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Nursing Care Plan

Nursing Diagnosis
Impaired Verbal Communication r/t sedation, presence of artificial airway, or decreased level of consciousness

Long Term Goal:
Patient is able to use a form of communication to get needs met and relate to his environment

Short Term Goals / Outcomes:
Patient and nurse will establish a means of communication
Patient will be able to effectively communicate and needs

Intervention

Rationale

Evaluation

Assess the patient’s primary and preferred means of communication (verbal, written, gestures)

Communication can be frustrating for both the nurse and patient.  It is critical that the nurse and patient determine the best method for each patient.

Patient can write words clearly on paper

Assess the patient’s preferred language and ability to understand written words, pictures and gestures

The nurse can not assume that the patient is grasping the information that is provided.  In recognition of the vast array of cultures and physical challenges that patient’s face, it is the nurse’s responsibility to communicate effectively

Patient speaks and reads English.

Recognize that the presence of an artificial airway will hinder the patient’s ability to communicate

When air does not pass over the vocal cords, sounds are not produced.  Other methods of communication will have to be established

Patient has an endotracheal tube present

Assess energy level

Fatigue and/ or shortness of breath can make communication difficult or impossible

Patient gets easily fatigued if frustrated when communicating

Anticipate patient needs and pay attention to non-verbal

Provides reassurance to the patient that someone is there to care for them and meet their needs

All patient needs were met

Listen attentively when the patient attempts to communicate.  Clarify your understanding of the patient’s communication

Decreases frustration and demonstrates caring

All patient needs were met

Never talk in front of the patient as though he or she can not hear or comprehend

This will prevent increasing the patient's sense of frustration and feelings of helplessness

Staff respectful of patient when talking

Keep distractions such as television and radio to minimum when talking to patients

This will keep the patient focused, decrease stimuli going to the brain for interpretation and enhance the nurse’s ability to listen

Television muted so patient can communicate more effectively

Don’t speak loudly unless hearing impaired

Loud talk does not improve the patient's ability to understand.

Calm, appropriate manner used to communicate effectively

Maintain eye contact with the patient when speaking. Stand close, within the patient’s line of vision

Eye contact lets the patient know that they have your attention when trying to communicate.  Patient’s with artificial airways may need to lip words and standing in front of the patient will allow the nurse a better view to understand the patient

All patient needs were met

Give the patient ample time to respond

It may be difficult for patient’s to respond under pressure, they may need extra time to convey thoughts

Patient and nurse able to communicate effectively

Praise the patient’s accomplishments and acknowledge their frustrations

Communication may be difficult and the patient is easily frustrated.  The inability to communicate enhances a patient’s sense of isolation and helplessness

Patient and nurse able to communicate effectively

Try to use phases that have a yes / no answer.  Use short sentences and convey one thought at a time.

This allows the patient to stay focused and reduces frustration.  This is common means to communicate as arms may be restricted due to the use of restraints

Patient able to respond to yes/no questions

Avoid finishing sentences for the patient.  Be calm and accepting during communication attempts.  Do not say you understand if you don’t

This may lead to frustration and decrease the patient’s trust in you

Patient and nurse able to communicate effectively

Use alternate methods of communicating such as word-and –phrase cards, writing pad and pencils, or picture boards

Alternate methods are especially helpful for patients with artificial airways

Patient can write words clearly on paper

Encourage family and friends to talk to patient even though they may not respond

This decreases the patient’s sense of isolation

Family talks to patient when visiting

Orient the patient to surroundings.  State procedural and task intentions when providing care

Not knowing who is providing care or where they are can be a stressor to the patient.  Patient may prefer that the nurse give them some indication of what they will be experiencing, especially if it will cause discomfort

Patient oriented and nods head in understanding of care.

 

Nursing Diagnosis
Pain r/t surgical site, traumatic injury, ischemic process, monitoring devices, routine nursing care and/or immobility

Long Term Goal:
Patient will be free of pain

Short Term Goals / Outcomes:
Patient will report pain less than 3 on 0-10 scale.
Patient’s vital signs will be within normal limits.

Intervention

Rationale

Evaluation

Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors

A good assessment of pain will help in the treatment and ongoing management of pain.

Patient reports pain as 3 on 0-10 scale; intermittent and sharp in incision area.

Monitor vital signs

Tachycardia, elevated blood pressure, tachypnea and fever may accompany pain.

Vital signs within normal limits.

Assess for probable cause of pain.

Different etiologic factors respond better to different therapies

Patient is experiencing pain from multiple traumatic injuries

Assess for non-verbal indicators of pain.

Facial grimacing, pulling at tubes, restlessness, resistance to passive motion and non-synchronous ventilation can all be indicators of pain.

Patient grimaces and stiffens when turning.

Give analgesics as ordered and evaluate the effectiveness.

Narcotics are indicated for severe pain.  For acute pain, analgesics should be administered intravenously and at the onset.  Subsequent doses, either intravenously or orally, should be around-the-clock to ensure consistent analgesia.

Analgesics given as ordered.  Patient reports pain relief after administration.

Assess appropriateness of a patient-controlled (PCA) analgesia

As the patient’s condition improves and becomes responsive he may be switched to PCA.

Patient awake and alert, PCA ordered

Anticipate the need for pain relief and respond immediately to complaints of pain.

The most effective way to deal with pain is to prevent it.  Early intervention can decrease the total amount of analgesic required.  Quick response decreases the patient’s anxiety regarding having their needs met and demonstrates caring.

Pain medication delivered prior to dressing changes with adequate relief.

Eliminate additional stressors when possible.  Provide rest periods, sleep and relaxation.

Outside sources of stress, anxiety and lack of sleep all may exaggerate the patient’s perception of pain.

Patient appears relaxed, is sleeping throughout the night.

Institute non-pharmacological approached to pain (detraction, relaxation exercises, music therapy, etc)

Non-pharmacological approaches help distract the patient from the pain.  The goal is to reduce tension and thereby reduce pain.

Patient is relaxing with radio playing.

If patient is on continuous intravenous analgesics, a daily interruption should occur if the patient:

  • has adequate pain control
  • is not receiving neuromuscular blocking agents
  • is hemodynamically stable
  • is stable on the ventilator

Daily interruption of continuous infusions of intravenous analgesics results in a decreased number of days on the ventilator and decrease in the length of stay

Daily interruption of continuous analgesia held for 60 minutes, patient awake and alert during interruption.

If patient is on patient controlled analgesia (PCA):

  • Dedicate an IV line for PCA only
  • Assess pain relief and the amount of pain the patient is requesting.
  • Educate patient and significant others on correct use of PCA.

Drug interaction may occur, if dedicated line is not possible consult pharmacist before mixing drugs. 

If demands for the drug are frequent the basal or lock-out dose may need increased to cover the patient’s pain.
If demands for the drug are very low, the patient may need further education of use of the PCA.

The patient and significant others must understand that the patient is the only one who should control the PCA.

PCA infusing without complications.  Patient and family understand purpose and use of PCA.  Patient is getting adequate pain relief with current dose.

For PCA:

  • Keep Narcan readily available.
  • Place “No additional analgesia” sign over head of bed.

 

In event of respiratory depression reversal agent must be available.

This prevents inadvertent analgesia overdosing.

Narcan on unit if needed.  Sign placed in room for safety.

 

Nursing Diagnosis
Anxiety r/t fear of the environment and threat to physical well being

Long Term Goal:
Patient will be anxiety free

Short Term Goals / Outcomes:
Patient will report a reduction in the level of anxiety experienced
Patient will demonstrate a reduction in the manifestations of anxiety

Intervention

Rationale

Evaluation

Assess patient’s anxiety using a reliable scale

Almost all patients in a critical care setting will experience some level of anxiety.  Using a sedation scale allows an objective assessment of the patient and prevents patients from being sedated too deeply for a long period of time.

Patient is a 0 on RAAS scale

Acknowledge awareness of patient’s anxiety

Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of these feelings.

Patient is restless at times.  Reoriented and reassured.

Maintain a calm manner while interacting with patient.

The health care provider can transmit his or her own anxiety to the hypersensitive patient.  The patient’s feeling of stability increases in a calm and non-threatening atmosphere.

Patient displays less anxiety when nurse talks to him.

Orient patient to the environment and new experiences or people as needed.

Orientation and awareness of the surroundings promote comfort and may decrease anxiety.

Patient explained all procedures and care before done, less anxious.

Use simple language and brief statements when instructing patient about nursing care and procedures.

While experiencing moderate to severe anxiety, patient may be unable to comprehend anything more than simple, clear and brief instructions.

Patient less anxious when oriented before care.

Assess patient for pain and treat prior to beginning sedation assessment.

Sedatives should only be used after providing adequate analgesia and treating reversible physiological causes of anxiety.  Pain, hypoxia, hypoglycemia, withdrawal, sleep deprivation and immobility are all potential reversible causes of anxiety.

Patient rates pain as a 0 on 0-10 scale.

Administer sedatives as ordered.

Sedatives are administered to provide an amnesic effect.  Ultra short acting agents should be used first because they achieve a steady state quickly and require fewer loading doses.

Patient receiving Propfol via continuous IV infusion for a RAAS goal of -1

Attempt daily weaning of sedatives when the patient is:

  • less than or equal to sedation goal on assessment scale
  • not being treated for delirium
  • not receiving neuromuscular blocking agents
  • hemodynamically stable
  • stable on the ventilator

Allows patient to receive the minimal amount of sedation necessary to achieve sedation goal, without being over sedated
Verify wording

Sedation is weaned daily while still maintaining sedation goal.

Assess the patient for an acute delirium at least once a shift, using an approved scale.

Many processes in the critical care environment and disease states can induce delirium.  Delirium can manifest as either an agitated (hyperactive) or quiet (hypoactive) state.  A mixed delirium can exist in the critical patient.  For delirium to be present the patient must display acute fluctuation in mental status accompanied by inattention; and either disorganized thought or a level of consciousness other than alert.

No signs of acute delirium exist

Administer haloperidol (Haldol), or a combination of haloperidol and lorazepam (Ativan) as ordered.

Haloperidol blocks dopamine receptors while lorazepam enhances the action of the inhibitory neurotransmitter GABA.  Lorazepam potentates the tranquilizing effects of haloperidol, so less needs administered.

Patient sleeping and calm after medications administered

Monitor for side effects of haloperidol and lorazepam.

The patient may experience potential life-threatening side effects such as QT prolongation and torsades de pointes.  These may result in sudden death especially if the drug is given IV push.

No side effects noted

Use non-pharmacological strategies:

  • promote restful sleep patterns
  • limit unnecessary noise
  • provide eyeglasses and hearing aids
  • reorient to surroundings

Anxiety may escalate with excessive conversation, noise and equipment around the patient.  Decreasing the stimulation in the environment and correcting any sensory deficiencies may help the patient to not misinterpret events and noises in the environment.

Patient resting calm, eyeglasses present, watching television.

Nursing Diagnosis
Disturbed Sleep Pattern r/t environment, patient care activities, discomfort, medication, withdrawal

Long Term Goal:
Patient will achieve optimal amounts of sleep

Short Term Goals / Outcomes:
Patient will appear rested or verbalize feelings of rest
Patient will show an improvement in the sleep pattern

Intervention

Rationale

Evaluation

Document observation of sleeping and wakeful behaviors.  Record number of sleep hours.  Note physical and/or physiological circumstances that interrupt sleep.

Lack of sleep can cause changes in metabolism, immune response and respiratory dysfunction.  These may lead to delayed healing and prolonged need for mechanical ventilatory support.  It may also be a factor in the development of ICU psychosis.  There are many factors in the critical care environment that can interrupt sleep.

Patient sleeping 30 -45 minutes at a time.  Wakes up every time caregiver enters room or monitor alarms.

Modify the environment by decreasing noise, comfortable temperature, darkness, closed door.

The environment must be conducive to sleep. 

Light dimmed and curtain drawn.  Patient requested extra blanket and is sleeping.

Provide a relaxing activity before bedtime.

A back rub, providing pillows for comfort, calming music, or reading can all help the patient relax before sleeping.

Back rub given and patient listening to CD player prior to falling asleep.

Administer hypnotics or sedatives as ordered.

Any medications prescribed for sleep should be short course of therapy and only used if less aggressive means are ineffective.

Patient requested medication for sleep.

Organize nursing care to provide minimal interruptions and allow for at least two hours of uninterrupted sleep.

It takes at least 60 -90 minutes to complete one sleep cycle.  The completion of an entire sleep cycle is necessary to benefit from sleep.

Patient sleeping a least 1 ½ a time.

 

Nursing Diagnosis
Imbalanced Nutrition: Less than body requirements r/t special diet modifications, NPO status, increased caloric needs

Long Term Goal:
Patient will ingest enough calories to meet metabolic demands

Short Term Goals / Outcomes:
Patient will maintain weight
Patient will demonstrate normal lab values (albumin, prealbumin, etc)
Patient will demonstrate timely wound healing

Intervention

Rationale

Evaluation

Obtain admission weight and weigh daily.

During aggressive nutritional support patient’s weight should remain stable or gain ¼ to ½ pound daily

Admission weight 100kg  Current weight 101kg

Obtain a nutritional history and prior etiological factors for reduced nutrition.

To ensure proper nutrition it is essential that the nurse obtain a history.  The history should include weight loss, food allergies, use of nutritional supplements, swallowing difficulties, nausea or vomiting, constipation or diarrhea, alcohol consumption and any special diet the patient was following.

Patient’s history negative for nutritional deficiency. Follows regular diet.

Monitor lab values that indicate nutritional status:

  • albumin / prealbumin

 

  • Transferrin

 

  • RBC and WBC counts

 

  • Electrolytes

 

 

Albumin indicates the degree of protein depletion. 2.5 g/dl indicates severe depletion.  Prealbumin is a more immediate indicator of protein adequacy.

Transferrin is important for iron transfer and typically depletes as serum protein decreases.

RBC and WBC are usually decreased in malnutrition, indicating anemia and decreased resistance to infection.

Potassium is typically increased and sodium is typically decreased in malnutrition.

 

Albumin 3.0 g/dl.  All other labs within normal range.

Consult with nutritionist to calculate patient’s caloric, protein and fluid requirements.

As the stress of a critical illness mounts, the patient requires increased calories and as much as 1.5 to 2 g/kg/day of protein.  Normally a patient will require about 1ml of fluid per calorie.

Patient requires 25 kcal/Kg/day and 1 gram protein.

Consult with nutritionist to calculate energy demand by using indirect calorimetry.

Indirect calorimetry uses a metabolic care to calculate basal energy expenditure.  This will guide how best to feed the patient.

Calculated by nutritionist.

If enteral feedings are being used:

  • start at slow rate and increase as tolerated
  • check residual every two to four hours

 

  • administer metoclopramide as ordered
  • check placement of the feeding tube

 

  • keep head of bed elevated between 30 and 45 degrees

 

  • change feeding system set-up every 24 hours
  • monitor for and prevent diarrhea

 

 

Continuous feeds and starting slow cause less gastro-intestinal upset

To prevent aspiration, residuals should be checked and feedings stopped if the residual is twice the amount of the hourly rate.

A motility agent to aid with high residuals

 

Visualization by x-ray should occur with insertion.  The best method to check placement is by obtaining aspirate from the tube with a pH less than five

To prevent aspiration of tube feeding contents and ventilator assisted pneumonia

To prevent bacterial colonization of the stomach

 

Diarrhea is common with enteral feedings.  If patient is receiving bolus feeds switching to continuous may decrease the occurrences.  If patient is lactose intolerant, switch to a feed that does not contain lactose.  Adequately diluting liquid medication with water may also help.

 

Enteral feedings being used.  Placement checked with aspirate of 4.5.

10ml residual obtained.  No signs of aspiration noted.

No diarrhea present.

If parenteral nutrition is being used:

  • full barrier precautions are used during insertion of the catheter
  • use a dedicated line for the infusion

 

  • change the solution bag and tubing every 24 hours

 

  • monitor for overfeeding

 

  • monitor blood glucose frequently

 

 

To prevent catheter related sepsis

 

The line should be a virgin port and nothing else administered through it to decrease the risk of precipitation forming in the catheter.

To prevent catheter related sepsis

 

Due to the high concentration of glucose and lipids overfeeding can occur.  Lipids should not be administered if the patient is receiving another lipid based medication

Due to the high glucose contents rapid shifts in glucose can occur with rate adjustments.

 

Parenteral nutrition infusion via left subclavian catheter.  No signs of infection noted.  Blood glucose within normal limits.

 

Nursing Diagnosis
Compromised Family Coping r/t overwhelming situation

Long Term Goal:
Family will develop methods to cope with present situation

Short Term Goals / Outcomes:
Family members will identify the effect patient’s illness has on the family unit.
Family members will identify resources available for help.
Family members will actively participate in care and decision making for the ill family member.
Family members will use supportive services and effective coping strategies.

Intervention

Rationale

Evaluation

Identify each family member’s understanding and beliefs about the situation.

Misconceptions about the prognosis, expectations for daily care and the role of the family in managing health problems needs to be clarified.

Family has dealt with patient admission to the hospital frequently.  Although tearful, they seem to understand all information given to them.  They ask appropriate questions.

Family meets with the healthcare team weekly for patient updates and understands the possible outcomes for the patient.

When visiting they talk to the patient and have calming effect.  They often pray with pastoral care during visiting.

Assess normal coping patterns in the family, including strengths, limitations and resources

Successful adjustment is influenced by previous experiences.  Families with a history of unsuccessful coping may need additional resources.

Identify and respect family’s coping mechanisms as appropriate.

Not all cultures or people display the same response to stress.  The nurse must respect and accept the way each individual responds to stress.

Evaluate resources or support systems available to the family.

In some situations there may be no readily available resources; other families may hesitate to notify other family members because of unresolved past conflicts.

Encourage the family to ask questions or express concerns.

The information the family needs will vary depending on the former experiences with the illness.

Provide honest, appropriate answers to family member’s questions.

Families must feel like they are getting truthful and consistent answers amongst healthcare providers to develop a sense of trust.

Schedule care conferences with the family and healthcare providers (physicians, nurses, etc) to discuss patient and family needs.

This aids the family in staying realistically involved, make decisions,  and address any concerns they may have surrounding the extent of care and prognosis of the patient.

Provide the family with a written orientation guide to the critical care environment.

This is a stressful and uncertain time for families.  Basic needs such as waiting area, telephone locations and how to contact the unit should be provided.  Some basic information about the equipment and common conditions should also be provided to relieve their anxiety.

Assign the same nurse to care for the patient whenever possible.

Consistent information from the same care provider will build trust with the family members.

Develop an individualized visitation policy based on the needs of the patient.

Allowing the family more access to the patient will enhance communication, provide the family with more opportunity to provide emotional support to the patient and allow more opportunities for teaching.

Educate the family on the patient’s condition and needed care.  Provide written material to reinforce teaching.

Clarification and education to the family may alleviate some anxiety and fears and help the family focus on realistic outcomes.

References:
Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St. Louis Taylor, K. Chapter 2. Care of the Critically Ill Patient






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