HTHSCI 1CC6 Study Guide - Final Guide: Orthostatic Hypotension, Palpitations, Therapeutic Relationship

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2 May 2016
Department
Professor
NURSING CARE PLAN
Patient: JD as per Gordon’s Assessment of September 30, 2011
Reference: Nursing Diagnosis Handbook by BettyJ. Ackley and Gail Ladwig, Seventh Edition.
Medical Surgical Nursing in Canada by Lewis, Heitkemper and Dirksen, First Canadian Edition
NURSING
DIAGNOSIS
(PROBLEM
IDENTIFICATION)
OUTCOME CRITERIA
(GOALS)
INTERVENTIONS & RATIONALE EVALUATION
Risk for further anxiety
r/t stress of health
condition, undergoing
diagnostic procedures
(colonoscopy) and
surgery (cholelithiasis).
To reduce anxiety and
stress within the next
couple of hours before
her surgery to avoid any
risk of complications r/t
stress, anxiety and fear.
Provide accurate, concrete information
about what is being done; including reasons
for the test procedures, preparation needed,
sensations to expect and usual procedures
undertaken. Discuss hospitalization and
prospective treatment as indicated.
Involves client in the plan of care and decreases
unnecessary anxiety about unknowns. Information
can decrease anxiety, thereby reducing
sympathetic stimulation. Provides knowledge base
from which client can make informed choices.
Encourage verbalization of concerns.
Assist client in expressing feelings by active
listening.
Establishes a therapeutic relationship. Assists the
clients in dealing with feelings, and provides
opportunity to clarify misconceptions. Effective
communication and support at this time can
diminish anxiety and promote healing.
Demonstrate and encourage relaxation
techniques such as visualization, deep
breathing exercises, and guided imagery (if
possible).
Learning ways to relax can be helpful in reducing
Goal was met. Her Vital
signs were stable.
Encouraging her to talk,
answering her concerns
watching television, texting
friends, talking to her
daughter on her cell
phone, relaxed her.
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Risk for injury
(fractures) r/t to falls as
evidenced by
diagnosis of
osteoporosis.
To ensure no falls or
injury during the shift. To
educate the patient
regards the cause of
disease and approaches
controlling it with minimal
side effects.
fear and anxiety. Learning these skills can be
important to recovery and prevention of recurrence.
Monitor psychological responses, such as
tachypnea, palpitations, dizziness,
headache, tingling sensations and
behavioural cues such as restlessness,
irritability, lack of eye contact and
combativeness or attack behaviour.
May be indicative of the degree of fear patient is
experiencing-patient may feel out of control of the
situation or reach a state of panic. However;
symptoms may also be related to physical
condition.
If the patient experiences dizziness
because of orthostatic hypotension when
getting up, teach methods to decrease
dizziness such as rising slowly, remaining
seated several minutes before standing,
flexing feet upward several times while
sitting.
Patient is on (Ramipril) anti-hypertensive
medications. One of the side effects of anti-
hypertnesive medication is hypotension.
Hypotension may cause dizziness.
Ensure hazard free environment with no
obstacles on the floor, non slippery floor,
use of shoes to provide a good grip. Also
advise the patient to wear glasses for good
visibility and have a well lit atmosphere.
Safety measures to prevent falls.
Health teach the patient to take calcium and
Vitamin D supplements as per the doctor’s
order. Do not overdose. Avoid taking
calcium within 1-2 hours of other
medications as well as with oxalic acid food
such as spinach and rhubarbs. Have lots of
Goal was met. No fall was
experienced during the
shift. Patient was
satisfied to know the
benefits of exercise. She
was grateful that she
learnt a lot from health
teaching.
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