Indonesian Nursing Intervention Standards (SIKI)

 

 

Aromatherapy 1.08233

 

Definition

Provide essential oils by inhalation, massage, steam bath, or compress to relieve pain, lower blood pressure, promote relaxation and comfort.

 

Action

Observation

- Identify preferred and disliked scent options

- Identify levels of pain, stress, anxiety, and mood before and after aromatherapy

- Monitor discomfort before and after administration (eg nausea, dizziness)

- Monitor problems that occur when giving aromatherapy (eg contact dermatitis, asthma)

- Monitor vital signs before and after aromatherapy

Therapeutic

- Choose the right essential oil according to the indication

- Perform a skin sensitivity test with a patch test (patch test) with a 2% solution on the folds of the arms or the folds of the back of the neck

- Administer essential oils by appropriate method (eg inhalation, massage, steam bath, or compress)

Education

- Teach how to store essential oils properly

- Recommend using essential oils in a variety of ways

- Recommend keeping essential oil packaging out of reach of children

Collaboration

- Consult the right and safe type and dosage of essential oils

 

Bandage Press 1.02028

 

Definition

Bandage the wound with pressure to prevent or stop bleeding.

 

Action

Observation

- Monitor bandage to monitor wound drainage

- Monitor the amount and color of drainage fluid from the wound

- Check the speed and strength of the distal pulse

- Check acral, skin condition and distal capillary refill

Therapeutic

- Put on gloves

- Elevate the injured body part above the level of the heart, if there is no fracture - Cover the wound with thick gauze

- Press the gauze firmly over the wound for

- Fix gauze with plaster after bleeding stops

- Press the artery (pressure point) that leads to the bleeding area

Education

- Explain the purpose and procedure of pressure dressing

- Suggest limiting movement in the injured area

 

 

Bibliotherapy 1.09254

 

Definition

Use literature to express feelings, actively solve problems, improve coping skills or knowledge.

 

Action

Observation

- Identify emotional, cognitive, developmental and situational needs

- Identify reading skills

 

Therapeutic

- Set therapy goals (eg emotional changes, personality development, learning new behaviors)

- Choose literature (stories, poems, essays, articles, books, or novels) based on reading ability, or according to the situation/feeling experienced

- Use pictures and illustrations

- Discuss the feelings expressed by the characters in the literature

- Discuss to compare images, characters, situations, or concepts in the literature with experienced situations

- Facilitate recognizing situations in the literature to make behavior change

- Continue reading sessions with role play sessions, both individually and in groups

- Give a pause of a few minutes so that the patient can reflect on the reading material

Education

- Explain the purpose and procedure of bibliotherapy

- Encourage reading in an audible voice, if necessary

- Recommend rereading

Collaboration

- Consult the librarian for proper book/literature searches

 

 

Anticipatory Guidance 1.12359

 

Definition

Prepares patient and family to anticipate developmental or situational crises.

 

Action

Observation

- Identify commonly used problem solving methods

- Identify possible developments or situational crises that will occur and their impact on individuals and families

 Therapeutic

- Facilitation of deciding how the problem will be solved

- Facilitate deciding who will be involved in solving problems

- Use case examples to improve problem solving skills

- Facilitation of identifying available resources

- Facilitation of adapting to changing roles

- Schedule visits at each stage of development or as needed

- Schedule follow-up to monitor or provide support.

- Provide a contact number where you can be reached, if necessary

- Involve family and related parties, if necessary

- Provide both printed and electronic references (eg educational materials, pamphlets)

Education

- Describe normal development and behavior

- Inform realistic expectations regarding patient behavior

- Practice the coping techniques needed to deal with developmental or situational crises

Collaboration

- Refer to community service agency, if necessary

 

 

Health System Guidance 1.12360

 

Definition

Identify and develop skills to address health problems.

 

Action

Observation

- Identification of individual, family and community health problems

- Identification of individual, family and community initiatives

Therapeutic

- Facilitate the fulfillment of health needs

- Facilitate the fulfillment of independent health needs

- Involve colleagues/friends to guide the fulfillment of health needs

- Prepare the patient to be able toCollaborationand cooperate in meeting health needs

Education

- Guiding to be responsible for identifying and developing the ability to solve health problems independently.

 

Code Management 1.02029

 

Definition

Coordinate emergency treatment to save the patient's life.

 

Action

Observation

- Monitor level of consciousness

- Monitor heart rhythm

- Monitor the provision of Advance Cardiac Life Support according to the available protocol

- Monitor the quality of cardiopulmonary resuscitation provided (eg compression depth, compression rate, full chest recoil, no interruptions)

- Accurate ECG interpretation for proper cardioversion/defibrillation, if necessary

- Check availability of emergency medicines

Therapeutic

- Call for help if the patient is unconscious

- Activate code blue

- Perform cardiopulmonary resuscitation, if necessary

- Make sure the airway is open

- Give rescue breaths, if necessary

- Install a heart monitor

- Minimize interruptions during compression and defibrillation

- Install venous access, if necessary

- Prepare for intubation, if necessary

- Provide opportunity for family to see patient during resuscitation, if necessary

- Provide support to families who are present during resuscitation

- End the procedure if there are signs of spontaneous circulation (eg palpable carotid pulse, regained consciousness)

- Perform post cardiac arrest care

Collaboration

- Collaboration of defibrillation or cardioversion, if necessary

- Collaborative administration of epinephrine or adrenaline, if necessary

- Collaborative administration of amiodarone, if necessary

 

Delegation 1.13476

 

Definition

Delegating formal authority and responsibility to others to carry out certain activities.

 

Action

Observation

- Identify delegated tasks

- Identify the right person to delegate

- Monitor performance in the implementation of delegation

Therapeutic

- Arrange delegation plans

- Set realistic goals and objectives

- Match tasks or obligations with staff's abilities

- Avoid taking back tasks that have already been delegated

- Control and coordinate staff work by measuring the achievement of goals based on standards

Education

- Explain the purpose of the delegation

- Train staff by assigning tasks and authority both in writing and verbally

 

 

Focus Group Discussion

Definition

Conduct semi-structured discussions to identify a problem in the group.

Action

Observation

- Identify the need for focus group discussions

- Identify discussion participants

- Record thoughts or ideas that come up in the discussion

 Therapeutic

- Arrange the room with a comfortable atmosphere, design the seating position

- Prepare tools (eg audio system, recorder, writing media)

- Conduct group orientation: greetings, participants are asked to provide their name and personal information

- Do time contract

- Convey the discussion will be recorded

- Direct questions to purpose and avoid irrelevant questions

- Give all participants the opportunity to participate during the discussion

- Motivate the interaction of participants to talk to each other, not necessarily to the facilitator

- Motivate participants who are reluctant to speak

- Limit participants who dominate the discussion through verbal and nonverbal cues

- Demonstrate an active listening attitude to be a model of behavior for participants

- Do in-depth exploration without directing participants

- Deliver summary verbally

- Provide discussion feedback in the form of analysis and reports

Education

- Explain the purpose and procedure of FGD

- Inform the topic to be discussed

 

Ambulance Support

Definition

Facilitate the patient to increase the activity of moving.

Action

Observation

- Identify the presence of pain or other physical complaints

- Identify physical tolerance for ambulation

- Monitor heart rate and blood pressure before starting ambulation

- Monitor general condition during ambulation

Therapeutic

- Facilitate ambulation activities with assistive devices (eg crutches, crutches)

- Facilitate physical mobilization, if necessary

- Involve the family to assist the patient in increasing ambulation

Education

- Explain the purpose and procedure of ambulation

- Recommend early ambulation

- Teach simple ambulation to be performed (e.g. walking from bed to wheelchair, walking from bed to bathroom, walking as tolerated)

 

Stop Smoking Support

Definition

Increase the desire and readiness of the smoking cessation process.

Action

Observation

- Identify the desire to quit smoking

- Identify efforts to quit smoking

Therapeutic

- Discuss the motivation for smoking cessation

- Discuss readiness for lifestyle changes

- Take a psycho approachEducationto support and guide smoking cessation efforts

Education

- Explain the immediate effect of quitting smoking

- Describe various interventions with pharmacotherapy (eg nicotine replacement therapy)

 

Emotional Support

Definition

Facilitates acceptance of emotional states during times of stress.

Action

Observation

- Identify the function of anger, frustration and tantrum for the patient

- Identify the thing that has triggered the emotion

Therapeutic

- Facilitate expressing feelings of anxiety, anger, or sadness

- Make supportive or empathetic statements during the grieving phase

- Perform touch to provide support (eg hug, pat – pat)

- Stay with the patient and ensure safety during anxiety, if necessary

- Reduce the demands of thinking when sick or tired

Education

- Explain the consequences of not facing guilt and shame

- Encourage to express feelings experienced (eg anxiety, anger, sadness)

- Encourage expressing previous emotional experiences and commonly used response patterns

- Teach the proper use of defense mechanisms

Collaboration

- Refer for counseling, if necessary

 

Self Hypnosis Support

Definition

Facilitates the use of self-administered hypnotic states for benefitTherapeutic.

Action

Observation

- Identify if self hypnosis can be used

- Identify the problem to be solved with self hypnosis

- Identify acceptance of self-hypnosis

- Identify myths and misconceptions about the use of self-hypnosis

- Identify the suitability of hypnotic suggestions

- Identify appropriate induction techniques (eg Chevreul pendulum illusion, relaxation, muscle relaxation, visualization exercises, attention to breathing, repeating key words/phrases)

- Identify appropriate deepening techniques (eg hand-to-face movements, imagination escalation techniques, fractionation)

- Monitor response to self-hypnosis

- Monitor progress achieved against therapy goals

Therapeutic

- Set self hypnosis goals

- Make a training schedule, if necessary

Education

- Describe the type of self-hypnosis as a support modality of therapy (eg hypnotherapy, psychotherapy, group therapy, family therapy)

- Teach self-hypnosis procedures according to needs and goals

- Suggest modifying the self-hypnosis procedure (frequency, intensity, technique) based on response and comfort.

 

Group Support

Definition

Facilitating the improvement of problem solving skills and feeling supported by groups of individuals with the same experiences and problems so that they better understand each other's situation.

Action

Observation

- Identify the problems that are actually experienced by the group

- Identification of groups having the same problem

- Identify barriers to attending group sessions (eg stigma, anxiety, insecurity)

- Identify rules and norms that need to be modified in the next session, if necessary

Therapeutic

- Prepare the environmentTherapeuticand relax

- Form groups with similar experiences and problems

- Start a group session by introducing all group members and the therapist

- Start with small talk, sharing information about each other and the reasons for joining the group

- Create rules and norms in groups within groups, especially confidentiality in groups

- Agree on the required number of sessions in the group

- Build a sense of responsibility in the group

- Discuss problem solving in groups

- Give individuals the opportunity to pause when they feel distressed by certain topics until they are able to participate again

- Provide a break in each session to facilitate individual conversations in groups

- Provide opportunities for mutual support in groups regarding problems and problem solving

- Give the group the opportunity to conclude the problem, problem solving and necessary support for each group member

- Avoid offensive, insensitive conversation or unnecessary/inappropriate humor.

- Provide media for communication needs outside the group (eg email, telephone, SMS, WA)

- Reflect on the benefits of group support at the beginning and end of each meeting

- End activities according to the agreed session.

Education

- Encourage group members to listen and provide support when discussing problems and feelings

- Advise to be honest in telling feelings and problems

- Encourage each group member to express dissatisfaction, complaints, criticism in the group in a polite manner

- Encourage the group to resolve dissatisfaction, complaints and criticism

- Teach relaxation at each session, if necessary.

 

 

 

Family Support Planning Care

Definition

Facilitate planning implementation of family health care.

Action

Observation

- Identify family needs and expectations about health

- Identify the consequences of not taking action with the family

- Identify family owned resources

- Identify actions the family can take

Therapeutic

- Motivation to develop attitudes and emotions that support health efforts

- Use the facilities and facilities that exist in the family

- Create optimal home environment changes

Education

- Inform the health facilities in the family environment

- Recommend using existing health facilities

- Teach the family how to care

 

Treatment Program Compliance Support

Definition

Facilitate the accuracy and regularity of undergoing a predetermined treatment program.

Action

Observation

- Identification of adherence to the treatment program

Therapeutic

- Make a commitment to undergo a good treatment program

- Make a schedule for family assistance to take turns accompanying patients during the treatment program, if necessary

- Document activities during the treatment process

- Discuss things that can support or hinder the course of the treatment program

- Involve the family to support the treatment program being undertaken

Education

- Inform the treatment program that must be undertaken

- Inform the benefits that will be obtained if you regularly undergo a treatment program

- Advise the family to accompany and care for the patient during the treatment program

- Advise the patient and family to consult the nearest health service, if necessary

 

Confidence Support

Definition

Facilitates the integration of beliefs into treatment plans to support recovery from health conditions.

Action

Observation

- Identify beliefs, problems, and treatment goals

- Identify long-term cure according to the patient's condition

- Monitor the patient's physical and mental health

Therapeutic

- Integrate confidence in treatment plan as long as it is not a safety hazard/risk, as needed

- Provide realistic expectations according to prognosis

- Facilitate meetings between family and health team to make decisions

- Facilitation gives meaning to health conditions

Education

- Explain the danger or risk that occurs as a result of negative beliefs

- Describe positive impact alternatives to meet beliefs and treatments

- Provide explanations that are relevant and easy to understand

 

Family Coping Support

Definition

Facilitates the enhancement of values, interests and goals in the family.

Action

Observation

- Identify emotional responses to current conditions

- Identify the psychological burden of prognosis

- Identify understanding of post-discharge care decisions

- Identification of conformity between the expectations of patients, families, and health workers

Therapeutic

- Listen to family problems, feelings and questions

- Accept family values ​​in a non-judgmental way

- Discuss medical and treatment plans

- Facilitate the expression of feelings between the patient and family or between family members

- Facilitate decision making in planning long-term care, if necessary

- Facilitate family members in identifying and resolving value conflicts

- Facilitate the fulfillment of basic family needs (eg housing, food, clothing)

- Facilitate family members through the process of death and grieving, if necessary

- Facilitation of acquiring the knowledge, skills and tools needed to sustain patient care decisions

- Act as a substitute for the family to calm the patient and/or if the family is unable to provide care

- Appreciate and support adaptive coping mechanisms used

- Provide visiting opportunities for family members

Education

- Inform the patient's progress regularly

- Inform about available health care facilities

Collaboration

- Refer for family therapy, if necessary

 

Meditation Support

Definition

Facilitates changes in level of consciousness by focusing specifically on thoughts and feelings.

Action

Observation

- Identify readiness for meditation

- Identification of acceptance of meditation

- Monitor the effectiveness of meditation

Therapeutic

- Provide a quiet environment

- Facilitate choosing words that have a calming effect (eg repeating the words 'one', 'ikhlas', 'patient', alhamdulillah', astaghfirullah')

- When finished, ask the patient to sit still for a few minutes with his eyes open

Education

- Advise ignore disturbing thoughts

- Advise to sit quietly in a comfortable position

- Suggest closing your eyes, if necessary

- Advise to focus attention on the breath while saying the word choice

- Advise relax all muscles and stay relaxed

- Recommend taking medication 1-2 times a day

 

Forgiving Support

Definition

Facilitate diversion of feelings of anger and resentment with empathy and humility.

Action

Observation

- Identify the source of anger and hatred

- Identify inhibiting beliefs and help uncover problems

- Identify feelings of anger, bitterness and resentment

Therapeutic

- Listen to the expression of feelings and thoughts empathetically

- Use presence, touch and empathy techniques, if necessary

- Facilitate overcoming obstacles to recovery in a spiritual way (eg prayer, guidance, being wise)

- Facilitation of worship activities, asking forgiveness / repentance to God (eg repentance prayer, confession of sins)

Education

- Explain that forgiveness is a process

- Explain that forgiveness has a health and healing dimension

- Teach emotional release and relaxation techniques

 

Mobilization Support

Definition

Facilitate the patient to increase the activity of physical movement.

Action

Observation

- Identify the presence of pain or other physical complaints

- Identify physical tolerance for movement

- Monitor heart rate and blood pressure before starting mobility

- Monitor general condition during mobilization

Therapeutic

- Facilitate mobilization activities with assistive devices (eg bed railings)

- Facilitate movement, if necessary

- Involve the family to assist the patient in improving movement

Education

- Explain the purpose and procedure of mobilization

- Recommend early mobilization

- Teach simple mobilizations to do (e.g. sitting in bed, sitting on the side of the bed, moving from bed to chair)

 

Worship Implementation Support

Definition

Facilitating recovery and healing in treatment through worship

Action

Observation

- Identification of the need for worship according to the religion adhered to

Therapeutic

- Provide safe and comfortable facilities for worship (eg places for ablution, prayer equipment, Qibla direction, worship equipment.)

- Facilitate consultation of medical and religious leaders on special procedures (eg donors, transfusions)

- Facilitate the use of worship as a source of coping

 

 

- Facilitate dietary needs according to the religion adopted (eg do not eat pork for Muslims, do not eat beef for Hindus)

- Facilitating the fulfillment of rituals in special situations (eg calling the baby to prayer, baptism, confession of sins, leading the creed during the time of death, facing the Qibla)

- Facilitate worship guidance by family and/or clergy

Collaboration

- Medical consultation related to worship that requires attention (eg fasting)

- Refer to clergy, professional counseling, and support groups in spiritual and ritual situations, where appropriate

 

 

Home Maintenance Support I.14501

Definition

Facilitate in maintaining a clean, safe home environment, and support the growth of family members.

Action

Observation

-Identify factors that contribute to the disruption of home maintenance (e.g. addition of new family members, sick family members, death, financial problems, poor health management)

Therapeutic

- Support family members in setting achievable goals regarding home maintenance

- Facilitation in washing dirty clothes

- Facilitate home repairs, if necessary

- Help the family use social support

- Coordination of the use of community resources

Education

- Teach strategies to create a safe and clean home environment

- Suggest modifications to the arrangement of home furnishings to make it easier to achieve

- Recommend using pest control services, if necessary

 

 

Alcohol Abuse Recovery Support I.09263

Definition

Facilitate the process of stopping alcohol abuse, improve health, well-being and quality of life.

Action

Observation

- Identification of acceptance and acknowledgment of helplessness against addiction experienced

- Monitor progress of alcohol abuse recovery

Therapeutic

- Facilitation of changing addictive behavior gradually

- Facilitate developing relationships that support calm and recovery

- Facilitate checking family beliefs that cause lifestyle dysfunction.

- Facilitate developing productive and responsible coping without alcohol abuse.

- Create an atmosphere of mutual support in the group

- Involve in support groups and relapse prevention

Education

- Explain the importance of recovering from alcohol abuse.

- Teach trauma recovery due to alcohol abuse

 

Substance Abuse Recovery Support I.09264

Definition

Facilitate the change process, stop substance abuse, improve health, well-being and quality of life.

Action

Observation

- Identification of acceptance and acknowledgment of helplessness against addiction experienced

Therapeutic

- Facilitate through the withdrawal phase until you are able to control your thoughts and behavior

- Facilitation of changing addictive behavior gradually

- Facilitation of identifying family patterns and beliefs that cause lifestyle dysfunction

- Facilitation of changing and correcting lifestyle errors during substance use

- Facilitation of developing productive and responsible coping

- Engage support groups

- Engage in relapse prevention group sessions

Education

- Explain the importance of recovering from substance abuse

- Teach recovery from trauma due to substance abuse

 

Role Appearance Support

Definition

Facilitates patient and family to improve relationships by clarifying and fulfilling role-specific behaviors.

Action

Observation

- Identify different roles and transition periods according to developmental level

- Identify the roles that exist in the family

- Identify unfulfilled roles

Therapeutic

- Facilitate adaptation of family roles to unwanted role changes

- Facilitation of role playing in anticipating other people's reactions to behavior

- Facilitate discussion of changes in the role of children for newborns, if necessary

- Facilitate discussion on the role of parents, if necessary

- Facilitate discussion about role adaptation when the child leaves the house, if necessary

- Facilitate discussion of expectations with family in reciprocal roles

Education

- Discuss the behaviors required for role development

- Discuss necessary role changes due to illness or disability

- Discuss changing roles in accepting parental dependence

- Discuss positive strategies for managing role change

- Teach new behaviors needed by patients/parents to fulfill roles

Collaboration

- Refer in groups to learn new roles

 

Decision Making Support I.09265

Definition

Provide information and support when making health decisions

Action

Observation

- Identify perceptions of the problem and information that triggers conflict

Therapeutic

- Facilitation of clarifying values ​​and expectations that help make choices

- Discuss the advantages and disadvantages of each solution

- Facilitate seeing the situation realistically

- Motivation reveals the expected treatment goals

- Facilitate collaborative decision making

- Respect the patient's right to accept or reject information

- Facilitation of explaining decisions collaboratively

- Respect the patient's right to accept or reject information

- Facilitate explaining decisions to others, if necessary

- Facilitate relationships between patients, families, and other health workers

Education

- Inform alternative solutions clearly

- Provide the information requested by the patient

Collaboration

- Collaboration with other health workers in facilitating decision making

 

Need Disclosure Support I.09266

Definition

Makes it easier to express needs and wants effectively.

Action

Observation

- Check for verbal communication disorders (eg inability to speak, difficulty expressing thoughts verbally)

Therapeutic

- Create a calm environment

- Avoid speaking loudly

- Ask questions with short answers, with a nod of the head if you have difficulty speaking

- Schedule a break in advance of visits and speech therapy sessions

- Facilitate communication with media (eg pencil and paper, computer, word cards)

Education

- Inform family and other health workers on communication techniques, and use them consistently

- Encourage family and staff to talk even if they are unable to communicate

Collaboration

- Refer to speech therapist, if necessary

 

Expression of Feelings Support I.09267

Definition

Makes it easy to express, understand and manage emotions

Action

Observation

- Identify emotional level

- Identify verbal and non-verbal cues

- Identify current feelings

- Identify the relationship between what is felt and behavior

Therapeutic

- Facilitation of expressing painful emotional experiences

- Facilitation of identifying interpersonal assumptions that underlie emotional experiences

- Facilitates consideration of delaying behavior in response to painful emotions

- Facilitate differentiating the expression of strong emotional expressions that are allowed and those that damage the relationship

- Facilitation of neutralizing negative emotions

Education

- Teach to express feelings assertively

- Inform suppressing feelings can affect interpersonal relationships

Guilt Feeling Support

Definition

Facilitate in overcoming painful feelings due to failure of responsibility

Action

Observation

- Identification of irrational beliefs

Therapeutic

- Facilitation of identifying emerging situations and responding to situations

- Facilitate identifying the reflection of destructive feelings

- Facilitation of identifying the impact of the situation on family relationships

- Facilitate understanding guilt is a common reaction to trauma, abuse, grief, disaster, or accident

- Facilitate spiritual support, if necessary

Education

- Guide to admit your own mistakes

- Teach to identify painful feelings of guilt

- Teach using thought-stopping techniques and substitution of thoughts with muscle relaxation when guilty thoughts continue to be felt

- Teach identifying options to prevent, replace, make amends, and resolve

 

Self Care Support I.11348

Definition

Facilitate the fulfillment of self-care needs

Action

Observation

- Identify age-appropriate self-care activity habits

- Monitor level of independence

- Identify the need for personal hygiene aids, dress, decorate, and eat

Therapeutic

- Provide a pleasant environmentTherapeutic(e.g. warm, relaxed, privacy)

- Prepare personal needs (eg perfume, toothbrush, and bath soap)

- Accompany in doing self-care until independent

- Facilitation to accept dependency

- Schedule a self-care routine

Education

- Advise to do self-care consistently according to ability

 

Self Care Support:CHAPTER/BAC I.11349

Definition

Facilitate the fulfillment of the need to urinate (BAK) and defecate (BAB)

Action

Observation

- Identify bowel habits according to age

- Monitor the patient's skin integrity

Therapeutic

- Unlock required clothes for easy elimination

- Support consistent use of toilets/commodes/potties/urinals

- Maintain privacy during elimination

- Change the patient's clothes after elimination, if necessary

- Clean the CHAPTER/BAK aids after use

- Practice urination / defecation according to schedule, if necessary

- Provide assistive devices (eg external catheter, urinal), if necessary

Education

- Advise BAK/CHAPTER regularly

- Advise to the bathroom/toilet, if necessary

 

Self Care Support: Dressing I.11350

Definition

Facilitating the fulfillment of clothing and decoration needs

Action

Observation

- Identify age and culture in helping to dress/adorn

Therapeutic

- Provide clothes in an easily accessible place

- Provide personal clothing, as needed

- Facilitate wearing clothes, if necessary

- Facilitation of decoration (eg combing hair, trimming mustache/beard)

- Maintain privacy while dressing

- Offer for laundry, if necessary

- Give credit for the ability to dress independently

Education

- Inform the available clothes to choose from, if necessary

- Teach wearing clothes, if necessary

 

Self Care Support:Eating/Drinking I.11351

Definition

Facilitate the fulfillment of food/drink needs.

Action

Observation

- Identify the recommended diet

- Monitor swallowing ability

- Monitor the patient's hydration status, if necessary

Therapeutic

- Create a pleasant environment during your meal

- Set a comfortable position to eat/drink

- Perform oral hygiene before eating, if necessary

- Put food on the side of the eye that is healthy

- Provide straws for drinking, as needed

- Prepare food at a temperature that increases appetite

- Prepare your favorite food and drink

- Provide assistance when eating / drinking according to the level of independence, if necessary

- Motivation to eat in the dining room, if available

Education

- Explain the position of food in patients with visual impairment using a clockwise direction (eg vegetables at 12 o'clock, rending at 3 o'clock)

Collaboration

- Collaboration of drug administration (eg. Analgesic, antiemetic), as indicated

 

Self Care Support:Bath I.11352

Definition

Facilitate the fulfillment of personal hygiene needs

Action

Observation

- Identify age and culture in helping personal hygiene

- Identify the type of assistance needed

- Monitor body hygiene (eg hair, mouth, skin, nails)

- Monitor skin integrity

Therapeutic

- Provide toiletries (eg soap, toothbrush, shampoo, skin moisturizer)

- Provide a safe and comfortable environment

- Facilitation of brushing teeth, as needed

- Facilities for bathing, as needed

- Maintain personal hygiene habits

- Provide assistance according to the level of independence

Education

- Explain the benefits of bathing and the impact of not bathing on health

- Teach the family how to bathe the patient, if necessary

 

Spiritual Development Support I.09269

Definition

Facilitates the development of the ability to identify, relate to, and find sources of food, purpose, strength and hope in life.

Action

Therapeutic

- Provide a quiet environment for self-reflection

- Facilitation of identifying spiritual problems

- Facilitate identifying barriers to self-knowledge

- Facilitation of exploring beliefs regarding the restoration of body, mind, and spirit

- Facilitate friendly relations with others and religious services

Education

- Encourage making spiritual commitments based on beliefs and values

- Encourage participation in worship activities (holidays, rituals) and meditation

Collaboration

- Refer to religious leaders/religious groups, if necessary

- Refer to support groups, self-help, or spiritual programs, if necessary

 

Persecution Protection Support I.09270

Definition

Facilitate the prevention and treatment of physical, psychological and/or sexual hazards.

Action

Observation

- Identify unpleasant or traumatic experiences (e.g. abuse, rejection, excessive criticism)

- Identification of relationships and ability to take responsibility between family members

- Identification of differences in treatment in the family

- Identify crisis situations that trigger abuse (eg poverty, unemployment, divorce, or death of a loved one)

- Identify difficulties trusting yourself and others

- Identify the level of social isolation in the family

- Identification of discrepancies in the description of the injury and/or trauma that occurred

- Identify any role inconsistencies (e.g. child comforting parents, or excessive or aggressive behavior)

- Check for signs of abuse

Therapeutic

- Listen to a chronological explanation of the injury and / or trauma that occurred

- Facilitate families to identify coping strategies for stressful situations

- Report the situation of suspected abuse to the authorities

Education

- Inform legal services relevant to the persecution incident

- Explain realistic expectations to children according to development

- Recommend hospitalization for further examination and investigation, if necessary

- Advise to contact the police if fiski's safety is threatened

Collaboration

- Refer to support groups or shelters, if necessary

- Refer family members at risk to appropriate specialists

Religious Persecution Protection Support

Definition

Facilitate high risk identification, control of religious relationships and activities.

Action

Observation

- Identify dependence on religious “leaders”

- Identify patterns of behavior, thoughts, and feelings

Identification History of religious and/or ritual abuse, methods, problem solving and coping, emotional stability, level of use of persuasive and manipulative techniques

- Identify signs of physical, emotional abuse, or religious addiction

- Monitor interactions with religious “leaders”

- Identification of religious functional networks

- Identify resources to meet individual and group religious needs and support

Therapeutic

- Offer appropriate worship activities for recovery for patients and families/religious groups

- Provide regular interpersonal support as needed

- Report suspected abuse against places of worship and/or legal authorities

Collaboration

- Refer to appropriate religious counseling

- Refer if there is suspected abuse of occult rituals

 

 

Elderly Persecution Protection Support

Definition

Facilitate the prevention and management of physical, sexual, emotional and exploitation harm in the elderly

Action

Observation

- Identification of dependence on caregivers (eg due to impaired mental status, limited economic resources, depression)

- Identify family crisis situations that trigger abuse (eg poverty, unemployment, divorce)

- Identification of caregivers who exhibit physical or mental health disorders

- Identify signs of physical, sexual and psychological abuse (e.g. lacerations, bruising, presence of dry semen or blood, low self-esteem, depression

- Identify signs of exploitation (eg not meeting basic needs with adequate resources)

- Identify unrealistic expectations of caregivers

- Monitor patient and caregiver interactions

Therapeutic

- Give positive affirmations about self-worth

- Facilitating families in identifying strategies for dealing with stressful situations

- Discuss indications of abuse with patients and caregivers separately

Education

- Teach how to solve problems in treatment

- Encourage expressing feelings (eg afraid, worried, sad, upset, angry)

- Recommend hospitalization for further examination and investigation, if necessary

- Suggest adjustments to the home environment to increase independence

- Encourage regular physical activity programs and appropriate exercise programs

- Promote self-care through exercise, strengthening and coping

- Inform community resources (e.g. address and telephone number of institutions that provide assistance to elderly home health services)

Collaboration

- Refer to physical therapy or exercise program, if necessary

- Refer to community nurse, if necessary

- Refer to human rights services, if necessary

 

 

Spouse Abuse Protection Support

Definition

Facilitate prevention and management of physical, sexual, emotional, and exploitation harm from household partners

Action

Observation

- Identification of risk factors related to domestic violence (eg history of domestic violence, abuse, rejection, excessive criticism, feelings of worthlessness, poverty, unemployment, financial dependence, infidelity)

- Identify a history of domestic violence domestic violence (eg multiple injuries, symptoms, sometic, multiple, chronic abdominal pain, chronic headache, pelvic pain, anxiety, depression, post-traumatic stress syndrome, and other psychiatric disorders)

- Identification of signs and symptoms of physical abuse (eg multiple wounds in various stages of healing; unexplained lacerations, bruises, on forearms; human bites)

- Identification of signs and symptoms of sexual assault (eg presence of dry semen/blood, external genitalia, dramatic changes in behavior or health with no known etiology)

- Identify signs and symptoms of emotional abuse (eg low self-esteem, depression, shyness and complacency, behavior, being overly cautious around partners)

- Identification of signs and symptoms of exploitation (e.g. inadequate basic needs provided when resources are adequate, confiscation of personal belongings, unexplained loss of social security, lack of knowledge of personal finance or legal issues)

- Identification of inconsistent explanations for wound causes

- Identify the match between the type of injury and the description of the cause

- Identify the use of community resources for violence prevention

- Identification of partner interactions (e.g. record of partner visitation time and length during hospitalization, partner's slight or excessive reaction)

- Identification of extreme compliance with partners such as surrendering to hospital procedures

- Identification of progressive deterioration of physical and emotional state

- Identify repeated visits to the clinic, emergency room, or medical due to minor problems

Therapeutic

- Conduct interviews with patients or other people who are aware of allegations of violence without their partners present

- Document evidence of physical or sexual abuse using standard recording devices and photographs

- Listen carefully when starting to talk about the problem

- Make a plan to record where violence is suspected

- Affirm positively that the patient is valuable

- Support victims to take action and make changes to prevent further violence

- Facilitate patients and families in developing strategies to deal with stress

- Discuss with patient and family to identify relationship strengths and weaknesses

- Create a safety plan to use in case of violence

- Reports of situations where abuse is suspected in accordance with applicable law

Education

- Recommend hospitalization for further examination and investigation, if necessary

- Encourage expressing concerns and feelings including fear, guilt, shame, and self-blame

- Inform about the shelter for victims of domestic violence, if necessary

Collaboration

- Refer patients who are at risk of violence or experiencing violence to appropriate specialists and/or services (eg community specialist nurses, human rights services, counselling, legal assistance)

 

 

Grieving Process Support

Definition

Facilitates completion of the grieving process for a meaningful loss

Action

Observation

- Identify the loss faced

- Identify the grieving process experienced

- Identify the nature of attachment to a lost object or deceased person

- Identify early reactions to loss

Therapeutic

- Show acceptance and empathy

- Motivation to want to express feelings of loss

- Motivation to strengthen the support of family or loved ones

- Facilitation of doing habits according to culture, religion, and social norms

- Facilitate expressing feelings in a comfortable way (eg reading a book, writing, drawing, or playing)

- Discuss coping strategies that can be used

Education

- Explain to the patient and family that denial, anger, bargaining, depression and acceptance are normal in the face of loss

- Advise identify the greatest fear of loss

- Encourage expressing feelings about loss

- Advise to go through the grieving process gradually

 

 

Grieving Process Support : Perinatal Death

Definition

Facilitate the process of grieving parents against perinatal death

Action

Observation

- Identify early reactions to infant death

Therapeutic

- Perform child birth habits according to religion and culture (eg. Azan)

- Provide baby equipment including child birth records (eg foot and hand stamps, photos, baby supplies )

- Involve parents in the funeral of the baby

- Move the baby to the morgue

- Prepare the corpse to be taken by the family to the funeral home

- Discuss necessary decision making (eg autopsy, genetic counselling)

- Discuss the characteristics of normal and abnormal grieving, including the precipitation of feelings

Education

- Inform the shape of the baby based on gestational age and duration of death

- Inform existing support groups, if necessary

- Advise parents to hold their baby when they are about to die, if necessary

- Encourage the family to see, hold and be with the baby for as long as they want

Collaboration

- Refer to religious leaders (eg Ustadz, pastors), social services and counselors, if necessary

 

 

Sibling Support

Definition

Facilitating siblings to adapt to their sibling's condition who is sick/chronic conditions/special needs

Action

Observation

- Identification of sibling's understanding of the condition of his brother

- Monitor sibling's response to difficulty adapting to the sibling's condition (eg, sensitivity, withdrawal, stress)

Therapeutic

- Motivation of parents to talk to the sibling about his brother's condition honestly

- Involve parents when providing information on the condition of their siblings

- Facilitate communication between sibling and his sibling

- Facilitate sibling to visit his sibling who is being treated

- Facilitate parents to manage sibling needs at home

- Facilitate sibling to see the difference between the similarities between himself and his sibling

- Give the opportunity to meet fellow sibling who has the same problem

- Give praise for being patient, for making sacrifices, or for helping

- Communicate sibling conditions to school nurses and teachers to provide support, if necessary

- Use media to facilitate sibling who can't meet his sibling(eg phone, photo, video)

Education

- Inform sibling about his brother's condition

- Inform sibling that he is not the cause of his brother's condition

 

 

 

Spiritual Support

Definition

Facilitates increased feelings of balance and connection with a greater power

Action

Observation

- Identify feelings of worry, loneliness and helplessness

- Identify views on the relationship between spirituality and health

- Identify the patient's hopes and strengths

- Identification of religious observance

Therapeutic

- Provide opportunities to express feelings about illness and death

- Give the opportunity to express and relieve anger appropriately

- Ensure that nurses are willing to support during times of helplessness

- Provide privacy and quiet time for spiritual activities

- Discuss beliefs about the meaning and purpose of life, if necessary

- Facilitate worship activities

Education

- Encourage interacting with family, friends, and/or other people

- Encourage participation in support groups

- Advise relaxation, meditation and guided imagination methods

Collaboration

- Arrange visits with clergy (eg Ustadz, priest, room, monk)

 

 

Financial Source Support

Definition

Facilitate proper management of financial resources to support care and Health

Action

Observation

- Identify the use of financial resources in accordance with the sources of funds owned

- Identification of facilities that can be used after discharge

- Identify the efficiency and effectiveness of using Health insurance

Therapeutic

- Conduct advocacy related to financing in accordance with institutional policies

- Record every financing activity

- Financial facilitation to discuss efforts to obtain financing sources

Education

- Explain the purpose and procedures for managing cost insurance (eg BPJS, JKN)

- Inform the financing of maintenance services

- Inform the guarantee that can be used

 

 

 

 

Self-responsibility Support

Definition

Facilitate to be responsible for one's own behavior and the consequences it causes

Action

Observation

- Identify perceptions about health problems

- Monitor the implementation of responsibilities

Therapeutic

- Give a chance to feel responsible

- Increase your sense of responsibility for your own behavior

- Avoid arguing or haggling about her role in the nursing room

- Provide reinforcement and positive feedback when carrying out responsibilities or changing behavior

Education

- Discuss the responsibilities of the caregiving profession

- Discuss the consequences of not carrying out responsibilities

 

 

Sleep Support

Definition

Facilitates regular sleep and wake cycles

Action

Observation

- Identify activity and sleep patterns

- Identification of sleep-disturbing factors (physical and/or psychological)

- Identify foods and drinks that interfere with sleep (eg coffee, tea, alcohol, eating close to bedtime, drinking lots of water before bed)

- Identification of sleeping pills consumed

Therapeutic

- Environmental modifications(eg lighting, noise, temperature, mattress and bedding)

- Limit naps, if necessary

- Facilitate stress relief before bed

- Implement a regular sleep schedule

- Perform procedures to increase comfort (eg massage, positioning, acuprocedural therapy)

- Adjust the schedule for administering medication and/or actions to support the sleep-wake cycle

Education

- Explain the importance of getting enough sleep during illness

- Advise to stick to bedtime habits

- Advise to avoid food/drink that disturbs sleep

- Advise the use of sleeping pills that do not contain suppressors of REM sleep

- Teach factors that contribute to disturbed sleep patterns (eg psychological, lifestyle, frequent shift work)

- Teach autogenetic auto relaxation or other non-pharmacological methods

 

Ventilation Support

Definition

Facilitates in maintaining spontaneous breathing to maximize gas exchange in the lungs

Action

Observation

- Identify the presence of accessory respiratory muscle fatigue

- Identify the effect of social change on respiratory status

- Monitor respiratory and oxygenation status (eg, rate and depth of breath, use of breathing aids, additional breath sounds, oxygen situation)

Therapeutic

- Maintain a patent airway

- Give semi fowler or fowler position

- Facilitate changing positions as comfortable as possible

- Provide oxygenation as needed (eg nasal cannula, face mask, rebreating or non-rebreating mask)

- Use a bag-valve mask, if necessary

Education

- Teach doing deep breathing relaxation techniques

- Teach to change position independently

- Teach effective coughing techniques

Collaboration

- Collaborative administration of bronchodilators, if necessary

 

 

Visitation Support

Definition

Facilitate the health team to visit patients in the ward

Action

Observation

- Identify the patient by asking at least two identities (eg full name, date of birth)

Therapeutic

- Introduce yourself to the patient

- Make sure the health team that comes is a team that handles patients

- Listen to the patient's response

- Accompany the patient during the visit

- Facilitate implementation of evidence-based recommendations to solve health problems

- Document the results of the visit in the integrated record

Education

- Advise the patient and family to ask questions if there are still things that are not understood

- Inform the progress of the results of the incident/problem visit

 

 

EducationActivity/Rest

Definition

Teach activity and rest arrangements

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide materials and media for regulating activities and rest

- Schedule the provision of health education according to the agreement

- Provide opportunities for patients and families to ask questions

Education

- Explain the importance of doing physical activity/exercise regularly

- Encourage involvement in group activities, play activities or other activities

- Suggest compiling a schedule of activities and rest

- Teach how to identify need for rest (eg fatigue, shortness of breath, breath on activity)

- Teach how to identify targets and types of activities according to ability

 

EducationHearing Aid I.12363

Definition

Teach activity and rest arrangements

Action

Observation

- Identification of readiness and ability to receive information

- Check the ears that need a hearing aid

Therapeutic

- Provide hearing aid materials and media

- Schedule the provision of health education according to the agreement

- Provide opportunities for patients and families to ask questions

Education

- Recommend cleaning cerumen if it covers the ear canal

- Recommend aligning the tip of the hearing aid with the ear

- Suggest turning the tip of the hearing aid forward and inserting it into the ear canal

- Recommend adjusting the volume to the patient's needs

 

EducationControlled Analgesia I.12364

Definition

Provide information on how to control pain with controlled analgesic agents

Action

Observation

- Identification of readiness, ability to receive information and perception of pain

- Identification of pain level and dose of opioid administration

- Identify the ability of patients and families to use controlled analgesia

Therapeutic

- Prepare PCA tools

- Schedule an appropriate time to explain controlled analgesia

 Education

- Explain the reason, timing and method of administering controlled analgesia

- Explain the side effects of excessive opioid administration

- Explain the actions to be taken when experiencing a loss of consciousness (eg stop PCA, call the hospital or health worker, elevate head 30 degrees)

- Teach how to identify the effectiveness of analgesia (eg reduction of pain scale)

- Inform to contact health workers if you have difficulty in adjusting the dose of the PCA device

- Demonstrate how to administer controlled analgesia doses

- Demonstrate how to record medication dosage and effectiveness

 

 

 

 

EducationEffective Weight I.12365

Definition

Provides information about optimal body weight and body fat percentage

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide materials and mediaEducation

- Schedule health education as agreed

- Give the family a chance to ask questions

Education

- Explain the relationship between food intake, exercise, weight gain and loss

- Describe medical conditions that can affect weight

- Explain the risk of being overweight and underweight

- Describe habits, traditions and culture, as well as genetic factors that influence body weight

- Teach how to manage weight effectively

 

EducationQuit Smoking I.12366

Definition

Provide information related to the impact of smoking and efforts to quit smoking.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide materials and mediaEducation

- Schedule health education as agreed

- Give the family a chance to ask questions

Education

- Describe the physical symptoms of nicotine withdrawal (eg headache, dizziness, nausea and insomnia)

- Describe smoking cessation symptoms (eg dry mouth, cough, itchy throat)

- Explain the psychosocial aspects that influence smoking behavior

- Inform about nicotine replacement products (eg chewing gum, nasal spray, inhaler)

- Teach how to quit smoking

 

 

EducationDehydration I.12367

Definition

Teach the management of fluid and electrolyte deficiency

Action

Observation

- Identify the ability of patients and families to receive information

Therapeutic

- Prepare materials, media and tools for fluid balance forms

- Determine the right time to provide health education in accordance with the agreement with patients and families

- Give the patient and family a chance to ask questions

Education

- Describe the signs and symptoms of dehydration

- Advise not only to drink water when thirsty, if you are exercising or doing strenuous activities

- Recommend drinking more

- Advise to increase consumption of fruits that contain a lot of water (eg watermelon, papaya)

- Advise how to give ORS, if necessary

- Advise to assess hydration status based on urine color

 

 

EducationPeritoneal Dialysis I.12368

Definition

Teaches how to remove the body's metabolic products through the peritoneal membrane independently

Action

 Observation

- Identify the ability of patients and families to receive information

- Monitor the patient's success on peritoneal dialysis

Therapeutic

- Prepare materials, media and props for peritoneal dialysis

- Schedule the right time to provide health education

- Give the patient and family the opportunity to ask questions

Education

- Explain about infection control (hand washing and sterile principles) in the implementation of peritoneal dialysis

- Describe control goals and problems/complications of peritoneal dialysis (eg redness, swelling, peritoneal fluid does not come out)

- Explain how to monitor fluid in and out of peritoneal dialysis

- Demonstrate the peritoneal dialysis procedure directly on the patient

- Instruct the patient/family to explain and re-demonstrate the peritoneal dialysis procedure

 

EducationDiet I.12369

Definition

Teach the amount, type and schedule of programmed food intake

Action

Observation

- Identify the ability of patients and families to receive information

- Identify the current level of knowledge

- Identify current and past eating habits

- Identify the patient's and family's perception of the programmed diet

- Identify financial limitations to provide food

Therapeutic

- Prepare materials, media and props

- Schedule the right time to provide health education

- Give the patient and family the opportunity to ask questions

- Provide a written meal plan, if necessary

Education

- Explain the purpose of dietary adherence to health

- Inform the foods that are allowed and prohibited

- Inform the possibility of drug and food interactions, if necessary

- Suggest maintaining semi-Fowler's position (30-45 degrees) 20-30 minutes after eating

- Recommend changing food ingredients according to the programmed diet

- Advise to do sports according to tolerance

- Teach how to read labels and choose the appropriate food

- Teach how to plan meals according to the program

- Recommend food recipes according to diet, collaboration if necessary

- Refer to nutritionist and include family, if necessary

 

EducationEdema I.12370

Definition

Provide information on handling and preventing fluid buildup both in the extremities and throughout the body

Action

Observation

- Identify the ability of patients and families to receive information

- Monitor the ability and understanding of patients and families afterEducation

Therapeutic

- Prepare materials, mediaEducation(e.g. fluid balance form)

- Schedule the right time to provide health education as agreed with patients and families

- Give the patient and family the opportunity to ask questions

Education

- Explain the definition, causes (decreased kidney function, hypoalbuminemia, heart failure, sodium retention), signs and symptoms of edema (dramatic weight gain, decreased urine output, less than normal blood albumin, pitting edema)

- Explain how to treat and prevent edema (eg weigh daily, fluid balance, diuretic drugs, high protein diet, low salt diet, antihypertensives)

- Instruct patient and family to re-explain Definition, causes, symptoms and signs, management and prevention of edema

 

EducationDrug Side Effects I.12371

Definition

Provide information to minimize side effects of programmed pharmacological agents

Action

Observation

- Identify the ability of patients and families to receive information

Therapeutic

- Prepare materials and mediaEducation

- Schedule the right time to provide health education as agreed with patients and families

- Give the patient and family the opportunity to ask questions

Education

- Explain the purpose of the drug given

- Explain the indications and contraindications of the drug to be consumed

- Explain how the drug works in general

- Explain the dose, how the drug works in general

- Explain the signs and symptoms if the medication being taken is not suitable for the patient

- Describe possible allergic reactions that occur during or after the drug is consumed, endangering the patient's life

- Suggest to see the expiration date of the drug to be consumed

- Advise to see the physical condition of the drug before consuming it

-Advise to immediately go to the nearest health facility if the reaction to the drug consumed endangers the patient's life

- Teach how to deal with unwanted drug reactions

 

EducationChest Physiotherapy I.12372

Definition

Teaches to mobilize airway secretions through percussion, vibration, and postural drainage

Action

Observation

- Identify the ability of patients and families to receive information

Therapeutic

- Prepare materials and mediaEducation

- Schedule the right time to provide health education as agreed with patients and families

- Give the patient and family the opportunity to ask questions

Education

- Explain contraindications to chest physiotherapy (eg exacerbations of acute COPD, osteoporosis)

- Explain the purpose and procedure of chest physiotherapy

- Describe the segment of the lung that contains excessive secretions

- Explain how to modify the position in order to tolerate the specified position

- Describe pneumatic, acoustic, or electric percussion instruments used, if necessary

- Explain how to move the hand stiff, in the area to be dried when the patient sucks or coughs 3-4 times

- Advise to avoid percussion of the spine, kidneys, female breasts, incisions, and broken ribs

- Teach to secrete secretions through deep breathing

- Teach coughing during and after the procedure

- Explain how to monitor the effectiveness of the procedure (eg pulse oximetry, vital signs, and comfort level)

 

 

EducationHemodialysis I.12373

Definition

Provide information about the blood cleansing process to increase the effectiveness of therapy and minimize the possibility of complications

Action

Observation

- Identify the ability of patients and families to receive information

Therapeutic

- Prepare hemodialysis materials, media and props

- Create media and hemodialysis evaluation format

- Schedule the right time to provide health education as agreed with patients and families

- Modify the health education process as needed

- Give the patient and family the opportunity to ask questions and express their feelings

Education

- Explain the meaning, signs and symptoms, impact, diet, things that patients with kidney failure should pay attention to

- Explain the benefits of monitoring fluid intake and output

- Teach how to monitor excess fluid volume (eg pitting edema, weight gain 1kg = 1 L of water, shortness of breath)

- Explain the importance of family support

 

EducationInfertility I.12374

 

Definition

Provide information to patients and partners about infertility

Action

Observation

- Identify the ability of patients and families to receive information

- Identify knowledge level

- Identify experience during infertility screening procedures

Therapeutic

- Schedule lessons with a partner

- Prepare the necessary media and tools

- Facility to determine ovulation period through basal body temperature, changes in vaginal secretions, and other physiological indicators

- Prepare patient physically and psychologically for gynecological examination

Education

- Describe the female reproductive cycle, if necessary

- Explain the purpose of the infertility examination procedure

- Explain infertility and its treatment

- Explain the effect of infertility on the couple's relationship

- Inform the infertility service center

 

EducationBladder Irrigation I.12375

 

Definition

Provides information about bladder irrigation

Action

Observation

- Identify the readiness and ability of patients and families to receive information

Therapeutic

- Prepare bladder irrigation materials, media and props

- Schedule the right time to provide health education according to the program that has been agreed upon by the patient and family

- Give the patient and family the opportunity to ask questions

Education

- Explain the definition, indication, purpose and benefits of bladder irrigation

- Explain about infection control and patient safety (hand washing and sterile principles)

- Demonstrate aseptic hand washing technique

- Recommend demonstrating aseptic hand washing technique

- Explain the tools, materials and procedures for bladder irrigation

- Demonstrate bladder irrigation procedures and fluid balance monitoring

- Explain the possible problems that can arise and their solutions during bladder irrigation

- suggest demonstrating bladder irrigation

- Advise to contact the nurse if you experience complications of bladder irrigation

 

 

 

 

EducationColostomy Irrigation I. 12376

 

Definition

Teaches how to care for and clean the colon and feces through artificial holes

Action

Observation

- Identify the need for colostomy irrigation

- Identify the readiness of patients and families to receive information

- Monitor the success and ability of patients and families in colostomy irrigation

Therapeutic

- Prepare materials, media and tools (eg infusion set, irrigation fluid, gloves, colostomy bag and other necessary equipment)

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the definition, procedure, indications, contraindications for colostomy irrigation

- Explain the principles of infection prevention (eg washing hands, wearing gloves)

- Explain the action to be taken if abdominal cramps are found in the irrigation process, namely reducing the rate of drip of irrigation fluid

- Explain that feces will come out about 40-60 minutes after irrigation fluid enters

- Explain how to record the actions taken and pay attention to the color and condition of the stoma and peristoma skin, note the color, consistency and amount of stool that comes out

- Recommend colostomy irrigation in the bathroom with a toilet seat, if needed

- Demonstrate how to do colostomy irrigation (including the location of the infusion hanger, irrigation with warm water, avoiding the presence of air, how to insert the irrigation hose into the stoma, irrigation water level, avoiding air in the hose, placing the irrigation bag right in the toilet hole, flowing enough water about 10-15 minutes)

- Demonstrate how to clean the stoma area and reinstall the stoma bag

 

 

 

 

EducationUrostomy Irrigation I.12377

 

Definition

Teach how to do irrigation urostomy independently

Action

Observation

- Identify the ability of patients and families to receive information

- Monitor the success of irrigation urostomy

Therapeutic

- Prepare materials, media and tools to explain urostomy irrigation

- Schedule the right time to provide health education as agreed with patients and families

Education

- Explain the definition and purpose of urostomy irrigation

- Describe signs of obstructed urosomy (eg no urine, abdominal pain)

- Explain the frequency of urostomy irrigation

- Explain how to monitor urine output

- Demonstrate the urostomy irrigation procedure

- Teach aseptic hand washing techniques and infection control

- Recommend recommend aseptic hand washing

- Recommend proper irrigation of urostomy

 

 

EducationChild Safety I.12378

 

Definition

Provide information on safety and prevention of injury to children.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Encourage monitoring of children when in risky places (eg outdoors, balconies, swimming pools)

- Advise to close accessible power sources

- Recommend arranging household furniture

- Recommend choosing toys that are appropriate for the child's age and are not dangerous

- Recommend storing dangerous objects (eg knives, other sharp objects) and hazardous liquids (eg floor cleaners, detergents) in a place out of reach

- Suggest to provide a barrier in the kitchen, bathroom, pool area

- Explain to parents and children about the dangers of traffic

- Teach the use of seat belts when driving

- Explain the safety of cycling to children (eg wearing a helmet; wearing an age-appropriate belt)

- Recommend the use of a stroller (child push chair), a special child seat safely

- Advise not to put the child in a high bed

- Teach children what to do when they feel they are in danger (eg ask an adult for help, scream, run immediately).

 

 

EducationBaby Safety I.12379

 

Definition

Provide information and support for the prevention of injury to infants.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Always keep an eye on the baby

- Advise not to leave the baby alone

- Advise to keep objects that pose a risk of harm to the baby (eg plastic bags, rubber, ropes, cloth, small objects, sharp objects, floor cleaners)

- Recommend installing a barrier on the side of the bed

- Advise to close the power source that is reached by the baby

- Recommend arranging household furniture at home

- Advise to provide barriers in risk areas (eg kitchen, bathroom, pool)

- Recommend using a special seat and seat belt for babies when driving

- Recommend the use of seat belts on strollers (baby pushchairs), baby seats safely

- Advise not to put the baby in a high bed

 

 

EducationGroup I.12380

 

Definition

Providing information in groups to solve physical and mental health problems

Action

Observation

- Identify the health needs of each group as individuals and group members with all aspects and health backgrounds

Therapeutic

- Place groups according to their potential

- Facilitate groups to overcome health problems they face

- Identification of improvement in health care programs and programs

Education

- Inform the group of health needs

Collaboration

- Consult with leaders, policy makers, government organizations in order to provide maximum support, ease of protection in health efforts as an effort to raise public awareness of health.

-Collaborationindividuals, groups or organizations to achieve the fulfillment of health needs and are committed to always strive for promotive and preventive

 

EducationFamily Planning I.12381

 

Definition

Providing information and facilitating mothers and partners in the use of contraceptives to regulate birth spacing

Action

Observation

- Identification of readiness and ability to receive information

- Identification of knowledge about contraceptives

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Screen the mother and partner for the use of contraception

- Do a physical examination

- Facilitation of mothers and partners in making decisions to use contraceptives

- Discuss religious, cultural, developmental, socio-economic considerations on the choice of contraceptives

Education

- Explain about the reproductive system

- Explain the methods of contraception

- Explain sexual activity after joining the family planning program

EducationChemotherapy I.12382

 

Definition

Teach patients and families to understand how they work and reduce the side effects of antineoplasmic agents

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the effect of antineoplasmic drugs on melignant cells

- Educate patient and family about effects on bone marrow function, hair follicles, sexual function and organ toxicity

- Teach patient and family how to prevent infection (eg avoiding crowds, maintaining hygiene and washing hands)

- Advise to report symptoms of fever, chills, nosebleeds, bruising, dark red/black stools

- Recommend avoiding the use of aspirin products

 

EducationHealth I.12383

 

Definition

Teach the management of disease risk factors and clean and healthy living behavior

Action

Observation

- Identification of readiness and ability to receive information

- Identify factors that can increase and decrease motivation for clean and healthy living behavior

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the risk factors that can affect health

- Teach clean and healthy living behavior

- Teach strategies that can be used to improve clean and healthy living behavior

 

EducationEnvironmental Safety I.12384

 

Definition

Teach the preparation of a physical environment that supports safety

Action

Observation

- Identification of readiness and ability to receive information

- Identify safety needs based on level of physical, cognitive and behavioral functioning

- Identification of safety hazards in the environment (eg physical, biological and chemical)

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Recommend eliminating environmental hazards

- Recommend providing assistive devices (eg handrails, non-slip mats)

- Encourage use of protective equipment (eg restraints, side rails, door covers, fences, gates)

- Inform emergency phone number

- Advise environmental screening program (eg lead, radon)

- Educate high-risk individuals and groups about environmental hazards

Collaboration

- Collaboration with other parties to improve environmental security

 

EducationHome Safety I.12385

 

Definition

Teach home management to improve and maintain home security.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Inform the importance of adequate lighting inside and outside the house

- Advise items in easily accessible areas

- Advise to ensure household appliances are in good condition

- Recommend making sure the cables are securely attached to the wall

- Recommend installation of fire detectors

- Recommend ensuring flammable items away from stoves or heaters

- Recommend ensuring the water heater is within the recommended temperature range or lower

- Recommend ensuring the installation of handrails in the required area, if necessary

- Recommend making sure the shower floor is not slippery

- Suggest to make sure the floor mats and carpets are neat and the floor is free of scattered items

- Teach how to put things at home to make it easier to move

 

EducationPsychomotor Skills I.12386

 

Definition

Provide information and support for performing psychomotor skills.

Action

 

Observation

- Identification of needs, readiness, learning ability

- Monitor the ability that has been achieved

Therapeutic

- Determine teaching methodology according to age, ability and needs

- Create a supportive environment

- Provide clear step by step instructions

- Make time for training sessions and take breaks to avoid fatigue

- Give positive feedback on achievements

- Provide information in written form (eg pictures, diagrams), if necessary

- Involve the family

Education

- Suggest doing skills one by one

- Guide to follow the appropriate movement stages

- Teach psychomotor skills

 

EducationEffective Communication I.12387

 

Definition

Teaches how to provide information to the interlocutor effectively.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the factors that can increase and decrease effective communication

- Teach how to convey messages appropriately

- Teach how to use effective communication

- Teach how to verify received messages

 

EducationUrinary Exercise I.12388

 

Definition

Teach the patient and family in achieving the ability to urinate.

Action

Observation

- Identify the ability of patients and families to receive information

Therapeutic

- Preparation of voiding training materials and props

- Determine the right time to provide health education in accordance with the agreement with patients and families

Education

- Explain the causes and problems in urination

- Teach communication methods used to express toileting needs, toileting patterns and toilet skills

- Describe what should be done to promote normal elimination, fall monitoring, and safety of the toilet environment

- Demonstrate how to practice urinating

- Suggest demonstrating urination exercises

 

EducationPhysical Exercise I.12389

 

Definition

Teach regular physical activity to maintain to remind fitness and health

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give a deal to ask

Education

- Explain the health benefits and physiological effects of exercise

- Explain the type of exercise that suits your health condition

- Describe the frequency, duration, and intensity of the desired exercise program

- Teach proper warm-up and cool-down exercises

- Teach techniques to avoid injury during sports

- Teach proper warm-up techniques to maximize oxygen absorption during physical exercise

 

EducationFever Management I.12390

 

Definition

Teach the management of body temperature that is more than normal.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain how to measure the patient's body temperature, pulse, respiration and blood pressure

- Teach how to give a warm compress

- Recommend using a hypothermic blanket as needed

- Recommend wearing clothes that absorb sweat

- Encourage adequate intake

- Teach how to monitor fluid intake and output

- Advise administration of analgesics, if necessary

 

EducationPain Management I.12391

 

Definition

Teach the management of body temperature that is more than normal.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the cause, period, and strategies for pain relief

- Advise self-monitoring of pain

- Advise use of analgesics appropriately

- Teach non-pharmacological techniques to reduce pain

 

EducationStress Management I.12392

 

Definition

Teach patients to identify and manage stress due to changes in daily life.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Teach relaxation techniques

- Teach assertive exercises

- Teach to make a regular exercise schedule

- Suggest a journaling stage to increase optimism and release burdens

- Encourage activities to please yourself (eg hobbies, playing music, painting nails)

- Encourage socializing

- Encourage good sleep every night (7-9 hours)

- Encourage laughter to relieve stress by reading or funny video clips

- Advise to establish communication with family and the profession of care giver

- Recommend compiling a structured schedule.

 

 

Provide information and advice about breastfeeding starting from antepartum, intrapartum and postpartum.

Observation

• Identification of readiness and ability to receive information

• Identification of breastfeeding goals and desiresTherapeutic

• Provide health education materials and media

• Schedule health education as agreed

• Provide opportunities to ask questions

• Support mothers increase self-confidence in breastfeeding

• Involve the support system: husband, family, health workers and the communityEducation

• Provide breastfeeding counseling

• Explain the benefits of breastfeeding for mother and baby

• Teach 4 (four) positions for breastfeeding and latch on correctly

• Teach antepartum breast care by compressing with cotton that has been given coconut oil

• Teach postpartum breast care (eg expressing breast milk, breast massage, oxytocin massage)

 

 

 

Teach behaviors to increase range of motion, muscle strength and mobility.

 

Observation

• Identification of readiness and ability to receive information

• Identification of indications and contraindications for mobilization

• Monitor patient/family progress to ask questions.Therapeutic

• Prepare materials, media and tools for pillows, gaitbelts

• Schedule health education time as agreed with patient and family

• Give the patient/family the opportunity to ask questionsEducation

• Explain the procedure, purpose, indications and contraindications of mobilization and the impact of immobilization

 

• Teach how to identify supporting facilities and infrastructure for mobilization at home

• Teach how to identify mobilization abilities (eg muscle strength, range of motion)

• Demonstrate how to mobilize in bed (eg body mechanics, shifting the patient in the opposite direction from the position to be tilted, tilting techniques, placing pillows for support)

• Demonstrate how to exercise range of motion (eg movement is done slowly, starting from the head to the extremity, moving all joints according to the normal range of motion, how to exercise range of motion on the side of the pareseed extremity using the normal extremity, frequency of each movement)

• Instruct the patient / family to demonstrate the mobilization of the right oblique / left tilt / range of motion exercises as demonstrated

 

 

 

Provide information to improve the ability to meet nutritional needs.

Observation

• Check nutritional status, allergy status, diet program, needs and ability to fulfill nutritional needs

• Identification of ability and appropriate time to receive informationTherapeutic

• Prepare materials and media such as types of nutrition, exchange food table, how to manage, how to measure food

• Schedule health education as agreed

• Provide opportunities to ask questionsEducation

• Explain to the patient and family food allergies, foods to avoid, the number of calories needed, the type of food the patient needs

• Teach how to carry out a diet according to the program (eg high protein, low salt, low calorie foods)

• Describe things to do before feeding (eg oral care, wearing dentures, medications to be given before eating)

• Demonstrate how to clean the mouth

• Teach patient/family to monitor calorie and food intake (eg using a diary)

• Teach patients and families to monitor nutritional deficiencies

• Teach demonstrating how to feed, count calories, prepare food according to the diet program.

 

 

Provide information about meeting the nutritional needs of children.

Observation

• Identification of readiness and ability to receive informationTherapeutic

• Provide health education materials and media

• Schedule health education as agreed

• Provide opportunities to ask questionsEducation

• Explain the need for balanced nutrition in children

• Explain the importance of providing food containing vitamin D and iron in prepubertal and puberty, iron especially in girls who have menstruated

• Recommend avoiding unhealthy snack foods (eg containing artificial sweeteners,

artificial coloring, preservatives, flavoring)

• Teach mothers to identify foods with balanced nutrition

• Encourage Clean and Healthy Lifestyle (PHBS) (eg washing hands before and after eating, washing hands with soap after using the toilet)

 

 

Provide information and provide support about nutrition and infant nutrition plastics.

Observation

• Identify the mother's or caregiver's readiness and ability to receive information

• Identify the ability of the mother or caregiver to provide nutritionTherapeutic

• Provide health education materials and media

• Schedule health education as agreed

• Give the mother or caregiver the opportunity to ask questionsEducation

• Describe early signs of hunger (eg baby is restless, opens mouth and shakes head, sticks out tongue, sucks fingers or hands)

• Recommend avoiding artificial sweeteners

• Encourage Clean and Healthy Lifestyle (PHBS) (eg washing hands before and after eating, washing hands with soap after using the toilet)

• Teach how to choose food according to the baby's age

• Teach how to adjust the frequency of feeding according to the baby's age

• Advise to continue breastfeeding when the baby is sick

 

 

 

 

 

Teach to understand information about the provision of essential nutrients through infusions that are inserted into the body.

Observation

• Identification of readiness and ability to receive informationTherapeutic

• Provide health education materials and media

• Schedule health education as agreed

• Provide opportunities to ask questions

Education

• Explain the purpose and procedure of parenteral nutrition

• Describe the potential side effects and complications of parenteral nutrition

• Explain the possibility of having fewer bowel movements while on parenteral therapy

• Explain the things that must be considered during parenteral therapy (eg condition of the venous access site and condition of the tube)

• Encourage regular checking of the mouth for signs of parotitis, glossitis and oral lesions.

 

 

 

Provide information and support for parenting and support physical, psychological, and social development based on age stages.

Observation

• Identify the understanding of parents/families about raising children

• Identify the readiness of parents to acceptEducationas well as the factors that hinder successEducation(eg cultural factors, language barrier, lack of interest)

Therapeutic

• Ask parents to explain their child's behavior

• Listen to every complaint and problem faced by parents

• Facilitate parents to ask questionsEducation

• Teach parenting techniques and communication skills

• Teach identifying sources of family support

• Teach to identify sources of family stressors (eg drug/alcohol abuse, domestic violence, maternal conflict, depression, divorce)

• Explain the stages of child development

• Describe approaches parents can use to help children express feelings in a positive way

• Describe attitudes or anticipatory actions at the child's age stage

 

 

 

 

 

Provide parenting information and support and physical care that babies need during the first year of life.

Observation

• Identification of knowledge and readiness of parents to learn about infant careTherapeutic

• Provide guidance on changes in infant sleep patterns during the first year

• Motivate parents to talk and read to babies

• conduct home visits as a monitoring and mentoring program for parentsEducation

• Explain the baby's nutritional needs

• Describe the development of teeth and oral hygiene during the first year

• Describe the change in elimination pattern in the first year

• Explain safety and prevention of injury to infants

• Encourage holding, hugging, massaging, playing and touching the baby

• Teach newborn care skills

• Teach how to treat and prevent diaper rash

• Teach how to stimulate baby's development (referring to the Ministry of Health stimulation)

 

 

Provide information and support to parents to understand their child at the adolescent stage.

Observation

• Identification of parents' preparation and ability to receive information

• Identification of factors influencing the programEducation(eg cultural values, negative experiences with health services)

Therapeutic

• Provide health education materials and media

• Schedule health education as agreed

• Give parents the opportunity to ask questions

• Provide reading material about youthEducation

• Describe the tasks or goals of adolescent development

• Describe the pattern of relationships between parents and adolescents

• Describe the coping mechanisms used by adolescents (eg denial)

• Teach normal physiological, emotional, cognitive, and adolescent characteristics

• Teach how to communicate with teenagers

• Teach to give warmth, express affection, teach discipline

• Teach identify ways in youth to manage anger

• Teach about attitudes toward adolescent behavior

• Teach to identify family stressors (eg parental depression, drug addiction, alcoholism, limited education, domestic violence, marital cloc, divorce)

 

 

 

Provide information and support to facilitate caregiver delivery of care.

Observation

• Identification of caregiver role understanding and readiness

• Identify caregiver sources of support and rest needsTherapeutic

• Provide support to caregivers during patient setbacks

• Support caregiver limitations and discuss with patient

• Facilitate caregivers to ask questionsEducation

• Explain the impact of children's dependence on caregivers

• Teach caregivers to explore their strengths and weaknesses

• Teach caregivers how to provide self-care support (eg bathing, defecating, dressing/dressing, eating/drinking)

 

 

 

 

Teach children the selection, preparation and administration of food and the need for dietary modification.

Observation

• Identify the understanding of parents or family regarding the selection of age-appropriate types of healthy food

Therapeutic

• Provide health education materials and media

• Schedule health education according to the agreement

• Provide opportunities to ask questionsEducation

• Explain balanced menu variations

• Explain the importance of a conducive environment at the time of feeding

• Explain the importance of maintaining children's oral hygiene

• Explain the importance of increasing patience in feeding children

• Encourage praise for the child's achievements and avoid punishment

• Teach parents to identify children's likes and dislikes

• Teach parents to choose healthy food ingredients according to their needs

• Teach parents to identify children's food and food habits

• Teach parents to serve food creatively and attractively

 

 

 

Provide information on the provision of essential nutrition through a central vein (total parenteral nutrition) or a peripheral vein (partial parenteral nutrition).

Observation

• Identification of readiness and ability to receive parenteral therapy information

• Identify therapy given according to age, condition, dose, rate, and route

• Identification of caloric and nutritional needsTherapeutic

• Provide health education materials and media

• Schedule an appropriate time to provide health education as agreed with the patient and family

• Provide opportunities to ask questionsEducation

• Explain the reasons and goals for parenteral nutrition

• Explain the effectTherapeuticand side effects of parenteral nutrition

• Explain the procedure for inserting parenteral nutrition access using pictures, if necessary

• Teach how to prevent side effects of parenteral nutrition

• Describe the symptoms and signs that should be reported (eg fever, site of insertion red, swollen, and hot)

 

 

Teach examination procedures to determine the status of the ovaries, uterus, or fetus.

Observation

• Identification of indications for examination

• Identification of knowledge about the benefits and objectives of the examination

Therapeutic

• Provide health education materials and media

• Schedule health education as agreed

• Provide opportunities to ask questions

• Prepare the patient physically and emotionally

• Involve family or loved ones, if necessaryEducation

• Explain the benefits and objectives of the examination

• Explain the inspection procedure

• Explain the preparation of the examination

• Explain the importance of carrying out regular checks, if necessary

• Inform the examination does not cause pain or discomfort

 

 

Teach prevention and early detection of infection in patients at risk.

Observation

• Check readiness and ability to receive informationTherapeutic

• Prepare materials, media about the causative factors, how to identify and prevent the risk of infection in hospitals and at home

• Schedule an appropriate time to provide health education as agreed with the patient and family

• Provide opportunities to ask questionsEducation

• Describe the signs and symptoms of local and systemic infection

• Inform the results of laboratory tests (eg leukocytes, WBC)

• Advise to follow precautions according to conditions

• Recommend limiting visitors

• Teach how to care for the skin on the edematous area

• Advise how to check the condition of the wound or surgical wound

• Encourage adequate nutrition, fluids, and rest

• Encourage adequate mobilization and exercise as needed

• Encourage deep breathing and coughing exercises as needed

• Advise administer antibiotics as prescribed

• Teach how to wash hands

• Teach cough etiquette

Education

 

Fall Prevention l.12407

 

Definition

Provide information on how to avoid injury

Action

Observation

-identification of cognitive and physical disorders that may cause falls

-Check readiness, ability to receive information and perception of fall risk

Therapeutic

-Prepare materials, media about the causative factors, how to identify and prevent the risk of falling in the hospital or at home

-Schedule the right time to provide Health Education as agreed with patients and families

-Give a chance to ask questions

Education

-Teach to identify behaviors and factors that contribute to the risk of falling and how to reduce all risk factors

-Teach to identify the level of weakness, how to walk and balance

-Advise asking for help when you want to achieve something difficult

-Explain the importance of walking aids to prevent falls such as canes, walkers or crutches

-Explain the importance of handrails on stairs, bathrooms and walking areas at home

-Recommend avoiding objects that children can climb (e.g. cupboards, stairs, high chairs)

-Teach modifying dangerous areas at home

 

 

EducationPressure Wound Prevention l.12408

 

Definition

Provide information on how to avoid damage to the integrity of the skin/tissue due to compression of blood vessels and tissues

Action

Observation

-Identify physical disorders that allow pressure sores to occur

-Check readiness, ability to receive information and perception of the risk of pressure sores

Therapeutic

-Prepare material about the causative factors, how to identify and prevent the risk of pressure sores in the hospital or at home

- Schedule the right time to provide Health Education as agreed with patients and families

Education

-Describe frequent locations of pressure sores (eg heels, tailbone, shoulders, ears)

-Teach to identify the factors that cause pressure sores

-Teach how to use the decubilus mat

-Teach how to maintain a healthy skin surface, identify skin surface damage such as redness, heat, bullae, corners

-Advise to keep moving according to ability and condition

-Demonstrate ways to increase circulation at pressure points (eg massage, change the position of the right side, left tilt, supine)

 

 

EducationPrevention of Osteoporosis l.12409

 

Definition

Provides information about avoiding bone loss

Action

Observation

-Identify readiness, ability to receive information and perception of osteoporosis risk

Therapeutic

-Prepare materials, media about the causative factors, how to identify and prevent osteoporosis risk

-Schedule the right time to provide Health Education as agreed with patients and families

Education

-Explain the symptoms and processes, diagnostic examinations, consequences and therapy for osteoporosis

-Describe strategies for preventing osteoporosis through nutrition (eg increasing calcium intake)

-Explain strategies for preventing osteoporosis through exercise

-Describe osteoporosis prevention strategies through risk factor modification

 

 

EducationUse of Aids l.12410

 

Definition

Provide information to patients about the use of assistive devices

Action

Observation

-Identify activities that are difficult to do with limitations

-Identify movement abilities (e.g. limitation of movement, muscle strength, and awareness)

Education

-Teach identifying the home environment and eliminating the causes of falls on the client (eg slippery floors, poor lighting)

-Explain the benefits of using assistive devices

-Describe the possible choice of tools

-Teach how to use tools

-Recommend checking the tools used regularly

-Advise to bring important items near the client

-Encourage the family to support the patient using assistive devices

 

 

 

EducationUse of Contraceptive Devices l.12411

 

Definition

Teach mothers and partners about methods or tools used to prevent pregnancy

Action

Observation

-Identify knowledge, general condition, previous use of contraception, obstetric and gynecological history of the mother

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Facilitate mothers to choose the right contraception

-Give a chance to ask questions

Education

-Explain to the mother and partner about the purpose, benefits, and side effects of using contraceptives

-Explain the mother and partner about the types of contraceptives

-Explain the mother and partner about the risk factors if the delivery is too frequent or too close

-Explain to the mother and partner about the productive and safe age for giving birth and the ideal distance to give birth

-Advise mother and partner to monitor complaints that arise while using contraceptives

-Encourage mothers to identify signs of problems with the number of children

-Advise mother and partner to plan the number of children

-Advise the mother to consult a doctor or other medical personnel for consideration

-Teach mothers and partners to calculate the fertile period and menstrual cycle

 

 

 

EducationRadial Pulse Measurement l.12412

 

Definition

Teaches how to measure the radial pulse

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give an opportunity to work

-Make sure the patient is comfortable and relaxed

-Document the results of the radial pulse measurement

Education

-Explain the procedure for measuring the radial pulse

-Recommend in a sitting or supine position

-Teach how to check radial pulsation

-Teach counting beats for 60 seconds, or count for 30 seconds and multiply by 2

-Teach to calculate the frequency, rhythm and volume of the pulse by noting the pattern and strength of the pulse

 

 

EducationRespiration Measurement l.12413

 

Definition

Teaches how to measure respiratory rate

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give a chance to ask questions

-Document the results of respiration measurements

Education

-Describe the purpose and procedure to be carried out

-Teach how to count respiration by observing the rise and fall of the chest when breathing

-Teach how to count respiration for 30 seconds and multiply by 2 or count for 60 seconds if respiration is irregular

 

 

EducationBody Temperature Measurement l.12414

 

Definition

Teach how to measure body temperature

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give a chance to ask questions

-Document the temperature measurement results

Education

-Explain the procedure for measuring body temperature

-Recommend continuing to hold the shoulders and hold the chest during axillary measurements

-Teach choosing the location of the oral or axillary temperature tip

-Teach how to place the tip of the thermometer under the tongue or the center of the axilla

-Teach how to read the results of mercury and/or electronic thermometers

 

 

EducationBlood Pressure Measurement l.12415

 

Definition

Teach how to measure blood pressure

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give a chance to ask questions

-Document the measurement of blood pressure obtained

Education

-Recommend resting at least 5 minutes before measuring pressure

-Recommend not smoking or drinking caffeine for at least 30 minutes

-Teach choosing the measurement position (eg lying down or sitting)

-Teach to wear cuffs on the upper arm

-Teach developing cuffs

-Teach to deflate the cuff (not faster than 2 to 3 mmHg/second)

-Teach how to determine systolic and diastolic blood pressure

-Inform the results of blood pressure measurements

 

EducationRisk Measurement l.12416

 

Definition

Provide information on preventing the risk of injury due to incorrect Actions.

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education before performing the procedure

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give a chance to ask questions

Education

-Advise to pay attention to the accuracy of dosage and timing of drug administration

-Recommend checking the expiration date of the drug

-Advise to use personal protective equipment (PPE) properly

-Teach how to store medicine properly

-Teach how to do hand hygiene

-Teach how to prevent nosocomial infections

-Teach injury prevention through the implementation of a patient safety system

 

 

EducationAlcohol Abuse l.12417

 

Definition

Teach adaptation of alcohol abuse prevention behavior to individuals, families, groups, or communities.

Action

Observation

-Identify knowledge about the effects of alcohol on the body

-Identify reading ability, cognitive, psychological, cultural status, and access to social and financial resources

-Identify the level of anxiety and readiness to learn

-Identify appropriate learning times and methods (e.g. discussion, question and answer, audio or visual, oral or written methods)

Therapeutic

-Plan a strategyEducation, including realistic goals

-Provide a conducive and optimal learning environment (eg in an empty classroom or therapy room)

-Give positive reinforcement to acquired abilities

-CreateEducationinteractive to trigger active participation duringEducation

Education

-Describe the negative effects of alcohol (eg alcohol's capacity for physiological and psychological dependence, effects on family functioning, effects on the fetus)

-Teach from simple to complex concepts

-Recommend repeating informationEducationabout alcohol abuse

 

 

EducationSubstance Abuse l.12418

 

Definition

Teach substance abuse prevention to individuals, families, groups, or communities

Action

Observation

-Identification of knowledge regarding the effects of substances on the body

-Identify reading ability, cognitive, psychological status, level of anxiety and culture

-Identify appropriate learning methods (e.g. discussion, question and answer, audio or visual, oral or written methods)

Therapeutic

-Plan a strategyEducation

-Schedule the time and intensity of learning according to ability

-Provide a conducive and optimal learning environment (eg in an empty classroom or therapy room)

-Give positive reinforcement to acquired abilities

-CreateEducationinteractive to trigger active participation duringEducation

Education

-Describe the factors that cause substance abuse (eg individual factors, environmental factors, family, school, peers, community)

-Describe clinical symptoms when using the substance (eg, staggering, slurred speech, apathy, drowsiness, aggressive, suspicious)

-Explain the adverse effects of substance abuse on health

-Explain the adverse effects of substance abuse on attitudes and behavior

-Teach how to avoid substance abuse

-Recommend repeating informationEducationabout substance abuse

 

 

EducationBaby Care l.12419

 

Definition

Provide information and support regarding independent infant care

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give a chance to ask questions

Education

-Explain the benefits of baby care

- Teach bathing babies by paying attention to room temperature 21-24c and within 5-10 minutes, 2 times a day

-Teach umbilical cord care

-Advise to monitor the baby's vital signs, especially the temperature 36.5c-37.5c

-Recommend to dry the baby before 9 am

-Teach baby massage

-Recommend immediately change the diaper if it is wet

-Recommend the use of baby clothes made of cotton

-Advise breastfeeding according to baby's needs

 

 

EducationSelf Care l.12420

 

Definition

Teaches the fulfillment of basic health needs self-care

Action

Observation

-Identify knowledge about self-care

-Identify reading ability, cognitive status, psychological, anxiety level, and culture

-Identify problems and barriers to self-care experienced

-Identify appropriate learning methods (eg discussion, question and answer, use of audio or visual aids, oral, written)

Therapeutic

-Plan a strategyEducation, including realistic goals

-Schedule learning time and intensity according to illness

-Provide an environment conducive to optimal learning (eg in an empty classroom or therapy room)

-CreateEducationinteractive to trigger active participation duringEducation.

-Give positive reinforcement to acquired abilities

Education

-Teach self-care, self-care practices, and activities of daily living

-Advise to demonstrate self-care practices according to ability

-Recommend repeating informationEducationabout self care

 

 

EducationDentures Treatment

 

Definition

Teach oral hygiene care and dentures

Action

Observation

-Identify readiness and ability to receive information

Therapeutic

-Provide Health Education materials and media

-Schedule Health Education as agreed

-Give a chance to ask

Education

-Explain the procedure for cleaning the mouth and dentures

-Recommend removing the lower dentures first then the upper teeth

-It is recommended to put a towel on the bottom of the cleaning tub and fill it with water

-Recommend checking dentures: cracked, sharp edges, or missing teeth

-Recommend removing the dentures for at least 1 hour, ideally overnight and placing the dentures in liquid for dentures or water

 

EducationAmbulance Technique

Definition

Provides information in promoting walking to maintain and restore body function.

Action

Observation

- Indication of readiness and ability to receive information

- Monitor the patient's progress in ambulation

Therapeutic

- Provide materials, media and walking aids (eg, cane, walker, crutches)

- Schedule health education as agreed

- Give the family a chance to ask questions

Education

- Explain the procedure and purpose of ambulation with or without assistive devices

- Encourage the use of footwear that facilitates walking and prevents injury

- Encourage use of seat belts during transfer and ambulation, if necessary

- Teach how to identify supporting facilities and infrastructure for ambulation at home

- Teach how to identify ambulation abilities (eg, muscle strength, range of motion)

- Teach to sit in bed, on the side of the bed (hanging), or in a chair, according to tolerance

- Teach yourself to position yourself properly during the transfer procedure

- Teach safe ambulation techniques

- Teach standing and ambulation within a certain distance

- Demonstrate how to ambulate without a walker

- Demonstrate how to ambulate with assistive devices (eg, walker, crutches, wheelchair, cane)

 

 

EducationRemembering Technique

Definition

Teaches memory stimulation techniques

Action

Observation

- Identification of readiness and ability to receive information

- Identification of memory technique knowledge

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Therapeutic

- Encourage use of written media (eg, list of objects, calendar, notebook)

- Encourage use of auditory media (eg, timer, alarm clock)

- Advise to use pictures or writings as a reminder of the location of the item (eg, where the shoe needs to be repaired)

- Encourage the family to help create a consistent environment

- Teach memory techniques (e.g., concentrating and orienting memory (e.g., concentrating and recalling memories, repeating information, making mental associations that put objects in the right place)

- Teach how to place objects in their place

 

EducationBreathing Technique

Definition

Teach breathing techniques to promote relaxation, relieve pain and discomfort

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the purpose and benefits of breathing techniques

- Explain the procedure of breathing technique

- Advise body position as comfortable as possible (eg, sitting, lying down)

- Suggest closing your eyes and full concentration

- Teach to do inspiration by inhaling air through the nose slowly

- Teach to do expiration by exhaling mouth air slowly

- Demonstrate inhale for 4 seconds, hold breath for 2 seconds and

exhale for 8 seconds

 

EducationTransfer Technique

Definition

Teach methods of moving patients with mobility limitations

Action

Observation

- Identify patient activities

- Identify the level of mobility and limitations in moving

- Identify level of awareness and ability to cooperate

Therapeutic

- Prepare equipment and patient area to be moved

- Adjust equipment and its height as needed and lock all wheels

- Hug and hold a baby or small child when moving it, according to conditions

Education

- Describe the type, method of moving/moving and the need for assistance

- Describe the number of people who are sufficient to help move

- Explain proper body mechanics during movement

- Advise to maintain patient privacy and honor

- Recommend raising the bed fence

- Advise to use the right transfer device when moving the patient

- Teach the technique of moving the patient with various positions and assistive devices

 

EducationAnticoagulant Therapy

Definition

Teach the safe use of anticoagulants to prevent thrombus formation

Action

Observation

- Identification of ability and readiness to receive information

Therapeutic

- Provide health education materials and media

- Schedule education according to agreement

- Give opportunity to ask questions

Education

- Explain the purpose and benefits of anticoagulant therapy

- Explain the side effects of anticoagulant therapy

- Explain the procedure of anticoagulant therapy

- Explain the signs of bleeding

- Teach how to prevent the risk of bleeding due to anticoagulant therapy

 

EducationFluid Therapy

Definition

Provide information to patients to achieve body fluid balance

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the importance of fluids for the body

- Explain the types and functions of fluids in the body

- Explain the problems that arise if the body lacks and excess fluids

- Explain administration of fluid therapy by looking at hemodynamic indicators (eg CO, MAP, PP, SBP, SV), if available

- Teach to overcome the problem of fluid deficiency and excess independently

- Teach the calculation of fluids according to the needs of the body

- Teach fluid administration by looking at hemodynamic indicators

 

EducationBlood Therapy

Definition

Teach the family in dealing with family members who are given blood therapy

Action

Observation

- Identification of readiness and ability to accept willingness

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the indications and contraindications of blood therapy

- Explain the procedure of administration and blood therapy

- Explain the handling procedure if there are side effects of blood therapy

- Teach how to monitor signs and symptoms of risks and side effects of blood therapy

 

Educationthermoregulation

Definition

Teach the patient to support a balance between heat production, heat gain, heat loss

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give a chance to weigh it

Education

- Teach warm compresses if you have a fever

- Teach how to measure temperature

- Recommend the use of clothes that can absorb sweat

- Advise to keep bathing the patient, if possible

- Advise administration of antipyretics, as indicated

- Recommend creating a comfortable environment

- Advise drink a lot

- Recommend the use of loose clothing

- Advise to take analgesics if you feel dizzy, as indicated

- Advise blood test if fever >3 days

 

 

EducationToilet Training

Definition

Provide information and support to determine the child's readiness to void independently and the mentoring strategy used.

Action

Observation

- Identification of ability and readiness to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Support parents to be creative and flexible throughout the process

Education

- Explain the need for opportunities for children to observe during the toileting process

- Explain the relevant information that parents need

- Explain the signs of readiness of parents/families to train children to urinate independently

- Advise to introduce children to toilet training equipment and processes

- Teach how to give praise for children's success

- Teach parents to identify children's readiness to urinate independently

- Teach parents to identify children's psychosocial readiness

- Teach strategies for independent potty training

- Teach how to take children to the toilet

 

EducationVaccine

Definition

Provide information and support in deciding immunizations

Action

Observation

- Identify the readiness of parents to acceptEducationas well as factors that hinder successEducation(eg, cultural factors, language barrier, lack of interest)

- Identify understanding of the purpose of administering vaccines

Education

- Explain the importance of giving vaccines and immunizations

- Describe the type of basic immunization recommended (eg, BCG, DPT, hepatitis B, polio, measles)

- Types of additional immunizations (eg, influenza, typhoid)

- Describe the affected vaccine in case of a special incident (eg, cholera, rabies)

- Explain the effect of vaccines in increasing immunity

- Describe vaccines required in case of special incidents (eg, cholera, rabies)

- Advise to meet the schedule for giving vaccines to children

 

EducationVitamin

Definition

Provides support information for modifying foods with the required vitamin content

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give a chance to the beta

Education

- Explain the benefits of vitamins for the body

- Explain the types of vitamins

- Explain the vitamin content of daily food

- Explain the importance of foods containing iron in adolescence, especially in girls who have menstruated

- Advise the consumption of vitamin supplements, if necessary

 

Edotracheal Tube Extubation

Definition

Removing the endotracheal tube from the airway through the mouth

Action

Observation

- Identify indications for endotracheal tube (ETT) removal

- Monitor for airway obstruction

- Monitor for breathing difficulties (eg, shortness of breath, use of accessory muscles to breathe)

- Monitor ability to swallow and speak

Therapeutic

- Position the patient supine

- Administer oxygen via an endotracheal tube at about 6 L/min, or as needed

- Perform mucus suction on the endotracheal tube and mouth, if necessary

- Ensure regular breathing pattern

- Deflate endotracheal balloon

- Remove the endotracheal tube

- Administer oxygen via nasal cannula or mask, as indicated

Education

- Encourage coughing and deep breaths

 

Chest Physiotherapy

Definition

Mobilizes airway secretions through percussion, vibration and postural dynamism

Action

Observation

- Identify indications for chest physiotherapy (eg, sputum hypersecretion, thick and retained sputum, prolonged bed rest)

- Identification of contraindications to chest physiotherapy (eg, acute COPD exacerbation, pneumonia without excessive sputum production, lung cancer)

- Monitor respiratory status (eg, rate, rhythm, breath sounds and depth of breath)

- Examine lung segments that contain excessive secretions

- Monitor the amount and character of sputum

- Monitor tolerance during and after the procedure

Therapeutic

- Position the patient according to the lung area that is experiencing sputum accumulation

- Use pillows to help with positioning

- Perform percussion with the palms cupped for 3-5 minutes

- Perform vibration with the palm of the hand flat along with the expiration of the mouth

- Perform chest physiotherapy at least two hours after eating

- Avoid percussion of the spine, kidneys, female breasts, incisions, and broken ribs

- Perform mucus suction to remove secretions, if necessary

Education

- Explain the purpose and procedure of chest physiotherapy

- Suggest the shape immediately after the procedure is complete

- Teach inspiration slowly and deeply through the nose during the physiotherapy process

 

Phototherapy for Mood/Sleep Disorders

Definition

Provides a dose of lighting to improve mood and/or nominalize the body's internal clock

Action

Observation

- Examination of the medical program for phototherapy (frequency, distance, intensity and duration of phototherapy)

- Monitor side effects of therapy (eg headache, eye fatigue, nausea, insomnia, hyperactivity)

Therapeutic

- Provide a light source for therapy

- Facilitation of adjusting the light source in preparation for therapy, according to indications

- Avoid therapy if side effects occur

- Modify therapy to reduce side effects, as indicated

Education

- Explain the goals and procedures of physiotherapy

 

Neonatal Physiotherapy

Definition

Provide fluorescent light therapy that is shown to the neonate's skin to reduce bilirubin levels

Action

Observation

- Monitor icteric in the sclera and skin of the baby

- Identify fluid requirements according to gestational age and body weight

- Monitor temperature and vital signs every 4 hours

- Monitor side effects of physiotherapy (eg hyperthermia, diarrhea, rash on the skin, weight loss of more than 8-10%

Therapeutic

- Prepare an incubator physiotherapy lamp or baby box

- Take off baby's clothes except diapers

- Leave the eye patch (eye protector/biliband)

- Measure the distance between the lamp and the baby's skin surface (30 cm or depending on the specifications of the phototherapy lamp)

- Let the baby's body be exposed to phototherapy rays continuously

- Change the baby's pad and diaper immediately if you have a bowel movement

- Use white linen to reflect as much light as possible

Education

- Advise the mother to breastfeed for about 20-30 minutes

- Encourage mothers to breastfeed as often as possible

Collaboration

- Collaboration of direct and indirect bilirubin venous blood examination

 

Risk Identification

Definition

Finding and analyzing possible risk factors that can interfere with health

Action

Observation

- Identification of biological, environmental and behavioral risks

- Periodic risk identification in each unit

- Identify new risks according to the predetermined plan

Therapeutic

- Determine a good and economical risk management method

- Perform risk management effectively

- Update planning regularly (eg monthly, quarterly, yearly)

- Create an action plan that has a clear timeline and responsibilities

- Document risk findings accurately

 

Induction Hypothermia

Definition

Maintain core body temperature between 32 -36o C and monitor side effects and prevent complications.

Action

Observation

- Monitor core body temperature

- Monitor skin color and temperature

 

EducationBaby Development l.12436

Definition

Teach patients and families to facilitate optimal gross motor, fine motor, language, cognitive, social and emotional development of infants.

Action

Observation

- Identify readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the process of baby development

- Describe activities that support baby's development

- Describe a safe and organized room for children to explore and learn

- Encourage building good interactions with babies

- Advise to provide age-appropriate toys or materials

- Recommend playing together with children

- Advise to monitor the child's medication if necessary

- Teach to identify special needs and adaptation needed

Collaboration

- Refer family to support group if necessary

 

 

EducationLabor l.12437

Definition

Provide information about the birth process.

Action

Observation

- Identify knowledge level

- Identify the mother's understanding of childbirth

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Provide positive reinforcement for changes in mother's behavior

Education

- Explain the method of delivery you want

- Explain preparation and place of delivery

- Advise mothers to take classes for pregnant women at gestational age of more than 36 weeks

- Advise the mother to use labor pain management techniques every time

- Advise mother to have enough nutrition

- Practice relaxation techniques to relieve labor anxiety and discomfort

- Teach mothers to recognize the signs of labor

- Teach mothers to recognize the danger signs of childbirth

 

EducationBaby Massage l.12438

Definition

Provide information and support for infant massage independently.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the benefits of baby massage

- Recommend using baby oil to massage the baby

- Recommend doing baby massage gently for -+ 15 minutes

- Recommend baby massage at least 2 times a day (morning and evening)

- Recommend setting the room temperature around 24oC

- Suggest to stop the massage for a few minutes if the baby is defecating

- Recommend massaging baby 30 minutes after feeding

- Suggest a gentle massage by rubbing and a little pressure

- Advise to clean the baby's body after the massage activity is over

 

 

 

EducationHygiene Behavior Pattern l.12439

Definition

Provide information to improve or maintain personal and environmental hygiene behaviors

Action

Observation

- Identification of readiness and ability to receive information

- Identify the ability to maintain personal and environmental hygiene

- Monitor the ability to perform and maintain personal and environmental hygiene

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Practice with your family how to maintain personal and environmental hygiene

Education

- Explain the problems that can arise as a result of not maintaining personal and environmental hygiene

- Teach how to maintain personal and environmental hygiene

 

 

 

 

 

 

EducationPreoperative l.12440

Definition

Provide information about preparation for surgery to improve surgical recovery and prevent complications that may occur as a result of surgery.

Action

Observation

- Identification of readiness and ability to receive information

- Identification of surgical experience and level of knowledge of surgery

- Identify expectations for surgery

- Identify patient and family anxiety

Therapeutic

- Provide health education materials and media

- Schedule health education according to agreement

- Take time to ask questions and discuss issues

Education

- Inform the schedule, location of the operation and the length of the operation will take place

- Inform the things that will be heard, smelled, seen, or felt during the operation

- Explain the preoperative routine

- Explain preoperative drugs, their effects and reasons for their use

- Describe pain control measures

- Explain the importance of early ambulation

- Recommend fasting for at least 6 hours before surgery

- Recommend not to drink at least 2 hours before surgery

- Teach coughing and deep breathing techniques

- Teach mobilization techniques in bed

- Teach leg training techniques

 

 

 

EducationTreatment Program l.12441

Definition

Teach the use of drugs safely and effectively.

Action

Observation

- Identify knowledge about recommended treatment

- Identification of the use of traditional medicine and possible effects on treatment

Therapeutic

- Facilitate written information or pictures to improve understanding

- Provide support to undergo a treatment program properly and correctly

- Involve the family to provide support to the patient during treatment

Education

- Explain the benefits and side effects of treatment

- Explain strategies for managing drug side effects

- Explain how to store, refill/repurchase, and monitor residual drugs

- Explain the finances and costs of the treatment program, if necessary

- Inform health facilities that can be used during treatment

- Recommend monitoring the progress of the effectiveness of treatment

- Advise to take medication as indicated

- Encourage to ask if there is something you do not understand before and after treatment is done

- Teach the ability to do self-medication

 

 

 

EducationProcedure for Action l.12442

Definition

Provide information about the actions to be taken to patients, both for diagnostic and therapeutic purposes.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

Education

- Explain the purpose and benefits of the action to be taken

- Explain the need for action to be taken

- Explain the advantages and disadvantages if the action is taken

- Describe the action steps to be taken

- Explain the patient's preparation before the procedure is performed

- Inform the duration of the action performed

- Encourage asking if there is something you don't understand before the action is taken

- Encourage cooperation when action is taken

- Teach techniques to anticipate/reduce discomfort due to action, if necessary

 

 

 

EducationFamily Process l.12443

Definition

Provide knowledge to minimize the effects of disruption of family processes

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Advise identifying and using existing social support

- Encourage parents to be involved in care while the child is being cared for

- Encourage families to stay connected with other family members

- Recommend minimizing disruption to family routines by facilitating family routine activities

- Teach how to identify the types and disorders of the family process

- Teach how to identify changing roles in family processes

- Teach family problem normalization strategies together with family members

 

 

 

EducationDisease Process l.12444

Definition

Provide information about the mechanism of disease emergence and cause signs and symptoms that interfere with the patient's health.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the causes and risk factors of the disease

- Describe the pathophysiological process of disease emergence

- Describe the signs and symptoms of the disease

- Explain the possibility of complications

- Teach how to relieve or overcome the symptoms you feel

- Teach how to minimize side effects of intervention or treatment

- Inform the patient's current condition

- Advise to report if you feel signs and symptoms are getting worse or can't

 

 

EducationAllergic Reaction 1.12445

Definition

Teaches how to identify, manage and prevent allergic reactions

Action

Observation

- Identify the ability of patients and families to receive information

- Monitor patient and family understanding of allergies

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Facilitate recognizing the cause of allergies

- Give the patient and family the opportunity to ask questions

Education

- Explain the definition, causes, symptoms and signs of allergies

- Explain how to avoid allergies

- Advise patient and family to provide allergy medicine

EducationCardiac Rehabilitation l.12446

Definition

Provides information to increase maximal functional activity in episodes of cardiac dysfunction.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Inform patients and families about access to emergency services available in the community, if necessary

- Advise maintain ambulation schedule, according to tolerance

- Advise patients and families to follow the entire series of rehabilitation programs

- Teach to monitor activity tolerance

- Teach patients and families to modify cardiac risk factors

- Teach how to deal with chest pain

- Teach practice techniques

 

 

 

EducationSexuality l.12447

Definition

Provide information in understanding the physical and psychosocial dimensions of sexuality.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Facilitate family awareness of children and youth and the influence of the media

Education

- Explain the anatomy and physiology of the male and female reproductive systems

- Describe the development of sexuality throughout the life cycle

- Describe the emotional development of childhood and adolescence

- Explain the effect of group and social pressure on sexual activity

- Explain the negative consequences of raising children at an early age

- Explain the risk of contracting sexually transmitted diseases and AIDS due to casual sex

- Encourage parents to become sexuality educators for their children

- Advise children/adolescents not to engage in sexual activity outside of marriage

- Promote assertive communication skills to resist peer and social pressure in sexual activity

 

EducationBaby/Child Stimulation l.12448

Definition

Provide appropriate stimulation information and support at each stage of the baby's/child's age.

Action

Observation

- Identify the readiness of parents to receive information

- Identify factors that hinder successEducation

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Give praise for the success of parents

Education

- Explain the baby gives behavioral cues that indicate his needs

- Describe stimulation that can help optimize infant/child development

- Teach how to identify baby/child behavioral cues

- Teach how to stimulate the development of gross motor, fine motor, and language according to the stages of the baby/child's age

 

 

EducationAdaptation Technique l.12449

Definition

Teach the process of adapting to change.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Describe the actionTherapeuticto overcome physical problems or disorders experienced

- Explain possible side effects due to current therapy/medication

- Teach how to identify the ability to adapt to the demands of current conditions/problems

- Teach how to identify depression, thought process disorders, and expression of suicidal ideation

- Teach how to identify adaptation difficulties experienced

- Advise to do the reminiscent process technique

- Inform the availability of resources

 

 

 

 

 

EducationAmbulation Technique l.12450

Definition

Provides information in promoting walking to maintain and restore body function

Action

Observation

- Identification of readiness and ability to receive information

- Monitor the patient's progress in ambulation

Therapeutic

- Provide materials, media and walking aids

- Schedule health education as agreed

- Give the family a chance to ask questions

Education

- Explain the procedure and purpose of ambulation with or without assistive devices

- Advise to use footwear that facilitates walking and prevents injury

- Encourage use of seat belts during transfer and ambulation, if necessary

- Teach how to identify supporting facilities and infrastructure for ambulation at home

- Teach how to identify ambulation ability

- Teach to sit in bed, on the side of the bed (hanging), or in a chair, as tolerated

- Teach yourself to position yourself properly during the transfer process

- Teach safe ambulation techniques

- Teach standing and ambulation within a certain distance

- Demonstrate how to ambulate without a walker

- Demonstrate how to ambulate with assistive devices

 

 

EducationRemembering Technique I.12451

 

Definition

Teach memory stimulation techniques.

Action

Observation

- Identification of readiness and ability to receive information

- Identification of memory engineering knowledge

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Therapeutic

- Encourage the use of written media (eg list of objects, calendar, notebook)

- Encourage use of auditory media (eg timer, alarm clock)

- Advise to use pictures or writings as a reminder of the location of the item (eg where the shoes need to be repaired)

- Encourage families to help create a consistent environment

- Teach memory techniques (eg concentration and recalling memories, repeating information, making mental associations and putting objects in the right place)

- Teach how to place objects in their place

 

EducationBreathing Technique I.12452

 

Definition

Teach breathing techniques to promote relaxation, relieve pain and discomfort.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the purpose and benefits of breathing techniques

- Explain the procedure of breathing technique

- Advise body position as comfortable as possible (eg sitting, lying down)

- Advise close your eyes and concentrate fully

- Teach to do inspiration by inhaling air through the nose slowly

- Teach to do expiration by exhaling mouth air slowly

- Demonstrate inhale for 4 seconds, hold breath for 2 seconds and exhale for 8 seconds

 

EducationTransfer Technique I.12453

 

Definition

Teach methods of moving patients with mobility limitations.

Action

Observation

- Identify patient activity recommendations

- Identify the level of mobility and limitations in moving

- Identify the level of awareness and ability to cooperate

Therapeutic

- Prepare equipment and patient area to be moved

- Adjust the equipment and its height as needed and lock all the wheels

- Hug and hold a baby or small child when moving it, according to conditions

Education

- Describe the type, method of moving/moving and the need for assistance

- Describe the number of people who are sufficient to help move

- Explain proper body mechanics during movement

- Advise to maintain patient privacy and dignity

- Recommend raising the bed fence

- Advise to use the right transfer device when moving the patient

- Teach the technique of moving the patient with various positions and assistive devices

 

EducationAnticoagulant Therapy I.12454

 

Definition

Teach the safe use of anticoagulants to prevent thrombus formation.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the purpose and benefits of anticoagulant therapy

- Explain the side effects of anticoagulant therapy

- Explain the procedure of anticoagulant therapy

- Explain the signs of bleeding

- Teach how to prevent the risk of bleeding due to anticoagulant therapy

 

EducationFluid Therapy I.12455

 

Definition

Provide information to patients to achieve body fluid balance.

 

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the importance of fluids for the body

- Explain the types and functions of calcium in the body

- Describe the composition and distribution of body fluids

- Explain the problems that arise if the body lacks or excess fluids

- Explain the administration of fluid therapy by looking at hemodynamic indicators (eg CO, MAP, PP, SBP, SV), if available

- Teach to overcome the problem of lack or excess fluid independently

- Teach fluid counting according to body needs

- Teach fluid administration by looking at hemodynamic indicators

 

EducationBlood Therapy I.12456

 

Definition

Teach families in dealing with family members who are given blood therapy.

 

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Explain the indications and contraindications of blood therapy

- Explain the procedure for administering blood therapy

- Explain the handling procedure if there are side effects of blood therapy

- Teach how to monitor signs and symptoms of risks and side effects of blood therapy

 

EducationThermoregulation I.12457

 

Definition

Teach the patient to support a balance between heat production, heat gain, and heat loss.

 

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

Education

- Teach warm compresses if you have a fever

- Teach how to measure temperature

- Recommend the use of clothes that can absorb sweat

- Advise to keep bathing the patient, if possible

- Advise administration of antipyretics, as indicated

- Recommend creating a comfortable environment

- Advise drink a lot

- Encourage the use of loose clothing

- Advise to take analgesics if you feel dizzy, as indicated

- Advise blood test if fever >3 days

 

EducationToilet Training I.12458

 

Definition

Provide information and support to determine the child's readiness to void independently and the mentoring strategy used.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Support parents to be creative and flexible throughout the process

Education

- Explain the need for opportunities for children to observe during the toileting process

- Explain the relevant information that parents need

- Explain the signs of readiness of parents/families to train children to urinate independently

- Advise to introduce children to toilet training equipment and processes

- Teach how to give praise for children's success

- Teach parents to identify children's readiness to urinate independently

- Teach parents to identify children's psychosocial readiness

- Teach strategies for potty training

- Teach how to take children to the toilet

 

EducationVaccine I.12459

 

Definition

Provide information and support in deciding immunizations.

Action

Observation

- Identify the readiness of parents to acceptEducationas well as factors that hinder successEducation(eg cultural factors, language barrier, lack of interest)

- Identify understanding of the purpose of administering vaccines

Education

- Explain the importance of giving vaccines and immunizations

- Describe the type of basic immunization recommended (eg BCG, DPT, hepatitis B, polio, measles)

- Describe the type of additional immunization (eg influenza, typhoid)

- Explain the effect of vaccines in increasing immunity

- Describe vaccines required in case of special incidents (eg cholera, rabies)

- Advise to adhere to the schedule for giving vaccines to children

 

EducationVitamin I.12460

 

Definition

Provide information and support for modifying foods with the required vitamin content.

Action

Observation

- Identification of readiness and ability to receive information

Therapeutic

- Provide health education materials and media

- Schedule health education as agreed

- Give opportunity to ask questions

- Support parents to be creative and flexible throughout the process

Education

- Explain the benefits of vitamins for the body

- Explain the types of vitamins

- Explain the vitamin content of daily food

- Explain the importance of giving foods that contain vitamins

- Explain the importance of foods containing iron in adolescence, especially in girls who have menstruated

- Advise the consumption of vitamin supplements, if necessary

 

Endotracheal Tube Extubation I.01003

 

Definition

Disconnect the endotracheal tube from the airway through the mouth.

Action

Observation

- Identify indications for endotracheal tube (ETT) removal

- Monitor for airway obstruction

- Monitor for breathing difficulties (eg shortness of breath, use of accessory muscles to breathe)

- Monitor ability to swallow and talk

Therapeutic

- Position the patient supine

- Administer oxygen via an endotracheal tube at about 6 L/min, or as needed

- Perform suctioning of mucus on the endotracheal tube and mouth, if necessary

- Ensure regular breathing pattern

- Deflate endotracheal balloon

- Remove the endotracheal tube

- Administer oxygen via nasal cannula or mask, as indicated

Education

- Encourage coughing and deep breaths

 

Chest Physiotherapy I.01004

 

Definition

Mobilizes airway secretions by percussion, vibration, and postural drainage.

Action

Observation

- Identification of indications for chest physiotherapy (eg hypersecretion of sputum, thick and retained sputum, prolonged bed rest)

- Identification of contraindications to chest physiotherapy (eg acute COPD exacerbation, pneumonia without excess sputum production, lung cancer)

- Monitor respiratory status (eg rate, rhythm, breath sounds and depth of breath)

- Examine lung segments that contain excessive secretions

- Monitor the amount and character of sputum

- Monitor tolerance during and after the procedure

Therapeutic

- Position the patient according to the lung area that has sputum accumulation

- Use pillows to help with positioning

- Perform percussion with the palms cupped for 3-5 minutes

- Perform vibrations with the palm of the hand flat at the same time exhaling through the mouth

- Perform chest physiotherapy at least two hours after eating

- Avoid percussion of the spine, kidneys, female breasts, incisions, and broken ribs

- Perform mucus suction to remove secretions, if necessary

Education

- Explain the purpose and procedure of chest physiotherapy

- Encourage coughing immediately after the procedure is complete

- Teach inspiration slowly and deeply through the nose during the physiotherapy process

 

Neonatal Phototherapy I.03091

 

Definition

Provide fluorescent light therapy aimed at the neonate's skin to reduce bilirubin levels.

Action

Observation

- Monitor icteric in the sclera and skin of the baby

- Identify fluid requirements according to gestational age and body weight

- Monitor temperature and vital signs every 4 hours

- Monitor for side effects of phototherapy (eg hyperthermia, diarrhea, rash on the skin, weight loss of more than 8-10%)

Therapeutic

- Prepare a phototherapy lamp and an incubator or baby box

- Take off baby's clothes except diapers

- Give an eye patch (eye protector / biliband) to the baby

- Measure the distance between the lamp and the baby's skin surface (30 cm or depending on the specifications of the phototherapy lamp)

- Let the baby's body be exposed to phototherapy rays continuously

- Change the baby's pad and diaper immediately if you have a bowel movement

- Use white linen to reflect as much light as possible

Education

- Advise the mother to breastfeed for about 20-30 minutes

- Encourage mothers to breastfeed as often as possible

Collaboration

- Collaboration of direct and indirect bilirubin venous blood examination

 

Risk Identification I.14502

 

Definition

Find and analyze possible risk factors that can interfere with health.

Action

Observation

- Identification of biological, environmental and behavioral risks

- Periodic risk identification in each unit

- Identify new risks according to the predetermined plan

Therapeutic

- Determine a good and economical risk management method

- Perform risk management effectively

- Update planning regularly (eg monthly, quarterly, yearly)

- Create an action plan that has a clear timeline and responsibilities

- Document risk findings accurately

 

Induction of Hypothermia I.14503

 

Definition

Maintains core body temperature between 32 - 36°C and monitors side effects and prevents complications.

Action

Observation

- Monitor core body temperature

- Monitor skin color and temperature

- Inform the operating time, arrival time, reception procedure, operating room and operating waiting room

- GiveEducationpreoperative

 

 

Assertive Practice

Definition

Teach the ability to express feelings, needs and opinions effectively by respecting the rights of others.

Action

Observation

- Identify barriers to assertiveness (eg developmental stage, medical condition, chronic/psychiatric and sociocultural)

- Monitor level of anxiety and discomfort related to changes in behavior

Therapeutic

- Facilitate recognizing and reducing cognitive distortions that hinder assertiveness

- Facilitation of differentiating assertive, passive and aggressive behavior

- Facilitation of identifying conflicting personal rights, responsibilities and norms

- Facilitate clarifying problems in interpersonal relationships

- Facilitate expressing positive and negative thoughts and feelings

- Facilitate identifying self-destructive thoughts

- Facilitation of distinguishing between thoughts and reality

- Give praise for efforts to express feelings and opinions

Education

- Advise to act assertively in a different way

- Practice assertive behavior (eg, making requests, saying no to requests that cannot be fulfilled, and starting and closing conversations)

 

 

Effective Cough Exercises

Definition

Train patients who do not have the ability to cough effectively to clear the larynx, trachea and bronchioles of secretions or foreign bodies in the airways

Action

Observation

- Identify cough ability

- Monitor for sputum retention

- Monitor for signs and symptoms of respiratory tract infection

- Monitor fluid input and output (eg quantity and characteristics)

Therapeutic

- Set the semi-Fowler or Fowler position

- Put a patch and bend on the patient's lap

- Discard secretions in the sputum

Education

- Explain the purpose and procedure of effective cough

- Suggest a deep breath through the nose for 4 seconds, held for 2 seconds and then out of the mouth with the lips pursed (rounded) for 8 seconds

- Recommend repeating deep breaths up to 3 times

- Encourage a strong cough immediately after the 3rd deep breath

Collaboration

- Collaborative administration of mucolytics or expectorants, if necessary

 

 

Urinary Exercise

Definition

Teach an ability to do urine elimination.

Action

Observation

- Re-examine the cause of urinary disturbances (eg, cognitive, loss of extremity/extremity function, loss of vision)

- Monitor urination pattern and ability

Therapeutic

- Avoid using indwelling catheters

- Prepare a safe toilet area

- Provide the equipment needed close and easy to reach (eg, commode chair, urinal bedpan)

Education

- Explain directions to the bathroom/toilet in visually impaired patients.

- Encourage adequate fluid intake to support urine output

- Encourage normal elimination with activity and exercise according to ability

 

 

Fecal Elimination Exercise

Definition

Teach an ability to train the intestines to evacuate at certain intervals

Action

 Observation

- Monitor intestinal peristalsis regularly

 Therapeutic

- Advise a consistent time to defecate

- Provide peivation, comfort and position that enhances the defecation process

- Use low enemas, if necessary

- Advise digital rectal dilatation, if necessary

- Change the faecal elimination exercise program, if necessary

Education

- Recommend consuming certain foods, according to the program or the results of the consultation

- Encourage adequate fluid intake as needed

- Encourage exercise according to tolerance

Collaboration

- Collaborative use of suppositories, if necessary

 

 

Memory Exercise

Definition

Teach the ability to improve memory.

Action

Observation

- Identify memory problems experienced

- Identification of errors against orientation

- Monitor behavior and memory changes during therapy

Therapeutic

- Plan teaching methods according to the patient's ability

- Memory stimulation by repeating the last thought, if necessary

- Correction of orientation errors

- Facilitate recall of past experiences, if necessary

- Facilitation of learning tasks (eg remembering verbal information and pictures)

- Facilitate concentration skills (eg, playing card pairs), if necessary

- Stimulation of using memory on recent events (eg, asking where he has been recently), if necessary

Education

- Explain the purpose and procedure of the exercise

- Teach appropriate memory techniques (eg, visual imagination, mnemonic devices, memory games, memory cues, association techniques, list making, computers, signage)

Collaboration

- Refer to occupational therapy, if necessary

 

 

Otogenic Exercise

Definition

Teach the ability of self-suggestion with feelings of pleasure and warmth aimed at relaxation.

Action

Observation

- Identification of indications for otogenic exercise

Therapeutic

- Prepare a quiet and comfortable environment

- Wear comfortable clothing that does not restrict movement

- Read the prepared statement (script), pause for a moment and ask to repeat it internally.

- Use statements that cause feelings of pleasure, lightness or a sense of floating in certain body parts

Education

- Explain the purpose and procedure of Otogenic exercise

- Encourage sitting in a chair or lying on your back

- Suggest repeating statements to yourself to get a deeper feeling on the targeted body part

- I suggest you practice for 15-20 minutes

- Suggest to stay relaxed for 15-20 minutes

- Recommend practicing 3 times a day

 

 

Pelvic Muscle Exercise

Definition

Teaches the ability to strengthen the ani and urogenital elevator muscles through repeated contractions to reduce urinary incontinence and premature ejaculation.

Action

Observation

- Monitor urine output

Therapeutic

- Give positive reinforcement while doing the exercise correctly

Education

- Suggest lying down

- Advise not to contract the stomach, legs and buttocks when doing pelvic muscle exercises

- It is recommended to increase the duration of relaxation contractions by 10 seconds with a cycle of 10-20 times, performed 3-4 times a day

- Teach to contract around the urethra and anus muscles such as holding a bowel movement for 5 seconds, then relax and relax with a cycle of 10 times

- Teach evaluating the exercise performed by stopping the urine for a moment when using it, once a week

- Advise exercise for 6-12 weeks

Collaboration

- Collaboration of medical rehabilitation to measure the strength of pelvic floor muscle contraction, if necessary

 

 

Impulse Control Exercise

Definition

Teach handling impulsive behavior

Action

 Observation

- Identify the problem experienced

- Identify possible and useful actions

Therapeutic

- Explain problem solving strategies according to developmental level and cognitive function

- Make behavior modifications, as needed

- Facilitate doing useful actions

- Provide positive reinforcement for successful actions taken

- Motivation to reward yourself

- Provide opportunities to practice problem solving (role-play) in the environmentTherapeutic

- Provide a step-by-step model of a problem-solving strategy

- Motivation to practice problem solving in social and interpersonal situations

Education

- Teach self-signaling to "stop and think" before acting impulsively

 

 

Breathing Exercises

Definition

Exercises to move the chest wall to improve airway clearance, increase lung expansion, strengthen respiratory muscles, and promote relaxation or a sense of comfort.

Action

Observation

- Identify indications for breathing exercises

- Monitor the frequency, rhythm and depth of breath before and after exercise

Therapeutic

- Provide a quiet place

- Position the patient comfortably and relaxed

- Place one hand on chest and one hand on stomach

- Make sure the hands on the chest are back and the palms on the stomach are moving forward while inhaling

- Take a deep breath slowly through your nose and hold it for a count of seven

- Count to eight exhale slowly through the mouth

Education

- Explain the purpose and procedure of breathing exercises

- Recommend repeating the exercise 4-5 times

 

 

Rehabilitation Exercise

Definition

Teaches the ability to optimize health, maintain health, restore independence after experiencing illness, degenerative processes, trauma, and others

Action

Observation

- Identify personal hygiene problems and skin problems

- Monitor training abilities and progress

- Monitor vital signs in every exercise

Therapeutic

- Motivation to be independent in activities

- Provide opportunities to improve skills in meeting daily needs

- Provide a safe and comfortable environment to prevent injury and infection

Education

- Explain rehabilitation goals and procedures

- Explain the need for activity restrictions

- Teach the use of assistive devices if needed (eg, cane, crutches, wheelchair)

- Exercise to empty the bowel or bladder

- Active and passive ROM exercises

Collaboration

- Collaboration with medical rehabilitation, if necessary

 

 

Range of Motion Exercise

Definition

Teaches the ability to use active and passive movements to maintain and restore joint flexibility

Action

Observation

- Identification of indications for exercise

- Identify limitation of joint movement

- Monitor the location of discomfort or pain when moving

Therapeutic

- Wear loose clothes

- Prevent injury during range of motion exercises

- Facilitation of optimizing body position for active and passive joint movement

- Perform passive movements with assistance according to indications

- Provide positive support when doing joint motion exercises

Education

- Explain the purpose and procedure of the exercise

- Encourage systematic passive and active range of motion

- Encourage sitting in bed or chair, if necessary

- Teach active range of motion according to the exercise program

Collaboration

- Collaboration with physiotherapists to develop exercise programs, if necessary

 

 

Limit Settings

Definition

Sets the expected and acceptable behavior parameters.

Action

Observation

- Identify expected and unexpected behavior

- Monitor the implementation of the expected behavior

Therapeutic

- Use a consistent, honest and non-judgmental approach

- Convey boundaries with positive sentences (eg, “wear your clothes”, rather than “such behavior is inappropriate”)

- Discuss what behavior is expected in a situation, if necessary

- Set limit setting behavior achievement

- Share established consequences and behavioral expectations with the nursing team

- Give rewards for performing the expected behavior

- Perform the consequences that have been set if you do not perform the expected behavior

- Modify consequences and behavioral expectations, if necessary

- Lower the limit setting if the patient's behavior is close to the expected behavior

Education

- Explain the benefits and expected consequences of the behavior

 

 

Central Venous Access Management

Definition

Identify and manage catheters inserted in central veins.

Action

Observation

- Identify indications for installation of central venous access

Therapeutic

- Put on a sterile gown

- Put on sterile gloves

- Make sure the needle is not clogged

- Three-way connection to all catheter ports

- Fill all catheter lumens with NaCl or heparinized saline

- Set supine position

- Turn your head against where the action is taking place

- Clean the skin with antiseptic and cover with a sterile doc

- Determine the puncture site of the upper 1/3 of the stemocleidomastoid, lateral to the carotid artery

- Insertion and aspirate

- Venous cannulation using the Seldinger technique when blood is seen

Education

- Explain the purpose and procedure to be carried out

Collaboration

- Collaborative chest x-ray examination to confirm the position of the catheter

 

 

Permanent Pacemaker Management

Definition

Identify and manage permanent cardiac pumping support using a pacemaker.

Destination

Observation

- Identify indications for a permanent pacemaker

- Monitor for signs that the pacemaker is working properly

- Monitor peripheral pulse

- Monitor hemodynamic response

- Monitor heart rhythm, symptoms of arrhythmia, ischemia or heart failure

- Monitor complications of pacemaker installation

- (eg, pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, PVC, infection, hiccups, muscle twitching)

- Monitor for pacemaker failure

Therapeutic

- Define the type and mode of the pacemaker

- Involve family in pacemaker treatment

Education

- Explain the indications, functions and complications of pacemaker implantation

- Recommend avoiding or using tools that cause electromagnetic interference

- Advise to perform regular check-ups with permanent pacemakers

- Advise not to operate a motorized vehicle until approved by a cardiologist

- Advise regular pacemaker monitoring

- Recommend repeat chest X-ray every year to confirm placement of pacemaker

- Recommend wearing a pacemaker wristband

- Recommend avoiding detector machines

- Teach how to recognize the signs and symptoms of pacemaker dysfunction

 

 

Temporary Pacemaker Management

Definition

Identify and manage the heart pump through insertion and use of a temporary pacemaker.

Action

Observation

- Identify indications for temporary pacemaker insertion

- Identify the pacemaker needed (eg, internal or external venous catheter, unipolar or bipolar, transthoracic, epicardia)

- Check the 12 lead ECG, if necessary

 

Bioterrorism Readiness I.09281

 

Definition

Prepare an effective response to bioterrorism events or disasters.

Action

Observation

 Identification of chemical, biological substances that have the potential to be used in terrorist activities (eg cyanide, anthrax, smallpox)

 Identify all available sources: medical, emergency and social agencies (eg BNPB, WHO)

 Identify signs and symptoms of exposure to biologic agents

 Identify the accuracy of information, especially about emergencies, potential disasters, and massive exposures.

Therapeutic

 Use relevant agency recommendations to address bioterrorism issues (eg WHO)

 Gain up-to-date knowledge of protective equipment, procedures, and isolation techniques

Use protective equipment (e.g. mist coat, headgear, gloves, respirator)

 Recognize and comply with all decontamination policies, procedures and protocols

Collaboration

 Report suspicious symptoms to triage officers and health agencies

 Consultation with epidemiologists and professionals regarding appropriate infection control

 

 

Cold Compress I.08234

 

Definition

Stimulates the skin and tissues with cold to reduce pain, inflammation and get the effectTherapeuticothers through exposure to cold.

Action

Observation

 Identify contraindications to cold compresses (eg decreased sensation, decreased circulation)

 Identify skin conditions for which cold compresses will be applied

 Check the temperature of the compressor

 Monitor skin irritation or tissue damage for the first 5 minutes

Therapeutic

 Choose a compression method that is convenient and easy to obtain (eg waterproof plastic bag, frozen gel pack, cloth or towel)

 Select the compression location

 Wrap the cold compress with a protective cloth/if necessary

 Apply cold compresses to the injured area

 Avoid using compresses on tissues exposed to radiation therapy

Education

 Explain the procedure for using cold compresses

 Recommend the act of adjusting the temperature setting independently without prior notification

 Teach how to avoid tissue damage due to cold

 

 

Hot Compress I.08235

 

Definition

Stimulate the skin and tissues with heat to reduce pain, muscle spasms, and get the effectTherapeuticothers to go through heat exposure.

Action

Observation

Identify contraindications to hot compresses (eg, decreased blood flow, decreased circulation)

 Identify the skin condition for which hot compresses will be applied

 Check the temperature of the compressor

 Monitor skin irritation or tissue damage for the first 5 minutes

Therapeutic

 Choose a compression method that is convenient and easy to obtain (eg waterproof plastic bags, hot water bottles, electric heating pads)

 Select the compression location

 Wrap the hot compress tool with a protective cloth / if necessary

 Apply hot compresses to the injured area

 Avoid using compresses on tissues exposed to radiation therapy

Education

 Explain the procedure for using a hot compress

 Recommend not adjusting temperature setting independently without prior notice

 Teach how to avoid tissue damage due to heat

 

 

 

Multidisciplinary Conference I.13481

 

Definition

Plan and evaluate the care provided together with other health workers.

Action

Observation

 Identify current nursing diagnoses

 Identify the patient's progress towards the achievement of the outcome/outcome set

Therapeutic

 Summarize the patient's health status

 Ask for input to improve the effectiveness of nursing interventions

 Revise patient care plan/if necessary

 Mutually agree on the goals/results to be achieved

 Describe data to facilitate evaluation of the patient's nursing plan

Education

 Describe nursing interventions that have been implemented

Describe the patient's and family's response to nursing interventions  

Counseling I.10334

 

Definition

Provide guidance to improve or support handling, problem solving, and interpersonal relationships.

Action

Observation

 Identify capabilities and provide reinforcement

 Identify family behaviors that affect the patient

Therapeutic

 Relationship buildingTherapeuticbased on trust and respect

 Give empathy, warmth, and honesty

 Set goals and length of counseling relationship

 Provide privacy and maintain confidentiality

 Reinforce new skills

 Facility to identify problems

Education

 Encourage expressing feelings

 Suggest making a list of alternative solutions to the problem

 Promote the development of new skills/if necessary

 Recommend replacing maladaptive habits with adaptive ones

 Advise to postpone decision making when stressed

 

 

Genetic Counseling I.10335

 

Definition

Provide guidance to parents regarding possible genetic disorders.

Action

Observation

 Identify knowledge, myths, perceptions, and misperceptions about birth defects or genetic conditions

 Identify response to genetic risk factors

Therapeutic

 Provide privacy and guarantee confidentiality

 Relationship buildingTherapeuticon the basis of trust and respect

 Schedule goals and genetic counseling sessions

 Provide decision making support

 Give a summary of the genetic counseling sessions that have been carried out

Education

 Explain risk estimates based on phenotype (patient characteristics), family history (genealogical analysis), genotype (genetics test results)

 Describe the history of the disease, treatment strategies, and prevention strategies

 Describe treatment options/management options for risk management of recurrence

Collaboration

 Refer to genetic health care specialist/if necessary

 Refer to community resources (eg genetic support groups) if necessary 

Lactation Counseling I.03093

 

Definition

Provide guidance on appropriate breastfeeding techniques in infant feeding.

Action

Observation

 Identify the mother's emotional state when breastfeeding counseling will be carried out

 Identify breastfeeding desires and goals

 Identification of problems that mothers experience during the breastfeeding process

Therapeutic

Use active listening techniques (e.g. sit at the same height, listen to mother's concerns)

 Praise the mother for proper behavior

Education

 Teach proper breastfeeding technique according to mother's needs

 

Nutrition Counseling I.03094

 

Definition

Provide guidance in modifying nutritional intake.

Action

Observation

 Identify eating habits and eating behaviors to be changed

 Identify progress of regular dietary modifications

 Monitor fluid intake and output, hemoglobin values, blood pressure, weight gain, and food buying habits

Therapeutic

 Build therapeutic relationships

 Agree on the timing of counseling

 Set realistic short term and long term goals

 Use nutritional standards according to the diet program in evaluating the adequacy of food intake

 Consider the factors that affect the fulfillment of nutritional needs (eg age, stage of growth and development, disease)

Education

Inform the need for dietary modifications (eg weight loss or gain, sodium or fluid restriction, cholesterol reduction)

Explain the nutrition program and the patient's perception of the programmed diet

Collaboration

 Refer to nutritionist/if necessary

 

Preconception Counseling I.10336

 

Definition

Provide guidance to couples of childbearing age before pregnancy.

Action

Observation

 Identification of medical history, drug use, ethnic background, occupation, diet, genetic disorders, and habits (eg smoking, alcohol and drug intake)

 Identify the couple's readiness to conceive

 Identify the place where the material health services are available for consultation/if necessary

Identify sexual history including frequency, timing of intercourse, use of pesticide lubricants, and postcoital habits (eg, douching).

 Perform screening if possible risk of tuberculosis, sexually transmitted diseases, hemoglobinopathies, and genetic defects

Therapeutic

 Relationship buildingTherapeuticand trust each other

 Support decision making about the feasibility of pregnancy, based on identified risk factors

 Discuss methods for identifying fertility, signs of pregnancy, and ways to confirm pregnancy

 Recommend self-care needed during the preconception period

Education

 Describe the risk factors for pregnancy

 Explain the relationship between early fetal development and drug use habits

Advise to check hemoglobin or hematocrit levels, Rh status, urine dipstick, toxoplasmosis, sexually transmitted diseases, rubella, and hepatitis, as indicated

Advise avoidance of pregnancy until appropriate treatment has been given (eg vaccine, rubella, Rh(D) immunoglobulin, immune serum globulin, or antibiotics)

Advise use of contraception until ready to get pregnant

 Advise to take early pregnancy and parenting classes

 Teach how to avoid teratogens (eg handling litter, cats, smoking cessation and alcohol)

Collaboration

 Refer genetic counseling for genetic risk factors/if necessary

Refer pre-delivery diagnostic tests (eg genetic, medical, or obstetric risk factors), if necessary

Sexuality Counseling I.07214

 

Definition

Provide sexual guidance to partners so that they are able to carry out their functions optimally.

Action

Observation

 Identification of knowledge level, reproductive system problems, sexuality problems and sexually transmitted diseases

 Identify timing of sexual dysfunction and possible causes

 Monitor stress, anxiety, depression and causes of sexual dysfunction

Therapeutic

 Facilitation of communication between patient and partner

 Provide opportunities for partners to share sexual problems

 Give praise for correct behavior

 Provide advice that is appropriate to the needs of the partner by using language that is easy to accept, understand and non-judgmental

Education

 Explain the effect of medication, health and disease on sexual dysfunction

 Inform the importance of modification in sexual activity

Collaboration

Collaborationwith a sexologist/if necessary

 

 

Consultation I.12461

 

Definition

Give consideration to solving nursing and/or health problems experienced by patients, families, groups, or communities.

Action

Observation

 Identify the purpose of the consultation

 Identify the problem that is the focus of the consultation

 Identify expectations of all parties involved

 Identify suitable consulting models

 Identify cost expectations/if necessary

Therapeutic

 Facilitation of written contract to determine consultation schedule agreement

 Respond professionally to acceptance or rejection of ideas

 Facilitation of deciding alternative solutions

Education

 Describe the problem experienced by the patient

 Explain alternative solutions that can be done by the patient / family

 Explain the advantages and disadvantages of each solution

 Encourage increased independence in solving problems

 

 

Consultation Via Phone I.12462

 

Definition

Give consideration to solving nursing and/or health problems experienced by patients, families, groups, or communities through telephone media

Action

 

 Observation

 Identify the purpose of consultation via telephone

 Identify the problem that is the focus of the consultation

 Identify the patient's ability to understand telephone information (e.g. hearing deficit, confusion, language barrier)

 Identify level of family support and involvement in care

 Identify psychological responses to situations and availability of support systems

 Identify safety risks for callers and/or other people

 Identify whether the problem requires further evaluation (use standard protocols)

 Identify cost expectations/if necessary

 Identify ways to contact the patient or family to receive a call back, if needed

Therapeutic

 Introduce yourself and the institution

 Obtain information about nursing and/or medical diagnoses/if necessary

 Get information on past health history and current therapy

 Inquire about chief complaint and current medical history according to standard protocol

 Respond in a professional manner to the acceptance or rejection of ideas

 The facility decides the choice of alternative solutions

 Involve family/significant others in treatment planning

 Maintain patient confidentiality

Education

 Describe the problem the patient is facing

 Explain alternative solutions that can be done by the patient / family

 Explain the advantages and disadvantages of each solution

 Inform educational programs, support groups for self-help groups that patients can use

 Encourage increased independence in solving problems

 

Positive Behavior Contract I.09282

 

Definition

Negotiating agreements to reinforce certain behavioral changes.

Action

Observation

 Identify mental and cognitive abilities to contract

 Identify the best ways and resources to achieve goals

 Identify barriers to implementing positive behaviors

 Monitor the implementation of non-conformance behavior and lack of commitment to fulfill the contract

Therapeutic

 Create an open environment for contracting behavior

 Facilitation of making written contracts

 Discuss the health behavior you want to change

 Discuss realistic and achievable short-term and long-term goals

 Discuss the development of a positive behavior plan

 Discuss ways of observing behavior (e.g. behavior progress tables)

 Discuss desired rewards when goals are achieved/if necessary

 Discuss the consequences or sanctions of not fulfilling the contract

 Set the time limit required for the implementation of realistic actions

 Contract review facility and objectives/if necessary

 Ensure the contract is signed by all parties involved/if necessary

 Involve family in contract process/if necessary

Education

 Suggest writing goals yourself/if necessary

 

Family Discussion Coordination I.12482

 

Definition

Balancing family activities to achieve common goals with family members.

Action

Observation

 Identify the health problems of each family member

Therapeutic

 Create a healthy home atmosphere and support the personality development of family members

 Family facilities discuss health problems experienced

 Maintain reciprocal relationship between family and health facilities

 Involve the family in making decisions to take the right action

 Provide care to sick family members

Education

 Encourage family members to take advantage of existing resources in the community 

Preoperative coordination I.14504

 

Definition

Coordinate patient preparation before undergoing surgery.

Action

Observation

 Identification of surgical plan (e.g. surgical technique, need for special surgical equipment)

 Identify the nature of the operation (e.g. elective, emergency)

 Identify the availability of operating rooms, ICU rungs, and hospitalization fees

 Check the patient's condition (eg history, physical examination, investigations)

Therapeutic

 Ensure informed consent has been taken

 Coordinate necessary diagnostic checks

 Coordinate operation scheduling if operation preparation has been fulfilled

 Register the patient to the operating room at least 24 hours before surgery, or according to institutional policy

 Reschedule surgery if operating room, ICU or ward is not available

Education

 Inform the treatment and diagnostic tests performed

 

Assertive Practice

Definition

Teach the ability to express feelings, needs, and opinions effectively by respecting the rights of others.

Action

Observation

- Identify barriers to assertiveness (eg developmental stage, chronic medical/psychiatric conditions, and socio-cultural)

- Monitor level of anxiety and discomfort related to behavioral changes

Therapeutic

- Facilitate recognizing and reducing cognitive distortions that hinder assertiveness

- Facilitation of differentiating assertive, passive, and aggressive behavior

- Facilitation of identifying conflicting personal rights, responsibilities and norms

- Facilitate clarifying problems in interpersonal relationships

- Facilitate expressing positive and negative thoughts and feelings

- Facilitate identifying self-destructive thoughts

- Facilitation of distinguishing between thoughts and reality

- Give praise for efforts to express feelings and opinions

Education

- Advise to act assertively in a different way

- Practice assertive behavior (eg making requests, saying no to unfulfilled requests, and starting and closing conversations)

Effective Cough Exercises

Definition

Train patients who do not have the ability to cough effectively to clear the larynx, trachea, and bronchioles of secretions or foreign bodies in the airways

Action

Observation

- Identify cough ability

- Monitor for sputum retention

- Monitor for signs and symptoms of respiratory tract infection

- Monitor fluid input and output (eg quantity and characteristics)

Therapeutic

- Set the semi-fowler or fowler position

- Put a patch and bend on the patient's lap

- Discard secretions in the sputum

Education

- Explain the purpose and procedure of effective cough

- Advise to inhale deeply through the nose for 4 seconds, hold it for 2 seconds, then remove it from the mouth with the lips pursed (rounded) for 8 seconds

- Recommend repeating deep breaths up to 3 times

- Encourage coughing forcefully immediately after the 3rd deep breath

Collaboration

- Collaborative administration of mucolytics or expectorants, if necessary

Urinary Exercise

Definition

Teach an ability to do urine elimination

Action

Observation

- Re-examine the cause of urinary disturbances (eg cognitive, loss of extremity/extremity function, loss of vision)

- Monitor urination pattern and ability

Therapeutic

- Avoid using indwelling catheters

- Set up a safe toilet area

- Keep the necessary equipment close and easy to reach (e.g. commode chair, bedpan, urinal)

Education

- Explain directions to the bathroom/toilet in patients with visual impairments

- Encourage adequate fluid intake to support urine output

- Encourage normal elimination with activity and exercise according to ability

Fecal Elimination Exercise

Definition

Teach an ability to train the intestines to evacuate at certain intervals.

Action

Observation

- Monitor intestinal peristalsis regularly

Therapeutic

- Advise consistent time to defecate

- Provide privacy, comfort and a position that enhances the defecation process

- Use low enemas, if necessary

- Advise digital rectal dilatation, if necessary

- Change the faecal elimination exercise program, if necessary

Education

- Recommend consuming certain foods, according to the program or the results of the consultation

- Encourage adequate fluid intake as needed

- Advise exercise according to tolerance

Collaboration

- Collaborative use of suppositories, if necessary

Memory Exercise

Definition

Teaches the ability to improve memory

Action

Observation

- Identify memory problems experienced

- Identification of errors against orientation

- Monitor behavior and memory changes during therapy

Therapeutic

- Plan teaching methods according to the patient's ability

- Memory stimulation by repeating the last thought thought, if necessary

- Correction of orientation errors

- Facilitate recall of past experiences, if necessary

- Facilitation of learning tasks (eg recalling verbal information and pictures)

- Facilitate concentration skills (eg playing pair cards) if necessary

- Stimulation of using memory on recent events (eg asking him where he has been recently) if necessary

Education

- Explain the purpose and procedure of the exercise

- Teach appropriate memory techniques (eg visual imagination, mnemonic devices, memory games, memory cues, association techniques, list making, computers, name boards)

Collaboration

- Refer to occupational therapy, if necessary

Otogenic Exercise

Definition

Teach the ability of self-suggestion with feelings of pleasure and warmth aimed at relaxation

Action

Observation

- Identify indications for otogenic exercise

Therapeutic

- Prepare a quiet and comfortable environment

- Wear comfortable clothing that does not restrict movement of the patient

- Read the prepared statement (script), pause for a moment and ask to repeat it internally

- Use statements that cause feelings of pleasure, lightness, or a sense of floating in certain body parts

Education

- Explain the purpose and procedure of otogenic exercise

- Encourage sitting in a chair or lying in a supine position

- Suggest repeating statements to yourself to get a deeper feeling on the targeted body part

- Suggest exercise for 15-20 minutes

- Suggest to stay relaxed for 15-20 minutes

- Recommend practicing three times a day

 

 

Pelvic Muscle Exercise

Definition

Teaches the ability to strengthen the ani and urogenital elevator muscles through repeated contractions to reduce urinary incontinence and premature ejaculation

Action

Observation

- Monitor urine output

Therapeutic

- Give urine output

Education

- Suggest lying down

- Advise not to contract the stomach, legs, and buttocks when doing pelvic muscle exercises

- It is recommended to increase the duration of contraction-relaxation by 10 seconds with a cycle of 10-20 times, performed 3-4 times a day

- Advise to contract around the urethra and anus muscles such as holding a bowel movement for 5 seconds then relax and relax with a cycle of 10 times

- Recommend evaluating the exercise done by stopping the urine for a moment when BAK, once a week

- Advise exercise for 6-12 weeks

Collaboration

- Collaboration of medical rehabilitation to measure the strength of pelvic floor muscle contraction, if necessary

 

 

Impulse Recognition Exercise

Definition

Teach handling impulsive behavior

Action

Observation

- Identify the problem experienced

- Identify possible and useful actions

Therapeutic

- Apply problem solving strategies according to developmental level and cognitive function

- Make behavior modifications, as needed

- Facilitate doing useful actions

- Provide positive reinforcement for successful actions taken

- Motivation to reward yourself

- Provide opportunities to practice problem solving (role-play) in the environmentTherapeutic

- Provide a step-by-step model of a problem-solving strategy

- Motivation to practice problem solving in social and interpersonal situations

Education

- Teach self-signaling to "stop and think" before acting impulsively

Breathing Exercises

Definition

Exercises to move the chest wall to improve airway clearance, increase lung expansion, strengthen the respiratory muscles, and promote relaxation or a sense of comfort.

Action

Observation

- Identify indications for breathing exercises

- Monitor the frequency of rhythm and depth of breath before and after exercise

Therapeutic

- Provide a quiet place

- Position the patient comfortably and relaxed

- Place one hand on the chest and one hand on the stomach

- Make sure the hands on the chest are back and the palms on the stomach are forward when you inhale

- Take a deep breath slowly through your nose and hold it for a count of seven

- Count to eight exhale slowly through the mouth

Education

- Explain the purpose and procedure of breathing exercises

- Recommend repeating the exercise 4-5 times

 

Rehabilitation Exercise

Definition

Teaches the ability to optimize health, maintain health and restore independence after experiencing illness, degenerative processes, trauma, and others.

Action

Observation

- Identify personal hygiene problems and skin problems

- Monitor training abilities and progress

- Monitor vital signs in every exercise

Therapeutic

- Motivation to be independent in activities

- Provide opportunities to improve skills in meeting daily needs

- Provide a safe and comfortable environment to prevent injury and infection

Education

- Explain the purpose and procedure of rehabilitation exercises

- Explain the need for activity restrictions

- Teach use of assistive devices if needed (eg crutches, crutches, wheelchair)

- Practice emptying the bowel/bladder

- Train active and passive ROM

Collaboration

- Collaboration with medical rehabilitation, if necessary

 

Range of Motion Exercise

Definition

Teaches the ability to use active and passive movements to maintain and restore flexibility

Action

Observation

- Identification of indications for exercise

- Identify limitation of joint movement

- Monitor the location of discomfort or pain when moving

Therapeutic

- Wear loose clothes

- Prevent injury during range of motion exercises

- Facilitation optimizes body position for active and passive joint movement

- Perform passive movements with assistance according to indications

- Provide positive support when doing joint motion exercises

Education

- Explain the purpose and procedure of the exercise

- Encourage passive and active range of motion if necessary

- Advise to sit in bed or in a chair, if necessary

- Teach active range of motion according to the exercise program

Collaboration

- Collaboration with physiotherapists to develop exercise programs, if necessary

Limit Settings

Definition

Setting the parameters of expected and acceptable behavior

Action

Observation

- Identify expected and unexpected behavior

- Monitor the implementation of the expected behavior

Therapeutic

- Use a consistent, honest and non-judgmental approach

- Convey boundaries in positive words (eg “wear your clothes”, rather than “such behavior is inappropriate”)

- Discuss what behavior is expected in a situation, if necessary

- Set limit setting behavior achievement

- Share established consequences and behavioral expectations with the nursing team

- Give rewards for performing the expected behavior

- Perform the consequences that have been set if you do not perform the expected behavior

- Modify consequences and behavioral expectations, if necessary

- Lower the limit setting if the patient's behavior is close to the expected behavior

Education

- Explain the benefits and expected consequences of the behavior

 

Central Venous Access Management

Definition

Identify and manage catheters inserted in central veins

Action

Observation

- Identify indications for central venous access

Therapeutic

- Put on a sterile gown

- Put on sterile gloves

- Make sure the needle is not clogged

- Three-way connection to all catheter ports

- Fill all catheter lumens with NaCl or heparinized saline

- Set supine position

- Turn your head against where the action is taking place

- Clean the skin with antiseptic and cover with a sterile doc

- Determine the puncture site of the upper 1/3 of the stemocleidomastoid, lateral to the carotid artery

- Perform local anesthesia

- Insert the needle attached to the empty syringe, into the middle of the triangle formed by the two lower ends of the stemocleidomastoid muscle and the calvicle

- Make sure the needle is inserted in the lateral position of the artery with the finger still palpating the carotid artery

- Insertion and aspirate

- Venous cannulation using the Seldinger technique when blood is seen

Education

- Explain the purpose and procedure to be carried out

Collaboration

- Collaborative chest x-ray examination to ensure catheter position

Permanent Pacemaker Management

Definition

Identify and manage permanent cardiac pumping support using pacemakers

Action

Observation

- Identify indications for a permanent pacemaker

- Monitor for signs that the pacemaker is working properly

- Monitor peripheral pulse

- Monitor hemodynamic response

- Monitor heart rhythm, symptoms of arrhythmia, ischemia, or heart failure (eg pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, PVC, infection, hiccups, muscle twitching)

- Monitor for pacemaker failure

Therapeutic

- Define the type and mode of the pacemaker

- Involve family in pacemaker treatment

Education

- Explain the indications, functions and complications of pacemaker implantation

- Recommend avoiding or using tools that cause electromagnetic interference

- Advise to carry out routine checks of permanent cardiac devices

- Advise not to operate a motorized vehicle until approved by a cardiologist

- Advise regular pacemaker monitoring

- Recommend repeat chest X-ray every year to confirm placement of pacemaker

- Recommend wearing a pacemaker wristband

- Recommend avoiding detector machines

- Teach how to recognize the signs and symptoms of pacemaker dysfunction

Temporary Pacemaker Management

Definition

Identifying and managing the heart pump through insertion and use of a temporary pacemaker

Action

Observation

- Identify indications for temporary pacemaker insertion

- Identify the pacemaker needed (eg internal or external venous catheter, unipolar or bipolar, transthoracic; epicardial)

- Check 12 lead ECG, if necessary

- Check peripheral circulation (eg peripheral pulses, edema, capillary refill) skin temperature and diaphoresis

- Continuous heart rhythm monitoring, if necessary

- Monitor for dysrhythmias and hemodynamic response to dysrhythmias

- Monitor for complications of pacemaker insertion (eg pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, infection)

- Monitor for pacemaker failure

Therapeutic

- Provide informed consent

- Prepare the selected pacemaker

- Attach external transcutaneous pacemaker electrodes

- Facilitation of pacemaker installation

- Take a chest X-ray after insertion of a temporary pacemaker

- Analysis of heart pump progress after temporary pacemaker insertion

Education

- Explain the indications, functions, and complications of pacemaker implantation

- Teach pacemaker precautions (eg restriction of movement, avoid self-management of pacemakers)

Collaboration

- Collaborative chest X-ray examination after temporary pacemaker insertion

- Check peripheral channels (eg, peripheral pulses, capillary refill edema), skin temperature and diaphoresis

Continuous heart rhythm monitoring, if necessary

- monitor dysrhythmias and hemodynamic response to dysrhythmias

-monitor for complications of pacemaker insertion (eg, pneumothorax, hemothorax, myocardial perforation, cardiac tamponade, hematoma, infection)

-monitor for pacemaker failure

Therapeutic

- provide informed consent

- prepare the selected pacemaker

- attach external transcutaneous pacemaker electrodes

-facilitating the installation of a pacemaker

- take a chest X-ray after insertion of a temporary pacemaker

- analysis of the progress of the cardiac pump after insertion of a temporary pacemaker

Education

Explain the indications, functions and complications of pacemaker implantation

- teach precautions for pacemaker disorders (eg, restriction of movement, avoid self-management of pacemakers)

Collaboration

- Collaborative chest X-ray examination after temporary pacemaker insertion

 

Management of anaphylaxis

Definition

Identifying and managing patients in anaphylactic shock

Action

Observation

- identification of patent airway

-identify vital signs (eg, blood pressure, pulse and respiratory rate, body temperature)

- identification of allergens

- monitor for early signs of shock (eg shortness of breath, seizures, arrhythmias, hypotension)

Monitor for early signs of hypervelomia due to excessive resuscitation (especially children and geriatrics)

-monitor for recurrent anaphylaxis

Therapeutic

-provide a comfortable position (eg supine with legs elevated)

-maintain a patent airway

- install 0.9% NaCI injection or ringer lactak, as needed

- give oxygen via mask 10-12 L/minute

- prepare the HCU or ICU room if necessary

Education

- recommend preparing allergy medications at home

- teach to prevent anaphylactic events

Collaboration

- Collaboration administration of antihistamines, if necessary

- Collaborative administration of corticosteroids, if necessary

- Collaborative administration of epinephrine or adrenaline, if necessary

 

 

Arrhythmia management

Definition

Identify and manage cardiac rhythm and/or rate disturbances that are potentially hemodynamically impairing or life threatening

Action

Observation

- check the onset and pace of arrhythmias

- identify the type of arrhythmia

- monitor the frequency and duration of arrhythmias

- monitor chest pain complaints (intensity, location, trigger and reliever factors)

- Monitor hemodynamic response due to arrhythmias

- monitor oxygen saturation

- monitor electrolyte levels

Therapeutic

- provide a quiet environment

- insert artificial airway (eg OPA, NPA, LMA, ETT) if necessary

- install intravenous access

-install a heart monitor

- record 12 lead ECG

- check the QT interval before and after administration of drugs that can prolong the QT interval

- perform the Valsalva maneuver

- do unilateral carotid massage

- give oxygen, according to identification

- prepare the installation of the ICD (impantable cardioverter defibrillator)

Collaboration

- Collaboration of antiarrhythmic administration, if necessary

- Collaboration of cardioversion, if necessary

- Collaboration of defibrillation, if necessary

 

 

Acid base management

Definition

Identify, manage and prevent complications due to acid base imbalance

Action

Observation

- identify the cause of acid base imbalance

- monitor the frequency and depth of breath

-monitor neurological status (eg level of consciousness, mental status)

- monitor heart rhythm and frequency

- monitor changes in pH, PaCO² and HCO³

Therapeutic

- take arterial blood specimens for AGD examination

-give oxygen as indicated

Education

- Explain the causes and mechanisms of acid-base disorders

Collaboration

- Collaboration of mechanical ventilation, if necessary

 

 

Acid-base management: Metabolic alkalosis

Definition

Identify and manage alkaline blood due to high bicarbonate

Action

Observation

- identify the cause of metabolic alkalosis (eg loss of gastric acid [vomiting, gastric injection] long-term diuretic therapy, excessive NaHCO³ administration, hyoercalcemia)

- monitor the frequency and depth of breath

- monitor vital signs

- monitor fluid intake and output

- monitor the impact of the central nervous system (eg confusion, stupor, seizures, coma, hyperactive reflexes)

- monitor respiratory impact (eg hypoventilation, bronchospasm)

- monitor cardiovascular impact (eg arrhythmia, decreased contractility, decreased cardiac output)

- Monitor the impact of the digestive tract (nausea, vomiting, diarrhea)

- monitor the results of blood gas analysis

Therapeutic

- maintain a patent airway

-adjust position to facilitate adequate ventilation

- maintain intravenous access

-give intravenous fluids, if necessary

Education

Explain the causes of metabolic alkalosis

Collaboration

- Collaboration of potassium in case of hypokalemia (eg NaCI+KCL)

 

 

Acid-base management of respiratory alkalosis

Definition

Identify and manage alkaline blood conditions due to carbon dioxide partial pressure

Action

Observation

- identification of causes of respiratory alkalosis (eg hyperventilation, anxiety, fear, pain, fever, sepsis, brain tumor, mechanical overventilation)

- monitor for hyperventilation

- monitor fluid intake and output

- monitor for worsening symptoms (periods of apnea, dyspnea, increased anxiety, increased pulse, headache, diaphoresis, blurred vision, hyperreflexia, dry mouth)

- monitor the impact of the central nervous system (paresthesias, seizures)

- monitor cardiovascular impact (arrhythmia, decreased cardiac output, hyperventilation)

-monitor the impact of the digestive tract (decreased appetite, nausea, vomiting)

- monitor blood gas results

Therapeutic

- maintain a patent airway

- maintain position for adequate ventilation

- maintain intravenous access

- propose bed rest, if necessary

- maintain hydration as needed

- give oxygen with a rebreathing mask

- Avoid correcting PCO² too quickly because metabolic acidosis can occur

Education

Explain the causes of respiratory alkalosis

- teach breathing exercises

- recommend quitting smoking

Collaboration

-Collaborationsedative administration, if necessary

- Collaboration of antidepressants, if necessary

 

 

Acid-base management: Metabolic acidosis

Definition

Identify and manage acidic blood conditions due to low bicarbonate

Action

Observation

- identification of causes of metabolic acidosis (diabetes mellitus, ARF, CKD, severe diarrhea, alcoholism, hunger, salicylate overdose, pancreatic fistula)

- monitor breathing patterns (frequency and depth)

- monitor fluid intake and output

- monitor the impact of the central nervous system (headache, anxiety, mental deficits, seizures, coma)

- monitor the impact of respiratory circulation (hypotension, hypoxia, arrhythmia, Kusmaull client)

- monitor the impact of the digestive tract (decreased appetite, nausea, vomiting)

- monitor the results of blood gas analysis

Therapeutic

- maintain a patent airway

- Provide semi-Fowler's position to facilitate adequate ventilation

- maintain intravenous access

- maintain hydration as needed

- give oxygen as indicated

Education

Explain the causes and mechanisms of metabolic adiosis

Collaboration

- Collaboration of bicarbonate administration, if necessary

 

 

Acid-base Management: Respiratory Acidosis

Definition

Identify and manage acidic blood conditions due to high partial pressure of carbon dioxide.

Action

Observation

- Identification of causes of respiratory acidosis (eg COPD, asthma, head injury, pulmonary edema, pneumonia, ARDS, pneumothorax, cardiac arrest, airway obstruction, respiratory depression, CNS depression, chest trauma, heart failure)

- monitor for hypoventilation

- monitor the frequency and depth of breath

- monitor the use of accessory muscles of breathing

- CRT monitor (Capillary Refill Time)

- monitor for indications of chronic respiratory acidosis (eg barrel chest, use of accessory muscles to breathe, clubbing nails)

- monitor central nervous system impact (eg decreased consciousness, confusion)

- monitor the results of blood gas analysis

- monitor for complications

Therapeutic

- maintain patent and clear airway

Administer low-flow oxygen in chronic hypercapnia (COPD)

- maintain intravenous access

- give oxygen, as indicated

- Avoid correcting hypercapnia too quickly because it can cause metabolic alkalosis.

Education

Explain the causes and mechanisms of respiratory acidosis

- recommend quitting smoking

- Advise to lose weight, if obese

- Teach breathing exercises

Collaboration

- Collaboration of mechanical ventilation, if necessary

- Collaboration Giving bronchodilators, if necessary

- Collaborative administration of opiate antidote (naloxone), if necessary

 

 

ASTHMA MANAGEMENT

Definition

Identify and manage airflow obstruction due to allergic reaction or airway hypersensitivity causing bronchospasm.

Action

Observation

-monitor the frequency and depth of breath

- Monitor for signs and symptoms of hypoxia (eg restlessness, agitation, loss of consciousness)

- Monitor for additional breath sounds (eg wheezing, wheezing)

- Monitor oxygen saturation

Therapeutic

- Give semi fowler position 30-40°

- Install pulse oximetry

- Perform mucus suction, if necessary

- Give oxygen 6-15 L via mask to maintain SpO2>90%

- Establish an intravenous line for drug administration and hydration

- Take blood samples for complete blood count and AGD

Education

- Recommend minimizing anxiety that can increase oxygen demand

- Encourage slow and deep breathing

- Advise purused-lip breathing

- Teach identifying and avoiding triggers (eg dust, animal dander, pollen, cigarette smoke, air pollutants, extreme environmental temperatures, food allergies)

Collaboration

- Collaborative administration of bronchodilators as indicated (eg Albuterol, metaproterenol)

- Collaborative administration of additional drugs if unresponsive to bronchodilators (eg Prednisolone, methylprednisole, aminophylline)

 

 

 

 

 

AUTOTRANSFUSION MANAGEMENT

Definition

Collects blood lost during surgery and returns it to the body.

Action

Observation

- Monitor blood pressure, pulse rate and respiratory rate during blood draw

Therapeutic

- Consider patient safety (contraindications: sepsis, tumor infection, blood containing hemostatic agents)

- Provide action approval letter

- Label the blood bag (name, medical record number, date and time of start of blood collection)

- Use the collected blood according to the procedure

- Maintain blood integrity during blood draw

- Prepare blood for reinfusion

- Document the time of blood collection, blood condition, type and amount of anticoagulant and blood volume

- Maintain infection control

Education

-explain the purpose and procedure of autotransfusion

Collaboration

- Collaboration Giving transfusion for 6 hours after blood collection

 

 

WEIGHT MANAGEMENT

Definition

Identify and manage body weight to keep it within the optimal range

Action

Observation

- Identify the patient's health conditions that can affect body weight

Therapeutic

- Calculate the patient's ideal weight

- Calculate the patient's fat and muscle percentage

- Facilitation of setting realistic weight targets

Education

- Explain the relationship between food intake, physical activity, weight gain and weight loss

- Explain the risk factors for being overweight and underweight

- Advise to record weight every week, if necessary

- Advise to record food intake, physical activity and changes in body weight

 

 

LIQUID MANAGEMENT

Definition

Identify and manage fluid balance and prevent complications due to fluid imbalance.

Action

Observation

- Monitor hydration status (eg pulse rate, pulse strength, acral, capillary refill, mucosal moisture, skin turgor, blood pressure)

- Daily weight monitoring

- Monitor weight before and after dialysis

- Monitor the results of laboratory tests (eg Hematocrit, Na, K, Cl, urine specific gravity, BUN)

- Monitor hemodynamic status (eg MAP, CVP, PAP, PCWP if available)

Therapeutic

- Record intake-output and calculate fluid balance 24 hours

- Provide fluid intake, as needed

- Give intravenous fluids, if necessary

Collaboration

- Collaborative administration of diuretics, if necessary

 

 

DEFIBRILATION MANAGEMENT

Definition

Identify and manage the asynchronous method of strong electrical currents to the heart through electrodes placed on the surface of the chest.

Action

Observation

- Check the rhythm on the monitor after 2 minutes of CPR

Therapeutic

- Perform cardiopulmonary resuscitation (CPR) until the defibrillator machine is ready

- Set up and start the defibrillator machine

- Attach ECG monitor

- Confirm cardiac arrest ECG rhythm (VF or pulseless VT)

- Set the amount of energy in asynchrinized mode (360 joules for monophasic and 120-200 joules for biphasic)

- Lift the paddle from the machine and apply jelly on the paddle

- Attach the sternum paddle (right) on the right side of the sternum below the clavicle and the apex paddle (left) on the midaxillary line at the height of the electrode V6

- Fill energy by pressing the charge button on the defibrillator machine and wait until the desired energy is reached

- Stop CPR when the defibrillator is ready

- Shouts that the defibrillator is ready (eg "I'm clear, you're clear, everybody's clear)

- Give a shock by pressing the buttons on both paddles at the same time

- Lift the paddle and continue CPR immediately without waiting for the rhythm results to appear on the monitor after defibrillation

- Continue CPR for up to 2 minutes

 

 

DELIRIUM MANAGEMENT

Definition

Identify and manage the environmentTherapeuticand safe in acute confusional status

Action

Observation

- Identify risk factors for delirium (eg age >75 years, cognitive dysfunction, visual/hearing impairment, decreased functional ability, infection, hypomyothermia, hypoxia, malnutrition, drug effects, toxins, sleep disturbances, stress)

- Identify the type of delirium (eg hypoactive, hyperactive, mixed)

-Monitor neurological status and delirium level

Therapeutic

- Provide good lighting

- Provide easy-to-read clock and calendar

- Avoid excessive sensory stimuli (eg television, intercom announcements)

- Apply physical restraint, as indicated

- Provide information about what happened and what could happen next

- Limit decision making

- Avoid validating misperceptions or inaccurate interpretations of reality (eg hallucinations, delusions)

- State perceptions in a calm, convincing, and not argumentative way

- Focus on what is recognized and meaningful in interpersonal interactions

- Do reorientation

- Provide a consistent physical environment and daily routine

- Use environmental cues to stimulate memory, reorient, and enhance appropriate behavior (e.g. environmental signs, pictures, clocks, calendars, and color codes)

- Give new information slowly, little by little, over and over again

Education

- Recommend family visits, if necessary

Collaboration

- Collaborative administration of anxiety medication or agitation, if necessary

 

 

Fever Management I.03099

Definition

Identify and manage elevated body temperature due to endogenous pyrogens

Action

Observation

- Monitor vital signs (eg body temperature, pulse rate, respiratory rate and blood pressure)

- Monitor fluid intake and output

- Monitor for complications due to fever (eg seizures, loss of consciousness, abnormal electrolyte levels, acid-base imbalance, arrhythmias)

Therapeutic

- Cover the body with blankets/clothes appropriately (eg blankets/thick clothes when feeling cold and blankets/thin clothes when feeling hot)

- Perform tapid sponge, if necessary

Education

- Recommend bed rest

- Recommend drinking more

Collaboration

- Collaboration of intravenous fluids and electrolytes, if necessary

- Collaborative administration of antipyretics, if necessary

- Collaboration of antibiotics, if necessary

 

 

Dementia Management I.09286

Definition

Identify and manage patients with chronic confusion.

Action

Observation

- Identify physical, social, psychological and behavioral histories.

- Identify activity patterns (eg sleep, taking medication, elimination, oral intake, self-care)

Therapeutic

- Provide a safe, comfortable, consistent, and low-stimulus environment (e.g. quiet music, simple decor, adequate lighting, eating with other patients)

- Orient the time, place and people

- Use distraction to solve behavioral problems

- Involve family in planning, providing and evaluating care

- Orientation facilities with symbols (e.g. decorations, signage, photo with names, capital letters)

- Involve individual or group activities according to cognitive abilities and interests

Education

- Advise to increase rest

- Teach family how to care for dementia

 

 

Management of Postpartum Depression I.09287

Definition

Identify and manage postpartum psychological adaptation disorders that occur weeks to months after delivery.

Action

Observation

- Identify medical history during the antepartum period

- Identify perceptions about current conditions

Therapeutic

- Involve the most important people

- Listen to patient complaints

- Facility to plan daily activities (eg nutrition, activity, rest, sleep)

- Recommend getting involved in a support group

- Support to keep interacting with the environment that can be a support system

Education

- Explain about baby care

- Suggest taking some time for yourself

 

Peritoneal Dialysis Management I.03100

Definition

Identify and manage the process of excreting metabolic waste, maintain fluid and electrolyte balance through the peritoneal blood vessels.

Action

Observation

- Identification of symptoms, signs and instructions for peritoneal dialysis (eg physical examination, laboratory) and patient and family readiness

- Check body weight, abdominal circumference before and after peritoneal dialysis

- Check the device, fluid and the connection of the catheter and infusion tube

- Check the patency of the peritoneal dialysis catheter

- Check for infection, antrophy and complications of peritoneal dialysis catheter insertion

- Monitor blood pressure, pulse, respiration, body temperature and response during dialysis

- Monitor complications of peritoneal dialysis (eg infection, respiratory distress, perforation or fluid leakage

Therapeutic

- Treat the peritoneal dialysis catheter insertion wound according to the protocol

- Warm the peritoneal dialysis fluid

- Manage dialysis fluid intake and output

Education

- Explain the purpose and procedure of peritoneal dialysis

- Describe signs of infection, bleeding, leakage, respiratory distress, dialysis fluid changes and abdominal pain

Collaboration

- Collaborative management of infection at the insertion site, peritonitis, peritoneal catheter obstruction

 

 

Diarrhea Management I.03101

Definition

Identify and manage diarrhea and its effects.

Action

Observation

- Identification of causes of diarrhea (eg gastrointestinal inflation, gastrointestinal irritation, infectious process, malabsorption, anxiety, stress, effects of drugs, bottle feeding)

- Identification of feeding history

- Identify symptoms of invagination (eg loud crying, pallor of the baby)

- Monitor stool color, volume, frequency, and consistency

- Monitor for signs and symptoms of hypovolemia (eg tachycardia, palpable red pulse, weak blood pressure, decreased blood pressure, decreased skin turgor, dry skin mucosa, slowed CRT, decreased body weight)

- Monitor skin irritation and ulceration in the perianal area

- Monitor the amount of diarrhea expenditure

- Monitor food preparation safety

Therapeutic

- Provide oral fluid intake (eg, sugar salt solution, ORS, pedialyte, renalyte)

- Install the intravenous line

- Give intravenous fluids (eg Ringer's acetate, Ringer's lactate), if necessary

- Take blood samples for complete blood count and electrolytes

- Take a stool sample for culture, if necessary

Education

- Advise small and frequent meals gradually

- Recommend avoiding gas-forming, spicy and lactose-containing foods

- Advise to continue breastfeeding

Collaboration

- Collaborative administration of antimotility drugs (eg loperamide, diphenoxylate)

- Collaborative administration of antispasmodic/spasmolytic drugs (eg Papaverin, belladonna extract, mebeverine)

- Collaboration of stool hardening drugs (eg Atapulgite, smectite, kaolin-pectin)

 

 

Dysreflexia Management I.06190

Definition

Identify and manage inappropriate autonomic reflexes and responses in cervical or thoracic lesions.

Action

Observation

- Identify stimuli that can trigger dysreflexia (eg bladder distention, renal calculi, infection, impaction of feces, rectal examination, suppositories, skin breakdown)

- Identify causes of dysreflexia triggers (eg bladder distention, fecal impaction, skin lesions, supportive stockings, and abdominal strapping)

- Monitor for signs and symptoms of autonomic dyslexia (eg paroxysmal hypertension, bradycardia, tachycardia, diaphoresis, above injury level, pallor below injury level, headache, chills without fever, pilomotor erection and chest pain)

- Monitor urinary catheter patency, if installed

- Monitor for hyperreflexia

- Monitor vital signs

Therapeutic

- Minimize stimuli that can trigger dysreflexia

- Provide Fowler's position, if necessary

- Insert a urinary catheter, if necessary

Education

- Explain the causes and symptoms of dysreflexia

- Explain the management and prevention of dysreflexia

- Instruct the patient and/or family if they experience signs and symptoms of dysreflexia

Collaboration

- Collaborative administration of intravenous antihypertensive agents, as indicated

Management of Drug Side Effects I.14505

Definition

Identify and manage undesirable effects of administration of pharmacological agents.

Action

Observation

- Check for signs and symptoms of drug side effects

- Identification of the cause of drug side effects (eg old age, decreased kidney function, high doses, inappropriate route of administration, inappropriate timing)

Therapeutic

- Stop giving the drug

- Report drug side effects according to SOP

- Provide first aid to minimize side effects, as needed

Education

- Explain the occurrence of drug side effects

- Advise to stop taking the drug

- Teach how to minimize drug side effects

Collaboration

- Consult the administration of medication for the management of side effects

 

 

Electroencephalography Management I.06191

Definition

Identify and manage diagnostic electroencephalography (EEG) uses

Action

Observation

- Identification of EEG diagnostic indications

- Check medication history that may interfere with test results (eg anticonvulsants, barbiturate sedatives)

Therapeutic

- Position lying back on a chair or in bed

- Stick the electrodes on the scalp

- Perform inspection procedures

Education

- Explain the purpose and procedure of EEG

- Inform the implementer, time and place of the implementation of the procedure

- Inform the electrode will not cause electric shock

- Advise relax with eyes closed

- Advise to remain silent during the procedure

 

 

 

Electroconvulsive Management I.06192

Definition

Identify and manage the safe and efficient management of electroconvulsive therapy (ECT).

Action

Observation

- Check vital signs, mental status, pulse oximeter, ECG before and after the procedure

- Monitor awareness and orient time/place

- Monitor for post-ECT side effects (eg muscle pain, headache, nausea, confusion, dislocation)

Therapeutic

- Provide emotional support, as needed

- Fast before the procedure

- Give loose clothes that i can open in front

- Perform pre-procedure preparation (eg removing dentures, jewelry, glasses, contact lenses, checking vital signs, making sure you have urinated)

- Install monitoring devices (eg EEG, EKG, pulse oximeter, blood pressure cuff)

- Install a bed safety fence

- Install dental braces

- Perform jaw thrusts during delivery of electrical stimulus

- Limit environmental stimulation

- Give oxygen, if necessary

Education

- Explain the purpose and procedure of ECT

 

 

Electrolyte Management I.03102

Definition

Identify and manage imbalances in serum electrolyte levels.

Action

Observation

- Identify signs and symptoms of electrolyte imbalance

- Identify causes of electrolyte imbalance

- Identification of electrolyte loss through fluids (eg diarrhea, drainage ileostromy, wound drainage, dlaphoresis)

- Monitor electrolyte levels

- Monitor side effects of electrolyte supplements

Therapeutic

- Give fluids, if necessary

- Provide proper diet (eg high potassium, low sodium)

- Instruct patient and family to modify diet, if necessary

- Install intravenous access, if necessary

Education

- Explain the types, causes and treatment of electrolyte imbalances

Collaboration

- Collaboration in providing electrolyte supplements (eg oral, NGT, IV) as indicated

 

 

Electrolyte Management: Hyperkalemia I.03103

Definition

Identify and manage excess serum potassium level >5.5 mEq/L.

Action

Observation

- Identify signs and symptoms of elevated potassium levels (eg irritability, restlessness, nausea, vomiting, tachycardia leading to bradycardia, ventricular fibrillation/tachycardia)

- Identification of causes of hypermatremia (eg rapid or excessive parenteral potassium administration, acidosis, cell catabolism)

- Monitor heart rhythm, heart rate, and ECG

- Monitor fluid intake and output

- Monitor serum and/or urine potassium levels

Therapeutic

- Take blood and/or urine specimens for potassium examination

- Install intravenous access, if necessary

- Give a low potassium diet

Education

- Advise low-potassium diet modification, if necessary

Collaboration

- Elimination of potassium (eg diuretics, kayexalate), as indicated

- Collaboration administration of insulin and IV glucose, as indicated

- Collaboration administration of 10% calcium gluconate 10 ml, as indicated

- Collaboration hemodialysis in patients with renal failure, as indicated.

 

 

 

 

Electrolyte Management: Hypercalcemia I.03104

Definition

Identify and manage elevated serum calcium levels >10.5 mFq/L.

Action

Observation

- Identify the cause of increased serum calcium levels

- Monitor fluid intake and output

- Monitor renal function (eg BUN, creatinine)

- Monitor the presence of digitalis poisoning

- Monitor for symptoms of hypercalcemia (eg, excess urine, excessive thirst, muscle weakness, poor coordination, anorexia, nausea, abdominal cramps, constipation, dysfunction)

- Monitor for psychosocial symptoms (eg confusion, memory weakness, slurred speech, lethargy, acute psychotic behavior, coma, depression)

- Monitor cardiovascular symptoms (eg dysrhythmias, prolonged PR intervals, sinus bradycardia, heart block, hypertension, cardiac arrest)

- Monitor digestive symptoms (eg anorexia, nausea, vomiting, constipation, papptic ulcer symptoms, abdominal pain, paralytic ileus)

- Monitor for neuromuscular symptoms (eg weakness, paresthesias, myalgia, headache, decreased reflex retention, weakness of coordination)

- Monitor for bone pain

- Monitor for electrolyte imbalance

- Monitor for indications of kidney stones (eg persistent pain, nausea, vomiting, hematuria)

Therapeutic

- Avoid giving vitamin D

- Avoid consulting foods that contain calcium (eg packaged foods, seafood, beans, broccoli, spinach and supplements)

Education

- Recommend consuming lots of fruits

- Encourage mobilization to prevent bone resorption

Collaboration

- Collaboration of drugs to treat hypercalcemia, if necessary

 

 

 

Electrolyte Management: Hypermagnesemia I.03105

Definition

Identify and manage elevated serum magnesium levels >2.5 mEq/L.

Action

Observation

- Identification of causes of elevated serum magnesium levels (eg magnesium infusion, parenteral nutrition antacid use, use of laxatives, lithium therapy, renal insufficiency)

- Monitor cardiovascular symptoms (eg heart block, hypotension, widening of the QRS)

- Monitor for neuromuscular symptoms (eg symptoms, latergi, confusion, paralysis, respiratory arrest)

Therapeutic

- Increase fluid intake, if necessary

- Take a blood sample for electrolyte check

Education

- Teach bed rest, if necessary

Collaboration

- Collaborative administration of calcium chloride and calcium gluconate, if necessary.

Electrolyte Management: Hypernatremia I.03106

Definition

Identify and manage excess serum sodium level >145 mEq/L.

Action

Observation

• Identify signs and symptoms of elevated sodium levels (eg thirst, fever, nausea, vomiting, restlessness, irritability, tachycardia, lethargy, confusion, seizures)

• Identification of causes of hypernatremia (eg excessive NaCl infusion or hypertension, diarrhea, fever, excessive sweating, diabetes, Chusing's syndrome, hyperaldosteronism)

• Check for signs of fluid overload (eg orthopnea, dyspnea, edema, short-term increase in weight, increased JVP/CVP, positive hepatojugular reflex)

• Monitor fluid intake and output

• Monitor serum and/or urine sodium levels

Therapeutic

• Establish intravenous access, if necessary

• Calculate fluid deficit with the formula: 4 mL × BW × (current Na - target Na)

• Give oral or intravenous fluids according to protocol or amount of fluid deficit

• Provide a low sodium diet

• Avoid rapid sodium correction to avoid the risk of cerebral edema

Education

• Advise low sodium diet modification, if necessary

Collaboration

Collaborationsodium correction at a decreasing rate of 1 mEq/L/hour.

 

 

 

Electrolyte Management: Hypokalemia

 

Definition

Identify and manage decreased serum or plasma potassium levels <3.5 mEq/L

Action

Observation

• Identify signs and symptoms of decreased potassium levels (eg muscle weakness, prolonged QT interval, fatigue, paresthesias, decreased reflexes)

• Identification of causes of hyponatremia (eg diarrhea, vomiting, nasogastric suctioning, diuretics, hyperaldosteronism, dialysis, insulin elevation)

• Monitor heart rhythm, heart rate and ECG

• Monitor fluid intake and output

• Monitor for signs and symptoms of respiratory failure (eg low PaO2, high PaCO2, respiratory muscle weakness)

• Monitor serum and/or urine potassium levels

• Monitor intravenous access for phlebitis and infiltration

Therapeutic

• Place a cardiac monitor (especially if potassium correction >10 mEq/hr)

• Install intravenous access, if necessary

• Give potassium supplements, as indicated

• Avoid giving KCl if urine output <0.5 mal/kgBW/hour

• Avoid intramuscular administration of potassium

• Avoid bolus administration of potassium

Education

• Advise dietary modifications high in potassium (eg bananas, leafy greens, tomatoes, chocolate), if necessary

Collaboration

Collaborationoral KCl administration (40-80 mEq in 100 ml NaCl) for 1 hour, in severe hypokalemia (<2.5 mEq/L), as indicated.

 

 

 

Electrolyte Management: Hypocalcemia

 

Definition

Identify and manage decreased serum calcium levels <8.5 mEq/L

Action

Observation

• Identify causes of decreased calcium levels (eg osteoporosis, pancreatitis, renal failure, vitamin D deficiency, chronic diarrhea)

• Identify clinical signs of hypocalcemia (eg tetany, numbness of the lips and fingers, muscle spasms in the face or extremities)

• Identify a history of taking calcium-depleting drugs (eg diuretics, antacids, aminoglycosides, caffeine, corticosteroids, phosphates, isoniazid)

• Monitor for decreased serum calcium levels

• Monitor fluid intake and output

• Monitor for side effects of calcium administration (eg digitalis poisoning, bradycardia, cardiac arrest, thrombophlebitis)

• Monitor for psychosocial symptoms (eg confusion, memory impairment, anxiety, psychotic behavior, depression, delirium, hallucinations)

• Monitor cardiovascular symptoms (eg decreased contractility, decreased cardiac output, hypotension, ST segment prolongation, prolonged QT interval, torsade de pointes)

• Monitor digestive symptoms (eg nausea, vomiting, constipation, abdominal pain)

• Monitor skin symptoms (eg eczema, alopecia, hyperpigmentation)

Therapeutic

• Maintain intravenous access

• Provide adequate vitamin D intake (eg vitamin supplements, meat)

Education

• Encourage increased calcium intake (eg salmon, sardines, fresh shellfish, beans, broccoli, spinach and supplements)

Collaboration

Collaborationcalcium, if necessary.

 

 

Electrolyte Management: Hypomagnesaemia

 

Definition

Identify and manage decreased serum magnesium levels <1.5 mEqL

Action

Observation

• Identify causes of decreased serum magnesium levels (eg hypokalemia, hypocalcemia)

• Identification of inadequate magnesium absorption (eg colonic resection surgery, pancreatic insufficiency, colonic inflammation)

• Monitor magnesium excretion (eg renal insufficiency, elderly)

• Monitor urinary excretion of excessive magnesium (eg diuretics, renal impairment, diabetic ketoacidosis)

• Monitor for side effects of parenteral magnesium administration (eg sweating, sensation of heat, hypocalcemia)

• Monitor for neuromuscular symptoms (eg weakness, leg cramps, paresthesias, tendon hyperactivity, dysphagia, nystagmus, seizures)

• Monitor central nervous system symptoms (eg lethargy, insomnia, agitation)

• Monitor for cardiovascular symptoms (eg sinus tachycardia, straight T wave, QRS widening, ectopic)

Therapeutic

• Establish intravenous access, if necessary

Education

• Encourage intake of magnesium-containing foods (eg green vegetables, legumes)

Collaboration

Collaborationcorrection of magnesium (eg magnesium sulfate, magnesium gluconate, magnesium lactate), if necessary.

 

 

 

Electrolyte Management: Hyponatremia

 

Definition

Identify and manage decreased serum or plasma sodium levels <135 mEq/L

Action

Observation

• Identify signs and symptoms of decreased sodium levels (eg disorientation, muscle twitching, headache, dry mucous membranes, postural hypotension, seizures, lethargy, loss of consciousness)

• Identification of causes of hyponatremia (eg diarrhoea, vomiting, nasogastric suctioning, fasting, hypertonic fluid infusion, polydipsia, SIADH, heart failure, primary hyperaldosteronism)

• Check for signs of fluid overload for indications of fluid restriction (eg orthopnea, dyspnea, edema, short-term increase in weight, increased JVP/CVP, positive hepatojugular reflex, additional breath sounds)

• Monitor fluid intake and output

• Monitor serum and/or urine sodium levels

• Monitor seizure symptoms in severe hyponatremia

Therapeutic

• Establish intravenous access, if necessary

• Calculate the sodium requirement with the formula: 0.6 × BB × (target Na - Na current)

• Perform fluid restriction (eg 1 L/24 hours), if necessary

• Give hypertonic NaCl (3% - 5%)

• Avoid correction of sodium more than 8 mEq in a 24-hour period

Education

• Encourage intake of foods containing sodium

Collaboration

Collaborationadministration of a high sodium diet, if necessary

Collaborationsodium correction, if necessary

Collaborationadministration of diuretics (eg furosemide 20-40 mg) in case of pulmonary congestion

 

 

 

Fecal Elimination Management

 

Definition

Identify and manage impaired faecal elimination patterns

Action

Observation

• Identification of bowel problems and use of laxatives

• Identification of medications that affect gastrointestinal conditions

• Monitor bowel movements (eg color, frequency, consistency, volume)

• Monitor for signs and symptoms of diarrhea, constipation, or impaction

Therapeutic

• Give warm water after eating

• Schedule defecation time with the patient

• Provide high-fiber foods

Education

• Describe the types of foods that help improve the regularity of intestinal peristalsis

• Encourage note the color, frequency, consistency, volume of feces

• Encourage increased physical activity, according to tolerance

• Encourage reduced intake of foods that increase gas formation

• Recommend consuming foods that contain high fiber

• Encourage increased fluid intake, if no contraindications

Collaboration

Collaborationadministration of anal suppositories, if necessary.

 

 

 

Urine Elimination Management

 

Definition

Identify and manage impaired urinary elimination patterns

Action

Observation

• Identify signs and symptoms of urinary retention or incontinence

• Identify factors causing urinary retention or incontinence

• Monitor urine elimination (eg frequency, consistency, aroma, volume and color)

Therapeutic

• Record times and urine output

• Limit fluid intake, if necessary

• Take a midstream urine sample or culture

Education

• Teach signs and symptoms of urinary tract infection

• Teach measuring fluid intake and urine output

• Teach taking midstream urine specimen

• Teach to recognize signs of urination and the right time to urinate

• Teach pelvic muscle strengthening therapy/urinary

• Encourage adequate drinking, if there are no contraindications

• Advise to reduce drinking before bed

Collaboration

Collaborationadministration of urethral suppositories, if necessary.

 

 

 

Energy Management

 

Definition

Identify and manage energy use to overcome or prevent fatigue and optimize the recovery process

Action

Observation

• Identify disorders of body function that cause fatigue

• Monitor physical and emotional exhaustion

• Monitor sleep patterns and hours

• Monitor location and discomfort during activities

Therapeutic

• Provide a comfortable environment and less stimulus (eg light, sound, visit)

• Passive and/or active range-of-motion exercises

• Provide relaxing distraction activities

• Facilitate bedside sitting, if unable to move or walk

Education

• Recommend bed rest

• Advise through activities gradually

• Advise to contact the nurse if signs and symptoms of fatigue do not subside

• Teach coping strategies to reduce fatigue

Collaboration

Collaborationwith a nutritionist on how to increase food intake.

 

 

 

Enuresis Management

 

Definition

Identify and manage voiding control capabilities

Action

Observation

• Identify the character of enuresis, urinary control abilities and constraints

Therapeutic

• Cover the mattress with bedding

• Limit fluid intake at night

• Schedule time to urinate with the patient

• Facilitation of diagnostic examination process (eg physical examination, cystoscopy, cystogram, laboratory)

Education

• Encourage urination before bed

• Encourage attention in the process of healing enuresis

Collaboration

Collaborationadministration of enuresis medication, if necessary.

 

 

 

Eating Disorder Management

 

Definition

Identify and manage poor diet, excessive exercise and/or excessive food and fluid expenditure

Action

Observation

• Monitor intake and output of food and fluids and caloric requirements

Therapeutic

• Weigh regularly

• Discuss eating behavior and appropriate amount of physical activity (including exercise)

• Perform behavioral contracts (eg target weight, behavioral responsibility)

• Accompany to the bathroom to observe the behavior of vomiting back food

• Provide positive reinforcement for target success and behavior change

• Give consequences if you don't reach the target according to the contract

• Plan a treatment program for home care (eg medical, counseling)

Education

• Encourage keeping a diary of feelings and situations that trigger food loss (eg intentional expulsion, vomiting, overactivity)

• Teach proper diet settings

• Teach coping skills for problem solving eating behavior

Collaboration

Collaborationwith a nutritionist about target weight, calorie requirements and food choices.

 

 

 

Hallucinations Management

 

Definition

Identify and manage security, convenience, and reality-oriented enhancements

Action

Observation

• Monitor behavior indicating hallucinations

• Monitor and adjust activity levels and environmental stimulation

• Monitor the content of hallucinations (eg violence or self-harm)

Therapeutic

• Maintain a safe environment

• Take safety measures when unable to control behavior (eg limit setting, territorial restrictions, physical restraint, exclusion)

• Discuss feelings and responses to hallucinations

• Avoid arguing about the validity of hallucinations

Education

• Encourage self-monitoring of the situation where the hallucinations occur

• Encourage talking to a trusted person for support and corrective feedback on hallucinations

• Encourage distraction (eg listening to music, engaging in activities and relaxation techniques)

• Teach patient and family how to control hallucinations

Collaboration

Collaborationadministration of antipsychotic and antianxiety drugs, if necessary.

 

 

 

Hemodialysis Management

 

Definition

Identify and manage the process of cleansing the blood of waste substances through filtering outside the body

Action

Observation

• Identify signs and symptoms and need for hemodialysis

• Identification of readiness for hemodialysis (eg vital signs, dry weight, fluid overload, contraindications to heparin administration)

• Monitor vital signs, signs of bleeding, and response during dialysis

• Monitor vital signs post hemodialysis

Therapeutic

• Prepare hemodialysis equipment (eg consumables, hemodialysis blood line)

• Perform dialysis procedures with aseptic principles

• Adjust filtration as needed to draw excess fluid

• Treat hypotension during dialysis

• Discontinue hemodialysis if life-threatening condition (eg shock)

• Take a blood sample to evaluate the effectiveness of hemodialysis

Education

• Explain the hemodialysis procedure

• Teach fluid restriction, insomnia treatment, prevention of HD access infection, and recognition of signs of worsening condition

Collaboration

Collaborationadministration of heparin in the blood line, as indicated.

 

 

Hemofiltration Management

 

Definition

Identify and manage patients with Hemofiltration

Action

Observation

• Identify the patient's condition (eg blood pressure, pulse, respiration and body temperature, weight, edema, fluid balance)

• Monitor hemodynamic status during the hemofiltration process

• Monitor ultrafiltration rate, hemodynamics and leakage

• Monitor for signs and symptoms of infection

• Monitor fluid intake and output every hour

Therapeutic

• Take blood samples for examination of kidney function, and electrolytes before therapy

• Use sterile technique to priming the hemofiltration blood line, when connecting the patient's arterial - blood line and vein

• Clear the hemofiltration circuit from air

• Administer heparin according to protocol

• Check the patency of blood line, arterial and venous connections

• Treat insertion site and tube according to protocol

• Stop hemofiltration if condition worsens

Education

• Explain the purpose and procedure of hemofiltration to patient and family.

 

 

 

Hyperglycemia Management

 

Definition

Identify and manage above normal blood glucose levels

Action

Observation

• Identify possible causes of hyperglycemia

• Identify situations that cause insulin requirements to increase (eg relapsing disease)

• Monitor blood glucose levels, if necessary

• Monitor for signs and symptoms of hyperglycemia (eg polyuria, polydipsia, polyphagia, weakness, malaise, blurred vision, headache)

• Monitor fluid intake and output

• Monitor urine ketones, blood gas analysis levels, electrolytes, orstatic blood pressure and pulse rate

Therapeutic

• Provide oral fluid intake

• Consult the media if signs and symptoms of hyperglycemia persist or worsen

• Facilitate ambulation if there is orthostatic hypotension

Education

• Recommend avoiding exercise when blood glucose levels are more than 250 mg/dL

• Advise self-monitoring of blood glucose levels

• Promote adherence to diet and exercise

• Teach indications and importance of urine ketone testing, if necessary

• Teach diabetes management (eg use of insulin, oral medications, monitor fluid intake, carbohydrate replacement, and professional help)

Collaboration

Collaborationadministration of insulin, if necessary

CollaborationIV fluids, if necessary

Collaborationpotassium, if necessary.

 

- Explain the effect of drugs on cancer cells and spinal cord function

- Advise diet as indicated (eg non-digestive, easy to digest, nutritious)

- Advise to report side effects of chemotherapy that are felt (eg fever, nosebleeds, excessive bruising, and mucus discharge)

- Teach how to prevent infection (eg limiting visits, washing hands)

- Teach relaxation and distraction techniques (imagination), as needed

- Teach energy management techniques, if necessary

- Teach managing fatigue by planning frequent breaks and limiting activitiesCollaboration

- Collaboration drug administration to control side effects (eg antiemetics)

 

 

Environmental Comfort Management I.08237

Definition

Identify dams, manage optimal environmental comfort.

Action

Observation

- Identify the source of discomfort (eg, room temperature, cleanliness)

- Monitor skin condition, especially in areas of protrusion (eg for signs of irritation or sores)

therapeutic

- Provide acceptance and beautification support to the smelly environment

- Place the bell in an easily accessible place

- Provide a quiet and supportive room

- Schedule social activities and visits

- Facilitate environmental comfort (eg regulate temperature, blankets, cleanliness)

- Get into a comfortable position (eg support with pillows, keep joints in motion)

- Avoid skin exposure to irritants (eg feces, urine)

Education

- Explain the objectives of environmental management

- Teach how to manage pain and injury, if necessary

 

 

Occupational Health Management I.14521

 

Definition

Identify and manage the work environment to improve worker health.

 

Action

Observation

- Identification of the worker's health (eg physical, mental, spiritual, social and behavioral functioning)

- Identification of standard occupational health procedures, administration and application of workplace regulations to standards

- Identification of risk factors for occupational diseases and accidents

- Monitor worker health regularly

Therapeutic

- Use labels or markings for substances or equipment that are hazardous to health

- Implement government programs related to occupational health

- Perform treatment in acute conditions

- Practice basic life support related to work-accident emergencies

Education

- Inform workers about substances or equipment that are harmful to health

- Teach about health and modification of a healthy work environment

Collaboration

- Refer to hospital for further treatment of work-related injuries and illnesses

 

 

 

Environmental Safety Management I.14513

 

Definition

Identify and manage the physical environment to improve safety

 

Action

Observation

- Identification of safety needs (eg physical condition, cognitive function and behavioral history)

- Monitor changes in environmental safety status

therapeutic

- Eliminate environmental safety hazards (eg physical, biological and chemical conditions), if possible

- Modify the environment to minimize hazards and risks

- Provide environmental safety aids (eg commode chair and handrails)

- Use protective devices (eg physical restraints, side rails, locked doors, fences)

- Contact authorities according to community issues (eg puskesmas, police, damakr)

- Relocation facility to a safe environment

- Conduct environmental hazard screening program (eg lead)

Education

- Teach individuals, deprivation and high risk groups of environmental hazards

 

 

 

Constipation Management I.04155

 

Definition

Identify and manage prevention and treat constipation/impact

Action

Observation

- Check for signs and symptoms of constipation

- Check bowel movements, stool characteristics (consistency, shape, volume and color)

- Identify risk factors for constipation (eg medications, bed rest and low fiber diet)

- Monitor for signs and symptoms of intestinal rupture and/or peritonitis

therapeutic

- Recommend a high-fiber diet

- Perform abdominal massage, if necessary

- Perform phase evaluation manually, if necessary

- Administer enemas or irrigation, if necessary

Education

- Explain the etiology of the problem and the rationale for action

- Encourage increased fluid intake, if there are no contraindications

- Practice bowel movements regularly

- Teach how to deal with constipation / impaction

Collaboration

- Consultation with the medical team about decreasing/increasing bowel sound frequency

- Collaborative use of split drugs, if needed

 

Environmental Management I.14514

 

Definition

Facilitate and manage the environment to obtain therapeutic benefits, and psychological well-being.

 

Action

Observation

- Identify the safety and comfort of the environment

therapeutic

- Arrange the position of the furniture neatly and affordable

- Set the appropriate ambient temperature

- Provide a clean and comfortable bed and environment

- Provide room deodorizer, if necessary

- Avoid direct exposure to the bathroom, toilet or equipment for elimination

- Change clothes regularly

- Avoid exposure to sunlight or unnecessary light

- Allow the family to stay with the patient

- Facilitate use of personal items (eg pajamas, robes, toiletries)

- Maintain consistency of health worker visits

- Give a bell or communication device to call the nurse

Education

- Explain how to create a safe home environment

- Explain how to deal with fire hazards

- Teach patients and families/visitors about infection prevention efforts

 

 

Communications Environmental Management I.14515

Definition

Identify and manage the physical, social, cultural, economic, and political environments that affect public health.

Action

Observation

- Perform skin health risks of environmental health problems

- Identification of known health risk risk factors

therapeutic

- Involve community participation in maintaining environmental security

Education

- Promote government policies to reduce disease risk

- Provide health education for risk groups

- Inform

Collaboration

- Collaboration in multidisciplinary teams to identify security threats in society

- Collaboration with other health teams in community health programs to address known risks

- Collaboration in the development of community action programs

- Collaboration with community groups in explaining government regulations

 

 

 

 

Environmental Manager: Preparing to Go Home I.14516

Definition

Identify and manage the home as a place to safely and effectively treat post-hospital patients

 

Action

Observation

- Identify the date and time of returning home

- Monitor the condition of the house to be ready to receive patients

therapeutic

- Prepare the necessary tools

- Prepare nursing progress notes

- Prepare notes on medicines, drug supplies, and utensils as needed

- Prepare the medicine you need at home

- Prepare an emergency response plan

- Do documentation of care

- Schedule visits for support personnel (eg clergy, social workers), if necessary

- Confirm arrangements for home transportation with a companion, if necessary

Education

- Prepare a health education plan at home as needed

Collaboration

- Consult the hospital nurse about home care

 

 

 

Medication Management I.14517

 

Definition

Identify and manage the use of pharmacological agents according to the treatment program.

Action

Observation

- Identify the use of onat according to the recipe

- Identify the expiration date of the drug

- Identification of knowledge and ability to undergo treatment programs

- Monitor the effectiveness and side effects of drug administration

- Monitor for signs and symptoms of drug poisoning

- Monitor serum blood (eg electrolytes, prothrombin), if necessary

- Monitor adherence to the treatment program

therapeutic

- Facilitate changes to treatment programs, if necessary

- Provide a visual and written source of information on treatment programs

- Facilitate patients and families to make lifestyle adjustments due to the treatment program

Education

- Teach patient and family how to administer medication (dose, storage, route and timing of administration)

- Teach how to handle or reduce side effects, if they occur

- Advise to contact health workers in case of drug side effects

 

Mood Management I.09289

Definition

Identify and manage safety, stabilization, recovery, and treatment of mood disorders (emotional states of a temporary nature).

Action

Observation

- Identify mood (eg signs, symptoms, medical history)

- Identify risks to the safety of yourself or others

- Monitri cognitive function (eg concentration, memory, decision-making ability)

- Monitor activity and environmental stimulation levels

therapeutic

- Facilitate the filling of self-report questionnaires (eg Bwck Depression Inventory, functional status scale), if necessary

- Provide opportunities to convey feelings in appropriate ways (eg sansack, art therapy, physical activity)

Education

- Explain about mood disorders and their treatment

- Advise active role in treatment and rehabilitation, if necessary

- Advise hospitalization as indicated (eg, safety risk, self-care deficit, social)

- Teach about triggers for mood disorders (eg, stressful situations, physical problems)

- Teach self-monitoring of mood (eg, level 1-10, journaling)

- Teach new clutch and problem solving skills

Collaboration

- Collaborate on taking medication, if necessary

- Refer for psychotherapy (eg behavior, relationships, interpersonal, family, group) if necessary

 

Nausea Manager I.03117

Definition

Identify and manage a bad feeling in the throat or stomach that can cause vomiting.

Action

Observation

- Identify the experience of nausea

- Identify nonverbal cues of discomfort (eg, infants, children, and those unable to communicate effectively)

- Identify the impact of nausea on quality of life (eg, appetite, activity, performance, role responsibilities, and sleep)

- Identification of factors causing nausea (eg, medications and procedures)

- Identification of antiemetics to prevent nausea (except nausea in pregnancy)

- Monitor nausea (eg, frequency, duration, and severity)

- Monitor nutritional and calorie intake

therapeutic

- Control environmental factors causing nausea (eg unpleasant odors, sounds and visual stimuli)

- Reduce or eliminate conditions that cause nausea (eg anxiety, fear, fatigue)

- Feed small and attractive amounts

- Give cold food, clear liquid, odorless and colorless, if necessary

Education

- Encourage rest and adequate sleep

- Encourage frequent mouth feeding, unless it stimulates nausea

- Encourage high-carbohydrate and low-fat meals

- Encourage use of non-pharmacological techniques to treat nausea (eg, biofeedback, hypnosis, relaxation, music therapy, acupressure)

Collaboration

- Collaborative administration of antiemetics, if necessary

 

 

 

 

Vomiting Management I.03118

 

Definition

Identify, prevent and manage the gastric expulsion reflex

 

Action

Observation

- identification of vomiting characteristics (eg color, consistency, presence of blood, time, frequency and duration)

- check vomit volume

- identification of dietary history (eg preferred, disliked and cultural foods)

- identification of factors causing vomiting (eg medication and procedures)

- identification of damage to the esophagus and posterior pharynx if vomiting is too long

- monitor the effect of vomiting management thoroughly

- Monitor fluid and electrolyte balance

Therapeutic

- control of environmental factors causing vomiting (eg, unpleasant odors, sounds, and unpleasant visual stimulation)

- reduce or eliminate conditions causing vomiting (eg, anxiety, acuteness)

- adjust position to prevent aspiration

- maintain a patent airway

- clean mouth and nose

- provide physical support during vomiting (eg help bending over or lowering the head)

- provide comfort during vomiting (eg cold compress on forehead, or provide dry and clean clothes)

- give fluids that do not contain carbonation at least 30 minutes after vomiting

Education

- recommend bringing a plastic bag to save vomiting

- recommend getting more rest

- encourage use of non-pharmacological techniques to manage vomiting (eg biofeedback, hypnosis, relaxation, music therapy, acupressure)

Collaboration

- Collaborative administration of antiemers, if necessary

 

 

 

Nephrostomy Manager I.04156

 

Definition

Identify and manage urine output via tube access from renal nephrons

 

Action

Observation

- monitor patent hose

- monitor for complications of nephrostomy placement (eg, bleeding, infection and signs of nephrostomy abnormalities (eg no urine, abdominal pain))

- monitoring the results of laboratory tests (eg kidney function and electrolytes)

- monitor daily fluid intake and output

therapeutic

- treat the insertion area according to the procedure

- perform irrigation nephrostomy, if necessary

- Empty the nephrostomy bag when it is 2/3 full

Education

- explain the signs of nephrostomy obstruction, bleeding and infection

- teach patient and family how to measure fluid intake and output

 

 

 

 

 

Nutrition Management I.03119

 

Definition

Identify and manage a balanced nutritional intake

 

Action

Observation

- identification of nutritional status

- identification of food allergies and intolerances

- identify your favorite food

- identification of calorie needs and types of nutrients

- identify the need for the use of a nasogastric tube

- monitor food intake

- weight monitor

- monitor the results of laboratory tests

therapeutic

- do oral hyglene before eating, if necessary

- facility to define dietary guidelines (eg food pyramid)

- serve food attractively and at the appropriate temperature

- feed high fiber to prevent constipation

- provide high-calorie and high-protein foods

- give dietary supplements, if necessary

- discontinue nasogastric tube feeding if oral intake can be tolerated

Education

- suggest a sitting position, if able

- recommend a programmed diet

Collaboration

- Collaborative administration of medication before meals (eg, pain relievers, antiemetics), if necessary

- Collaboration with nutritionists to determine the number of calories and types of nutrients needed, if necessary

 

 

Parenteral Nutrition Management I.03120

Definition

Identify and administer nutrition without going through the gastrointestinal tract but through the blood vessels

Action

Observation

- identification of indications for parenteral nutrition (eg impaired absorption of food, bowel rest, intestinal motility disorders, enteral route is not possible)

- an indication of the type of access required (eg peripheral, central)

 

 

 

 

Hyperthermia Management l.15506

 

Definition

Identify and manage increased body temperature due to thermoregulatory dysfunction.

Action

Observation

- Identify causes of hyperthermia (eg dehydration, exposure to hot environments, use of incubators)

- Monitor body temperature

- Monitor electrolyte levels

- Monitor urine output

- Monitor complications due to hyperthermia

Therapeutic

- Provide a cool environment

- Loosen or remove clothing - Wet and fan the body surface

- Give oral fluids

- Change linen every day or more often if you have hyperhidrosis (excessive sweating)

- Apply external cooling (eg hypothermic blanket or cold compress on forehead, neck, chest, abdomen, axilla)

- Avoid giving antipyretics or aspirin

- Give oxygen, if necessary

Education

- Recommend bed rest

Collaboration

- Collaboration of intravenous fluids and electrolytes, if necessary

 

 

Management of Hypervolemia l.03144

 

Definition

Identify and manage excess intravascular and extracellular fluid volume and prevent complications.

Action

Observation

- Check for signs and symptoms of hypervolemia (eg orthopnea, dyspnea, edema, JVP/CVP binding, positive hepatojugular reflex, additional breath sounds) - Identify causes of hypervolemia - Monitor hemodynamic status (eg heart rate, blood pressure, MAP, CVP, PAP , PCWP, CO, CI), if available - Monitor fluid intake and output - Monitor for signs of hemoconcentration (eg sodium levels, BUN, haemtrocyte, urine specific gravity) - Monitor for signs of increased plasma oncotic pressure (eg increased protein and albumin levels) - Monitor infusion rate closely - Monitor side effects of diuretics (eg orthostatic hypotension, hypovolemia, hypokalemia, hyponatremia)Therapeutic- Weigh every day at the same time - Limit fluid and salt intake - Elevate head of bed 30-40⁰CEducation- Advise to report if urine output <0.5 mL/kg/hour in 6 hours - Advise to report if weight gain >1 kg in a day - Teach how to measure and record fluid intake and output - Teach how to limit fluidsCollaboration- Collaboration in administering diuretics - Collaboration in replacing potassium loss due to diuretics - Collaboration in administering continuous renal replacement therapy (CRRT), if necessary

 

 

Management of Hypoglycemia l.03115

 

Definition

Identify and manage low blood glucose levels

Action

Observation- Identify signs and symptoms of hypoglycemia - Identify possible causes of hypoglycemiaTherapeutic- Give simple carbohydrates, if necessary - Give glucagon, if necessary - Give complex carbohydrates and protein according to diet - Maintain a patent airway - Maintain IV access, if necessary - Call emergency medical services, if necessaryEducation- Advise carrying simple carbohydrates at all times - Advise wearing appropriate emergency identification - Advise monitoring of blood glucose levels - Advise discussion with diabetes care team about adjusting medication regimen - Explain interactions between diet, insulin/oral agents, and exercise - Teach management of hypoglycemia (eg signs and symptoms, risk factors, and treatment of hypoglycemia) - Teach self-care to prevent hypoglycemia (eg reduce insulin/oral agents and/or increase food intake for exercise.Collaboration- Collaborative administration of dextorse, if necessary - Collaborative administration of glucagon, if necessary

 

 

Hypothermia Management l.14507

 

Definition

Identify and manage body temperature below normal range

Action

Observation

- Monitor body temperature

- Identification of causes of hypothermia (eg exposure to low environmental temperatures, light clothing, hypothalamic damage, decreased metabolic rate, subcutaneous fat deficiency)

- Monitor for signs and symptoms due to hypothermia (mild hypothermia: tachypnea, dysarthria, chills, hypertension, diuresis; moderate hypothermia: arrhythmia, apathy, coagulopathy, decreased reflexes; severe hypothermia: oliguria, absent reflexes, pulmonary edema, abnormal acid-base)

Therapeutic

- Provide a warm environment (eg adjust room temperature, incubator)

- Change wet clothes and/or linen

- Perform passive heating (eg blankets, head coverings, heavy clothing)

- Lakukan penghangatan aktif eksternal (mis. kompres hangat, botol hangat, selimut hangat, perawatan metode kangguru)

- Lakukan penghangatan aktif internal (mis. infus cairan hangat, oksigen hangat, lavase peritoneal dengan cairan hangat)

Edukasi

- Anjurkan makan/minum hangat

 

 

Manajemen Hipovolemia l.03116

 

Definisi

Mengidentifikasi dan mengelola penurunan volume cairan intravaskuler

Tindakan

Observasi - Periksa tanda dan gejala hipovolemia (mis. frekuensi nadi meningkat, nadi teraba lemah, tekanan darah menurun, tekanan nadi menyempit, turgor kulit menurun, membran mukosa kering, volume urin menurun, hematokrit meningkat, haus, lemah) - Monitor intake dan output cairan Terapeutik - Hitung kebutuhan cairan - Berikan posisi modified Trendelenburg - Berikan asupan cairan oral Edukasi- Advise to increase oral fluid intake - Advise to avoid sudden position changesCollaboration- Collaborative administration of isotonic IV fluids (eg NaCl, RL) - Collaborative administration of hypotonic IV fluids (eg glucose 2.5%, NaCl 0.4%) - Collaboration administration of colloid fluids (eg albumin, Plasmanate) - Collaboration product administration blood

 

 

Immunization/Vaccination Management l.14058

 

Definition

Identify and manage active and passive immune administration

Action

Observation- Identification of medical history and history of allergies - Identification of contraindications to immunization (eg anaphylactic reactions to previous vaccines and/or severe illness with or without fever) - Identification of immunization status at each visit to health servicesTherapeutic- Give the baby an injection in the anterolateral thigh - Document vaccination information (eg manufacturer's name, expiration date) - Schedule immunizations at appropriate time intervalsEducation- Explain the purpose, benefits, reactions that occur, schedule, and side effects - Inform immunizations that are required by the government (eg Hepatitis B, BCG, diphtheria, tetanus, pertussis, H. influenza, polio, measles, measles, rubella) - Inform immunizations that protects against diseases but which are not currently required by the government (eg influenza, pneumococcal) - Inform vaccinations for special events (eg, rabies, tetanus) - Inform the delay of immunization does not mean repeating the immunization schedule again - Inform National Immunization Week service providers who provide free vaccine

 

 

Urinary Incontinence Management l.04154

 

Definition

Identify and manage patients with urinary incontinence

Action

Observation- Identify causes of urinary incontinence (eg impaired cognitive function, spinal cord injury, medications, age, surgery history) - Identify feelings and perceptions of urinary incontinenceTherapeutic- Provide clothing and an environment that supports the urinary incontinence program - Take a urine sample for a complete urine examination or cultureEducation- Explain the definition, types and causes of urinary incontinence - Discuss the urinary incontinence program (eg schedule drinking and urination, taking diuretics, strengthening exercises for urinary muscles)Collaboration- Collaboration with medical and physiotherapists to treat urinary incontinence, if necessary

 

 

Isolation Management l.14509

 

Definition

Identify and manage patients who are at risk of transmitting disease, injuring or harming others

Action

 Observation- Identify patients requiring isolation (eg - Screen isolated patients with criteria (eg cough >2 weeks, temperature >37°C, travel history from endemic areas)Therapeutic- Place one patient for one room - Put standard awareness posters on patient room doors - Provide all daily necessities and simple checks in patient rooms - Docontaminate medical equipment as soon as possible after use - Perform hand hygiene at 5 moments (eg before contact with the patient, before aseptic procedures, after contact with the patient, after contact with the patient's body fluids after contact with the patient's environment) - Put on personal protective equipment according to SOP (eg gloves, mask, apron)

- Remove personal protective equipment immediately after contact with the patient - Dress yourself and wash at 60°C - Put linens that have been exposed to body fluids in the infectious trolley - Minimize patient contact, as needed - Clean room and surroundings at all times days with disinfectant (eg 0.5% chlorine) - Limit patient transportation as necessary - Wear a mask during the transportation process - Limit patient visitors - Ensure patient rooms are always under negative pressure - Avoid visitors under 12 years oldEducation- Teach family and visitors hand hygiene - Advise family/visitors to report before going to patient's room - Advise family/visitors to perform hand hygiene before entering and after leaving the room

 

 

Airway Management l.01011

 

Definition

Identify and manage a patent airway.

Action

Observation

- Monitor breathing patterns (frequency, depth, effort of breathing)

- Monitor additional breath sounds (eg, gurgling, wheezing, wheezing, dry ronkhi) - Monitor sputum (amount, color, smell)Therapeutic

- Maintain a patent airway with head-tilt and chin-lift (jaw-thrust if cervical trauma is suspected)

- Position semi-Fowler or Fowler

- Give warm drink

- Perform chest physiotherapy, if necessary, suction mucus for less than 15 seconds

- Perform hyperoxygenation before endotracheal suctioning

- Remove blockage of solid objects with McGill forceps

- Give oxygen, if necessary

Education

- Recommend fluid intake 2000 ml / day if not contraindicated

- Teach effective coughing techniques

Collaboration

- Collaborative administration of bronchodilators, expectorants, mucolytics, if necessary,

 

 

Artificial Airway Management l.01012

 

Definition

Identify and manage endotracheal tube and tracheostomy

Action

Observation- Monitor the position of the endotracheal tube (ETT), especially after changing positions - Monitor the ETT balloon pressure every 4-8 hours - Monitor the skin of the tracheostomy stoma area (eg redness, drainage, bleeding)Therapeutic- Reduce balloon pressure periodically every shift - Insert oropharyngeal airway (OPA) to prevent ETT biting - Prevent ETT from kinking - Give 100% pre-oxygenation for 30 seconds (3-6 ventilations) before and after inhalation - Give volume pre-oxygenation (bagging or mechanical ventilation) 1.5 times the tidal volume - Perform mucus suctioning for less than 15 seconds if needed (not on a regular basis) - Change ETT fixation every 24 hours - Change ETT position alternately (left and right) every 24 hours hours - Perform oral care (eg with toothbrush, gauze, lip balm) - Perform tracheostoral stoma treatmentEducation- Explain the patient and/or family the purpose and procedure for inserting an artificial airwayCollaboration- Collaborate on re-intubation if a mucous plug is formed that cannot be suctioned.

 

 

Case Management l.14510

 

Definition

Coordinate the care of certain patients to reduce costs, reduce the use of resources and improve the quality of health services and achieve the expected results

Action

Observation- Identify patients who require case management (eg high cost, high volume, high risk) - Identify required resources or services - Monitor cost effectiveness of careTherapeutic- Obtain patient or family consent to be involved in case management programs - Build relationships with patients, families and other health workers, as needed Use effective communication with patients, families and other health workers - Check patient's health status - Determine desired outcomes achieved by considering input from the patient/family - Determine the nursing plan to be implemented taking into account input from the patient/family - Advocacy for the patient, if necessary - Modify the nursing plan to increase cost effectiveness, if necessary - Document all case management activities - Document effectiveness case management feeEducation- Explain the role of the case manager to patients and families - Teach patients and families the importance of self-careCollaboration- Coordinate patient care with other health professionals (eg other nurses, doctors, social workers, physiotherapists)

 

 

Management of Unwanted Pregnancy l.07216

 

Definition

Identify and manage decision-making regarding unplanned pregnancies

Action

Observation- Identify values ​​and beliefs about pregnancy - Identify choices about pregnancy

Therapeutic

- Facilitation of expressing feelings

- Discuss the values ​​and false beliefs about pregnancy - Discuss the conflicts that occur with the presence of pregnancy

- Facilitate developing problem solving techniques

- Provide pregnancy counseling

- Facilitation of identifying support systems

Education

- Inform the importance of improving nutritional status during pregnancy

- Inform the changes that occur during pregnancy

Collaboration

- Refer if experiencing pregnancy complications

 

 

Seizure Management l.06193

 

Definition

Identify and manage muscle contractions and uncontrolled movements

Action

Observation

- Monitor for recurrent seizures

- Monitor seizure characteristics (eg motor activity, and seizure progression)

- Monitor neurological status

- Monitor vital signs

Therapeutic

- Lay the patient so as not to fall

- Provide a soft pad under the head, if possible

- Maintain a patent airway

- Loosen clothes, especially around the neck

- Accompany during seizure period

- Keep away dangerous objects, especially sharp objects

- Record the duration of the seizure Reorient after the seizure period

- Document the period of occurrence of seizures

- Install IV access, if necessary - Give oxygen, if necessary

Education

- Instruct the family to avoid putting anything into the patient's mouth during the seizure period

- Advise the family not to use violence to restrain the patient's movement

Collaboration

- Collaborative administration of anticonvulsants, if necessary

 

 

Chemotherapy Management l.14511

 

Definition

Identify and manage administration of antineoplastic agents

Action

Observation- Check conditions before chemotherapy - Monitor side effects and toxic effects of treatment (eg hair loss, sexual dysfunction) - Monitor nausea and vomiting due to chemotherapy - Monitor nutritional status and weightTherapeutic- Avoid aspirin products - Limit environmental stimuli (eg sound, light, and smell) - Provide adequate fluid intake - Perform hair care measures (eg avoid extreme milk, comb gently) - Plan alternative replacements for hair loss (eg wigs) , scarf, hat, turban) - Give chemotherapy drugs according to the programEducation- Explain the purpose and procedure of chemotherapy - Explain the effect of drugs on cancer cells and spinal cord function - Advise diet as indicated (eg non-digestive, easy to digest, nutritious) - Advise to report side effects of chemotherapy felt (eg fever, nosebleeds, excessive bruising, and mucus discharge) - Teach how to prevent infection (eg limiting visits, washing hands) - Teach relaxation and distraction (imagination) techniques, as needed - Teach energy management techniques, if necessary - Teach managing fatigue by planning frequent breaks and limit activities

 

Pain Management I.08238

Definition

Identify and manage sensory or emotional experiences associated with tissue or functional damage of sudden or slow turnover and of mild to severe and constant intensity.

Action

Observation

- Identify the location, characteristics, duration, frequency, quality, intensity of pain

- Identify pain scale

- Identify non-verbal pain responses

- Identify factors that aggravate and relieve pain

- Identify knowledge and beliefs about pain

- Identify the influence of culture on pain response

- Identify the effect of pain on quality of life

- Monitor the success of complementary therapies that have been given

- Monitor side effects of using analgesics

Therapeutic

- Provide non-pharmacological techniques to reduce pain (eg TENS, hypnosis, acupressure, music therapy, biofeedback, massage therapy, aroma therapy, guided imagination techniques, warm/cold compresses, play therapy)

- Control of environmental aggravating pain (eg room temperature, lighting, noise)

- Facilitate rest and sleep

- Consider the type and source of pain in the selection of pain relief strategies

Education

- Explain the causes, periods, and triggers of pain

- Explain pain relief strategies

- Advise self-monitoring of pain

- Advise use of analgesics appropriately

- Teach non-pharmacological techniques to reduce pain

Collaboration

- Collaborative administration of analgesics, if necessary

 

Overdose Management I.14518

Definition

Identify and manage patients who show toxic effects from taking one or more drugs.

Action

Observation

- Monitor respiratory, cardiac, gastrointestinal, renal, and neurological status

- Monitor vital signs

- Monitor for specific symptoms of the drug being taken (eg pupillary constriction, hypotension, and bradycardia for opiate overdose; nausea, vomiting, diaphoresis, right upper quadrant pain 48-72 hours after acetaminophen overdose; pupillary dilation, tachycardia, seizures, and chest pain in cocaine overdose)

- Monitor suicidal tendencies

Therapeutic

- Keep the airway open

- Adjust in proper position (eg bedside rails, position bed low, keep dangerous objects away, place security personnel close to patient room)

- Perform toxicological screening and system function tests (eg. Screening of urine and serum drugs, arterial blood gases, electrolyte levels, liver enzymes, blood urea nitrogen, creatinine). If necessary

- Install intravenous access

- Treat hyperthermia (eg ice packs in hyperthermia due to amphetamine or cocaine intoxication)

- Overcome hallucinations or delusions

- Convey that the nurse understands the patient's fears or other feelings

- Build good rapport with patient and family (e.g. use a non-judgmental approach)

Education

- Instruct the family to carry out follow-up care according to the patient's needs

- Teach prevention of aspiration and seizures to families and caregivers

- Teach how to minimize the potential for accidental overdose (eg keep medicines in containers, deal with consumption or memory problems, and keep medicines out of reach of children)

- Teach proper use of drugs

Collaboration

- Coordination with craft control center for definitive treatment

- Collaborative administration of specific agents (eg antiemetics, naloxone, thiamine, glucose, flumazenil, calcium, vasopressors, antiarrhythmics, inotropics)

- Collaborative administration of agents or procedures to minimize drug absorption and increase drug excretion (eg Ipecac, activated charcoal, gastric lavage, hemodialysis, laxatives, transfusion, changing urine and serum pH, intestinal irrigation)

 

 

Anger Control Management I.14518

Definition

Identify and manage angry expressions in an adaptive and nonviolent way.

Action

Observation

- Identify causes/triggers of anger

- Identify behavioral expectations for angry expressions

- Monitor the potential for non-constructive aggression to act before being aggressive

- Monitor progress by generating data, if necessary

Therapeutic

- Use a calm or reassuring approach

- Facilitate adaptive expression of anger

- Prevent physical damage from angry expressions (eg using weapons)

- Prevent aggression-inducing activities (eg punching bags, pacing, over-exercising)

- Perform external controls (eg restraint, time out, and exclusion), if necessary

- support implementing anger control strategies and adaptive anger expression

- Provide reinforcement for the successful implementation of anger control strategies

Education

- Explain the meaning, function of anger, frustration, and angry response

- Advise to ask the nurse or family for help when tension increases

- Teach strategies to prevent maladaptive angry expressions

- Teach methods to modulate strong emotional experiences (eg assertive exercises, relaxation techniques, journaling, energy channeling activities)

Collaboration

- Collaboration of drug administration, if necessary

Hormone Replacement Management I.07217

Definition

Identify and manage supplemental hormone administration

Action

Observation

- Identify reasons for choosing hormone replacement therapy

- Identify medical history and use of hormone therapy

- Identification of alternative hormone replacement therapy

- Monitor side effects of hormone replacement therapy

- Monitor vital signs

Therapeutic

- Take samples for investigation (laboratory)

- Facilitate the decision to continue or stop hormone replacement therapy

- Facilitate changes to hormone replacement therapy with primary health care providers

Education

- Explain the benefits and side effects of hormone replacement therapy

- Teach how to use hormone replacement

- Teach how to recognize the side effects of hormone replacement therapy

 

 

I.09325

Management of Increased Intracranial Pressure

Definition

Identify and manage increased pressure in the cranial cavity

Action

Observation

- Identify causes of increased ICP (eg metabolic disturbances, cerebral oedema)

- Monitor for signs of increased ICP symptoms (eg increased blood pressure, dilated pulse pressure, bradycardia, irregular breathing patterns, decreased consciousness)

- Monitor MAP (Mean Arterial Pressure)

- Monitor CVP (Central Venous Pressure)

- Monitor PAWP, if necessary

- Monitor PAP, if necessary

- Monitor ICP (intracranial pressure)

- Monitor CCP (cerebral perfusion pressure)

- ICP wave monitor

- Monitor respiratory status

- Monitor fluid intake and output

- Monitor cerebro-spinal fluid (eg color, consistency)

Collaboration

- Collaboration of sedation and anticonvulsants, if necessary

- Collaborative administration of osmotic diuretics, if necessary

- Collaboration in providing stool softeners, if necessary

 

 

I.09291

Substance Abuse Management

Definition

Identify and manage patients who show toxic effects as a result of taking one or more drugs

Action

Observation

- Identify causes of dependence or substance abuse

- Identification of ineffective denial behavior

- Check for signs and symptoms of intoxication

- Check patients and their luggage randomly

Therapeutic

- Meet basic needs such as security, personal hygiene, comfort, quiet environment

- Fix misconceptions, don't blame others

- Maintain self-discipline with strict supervision

- Put limits on manipulative behavior

- Limit access to substance use

- Consistently, non-judgmentally and punitive

Education

- Destroy focuses on the present and future, not the past

- Advise patient and family to follow strict hospital rules effectively (e.g. not to smuggle substances)

- Suggest to join the group program

- Advise for regular outpatient treatment and adhere to medication when going home

- Teach relapse prevention skills, supportive skills and developmental tasks

- Explain the dangers of using invasive devices to enter the body (eg abscess, HIV)

Collaboration

- Collaboration in the provision of substitution therapy according to indications

 

 

I.02040

Bleeding Management

Definition

Identify and manage blood loss when bleeding occurs

Action

Observation

- Identify the cause of bleeding

- Check for blood in vomit, sputum, feces, urine, NGT discharge, and wound drainage, if necessary

- Check the size and characteristics of the hematoma, if any

- Monitor the occurrence of bleeding (nature and amount)

- Monitor hemoglobin and hematocrit values ​​before and after blood loss

- Monitor blood pressure and hemodynamic parameters (central venous pressure and pulmonary capillary or arterial wedge pressure), if any

- Monitor fluid intake and output

- Monitor blood coagulation (prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation, and platelet count), if any

- Monitor tissue oxygen delivery (eg PaO2, SaO2, hemoglobin and cardiac output)

- Monitor signs and symptoms of massive bleeding

Therapeutic

- Rest the area that is bleeding

- Give a cold compress, if necessary

- Apply pressure or pressure dressing, if necessary

- Elevate bleeding externalities

- Maintain IV access

Education

- Explain the signs of bleeding

- Advise to report if you find signs of bleeding

- Recommend limiting activity

Collaboration

- Collaborative fluid administration, if necessary

- Collaboration of blood transfusion, if necessary

 

 

I.02041

Management of Late Pregnancy Bleeding

Definition

Identify and manage vaginal blood loss 500 cc at 20 weeks gestation or more

Action

Observation

- Identify history of blood loss (eg number, pain and presence of blood clots)

- Identify the cause of bleeding loss

- Identify a history of bleeding in late pregnancy (eg Abruption, PIH, and placenta previa)

- Identification of estimated gestational age using HPHT (first day of last menstrual period) and ultrasound (gestational age, TBJ, and location of the placenta)

- Identify obstetric history, if necessary

- Examine the perineum to assess the color, amount, consistency and odor of bleeding (COCA: color, odor, consistency, amount)

- check for uterine contractions or increased strength of uterine muscle tone

- Monitor maternal vital signs based on blood loss

- FHR monitor (eg frequency, strength, rhythm in 1 minute)

- Monitor intake and output

- Monitor CTG for uteroplacental insufficiency (eg decelerations, decreased variability, and no accelerations found)

- Monitor the results of ultrasound examinations (eg location of the placenta, gestational age, condition of the fetus)

Therapeutic

- Fetal resuscitation if there are signs of uteroplacental insufficiency

- Install the intravenous line

- Give oxygen, if necessary

- (IV line, oxygen, preparation for transfusion)

- Facilitation of bed rest or activity restriction

- Position the lower extremities higher

- Prepare for labor, if necessary (threatening both mother and fetus)

Education

- Advise to reduce bleeding risk (eg smoking restriction, abstinence from sex, bed rest, constipation management)

- Teach how to recognize old and new bleeding

Collaboration

- Collaborative fluid administration, if necessary

- Collaboration of blood transfusion, if necessary

 

 

I.02042

Management of Antepartum Bleeding is Maintained

Definition

Identify and manage manageable bleeding in pregnancy

Action

Observation

- Identify history of blood loss (eg number, pain and presence of blood clots)

- Identify the cause of bleeding

- Identify history related to bleeding in early pregnancy

- Identification of estimated gestational age using HPHT (first day of last menstrual period) and ultrasound (gestational age, TBJ, and location of the placenta)

- Identify obstetric history, if necessary

- Examine the vagina to assess the color, amount, consistency and smell of bleeding (COCA: color, odor, consistency, and amount)

- check for uterine contractions or increased strength of uterine muscle tone

- Monitor maternal vital signs based on blood loss

- Monitor CTG for uteroplacental insufficiency (eg decelerations, decreased variability, and no accelerations found)

- Monitor fluid intake and output

Therapeutic

- Position the lower extremities higher

- Install IV Line

- Give oxygen, if necessary

- Perform fetal resultifation if there are signs of uteroplacental insufficiency

Education

- Advise bed rest until bleeding stops

- Advise to reduce bleeding risk (eg smoking restriction, abstinence from sex, bed rest, constipation management)

- Teach how to recognize old and new bleeding

Collaboration

- Collaborative fluid administration, if necessary

- Collaboration of blood transfusion, if necessary

 

 

I.02043

Management of Antepartum Bleeding Not Maintained

Definition

Identifying and managing bleeding in untenable pregnancy

Action

Observation

- Identify history of blood loss (eg number, pain and presence of blood clots)

- Identify the cause of bleeding loss

- Identification of estimated gestational age using HPHT (first day of last menstrual period) and ultrasound (gestational age, TBJ, and location of the placenta)

- Identify obstetric history, if necessary

- Examine the vagina to assess the color, amount, consistency and smell of bleeding (COCA: color, odor, consistency, and amount)

- check for uterine contractions or increased strength of uterine muscle tone

- Monitor maternal vital signs based on blood loss

- Monitor intake and output

Therapeutic

- Position the lower extremities higher

- Position the lower extremities higher

- Install IV Line

- Give oxygen, if necessary

- Facilitation of accepting the grieving and loss process

Education

- Advise to reduce bleeding risk (eg smoking restriction, abstinence from sex, bed rest, constipation management)

- Teach how to recognize old and new bleeding

Collaboration

- Collaborative fluid administration, if necessary

- Collaboration of blood transfusion, if necessary

- Collaborative curettage, if necessary

I.02044

Vaginal Bleeding Management

Definition

Identify and manage vaginal blood loss

Action

Observation

- Identification of maternal complaints (eg profuse bleeding, dizziness, blurred vision)

- Monitor the condition of the uterus and abdomen (eg TFU above the umbilicus, feels soft, lumps)

- Monitor consciousness and vital signs

- Monitor blood loss

- Monitor hemoglobin levels

Therapeutic

- Position supine or trendelenburg

- Install pulse oximetry

- Give oxygen via nasal cannula 3 liters per minute

- Install the IV line with a transfusion set tube

- Insert a catheter to empty the bladder

- Take blood for a complete blood count

Collaboration

- Collaborative administration of uterotonics

- Collaborative administration of anticoagulants

 

Anaphylactic Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet the needs of the tissues caused by blocked blood vessels due to allergic reactions and histamine production.

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP, MAP)

- Monitor oxygenation status (pulse oximetry, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Monitor level of consciousness and pupillary response

Therapeutic

- Maintain a patent airway

- Administer oxygen to maintain oxygen saturation > 94%

- Preparation for intubation and mechanical ventilation, if necessary

- Give shock position (modified Trendelenberg)

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression, if necessary

Collaboration

- Collaborative administration of epinephrine

- Collaborative administration of dipenhydramine, if necessary

- Collaborative administration of bronchodilators, if necessary

- Collaborative cricothyroidotomy, if necessary

- Collaborative endotracheal intubation, if necessary

- Collaboration of fluid resuscitation, if necessary

 

 

Hypovolemic Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet tissue needs due to excessive fluid/blood loss.

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP, MAP)

- Monitor oxygenation status (oximetry, pulse, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Check the level of consciousness and pupil response

- Check the entire body surface for the presence of DOTS (deformity, open wound / open wound, tendemess / tenderness, swelling / swelling)

 Therapeutic

- Maintain a patent airway

- Give oxygen to maintain oxygen saturation > 94%

- Preparation for intubation and mechanical ventilation, if necessary

- Perform direct pressure (direct pressure) on external bleeding

- Give shock position (modified Trendelenberg)

- Install a large IV line (eg number 14 or 16 )

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression

- Take blood samples for complete blood and electrolyte checks

Collaboration

- Collaboration of 1-2 L crystalloid fluid infusion in adults

- Collaborative administration of crystalloid fluid infusion of 20 mL/kg BW in children

- Collaboration of blood transfusion, if necessary

 

 

Cardiogenic Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet tissue needs due to decreased heart pumping function.

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP, MAP)

- Monitor oxygenation status (pulse oximetry, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Monitor level of consciousness and pupillary response

- Check the entire body surface for the presence of DOTS (deformity, open wound / open wound, tendemes / tenderness, swelling / swelling)

- 12 lead ECG monitor

- Monitor chest X-ray (eg, pulmonary congestion, pulmonary edema, cardiac enlargement)

- Monitor cardiac enzymes (eg, CK, CKMB, Troponin)

- Identify the root cause of the problem (eg, volume, pump or cadence)

Therapeutic

- Maintain a patent airway

- Administer oxygen to maintain oxygen saturation > 94%

- Preparation for intubation and mechanical ventilation, if necessary

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression, if necessary

Collaboration

- Collaboration inotropic administration (eg, dobutamine), if TDS 70-100 mmHg without signs / symptoms of shock

- Administer oxygen to maintain oxygen saturation > 94%

- Preparation for intubation and mechanical ventilation, if necessary

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression

Collaboration

- Collaborative administration of vasopressors (eg, phenylephrine)

- Collaborative administration of atropine to treat bradycardia, if necessary)

- Collaborative administration of methylprednisolone

 

 

Obstructive Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet tissue demands caused by restriction of right ventricular diastolic filling due to compression of the heart (eg, cardiac tamponade, orax tension pneumothus, or pulmonary embolism).

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP, MAP)

- Monitor oxygenation status (pulse oximetry, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Monitor level of consciousness and pupillary response

- Check the entire body surface for DOTS (deformity, open wound, tendemess/tenderness, swelling/swelling)

- Identify the cause as early as possible

Therapeutic

- Maintain a patent airway

- Give oxygen to maintain oxygen saturation > 94%

- Preparation for intubation and mechanical ventilation, if necessary

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression

- Take blood samples for complete blood count, electrolytes and coagulation

Collaboration

- Collaboration pericardiocentesis, if cardiac tamponade

- Collaboration needie decompression or chest tube, if tension pneumothorax

- Collaboration antithrombolytic therapy, if pulmonary embolism

 

 

Septic Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet tissue requirements caused by massive infection and release of endotoxins.

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP, MAP, CVP)

- Monitor oxygenation status (pulse oximetry, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Monitor level of consciousness and pupillary response

- Check the entire body surface for DOTS (deformity, open wound, tendemess/tenderness, swelling/swelling)

- Monitor culture (eg, blood, exudate, urine, sputum)

Therapeutic

- Maintain a patent airway

- Administer oxygen to maintain oxygen saturation > 94%

- Preparation for intubation and mechanical ventilation, if necessary

- Preparation for intubation and mechanical ventilation, if necessary

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression, if necessary

Collaboration

- Collaboration inotropic administration (eg, dobutamine), if TDS 70-100 mmHg without signs / symptoms of shock

- Collaborative administration of vasopressors (eg, dopamine), if the TDS 70-100 mmHg is accompanied by signs/symptoms of shock

- Collaborative administration of strong vasopressors (eg, norepinephrine), if TDS < 70 mmHg

- Collaborative administration of antiarrhythmics, if necessary

- Collaboration intra-aortic pump, if necessary

 

 

 

 

 

Neurogenic Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet tissue needs caused by massive blood vessel dilation due to spinal injury and loss of sympathetic tone.

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP, MAP)

- Monitor oxygenation status (pulse oximetry, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Monitor level of consciousness and pupillary response

- Monitor hypothermia due to hypothalamic dysfunction

- Check the entire body surface for the presence of y (deformity, open wound / open wound, tendemess / tenderness, swelling / swelling

Therapeutic

- Maintain a patent airway

- Perform spinal stabilization (eg, cervical collar)

- Give oxygen to maintain oxygen saturation > 94

- Preparation for intubation and mechanical ventilation, if necessary

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression

 

 Collaboration

- Collaborative administration of vasopressors (eg, phenylephrine)

- Collaborative administration of antropine to treat bradycardia, if necessary)

- Collaborative administration of methylprednisolone

 

 

Health Technology Management

Definition

Identify and manage various technology tools to monitor, improve or maintain health.

Action

Observation

- Identify the use of equipment to support patient health

- Monitor the effect of using equipment on the patient's physiological, psychological, and social functions

Therapeutic

- Provide standby or emergency equipment, if necessary

- Change or replace patient care equipment, according to protocol

- Keep equipment in good condition

- Calibrate equipment regularly, according to protocol

- Store emergency equipment in an easy-to-reach place

- Verification of data downloaded from biomedical equipment to electronic health records

- Display clinical summary and trend analysis of data related to patient's condition

- Compare the patient's condition data obtained from the confinement with the results of the nurse's assessment

- Ethical decision-making facilities regarding the use of life support equipment, if necessary

- Interaction facilities between family members and patients receiving life support equipment

Education

- Explain the potential risks and benefits of using the equipment

- Teach how to operate the equipment

Collaboration

- Collaboration with electromedics to check equipment regularly, if necessary

- Consultation with other health professionals regarding recommendations for appropriate equipment for patients

 

 

Reproductive System Technology Management

Definition

Identify and manage various infertility technologies safely and effectively.

Action

Observation

- Check follicular growth with ultrasound

Therapeutic

- Prepare for embryo transfer

- Take a pregnancy test

Education

- Explain the risks, possibility of miscarriage, ectopic pregnancy and ovarian hyperstimulation

- Describe the symptoms of ovarian hyperstimulation

- Describe treatment modalities (eg, intrauterine insemination in vitro fertilization-embryo transfer (IVF-ET), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT)

- Teach ovulation prediction and detection techniques (eg basal and urine tests)

- Teach giving ovulation stimulants

 Collaboration

- Collaboration in the implementation of screening with the in vitro fertilization team

- Refer to preconception counselling, if necessary

- Refer genetic counseling, if necessary

- Refer to infertility support group, if necessary

 

 

Radiation Therapy Management

Definition

Identify and manage side effects of radiation treatment.

Action

Observation

- Monitor side effects and toxic effects of therapy

- Monitor changes in skin integrity

- Monitor anorexia, nausea, vomiting, taste changes, esophagitis, and diarrhea

- Monitor for signs and symptoms of systemic infection, anemia, and bleeding

 Therapeutic

- Provide skin care in case of infection

- Limit visits

Education

- Explain the purpose and procedure but radiation

- Explain the effects of radiation on malignant cells

- Explain protection protocols to patients, families, and visitors

- Recommend cleaning the mouth using a dental cleaning tool, if necessary

- Encourage adequate fluid intake and nutrition

- Teach how to deal with fatigue by planning rest periods and limiting activities

- Teach how to prevent infection (eg, avoiding crowds, maintaining hygiene, and washing hands)

Collaboration

- Collaborative drug administration or control of side effects (eg, antiemetics)

 

 

Rape Trauma Management

Definition

Identify and manage emotional and physical support after a rape has occurred.

Action

Observation

- Identify whether you have cleaned up after rape

- Identification of mental status, physical condition (eg, clothing, dirt, and debris), occurrence, evidence of abuse, and gynecological history

- Identify cuts, bruises, bleeding, lacerations, or other signs of physical injury

Therapeutic

- Provide assistance during treatment

- Perform rape screening procedures (eg label, store soiled clothing, vaginal secretions and hair)

- Secure samples as evidence of legal proceedings, if necessary

- Perform Crisis intervention, if necessary

- Offer pessary medication and prophylactic antibiotics

- Refer to rape advocacy program

- Documentation according to protocol

Education

- Describe the legal process available

- Explain the procedure of rape examination and informed consent action

Collaboration

- Collaboration HIV testing, if indicated

 

 

Thrombolytic Management

Definition

Identify and manage the use of drugs to destroy or dissolve blood clots (thrombus).

Action

Observation

- Check for contraindications to thrombolytic therapy (eg, history of trauma or surgery, stroke, neurosurgery in the last 2 months, gastrointestinal ulcers)

- Monitor blood pressure (every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours and every 60 minutes for the next 16 hours)

- Monitor the insertion site for signs of bleeding or haematoma (eg, every 15 minutes for the first 1 hour, every 30 minutes for the second 1 hour, and every 1 hour until therapy is discontinued)

- Monitor response to therapy (eg, normalization of the ST segment, reduced chest pain, dysrhythmias do not occur, decreased cardiac enzyme levels)

Therapeutic

- Put on cardiac monitor during button therapy and 12-24 hours after

- Give oxygen to maintain 5aO²>94%

- Install intravenous access

- Administer thrombolytic agents as indicated

- Avoid headboard > 15 °

- Maintain bed rest for 6 hours after therapy

- Stop immediately thrombolytic infusion if bleeding and allergies occur

- Apply pressure on the insertion site for 30 minutes if bleeding occurs

Education

- Explain the purpose and procedure of administering thrombolytics

- Explain the side effects of thrombolytic administration

- Instruct the extremity of the insertion side to remain straight

- Advise limiting activities to reduce the risk of injury and bleeding

Collaboration

- Collaboration of brain CT Scan examination after 12-24 hours for neurological evaluation, if necessary

 

 

Unilateral Neglect . Management

Definition

Identify and manage impaired perceptual abilities.

Action

Observation

- Check mental status

- Check motor function and sensory function

- Check attention and effective response

- Monitor abnormal responses to three main types of stimuli: sensory, visual, and auditory

Therapeutic

- Provide realistic feedback on perceptual deficits

- Perform basic needs care

- Position the affected extremity correctly and safely

- Place needed tools close to reach

- Reset the environment as needed

- Avoid moving the device that the patient has memorized

- Facilities for daily activities

Therapeutic

- Train active and/or passive ROMs, if necessary

- Recommend doing active and/or passive ROM on a regular basis

Collaboration

- Collaboration with an occupational therapist to facilitate reintegration of the affected body part

 

 

Mechanical ventilation management

Definition

Identify and manage the administration of artificial respiration through a device that is inserted into the trachea.

Action

Observation

- Check for mechanical indications (eg, respiratory muscle fatigue, neurologic dysfunction, respiratory acidosis)

- Monitor effect of ventilator on oxygenation status (eg, lung sounds, lung X-ray, AGD, SaO² SvO², ETCO², patient subjective response)

- Monitor the criteria for the need for ventilator weaning

- Monitor for negative effects of the ventilator (eg, tracheal devlation, barotrauma, volutrauma, decreased output or in other situations)

- Teach stress reduction techniques (eg breathing exercises, massage, progressive relaxation, guided imagination, biofeedback, touch therapy, murattal therapy, music therapy, humor therapy, laughter therapy, meditation)

 

 

Shock Management

Definition

Identify and manage the body's inability to provide oxygen and nutrients to meet tissue requirements.

 

Action

Observation

- Monitor cardiopulmonary status (frequency and strength of pulse, respiratory rate, BP MAP)

- Monitor oxygenation status (pulse oximetry, AGD)

- Monitor fluid status (input and output, skin turgor, CRT)

- Monitor level of consciousness and pupillary response

- Check the entire body surface for the presence of DOTS (deformity, open wound/open wound, tendemess/tenderness, swelling/swelling)

Therapeutic

- Maintain a patent airway

- Administer oxygen to maintain oxygen saturation >94%

- Preparation for intubation and mechanical ventilation, if necessary

- Give shock position (modified Trendelenberg)

- Install line IV

- Place a urinary catheter to assess urine production

- Insert a nasogastric tube for gastric decompression

Collaboration

- Collaboration of 1-2 L crystalloid fluid infusion in adults

- Collaborative administration of crystalloid fluid infusion of 20 mL/kgBW in children

- Collaboration of blood transfusion, if necessary

 

FETAL ELECTRONIC MONITORING

Definition

Collects and analyzes fetal heart rate data for movement, external stimulation, or uterine contractions.

Action

Observation

- Identification of pregnancy history and medical risk factors that require fetal examination

- Identification of mother's knowledge about the purpose of pregnancy examination

- Identification of oral intake, including diet, smoking and drug use

- Check mother's vital signs

Therapeutic

- Perform Leopold's maneuver

- Place the tocotransducer correctly to observe the frequency, duration and strength of uterine contractions

- Provide vibroacoustic stimulation if necessary

Education

- Explain the purpose and procedure of electronic fetal monitoring

- Explain the signs of a normal fetal heart rate

- Inform inspection results

- Inform the next pregnancy checkup schedule

 

 

CARDIOTOCOGRAPHY MONITORING (CTG)

Definition

Collect and analyze data on the electronic response of the fetal heart rate and uterine contractions during the latent phase, active phase until labor.

Action

Observation

- Identify the condition of the mother and fetus

- Identification of maximum punctum by leopold examination (DJJ is clear)

- Monitor mother's vital signs

- Monitor uterine contractions

- Monitor FHR every 30 minutes in each latent phase, active phase, labor phase

- Monitor FHR with Doppler or Leanec before delivery

- Identify signs of fetal distress such as FHR more than 160*/minute, less than 120*/minute Decreased fetal movement

Therapeutic

- Install the transducer shop properly

- Remove the electronic monitor if necessary

- Document CTG results (short-term variability, acceleration, or deceleration of fetal heart rate and uterine contractions)

Education

- Inform the reason and purpose of CTG monitoring for 30 minutes

- Instruct the mother to tilt to the left if the FHR is difficult to find

- Inform the mother to press the button when feeling the fetal movement

Collaboration

- Collaborate if there are danger signs of fetal distress and decreased contractions before delivery

 

 

MONITORING OF LABORATORY RESULTS

Definition

Collect and analyze laboratory data

Action

Observation

- Identification of required laboratory tests

- Monitor the required laboratory results

- Check the suitability of laboratory results with the patient's clinical appearance

Therapeutic

- Take a sample of blood/sputum/pus/tissue or other according to the protocol

Collaboration

- Collaboration with doctors if laboratory results require media intervention

 

 

INVASIVE HEMODYNAMIC MONITORING

Definition

Collects and analyzes data on blood pressure, flow and oxygenation parameters through devices supplied via arterial, pulmonary artery or central venous catheters to assess cardiovascular function and response.

Action

Observation

- Monitor heart rate and rhythm

- Monitor TDS, TDD, MAP, central venous pressure, pulmonary artery pressure, pulmonary artery seed pressure

- Monitor cardiac output and cardiac index

- Monitor hemodynamic waveforms

- Monitor perfusion distal to the insertion site every 4 hours

- Monitor for signs of infection and bleeding at the insertion site

- Monitor for signs of complications due to tube insertion (eg, pneumothorax, flexed tube, air embolism)

Therapeutic

- Accompany the patient during the insertion and removal of the hemodynamic route catheter

- Perform Allen's test to assess ulnar collaterals before cannulation of the radial artery

- Make sure the hose set is properly strung and attached

- Confirm the correct position of the tube by x-ray examination, if necessary

- Position the transducer on the right atrium (phlebostatic axis) every 4-2 hours to calibrate and zero the device

- Ensure balloon deflation and Return to normal position after measurement of pulmonary artery wedge pressure (PAWP)

- Change the tube and IV fluids every 24-72 hours according to the protocol

- Change the dressing at the insertion area with sterile technique

- Set the monitoring time interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results if necessary

- Recommend limiting movement/activity while the catheter is in place

 

 

NEONATUS MONITORING

Definition

Collect and analyze data on neonates and monitor the condition of neonates

Action

Observation

- Identify the health status of the neonate

- Monitor consciousness/neurological status, cardiovascular, respiratory, temperature, skin color or spO2 using the newborn early warning system (NEWS) form

- monitor the growth of neonates

- monitor the development of the neonate

- identification of signs of violence, neglect in neonates

 

Therapeutic

- Set the monitoring time interval according to the condition of the neonate

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring to parents

- Inform the results of monitoring to parents, if necessary

 

 

NEUROLOGICAL MONITORING

Definition

Collect and analyze data to prevent or minimize neurological complications.

Action

Observation

- Monitor size, shape, symmetry, and pupil reactivity

- Monitor level of consciousness (eg using Glasgow coma scale)

- Monitor orientation level

- Monitor recent memories, attention span, past memories, mood and behavior

- Monitor vital signs

- Monitor respiratory status: blood gas analysis, pulse oximetry, breath depth, breathing pattern, and respiratory effort

- Monitor invasive hemodynamic parameters if necessary

- Monitor ICP (intracranial pressure) and CPP (Cerebral perfusion pressure)

- Monitor corneal reflex

- Monitor cough and gag reflex

-Monitor muscle rhythm, motor movement, gait, and proprioception

- Monitor grip strength

- Monitor for tremors

- Monitor facial symmetry

- Monitor visual disturbances: diplopia, nystagmus, visual field cutting, blurred vision and visual acuity

- Monitor complaints of headaches

- Monitor speech characteristics: fluency, presence of aphasia, or difficulty finding words

- Monitor sharp/blunt or hot/cold discrimination

- Monitor for paraesthesia (numbness and tingling)

- Monitor sweat pattern

- Monitor Babinski's response

- Monitor Cushing response

- Monitor craniotomy or laminectomy dressing for drainage

- Monitor response to treatment

Therapeutic

- Increase the frequency of neurological monitoring if necessary

- Avoid activities that increase intracranial pressure

- Set the monitoring time interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results if necessary

 

 

NUTRITION MONITORING

Definition

Collect and analyze data related to intake and nutritional status.

Action

Observation

- Identification of factors that affect nutritional intake (eg knowledge, food availability, religion/belief, culture, inadequate chewing, swallowing disorders, use of drugs or postoperatively)

- Identify changes in weight

- Identification of skin disorders (eg excessive bruising, non-healing wounds, and bleeding)

- Identify abnormalities in hair (eg dry, thin, rough and easily broken)

- Identify eating patterns (eg food likes/dislikes, fast food consumption, eating in a hurry)

- Identify nail abnormalities (eg spoon-shaped, cracked, easily broken, and jagged)

- Identify the ability to swallow (eg facial motor function, swallowing reflex, and gag reflex)

- Identification of abnormalities of the oral cavity (eg inflammation, bleeding gums, dry and cracked lips, sores)

- Identify elimination disorders (eg diarrhea, blood, mucus, and irregular elimination)

- Monitor nausea and vomiting

- Monitor oral intake

- Monitor conjunctival color

- Monitor laboratory results (eg cholesterol levels, serum albumin, transferrin, creatinine, hemoglobin, hematocrit, and blood electrolytes)

Therapeutic

- Weigh the weight

- Anthropometric measurements of body composition (eg body mass index, waist measurement and skinfold measurement)

- Calculate weight change

- Set the monitoring time interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results if necessary

 

 

RESPIRATION MONITORING

Definition

Collect and analyze data to ensure airway patency and effective gas exchange.

 

 

Action

Observation

- Monitor the frequency, rhythm, depth and effort of breathing

- Monitor breathing patterns (such as bradypnea, tachypnea, hyperventilation, Kussmaul, Cheyne-stokes, biot, ataxic)

- Monitor the ability to cough effectively

- Monitor for sputum production

- Monitor for airway obstruction

- Palpate for symmetry of lung expansion

- Auscultate breath sounds

- Monitor oxygen saturation

- Monitor the value of AGD

- Monitor chest x-ray results

Therapeutic

- Set the respiratory monitoring interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results if necessary

 

 

FALL RISK MONITORING

Definition

Collect and analyze the risk of experiencing physical damage and health problems due to falls.

Action

Observation

- Identify the patient's cognitive or physical deficits that may increase the potential for falls in certain environments

- Identify behaviors and factors that influence the risk of falling

- Identification History of falls

- Identify environmental characteristics that may increase the potential for falls (eg slippery floors and open stairs)

- Monitor skill, balance and fatigue level by ambulance

- Monitor ability to move from bed to chair and vice versa

- Check perception of balance if necessary

Therapeutic

- Set the monitoring interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results if necessary

 

 

VITAL SIG MONITORING

Definition

Collect and analyze data from measurements of vital cardiovascular functions, respiration and body temperature.

Action

Observation

- Monitor blood pressure

- Monitor pulse (frequency, strength, rhythm)

- Monitor breathing (frequency, depth)

- Monitor body temperature

- Monitor pulse oximetry

- Monitor pulse pressure (difference in TDS and TDD)

- Identify the cause of changes in vital signs

Therapeutic

- Set the monitoring interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results

 

 

INTRACRANIAL PRESSURE MONITORING

Definition

Collect and analyze data related to pressure regulation in the intracranial space

Action

Observation

- Identify causes of increased ICP (eg, space-occupying lesions, metabolic disturbances, cerebral edema, increased venous pressure, obstruction of cerebrospinal fluid flow, idiopathic intracranial hypertension)

- Monitor increase in TD

- Monitor pulse pressure widening (difference in TDS and TDD)

- Monitor decreased heart rate

- Monitor irregularity of breath rhythm

- Monitor decreased level of consciousness

- Monitor for slowing or asymmetry of pupillary response

- Monitor CO2 levels and maintain within indicated ranges

- Monitor cerebral perfusion pressure

Monitor the amount, rate, and characteristics of cerebrospinal fluid drainage

- Monitor the effects of ICT environmental stimuli

Therapeutic

- Take a sample of cerebrospinal fluid drainage

- Transducer calibration

- Maintain the sterility of the monitoring system

- Maintain a neutral head and neck position

- Flush monitoring system if necessary

- Set the monitoring interval according to the patient's condition

- Document monitoring results

Education

- Explain the purpose and procedure of monitoring

- Inform monitoring results if necessary

 

 

INSTALLATION OF SAFETY EQUIPMENT

Definition

Take Actions to ensure the safety of self and others.

Action

Observation

- Identification of patient safety needs (based on level of physical and cognitive function and previous behavioral history)

Therapeutic

- Install safety devices (eg restraints, bed railings, doors and locks) to limit physical mobility or access in hazardous situations, as needed.

- Assisting during activities outside the emergency room if necessary

- Provide low bed and assistive devices (eg ladder bed, supports) if necessary

- Provide indoor furniture that does not fall easily

- Provide a tool to call the nurse

- Respond to every call immediately

Education

- Advise to keep away dangerous items (eg carpets, furniture)

 

Elastic Stocking Fitting I.02061

Definition

Put on flexible stockings that have a compressive effect on the lower leg veins to increase venous return to the heart

Action

Observation

- Identification of risk factors for venous thromboembolism

- Identify contraindications for stockings (eg, peripheral arterial disease, pressure sores on the heels, peripheral neuropathy).

- Monitor the presence of cyanosis, decreased pedis pulse, tingling, pain in the lower extremities tarapeutik.

- Choose the right stocking size.

- Elevate the lower leg for 15 minutes before placing stockings.

- Installing stockings correctly or according to the manufacturer's instructions.

- Keep the end of the stocking 2.5-5 cm below the joint.

- Make sure the stockings are free from wrinkles and the ends of the stockings are not rolled up

Education

- Explain the purpose and steps of the procedure.

- Teach how to put on and take off stockings independently.

- Recommend removing stockings for 30 minutes on each shift.

- Advise to report any complaints during the installation of stockings (eg pain, tingling)

 

 

Administration of Analgesics I.08243

Definition

Prepare and administer pharmacologic agents to reduce or eliminate pain.

Action

Observation

- Identify characteristics of pain (eg, trigger, reliever, quality, location, intensity, frequency, duration)

- Identify a history of drug allergy.

- Identify the suitability of the type of analgesic (eg, narcotic, non-narcotic, or NSAID) with the severity of pain

- Monitor vital signs before and after administration of analgesics.

- Monitor the effectiveness of analgesics.

Tarapeutik

- Discuss the type of analgesic preferred to achieve optimal analgesics, if necessary

- Consider continuous infusion, or bolus of opioids to maintain serum levels.

- Set target analgesic effectiveness to optimize patient response.

- Document response to analgesic effects and unwanted effects.

Education

- Explain the effects of therapy and side effects of drugs.

- Collaboration in giving dose and type of analgesic, according to indications

 

Administration of Anesthesia I.08244

Definition

Prepare and administer anesthetic drugs and monitor patient response during administration

Action

Observation

- Identification of anesthetic user history (physical condition, allergic response and contraindications to specific anesthetic drugs or techniques)

- Check the safety of all anesthetic equipment before anesthesia is administered

- Monitor vital signs throughout the anesthetic phase

Tarapeutik

- Get informed consent

- Ensure availability of essential recycling and resuscitation equipment

- Move from gurney to operating table

- Adjust the position to prevent peripheral nerve damage

- Ensure safety and security during the anesthesia phase

- Transfer to intensive care unit

- Provide a comprehensive report to the nursing staff of the room when transferred

Education

- Explain the purpose and steps of the anesthetic procedure