factors (Santos et al, 2013). c. The metastatic behavior or “natural history” of cancer varies according to the primary site of diagnosis— (continues on page 946)

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metastatic pattern for primary breast cancer may be from the breast to the bone, lung, liver, and/or brain. II. Classification a. Four main classifications of cancer according to tissue type: i. Lymphomas: cancers originating in infection-fighting organs ii. Leukemias: cancers originating in blood-forming organs iii. Sarcomas: cancers originating in bones, muscle, or connective tissue iv. Carcinomas: cancers originating in epithelial cells b. Within these broad categories, a cancer is classified by histology, stage, and grade (tumor profiling). III. Etiology a. Cellular disease that can arise from any body tissue with manifestations that result from failure to control the proliferation and maturation of cells b. Multiple risk factors or cancer-causing agents: i. Chemicals ii. Radiation iii. Viruses iv. Human behaviors and lifestyles that affect cancer risk v. Tobacco use vi. Poor nutrition vii. Inactivity, obesity viii. Sun exposure

ix. Workplace or occupational exposure x. Pollution—air, water, soil c. Biological factors that may increase or reduce risk: i. Inflammation ii. DNA repair mechanisms iii. Immunologic responses iv. Heredity 1. 75% of cancers are sporadic or manifest in one body organ at an expected age. 2. 10% to 15% are familial, or two or more siblings are diagnosed with the same cancer at a specific age. 3. 5% to 10% of cancers are hereditary or the result of a single gene expression (Santos et al, 2013). IV. Statistics a. Morbidity: In 2018, the American Cancer Society (ACS) projected 1,735,350 new cancer cases in the United States. In 2010, cancer was the first-listed diagnosis in 1.2 million hospital discharges (CDC, 2010b). b. Mortality: The American Cancer Society (ACS) estimates almost 610,000 deaths from all types of cancer in 2018. c. Cost: The National Cancer Institute (NCI) reports that national expenditures for cancer care in 2016 were an estimated $63.8 billion just for the top 5 cancers of 18 listed types (breast, colorectal, prostate, lymphoma, and lung) (NCI, 2017).

G L O S S A R Y Adenocarcinoma: Cancer arising in gland-forming tissue. An example is breast cancer. Adjuvant therapy: Treatment given in addition to the primary treatment. Alopecia: Hair loss. Biotherapy: Treatment to boost or restore the ability of the immune system to fight cancer. Also used to decrease the side effects caused by some cancer treatments. Agents used in biotherapy include monoclonal antibodies, growth factors, and vaccines. Cachexia: Loss of body weight and muscle mass as a result of anorexia, nausea and vomiting, or hypermetabolism. Cancer-related fatigue (CRF): Persistent and subjective sense of tiredness that can occur with cancer or cancer treatment, which interferes with usual functioning and can drastically affect the client’s quality of life. Carcinogen: Any substance that causes cancer. Carcinoma: Cancer that begins in the lining or covering of an organ. Desquamation: Shedding of the skin as a reaction to radiotherapy. In its mildest form, it is “dry” when the skin flakes in a powdery form. In a more severe form (“wet”), the deeper layers of the skin are exposed. Genome: The expanded study of genetics that no longer focuses on specific genes but on a person’s entire genetic content and interacting factors that regulate or modify gene expression (Santos et al, 2013). Holistic Needs Assessment (HNA): Specific terminology to describe assessing all aspects of the life of a client diagnosed with cancer (Taylor et al, 2012). In the United States, this term is synonymous with palliative needs assessment.

Metastasis: Spread of cancer to another organ, usually through the bloodstream. Mucositis: A complication of some cancer therapies in which the lining of the digestive system becomes inflamed; often seen as sores in the mouth. Nadir: Period of time following chemotherapy treatment when blood counts generally are at their lowest levels and client is at greatest risk of developing infection and other blood-related side effects. Palliative care: “An approach that improves the quality of life of patients and their families facing the problems associated with life-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (World Health Organization [WHO], 2002). Peripheral progenitor cell (stem cell) transplant: Method of replacing blood-forming cells destroyed by cancer treatment. Immature blood cells (stem cells) in the circulating blood that are similar to those in the bone marrow are given to the client after treatment. Radiation dermatitis: Skin condition that is a common side effect of radiation therapy. The affected skin becomes painful, red, itchy, and blistered. Staging: Classification of the primary tumor (T), lymph node involvement (N), combined with tests to see if the cancer has metastasized (M). Stomatitis: Inflammation of the mucous membranes of the mouth. Superior vena cava syndrome (SVCS): Condition in which a tumor presses against the superior vena cava—the large vein that carries blood from the head, neck, arms, and

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CHAPTER 14

G L O S S A R Y

(continued)

Weight-related distress (WDR) and/or eating-related distress (ERD): Syndrome, common in advanced cancer, and characterized by resistance to eating, poor and capricious appetite, a disconnection of oral intake and ability to gain weight, or continuous efforts to eat. The client’s SOs may have feelings of deep concern, frustration, and insufficiency in their efforts to prepare appealing food and be more concerned about client’s weight loss than is the client (also sometimes known as “anorexiacachexia syndrome”) (Hopkinson et al, 2013).

CARE SETTING

RELATED CONCERNS

Cancer centers may focus on staging and major treatment modalities for complex cancers. Treatment for managing adverse effects, such as malnutrition and infection, may take place in short-stay, ambulatory, or community setting. More cancer clients are receiving care at home because of personal choice and healthcare costs. Cancer treatment needs to be age and life stage appropriate. Over 70% of children diagnosed with cancer mature into adulthood and present with special nursing needs (McInally & Cruickshank, 2013).

Adult leukemias, page 569 Adult lymphomas, page 582 Hysterectomy, page 666 Lung cancer: postoperative care, page 159 Mastectomy, page 675 Palliative/end-of-life care—hospice, page 970 Pediatric considerations, page 993 Prostatectomy, page 694 Psychosocial aspects of care, page 835 Sepsis/septic shock, page 772 Total nutritional support: parenteral/enteral feeding, page 525 Urinary diversions/urostomy (postoperative care), page 645

General: Cancer: General Considerations

chest to the heart. This pressure blocks blood flow to the heart and may cause coughing, difficulty in breathing, and swelling of the face, neck, and upper arms. Tumor: An abnormal mass of tissue, either benign (noncancerous) or malignant (cancerous). Tumor marker: Substance detectable in the blood or urine that suggests the presence of cancer. Vein flare: Painless local allergic reaction identified by redness along the vein used to infuse chemotherapeutic agent; urticaria or hives may also be present. Usually subsides within 30 to 60 minutes without treatment.

C L I E N T A S S E S S M E N T D ATA B A S E Data depend on organs or tissues involved and stage of disease. A holistic needs assessment (HNA) should be completed for every client/ family diagnosed with cancer to prioritize care (Taylor et al, 2012). Refer to appropriate plans of care for additional assessment information.

DIAGNOSTIC DIVISION M AY R E P O R T

M AY E X H I B I T

Activity/Rest • Weakness and fatigue (most prevalent problems reported by clients with advanced cancer) (Girgis et al, 2006) • Changes in rest pattern and usual hours of sleep per night • Presence of factors affecting sleep, such as pain, anxiety, night sweats, more frequent elimination needs • Limitations of participation in hobbies, exercise, usual activities

• Inability to maintain usual routines or desired level of activity or work • Lack of energy • Disinterest in surroundings • Compromised concentration

Circulation • Palpitations • Chest pain on exertion

• Changes in blood pressure (BP) • Fluctuations in heart rate

Ego Integrity • Stress factors—financial, job, role changes • Ways of handling stress—smoking, drinking, delay in seeking treatment, religious or spiritual crisis

• Denial, withdrawal, anger • Depression (continues on page 948)

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C L I E N T A S S E S S M E N T D ATA B A S E (contd.) M AY R E P O R T

(continued)

M AY E X H I B I T

(continued)

• Concern about changes in body image (e.g., alopecia, disfiguring lesions, surgery, profound weight loss, edema, weight gain, or rash) • Denial of diagnosis • Feelings of powerlessness, hopelessness, helplessness, worthlessness, guilt, loss of control • Eating-related distress (ERD) or weight-related distress (WRD): Client and caregivers may express feelings of frustration, hopelessness, pressure, failure to meet exceptions (Hopkinson et al, 2013).

Elimination • Changes in bowel pattern—blood in stools, pain with defecation, constipation, or diarrhea • Changes in urinary elimination—pain or burning on urination, hematuria, frequent urination or nocturia

• Changes in bowel sounds • Abdominal distention • Diarrhea • Dysuria, frequency, incontinence

Food/Fluid • Poor dietary habits, • Anorexia, resistance to eating, poor, or capricious appetite (ERD, WRD) • Altered sense of taste • Nausea and vomiting • Difficulty swallowing, mouth sores • Food intolerances

• Changes in weight, severe weight loss, cachexia • Wasting of muscle mass • Changes in skin moisture or turgor • Edema • Ulcerations of oral mucosa

Neurosensory • Dizziness, syncope • Lack of coordination, unstable balance • Numbness or tingling of extremities • Sensation of coldness • Difficulty performing fine motor skills such as buttoning shirt

Pain/Discomfort • Varying degrees of pain from mild discomfort to severe pain. Younger age (