Below contains the list of nursing diagnoses approved by NANDA-I.

Health Perception and Management Pattern

1. Contamination
2. Disturbed energy field
3. Effective therapeutic regimen management
4. Health-seeking behaviors
5. Ineffective community therapeutic regimen management
6. Ineffective family therapeutic regimen management
7. Ineffective health maintenance
8. Ineffective protection
9. Ineffective therapeutic regimen management
10. Noncompliance
11. Readiness for enhanced immunization status
12. Readiness for enhanced therapeutic regimen management
13. Risk for contamination
14. Risk for falls
15. Risk for infection
16. Risk for injury (trauma)
17. Risk for perioperative positioning injury
18. Risk for poisoning
19. Risk for suffocation

NANDA Nursing Diagnosis List Original source at: Nurseslabs

Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections, can only be given intravenously.

Before Anything Else do an Assessment

Determine the following:

• The type and amount of solution to be infused
• The exact amount (dose) of any medications to be added to a compatible solution
• The rate of flow or the time over which the infusion is to be completed
• Assess for any allergies (e.g., to tape or povidone-iodine)

Assess the following:

• Vital signs for baseline data
• Skin turgor
• Allergy to latex, tape or iodine
• Bleeding tendencies
• Disease or injury to extremities
• Status of veins to determine appropriate venipuncture site

Purposes of Intravenous Therapy

• To supply fluid when clients are unable to take in an adequate volume of fluids by mouth
• To provide salts and other electrolytes needed to maintain electrolyte imbalance
• To provide glucose (dextrose), the main fuel for metabolism
• To provide water-soluble vitamins and medications
• To establish a lifeline for rapidly needed medications.

Implementation

Preparation:

• Introduce self and verify the client’s identity.
• Explain the procedure to the client. A venipuncture can cause discomfort for a few seconds, but there should be no discomforts while the solution is flowing.
• Use a doll to demonstrate for children and explain the procedure to the parents.

Performance:

1. Open and prepare the infusion set.
2. Spike the solution container
3. Apply a medication label to the solution container if a medication is added
4. Apply a timing label on the solution container
5. Hang the solution on the pole. It should be suspended about 1m above the client’s head to enable gravity to overcome venous pressure and facilitate flow of the solution into the vein.
6. Partially fill the drip chamber with solution
7. Prime the tubing Perform hand hygiene just prior to client contact.
   1. a. Remove the protective cap and hold the tubing over a container.
   2. b. Release the clamp and let the fluid run through the tubing
   3. c. Reclamp the tubing and replace the tubing cap, maintaining sterile technique.
   4. d. For caps with airvent, do not remove the cap when priming the tubing.
8. Select the venipuncture site
9. 1. a. Use the client’s nondominant arm, unless contraindicated.
   2. b. Identify possible venipuncture sites by looking for veins that are relatively straight, not sclerotic or tortuous, and avoid venous valves.
   3. c. The vein should be palpable, but may not be visible, especially in clients with dark skin.
   4. d. Consider the catheter length; look for a site sufficiently distal to the wrist or elbow that the tip of the catheter will not be at a point of flexion.
   5. e. Check agency protocol about shaving.
   6. f. Place a towel or bed protector under the extremity to protect linens.

10.  Dilate the vein.

1. a. Place the extremity in a dependent position (lower than the client’s heart). Gravity slows venous return and distends the veins. Distending the veins makes it easier to insert the needle properly.
2. b. Apply a tourniquet firmly 15 to 2 cm above the venipuncture site. Explain that it will feel tight. Tourniquet must be tight enough to occlude venous flow but not so tight that it occludes arterial flow. Obstructing arterial flow inhibits venous filling. If a radial pulse can be palpated, the arterial flow is not obstructed.
3. c. If the vein is not sufficient dilated:
   1. i.      Massage or stroke the vein distal to the site and in the direction of venous flow toward the heart. This action helps fill the vein.
   2. ii.      Encourage the client to and unclench the fist. Contracting muscles compresses the distal veins, forcing blood along the veins and distending them.
   3. iii.      Light tap the vein with your fingertips. Tapping may distend the vein.
   4. d. If the preceding steps fail to distend the vein so that it is palpable, remove the tourniquet and wrap the extremity in a warm, moist towel for 10 to 15 minutes. Heart dilates superficial blood vessels, causing them to fill. Then repeat step 10.

11.  Put on clean gloves and clean the venipuncture site. Gloves protect the nurse from contamination by the client’s blood.

1. a. Clean the site with topical antiseptic swab. Some may use anti-infective solution such as povidone-iodine. Check for allergies.
2. b. Use a circular motion, moving from the center outward for several inches. This motion carries microorganisms away from the site entry.
3. c. Permit solution to dry on the skin. Povidone-iodine should be in contact with the skin for 1 minute to be effective.

12.  Insert the catheter and initiate infusion.

1. a. Use the nondominant hand to pull the skin taut below the entry site. This stabilizes the vein and makes the skin taut for needle entry. It can also make initial tissue penetration less painful.
2. b. Hold the over-the-needle catheter at a 15-to 30-degree angle with bevel up, insert the catheter through the skin and into the vein. Sudden lack of resistance is felt as the needle enters the vein. Jabbing, stabbing or quick thrusting should be avoided because it may cause rupture of delicate veins.
3. c. Once blood appears in the lumen or you feel the lack of resistance, lower the angle of the catheter until it almost parallel with the skin and advance the needle catheter approximately 1cm father.
4. d. Holding the needle portion steady, advance the catheter until the hub is at the venipuncture site. The catheter is advanced to ensure that it, and not just the metal needle, is in the vein.
5. e. Release the tourniquet.
6. f. Put pressure on the vein proximal to the catheter to eliminate or reduce blood oozing out of the catheter. Stabilize the hub with thumb and index finger of the nondominant hand.
7. g. Remove the protective cap from the distal end of the tubing and hold it ready to attach tot the catheter, maintaining the sterility to the end.
8. h. Carefully remove the needle, engage the needle safety device, and attach the end of the infusion tubing to the catheter hub.
9. i. Initiate the infusion.

13.  Tape the catheter

1. a. Tape the catheter by the “U” method or according to the manufacturer’s instructions. Using three strips of tape (about 3 inches long).

14.  Dress and label the venipuncture site and tubing according to agency policy.

1. a. Use a transparent occlusive dressing if there is an allergy.
2. b. Discard the tourniquet. Remove soiled gloves and discard appropriately.
3. c. Loop the tubing and secure it with tape. Looping and securing the tubing prevent the weight of the tubing or any movement from pulling on the needle or catheter.
4. d. Label the dressing with the date and time of insertion, type, gauge of catheter used, and your initials.
5. e. Ensure appropriate infusion flow.
   1. i.      Apply padded arm board to splint the joint, as needed.
   2. ii.      Adjust the infusion rate of flow according to the order.
   3. f. Label the IV tuving
      1. i.      Label the tubing with the date and time of attachment and your initials. Labeling ensure that it is changed at regular intervals.

15.  Document the relevant data, including assessments.

1. a. Record the start of the infusion on the client’s chart.
2. b. Include the date and time of the venipuncture
3. c. Amount of solution used, including any additives
4. d. Container number
5. e. Flow rate
6. f. Type, length and gauge of the needle or catheter
7. g. Venipuncture site, how many attempts were made and location of each attempt
8. h. The type of dressing applied
9. i. And the client’s general response.

Intravenous Fluids

There are two types of fluids that are used for intravenous drips; crystalloids and colloids.

Crystalloids

Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Ringer’s lactate or Ringer’s acetate is another isotonic solution often used for large-volume fluid replacement. A solution of 5% dextrose in water, sometimes called D5W, is often used instead if the patient is at risk for having low blood sugar or high sodium.

The choice of fluids may also depend on the chemical properties of the medications being given. Intravenous fluids must always be sterile. Crystalloids are commonly used for rehydration, and electrolyte replacement.

Colloids

Colloids contain larger insoluble molecules, such as gelatin; blood itself is a colloid. Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is decreased by crystalloids due to hemodilution. Another difference is that crystalloids generally are much cheaper than colloids. Colloids have large particles in them so they are not as easilly absorbed into the vascular bed. Because of this property colloids are used to replace lost blood, maintain healthy blood pressure, and volume expansion.

How to Start an Intravenous (IV) Infusion Original source at: Nurseslabs

• PBSC collection: unfamiliarity with mobilization and apheresis procedures
• Unfamiliarity with bone marrow harvest procedure, postoperative care, and recovery

Defining Characteristics

• Verbalized lack of knowledge or misconceptions
• Expressed need for information
• Multiple questions
• Increased anxiety

Common Expected Outcomes

• Patient or significant others verbalize understanding of the PBSC collection or the bone marrow harvest procedure and recovery.

Assessment

1. Assess the patient’s understanding of mobilization procedures for PBSC donation and collection. This procedure is used more commonly.
2. Assess the patient’s understanding of bone marrow harvest procedure, postoperative care, self-care on bone marrow aspiration sites, potential complications, and marrow recovery.
   Adults learn best when teaching builds on previous knowledge or experience. The patient may have prior incorrect or inaccurate knowledge from family, friends, or media.

Interventions

• Instruct the patient on the following:
  • Bone marrow harvest preoperative care:
    • Database: laboratory values (including complete blood count, chemistry profile, blood typing, viral testing, and cytomegalovirus status), electrocardiogram, chest radiograph. These tests determine the health status of the donor prior to bone marrow collection.
    • Histocompatibility testing (human leukocyte antigen typing) for allogeneic donation. Issues of compatibility between donor and recipient tissue require extensive testing and screening.
    • Self-donation of blood. This is used as replacement transfusion during bone marrow harvest to prevent risk of transfusion-related complications (hepatitis, human immunodeficiency virus).
    • Ferrous sulfate three times daily for 7 to 10 days before bone marrow harvest. This provides iron, which is essential in the formation of hemoglobin.
  • Bone marrow aspiration:
    • Procedure for aspiration and the anatomical sites to be used. Aspiration is performed in the operating room by inserting special needles into the center of the pelvis bones and aspirating the liquid marrow into syringes. Several needle insertions and aspirations (20 to 30) are required to collect the desired amount of marrow stem cells. The procedure lasts 1 to 2 hours.
    • Amount of bone marrow to be harvested. About 500 to 1000 mL, depending on the number of marrow stem cells needed for engraftment. This is determined by the recipient’s body size, the concentration of bone marrow cells, and the type of donor. The aspirated marrow volume is replenished by the donor in about 2 to 3 weeks.
  • Processing of bone marrow:
    • Filtering of aspirated marrow to remove fat and bone particles. Pulmonary complications from fat emboli are a potential complication for the recipient after transplantation.
    • Collection of marrow stem cells into standard blood administration bags or processing and cryopreservation of bone marrow cells if donation is autologous. This is used for further processing or for intravenous infusion into the recipient.
  • Postoperative care:
    • Hold pressure for 5 to 10 minutes at the site; if oozing is still visible, repeat.
    • Instruct the patient to lie on the site to maintain pressure.
      
    • Transfer from operating room to recovery room until the patient recovers from anesthesia. The patient’s neurological and cardiopulmonary status needs to be carefully monitored during recovery from anesthesia.
    • Arrangement for same-day discharge or transfer to nursing unit if further observation is indicated. Most patients can be discharged soon after recovery, on the same day as donation.
  • Potential complications:
    • Anesthesia-related complications. These complications include respiratory and neurological problems.
    • Bleeding from aspiration sites. Blood loss can lead to anemia and hypovolemia.
    • Pain at aspiration site. Tenderness is expected, but severe pain may indicate hematoma formation or infection.
    • Paresthesia (tingling or sharp pain radiating from the posterior iliac crest to the thigh and/or calf). This is caused by needle irritation or injury to the sacral nerve plexus during aspirations.
  • Site care:
    • Importance of keeping puncture sites clean, dry, and dressed for 72 hours after harvest or until healed. These measures reduce the risk of infection.
    • Signs and symptoms of infection to report. The patient needs to recognize and report fever, redness, or drainage from the site.
  • Pain management:
    • Use of analgesics. These drugs relieve pain.
    • Avoidance of pressure against iliac crest; wearing of loose, nonrestrictive clothing. These measures promote comfort.
    • Use of shoes with low heels (e.g., sandals, tennis shoes) Flat heels prevent “foot shock” (sensation of dull or sharp “ache” radiating from heel to pelvic bone).
  • Anemia:
    • Continuation of iron tablets three times daily for 2 weeks after bone marrow harvest. This supplement is taken to restore normal hemoglobin and hematocrit.
    • Transfusion of prior-donated autologous red blood cells. This measure is used to treat severe anemia.
    • Instruct the patient on PBSC collection:
      
      • For an autologous donor, chemotherapy and growth factors are administered before collection to stimulate increased production of stem cells (mobilization); in allogeneic donors, growth factors only are used for mobilization.
      • Blood is removed through a large-bore catheter and run through an apheresis machine to remove stem cells. The remaining blood is returned to the patient.
      • The procedure is performed in an outpatient setting over 2 to 4 hours for several days.
      • Collected stem cells are preserved in a manner similar to cells harvested from bone marrow.
        
      • Stem cells must be stimulated to move from the bone marrow into the bloodstream so they can be collected via apheresis. Autologous donors often receive chemotherapy as part of the mobilization protocol because they can benefit from the anti-tumor effect. Allogenic donors should not receive chemotherapy; stem cells are mobilized with growth factors alone.
  • Activity:
    • Return to all activities as tolerated. Within a few weeks, the donor’s body will have replenished the donated marrow.

Stem Cell Collection Nursing Care Plans: Deficient Knowledge Original source at: Nurseslabs

Cranial nerves assessment can be tedious and sometimes we forget how to do assess a nerve.

With that problem, NursesLabs will give you a “Cranial Nerve Assessment form” to help you document your cranial nerves assessment easily and accurately.

Cranial- Nerves- Assessment- Form

Cranial Nerves Cheat Sheet

How to Assess Cranial Nerves? Cranial Nerves Assessment Cheat Sheet Original source at: Nurseslabs

So, here are a list of keywords, assessment mnemonics which you can use to quickly and accurately assess a variety of patients.

ASSESSMENT FOR ALERTNESS

SAMPLE HISTORY ASSESSMENT

DCAP-BTLS Rapid Assessment

CAGE: Diagnostic Tool for Alcohol Problems

ABCDEFGHI TRAUMA ASSESSMENT

CAUTION: SEVEN WARNING SIGNS OF CANCER

Sources:

• Adapted from Clinical Nursing Pocket Guide

How to: Perform Nursing Assessment Effectively Original source at: Nurseslabs