VII.

NURSING MANAGEMENT
a. Ideal Nursing Management (NCP)

Problem: Risk for Impaired Skin Integrity

Nursing Diagnosis: Risk for Impaired Skin Integrity related to Diabetes as evidenced by Lesions and Sores on Extremities
Cause analysis: Cellulitis is a localized or diffuse inflammation of connective tissue with severe inflammation of dermal and subcuta-
neous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria and often occurs where the skin has
previously been broken, cracks in the skin, cuts, blisters, burns, insect bites, and surgical wounds.

Cues Objectives Nursing Intervention Rationale Evaluation
Subjective:
Not applica-
ble




Objective:
Swelling
Presence
of erythema
on right leg,
Scaly ap-
pearance
STO:
After 8 hours the patients
family will be taught what
a part of the patients
body is at most risk for
skin break down. They will
also be taught how to do
a simplified skin assess-
ment and what to look for
if there is a breakdown or
change in skin.

LTO:
After 3 to 4 days of duty
the family will be able to
do a simplified skin as-
sessment on their own.

INDEPENDENT:
1. For a client with limited mo-
bility, monitor condition of
skin covering bony promi-
nences.

2. Teach the client skin as-
sessment and ways to mon-
itor for skin breakdown.




3. Monitor skin conditions at
least once a day for color or
texture changes, or lesions.

4. Determine whether the cli-
ent is experiencing loss of
sensation

1. Pressure ulcers usually occur
over bony prominences, such as
the sacrum, coccyx, and heels.


2. Early assessment and interven-
tion helps prevent the develop-
ment of serious problems. Basic
elements of a skin assessment
are assessment of temperature,
color, moisture, and intact skin.

3. Systematic inspection can identi-
fy impending problems early.


4. Excessive bathing, especially in
hot water can exacerbate the
condition leading to complica-
tions.

STO:
After 8 hours, the patients
family was taught what a
part of the patients body
is at most risk for skin
break down. They were
taught how to do a simpli-
fied skin assessment and
what to look for if there is
a breakdown or change in
skin.

LTO:
After 3 to 4 days of duty
the family was able to do
a simplified skin assess-
ment on their own.


Problem: infection

Nursing Diagnosis: Infection related to insufficient knowledge how to avoid pathogens
Cause analysis: Diabetes is a condition in which there is increase number glucose in the blood. This condition can lead to increase in
viscosity and may affect wound healing. Also, because of the increase in glucose in the blood it is a good medium for bacterial growth.

Cues Objectives Nursing Intervention Rationale Evaluation
Subjective:
Not applicable


Objective:
Swelling
Presence of
erythema on
right leg,
Scaly ap-
pearance
STO:
. After 8 hrs. of giving
effective nursing inter-
ventions the patients
family will identify inter-
ventions to pre-
vent/reduce risk of
spread of infection.

LTO:
Within 3 days of giv-
ing effective nursing
interventions, the fami-
ly will demonstrate
techniques/initiate life-
style changes to pro-
mote safe environment.
INDEPENDENT:
1. Teach the patient and the family
member of proper foot care in dia-
betic patients.


2. Instruct the patient to avoid walking
barefooted, avoid wearing tight
shoes/sandals.

3. Assess for any signs of infection
(break in the skin, bruises, swelling).

4. Maintain aseptic technique in inva-
sive procedures. Observe proper
hand washing when handling the
patients wound.


1. Careful and proper foot care
is important in diabetic pa-
tients since they are at risk of
gangrene.

2. These can cause trauma to
the foot and can progress to
complications.

3. Early detection can prevent
further complications and
good prognosis.


4. To prevent contamination.





After 8 hrs. of giving ef-
fective nursing interven-
tions the patients family
was able to identify inter-
ventions to pre-
vent/reduce risk of
spread of infection.

LTO:
Within 3 days of giving
effective nursing inter-
ventions, the family was
able to demonstrate
techniques/initiate life-
style changes to promote
safe environment.








Problem: Decreased Cardiac Output

Nursing Diagnosis: Decreased cardiac output related to fluid imbalances affecting circulating volume myocardial workload and sys-
temic vascular resistance (SVR) alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia) accumulation of toxins
(urea), soft-tissue calcification (deposition of calcium phosphate)
Taxonomy: Activity-Exercise Pattern
Cause Analysis: Loss of excretory renal function that may lead to decreased phosphate excretion and calcium absorption causes tis-
sue calcifications. Decreased excretion of nitrogenous wastes accumulates urea in the system. Decreased sodium reabsorption in tu-
bule affects fluid balances. Losses of nonexcretory renal function of the kidney will lead to failure to produce erythropoietin. Thus leads
to anemia. In order to pump more blood into the body, the heart muscle requires more oxygenated blood to meet own needs. Calcifica-
tions of the involuntary muscles affects contractility thus affects volume of blood ejected per minute (p884,1435, 1441 Medical-Surgical
Nursing by Black et.al)
Cues Goal Nursing Intervention Rationale Evaluation
Subjective:
Not applicable

Objective:
Increased
heart rate
Dysrhythmi-
as
Changes in
BP (hypoten-
si-
on/hypertensi
on)
Extra heart
sounds
Diminished
peripheral
pulses
Edema

STO: After 2 hrs
of effective nurs-
ing intervention,
significant others
would be able to
become knowl-
edgeable and
knowledgeable
about the diag-
nostic tests she
will undergo.

LTO: After 8 hrs.
of effective nurs-
ing interventions,
patient would be
able to maintain
cardiac output
Independent
1. Auscultate heart and lung
sounds. Evaluate presence of
peripheral edema/vascular
congestion and reports of
dyspnea.

2. Assess presence/degree of
hypertension: monitor BP;
note postural changes, e.g.,
sitting, lying, standing.

3. Investigate reports of chest
pain, noting location,
radiation, severity (010
scale), and whether or not it
is intensified by deep
inspiration and supine


1. S
3
/S
4
heart sounds with muffled tones, tachycardia,
irregular heart rate, tachypnea, dyspnea, crackles,
wheezes, and edema/jugular distension suggest HF.

2. Significant hypertension can occur because of
disturbances in the renin-angiotensin-aldosterone
system (caused by renal dysfunction). Although
hypertension is common, orthostatic hypotension may
occur because of intravascular fluid deficit, response
to effects of antihypertensive medications, or uremic
pericardial tamponade.

3. Although hypertension and chronic HF may cause
MI, approximately half of CRF patients on dialysis
develop pericarditis, potentiating risk of pericardial
effusion/tamponade.

STO: After 2 hrs.
of effective nurs-
ing intervention,
significant others
were able to be-
come knowl-
edgeable about
the diagnostic
tests she will
undergo.

LTO: After 8 hrs.
of effective nurs-
ing interventions,
patient was able
to maintain car-
diac output as
evidenced by BP
and heart rate































as evidenced by
BP and heart
rate within pa-
tients normal
range; peripheral
pulses strong
and equal with
prompt capillary
refill time.
position.


4. Evaluate heart sounds
(note friction rub), BP, pe-
ripheral pulses, capillary refill,
vascular congestion, temper-
ature, and sensori-
um/mentation.

5. Assess activity level,
response to activity.

Collaborative
6. Monitor
laboratory/diagnostic studies,
e.g.:
Electrolytes (potassium,
sodium, calcium,
magnesium), BUN/Cr;
Chest x-rays.

7. Administer
antihypertensive drugs,

8. Prepare for dialysis.

9. Assist with pericardiocen-
tesis as indicated.
4. Presence of sudden hypotension, paradoxic pulse,
narrow pulse pressure, diminished/absent peripheral
pulses, marked jugular distension, pallor, and a rapid
mental deterioration indicate tamponade, which is a
medical emergency.

5. Weakness can be attributed to HF and anemia.



6. Imbalances can alter electrical conduction and
cardiac function.
Chest x-rays is useful in identifying developing
cardiac failure or soft-tissue calcification.


7. Reduces systemic vascular resistance and/or renin
release to decrease myocardial workload and aid in
prevention of HF and/or MI.

8. Reduction of uremic toxins and correction of
electrolyte imbalances and fluid overload may
limit/prevent cardiac manifestations, including
hypertension and pericardial effusion.

9. Accumulation of fluid within pericardial sac can
compromise cardiac filling and myocardial
contractility, impairing cardiac output and potentiating
risk of cardiac arrest.

within patients
normal range;
peripheral puls-
es strong and
equal with
prompt capillary
refill time.


Problem: Activity intolerance
Nursing Diagnosis: Activity intolerance related to generalized weakness and fatigue.
Taxonomy: Exercise and Activity
Cause Analysis: Muscle activity, loss of energy results from reduction in the oxygen available in the muscle. Hemoglobin major
component of RBC, binds easily with oxygen necessary for the protection of body from fatigue and activity intolerance. (Reference:
Medical-Surgical Nursing 6
th
ed. By Black et.al, p454.
Cues Goal Nursing Intervention Rationale Evaluation
Subjective:
Not applica-
ble


Objective:
The pa-
tient is al-
ways lying
in bed and
always
sleeping.
The pa-
tient face
appears to
be gener-
ally weak.
Appears
to be ex-
hausted
The pa-
tient has
sunken
eyeballs.


Short term objective:

After 8 hours of giving
nursing intervention and
health teaching the signif-
icant others will be able to
verbalize an understand-
ing of the need to gradual-
ly increase activity based
on testing, tolerance, and
symptoms. And express-
es an understanding of
the need to balance rest
and activity.
Long term objective:

After 3 days of giving
nursing intervention and
health teaching the signif-
icant others will be able to
participate in prescribed
physical activity and
demonstrates increased
activity tolerance.

Independent:
=Determine cause of activity intoler-
ance and determine if its cause is
physical, psychological, or motiva-
tional.

=Monitor and record clients ability
to tolerate activity.
=Teach client the need to pace ac-
tivity ad rest after meals.
=Observe for pain before activity
and, if possible, treat pain before
activity.

=Perform passive range of motion
exercises if client is unable to toler-
ate activity.

=Encourage client to change posi-
tion from supine to sitting several
times daily and to avoid prolonged
bed rest.

Dependent:
Administration of medication de-
pends on physicians order.
Refer to Physical therapies for
further activity.

-Determining the cause of a disease
can help direct appropriate interven-
tions.


-To determine the level of maximum
performance of activity.

-Rest periods decrease oxygen con-
sumption.
-Pain restricts the client from achiev-
ing a maximum activity level and is
often exacerbated by movement.
-Inactivity rapidly contributes to mus-
cle shortening and changes in periar-
ticular and cartilaginous joint struc-
ture.

-Immobilization and enforced bed rest
in the supine position have considera-
ble adverse effects on nearly every
system in the body.

Collaboration with other health care
workers will promote the healing
process of the patient.
Short term objective:

After 8 hours of giving
nursing intervention and
health teaching the sig-
nificant others was able
to verbalize an under-
standing of the need to
gradually increase ac-
tivity based on testing,
tolerance, and symp-
toms. And expresses an
understanding of the
need to balance rest
and activity.
Long term objective:

After 3 days of giving
nursing intervention and
health teaching the sig-
nificant others was able
to participate in pre-
scribed physical activity
and demonstrates in-
creased activity toler-
ance.

Problem: Increased Blood pressure
Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular resistance secondary to atherosclerotic aorta.
Taxonomy: Activity-Exercise Pattern
Cause Analysis: Long standing elevated blood pressure may result in increased stiffness of the vessels walls, leading to vessel injury
resulting inflammatory response within Hypertension can also increase the work of the left ventricle which must pump harder to eject
blood into the arteries, over time, the increased workload causes the heart to enlarge and thicken that may eventually lead to cardiac
failure. (Med. Surg Nursg. 10
th
by Smeltzer and Bare p. 718) Reference: Nurses Pocket Guide Book, 9
th
edition by Doenges et.al p.142
Cues Goal Nursing Intervention Rationale Evaluation

Subjective:
Not applica-
ble




Objective:
BP- 140/100
Restless
Lying in bed










Short term objec-
tive:
After 8 hours
of giving effective
dependent and
independent
nursing care, the
patient will
demonstrate in-
crease perfusion
as evidenced by
decreased BP.

Long term objec-
tive:
Within 3
days giving effec-
tive nursing care,
the patient will
display hemody-
namic stability as
evidenced of BP
within acceptable
range.

Independent:
Identify changes related to systemic peripheral
alterations in circulation.

Elevate head of bed and maintain head neck in
midline or neutral position.

Measure urine output on a regular schedule of
shift provide adequate fluid depending on clients
need.

Cautioned client to avoid activities that increase
cardiac workload. And review ways of avoiding
constipation and encourage quiet, restful atmos-
phere.

Provide for diet restriction and increase frequent
small feedings.

Dependent:
Administration of Medication depends of physi-
cians order:


To assess causative/ contributing
factors

To provide circulation/ venous
drainage

To provide baseline data



Conserves energy and lowers tis-
sue oxygen demands.



To maintain adequate nutrition
and fluid balance.


These medications are cardiac
medication, which is very effective
in-patient with increase BP or
hypertension.

Short term objective:
After 8 hours of
giving effective de-
pendent and inde-
pendent nursing care,
the patient was able to
demonstrate increase
perfusion as evi-
denced by decreased
BP.

Long term objective:
Within 3 days giving
effective nursing care,
the patient was able to
display hemodynamic
stability as evidenced
of BP within
acceptable range

b. Actual Nursing Management (SOAPIE)












S
Sakit dapit sa akong tiyan og akong tiil tungod sa opera, as verbalized by
the client.
O
>Tachypnea
>RR: 24cpm
>Lethargic and restless
>Limited range of motion
A
Ineffective breathing pattern related to post surgical state; pain, muscular
impairment, decreased energy/fatigue
P
After 30 minutes of nursing interventions, the patient will experience less-
ened difficulty of breathing.

I
Maintained patient airway by head tilt, jaw hyperextension, oral
pharyngeal airway.
Observed respiratory rate/depth.
Auscultated breath sounds.
Showed patient how to splint incision. Instruct in effective breathing
techniques.
Elevated head of bed, maintain low-Fowlers position.

E
At the end of 30 minutes of nursing interventions, the patient was able to
experience lessened difficulty of breathing.
S
Sakit dapit sa akong tiyan og akong tiil tungod sa opera,
as verbalized by the client.
O
>Facial grimace, guarding, numbness, pain: pain scale
rated at 7/10 & 8/10.
A

Acute pain related to surgical incision.

P

After 1 hr. of nursing intervention, patient will report pain
relieved/controlled. Appear relaxed, able to rest/sleep.

I
Provided with diversional activity e.g talking with
the patient.
Maintained immobilization of affected part by
means of bed rest.
Encouraged patient to verbalized concerns
Instructed not to move/touched the affected part.
Provided emotional support and encouraged to
perform deep breathing exercises
Assisted in administering Tramadol 100mg IVTT
E
At the end of 1 hr. nursing intervention, the patient was
able to report pain relieved/controlled, appeared relaxed,
and verbalized tolerable level of pain rated 6/10












S
No Subjective cues
O
>Portal of entry of microorganism because of surgical
incision.
A

Risk for infection related to inadequate primary defenses
such as broken skin and traumatized tissues.

P

After 1 hr. of nursing intervention, patient will be able to
demonstrate techniques to prevent risk of infections.

I
Inspected the skin for preexisting irritation or
breaks in continuity.
Instructed patient not to touch the insertion sites.
Stressed proper hand hygiene by all caregivers be-
tween client.
Educated to maintain sterile technique.
Emphasized necessity of taking antivi-
rals/antibiotics as directed.
E
At the end of 1 hr. nursing intervention, the patient was
able to demonstrate techniques to prevent risk of infec-
tions.













HEALTH TEACHINGS
Medications
Instructed client as well as the significant others about the indications and
mechanisms of actions of each drug that the doctor ordered so that without
hesitation they will really comply all the medications given with them.
Adherence to the medication promotes improvement of condition.
Exercise
Encouraged frequent changes of position according to his comfort like sitting
on bed if his body can tolerate and by turning to sides to prevent pneumonia
and bedsores.
Avoid over strenuous activities
Encouraged passive range of motion to promote proper circulation and pre-
vent muscle atrophy/complication brought by immobility.
Instructed also the client at home to balance his daily activities especially
when discharged.
Encouraged patient to do deep breathing exercises/ Relaxation Technique
Treatment
Advised/Emphasized the importance to adhere to treatment regimen. That is
to facilitate faster improvement of present condition and prevent complication.
Bed rest is important to prevent over fatigability then ambulate with in tolera-
ble limits.
Taught the importance of proper hygiene.
Encouraged to do warm compresses in the affected part.
Encouraged to apply lotion such as Johnson lotion and petroleum jelly to his
dry and cracked skin to prevent further skin injury.
Advised to go to their health center for check up monitoring. This should be
done once in the week.
Increased fluid intake up to 6-8 glasses a day.


Outpatient (CHECK-UP)
Instructed the clients family to come back one week after discharged for fur-
ther follow-up and evaluation of the clients health condition. This is very im-
portant so that the health condition of the client will be evaluated if there is
better improvement. The physician should see and examine the physical ap-
pearance of the client.
Diet
Taught the importance of eating green leafy vegetables such as alugbati, ma-
lunggay, saluyot because this will prevent constipation especially at this time
because his peristalsis decreases due to limited movement.
Encouraged low salt intake. The use of salt as a flavoring agent needs to be
controlled because this is usually the cause of fluid retention.
Encouraged intake of vitamin C, such as home made lemonade and oranges
because the patient has post-surgical incision that will aid in healing.
Increased intake of protein because this is important for skin integrity.
Increased intake of fruits and vegetables because this can provide vitamins
and minerals for nutrition.





Precautions should be taken to prevent the bedridden patient with prolonged coma
from the development of decubitus ulcers as well as nococomial infections such as
pneumonia and bladder infections secondary to an indwelling catheter.