Question

Note: no handwriting all typed.

Provide nursing interventions for each of the following nursing diagnosis:

• Pain, acute
• Fatigue
• Infection, risk for
• Tissue perfusion, ineffective
• Fluid volume, risk for deficient
• Urinary elimination, impaired
• Injury, risk for
• Knowledge, deficient
• Anxiety; fear
• Coping, ineffective

Answer 1

Nursing Diagnosis

1. PAIN, ACUTE

INTERVENTION

• Acknowledge the report of the pain immediately ( pain can be aggravated with anxiety and fear especially when pain is delayed. An immediate response to report of pain decrease the anxiety in patient

• Get rid of additional stressors and discomfort ( exaggeration of pain depends upon environmental, interpersonal and intrapsychic factors)

• Provide rest period for sleep and relaxation (pain may exaggerate based on exhaustion)

• Determine appropriate pain relief method ( pharmacological and non-pharmacological method )

• Pharmacological method (opioid and non opioid can be given to relieve pain of the patient as per doctors prescription)

Non-pharmacological method (music therapy, breathing exercises, imagery technique)

2. FATIGUE

​​​​INTERVENTION

• Restrict environmental stimuli, especially during planned time of rest and sleep (noise of visitors, environmental distraction limits patients rest and sleep and thus contribute to fatigue)
• Promote sufficient nutrition intake ( Adequate intake of balanced diet helps patient energy levels)
• Provide comfort such as judicious touch Or massage or cool shower ( these may reduce nervous energy)
• Encourage Ventilation of feeling about impact of fatigue (acknowledgement of fatigue as physically or mentally challenge is coping)

3. INFECTION, RISK FOR

INTERVENTION

• ​​​​​​Maintain asepsis during each procedure ( aseptic techniques prevent transmission of pathogens to patients)
• Encourage protein and calorie rich food (Helps support immune system responsive)
• Teach the patient to wash hands before and after toilet, meal and after self care (patient tend to spread infection from one part of the body to other)
• Limit visitors ( restrictions on visitation reduces transmission of pathogens)
• Take antibiotics as prescribed (if infection occurs taking antibiotics as prescribed helps in recovery of patient and thus prevents further transmission)

4.TISSUE PERFUSION,INEFFECTIVE

INTERVENTION

• Submit the patient to diagnostic tests as indicated (To rule out exact reason)
• Check for fluid balance(sufficient fluid intake optimizes cardiac output needed for tissue perfusion.)
• Note renal output (reduce renal perfusion takes place due to vascular occlusion)
• ​Maintain oxygen therapy as prescribed (to enhance myocardial perfusion)
• Administer nitroglycerin as prescribed (to enhance myocardial perfusion)
• Check mental status, perform neurological examination (helps in review trend in level of consciousness)