NS1233- NURSING DIAGNOSES & INTERVENTIONS PRINCIPLES OF ASEPSIS i. Risk for infection related to low immune system.

m. Nursing outcomes: Reduce clients risk of getting infection and to increase clients immune system. Interventions: 1. Perform skin assessment for the client to observe for any broken skin such as pressure sore. 2. Perform hand wash before and after caring for client to minimize transmission of microorganism to the client. 3. Ensure the environment is clean such as clean bed sheets to prevent infection to the client. 4. Practice sterile technique while doing sterile procedures to minimize the risk for infection. 5. Transfer client into a reverse isolation room as ordered by physician to reduce the risk of client getting infection. 6. Advise client to take more well-balanced diet such as diet high in protein and vitamin to increase body immune system. 7. Maintain medical and surgical asepsis while doing procedure for the client to reduce the risk of infection. 8. Wear PPE before entering clients reverse isolation room to protect client from cross infection. ii. Risk for infection due to poor aseptic technique. Nursing outcome: Risk for infection is reduced by maintaining aseptic technique. Interventions: 1. Perform hand wash before and after each procedure to minimize the risk for infection. 2. Switch off the fan while doing procedures such as dressing to prevent microorganisms from entering the wound.

3. Ensure that all surgical items are clean and sterile to prevent infection. 4. Ensure that clean hands and all sterile items are always above waist level because anything below waist is considered unsterile or contaminated. 5. Ensure that clients environment is clean and well ventilated to prevent the growth of microorganism. FLUIDS & ELECTROLYTE IMBALANCE i. Risk for fluid and electrolyte imbalance related to severe vomiting. Nursing Outcome: Clients fluid and electrolyte is normal and client does not have anymore vomiting. Intervention: 1. Assess clients condition such as vital signs and signs and symptoms of dehydration such as hypotension, dry skin, weak rapid pulse, and excessive thirst. 2. Administer IV infusion as ordered by physician to rehydrate client to prevent fluid and electrolyte imbalance. 3. Assess clients lab result to observe for any signs of electrolyte imbalance. 4. Advise client to take more fluid and well-balanced diet if client is able to tolerate orally to maintain fluid and electrolyte balance. 5. Administer medication as ordered by physician to stop the vomiting. 6. Monitor clients intake and output chart to assess how much fluid is client taking and to assess the severity of the vomiting to reduce the risk for fluid and electrolyte imbalance. ii. Excess fluid volume related to acute renal failure. Nursing outcome: Clients fluid volume is back to normal. Interventions: 1. Assess clients vital signs such as BP, pulse, and respirations for signs of hypervolemia. 2. Conduct a physical assessment for client to observe for edema, shortness or breath, wheezing sounds, or lethargy.

3. Restrict clients fluid intake to reduce the excess fluid volume. 4. Monitor clients intake and output chart to ensure client is not taking too much fluid and is passing adequate urine at least 30 ml/ hour. 5. Administer medication such as diuretics as prescribed by physician to encourage more fluid output to reduce the fluid in the body. 6. Monitor clients IV infusion closely if it is ordered by physician to ensure that the infusion is running at the correct rate to prevent fluid overload. 7. Explain to the client about taking less fluid so client will understand and cooperate. 8. Design a fluid plan for the client to ensure that client is getting adequate fluid as ordered by physician. iii. Activity intolerance related to fluid volume excess, fatigue, and weakness. Nursing outcome: Client is able to tolerate daily activity with no fatigue and weakness and clients fluid volume is balanced. Interventions: 1. Assess clients condition such as vital signs, edema, and shortness of breath before planning an activity for the client. 2. Assist client in activity daily living such as providing bed bath for the client. 3. Advise client to take less fluid by providing an explanation to the client so client can understand and cooperate better. 4. Advise client to rest if client is feeling too weak and tired to do any activities. 5. Administer diuretics to the client as ordered by the physician to reduce the fluid excess. 6. Advise client to do small exercises according to clients tolerance such as moving from bed to chair to prevent client from getting too fatigued.

iv.

Impaired gas exchange related to pulmonary congestion. Nursing outcome: Client is able to have optimal ventilation. Interventions: 1. Assess clients vital signs and general condition such as respiration rate and the rhythm to ensure that client is not in respiratory distress. 2. Monitor clients ABG result to assess the progress of the disease. 3. Administer adequate oxygen to the client if client is in respiratory distress. 4. Administer medication such as bronchodilator and expectorant to dilate the bronchus and to encourage secretion of phlegm. 5. Teach client to do deep-breathing and coughing exercise to achieve maximum lung expansion and also to loosen the mucus from the lungs. 6. Do suctioning of phlegm if client is unable to cough out the phlegm or as ordered by the physician so client will be able to breathe better. 7. Collect sputum from client and to send to the lab for culture and sensitivity so appropriate antibiotic can be given.

CARE OF CLIENT WITH IV i. Risk for phlebitis related to poor aseptic technique secondary to intravenous infusion. Nursing outcome: Client does not have phlebitis. Interventions: 1. Assess intravenous infusion site for signs of inflammation such as redness, warm to touch, swelling and pain. 2. Perform hand wash before and after attending to the client to prevent cross-infection. 3. Clean the IV site with alcohol swab to clean the site from microorganism. 4. Ensure that the ends of the tubing which will be connected to the client is sterile by covering it to maintain the sterility.

5. Switch off the fan before doing the procedure to prevent the transmission of microorganism to the sterile field. 6. Change the IV plaster if it is wet or stained to prevent the growth of microorganism. 7. Discontinue the IV infusion if any signs of phlebitis is detected to prevent further complication. ii. Risk for hypervolemia related to overload of intravenous fluid secondary to intravenous infusion. Nursing outcome: Clients normal fluid volume is maintained. Interventions: 1. Assess clients vital signs for hypertension, rapid respirations with wheezing sounds, and full bounding tachycardia which may indicate signs of hypervolemia. 2. Perform a physical assessment for signs of fluid overload such as lungs auscultation to hear for any crackles and assess for any edema of lower limbs. 3. Calculate the IV drip flow rate as prescribed by the physician before running the drip to prevent hypervolemia due to fluid overload. 4. Maintain the prescribed flow rate to ensure that it is running at the correct rate because if the flow rate is too fast, it can cause hypervolemia due to fluid overload. 5. Use IV infusions pumps to control the flow rate of the infusions to prevent hypervolemia.

INFECTION & INFLAMMATION i. Risk for pressure ulcer related to immobility. Nursing outcome: Client does not have pressure ulcer. Interventions: 1. Perform a skin assessment for the client especially at bone prominent areas to assess for any skin breakdown which may later develop into pressure ulcer. 2. Apply mild lotion or moisturizer on clients skin if it is dry and massage gently and slowly to avoid skin friction to prevent skin breakdown. 3. Change the position of the client every 2 hours by turning the client to prevent pressure ulcer. 4. Ensure that clients bed sheet is free of wrinkles to decrease the friction of clients skin with the bed sheet as it will cause pressure ulcer. 5. Use ripple mattress for the client as ripple mattress will distribute the pressure points evenly which will help in preventing pressure ulcer. 6. Avoid shear and friction while positioning the client to prevent skin breakdown. ii. Risk for impaired skin integrity related to incontinence. Nursing outcome: Clients skin integrity is maintained with no skin breakdown. Interventions: 1. Assess clients skin for any signs of skin lesions and also the condition of the skin such as dryness, moist, the colour, and the skin texture. 2. Maintain clients hygiene by changing the diaper regularly and when it is soiled to prevent pressure ulcer because a moist environment will cause skin breakdown more easily. 3. Change clients bed sheet and clothes if it is soiled due to clients incontinence because moist environment will cause the skin to breakdown easily.

4. Maintain clients hygiene by performing bed bath if client is immobile and ensure that sacral area is clean and dry to prevent pressure sore. 5. Insert CBD for the client due to the incontinence if ordered by the physician. PERIOPERATIVE CARE i. Anxiety related to lack of knowledge about surgery. Nursing outcome: Client is less anxious after providing client the knowledge about the surgery. Interventions: 1. Assess clients level of anxiety by asking the client how they feel and the reason of the anxiety. 2. Provide information to the client and family members if they are with the client and encourage client to ask questions to know the level of clients knowledge about the surgery. 3. Inform the client about what to expect after the surgery such as sutured wound, surgical drain, level of pain, drowsiness, and feeling of nausea and vomiting might present so client will feel less anxious post operative. 4. Provide a counsellor for the client so that clients emotional and spiritual needs are taken care of to help client to overcome their anxiety. 5. Administer medications such as anti-anxiety or sedatives as ordered by the surgeon to reduce their anxiety. ii. Deficient knowledge related to lack of education about perioperative process. Nursing outcome: Client is educated about the perioperative process and verbalised understanding about the process. Interventions: 1. Assess clients level of understanding about the perioperative process by asking client questions related to the process. 2. Encourage client to ask questions about the perioperative process so that proper information can be given to the client.

3. Explain to the client the need of pre-operative tests such as blood tests, ECG, and CXR as baseline data before the surgery. 4. Educate client on deep-breathing and coughing exercise, leg exercises and how to move post operative and explain to client the importance of all the exercises to avoid post operative complications. 5. Explain to the client about the need to keep NBM at least 8 hours before the surgery to prevent complication post operation. 6. Advise the client to get enough rest and sleep a day before the surgery to encourage good wound healing after the surgery. 7. Inform client about skin preparation as required by the surgeon and the site of shaving to reduce the risk of infection. 8. Inform client about pre-medication which will be given 1 hour prior for surgery as a preparation for the surgery and also as prevention of complication such as gastritis, nausea, and vomiting. 9. Advise client to void before administering the pre-medication to avoid client from falling once sedatives are given to the client. 10. Advise client to remove all jewelries, hair clips, contact lenses, wig, makeup, and cutex so that assessment can be made during operation. iii. Risk for atelectasis and pneumonia related to lack of mobility post operative. Nursing outcome: Client does not have post operative complications. Interventions: 1. Assess clients level of pain due to the operation because pain limit clients mobility. 2. Explain to client the importance of mobilising to prevent post operative complications. 3. Educate client on deep-breathing and coughing exercises to prevent atelectasis and pneumonia. 4. Advise client to do deep-breathing and coughing exercise at least every 2 hours or as tolerated by client to achieve maximum lung expansion and to mobilise secretions.

5. Educate client on moving and splinting technique to reduce the pain at the operative site and also to prevent wound dehiscence during ambulation. 6. Encourage client to turn from side to side at least every 2 hours to achieve maximum lung expansion and also to prevent pressure ulcer. 7. Administer analgesics for client if the pain is severe so client will be able to mobilise with less pain. iv. Pain related to post operative wound. Nursing outcome: Clients pain is reduced or pain free. Interventions: 1. Assess clients level of pain by asking the client the severity of the pain using pain scale. 2. Administer analgesic such as morphine to the client as prescribed by surgeon to reduce the pain. 3. Educate client about splinting technique over the operative site while moving to reduce the pain. 4. Educate client on how to use PCA (Patient-controlled analgesia) when there is pain to help client in reducing the pain. 5. Perform dressing as ordered by the surgeon gently to avoid causing too much pain and discomfort for the client. 6. Administer analgesic or sedatives as prescribed by the surgeon prior for dressing to reduce the pain. BURN & SCALDS i. Burn shock related to severe burn. Nursing outcome: Clients condition is stabilised. Interventions: 1. Assess clients condition for signs of burn shock such as severe hypovolemia and hyperventilation and the severity of the burn by using Rule of nines.

2. Insert 2 large bore cannula to administer IV fluids and medications to the client. 3. Administer IV Hartmanns as ordered by the doctor to replace fluid loss due to burn. 4. Administer vasoactive medications as ordered by doctor to increase the low blood pressure due to burn shock. 5. Administer adequate oxygen to the client if client is having difficulty in breathing or low oxygen saturation. 6. Assess for any hoarseness of voice which may indicate respiratory tract injury. 7. Intubate client if there is burn to the face, neck, or chest to administer adequate ventilation to the client because respiratory tract injury causes airway constrictions due to edema. 8. Take blood for ABG to assess for gas imbalances such as respiratory alkalosis and respiratory acidosis. 9. Administer medication such as bronchodilator and mucolytic agents to dilate constricted bronchial passage and to liquefy sputum and aid in expectoration. 10. Cover client with blanket to prevent heat loss. ii. Risk for ineffective airway clearance related to lung congestion secondary to smoke inhalation. Nursing outcome: Client is able to achieve optimal ventilation. Interventions: 1. Assess client for signs of respiratory distress such as shortness of breath, wheezes, or stridor which indicate ineffective airway clearance. 2. Obtain an ABG as ordered by the doctor to assess for gas imbalances and carbon monoxide poisoning due to smoke inhalation which may cause ineffective ventilate.

3. Administer medication such as bronchodilator and mucolytic agents to dilate constricted bronchial passage and to liquefy sputum and aid in expectoration. 4. Administer oxygen if the client is having difficulty in breathing. 5. Intubate client as ordered by the doctor to ventilate client. 6. Obtain a CXR as ordered by doctor to assess the lung condition. iii. Risk for ineffective tissue perfusion related to peripheral constriction secondary to circumferential burn wounds of the arms. Nursing outcome: Client has adequate tissue perfusion with improved circulation. Interventions: 1. Assess for pulse of the arms to ensure that there is blood circulation to prevent necrosis of the tissue. 2. Assess the extremity hourly for warmth, colour, sensation, and capillary refill for signs of absence blood flow. 3. Observe the client closely for any complain of numbness or tingling sensation of the fingers. 4. Advise the client to remove any jewelries such as ring, bracelet, or watch to prevent further constriction which will cause decreased blood flow. 5. Prepare client for escharotomy if it is ordered by surgeon to relief the constriction caused by circumferential burn wounds. iv. Impaired physical mobility related to formation of contractures secondary to burn wounds. Nursing outcome: Client regains physical mobility. Interventions: 1. Perform active or passive ROM exercises to all joints every 2 hours to prevent further loss of motion and to improve functional status. 2. Advise client to perform exercises on their own to restore movement and to prevent contractures.

3. Assist client in ambulating once clients condition is stable according to clients tolerance and explain to client the importance of ambulating to gain full cooperation from the client. 4. Apply splints as ordered by doctor and reposition client hourly to prevent further formation of contractures. 5. Administer analgesia for the client as ordered to promote clients comfort during exercising sessions. 6. Advise client to wear support garment such as Jobst garment to reduce scarring because scarring can cause contractures.