The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Discover the best professional documents and content resources in AnyFlip Document Base.
Published by cikgu online, 2020-01-20 20:56:53

INTRODUCTION OF NURSING 1.4 The Nursing Process (PART 2)


1.4 The Nursing Process




3. Nursing Care Plan

a. Nursing diagnosis

b. 8 step nursing diagnosis

• Review the assessment

• Cluster the data

• Select possible nursing diagnosis

• Differentiate among possible diagnosis

• Identify appropriate diagnosis

• Determine related factors

• Discuss the diagnosis with the client

• Formulate the nursing diagnosis


b. Plan the nursing care

• Establish priorities

• Identify and write outcome

• Identify nursing interventions

• Develop evaluative strategies

• Communicating and recording

c. Implementing

• Types of interventions

• Skills of implementing interventions

• Continue data collection and modify the plan of care as needed


d. Evaluation

• Measure how well the patient has achieved desire outcome

• Identify factors contributing to the patient success or failure

• Modify the plan of care if indicated




• Body temperature below the normal range.

• Normal body temperature is around 37 °C (98.6 °F).

• occurs as the body temperature falls lower than normal; usually

below 35 °C (95 °F).


• Occurs when the body fails to produce heat during metabolic processes, in cells

that support vital body functions.

➢Most heat is lost from the skin’s surface through convection, conduction,

radiation, and evaporation.

➢When the body temperature drops, the heart, nervous system and other

organs can’t work normally leading to complete failure of the heart

and respiratory system and eventually to death.


• can be classified as inadvertent (seen postoperatively), intentional

(for medical purposes), or accidental (exposure related).

• Inadvertent perioperative hypothermia is a common consequence of


• Intentional hypothermia is an induced state generally directed at

neuroprotection after an at-risk situation usually after cardiac arrest.


• Accidental hypothermia usually results from sudden exposure in an

inadequately prepared person such as an inadequate shelter for a

homeless person or someone exposed in a winter storm or motor

vehicle accident.

• Older adults are particularly exposed to accidental hypothermia due

to age-related changes in normal thermoregulation.

Related Factors

• Here are some factors that may be related to Hypothermia:

➢Alcohol and drug use

➢Decreased metabolic rate

➢Exposure to cold environment

➢Extreme evaporative heat loss from skin


➢Inability to shiver

➢Inadequate nutrition

➢Poor clothing



Defining Characteristics

• Hypothermia is characterized by the following signs and symptoms:

• Body temperature below normal range

• Cool, pale skin

• Dizziness

• Hypertension

• Increased HR

• Lack of coordination

• Piloerection

• Shivering

• Slow capillary refill

Goals and Outcomes

The following are the common goals and expected outcomes

for Hypothermia:

• Patient maintains a core body temperature Patient maintains a core

body temperature within 36.8 to 37.2 celsius.

• Patient manages HR and BP within normal limits; skin is warm.

Nursing Assessment

• Assessment is required in order to distinguish possible problems that

may have lead to Hypothermia.

Assessment Rationales

Causative factors guide the appropriate treatment.

Assess for precipitating Older patients have a decreased metabolic rate and

situations and risk factors. reduced shivering response; therefore the effects of

cold may not be immediately manifested.

Nursing Assessment

Assessment Rationales

For alert patients, oral temperature is regarded as

more reliable than tympanic or axillary. For

Note and monitor patient’s hypothermic patients, core temperature can be

temperature. monitored using a temperature-sensitive pulmonary

artery catheter or bladder catheter.

HR and BP drop as hypothermia progresses.

Monitor the patient’s HR, Moderate to severe hypothermia increases the risk

heart rhythm, and BP. for ventricular fibrillation, along with other


Nursing Assessment

Assessment Rationales

Evaluate the patient for

drug abuse use,including anti These groups of drugs contribute to

psychotics, opioids, and vasodilation and heat loss.


Poor nutrition contributes to

Evaluate the patient’s decreased energy reserves and

nutrition and weight. restricts the body’s ability to generate

heat by caloric consumption.

Nursing Assessment

Assessment Rationales

Hypothermia initially precipitates peripheral

vascular constriction as a compensatory

mechanism to minimize heat loss from

extremities. The patient’s skin will look pale

Assess the patient’s peripheral and cool to the touch with delayed capillary

perfusion at frequent intervals. refill. As hypothermia advances, vasodilation

transpires, furthering heat loss. The patient’s

skin becomes warm and less pale. The

patient may start to remove clothing and bed


Nursing Assessment

Assessment Rationales

Decreased output may

indicate dehydration or poor renal perfusion.
Monitor fluid intake
Avoid fluid overload to prevent pulmonary
and urine output (and/or central
edema, pneumonia, and taxing an already
venous pressure).
compromised cardiac and renal status.

Check for electrolytes,
Acidosis may emerge from hypoventilation
arterial blood gases, and oxygen and hypoxia.

saturation by pulse oximetry.

Nursing Assessment

Assessment Rationales

Evaluate for the presence of
Severe hypothermia generates ice crystals to
frostbite, if the patient has had form inside cells. The cells eventually burst

prolonged exposure to a cold
and die.

Assess the patient’s readiness to

reach a toileting facility, both This allows the nurse to plan for assistance.

independently and with assistance.

Nursing Assessment

Assessment Rationales

Assess the patient’s typical pattern
This information is the source for an
of urination and occurrence
individualized toileting program.
of incontinence.

Nursing Interventions

• The following are the therapeutic nursing interventions

for Hypothermia:

Interventions Rationales

These methods provide for a more
Regulate the environment
gradual warming of the body. Rapid
temperature or relocate the patient
warming can induce ventricular
to a warmer setting. Keep the

fibrillation. Moisture promotes
patient and linens dry.
evaporative heat loss.

Nursing Interventions

• The following are the therapeutic nursing interventions

for Hypothermia:

Interventions Rationales

Body temperature should be raised no

more than a few degrees per hour.

Vasodilation occurs as the patient’s core
Control the heat source according to the
temperature increases leading to a
patient’s physical response.
decrease in BP. Hypotension, metabolic

acidosis, and dysrhythmias are

complications of rewarming.

Nursing Interventions

• The following are the therapeutic nursing interventions

for Hypothermia:

Interventions Rationales

Give extra covering (passive warming),

such as clothing and blankets; cover Warm blankets provide a passive method

postoperative patients with heat-retaining for rewarming.


Give heated oral fluids for alert patients. Warm fluids produce a heat source.

Nursing Interventions

• The following are the therapeutic nursing interventions

for Hypothermia:

Interventions Rationales

• Provide extra heat source:Heat lamp,

radiant warmer
These measures raise the core
• Warming pads, mattress, or blankets
temperature and improve circulation.
• Submersion in a warm bath
Core warming is indicated when body
• Heated, moisturized oxygen
temperature is below 30 °C (86 °F).
• Warmed intravenous fluids or lavage


Nursing Interventions

• The following are the therapeutic nursing interventions

for Hypothermia:

Interventions Rationales

Avoid manually rubbing, scrubbing, or Rubbing can further damage frozen

massaging areas of frostbite. tissue.

Explain all procedures and treatment to Repeated explanations are needed to

the patient and SO. avoid confusion.

Nursing Diagnoses

• Activity Intolerance • Impaired Gas Exchange

• Acute Confusion • Impaired Oral Mucous Membrane

• Acute Pain • Impaired Physical Mobility

• Anxiety • Impaired Swallowing

• Caregiver Role Strain • Impaired Tissue (Skin) Integrity

• Constipation • Impaired Urinary Elimination

• Chronic Pain - Functional Urinary Incontinence

• Decreased Cardiac Output - Reflex Urinary Incontinence

• Deficient Fluid Volume - Stress Urinary Incontinence

• Deficient Knowledge - Urge Urinary Incontinence

• Diarrhea

Nursing Diagnoses

• Impaired Verbal Communication • Risk for Aspiration

• Ineffective Airway Clearance • Risk for Bleeding

• Ineffective Breathing Pattern • Risk for Falls

• Ineffective Coping • Risk for Infection

• Ineffective Therapeutic Regimen • Risk for Injury

Management • Risk for Unstable Blood Glucose

• Ineffective Tissue Perfusion Level

• Latex Allergy Response • Self-Care Deficit

• Powerlessness • Urinary Retention

• Rape Trauma Syndrome

Evaluating Patient After Delivering


Care plan objectives Evaluation

• Patient maintains a core body • Patient temperature, HR and BP

temperature within 36.8 to 37.2 was between normal range.


• Patient manages HR and BP

within normal limits; skin is


Click to View FlipBook Version