Diarrhea |
Bowel Incontinence Care - 0410 |
- Determine physical or psychological cause of fecal incontinence. - Determine onset and type of incontinence, frequency of episodes, and any related change in bowel function or stool consistency. - Eliminate the cause of incontinence if possible. - Wash perianal area with soap and water and dry it thoroughly after each stool. - Protect the skin from excess moisture of urine, stool or perspiration with a moisture barrier cream, as needed. - Monitor perianal skin for the development of pressure ulcers and for infection. - Monitor for adequate bowel evacuation. - Avoid foods that cause diarrhea. - Administer prescribed medication for diarrhea. |
Diarrhea Management - 0460 |
- Determine history of diarrhea. - Identify factors that may cause or contribute to diarrhea. - Monitor for signs and symptoms of diarrhea. - Monitor skin in perianal area for irritation and ulceration. - Measure diarrhea/bowel output. |
Bowel Management - 0430 |
- Note date of last bowel movement. - Monitor bowel movements including frequency, consistency, shape, volume, and color, as appropriate. - Monitor bowel sounds. - Monitor for signs and symptoms of diarrhea, constipation, and impaction. - Insert rectal suppository, as needed. |
Class D: Nutrition Support
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Clinical Indicators
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Nursing Interventions
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Activities
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Naso/oroenteral tube diet |
Enteral Tube Feeding - 1056 |
- Insert nasogastric, nasoduodenal, or nasojejunal tube, according to agency protocol. - Apply anchoring substance to the skin and secure feeding tube with tape. - Monitor for proper placement of the tube by inspecting oral cavity, checking for gastric residual, or listening while air is injected and withdrawn, according to agency protocol. - Elevate head of the bed 30 to 45 degrees during feedings. - Discontinue feeding 30 to 60 minutes before putting in a head down position. - Turn off the tube feeding one hour prior to a procedure or transport if the patient needs to be less than 30 degrees. - Irrigate the tube every 4 to 6 hours as appropriate during continuous feedings and after every intermittent feeding. - Use clean technique in administering tube feeding. - Check gravity drip rate or pump rate every hour. - Slow tube feeding rate and/or decrease strength to control diarrhea. |
Class D: Nutrition Support
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Clinical Indicators
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Nursing Interventions
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Activities
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Naso/oroenteral tube diet |
Enteral Tube Feeding - 1056 |
- Monitor for sensation of fullness, nausea, and vomiting. - Check residual every 4 to 6 hours for the first 24 hours, then every 8 hours during continuous feedings. - Check residual before each intermittent feeding. - Hold tube feedings if residual is greater than 150 cc or more than 110% to 120% of the hourly rate in adults. - Keep cuff of endotracheal or tracheostomy tube inflated during feeding, as appropriate. |
Class E: Physical Comfort Promotion
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Clinical indicators
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Nursing Interventions
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Activities
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Pain |
Pain Management - 1400 |
- Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors. - Observe the nonverbal cues of discomfort, especially in those unable to communicate effectively. - Assure patient attentive analgesic care. - Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient's response to pain. - Provide information about the pain, such as causes of the pain, how long it will last, and anticipated discomforts from procedures. - Control environmental factors that may influence the patient's response to discomfort. - Select and implement a variety of measures (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate. - Provide the person optimal pain with prescribed analgesics. - Assure pretreatment analgesia and/or nonpharmacologic strategies prior to painful procedures |
Domain 2 - Physiological: Complex
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Class H: Drug Management
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Clinical indicators
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Nursing Interventions
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Activities
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Pain |
Analgesic Administration - 2210 |
- Determine pain location, characteristics, quality, and severity before medicating patient. - Check medical order for drug, dose and frequency of analgesic prescribed. - Choose the appropriate analgesic or combination of analgesic when more than one is prescribed. - Determine analgesic selection, based on the type and severity of pain. - Determine the preferred analgesic, route of administration, and dosage to achieve optimal analgesia. - Choose the IV route, rather than IM, for frequent pain medication injections, when possible. - Monitor vital signs before and after administering narcotic analgesic with first-time dose or if unusual signs are noted. - Attend to comfort needs and other activities that assist relaxation to facilitate response to analgesia. - Administer analgesics around the clock to prevent peaks and troughs of analgesia, especially with severe pain. - Administer adjuvant analgesics and/or medications when needed to potentiate analgesia. - Consider use of continuous infusion, either alone or in conjunction with bolus opioids, to maintain serum levels. - Institute safety precautions for those receiving narcotic analgesic, as appropriate. - Instruct to request PRN pain medication before the pain is severe. - Evaluate the effectiveness of analgesics at regular frequent intervals after each administration, but, especially after the initial doses, also observing for any signs and symptoms of untoward effects. - Document response to analgesic and any untoward effects. - Evaluate and document level of sedation for patients receiving opioids. - Implement actions to decrease untoward effects of analgesics. |
Sedation |
Sedation Management - 2260 |
- Check for drug allergies. - Instruct the patient and/or family about effects of sedation. - Evaluate the patient's level of consciousness and protective reflexes before administering sedation. - Administer medication as per physician's order or protocol, titrating carefully, according to patient's response. - Monitor the patient's levels of consciousness and vital signs, oxygen saturation, and EKG, as per agency protocol. - Monitor the patient for adverse effects of medication, including agitation, respiratory depression, hypotension, undue somnolence, hypoxemia, arrhythmias, apnea, or exacerbation of a preexisting condition. |
Class K: Respiratory Management
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Clinical indicators
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Nursing Interventions
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Activities
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Mechanical ventilatory assistance |
Mechanical Ventilation Management: Invasive - 3300 |
- Monitor for conditions indicating a need for ventilation support. - Monitor for impending respiratory failure. - Initiate setup and application of the ventilator. - Ensure that ventilator alarms are on. - Routinely monitor ventilator settings, including temperature and humidification of inspired air. - Check all ventilation connections regularly. - Monitor for factors that increase the patient/ventilator work of breathing (e.g., morbid obesity, pregnancy, biting ET). - Monitor for symptoms that indicate increased work of breathing. - Monitor the effectiveness of mechanical ventilation on patient's physiological and psychological state. - Provide care to alleviate patient distress (e.g., positioning, sedation and/or analgesia, tracheobronchial toileting). - Provide patient with a means for communication (e.g., paper nad pencil, alphabet board). |
Class K: Respiratory Management
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Clinical indicators
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Nursing Interventions
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Activities
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Mechanical ventilatory assistance |
Mechanical Ventilation Management: Invasive - 3300 |
- Monitor ventilator pressure readings, patient/ventilator synchronicity, and patient breath sounds. - Perform suctioning based on presence of adventitious breath sounds and/or increased inspiratory pressure. - Monitor pulmonary secretions for amount, color and consistency and regularly document findings. - Monitor for adverse effects of mechanical ventilation (e.g., tracheal deviation, infection, barotrauma, gastric distention, subcutaneous emphysema). - Monitor for mucosal damage to oral, nasal, tracheal or laryngeal tissue from pressure from artificial airway, high cuff pressure, or unplanned extubations. - Use commercially tube holders rather than tape or strings to fixate artificial airways to prevent unplanned extubations. - Position to facilitate ventilation/perfusion matching, as appropriate. |
Artificial Airway Management - 3180 |
- Provide an oropharyngeal airway or bite block to prevent biting on the endotracheal tube, as appropriate. - Inflate endotracheal/tracheostomy cuff using minimum occlusive volume technique or minimal leak technique. - Maintain inflation of the endotracheal/tracheostomy cuff at 15 to 25 mm Hg during mechanical ventilation and during and after feeding. - Monitor cuff pressure every 4 to 8 hours during expiration using a three-way stopcock, calibrated syringe, and manometer. - Check cuff pressure immediately after delivery of any general anesthesia or manipulation of endotracheal tube. - Change the endotracheal tapes/ties every 24 hours, inspect the skin and oral mucosa, and reposition the endotracheal tube to the other side of the mouth. - Loosen commercial endotracheal tube holders at least once a day, and provide skin care. - Auscultate for presence of lung sounds bilaterally after insertion and after changing endotracheal/tracheostomy ties. - Note the centimeter reference marking on endotracheal tube to monitor for possible displacement. - Assist with chest x-ray examination, as needed, to monitor the position of tube. - Minimize leverage and traction on the artificial airway by suspending ventilator tubing from overhead supports, using flexible catheter mounts and swivels, and supporting tubes during turning, suctioning, and ventilator disconnection and reconnection. - Monitor for presence of crackles and rhonchi over large airways. - Monitor secretions color, amount and consistency. - Perform oral care, as needed. - Monitor for decrease in exhale volume and increase in inspiratory pressure in patients receiving mechanical ventilation. - Institute measures to prevent spontaneous decannulation (i.e., secure artificial airway with tapes or ties, administer sedation and muscle paralyzing agent, use arm restraints), as appropriate. - Provide trachea care every 4 or 8 hours as appropriate: Clean inner cannula, clean and dry the area around the stoma, and change the tracheostomy tie. - Inspect skin around the tracheal stoma for drainage, redness, irritation, and bleeding. - Shield the tracheostomy from water. |
Class N: Tissue Perfusion Management
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Clinical indicators
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Nursing Interventions
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Activities
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Altered heart rate |
Hemodynamic Regulation - 4150 |
- Perform a comprehensive appraisal of hemodynamic status (i.e., check blood pressure, heart rate, pulse, jugular venous pressure, central venous pressure, right and left atrial and ventricular pressures, and pulmonary artery pressure), as appropriate. - Monitor and document blood pressure, heart rate, rhythm, and pulse. - Monitor pacemaker function, if appropriate. - Administer antiarrhythmic medications, as appropriate. - Monitor the effects of medications. |
Domain 3 - Behavioral
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Class T: Psychological Comfort Promotion
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Clinical indicators
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Nursing Interventions
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Activities
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Anxiety |
Anxiety Reduction - 5820 |
- Use a calm, reassuring approach. - Explain all procedures, including sensations likely to be experienced during the procedure. - Stay with patient to promote safety and reduce fear. - Encourage verbalization of feelings, perceptions, and fears. - Identify when level of anxiety change. - Help patient identify situations that precipitate anxiety. - Administer medication to reduce anxiety, as appropriate. - Assess for verbal and nonverbal signs of anxiety. |
Domain 4 - Safety
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Class V: Risk Management
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Clinical indicators
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Nursing Interventions
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Activities
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Psychomotor agitation, delirium |
Delirium Management - 6440 |
- Identify etiological factors causing delirium. - Initiate therapies to reduce or eliminate factors causing delirium. - Recognize and document the motor subtype of delirium. - Monitor neurological status on an ongoing basis. |
Domain 4 - Safety
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Class V: Risk Management
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Clinical indicators
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Nursing Interventions
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Activities
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Psychomotor agitation, delirium |
Delirium Management - 6440 |
- Acknowledge the patient's fears and feelings. - Allow the patient to maintain rituals that limit anxiety. - Administer PRN medications for anxiety or agitation, but limit those with anticholinergic side effects. - Reduce sedation in general, but do control pain with analgesics, as indicated. - Remove stimuli, when possible, that create excessive sensory stimuli. - Maintain a well-lit environment that reduces sharp contrasts and shadows. - Maintain a hazard-free environment. - Use physical restrictions, as needed. - Inform patient of person, place, and time, as needed. - Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation. |