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5880


Calming Technique


Definition: Reducing anxiety in patient experiencing acute distress


Activities:



• Maintain calm, deliberate manner


• Maintain eye contact with patient


• Reduce or eliminate stimuli creating fear or anxiety


• Stay with patient


• Reassure patient of personal safety or security


• Identify significant others whose presence can assist patient


• Hold and comfort an infant or child


• Rock an infant, as appropriate


• Speak softly or sing to an infant or child


• Offer pacifier to infant, as appropriate


• Instruct patient on techniques to use to calm an infant (e.g., speak to infant, hand on belly, restraining arms, picking up, and holding and rocking)


• Provide time and space to be alone, as appropriate


• Sit and talk with patient


• Facilitate the patient’s expression of anger in a constructive manner


• Rub forehead, as appropriate


• Offer warm fluids or milk


• Offer back rub, as appropriate


• Offer warm bath or shower


• Instruct patient on methods to decrease anxiety (e.g., slow breathing techniques, distraction, visualization, meditation, progressive muscle relaxation, listening to soothing music), as appropriate


• Provide antianxiety medications, as needed


1st edition 1992, revised 2013



4035


Capillary Blood Sample


Definition: Obtaining an arteriovenous sample from a peripheral body site, such as the heel, finger, or other transcutaneous site


Activities:



• Verify correct patient identification


• Minimize anxiety for the patient using age-appropriate procedures


• Maintain standard precautions


• Select puncture site (e.g., outer lower aspect of heel, sides of distal phalanges of the fingers or toes, alternative sites such as the forearm)


• Puncture outer aspect of heel no deeper than 2.4 mm on infants


• Warm the site for approximately 5 minutes if specimen is to be an arterialized sample, according to agency protocol


• Use aseptic technique during skin puncture


• Puncture skin manually with a lancet or an approved penetration device according to manufacturer’s specifications


• Wipe off first drop of blood with dry gauze, as per manufacturer’s specifications or agency protocol


• Collect blood in manner appropriate to test being performed (e.g., allow a drop of blood to fall onto manufacturer’s specified area of filter paper or test strips, draw blood into tubes by capillary action as droplets form)


• Apply intermittent pressure as far away from the puncture site as possible to promote blood flow


• Avoid hemolysis caused by excessive squeezing or “milking” of puncture site


• Follow manufacturer’s guidelines regarding timing on tests and preservation of blood sample (e.g., sealing blood tubes), as necessary


• Label specimen as necessary, according to agency protocol


• Send specimen to laboratory, as necessary


• Bandage site, as necessary


• Teach and monitor self-sampling capillary blood, as appropriate


• Dispose of equipment properly


• Document completion of capillary blood sampling


4th edition 2004



4040


Cardiac Care


Definition: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function


Activities:



• Routinely monitor patient physically and psychologically per agency policy


• Ensure activity level that does not compromise cardiac output or provoke cardiac events


• Encourage gradual increase in activity when condition is stabilized (i.e., encourage slower paced activities or shorter periods of activity with frequent rest periods following exercise)


• Instruct the patient on the importance of immediately reporting any chest discomfort


• Evaluate any episodes of chest pain (e.g., intensity, location, radiation, duration, and precipitating and alleviating factors)


• Monitor ECG for ST changes, as appropriate


• Perform a comprehensive appraisal of peripheral circulation (i.e., check peripheral pulses, edema, capillary refill, color, and temperature of extremity) routinely per agency policy


• Monitor vital signs frequently


• Monitor cardiovascular status


• Monitor for cardiac dysrhythmias, including disturbances of both rhythm and conduction


• Document cardiac dysrhythmias


• Note signs and symptoms of decreased cardiac output


• Monitor respiratory status for symptoms of heart failure


• Monitor abdomen for indications of decreased perfusion


• Monitor fluid balance (e.g., intake/output and daily weight)


• Monitor appropriate laboratory values (e.g., cardiac enzymes, electrolyte levels)


• Monitor pacemaker functioning, if appropriate


• Evaluate blood pressure alterations


• Evaluate the patient’s response to ectopy or dysrhythmias


• Provide antiarrhythmic therapy according to unit policy (e.g., antiarrhythmic medication, cardioversion, or defibrillation), as appropriate


• Monitor patient’s response to antiarrhythmic medications


• Instruct the patient and family on treatment modalities, activity restriction, and progression


• Arrange exercise and rest periods to avoid fatigue


• Restrict smoking


• Monitor the patient’s activity tolerance


• Monitor for dyspnea, fatigue, tachypnea, and orthopnea


• Establish a supportive relationship with the patient and family


• Identify the patient’s methods of handling stress


• Promote effective techniques for reducing stress


• Perform relaxation therapy, if appropriate


• Recognize psychological effects of underlying condition


• Screen patients for anxiety and depression, encouraging treatment with suitable antidepressants, as indicated


• Encourage noncompetitive activities for patients at risk for impaired cardiac function


• Discuss modifications in sexual activity with patient and significant other, if appropriate


• Instruct patient and family on the aims of care and how progress will be measured


• Ensure that all staff are aware of these goals and are working together to provide consistent care


• Refer to heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life, as appropriate


• Offer spiritual support to the patient and family (i.e., contact a member of the clergy), as appropriate


1st edition 1992; revised 2000, 2013




4044


Cardiac Care: Acute


Definition: Limitation of complications for a patient recently experiencing an episode of an imbalance between myocardial oxygen supply and demand resulting in impaired cardiac function


Activities:



• Evaluate chest pain (e.g., intensity, location, radiation, duration, and precipitating and alleviating factors)


• Instruct the patient on the importance of immediately reporting any chest discomfort


• Provide immediate and continuous means to summon nurse, and let the patient and family know calls will be answered immediately


• Monitor ECG for ST changes, as appropriate


• Perform a comprehensive appraisal of cardiac status including peripheral circulation


• Monitor cardiac rhythm and rate


• Auscultate heart sounds


• Recognize the frustration and fright caused by inability to communicate and exposure to strange machinery and environment


• Auscultate lungs for crackles or other adventitious sounds


• Monitor the effectiveness of oxygen therapy, if appropriate


• Monitor determinants of oxygen delivery (e.g., PaO2 and hemoglobin levels and cardiac output), if appropriate


• Monitor neurological status


• Monitor intake and output, urine output, and daily weight, as appropriate


• Select best EKG lead for continuous monitoring, as appropriate


• Obtain 12-lead EKG, as appropriate


• Draw serum, CK, LDH, and AST levels, as appropriate


• Monitor renal function (e.g., BUN and Cr levels), as appropriate


• Monitor liver function tests, if appropriate


• Monitor lab values for electrolytes that may increase the risk of dysrhythmias (e.g., serum potassium and magnesium), as appropriate


• Obtain chest x-ray, as appropriate


• Monitor trends in blood pressure and hemodynamic parameters, if available (e.g., central venous pressure and pulmonary capillary or artery wedge pressure)


• Provide small, frequent meals


• Provide appropriate cardiac diet (i.e., limit intake of caffeine, sodium, cholesterol, and food high in fat)


• Refrain from giving oral stimulants


• Substitute artificial salt, if appropriate


• Limit environmental stimuli


• Maintain an environment conducive to rest and healing


• Avoid causing intense emotional situations


• Identify the patient’s methods of handling stress


• Promote effective techniques for reducing stress


• Perform relaxation therapy, if appropriate


• Refrain from arguing


• Discourage decision making when the patient is under severe stress


• Avoid overheating or chilling the patient


• Refrain from inserting a rectal tube


• Refrain from taking rectal temperatures


• Refrain from doing a rectal or vaginal examination


• Delay bathing, if appropriate


• Instruct the patient to avoid activities that result in the Valsalva maneuver (e.g., straining during bowel movement)


• Administer medications that will prevent episodes of the Valsalva maneuver (e.g., stool softeners, antiemetics), as appropriate


• Prevent peripheral thrombus formation (i.e., turn every 2 hours and administer low-dose anticoagulants)


• Administer medications to relieve or prevent pain and ischemia, as needed


• Monitor effectiveness of medication


• Instruct patient and family on the aims of care and how progress will be measured


• Ensure that all staff are aware of these goals and are working together to provide consistent care


• Offer spiritual support to the patient and family (i.e., contact a member of the clergy), as appropriate


1st edition 1992; revised 2000, 2013




4046


Cardiac Care: Rehabilitative


Definition: Promotion of maximum functional activity level for a patient who has experienced an episode of impaired cardiac function that resulted from an imbalance between myocardial oxygen supply and demand


Activities:



• Monitor the patient’s activity tolerance


• Maintain ambulation schedule, as tolerated


• Encourage realistic expectations for the patient and family


• Instruct the patient and family on appropriate prescribed and over-the-counter medications


• Instruct the patient and family on cardiac risk factor modification (e.g., smoking cessation, diet, and exercise), as appropriate


• Instruct the patient on self-care of chest pain (i.e., take sublingual nitroglycerine every 5 minutes three times; if chest pain is unrelieved, seek emergency medical care)


• Instruct the patient and family on the exercise regimen, including warm-up, endurance, and cool-down, as appropriate


• Instruct the patient and family on any lifting/pushing weight limitations, if appropriate


• Instruct the patient and family on any special considerations with activities of daily living (i.e., isolate activities and allow rest periods), if appropriate


• Instruct the patient and family on wound care and precautions (e.g., sternal incision or catheterization site), if appropriate


• Instruct the patient and family on follow-up care


• Coordinate patient referrals (e.g., dietary, social services, and physical therapy)


• Instruct the patient and family on access of emergency services available in their community, as appropriate


• Screen patient for anxiety and depression, as appropriate


1st edition 1992; revised 2000, 2013




4050


Cardiac Risk Management


Definition: Prevention of an acute episode of impaired cardiac function by minimizing contributing events and risk behaviors


Activities:



• Screen patient for risk behaviors associated with adverse cardiac events (e.g., smoking, obesity, sedentary lifestyle, high blood pressure, history of previous cardiac events, family history of cardiac events)


• Identify patient’s readiness to learn lifestyle modification (e.g., diet, smoking, alcohol intake, exercise, and cholesterol levels)


• Instruct patient and family on signs and symptoms of early cardiac disease and worsening cardiac disease, as appropriate


• Instruct patient and family on cardiac risk factor modification, as appropriate


• Prioritize areas for risk reduction in collaboration with patient and family


• Instruct patient and family to monitor blood pressure and heart rate routinely and with exercise, as appropriate


• Encourage exercise as indicated by patient cardiac risk factor


• Instruct the patient on regular and progressive exercise, as appropriate


• Encourage 30 minutes of exercise daily, as appropriate


• Instruct patient on need to achieve exercise goals in incremental periods of 10 minutes multiple times daily, if intolerant to sustained 30 minute activities


• Instruct patient and family on symptoms of cardiac compromise indicating need for rest


• Instruct patient and family on strategies for restricting or eliminating smoking


• Instruct patient and family on strategies for a heart healthy diet (e.g., low sodium, low fat, low cholesterol, high fiber, adequate fluid, appropriate caloric intake)


• Encourage patient to keep caloric intake at a level that achieves desired weight


• Instruct patient and family on therapies to reduce cardiac risk (e.g., medication therapies, blood pressure monitoring, fluid restrictions, alcohol restrictions, cardiac rehabilitation)


• Provide both verbal and written information to patient, family, and caregivers for all pertinent cares, as indicated


• Focus care and treatment goals to enable the patient to maintain weight control, to remain a nonsmoker, and to remain as active as possible


• Refer to heart failure program or cardiac rehabilitation program for lifestyle changes, as appropriate


• Alleviate patient’s anxieties by providing accurate information and correcting any misconceptions


• Screen patient for anxiety and depression, as appropriate


• Identify the patient’s methods of handling stress


• Promote effective techniques for reducing stress


• Perform relaxation therapy, if appropriate


• Monitor patient’s progress at regular intervals


1st edition 1992; revised 2013



7040


Caregiver Support


Definition: Provision of the necessary information, advocacy, and support to facilitate primary patient care by someone other than a health care professional


Activities:



• Determine caregiver’s level of knowledge


• Determine caregiver’s acceptance of role


• Accept expressions of negative emotion


• Acknowledge difficulties of caregiving role


• Explore strengths and weaknesses with the caregiver


• Acknowledge dependency of patient on caregiver, as appropriate


• Make positive statements about caregiver’s efforts


• Encourage caregiver to assume responsibility, as appropriate


• Provide support for decisions made by caregiver


• Encourage the acceptance of interdependency among family members


• Monitor family interaction problems related to care of patient


• Provide information about patient’s condition in accordance with patient preferences


• Teach caregiver the patient’s therapy in accordance with patient preferences


• Teach caregiver techniques to improve security of patient


• Provide for follow-up health caregiver assistance through phone calls and/or community nurse care


• Monitor for indicators of stress


• Explore with caregiver how she/he is coping


• Teach caregiver stress management techniques


• Educate caregiver about the grieving process


• Support caregiver through grieving process


• Encourage caregiver participation in support groups


• Teach caregiver health care maintenance strategies to sustain own physical and mental health


• Foster caregiver social networking


• Identify sources of respite care


• Inform caregiver of health care and community resources


• Teach caregiver strategies to access and maximize health care and community resources


• Act for caregiver if overburdening becomes apparent


• Notify emergency services agency/personnel about the patient’s stay at home, health status, and technologies in use with consent of patient and family


• Discuss caregiver limits with patient


• Provide encouragement to caregiver during times of setback for patient


• Support caregiver in setting limits and taking care of self


1st edition 1992; revised 2004




7320


Case Management


Definition: Coordinating care and advocating for specified individuals and patient populations across settings to reduce cost, reduce resource use, improve quality of health care, and achieve desired outcomes


Activities:



• Identify individuals or patient populations who would benefit from case management (e.g., high cost, high volume, and/or high risk)


• Identify payment source for case management service


• Explain the role of the case manager to patient and family


• Explain the cost of service to patient and/or family before rendering care


• Obtain patient or family’s permission to be enrolled in a case management program, as appropriate


• Develop relationships with patient, family, and other health care providers, as needed


• Use effective communication skills with patient, family, and other health care providers


• Treat patient and family with dignity and respect


• Maintain patient and family confidentiality and privacy


• Assess patient’s physical health status, mental status, functional capability, formal and informal support systems, financial resources, and environmental conditions, as needed


• Determine treatment plan with input from patient and/or family


• Explain critical paths to patient and family


• Individualize critical path for patient


• Determine outcomes to be obtained with input from patient and/or family


• Discuss plan of care and intended outcomes with patient’s physician


• Negotiate work schedule with the nurse manager (head nurse) to attend weekly group practice meetings, as needed


• Integrate care management information and revised interventions (processes) into intershift report and group practice meetings, as needed


• Evaluate progress toward established goals on a continual basis


• Revise interventions and goals as necessary to meet patient’s needs


• Identify resources and/or services needed


• Coordinate provision of needed resources or services


• Coordinate care with other pertinent health care providers (e.g., other nurses, physicians, social workers, third-party payers, physical therapists)


• Provide direct care as necessary


• Educate patient and/or family on importance of self-care


• Encourage appropriate patient and/or family decision-making activities


• Document all case management activities


• Monitor plan for quality, quantity, timeliness, and effectiveness of services


• Facilitate access to necessary health and social services


• Assist patient and/or family with access to the health care delivery system


• Guide patient and/or family through the health care delivery system


• Assist patient and/or family in making informed decisions regarding health care


• Advocate for patient as necessary


• Recognize need to merge patient, clinical, and financial concerns


• Notify patient and/or family of change in service, termination of service, and discharge from case management program


• Promote efficient use of resources


• Monitor cost effectiveness of care


• Modify care to increase cost effectiveness, as needed


• Establish quality improvement program to evaluate case management activities


• Document cost effectiveness of case management


• Report outcomes to insurers and other third-party payers


• Market services to individuals, families, insurers, and employers

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Dec 3, 2016 | Posted by in NURSING | Comments Off on C

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