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Nursing

Outcomes
SUBJECTIVE
The patient will
report absence of
The patient
pain or a decrease

verbalize I
felt sickly hot The patient will

and weak.
participate in ADLs
The patient
and therapeutic

activities without
verbalize
limitation by pain.
slight
tingling
sensation The patients will
when peeing. report less

Throat pain
respiratory distress
and will participate
in ADLs with
diminishing
OBJECTIVE
dyspnea or
fatigue.
Elevated
temperature( The patients

38.9 degree
weight will be
Celsius)
maintained or

Blood in
weight loss
urine
minimized.

Weak in
a. The patient will
appearance

not develop a
Oxygen
pressure sore.

saturation:

88%
The patient will be
Dyspnea
independent in

Pain scale:10 self-care (feeding,


Weight: From bathing, toileting,

60 kls.-55 kls.
Assessment

Nursing Interventions
PAIN
assessment for the presence and characteristics of pain (location, quality, and
intensity on a 0-to-10 scale, and its aggravating and relieving factors)
administering analgesics and adjuvant agents and evaluating their efficacy
advocating for around-the-clock dosing (versus as-needed dosing) of
analgesics for chronic pain, preferably by the oral route
evaluating and preventing untoward side effects (e.g., constipation from
chronic opiate or tricyclic antidepressant use);
using nonpharmacologic techniques as appropriate, such as assuring
adequate periods of undisturbed rest, positioning, heat and cold applications,
warm baths, massage, and other relaxation techniques
educating the patient and family regarding (a) reporting pain at its onset and
before it becomes disabling, (b) how to use the 0-to-10 scale to rate pain
intensity, (c) reporting uncontrolled or inadequately controlled pain, (d) the
medications used to control pain and for side effect management, and (e)

nonpharmacologic measures to relieve pain.

Symptom Management

FEVER
Drink plenty of fluids (water, juice, noncaffeinated beverages) at least 6-8
glasses per day. Get plenty of rest to conserve
energy and avoid fatigue.
Take tablets or other medicine as directed by
your doctor or nurse to lower your fever or
high temperature.
If you are taking antibiotics, be sure to take
all of the medication (complete the
course).
Take your temperature when you feel sick. If
it is more than 99F (3 8C), take it
again in 3 to 4 hours.
Avoid sponge baths while using fans as these
may cause you to have chills and
shivering. Shivering causes the temperature
IMPAIRED GAS EXCHANGE
to rise even higher and should be avoided
respiratory assessment (e.g., reporting any increased shortness of breath,
when possible.
cough, or chest pain) and pulse oximetry
administering and titrating oxygen to a physician-prescribed oxygen saturation Keep the skin dry and covered.
level
FATIGUE
administering antibiotics and monitoring for side effects
Do small tasks to avoid fatigue.
administering opioids (e.g., morphine) for palliation
Drink energy drinks (cg. Gatorade. Lucozade)
assisting with ADLs
and take oral rehydration solution.
organizing care to provide maximal periods of rest
Rise slowly when waking up sit up first.
repositioning the patient as necessary to facilitate excursion and promote
Drink solution from boiled beetroot.
postural drainage
educating the patient regarding purse-lipped breathing to decrease tachypnea Chew 2 to 3 cloves of garlic three times a day.
When cooking vegetables ensure that they
and anxiety
are not overcooked as vitamins get
preparation for a pulmonary diagnostic work-up.

Advance Care Planning

Spiritual Care

Health care providers can


Facilitating and
assist patients and families
Conducting Prayers
by
(a.)discussing the benefits of The nurse will
health care and social
facilitate prayers
support programs,
for patients by
unemployment insurance,
finding space and
workers compensation,
time for praying.
pension plans, insurance,
and union or association
The patient will
benefits;
strongly expressed
prayers to help
(b.)emphasizing the
them in enhancing
importance of organizing
hope and bringing
information and documents
harmony among
so that they are easily
mind, soul, and
located and accessible;
body, and
consequently in
(c.)suggesting that financial
attaining serenity
matters be in order, such as
and inner healing.
power of attorney or bank
accounts, credit cards,
Reading of Holy
property, legal claims, and
Scriptures
income tax preparation;
The nurse may sit with
(d.) discussing advance
her patients and
directives or power of
reads, and refers to
attorney for care and
relevant passages
treatment, as well as
from the Bible or
decisions
encourage the
related to the chosen setting
patient to read

Co Morbid Management

Evaluation

The patients pain


TUBERCULOSIS
level decreases
Diagnostic: Smear-negative, culturefrom scale of 10
positive TB for advanced
to 2.
immunosuppression. Bronchoscopy with
The patient was able
bronchoalveolar lavage & transbronchial
to participate in
biopsy may be useful in the evaluation of
ADLs.
persons with abnormal chest radiograph
The patient was able
imagery when sputum smear results are
to breathe without
negative.
any distress.
The patient weight
Treatment: The first 2 months of treatment
loss was
is often referred to as the intensive phase,
minimized, from
and typically entails the use of 4 drugs-previous 55 kls to
rifampin (or other rifamycin), Isoniazide,
57 kls.
pyrazinamide, and ethambutol--followed
The patient wasnt
by 4 months (called the continuation phase)
able to develop
with rifampin and Isoniazide alone.
bedsore.
as long as the regimen contains Isoniazide The patient was able
and a rifamycin for the duration of TB
to fed, bathe
treatment. As for HIV-uninfected individuals,
himself.
the standard recommendation for HIVThe patient was able
coinfected individuals with pulmonary TB is
to ambulate
a 6-month course of treatment, with
without
extension to 9 months for patients with
assistance.
cavitary lung disease and culture positivity at
2 months of TB treatment.

PNEMUCCOCAL INFECTION
Diagnostic: the sputum Gram's stain-

Latest:57 kls. mobility).


The patient will not IMBALANCED NUTRITION LESS THAN BODY REQUIREMENT

harm self or others


assessment and ongoing monitoring of weight, intake and output, ability to feed
during
hospitalization.
oneself, ability to swallow, symptoms interfering with food and fluid intake,
The patient will get
orthostatic V.S., skin turgor, and cultural food preferences

out of bed,
feeding the patient and encouraging oral intake
transfer, or
administering intravenous hydration, appetite stimulants, antidiarrheals, and
ambulate.
antiemetics as ordered
advising the physician of uncontrolled symptoms that interfere with intake and

advocating for work-up and/or symptomatic control


obtaining consultations from a dietician for specific diet prescriptions
educating the patient regarding adequate fluid intake (at least 2 to 3 liters/day);
the role of nutrition in acute illness recovery; and the clinically significant drug
nutrient interactions
encouraging family and friends to bring the patient's favorite foods.

IMPAIRED SKIN INTEGRITY


assessing pressure ulcer risk factors, condition of the skin, and presence of
wound(s), as well as wound size, location, condition of surrounding tissue,
evidence of granulation, odor, amount and color of drainage, and current skin
and wound care regimens;
initiating pressure ulcer prevention activities if the patient is at risk (e.g.,
establishing a turning schedule if the patient is unable to turn in bed, providing
pressure-relieving mattresses or special beds, and instituting a bladder
training program as appropriate)
consulting with a dietician or nutritionist to determine the need for nutritional
support
consulting with the nursing wound care specialist, if available, regarding
appropriate wound cleaning and dressing plan

destroyed.
Try relaxing or stress-reducing activities such
as deep-breathing exercises, meditation,
personal quiet time, massage. listening to
music or relaxation tapes, getting involved in
activities (e.g. volunteer work) taking walks
Eat more of the following foods: oatmeal and
other whole grain cereals, fruit and raw
vegetables, whole grain baked goods
yoghurt and low or non-dairy products.
Limit the following foods: sugary & fast foods
and other high fat foods. Reduce alcohol
and caffeine intake, as these tend to make
you sluggish later.
Develop a routine of going to bed in the
evening and getting up each morning at the
same time. A good night s sleep can help
you think more clearly. Naps are okay. But
keep them short and early in the day.
Avoid or reduce your use of alcohol and other
mood-altering non-prescription drugs (eg..
cocaine, speed. dagga. glue)
NIGHT SWEATS
Keep your skin warm and dry.
Wear light cotton clothing and use fewer
blankets.
open windows to allow ventilation and fresh
air.
Drink plenty of fluids (water. juice. noncaffeinated beverages) at least six to
eight glasses per day.
Drink cold water.

for dying;
(e.) discussing the patients
wishes regarding their death

Whom does the patient


want at the bedside?
What rituals are important to
the dying patient?
Does the patient wish an
autopsy?
What arrangements does the
patient want regarding the
funeral services and burial?
Where donations in
remembrance should be
sent?
It is important to realize that
these issues should be
discussed at relevant stages
in the persons illness, in a
manner that is both
respectful to the patients
wishes and strengths and
that promotes the patients
sense of control over his or
her life and death.
Health care providers must
also understand the concept
of competency, a state in
which the person is capable
of taking Iegal acts,
consenting or refusing

bible.
The patient will
thought that reading
Holy Scriptures
promoted hope and
peace
.
Pastor Consultation
Organizing a visit from
a pastor (or priest)
so that the patient
will be blessed.
Encouraging Patients
to Trust
God/Supreme
Being/Creator.
The nurse may give
an advice to the
patient about having
a strong faith for the
patient's healing.
Demonstration of
Love, Compassion,
and Forgiveness

The nurse may


emphasize the
goodness of love,
compassion and

there are few epithelial cells, many


polymorphonuclear leukocytes, predominant
bacterial morphology. Blood cultures are
very specific and clinicians should obtain
them in all HIV-1 infected patients suspected
of having serious pneumococcal infection.
Treatment: HIV-1 seropositive patients with
moderate to severe pneumococcal
pneumonia should be hospitalized and
treated with parenteral antimicrobial
agents. For hospitalized patients with
documented penicillin-sensitive (MIC <0.1
micrograms/mL) pneumococcal pneumonia,
penicillin (500,000 to 2,000,000 units
intravenously every 4 to 6 hours) is the drug
of choice. Alternative antibiotics would
include ampicillin, first generation
cephalosporins, macrolides, and
clindamycin. Milder cases of communityacquired pneumococcal pneumonia may be
treated with an oral regimen as an
outpatient: oral penicillins, first or second
generation cephalosporins, or macrolides
would be appropriate. Most patients should
be treated for approximately 10 days. The
duration of therapy is the same regardless of
whether or not the patient received
intravenous or oral regimens.
CANDIDIASIS
Diagnostic: Oropharyngeal cultures often
demonstrate Candida species, but alone are
not diagnostic because colonization is

educating the patient or in-home caregiver regarding the skin and wound care
regimen
advocating for rehabilitation consultation, if appropriate, to increase the
patient's mobility
consulting with the social worker or discharge planner regarding the patient's
continuing wound care needs after discharge.

Sponge yourself with tepid water.


Change your clothing and linen regularly.
Place a towel over your pillow in cases of
profuse sweating.
After you wake up. towel dry, apply lotion to
your skin, and then put on dry clothes.
Have a change of clothes or dry linen nearby.
especially when sweats occur at night.
Talk to your doctor or nurse about taking any
medication before going to bed at night

SELF CARE DEFICIT


assessing the patient's ability to perform ADLs (self-care ability), motor and
sensory function, bowel and bladder management, and other symptoms
interfering with patient's ability to manage ADLs
assisting with those areas the patient cannot manage independently
obtaining needed supplies and equipment

advocating for aggressive symptom management


recommending rehabilitation consultation as appropriate
identifying the patient's continuing care needs, including the need for
placement after discharge
educating the patient/caregiver regarding ADL management - that is, bathing,
transfers (e.g., from sitting to standing, from bed to chair), using such assistive

devices as a cane or walker, eating, bowel and bladder management, and


medication management.

PSYCHOSOCIAL CONCERNS/ INEFFECTIVE COPING


assessing and monitoring on an ongoing basis for the concerns such as
patients with dual and triple diagnoses (HIV infection, substance use, and
psychiatric illness) will require more intensive interventions.

determining previous coping strategies, beliefs and concerns regarding illness,


previous hospital experiences, and ability to communicate needs and to ask
for help

determining access to basic services


creating an environment of acceptance and respect for human dignity

treatment, writing a will or


Power of attorney.

forgiveness to the
patient.
Taking interest and
listening actively
and being present
were important
aspects of a
human interaction.
Demonstrating
empathy and
sympathy helps
patients cope with
illness.

In assessing the patients


competency, the health
provider must
a) question whether the
decision maker knows
the nature and effect of

the decision to be made.


(b.)understands the
consequences of his or
SHORTNESS OF BREATHE
her actions,
Try relaxing or stress-reducing activities such
(c.)determine if the decision
as deep-breathing exercises, meditation,
is consistent with an
Maintaining and
personal quiet time, massage, listening to
individual's life history,
Demonstrating Moral
music or relaxation tapes, getting involved in
lifestyle, previous actions, and Ethical
activities (e.g. volunteer work), taking walks,
and best interests.
Behaviour
leisure reading taking a warm bath. Tal-Chi
When an individual is
etc.
competent, and in
The Nurse should
Sit up straight to expand the chest as much as
anticipation of the future
demonstrate moral
possible.
loss of competency, he or
and ethical
Take a walk daily at your own pace in your
she may initiate advance
behaviours such as
home or outside. Muscles that are weak
directives such as a living
being polite,
from lack of activity or exercise can make
will and/or the designation
honest, faithful,
you feel short of breath with any movement.
of a health core proxy,
and respectful of
Routine exercise can reduce your shortness
who will carry out the
individuals
of breath related to muscle weakness.
patients health care
regardless of
Try to use these breathing strategies. The key
wishes or make health
religious beliefs
is to inhale and breathe out slowly where
care decisions in the event
were considered
possible.
that the patient becomes
spiritual care
Pursed Lips Breathing: Breathe in normally
incompetent.
interventions.
through the nose while counting s-l-o-w-l-y
to two; purse lips, as if about to whistle:
The patient may also give an Counseling and

common. The diagnosis of OPC can be


confirmed by examining a 10% potassium
hydroxide (KOH) slide preparation of a
scraping from an active lesion.
Pseudohyphae and budding yeast are
characteristic findings.
Treatment:Classes of antifungal agents
include polyenes (nystatin and
amphotericin B), which bind to ergosterol in
the fungal cell membrane and induce
osmotic instability and loss of membrane
integrity; azoles, including the imidazoles
(clotrimazole) and triazoles (ketoconazole,
itraconazole, fluconazole, voriconazole,
ravuconazole, and posaconazole), which
inhibit fungal cytochrome P450-dependent
enzymes, resulting in the impairment of
ergosterol biosynthesis and depletion of
ergosterol from the fungal cell membrane;
pyrimidine synthesis inhibitors, including
5-fluorocytosine (flucytosine), which inhibits
DNA and RNA synthesis in fungal
organisms; and the echinocandins
(caspofungin, micafungin and
anidulafungin), cyclic lipopeptides that
inhibit beta-1:3 glucan synthase, an enzyme
involved in fungal wall cell biosynthesis
HERPES SIMPLEX VIRUS
Diagnosis: Polymerase chain reaction
(PCR) testing of samples taken from
mucocutaneous lesions yields consistently
higher rates of HSV detection than does viral

determining the patient's knowledge of illness and treatment while providing


accurate information appropriate to a patient's understanding
encouraging honest, consistent communication between hospital staff and the
patient and the patient's self-identified support system
referring the patient to a social worker for assistance with basic services (e.g.,
housing, food) and community resources (e.g., delivered meals, volunteer
services for chores or support)
referring the patient to counselors and/or a chaplain for psychosocial support
and spiritual counseling if indicated
monitoring for any maladaptive response, such as suicidal ideation, verbal
threats, or assaultive behavior; setting explicit, appropriate behavioral limits;
protecting the patient, self, and others (calling security if there is a threat of
violence); and consulting with a physician for psychiatric evaluation and or
chemical restraints
providing patient opportunities for choice as much as possible;
referring the patient with a history of substance use to a substance abuse
counseling service if the patient agrees and such a service is available,
monitoring for signs and symptoms of intoxication and or withdrawal,
advocating for symptom control, and relying on protocol to manage the person
who is using drugs or alcohol in-house
for patients expected to die in the hospital, activating the nursing standard of
care for the adult dying patient and subsequent section concerning the dying
patient).

breathe out slowly through your pursed lips


(take twice as long as you did to breathe in count slowly to four).
Controlled or Paced Breathing: This is the
use of Pursed Lips Breathing with activities
which make you winded, such as climbing
stairs, walking quickly or lifting heavy
objects. The key is to inhale slowly (at rest if
possible) and exhale through pursed lips
while performing the work. Focus on
breathing out slowly and evenly.

RISK FOR FALL/ INJURY


assessing for fall risk factors (e.g., confusion, mobility problems, incontinence,

orthostatic hypotension)
informing all other caregivers about patients at risk for fall
instructing the patient and family to request assistance when the patient is

transferring (e.g., from bed to chair) or ambulating


keeping the call light, bedpan, urinal, and belongings within the patient's reach
keeping the bed in low position with side rails up

increasing direct observations and, if necessary, moving the patient's room

individual the power of


Reassurance
attorney regarding financial
matters and care or
The nurse will counsel
treatment issues, advance
and provide
directives include the
reassurance to
patients decisions
patients as
regarding such lifesignificant spiritual
sustaining treatments as
care interventions.
cardiopulmonary
(eg..making a
resuscitation, use of
patient pain free,
vasoactive drips to sustain
and reducing
blood pressure and heart
patients fears
rate, dialysis, artificial
related to surgery)
nutrition and hydration, and
the initiation or withdrawal
of ventilator support.

WEIGHT LOSS
Eat and drink a lot.
Eat frequent, small meals.
Take multivitamins.
Add garlic to your food.
The signing of advance
Keep track of your weight by weighing
directives must be
yourself or by looking for changes in the way
witnessed by two
your clothes fit.
individuals who are not
Cook and eat with friends or family to make
related to the patient or
meals enjoyable.
involved in the patients
Eat high-protein high-calorie foods and
treatment.
snacks such as peanut butter and jelly,
sandwiches, crackers and cheese, pudding Individuals who are mentally
and yoghurt.
competent can revoke at
Add instant breakfast drinks, milk shakes or
any lime their advance
other supplements to your diet and drink
directives. If a patient is
them any time of the day.
deemed mentally
Take a multivitamin with at least 100%
incompetent, state statutes
Recommended Daily Allowance (RDA)
may allow the court to
every day.
designate a surrogate
Keep foods that are easy to prepare on hand
decision-maker for the

culture analysis.For asymptomatic


individuals, type-specific serologic testing
based on glycoprotein G can accurately
distinguish HSV-1 and HSV-2 infections with
high sensitivity and specificity.
Treatment: The nucleoside analogues
acyclovir, valacyclovir, and famciclovir inhibit
HSV-1 and HSV-2 replication through
specific inhibition of a virally encoded
thymidine kinase. More than 2 decades of
experience with acyclovir (now available in
generic formulations) has demonstrated that
these compounds are safe and effective for
treatment of HSV reactivation. Antiviral
chemotherapy provides clinical benefits both
as episodic treatment of symptomatic
patients and as suppressive therapy for
prevention of recurrent disease.

nearer to the nurses' station


(e.g.. frozen and canned foods).
offering frequent assistance with ADLs
Eat fresh thins and vegetables.
using safety devices (e.g., bed alarms)
consulting with the physician regarding need for sedation or physical restraints
if the patient is a danger to himself or herself and one-on-one observation is
impossible; providing the necessary care, support, and monitoring if physical
restraints are used.

patient.