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Nursing Analysis

Nursing Analysis

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Published by Mamot Mot

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Categories:Types, School Work
Published by: Mamot Mot on Sep 19, 2010
Copyright:Attribution Non-commercial

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05/24/2012

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 Nursing Analysis1.
 
Safe, effective care environmenta.
 
High risk for injury b.
 
Knowledge deficitc.
 
High risk for infection2.
 
Physiological integritya.
 
Decreased cardiac output b.
 
Impaired gas exchangec.
 
Activity intolerance3.
 
Psychosocial integritya.
 
Ineffective individual coping b.
 
Anxietyc.
 
Body image disturbance4.
 
Health promotion/maintenancea.
 
Impaired adjustment b.
 
Health-seeking behaviorsc.
 
 NoncomplianceGeneral Nursing Planning, Implementation, and EvaluationGoal 1: Client will maintain patent airway and adequate oxygenation.Implementation1.
 
Monitor respiratory status (e.g., vital signs breath sounds, skin color).2.
 
Reduce anxiety.3.
 
Limit or space activities to decrease O
2
need,4.
 
Turn frequently if on bed rest.5.
 
Place in Fowler¶s position to increase air exchange.6.
 
Humidity air 7.
 
Administer O
2
as needed.8.
 
Cough and deep-breathe frequently.9.
 
Avoid sedatives that depress respirations and cough reflex (e.g., narcotics).10.
 
Force fluids to liquefy bronchial secretions.11.
 
Suction as needed; provide hyperoxygenation before and after suctioning to decrease chancesof hypoxia.12.
 
Carry out postural drainage to promote drainage of lung and bronchi by gravity, if needed.a.
 
Give humidified air or bronchodilators 10-15 minutes before. b.
 
Do not longer than 15 minutes at one timec.
 
Clapping or vibrating helps loosen secretionsd.
 
Avoid clapping or vibrating over sternum, breast tissue, below ribse.
 
Follow with coughing to be effective; do not allow client to cough in head-down positionEvaluationClient is well-oxygenated (PO
2
is greater than 80 mm Hg.)
 
Goal 2: Client¶s cardiac work load will be decreased.Implementation1.
 
Monitor cardiovascular status (e.g., vital signs, pulse deficit, skin color.2.
 
Limit activity to decrease O
2
need.3.
 
Promote rest.4.
 
Administer O
2
as needed.5.
 
Monitor I&O of fluids to detect circulatory overload.6.
 
Give diuretics as ordered to reduce circulating blood volume (see Table 3-15).7.
 
Prevent constipation (e.g., use stool softeners).8.
 
Reduce anxiety.EvaluationClient¶s cardiac work load is decreased; pulse decreases from 100 to 84.Goal 3: Client will remain free from the hazards of immobility.Implementation1.
 
Turn frequently.2.
 
Deep-breathe and cough as needed.3.
 
Provide passive ROM exercises as needed.4.
 
Teach client ankle flexion exercises.5.
 
Give good back care.6.
 
Apply antiembolic hose.7.
 
Give anticoagulants if ordered (see Table 3-10.EvaluationClient remains free from thrombophlebitis, decubitus ulcers, pulmonary consolidation.SELECTED HEALTH PROBLEMS RESULTING IN INTERFERENCE WITH CARDIACFUNCTIONCardiopulmonary ArrestGeneral Information1.
 
Definition: sudden cessation of adequate cardiac and pulmonary function2.
 
Classification: medical emergency Nursing ProcessASSESSMENT1.
 
Responsivenessa.
 
Tap or gently shake victim. b.
 
Shout ³Are you OK2.
 
A-airway ± determine airway patency3.
 
B-breathinga.
 
Determine breathlessness in 3-5 seconds
 
a.
 
Place ear over mouth and nose of victim and listen for air escaping during exhalation. b.
 
Look for chest to rise and fall.c.
 
Feel for flow of air.1.
 
C-circulationa.
 
Determine pulselessness in 3-10 seconds. b.
 
Check carotid pulse.Analysis (See p. 131)Planning, Implementation, and EvaluationGoal 1: Unresponsive victim will be recognized promptly and receive emergency medical services(EMS) intervention as soon as possible.Implementation1.
 
Determine unresponsiveness quickly.2.
 
If unresponsive, activate EMS system immediately, before beginning CPR; i.e., phone 911 or equivalent emergency number.EvaluationUnresponsive victim receives EMS intervention within 10 minutes of collapse.Goal 2: Breathless, unresponsive victim will have an pen airway and receive adequate ventilation.Implementation1.
 
Place victim in supine position on flat, firm surface.2.
 
Assume rescuer position at victim¶s side.3.
 
Clear airway of foreign matter if present (finger sweep).4.
 
Open airway by head tilt ± chin lift maneuver (lifts tongue away from back of throat).5.
 
Watch for breathing.6.
 
If spontaneous breathing is obvious, roll unresponsive victim without cervical trauma ontohis/her side (recovery position) and maintain open airway.7.
 
If no breathing, ventilate mouth-to-mouth.8.
 
Take deep breath and give two initial slow breaths of 1 ½ - 2 seconds eacha.
 
Keep airway open with head tilt-chin lift maneuver  b.
 
Pinch nose closed with thumb and index finger c.
 
Seal lips around victim¶s lips to create airtight seal.9.
 
If unable to ventilatea.
 
Reposition head  b.
 
Ventilate10.
 
If still unable to ventilate, use Heimlich¶s maneuver (subdiaphragmatic abdominal thrust) toclear airway of foreign body.11.
 
Watch for breathing.

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