tag:blogger.com,1999:blog-34440781562010783862024-03-24T23:10:37.904-07:00Buerger's Diseaseneil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.comBlogger25125tag:blogger.com,1999:blog-3444078156201078386.post-23261879262116376922010-09-06T16:41:00.001-07:002010-09-07T03:11:33.449-07:00Lydia Hall's Care, Core, and Cure Theory in Patient with Thromboangiitis Obleterans (Buerger's Disease)<div style="text-align: justify;"><b>Rationale of the Study</b><br />
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Buerger’s disease also known as Thromboangiitis Obliterans is a rare arterial vascular disease characterized by acute inflammatory lesions and occlusis thrombosis of the small and medium arteries and veins. The legs, feet, upper limbs. (Canobbio, 2006; Black and Hawks, 2005). The distal tips of hands and feet are pale, but as the disease progresses, the hands and feet become reddened when held in a dependent position (White, 2000; White and Duncan, 2002).<br />
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This disorder occurs in 6 of every 10,000 people. Incidence is highest among males aged 20 to 40 who have history of smoking or chewing tobacco. Recently has been increasing in prevalence in women. Although the classic patient is a heavy smoker, there may be association with passive exposure to smoke. More recent have revealed a notable increase in the number of women affected, with 8 to 23%. Because there has been a significant increase in the use of tobacco by women over the past several decade (Rajagopalan et. al., 2004; Beers, 2003). It is associated with a 30% of major amputation rate over 5-20 years (Cuschiere, 2003).<br />
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Tobacco is a slow, insidious, but most malignant poison. In whatever form it is used, it tells upon the constitution; it is all the more dangerous because its effects are slow and at first hardly perceptible. It excites and the paralyzes the nerves. Among children and youth the use of tobacco is working untold harm. The unhealthful practices of past generations affect the children and youth of today (White, 2001).<br />
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A growing number of young Filipinos are picking up smoking despite new restrictions on tobacco advertising, according to a nationwide study. Based on health report in 2005, there are 20 million of Filipinos who are smoking. Four million youth, aged between 11 and 19, are smokers, said the 2007 survey commissioned by the World Health Organization and the health department. The youth group made up 23 percent of all Filipino smokers, compared to about 18 percent in 2005. "This 23 percent could further increase in a matter of three years," said Maricar Limpin, a doctor who leads an anti-smoking lobby, Framework on Tobacco Control of the Philippines Alliance (Varona, 2009).<br />
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Government data shows smoking is linked to five of the top 10 leading causes of deaths in the Philippines, where up to 35 percent of the country's 89 million people are tobacco users (www.yehey.com). It is interesting to know the leading disease and health condition that kill Filipinos everyday. Based from the Department of Health’s Health Statistics and was updated last January 2007 that the second Philippines’ top killer is the Vascular System Disease. It is closely related to the number one top killer which is the Heart Disease. The disease that affect the circulatory system or the blood vessels may include periphery artery disease, all types of aneurysms and dissections, atherosclerosis, Buerger’s Disease, Raynaud’s phenomenon, and arterial embolism and thrombosis (www.emeritus.blogspot.com)<br />
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Considering the figures that were stated, it is evident that Buerger’s disease is indeed rising in the Philippines that needs to be addressed early, especially since the disease is highly preventable through proper health teaching, education and by living a healthy lifestyle. With proper handling and adherence to the management program of the disease, complication and debilitating conditions can also be prevented in order to promote a quality of life that could be beneficial not only to the patient, but also to the community.<br />
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As a result of this study, a holistic care management can be proposed which would be used in managing a patient with Buerger’s disease and preventing such complication.<br />
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The researcher is a registered nurse, a volunteer public health nurse at Rural Health Unit II in Lipata, Minglanilla, Cebu, and was trained as an orthopedic nurse at Vicente Sotto Memorial Medical Center in Ward VIII for three (3) months. Qualified by his experience and educational background, the researcher is highly competent in conducting a case study that would benefit not only the client but the family and the community as a whole.<br />
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During the researcher’s exposures and experiences, the researcher saw the suffering of the client so as the family or significant others in giving care. The researcher saw the struggle and regret of the client, which can be prevented by stopping the cigarette smoking. Acknowledging the fact that the disease is increasing statistically, still the people are unaware of the disease.<br />
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Lydia Hall’s Nursing Model is believed to be applicable to the patient suffering from Buerger’s disease. By making this study, buerger’s disease will be minimal or under control case in the country, and the nurse will be guided on how to handle and deliver a holistic quality nursing care to the client.<br />
Theoretical Background<br />
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This study is anchored on Lydia Hall’s Care, Core, and Cure Model. Care alludes to the hands on intimate bodily care of the client implies a comforting, nurturing relationship. Core involves the therapeutic use of self in communicating with the patient. The nurse reflects questions appropriately and helps the client clarify motives and goals facilitating the process of increasing the client’s awareness. Cure is the aspect of nursing involved with administration of medication and treatments. The nurse functions in this role as an investigator. The major outcome of nursing care is rehabilitation and feelings of self-actualization by the patient (Taylor, Lillis, and LeMone, 2005; Basavanthappa, 2007).<br />
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According to Tomey and Alligood (2002) Hall sees that nursing can and should be professional, that patients should be cared for only by a professional registered nurse who can take total responsibility for the care and teaching of the clients. The professional nurse functions most therapeutically when patients have entered the second stage of their hospital stay. The second stage is the recuperating, or non acute, phase of illness. The first stage of illness is a time of biological crisis, with nursing being ancillary to medicine. After the crisis period, the patient is more able to benefit and learn from the teaching that nurses can offer.<br />
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Potter (2004) pointed that Teaching presents correct principles, procedures and techniques of the health care to clients and informs clients about their health status. As nursing responsibility, teaching is implemented in all health care settings. The nurse is responsible for assessing the learning needs of clients and is accountable for the quality of education delivered.<br />
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Nursing is complex. The patient is complex. Not only is the patient a human being, bringing the influences of his or her culture and environment, but the patient may be suffering from an illness that medicine is still struggling to understand and treat. The nurse giving the care is also a unique human being, interacting with the patient in a complex process of teaching and learning. Nursing expertise centers around the body, because Hall viewed the patient as composed of Body, Pathology, and Personality. The uniqueness of nursing lies not only in knowing bodily care, but also in knowing how to modify these process and treatment and amend them in line with the personality of the patient (Tomey and Alligood, 2002).<br />
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Client achieves their maximal potential through a learning process, therefore the chief therapy they need is teaching. Rehabilitation is a process of learning to live within limitations. Physical and mental skills must be learned, but a prerequisite is learning about oneself as a person, becoming aware of feelings and behaviors, and clarifying motivations. Hall believed that the professional nurse, educated in communication skills, could best facilitate the teaching-learning process (Tomey and Alligood, 2002).<br />
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Hall was not pleased with the concept of team nursing. She said, “Any career that is defined around the work that has to be done, is a trade.” She vehemently opposed the idea of anyone other than educated, professional nurses taking direct care of patients and she decried the fact that nursing has trained non-professionals to function as practical nurses so professional nurses function as practical doctors (Tomey and Alligood, 2002).<br />
Llyod (2007) pointed that it is an organizational system in which nurses carry out individual assessments of the clients’ needs and is basic on the relationship between specific nurse and specific client. It encourages professionalism in nursing practice. It also improves the quality of care and increases satisfaction of clients and nurses.<br />
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There are two phases of medical care practiced in medical centers: (1) biological crises and (2) evaluative medicine. The biological crises phase involves intensive medical and diagnostic treatment of the patient. The evaluative medicine phase follows and generally, it is the time when the patient is observed to appraise whether he or she is meeting the doctor’s goals (Tomey and Alligood, 2002).<br />
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Hall proposed that the nursing functions differ, using the three interlocking circles to represent aspects of the patient. She labeled the circles as the body (the care), the disease (the cure), and the person (the core). Nurses function in all three circles but to different degrees. They also share the circles with other providers. Hall believed that professional nursing care hastened recovery and that as less medical care was needed, more professional nursing care and teaching were necessary.<br />
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Hall viewed illness and rehabilitation experiences in which the nurse’s role was to guide and teach the client through personal care giving (Ellis and Hartley, 2004).<br />
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Care. The care circle represents the nurturing component of nursing and is exclusive to nursing. Nurturing involves using the factors that make up the concept of mothering (care and comfort of the person) and provide for teaching-learning activities (George, 2001).<br />
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The professional nurse provides care to the body of the client and will help the client to his activities of daily living such as eating, bathing, eliminating, and dressing. In providing the care, the main goal of the nurse is to provide comfort to the patient.<br />
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In providing care for a patient at the basic need level presents the nurse and patient with opportunity for closeness. As closeness develops, the patient can share and explore feelings with the nurse. The opportunity to explore feelings represents the teaching-learning aspect of nurturing.<br />
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George (2001) said that when functioning in the care circle, the nurse applies knowledge of the natural and biological sciences to provide a strong theoretical base for nursing implementations. In interactions with the patient the nurse’s role needs to be clearly define. A strong theory base allows the nurse to maintain a professional status rather than a mothering status, while at the same time incorporating closeness and nurturance in giving care. The patient views the nurse as a potential comforter, one who provides care and comfort through the laying on of hands.<br />
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Core. The core circle of the client care based in the social sciences, involves the therapeutic use of self, and is shared with other members of the health team. The professional nurse, by developing an interpersonal relationship with the client, is able to help the patient verbally express feelings regarding the disease process and its effects. Through such expression the patient is able to gain self-identity and further develop maturity. Hall (1965) says to look at an listen to self is often too difficult without the help of a significant figure (nurturer) who has learned how to hold up a mirror and sounding board to invite the behaver to look and listen to himself. If he accepts the invitation, he will explore the concerns in his acts and as he listen to his exploration through reflection of the nurse, he may uncover in sequence his difficulties, the problem area, his problem, and eventually the threat which is dictating his out-of-control behavior.<br />
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The professional nurse, by use of the reflective technique (acting as a mirror for the client), helps the patient look at and explore feelings regarding his or her current health status and related potential changes in lifestyle. The nurse uses a freely offered closeness to help the patient bring into awareness the verbal and nonverbal messages being into sent to others. Motivations are discovered through the process of bringing into awareness the feelings being experienced. With this awareness the patient is now able to make conscious decisions based on understood and accepted feelings and motivations. The motivation and energy necessary for healing exist within the patient, rather than in the health care team (George, 2001).<br />
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Cure. The cure circle of client care is based in the pathological and therapeutic sciences and is shared with other members of the health team. The professional nurse helps the client and family through the medical, surgical, and rehabilitative prescriptions made by the physician. During this aspect of nursing care, the nurse is an active advocate of the patient.<br />
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George (2001) The nurse’s role during the cure aspect is different from the care circle because many of the nurse’s actions take on a negative quality of avoidance of pain rather than a positive quality of comforting. This is negative in the sense that the client views the nurse as a potential cause of pain, one who is involved in such actions as administering injections, versus the potential comforter who provides care and comfort.<br />
Hall places the motivation and energy needed for healing within the client. This aspect of her theory influences the nurse’s total approach to the five phases of the nursing process; assessment, diagnosis, planning, implementation, and evaluation.<br />
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George (2001) said that he assessment phase involves the collections of date about the health status of the individual. According to hall, the process of data collection is directed for the benefit of the patient rather than for the benefit of the nurse. Data collection should be directed toward increasing the patient’s self-awareness. Through use of observation and reflection, the nurse is able to assist the client t in becoming aware of both verbal and nonverbal behaviors. In the individual, increased awareness of feelings and needs in relation to health status increases the ability for self-healing.<br />
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The assessment phase also pertains to guiding the patient through the cure aspect of nursing. The health team collects biological data (physical and laboratory) to help the client and family understand and progress through the medical regimen.<br />
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During this phase the nurse determines the client’s learning need and readiness to learn. The nurse then interpret the data to formulate nursing diagnoses reflecting the identified needs.<br />
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The second phase is the nursing diagnosis, or statement of the patient’s need or problem area. How a nurse envisions the nursing role influences the interpretation of assessment data and conclusions reached. Viewing the patient as the power of self-healing directs conclusions differently than if the healing power rests in the physician or nurse. The patient is the one in control, the one who identifies the need (George, 2001).<br />
Planning involves setting priorities and mutually establishing patient—centered goals. The client decides what is of highest priority and also what goals are desirable.<br />
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The core is involved in planning. The role of the nurse is to use reflection to help the client become aware of and understand needs, feelings, and motivations. Once motivations are clarified, Hall indicates that the client is the best person to set goals and arrange priorities. The nurse seeks to increase patient awareness and to support decision making based on the client’s new level of awareness. The nurse works with the client to help keep the goals consistent with the medical prescription. The nurse needs to draw on a knowledge base in the social and scientific areas to present the client with creative alternatives from which to choose (George, 2001; Basavanthappa, 2007).<br />
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Implementation involves the actual institution of the plan of care. This phase is the actual giving of nursing care. In the care and core circles, the nurse works with the patient, helping with bathing, dressing eating, and other care and comfort needs. The professional nurse uses a “permissive nondirective teaching-learning approach” to implement nursing care, thus helping the patient reach the established goals. This include “helping the patient with his feelings, providing requested information and supporting patient-made decisions” the nurse also helps the patient and family to help them understand and implement the medical plan (George, 2001; Basavanthappa, 2007).<br />
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Evaluation is the process in which the nurse will check if the goals are met or not. It is phase that the nurse will decide if the things that are done to the client is effective and successful. Timby (2009) and Smith (2007) although this is considered the last step, the entire process is ongoing. During this phase, nurse compares the actual to the expected outcomes or selected alternative plans of action when expected outcomes are not met.<br />
Lydia Hall’s nursing theory has a limitation of its application to the patient care. The first of these areas is the stage of illness. Hall applies her ideas of nursing to a patient who has passed the acute stage of biological stress- that is, the patient who is experiencing the acute stage of illness is not included in Hall’s approach to nursing care. However, it is possible to apply the care, core, and cure ideas to the care of those who are acutely ill. The acutely ill individual often needs care in relation to basic needs, as well as core awareness of what is going on and, in cure understanding of the plan of medical care (George, 2001).<br />
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Another limitation of the theory is the age of the client. Hall refers the adult client in the second stage of their illness, thus limiting all younger clients. However, it would be possible to apply Hall’s theory with younger individuals. Certainly adolescents younger than age 16 are capable of seeking self-identity.<br />
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A third limiting factor is the description of how to help a person toward self-awareness. The only tool to be used is “reflection” in therapeutic communication; the emphasis of reflection arises from the belief that both the problem and the solution lie in the individual and that the nurse’s function is to help the individual find them. There are some techniques can also be use like active listening and nonverbal support, may also be used to facilitate the development of self-identity.<br />
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Fourth, the family is mentioned only in the cure circle. This means that the nursing contact with the families is used only in regard to the patient’s own medication care. It does not allow for helping a family increase awareness of family’s self.<br />
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Lastly, Hall’s theory relates only to those who are ill. This w9ould indicate no nursing contact with the healthy individuals, family, or communities, and it negated the concept of health maintenance and health care to prevent illness (George, 2001).<br />
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Although the study is anchored mainly on Lydia Hall’s Care, Core, and Cure model, but other theories were also used in support to support the study.<br />
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Undan (2004) further points out that from the theory of Faye Glenn Abdellah, defined nursing as service to individual and families. She conceptualized nursing as an art and a science that mold the attitudes, intellectual competencies and technical skills of the individual nurse into the desire and ability to help people, sick or well, and cope with their health needs.<br />
Jean Watson’s theory of human caring in nursing proposes human caring as the moral ideal of nursing. In her definition for nursing consists of transpersonal human-to-human attempts to protect, enhance and preserve humanity by helping a person find meaning in illness, suffering, pain, and existence. Nurses participate in human caring to protect, enhance, and preserve humanity by assisting individuals to find meaning in illness, pain, and existence and to help others gain self knowledge, self-control, and self-healing. Watson’s conceptualizations of caring embody the essence of professional nursing practice. The nurses assist patients to find meaning in their existence, patient’s gain self-knowledge, self-control, self-love, choice, and self-determination in health decisions and lifestyle management. She articulates a holistic viewpoint of patient care (Rice, 2006; Hood, 2006).<br />
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Virginia Henderson’s theory, believed that the unique function of the nurse is to assist the individual, sick and well, in the performance of those activities contributing to health or its recovery the nurse would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. Henderson defined the patient as someone who needs nursing care (McEwen and Wills, 2007). </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-27848582916630631572010-09-06T16:40:00.003-07:002010-09-06T16:40:51.997-07:00Cardiovascular System<div style="text-align: justify;">The main functions of the cardiovascular system are the (1) rapid transport of nutrients (Oxygen, amino acid, glucose, fatty acids, water, etc) and waste product. (2) Hormonal control, by transporting hormones to their target organs, and by secreting its own hormones (e.g. atrial natriuretic peptide). (3) Temperature regulation, by controlling heat distribution between the body core and the skin. (4) reproduction, by producing erection of the penis. (5) Host defense, transporting immune cells, antigen and other mediator (e.g. antibodies) (Fagan, 2002; Ehrlich and Schroeder, 2005).<br />
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The heart and circulatory system make up your cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from your heart to the rest of your body through a complex network of arteries, arterioles, and capillaries. Blood is returned to the heart through venules and veins. If all the vessels of this network in your body were laid end-to-end, they would extend for about 60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth more than twice! (www.innerbody.com; www.texasheartinstitute.org).<br />
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The circulatory system carries blood to all part of the human body. The one that carry the oxygenated blood away from the heart are the arteries, and the one that carry a poor oxygenated blood back to the heart are the veins<br />
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In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to your heart (Alforn and Hill, 2003).<br />
In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vessels that carry oxygen-poor blood are colored blue.<br />
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There were twenty (20) major arteries make a path through the tissues in the body, they will branch in a smaller arteries called the arterioles. Arterioles further branch into capillaries, where the oxygen and nutrients exchange is taking place (Schunke, 2006). Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to your heart to pick up oxygen. It serves as the communicator between the arteries and the veins. In addition to being the transporters of blood products, capillaries allow for waste products to enter. In this way they perform an important function because waste is ultimately transported out of the body through this interchange (www.wisegeek).<br />
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Arterial walls are composed of elastic tissue and smooth muscle. It is their elastic nature and the presence of substantial muscle tissue that allows them to expand and contract as the heart beats. This allows them to even out the increase in pressure caused by each beat (www.jonbarron.org)<br />
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Veins are thinner walled than arteries and have less elastic tissue, and much, much less smooth muscle tissue. Instead, veins make use of valves and the muscle contraction of your body's major skeletal muscles to squeeze blood along. This is the reason one asked to get up and walk around on a long plane flight—to prevent blood from pooling in the legs. As a side note, the lack of muscle in the walls of veins makes them more susceptible to bleeding when injured since there is no muscle to clamp down (www.jonbarron.org).<br />
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Blood is essential to transport oxygen and nutrients to the tissues; carbon dioxide and other waste product of the cell metabolism to the excretory organs; and leukocytes, hormones, and anti-bodies to various locations in the body. The volume of blood which varies with the size of the individual, is about five (5) quarts in the average man. Almost half of the blood consists of cellular elements; red cells, white cells, and platelets suspended in a viscous fluid called blood plasma. But in addition to the water, plasma contains salts, sugar (glucose), and other substances. And, most important, plasma contains proteins that carry important nutrients to the body’s cells and strengthen the body’s immune system so it can fight off infection (Crowley, 2009).<br />
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Blood is actually a tissue. It is thick because it is made up of a variety of cells, each having a different job. In fact, blood is actually about 80% water and 20% solid. We know that blood is made mostly of plasma (contains a variety of proteins and many other small molecules and ions). But there are 3 main types of blood cells that circulate with the plasma (Wilhelm. et. al., 2001). <br />
• Platelets, which help the blood to clot. Clotting stops the blood from flowing out of the body when a vein or artery is broken. Platelets are also called thrombocytes.<br />
• Red blood cells, also called as the erythrocyes which carry oxygen. Of the 3 types of blood cells, red blood cells are the most abundant. In fact, a healthy adult has about 35 trillion of them. The body creates these cells at a rate of about 2.4 million a second, and they each have a limited life span of about 100 to 120 days (Marieb, 2006).<br />
• White blood cells, ward off infection. These cells, which come in many shapes and sizes, are vital to the immune system. When the body is fighting off infection, it makes them in ever-increasing numbers. Still, compared to the number of red blood cells in the body, the number of white blood cells is low. Most healthy adults have about 700 times as many red blood cells as white ones. White blood cells are also called leukocytes. Types of white blood cells are the neutrophil, eosinophil, basophil, monocytes, B and T lymphocyes (Gordon and Golany, 2006; www.texasheartinstitute.org). </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-13120389769830253332010-09-06T16:40:00.001-07:002010-09-06T16:40:29.978-07:00Pathophysiology of Buerger's Disease<div style="text-align: justify;">Pathophysiology<br />
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Smoking is very closely related to Buerger's disease and smoking history is one of the critera for diagnosing the disease. In general if the patient absolutely abandons smoking the course of the disease will be invariably benign, but if smoking continues any treatment will ultimately be futile. Though "passive smoking" has adverse effect on cardiovascular system, non smokers should never develop the disease. Active smokers can be identified by measuring levels of nicotine, the major metabolite of nicotine in urine. Since all smokers do not develop the disease an immunopathogenesis is considered probable. It has been proposed in Japanese that presence of a gene linked to some HLA antigens might control the susceptibility to the disease (www.indiandoctors.com).<br />
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Most patients with Buerger’s are heavy smokers, but some cases occur in patients who smoke “moderately”; others have been reported in users of smokeless tobacco. It has been postulated that Buerger’s Disease is an “autoimmune” reaction (one in which the body’s immune system attacks the body’s own tissues) triggered by some constituent of tobacco (www.karr.net).<br />
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Mogotlane (2005) said that nicotine in cigarette acts as a vasoconstrictor so there will be less oxygen supply to the extremities, and in addition, is thought to alter the surface properties of platelets so that they become more stick, increasing the risk of clots formation causing further damage.<br />
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Although this condition is different from atherosclerosis, Buerger’s disease in older patients may also be followed by atherosclerosis of the larger vessels after involvement of the smaller vessels. The patient’s ability to walk may be severely limited. Patients are at higher risk for non healing wounds because of impaired circulation (Smeltzer and Bare, 2004).<br />
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Onset of the disease is gradual and first occurs in the feet or hands. Inflammation occurs in small and medium-sized arteries and veins near the surface of the limb. In advanced cases, blood vessels in other parts of the body may be affected. There is a progressive decrease in the blood flow to the affected areas. The pulse in arteries of the feet is weak or undetectable. The lack of blood flow can lead to gangrene, which is decay of tissue due to restricted blood supply (Zhang, 2008).<br />
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Symptoms. The thromboangiitis obliterans (Buerger’s disease presents with a triad of symptoms and signs: digital arteries occlusion, Raynaud’s phenomenon, and migrating superficial vein thrombophlebitis (Lilly, 2007).<br />
Early symptoms include decrease in the blood supply (arterial ischemia) and superficial (near the skin surface) phlebitis. The main symptom is pain in the affected areas is the outstanding manifestation. A cold sensitivity in the hands with color changes, similar to that seen in Raynaud's disease, can develop and may be another early manifestation. In this case, the hands turn color--white, blue, and then intense rubor or reddish blue discoloration (Zhang, 2008; Smeltzer and Bare, 2004).<br />
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Claudication type of pain is common with pain in the arch of the foot. Various types of paresthesias may occur. Pulsations in the posterior tibial and dorsalis pedis arteries are weak or absent. In advance cases, the extremities may be abnormally red or cyanotic, particularly when dependent (Black and Hawks, 2005). </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-8250736665284488152010-09-06T16:39:00.003-07:002010-09-06T16:39:58.768-07:00Diagnostic Test for Buerger's Disease<div style="text-align: justify;">Diagnoses. <br />
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Leslie (2004) said that no Formal set of diagnostic studies exist to determine if the patient has Buerger’s disease. It can be a diagnosis of exclusion after a complete history taking and physical examinations have been performed. The commonly followed diagnostic criteria are below although the criteria tend to differ slightly from author to author. <br />
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1.) Typically between 20-40 years old and male, although recently females have been diagnosed. 2.) Current (or recent) history of tobacco use. 3.) Presence of distal extremity ischemia In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischemia or ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing such as ultrasound. 4.) Exclusion of other autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests. 5.) Exclusion of a proximal source of emboli by echocardiography and arteriography. 6.) Consistent arteriographic findings in the clinically involved and noninvolved limbs.<br />
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Buerger’s disease can be mimicked by a wide variety of other diseases that cause diminished blood flow to the extremities. These other disorders must be ruled out with an aggressive evaluation, because their treatments differ substantially from that of Buerger’s Disease. For Buerger’s there is no treatment known to be effective.<br />
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Diseases with which Buerger’s Disease may be confused include atherosclerosis (build–up of cholesterol plaques in the arteries), endocarditis (an infection of the lining of the heart), other types of vasculitis, severe Raynaud’s phenomenon associated with connective tissue disorders (e.g., lupus or scleroderma), clotting disorders of the blood, and others (Domingo, 2007).<br />
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Angiograms of the upper and lower extremities can be helpful in making the diagnosis of Buerger’s disease. In the proper clinical setting, certain angiographic findings are diagnostic of Buerger’s. These findings include a corkscrew appearance of arteries that result from vascular damage, particularly the arteries in the region of the wrists and ankles. Angiograms may also show occlusions (blockages) or stenoses (narrowings) in multiple areas of both the arms and legs. The changes are particularly apparent in the blood vessels in the lower right hand portion of the picture (the ulnar artery distribution) (www.vascularweb.org).<br />
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In order to rule out other forms of vasculitis (by excluding involvement of vascular regions atypical for Buerger’s), it is sometimes necessary to perform angiograms of other body regions (e.g., a mesenteric angiogram).<br />
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Skin biopsies of affected extremities are rarely performed because of the frequent concern that a biopsy site near an area poorly perfused with blood will not heal well (www.vasculitisfoundation.org).<br />
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Doppler ultrasonography can detect the direction, velocity, and turbulence of blood flow. May show diminished circulation in the peripheral vessel (www.lifesteps.com).<br />
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Plethysmoghraphy is a test used to measure changes in blood flow or air volume in different parts of the body. It may be done to check for blood clots in the arms and legs, or to measure how much air you can hold in your lungs. It detects decreased circulation in the peripheral vessels (www.nlm.nih.gov).<br />
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Arteriography on the other hand is a common procedure done by injecting a dye by x-ray into the bloodstream. Then X-ray pictures are taken and studied to see if arteries are damaged. It locates lesions and rules out atherosclerosis (www.americanheart.org).<br />
<br />
The Allen's test the doctor may conduct a simple test called the Allen's test to check blood flow through the arteries carrying blood to his/her hands. In the Allen's test, onemake a tight fist, which forces the blood out of your hand. The doctor presses on the arteries at each side of his/her wrist to slow the flow of blood back into the hand, making his/her hand lose its normal color. Next, the client will open his hand and the doctor releases the pressure on one artery then the other. How quickly the color returns to the hand may give a general indication about the health of arteries. Slow blood flow into hand may indicate a problem, such as Buerger's disease (www.mayoclinic.com).<br />
<br />
Blood Test. A deficient in protein C or protein S, or even anti-thrombin III may also be associated with venous or arterial; occlusion and leads to rejection of the diagnosis (rheumatology.oxfordjournals.org). is also performed to identify other causes of narrowed or blocked arteries, such as inflammation of blood vessels due to autoimmune disorder. Such procedure include the erythrocyte sedimentary rate (ESR) and tests for C-reactive protein, which is produced only when inflammation is present (Beers, 2004).<br />
<br />
Urinalysis creatinemia (The presence of excessive creatine in the blood) and studies of urinary sedimentary and proteinuria (albuminuria or urine albumin—is a condition in which urine contains an abnormal amount of protein) demonstrate the absence of renal damage suggestive of autoimmune diseases (www.rheumatology.org; www. medical-dictionary. The free dictionary.com ; kidney.niddk.nih.gov ). </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-50498046184519837232010-09-06T16:39:00.001-07:002010-09-06T16:39:30.232-07:00Medical and Nursing Intervention, Prevention Complication, and Prognosis<div style="text-align: justify;">Medication Treatment. <br />
<br />
Vasodilators such as phenoxybenzamine. Vasodilators are given in Buerger’s disease to increase the lumen of the arteries and improve the flow of blood to the legs.<br />
<br />
Nonsteroidal anti-inflammatory and opioids are given to the client to provide comfort form the pain in the affected part. These medications are particularly useful not only because they help decrease pain, but they also help control swelling and inflammation (www.orthopedics.about.com).<br />
<br />
Anti-coagulants such as coumarin, dipyramidole and aspirin, 325 mg PO (by mouth), are used to prevent clot formation in the affected vessels. In addition to relieving pain and reducing inflammation (www.surgeryencyclopedia.com)<br />
<br />
Calcium Channel blockers such as nifedipine. Calcium-channel blockers are used to <br />
produce vasodilatation in the affected blood vessels. It also act by relaxation of the smooth muscle of the arterial wall (Katzong, 2007).<br />
<br />
Statins lower cholesterol level in the blood resulting in an increased clearance in the bloodstream, which reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with Buerger’s disease (Stump, 2008).<br />
<br />
Surgical Management<br />
<br />
Surgical Bypass of the larger blood vessel in the affected limb may be carried out in the severe cases of the disease to improve circulation. Lumbar sympathectomy in which the sympathetic nerve supply to the blood vessels of the legs is cut, indicated for relief of intractable rest pain and healing of refractory ulcers, often in conjunction with digital amputation.<br />
<br />
Local debridement may be used to remove local areas gangrene. Local care is the other main component. Amputation may be required if gangrene is persistent and for patients with severe rest pain<br />
<br />
Nursing Management<br />
<br />
Non-pharmacological measures in the treatment for Buerger’s disease are directed towards improving blood flow to the affected area and exacerbating factors (Lippincott Williams & Wilkins, 2006).<br />
<br />
Positioning. Let the client lie on the bed and elevate the legs for 1-2 minutes or until they blanch. Then let the patient sit on the side of the bed and hold the feet down until become pink. Let the client do this 5 times each, 3 times a day.<br />
Instruct the client no to sit for long periods of time without getting up and walking. Sleep on the firm mattress. Never cross the legs of the knee (Ferrell, 2004).<br />
<br />
Clothing. Items of clothing that constrict the circulation must be avoided and the limbs should be kept warm while avoiding direct exposure to heat, as cold may <br />
precipitate vasoconstriction.<br />
<br />
Prevention. Peripheral vascular disease is related to the avoidance of the risk behavior, smoking cessation, elimination of chewing tobacco, and marihuana, and avoidance of nicotine replacement and exposure to second-hand smoking (Levy, et al, 2005).<br />
<br />
Weight. Must be controlled. Body Mass Index (BMI) can be used to indicate if you are overweight, obese, underweight or normal. Because of these problems, this body mass index calculator shows extra statistics to help patient to be informed and judge the body compared to others of the same height and age. The patient should have an average range from 18.5 – 24.9 (www.halls.md; www.caloriecontrol.org)<br />
<br />
Exercise. A special exercise program can be developed to improve the efficiency of the blood supply to the legs. Regular exercise, especially walking is a good preventive measure because exercise improves the circulation generally (Mogotlane, 2005).<br />
<br />
Buerger-Allen exercises consist of elevating them at that angle for 2 to 3 minutes. <br />
<br />
The legs are then lowered to a dependent position until they become red and supported at that level for 5 to 10 minutes. The legs then placed flat on the bed with the client in a supine position for 10 minutes. The exercises are repeated as tolerated by the client (White, 2000).<br />
<br />
Diet. Must have a food preparation should provide complete nutrient as well as supplies carbohydrates, proteins, fats, vitamins, minerals and fiber in their normal proportions. It is the basis for all diet modifications (Varona, 2003).<br />
B vitamins they help blood circulation and are needed for good metabolism. This family of vitamins aids the body with stress and its effects.<br />
<br />
Essential fatty acids helpful in improving blood circulation, good for the heart and cardiovascular health. Fatty acids are found in omega fatty acids from fish oil, flax seed oil, and borage seed oil.<br />
<br />
Coenzyme Q10 improves circulation, some supplements will include reishi mushroom which helps boost the immune system as well. <br />
<br />
Multi-vitamin and Mineral supplement contains B vitamins, vitamin E , calcium, zinc, and magnesium, which all are helpful in both the treatment and prevention of Buerger's disease as well as promote good circulation health. Nutrients in a daily supplement are required for good general health and well being (www.go-symmetry.com).<br />
<br />
Zinc, Calcium, Magnesium, Vitamin A, and Carotenoids helps circulation and to protect arteries from stress caused by sudden blood pressure changes, women often are low in calcium but need the other vitamins and minerals to properly absorb the calcium into their body (www.go-symmetry.com). <br />
<br />
Local wound care. Limited debridement, appropriate dressings, and IV antibiotics for cellulites. Moisturation of non ulcerated skin to prevent from drying.<br />
<br />
Foot and toe care. Taking care of the toe and foot is very important to the client with Buerger’s disease. It helps prevent wounds or foot ulcers from becoming infected and painful or resulting to gangrene. Foot ulcers require meticulous care. Such care is needed to treat infection, to protect the skin from further damage, and to enable the person to continue to walk (Beers, 2004).<br />
<br />
Low blood flow to the extremities means the body cannot resist infection as easily. Small cuts and scraped can easily turn into serious infections. Clean any cuts with water and cover with a clean bandage. Keep an eye on any cuts or scrapes to make sure they are healing well. If it get worse or heal slowly contact the physician promptly (www.mayoclinic.com).<br />
<br />
Inspect the feet daily for cracks, sores, corns, calluses, erythema, discoloration, or trauma, using mirrors as necessary for adequate visualization, wash feet daily with mild soap and warm water; check water temperature with water thermometer or elbow, dry the foot gently and thoroughly, use a lubricant, such as lanolin, for dry skin, or use moisturizer to soften it and avoid putting lotion between toes.<br />
Use unmedicated power to keep the feet dry, prevent ingrown toenails. Cut toenails straight across and not too short. (A podiatrist may have to cut the nails; tell the podiatrist that peripheral arterial disease is present). Have a podiatrist treat corns or calluses.<br />
<br />
Change socks and stockings daily and shoes often to prevent infection from moisture or dirt, wear loose wool socks to keep the feet warm, do not wear tight garters or stockings with tight elastic tops, wear shoes that fit well and have wide toe spaces and do not wear open shoes or walk barefoot.<br />
<br />
Alternate between at least two pairs of properly fitted shoes to avoid potential for pressure points that can occur by wearing one pair only, ask the podiatrist about a prescription for special shoes if the feet are deformed, do not use hot water bottles for heating pads, attend to any foot injury immediately, and seek medical attention to avoid any potential complication and do not go barefoot indoors and outdoors (Swearingen, 2002; Beers 2004).<br />
<br />
Emotional Support. Provide an emotional support. If necessary, refer the client for psychological counseling to help cope with restrictions imposed by this chronic disease. If the client undergone amputation, assess rehabilitative need, especially regarding changes in body image. Refer to the physical therapists, occupational therapist, and social service agencies, as needed (Lippincott Williams & Wilkins, 2009). <br />
<br />
Spiritual. Care is important in dealing of clients with any kind of disease. <br />
<br />
Promoting peace of mind and a sense of wholeness and well-being. Some client adhere to specific beliefs and ideals as a way of life, and these carry over into the most basic aspects of health and illness.(Mauk & Schmidt, 2004).<br />
<br />
Encourage the client to allocate time for prayer and meditation each day and give Bile verse such as Jeremiah 33:3 (King James Version) “Call unto me, and I will answer thee, and show thee great and mighty things, which thou knowest not” and James 5:15 (King James Version) “And the prayer of faith shall save the sick, and the Lord shall raise him up; and if he have committed sins, they shall be forgiven him”. <br />
<br />
Complication. Without smoking cessation, Buerger’s disease progresses inexorably through an obliterative vascular process, leading to coolness of the digits, hands, and feet; paresthesias; intermittent claudication symptoms; skin ulcerations over the fingers and toes; and gangrenous infarctions of the extremities. Once established, the disease may be maintained by even small exposures to tobacco (even smokeless tobacco or second-hand smoke). Failure to stop smoking is associated with a dramatic increase in the risk of limb loss by amputation. (Papadakis, 2006; Imboden, 2007).<br />
<br />
Prognosis. If smoking cessation can be achieved, the outlook fro the disease may be better than in patients with premature peripheral vascular disease. If smoking cessation is not achieved then the prognosis is generally poor, with amputation of the affected part is the eventual outcome. (McPhee, 2008; www.ahealthyme.com). More than 90% of the patients who quit smoking avoid amputation (Papadakis, 2006).<br />
<br />
Buerger's is not immediately fatal, but life-shortening. Death rate has not been consistently shown as higher in patients who do not cease smoking but for this and other health concerns quitting is highly recommended. Female patients tend to show much higher longevity rates than men (www.answers.com).<br />
<br />
Prevention. Smoking is the only known causative agent for this disease and should be avoided and also nicotine products . Avoid cold temperature and other condition that reduce circulation to the hands and feet. (www.lifesteps.com; Papadakis, 2006).<br />
<br />
Quit Smoking. Decide to quit smoking – the power of will is very important, the most hard days after smoking is the first three (3) days, think about some issues like: The future for itself and loved ones, Cost lots of money, shortens man’s life span, health problems (throat cancer, lung cancer, emphysema, hardening of the arteries, slowing of mental activity, cholesterol build up and blood pressure problems).<br />
<br />
Learn to depend on prayers, carry some Bible promises like Philippians 4:13 – “I can do all things through Christ which strengtheneth me” and 1 Corinthians 15:57 – “But thanks be to God, which giveth us the victory through our Lord Jesus Christ”. <br />
Believe that these promises were written just for you and your need, just now. Repeat them all.<br />
<br />
Get rid of all tobacco products, including ash trays and all the rest, stay away from other smokers as much as possible for the next few weeks. Two or even three times a day, take a warm bath for 15 – 20 minutes at a time. Relax and enjoy it. This will help soak the poisons out quicker.<br />
<br />
Do deep breathing exercise every time you crave to smoke. Slowly take in as much air then exhale slowly. Repeat saying “I choose not to smoke”. Go out in an open air and breathe deeply. There is energy in fresh air; and it is helping to clean out<br />
Drink at least 6 – 8 glasses of water daily. Do this between meals. This helps flush out poisons, take no alcoholic beverages, none at all. They will cloud the mind, weaken the power of will, and could lead to smoking again. Eat lots of fresh fruits and vegetables. Especially oranges, the vitamin C in oranges help destroy the poisons in the body, lessening the craving.<br />
<br />
Walk outdoors for 15-30 minutes after each meal, breathing deeply going out. Don’t sit after a meal; for this is the time a person wants to smoke. The craving for a smoke only last for 3-5 minutes; then it returns later for another 3-5 minutes. As the time passes, it gets easier to resist the urge. Open up the curtains, raise the windows, and let the purifying sunlight and air. There is tobacco odor all over the house. Get it out. It is very important.<br />
<br />
Avoid mustard, spices, pepper, vinegar, ketchup, hot sauce, chili, and hoarseradish. These foods tend to arouse craving, skip all sweets, pastries, cake, ice cream, and chocolate during the first 10 days. Avoid rich, sugar-heavy desert. A lot of sugar in the diet makes a person more jumpy and irritable. This is because it steals B vitamins and minerals, especially calcium. Calcium helps strengthen and calm the nerves.<br />
<br />
Heavy smokers often like spiced foods; they frequently eat a heavy meat diet, plus gravies, fried foods, and other rich foods. Avoid them, do not use fish, fowl, meat, tea, coffee, or cola beverages. The uric acid, ammonia, purines, and other wastes in meat is what gives it that special flavor. It stimulates the nerves increases the craving for nicotine and alcohol. The caffeine in tea, coffee, and cola drinks can so trigger the nerves that, in matter of minutes, a person will have an uncontrollable desire to light up.<br />
<br />
Carrot sticks or raw celery at the close of a meal will lessen the craving to smoke. Chewing raisins help somewhat. Carry a small package of raisins in the pocket. Hot water with lemon juice is helpful. Go on a fast for a day or two a time, drinking only hot water and lemon juice. That will clean the poisons out the fastest. Remember the quicker they eliminated, the quicker the craving will go. Keep positive. Keep busy doing something. Keep praying. Keep thanking God. Keep thinking of the brighter future of you and your loved ones Ferrel, 2004. </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-61100929133477540662010-09-06T16:38:00.002-07:002010-09-06T16:38:36.246-07:00Nursing Care Plan : Identified Nursing Problem: Impaired Physical Mobility related to activity intolerance, musculoskeletal impairment, limited strength, and pain/discomfort.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative state involve some degree of immobility (e.g., leg fracture, trauma). <br />
<br />
Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobility joint, and gait changes affecting balance can significantly compromise the mobility of older clients. <br />
<br />
Mobility is paramount if the older clients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Older client are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment. <br />
<br />
Gulanick, 2007<br />
<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess for impediments to immobility.<br />
R: Identify the specific cause guides design of an optimal treatment plan.<br />
<br />
I: Assess the client’s ability to perform ADLs effectively and safely on a daily basis using an appropriate assessment tool, such as the functional independence measures (FIM).<br />
R: Restricted movement affects the ability to perform most ADLs. A variety of assessment tools are available, depending on the clinical setting. Such tools provide objective data for baselines.<br />
<br />
I: Assess ability to ability to perform ROM to all joints.<br />
R: This provides baseline measurement for future evaluation and guides therapy. Testing by a physical therapist may be needed.<br />
<br />
I: Assess the client’s and caregiver’s knowledge of immobility and it’s implications.<br />
R: Even the clients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression.<br />
<br />
I: Assess for developing thrombophlebitis (e.g., calf pain Homan’s sign, redness, localized swellings, and rise in temperature).<br />
R: Bed rest or immobility promotes clot formation.<br />
<br />
I: Assess skin integrity. Check for sign of redness and tissue ischemia.<br />
R: Regular examination of the skin (especially over bonny prominences) will allow for prevention or early recognition and treatment of pressure sores.<br />
<br />
I: Monitor input and output record and nutritional pattern. Assess nutritional needs as they relate to immobility.<br />
R: Pressure sores develop more quickly in clients with nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program.<br />
<br />
I: Assess elimination status (e.g., usual pattern, present patterns, signs of constipation).<br />
R: Immobility promotes constipation.<br />
<br />
I: Assess emotional response to disability or limitation.<br />
R: Acceptance of temporary or more permanent limitations can vary widely among individuals. Each person has his or her own definition of acceptable quality of life.<br />
<br />
I: Evaluate need for home assistance.<br />
R: Obtaining appropriate assistance for client can ensure safe and proper progress of activity.<br />
<br />
I: Evaluate the safety of the immediate environment.<br />
R: Obstacles such as throw rugs, can further impede one’s ability to ambulate safely.<br />
<br />
I: Encourage and facilitate early ambulation and other ADLs when possible. Assist in initial change: dangling legs, sitting in chair, ambulation.<br />
R: The sooner the client becomes mobile, the less chance that debilitation will occur.<br />
<br />
I: Provide positive reinforcement during activity.<br />
R: Clients may be reluctant to move or initiate new activity due to fear of falling. A positive approach allows the learner to feel good about learning accomplishments.<br />
<br />
I: Allow the client to perform tasks at his own rate. Do not rush the client. Encourage independent activity as able and safe.<br />
R: Health care team and family care givers are often in hurry and do more for clients than needed, thereby slowing the client’s recovery and reducing his self-esteem.<br />
<br />
I: Encourage to turn every 2 hours as needed. <br />
R: Turning the clients optimizes circulation to all tissue and relieves pressure.<br />
<br />
I: Perform passive or active ROM exercise to all extremities.<br />
R: Exercise promotes increased venous return, prevents stiffness, and maintain muscle strength and endurance. To be most effective, all joints should be exercised to prevent contractures.<br />
<br />
I: Encourage resistance training exercise using light weights when appropriate.<br />
R: Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling.<br />
<br />
I: Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated.<br />
R: Liquids optimize hydration status and prevent hardening of the stool.<br />
<br />
I: Teach energy-saving techniques.<br />
R: These optimize the client’s limited reserves.<br />
<br />
I: Assist the client in accepting limitations. Emphasize abilities.<br />
R: Quality of life is influenced by a variety of factors that can extend beyond only physical function.<br />
I: Explain progressive activity to the client. Help the client or caregivers establish reasonable and obtainable goals.<br />
R: Information promotes awareness of the treatment plan. Setting small, attainable goals help increase self-confidence and promotes adherence.<br />
<br />
I: Instruct the client or caregivers regarding hazards of immobility. Emphasize importance of measures such as position change, ROM, coughing, and exercise.<br />
R: Information enables the client to assume some control over rehabilitation process.<br />
<br />
I: Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of pain, not beyond.<br />
R: “no pain, no gain” is not always true.<br />
<br />
I: Instruct the client and family regarding the need to make the home environment safe.<br />
R: A safe environment will help prevent injury related to falls.<br />
<br />
Gulanick, 2007; Doenges, et al, 2002; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-76776787545844790462010-09-06T16:38:00.000-07:002010-09-06T16:38:04.080-07:00Nursing Care Plan: Non-Compliance with treatment regimen related to low socio-economic status, difficulty in understanding the disease.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Adherence is the extent to which an individual’s behavior taking medications, following diets, or making lifestyle changes coincides with medical or health advice. Degree of adherence may range from disregarding every aspect of the recommendations to following the total therapeutic plan.<br />
<br />
Factors influencing the compliance of the patient are motivation to become well, degree of lifestyle change necessary, perceived severity of the health care problem, value place on reducing the threat of illness, difficulty in understanding and performing specific behaviors, degree of inconvenience of the illness itself or of the regimens, beliefs that the prescribed therapy or regimen will or will not help, specific cultural heritage that may make adherence difficulty, degree of satisfaction and quality type of relationship with the health care provider and overall cost of prescribed therapy.<br />
<br />
Preventing illness may not have as high priority among as generating and maintaining the income, even when prevention is priority. The poor may not have be able to afford regular medical examination, housing or nutritious food that promotes health. It is important to them to work than to lose a day’s pay visiting the physician. Reliance on public assistance and inability to afford health care insurance limit both low income person’s access to health care and the type of care available.<br />
<br />
Berman, et al, 2002<br />
<br />
<br />
<br />
Intervention and Rationale<br />
I Assess client reason for non-compliance, health beliefs and cultural influence.<br />
R: Listening to client’s reason may identify concerns and help to establish a plan of care.<br />
<br />
I: Determine family’s knowledge of illness and treatment. Taught them the illness and purpose of the treatment regimen.<br />
R: Compliance is increased by knowledge to the therapeutic regimen.<br />
<br />
I: Assess the possible contributing factors leading to non-compliance.<br />
R: A client who is noncompliant is expressing a need; the behavior has meaning and helps patient meet their needs.<br />
<br />
I: Assess financial resources and refer to social services as necessary.<br />
R: Inability to afford health care is a major contributing factor in noncompliance. <br />
<br />
I: Avoid using threats, pressure and inappropriate fear of arousal to increase compliance.<br />
R: These measures are unethical and generally ineffective. <br />
<br />
I: Develop a therapeutic relationship based on active listening.<br />
R: Compliance is increased when the family feels that the health care provider is interested in genuinely cares how the family is doing. <br />
<br />
I: Consult with primary practitioner regarding the possibility of exemplifying the health care regimen so that it is more easily fits into client’s lifestyle. <br />
R: The more the complex the regimen, the less likely they will follow it.<br />
<br />
I: Encourage significant and family to follow treatment regimen as much as possible despite financial constraints.<br />
R: For effectiveness of pharmacological treatment and use for good of the patient.<br />
<br />
I: Discuss non-compliance with instruction and programs with SO.<br />
R: To determine rationale for assistance.<br />
<br />
I: Provide accurate information about the treatment regimen: present clear understanding of the drugs positive effect, explain how the medication works and why it helps, etc. at the patient’s ability.<br />
R: Individuals who perceive a relationship between their actions and outcomes want a great deal of information about their illness and treatment in order to control the disease. Other who do not necessary rely on internal cues will comply more with the prescribed regimen when the information is presented accurately by a professional they believe to be an authority.<br />
<br />
I: Make a compliance contract with client review it periodically.<br />
R: Often clients will be more compliant initially but as time lapses and the condition becomes chronic, compliance tends to decrease.<br />
<br />
I: Note length of illness.<br />
R: Clients tend to become passive and dependent in long-term, debilitating illnesses.<br />
<br />
I: Be aware of nurse/ healthcare provider’s attitudes and behaviors toward the client.<br />
R: Some care providers may be enabling client whereas others’ judgmental attitudes any impede treatment progress.<br />
<br />
I: Develop therapeutic nurse-client relationship.<br />
R: Promotes trust, provides atmosphere in which client and significant other(s) can freely express views and concerns.<br />
<br />
I: Explore client’s involvement in or lack of mutual goal setting.<br />
R: Patient will be more likely to follow through on goals he/she participated in developing.<br />
<br />
I: Review treatment strategies. Identify which interventions in the plan of care are most important in meeting therapeutic goals and which are least amenable to compliance.<br />
R: Sets priorities and encourages problem solving areas of conflict.<br />
<br />
I: Provide for continuity of care in and out of the hospital/ care setting, including long-range-plans.<br />
R: Supports trust and facilitates progress toward goals.<br />
<br />
I: Have client paraphrase instructions/ information heard.<br />
R: Helps validate client’s understanding and reveals misconceptions.<br />
<br />
I: Accept the client’s choice/ point of view, even if it appears to be self-destructive. Avoid confrontation regarding beliefs.<br />
R: To maintain open communication.<br />
<br />
I: Establish graduate goals or modified regimen as necessary e.g. patient to stop smoking cigarette.<br />
R: May improve quality of life, encouraging progression to more advanced goals.<br />
<br />
I: Develop a system for self-monitoring. Share data pertinent to client’s condition e.g. laboratory results blood pressure.<br />
R: Provide sense of control and enables client to follow own progress and to assist with making choices.<br />
<br />
I: May use of social workers, government welfare agencies, government officials and resources to assist the family in their financial problem.<br />
R: They can provide support and assist in financial arrangement by allocating amount from government and other charitable agencies.<br />
<br />
Doenges, et al, 2006; Gulanick, 2007; Kruse, et al. 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com3tag:blogger.com,1999:blog-3444078156201078386.post-55373266992339144012010-09-06T16:37:00.003-07:002010-09-06T16:37:33.448-07:00Nursing Care Plan: Risk for fall related to amputation, body weakness, and old age.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Falls are a major safety risk for adults, especially older adults. Evidence indicates that about 30% to 40% of older adults experience at least one serious fall per year. The consequences of these falls for the older adult represent a major health concern. Injuries sustained as a result of a fall include soft tissue injury, fractures (hip, spine, and wrist), and traumatic brain injury. Fall-related injuries are associated with prolonged hospitalizations for older adult. The quality of life for older adults is significantly changes following a fall-related injury. Death rate from fall-related injuries and their complications increases with the age of the patient.<br />
<br />
Prevention of falls is an important dimension of the nursing care of patients in hospitals and long-term care settings. Implementation of policies and procedures designed to prevent falls is an essential part of nursing care in any health care setting. Fall prevention strategies need to promote patient dignity and functional independence by significantly limiting the use of physical restraints to maintain safety. Nurses also have a major role in educating patients, families, and caregivers about prevention of falls in the home.<br />
<br />
(Gulanick, 2007)<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess the client for factors known to increase fall risk such as: History of falls.<br />
R: Evidence indicates that a person who has sustained one or more falls in the past year is more likely to fall again.<br />
<br />
I: Mental status changes.<br />
R: Confusion and impaired judgment increase the person’s risk for falls.<br />
<br />
I: Age-related physical changes.<br />
R: Normal changes associated with aging increase the person’s risk for falling. These changes include decreased visual capacity, impaired color perception, change in center of gravity, decreased muscle strength, decreased endurance, altered depth perception, and delayed response and reaction times.<br />
<br />
I: Sensory deficit.<br />
R: Impaired vision and hearing limit the person’s ability recognize hazards in the environment.<br />
<br />
I: Disease-related symptoms.<br />
R: Increased incidence of falls has been demonstrated in persons with symptoms such as orthostatic hypotension, dizziness, weakness, fatigue, and confusion.<br />
<br />
I: Unsafe clothing.<br />
R: Poor-fitting shoes, long robes, or long pants legs can limit a person’s ambulation and increase fall risk.<br />
<br />
I: Assess the client’s environment for factors known to increase fall risk such as unfamiliar setting, inadequate lighting, wet surfaces, waxed floors, clutter, and objects on floor.<br />
R: Clients who are not familiar with the placement of furniture and equipment in their room are more likely to experience a fall. Anything that blocks or limits a clear, straight path for ambulation can contribute to a person’s fall risk.<br />
<br />
I: Ensure appropriate room lighting, especially at night.<br />
R: Older adults with reduced visual capacity will benefit from adequate lighting, especially in an unfamiliar environment. Using a night light helps increase visibility if the client must get up at night.<br />
<br />
I: Encourage the client to wear shoes or slippers with nonskid soles when ambulating.<br />
R: Nonskid footwear provides sure footing for the client with diminished foot and toe lift when walking.<br />
<br />
I: Provide the client with a chair that has a firm seat and arms on both sides.<br />
R: This chair style is easier to get out of, especially when the client experiences weakness and impaired balance when transferring from bed to chair.<br />
<br />
I: Encourage the client to participate in a program of regular exercise.<br />
R: Evidence suggested that people who engage in regular exercise and activity will strengthen muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk of falls and limits injury that is sustained when a fall occurs.<br />
<br />
I: Educate the client and family members about risk factors for fall in the home. Adaptation to increase safety.<br />
R: About 40% of older adults living in the community sustain at least one fall per year. Falls are the leading cause of accidental death in the home setting.<br />
<br />
I: Place bright, nonskid strips on the edge of stair treads. May install handrails on both sides of stairs from top to bottom if necessary.<br />
R: Older adults have problems differentiating shades of the sane color and have diminished depth perception. These physiological changes make it difficult to see the edge of a stair tread that is a uniform color.<br />
<br />
I: Ensure all rugs are securely fastened to the floors or removed.<br />
R: Loose throw rugs increase the risk of slipping and falling.<br />
<br />
I: Rearrange furniture to have a clear pathway between rooms. Keep traffic patterns free of clutter and electrical cords.<br />
R: People with diminished strength are less able to negotiate around obstacles on their paths.<br />
<br />
I: Increase lighting at the top and bottom of stairs. Use nightlight in bathrooms, bedrooms, and hallways.<br />
R: Older adults have poor vision at night and in dimly lit areas.<br />
<br />
I: May refer the family to community resources for assistance in making home safety modifications.<br />
R: Many community service organizations provide financial assistance to help older adults make safety improvements in their homes as necessary.<br />
<br />
Gulanick, 2007; Doenges, et al, 2002; Kruse, et al. 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-53384176545537839772010-09-06T16:37:00.001-07:002010-09-06T16:37:07.616-07:00Nursing Care Plan: Self-Care deficit related to depression, discouragement, loss of mobility, energy deficit, general debilitation and perceptual/cognitive impairment.<div style="text-align: justify;">Scientific Basis: <br />
<br />
The nurse may encounter the patient with a self-care deficit in the hospital or in the community. The deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery, or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself or herself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to suit the patient’s physical limitations. The nurse coordinates services to maximize the independence of the patient and to ensure that the environment the patient lives in is safe and supportive of his or her special needs.<br />
<br />
Alteration in physical ability may interfere with the individual’s performance of activities of daily living. Patients who are unable to participate on their own are dependent upon others to meet basic needs and are at risk for problems such as poor hygiene.<br />
<br />
Self-care refers to those activities of an individual performs independently throughout the life to maintain personal well-being. Most adults care for themselves, whereas a person weakened by illness or disability require assistance with self-care activities.<br />
<br />
Kozier, 2007; Gulanick, 2007; Neal, 2004<br />
<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Determine current capabilities (0–4 scale) and barriers to participation in care.<br />
R: Identifies need for/level of interventions required.<br />
<br />
I: Assess ability to carry out ADL’s on regular basis. Determine the aspects of self care that are problematic to the client.<br />
R: The client may only require assistance with some self-care measures.<br />
<br />
I: Assess specific cause of each deficit (e.g., weakness, visual problems, cognitive impairment). <br />
R: Different etiologic factors may require more specific interventions to enable self care.<br />
<br />
I: Encouraging independence, but intervene when client cannot perform.<br />
R: To decrease frustration.<br />
<br />
I: Use consistent routines and allow adequate time for client to complete the tasks<br />
R: This helps client organize and carry out self-care skills.<br />
<br />
I: Provide positive reinforcement for all activities attempted; no partial achievements.<br />
R: This provides the client with an external source of positive reinforcement.<br />
<br />
I: Encouraged client to comb own hair. Suggested hairstyles that are low maintenance.<br />
R: To enable the client to maintain autonomy for as long as possible.<br />
<br />
I: Involve client in formulation of plan of care at level of ability.<br />
R: Enhances sense of control and aids in cooperation and maintenance of independence.<br />
<br />
I: Encourage self-care. Work with present abilities; do not pressure client beyond capabilities. Provide adequate time for client to complete tasks. Have expectation of improvement and assist as needed.<br />
R: Doing for oneself enhances feeling of self-worth. Failure can produce discouragement and depression.<br />
<br />
I: Provide and promote privacy, including during bathing/ showering.<br />
R: Modesty may lead to reluctance to participate in care or perform activities in the presence of others.<br />
<br />
I: Shampoo/style hair as needed. Provide/assist with manicure.<br />
R: Aids in maintaining appearance. Shampooing may be required more/less frequently than bathing schedule.<br />
<br />
I: Acquire clothing with modified fasteners as indicated.<br />
R: Use of Velcro instead of buttons/shoelaces can facilitate process of dressing/undressing.<br />
<br />
I: Encourage/assist with routine mouth/teeth care daily.<br />
R: Reduces risk of gum disease/tooth loss; promotes proper fitting of dentures.<br />
<br />
I: Provided supervision for each activity until client performed skill competently and is safe in independent care; evaluated regularly making sure that client is maintaining skill level and remains safe in environment.<br />
R: The client’s ability to perform self-care measures may change often over time and will need to be assessed regularly.<br />
<br />
Doenges, et al, 2008; Kruse, et al, 2003; Gulanick, 2007 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com1tag:blogger.com,1999:blog-3444078156201078386.post-50317554741605234252010-09-06T16:36:00.003-07:002010-09-06T16:36:43.874-07:00Nursing Care Plan: Anxiety [mild]/Fear related to threat of death (perceived or actual) threat to, or change in health status (progressive/debilitating disease, terminal illness); interaction patterns, role function/status, environment (safety), and economic status.<div style="text-align: justify;">Scientific Basis: <br />
<br />
The emotional response of the patient during illness is of extreme importance. The mind-body-spirit connection is well established; it is known, for example, that when a physiological response occurs, there is a corresponding psychological response.<br />
<br />
A common reaction to stress is anxiety, a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationship.<br />
<br />
An actual or perceived threat to life, health, self-esteem, or role cause anxiety. Fear is the response to known factors. Questions arise as to whether the individual will survive of be able to continue previous life-style. Individuals feel anxious whenever they are threatened, whether the threat is perceived or actual. High levels of anxiety however, can be overwhelm the person and impair the ability to think and function. As the severity of the anxiety increases, the person is less able to function; thereby it threatens his health status and condition.<br />
<br />
DeLaune and Ladner, 2002; Berman, et al, 2008<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Note palpitations, elevated pulse/respiratory rate.<br />
R: Changes in vital signs may suggest the degree of anxiety patient is experiencing or reflect the impact of physiological factors, e.g., endocrine imbalances, medications.<br />
<br />
I: Acknowledge fear/anxieties. Validate observations with patient, e.g., “You seem to be afraid.”<br />
R: Feelings are real, and it is helpful to bring them out in the open so they can be discussed and dealt with.<br />
<br />
I: Assess degree/reality of threat to client and level of anxiety (e.g., mild, moderate, severe) by observing behavior such as clenched hands, wide eyes, startle response, furrowed brow, clinging to family/staff, or physical/verbal lashing out.<br />
R: Individual responses can vary according to cultural beliefs/traditions and culturally learned patterns. Distorted perceptions of the situation may magnify feelings.<br />
<br />
I: Note narrowed focus of attention (e.g., client concentrates on one thing at a time).<br />
R: Narrowed focus usually reflects extreme fear/panic.<br />
<br />
I: Observe speech content, vocabulary, and communication patterns, e.g., rapid/slow, pressured speech; words commonly used, repetition, use of humor/laughter, swearing.<br />
R: Provides clues about such factors as the level of anxiety, ability to comprehend what is currently happening, cognition difficulties, and possible language differences.<br />
<br />
I: Assess severity of pain when present. Delay gathering of information if pain is severe.<br />
R: Severe pain and anxiety leave little energy for thinking and other activities.<br />
<br />
I: Orient to environment and new experiences or people as needed.<br />
R: Orientation and awareness of the surroundings promotes comforts and may decrease anxiety.<br />
<br />
I: Identify client’s/SO’s perception(s) of the situation<br />
R: Regardless of the reality of the situation, perception affects how each individual deals with the illness/stress.<br />
<br />
I: Acknowledge reality of the situation as client sees it, without challenging the belief.<br />
R: Client may need to deny reality until ready to deal with it. It is not helpful to force client to face facts.<br />
<br />
I: Evaluate coping/defense mechanisms being used to deal with the perceived or real threat.<br />
R: May be dealing well with the situation at the moment; e.g., denial and regression may be helpful coping mechanisms for a time. However, continued use of such mechanisms diverts energy client needs for healing, and problems need to be dealt with at some point in time.<br />
<br />
I: Review coping mechanisms used in the past, e.g., problem-solving skills, recognizing/asking for help.<br />
R: Provides opportunity to build on resources client/SO may have used successfully.<br />
<br />
I: Assist client to use the energy of anxiety for coping with the situation when possible.<br />
R: Moderate anxiety heightens awareness and can help motivate client to focus on dealing with problems.<br />
<br />
I: Maintain frequent contact with client/SO. Be available for listening and talking as needed.<br />
R: Establishes rapport, promotes expression of feelings, and helps client and SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.<br />
<br />
I: Acknowledge feelings as expressed (e.g., use of Active-<br />
Listening, reflection). If actions are unacceptable, take necessary steps to control/deal with behavior. (Refer to ND: Violence, risk for.)<br />
R: Often acknowledging feelings enables client to deal more appropriately with situation. May need chemical/physical control for brief periods.<br />
<br />
I: Identify ways in which client can get help when needed, including telephone numbers of contact persons.<br />
R: Provides assurance that staff/resources are available for assistance/support.<br />
<br />
I: Stay with or arrange to have someone stay with client as indicated.<br />
R: Continuous support may help client regain internal locus of control and reduce anxiety/fear to a manageable level.<br />
<br />
I: Provide accurate information as appropriate and when requested by client/SO. Answer questions freely and honestly and in language that is understandable by all. Repeat information as necessary; correct misconceptions.<br />
R: Complex and/or anxiety-provoking information can be given in manageable amounts over an extended period. As opportunities arise and facts are given, individuals will accept what they are ready for. Note: Words/phrases may have different meanings for each individual; therefore, clarification is necessary to ensure understanding.<br />
<br />
I: Avoid empty reassurances, with statements of “everything will be all right.” Instead, provide specific information: e.g., “Your heart rate is regular, your pain is being easily controlled, and that is what we want”<br />
R: It is not possible for the nurse to know how the specific situation will be resolved, and false reassurances may be interpreted as lack of understanding or honesty, further isolating client. Sharing observations used in assessing condition/prognosis provides opportunity for client/SO to feel reassured.<br />
<br />
I: Note expressions of concern/anger about treatment or staff.<br />
R: Anxiety about self and outcome may be masked by comments or angry outbursts directed at therapy/caregivers.<br />
<br />
I: Ask client/SO to identify what he or she can/cannot do about what is happening.<br />
R: Assists in identifying areas in which control can be exercised and those in which control is not possible.<br />
<br />
I: Provide as much order and predictability as possible in scheduling care/activities, visitors.<br />
R: Helps client anticipate and prepare for difficult treatments/movements, as well as look forward to pleasant occurrences.<br />
<br />
I: Instruct in ways to use positive self-talk, e.g., “I can manage this pain for now”<br />
R: Internal dialogue is often negative. When this is shared out loud, client becomes aware and can be directed in the use of positive self-talk, which can help reduce anxiety.<br />
<br />
I: Encourage client to develop regular exercise/activity program.<br />
R: Helpful in reducing level of anxiety; has been shown to raise endorphin levels to enhance sense of well-being.<br />
<br />
I: Encourage/instruct in guided imagery/relaxation techniques; e.g., imaging a pleasant place, use of music/tapes, deep-breathing, meditation, and mindfulness.<br />
R: Promotes release of endorphins and aids in developing internal locus of control, reducing anxiety. May enhance coping skills, allowing body to go about its work of healing. Note: Mindfulness is a method of being in the here and now, concentrating on what is happening in the moment.<br />
<br />
I: Provide touch, Therapeutic Touch, massage, and other adjunctive therapies as indicated.<br />
R: Aids in meeting basic human need, decreasing sense of isolation, and assisting client to feel less anxious. Note: Therapeutic Touch requires the nurse to have specific knowledge and experience to use the hands to correct energy field disturbances by redirecting human energies to help or heal.<br />
<br />
I: Use simple language and brief statements when instructing about self care measure, diagnostic or surgical procedures.<br />
R: When experiencing moderate to severe anxiety, the patient may be unable to comprehend anything more than simple, clear, and brief instructions.<br />
<br />
I: Refer to social service or other appropriate agency for assistance. Have case manage and social worker discuss modifications of medical aid if client is eligible for these resources.<br />
R: Often client is not aware of the resources available providing current information about individual courage/ limitations and other possible sources of support will assist with adjustment to situation.<br />
<br />
Gulanick, 2007; Doenges, et al, 2006; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-16836606076795768462010-09-06T16:36:00.001-07:002010-09-06T16:36:16.043-07:00Nursing Care Plan: Caregiver role strain related to illness severity, unpredictability of illness course, knowledge deficit, and increasing clients care needs.<div style="text-align: justify;">Scientific Basis: <br />
<br />
The focus of this care plan is on the supportive care rendered by family, significant others, or caregivers responsible for meeting the physical and/or emotional needs of the patient. With limited access to health care for many people, most disease are diagnosed and managed in the outpatient setting. <br />
<br />
Today’s health care environment places high expectations on the designated caregiver, whether a family member or someone to hire. For many older patients, the only caregiver is a fragile spouse overwhelmed by his or her own health problems. Even in cultures where care of the ill is the anticipated responsibility of family members, the complexities of today’s medical regimens, the chronicity of some of disease processes, and the burdens of the caregiver’s own family or environmental milieu provide and overwhelming challenge.<br />
<br />
Caregivers have special needs for knowledge and skills in managing the required activities, access to affordable community resources, and recognition that the care they are providing is important and appreciated. People undergoing the role strain are frustrated because they feel inadequate or unsuited to a role. <br />
<br />
Gulanick, 2007; Taylor, et al, 2005; Gulanick, 2007<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Establish relationship with the caregiver and care recipient.<br />
R: This facilitates assessment and intervention.<br />
<br />
I: Assess caregiver-care recipient relationship.<br />
R: Dysfunctional relationship can result in ineffective, fragmented care or even to neglect or abuse.<br />
<br />
I: Assess family communication pattern.<br />
R: open communication in the family creates a positive environment, whereas concealing feelings creates problems for caregiver and care recipient.<br />
<br />
I: Assess family resources and support systems.<br />
R: Family and social support is related positively to coping effectiveness. Some cultures are more accepting of this responsibility. However, factors such as blended family unit aging, geographical distances between family members, and limited financial resources may hamper coping effectiveness.<br />
<br />
I: Assess the caregiver’s appraisal of the care giving situation, level of understanding, and willingness to assume caregiver role.<br />
R: Individual responses to potentially stressful situations are mediated by an appraisal of the personal meaning of the situation. For some, care giving is viewed as a “duty”; for others it may be an act of love.<br />
<br />
I: Assess for neglect and abuse of the care recipient and take necessary steps to prevent injury to the care recipient and strain on the caregiver.<br />
R: Safe and appropriate care are priority nursing concerns. The nurse must remain a client advocate.<br />
<br />
I: Assess the caregiver’s health.<br />
R: Even though strongly motivated to perform the role of caregiver, the person, may have physical impairments or cognitive impairments that affect the quality of the care giving activities.<br />
<br />
I: Encourage the caregiver to identify available family and friends who can assist with care giving.<br />
R: Successful care giving should not be the sole responsibility of one person. In some situations there may be no readily members hesitate to notify other family members or significant others because of unresolved conflicts in the past.<br />
<br />
I: Encourage involvement of the other family members to relieve pressure on the primary caregiver.<br />
R: Caring for a family member can be a mutually rewarding and satisfying family experience.<br />
<br />
I: Suggest that the caregiver use available community resources.<br />
R: This provides opportunity for multiple competent providers and services on a temporary or more extended period.<br />
I: Encourage the caregiver to set aside time for self. This could be simple as a relaxing bath, time to read a book/newspaper, or going out with friends.<br />
R: Having own time helps conserve physical and emotional energy.<br />
<br />
I: Teach the care giver stress-reducing techniques.<br />
R: It is important that the caregiver has the opportunity to relax and reenergize emotionally throughout the day.<br />
<br />
I: Encourage the caregiver in support group participation.<br />
R: Groups that come together for mutual support can be quite beneficial in providing education and anticipatory guidance. A group can meet in the home, social setting, by telephone.<br />
<br />
I: Acknowledge the caregiver’s role and its values.<br />
R: Caregivers have identified how important it is to feel appreciated for their efforts.<br />
<br />
I: Encourage the care recipient to thank the caregiver for care given.<br />
R: Feeling appreciated decreases feelings of strain.<br />
<br />
I: Provide time for the caregiver to discuss problems, concerns, and feelings. Ask the caregiver how he or she is managing.<br />
R: As a caregiver, the nurse is in an excellent position to provide emotional support and provide guidance throughout this challenging period.<br />
<br />
I: Provide information on the disease process and management strategies.<br />
R: Accurate information increases understanding of the care recipient’s condition and behavior. Caregivers may have an unrealistic picture of the extent of care required at the present time.<br />
<br />
Gulanick, 2007; Doenges, et al, 2002; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-32603746220656340522010-09-06T16:35:00.004-07:002010-09-06T16:35:53.953-07:00Nursing Care Plan: Coping, ineffective/Decisional Conflict related to situational crises/personal vulnerability; multiple life changes/maturational crises, age/developmental stage, inadequate level of confidence in ability to cope, perception of control; high degree of threat; support no vacations/inadequate relaxation, impaired adaptive behaviors and problem-solving skills, severe pain/overwhelming threat to self unclear personal values/beliefs; perceived threat to value system; lack of experience/interference with decision making and lack of information.<div style="text-align: justify;">Scientific Basis: <br />
<br />
For most persons, everyday life includes shares of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends in part on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. <br />
<br />
Socio-cultural and religious factors may influence how people view and handle their problems. Some cultures may prefer privacy and avoid sharing their fear in public, even to health care providers. As resources become limited and problems become more acute, this strategy may prove ineffective. Vulnerable populations such as patients, those in adverse socioeconomic situations, those with complex medical problems such as those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors. Such problems can occur in any setting (e.g., during hospitalization for an acute event, in the home or rehabilitation environment as a result of chronic illness, or in response to another threat or loss).<br />
<br />
NANDA define ineffective individual coping as an “inability to form a valid appraisal of the stressors, inadequate choices of practical responses, and/or inability to use available resources. Stimuli likely to cause ineffective coping in illness, pain and incapacitation, lack of sleep, stressful hospital environment and treatment procedures, loss of control over what’s happening to self, loss of hope, lack of meaningful contact with loved ones, uncertain future.<br />
<br />
Conditions and stimuli to cause ineffective coping are perception on a harmful stimulus or cues that a harmful stimulus is imminent, perception that the harmful stimulus threatens the individual’s goals or values and perception that the patient’s resources aren’t equally to coping with the threat.<br />
<br />
The period of impact begins immediately after injury and is characterized by shock, disbelief and feelings of being overwhelmed. The client and family members may be aware of what is happening but may be coping to the situation poorly.<br />
<br />
Black and Hawks, 2004; Gulanick, 2007; Doenges, et al, 2002; Holloway, 2004<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Review pathophysiology affecting client and extent of feelings of hopelessness/helplessness/loss of control over life, level of anxiety; perception of situation.<br />
R: Indicators of degree of disequilibrium and need for intervention to prevent or resolve the crisis. Studies suggest that up to 85% of all physically ill people are depressed to some degree. Impairment of normal functioning for more than 2 wk, especially in presence of chronic condition, may reflect depression, requiring further evaluation.<br />
<br />
I: Establish therapeutic nurse-client relationship.<br />
R: Client may feel freer in the context of this relationship to verbalize feelings of helplessness/powerlessness and to discuss changes that may be necessary in client’s life.<br />
<br />
I: Note expressions of indecision, dependence on others, and inability to manage own ADLs.<br />
R: May indicate need to lean on others for a time. Early recognition and intervention can help client regain equilibrium.<br />
<br />
I: Assess presence of positive coping skills/inner strengths, e.g., use of relaxation techniques, willingness to express feelings, use of support systems.<br />
R: When the individual has coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the individual’s sense of control. However, limitations of condition may impact choices available to client; e.g., playing musical instrument to relieve stress may not be possible for individual with tremors or hemiparesis, but listening to tapes/CDs may provide some degree of comfort.<br />
<br />
I: Encourage client to talk about what is happening at this time and what has occurred to precipitate feelings of helplessness and anxiety.<br />
R: Provides clues to assist client to develop coping and regain equilibrium.<br />
<br />
I: Evaluate ability to understand events. Correct misperceptions, provide factual information.<br />
R: Assists in identification and correction of perception of reality and enables problem solving to begin.<br />
<br />
I: Provide quiet, non stimulating environment. Determine what client needs, and provide if possible. Give simple, factual information about what client can expect and repeat as necessary.<br />
R: Decreases anxiety and provides control for client during crisis situation.<br />
<br />
I: Allow client to be dependent in the beginning, with gradual resumption of independence in ADLs, self-care, and other activities. Make opportunities for client to make simple decisions about care/other activities when possible, accepting choice not to do so.<br />
R: Promotes feelings of security (client will know nurse will provide safety). As control is regained, client has the opportunity to develop adaptive coping/problem solving skills.<br />
<br />
I: Accept verbal expressions of anger, setting limits on maladaptive behavior.<br />
R: Verbalizing angry feelings is an important process for resolution of grief and loss. However, preventing destructive actions (such as striking out at others) preserves client’s self-esteem.<br />
<br />
I: Discuss feelings of self-blame/projection of blame on others.<br />
R: Although these mechanisms may be protective at the moment of crisis, they eventually are counterproductive and intensify feelings of helplessness and hopelessness.<br />
<br />
I: Note expressions of inability to find meaning in life/reason for living, feelings of futility or alienation from God.<br />
R: Crisis situation may evoke questioning of spiritual beliefs, affecting ability to cope with current situation and plan for the future.<br />
<br />
I: Promote safe and hopeful environment, as needed. Identify positive aspects of this experience and assist client to view it as a learning opportunity.<br />
R: May be helpful while client regains inner control. The ability to learn from the current situation can provide skills for moving forward.<br />
<br />
I: Provide support for client to problem-solve solutions for current situation. Provide information and reinforce reality as client begins to ask questions; look at what is happening.<br />
R: Helping client/SO to brainstorm possible solutions (giving consideration to the pros and cons of each) promotes feelings of self-control/esteem.<br />
<br />
I: Provide for gradual implementation and continuation of necessary behavior and lifestyle changes. Reinforce positive adaptation/new coping behaviors.<br />
R: Reduces anxiety of sudden change and allows for developing new and creative solutions.<br />
<br />
I: Refer to other resources as necessary (e.g., clergy, psychiatric clinical nurse specialist/psychiatrist, family/marital therapist, addiction support groups).<br />
R: Additional assistance may be needed to help client resolve problems/make decisions.<br />
<br />
Doenges, et al, 2002; Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-63013456389357949392010-09-06T16:35:00.002-07:002010-09-06T16:35:30.127-07:00Nursing Care Plan: Disturbed body image related to change in body structure and function.<div style="text-align: justify;">Scientific Basis: <br />
<br />
The image of physical self, or body image, is how a person perceives the size appearance, an functioning of the body and its parts. Body image has both cognitive and affective aspects. The cognitive is the knowledge of the material body; the affective includes the sensations of the body, such as pain, pleasure, fatigue, and physical movement. Body image is the sum of these attitudes, conscious and unconscious, that a person has toward his or her body. The individual who has a body image disturbance may hide or not look at or touch a body part that is significantly changes in structure by illness or trauma. Some individuals may also express feelings of helplessness, hopelessness, powerlessness, and vulnerability, and may exhibit self-destructive behavior such as over- or under eating or suicide attempts.<br />
<br />
The attitude is dynamic and is altered through interaction with other persons and situations, and is influenced by age and developmental level. As an important part of one’s self-concept, body image disturbance can have a profound impact on how individuals view their overall selves. In cultures where one’s appearance is important, variations from the norm can result in body image disturbance. The importance that an individual places on a body part or function may be more important in determining the degree of disturbance that the actual alteration in structure or function.<br />
<br />
Gulanick, 2007; Bearman, et at, 2008; Taylor, et al, 2005<br />
<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess perception of change in structure or function of the body part.<br />
R: The extent of the response is more related to the value or importance the client places on the part or function than the actual value or importance. Even when an alteration improves the overall health of the individual, the alteration may result in a body image disturbance.<br />
<br />
I: Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities.<br />
R: Changes in body image can have an impact on the person’s ability to carry out daily roles and responsibilities.<br />
<br />
I: Assess impact of body image disturbance in relation to the client’s developmental stage.<br />
R: In every developmental stage, they see their body image differently.<br />
<br />
I: Note the client’s behavior regarding the actual or perceived change body part or function.<br />
R: There is a broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.<br />
<br />
I: Note the frequency of the client’s self-critical remarks.<br />
R: Negative statements about the affected body part indicate limited ability to integrate the change into the client’s self-concept.<br />
<br />
I: Acknowledge normalcy of emotional response to actual change in body structure or function.<br />
R: Stages of grief over loss of a body part or function is normal and typically involves a period of denial, the length of which varies between individuals.<br />
<br />
I: Help the client identify actual changes.<br />
R: clients may perceive changes that are not present or real, or they place an unrealistic value on a body structure or function.<br />
<br />
I: Support and encourage client; provide care with a positive, friendly attitude.<br />
R: Caregivers sometimes allow judgmental feelings to affect the care of client and need to make every effort to help patient feel valued as a person.<br />
<br />
I: Encourage verbalization of positive or negative feelings about the actual or perceived change.<br />
R: It is worthwhile to encourage the client to separate feelings about changes in body structure and/or function from feelings about self-worth. Expression of feelings can enhance the person’s coping strategies.<br />
<br />
I: Assist the client in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities.<br />
R: Opportunities for positive feedback and success in social situations may hasten adaptation.<br />
<br />
I: Demonstrate positive caring in routine activities.<br />
R: Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the client plans to return to home, work, and other activities.<br />
<br />
I: Teach the client about the normalcy of body image disturbance and the grief process.<br />
R: The person experiencing a body image changes needs new information to support cognitive appraisal of the change.<br />
<br />
I: Teach the client adaptive behavior (e.g., wearing shoes)<br />
R: This compensates for the actual changed body structure and function.<br />
<br />
I: Encourage family/SO to verbalize feelings, visit freely/participate in care.<br />
R: Family members may feel guilty about client’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to client. Participation in care helps them feel useful and promotes trust between staff, client, and SO.<br />
<br />
I: Help the client identify ways of coping that have been useful in the past.<br />
R: Asking client to remember other body image issues and how they were managed may help the client adjust to current issue.<br />
<br />
I: May refer the client and caregivers to support groups composed of individuals with similar alterations.<br />
R: Lay persons in similar situations offer a different type of support, which is perceived as helpful.<br />
<br />
Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-32621611644058086382010-09-06T16:35:00.000-07:002010-09-06T16:35:06.252-07:00Nursing Care Plan: Family Coping: readiness for enhanced related to knowledge deficit regarding illness prognosis, inaccurate, incomplete, or conflicting information and inadequate coping method.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Family coping mechanisms are the behaviors families use to deal with stress or changes imposed from either within or without. Coping mechanisms can be viewed as an active method of problem solving developed to meet life’s challenges. Families may use coping patterns rather consistently over time or may challenge their coping strategies when new demands are made on the family. The success of a family largely depends on how well it copes with the stresses it experiences. Nurses working together with families realize the importance of assessing coping mechanisms as a way of determining how families relate to stress.<br />
<br />
The stress that affects an ill person affects the person’s family members or significant others. When family is viewed as a system, the behavior of the individual’s behavior in turn affects the family. Stressors for the family include changes in the family structure and roles, anger and feelings of helplessness and guilt, loss of control over normal routines, and concern for future financial stability.<br />
<br />
The family is disrupted as members abandon their usual activities and focus their energy on restoring family equilibrium. Roles and responsibilities previously assumed by the ill person are delegated to other family members, or those functions may remain undone for duration of the illness. The family’s ability to deal with the stress of illness depends on the members’ coping skills.<br />
<br />
Berman, et al, 2008; Taylor, et al, 2005<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Provide opportunities for family to talk with client and/or caregiver(s).<br />
R: Reduces anxiety and allows expression of what has been learned and how they are managing, as well as opportunity to make plans for the future and share support.<br />
<br />
I: Assess normal coping patterns in the family, including strengths, limitations, and resources.<br />
R: Successful adjustment is influenced by previous coping success. Families with a history of unsuccessful coping may need additional resources.<br />
<br />
I: Listen to family’s expressions of hope, planning, effect on relationships/life, change of values.<br />
R: Provides clues to avenues to explore for assistance with growth.<br />
<br />
I: Provide opportunities for and instruction in how SOs can care for client. Discuss ways in which they can support client in meeting own needs.<br />
R: Enhances feelings of control and involvement in situation in which SOs cannot do many things. Also provides opportunity to learn how to be most helpful when client is discharged from care.<br />
<br />
I: Determine ability of family members to provide necessary care.<br />
R: Safe and appropriate care are priority nursing concerns. The nurse may have to intervene with suggestions for additional resources, as appropriate.<br />
<br />
I: Provide a role model with which family may identify.<br />
R: Having a positive example can help with adoption of new behaviors to promote growth.<br />
<br />
I: Discuss importance of open communication. Role-play effective communication skills of Active-Listening, “messages,” and problem solving.<br />
R: Helps individuals to express needs and wants in ways that will develop family cohesiveness. Promotes solutions in which everyone wins.<br />
<br />
I: Encourage family to learn new and effective ways of dealing with feelings.<br />
R: Effective recognition and expression of feelings clarify situation for involved individuals.<br />
<br />
I: Encourage seeking help appropriately. Give information about available persons and agencies.<br />
R: Permission to seek help as needed allows them to choose to take advantage of available assistance/resources.<br />
<br />
I: Assist family to support the client in meeting own needs within ability and/or constraints of the illness or condition.<br />
R: Provides a way to allow family member to take an active role in the care of the client.<br />
<br />
I: Recognize the primary caregiver’s need for relief from continuing care responsibility. Assess the role of the client in the family structure.<br />
R: The role of family members varies among culture.<br />
<br />
I: Evaluate resources or support systems available to the family.<br />
R: In some situations there may be no readily available resources; however, often family members hesitate to notify other family members or significant others because of unresolved conflicts in the past.<br />
<br />
I: May refer to specific support group(s) as indicated.<br />
R: Provides opportunities for sharing experiences; provides mutual support and practical problem solving; and can aid in decreasing alienation and helplessness.<br />
<br />
Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-86301533094694319332010-09-06T16:33:00.001-07:002010-09-06T16:33:51.571-07:00Nursing Care Plan: Grieving, anticipatory related to perceived, actual, or potential loss of physiopsychosocial well-being, personal possessions, or SO and cultural beliefs about aging/debilitation.<div style="text-align: justify;">Scientific Basis: <br />
Anticipatory grieving is a state in which an individual grieves before an actual loss. It may apply to individuals who have had a perinatal loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. Intense mental anguish or a sense of deep sadness may be experiences by patients and their families as they face long-term illness or disability. Grief is an aspect of the human condition that touches every individual, but how an individual or a family system responds to loss and how grief is expressed varies widely. That process is strongly influenced by factor such as age, gender, and culture, as well as personal and intrafamilial reserves and strengths. The nurse must recognize the anticipatory grief is real grief and that, in all likelihood, as the loss actually occurs, it will evolve into grief based on an accomplished event. The nurse will encounter the patient and family experiencing anticipatory grief in the hospital setting, but increasingly, with more hospice services provided in the community, the nurse will find patient struggling with these issues in their own homes where professional help may be limited or fragmented. This care plan discusses measures the nurse can use help the patient and family members begin the process of grieving.<br />
<br />
Grief is the emotional reaction to loss or perceived loss (is felt by the person but is intangible to others; loss of youth, financial independence, and of a valued environment), anticipatory loss, in which a person displays loss and grief behaviors for a loss that has yet to take place. Individual diagnosis with severe diseases perceives a threat to life, health, self-esteem and role. The threat may be viewed as a loss or potential loss. Grief is the process of making loss a reality. Anyone experiencing or perceiving a loss must grieve. The actual grief process may begin with anticipation for the loss.<br />
<br />
Neal, et al, 2004; Gulanick, 2007; Taylor, et al, 2005<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess emotional state. Note cultural beliefs, expectations.<br />
R: Anxiety and depression are common reactions to changes/losses associated with long-term illness or debilitating condition. In addition, changes in neurotransmitter levels (e.g., increased monoamine oxidase [MAO] and serotonin levels with decreased norepinephrine) may potentiate depression in elderly patients. Personal expectations may affect response to change.<br />
<br />
I: Determined as to what stage is the client in grieving.<br />
R: To provide appropriate care.<br />
<br />
I: Denial: Be aware of avoidance behaviors: anger, withdrawal, and so forth. Allow client to talk about what he or she chooses, and do not try to force client to “face the facts”;<br />
R: Denying the reality of diagnosis and/or prognosis is an important phase in which client protects self from the pain and reality of the threat of loss. Each person does this in an individual manner based on previous experiences with loss and cultural/ religious factors.<br />
<br />
I: Anger: Note behaviors of withdrawal, lack of cooperation, and direct expression of anger. Be alert to body language and check meaning with client, noting congruency with verbalizations. Encourage/allow verbalization of anger, acknowledge feelings, set limits regarding destructive behavior;<br />
R: Denial gives way to feelings of anger, rage, guilt, and resentment. Client may find it difficult to express anger directly and may feel guilty about normal feelings of anger. Although staff may have difficulty dealing with angry behaviors, acceptance allows patient to work through the anger and move on to more effective coping behaviors.<br />
<br />
I: Bargaining: Be aware of statements such as “. . . if I do this, my problem will be fixed.” Allow verbalization without confrontation about realities;<br />
R: Bargaining with care providers or God often occurs and may be helpful in beginning resolution and acceptance. Patient may be working through feelings of guilt about things done or undone.<br />
<br />
I: Depression: Give client permission to be where he or she is. Provide hope within parameters of individual situation without giving false reassurance. Provide comfort and availability, as well as caring for physical needs;<br />
R: When patient can no longer deny the reality of the loss, feelings of helplessness and hopelessness replace feelings of anger. Client needs information that this is a normal progression of feelings.<br />
<br />
I: Acceptance: Respect client’s needs and wishes for<br />
quiet, privacy, and/or talking.<br />
R: Having worked through the denial, anger, and depression, client often prefers to be alone and does not want to talk much at this point. Client may still cling to hope, which can be sustaining through whatever is happening at this point.<br />
<br />
I: Review past life experiences/ previous loss, role changes and coping skills, noting strengths/ success.<br />
R: Useful in dealing with current situation and problem solving existing needs.<br />
<br />
I: Make time to listen to client. Encourage free expression of hopeless feelings and desire to die.<br />
R: It is more helpful to allow these feelings to be expressed and dealt with than to deny or ignore them. <br />
<br />
I: Assess suicidal potential.<br />
R: May be related to physical disease, social isolation, and grief. Note: Studies indicate women are three times as likely to attempt suicide; however, men are three times as likely to succeed.<br />
<br />
I: Involve SO in discussions and activities to the level of their willingness.<br />
R: When SOs are involved, there is more potential for successful problem solving. Note: SO may not be available or may not choose to be involved.<br />
<br />
I: Provide liberal touching as individually accepted.<br />
R: Conveys sense of concern/closeness to reduce feelings of isolation and enhance sense of self-worth. Note: Touch may be viewed as a threat by some patients and escalate feelings of agitation/anger.<br />
<br />
I: Identify spiritual concerns. Discuss available resources and encourage participation in religious activities as appropriate.<br />
R: Search for meaning is common to those facing changes in life. Participation in religious/spiritual activities can provide sense of direction and peace of mind.<br />
<br />
I: Assist with/plan for specifics as necessary (e.g., Advance Directives to determine code status/Living Will wishes, making of will, funeral arrangements if appropriate).<br />
R: Having these issues resolved can help client/SO deal with the grieving process and may provide peace of mind.<br />
<br />
I: Provide an open, nonjudgmental environment. Used therapeutic communication skills of active listening acknowledgment.<br />
R: Promotes and encourages realistic dialogue about feeling and concerns.<br />
<br />
I: Encourage verbalization of thought/concerns<br />
R: Client may feel supported in expression for feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation. <br />
<br />
I: Reinforced teaching regarding disease process and treatments and provided information as requested.<br />
R: Client/significant others benefits from factual information. Individuals may ask direct questions and honest answers promote trust and reassurance that corrects information will be given.<br />
<br />
I: Provided realistic information about health status without false reassurance or taking away life<br />
R: Defensive retreat occurs weeks to months after loss. Pt attempts to maintain what he has been lost; denial, wishful thinking, unwillingness to participate in self-care and indifference may be seen.<br />
<br />
I: Recognize that each client is unique and will progress at own pace.<br />
R: Time frames vary widely. Cultural, religious, ethnic, individual differences impact on manner of grieving.<br />
<br />
I: Establish rapport with client and significant others. Listen and encourage pt significant others to verbalize feelings.<br />
R: This open lines of communication and facilitate successful resolution of grief.<br />
<br />
I: Accepted need to deny loss as part of normal grief process.<br />
R: Realization occurs weeks to months after loss. Reality continues to be over whelming sadness, anger, guilt, hostility may be seen.<br />
<br />
I: Be honest in answering questions, providing information.<br />
R: Enhances sense of trust and nurse-client relationship.<br />
<br />
I: Discuss issues, such as what is in the power of the individual to change and what is beyond control.<br />
R: Recognition of these factors helps client focus energy for maximal benefit/ outcome.<br />
<br />
Doenges, et al, 2002, Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-41367065670774065712010-09-06T16:32:00.003-07:002010-09-06T16:32:56.819-07:00Nursing Care Plan: Grieving, anticipatory related to perceived, actual, or potential loss of physiopsychosocial well-being, personal possessions, or SO and cultural beliefs about aging/debilitation.<div style="text-align: justify;">Scientific Basis: <br />
Anticipatory grieving is a state in which an individual grieves before an actual loss. It may apply to individuals who have had a perinatal loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. Intense mental anguish or a sense of deep sadness may be experiences by patients and their families as they face long-term illness or disability. Grief is an aspect of the human condition that touches every individual, but how an individual or a family system responds to loss and how grief is expressed varies widely. That process is strongly influenced by factor such as age, gender, and culture, as well as personal and intrafamilial reserves and strengths. The nurse must recognize the anticipatory grief is real grief and that, in all likelihood, as the loss actually occurs, it will evolve into grief based on an accomplished event. The nurse will encounter the patient and family experiencing anticipatory grief in the hospital setting, but increasingly, with more hospice services provided in the community, the nurse will find patient struggling with these issues in their own homes where professional help may be limited or fragmented. This care plan discusses measures the nurse can use help the patient and family members begin the process of grieving.<br />
<br />
Grief is the emotional reaction to loss or perceived loss (is felt by the person but is intangible to others; loss of youth, financial independence, and of a valued environment), anticipatory loss, in which a person displays loss and grief behaviors for a loss that has yet to take place. Individual diagnosis with severe diseases perceives a threat to life, health, self-esteem and role. The threat may be viewed as a loss or potential loss. Grief is the process of making loss a reality. Anyone experiencing or perceiving a loss must grieve. The actual grief process may begin with anticipation for the loss.<br />
<br />
Neal, et al, 2004; Gulanick, 2007; Taylor, et al, 2005<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess emotional state. Note cultural beliefs, expectations.<br />
R: Anxiety and depression are common reactions to changes/losses associated with long-term illness or debilitating condition. In addition, changes in neurotransmitter levels (e.g., increased monoamine oxidase [MAO] and serotonin levels with decreased norepinephrine) may potentiate depression in elderly patients. Personal expectations may affect response to change.<br />
<br />
I: Determined as to what stage is the client in grieving.<br />
R: To provide appropriate care.<br />
<br />
I: Denial: Be aware of avoidance behaviors: anger, withdrawal, and so forth. Allow client to talk about what he or she chooses, and do not try to force client to “face the facts”;<br />
R: Denying the reality of diagnosis and/or prognosis is an important phase in which client protects self from the pain and reality of the threat of loss. Each person does this in an individual manner based on previous experiences with loss and cultural/ religious factors.<br />
<br />
I: Anger: Note behaviors of withdrawal, lack of cooperation, and direct expression of anger. Be alert to body language and check meaning with client, noting congruency with verbalizations. Encourage/allow verbalization of anger, acknowledge feelings, set limits regarding destructive behavior;<br />
R: Denial gives way to feelings of anger, rage, guilt, and resentment. Client may find it difficult to express anger directly and may feel guilty about normal feelings of anger. Although staff may have difficulty dealing with angry behaviors, acceptance allows patient to work through the anger and move on to more effective coping behaviors.<br />
<br />
I: Bargaining: Be aware of statements such as “. . . if I do this, my problem will be fixed.” Allow verbalization without confrontation about realities;<br />
R: Bargaining with care providers or God often occurs and may be helpful in beginning resolution and acceptance. Patient may be working through feelings of guilt about things done or undone.<br />
<br />
I: Depression: Give client permission to be where he or she is. Provide hope within parameters of individual situation without giving false reassurance. Provide comfort and availability, as well as caring for physical needs;<br />
R: When patient can no longer deny the reality of the loss, feelings of helplessness and hopelessness replace feelings of anger. Client needs information that this is a normal progression of feelings.<br />
<br />
I: Acceptance: Respect client’s needs and wishes for<br />
quiet, privacy, and/or talking.<br />
R: Having worked through the denial, anger, and depression, client often prefers to be alone and does not want to talk much at this point. Client may still cling to hope, which can be sustaining through whatever is happening at this point.<br />
<br />
I: Review past life experiences/ previous loss, role changes and coping skills, noting strengths/ success.<br />
R: Useful in dealing with current situation and problem solving existing needs.<br />
<br />
I: Make time to listen to client. Encourage free expression of hopeless feelings and desire to die.<br />
R: It is more helpful to allow these feelings to be expressed and dealt with than to deny or ignore them. <br />
<br />
I: Assess suicidal potential.<br />
R: May be related to physical disease, social isolation, and grief. Note: Studies indicate women are three times as likely to attempt suicide; however, men are three times as likely to succeed.<br />
<br />
I: Involve SO in discussions and activities to the level of their willingness.<br />
R: When SOs are involved, there is more potential for successful problem solving. Note: SO may not be available or may not choose to be involved.<br />
<br />
I: Provide liberal touching as individually accepted.<br />
R: Conveys sense of concern/closeness to reduce feelings of isolation and enhance sense of self-worth. Note: Touch may be viewed as a threat by some patients and escalate feelings of agitation/anger.<br />
<br />
I: Identify spiritual concerns. Discuss available resources and encourage participation in religious activities as appropriate.<br />
R: Search for meaning is common to those facing changes in life. Participation in religious/spiritual activities can provide sense of direction and peace of mind.<br />
<br />
I: Assist with/plan for specifics as necessary (e.g., Advance Directives to determine code status/Living Will wishes, making of will, funeral arrangements if appropriate).<br />
R: Having these issues resolved can help client/SO deal with the grieving process and may provide peace of mind.<br />
<br />
I: Provide an open, nonjudgmental environment. Used therapeutic communication skills of active listening acknowledgment.<br />
R: Promotes and encourages realistic dialogue about feeling and concerns.<br />
<br />
I: Encourage verbalization of thought/concerns<br />
R: Client may feel supported in expression for feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation. <br />
<br />
I: Reinforced teaching regarding disease process and treatments and provided information as requested.<br />
R: Client/significant others benefits from factual information. Individuals may ask direct questions and honest answers promote trust and reassurance that corrects information will be given.<br />
<br />
I: Provided realistic information about health status without false reassurance or taking away life<br />
R: Defensive retreat occurs weeks to months after loss. Pt attempts to maintain what he has been lost; denial, wishful thinking, unwillingness to participate in self-care and indifference may be seen.<br />
<br />
I: Recognize that each client is unique and will progress at own pace.<br />
R: Time frames vary widely. Cultural, religious, ethnic, individual differences impact on manner of grieving.<br />
<br />
I: Establish rapport with client and significant others. Listen and encourage pt significant others to verbalize feelings.<br />
R: This open lines of communication and facilitate successful resolution of grief.<br />
<br />
I: Accepted need to deny loss as part of normal grief process.<br />
R: Realization occurs weeks to months after loss. Reality continues to be over whelming sadness, anger, guilt, hostility may be seen.<br />
<br />
I: Be honest in answering questions, providing information.<br />
R: Enhances sense of trust and nurse-client relationship.<br />
<br />
I: Discuss issues, such as what is in the power of the individual to change and what is beyond control.<br />
R: Recognition of these factors helps client focus energy for maximal benefit/ outcome.<br />
<br />
Doenges, et al, 2002, Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-78112697128416323862010-09-06T16:32:00.001-07:002010-09-06T16:32:19.483-07:00Nursing Care Plan: Knowledge, deficient regarding condition, treatment program, self-care, and discharge needs related to lack of exposure and information, misinterpretation of information and unfamiliarity with information resources.<div style="text-align: justify;">Scientific Basis:<br />
<br />
A deficit in knowledge is commonly experienced by individuals coping with new medical diagnosis varied pharmacological and treatment regimens, unfamiliar and often complex problems, as well as by individuals entering stages or role relationships that demand new pattern of response.<br />
<br />
Some patients may have access to information or know where to seek it, others may have providers who are not teaching them or who cannot be understood. This lack of an open information, flowing relationship with provider often causes the client to misinterpret information or forget it because of the disuse/ lack of reinforcement for correct use.<br />
<br />
Because of the patient’s education is considered a skill reimbursed by Medicare & other commercial insurance carriers. It is important for the nurse to include knowledge deficit in the plan of care. The deficit in knowledge may relate to clients lack of information about their disease process, medication or resources <br />
<br />
Patients needs to be aware of the activities that reduce the risk, signs and symptoms of complications, and what to do when the condition manifest.<br />
<br />
Kozier, et al, 2007; Perry and Potter, 2002 <br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess motivation and willingness of client.<br />
R: Some clients are ready to learn soon after they are diagnosed<br />
<br />
I: Assess ability to learn or perform desired health-related care.<br />
R: Cognitive impairments need to be identified so an appropriate teaching plan can be designed.<br />
<br />
I: Identify any existing misconceptions regarding materials to be taught.<br />
R: This provides starting point in education.<br />
<br />
I: Determine cultural influences on health teaching.<br />
R: Providing a climate of acceptance allows clients to be themselves and to hold their own beliefs as appropriate.<br />
<br />
I: Determine client’s learning style especially if client had learned and retained new information in the past.<br />
R: Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method facilitates success in mastery of knowledge.<br />
<br />
I: Determine client’s baseline of knowledge regarding the disease process.<br />
R: Provides information regarding understanding of the patient’s knowledge.<br />
<br />
I: Review pathophysiology of condition and signs/symptoms of possible complications, e.g., gangrene and further amputation.<br />
R: Provides a knowledge base from which client can make<br />
informed choices and understand/identify healthcare needs.<br />
<br />
I: Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly. <br />
R: Promotes optimal learning environment when client show willingness to learn. Family members may assist with helping the client to make informed choices regarding the treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.<br />
<br />
I: Encourage questions.<br />
R: Learners often feel shy or embarrassed about asking questions and often wants permission to ask them.<br />
<br />
I: Provide an atmosphere of respect, openness, trust, collaboration, quiet without interruption.<br />
R: This is especially important when providing education to the clients with different values and beliefs about health and illness, and it allows more concentration to the topic being discussed.<br />
<br />
I: Explain purpose of activity restrictions and need for balance between activity/rest.<br />
R: Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.<br />
<br />
I: Establish appropriate exercise/activity program<br />
R: Aids in developing collateral circulation, enhances venous return, and prevents recurrence.<br />
I: Problem-solve solutions to predisposing factors that may be present, e.g., employment that requires prolonged standing/sitting, wearing restrictive clothing(girdles/garters),<br />
R: Actively involves patient in identifying and initiating lifestyle/ behavior changes to promote health and prevent recurrence of condition/development of complications.<br />
<br />
I: Recommend sitting with feet touching the floor, avoiding crossing of legs.<br />
R: Prevents excess pressure on the popliteal space.<br />
<br />
I: Stress importance of medical follow-up/laboratory testing.<br />
R: Understanding that close supervision of anticoagulant therapy is necessary (therapeutic dosage range is narrow and complications may be deadly) promotes client participation.<br />
<br />
I: Instruct in meticulous skin care of lower extremities, e.g.,<br />
prevent/promptly treat breaks in skin and report development of lesions/ulcers or changes in skin color.<br />
R: Chronic venous congestion/postphlebotic syndrome ma develop (especially in presence of severe vascular involvement and/or recurrent episodes), potentiating risk of stasis ulcers/infection.<br />
<br />
I: Focus teaching sessions on a single concept or idea.<br />
R: This allows the learner to concentrate more completely on material being discussed. Highly anxious and older clients have reduced short-term memory and benefit from mastery of one concept at a time.<br />
<br />
I: Document progress of teaching and learning.<br />
R: This allows additional teaching to be based on what the learner has completed, thus enhancing the learner’s self-efficacy and encouraging the most cost-effective teaching.<br />
<br />
Gulanick, 2007; Doenges, et. al, 2006; Kruse, et. al. 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-65238884640031377392010-09-06T16:31:00.001-07:002010-09-06T16:31:36.144-07:00Nursing Care Plan: Self-Esteem, situational low related to biophysical, psychosocial, cognitive, perceptual, cultural, and/or spiritual crisis, e.g., changes in health, status/body image, role performance, personal identity; loss of control of some aspect of life, maturational transitions, and perceived/anticipated failure at life event(s).<div style="text-align: justify;">Scientific Basis: <br />
<br />
Self-esteem is one’s judgment of one’s own worth, that is, how that person’s standards and performances compare to others and to one’s ideal self. As an adult, a person who has high self-esteem has feelings of significance, of competence, of the ability to cope with life, and of control over one’s destiny, stress related to prolonged illness can substantially lower a person’s self-esteem. In health care, persons who believe that their condition is viewed negatively by society may have lower self-esteem.<br />
<br />
Often client experience emotional crisis because of the physical effect of the disease. A client may have a grief of these perceived changes in the body image. The feelings of loss on the visibility of the loss, the function of the loss and the amount investment.<br />
<br />
The state in which an individual who previously had positive self-esteem, experiences negative feelings about self in response to an event (loss, change), continuation of these negative self-appraisals over time can lead to chronic low self-esteem.<br />
<br />
Moyet, 2006; Berman, et al, 2008; Ignatavicius and Workman, 2002<br />
<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Ask what client would like to be called.<br />
R: Shows courtesy/respect and acknowledges person.<br />
<br />
I: Identify SO from whom client derives comfort and who should be notified in case of emergency.<br />
R: Allows provisions to be made for specific person(s) to visit or remain close, and provides needed support for client. Note: May or may not be legal next of kin.<br />
<br />
I: Identify basic sense of self-esteem; image client has of existential, physical, psychological self. Identify locus of control.<br />
R: May provide insight into whether this is a single episode or recurrent/chronic situation and can help determine needs and treatment plan. It is helpful to know whether the individual’s locus of control is internal or external to provide most helpful interventions.<br />
<br />
I: Determine client’s perception of threat to self.<br />
R: client’s perception is more important than what is really happening and needs to be dealt with before reality can be addressed.<br />
<br />
I: Active-Listen client concerns and fears.<br />
R: Conveys sense of caring and can be helpful in identifying patient’s needs, problems, and coping strategies and how effective they are. Provides opportunity to duplicate and begin a problem-solving process.<br />
<br />
I: Assess degree to which patient feels loved and respect by others.<br />
R: The manner in which one treated by others influence self-esteem. Feeling loved and respected despite disabilities implies that one is valued by others support self-esteem.<br />
<br />
I: Encourage verbalization of feelings, accepting what is said.<br />
R: Helps client/SO begin to adapt to change, and reduces anxiety about altered function/lifestyle.<br />
<br />
I: Discuss stages of grief and the importance of grief work.<br />
R: Grieving is a necessary step for integration of change/loss into self-concept.<br />
<br />
I: Provide non threatening environment, listen and accept client as presented.<br />
R: Promotes feelings of safety, encouraging verbalization<br />
<br />
I: Observe nonverbal communication, e.g., body posture and movements, eye contact, gestures, use of touch. <br />
R: Nonverbal language is a large portion of communication and therefore is extremely important. How the person uses touch provides information about how it is accepted and how comfortable the individual is with being touched.<br />
<br />
I: Reflect back to client what has been said, e.g., “it upset you when he told you that.”<br />
R: Clarification and verification of what has been heard promotes understanding and allows client to validate information, otherwise assumptions may be inaccurate.<br />
<br />
I: Observe and describe behavior in objective terms.<br />
R: All behavior has meaning, some of which is obvious and some of which needs to be identified. This is a process of educated guesswork and requires validation by client.<br />
<br />
I: Identify age and developmental level.<br />
R: Age is an indicator of the stage of life patient is experiencing, e.g., adolescence, middle age. However, developmental level may be more important than chronological age in anticipating and identifying some of client’s needs. Some degree of regression occurs during illness, depending on many factors such as the normal coping skills of the individual, the severity of the illness, and family/cultural expectations.<br />
<br />
I: Discuss client’s view of body image and how illness/ condition might affect it.<br />
R: Client’s perception of a change in body image may occur suddenly or over time (e.g., actual loss of a body part through injury/surgery, or a perceived loss) or be a continuous subtle process (e.g., chronic illness or aging). Awareness can alert the nurse to the need for appropriate interventions tailored to the individual need.<br />
<br />
I: Encourage discussion of physical changes in a simple, direct, and factual manner. Give realistic feedback and discuss future options, e.g., rehabilitation services.<br />
R: Provides opportunity to begin incorporating actual changes in an accepting and hopeful atmosphere.<br />
<br />
I: Acknowledge efforts at problem solving, resolution of current situation, and future planning.<br />
R: Provides encouragement and reinforces continuation of desired behaviors.<br />
<br />
I: Recognize client’s pace for adaptation to demands of current situation.<br />
R: Failure to acknowledge client’s need to take time and/or pressuring client to “get on with it” conveys a lack of acceptance of the person as an individual and may result in feelings of lowered self-esteem.<br />
<br />
I: Introduce tasks at client’s level of functioning, progressing to more complex activities as tolerated.<br />
R: Provides opportunity for client to experience successes, reaffirming capabilities and enhancing self-esteem.<br />
<br />
I: Ascertain how client sees own role within the family system, e.g., breadwinner, homemaker, husband/father. <br />
R: Illness may create a temporary or permanent problem in role expectations. Sexual role and how client views self in relation to the current illness also play important parts in recovery.<br />
<br />
I: Assist client/SO with clarifying expected roles and those that may need to be relinquished or altered. <br />
R: Provides opportunity to identify misconceptions and begin to look at options; promotes reality orientation.<br />
<br />
I: Determine client awareness of own responsibility for dealing with situation, personal growth.<br />
R: Conveys confidence in client’s ability to cope. When client acknowledges own part in planning and carrying out treatment plan, he has more investment in following through on decisions that have been made.<br />
<br />
I: Assess impact of illness/surgery on sexuality. <br />
R: Sexuality encompasses the whole person in the total environment. Many times problems of illness are superimposed on already existing problems of sexuality and can affect client’s sense of self-worth. Some problems are more obvious than others, such as illness involving the reproductive parts of the body. Others are less obvious, such as sexual values, role in family, e.g., wage earner and parent.<br />
<br />
I: Be alert to comments and innuendos, which may mean client has a concern in the area of sexuality.<br />
R: People are often reluctant and/or embarrassed to ask direct questions about sexual/sexuality concerns.<br />
<br />
I: Be aware of caregiver’s feelings about dealing with the subject of sexuality.<br />
R: Nurses/caregivers are often as reluctant and embarrassed in dealing with sexuality issues as most clients. <br />
<br />
I: Provide information and referral to hospital and community resources.<br />
R: Enables client/SO to be in contact with interested groups with access to assistive and supportive devices, services, and counseling.<br />
<br />
I: Support participation in group/community activities, e.g., assertiveness classes, volunteer work, support groups. <br />
R: Promotes skills of coping and sense of self-worth.<br />
<br />
I: May refer to psychiatric support/therapy group, social services, as indicated. <br />
R: May be needed to assist client/SO to achieve optimal recovery.<br />
<br />
I: May refer to appropriate resources for sex therapy as need indicates.<br />
R: May be someone with comfort level and knowledge who is available, or may be necessary to refer to professional resources for additional help and support.<br />
<br />
Doenges, et al, 2008; Kruse, et al, 2003; Gulanick, 2007 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-79577643299865187742010-09-06T16:27:00.003-07:002010-09-06T16:27:44.811-07:00Nursing Care Plan: Spiritual distress related to physical/ psychological stress; energy-consuming anxiety, situation, loss(es)/intense suffering, separation from religious/cultural ties, and challenged belief and value system.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Spiritual distress is an experience of profound disharmony in the person’s belief or value system that threatens the meaning of his or her life. During spiritual distress the patient loses hope, questions his or her belief system, or feels separated from his or her personal source of comfort and strength. Pain, chronic or terminal illness, impending surgery, and the death or illness of loved ones are crises that may cause spiritual; distress. Being physically separated from family and family culture contributes to feeling alone and abandoned. Nurses in the hospital, home care, and ambulatory settings can assist the patient in reestablishing a sense of spiritual being.<br />
<br />
Spirituality refers to that of being human that seeks meaningfulness through intra-, inter-, and transpersonal connection. Spirituality generally involves a belief in a relationship with some power, creative force, divine being, or infinite source of energy.<br />
<br />
Spiritual distress refers to a change to the spiritual well-being or the belief system that provides strength, hope, and meaning to life. Some factors that may be associated with or contribute to person’s spiritual concerns. Physiologic problems, treatment related concerns, and situational concerns. Physiologic problems include having a medical diagnosis of a terminal of debilitating disease, experience pain, experiencing the loss of a body part or function. Treatment related factors include recommendation to dietary restriction, surgery, amputation of a body part. <br />
<br />
Carpenito-Moyet, 2006; Gulanick, 2007; Berman, et al, 2008<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Determine client’s religious/spiritual orientation, current involvement, and presence of conflicts.<br />
R: Provides baseline for planning care and accessing appropriate resources.<br />
<br />
I: Be aware of influence of caregiver’s belief system.<br />
R: It is still possible affect to be helpful to client while remaining neutral/ not espousing own beliefs.<br />
<br />
I: Establish environment that promotes free expression of feelings and concerns. Provide calm, peaceful setting when possible.<br />
R: Promotes awareness and identification of feelings so they can be dealt with.<br />
<br />
I: Listen to client/SO’s reports/expressions of anger, concern, alienation from God, belief that situation is a punishment for wrongdoing, and so forth.<br />
R: Helpful to understand client/SO’s point of view and how they are questioning their faith in the face of tragedy.<br />
<br />
I: Note sense of futility, feelings of hopelessness and helplessness, lack of motivation to help self.<br />
R: These thoughts and feelings can result in the client feeling paralyzed and unable to move forward to resolve the situation.<br />
<br />
I: Listen to expressions of inability to find meaning in life, reason for living. Evaluate for suicidal ideation.<br />
R: May indicate need for further intervention to prevent suicide attempt.<br />
<br />
I: Determine support systems available to client/SO(s).<br />
R: Presence or lack of support systems can affect client’s recovery.<br />
<br />
I: Ask how you can be most helpful. Convey acceptance of client’s spiritual beliefs/concerns.<br />
R: Promotes trust and comfort, encouraging client to be open about sensitive matters.<br />
<br />
I: Make time for nonjudgmental discussion of philosophic issues/questions about spiritual impact of current events/situation.<br />
R: Helps client to begin to look at basis for spiritual confusion. Note: There is a potential for care provider’s belief system to interfere with client finding own way. Therefore it is most beneficial to remain neutral and not espouse own beliefs.<br />
<br />
I: Discuss difference between grief and guilt and help client to identify and deal with each, assuming responsibility for own actions, expressing awareness of the consequences of acting out of false guilt.<br />
R: Blaming self for what has happened impedes dealing with the grief process and needs to be discussed and dealt with.<br />
<br />
I: Use therapeutic communication skills of reflection and Active-Listening.<br />
R: Helps client find own solutions to concerns.<br />
I: Discuss use of/provide opportunities for client/SO to experience meditation, prayer and forgiveness. Provide information that anger with God is a normal part of the grieving process. <br />
R: Can help to heal past and present pain.<br />
<br />
I: Assist client to develop goals for dealing with life situation.<br />
R: Enhances commitment to goal, optimizing outcomes and promoting sense of hope.<br />
<br />
I: Develop therapeutic nurse-client relationship. Ask how you can be most helpful. Convey acceptance of client’s spiritual beliefs/ concerns.<br />
R: Promotes trust and comfort, encouraging client to be open about sensitive matters.<br />
<br />
I: Help client find a reason for living.<br />
R: Promotes sense of hope and willingness to continue efforts to improve situation.<br />
<br />
I: Identify and may refer to resources that can be helpful (e.g., pastoral/parish nurse or religious counselor, crisis counselor, psychotherapy)<br />
R: Specific assistance may be helpful to recovery, (e.g., relationship problems, suicidal ideation).<br />
<br />
I: Encourage participation in support groups if possible.<br />
R: Discussing concerns and questions with others can help client resolve feelings.<br />
<br />
Doenges, et al, 2002; Gulanick, 2007 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-14524381360439840212010-09-06T16:27:00.001-07:002010-09-06T16:27:22.083-07:00Nursing Care Plan: Activity Intolerance related to generalized weakness, sedentary lifestyle, insufficient sleep or rest periods and pain.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in older patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity.<br />
<br />
Activity may also related to factors such as obesity, malnourishment, anemia, side of effects of medication, or are to reduce as depression or lack of confidence to exert oneself. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity. And assist the client to maintain a satisfactory quality of life.<br />
<br />
Gulanick, 2007<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Monitor vital signs before and immediately after activity.<br />
R: Vital signs should return to baseline levels in 3 minutes. The development of dyspnea may indicate a need for an alteration in exercise regimen or medication.<br />
<br />
I: Identify causative factors leading to intolerance of activity.<br />
R: To plan for appropriate intervention.<br />
<br />
I: Determine the client’s perception of cause of fatigue or activity intolerance.<br />
R: These may be temporary or permanent, physical, psychological.<br />
<br />
I: Asses the client’s level of mobility.<br />
R: This aids in defining what the client is capable of, which is necessary before setting realistic goals.<br />
<br />
I: Assess nutritional status.<br />
R: Adequate energy reserves are required for activity.<br />
<br />
I: Assess potential for physical injury with activity. Including safety of the immediate environment.<br />
R: Injury may be related to falls, or overexertion. Obstacles such as throw rugs, toys etc which can impede one’s ability to ambulate safely.<br />
<br />
I: Assess the need for ambulation aids: cane or equipment modification for activities of daily living (ADLs).<br />
R: Some aids may require more energy expenditure for clients who have reduced upper arm strength. Adequate assessment of energy requirements is indicated.<br />
<br />
I: Assess vital signs such as the heart rate.<br />
R: Heart rate should not increase more than 20 to 30 beats/minute above resting with routine activities. This number will change depending on the intensity of exercise the client is attempting.<br />
<br />
I: Check for orthostatic blood pressure.<br />
R: Older clients are more susceptible to drops in blood pressure with position change.<br />
<br />
I: Monitor the client’s sleep patter and amount of sleep achieved over the past few days.<br />
R: Difficulties sleeping need to be addressed before activities progression can be achieved.<br />
<br />
I: Assess emotional response to change in physical status.<br />
R: Depression resulting from the inability to perform required activities can further aggravate activity intolerance.<br />
<br />
I: Establish guidelines and goals of activity with the clients and caregiver.<br />
R: Motivation is enhanced if the client participates in goal setting. Depending on the etiological factors of activity intolerance, some clients may be able to live independently and work outside the home. Other clients with chronic debilitating disease may remain.<br />
<br />
I: Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation.<br />
R: Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period.<br />
<br />
I: Refrain from performing nonessential procedures.<br />
R: Clients with limited activity tolerance need to prioritize tasks.<br />
<br />
I: Anticipate the client’s need.<br />
R: This reduces risk for falling while reaching.<br />
<br />
I: Assist with ADLs as indicated: however, avoid doing for client what they can do for themselves.<br />
R: Assisting the client with ADLs allows for conservation of energy/ caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the client’s activity tolerance and self-esteem.<br />
<br />
I: Encourage physical activity consistent with client’s energy resources.<br />
R: This promotes a sense of autonomy while being realistic about capabilities.<br />
<br />
I: Assist client to plan with activities for times when they have most energy.<br />
R: This promotes a sense of autonomy while being realistic about capabilities.<br />
<br />
I: Encourage verbalization of feelings regarding limitations.<br />
R: Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping.<br />
<br />
I: Encourage active ROM exercises. If further reconditioning is needed, confer with rehabilitation personnel.<br />
R: Exercise maintains muscle strength.<br />
<br />
I: Provide emotional support while increasing activity. Promote positive attitude regarding abilities<br />
R: Clients may be fearful of overexertion. Appropriate supervision during early efforts can enhance confidence.<br />
<br />
I: Encourage the client to choose activities gradually build endurance.<br />
R: Physically inactive clients need to improve functional capacity through repetitive exercises over a longer period of time. Strength training is valuable in enhancing endurance for many ADLs.<br />
<br />
I: May provide the client with the adaptive equipment needed for completing ADL activities.<br />
R: Appropriate aids will enable the client to achieve optimal independence for self-care.<br />
<br />
I: Teach the client and caregivers to recognize signs of physical over activity.<br />
R: This promotes awareness of when to reduce activity.<br />
<br />
I: Involve client and caregivers in goal setting and care planning.<br />
R: Setting, attainable goals can increase self-confidence and self-esteem.<br />
<br />
I: Assist in assigning priority to activities to accommodate energy levels.<br />
R: With a reduced functional capacity, pacing of priority tasks first may be better meet the client’s needs.<br />
<br />
I: Teach ROM and strengthening exercises.<br />
R: Exercise promotes increased venous return, prevents contractures, and maintain / increases muscle strength.<br />
<br />
I: Encourage client to verbalize concerns about discharge and home environment.<br />
R: This can reduce feelings of anxiety and fear and open doors for ongoing communication.<br />
<br />
I: Teach conservation techniques, such as the following:<br />
R: These reduces oxygen consumption, allowing more prolonged activities.<br />
<br />
I: Sitting to do the task.<br />
R: Standing requires more work.<br />
<br />
I: Change position often.<br />
R: This distributes work to different muscles to avoid fatigue.<br />
<br />
I: Pushing rather than pulling.<br />
R: This reduces metabolic work.<br />
<br />
I: Sliding rather than lifting.<br />
R: This reduces upper body work.<br />
<br />
I: Working at an even pace.<br />
R: This allows enough time so not all work is completed in a short period.<br />
<br />
I: Placing frequently used items within easy reach. <br />
R: This avoids bending and reaching.<br />
<br />
I: Resting at least 1 hour after meals before starting a new activity.<br />
R: Energy is needed to digest food.<br />
<br />
I: Organizing a work-rest-work schedule.<br />
R: This reduces strain on energy resources.<br />
<br />
Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003</div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-22707492805269593532010-09-06T16:26:00.003-07:002010-09-06T16:26:54.143-07:00Nursing Care Plan: Acute pain related to diminished arterial circulation and oxygenation of tissues with production/ accumulation of lactic acid in tissues, and inflammatory process.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Buerger’s disease is an inflammatory of small and medium arteries and veins that leads to vascular obstruction. At first, pain in the palm of the hand and arch of the foot is the main symptoms. Pain becomes more severe with disease progressions, and as ischemia affects the nerves, the client may experience numbness, burning pain when at rest, and decreased sensation in the hands and lower extremities.<br />
<br />
Pain is highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by sufferer.<br />
<br />
Gulanick, 2007; White, 2002<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess degree and characteristics of discomfort/pain. Note guarding of extremity. Palpate leg with caution.<br />
R: Degree of pain is directly related to extent of circulatory deficit, inflammatory process, degree of tissue ischemia, and extent of edema associated with thrombus development. Changes in characteristics of pain may indicate progression of problem/development of complications.<br />
<br />
I: Assess for referred pain as appropriate.<br />
R: To help determine possibility of underlying condition or organ dysfunction requiring treatment.<br />
<br />
I: Maintain bed rest during acute phase<br />
R: Reduces discomfort associated with muscle contraction and movement.<br />
<br />
I: Anticipate need for pain relief.<br />
R: One can most effectively deal with pain by preventing it. Early detection and intervention may decrease the total amount of analgesic required.<br />
<br />
I: Monitory severity of pain rating scale. Note location, quality and associated manifestation of skin, aggregation factors that increase pain and factors that alleviate the pain.<br />
R: The single most reliable indicator of the existence of pain is the client’s self report.<br />
<br />
I: Elevate affected extremity.<br />
R: Encourages venous return to facilitate circulation, reducing stasis/edema formation.<br />
<br />
I: Encourage client to change position frequently<br />
R: Decreases/prevents muscle fatigue, helps minimize muscle spasm, maximize circulation to tissues.<br />
<br />
I: Monitor vital signs, noting elevated temperature.<br />
R: Elevations in heart rate may indicate increased pain/discomfort or occur in response to fever and inflammatory process. Fever can also increase client’s discomfort.<br />
<br />
I: Provide rest periods to facilitate comfort, sleep, and relaxation.<br />
R: The client’s experiences of pain may become exaggerated as the result of fatigue.<br />
<br />
I: Help the client use non-pharmacological methods to control pain such as listening to music, watching TV and therapeutic massage.<br />
R: Cognitive and behavioral strategies can restore client’s sense of control, personal efficiency and active participation in care, and by using mental picture distract oneself from painful stimuli, and heightens one’s concentration upon non-painful stimuli to decrease awareness and experience of pain.<br />
<br />
I: Plan care activities around periods of greatest comfort whenever possible.<br />
R: Pain diminishes activity or participation.<br />
<br />
I: Note non-verbal cues e.g. restlessness, reluctance to move, tachycardia, diaphoresis etc. <br />
R: Non-verbal cues maybe both physiological and psychological and maybe used in conjunction with verbal cues to identify extent of severity of the problem.<br />
<br />
Gulanick, 2007; Doenges, et al, 2006; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-13040913619972170592010-09-06T16:26:00.001-07:002010-09-06T16:26:30.717-07:00Nursing Care Plan: Fatigue related to decreased oxygen supply, inadequate tissue oxygenation, sleep deprivation, poor physical condition.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Fatigue is a subjective complaint with both acute and chronic illnesses. In acute illness, fatigue may have a protective function that keeps the persons from sustaining injury from overwork in a weakened condition. As a common symptom, fatigue is associated with a variety of physical and psychological conditions. The patient with a chronic illness experiencing fatigue may be unable to work full-time and maintain acceptance performance on the job. The economic impact on the individual and the family can be significant. The social effects of fatigue occur as the person decreases his participation in social activities.<br />
<br />
Feelings of discomfort will enable the tissue to respond to the stimulation that normally cause the muscle to constrict and fatigue is felt to restore energy. Inadequate nutrition intake, abnormal fluid and electrolyte status, and metabolic demands may all contribute to this problem. <br />
<br />
One of the ways on how body compensates for tissue hypoxia is to increase cardiac output with achieved by increase HR and increase stroke volume to meet oxygen demands of the tissues. Hence, increase cardiac workload, increases body activity causing fatigue. <br />
<br />
Monahan, 2007; Neal, et al, 2004; Black and Hawks, 2005; Gulanick, 2007<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Monitor physiological response to activity like changes in blood pressure (BP) heart rate (HR), or respiratory rate (RR)<br />
R: Tolerance varies greatly, depending on the stage of their disease process, nutritional state and fluid balance.<br />
<br />
I: Assess the client’s emotional response to fatigue, sleep patterns and other factors that may be aggravating fatigue<br />
R: Recognition of the onset of fatigue assists the patient to maximize the benefits of resting periods.<br />
<br />
I: Assess nutritional intake of calories, protein, minerals, and vitamins.<br />
R: Fatigue may be a symptom of protein-calorie malnutrition, vitamin deficiencies, or iron deficiencies.<br />
<br />
I: Assess the client’s ability to perform activities of daily living (ADL).<br />
R: Fatigue can limit the person’s ability to participate in self-care and perform his role responsibilities in the family or society.<br />
<br />
I: Established realistic activity goals with the patient. <br />
R: Provides a sense of control and feelings of accomplishment.<br />
<br />
I: Assist with sitting up, or ambulation; keep bed in low position and clear pathways of furniture.<br />
R: Frequent rest periods are needed to restore/ conserve energy. Planning allows client to be active during times when energy level is higher, which may restore a feeling of well-being and a sense of control.<br />
<br />
I: Encourage client to do whatever is possible like self-care, sitting up on bed/chair, walking. Increase activity level as indicated.<br />
R: Increase strength/ stamina and enables client to become more active without undue fatigue.<br />
<br />
I: Provide passive/ active ROM exercises to client.<br />
R: Development of healthy lean muscle mass depends on provision of isotonic and isometric exercises. <br />
<br />
I: Assist with self-care needs as necessary.<br />
R: Generalized weakness may make ADLs almost impossible for client to complete.<br />
<br />
I: Identify energy conservation techniques, e.g., sitting, breaking ADLs into manageable segments. Keep travel ways clear of furniture. Provide and assist with ambulation/self-care needs. <br />
R: Weakness may make ADLs almost impossible for client to complete. Protects client from injury during activities.<br />
<br />
I: Limit client’s scheduled activities and provided frequent rest periods and provides conducive environment for adequate sleep and rest, plan nursing care in segments with adequate time for undisturbed rest and instructed client on relaxation techniques (deep breathing).<br />
R: Good relaxation skills assist the client to maximize the benefits of resting periods<br />
<br />
I: Plan and provided rest periods between activities.<br />
R: To provide adequate rest and reduce unnecessary energy expenditure.<br />
<br />
I: Instruct in stress management techniques, e.g., breathing exercises, visualization, music and light therapy.<br />
R: Reduction of stress factors in patient’s life can minimize energy output.<br />
<br />
I: Establish realistic activity goals with the client.<br />
R: Enhances commitment to promoting optimal outcomes.<br />
<br />
I: Provide environment conducive to relief of fatigue.<br />
R: Temperature and level of humidity are known to affect exhaustion.<br />
<br />
I: Teach the client and family task organization techniques and time management.<br />
R: Organization and time management can help the client conserve energy and prevalent fatigue.<br />
<br />
I: Encourage the client and family to verbalize feelings about the impact of fatigue.<br />
R: Fatigue can have a profound negative influence on family processes and social interaction.<br />
<br />
Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com1tag:blogger.com,1999:blog-3444078156201078386.post-24043828828690493542010-09-06T16:19:00.002-07:002010-09-06T16:19:34.757-07:00Nursing Care Plan: Risk for fluid volume deficit related to inadequate fluid intake, active fluid loss (perspiration), and old age.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital out patient center, or home setting. <br />
<br />
The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment paramount to prevent potentially life-threatening hypovolemic shock. Older clients are more like to develop fluid imbalances.<br />
<br />
Gulanick, 2007<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Obtain client’s history to ascertain the probable cause of the fluid disturbance.<br />
R: This can help guide interventions. Causes may include acute trauma and bleeding, reduced fluid intake from changes in cognition.<br />
<br />
I: Assess or instruct the client to monitor weight daily and consistently, with the same scale and preferably at the same time of day.<br />
R: This facilitates accurate measurement and follows trends.<br />
<br />
I: Evaluate fluid status in relation to dietary intake. Determine whether the client on fluid restriction.<br />
R: Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods.<br />
<br />
I: Measure and record intake and output.<br />
R: Accurate documentation helps identify fluid losses/replacement needs and influences choice of interventions. Note: Ability to concentrate urine declines with age, increasing renal losses despite general fluid deficit.<br />
<br />
I: Monitor vital signs noting changes in blood pressure, heart rate and rhythm, and respirations. Calculate pulse<br />
pressure.<br />
R: Hypotension, tachycardia, increased respirations may indicate fluid deficit, e.g., dehydration/hypovolemia. Although a drop in blood pressure is generally a late sign of fluid deficit (hemorrhagic loss), widening of the pulse pressure may occur early, followed by narrowing as bleeding continues and systolic BP begins to fall.<br />
<br />
I: Monitor skin temperature, palpate peripheral pulses.<br />
R: Cool/clammy skin, weak pulses indicate decreased peripheral circulation and need for additional fluid replacement.<br />
<br />
I: Monitor blood pressure for orthostatic changes (from lying supine to high-Fowler’s).<br />
R: Postural hypotension is a common manifestation in fluid loss. Note the following orthostatic hypotension significance: (Greater than 10 mmHg drop: circulating blood volume is decreased by 20%. ; Greater than 20 to 30 mmHg drop: circulating blood volume is decreased by 40%.) <br />
<br />
I: Assess skin turgor and mucous membrane for signs of dehydration.<br />
R: The skin in older clients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.<br />
<br />
I: May serum electrolytes and urine osmolality, and report abnormal values.<br />
R: Elevated hemoglobin and elevated blood urea nitrogen suggest fluid deficit. Urine specific gravity is likewise increased.<br />
<br />
I: Monitor mental status changes.<br />
R: Dehydration may alter mental status, especially among older adults. Manifestations may include restlessness, anxiety, lethargy, and confusion.<br />
<br />
I: Determine the client’s fluid preferences: type, temperature (cold or hot).<br />
R: Selecting those fluids that the client enjoys drinking cam facilitate replacement therapy.<br />
<br />
I: Encourage the client to drink prescribed fluid amounts.<br />
R: Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older clients have a decreased sense of thirst and may need ongoing reminders to drink.<br />
<br />
I: Plan daily activities.<br />
R: Planning prevents client from being too tired at mealtimes.<br />
<br />
I: Provide oral hygiene.<br />
R: Attention to mouth care promotes interest for drinking.<br />
<br />
I: Describe or teach causes of fluid losses or decreased fluid intake.<br />
R: Information is key to managing the problem.<br />
<br />
I: Explain or reinforce rationale and intended effect of treatment program. Information the client or caregiver of importance of maintaining prescribed fluid intake and special diet.<br />
R: Follow-up care will be the client’s and/or caregiver’s responsibility. Information is needed for making correct choices.<br />
<br />
I: Teach interventions to prevent future episodes of inadequate intake.<br />
R: Client’s need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.<br />
<br />
Gulanick, 2007; Kruse, et al, 2003 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-42548039204609073152010-09-06T16:19:00.000-07:002010-09-06T16:19:09.874-07:00Nursing Care Plan: Risk for imbalanced temperature related to age, inappropriate clothing and dugs.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Risk for altered body temperature exist for all persons, but some situation and individual physical capacities places risk on certain individuals. Older patients are physically incapable of compensating for environmental exposures and are greater risk in life-threatening events. <br />
<br />
The older adult has difficulty responding to changes in environmental temperature because of slowed circulation, decreased heat-generating activities, change in skin function. Healthy persons, such as the athlete who is performing under extremely hot conditions, are also at risk. Prevention is accomplished by providing education specific to individual needs.<br />
<br />
Gulanick, 2007<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess for presence of risk factors such as infection.<br />
R: The immune response is fever. The hypothalamus “set point” is higher during fever. The heat regulation mechanism controls heat production and conservation to maintain body core temperature at a higher level.<br />
<br />
I: Monitor heart and respiratory rate.<br />
R: This may be increased or decreased.<br />
<br />
I: Monitor fluid balance.<br />
R: Dehydration may precipitate decrease in the temperature.<br />
<br />
I: Check blood pressure.<br />
R: This may be increased or decreased.<br />
<br />
I: Check skin condition.<br />
R: Skin may change in color and temperature.<br />
<br />
I: Check mental status.<br />
R: Changes occur with increase or decrease in the core temperature.<br />
I: Measure temperature at frequent intervals. Use the same instrument and method at each intervals,<br />
R: A change of this type usually causes a variance in the .temperature obtained.<br />
<br />
I: Provide or instruct SO in the following preventive measure (control environment).<br />
R: Older clients or persons need a warmer environment.<br />
<br />
I: Provide appropriate clothing or covering.<br />
R: Buerger’s disease client needs to avoid exposure of hands and feet to extreme cold.<br />
<br />
I: Provide adequate fluid and dietary intake.<br />
R: Dehydration contributes to development of hyperthermia.<br />
<br />
I: Explain preventions of risk factors and consequences of development of temperature alterations.<br />
R: Clients can implement appropriate environmental temperature controls when they understand the risks associated with changes in body temperature.<br />
<br />
I: Ensure the client can read the thermometer being used.<br />
R: Older persons may have difficulty visualizing a mercury thermometer.<br />
<br />
Gulanick, 2007; Kruse, et al, 2003; Doenges, et al, 2008 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0tag:blogger.com,1999:blog-3444078156201078386.post-9654127298615646352010-09-06T16:17:00.001-07:002010-09-06T16:17:46.801-07:00Nursing Care Plan: Sleep pattern disturbance: frequent awakenings and difficulty falling asleep related to generalized weakness, environmental discomfort, and pain/discomfort.<div style="text-align: justify;">Scientific Basis: <br />
<br />
Sleep is required to provide energy for physical and mental activities. The sleep-wake cycle is complex, consisting of different stages of consciousness: rapid eye movement (REM) sleep, non-REM sleep, and wakefulness. As persons age, the amount of time spent in REM diminishes. The amount of sleep that individuals require varies with age and personal characteristics. In general, the demands for sleep and wakefulness may be temporary or chronic. Such disruption may result in both subjective distress and apparent impairment in function abilities. <br />
<br />
Adequate rest is extremely important but may be difficult to obtain because of distressing symptoms charge in health status interfere with the patient’s normal sleep awake pattern. Discomfort also contributes in sleep. Any conditions that result in discomfort have the potential to disrupt sleep.<br />
<br />
Changes in environment health and routine combined with hospital routines interferes with patient normal sleep-wake pattern. Weakness and discomfort can continue to disrupt sleep. Other factors that contribute to sleep fragmentation include stimuli that tend to awaken people in the middle of the night. Internal stimuli such as discomfort are frequent disturbances. Any illnesses that cause physical discomfort can result in sleep problems.<br />
<br />
Adequate rest is extremely important but may be difficult to obtain because if distressing symptoms/ change in health status interfere with the patient’s sleep-awake pattern. Any condition that may result in discomfort, injury and environmental factors has potential to disrupt sleep.<br />
<br />
Lippincott Williams & Wilkins., 2002; Gulanick, 2007; Kozier, et al, 2007; Black, J & Hawks, J, 2005<br />
<br />
<br />
Intervention and Rationale<br />
<br />
I: Assess past pattern of sleep nature.<br />
R: Different individuals has different pattern of sleeping.<br />
<br />
I: Assess possible cause of sleep disturbance.<br />
R: For planning of appropriate intervention.<br />
<br />
I: Assess pain-PQRST.<br />
R: An accurate assessment of the client’s pain is necessary for appropriate and effective intervention.<br />
<br />
I: Ascertain usual sleep pattern and changes that are occurring, naps, awakenings and frequency and client’s complaints of lack of rest.<br />
R: Provides information to alleviate sleep deprivation in relation to age-related changes and to identify and establish plan of care.<br />
<br />
I: Provide calm and quite environment.<br />
R: Helps to promote conducive atmosphere for restful sleep.<br />
<br />
I: Establish a regular bedtime and wake up time for all days. Eliminate lengthy naps.<br />
R: To prevent destruction of biologic rhythm.<br />
<br />
I: Ensure appropriate temperature and ventilation.<br />
R: To keep environment conducive for sleep.<br />
<br />
I: Schedule and plan activities.<br />
R: Enhance client participation and promotes relaxation.<br />
<br />
I: Instruct client/SO to avoid caffeinated drinks like cola and coffee.<br />
R: May irritate the bladder which can cause diuresis over stimulation prevents client from falling asleep, delays client falling asleep and shortens the REM part of sleep.<br />
<br />
I: Suggest engaging in relaxing activity before retiring such as: warm bath, calm music, reading books and relaxation exercise.<br />
R: Relaxation techniques frequently help promote sleep.<br />
<br />
I: Instruct to avoid large amount of fluid intake before bedtime.<br />
R: For clients may need to void during night time.<br />
<br />
I: Instruct to avoid strenuous activity before bedtime, end the day peacefully by avoiding exciting TV programs and arguments.<br />
R: To reduce stress and promote sleep.<br />
<br />
I: Limit visit hours for 1-2 hours only per day between 9-12 am or 2-4 pm.<br />
R: To promote adequate rest.<br />
<br />
I: Provide warm drinks, extra cover prior to bedtime.<br />
R: Ritualistic procedures may prevent breaks in established routines and promote comfort and relaxation prior to sleep.<br />
I: Discourage the consumption of alcohol.<br />
R: Alcohol interrupts will the sleep with the client, and it decreases the REM of sleep.<br />
<br />
I: May provide a dark environment prior to sleep.<br />
R: Serotonin plays an important role during sleeping, serotonin increase in a dark environment.<br />
<br />
I: Final meal should be light and 3-4 hours before sleeping.<br />
R: An overload digestive system prevents peaceful sleep.<br />
<br />
I: Encourage participation in regular exercise program during the day.<br />
R: To aid in stress control/release of energy. Exercise at bed time may stimulate rather than relax patient and actually interfere with sleep.<br />
<br />
Gulanick, 2007; Comer, 2003; Doenges, et al, 2002 </div>neil philippihttp://www.blogger.com/profile/15415770436086097019noreply@blogger.com0