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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