NURSING MANAGEMENT : WITH THEORY APPLICATION

OREM’S GENERAL THEORY OF NURSING

 Theory of self care

 Theory of self-care deficit
 Theory of nursing system

For my patient, the theory is based on “Theory of Nursing System”.

 Describes how patient’s self care needs will be met by the nurse, the patient, or both.
 Scope of nursing responsibility in health care situations
 Reasons for nurses’ relationship with patients
 Orem recognized that specialized technologies are usually developed by members of health professionals.

OREM’S THEORY BASED CARE PLAN

Objectives :

 To assess the patient condition by various methods explained by nursing theory

 To identify the needs of the patient
 To select a theory for the application according to the need of the patient and solve the identified problems of the patient.

List of Nursing diagnosis for care of patient under mechanical ventilator :

1. Ineffective tissue perfusion

2. Ineffective airway clearance
3. Fluid volume excess
4. Imbalanced nutrition less than body requirement
5. Risk for ventilator associated pneumonia
6. Risk for impaired skin integrity
 7. Risk for infection related to presence of invasive lines and catheters
8. Risk for self extubation
9. Potential for pulmonary infection

Nursing Care Plan

Date Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

25.2.20 Objective data : Ineffective tissue To 1.Assess skin colour, 1. Cold, clammy, pale 1.Patient has pale skin. Hemorrhage is
perfusion related to prevent temperature skin is compensatory to Temperature – 97.6 F prevented as
Patient has
decreased cardiac hemo- low cardiac output and evidenced by
1. Pale
output, upper rrhage oxygen desaturation absence of
conjunctiva
gastrointestinal bleeding,
2.Weak
bleeding that may 2.Monitor ECG for 2.Cardiac dysrhythmias 2.Atrial fibrillation was stable vital
peripheral pulse
hemorrhage rate, rhythm and may occur from low present, Inj. Lignocaine signs.
3.cold, clammy
secondary to the ectopy. perfusion, acidosis or and amiodarone was
skin
diseased condition as hypoxia. administered, returned
4.Decreased
evidenced by to sinus rhythm.
skin turgor
decreased urine
5.Admitted with
output, low blood 3.Assess heart rate 3.As most patients have 3.Patient’s vital signs
cardiac arrest
pressure and blood pressure for compensatory are stable under
and shock on
signs of shock tachycardia and low ventilator support.
24.2.20.
blood pressure in Pulse – 74 b/min
response to reduced BP – 114/68 mmHg
cardiac output.

4.Check peripheral 4.Signs of reduced 4.Peripheral pulse is 78

pulse and capillary stroke volume and b/min,
refill. cardiac output. Capillary refill is 4 sec.

5. Monitor urine 5.Fluid and sodium 5.Patient has oliguria

output retention may occur (sign of decreased renal
 perfusion)

6.Assess Central 6.It provides 6. CVP is maintained

venous pressure information on filling within 5 to 7 mm Hg
pressure of right side of
the heart.

7.Monitor for 7.This can lead to 7.Patient is on Inj

hemorrhage bleeding decreased blood Trelipressin 2 mg to
from gums, malena, volume and reduced control the upper
hematuria, cardiac output. gastrointestinal
hematemasis. bleeding.

8.Suction the 8.To prevent easy 8.ET and oral

endotracheal bleeding suctioning was done
secretions only when twice in my shift.
required.

9.Monitor gastric 9.For early 9.Ryles tube was put on

aspirate for evidence management continuous aspiration,
of bleeding colour of aspirate was
minimal amount of
clear fluid.

25.2.20 Objective data : Ineffective airway Improve 1.Assess airway for 1.To promote 1.Airway function is Patient
clearance related to respi- patency. respiratory function assessed hourly. maintains
Patient has increased mucus ratory clear, open
1.Crackles production status, 2.Auscultate lungs 2.Abnormal breath 2.Bronchial breaths airway as
2.Resp rate – 34 associated with maintain sounds sounds may be due to present evidenced by
breaths/min mechanical clear, mucus accumulation. normal breath
3.SPO2 – 92 % ventilation as open sounds, normal
evidenced by oxygen airway. 3.Assess respirations 3.These may be 3.Bronchial breaths rate and depth
saturation 92 %, for quality, rate, compensatory response present of respiration.
restlessness, pattern, depth, to airway obstruction. Resp rate – 24
increased respiratory dyspnea or use of breaths/min ABG :
rate. accessory muscles. PH – 7.44
PCO2 – 37.4
4.Determine the need 4.To prevent the 4.Suction was done PO2 – 106
and for effective secretions from twicw in 6 hours shift. SO2 - 98.6 %
suctioning blocking the upper HCO3 – 25.7
respiratory tract

5.Oxygenate before 5.Pre-oxygenation will 5.Pre-oxygenation was

and after suctioning prevent desaturation. done to maintain 100 %
saturation.

6.Keep strict vigil on 6.To prevent 6.Hourly vital signs are

the cardiac monitor, desaturaturation. recorded.
pulse oximeter during
and soon after
suctioning.

7.Assess the quality, 7.Unusual appearance 7.Tracheal secretions

colour, amount and of secretion may cause are thick, non-sticky.
consistency of infection, tenacious
tracheal secretion. secretions and airway
resistance.

8.Turn and reposition 8.To mobilize 8.Nebulization is done

patient every 2nd secretions with Duolin three times
hourly, nebulize the a day.
patients with Chest physiotherapy is
bronchodilators and provided in every shift.
effective chest
 physiotherapy .

9.Elevate head of the 9.To prevent aspiration 9.Semi-fowler position

bed atleast 30 degree. of tracheal secretion. provided in my shift.

10.Secure ET tube 10.To prevent tube 10.ET cuff pressure is

properly and check dislodgement or leakge maintained at 25 cm of
cuff pressure. of air around the ET H2O.
tube.

11.Monitor ABG 11.To identify 11. ABG is done once

value. repiratory acidosis or in my shift according to
alkalosis. LCICU protocol.

12.View chest X-ray 12.To identify 12.Chest is clear.

pneumonia,
pneumothorax,
diaphragmatic
dysfunction.

25.2.20 Objective data : Fluid volume excess To 1.Maintain sodium 1.To avoid fluid 1.Patient was on : Goal was
related to ascites and restore and fluid restriction as overload. Infusion Plasmolyte : fulfilled to
Patient has edema formation on normal prescribed. ½ DNS at 60 ml/hr some extent as
Ascites lower limbs fluid ascetic fluid
Edema on lower secondary to the volume 2.Administer 2.To maintain adequate 2.Patient is on Infusion was aspirated.
limbs diseased condition as and diuretics, potassium urine output Vasopressin at 1.2 ml/hr
evidenced by relief and protein
presence of acitic from supplements as
fluid and pedal abdo- prescribed.
edema. minal
dis- 3.Record intake and 3.To notify physicial 3.Patient has oliguria,
comfort output in every shift. about renal dysfunction 25 to 30 ml / hr.
 4.Measure and record 4.Increase in abdominal 4.Abdominal girth is
abdominal girth daily. girth means more fluid 106 cm with visible
accumulation. veins.

5.Keep the articles 5.To drain ascetic fluid 5. Two litres of ascetic
ready at bedside for fluid was aspirated.
paracentesis.

26.2.20 Objective data : Altered nutritional Maintain 1.Administer 1.To maintain 1. Patient was on : Nutritional
status less than body nutri- intravenous fluids nutritional and Infusion Plasmolyte : status is same
Patient is requirement related tional hydration status of ½ DNS at 60 ml/hr as before.
Nil per oral to mechanical health patient
(NPO) status ventilator support,
NPO status 2.Administer drugs 2.To prevent 2.Patient is on injection
Under shock secondary to that are sources of hypoglycaemia Dextrose 25% at 10
diseased condition as carbohydrate and ml/hr.
evidenced by poor calories.
muscle tone.
3.Administer drugs 3.To reduce edema and 3.Injection 5 %
that will mobilize ascites Albumin is
fluids from administered at 30 ml/hr
extracellular tissue to
intracellular space.

4.Administer drugs 4.To prevent 4.Injection Optinuron 1

that will help in hemorrhage and ampule is given with
metabolism of fats and nutritional deficiencies. 100 ml Normal saline
proteins. once daily.
Date Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

26.2.20 Objective data : Potential for To 1.Provide oral care 1.As oral cavity is the 1. Oral care was given Patient’s oral
ventilated associated prevent every 2nd hourly primary source of with chlorhexidine hygiene is
Patient has pneumonia related to venti- contamination of the mouthwash twice in my maintained as
Coated tongue 48 hours lator lungs in intubated and shift. evidenced by
Halitosis endotracheal asso- compromised patients. clean tongue,
Poor oral care intubation secondary ciated teeth.
to the diseased pneu- 2. Moisten lips with 2.To prevent cracking 2. Moistened the lips
condition. monia glycerine. of lips. with lubricant.

3.Suction oral 3. As secretions pool in 3.Suctioning done as

secretions from oro-pharynx because of and when required
mouth. inflated tracheal cuff.

4. Assess for pressure 4. To prevent Angular 4.ET tube is positioned

areas at the corner of stomatitis at the alternate side of
the mouth. the mouth everyday.

5. Maintain aspetic 5.To prevent infection. 5. Oral care is given by

technique during oral hand washing, wearing
care. gloves, using sterile
bowl and artery forceps
and sterile gauze pieces.

6.Scrub teeth, tongue 6.To prevent injury 6.The same is followed

and gum line in small during oral care.
circular motion.

7.Document oral care 7.To know the normal 7.Documented oral care
in flow sheet. and abnormal findings. in ICU chart.
 8.Administer Infusion 8. To prevent peptic 8.Infusion pantocid
pantocid. ulcer disease. (80 mg) is continuining
at 4 ml/hr.

9.Keep the patient in 9. To prevent aspiration 9.Head end is elevated

semi-fowler position of tracheal secretion. at 30 degree.

26.3.20 Objective data : Potential for To 1.Assess the potential 1.For early 1.Areas of bony Patient’s skin
impaired skin prevent areas for development identification and prominences are is intact.
Patient has integrity related to pressure of pressure ulcers. management. assessed for redness.
Braden score - prolonged bed ridden ulcers
10 condition, poor 2. Use soft restrain 2. To minimise the risk 2.Finger resprain is
nutritional status. whenever necessary for device related done for the patient.
pressure injury

3.Reposition patient 3.To prevent pressure 3.Repositioning is done

second hourly and sore and joint stiffness according to the
provide skin care 2nd and blood circulation. position clock.
hourly by giving back
massage.

4. Use Alpha (air) 4.To reduce pressure on 4.Patient is on alpha

mattress for the bony prominence mattress from the first
patient and keep the day of ICU admission.
bedsheet wrinkle free.

5.Reposition ET tube 5. To prevent device 5. ET tube is positioned

at alternate sides of related pressure ulcers at the alternate side of
the mouth the mouth everyday.

6.Change the fixation 6.To prevent device 6.Position of fixation is

of NG tube everyday related pressure injury changed over alternate
 and plaster should be side of face.
changed daily.

7. Elevate edematous 7.To prevent skin 7.Lower and upper

extremities and breakdown and limbs are elevated on
prevent rupture of infection. pillows.
blisters.
27.3.20 Objective data : Potential for Mini- 1. Maintain hand 1.To reduce chances of 1.Hand washing and Chances of
infection related to mize the hygiene cross infection. hand rub is used infection is
Patient has presence of invasive risk of frequently before and reduced to
lines, catheters, infection after aseptic technique. much extent as
Right internal prolonged evidenced by
jugular line ventilation under 2.Monitor patient’s 2.Increase in body 2.Patients body no signs and
mechanical temperature temperature more than temperatue is within symptoms of
Left radial ventilator. normal may indicate normal range, infection.
arterial line infection. Temp – 97 F

Foley’s catheter 3. Maintain sterile 3.To prevent VAP and 3.Sterile gloves, sterile
technique when cross infection normal saline is used.
Ryles tube suctioning through ET Care taken to prevent
tube. suction catheter from
Ascites touching the
surrounding areas.
On mechanical
ventilator 4.Close the eyes by 4.To prevent corneal 4.Eye care is given with
taping if there is no drying and injury or sterile water, eyelids are
blinking reflex. infection. closed with micropore
strips.

5.Provide urinary 5.To prevent catheter 5.Care taken by giving

catheter care in each associated infections. catheter care with
shift. normal saline, emptying
 the urine bag when ¾
full, not touching the
urine bag on floor.

6.Scrub the hub site of 6.To prevent infections 6.Scrubbing of hubsite

central line catheter is done with alcohol
before administering swab for 30 seconds.
drugs or connecting
IV lines.

7.Maintain bundle 7.To record care given 7.Bundle checklist is

checklist for VAP, in each shift and any maintained in every
CAUTI, CLABSI. abnormal findings. shift.

8.Change the HME 8.HME filter protects 8.HME filter is replaced

filter (heat and against airborn with sterile HME daily.
moisture exchange) microbes and prevents
daily. drying of respiratory
mucosa.

26.2.20 Objective data : Potential for injury To 1.Assess the position 1.To reduce the risk of 1.Sufficient length of Risk for self
related to prevent of ventilator tubing to trauma to the trachea. the C-circuit was extubation was
Patient has endotracheal chances avoid pulling or maintained and C- minimized to
intubation, altered of injury distorsion of the tube. circuit stand was used much extent.
Altered level of level of and self for support.
consciousness, consciousness, risk extu-
for self extubation. bation. 2.Monitor cuff 2.To minimize chances 2.Cuff pressure is
ET tube, pressure every 8 hrs to of decreased blood checked once in each
maintain pressure less circulation and shift.
Finger restrain than 25 cm of H2o necrosis.

Invasive lines 3. Provide safe 3. To prevent fall. 3.Side rails were up all
 (CVP line, environment (side the time.
Ryle’s tube, rails to prevent fall,
Foley’s catheter) pillows)

4. Assess every 2nd 4.Restrains are used 4.The patient was

hourly for the need to with agitated or sedated, no agitation or
restrain the patient. delirious patients. restlessness.
5.Secure all the 5.To prevent 5.CVP line is secured
invasive lines and dislodgement. properly with tegaderm
catheters with and covered with green
adhesive tape. sheet,
Foleys catheter and
ryles tube are secured
with micropore .

Any others :
Nursing diagnosis : Knowledge deficit related to new environment, ventilator parameters and hemodynamic monitoring and care of
ventilated patients

Goal : To demons-trate know-ledge of mechanical venti-lation and care involved.

Interventions :
1. Monitor vital signs hourly
2. Never keep ventilator alarm muted and never ignore cause for the alarm
3. Check tubings for obstruction
4. Never use the top of the ventilator as a desk or keep fluid bottles on or near ventilator
5. Record and document
- Mode
 - Rate
- Fio2
- Tidal volume
- Pressure support
- PEEP

6. During mechanical ventilation, observe for

- ET tube obstruction
- airway dryness
- self extubation
- cuff leak

7. Ensure that the ET tube plaster is fully secured.

8.Keep resuscitation bag at the patient’s bedside