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.

NOC Outcome

NIC Interventions

• Teaching: Preoperative; Teaching: Procedure/Treatment

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.

Deficient Knowledge | Stem Cell Collection NCP Original source at: Nurseslabs

• Bone marrow harvest: Interruption of skin and bone integrity secondary to bone marrow aspirations

Common Expected Outcome

• Patient is free of infection, as evidenced by normal temperature and lack of drainage from puncture sites, or by lack of signs and symptoms of infection from the central venous catheter.

NOC Outcomes

NIC Intervention

• Wound Care

Ongoing Assessment

1. Observe or encourage the patient to observe the puncture sites during dressing change for evidence of infection: redness, tenderness, warmth, swelling; drainage from skin puncture sites; persisting or increasing pain at the operative site or surrounding area; elevated body temperature. Osteomyelitis is a possible complication of bone marrow aspiration. Bone marrow donors can also get cutaneous infections if the puncture sites are not properly cared for.
2. Instruct the patient to report first signs of infection. Early assessment facilitates prompt treatment.
3. While the patient is hospitalized, obtain culture, if ordered, before the wound is cleansed. This is required to obtain a true sample of microorganisms present.

Interventions

1. Change or instruct the patient to change the postoperative pressure dressing the day after harvest. Moist dressings can harbor pathogens. Pressure dressings should remain in place for 24 hours to reduce the incidence of bleeding and hematoma formation.
2. Instruct the patient to use clean technique when performing daily dressing changes: wipe over each skin puncture site with prescribed antiseptic; let dry; apply small amount of antiseptic ointment to each puncture site; cover with sterile adhesive bandage; keep dressings dry and intact. This technique reduces the risk of infection.

Risk for Infection | Stem Cell Collection Nursing Care Plans Original source at: Nurseslabs

• New condition
• Unfamiliarity with disease and treatment

Defining Characteristics

• Questions
• Requests for more information
• Verbalized misconceptions or misinterpretation

Common Expected Outcomes

• Patient verbalizes correct understanding of DI and the medications used in treatment.

• Teaching: Disease Process;
• Teaching: Prescribed Medication

Ongoing Assessment

1. Assess level of knowledge of DI cause and treatment. An individualized teaching plan is based on the patient’s current knowledge and desire for additional information.
2. Assess readiness to learn. Rapid fluid loss from polyuria can lead to impaired cognitive function. This change in mental status can limit the patient’s ability to learn new information.

Nursing Interventions

1. Give written information concerning the diagnosis and treatment of DI:
   • Water deprivation ADH stimulation test
     • This test may be done to differentiate nephrogenic causes from neurogenic causes of DI. The patient is instructed to take nothing by mouth (NPO) for 12 hours before a blood sample is drawn to measure ADH levels. The ADH level is increased in nephrogenic DI and decreased in neurogenic (central) DI. Vasopressin may be given to evaluate renal response. There is no response to the drug in nephrogenic DI.
   • Computed tomography scan or magnetic resonance imaging
     • These scans may be ordered if a pituitary tumor is suspected.
   • Desmopressin acetate (DDAVP)
     • This is the drug of choice for the management of DI. This medication is a synthetic form of ADH and is administered intranasally.
   • Aqueous form of ADH (vasopressin)
     • This drug has a shorter half-life than DDAVP and therefore requires more frequent daily administration. Vasopressin is usually given parenterally and is not recommended for the long-term management of chronic DI.
   • Other drugs used in combination to manage DI, including chlorpropamide (Diabinese), clofibrate (Atromid), carbamazepine (Tegretol), and hydrochlorothiazide
     • These secondary drugs work on the kidney or the posterior pituitary gland to increase pituitary release of ADH or increase renal response to ADH.

1. Teach the patient the necessity of closely monitoring fluid balance, including daily weights (same time of day with same amount of clothing), fluid intake and output, and measurement of urine specific gravity. This assists the patient in monitoring the condition so that adjustments can be made accordingly, helping prevent undertreatment or overtreatment with the medication.
2. Discuss when to seek further medical attention (at signs of underdosage or overdosage of medications).  Patients with chronic disease need to be able to recognize important changes in their condition to avert complications and possible hospitalization.
3. Instruct the patient to wear a medical alert bracelet, listing DI and the medications that the patient is using.  This allows for prompt intervention in the event of an emergency.

Deficient Knowledge | Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

• Impending surgery or apheresis procedure
• Threat of anesthesia
• Anticipated pain
• Feelings about HSC recipient (if allogenic recipient)
• Responsibility of being a donor
• Fear of the unknown
• Fear of injections (needed for administration of growth factors)

Defining Charactersitics

• Increased questioning
• Restlessness
• Tense appearance
• Uncertainty
• Jitteriness
• Apprehension

Common Expected Outcomes

• Patient verbalizes reduction in fear.
• Patient verbalizes ability to cope.
• Patient expresses willingness, commitment, and positive feelings about being a donor.

NOC Outcome

NIC Intervention

• Anxiety Reduction

Assessment

• Determine what the patient is most fearful of. This helps guide the treatment plan.
• Assess the patient’s relationship with the recipient and the circumstances under which the patient became a stem cell donor. The patient may feel “obligated” or “pressured” to donate HSCs, especially when it is the only tissue “match” suitable for transplantation.

Therapeutic Interventions

1. Acknowledge your awareness of the patient’s fear. This validates the feelings that the patient is having and communicates acceptance of these feelings.
2. Encourage verbalization of feelings, especially about the donor’s role, if appropriate. Donors may feel they are a “last resort” and that the recipient’s fate rests with them.
3. Assist the patient in identifying strategies used to deal with fear in the past that were helpful or comforting. This helps the patient focus on his or her fear as being a natural part of life and something that can continue to be dealt with successfully.
4. Provide environment of confidence and reassurance.

Fear | Stem Cell Collection Nursing Care Plan Original source at: Nurseslabs

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

Nursing Diagnosis

Constipation

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Bowel Elimination
• Medication Response
• Self-Care Toileting

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Constipation/Impaction Management
• Bowel Training
• Teaching: Prescribed Medication

NANDA Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

• Constipation is a common, yet complex problem; it is especially prevalent among elderly patients. Constipation often accompanies pregnancy.
• Diet, exercise, and daily routine are important factors in maintaining normal bowel patterns. Too little fluid, too little fiber, inactivity or immobility, and disruption in daily routines can result in constipation. Use of medications, particularly narcotic analgesics or overuse of laxatives, can cause constipation.
• Overuse of enemas can cause constipation, as can ignoring the need to defecate.
• Psychological disorders such as stress and depression can cause constipation.
• Because privacy is an issue for most, being away from home, hospitalized, or otherwise being deprived of adequate privacy can result in constipation.
• Because “normal” patterns of bowel elimination vary so widely from individual to individual, some people believe they are constipated if a day passes without a bowel movement; for others, every third or fourth day is normal.
• Chronic constipation can result in the development of hemorrhoids; diverticulosis (particularly in elderly patients who have a high incidence of diverticulitis); straining at stool, which can cause sudden death; and although rare, perforation of the colon.
• Constipation is usually episodic, although it can become a lifelong, chronic problem.
• Because tumors of the colon and rectum can result in obstipation (complete lack of passage of stool), it is important to rule out these possibilities.

• 

  Excessive water removal causes hard stools

 Defining Characteristics

• Infrequent passage of stool
• Passage of hard, dry stool
• Straining at stools
• Passage of liquid fecal seepage
• Frequent but nonproductive desire to defecate
• Anorexia
• Abdominal distention
• Nausea and vomiting
• Dull headache, restlessness, and depression
• Verbalized pain or fear of pain

Related Factors

• Inadequate fluid intake
• Low-fiber diet
• Inactivity, immobility
• Medication use
• Lack of privacy
• Pain
• Fear of pain
• Laxative abuse
• Pregnancy
• Tumor or other obstructing mass
• Neurogenic disorders

Expected Outcomes

• Patient passes soft, formed stool at a frequency perceived as “normal” by the patient.
• Patient or caregiver verbalizes measures that will prevent recurrence of constipation.

Ongoing Assessment

1. Assess usual pattern of elimination; compare with present pattern. Include size, frequency, color, and quality. “Normal” frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is “normal” for each individual.
2. Evaluate laxative use, type, and frequency. Chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Over time, the colon becomes atonic and distended.
3. Evaluate reliance on enemas for elimination. Abuse or overuse of cathartics and enemas can result in dependence on them for evacuation, because the colon becomes distended and does not respond normally to the presence of stool.
4. Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake. Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation.
5. Assess activity level. Prolonged bed rest, lack of exercise, and inactivity contribute to constipation.
6. Evaluate current medication usage that may contribute to constipation. Drugs that can cause constipation include the following: narcotics, antacids with calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, and iron and calcium supplements.
7. Assess privacy for elimination (e.g., use of bedpan, access to bathroom facilities with privacy during work hours). Many individuals report that being away from home limits their ability to have a bowel movement. Those who travel or require hospitalization may have difficulty having a bowel movement away from home.
8. Evaluate fear of pain. Hemorrhoids, anal fissures, or other anorectal disorders that are painful can cause ignoring the urge to defecate, which over time results in a dilated rectum that no longer responds to the presence of stool.
9. Assess degree to which patient’s procrastination contributes to constipation. Ignoring the defecation urge eventually leads to chronic constipation, because the rectum no longer senses, or responds to, the presence of stool. The longer the stool remains in the rectum, the drier and harder (and more difficult to pass) it becomes.
10. Assess for history of neurogenic diseases, such as multiple sclerosis or Parkinson’s disease. Neurogenic disorders may alter the colon’s ability to perform peristalsis.

Therapeutic Interventions

1. Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically. Patients, especially elderly patients, may have cardiovascular limitations, which require that less fluid is taken.
2. Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a minimum of 20 g of dietary fiber per day is recommended. Fiber passes through the intestine essentially unchanged. When it reaches the colon, it absorbs water and forms a gel, which adds bulk to the stool and makes defecation easier.
3. Encourage patient to consume prunes, prune juice, cold cereal, and bean products. These are “natural” cathartics because of their high-fiber content.
4. Encourage physical activity and regular exercise. Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation.
5. Encourage a regular time for elimination. Many persons defecate following first daily meal or coffee, as a result of the gastrocolic reflex; depending on the person’s usual schedule, any time, as long as it is regular, is fine.
6. Encourage isometric abdominal and gluteal exercises. Exercises, unless contraindicated, strengthen muscles needed for evacuation.
7. Digitally remove fecal impaction. Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially elderly patients, may not be able to pass these stools without manual assistance.
8. Suggest the following measures to minimize rectal discomfort:

• • Warm sitz bath
  • Hemorrhoidal preparations. These shrink swollen hemorrhoidal tissue.

1. For hospitalized patients, the following should be employed:

• • Orient patient to location of bathroom and encourage use, unless contraindicated. A sitting position with knees flexed straightens the rectum, enhances use of abdominal muscles, and facilitates defecation.
  • Offer a warmed bedpan to bedridden patients; assist patient to assume a high-Fowler’s position with knees flexed. This position best uses gravity and allows for effective Valsalva maneuver.
  • Curtain off the area. This provides privacy.
  • Allow patient time to relax.

Education/Continuity of Care

1. Consult dietitian if appropriate. Persons unaccustomed to a high-fiber diet may experience abdominal discomfort and flatulence; a gradual increase in fiber intake is recommended.
2. Explain or reinforce to patient and caregiver the importance of the following:

• A balanced diet that contains adequate fiber, fresh fruits, vegetables, and grains Twenty grams per day is recommended.
• Adequate fluid intake Drink 8 glasses/day or 2000 to 3000 ml/day.
• Regular meals successful bowel training relies on routine.
• Regular time for evacuation and adequate time for defecation
• Regular exercise/activity
• Privacy for defecation
• Teach patients and caregivers to read product labels. It is important for patients and caregivers to determine the fiber content per serving.

1. Teach use of pharmacological agents as ordered, as in the following:

• Bulk fiber (Metamucil and similar fiber products). These increase fluid, gaseous, and solid bulk of intestinal contents.
• Stool softeners (e.g., Colace). These soften stool and lubricate intestinal mucosa.
• Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia). These irritate the bowel mucosa and cause rapid propulsion of contents of small intestines.
• Suppositories. These aid in softening stools and stimulate rectal mucosa; best results occur when given 30 minutes before usual defecation time or after breakfast.
• Oil retention enema. This softens stool.

Source (1) (2) (3)

Constipation Nursing Diagnosis 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

• Compromised endocrine regulatory mechanism
• Neurohypophyseal dysfunction
• Hypopituitarism
• Hypophysectomy
• Nephrogenic DI

Defining Characteristics

• Polyuria
• Output exceeds intake
• Polydipsia (increased thirst)
• Sudden weight loss
• Urine specific gravity less than 1.005
• Urine osmolality less than 300 mOsm/L
• Hypernatremia (sodium greater than 145 mEq/L)
• Altered mental status
• Requests for cold or ice water

Common Expected Outcomes

• Patient experiences normal fluid volume as evidenced by absence of thirst, normal serum sodium level, and stable weight.

NOC Outcomes

NIC Interventions

• Fluid Monitoring; Fluid Management; Electrolyte Management

Ongoing Assessment

1. Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period. With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI.
2. Monitor for increased thirst (polydipsia). If the patient is conscious and the thirst center is intact, thirst can be a reliable indicator of fluid balance. Polyuria and polydipsia strongly suggest DI. Also, the DI patient prefers ice water.
3. Weigh daily. Weight loss occurs with excessive fluid loss.
4. Monitor urine specific gravity. This may be 1.005 or less.
5. Monitor serum and urine osmolality. Urine osmolality will be decreased and serum osmolality will increase.
6. Monitor urine and serum sodium levels. The patient with DI has decreased urine sodium levels and hypernatremia.
7. Monitor serum potassium. Hypokalemia may result from the increase in urinary output of potassium.
8. Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension). Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume.

Nursing Interventions

1. Allow the patient to drink water at will. Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water.
2. Provide easily accessible fluid source, keeping adequate fluids at bedside. This encourages fluid intake.
3. Administer intravenous (IV) fluids: IV fluids are indicated if the patient cannot take in sufficient fluids orally.

• 5% dextrose in water or 0.45% sodium chloride. Hypotonic IV fluids provide free water and help lower serum sodium levels gradually.
• 0.9% sodium chloride. Isotonic fluids may be indicated for the patient who has sustained significant fluid loss and is hemodynamically unstable. Once circulatory volume has been restored, hypotonic IV fluids can be given.

1. Administer medication as prescribed.  Aqueous vasopressin is usually used for DI of short duration (e.g., postoperative neurosurgery or head trauma). Pitressin tannate (vasopressin) in oil (the longer-acting vasopressin) is used for longer-term DI. Patients with milder forms of DI may use chlorpropamide (Diabinese), clofibrate (Atromid), or carbamazepine (Tegretol) to stimulate release of ADH from the posterior pituitary and enhance its action on the renal tubules. Hydrochlorothiazide (HydroDIURIL) may also be used for nephrogenic DI.
2. If vasopressin is given, monitor for water intoxication or rebound hyponatremia. Overmedication can result in volume excess.

Deficient Fluid Volume | Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs