ASTHMA


Major Side Effects Nursing Intervention
albuterol, terbutaline (theophyline tremor dizziness palpitation -do not exceed prescribed dose -notify physician if client becomes non-responsive to usual dose
theophyline arrhythmias, seizures - monitor vital signs -maintenance: teach client to take at regular intervals during day
corticosteroids cushing's syndrome - do not discontinue abruptly (may trigger adrenal insufficiency crisis)

ANTIARRHTHMIC DRUGS

- all antiarrhythmics have the potential to worsen arrhythmia ->bradycardias, tachycardias, hypotension - instruct client to take exactly as prescribed


Major Side Effects Nursing Intervention
procainamide reversible lupus erythematosus -discontinue, under medical supervision if lupus occurs
phenytoin gingival hyperplasia -teach client proper mouth and dental care
quinidine potentiates digitoxin toxicity -monitor apical heart rate and blood pressure -monitor ECG

ANTICOAGULANTS


Antagonist (in case of Overdose) Nursing Interventions
heparin (immediate effect) protamine sulfate -do not give IM(hematoma and pain) -watch for bleeding, bruises -teach client to avoid aspirin -monitor partial thromboplastin time (PTT)
warfarin (takes 4-5 days for full effect) oral vitamin k -watch for bleeding, bruises -teach client to avoid aspirin -if ongoing therapy: client should carry medical alert card -monitor prothrombin time (PT)
streptokinase, urokinase (to dissolve thrombi) aminocaproic acid -risk of severe bleeding have blood available for transfusion

INOTROPIC DRUGS

- increased strength of cardiac contraction -> increased stroke volume -> increased cardiac output


Major Side Effects Nursing Intervention
digoxin, digitoxin low therapeutic index!!! (= high risk of toxicity -take apical pulse for full minute, monitor ECG -don't give if hearth rate is low (<60bpm) -monitor potassium levels (risk of enhanced toxicity)
dobutamine, dopamine hypertension, headache, angina -alert physician if arrhythmia, chest pain or dyspnea occur
extracardiac: -nausea, abdominal pain -fatigue -confusion, disorientation -color misperception: yellow halos cardiac: - AV block, arrhythmias Toxicity of DIGITALIS is enhanced by: >hypokalemia >alkalosis >hypoxia

DIURETICS


Major Side Effects Nursing Intervention
furosemide (loop diuretics) hypokalemia -recommend foods rich in potassium: bananas, prunes... -watch for signs of hypokalemia: muscle weakness, cramps
thiazides hypokalemia hyperglycemia -recommend foods rich in potassium: bananas, prunes... -watch for signs of hypokalemia: muscle weakness, cramps -monitor blood glucose
spirinolactone (potassium sparing) gynecomastia menstrual irregularity -clients need to be advised of possible endocrine effects -teach client to avoid excessive dietary potassium
mannitol (osmotic diuretic) transient plasma volume increase -monitor vital signs and central venous pressure
potensiates digitalis toxicity .

NITRITES


Major Side Effects Nursing Intervention
nitroglycerin. ISDN headache, dizziness orthostatic hypotension -occasional headache: aspirin or acetaminophen -frequent headache: may have to adjust dosage -instruct client to rise slowly from sitting position -instruct client to protect drug from light, heat and moisture

Care Plan

Alteration in Bowel Elimination: Constipation

Alteration in Bowel Elimination: Diarrhea

Activity Intolerance

Alteration in Comfort: Pain

Alteration in Family Processes

Alteration in Health Maintenance

Alteration in Nurtition: More Than Body Requirement

Alteration in Nutrition: Less Than Body Requirement

Alteration in Parenting

Alteration in Patterns of Urinary Elimination: Inc...

Alteration in Patterns of Urinary Elimination: Ret...

Alteration in Sensory Perceptual

Alteration in Thought Processes

Alterations in Cardiac Output: Decreased

Altered Growth and Development

Altered Sexuality Patterns

Anxiety

Comfort: Chest Pain

Discharge Care Plan

Disuse Syndrome

Diversional Activity Deficit

Fluid Volume Deficit

Fluid Volume Excess

Greiving

Hyperthermia

Hypothermia

Impaired Adjustment

Impaired Gas Exchange

Impaired Home Maintenance Management

Impaired Physical Mobility

Impaired Skin Integrity

Impaired Social Interaction

Impaired Verbal Communication

Ineffective Airway Clearance

Ineffective Breathing Patterns

Ineffective Individual Coping

Knowledge Deficit

Noncompliance

Potential for Infection

Powerlessness

Rape Trauma Syndrome

Self Care Deficit: Bathing

Self Care Deficit: Dressing and Grooming

Sleep Pattern Disturbance

Social Isolation

Spiritual Distress

Violence

Violence

Violence

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Acute agitation
(_) Poor impluse coordination
(_) Mania
(_) Feelings of helplessness
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) History of harm to others (_) Destruction of property
(_) Overt aggressive acts
Minor:
(
May be present)
(_) Acute agitation (_) Suspiciousness (_) Persecutory delusions (_) Inflexible
(_) Verbal threats of physical assault (_) Low frustration tolerance
(_) Poor impulse control (_) Feelings of helplessness (_) Excessively controlled

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Experience control of behavior with assistance from others.

(_) Describe causation and possible preventative measures.

(_) Other:

(_) Assess patient's potential for violence and past history.

(_) Maintain patient's personal space, (i.e. allow 5 times greater space than that for individual in control).

(_) Seclusion: Check q _____

(_) Restraints:__________ Check q ___

(_) Set limits:_____________________

(_) Decrease noise level.

(_) Provide environment that provides safety and reduces agitation:
________________________
________________________

(_) Acknowledge feelings.

(_) Explore the precipitating event.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Spiritual Distress

Spiritual Distress

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Pain
(_) Trauma
(_) Loss of body part/function
(_) Terminal illness
(_) Death of s/o
(_) Unable to practice religious rituals
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Experiences a disturbance in belief system.
Minor:
(
May be present)
(_) Questions credibility of belief system.
(_) Demonstrates discouragement or despair.
(_) Is unable to practice usual religious rituals.
(_) Has ambivalent feelings (doubts) about beliefs.
(_) Expresses that he/she has no reason for living.
(_) Feels a sense of spiritual emptiness.
(_) Shows emotional detachment from self and others.
(_) Expresses concern, anger, resentment, fear - over the meaning of life, suffering, death.
(_) Requests spiritual assistance for a disturbance in belief system.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Continue spiritual practices not detrimental to health.

(_) Express decreasing feelings of guilt and anxiety.

(_) Express satisfaction with spiritual condition.

(_) Other:

(_) Assess current level of spiritual state: Comfort, distress, desire for minister, priest, rabbi to visit, desire to practice religious rituals.

(_) Implement patient requests regarding spiritual needs.

(_) Contact spiritual/religious advisor of patients choice.

(_) Discuss impact of stress on challenging one's spiritual beliefs.

(_) As patient desires, allow opportunity to discuss belief system, the meaning of illness/suffering within this system.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Social Isolation

Social Isolation

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Death of s/o
(_) Divorce
(_) Substance abuse
(_) Illness:____________________________
____________________________________
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Expressed feelings of unexplained dread or abandonment
(_) Desire for more contact with people
Minor:
(
May be present)
(_) Time passing slowly (_) Inability to concentrate and make decisions
(_) Feelings of uselessness (_) Doubts about ability to survive

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Identify the reasons for his/her feelings of isolation.

(_) Identify ways of increasing meaningful relationships.

(_) Identify appropriate diversional activities.

(_) Other:

(_) Encourage patient to verbalize feelings.

(_) Assist to identify causative and contributing factors.

(_) Assist to reduce or eliminate causative and contributing factors:
________________________
________________________
________________________

(_) Assist to identify diversional activities. (See Diversional Activity Deficit)

(_) Initiate referrals as needed or increase social relationships:
________________________
________________________
________________________

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Sleep Pattern Disturbance

Sleep Pattern Disturbance

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Impaired oxygen transport
(_) Impaired elimination
(_) Impaired metabolism
(_) Immobility
(_) Medication
(_) Hospitalization
(_) Lack of exercise
(_) Anxiety response
(_) Life-style disruptions
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Difficulty falling or remaining asleep
Minor:
(
May be present)
(_) Fatigue on awakening or during the day
(_) Dozing during the day (_) Agitation (_) Mood alterations

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Demonstrate an optimal balance of rest and activity A.E.B. ___ hours of uninterrupted sleep at night.

(_) Remain awake during the day.

(_) Other:

(_) Explore with patient potential contributing factors.

(_) Maintain bedtime routine per patient preference.

  • Likes to go to bed @ ___ pm.
  • Prefers quiet
  • Darkness
  • Night light
  • Music

(_) Takes sleeping pill as ordered by a physician @ ____ pm.

(_) Provide comfort measures to induce sleep:

  • Back rub
  • Herbal tea-warm milk
  • Pillows for support
  • Bedtime snack when appropriate.
  • Pain medication if needed.
  • Other:

(_) Limit nighttime fluids to:________

(_) Void before retiring.

(_) Coordinate treatment/meds to limit interruptions during sleep period.

(_) Limit the amount and length of daytime sleeping:____________

(_) Increase daytime activity:______
________________________
________________________
________________________

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Self Care Deficit: Dressing and Grooming

Self Care Deficit: Dressing and Grooming

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Neuromuscular impaitment:___________________________
(_) Impaired visual actuity
(_) Immobility
(_) Weakness
(_) Decreased level of consciousness
(_) Other:___________________________________________
___________________________________________________
___________________________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Impaired ability to put on or take off clothing.
(_) Unable to obtain or replace article of clothing.
(_) Unable to fasten clothing.
(_) Unable to groom self satisfactorily

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Demonstrate increased ability to dress/groom self.

(_) Demonstrate ability to cope with the necessity of having someone else assist him/her in performing the task.

(_) Demonstrate ability to learn how to use adaptive devices to facilitate optimal independence in the task of dressing/grooming.

(_) Other:

(_) Allow sufficient time for dressing and undressing, since the task may be tiring, painful, and difficult.

(_) Promote independence in dressing through continual and unaided practice.

(_) Choose clothing that is loose fitting, with wide sleeves and pant legs, and front fasteners.

(_) Lay clothes out in the order in which they will be needed to dress.

(_) Avoid placing clothing to blind side if patient has field cut, until patient is visually accommodated to surroundings; encourage patient to turn head to scan entire visual field.

(_) Consult/refer to PT/OT for teaching application of prosthetics.

(_) Provide dressing aids as necessary (dressing stick, swedish reacher, zipper pull, button-hook, long handled shoehorn, shoe fasteners adapted with elastic laces, velcro closures, flip back tongues).

(_) Plan for person to learn and demonstrate one part of an activity before progressing further.

(_) Make consistent dressing/grooming routine to provide a structured program to decrease confusion.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Self Care Deficit: Bathing

Self Care Deficit: Bathing

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Neuromuscular impairment
(_) Visual disorders
(_) Trauma or surgical procedure
(_) External devices
(_) Aging process
(_) Musculoskeletal disorders
(_) Immobility
(_) Nonfuntioning or missing limbs
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Unable or unwilling to wash body or body parts.
(_) Unable to obtain water.
(_) Unable to regulate temperature or water flow.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Perform bathing activity at expected optimal level.

(_) Demonstrate use of adaptive devices for bathing.

(_) Other:

(_) Assess for causative factors.

(_) Provide opportunities to relearn or adapt to activity.

(_) Teach patient to use affected extremity to accomplish tasks.

(_) Consistent bathing routing at ___ am/pm every day.

(_) Provide as much privacy as possible by pulling curtains and closing doors.

(_) Provide equipment within easy reach.

(_) Encourage independence.

(_) Reinforce success for task accomplished.

(_) OT consult for:

  • Adaptive devices
  • Safety measures for home
  • Other:

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Rape Trauma Syndrome

Rape Trauma Syndrome

(_)Actual (_) Potential

Related To:
[Check those that apply]
Somatic Response:
(_) Gastrointestinal irritability (N/V, anorexia)
(_) Genitourinary discomfort (pain, puritus)
(_) Skeletal muscle tension (spasm, pain)
(_) Other:___________________________
___________________________________
Sexual responses:
(_) Mistrust of men (if victim is woman)
(_) Change in sexual behavior
Other:_____________________________
__________________________________
Psychological responses:
(_) Denial
(_) Emotional shock
(_) Anger
(_) Fear
(_) Guilt
(_) Panic on seeing assailant or scene of attack
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Reports or evidence of sexual asault
Minor:
(
May be present)
If the victim is a child, parent(s) may experience similar responses:
Acute Phase:
  • Somatic responses: Gastro-intestnal irritability (N/V, anorexia) Genitourinary discomfort (pain, pruritus) Skeletal muscle tension (spasm, pain)
  • Psychological responses: Denial, emotional shock, anger, fear of being alone or that the rapist will return [a child victim will fear punishment, repercussions, abandonment, rejection] guilt, panic on seeing assailant or scene of attack
  • Sexual responses: Mistrust of men (if victim is a woman), change in sexual behavior.

Long term phase:

  • Any response of the acute phase may continue if resolution does not occur.
  • Psychological responses: Phobias, nightmares, or sleep disturbances

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Experience decreased symptoms of:

(_) Discuss assult.

(_) Express feelings concerning the assault and the treatment.

(_) Identify members of support system and utilize them appropriately.

(_) Return to pre-crisis level of functioning.

(_) Other:

(_) Assess for psychological responses:
  • Phobias
  • Denial
  • Anger
  • Depression
  • Guilt
  • Other:

(_) Inspect urine and external genitalia for bleeding.

(_) Observe patient's behavior carefully and record objective data.

(_) Promote trusting relationship.

(_) Provide crisis counseling within one hour of rape trauma event.

(_) Help patient meet personal needs of:
________________________

(_) Allow patient to express feelings.

(_) Discuss with patient previous coping mechanisms.

(_) Explore with patient her/his strengths and resources.

(_) Offer feedback to patient on feelings verbalized.

(_) Explore sexual concerns with patient.

(_) Initiate health teaching and referrals as necessary.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Powerlessness

Powerlessness

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Inability to communicate:________________________
(_) Inability to perform ADL:________________________
(_) Inability to perform role responsibilities:_____________
______________________________________________
(_) Progressive debilitating disease:_________________
(_) Hospital or institutional limitations:_________________
______________________________________________
(_) Other:______________________________________
______________________________________________
______________________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Overt or covert expressions of dissatisfaction over inability to control situation. (exg: illness, prognosis, care, recovery rate)
Minor:
(
May be present)
(_) Refuses or is reluctant to participate in decision-making (_) Apathy (_) Resignation
(_) Aggressive/violent/acting out behavior (_) Anxiety (_) Uneasiness (_) Depression

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Identify factors that can be controlled:

(_) Makes decisions regarding treatment and future when possible.

(_) Other:

(_) Assess causative or contributing factors.

(_) Assess patient's usual response to problems:

  • Internal - how individual makes own changes
  • External - expects others to control problems or leaves to fate, or luck

(_) Increase communication

  • Explain all procedures and..
  • Treatments
  • Medications
  • Results of labs/tests
  • Condition
  • All changes
  • Rules
  • Options
  • Other:

(_) Allow time to answer questions (15 min. ea shift)

(_) Realistically point out positive changes in person's condition.

(_) Allow patient to make as many decisions as possible.

(_) Provide opportunities for patient and family to participate in care.

(_) Encourage participation from patient who depends on others to make own decisions.

(_) Encourage patient to verbalize feelings and concerns.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Potential for Infection

Potential for Infection

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Alteration in skin integrity:___________________________
__________________________________________________
(_) Bone marrow depression.
(_) Indwelling catheter:________________________________
(_) Nutritional deficiencies:______________________________
__________________________________________________
(_) Surgical/invasive procedures:________________________
__________________________________________________
(_) Other:__________________________________________
_________________________________________________
__________________________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Altered production of leukocytes.
(_) Altered immune response.
Minor:
(
May be present)
(_) Altered circulation.
(_) Presence of favorable conditions for infection.
(_) History of infection.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Remain infection free A.E.B.:

(_) Demonstrate complete recovery from infection A.E.B.:

(_) Other:

(_) Assess temperature q ___ hrs.

(_) Inspect and record signs of erythema, induration, foul smelling drainage, from or around wound, skin, invasive line, mouth/throat, or other site q ___ hrs.

(_) Asses for cloudiness of urine q ___ hrs.

(_) Report abnormal changes in WBC count and/or pathogenic growth on cultures.

(_) Utilize good handwashing techinque.

(_) Visitors and health care workers with active infection are to avoid contact with patient.

(_) Avoid invasive prodecures; i.e. rectal temperatures, bladder catheters, etc.

(_) Encourage high protein/high carbohydrate foods/fluids when indicated.

(_) Explore with patient potential etiological factors which potentiate infection and include appropriate health teaching.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Noncompliance

Noncompliance

(_) Exercise (_) Follow-up Care (_) Medication (_) Other

Related To:
[Check those that apply]
(_) Chronic illness
(_) Fatigue
(_) Depression
(_) Non supportive family
(_) Inadequate/incomplete instructions
(_) Denial of Dx
(_) Side effects of therapy/med
(_) Impaired ability to perform tasks
(_) Expensive therapy
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Verbalization of non-compliance or non-participation or confusion about thrapy and/or
(_) Direct observation of behavior indicating non-compliance
Minor:
(
May be present)
(_) Missed appointments (_) Partially used or unused medications
(_) Progression of disease process. (_) Persistance of symptoms

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Demonstrate compliance with:

(_) Other:

(_) Assess patient's:
  • Understanding of disease process
  • Barriers to compliance
  • Life-style
  • Support system
  • Perception of non-compliance
  • Other:

(_) Allow patient and s/o to verbalize feelings about situation/

(_) Adapt regime to patient's level of comprehension.

(_) Involve patient - s/o in planning compliance.

(_) Emphasize positive aspects of compliance.

(_) Instruct patient - s/o about meds:

  • Side effects
  • Dosage
  • Other:

(_) Set goals with patient.

(_) Consult with:

  • PT
  • OT
  • Home Health
  • Social Services

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Knowledge Deficit

Knowledge Deficit

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) New diagnosis:_____________________________
(_) Language differences:________________________
(_) Hospitalization
(_) Diagnostic test:_____________________________
(_) Surgical procedure:__________________________
(_) Medications:_______________________________
(_) Pregnancy
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Verbalizes a deficiency in knowledge or skill. (_) Requests information.
(_) Expresses and inaccurate perception of health status.
(_) Does not correctly perform a desired or prescribed health behavior.
Minor:
(
May be present)
(_) Lack of integration of treatment plans into daily activities.
(_) Exhibits or expresses psychological alteration, (anxiety, depression) resulting from misinformation or lack of information.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Describe disease process, causes, factors contributing to symptoms.

(_) Describe procedure(s) for disease or symptom control.

(_) Identify needed alterations in lifestyle.

(_) Other:

(_) Assess patient's readiness to learn by assessing emotional respose to illness:
  • Acceptance
  • Anger
  • Anxiety
  • Denial
  • Depression
  • Other:

(_) Allow person to work through and express intense emotions prior to teaching.

(_) Examine patient's health beliefs:
________________________
________________________

(_) Assess patient's desire to learn.

(_) Assess preferred learning mode:

  • Auditory
  • Group
  • One to one
  • Visual
  • Other:

(_) Assess literacy level.

(_) Provide health teaching and referrals: ___________________
________________________
________________________
________________________

(_) Plan and share necessity of learning outcomes with patient - s/o.

(_) Evaluate patient - s/o behaviors as evidence that learning outcomes have been achieved:
________________________
________________________
________________________

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Ineffective Individual Coping

Ineffective Individual Coping

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Illenss:____________________________
____________________________________
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Change in usual communication patterns (in acute).
(_) Verbalization of inability to cope.
(_) Inappropriate use of defense mechanisms.
(_) Inability to meet role expectations.
Minor:
(
May be present)
(_) Anxiety (_) Reported life stress. (_) Inability to problem-solve.
(_) Alteration in social participation. (_) Destructive behavior toward self or others.
(_) High incidence of accidents. (_) Frequent illnesses.
(_) Verbalization of inability to ask for help. (_) Verbal manipulation.
(_) Inability to meet basic needs.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Verbalize feelings related to emotional state.

(_) Identify individual strengths.

(_) Identify coping mechanisms (new and old).

(_) Utilize effective coping mechanisms as evidenced by:

(_) Other:

(_) Encourage verbalization of feelings, perceptions, and fears.

(_) Assist to set realistic goals.

(_) Encourage independence by:
________________________
________________________
________________________

(_) Assist with identification of petential solutions to present problems.

(_) Consult with:

  • Pastoral care
  • Social services
  • Psych services
  • Other:

(_) Identify problems that cannot be controlled.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Ineffective Breathing Patterns

Ineffective Breathing Patterns

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Allergic response
(_) Anesthesia
(_) Aspiration
(_) COPD
(_) Decreased lung compliance
(_) Fatigue
(_) History of smoking
(_) Immobility
(_) Medications (narcotics, sedatives, analgesics)
(_) Neuromuscular impairment (eg. MS, Guillain-Barre)
(_) Surgery or trauma
(_) Pain
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Changes is respiratory rate or pattern from baseline.
(_) Changes in pulse (rate, rythm).
Minor:
(
May be present)
(_) Orthopnea (_) Tachypnea (_) Hyperpnea
(_) Splinted, guarded respirations.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Demonstrate an effective respiratory rate, depth, and pattern A.E.B.:

  • Color pink/ absence of cyanosis.
  • Absence of diminished breath sounds.

(_) Other:

(_) Assess color, respiratory rate, depth, effort, rythm and breath sounds q ___ hours.

(_) Position to facilitate optimum breathing patterns:

  • HOB elevated ___ degrees.
  • Turn q ___ hours.

(_) Cough and deep breath q ___ hours.

(_) Increase activity as tolerated to promote maximum diaphragmatic excursion: _______________
________________________
________________________
________________________

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Ineffective Airway Clearance

Ineffective Airway Clearance

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Atrificial airway
(_) Excessive or thick secretions
(_) Inability to cough effectively
(_) Infection
(_) Obstruction/restriction
(_) Pain
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Ineffective cough.
(_) Inability to remove airway secretions.
Minor:
(
May be present)
(_) Abnormal breath sounds.
(_) Abnormal respiratory rate, rythm, depth.

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Maintain patent airway A.E.B.:

  • Clear breath sounds or breath sounds consistent with own baseline.
  • Respirations easy and un-labored.
  • Normal resp. rate.

(_) Other:

(_) Assess respiratory rate, depth, rythm, effort, and breath sounds q ___ hours.

(_) Position: HOB elevated ___ degrees.

(_) Promote optimum level of activity for best possible lung expansion:

  • Ambulate q ___ for ___ min.
  • Chair q ___ for ___ min.
  • Turn/reposition q ___.

(_) Suction q ___ hours (and prn) per:

  • Nasal
  • Oral
  • Tracheal

(_) Encourage fluids when indicated.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

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