8 TAHBSO Nursing Care Plans

• irritability
• impaired physical mobility
• disturbed sleep pattern
• facial mask
• diaphoresis
• restlessness
• facial grimaces

1. Establish rapport
2. Emphasize ordered diet
3. Monitor vital signs
4. Provide comfort measures
5. Encourage deep breathing
6. Provide safety measure
7. Develop communicationreview procedures/expectations and tell client when treatment will hurt
8. Administer analgesics as indicated to maximal dosage as needed

1. To gain trust
2. To encourage patient not to eat untolerated food
3. To obtain baseline data
4. To satisfy the confinement of patient
5. To inhibit pain
6. To prevent from injury
7. To alter pain and diminish emotional stress
8. To reduce concern of unknown and associated muscle tension & To maintain acceptable level of pain.

• reduction in body temperature below normal range
• shivering
• cool skin
• pallor
• slow capillary refill
• cyanotic nail beds
• hypertension
• tachycardia

1. Establish rapport
2. Monitor  vital signs
3. Remove wet clothing and prevent pooling of antiseptic solutions under client in OR
4. Wrap in warm blanket
5. Avoid use of heat clamps or hot water bottles
6. Administer medications to prevent shivering
7. Use hyperthermia blanket
8. Administer fluids during rewarming
9. Keep client quiet
10. Provide well-balance high calorie diet
11. Perform range-of-motion exercises, provide support hose, reposition, do cough/deep breathing exercises, avoid restrictive clothing
12. Protect skin by repositioning, applying lotion and avoid direct contact with heating appliance or blanket
13. Provide patent airway with humidified oxygen when used

1. To gain trust
2. To obtain baseline data
3. These measures protect patient from heat loss
4. To promote heat
5. Surface rewarming can lead to rewarming  shock due to surface vasodilation
6. To avoid increasing in temperature
7. To warm patient
8. To prevent hypovolemic shock
9. To reduce potential for fibrillation in cold heart
10. To replenish glycogen stores and nutritional balance
11. To reduce circulatory stasis
12. impaired circulation can result in severe tissue damage
13. To provide heat

• headache

O The patient may manifest:

• increase in body temperature above normal range
• flushed skin, warm to touch
• tachycardia
• seizures or  convulsions

1. Establish rapport
2. Monitor  vital signs
3. Monitor body temperature every 4 hours or more often if indicated
4. Loosen patient’s clothingand remove blankets
5. Apply ice bags to axilla or groin and do TSB
6. Administer antipyretic as ordered
7. Observe patient for confusion or disorientation
8. Determine patient’s preference for liquids
9. Keep liquids at bedside and within reach
10. Monitor intake and output accurately
11. Administer I.V fluid as ordered
12. Give patient oresol
13. Provide supplement oxygen
14. Maintain bed rest
15. Provide high-caloric diet, tube feedings or parenteral nutrition

1. To gain trust
2. To obtain baseline data
3. To evaluate effectiveness of interventions
4. To promote heat loss through radiation and conduction
5. To promote heat loss through evaporation
6. To reduce fever
7. Changes LOC may result from tissue hypoxia
8. Offering patient liquids he prefers promotes adequate hydration
9. To allow patient easy access
10. To identify changes and progress of the treatment
11. These measure prevents excessive loss of water, sodium chloride and potassium
12. To replace loss fluid and electrolytes
13. To offset increase oxygen demands and consumption
14. To reduce metabolic demands
15. To meet increased metabolic demands

• concerns due to change in life event
• fear
• nausea
• abdominal pain
• fatigue
• sleep disturbance
• urinary hesitancy

O The patient may manifest:

• poor eye contact
• extraneous movement
• restlessness
• irritability
• anorexia
• insomnia
• impaired attention
• Trembling, hand tremors

1. Establish rapport
2. Monitor  vital signs
3. Listen attentively; allow patient to express feelings verbally
4. Identify and reduce as many environment stressors
5. Provide accurate information about the situation
6. Provide comfort measures like back rub and soft music
7. Use cognitive therapy
8. Refer patient to professional mental health resources

1. To gain trust
2. To obtain baseline data
3. To allow patient to identify anxious behaviors and discover source of anxiety
4. Anxiety commonly results from lack of trust in the environment
5. Helps the patient what is reality based
6. To decrease autonomic response to anxiety
7. To correct faulty catastrophic interpretations of physical symptoms
8. To provide ongoing mental health assistance

• Pale skin
• Impaired physical mobility
• Irritability
• Weakness
• Pain= 5/10
• Activity intolerance
• Stress

1. Establish rapport
2. Monitor vital signs
3. Evaluate the need for individual assistance and discuss lifestyle changes imposed by fatigue state
4. Establish realistic activity goals with client
5. Instruct client in ways to monitor responses to activity and significant signs and symptoms

1. To gain trust
2. To obtain maintenance data
3. To determine degree of fatigue
4. Enhance commitment in promoting optimal outcomes
5. To indicate the need to alter activity level

• -problem such as loss of sexual desire
• - inability to achieved desired satisfaction
• -conflicts involving values

O the patient manifested:

• -alteration in relationship with SO
• -Change of interest in self and others

1. Establish rapport
2. Monitor vital signs
3. Obtain sexual history including usual patterns of functioning and level of desires
4. Be alert to comments of client
5. identify current stressors in individual situations
6. Avoid making value judgments
7. Establish therapeutic nurse-client relationship
8. Provide ways to obtain privacy

1. To gain trust
2. To obtain maintenance data
3. To maximize communication and understanding
4. Sexual concerns are often disguised as humor, sarcasm, or offhand remarks
5. These factors may be producing enough anxiety to cause depression
6. They do not help the client
7. To promote treatment and facilitate sharing of sensitive information
8. To allow sexual expression for individual between partners without embarrassment

• Weakness
• -Pallor-with dry and intact dressing on the area.
• -Pain over the incision
• -Irritability
• -Presence of intact dressing
• -Impaired physical mobility
• Diaphoresis
• Fever
• Seizures

1. Establish rapport
2. Monitor V.S.
3. Note signs and symptoms of sepsis
4. Provide wound healing such as cleaning of wound
5. Provide care, change dressing as needed
6. Encourage increase intake of Vitamin C
7. Encourage deep breathing exercise

1. To gain trust
2. To obtain baseline data
3. To reduce complication and monitor for infection
4. To reduce risk for infection
5. To promote healing to the incision
6. To prevent infection to increase immune resistance
7. To increase healing of wound

• thirst
• weakness
• decrease urine output
• sudden weight loss
• decrease skin turgor
• dry mucous membranes
• sunken eyeballs
• change in mental state

1. Establish rapport
2. Monitor vital signs
3. Encourage increase oral fluid intake
4. Provide supplemental fluids as ordered
5. Monitor intake and output
6. Provide safety measures
7. Encourage the use of oresol

1. To gain trust
2. To obtain maintenance data
3. To replace loss fluids
4. Prevents peak in fluid level
5. To ensure accurate picture of fluid status
6. Confusion can lead to accidents
7. To replace loss electrolyte.