Nursing Care Plan for Pancreatitis

Nursing diagnosis: risk for deficient Fluid Volume/Bleeding

Risk factors may include
Excessive losses—vomiting, gastric suctioning
Increase in size of vascular bed (vasodilation effects of kinins)
Third-space fluid transudation, ascites formation
Alteration of clotting process, hemorrhage

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain adequate hydration as evidenced by stable vital signs, good skin turgor, prompt capillary refill, strong peripheral pulses, and individually appropriate urinary output.

Nursing intervention with rationale:
1. Auscultate heart sounds; note rate and rhythm. Monitor and document rhythm and changes.
Rationale: Cardiac changes and dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypokalemia and hypocalcemia. Hyperkalemia may occur related to tissue necrosis, acidosis, and renal insufficiency and may precipitate lethal dysrhythmias if uncorrected. Note: Cardiovascular complications are common in severe pancreatitis and include myocardial infarction (MI), pericarditis, and pericardial effusion with or without tamponade.

2. Monitor blood pressure (BP), noting trends. Measure central venous pressure (CVP), if available.
Rationale: Fluid sequestration with shifts into third space, bleeding, and release of vasodilators (kinins) and cardiac depressant factor triggered by pancreatic ischemia may result in profound hypotension. Reduced cardiac output and poor organ perfusion can precipitate widespread systemic complications. Systemic infection (septic shock) is also possible, exacerbating hypovolemic status.

3. Investigate changes in sensorium: confusion and slowed responses.
Rationale: Changes may be related to hypovolemia, hypoxia, electrolyte imbalance, or impending delirium tremens (in client with acute pancreatitis secondary to excessive alcohol intake). Severe pancreatic disease may cause toxic psychosis.

4. Measure intake and output (I&O), including vomiting or gastric aspirate, and diarrhea. Calculate 24-hour fluid balance.
Rationale: Indicators of replacement needs and effectiveness of therapy.

5. Note decrease in urine output (less than 400 mL/24 hours).
Rationale: Oliguria may occur, signaling renal impairment or acute tubular necrosis (ATN), related to increase in renal vascular resistance or altered renal blood flow.

6. Record color and character of gastric drainage, measure pH, and note presence of occult blood.
Rationale: Risk of gastric hemorrhage is high.

7. Weigh, as indicated; correlate with calculated fluid balance.
Rationale: Weight loss may suggest hypovolemia; however, edema, fluid retention, and ascites may be reflected by increased or stable weight, even in the presence of muscle wasting.

8. Note poor skin turgor, dry skin and mucous membranes, or reports of thirst.
Rationale: Further physiological indicators of dehydration.

9. Observe and record peripheral and dependent edema. Measure abdominal girth if ascites present.
Rationale: Edema and fluid shifts occur as a result of increased vascular permeability, sodium retention, and decreased colloid osmotic pressure in the intravascular compartment.

10. Inspect skin for petechiae, hematomas, and unusual wound or venipuncture bleeding. Note hematuria, mucous membrane bleeding, and bloody gastric contents.
Rationale: Disseminated intravascular coagulation (DIC) may be initiated by release of active pancreatic proteases into the circulation. The most frequently affected organs are the kidneys, skin, and lungs.

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Nursing Care Plan for Dementia

Nursing diagnosis: risk for Injury/Trauma

Risk factors may include
Inability to recognize or identify danger in environment, impaired judgment
Disorientation, confusion, agitation, irritability, excitability
Weakness, muscular incoordination, balancing difficulties, disturbed perception (e.g., missing chairs, steps)
Seizure activity

Possibly evidenced by:
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Family/Caregiver(s) Will
Safe Home Environment
Recognize potential risks in the environment.
Identify and implement steps to correct or compensate for individual factors.

Client Will
Physical Injury Severity
Be free of injury.

Nursing intervention with rationale:
1. Assess degree of impairment in ability and competence and presence of impulsive behavior.
Rationale: Identifies potential risks in the environment and heightens awareness of risks so caregivers are more alert to dangers. Clients demonstrating impulsive behavior are at increased risk of injury because they are less able to control their own behavior/actions.

2. Assist caregiver to identify any risks or potential hazards and visual-perceptual deficits that may be present.
Rationale: Visual-perceptual deficits increase the risk of falls.

3. Eliminate or minimize identified hazards in the environment.
Rationale: A person with cognitive impairment and perceptual disturbances is prone to accidental injury because of the inability to take responsibility for basic safety needs or to evaluate the unforeseen consequences, such as lighting a stove or cigarette and forgetting about it, mistaking plastic fruit for the real thing and eating it, or misjudging distance involving chairs and stairs. Preventive measures can contain client without constant supervision. Activities promote involvement and keep client occupied.

4. Lock outside doors as appropriate, especially in evening and night. Do not allow access to stairwell or exit. Provide supervision and activities for client who is regularly awake during the night. Recommend use of “child-proof locks”; secure such items as medications, cleaning products, poisonous substances, tools, and sharp objects. Remove stove knobs and burners.
Rationale: As the disease worsens, the client may compusively handle or fidget with objects, including locks, or put small items in mouth, which potentiates possibility of accidental injury and death.

5. Monitor behavior routinely, note timing of behavioral changes, increasing confusion, and hyperactivity. Initiate least restrictive interventions before behavior escalates.
Rationale: Early identification of negative behaviors with appropriate action can prevent need for more stringent measures. Note: Sundowner’s syndrome develops in late afternoon or early evening, requiring programmed interventions and closer monitoring at this time to redirect and protect client.

6. Distract or redirect client’s attention when behavior is agitated or dangerous, for example climbing out of bed. Place bed in low position and mattress on floor, as indicated.
Rationale: Maintains safety while avoiding a confrontation that could escalate behavior or increase risk of injury.

7. Obtain and have client wear identification jewelry, such as bracelet or necklace showing name, phone number, and diagnosis.
Rationale: Facilitates safe return of client if lost. Because of poor verbal ability and confusion, these persons may be unable to state name, address, and phone number. Client may wander, exhibit poor judgment, and be detained by police, appearing confused, irritable, or having violent outbursts.

8. Dress according to physical environment and individual need.
Rationale: The general slowing of metabolic processes results in lowered body heat. The hypothalamic gland may be affected by the disease process or by aging, causing client to feel cold. Client may have seasonal disorientation and may wander out in the cold. Note: Leading causes of death in these clients include pneumonia and accidents.

9. Monitor for medication side effects and signs of overmedication— extrapyramidal signs, orthostatic hypotension, visual disturbances, and gastrointestinal (GI) upsets.
Rationale: Client may not be able to report signs or symptoms, and drugs can easily build up to toxic levels in the elderly. Dosages or drug choice may need to be altered.

10. Administer medications as appropriate, such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), or ziprasidone (Geodon).
Rationale: Some antipsychotics are favored to control agitation, aggression, halluncinations, thought disturbances, and wandering because of their lessened propensity to cause anticholinergic and extrapyramidal side effects. May help moderate “sundowning” behaviors. Note: Condition may be related to deterioration of the suprachiasmatic nucleus of the hypothalamus which controls the sleep–wake cycle.

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Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Ultrafiltration
Fluid restrictions, actual blood loss—systemic heparinization or disconnection of the shunt

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membranes, absence of bleeding, and appropriate weight.

Nursing intervention with rationale:
1. Measure all sources of intake and output (I&O). Have client keep diary.
Rationale: Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis clients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.

2. Weigh daily as well as before and after dialysis run.
Rationale: Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal. Dry weight determines how much excess fluid has been removed and serves as a guide for subsequent dialysis run time and solution.

3. Monitor BP, pulse, and hemodynamic pressures, if available, during dialysis.
Rationale: Hypotension, tachycardia, and falling hemodynamic pressures suggest volume depletion.

4. Ascertain whether diuretics and antihypertensives are to be withheld.
Rationale: Dialysis potentiates hypotensive effects if these drugs have been administered.

5. Verify continuity of shunt or access catheter.
Rationale: Disconnected shunt or open access permits exsanguination.

6. Apply external shunt dressing. Permit no puncture of shunt.
Rationale: Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.

7. Place client in a supine or Trendelenburg position, as necessary.
Rationale: Maximizes venous return if hypotension occurs.

8. Assess for oozing or frank bleeding at access site, mucous membranes, or incisions and wounds. Hematest stools or any drainage.
Rationale: Systemic heparinization during dialysis prolongs clotting times and places client at risk for bleeding, especially during the first 4 hours after procedure.

9. Monitor laboratory studies, as indicated, such as the following: Hemoglobin/hematocrit (Hgb/Hct)
Rationale: May be reduced because of anemia, hemodilution, or actual blood loss.

10. Reduce rate of ultrafiltration during dialysis, as indicated.
Rationale: Reduces the amount of water being removed and may correct hypotension or hypovolemia.

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Nursing Care Plan for Urinary Diversion

Nursing diagnosis: risk for infection

Risk factors may include
Inadequate primary defenses—break in skin or incision, reflux of urine into urinary tract

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Knowledge: Infection Control
Verbalize understanding of individual causative or risk factors.
Demonstrate techniques or lifestyle changes to reduce risk.

Nursing intervention with rationale:
1. Empty ostomy pouch when it becomes one-third full, once continuous pouch drainage is discontinued.
Rationale: Reduces risk of urinary reflux and maintains integrity of appliance seal if pouch does not have an antireflux valve.

2. Document urine characteristics and note whether changes are associated with reports of flank pain.
Rationale: Cloudy, odorous urine indicates infection, possibly pyelonephritis; however, urine normally contains mucus after a conduit procedure because of normal secretions of the intestine.

3. Report sudden cessation of urethral drainage.
Rationale: Constant drainage usually subsides within 10 days; however, abrupt cessation may indicate plugging and lead to abscess formation.

4. Note red rash around stoma.
Rationale: Rash is most commonly caused by yeast. Urine leakage or allergy to appliance or products may also cause red, irritated areas.

5. Inspect incision line around stoma. Observe and document wound drainage, signs of incisional inflammation, and systemic indicators of sepsis.
Rationale: Provides baseline and comparative reference. Complications may include interrupted anastomosis of intestine or ureteral conduit, with leakage of bowel contents into abdomen or urine into peritoneal cavity.

6. Change dressings, as indicated, when used.
Rationale: Moist dressings act as a wick to the wound and provide media for bacterial growth.

7. Assess skinfold areas in groin, perineum, and under arms and breasts.
Rationale: Use of antibiotics and trapping of moisture in skinfold areas increases risk of Candida infections.

8. Monitor vital signs.
Rationale: An elevated temperature suggests incisional infection, urinary tract infection (UTI), or respiratory complications.

9. Auscultate breath sounds.
Rationale: Client is at high risk for development of respiratory complications because of length of time under anesthesia. Often this client is older and may already have a compromised immune system. Also, painful abdominal incisions cause client to breathe more shallowly than normal and to limit coughing effort. Accumulation of secretions in respiratory tract predisposes to atelectasis and infections.

10. Obtain specimens of exudates, urine, sputum, and blood, as indicated.
Rationale: Identifies source of infection and most effective treatment. Infected urine may cause pyelonephritis. Note: Urine specimen must be obtained from the conduit because the pouch is considered contaminated.

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Nursing Care Plan for Prostatectomy

Nursing diagnosis: acute Pain related to irritation of the bladder mucosa; reflex muscle spasm associated with surgical procedure or pressure from bladder balloon
(traction)

Possibly evidenced by
Reports of painful bladder spasms
Facial grimacing, guarding, restlessness
Autonomic responses

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and sleep and rest appropriately.
Pain Control
Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.

Nursing intervention with rationale:
1. Assess pain, noting location, intensity (0 to 10 scale), and characteristics.
Rationale: Changes in pain reports may indicate developing complications requiring further evaluation and intervention. Note: Sharp, intermittent pain with urge to void and passage of urine around catheter suggests bladder spasms, which tend to be more severe with suprapubic or TUR approaches and usually decrease within 48 hours.

2. Maintain patency of catheter and drainage system. Keep tubing free of kinks and clots.
Rationale: Maintaining a properly functioning catheter and drainage system decreases risk of bladder distention and spasm.

3. Promote intake of up to 3,000 mL/day, as tolerated.
Rationale: Decreases irritation by maintaining a constant flow of fluid over the bladder mucosa.

4. Give client accurate information about catheter, drainage, and bladder spasms.
Rationale: Allays anxiety and promotes cooperation with necessary procedures.

5. Provide comfort measures, such as position changes, back rub, Therapeutic Touch, and diversional activities. Encourage use of relaxation techniques, including deepbreathing exercises, visualization, and guided imagery.
Rationale: Reduces muscle tension, refocuses attention, and may enhance coping abilities.

6. Provide sitz baths or heat lamp, if indicated.
Rationale: Promotes tissue perfusion and resolution of edema and enhances healing in perineal approach.

7. Administer antispasmodics, such as the following: Oxybutynin (Ditropan), flavoxate (Urispas), B & O suppositories
Rationale: Relaxes smooth muscle to provide relief of spasms and associated pain.

8. Administer Propantheline bromide (Pro-Banthine).
Rationale: Relieves bladder spasms by anticholinergic action. Usually discontinued 24 to 48 hours before anticipated removal of catheter to promote normal bladder contraction.

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Nursing Care Plan for Rheumatoid Arthritis

Nursing diagnosis: acute/chronic Pain related to injuring agents—distention of tissues by accumulation of fluid/inflammatory process, destruction of joint

Possibly evidenced by
Reports of pain, discomfort; fatigue
Self-narrowed focus
Distraction behaviors; autonomic responses
Guarding, protective behavior

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and able to sleep, rest, and participate in activities appropriately.
Pain Control
Follow prescribed pharmacological regimen.
Incorporate relaxation skills and diversional activities into pain control program.

Nursing intervention with rationale:
1. Investigate reports of pain, noting location, and intensity using a scale of 0 to 10 or similar. Note precipitating factors and nonverbal pain cues.
Rationale: Self-report should be the primary source of pain assessment in determining pain management needs and effectiveness of program.

2. Recommend or provide firm mattress or bedboard and small pillow. Elevate linens with bed cradle as needed.
Rationale: Soft or sagging mattress and large pillows prevent maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed, painful joints.

3. Suggest client assume position of comfort while in bed or sitting in chair. Promote bedrest when indicated, but resume movement as soon as possible.
Rationale: In severe disease or acute exacerbation, total bedrest may be necessary until objective and subjective improvements are noted to limit pain and injury to joint. Note: Immobility is known to worsen arthritis pain and stiffness.

4. Place and monitor use of pillows, sandbags, trochanter rolls, and splints.
Rationale: Rests painful joints and maintains neutral position. Note: Use of splints can decrease pain and may reduce damage to joint; however, prolonged inactivity can result in loss of joint mobility and function.

5. Encourage frequent changes of position. Assist client to move in bed, supporting affected joints above and below, avoiding jerky movements.
Rationale: Prevents general fatigue and joint stiffness. Stabilizes joint, decreasing joint movement and associated pain.

6. Recommend that client take warm bath or shower on arising and/or at bedtime. Apply warm, moist compresses to affected joints several times a day. Monitor water temperature of compresses, baths, and so on.
Rationale: Heat promotes muscle relaxation and mobility, decreases pain, and relieves morning stiffness. Sensitivity to heat may be diminished and dermal injury may occur.

7. Encourage use of stress management techniques, such as progressive relaxation, biofeedback, visualization, guided imagery, self-hypnosis, and controlled breathing. Provide Therapeutic Touch.
Rationale: Promotes relaxation, provides sense of control, and may enhance coping abilities.

8. Involve client in diversional activities appropriate for individual situation.
Rationale: Refocuses attention, provides stimulation, and enhances selfesteem and feelings of general well-being.

9. Medicate before planned activities and exercises, as indicated.
Rationale: Promotes relaxation, reduces muscle tension and spasms, facilitating participation in therapy.

10. Monitor for development of skin rash in clients usingcyclo-oxgenase-2 (COX-2) inhibitors, especially those allergic to sulfur.
Rationale: Severe, life-threatening skin reactions, such as toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme, may develop within the first 2 weeks of treatment or later on, indicating need for prompt discontinuation of medication.

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Nursing Care Plan for Cancer

Nursing diagnosis: acute/chronic Pain related to disease process—compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a
nerve pathway, inflammation, metastasis to bones; side effects of various cancer therapy agents

Possibly evidenced by
Reports of pain
Self-focusing, narrowed focus
Alteration in muscle tone; facial mask of pain
Distraction/guarding behaviors
Autonomic responses, restlessness (acute pain)

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report maximal pain relief or control with minimal interference with activities of daily living (ADLs).
Pain Control
Follow prescribed pharmacological regimen.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing intervention with rationale:
1. Determine pain history, for example, location of pain, frequency, duration, and intensity using a rating scale (scale of 0–10), or verbal rating scale—“no pain” to “excruciating pain”; and relief measures used. Believe client’s report.
Rationale: Information provides baseline data to evaluate need for, and effectiveness of, interventions. Pain of more than 6 months’ duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. Note: The pain experience is an individualized one composed of both physical and emotional responses.

2. Determine timing and precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, intravenous (IV), topical, transmucosal, epidural, or patch medications.
Rationale: Pain may occur near the end of the dose interval, indicating need for higher dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or occur spontaneously, requiring use of short half-life agents for rescue or supplemental doses.

3. Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client and SO about what to expect.
Rationale: A wide range of discomforts are common such as incisional pain, burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer.

4. Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV.
Rationale: Promotes relaxation and helps refocus attention.

5. Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch.
Rationale: Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain.

6. Provide cutaneous stimulation, such as heat and cold packs, or massage.
Rationale: May decrease inflammation, muscle spasms, reducing associated pain.

7. Be aware of barriers to cancer pain management related to client, as well as the healthcare system.
Rationale: Clients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; belief that pain has meaning, such as “God wills it,” they should overcome it; or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities.

8. Administer analgesics, as indicated, for example: Opioids such as codeine, morphine (MSContin, Kadian), oxycodone (oxycontin), hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic, Actiq, Fentora), or oxymorphone (Numorphan, Opana
Rationale: Effective for localized and generalized moderate to severe pain, with long-acting or controlled-release forms available. Routes of administration include oral; transmucosal; transdermal; nasal; rectal; and subcutaneous, IV, epidural, and intrathecal infusions, which may be delivered via patientcontrolled analgesia (PCA). Fentanyl citrate (Oralet) is available as a transmucosal agent that is absorbed through the mucosa of the inner cheek. Note: Intramuscular (IM) route is not recommended for pain medications because absorption is not reliable, in addition to being painful and inconvenient.

9. Prepare for and assist with procedures such as nerve blocks, cordotomy, commissural myelotomy, or radiation therapy.
Rationale: May be used in severe, intractable pain unresponsive to other measures. Note: Radiation is especially useful for bone metastasis and may provide fast onset of pain relief even with only one treatment.

10. Refer to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, as indicated.
Rationale: May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration to decrease perception of pain.

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Nursing Care Plan for Pediatric Considerations

Nursing diagnosis: acute/chronic Pain related to injuring agents—biological, chemical, physical, psychological

Possibly evidenced by
Verbal cues
Changes in appetite and eating, sleep pattern
Guarding, protective behavior; restlessness, moaning, crying, irritability
Autonomic responses

Desired Outcomes/Evaluation Criteria—Child Will
Pain Level
Report or indicate pain is relieved or controlled.
Manifest decreased restlessness and irritability.
Demonstrate age-appropriate blood pressure (BP), pulse, and respiratory rates.
Pain Disruptive Effects
Participate in usual activities within level of ability.

Nursing intervention with rationale:
1. Perform routine comprehensive pain assessment, including location, characteristics, onset, duration, frequency, quality, and severity using some type of rating scale, such as numbers or visual analog, facial expressions, or color scale.
Rationale: Assessment of children involves observational skills and may require enlisting the aid of parent or caregiver to clarify cues and verbalizations. Choice of rating scale is dependent on age and developmental level (Suresh, 2002).

2. Accept child’s description of pain, noting precipitating, exacerbating, and relieving factors.
Rationale: Pain is subjective and cannot be experienced by others. Note: In presence of chronic pain situation, use of a pain diary may be appropriate for adolescents (Suresh, 2002).

3. Investigate changes in frequency or description of pain.
Rationale: May signal worsening of condition or development of complications.

4. Observe for guarding, rigidity, crying, and restlessness.
Rationale: Nonverbal expressions, body movement, and behavioral state may signal pain or changes in pain severity, especially in infants and younger children (Suresh, 2002).

5. Monitor heart rate, BP using correctly sized cuff, and respiratory rate, noting age-appropriate normals and variations.
Rationale: Changes in autonomic responses may indicate increased pain before child verbalizes. Note: Autonomic responses change with acute pain, not chronic pain. BP may be lower than normal or higher than normal.

6. Note location and type of surgical incisions or trauma.
Rationale: Influences degree and severity of pain manifestations.

7. Identify ways to avoid or minimize pain, such as splinting surgical incisions during coughing, sleeping on a firm mattress, or wearing brace on sprains.
Rationale: Many factors may reduce pain intensity based on specific situation. Child can quickly learn and use such pain management techniques, enhancing sense of control as well as comfort.

8. Review procedures and expectations and tell child when it will hurt. Provide distraction during painful procedures, such as deep breathing or counting, or looking at something that interests child.
Rationale: Although the procedure may still be stressful, child will find it easier to handle if he or she knows what to expect and has developed coping strategies.

9. Collaborate in treatment of underlying conditions or disease process.
Rationale: Treating cause, when possible, can eliminate pain.

10. Administer medications, such as opioid and nonsteroidal analgesics, as indicated. Use multiple routes to deliver analgesia, such as oral, nebulized, transdermal, or patientcontrolled analgesia (PCA), as indicated by current situation.
Rationale: Depending on the cause and type of pain, as well as its chronicity, various means of pain management may be needed to overcome or control pain.

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Nursing Care Plan for Total Joint Replacement

Nursing diagnosis: knowledge deficit related to lack of exposure or recall, information misinterpretation

Possibly evidenced by
Questions, request for information, statement of misconception
Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Disease Process
Verbalize understanding of surgical procedure and prognosis.
Correctly perform necessary procedures and explain reasons for the actions.

Nursing intervention with rationale:
1. Review disease process, surgical procedure, and future expectations.
Rationale: Provides knowledge base from which client can make informed choices. The majority of total joint surgeries are elective, and preoperative education is done in some form in the surgeon’s office or in the admitting facility. Postsurgical review of process and expectations may be needed, or desired.

2. Encourage alternating rest periods with activity.
Rationale: Conserves energy for healing and prevents undue fatigue, which can increase risk of injury or fall.

3. Stress importance of continuing prescribed exercise and rehabilitation program within client’s tolerance—crutch or cane walking, weight-bearing exercises, stationary bicycling, or swimming.
Rationale: Increases muscle strength and joint mobility. Most clients will be involved in formal outpatient rehabilitation, home-care programs, or be followed in extended-care facilities by physical therapists. Note: Muscle aching indicates too much weightbearing or activity, signaling a need to cut back.

4. Review activity limitations, depending on joint replaced: for hip or knee—sitting for long periods or in low chair or toilet seat, recliner; jogging, jumping, excessive bending, lifting, twisting, or crossing legs.
Rationale: Prevents undue stress on implant. Long-term restrictions depend on individual situation and physician protocol.

5. Discuss need for safe environment in home including removing scatter rugs and unnecessary furniture, and use of assistive devices, such as hand rails in tub and toilet, raised toilet seat, and cane for long walks.
Rationale: Reduces risk of falls and excessive stress on joints.

6. Review and have client or caregiver demonstrate incisional or wound care.
Rationale: Promotes independence in self-care, reducing risk of complications.

7. Identify signs and symptoms requiring medical evaluation: fever or chills, incisional inflammation, unusual wound drainage, pain in calf or upper thigh, or development of sore throat or dental infections.
Rationale: Bacterial infections require prompt treatment to prevent progression to osteomyelitis in the operative area and prosthesis failure, which could occur at any time, even years later.

8. Review procedure for removal of painball catheter if not discontinued before discharge.
Rationale: Medication may infuse for up to 5 days and if client removes catheter after discharge it is important to check for black marking on tip to ensure tubing is removed intact.

9. Review drug regimen, for example, anticoagulants or antibiotics for invasive procedures (e.g., tooth extraction).
Rationale: Prophylactic therapy may be necessary for a prolonged period after discharge to limit risk of thromboemboli and infection. Procedures known to cause bacteremia can lead to osteomyelitis and prosthesis failure.

10. Identify bleeding precautions—for example, use of soft toothbrush, electric razor, avoidance of trauma, or forceful blowing of nose—and necessity of routine laboratory follow-up.
Rationale: Reduces risk of therapy-induced bleeding or hemorrhage.

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Nursing Care Plan for Burns

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate primary defenses—destruction of skin barrier, traumatized tissues
Inadequate secondary defenses—decreased Hgb, suppressed inflammatory response
Environmental exposure, invasive procedures

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Burn Healing
Achieve timely wound healing free of purulent exudate and be afebrile.

Nursing intervention with rationale:
1. Implement appropriate isolation techniques, as indicated.
Rationale: Dependent on type and extent of wounds, and the choice of wound treatment (e.g., open versus closed); isolation may range from simple wound and skin to complete or reverse to reduce risk of cross-contamination and exposure to multiple bacterial flora.

2. Emphasize and model good hand-washing technique for all individuals coming in contact with client.
Rationale: Prevents cross-contamination and reduces risk of acquired infection.

3. Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered linens and gowns.
Rationale: Prevents exposure to infectious organisms.

4. Monitor and limit visitors, if necessary. Explain isolation procedure to visitors, if used. Supervise visitor adherence to protocol as indicated.
Rationale: Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against client’s need for family support and socialization.

5. Shave/clip all hair from around burned areas to include a 1-inch border (excluding eyebrows). Shave facial hair (men) and shampoo head daily.
Rationale: Hair is a good medium for bacterial growth; however, eyebrows act as a protective barrier for the eyes. Regular shampooing decreases bacterial fallout into burned areas.

6. Examine unburned areas such as groin, neck creases, and mucous membranes; and vaginal discharge routinely.
Rationale: Opportunistic infections (e.g., yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy.

7. Provide special care for eyes, for example, use eye covers and tear formulas as appropriate.
Rationale: Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.

8. Prevent skin-to-skin surface contact—wrap each burned finger or toe separately; do not allow burned ear to touch scalp.
Rationale: Prevents adherence to the surface that it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis.

9. Examine wounds daily; note and document changes in appearance, odor, or quantity of drainage.
Rationale: Identifies presence of granulation tissue indicating healing and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong, sweet, musty smell at a graft site is indicative of Pseudomonas.

10. Monitor vital signs for fever and increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.
Rationale: Indicators of sepsis—often occurring with full-thickness burn—requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.

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Nursing Care Plan for Urinary Tract Infection (UTI)

Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra. Approximately 20% to 25% of women have a UTI sometime during their lifetime, and acute UTIs account for approximately 7 million healthcare visits per year for young women. About 20% of women who develop a UTI experience recurrences. Women are more prone to UTIs than men because of natural anatomic variations. The female urethra is only about 1 to 2 inches in length, whereas the male urethra is 7 to 8 inches long. The female urethra is also closer to the anus than is the male urethra, increasing women’s risk for fecal contamination. The motion during sexual intercourse also increases the female’s risk for infection.

Urinary reflux is one reason that bacteria spread in the urinary tract. Vesicourethral reflux occurs when pressure increases in the bladder from coughing or sneezing and pushes urine into the urethra. When pressure returns to normal, the urine moves back into the bladder, taking with it bacteria from the urethra. In vesicoureteral reflux, urine flows backward from the bladder into one or both of the ureters, carrying bacteria from the bladder to the ureters and widening the infection. If they are left untreated, UTIs can lead to chronic infections, pyelonephritis, and even systemic sepsis and septic shock. If infection reaches the kidneys, permanent renal damage can occur, which leads to acute and chronic renal failure.

The pathogen that accounts for about 90% of UTIs is Escherichia coli. Other organisms that are commonly found in the gastrointestinal tract and may contaminate the genitourinary tract include Enterobacter, Pseudomonas, group B beta-hemolytic streptococci, Proteus mirabilis, Klebsiella species, and Serratia. Two growing causes of UTI in the United States are Staphylococcus saprophyticus and Candida albicans. Predisposing factors are urethral damage from childbirth, catheterization, or surgery; decreased frequency of urination; other medical conditions such as diabetes mellitus; and in women, frequent sexual activity and some forms of contraceptives (poorly fitting diaphragms, use of spermicides).

Nursing care plan assessment and physical examination
The patient with a UTI has a variety of symptoms that range from mild to severe. The typical complaint is of one or more of the following: frequency, burning, urgency, nocturia, blood or pus in the urine, and suprapubic fullness. If the infection has progressed to the kidney, there may be flank pain (referred to as costovertebral tenderness) and low-grade fever.

Question the patient about risk factors, including recent catheterization of the urinary tract, pregnancy or recent childbirth, neurological problems, volume depletion, frequent sexual activity, and presence of a sexually transmitted infection (STI). Ask the patient to describe current sexual and birth control practices because poorly fitting diaphragms, the use of spermicides, and certain sexual practices such as anal intercourse place the patient at risk for a UTI.

Physical examination is often unremarkable in the patient with a UTI, although some patients have costovertebral angle tenderness in cases of pyelonephritis. On occasion, the patient has fever, chills, and signs of a systemic infection. Inspect the urine to determine its color, clarity, odor, and character. Surveillance for STIs is recommended as part of the examination.

UTIs rarely result in disruption of the patient’s normal activities. The infection is generally acute and responds rapidly to antibiotic therapy. The general guidelines to increase fluid intake and concomitant frequent urination may be problematic for some patients in restrictive work environments. The accompanying discomfort may result in temporary restriction of sexual activity, especially if an STI is diagnosed.

Nursing care plan primary nursing diagnosis: Altered urinary elimination related to infection.

Nursing care plan intervention and treatment plan
An acid-ash diet may be encouraged. A diet of meats, eggs, cheese, prunes, cranberries, plums, and whole grains can increase the acidity of the urine. Foods not allowed on this diet include carbonated beverages, anything containing baking soda or powder, fruits other than those previously stated, all vegetables except corn and lentil, and milk and milk products. Because the action of some UTI medications is diminished by acidic urine (nitrofurantoin), review all prescriptions before instructing patients to follow this diet.

UTIs are treated with antibiotics specific to the invading organism. Usually, a 7- to 10-day course of antibiotics is prescribed, but shortened and large single-dose regimens are currently under investigation. Most elderly patients need a full 7- to 10-day treatment, although caution is used in their management because of the possibility of diminished renal capacity. Women being treated with antibiotics may contract a vaginal yeast infection during therapy; review the signs and symptoms (cheesy discharge and perineal itching and swelling), and encourage the woman to purchase an over-the-counter antifungal or to contact her primary healthcare provider if treatment is indicated.

Encourage patients with infections to increase fluid intake to promote frequent urination, which minimizes stasis and mechanically flushes the lower urinary tract. Strategies to limit recurrence include increasing vitamin C intake, drinking cranberry juice, wiping from front to back after a bowel movement (women), regular emptying of the bladder, avoiding tub and bubble baths, wearing cotton underwear, and avoiding tight clothing such as jeans. These strategies have been beneficial for some patients, although there is no research that supports the efficacy of such practices.

Encourage the patient to take over-the-counter analgesics unless contraindicated for mild discomfort but to continue to take all antibiotics until the full course of treatment has been completed. If the patient experiences perineal discomfort, sitz baths or warm compresses to the perineum may increase comfort.

Nursing care plan discharge and home health care guidelines
Treatment of a UTI occurs in the outpatient setting. Teach the patient an understanding of the proposed therapy, including the medication name, dosage, route, and side effects. Explain the signs and symptoms of complications such as pyelonephritis and the need for follow-up before leaving the setting. Explain the importance of completing the entire course of antibiotics even if symptoms decrease or disappear. If the patient experiences gastrointestinal discomfort, encourage the patient to continue taking the medications but to take them with a meal or milk unless contraindicated. Warn the patient that drugs with phenazopyridine turn the urine orange.

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Nursing Care Plan for Pneumonia

Pneumonia is an infection of the lungs involving alveoli that are in contact with bronchioles or complete lobes. The disease is identified by the causative agents that may be bacterial, viral, fungal, or protozoan and may be termed lobar or bronchopneumonia.

Nursing Diagnosis: Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain caused by positioning and coughing; decreased energy and fatigue caused by inflammatory process; decreased lung expansion caused by pain and fatigue resulting in hypoventilation.

Expected Outcomes: Adequate ventilation evidenced by respiratory rate, depth and ease within baseline limits.

Intervention and Rationale:
I. Assess for:

Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.

II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.

ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.

III. Administer:
Oxygen therapy via cannula - maintain optimal oxygen level.

Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough

Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.

IV. Perform or Provide:
Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.

Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.

Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.

Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes


Postural drainage and percussion PRN - mobilizes secretion.
Suction secretions if cough ineffective - removal if unable to bring up secretions.

Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.

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Nursing Care Plan for Kidney Stones (Renal Calculi)

Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate; however, uric acid, struvite, and cystine are also calculus formers. Renal calculi vary in size, with 90% of them smaller than 5 mm in diameter; some, however, grow large enough to prevent the natural passage of urine through the ureter. Calculi may be solitary or multiple. Approximately 80% of these stones are composed of calcium salts. Other types are the struvite stones (which contain magnesium, ammonium, and phosphate), uric acid stones, and cystine stones. If the calculi remain in the renal pelvis or enter the ureter, they can damage renal parenchyma (functional tissue). Larger calculi can cause pressure necrosis. In certain locations, calculi cause obstruction, lead to hydronephrosis, and tend to recur. Although renal calculi can form anywhere in the urinary tract, they are most commonly found in the renal pelvis and calyces. Renal calculi can remain asymptomatic until passed into a ureter and/or urine flow is obstructed, when the potential for renal damage is acute.

The precise cause of renal calculi is unknown, although they are associated with dehydration, urinary obstruction, calcium levels, and other factors. Patients who are dehydrated have decreased urine, with heavy concentrations of calculus-forming substances. Urinary obstruction leads to urinary stasis, a condition that contributes to calculus formation. Any condition that increases serum calcium levels and calcium excretion predisposes people to renal calculi. These conditions include an excessive intake of vitamin D or dietary calcium, hyperparathyroidism,
heredity factors, and immobility. Metabolic conditions such as renal tubular acidosis, elevated serum uric acid levels, and urinary tract infections associated with alkaline urine have been linked with calculus formation. Cystine stones are associated with hereditary renal disease.

Physical Assessment of this nursing care plan

Symptoms of renal calculi usually appear when a stone dislodges and begins to travel down the urinary tract and enters the ureter. Establish a history of pain, and determine the intensity, duration, and location of the pain. The location of the pain varies according to the placement of the stone. The pain usually begins in the flank area but later may radiate into the lower abdomen and the groin. Ask if the pain had a sudden onset. Patients may relate a recent history of hematuria, nausea, vomiting, and anorexia. In cases in which a urinary tract infection is also present, the patient may report chills and fever. Determine the patient’s history to identify risk factors.

Inspection reveals a patient in intense pain who is unable to maintain a comfortable position. Assess the patient for bladder distension. Monitor the patient for signs of an infection such as fever, chills, and increased white blood cell counts. Assess the urine for hematuria. Auscultate the patient’s abdomen for normal bowel sounds. Palpate the patient’s flank area for tenderness. Percussion of the abdominal area is normal, but percussion of the costovertebral angle elicits severe pain.

Patients with renal calculi may be extremely anxious because of the sudden onset of severe pain of unknown origin. Assess the level of the pain, as well as the patient’s ability to cope. Since diet and lifestyle may contribute to the formation of calculi, the patient may face lifestyle changes. Assess the patient’s ability to handle such changes.

Diagnostic Studies

Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones).
Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated.
Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes.
Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis.

Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.

CBC: Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure). RBCs: Usually normal. WBCs: May be increased, indicating infection/septicemia.
Parathyroid hormone (PTH): May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)

KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter.

IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi.

Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.

CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension.

Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.
Nursing Priorities
Alleviate pain.
Maintain adequate renal functioning.
Prevent complications.
Provide information about disease process/prognosis and treatment needs.
Primary Nursing Diagnosis: Altered urinary elimination related to the blockage of ureter with a calculus.

Nursing Care Plan/Intervention
In about 80% of cases, renal calculi of 5 mm or less are treated conservatively with vigorous hydration, which results in the stone passing spontaneously. Increased fluid intake is ordered orally or intravenously (IV) to flush the stone through the urinary tract. Unless contraindicated, maintain hydration at 200 mL per hour of IV or orally. Strain the patient’s urine to detect stones that are passed so they can be analyzed.

For calculi that are larger than 5 mm or that cannot be passed with conservative treatment, surgical removal is performed. Percutaneous ultrasonic lithotripsy or extracorporeal shock wave lithotripsy (ESWL) uses sound waves to shatter calculi for later removal by suction or natural passage. Calculi in the ureter may be removed with catheters and a cystoscope (ureteroscopy), while a flank or lower abdominal surgical approach may be needed to remove calculi from the kidney calyx or renal pelvis.

Initially, the most important nursing interventions concentrate on pain management. Teach relaxation techniques, diversional activities, and position changes. Help promote the passage of renal calculi. Encourage the patient to walk, if possible. Offer the patient fruit juices to help acidify the urine. Teach the patient the importance of proper diet to help avoid a recurrence of the renal calculi, with particular emphasis on adequate hydration and avoiding excessive salt and protein intake.

To reduce anxiety, give the patient and family all pertinent information concerning the treatment plan and any diagnostic tests. Preoperatively, explain the procedure and what to expect afterward. For patients who are undergoing a flank or abdominal incision, teach deep breathing and coughing exercises. Give postoperative care and monitor for signs of infection or pneumonia. Do not irrigate urinary drainage systems without consulting with the physician.

Health Teaching
Instruct the patient to increase fluid intake to enhance the passage of the stone. Instruct the patient to strain all urine, and, if a stone is obtained, emphasize the importance of returning the stone to the physician for analysis. If the patient has passed the stone and it has been analyzed, teach the necessary dietary changes, fluid intake requirements, and exercise regimen to prevent future stone formation. Patient should drink at least 2.5 L a day of fluid to prevent recurrences.

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Nursing Care Plan for Gunshot Wound

Penetrating trauma from a gunshot wound (GSW) can cause devastating injuries. The most commonly injured organs and tissues are the intestines, liver, vascular structures, spleen, and intrathoracic structures. Evaluating injuries is difficult; it is important to determine the type of weapon, energy dissipated from the weapon, firing range of the weapon at the time of injury, and characteristics of the injured tissue. Gunshot wound can lead to the need for extensive débridement, resection, or amputation. Among the many complications are sepsis, exsanguination, and death. In the United States, gunshot wound account for approximately 30,000 deaths a year. Approximately 57% of gun deaths are suicides, 39% are homicides, and the rest are from other causes, primarily an unintentional death. In the Unied States, 4% of the world’s population possesses 50% of the world’s privately owned firearms. Gunshot wound can be perforating, when the bullet exits the body, or penetrating, when the bullet is retained in the body.

The energy of the missile is dissipated into tissues of the body, causing destruction of vital and nonvital structures. When the missile enters the body, it creates a temporary cavity, which stretches, distorts, and compresses the surrounding anatomic structures. The cavity that is produced often has a greater diameter than the missile itself. In a situation called “blast effect” or “muzzle blast,” damage occurs in structures outside the direct path of the missile. High-velocity missiles (bullets from shotguns, rifles, or high-caliber handguns) cause extensive cavitation and significant tissue destruction, while low-velocity missiles (bullets from low-caliber handguns) have limited cavitation potential with less tissue destruction. Another characteristic of missiles is the yaw, which is the amount of tumbling and movement of the nose of the missile that occurs. The more yaw, the greater the tissue damage.

Nursing care plan assessment and physical examination
Establish a history of the weapon, including the type, caliber, and range at which it was fired. Determine if the gunshot woundwas self-inflicted, as well as the patient’s hand dominance and tetanus immunization history.

The initial evaluation is always focused on assessing the airway, breathing, circulation, disability (neurological status), and exposure (completely undressing the patient), which are done simultaneously by the trauma resuscitation team. The secondary survey is a head-to-toe assessment, including vital signs. After completing the primary survey, begin the secondary survey with a complete head-totoe assessment. Examine the patient’s entire skin surface carefully for abrasions, open wounds, powder burns, and hematomas, paying special attention to skin folds, groin, and axillae. Assess the patient’s abdomen, back, and extremities for lacerations, wounds, abrasions, and deformities. Some high-velocity weapons may cause extensive tissue destruction and fractures. Inspect the patient for both entrance and exit wounds.

Perform a thorough fluid volume assessment on at least an hourly basis until the patient is stabilized. This assessment includes hemodynamic, urinary, and central nervous system parameters. Notify the physician of overt bleeding and of any early indications that hemorrhage is continuing; this includes delayed capillary refill, tachycardia, urinary output less than 0.5 mL/kg per hour, and alterations in mental status, including restlessness, agitation, and confusion, as well as decreases in alertness. Body weights are helpful in indicating fluid volume status; note that many of the critical care beds have incorporated bed scales.

The violent and often unexplained nature of this type of trauma can lead to ineffective coping for both the patient and the family. Determine if the patient is at risk from herself or himself or others by questioning the patient, significant others, or police. If the patient is on police hold, determine the patient’s and family’s response to the pending legal charges.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to airway obstruction secondary to tissue trauma.

Nursing care plan intervention and treatment
Maintaining a patent airway, maintaining oxygenation and ventilation, and supporting the circulation are the first priorities. Assist with endotracheal intubation and mechanical ventilation. Maintain the PaO2 at greater than 100 mm Hg and the PaCO2 at 35 to 45 mm Hg. The patient may require placement of a tube thoracostomy to drain blood and relieve a pneumothorax.

Restoring fluid volume status is critical in maximizing tissue perfusion and oxygenation; the use of pressure infusers and rapid volume/warmer infusers for trauma patients requiring massive fluid replacement is essential. Administering warm blood products and crystalloids assists in maintaining normothermia. Be prepared to administer vasopressors after fluid volume status is stabilized. Patients who require massive fluid resuscitation are at risk for developing hypothermia, which exacerbates existing coagulopathy and compounds their hemodynamic instability.

Paramount in managing patients is a rapid fluid resuscitation with blood, blood products, colloids, and crystalloids through a large-bore peripheral intravenous (IV) catheter or a large-bore trauma catheter.

Patients frequently require surgical exploration to identify specific injuries and control hemorrhage. After surgical exposure is obtained, any of the following may be required: assessment of structures, control of hemorrhage, débridement, resection, or amputation. If definitive surgical intervention is not possible because of the patient’s instability, a temporizing method known as “damage control” may be instituted. Damage control consists of the placement of packing to achieve a temporary tamponade, correction of coagulopathy, and aggressive management of hypothermia. The patient is then transferred to the critical care unit for continued monitoring and stabilization. The “second look” surgical exploration is generally done in 24 hours for definitive surgical intervention.

In the emergency phase of treatment, maintain the patient in a supine position unless it is contraindicated because of other injuries. Ensure adequate airway and breathing in this position. Avoid Trendelenburg’s position because it may have negative hemodynamic consequences, increase the risk of aspiration, and interfere with pulmonary excursion. If the patient can tolerate the position, elevate the head of the bed to limit the risk of aspiration and to improve gas exchange.

Wound care varies, depending on the severity of wounds, whether an open fracture is present, and what type of fixation device is applied. Wounds and any exposed soft tissue and bone are covered with wet, sterile saline dressings. Standard Betadine-soaked dressings may not be used because of the need to limit iodine absorption and skin irritation. To decrease the risk of infection of the patient, use a gown, mask, gloves, and hair covers in caring for patients with extensive wounds. Document the size, description, and healing of the wound each day, and notify the surgeon if there are signs of wound infection. Use universal precautions in handling all bloody drainage.

If another person has initiated the violence toward the patient, consider assigning him or her a pseudonym for all hospital records to prevent another assault. Do not provide any information about the patient over the phone unless you are sure of the caller’s name and relationship to the patient. If you fear for the patient’s safety, talk to hospital security about strategies to ensure the patient’s safety. If the patient has a self-inflicted injury, make a referral to a clinical nurse specialist or discuss a psychiatric consultation with the surgeon. If the patient is self-destructive, initiate suicide precautions according to unit protocol.

If the patient is being held by police, remember that the patient receives competent and compassionate care even when under arrest. Determine from hospital policy the regulations about visitors if the patient is held by the police. Provide a supportive atmosphere to promote healing of the injury, but use care to avoid being drawn into the legal aspects of the patient’s arrest.

Nursing care plan discharge and home health care guidelines
To prevent complications of wound infection and impaired wound healing, review wound care instructions with the patient and family. Verify that they can demonstrate proper care with understanding and accuracy. Verify that the patient understands all medications, including dosage, route, action, and adverse effects. Provide written instructions to the patient or family. Review with the patient all follow-up appointments that are arranged. If home care is necessary, verify that appropriate arrangements have been completed. Make sure that patients with self-inflicted wounds have counseling and support before and after the discharge.

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Nursing Care Plan for Hyperthermia

Nursing diagnosis: Hyperthermia related to increased metabolic rate, illness; dehydration; direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation

Possibly evidenced by
Increase in body temperature higher than normal range
Flushed skin, warm to touch
Increased respiratory rate, tachycardia

Desired Outcomes/Evaluation Criteria—Client Will
Thermoregulation
Demonstrate temperature within normal range and be free of chills.
Experience no associated complications.

Nursing intervention with rationale:
1. Monitor client temperature—degree and pattern. Note shaking chills or profuse diaphoresis.
Rationale: Temperature of 102 F to106 F (38.9 C–41.1 C) suggests acute infectious disease process. Fever pattern may aid in diagnosis: sustained or continuous fever curves lasting more than 24 hours suggest pneumococcal pneumonia, scarlet or typhoid fever; remittent fever varying only a few degrees in either direction reflects pulmonary infections; and intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher than 102 F (38.9 C).

2. Monitor environmental temperature. Limit or add bed linens, as indicated.
Rationale: Room temperature and linens should be altered to maintain near-normal body temperature.

3. Provide tepid sponge baths. Avoid use of alcohol.
Rationale: Tepid sponge baths may help reduce fever. Note: Use of ice water or alcohol may cause chills, actually elevating temperature. Alcohol can also cause skin dehydration.

4. Administer antipyretics, such as acetylsalicylic acid (ASA) (aspirin) or acetaminophen (Tylenol).
Rationale: Antipyretics reduce fever by its central action on the hypothalamus; fever should be controlled in clients who are neutropenic or asplenic. However, fever may be beneficial in limiting growth of organisms and enhancing autodestruction of infected cells.

5. Provide cooling blanket, or hypothermia therapy, as indicated.
Rationale: Used to reduce fever, especially when higher than 104 F to 105 F (39.5 C–40 C), and when seizures or brain damage are likely to occur.

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