Medical-surgical plan of care
3. Imbalanced nutrition, less
Prioritized NANDA
1. Hypothermia 00006
Nursing Diagnoses:
• Exposure to cool environment
age, consumption of alcohol,
decreased metabolic rate AEB
frostbite, temp of 93.8° F,
Related to, secondary, inactivity, inadequate clothing
and as evidenced by
characteristics
Outcomes: NOC Thermoregulation 0800
Indicators: (1-5: severely,
substantially, moderately, mildly, substantial, moderate, mild, or
or not compromised)
• Hypothermia
• Frostbite
• Skin color changes
• Dehydration
• Reported thermal comfort
• Increased skin temperature
Vital signs 0802
Indicators: (1-5: severe,
substantial, moderate, mild, or
no deviation from normal range)
• Body temperature
• Apical heart rate
• Respiratory rate
• Systolic blood pressure
• Diastolic blood pressure
Interventions: NIC Major interventions:
Hypothermia Treatment 3800
Definition: Rewarming and
surveillance of a patient whose
core body temperature is below
35° C.
Activities
Remove the patient from the
cold, and place in a warm
environment.
Remove cold, wet clothing and
replace with warm, dry clothing.
Monitor patient's temperature,
using a low-recording
thermometer if necessary.
Institute a continuous core
temperature monitoring device,
as appropriate.
Monitor for underlying medical
conditions that may precipitate
hypothermia (e.g., diabetes,
myxedema, or anorexia
nervosa).
2. Ineffective tissue
perfusion: Peripherial 00204
• Damage to extremities from
prolonged exposure to cold AEB increase metabolic need AEB
cap refill > 3sec, altered mental poor muscle tone, low Na+
status, behavioral changes,
extremity weakness, changes in
motor response, dyspnea,
changes in papillary reactions,
speech abnormalities, altered
sensation, diminished pulses, 2°
hypothermia (vasoconstriction),
AEB hypoventilation RR:8bpm
• Acute pain r/t decreased
circulation from prolonged
exposure to cold
• Impaired skin and integrity r/t
freezing of skin
Circulation status 0401
Indicators: (1-5: severe,
no deviation from normal range)
• Mean blood pressure
• R/L pedal pulse
• R/L femoral pulse
• Oxygen saturation
• Capillary refill
Sensory function, cutaneous
2400
Indicators: (1-5: severe,
substantial, moderate, mild, or
none)
• Paresthesia
• Tingling
• Loss of sensation
Major interventions:
Peripheral Sensation
Management 2660
Definition: Prevention or
minimization of injury or
discomfort in the patient with
altered sensation.
Activities
Monitor sharp/dull and/or
hot/cold discrimination.
Monitor for paresthesia:
numbness, tingling,
hyperesthesia, and
hypoesthesia.
Encourage patient to use the
unaffected body part to
determine temperature of food,
liquids, bathwater, and so on.
Encourage patient to use the
unaffected body part to identify
location and texture of objects.
Instruct patient or family to
monitor position of body parts
while bathing, sitting, lying, or
changing position.
than body requirements
00002
• Chemical dependence (EtOH),
(112), high K- (5.2)
Nutritional status 1004
Indicators: (1-5: severe,
substantial, moderate, mild, or
no deviation from normal range)
• Nutrient intake
• Fluid intake
• Energy
• Hydration
• Muscle tone
Nutritional status,
biochemical measures 1005
Indicators: (1-5: severe,
substantial, moderate, mild, or
no deviation from normal range)
• Serum albumin
• Serum creatinine
• H/H
• Lymphocytes
• CBS
Major interventions:
Fluid/Electrolyte
Management 2080
Definition: Regulation and
prevention of complications from
altered fluid and/or electrolyte
levels.
Activities:
Monitor for abnormal serum
electrolyte levels, as available.
Obtain laboratory specimens for
monitoring of altered fluid or
electrolyte levels (e.g.,
hematocrit, BUN, protein,
sodium, and potassium levels),
as appropriate.
Weigh daily and monitor trends.
Give fluids, as appropriate.
Promote oral intake (e.g.,
provide oral fluids that are the
patient's preference, place in
easy reach, provide a straw, and
provide fresh water), as
appropriate.
 Place on a cardiac monitor, as Instruct patient to use timed Set an appropriate intravenous
appropriate. intervals, rather than presence infusion (or blood transfusion)
of discomfort, as a signal to alter flow rate.
position.

Monitor for and treat ventricular Use pressure-relieving devices, Monitor laboratory results
defibrillation. as appropriate. relevant to fluid balance (e.g.,
hematocrit, BUN, albumin, total
protein, serum osmolality, and
urine specific gravity levels).
Administer warmed (37° to 40 Protect body parts from extreme Monitor hemodynamic status,
°C) IV fluids, as appropriate. temperature changes. including CVP, MAP, PAP, and
PCWP levels.

Administer heated oxygen, as Immobilize the head, neck, and Keep an accurate record of
appropriate. back, as appropriate. intake and output.

Institute active external Monitor ability to void or Maintain intravenous solution

rewarming measures (e.g.,
immersion in warm water,
application of hot water bottles,
and placement on a heating
blanket), as appropriate.
defecate. containing electrolyte(s) at
constant flow rate, as
appropriate.

Institute active core rewarming Establish a means of voiding, as Monitor patient's response to
techniques (e.g., colonic lavage, appropriate. prescribed electrolyte therapy.
hemodialysis, peritoneal dialysis,
and extracorpeal blood
rewarming), as appropriate.

Monitor for rewarming shock.
Administer plasma volume
expanders, as appropriate.
Monitor skin color and
temperature
Establish a means of bowel
evacuation, as appropriate.
Administer analgesics, as
necessary.
Monitor for thrombophlebitis and Monitor for side effects of
deep vein thrombosis
Monitor for manifestations of
electrolyte imbalance.
Provide prescribed diet
appropriate for specific fluid or
electrolyte imbalance (e.g., low-
sodium, fluid-restricted, renal,
and no added salt).
prescribed supplemental
electrolytes (e.g., GI irritation)

Monitor vital signs, as
appropriate.
Monitor for bradycardia.
Discuss or identify causes of Consult physician if signs and
abnormal sensations or symptoms of fluid and/or
sensation changes. electrolyte imbalance persist or
worsen.
Instruct patient to visually Administer prescribed
monitor position of body parts, if supplemental electrolytes, as
proprioception is impaired. appropriate.

Monitor for electrolyte Monitor for fluid loss (e.g.,

imbalance. bleeding, vomiting, diarrhea,
perspiration, and tachypnea).

Monitor for acid-base imbalance.

Monitor intake and output.

Monitor cardiac output, PCWP,

SVR, and RAP, using invasive
hemodynamic monitoring as
appropriate.

Monitor respiratory status.

Monitor nutritional status.

Evidenced-based (Trevisan et al, 2008; see also Anton et al, 2006; Delaney et al, 2006; Ducharme & Brajkovic,
Research 2005; Smith, 2004; Rutledge et al, 2000, pt. 1; Rutledge et al, 2000, pt. 2).

Outcomes Evaluation and

Discharge date/1.5 weeks post ER admssion
Management

NOC average score of 4 (mild NOC average score of 4 (mild NOC average score of 4 (mild
deviation/compromise) for deviation/compromise) for deviation/compromise) for
thermoregulation and vital signs thermoregulation and vital signs thermoregulation and vital signs
at ER d/c at ER d/c at ER d/c
Maintained and achieved a
temperature WNL at d/c
Remain free of complication;
malignant hypertension,
hypotension, cardiac arrest
Assess current level of comfort
as acceptable
Express the need to achieve an
enhanced level of comfort
Identify strategies to enhance
comfort
Perform appropriate
interventions as needed for
increased comfort
Evaluate the effectiveness of
interventions at regular intervals and risks of treatment options
Maintain an enhanced level of
comfort when possibl
Demonstrated adequate tissue
perfusion AEB palpable
peripheral pulses, warm and dry d/c
skin, adequate urinary output,
absence of respiratory distress at
d/c
Have near normal reactive pupils Maintain or have adequate U/O
by EOS
Have adequate PO and IV intake
by EOS
6 months later
Demonstrate continued
commitment to integration of
therapeutic regimen into daily
living routines
Describe integration of
therapeutic regimen into daily
living
Review treatment options with
providers
Ask questions about the benefits
Communicate decisions about
treatment options to providers in
relation to personal preferences,
values, and goals
Maintained and achieve near
normal lab values; H/H 11/35 at
by EOS
Meet personal health-related
goals
Explain how to incorporate new
health regimen into lifestyle
Demonstrate knowledge of new
information
List sources to obtain
information
State willingness to enhance
self-concept
State satisfaction with thoughts
about self, sense of worthiness,
role performance, body image,
and personal identity
Demonstrate actions that are
congruent with expressed
feelings and thoughts
State confidence in abilities
Accept strengths and limitations
 Psychiatric Plan of care
Prioritized NANDA
1. Impaired Memory 00131
Nursing Diagnoses:
• Alcohol abuse AEB
confabulation, confusion, severe stressors, AEB client's CIWA
short term memory loss. Mini
mental status exam score 11 out Drinking Questionaire score of
Related to, secondary, possible 30. Severe Impairment 55 out of 100. Alcohol Use
and as evidenced by Battery tested 60 out 130 points. Inventory Scale 30 out of 40
characteristics
Outcomes: NOC Memory 0908
Indicators: (1-5: severely,
substantially, moderately, mildly, sometimes, often, consistently
or not compromised)
• Recalls immediate information
accurately
• Recalls remote information
accurately
• Recalls recent information
accurately
• Dehydration
• Reported thermal comfort
• Increased skin temperature
Interventions: NIC Major interventions:
Memory Training 4760
Assess with Mini mental status
exam and Severe Impairment
Battery test.
Assess nutitional status and
supplement diet with vitamins
and high quality nutrition.
Note client's current level of
stress.
Look for signs of depression,
such as weight loss, sad affect,
insomnia.
2. Dysfunctional Grieving
00136
• Alcohol use to deal life
score of 24 and Personal
(severe alcoholism); craving for
alcohol. Physical symptoms of
alcohol withdrawal such as
tremors, nausea, vomiting.
Grief Resolution 1304
Indicators: (1-5: never, rarely,
demonstrated)
• Verbalizes reality of loss
• Verbalizes acceptance of loss
• Describes meaning of the loss
• Discusses unresolved
conflict(s)
• Reports absence of somatic
distress
• Reports decreased
preoccupation with loss
• Maintains personal grooming
and hygiene
• Reports adequate sleep
• Reports adequate nutrition
intake
• Reports normal sexual desire
• Seeks social support
• Shares loss with significant
others
• Reports involvement in social
activities
• Progresses through stages of
grief
• Expresses positive
expectations about the future
Major interventions:
Grief Work Facilitation 5290
Monitor client's risk for self
harm.
Observe for contributing factors Support system enhancement.
such as poor self-esteem, grief,
lack problem-solving skills, lack
of support.
Verbal and therapeutic
communication approaches.
Employ active listening.
3. Impaired Coping 00069
• Lack of resolution to former
grieving response AEB use of
alcohol to deal with grief.
Hamilton Scale for Depression
Rating 23, severe depression.
Geriatric Depression Scale 25 out
of 30, depressed. Physical
symptoms of a flat affect, anger,
and detachment.
Coping 1302
Indicators: (1-5: severe,
substantial, moderate, mild, or
no deviation from normal range)
•Identifies effective coping
patterns
•Identifies ineffective coping
patterns
•Verbalizes sense of control
•Reports decrease in stress
•Verbalizes acceptance of
situation
•Uses personal support system
•Identifies multiple coping
strategies
•Uses effective coping strategies
Reports decrease in negative
feelings
•Reports increase in
psychological comfort
Major interventions:
Counseling 5240
Grief work facilitation through
cognitive behavioral therapy.
Improve communication with
client.
Encourage client to be aware of
his feelings and express them as
appropriate.
 Treat with antidepressants for
depression.
Have client work on puzzles,
Scrabble, crossword puzzles.
Perform a weekly Mini Mental
Status Exam.
Reteach activities of self care
and monitor progress.
Evidenced-based
(Gartlehner et al, 2008; see also Luckens et al, 2006; Sattar et al, 2007; Agabio, 2004).
Research
Outcomes Evaluation and
Management
NOC (Impaired Memory) average NOC (Dysfunctional Grieving)
score of 4 (mild compromise) for average score of 4 (often
every indicator throughout entire demonstrated) before time of
span of care
Confusion Mini mental exam
scored 20 out of 30. Severe
Impairment Battery scored 90.
Confusion and short term
memory improved from severe
to mild.
Confabulation stopped.
Identify client strengths. Refer to spiritual counseling if
desired.
Have client identify stressors. Identify grief counseling through
Peace Hospice.
Cognitive restructuring. Allow client to grieve in his own
time and own way.
Assist client to set realistic goals. Assess influence of cultural
beliefs, norms and values on
client's grief and mourning
practices.
Encourage client to make choices Demonstrate a caring and
and participate in planning care. support approach.
Encourage client to exercise to Validate the client's feelings
deal with anxiety and stress. regarding the loss.
Discuss alternative coping
strategies.
6 months later
NOC (Personal autonomy)
average score of 4 (mild
deviation) throughout the
relocation from Missouri River majority of care once released
Manor to Lodge from hospital into Missouri River
Manor and into the Lodge
Personal Drinking Questionaire Hamilton Scale for Depression
score increased to 85, meaning Rating 10, mild depression.
the client recognizes they have a
drinking problem. Alcohol Use
Inventory Scale score of 0.
Alcohol abstinence. Geriatric Depression Scale
improved to 9.
Improved decision making. Grief resolution.
Increase in self control. Mood equilibrium.
Increase in psychological Personal well-being
comfort.
Effective behaviors to decrease Psycho-social adjustment.
stress.
Client is able to discuss meaning
of the loss to his life.
 Case management plan of care
Outcomes: NOC Family functioning 2602
Indicators: (1-5: never, rarely,
sometimes, often, consistently
demonstrated).
• Cares for members
• Regulates behavior
• Allocates responsibilities
• Adapts to crises
• Obtains resources
• Express commitment
Interventions: NIC Major interventions:
Family Involvement
Promotion 7110
Definition: Assisting and
Definition: Facilitating
instructing a person to perform
participation of family members
instrumental activities of daily
in the emotional and physical
living (IADL) needed to function
care of the patient.
in the home or community.
Activities
Establish a personal relationship Determine individual's need for
with the patient and family
members who will be involved in
care.
Identify family members'
capabilities for involvement in
care of the patient.
Identify family members'
preferences for involvement with contacting support and
patient.
Identify family members'
expectations for the patient.
Anticipate and identify family
needs.
Encourage the family members
and the patient to assist in the
development of a plan of care.
Encourage the family members
and patient to be assertive with
health care professionals.
Monitor involvement in patient's
care by family members.
Encourage care by family
members during hospitalization
or care in a long-term care
facility.
Facilitate understanding of the
medical aspects of the patient's
condition for family members.
Self care: specific to ADL's
0300
Indicators: (1-5: severe,
substantial, moderate, mild, or
no compromise).
• Eating
• Dressing
• Bathing
• Hygiene
• Walking
• Toileting
Major interventions:
Self-Care Assistance: IADL
1805
Activities
assistance with IADLs.
Determine needs for safety-
related changes in the home.
Provide for methods of
assistance people.
Provide cognitive enhancing
techniques.
Instruct individual on alternative
methods of transportation.
Obtain tools to assist in daily
activities.
Determine financial resources
and personal preferences
regarding modifications.
Determine whether individual's
monthly income is sufficient to
cover ongoing expenses.
Assist individual in establishing Inform patient of available
methods and routines for
cooking, cleaning, and shopping. resources (e.g., medication
Determine if physical or
cognitive ability is stable or
declining and respond to
changes in either, accordingly.
Personal autonomy 1614
Indicators: (1-5: never, rarely,
sometimes, often, consistently
demonstrated).
• Informed life decisions
• Considers other opinions
• Expresses independence
• Expresses satisfaction
• Participates in decisions
• Asserts personal preferences
Major interventions:
Financial Resource
Assistance 7380
Definition: Assisting an
individual/family to secure and
manage finances to meet health
care needs.
Activities:
Determine patient's current use
of health care system and the
financial impact of this use.
Assist patient to identify financial
needs, including analysis of
assets and liabilities.
Determine patient's cognitive
ability to read, fill out forms,
balance checkbook, manage
money.
Prioritize patient's daily living
needs and assist patient to
develop a plan to meet those
needs.
Devise a plan of care to
encourage patient/family to
access appropriate levels of care
in the most cost-effective
manner.
Inform patient of services
available through state and
federal programs.
Determine if patient is eligible for
waiver programs.
Refer patient who may be
eligible for state or federally
funded programs to appropriate
individuals.
resources and assist in accessing
assistance program, county relief
program).
Assist patient to develop a
budget and/or make referral to
appropriate financial resource
person (e.g., financial planner,
estate planner, consumer
counselor), as needed.
 Provide the support needed for Consult with occupational and/or Assist patient to fill out
the family to make informed physical therapist to deal with applications for available
decisions. physical disability. resources, as needed.

Identify family members'

Refer to family and community
perception of the situation, Assist patient in long-term care
services, as needed.
precipitating events, patient's placement planning, as needed.
feelings, and patients' behaviors.

Assist patient to assure money is

Identify other situational
in secure place (i.e., bank), as
stressors for family members.
needed.

Determine level of patient Encourage family to be involved

dependence on family members in financial management, as
as appropriate for age or illness. appropriate.

Represent economic needs of

Encourage focus on any positive
patients at multidisciplinary
aspects of the patient's situation.
conferences, as needed.
Collaborate with community
Identify and respect coping agencies to provide needed
mechanisms used by family services to patient.
members.

Identify with family members the Monitor for signs and symptoms
patient's coping difficulties. of fluid retention.

Identify with family members the

patient's strengths and abilities
with family.

Inform family members of

factors that may improve
patient's condition.

Encourage family members to

keep or maintain family
relationships, as appropriate.
Facilitate management of the
medical aspects of illness by
family members.

Evidenced-based
(Wetzels et al, 2007; see also Fisher et al, 2008; Hertz et al, 2005; Zwicker & Picariello, 2003).
Research

Outcomes Evaluation and

6 months later
Management

NOC (Family functioning)
average score of 5 (consistently
demonstrated) for every
indicator throughout entire span
of care
NOC (Self care: specific to
ADL's) average score of 4 (mild
compromise) before time of
relocation from Missouri River
Manor to Lodge
NOC (Personal autonomy)
average score of 4 (consistently
demonstrated) throughout the
majority of care once released
from hospital into Missouri River
Manor and into the Lodge

Express feelings (family) Assess current level of self-care Have the resources to cope
activities as acceptable physically and emotionally with
the chronic illness process

Identify ways to cope effectively Express the need or desire to Use community resources to
and use appropriate support enhance level of self-care assist with treatment needs
systems (family)

Treat impaired family member as Seek out health-related Caregiver will feel supported
normally as possible to avoid information as needed
overdependence (family)

Meet physical, psychosocial, and Identify strategies to enhance Caregiver will report low or no
spiritual needs of members or self-care feelings of burden or distress
seek appropriate assistance
(family)
Demonstrate knowledge of Perform appropriate Caregiver will maintain own
illness or injury, treatment interventions as needed physical and
modalities, and prognosis psychological/emotional health
(family)

Participate in the development of Monitor level of self-care Caregiver will identify resources
the plan of care to the best of available to help in giving care
ability (significant person)

Identify ways to cope effectively Evaluate effectiveness of self- Caregiver will verbalize mastery
and use appropriate support care interventions at regular of the care situation, feeling
systems (family) intervals confident and competent to
provide care

Meet physical, psychosocial, and Care receiver will obtain quality

spiritual needs of members or and safe care
seek appropriate assistance
(family)

Demonstrate knowledge of
potential environmental,
lifestyle, and genetic risks to
health and use appropriate
measures to decrease possibility
of risk (family)

Focus on wellness, disease

prevention, and maintenance
(family and individual)

Seek balance among exercise,

work, leisure, rest, and nutrition
(family and individual)