CJE Health and Illness

obesity clinical problem 1

body weight problem

obesity risk factors

BMI over 30

poor diet/activity

comorbidities

alcohol

obesity goal/outcomes 4

patient will: achieve a healthy weight

be free from complication

achieve good nutrition

adhere to treatment

obesity interventions: assess

weight history

daily diet

eating disorders

metabolic conditions

mental health

labs (lipids)

body image

obesity interventions: act 5

motivational interviewing

dietician/counseling referral

supplements

local resources

*mutually agreed on

obesity interventions: educate 4

healthy diet

exercise plan

consequence of obesity

local resources

obesity: reflect/reassess

weight

labs

adherence

complications

stress and coping cause

sudden hospital admission (sepsis, code, surgery, cancer)

stress/coping clinical problems 3

risk for impaired coping

risk for disturbed body image

dependent on condition

stress/coping goals and outcomes 3

demonstrate effective coping

report decreased levels of stress

avoid complications related to stress

stress/coping interventions: assess 4

stress level

LOC

knowledge

current coping

stress/coping interventions: act 3

provide reassurance that is honest

involve family

contact chaplain/social worker

stress/coping interventions: educate 2

give information

orient them to where they are and what happens

over/undereating 3

emotional coping mechanism

disconnecting from body's wisdom about hunger from + food

restricting food for control

over/undereating clinical problems 3

nutritionally compromised

disturbed body image

risk for obesity/underweight

over/undereating goals and outcomes 3

display healthy eating habits

express + body image

display effective coping

over/undereating interventions: assess

patient's dietary habits

motivation behind disordered eating

marker nutrients (Fe, Ca)

over/undereating interventions: act

refer to counseling/dietician as needed

small changes agreed on by the patient

address larger cause

over/undereating interventions: educate 3

resources/support groups

healthy changes

coping strategies

caregiver role strain 5

when person feel difficulty getting role done

financial burden

role change

increased responsibility

change in family

caregiver role strain clinical problems 4

impaired coping

caregiver role strain

stress overload

ineffective family coping

caregiver role strain intervention: assess 7

saying negative things about pt

resentment of patient

social withdrawal

health problems

complains about physical issues

ask them who can help you

ask if they know about community resources

caregiver role strain intervention: act/educate 5

sit with them/teach them stress relief

coach them with anger management

get in support group

acknowledge how hard they are working

thank them for their effort

mobility risk factors 3

*hospitalization

neurological

musculoskeletal

chronic pain

mobility populations at risk

elderly especially women

consequences of immobility 3

DVT lead to PE

pneumonia

pressure ulcers

how to prevent mobility consequences 3

intermittent sequential compression devices

incentive spirometer

Q2 turns

mobility nursing intervention/prevention: primary 7

physical activity

optimal nutrition (↑protein/ca)

ideal body weight

adequate sleep

injury prevention

fall prevention

environment safety check

mobility nursing intervention/prevention: secondary 2

BMAT and morse fall risk

vision screenings

mobility nursing intervention/prevention: tertiary 7

Q2 turns/repositioning

braden scale skin assessments

sequential compression devices

incentive spirometer

ROM/PT/OT

medications

surgery (immobilization/assistive devices)

mobility: osteoarthritis 4

come type of arthritis

gradual deterioration of cartilage and joints

bone on bone frictions

happens in hips/knees/vertebrae

mobility: osteoarthritis risk factors 6

over 60 years old especially women

obese

history of joint injuries

occupations with repeat stress

genetics

congenital deformities

mobility: osteoarthritis symptoms 6

pain with movement

tenderness

stiffness especially in the morning

decreased ROM

grating sensation

bone spurs

mobility: osteoarthritis nursing tertiary prevention

lifestyle: stay active and maintain healthy weight

meds: ACETAMINOPEN, otc nsaids + proton pump inhibtior to prevent GI ulcers

collaborative: PT, OT, joint replacement surgery, acupuncture, music therapy, swimming, yoga

mobility hip fracture risk 2

over 65 years old

high fall risk

mobility: hip fracture surgical/post op treatment 8

ORIF/CRIF; partial/total arthroplasty

suppot ABduction/ROM

pain management

prevent immobility consequences (DVT, pneumonia, pressure ulcers)

skin integrity

infection

incontinence

constipation

mobility hip fracture assistive devices 7

grab bars

non-slip mats

bath/shower seats

cane

sock aid

long handle reachers

crutches/walker

mobility hip fracture outcomes 4

may never get full fnc back

20% die within one year

psychological trauma

complications due to immobility

hip fracture clinical problems and priorities

cp: risk for DVT and venous stasis to fracture/surgery

p: ABCs then tissue perfusion (clots, PE, stroke)

hip fracture goal and outcome

g: promote circulation and anticoagulation

o: patient will be free of DVT, verbalize purpose of anticoagulation meds and comply with SCD use

hip fracture intervention + rationale

i: administer anticoagulant properly, educate pt about side effects or med, encourage SCD use

r: anticoagulants and SCA promote circulation and prevent VTE complications

spinal cord injury cause

MVA, fall, violence, sports that causes compression, hyperflexion, laceration or severing of cord

spinal cord injury risk

males ages 15-36 years old

spinal cord injury symptoms

partial or complete paraplegia (full 6 months to see impact)

spinal cord injury nursing intervention 9

exercise for self care

mobilization with stabilizer devices

prevent atrophy and contractures

assistive devices

teach bowel/catheter program

sexual fnc program

maintain skin integrity

psychological coping

prevent infection

spinal cord injury clinical problem

risk for injury related to cervical spine instability secondary to MVA

spinal cord injury priority

ABCs then prevent further injury

spinal cord injury goal/outcome

g: prevent further injury to spinal cord

o: stabilized verteral column and alignment maintained

spinal cord injury intervention + rationale

i: turn using log roll technique, monitor halo pin insertion site for loose pins, monitor skin integrity under device

r: following instructions for halo helps prevent complications and using log roll will prevent further damage to spinal cord

ways to provide comfort 9

therapeutic communication

build relationship

keep room clean

spiritual comfort

provide privacy

pain relief

hygiene

intellectual stimulation

healing environment

what is pain (interrelated to comfort)

whatever the pt says it is whenever the pt says it is

how to tell if pt is in pain

ask them

physiological indicators (grimacing, clenching teeth, tears, altered breathing, shaking, rocking, sympathetic response)

populations at risk for pain 5

elderly

neonates

ICU

anyone who cannot speak for themselves

highest risk: NICU

assessment for pain 4

OPQRSRU

FACES for 4-16yrs

Neonatal pain agitation & sedation scale (crying, behavior, face expression, extremities, vitals)

assess for end of dose failure

pain clinical problems

acute pain

chronic pain

abdominal pain

nursing interventions for pain 6

communicate

administer pain meds on time

use non-pharm methods

call for orders

decrease fear/anxiety

NSAIDS

ways to really help control pain

multimodal: nonopioid, opioid, adjuvant

given pt PCAs and use adjuvants

watch for side effects of opioids (sedation, resp. depression, N/V/C)

new post op patient (comfort) cause 4

post op pain is perceived before fully consciousness

related to incisions and other surgical work

assess verbal/nonverbal signs of pain

consider type of anesthesia

new post op patient risk factors 2

anyone post op

anyone who cannot speak for themself

new post op patient symptoms 2

non verbal/verbal signs

watch vitals

new post op patient nursing intervention 4

narcotics/opiates

NSAIDs

advocate for pt

PCAs

sickle cell anemia (comfort) etiology 3

autosomal recessive most likely in African American

cells become rigid/clump

sickled cells are destroyed cause anemia, jaundice, pain, organ damage, disability, ischemia

sickle cell anemia clinical problem, evidence and cause

cp: acute pain

e: pt reports pain, tachycardia, HTN, tachypena, restlessness

c: sickle cell crisis

sickle cell anemia priority

ABCs then acute pain relief

sickle cell anemia intervention+rationale: assess

i: assess pain, monitor vitals, assess knowledge of pain mgmt and assess knowledge of prevention

r: assessing knowledge prevents reaching pt what they already know, routine monitoring aids in detecting changes in condition and potential complications

sickle cell anemia intervention+rationale: action

i: obtain order for pain meds, document, therapeutic comm.

r: safe medication admin requires order and documentation and the way the nurse interacts with pt affect quality of life

sickle cell anemia intervention+rationale: teaching

pain mgmt includes deep breathing/heat, prevent crisis like handwashing, immune support, hydration, nutrition

r: nonpharm methods can complement pharm treatment of pain, prevention restores pt sense of self control/crisis

hyperemesis gravidarum 2

excessive vomiting during pregnancy

unknown cause but can be related to hormone levels

Hyperemesis Gravidarum clinical problems 4

nutritional deficit

metabolic imbalance

risk for complications to fetus

difficulty coping

Hyperemesis Gravidarum interventions

assess: nutrition, hydration, and triggers

action: administer meds, refer to acupuncture, administer IV/NG

teach: nonpharm nausea relief, prescription use

failure to thrive clinical problems 7

infant feeding problem

inadequate caloric intake

breastfeeding problem

lactation problem

nutrition problem

body weight problem

impaired GI fnc

failure to thrive interventions 6

assess health history

monitor dietary intake

monitor output

assess need for tube feedings

assess home life

interdisciplinary team is KEY

failure to thrive education 5

teach about breastfeeding techniques

teach successful bottle feeding

teach cause of problem

teach infant feeding cues

teach importance of maternal nutrition

nursing interventions for pancreatitis 8

nasogastric tube to low intermittent suction

pain meds

NPO

nutritional needs: enteral feeds or TPN

bowel rest to decrease stimulus

NG tube for nausea

lifestyle changes : drinking, diet, HIGH PROTEIN, LOW FAT

patient education

nursing interventions for laryngeal cancer 2

increased aspiration risk: lift HOB

management of G tube: flush meds, hydration needs, check placement

laryngeal cancer/pancreatitis interventions 8

assess need for enteral/parenteral feedings

assess/manage blood glucose

oral care

assess diet history

teach medication regimen

therapeutic communication

collaborate with nutritionist

administer fluids/electrolytes

laryngeal cancer/pancreatitis education

teach ways to reduce risk of infections

teach expectations

teach appropriate food/diet plan

teach lifestyle changes

give community resources

atopic dermatitis clinical problems 2

impaired tissue integrity

disturbed body image

atopic dermatitis interventions 2

skin hydrations

antihistamines

atopic dermatitis education 11

self esteem

coping

preventive measures

education

thick cream moisturizers

hydrating bath with mild soap

short shower

wearing cotton fabrics

washing clothes with mild detergent

humidifying in winter

antihistamines

surgical wounds/burns clinical problems 9

impaired tissue integrity

inadequate tissue perfusion

musculoskeletal problem

negative self image

nutritionally compromised

pain

personal care problem

risk for infection

sensory deficit

surgical wounds/burns interventions 10

assess/restore skin integrity

assess/improve mobility

Q2 turns

prevent incontinence

assess risk for infection

collaborate with nutrition

collaborate with case management

assess fluid/electrolyte balance

administer fluids/electrolytes

assess with braden scale

surgical wounds/burns education 6

teach nutrition (HIGH PROTEIN/VIT C)

teach process of wound healing

teach wound care

teach importance of adequate rest

teach importance of mobility

teach how to participate in ADLs

c-diff (elimination) clinical problems 5

Impaired Bowel Function

Risk for dehydration

Risk for inadequate nutrition

Pain

Risk for impaired skin integrity

c-diff (elimination) interventions 10

increase oral intake

contact precautions

admin pain meds

finish antibiotics

specimen collection

small meals

monitor I&O

inspect abdomen

assess for dehydration

assess fluid and electrolyte balance

colon cancer clinical problems 4

impaired bowel fnc

fatigue

inadequate nutrition

pain

colon cancer (constipation) interventions 9

increase oral food intake

small frequent meals

pain med administration

stool softener

inspect abdomen

encourage physical activity

assess bowel

educate to eat high fiber diet

educate about drinking enough water

post partum mother (urinary incontinence) clinical problems 3

impaired urinary fnc (stress incontinence)

risk for social isolation

deficient knowledge

post partum mother (urinary incontinence) interventions 3

Pt referral for pelvic floor rehab

support group

teach about kegal exercise

post partum mother (urinary incontinence) education 4

assess fluid intake/urination

avoid alcohol and caffeine

kegel exercise

therapeutic communication

psychological bowel withholding clinical problems 6

impaired bowel fnc

ineffective coping

fear

pain

self care deficit

anxiety

psychological bowel withholding intervention 6

prescribe dose of mag citrate

increase fluid and fiber

educate about bowel program

stool softeners prn

assess consistency of stool

therapeutic communication

psychological bowel withholding education 5

bowel training program

mag citrate education

nutrition education

discourage punishment

reassure parents

OSA (sleep deprivation) clinical problem 5

impaired sleep

altered BP

fatigue

impaired respiratory fnc

impaired cardiac fnc

OSA (sleep deprivation) intervention 6x

assess for risk factors/manifestations for sleep apena

comprehensive sleep history

assess via Epworth scale

sleep study

CPAP

tonsillectomy

OSA (sleep deprivation) education 5

cpap usage

cleaning cpap

avoiding alcohol

when to notify the provider

daytime sleepiness precautions

insomnia clinical problem

impaired sleep

insomnia interventions 10

assess via Epworth scale

sleep study

environmental controls

dietary adjustments

administer sleep aids

reduce noise level

appropriate temperature

reduced lights in the room

non-pharmacological sleep aids

establishing periods of rest and sleep

sepsis clinical problem 2

infection (hypotension, tachypena, confused, elevated wbs, serum lactate)

impaired oxygenation

sepsis interventions 8

fluids

antibiotics

therapy

ventilation

close monitoring of vitals

serial labs

TPN nutrition

pain management