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
Observation️
- 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
- Inform the
expected target of administration of anesthesia
Collaboration
- Collaborative
administration of anesthesia, as indicated
- Collaborative
administration of drugs and preanesthetic fluids, as indicated
- Consult
diagnostic and laboratory results, based on health status and surgery plan
- Collaborative
administration of drugs and/or additional fluids to maintain physiological
homeostasis, if necessary
Giving Enema
I.04158
Definition
Administer the
solution into the lower gastrointestinal tract.
Action
Observation
- Identify reasons
for administering enemas (eg gastrointestinal cleansing, drug administration,
reduction of distension)
- Identification
of contraindications to enema (eg glaucoma and increased intracranial pressure)
- Monitor the
character of impurities and solutions (eg color, amount and appearance)
- Monitor response
to procedure including signs of intolerance (eg rectal bleeding, distention,
abdominal pain, palpitations, diaphoresis, pallor and shortness of breath,
diarrhea, constipation, and impaction)
Therapeutic
- Provide privacy
- Give the right
position (Sims' position for adults and dorsal recumbent for children)
- Apply under the
hips and buttocks
- Provide a bath
blanket and open only the rectum area
- Apply a warm
temperature to the irrigation solution
- Groove height of
the enema tube 30-45 cm (for high enemas), 30 cm (for regular enemas), 7.5 cm
(for low enemas)
- Insert the end
of the tube that has been lubricated into the rectum, to a depth of 7.5-10 cm
(adults), 7.5-10 cm (adolescents), 5-7.5 (children), 2.5-3.75 ( baby)
- Enter the liquid
enema
- Ask the patient
to hold fluids for 2-10 minutes
- Facilitate
cleaning of the perineum
Education
- Explain the
procedure to the patient or family, the sensations to be expected during and
after the procedure (eg distension and urge to defecate)
- Advise to take a
deep breath before adding fluids
Giving Testimony
I.13485
Definition
Provide
information for the purposes of investigation, prosecution and justice related
to nursing services.
Action
Observation
- Identification
of summons is carried out by investigators/investigators from the
Police/Prosecutors/KPK/Civil Servant Investigators (PNS)/Courts
- Identification
of summons addressed to the leadership (for nurses who are still active)
- The
identification of the summons is forwarded to the person concerned (for retired
nurses)
- Identification
in the summons contains an article on the alleged criminal act
Therapeutic
- Collect
information related to the case
- Prepare your
identity
- Prepare a
chronology of problems
- Prepare the
necessary documents
- Follow the title
case
- Fulfill the
summons before the forced summons is made (if you have been properly summoned
twice in a row but are not present without a valid reason)
- Request letter
of assignment or official travel letter, if necessary
Collaboration
- Coordinate with
investigators if the summons does not include an article on the alleged
criminal act
Giving Baby
Sucking Opportunities I.03124
Definition
provide an
opportunity for the baby to make skin contact with the mother and baby so that
the baby is able to suckle on the mother's breast.
Action
Observation
- Monitor baby's
breathing
- Monitor vital
signs and bleeding after delivery
Therapeutic
- Give the mother
the opportunity to join (rooming in)
- Facilitate
mother for semi fowler's position
- Facilitate
mothers to find a comfortable position
- Undress mommy's
top
- Avoid cleaning
the mother's chest from sweat
- Undress baby,
put on baby diaper and hat
- Place the baby
in the prone position directly between the mother's breasts
- Provide warmth
by blanketing the baby and wearing a hat
- Give time to the
baby when breastfeeding begins
- Give the mother
the opportunity to position and hold the baby correctly
- Move the baby
after the baby is finished feeding by removing the mother's nipples
- Place the baby
next to the mother or the baby's bed next to the mother's bed, making it easier
to start breastfeeding again
Education
- Suggest giving
the baby a chance for more than 1 hour or until the baby shows that he is ready
to suckle.
Feeding I.03125
Definition
Provide oral
nutrition in patients who are unable to eat independently.
Action
Observation
- Identification
of programmed foods
- Identification
of swallowing ability
- Check mouth for
residue at the end of a meal
Therapeutic
- Perform hand and
mouth hygiene before eating
- Provide a
pleasant environment during meal times (eg keep urinals, bedpans out of sight)
- Give a sitting
position or semi-Fowler when eating
- Give warm food,
if possible
- Provide straws,
as needed
- Provide food as
desired, if possible
- Offer to smell
food to stimulate appetite
- Maintain
attention while breastfeeding
- Wash your face
and hands after eating
Education
- Advise parents
or family to help give meaning to the patient
Collaboration
- Collaborative
administration of adequate analgesics before meals, if necessary
- Collaborative
administration of antiemethyl before meals, if necessary
Internal Feeding
I.03126
Definition
Prepare and
provide nutrition via gastrointestinal tube
Action
Observation
- Check the
position of the nasogastric tube (NGT) by checking for gastric residue or
auscultating airflow
- Monitor the drip
of food on the pump every hour
- Monitor
fullness, nausea, and vomiting
- Monitor gastric
residue every 4-6 hours for the first 24 hours, then every 8 hours during
enteral feeding, if necessary
- Monitor bowel
movements every 4-6 hours, if necessary
Therapeutic
- Use clean
technique in tube feeding
- Mark the hose to
maintain the exact location
- Elevate the head
of the bed 30-45 degrees during feeding
- Measure residue
before feeding
- Hug and talk to
baby during feeding to stimulate feeding activity
- Tube irrigation
with 30 ml of water every 4-6 hours during feeding and after intermittent
feeding
- Avoid feeding 1
hour before the procedure or patient transfer
- Avoid feeding if
the residue is more than 150 cc or more than 110%-120% of the amount of food
per hour
Education
- Explain the
purpose and steps of the procedure
Collaboration
- Collaboration
X-ray examination to confirm the position of the tube, if necessary
- Collaboration in
the selection of types and quantities of enteral food
Parental Feeding
I.03127
Definition
Provide nutrition
through a vein either centrally (for total parental nutrition) or peripheral
vein (for partial parental nutrition) in patients who cannot meet their
nutritional needs through oral or enteral routes.
Action
Observation
- Identify the
therapy given according to age, condition, dose, rate, and route
- Monitor for
signs of phlebitis, inflammation, and thrombosis
- Monitor
laboratory values (eg BUN, creatinine, blood sugar, electrolytes, liver
function)
- Monitor weight
- Monitor urine
production
- Monitor the
amount of fluid in and out
Therapeutic
- Wash hands and
put on gloves
- Use aseptic
technique in tube care
- Label the
parental food container with the date, time, and nurse's initials
- Set the infusion
rate, concentration and volume to be inserted
- Make sure the
infusion alarm is turned on and working, if available
- Change dressing
every 24-48 hours
- Change the
infusion set a maximum of 2x24 hours
- Change the
position of the infusion installation a maximum of 3x24 hours (peripheral)
- Avoid taking
blood samples and administering drugs in parenteral nutrition tubes
Education
- Explain the
purpose and steps of the procedure
Drug
Administration I.02062
Definition
Prepare,
administer, and evaluate the effectiveness of programmed pharmacological
agents.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor vital
signs and laboratory values prior to drug administration, if necessary
- Monitor side
effects, toxicity, and drug interactions
Therapeutic
- Observe safe and
accurate drug administration procedures
- Avoid
interruptions when preparing, verifying or administering medication
- Do the six
principles right (patient, drug dose, route, time, documentation)
- Pay attention to
the schedule for giving hypnotics, narcotics, and antibiotics
- Avoid
administering drugs that are not properly labeled
- Dispose of
unused or expired drugs
- Facilitate
taking medication
- Sign the administration
of narcotics, according to the protocol
- Document drug
administration and response to medication
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Explain the factors
that can increase and decrease the effectiveness of the drug
Administration of
Inhaled Drugs I.01015
Definition
Prepare and
administer pharmacological agents in the form of aerosol sprays, vapors or fine
powders to obtain local or systemic effects.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor vital
signs and laboratory values prior to drug administration, if necessary
- Effect monitorTherapeuticdrug
- Monitor side
effects, toxicity, and drug interactions
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Shake the
inhaler for 2-3 seconds before use
- Remove the inhaler
cover and hold it best
- Position the
inhaler in the mouth towards the throat with the lips tightly closed
Education
- Encourage slow
and deep breathing while using the nebulizer
- Suggest holding
your breath for 10 seconds
- Encourage slow
expiration through the nose or with pursed lips
- Teach patients
and families about how to administer drugs
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects of
the drug
- Explain the
factors that can increase and decrease the effectiveness of the drug
Interpleura Drug
Administration I.01016
Definition
Prepare and
administer pharmacological agents through a catheter to diffuse into the
pleural space
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor vital
signs and laboratory values prior to drug administration, if necessary
- Effect monitorTherapeuticdrug
- Monitor side
effects, toxicity, and drug interactions
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Ensure the
correct position of the intrapleural catheter with x-ray, if necessary
- Aspiration of
intrapleural fluid before drug administration
- Delay drug
administration if there is >2 cc of return fluid when checking the catheter
- Prepare medicine
aseptically
- Administer
medication through an intrapleural catheter intermittently or continuously, as
needed
- Connect the
intrapleural catheter to the pumping machine, if necessary
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Explain the
factors that can increase and decrease the effectiveness of the drug
Intradermal Drug
Administration I.14531
Definition
Prepare and
administer pharmacological agents via the intradermal route.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor drug
reactions according to the specified time
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Determine the
correct syringe as needed
- Prepare the dose
from the ampoule or vial correctly
- Choose the
correct injection area
- Avoid areas of
skin that are bruised, inflamed, edematous, lesions, or discolored
- Use aseptic
technique
- Insert the
needle at 5-15o to a depth of 3 mm
- Inject the drug
slowly, while observing the emergence of small bumps (blisters) on the skin
surface
- Mark the
injection area
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Advise not to
touch the area of the lump (blister)
- Advise to report
to nurse if you feel any complaints after drug administration (eg itching,
redness, heat)
Intramuscular Drug
Administration I.02063
Definition
Prepare and
administer pharmacological agents via the intramuscular route
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor drug
reactions according to the specified time
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Determine the
correct syringe as needed
- Prepare the dose
from the ampoule or vial correctly
- Select the
correct injection site (eg vastus lateralis, ventrogluteal, deltoid)
- Avoid areas of
skin that are bruised, inflamed, edematous, lesions, or discolored
- Use aseptic
technique
- Perform the
Z-track technique to prevent the drug from escaping into the subcutaneous
tissue and skin
- Insert the needle
at an angle of 90o
- Aspirate before
injecting medicine
- Inject drugs
slowly
- Remove the
needle after waiting 10 seconds after injecting the drug
- Avoid massaging
the injection area
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Advise not to
massage (massage) the injection area
Intraseous Drug
Administration I.02064
Definition
Prepare and
administer pharmacological agents by needle through the cortex of the bone.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor expected
and unexpected drug reactions
Monitor for signs
and symptoms of fluid or drug extravasation, infection or fat embolism
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Determine the
type and size of the needle and the correct stylet according to your needs
- Prepare the dose
from the ampoule or vial correctly
- Immobilize the
extremities
- Facilitate
insertion of intraosseous access
- Fixation of
intraosseous access with dressings and plasters
- Aspirate
intraosseous access before injecting the drug to ensure the correct position of
the needle tip according to the protocol
- Connect the hose
with a needle and flow it by gravity or pressure, according to the required
flow rate
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
Intraspinal Drug
Administration I.06199
Definition
Prepare and
administer pharmacological agents via the epidural or intrathecal route.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Check the drip
rate for therapeutic accuracy
- Monitor vital
signs and neurological status
- Monitor motor
and sensory function
- Monitor the
cleanliness of the epidural or intrathecal catheter insertion site
- Monitor for
signs of infection at the site of epidural or intrathecal catheter insertion
- Monitor for
signs of central nervous system infection (eg fever, altered level of
consciousness, nausea and vomiting)
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Maintain aseptic
technique
- Aspiration of
cerebral spinal fluid before administering the drug
- Mark tubing as
intrathecal or epidural
- Inject the drug
slowly according to the procedure steps
- Catheter
fixation secured to the skin
- Fixation of all
hose connections
Collaboration
- Collaboration
with the medical team if the insertion site shows signs of infection.
Administration of
Intravenous Drugs I.02065
Prepare and
administer pharmacological agents by intravenous catheter.
Action
Observation
- Identify
possible allergies, drug interactions and contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Monitor vital
signs and laboratory values prior to drug administration, if necessary
- Effect monitorTherapeuticdrug
- Monitor side
effects, toxicity, and drug interactions
Therapeutic
- Do the correct
name principles (sand, medication, dose, time, route, and documentation)
- Ensure
correctness and patency of IV catheters
- Mix the medicine
into a bag, bottle, or biuret, as needed
- Give IV drugs at
the right speed
- Paste the label
description of the drug name and dose on the IV fluid container
- Use a pump
machine for continuous drug administration, if necessary
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Explain the
factors that can increase and decrease the effectiveness of the drug
Definition
Administration of
Skin Drugs I.14532
Prepare and
administer pharmacological agents to treat skin disorders.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Effect monitorTherapeuticdrug
- Monitor local
effects, system effects and drug side effects
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Wash hands and
put on gloves
- Clean the skin
and remove the previous medicine
- Apply the
topical agent on the skin that is not injured, irritated or sensitive
- Avoid exposure
to ultraviolet light on the skin receiving tropical drugs
Education
- Explain the type
of drug, administration device, expected action, and side effects before
administration
- Explain the
factors that can increase and decrease the effectiveness of the drug
- Teach
self-administration techniques, if necessary
Administration of
Nasal Drugs I.01017
Definition
Prepare and
administer pharmacological agents, in the form of drops through the nose to
obtain systemic local effects.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Effect monitorTherapeuticdrug
- Monitor local
effects, systemic effects and drug side effects
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Clean the
nostrils with a tissue or cotton bud, if necessary
- Drop the drug
with a distance of 1 cm above the nostril
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Recommend lying
with head hyperextended, if not contraindicated
- Encourage mouth
breathing during drug administration
- Advise to remain
supine for 5 minutes after drug administration
- Teach self-administration
techniques, if necessary
Oral Drug
Administration I.03128
Definition
Prepare and
administer pharmacological agents by mouth for local or systemic effects.
Action
Observation
- Identification
of possible allergic interactions, and drug contradictions (eg, impaired
swallowing, nausea/vomiting, intestinal inflammation, decreased peristalsis,
decreased consciousness, fasting program)
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Effect monitorTherapeuticdrug
- Monitor local
effects, systemic effects and drug side effects
- Monitor risk of
aspiration, if necessary
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Give oral
medication before eating or after eating, as needed
- Mix the medicine
with syrup, if necessary
- Put the
sublingual medication under the patient's tongue
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Advise not to
swallow sublingual drugs
- Advise not to
eat/drink until all sublingual medication is dissolved
- Teach patients
and families about how to administer medication independently
Administration of
Rectal Drugs I.04159
Definition
Prepare and
administer suppository pharmacological agents rectally
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Identification
of gastrointestinal disorders (eg constipation, diarrhea)
- Effect monitorTherapeuticand side effects of drugs
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Wash hands and
put on gloves
- Give sims position
- Lubricate the
glove of the index finger on the dominant hand
- Instruct slow
deep breaths through the mouth to relax the anal sphincter
- Insert the drug
slowly through the anus
Education
- Explain the type
of drug, the reason for giving it, the method of administration, the effectTherapeuticand side effects of drugs
before administration
- Suggest to
maintain position for 5 minutes
- Teach
self-administration techniques, if necessary
Subcutaneous Drug
Administration I.013129
Definition
Prepare and
administer drugs by subcutaneous route.
Action
Observation
- Identification
of possible allergies, interactions, and contraindications to drugs
- Verify drug
orders according to indications
- Check the
expiration date of the drug
- Effect monitorTherapeuticdrug
- Monitor side
effects, toxicity, and drug interactions
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Practice aseptic
technique
- Choose the
appropriate syringe
- Rotate injection
site systematically
- Avoid injection
sites that have edema, masses, cuts, bruises, abrasions, or infections
- Use the
abdominal area when giving subcutaneous heparin
- Insert needle
quickly at an angle of 45-90°, depending on body size
- Avoid massaging
the injection area
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Teach patients
and families about drug injection independently
Topical Drug Administration
I.14533
Definition
Prepares and
delivers pharmacological agents to the skin surface.
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders according to indications
- Check the expiration
date of the drug
- Effect monitorTherapeuticdrug
- Monitor local
effects, systemic effects and drug side effects
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Wash hands and
put on gloves
- Provide privacy
- Clean the skin
- Apply topical
medication to intact skin or mucous membranes (except the use of drugs to treat
lesions)
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Teach patients
and families about how to administer medication independently
Vaginal Drug
Administration I.07222
Definition
Prepare and
administer pharmacological agents vaginally
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify drug
orders before administering drugs
- Check the
expiration date of the drug
- Effect monitorTherapeuticdrug
- Monitor side
effects, toxicity, and drug interactions
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Wash hands and
put on gloves
- Protect patient
privacy
- Position dorsal
recumbent, lithotomy or sims
- Clean the
vaginal area
- Apply a
water-soluble lubricant to the tip of the suppository
- Give lubricant
and forefinger
- Insert the tip
of the suppository into the vagina to a depth of 7.5-10 cm
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
- Suggest to stay
lying down for 5-10 minutes
- Teach patients
and families about how to administer medication independently
Ventricular Drug
Administration I.06200
Definition
Prepare and
administer pharmacological agents into the lateral ventricles of the brain
Action
Observation
- Identify
possible allergies, interactions, and drug contraindications
- Verify orders
according to indications
- Check the
expiration date of the drug
- Effect monitorTherapeuticdrug
- Monitor side
effects, toxicity, and drug interactions
- Monitor
neurological status
- Monitor for
signs of central nervous system infection (eg fever, altered level of
consciousness, nausea and vomiting)
- Monitor vital
signs
Therapeutic
- Do the six
principles right (patient, drug, dose, time, route, documentation)
- Wash hands and
put on gloves
- Use aseptic
technique
- Shave hair at
the site of drug administration, if necessary
- Fill the
reservoir with cerebrospinal fluid by applying pressure with the thumb
- Take
cerebrospinal fluid before injection, pay attention to the presence of blood or
cloudy color
- Inject the drug
slowly according to the procedure
- Press the
reservoir with the index finger to mix the drug with the cerebrospinal fluid
- Apply dressing,
if necessary
Education
- Explain the type
of drug, the reason for giving it, the expected action, and the side effects
before administration
I.05180 . splint
Definition
Stabilizes,
immobilizes, and protects the injured body part using support.
Action
Observation
- Identify the need
for a splint (eg fracture, dislocation)
- Monitor distal
to the area of injury (eg pulse pulse, capillary refill, motor movement and
sensation) on the injured body part
- Monitor for
bleeding in the injured area
- Identification
of suitable splint material (e.g. straight and hard, length of splint across
two joints)
Therapeutic
- Cover open
wounds with a bandage
- Treat bleeding
before the splint is placed
- Minimize
movement, especially in the injured area
- Give paddai to
splints
- Joint immobilization
above and below the injured area
- Support your
feet using a footboard, if available
- Place the
injured extremity in a functional position, if possible
- Place the splint
in the position of the body as it was found
- Use both hands
to support the injured area
- Use a sling
Education
- Explain the
purpose and steps of the procedure before placing the splint
- Describe the
signs and symptoms of compartment syndrome (5p: pulseless, paresthesias, pain,
paralysis, palor)
- Recommend
limiting movement in the injured area
Fertility
Maintenance I.017223
Definition
Efforts to
maintain and increase the fertility of the reproductive system.
Action
Observation
- Identify the
level of knowledge about fertility
- Identification
of reproductive organ health history
Therapeutic
- Prevent
malnutrition and obesity during reproductive age
- Prevent
consumption of: alcohol, caffeine, cigarettes, and drugs
- Prevent exposure
to radiation and chemical environments
- Discuss factors
related to fertility (eg age, nutrition, weight, PMS)
- Discuss the
benefits and impacts of contraceptives that will be used for future fertility
Education
- Recommend
planning a pregnancy less than 35 years old
- Teach prevention
of sexually transmitted diseases
- Recommend avoiding
IUDs to delay the first pregnancy
- Advise to check
and treat early if you have a history of fertility problems
Collaboration
- Refer for
screening for health problems that may impact fertility (eg amenorrhea,
diabetes, endometriosis and thyroid disease)
Emergency Set
Completeness Check I.14534
Definition
Systematic
inspection and maintenance of emergency equipment and materials.
Action
Observation
- Identify the
completeness and availability of tools and easy to use when needed
- Check expiration
date for all equipment including medicines
Therapeutic
- Compare the list
of existing tools according to minimum standards
- Replace lost or
obsolete supplies and equipment
- Trial of use of
the device (eg laryngoscope adjustment and laryngoscope light bulb examination)
- Ensure
defibrillator conforms to protocol, including low energy release trials (less
than 200 joules)
- Clean the
equipment after use
- Make sure the
tool is in a safe condition
Breast Examination
I.07224
Definition
Inspect and
palpate the breast and related areas to identify breast health
Action
Observation
- Identification
of risk factors for breast cancer (eg age at first pregnancy, age of merache,
age of menopause, family history, history of breast disease, appropriate status
and history of breastfeeding)
- Identify
complaints of pain, discomfort, discharge, changes in breast and nipple shape
- Breast
inspection (eg size, shape, texture and skin color such as redness, breast skin
retraction)
- Check if there
is fluid coming out of the nipple by placing the thumb and index finger around
the nipple, then press gently, and pay attention to whether there is fluid
coming out
- Inspection and
palpation of lymph nodes, including the supraclavicular, infraclavicular,
Lateral, central,
subscapular and anterior
- Palpate the
breast using 3 fingers on the examiner's dominant hand
- Monitor the
presence of mastectomy scars, lesions, abdominal tissue, redness, erythema
Therapeutic
- Set a
comfortable position for inspection and maintain privacy
- Perform
examination in the supine position
- Ask to remove
top clothes
- Ask to use four
positions during a breast inspection: both arms at the sides of the body, both
hands placed on the waist while the front shoulders are tilted forward so that
the breast position looks hanging, both hands behind the head with elbows
folded
- Record the
number, size, location, consistency and movement of nodes
- Place a small
roll of towel or pillow under your shoulders and place your hands under your
head under your head
- Perform the
examination in a circular motion and press the breast tissue against the chest
wall
- Check the four
quadrants of the breast to the base of the breast and repeat on the other
breast
- Note presence of
mass (eg location, size, movement, consistency)
- Note the
symmetry of the breast (eg differences in shape, size, nipples, wrinkles or
indentations in the skin)
Education
- Explain the
procedure before the inspection is carried out
- Teach to do
breast self-examination
- Recommend
regular mammography checks according to: age, risk factors, and patient's
condition.
Brain Mapping
I.060201
Definition
Implementation of
brain mapping diagnostic test for comprehensive analysis of wave frequencies
Action
Observation
- Monitor sleep
disturbances, medications, blood sugar, eye, head or leg movements until the
procedure is complete
Therapeutic
- Make sure not to
use hair dye, make-up and contact lenses
- Wash/wash hair
to remove dirt
- Make sure not to
give sedatives and caffeine four hours before the examination
- Take head
measurements to determine where to place the electrodes
- Install the
electrodes at the specified location
- Make a recording
(lasts for 15-20 minutes)
- Ask to open and
close eyes, and breathe faster (hyperventilation)
- Overcome
according to protocol, if seizures
Education
- Explain the
purpose and steps of the procedure
- Encourage a good
night's sleep before the examination
- Encourage
nutritious meals, one to two hours before the examination (eg high in protein)
- Advise to avoid
foods containing sugar before the examination
- Advise voiding
before examination
- Encourage
relaxation during the examination and follow the operator's instructions
Allergy Prevention
L.14535
Definition
Identify and
reduce the patient's risk of developing allergies.
Action
Observation
- Identification
of allergy history (drugs, food, dust, air)
- Monitor for
reactions to drugs, food, latex, blood transfusions or blood products or other
allergens
Therapeutic
- Give signs of
allergies in medical records
- Put the allergy
sign bracelet on the arm
- Stop exposure to
allergens
- Do an allergy
test before giving the drug
Education
- Teach to avoid
and prevent exposure to allergens
Collaboration
- Collaboration
with health workers in allergy prevention (eg doctors, nutritionists)
Aspiration
Prevention L.01018
Definition
Identify and
reduce the risk of food/liquid particles entering the lungs.
Action
Observation
- Monitor with
awareness, cough, vomiting and ability to swallow
- Monitor
respiratory status
- Monitor breath
sounds, especially after eating/drinking
- Check gastric
residue before giving oral intake
- Check the
patency of the nasogastric tube before giving oral intake
Therapeutic
- Position the
semi-Fowler (30-45 degrees) 30 minutes before giving oral intake
- Maintain a
semi-Fowler's position (30-45 degrees) in an unconscious patient
- Maintain a
patent airway (eg, head tilt, chin lift, jaw thrust, in line technique)
- Maintain inflated
endotracheal tube (ETT) balloon
- Perform airway
suction, if the production of secretions increases
- Provide suction
in the room
- Avoid feeding
through a gastrointestinal tube, if the residue is a lot
- Give small or
soft food
- Give oral
medication in liquid form
Education
- Advise eat
slowly
- Suggest
strategies to prevent aspiration
- Advise chewing
or swallowing techniques, if necessary
Suicide Prevention
L.14538
Definition
Identify and
reduce the risk of self-harm with the intent of ending one's life.
Action
Observation
- Identify
symptoms of suicide risk (eg, mood disorders, hallucinations, delusions, panic,
substance abuse, sadness, personal disturbances)
- Identify
suicidal thoughts and desires
- Monitor the
hazard-free environment on a regular basis (eg, personal items, razors,
windows)
- Monitor for
changes in mood or behavior
Therapeutic
- Involve in self
care planning
- Involve family
in treatment planning
- Take a direct,
non-judgmental approach when discussing suicide
- Provide a
secure, easy-to-monitor environment (e.g., a bed near the nurse's office)
- Increase
supervision under certain conditions (eg, staff meetings, shift changes)
- Implement
protective interventions (eg, area restrictions, physical restraints), if
needed
- Avoid repeated
discussions about previous suicides, present and future-oriented discussions
- Discuss plans
for dealing with suicidal ideation in the future (eg, who to contact, where to
go for help)
- Make sure the
medicine is swallowed
Education
- Encourage
discussing feelings experienced with others
- Encourage use of
support sources (eg, spiritual services, service providers)
- Explain suicide
prevention measures to family or loved ones
- Inform community
resources and available programs
- Refer to mental
health services, if necessary
Collaboration
- Collaboration in
administering antianxiety drugs, or antipsychotics, as indicated
- Collaboration of
safety measures to PPA
- Refer to mental
health services, if necessary
-
Injury Prevention
L.14537
Definition
Identify and
reduce the risk of experiencing harm or physical harm.
Action
Observation
- Identify areas
of the environment that have the potential to cause injury
- Identification
of drugs that have the potential to cause injury
- Identify fit of
footwear or elastic stockings on lower extremities
Therapeutic
- Provide adequate
lighting
- Use a night
light during bedtime
- Socialize
patients and families with the environment of the ward (eg, use of telephones,
beds, room lighting and bathroom locations)
- Use floor mats
if there is a risk of serious injury
- Provide non-slip
footwear
- Provide bedpan
or urinal for elimination in bed, if necessary
- Make sure the
call bell or phone is within easy reach
- Make sure
personal items are easy to reach
- Keep the bed in
the lowest position when in use
- Make sure the
wheels of the bed or wheelchair are locked
- Use bed guards
in accordance with the policies of health care facilities
- Consider using a
personal electronic realm or sensor realm on a bed or chair
- Discuss the
necessary exercises and physical therapy
- Discuss
appropriate mobility aids (eg, cane or walker)
- Discuss with
family members who can accompany the patient
- Increase
frequencyObservationand patient
monitoring, as needed
Education
- Explain the
reasons for fall prevention interventions to patients and families
- Suggest changing
positions slowly and sitting for a few minutes before standing up
Embolism
Prevention L.02066
Definition
Identify and
reduce risk of obstruction to blood flow due to embolus (eg, postoperative,
blood, air)
Action
Observation
- Examine the
patient's medical history in detail for risk factors (eg, postoperative
fracture, chemotherapy, pregnancy, postpartum, immobilization, paralysis, COPD
extremity edema, stroke, previous history of DVT)
- Examine
Virchow's triad (venous stasis, hypercoagulability, and trauma resulting in
damage to the vascular intima)
- Monitor for new
symptoms and wheezing, hemoptysis, pain on inspiration, pleuritic pain)
- Monitor
peripheral circulation (eg, peripheral pulses, edema, CRT, color, temperature
and presence of pain in the extremities
Therapeutic
- Position the
limb at risk of embolism 200 above the heart position
- Fit stockings or
intermittent pneumatic compression devices
- Remove stockings
or pneumatic compression devices intermittently for 15-20 minutes every 8 hours
- Perform active
and passive range of motion exercises
- Change position
every 2 hours
- Avoid massaging
or pressing the extremity muscles
Education
- Encourage leg
flexion and extension at least 10 times every hour
- Encourage
reporting excessive bleeding (eg, unusual nosebleeds, vomiting blood, bloody
urine, bleeding gums, vaginal bleeding, heavy menstrual bleeding, bloody
stools). Unusual pain or swelling, blue or purple coloration of the toes, pain
in the toes, ulcers or white spots in the mouth or throat
- Recommend
quitting smoking
- Advise to take
anticoagulant drugs according to the time and dose
- Encourage intake
of foods high in vitamin K
- Recommend
avoiding sitting with crossed legs or long sitting with legs hanging
- Teach taking
precautions (eg, walk, drink a lot, avoid alcohol, avoid long-term
immobilization)
Collaboration
- Collaborative
administration of thrombolytics, if necessary
- Collaborative
administration of low-dose anticoagulants or high-dose antiplatelet agents (eg,
heparin, clopidogrel, warfarin, aspirin, dipyridamole, dextran), if necessary
- Collaboration of
intravenous promethazine administration in 25cc-50cc 0.9% NaCl solution with
slow flow
Prevention of
Malignant Hyperthermia L.14538
definition
Identify and
reduce hypermetabolic responses to pharmacological agents used during surgery
Action
Observation
- Identify a
history of malignant hyperthermia, muscle disorders, or postoperative fever
- Monitor vital
signs, including core body temperature
Monitor for signs
of malignant hyperthermia (eg, hypercarbia, hyperthermia, tachycardia,
tachypnea, metabolic acidosis, arrhythmias, cyanosis, crooked skin, muscle
strength, profuse sweating, and unstable blood pressure)
- Monitor
laboratory values (eg, increased CO2 with decreased oxygen saturation,
increased serum calcium, increased potassium, metabolic acidosis, hematuria,
and myoglobinuria)
- ECG monitor
- Monitor vital
signs (eg, coagulopathy, renal failure, hypothermia, pulmonary edema,
hyperkalemia, neurologic sequelae, muscle necrosis, and recurrent symptoms
after treatment)
- Monitor the
direction of urine
Therapeutic
- Install the
cooling mat under the body
- Give cold
compress
- Install two-way
IV
- Provide
hyperventilation with 100% high flow oxygen
- Insert NGT and
urinary catheter, if necessary
- Minimize
environmental stimuli
- Provide
emergency equipment
Education
- Explain the
causes and mechanisms of malignant hyperthermia
Collaboration
- Collaboration of
diagnostic tests (eg, muscle contracture testing, molecular genetic testing),
if necessary
- Collaborative
use of non-nitrogen anesthetic agents (eg, opioids, benzodiazepines, local
anesthetics, nitrous oxide, and barbiturates)
- Collaboration of
airway intubation, if necessary
- Collaborative
fluid administration, if necessary
Prevention of
L.14539 . Infection
Definition
Identify and
reduce the risk of being attacked by pathogenic organisms
Action
Observation
- Monitor for
signs and symptoms of local and systemic infection
Therapeutic
- Limit the number
of visitors
- Give skin care
to the edema area
- Wash hands
before and after contact with patients and the patient's environment
- Maintain aseptic
technique in high risk patients
Education
- Describe the
signs and symptoms of infection
- Teach how to
wash hands properly
- Teach cough
etiquette
- Teach how to
check the condition of a wound or surgical wound
- Recommend
increasing nutritional intake
- Recommend
increasing fluid intake
Collaboration
- Collaborating on
immunization, if necessary
Fall Prevention
L.14541
Definition
Identify and
reduce the risk of falling due to changes in physical or psychological
conditions.
Action
Observation
- Identification
of risk factors for falls (eg, age >65 years, decreased level of
consciousness, cognitive deficits, orthostatic hypotension, balance disorders,
visual disturbances, neuropathy)
- Identify the
risk of falling at least once every shift or according to institutional policy
- Identify
environmental factors that increase the risk of falling (eg, slippery floors,
poor lighting)
- Calculate fall
risk using a scale (eg fall morse scale, humpty dumpty scale), if necessary
- Monitor ability
to move from bed to wheelchair and vice versa
Therapeutic
- Orient the room
to the patient and family
- Make sure the
wheels of the bed and wheelchair are always locked
- Install the bed
handrail
- Set mechanical
bed in low position
- Place patients
at high risk of falling close to the nurse's monitoring from the nurse station
- Use a walking
aid (e.g. wheelchair, walker)
- Keep the calling
bell within reach of the patient
Education
- Advise to call
the nurse if you need help moving
- Recommend using
non-slippery footwear
- Advise to
concentrate to maintain body balance
- Advise to spread
the distance between the two legs to improve balance when standing
- Teach how to use
the calling bell to call the nurse
Fire Prevention
L.14541
Definition
Identify and
reduce the risk of fire
Action
Observation
- Identify
potential fires
Therapeutic
- Keep lighters
and matches out of the reach of children
- Keep flammable
objects out of reach of ignition sources
- Use power tools
sparingly
- Plan evacuation
routes
Education
- Advise to turn
off cigarette butts before throwing them in the trash
- Advise not to
leave heat or fire sources (eg stoves, kerosene lamps, irons) on unattended
- Advise not to
refuel while smoking
- Recommend
getting used to immediately turning off the stove, lights and electric tools
after use or when leaving the house
- Teach how to
extinguish fire properly
- Teach how to use
a small fire extinguisher (APAR)
Seizure Prevention
L.14542
Definition
Identify and
reduce the risk of muscle contractions and uncontrolled movements
Action
Observation
- Monitor
neurological status
- Monitor vital
signs
Therapeutic
- Lay the patient
so as not to fall
- Lower the bed
height
- Install the bed
side rail
- Provide a soft
pad under the head, if possible
- Keep away
dangerous objects, especially sharp objects
- Provide suction
at the bedside
Education
- Suggest to
report immediately if you feel an aura
- Advise not to
drive
- Teach the family
first aid for seizures
Collaboration
- Collaborative
administration of anticonvulsants, if necessary
Prevention of
Constipation L.04160
Definition
Identify and
reduce the risk of a decrease in the normal frequency of defecation accompanied
by difficulty in removing incomplete feces
Action
Observation
- Identify risk
factors for constipation (eg, inadequate fiber intake, inadequate fluid intake,
aganglionic, abdominal muscle weakness, lack of physical activity)
- Monitor for
signs and symptoms of constipation (eg, defecation less than 2 times a week,
long/difficult defecation, hard stools, decreased peristalsis)
- Identify
cognitive status to communicate needs
- Identify the use
of drugs that cause constipation
Therapeutic
- Limit drinks
containing caffeine and alcohol
- Schedule BAK
routines
- Do abdominal
massage
- Give acupressure
therapy
Education
- Explain the
causes and risk factors for constipation
- Advise to drink
water as needed (1500-200 ml / day)
- Recommend
consuming fibrous foods (25-30 grams / day)
- Encourage
increased physical activity as needed
- Suggest walking
15-20 minutes 1-2 times/day
Collaboration
- Collaboration
with nutritionists, if necessary
Pressure Wound
Prevention L.14543
Definition
Identify and
reduce the risk of tissue death in areas of bony prominence due to continuous
pressure or friction
Action
Observation
- Check pressure
sores using a scale (eg noton's scale, braden's scale)
- Check for
previous pressure sores
- Monitor the
temperature of the stressed skin
- Monitor weight
and changes
- Daily skin
status monitor
- Closely monitor
the reddened area
- Monitor skin
over bony prominences or pressure points when changing positions
- Monitor sources
of pressure and friction
- Monitor
individual mobility and activity
Therapeutic
- Dry areas of
skin that are moist from sweat, wound fluids, and fecal or urinary incontinence
- Use a barrier
such as lotion or water-absorbing pads
- Change position
carefully every 1-2 hours
- Schedule
position changes
- Provide
cushioning on pressure points or bony prominences
- Keep the sheets
dry, clean and no wrinkles / creases
- Use a special
mattress, if necessary
- Avoid massage
over bony prominences
- Avoid applying
lotion to the injured or red area
- Avoid giving
using warm water and harsh soap when bathing
- Ensure adequate
food intake, especially protein, vitamins B and C, iron, and calories
Education
- Explain the
signs of skin damage
- Advise to report
if you find signs of skin damage
- Teach how to
care for the skin
Prevention of
Substance Abuse L.09298
Definition
Identify and reduce
the risk of lifestyle use of alcohol or drugs.
Action
Observation
Identify possible
substance abuse risk behaviors
Therapeutic
- Motivation to
tolerate increased stress levels
- Motivation to
anticipate the environment that causes stress
- Motivation of
decision making in choosing a lifestyle
- Motivation to
join the program at school, work or social
- Family
motivation to support substance prohibition policy
- Discuss stress
reduction strategies
- Discuss how to
prepare yourself in stressful conditions
- Involve in group
activity programs in the community and services
- Support to
participate in community groups, such as SADD (Students Against Destructive
Decisions) and MADD (Mothers Against Drunk Diving)
- Support programs
that regulate the sale and distribution of substances (eg minors)
- Facilitation in
organizing activities for youth (eg recreation, reunions)
- Facilitation in
coordinating various community groups
Education
- Practice
assertive skills
- Train the mind
and behavior in reducing stress conditions
- Advise to avoid
social isolation behavior
- Teach family
about substance use
- Teach families
to identify signs and symptoms of addiction
- Encourage
families to participate in children's activities at school
Prevention of
Bleeding I.02067
Definition
Identify and
reduce the risk or complication of the stimulus that causes bleeding or the
risk of bleeding.
Action
Observation
- Monitor for
signs and symptoms of bleeding
- Monitor
hematocrit/hemogoblin values before and after blood loss
- Monitor
orthostatic vital signs
- Monitor
coagulation (eg prothrombin time (PT), partial thromboplastin time (PTT),
fimbrinogen, fibrin and/or platelet degradation)
Therapeutic
- Maintain bed
rest during bleeding
- Limit invasive
measures, if necessary
- Use decubitus
prevention mattress
- Avoid measuring
rectal temperature
Education
- Describe the
signs and symptoms of bleeding
- Recommend
wearing socks when ambulation
- Advise to
increase fluid intake to avoid constipation
- Advise to avoid
aspirin or anticoagulants
- Recommend
increasing food intake and vitamin K
- Prompt to report
immediately if bleeding occurs
Collaboration
- Collaboration in
the administration of bleeding control drugs, if necessary
- Collaborative
administration of blood products, if necessary
- Collaboration in
providing stool softeners, if necessary
Prevention of
Violent Behavior I.14544
Definition
Minimize anger
that is expressed excessively and uncontrollably verbally to the point of
injuring others and/or damaging the environment.
Action
Observation
- Monitor for
potentially hazardous objects (eg sharp objects, ropes)
- Monitor the
safety of goods brought by visitors
- Monitor during
use of potentially hazardous items (eg razors)
Therapeutic
- Maintain a
hazard-free environment on a regular basis
- involve family
in care
Education
- Encourage
visitors and families to support patient safety
- Practice how to
express feelings assertively
- Practice
reducing verbal and nonverbal anger (eg relaxation, storytelling)
Environmental Risk
Prevention
Definition
An activity to
minimize risk, detect the occurrence of disease, and injury in a population or
society at risk from the environment.
Action
Observation
- Identification
of environmental risks that can damage/harm health
- Identify parties
who can help the community for protection from environmental hazards
- Monitor incidents
of injury related to environmental hazards
Therapeutic
- Analysis of the
level of risk associated with the environment (eg housing, water, food,
radiation and violence)
- Cooperating with
related parties to improve environmental safety
- Advocacy with
the community for the design of a safe environment and its security system
- Facilitate
community members to make modifications to a safe environment
Education
- Inform the
population at risk of possible hazards from the surrounding environment
Collaboration
- Collaboration
with relevant health workers, if necessary
Shock Prevention
Definition
Identify and
reduce the risk of the body's inability to provide oxygen and nutrients to meet
tissue needs.
Action
Observation
- Monitor
cardiopulmonary status (pulse rate and strength, respiratory rate, BP, MAP)
- Monitor
oxygenation status (pulse oximetry, ER)
- Monitor fluid
status (input and output, skin turgor, CRT)
- Monitor level of
consciousness and pupillary response
- Check allergy
history
Therapeutic
Give oxygen to
maintain oxygen saturation >94%
- Prepare for
intubation and mechanical ventilation, if necessary
- Install IV line,
if necessary
- Insert a urinary
catheter to assess urine output, if necessary
- Do a skin test
to prevent allergic reactions
Education
- Explain the
causes/risk factors for shock
- Describe the
early signs and symptoms of shock
- Advise to report
if you find / feel the early signs and symptoms of shock
- Advise to
increase oral fluid intake
- Recommend
avoiding allergens
Collaboration
- Collaboration IV
administration, if necessary
- Collaboration of
blood transfusion, if necessary
- Collaborative
administration of anti-inflammatory, if necessary
Prevention of
Delusions I.09299
Definition
Identify and
reduce the risk or complication of belief in erroneous conclusions about
external reality.
Action
Observation
- Identify mental
and physical health
- Identify
previous treatment and medication history
- Identify
cultural backgrounds that can affect mental health
- Identify
triggers for delusions (eg stress, anxiety)
- Identify
delusional goals and/or needs
- Monitor recovery
and medication adherence
- Monitor physical
health (eg body weight, TTV)
- Monitor the
frequency and intensity of delusions every day
Therapeutic
- Make sure the
patient is in a safe environment
- Validate any
erroneous beliefs
- Facilitate the
fulfillment of delusional needs
- Motivation to
discuss delusional thoughts or reasoning
Education
- Inform that the
nurse does not share the patient's delusions with others
- Practice the
ability to fulfill delusional needs that are not being met (e.g. behavioral,
thought, assertive training)
- Practice mind
control (eg mind extraction techniques)
- Teach family in
handling delusions at home
- Teach patients
and families to control regularly
Collaboration
- Collaboration on
the provision of psychopharmaceuticals, if necessary
Family Assistance
Definition
Accompany family
and/or family members in undergoing treatment regimens and/or dealing with health
problems.
Action
Observation
- Identify family
relationships related to family health problems
- Identification
of hampered family health tasks
- Identify
possible spiritual support for the family
Therapeutic
- Reassure the
family that their family members will be given the best service
- Give realistic
expectations
- Build a trusting
relationship with your family
- Listen to the
wishes and feelings of the family
- Support adaptive
coping mechanisms that families use
- Family advocacy,
if necessary
Education
- Teach family
coping mechanisms
Parental
Assistance with I.10337
The child with
special needed
Definition
Provide
consultative support and so that parents are able to facilitate optimal growth
and development of children with special needs.
Action
Observation
- Identification
of parent/family acceptance of the child's condition
Therapeutic
- Facilitate
parents/family to express negative feelings
- Discuss with
parent/family resources
- Plan together
the needs of the child
- Support
parents/families to find support groups and integrated and inclusive education
- Facilitate
parents/families to get the information they need
Education
- Teach parents
about the principle of normalization
- Provide guidance
(coaching) in solving developmental and health problems of children
Surgical
Assistance I.14546
Definition
Facilitate and
manage surgical equipment packages during surgery.
Action
Observation
- Identification
of instruments, equipment, and equipment in a complete and sterile condition
Therapeutic
- Visit the
patient who will be operated on at least the day before surgery to provide an
explanation / introduce the surgical team
- Prepare the
necessary equipment and instruments
- Prepare the
operating room in a ready-to-use state
- Prepare a set of
sterile instruments according to the type of surgery
- Prepare
antiseptic/disinfectant fluids, and materials as needed for surgery
- Give a warning
to the surgical team if there is a deviation from the aseptic procedure
- Facilitate
surgeons wearing sterile gowns and gloves
- Arrange sterile
instruments on the mayo table according to the order of the surgical procedure
- Give the skin
disinfection material for the area to be cut
- Give sterile
cloth for draping procedure
- Give instruments
to the surgeon according to the sequence of procedures and the need for surgery
correctly and correctly
- Prepare sewing
thread in a ready-to-use state, as needed
- Clean the
instrument from blood at the time of surgery to maintain the sterilization of
the instrument from the mayo table
- Count gauze,
needles and instruments
- Prepare a liquid
to wash the wound
- Clean the skin
around the wound after the wound is stitched
- Cover the wound
with sterile gauze
- Prepare
laboratory/pathological examination materials, if any
- Fixation of
drain and catheter, if attached
- Change the loom,
patient gown and cover and transfer the patient from the operating table to the
stroller
- Count all
instruments before being removed from the operating room
- Ensure that
surgical records and documentation are complete
- Cleaning used
instruments
- Wrap the
instrument according to the type, material, use and size
- Clean the
operating room after surgery is complete
- Coordinate with
the room nurse about the patient's condition and the procedures that have been
carried out
Education
- Inform the
surgeon about the results of the calculation of the number of tools, gauze and
the number of needles before the operation begins and before the wound is
closed layer by layer
- Inform the
patient's status and progress to the family, if necessary
Breastfeeding
Assistance I.03130
Definition
Facilitating
mothers in breastfeeding activities so that they can be maintained.
Action
Observation
- Monitor mother's
ability to breastfeed
- Monitor baby's
ability to suckle
Therapeutic
- Accompany the
mother during breastfeeding activities
- Support mothers
to increase their confidence to breastfeed by using dolls while helping mothers
position their babies
- Accompany the mother
in positioning the baby correctly for the first feeding
- Give mothers
praise, information and advice on positive behavior in breastfeeding
- Discuss problems
during breastfeeding (eg pain, swelling of the breasts, sores on the nipples
and seek solutions)
Education
- `Teach the
mother about the signs that the baby is ready to feed (eg. the baby looks for
the nipple, salivates, puts his finger in his mouth and the baby cries)
- Teach the mother
to express breast milk to be smeared on the nipples before and after
breastfeeding, so that nipple flexibility is maintained
- Teach the mother
to direct the baby's mouth from the bottom towards the mother's nipple
- Teach
breastfeeding positions (eg cross cradle, cradle, foot ball and reclined
position followed by proper attachment)
- Teach proper
attachment: the mother's stomach and the baby are facing each other, the baby's
hands and feet are in a straight line, the baby's mouth is wide open and the
baby's chin is against the mother's breast to avoid blisters on the nipples
- Teach expressing
breast milk with finger position at 12-6 and 9-3
- Inform the
mother to breastfeed on one breast until the baby releases the mother's nipple
- Inform the
mother to always empty the breast on the breast that has not been breastfed by
expressing breast milk
Joint Goal Setting
I. 12464
Definition
Identify, develop
and prioritize shared care goals with the patient as a basis for developing a
treatment plan.
Action
Observation
- Identify the
goals to be achieved
- Identify ways to
achieve goals constructively
Therapeutic
- State the goal
in positive and clear sentences
- Set a scale for
achieving goals, if necessary
- Facilitation of
breaking down complex goals into small easy steps
- Clearly define
nurse and patient roles
- Discuss
available resources to meet goals
- Discuss the
development of plans to meet goals
- Prioritize
activities that can help achieve goals
- Facilitation in
identifying the expected results for each objective
- Set realistic
time limits
- Discuss
measurement indicators for each goal (eg behavior)
- Set periodic
evaluations to assess progress against goals
- Calculate goal
achievement score
- Modify the plan
if the goal is not achieved
Education
- suggest knowing
the problems experienced
- encourage
developing realistic expectations
- suggest
identifying own strengths and abilities
- suggest
identifying values and belief systems when setting goals
- suggest
identifying realistic and achievable goals
Arterial Blood
Sampling I.02069
Definition
Taking arterial
blood to get the value of the partial pressure of oxygen, carbon dioxide and
blood acid base.
Action
Observation
- identification
of arterial blood test orders as indicated
Brachial or radial
artery palpation
- do allen's test
before puncturing the radial artery
- select the
appropriate size and type of needle
- choose the right
blood sample tube
Therapeutic
- maintain
universal precautions
- Clean the
puncture area with an antiseptic
- rinse the
syringe with heparin
- remove all air
bubbles from the syringe
- stabilize
arteries by stretching the skin
- insert the
needle directly above the pulse at an angle of 45-60 degrees
- aspiration of
blood 3-5 cc
- pull the needle
after the sample is obtained
- press the
puncture area for 5-15 minutes
- label the sample
tube
- send specimens
to the laboratory
- document
temperature, oxygen saturation, delivery method, site of insertion, and
assessment of blood flow after insertion
- perform result
interpretation
Education
- explain the purpose
and steps of the procedure before taking blood
- inform the
results of blood sample examination, if necessary
Venous Blood
Sampling
Definition
Taking blood
samples through the intravenous for laboratory examination.
Action
Observation
• Identification
of venous blood test orders, as indicated
• Select a vein
with consideration of the amount of blood needed, mental status, comfort, age,
condition of the vein, presence of fistula, arteriovenous shunt
• Select the
appropriate needle size and type
• Choose the right
blood sample tube.
Therapeutic
• Maintain
universal precautions
• Dilate blood
vessels with tourniquets and clench fists
• Clean the
puncture site with an antiseptic in a circular motion
• Perform stabbing
at an angle of 20-30 degrees
• Aspiration of
blood samples
• Remove the
needle and apply pressure to the puncture site
• Apply dressing,
if necessary
• Label the sample
tube
• Send samples to
the laboratory
• Dispose of
needles in closed containers, according to procedure.
Education
• Explain the
purpose and steps of the procedure in taking blood
• Inform the
results of the blood sample examination, if necessary.
Specimen Taking
Definition
Collect specimens
for diagnostic examination.
Action
Observation
• Identification
of sampling orders as indicated
• Check the
patient's condition prior to sampling (eg consciousness, vital signs, condition
of organs or site of collection)
• Monitor for side
effects after sampling.
Therapeutic
• Facilitation of
patients during the specimen collection process carried out by the medical team
• Apply aseptic
principles and safety during specimen collection
• Manage side
effects that occur in the patient.
Education
• Explain the
purpose and steps of the sampling procedure.
Collaboration
•Collaborationfor further treatment.
Position Setting
Definition
Placing body parts
to promote physiological and/or psychological health.
Action
Observation
• Monitor
oxygenation status before and after changing positions
• Monitor the traction
device for accuracy.
Therapeutic
• Place on the
mattress/bedTherapeuticright
• Place in
positionTherapeutic
• Place frequently
used objects within reach
• Place the buzzer
or call light within reach
• Provide a
firm/solid mattress
• Adjust the preferred
sleeping position, if not contraindicated
• Adjust position
to reduce tightness (eg semi-Fowler)
• Adjust the
position that improves drainage
• Position in
proper body alignment
• Immobilize and
support the injured body part appropriately
• Elevate the
affected body part properly
• Elevate limb 20
degrees or more above heart level
• Elevate the head
of the bed
• Give the right
pillow to the neck
• Provide support
to areas of edema (eg, pillows under arms and scrotum)
• Position to
facilitate ventilation/perfusion (eg, prone/good lung down)
• Motivation to do
active or passive ROM
• Motivation is
involved in changing positions, as needed
• Avoid placing in
positions that can increase pain
• Avoid placing
the amputated stump in a flexed position
• Avoid positions
that put strain on the wound
• Minimize
friction and drag when changing positions
• Change position
every 2 hours
• Change position
with log roll technique
• Maintain
position and traction integrity
• Schedule in
writing for a change of position.
Education
• Inform when a
position change will be made
• Teach how to use
good posture and good body mechanics during position changes.
Collaboration
•Collaborationpremedication before changing
positions, if necessary.
Physical Restraint
Definition
Use mechanical
restraint devices to limit physical mobility and lower the risk of injury to
the patient.
Action
Observation
• Identify the
need for restraint
• Monitor response
to procedures
• Monitor and
provide psychological comfort
• Monitor skin
condition in the area of restraint.
Therapeutic
• Create a safe
environment
• Provide adequate
staff to exercise restraint
• Appoint nursing
staff to direct the team and patient during restraint
• Secure the
patient's reach
• Diversion
activity facilities (eg television, visitors, cell phones), if necessary
• Periodic
position change facility
• Facilities for
nutritional needs, elimination, hydration, and personal hygiene
• Engage in
activities to improve assessment and orientation
• Involves making
a decision to switch to a less stringent intervention.
Education
• Explain the
purpose and steps of the procedure in easy-to-understand language
• Explain the
risks and benefits of restraint
• Exercise joint
range of motion according to the patient's condition.
Collaboration
•Collaborationadministering medication for
restlessness or agitation, if necessary.
Chemical Restraint
Definition
Management,
monitoring, and discontinuation of psychotropic agents used to control
individual extreme behavior.
Action
Observation
• Identify the
need for restraint (eg, agitation, violence)
• Monitor
medication and allergy history
• Monitor response
before and after restraint
• Monitor level of
consciousness, vital signs, skin color, temperature, sensation, and condition
regularly
• Monitor
nutritional, fluid and elimination requirements.
Therapeutic
• Perform
supervision and surveillance in monitoring actions
• Provide a
comfortable position to prevent aspiration and skin damage
• Change body
position periodically
• Involve patient
and/or family in decision making.
Education
• Explain the
purpose and procedure of restraint
• Exercise joint
range of motion according to the patient's condition.
Collaboration
•Collaborationadministration of
psychotropic agents for chemical restraint.
Critical Path
Development
Definition
Determine the
priority of a group of activities through decision making in critical
conditions.
Action
Observation
• Identification
of activities and dependencies
• Identify the
duration of each activity
• Identify the
fastest time to start (early star), fastest time to finish early and last time
• Identify the
project and prepare a breakdown structure of the work breakdown
Terpeuttik
• Design the
relationship between activities
• Decide which
activities should come first and which should follow the others
• Draw a network
that connects all activities
• Set estimated
time and each activity
• Calculate the
longest time path through the network
• Use the network
to help with project planning, scheduling and control
• Apply
mathematical analysis methods
• Simplify
planning and scheduling large and complex projects
• Combine all
activity duration hypotheses
• Develop a
framework, activity framework and time target
• Mark each
activity with a target time according to priority
• Analysis of the
complex interrelated and interdependent scheduling and monitoring of each other
• Schedule
activities in a practical and efficient order
• Determine the
possible trade-off (possible trade-off) between time and cost
• Determine the
probability of completion of a particular project.
Community Health
Development
Definition
Facilitate group
or community members to identify community health issues and implement existing
solutions.
Action
Observation
• Identify health
problems or issues and their priorities
• Identification
of potential or assets in the community related to the issues at hand
• Identify
strengths and partners in health development
• Identification
of leaders/characters in the community.
Therapeutic
• Give every
member of the community the opportunity to participate according to their
assets
• Involve
community members to raise awareness of health issues and problems faced
• Involve
communities in deliberation to define health issues and develop work plans
• Involve the
community in the planning and implementation process and its revision
• Involve
community members in developing health networks
• Maintain open
communication with community members and parties involved
• Strengthen
communication between individuals and groups to discuss common interests
• Facility
organizational structure to improve communication and negotiation skills
• Develop
strategies in conflict management
• Unite community
members with common community ideals
• Build commitment
among community members
• Development of
mechanisms for involvement of local, regional and even national levels related
to communication health issues.
Facility
Introduction
Definition
Provide information
on health care facilities that can be used by patients.
Action
Observation
• Identification
of knowledge about health facilities.
Therapeutic
• Inventory of
patient belongings (eg dentures, hearing aids, cash).
Education
• Explain hospital
service regulations (eg, daily service activities in the room, visiting hours,
wearing of patient's personal clothes, inpatient admission procedures, deposit
payments, special pre and postoperative procedures)
• Describe safety
systems (eg evacuation routes, location of fire emergency exits, use of patient
identification wristbands, fall prevention)
• Inform the room
facilities used (eg, bathroom, nurse call system, television use, telephone
use)
• Inform physical
facilities (eg, location of rooms, beds, bathrooms, toilets)
• Inform the rooms
and equipment in the room (eg, the location of the nurse station, the use of
bedside monitors, ventilators, syringe pumps)
• Inform the
patient's daily needs (eg food service, telephone number, room/room, nurse's
attention when the nurse is giving medicine, doctor's visitation procedure).
Traditional
Therapeutic Use
Definition
Using actions that
refer to experience, knowledge and skills acquired from generation to
generation or through training and applied according to the values believed
by the community.
Action
Observation
• Identification
of health problems experienced
• Identify signs
and symptoms related to health problems
• Identify medical
history, medications, and allergies
• Identify current
and past therapy and reasons for discontinuing therapy
• Identification
of possible traditional therapies
• Monitor side
effects of therapy
• Monitor response
to therapy.
Therapeutic
• Record and study
the impact of some traditional therapies on health problems.
Education
• Explain
rationale, expected results and duration of therapy to be carried out
• Explain the need
for traditional therapy in overcoming the problem of the disease.
Collaboration
•Collaborationwith other health
professionals regarding evidence-based therapy, if necessary.
Airway Suction
Definition
Provide secretions
by inserting a negative pressure suction catheter into the mouth, nasopharynx,
trachea and endotracheal tube (ETT)
Action
Observation
• Identification
of the need for suction
• Auscultate
breath sounds before and after suctioning
• Monitor
oxygenation status (SaO2 and SvO2), neurological status (mental status,
intracranial pressure, cerebral perfusion pressure) and hemodynamic status (MAP
and heart rhythm) before, during and after the procedure
• Monitor and
record the color, amount and consistency of secretions.
Therapeutic
• Use aseptic
technique (eg use gloves, goggles or mask, if necessary)
• Use sterile and
disposable procedures
• Use closed
suction technique, as indicated
• Choose a suction
catheter size that covers no more than half the diameter of the ETT, perform
oral, nasopharyngeal, tracheal and/or endotracheal tube (ETT) suctioning
• Give oxygen with
a high concentration (100%) at least 30 seconds before and after the procedure
• Suck more than
15 seconds
• Perform ETT
suction with low pressure (80-120 mmHg)
• Apply suction
only along the ETT to minimize invasiveness
• Stop suctioning
and administer oxygen therapy if experiencing conditions such as bradycardia,
decreased saturation
• Perform a
culture and sensitivity test for secretions, if necessary.
Education
• Encourage deep
breathing techniques, before performing nasothacheal suctioning.
• Encourage deep
and slow breathing during suction catheter insertion.
Infection Control
Definition
Controlling the
spread of infection and worsening complications due to infection.
Action
Observation
• Identification
of patients with infectious infectious diseases.
Therapeutic
• Apply universal
precautions (eg, aseptic hand washing, use of personal protective equipment
such as masks, gloves, face shields, eye protection, aprons, boots according to
the mode of transmission of microorganisms)
• Place in
positive pressure isolation room for immunocompromised patients
• Place in a
negative pressure isolation room for patients at risk of spreading infection
via droplets or air
• Sterilization
and disinfection of tools, furniture, floors, as needed
• Use hepafilters
in special areas (eg operating rooms)
• Give special
signs to patients with infectious diseases.
Education
• Teach how to
wash hands properly
• Teach coughing
and/or sneezing etiquette.
Intraoperative
Infection Control
Definition
Prevent and
control the spread of infection intraoperatively
Action
Observation
• Identification
of patients with infectious diseases
• Check air
circulation in operating room, according to protocol
• Check that the
tools or instruments to be sterilized are free of dirt (eg blood/other body
fluids, free of rust, sharpness)
• Check the suitability
of sterile equipment to be used for surgery (eg sterilization date/expiration
date, suitability of instrument wrapping)
• Check the
suitability of the laminar airflow ventilator system
• Check the
suitability of oxygen panels, and other supporting equipment.
Terpeuttik
• Apply general
precautions (eg, aseptic hand washing, use personal protective equipment such
as masks, gloves, face shields, eye protection, aprons, boots according to the
mode of transmission of microorganisms)
• Maintain body temperature
within normal range
• Disinfect skin
with 2% chlorhexidine or according to protocol
• Give antibiotic
prophylaxis as indicated
• Use disposable
clothing, linens, pads, drapes, and wound protectors
• Use hepafilters
in special areas (eg operating rooms)
• Avoid using UV
lamps to sterilize the operating room
• Give special
signs to patients with infectious diseases.
Use liver in
special areas (eg operating room)
Avoid using UV
lamps to sterilize the operating room
Give special signs
for patients with infectious diseases
Health Control Via
Phone l.14553
Definition
Control and
evaluate the patient's health status continuously and periodically, through
telephone communication technology.
Action
Observation
Patient
identification
Ask the last
condition
Therapeutic
Make patient
control schedule
Call by phone one
day before the controversy. Offer whether you want to receive care at home or
at a health facility
Register for the
service to be visited
Prepare sex
service with perjaryan and request type of serviceEducation
Recommend
contacting the calf center if there is a change in health status
Tobacco Abuse
Control 1.09302
Definition
Prevent and
control the use of tobacco metal through cigarettes to reduce the harmful
effects of tobacco consumption.
Action
Observation
Identification of
smoking history
Identify environmental
conditions that cause smoking (eg being around other people who smoke, frequent
visits to non-smoking areas)
Identify
psychosocial aspects (eg positive and negative feelings) that influence
behavior
Monitor readiness
to quit smoking
Therapeutic
Create custom
treatment plans and troubleshooting
Schedule
monitoring via telephone or home visits for 2 years
Provide
non-smoking role models
Discuss the
reasons and obstacles to quitting smoking
Discuss physical
symptoms and nicotine withdrawal (eg headache, dizziness, nausea, irritability,
and insomnia)
Discuss symptoms
experienced after quitting smoking (eg dry mouth, cough, itchy throat)
Discuss planning,
strengthening and smoking cessation methods
Discuss the
smoking cessation program again, if it relapses
Education
Describe the
symptoms that physical withdrawal is temporary
Describe tobacco
substitute products (eg patches, chewing gum, nasal sprays, inhalers)
Recommend avoiding
smokeless, dipped and chewed tobacco
Encourage
maintaining a smoke-free lifestyle (eg celebrate quitting, use smoking money as
savings)
Advise avoiding
diet when trying to quit smoking
Suggest keeping
the to-do list in an accessible place (eg trouser pocket)
Encourage
participation in support group activities
Advise patients
who smoke again by evaluating the program
Practice craving
control development (eg spending time with friends who don't smoke, relaxation
exercises)
Practice assertive
ways to control yourself in a smoking environment
Collaboration.
Refer to group
program or therapist, if necessary
️Collaborationwith national and local
resource organizations regarding the program
Substance Abuse
Control I.109303
Definition
Controlling the
use of substances that are not in accordance with medical indications that can
lead to addiction to death.
Action
Observation
Identify factors
that cause stress
Identify the
physical changes experienced
Identify events
leading to substance use in a nonjudgmental manner
Validate
frustration or anger in dealing with problems
Therapeutic
Give positive
feedback and support every time doing social skills
Discuss planning
the schedule of daily or weekly activities
Make a schedule on
the calendar, if necessary
Education
Encourage
recording activities, feelings, and thoughts in a journal
Encourage
immediate overcoming of substance urges (eg controlling cravings, resisting,
ending and avoiding)
Teach how to avoid
substance use in the future
Teach families to
provide support and involvement in care programs
Practice increased
motivation (eg area of afferation, positive thinking)
Practice positive
attitudes towards substance use problems
Practice social
skills (eg eye contact, attentive listening, nodding, social conversation)Collaboration
Refer to mental
health and dependency services
Fetal Movement
Measurement 114554
Definition
Counting fetal
movement begins at 28 weeks of gestation.
Action
Observation
Identification of
mother's knowledge and ability to calculate fetal movement Monitor needle
movement
Therapeutic
Count and record
fetal movements (minimum 10 movements in 12 hours)
Perform a CTG
(candiotocography) examination to determine the frequency and regularity of the
fetal heart rate and maternal uterine contractions
« Record the
number of fetal movements in 12 hours per day
: Give oxygen 2 3
Umenut if fetal movement has not reached 10 times in 12 hours
Education
Explain the
benefits of counting fetal movements to improve the relationship between mother
and fetus
Advise the mother
to meet nutritional needs before calculating fetal movements
Suggest a left
tilted position when calculating fetal movements, so that the fetus can get the
Ooks gene optimally by increasing the fetomatemnal circulation.
Instruct the
mother to immediately notify the nurse if the fetal movement does not reach 10
times in 12 mM
So mom how to
count fetal movements
Collaboration
️Collaborationwith the medical team If
fetal distress is found
Forensic Data
Collection I.114555 |
Definition
Collect patient
data in order to provide forensic reports.
Action
Observation
Identify the
location of the wound in two dimensions
Identify wound
sequence by numbering (eg first, second, etc.), if possible Identify wound path
Therapeutic
Draw a physical
wound with size, color, type of wound, location (add depth and Cross line as
indicated)
Record all bruises
immediately because the marks will fade and disappear
Distinguish
laceration from incision wound and puncture wound
Draw the position
of the gunshot wound using a clockwise direction
Draw any bruising
around the wound or discoloration of the gunshot wound
Use body diagrams
and photographs to complete written reports
Get all aspects
identified (eg scars, tattoos, nail polish, body piercing, skin lesions)
Take the initial
photo as a full body photo before the injury is cleaned up
Take the next set
of photos as a mnid-range
Make sure that two
photos are obtained with a bookmark (one with a pointer and one without a clue)
to ensure that nothing is covered in a photo with a bookmark
Make sure the
photos of the wound are taken perpendicular to the skin surface to prevent
distortion
Make sure that the
photo includes the measuring scale to get the point of view
Make sure the
color scale is added to the color wound photo to avoid color distortion
Wash the area of
wounds and blemishes dry before shooting to avoid a wet spotlight
Describe clothing
(e.g. brand, size), jewelry and personal items
Record where the
item was found (eg a metal watch on the left wrist) Record information related
to the item (eg gunshot wound with soot on clothes)
Make sure all
items are photographed
Collect and pack
all specimens in paper bags with clear labels
Record date, time,
penis and specimen collection method
Use an all
evidence sealing protocol for all specimens
Record additional
formations or events that unfold later as an SDendum report
Plan daily
follow-up visits with the victim, if possible
Education
Explain the
purpose and procedure of forensic data collection
Provide
appropriate counseling and follow-up care for victims and their families, as
appropriate
Wound Stitching”
l.114556
Definition
Connect the ends
of the wound using a needle and stencil suture thread.
Action
Observation
Identify a history
of allergy to anesthetics 3225/5145
Identify the
history of kelod
Identify the
appropriate type of sewing thread
Identify the
appropriate needle type
Identify the
suture method that flares by wound type
Therapeutic
Shave the hair
around hika
Clean the wound
area with an antiseptic solution
Do steri pekruk
Give topical
anesthetic or injection in the wound area
Stitch the wound
inserting the needle perpendicular to the skin surface
Pull the stitches
tight enough so the skin doesn't bend and stays tight with the cover
Education
Explain the
purpose and procedure of action - Explain the signs of infection
Teach how to care
for stitches
Inform about the time
of seam releaseCollaboration
Collaboration
suturing deep
wounds, faces, joints, or potentially infectious wounds
Flatus Drop
l.04161
Definition
Prevention of
fiatus formation and fasciculation of excessive gas expulsion.
Action
Observation
Monitor the
feeling of bloating, abdominal distension and abdominal pain
Bowel sound
monitor
Monitor side
effects of drug administration
Therapeutic
Give tilt position
Limit oral intake
if the gastrointestinal system is underactive
Education
Encourage avoiding
conditions that cause excessive swallowing of air (eg chewing gum, drinking
carbonated drinks, eating quickly, chewing)
Advise to avoid
foods that cause flatulence (eg beans, cabbage, turnips, onions, cauliflower,
cucumbers)
Encourage regular
defecation
Collaboration
️Collaborationadministration of
anti-pharyngeal drugs, if necessary
️Collaborationadministration of laxatives,
suppositories, or enemas, if necessary
Mechanical
Ventilation Weaning I.01021
Definition
Allows the patient
to breathe without the aid of bloom ventilation.
Action
Observation
Check ability to
wean (including stable hemodynamics, optimal condition, free of infection)
Monitor predictors
of ability to tolerate weaning (eg respiratory rate, vital capacity, Vd/VI.
MVV, inspiratory strength, FEVI1. negative respiratory pressure)
Monitor for signs
of respiratory muscle fatigue (eg, increased PaCO, sudden, rapid and shallow breathing,
paradoxical abdominal wall movement), hypoxia, and tissue tupxia during
weaning.
Morutor fluid and
electrolyte status
Therapeutic
Position the
patient in a semi-Fowler's position (30 - 45 degrees)
Perform airway
suctioning, Aka necessary
Give chest
physiotherapy. xka need
Perform upcobse
weaning (30-120 minutes with ventilator-assisted spontaneous breathing)
Use relaxation
techniques, if necessary
Avoid imposition
of pharmacologic sedation during weaning trials
Benefit
psychological support
Education
Teach how to
control breath during weaning
Collaboration
️Collaborationadministration of drugs that
increase airway patency and gas exchange
Cultural
Intercession 1.13487
Definition
Respect the
cultural differences and similarities of patients in providing care throughout
the range of health and illness in accordance with the cultural values of the
patient.
Action
Observation
identification of
conceptual differences between patient and nurse regarding the disease process
Therapeutic
Be calm and not in
a hurry when interacting with patients
Discuss cultural
gaps between patients and caregivers
Understand patient
culture
Use
easy-to-understand language
Involve family in
treatment planning
Give an
opportunity to understand the information provided
Translate terms
into language the patient can understand
Use a third party,
if necessary
Negotiate if the
conflict is not resolved
Education
Inform about the
health care system
Mechanical Cardiac
Support Device Maintenance I.02072
Definition
Identify and treat
patients who have mechanical devices attached to support cardiac function and
circulation.
Action
Observation
Monitor pulse
strength, skin color, capillary refill and temperature in peripheral areas
Monitor for pain
in the lower extremities
Monitor for
swelling in the lower extremities
Monitor inflation
and IABP (intraaortic ballan pump) deflation
Optimal monitoring
of diastolic augmentation level
Therapeutic
Maintain
anticoagulant levels according to the recommended dose
Perform ankle
range of motion exercises (ftex and extension) every 1 - 2 hours
Maintain supine
position with head of bed up to 15” «
Keep the
cannulated extremity in a straight position
Maintain balloon
volume to ensure optimal diatotic augmentation
Use gentle
restraints on the canned extremity, if necessary
Make sure the
intra-aortic balloon is refilled in 1-2 hours, or according to the machine's
bpe
Minimize indoor
noise
Involve patient in
decision making regarding his/her care, if possible
Education
Inform the date
and time and orient the patient regularly
Advise to avoid
thigh flexion movements
Encourage the
family to express feelings and emotional stress that is felt
Advise realistic
expectations on the family for the development of the patient's condition
Amputation
Treatment 1.14557
Definition
Promote physical
and psychological healing before and after amputation of body parts.
Action
Observation
Monitor for edema
on stwnp
Monitor for
phantom pain in the legs (eg burning, cramping, throbbing, crushing, or
tingling sensations)
Regularly monitor
the prosthesis (eg stability, ease of movement, energy efficiency, appearance
of walking)
Monitor wound
healing in the incision area
Monitor
psychological problems (eg depression, anxiety)
Identify lifestyle
modifications and necessary assistive devices (eg house and car)
Identify
modifications in clothing, as needed
Therapeutic
Motivation to
participate in deciding the amputation. If possible
Facilitate the use
of pressure-reducing mattresses/mattresses
Position the siimp
(the butt / yung part of the amputation) in the proper body alignment
Place the stump
below the knee (balow-the-knee) in the extended position
Avoid placing the
stwnp in a hanging position to reduce edema and vascular stasis. Avoid changing
the stump dressing immediately after surgery as long as there are no seepage or
signs of infection.
Wrap the stump as
needed
Make the stump
conical by wrapping it to fit the prosthesis
Take
non-pharmacological pain relief (mus. TENS, phonophoresis, statement), as
needed
Facilitate the
process of grieving the loss of a body part
Motivation to take
care of the stump independently
Discuss the
long-term goals of the rehabilitation program (eg walking without support)
Education
Explain that
phantom pain can occur several weeks after surgery and can be triggered by
pressure on other areas
Advise to avoid
sitting in the first time
Teach
postoperative exercises (mus. range of motion exercises, breathing exercises,
and crunches) Teach self-care after discharge from hospital
Teach signs and
symptoms to report to health care facilities (eg chronic pain, skin breakdown,
tingling, palpable pulse, chills)
Teach care and use
of prosthesis
Collaboration
Refer to
specialist services for modification or treatment of prosthesis complications
Incision Area
Treatment 1.14558
Definition
Identify and
improve wound healing closed with sutures. kip. or staples.
Action
Observation
Check the incision
site for redness, swelling, or signs of dehiscence or evisceration
Identify drainage
characteristics
Monitor the
healing process of the incision area
Monitor for signs
and symptoms of infectionTherapeutic
Clean the incision
area with proper cleanser
Wipe the incision
area and the clean area to the less clean area
Clean the area
around the drain or drainage tube
Maintain drainage
tube position
Give antiseptic
ointment. if necessary
Change wound
dressing on schedule
Education
Explain the
procedure to the patient, using assistive devices
Teach to minimize
pressure at the incision site
Teach how to care
for the incision area
Baby care l.10338
Definition
Identifying and
caring for baby's health
Action
Observation
- Monitor baby's
vital signs (especially temperature 36.5 c, 37.5 c)
Therapeutic
- Bathing the baby
with a temperature of 21-24 c
- Bathe the baby
within 5-10 minutes and 2 times a day
- Treat the
umbilical cord openly (the umbilical cord is not wrapped in anything)
- Clean the base
of the umbilical cord with a cotton stick that has been given boiled water
- Wear the baby's
diaper under the umbilicus if the umbilical cord has not come off
- Do baby massage
- Change baby's
diaper if it gets wet
- Wear baby
clothes from under cotton
Education
Advise the mother
to breastfeed according to the baby's needs
- Advise the mother
how to take care of the baby at home
- Advise how to
give complementary feeding to babies > 6 months
DIALISIS TREATMENT
I.03131
Definition
Identifying and
treating patients who will choose dialysis therapy as an option for treating
kidney failure
Action
Observation
- Identify the
symptoms and signs of dialysis (eg physical examination, laboratory, other
investigations)
therapeutic
- Discuss options
for dialysis therapy (hemodialysis, peritoneal dialysis)
- Give opportunity
and time to decide on dialysis therapy options
- Accompany
patients and families in the decision-making process
- Prepare the
patient psychologically and physically for dialysis
- Monitor the
effectiveness of dialysis therapy
- Record patient
progress
Education
- Explain the advantages
and disadvantages of each dialysis therapy
PULMONARY EMBOLY
TREATMENT l.02074
DEFINITION
Identifying and
managing patients with pulmonary circumcision occlusion
ACTION
OBSERVATION
- Monitor for
changes in respiratory and cardiovascular status (eg wheezing, hemoptysis,
dyspnea, tachypnea, tachycardia, syncope)
Monitor for chest,
shoulder, back or pleural pain (eg, intensity, location, radiation, duration
and aggravating and reducing factors)
Monitor for signs
of inadequate tissue oxygenation (eg, pallor, cyanosis, CRT, slowed down)
- Monitor baby for
additional breaths
- Monitor for
signs and symptoms of respiratory failure (eg low Pa02, increased paC02,
respiratory muscle fatigue)
- Monitor side
effects of anticoagulants
THERAPEUTIC
- Put on elastic
socks, if necessary
- Put on
intermittent pneumatic compression socks for 15-20 minutes every 8 hours
- Avoid
antecubital intravenous access
- Perform active
or passive range of motion
- Change position
every 2 hours
EDUCATION
- Explain the
mechanism of pulmonary embolism
- Teach deep
breathing techniques
- Teach the
importance of anticoagulation for 3 months
- Teach prevention
of recurrent thromboembolism
- Teach to move
the leg in flexion and extension 10 times every hour, if necessary
COLLABORATION
- Collaboration of
thrombolytic therapy (eg treptokinase, urokinase, activase)
- Collaboration
administration of low-dose anticoagulants and high-dose anti-platelet agents
(eg heparin infarct, clopidogrel, warfarin, aspirin, dipyrimal, dextran)
- Collaboration
diagnostic examination to rule out symptoms of similar diseases (eg acute
myocardial infarction, pericarditis, oar dissection, pneumonia, pneumothorax,
peptic ulcer, rupture, gastritis)
Peripheral
embolism TREATMENT I.02074
DEFINITION
Identifying and
managing patients with peripheral occlusion
ACTION
OBSERVATION
- Examine the
peripheral circulation thoroughly (eg peripheral pulses, edema, capillary
refill, color and temperature of the extremities)
- Monitor pain in
the affected area
- Monitor for
signs of decreased venous circulation (eg increased extremity circumference,
swelling and tenderness, increased pain in a dependent position, persistent
pain on moving the extremity, hard palpable veins, enlarged superficial veins,
cramping, redness and warmth, numbness and tingling, changes skin color, fever)
- Monitor
prothrombin time (PT) and partial thromboplastin time (PTT)
- Monitor side
effects of anticoagulants
THERAPEUTIC
- Elevate the
injured area 20 degrees above the heart
- Use elastic legs
- Use intermittent
pneumatic compression socks, if necessary
- Remove elastic
socks or intermittent pneumatic compression for 12-20 minutes every 8 hours
- Perform active
or passive range of motion
- Change position
every 2 hours
- Avoid
antecubital intravenous access
- Avoid massaging
or compressing injured muscles
EDUCATION
Describe the
mechanism of peripheral embolism
- Advise not to
sit crossed legs or legs in the old form
- Advise to avoid
the Valsalva maneuver
- Advise ways to
prevent peripheral embolism (eg, walk, drink plenty of fluids, avoid alcohol,
avoid long-term immobility, hanging legs)
- Teach the
importance of anticoagulation for 3 months
COLLABORATION
-Collaborationadministration of
anticoagulants
- Collaborative
administration of promethazine in 0.9% NaCI 25-50 cc slowly and avoid dilution
less than 10cc
- Collaborative
administration of low-dose anticoagulants and high-dose anti-platelet agents
(eg heparin, clopidogrel, warfarin, aspirin, dipyridamole, dextran)
GIPS TREATMENT
I.05181
DEFINITION
Identifying and
treating patients undergoing immobilization of the extremity with a cast
ACTION
OBSERVATION
- Identify changes
in sensation or increase in pain at the fracture site
- Monitor for
signs of infection (eg, cast odor, erima, fever)
- Monitor for
signs of impaired circulation or neurologic function (eg, pain, pallor,
unpalpable pulse, paresthesias, paralysis [5P])
- Monitor
circulation and neurological function proximal and distal to the plaster cast
- Monitor for
signs of drainage from the wound under the cast
- Check for cracks
or damage to the plaster
THERAPEUTIC
- Support the cast
with pillows until the cast is dry
- Clean the skin
around the installation area from the rest of the plaster material
- Treat
circulatory disturbances immediately (eg reposition cast, perform limb range of
motion, relieve due to cast pressure)
- Position the
cast on the pillow to reduce tension
- Elevate the
extremity in the cast above the level of the heart
- Use arm sligs
for support, if necessary
- Provide padding
on the edge of the plaster
- Avoid placing
the plaster on a hard or sharp surface during the drying period
- Avoid pressing
the plaster during the drying period
- Avoid getting
the cast wet (e.g. wear appropriate protection when showering or protective
socks or gloves)
COLLABORATION
- Inform the cast
will feel warm during the installation process until it dries
- Inform the need
to limit activities during the drying period of the plaster
- Advise not to
scratch the skin under the cast
- Advise how to
care for the cast
FECAL INCONTINENCE
TREATMENT I.04162
DEFINITION
Identify and treat
patients who experience involuntary (unconscious) expulsion of feces
ACTION
OBSERVATION
- Identification
of causes of fecal and psychological incontinence (eg lower motor nerve
disorders, decreased muscle tone, rectal sphincter disorders, diarrhea,
chronic, cognitive impairment, excessive stress)
- Identification
of changes in the frequency of defecation and the intensity of faeces
- Monitor adequacy
of faecal evacuation
- Monitor diet and
fluid requirements
- Monitor side
effects of drug administration
SPECIALIZED
- Clean perianal
blood with soap and water
- Keep the bed and
clothes clean
- Implement a
bowel exercise program (bowel training) if necessary
- Schedule a bowel
movement in bed, if necessary
- Provide
protective pants / diapers / diapers, as needed
- Avoid foods that
cause diarrhea
EDUCATION
- Explain the
definition, types of incontinence, causes of fecal incontinence
- Suggest noting
the characteristics of the faeces
COLLABORATION
- Collaboration of
diarrhea medication (eg loperamide, atropine)
URINE INCONTINENCE
TREATMENT I. 04163
DEFINITION
Identifying and
treating patients with involuntary (unconscious) urination
ACTION
OBSERVATION
- Identification
of causes of urinary incontinence (eg neurological dysfunction, spinal cord
disorders, detrusor reflex disorders, drugs, age, surgery history, impaired
cognitive function)
- Identify the
patient's feelings and perceptions of urinary incontinence
- Monitor the
effectiveness of drugs, surgery and urinary mobility therapy
- Monitor BAK
habits
TERAOEUTIC
- Clean the
genitals and surrounding skin regularly
- Give praise for
hygiene to prevent incontinence
- Create a
schedule for taking drugs
- Take a urine
sample for a complete urine examination or culture
EDUCATION
- Explain the
definition, types of incontinence, causes of urinary incontinence
- Describe the
treatment program for urinary incontinence
- Describe the
type of use and the environment that supports the voiding process
- Recommend
limiting fluid consumption for 2-3 hours before bed
- Instruct to
monitor fluid in and out and urine elimination patterns
- Recommend
drinking at least 1500cc/day if not contraindicated
- Recommend
avoiding coffee, soft drinks, tea and chocolate
- Encourage
consumption of fruits and vegetables to avoid constipation
COLLABORATION
- Refer to an
incontinence specialist
SKIN INTEGRITY
TREATMENT I.11353
DEFINITION
Identify and treat
skin to maintain integrity, moisture and prevent the development of
microorganisms
ACTION
OBSERVATION
- Identification
of causes of impaired skin integrity (eg changes in circulation, changes in
nutritional status, decreased humidity, extreme environmental temperatures,
decreased mobility)
THERAPEUTIC
- Change position
every 2 hours if bed rest
- Perform massage
on bony prominence areas, if necessary
- Clean the
perineal with warm water, especially during diarrhea
- Use petroleum or
oil based products on dry skin
- Use mild/natural
and hypoallergenic products on sensitive skin
- Avoid
alcohol-based products on dry skin
EDUCATION
- Recommend using
a moisturizer (eg lotion, serum)
- Recommend
drinking enough water
- Recommend
increasing nutritional intake
- Advise to
increase the intake of fruits and vegetables
- Recommend
avoiding exposure to extreme temperatures
- It is
recommended to use a minimum of 30 SPF sunscreen when you are at home
- Advise to take a
shower and use soap sparingly
HEART CARE I.02075
DEFINITION
Identify, treat
and limit complications resulting from an imbalance between myocardial supply
and consumption
ACTION
OBSERVATION
- Identification
of primary signs/symptoms of decreased cardiac output (including dyspnea, fatigue,
edema, orthopnea, paroxysmal noctumal dyspnea, increased CVP)
- Identify
secondary signs/symptoms of decreased cardiac output (including weight gain,
hepatomegaly, jugular venous distention, palpitations, wet rales, oliguria,
cough, pale skin)
- Monitor blood
pressure (including orthostatic blood pressure, if necessary)
- Monitor fluid
intake and output
- Monitor weight
every day at the same time
- Monitor oxygen
saturation
- Monitor chest
pain complaints (eg, intensity, location, radiation, duration of precision that
reduces pain)
- Monitor ECG12
leads
- Monitor
arrhythmias
- Monitor cardiac
laboratory values (eg electrolytes, cardiac enzymes, BNP, NT pro-BPN)
- Monitor the
function of the heart trigger device
- Check blood
pressure and pulse rate before and after activity
- Check blood
pressure and pulse rate before administering drugs (eg beta blockers, ACE
inhibitors, calcium channel blockers, digoxin)
THERAPEUTIC
- Position the
patient in semi-Fowler's and feet down or in a comfortable position
- Provide
heart-appropriate diet (eg limit intake of caffeine, sodium, cholesterol, and
high-fat foods)
- Use intermittent
elastic or pneumatic stockings, as indicated
- Facilitate
patients and families for healthy lifestyle modification
- Provide
relaxation therapy to reduce stress, if necessary
- Provide
emotional and spiritual support
Give oxygen to
maintain oxygen saturation >94%
EDUCATION
- Encourage
physical activity according to tolerance
- Encourage
physical activity against
- Advise quit smoking
- Instruct patient
and family to measure daily weight
- Instruct the
patient and the patient's family to measure daily intake and output
COLLABORATION
- Collaboration of
antiarrhythmic administration if necessary
- Collaboration to
cardiac rehabilitation program
ACUTE HEART
TREATMENT I. 02076
DEFINITION
Identify and
manage patients with recent episodes of imbalance between myocardial oxygen
supply and demand
ACTION
OBSERVATION
- Identify the
characteristics of chest pain (including trigger factors and tinkering,
quality, location, radiation, scale, duration and frequency
- Monitor 12 lead
ECG for ST and T . changes
- Monitor
arrhythmias (rhythm and frequency abnormalities)
- Monitor
electrolytes receiving increased risk of arrhythmias (eg potassium, serum
magnesium)
- Monitor cardiac
enzymes (eg CK, CK-MB, Troponin T, Troponin 1)
- Monitor oxygen
saturation
- Identification
of stratification in acute coronary syndromes (eg TMI score, killip, crusades)
THERAPEUTIC
- Maintain bed
rest for at least 12 hours
- Install
intravenous access
- Satisfy until
pain free
- Provide
relaxation therapy to reduce anxiety and stress
- Provide a
conducive environment for rest and recovery
- Prepare for
percutaneous coronary intervention, if necessary
- Provide
emotional and spiritual support
EDUCATION
- Advise
immediately report chest pain
- Advise to avoid
Valsalva maneuver (eg straining during defecation or coughing)
- Explain the
actions taken by the patient
- Suggest
techniques to reduce anxiety and strength
COLLABORATION
- Collaborative
administration of antiplatelet, if necessary
- Collaborative
administration of antiplatelets (eg nitroglycerin, beta blockers, calcium
channel blockers)
- Collaborative
administration of morphine, if necessary
- Collaboration in
giving intotropes, if necessary
- Collaborative
administration of drugs to prevent Valsalva maneuver (eg stool softeners,
antiemetics)
- Collaboration of
thrombus prevention with anticoagulants if necessary
- Collaborative
chest x-ray examination, if necessary
I.O2O77 cadaver
treatment
DEFINITION
Provide care for
patients who have died
ACTION
OBSERVATION
- Identification
of culture and beliefs in body management
THERAPEUTIC
- Report to the
relevant officer that the patient has died (eg head of the room, supervisor
- Close your jaw
and close your eyes
- Position the
arms at the side of the body or held together (according to the patient's
religion or beliefs)
- Remove external
objects from the body (eg urinary catheters, intravenous catheters, monitor
leads)
- Clean the corpse
thoroughly
- Cover the body
with a clean cloth to the chin or head
- Provide
emotional and spiritual support for the family
- Provide privacy
if the family wants to see the patient's body
- Label the body's
personal belongings
- Move the corpse
to a special room or morgue
- Facilitate
families going through the grieving process
EDUCATION
- Teach through
the grieving process gradually, if necessary
- Explain the
administrative procedures for handing over the corpse and/or corpse items to
the family
COLLABORATION
- Collaboration
with clergy in accordance with institutional policies, if necessary
FOOT CARE I.11354
DEFINITION
Identify and treat
feet for relaxation, hygiene and skin health needs
ACTION
OBSERVATION
- Identify the
usual foot care
- Check for
irritation, cracks, lesions, calluses, deformities, or edema
- Check for nail
thickness and discoloration
- Monitor the
moisture level of the feet
- Monitor gait and
weight distribution on the feet
- Monitor the cleanliness
and general condition of shoes and socks
- Monitor for
peripheral neuropathy with the Semmes-Weinstein monofilament test
- Monitor blood
sugar levels or HbA value 1c <7%
THERAPEUTIC
- Dry between the
toes
- Give foot
moisturizer, as needed
- Clean and/or
trim nails, if necessary
- Perform wound
care as needed
EDUCATION
- Inform the
importance of foot care
- Teach how to
prepare and cut nails
- Teach to wear
shoes with the appropriate size
- Recommend the
provision of moisturizing absorbent powder, if necessary
- It is
recommended to check the inside of the shoe before putting it on
- Suggest
monitoring the temperature of the feet using the back of the hand
- Advise the
importance of foot examination, especially when sensation is reduced
- Advise to avoid
pressing on the ulcerated foot by using a stick or special shoes
COLLABORATION
- Refer a
podiarist to trim thickened nails,
Kangaroo Care
1.14559
Definition
Perform the act of
caring for the baby through skin-to-skin contact between parents and a stable
premature baby.
Action
Observation
- Monitor parental
factors that influence their involvement in care
Therapeutic
- Ensure the
baby's physiological status is met in care
- Provide a quiet,
comfortable and warm environment
- Give the chair
to the parents, if necessary
- Position the
baby face down perpendicular to the parent's chest
- Tilt the baby's
head to the right or left with the head slightly tilted (extension)
- Avoid pushing
the baby's head in flexion and hyperextension
- Leave baby naked
wearing only diaper, socks and hat
- Position the
baby's pelvis and arms in a flexed position
- Position the
baby secured with a long cloth or other fastener
- Make the tip of
the strap just under the baby's ear
Education
- Explain the
purpose and procedure of kangaroo care
- Explain the
advantages of skin-to-skin contact for parents and babies
- Encourage
parents to wear comfortable clothes with an open front
Peripheral Central
Catheter Treatment l.02078
Definition
Identify and treat
catheters that are inserted peripherally to access the central circulation.
Action
Observation
- Identify the
need for catheter use (eg administration of peripheral irritating drugs)
-Identify the
appropriate size and type of catheter
- Identification
of easily accessible veins (eg, basilic or cephalic vein)
- Ensure that
there are no contraindications to insertion (eg invisible and palpable veins,
skin infection or hematoma, sepsis, abnormal bleeding)
- Monitor the
position of the tip of the catheter with X-ray examination
- Monitor for
complications (eg bleeding, nerve or tendon damage, cardiac decompression,
respiratory distress, or catheter embolism)
- Monitor for signs
of phlebitis (eg pain, redness, warm skin and edema)
Therapeutic
- Determine
catheter tip placement (eg superior vena cava, bracheocephalic vein, axillary
or subclavian vein)
- Position supine
with arms parallel to the body
- Measure the
distance for insertion of the catheter Prepare the insertion area
- Ask to turn
towards the arm where the insertion is with the chin touching the chest
- Insert the
catheter with the sterile technique
- Connect the
extension tube and aspirate
- Rinse with
heparin and normal saline
- Fix the catheter
using a sterile transparent dressing
- Perform catheter
removal, as indicated
Education
- Explain the
purpose, benefits and risks of catheter insertion before insertion
- Instruct to
report signs of infection (eg fever, chills, dry puncture site)
Urine Catheter
Treatment 1.04164
Definition
Identify and treat
patients undergoing urinary catheterization.
Action
Observation
- Monitor urinary
catheter patency
- Monitor for
signs and symptoms of urinary tract infection
- Monitor for
signs and symptoms of obstruction to the flow of urine
- Monitor for
leaks of catheters, tubes and urine bags
- Monitor fluid
input and output (amount and characteristics)
Therapeutic
- Use aseptic
technique during urinary catheter care
- Make sure the
catheter tube and urine bag are free from folds
- Make sure the
urine bag is placed below the level of the bladder and not on the floor
- Perform perineal
care (perineal hygiene) at least 1 time a day Perform routine irrigation with
isotonic fluids to prevent bacterial colonization
- Empty the urine
bag when the urine bag is half filled
- Change catheter
and urine bag regularly according to protocol or as indicated
- Remove urinary
catheter as needed
- Maintain privacy
during actions
Education
Explain the
purpose, benefits, procedures, and risks before catheter insertion
High Risk
Pregnancy Care 1.14560
Definition
Identify and care
for mothers at risk during pregnancy according to established service
standards.
Action
Observation
- Identification
of pregnancy risk factors (eg diabetes, hypertension, lupus erythematosus,
herpes, hepatitis, HIV, epilepsy)
- Identification
of obstetric history (eg prematurity, postmaturity, preeclampsia, multifetal
pregnancy, intrauterine growth retardation, abruption, placenta previa, Rh
sensitization, premature rupture of membranes, and family history of genetic
disorders)
- Social and
demographic identification (eg, maternal age, race, poverty, late or no
prenatal care, physical abuse, and substance abuse)
- Monitor physical
and psychosocial status during pregnancy
Therapeutic
- Accompany mother
when she feels anxious
- Discuss safe
sexuality during pregnancy
- Discuss
discomfort during pregnancy
- Discuss labor
and birth preparation
Education
- Explain the risk
of the fetus experiencing premature birth
- Inform about
possible interventions during delivery (eg intrapartum electronic fetal
monitoring, induction, cesarean care)
- Advise self-care
to improve health
- Advise mother to
be active and get enough rest
- Teach how to
count fetal movements
- Teach safe
activities during pregnancy
- Teach to
recognize danger signs (eg bright red vaginal bleeding, changes in amniotic
fluid, decreased fetal movement, contractions before 37 weeks, headache, visual
disturbances, epigastric pain, and rapid weight gain with facial edema)Collaboration
- Collaboration
with specialists if signs and dangers of pregnancy are found
Second and Third
Trimester Pregnancy Care 1.14561
Definition
Identifying and
caring for pregnant women at week 14 to term (38-40 weeks).
Action
Observation
- Monitor vital
signs
- Weigh the weight
Measure the height of the fundus
- Check fetal
movement
- Check fetal
heart rate
Therapeutic
- Maintain correct
posture
- Perform regular
dental and oral hygiene
- Keep nails short
and clean
- Keep the vulva
and vagina clean
- Elevate legs at
rest
- Give warm and
cold compresses on the back
- Involve family
for support
Education
- Recommend
avoiding fatigue
- Advise to use
cotton underwear and not tight
- Recommend using
a supportive bra
- Recommend
comfortable shoes and socks
- Suggest a
sitting or standing position for too long and crossing your legs at your knees
- Encourage
regular physical exercise
- Teach relaxation
techniques
Collaboration
- Collaboration
ultrasound examination
- Collaboration
laboratory tests (eg Hb, protein, glucose)
- Refer if you
have problems or pregnancy complications
First Trimester
Pregnancy Care 1.15562
Definition
Identify and care
for pregnant women in the first week to the 13th week of pregnancy.
Action
Observation
- Identification
of pregnancy risk factors (eg preterm delivery, preeclampsia, DM)
- Identification
of smoking history, immunization during pregnancy, contraceptive use
- Identification
of family history of congenital abnormalities
- Monitor vital
signs
- Weigh the weight
- Measure fundal
height
- Check fetal
movement
- Check fetal
heart rate
Therapeutic
- Perform
depression screening in pregnancy
- Perform regular
dental and oral care
- Motivation to
eat small portions but often
- Set rest time
between activities
- Limit fluid
intake before bed
Education
- Advise not to
let the stomach be empty or too full
- Recommend
consuming dry carbohydrates with a warm drink when you wake up
- Advise to avoid
foods that contain lots of fat, gas, spices that stimulate nausea
- Advise to stop
smoking
- Recommend
avoiding excessive activity
- Recommend
regular pregnancy check-ups
- Recommend
laboratory tests (eg Hb, glucose, albumin, ketones)
Collaboration
- Collaboration
ultrasound examination to determine gestational age
Comfort Treatment
1.08245
Definition
Identify and treat
patients to increase comfort.
Action
Observation
- Identify
unpleasant symptoms (eg nausea, pain, itching, shortness of breath)
- Identify
understanding of the condition, situation and feelings
- Identify
emotional and spiritual problems
Therapeutic
- Provide a
comfortable position
- Give a cold or
warm compress
- Create a
comfortable environment
- Give massage
- Give acupressure
therapy
- Give hypnosis
therapy
- Support families
and caregivers involved in therapy/treatment
- Discuss the
situation and the desired therapy/treatment options
Education
- Explain about
the condition and treatment/treatment options
- Teach relaxation
therapy - Teach breathing exercises
- Teach
distraction techniques and guided imagination
Collaboration
- Collaborative
administration of analgesics, antipruritus, antihistamines, if necessary
Nail Care 1.11355
Definition
Identify and treat
nails so that they are clean and healthy and do not experience skin lesions due
to improper nail care.
Action
Observation
- Monitor the
cleanliness and health of nails
- Monitor changes
that occur in nails
Therapeutic
- Soak nails in warm
water
- Facilitate nail
cutting and cleaning, as needed
- Clean nails with
natural ingredients (eg water, lemon, starfruit)
- Clean the
underside of the nail with a nail cleaner
- Apply warm olive
oil on the nails
- Moisturize the
area around the nails to prevent dryness
- Facilitate
applying nail polish, if necessary
Education
- Recommend
cutting and cleaning nails regularly
- Encourage
consumption of foods rich in biotin (eg milk, eggs, nuts)
Preoperative Skin
Care 1.14563
Definition
Identify and treat
the skin around the operating area prior to surgery.
Action
Observation
- Identification
of skin conditions at the surgical site (eg rash, abrasion, laceration)
Therapeutic
- Carry out the
procedure as close as possible to the operating time
- Undress the area
to be operated on up to 30 cm around the area to be incised
- Shave hair in
the operating area
- Recommend
removing all jewelry
- Clean the skin
by rubbing soap or chlorhexidine
- Gently rub the
folded skin area
- Clean nail
polish
- Dry the surgical
preparation area with a clean towel
Education
- Explain
procedures to reduce anxiety
Contact Lens Care
1.06202
Definition
Identify and treat
patients who wear contact lenses and prevent problems from wearing contact
lenses
Action
Observation
- Identify the
level of understanding of lens care
- Monitor for
lesions and ecchymoses in the area around the eyes
Therapeutic
- Wash and dry
hands before touching contact lenses
- Use contact
lenses that suit your needs
- Clean and soak
contact lenses with a special cleaning fluid for contact lenses
- Rub gently when
cleaning lenses
- Avoid wearing
contact lenses for 24 hours without ever removing them
Education
- Recommend caring
for contact lenses properly, according to the type of contact lens
- Recommend
removing contact lenses before going to bed, bathing and swimming
- Advise to avoid
exposure to irritating substances during contact lens use (eg dust, fumes,
soaps, sprays)
- It is
recommended to use UV protection glasses or wear a wide hat if you are in the
hot sun
- Advise to report
immediately if any complaints occur (eg redness, pain, excessive tearing, eye
changes and discomfort)
Wound Care 1.14564
Definition
Identify and
improve wound healing and prevent wound complications.
Action
Observation
- Monitor wound
characteristics (eg drainage, color, size, odor)
- Monitor for
signs of infection
Therapeutic
- Remove the
bandage and plaster slowly
- Shave the hair
around the wound area, if necessary
- Clean with
liquid NaCl or non-toxic cleaner, as needed
- Clean necrotic
tissue Apply an appropriate ointment to the skin/lesion, if necessary
- Apply dressings
according to the type of wound Maintain sterile technique when performing wound
care
- Change the
dressing according to the amount of exudate and drainage
- Schedule
position changes every 2 hours or according to the patient's condition
- Provide a diet
with calories 30-35 kcal/kgBW/day and protein 1.25-1.5 g/kgBW/day
- Give vitamin and
mineral supplements (eg vitamin A, vitamin C, zinc, amino acids), as indicated
- Give TENS
(transcutaneous nerve stimulation) therapy, if necessary
Education
- Describe the
signs and symptoms of infection
- Recommend
consuming high-calorie and protein foods
- Teach wound care
procedures independently
Collaboration
Collaborationdebridement procedures (eg
enzymatic, biologic, mechanical, autolytic), if necessary - Collaborative
administration of antibiotics, if necessary
Burn Treatment
1.14565
Definition
Identify and treat
acute and chronic wounds due to thermal trauma.
Action
Observation
- Identify the
cause of the burn
- Identify the
duration of the burn and the history of previous wound care
- Monitor wound
condition (eg percentage of wound size, degree of wound, bleeding, wound bed
color, infection, exudate, wound odor, wound edge condition)
Therapeutic
- Use aseptic
technique during wound care
- Remove the old
dressing to avoid pain and bleeding
- Soak with
sterile water if the bandage is sticky on the wound
- Clean the wound
with sterile liquid (eg 0.9% Naci, antiseptic solution)
- Do relaxation
therapy to reduce pain
- Schedule the
frequency of wound care based on the presence or absence of infection, the
amount of exudate and the type of dressing used
- Use a modem
dressing according to the wound condition (eg hyrocolloid, polymer, crystalline
cellulose)
- Provide a diet
with calories 30-35 kcal/KGBB/day and protein 1.25-1.5 g/kgBW/day
- Give vitamin and
mineral supplements (eg vitamin A, vitamin C, zinc, amino acids), as indicated
Education
- Describe the
signs and symptoms of infection
- Recommend consuming
high-calorie and protein foods
Collaboration
- Collaborative
debridement procedures (eg enzymatic, biologic, mechanical, autolytic), if
necessary
- Collaboration of
antibiotics, if necessary
Pressure Wound
Treatment 1.14566
Definition
Identify and treat
wounds caused by compression of bony prominences.
Action
Observation
- Monitor wound
condition (including wound size, wound degree, bleeding, wound base color,
infection, exudate, wound odor, wound edge condition)
- Monitor for
signs and symptoms of infection in the wound
- Monitor
nutritional status (eg caloric intake, protein)
Therapeutic
- Clean the skin
around the wound with soap and water
- Clean the inside
of the wound using 0.9% NaCl
- Perform a
bandage on the wound, if necessary Apply ointment, if necessary
- Use special beds
and mattresses, if necessary. Keep the head of the bed at the lowest tolerable
position
- Schedule
position changes every 2 hours or according to the patient's condition
- Provide a diet
with calories 30-35 kcalkgBW/day and protein 1.25-1.5 g/kgBW/day
- Give vitamin and
mineral supplements (eg vitamin A, vitamin C, zinc, amino acids), as indicated
Education
- Advise to report
signs of skin damage
- Advise to avoid
sitting for long periods of time
- Teach wound care
procedures
Collaboration
- Collaborative
debridement procedures (eg enzymatic, biologic, mechanical, autolytic), if
necessary
- Collaboration of
antibiotics, if necessary
Eye Care I.06203
Definition
Identify and treat
eye health and prevent swelling of the eye.
Action
Observation
- Monitor for
redness, exudate, or ulceration
- Monitor corneal
reflex
Therapeutic
- Cover eyes to
prevent diplopia
- Apply eye drops,
if necessary
- Apply eye
ointment. if necessary
- Plaster the
eyelid to close, if necessary
Education
- Advise not to
touch the eyes
- Advise not to be
exposed to dust and pollution
- Advise not to be
exposed to bright light for too long eg. television)
- Recommend
avoiding the use of contact lenses for more than 19 hours
- Recommend
avoiding reading in dim lighting
- Recommend
consuming foods rich in vitamin A
- It is
recommended to use UV protection glasses or wear a wide hat if under the hot
sun
Oral Care I.11356
Definition
Identify and treat
oral health and prevent complications.
Action
Observation
- Identification
of general conditions (eg consciousness, breathing apparatus, hemodynamics,
coagulation disorders, use of anticoagulant drugs, dentures)
- Identify oral
conditions (eg wounds, dental caries, plaque, canker sores, tumors)
- Monitor oral
hygiene. tongue and gums
Therapeutic
- Choose a
toothbrush according to the patient's condition
- Avoid treating
your mouth with a toothbrush if you have thrombocytopenia
- Position
semi-Fowler or Fowler
- Keep tools
within reach for self-care
- Facilitate
self-brushing
- Clean dentures
separately
- Brush your teeth
at least 2 times a day
- Brush your teeth
and direct your gums to each of the upper and lower teeth
- Use suction atat
to suck saliva from the mouth in patients with decreased consciousness
- Use
chiorhexidino liquid or as per institution policy
- Use floss to
remove plaque that a toothbrush cannot reach
- Clean the tools
that have been used
Education
- Explain the
procedure to the patient and family
- Recommend
changing your toothbrush every 3-4 months
- Advise to have a
dental checkup every 6 months
Neonatal Care
I.03132
Definition
Identifying and
caring for infants after birth up to 28 hart.
Action
Observation
- Identify the
condition of the baby's care after birth (eg adequate months, clear amniotic
fluid or mixed with meconium, spontaneous crying, muscle tone)
- Monitor baby's
vital signs (especially temperature)
Therapeutic
- Perform early
breastfeeding initiation (IMD) as soon as the baby is born
- Give vitamin K 1
mg intramuscularly to prevent bleeding
- Bathe for 5-10
minutes, at least once a day
- Take a warm bath
(36-37°C)
- Use soap that
contains provitamin B5
- Apply baby oil
to retain skin moisture
- Treat the
umbilical cord openly (unwrapped)
- Clean the
umbilical cord with sterile water or boiled water
- Wear cotton
clothes and materials
- Blankets to
maintain warmth and prevent hypothermia
- Change diaper
immediately if it gets wet
Education
- Recommend not to
put anything on the umbilical cord
- Instruct the
mother to breastfeed the baby every 2 hours
- Encourage
burping baby after being followed
- Advise mother to
wash hands before touching baby
Neurovascular
Treatment I.06204
Definition
Identify and treat
patients with impaired sensation and circulation in the extremities.
Action
Observation
- Monitor for
abnormal skin color changes (eg pale, bluish, purplish, blackish)
- Monitor
extremity temperature (eg hot, warm, cold)
- Monitor for
limitation of extremity movement (eg active without pain, active with pain,
passive without pain, passive with pain)
- Monitor changes
in sensation of extremities (eg full, partial)
- Monitor for
swelling
- Monitor for
changes in extremity satisfaction (eg strong, weak, not palpable)
- Monitor
capillary refill time
- Monitor for pain
- Monitor vital
signs
- Monitor for
signs of compartment syndrome
Therapeutic
- Elevate
extremities (not above heart level)
- Maintain
anatomical alignment of the extremities
Educational
- Explain the
importance of performing neurovascular monitoring
- Encourage
regular movement of the extremities
- Advise to report
if found abnormal changes in neurovascular monitoring
-Teach how to do
neurovascular monitoring
-Teach passive/active
range of motion exercises
Care After
Caesarean Section I.14567
Definition
Identifying and
providing care in the post-cesarean section.
Action
Observation
- Identification
of pregnancy and childbirth history
- Monitor mother's
vital signs
- Monitor
physiological responses (eg pain, uterine changes, airway patency and lochia)
- Monitor the
condition of the wound and dressing
Therapeutic
- Discuss the
patient's feelings, questions and concerns regarding surgery
- Transfer the
patient to the puerperal ward
- 6 hours
self-mobilization motivation
- Facilitate
skin-to-skin contact with baby
- Provide adequate
follow-up support, if possible
Education
- Inform the
mother and family about the condition of the mother and baby
- Teach extremity
exercises, position changes. cough and deep breath
- Advise mother
how to breastfeed. If possible
- Advise mother to
consume TKTP nutrition
Postanesthetic
Care I.06205
Definition
Identifying and
treating patients after general or regional anesthesia.
Action
Observation
- Monitor
respiratory function (eg airway patency, respiratory rate and oxygen
saturation)
- Monitor
cardiovascular function (eg pulse rate, blood pressure and ECG)
- Monitor
neurovascular function (eg pulse, motor, sensory)
- Monitor mental
status (eg level of consciousness)
- Monitor body
temperature
- Monitor pain
- Monitor fluid
status
- Monitor nausea
and vomiting
- Monitor urine
output and emptying
- Monitor drainage
and bleeding
Therapeutic
- Provide privacy,
as needed
- Adjust the
height of the bed, as needed
- Warm the
patient's body (eg electric heating blankets, cloth blankets) to prevent
hypothermia and chills, as needed
- Provide verbal
or tactile stimulation, if necessary
- Perform cocking
(restraint), if necessary
- Provide
emotional support to patient and family. if necessary
- Get reports and
operating room nurses and stylists/anesthesiologists
- Give oxygen
Educational
- Practice deep
breathing and coughing techniques
collaboration
- Collaborative
administration of antiemetics
- Collaborative
administration of meperidine for the prevention of post-anesthesia shivering
Postpartum Care
I.0725
Definition
Identifying and
caring for the mother immediately after birth for up to six weeks.
Action
Observation
- Monitor vital
signs
- Monitor lochia
state (eg color, amount, odor and clot)
- Examine the
perineum or tears (redness, edema, ochimosis, discharge, suture union)
- Monitor pain
- Monitor
digestion status
- Monitor Homan's
sign
- Identify the
mother's ability to care for the baby
- Identification
of problems with psychological adaptation of postpartum mothers
Therapeutic
- Empty bladder
before examination
- Fundal massage
until the contract is strong, if necessary
- Support mother
to perform early ambulation
- Borikan comfort
to mother
- Facilitate the
mother to urinate normally
- Facilitate
optimal bonding between mother and baby
- Discuss the need
for activity and rest during the postpartum period
- Discuss the
physical and psychological changes of postpartum mothers
- Discuss
postpartum sexuality
- Discuss the use
of contraceptives
Education
- Explain the
danger signs of postpartum to mother and family
- Explain routine
checks on mother and baby
- Teach proper
perineal care
- Teach the mother
to deal with pain non-pharmacologically (eg distraction techniques,
imagination)
- Teach the mother
to reduce the problem of venous thrombosis
Collaboration
- Refer to a
lactation counselor, if necessary
Patient Care
Terminal I.09304
Definition
Identify and treat
patients who have no hope of recovery.
Action
Observation
- Identification
of general conditions (eg physical, psychological, spiritual)
Therapeutic
- Give a chance to
express feelings
- Provide
opportunities to meet needs
- Provide
emotional support to family and loved ones
- Facilitate the
fulfillment of basic needs (eg fluids, nutrition, personal hygiene, comfort)
- Facilitate
disclosure of messages or wills
- Facilitating the
family to accept the patient's loss
Education
- Teach the family
about the grieving process and its handling
Collaboration
- Collaboration of
anti-pain medication, if it hurts
- Collaboration
with clergy to meet religious-spiritual needs
Perineal Care
I.07226
Definition
Take action to
maintain the integrity of the perineal skin and reduce discomfort
perineum.
Action
Observation
- Inspection of
perineal incisions or tears (eg epistotomies)
Therapeutic
- Facilitation in
cleaning the perineum
- Keep the
perineum dry
- Give a
comfortable position
- Give an ice
pack, if necessary
- Clean the
perineal area regularly
- Give pads that
absorb liquid
Education
- Teach patients
and families toObservationabnormal signs of
the perineum (eg infection, redness, abnormal discharge)
Collaboration
- Collaborative
administration of anti-inflammatory. if necessary
- Collaborative
administration of analgesics, if necessary
- Collaborative
purchase of analgesics, if necessary
Developmental Care
I.10339
Definition
Identify and treat
to facilitate optimal development in aspects of
fine motor, gross
motor, language, cognitive, social, emotional at every stage of the child's
age.
Action
Observation
- Identify the
achievement of children's developmental tasks
- Identify the
behavioral and physiological cues that the baby displays (eg hunger,
discomfort)
Therapeutic
- Keep touch to a
minimum in premature babies
- Give a touch
that is gentle and does not hesitate
- Minimize pain
- Minimize room
noise
- Slow down an
environment that supports optimal development
- Motivate
children to interact with other children
- Provide
activities that motivate & interact with other children
- Facilitate
children to share and take turns
- Support children
to express themselves through positive rewards or feedback for their efforts
- Maintain good
comfort
- Facilitate
children to practice self-fulfillment skills (eg eating,
brush teeth, wash
hands, put on clothes)
- Sing with
children favorite songs
- Read stories or
fairy tales
- Support
children's participation in school, extracurricular and community activities
Education
- Explain to
parents and/or caregivers about the child's developmental milestones and
child's behavior
- Encourage
parents to touch and hold their baby
- Encourage
parents to interact with their children
- Encourage
children to interact skills
- Teach children
assertive techniques
Collaboration
- Refer for
counseling, if necessary
Maternity Care
I.07227
Definition
Identify and
manage the labor process and prevent complications
Action
Observation
- Identify the
conditions of the delivery process
- Monitor the
patient's physical and psychological condition
- Monitor maternal
well-being (eg vital signs, contractions, duration, frequency and strength)
- Monitor fetal
well-being (10x fetal movement in 12 hours) continuously (FHR and amniotic
fluid volume)
- Monitor the
progress of labor
- Monitor for
signs of labor (pushing urges, pressure on the anus, protruding perineum,
opening of the vulva)
- Monitor progress
of opening using a pathograph during active phase
- Monitor the
level of pain during labor
- Perform Leopold
checks
Therapeutic
- Provide
alternative methods of pain relief (eg massage, aromatherapy, hypnosis)
Education
- Explain the
delivery assistance procedure
- Inform the will
of childbirth
- Suggest
relaxation techniques
- Advise tibuu to
empty the bladder
- Advise mother to
have enough nutrition
- Teach mothers
how to recognize the signs of labor
- Teach mothers to
recognize the danger signs of childbirth
High Risk
Maternity Care 1.07228
Definition
Provide delivery
care for multiple or malpositioned fetuses
Action
Observation
- Identify the
general condition of the patient
- Monitor vital
signs
- Monitor for
abnormalities of vital signs in the mother and
- Monitor for
signs of labor
- Monitor fetal
heart rate
- Identify the
position of the fetus using ultrasound
- Identification
of postpartum bleeding
Therapeutic
- Prepare
appropriate equipment including fetal monitor, ultrasound, anesthesia machine,
neonatal resuscitation supplies, forceps, extra baby warmer
- Support the
closest person to accompany the patient
- Use universal
precautions
- Do a perineal
scrub
- Facilitates
manual rotation of the fetal head from the occiput posterior to the anterior
position
- Perform amniotic
membranes
- Facilitate
forceps or vacuum extraction, if necessary
- Perform neonatal
resuscitation, if necessary
- Facilitate
mother recovering from anesthesia, if necessary
- Motivate the
interaction of parents with newborns immediately after delivery
- Document the
procedure (eg anesthesia, forceps, vacuum extraction, suprapubic pressure,
McRobert maneuver, neonatal resuscitation)
Education
- Explain the
procedure for the action to be taken
- Describe newborn
characteristics associated with high-risk births (eg bruising and forceps
markings)
Collaboration
- Coordinate with
standby team (eg neonatologist, neonatal intensive care nurse,
anesthesiologist)
-
Co-administration of maternal anesthesia, as needed.
Pre Cesarean Care
I.07229
Definition
Identify and
provide care prior to cesarean delivery.
Action
Observation
- Identification
of pregnancy and childbirth history
- Identification
of drug allergy history
- Perform
laboratory tests
- Monitor mother's
vital signs
- Monitor fetal
heart rate for 1 minute
Therapeutic
- Discuss feelings,
questions and concerns regarding surgery
- Prepare for
surgery (eg physical preparation, psychological preparation)
- Insert IV line
(including preparation for transfusion)
- Insert urinary
catheter
Education
- Explain the
reason for the need for surgery
- Advise your
partner or the closest person to be present at the time of delivery
- Explain the
process of cesarean section delivery
Collaboration
- Collaboration of
premedication
Hair Care l. 11357
Definition
Identify and treat
healthy hair and scalp.
Action
Observation
- Identification
of the patient's condition (eg awareness of shampoo allergy, hemodynamics,
contraindications to hair washing, scalp and hair hygiene, hair strength)
- Monitor hair
loss
Therapeutic
- Prepare
equipment according to existing facilities
- Protect patient
privacy
- Adjust the
position with the head propped up with pillows so as not to wet the body (or
allow the patient to be in a Fowler's or semi-Fowler's position)
- Wash hair by
doing massage
- Perform eradication
of lice and hair eggs, if any
- Dry the hair
according to the ability of the hairdryer
Education
- Explain the
procedure and purpose of hair care
- Teach washing
hair according to ability
Urine Retention
Treatment I. 04165
Definition
Identify and
relieve bladder distension
Action
Observation
- Identification
of causes of urinary retention (eg increased urethral pressure, damage to
reflex arcs, neurologic dysfunction, effects of pharmacological agents (eg
atropine, belladonna, psychotics, arthistamines, opiates, calcium channel
blockers)
- Monitor fluid
intake and output
- Monitor the
level of bladder distension by palpation / percussion
Therapeutic
- Provide privacy
for urination
- Provide voiding
stimulation (eg running tap water, flushing toilet, cold compress on abdomen)
- Perform the
Crede maneuver, if necessary
- Insert a urinary
catheter, if necessary
- Facilitate
urination at regular intervals
Education
- Explain the
cause of urinary retention
- Instruct the
patient or family to record urine output
- Teach how to do
urinary stimulation
Hose Maintenance
I. 14568
Definition
Identify and treat
patients with external tubing
Action
Observation
- Identification
of indications for hose installation
- Hose patent
monitor
- Monitor the
number, color and consistency of the drainage hose
- Monitor the skin
around the tube insertion (eg redness and skin breakdown)
Therapeutic
- Perform hand
hygiene before and after hose treatment
- Provide a hose
long enough to maximize mobilization
- Empty the
holding bag, as indicated
- Connect the hose
with a vacuum cleaner, if necessary
- Change the hose
regularly, according to indications
- Perform skin
care for the tube incision area
- Motivation to
increase physical activity gradually
- Clamp the hose
when mobilizing
- Provide
emotional support
Education
- Explain the
purpose and procedure of hose installation
- Teach how to
care for the hose
- Teach about the
signs of infection
Chest Tube
Treatment I. 01022
Definition
Identify and manage
patients with chest tube insertion
Action
Observation
- Identification
of indications for chest tube insertion
- Monitor for air
leakage from chest tube
- Monitor the
function, position and patency of the flow of the hose (fluid undulation in the
hose)
- Monitor for
signs and symptoms of pneumothorax
- Monitor the
decrease in bubble production, undulations, and waves in the liquid collection
tube
- Monitor the
amount of fluid in the tube (seal)
- Monitor the
position of the hose with X-rays
- Monitor crepitus
around the chest tube
- Monitor for
signs of intrapleural fluid accumulation
- Monitor the
volume, color, and consistency of drainage from the lungs
- Monitor for
signs of infection
Therapeutic
- Perform hand
hygiene before and after insertion or maintenance of chest tube
- Make sure the
hose connection is closed flat
- Clamp the hose
when changing the tube
- Provide a hose
long enough to facilitate movement
- Perform a
culture of fluid from the chest tube, if necessary
- Facilitate coughing,
deep breaths and change positions every 2 hours
- Perform
maintenance in the area of solatip hose installation 48-72 or as needed
- Replace the tube
(seal) regularly
- Perform chest
tube removal, as indicated
Education
- Explain the
purpose and procedure of hose installation
- Teach how to
care for the hose
- Teach to
recognize signs of infection
Gastrointestinal
Hose Treatment I. 03133
Definition
Identify and care
for the gastrointestinal tube
Action
Observation
- Identify
indications for gastrointestinal tube insertion (eg patient awareness, ability
to swallow, frequency of vomiting, fasting status)
- Monitor the
patency of the gastrointestinal tube
- Monitor for
injuries around the nostrils due to fixation
- Monitor
complaints of nausea/vomiting, abdominal distension, bowel sounds, fluids and
electrolytes
- Monitor fluid
balance, amount and characteristics of fluid coming out of the tube, residue
before feeding
Therapeutic
- Fixation of the
tube at the nose or above the lip
- Change the hose
every 7 days or according to the protocol
- Irrigation hose
according to protocol
- Treat nose and
mouth every shift or according to protocol
- Maintain mouth
moisture
- Remove
gastrointestinal tube, as indicated
Education
- Explain the purpose
and procedure of hose installation
- Teach patients
and families how to care for the hose
Umbilical Tube
Treatment l. 14569
Definition
Identify and treat
umbilical infusion access
Action
Observation
- Monitor for
signs of infection in the area around the umbilical cord
- Monitor for
bleeding
- Monitor for
signs of tube detachment (eg redness around the umbilical, presence of blood
clots in the catheter)
- Identify the
presence of blood clots and air bubbles
Therapeutic
- maintain aseptic
and antiseptic principles
- maintain the
need for plaster attachment
- keep baby in
supine position
- rinse the
catheter with heparin
- change the
stopcock daily, if necessary
- remove the
catheter by pulling the catheter slowly for 5 minutes or according to the protocol
Education
- teach the mother
how to care for the umbilical tube
- Instruct the
mother to keep the umbilical area dry and clean
Circulation
Treatment l. 02079
Definition
Identify and treat
local areas with limited peripheral circulation.
Action
Observation
- check peripheral
circulation (eg peripheral pulse, edema, capillary refill, color, temperature,
anklebrachial index)
- identification
of risk factors for circulatory disorders (eg diabetes, smoking, the elderly, hypertension
and high cholesterol levels)
- monitor heat,
redness, pain, or swelling in the extremities
Therapeutic
- avoid infusion
or blood collection in areas of limited perfusion
- avoid measuring
blood pressure in extremities with limited perfusion
- avoid pressing
and placing a tourniquet on the injured area
- do infection
prevention
- do foot and nail
care
- do hydration
Education
- recommend
quitting smoking
- recommend
regular exercise
- recommend
checking the bath water to avoid sunburn
- recommend using
blood pressure-lowering, anticoagulant, and cholesterol-lowering drugs, if
necessary
- recommend taking
blood pressure control medication regularly
- recommend
avoiding the use of beta-blocking drugs
- recommend proper
skin care (eg moisturizing dry skin on feet)
- recommend a
vascular rehabilitation program
- teach a diet
program to improve circulation (eg low in saturated fat, omega 3 fish oil)
- inform emergency
signs and symptoms that must be reported (eg pain that does not go away at
rest, wound does not heal, loss of feeling)
Circumcision
Treatment l. 14570
Definition
Identify and treat
circumcision wounds and prevent complications that may occur due to
circumcision
Action
Observation
- identification
of general conditions (eg blood pressure, pulse, respiration and body
temperature, pain level, date of circumcision
- check the
condition of the wound (eg wound size, type of wound, bleeding, wound bed
color, infection, exudate, wound odor, condition of wound margins)
- monitor for
bleeding (eg dressing color, seepage)
- monitor the
occurrence of post-circumcision complications (eg penile concelead, phisomosis,
skin bridge, urinary retention, fistula, necrosis, iatrogenic hypospadias)
- monitor urine
output and pain when urinating
Therapeutic
- apply aseptic
technique while treating circumcision wounds
- apply atraumatic
care to pediatric patients
- Soak the penis
with warm antiseptic liquid warm nails for 10-15 minutes if the bandage is
attached to the penis
- take off the
bandage slowly
- change dressing
every day or as indicated
- use modern
dressings according to wound conditions
- record the
progress of the wound
- stop the
bleeding, if it occurs
Education
- explain the
procedure to be carried out
- recommend
keeping the incision area clean and dry
- recommend the
use of special protective pants to prevent pain due to clothing friction
Collaboration
- Collaboration of
antibiotics, if necessary
- Collaborative
administration of analgesics, if necessary
Skin Graft
Treatment l. 14571
Definition
Identify and treat
patients with skin graft wounds
Action
Observation
- monitor general
condition (eg fever, blood pressure, pulse, respiration and body temperature)
- monitor skin
graft condition (eg wound size, hematoma, graft contracture, necrosis)
- monitor for
signs of infection in the skin graft wound (eg bleeding, signs of infection,
exudates)
Therapeutic
- apply aseptic
technique while treating skin graft wounds
- do skin graft
wound care every 2 days or according to the condition of the wound
- clean the wound
with 0.9% NaCl or aquadest
- clean the blood
/ fluid that dries up and the necrosis is getting wider
- protect skin
graft wounds from trauma and friction
- use a modem
dressing according to the condition of the wound
- record wound
progression (eg wound size, signs of infection, hematoma, graft contracture,
necrosis, exudate, patient complaints)
Education
- explain the
procedure to be carried out
- recommend
keeping the incision area clean and dry
- recommend
consuming high-calorie and high-protein foods
Stoma Treatment l.
04166
Definition
Identify and
maintain stoma hygiene and health and prevent complications
Action
Observation
- check the
patient's general condition (eg consciousness, vital signs)
- check the
condition of the patient's stoma (eg time of stoma creation, stoma type, stoma
characteristics, stool characteristics complications)
- identification
of abilities and knowledge of stoma
Therapeutic
- free up stoma
area and clothes
- apply aseptic
and safety techniques during stoma care
- remove and free
the stoma from the previous bag
- Clean the stoma
with warm clean water and soap
- measure stoma
with measurement guide
- prepare a new
plate and stoma bag
- use paste or
powder as needed
- install the new
buckle pocket and stoma plate
Education
- explain the
procedure to be carried out
Collaboration
- Collaboration in
case of herniation, atrophy, or worsening of the stoma
Ear Care l. 06206
Definition
Identify, treat
and prevent ear and hearing disorders.
Action
Observation
- check hearing
function
- monitor for
signs and symptoms of ear infection (eg inflammation and discharge)
- monitor for
signs and symptoms of ear dysfunction (eg pain, tenderness, itching, hearing
changes, tinnitus, vertigo)
- do a hearing
test, if necessary
Therapeutic
- clean the outer
ear
- clean the ear
wax with a soft cotton
- perform ear
irrigation, if necessary
- avoid exposure
to loud sounds
Education
- describe the
signs and symptoms of hearing dysfunction
- inform parents
of vaccines that can prevent hearing loss (eg rubella, measles, mumps)
- recommend using
earplugs when swimming or on an airplane, if necessary
- teach how to
clean the outer ear
- teach how to use
and care for hearing aids
Pregnancy
Termination Treatment l. 07230
Definition
Identify and
provide pregnancy termination care (carry out spontaneous or elective abortion)
in accordance with established service standards
Action
Observation
- monitor for
signs of spontaneous abortion (eg cessation of cramping, increased pelvic
pressure, and loss of amniotic fluid)
- monitor vital
signs
- monitor for
signs of shock
- monitor bleeding
and ram
- do a vaginal
exam
Therapeutic
- give informed
consent
- prepare
physically and psychologically for the abortion procedure
- family
motivation to provide emotional support
- put intravenous
line
- Facilitation of
delivery, according to the gestational age of the fetus
Education
- describe the
procedure to be performed (eg suction curettage, dilation and curettage, and
evaluation of the uterus)
- describe the
sensations that may be experienced
- recommend
reporting if there are signs of increased bleeding, increased cramping, clots
or tissue
Collaboration
- Collaboration of
giving oxytocin after delivery
- Collaborative
administration of analgesics
- Collaboration of
antibiotics
- Collaborative
administration of drugs to terminate pregnancy, as indicated (eg prostaglandin
suppositories, intraamniotic prostaglandins, intravenous oxytocin)
- Describe the
sensations that may be experienced
- Advise to report
if there are signs of increased bleeding, increased cramping, clots or tissue
Collaboration
- Collaboration of
giving oxytocin after delivery
- Collaborative
administration of analgesics
- Collaboration of
antibiotics
- Collaborative
administration of drugs to terminate pregnancy, as indicated (eg prostaglandin
suppositories, intraamniotic prostaglandins, intravenous oxytocin)
Bed rest treatment
l.14572
Definition
Increase comfort
and safety and prevent complications in patients undergoing bed rest.
Action
Observation
- Monitor skin
condition
- Monitor bed rest
complications (eg loss of muscle mass, back pain, constipation, stress,
depression, confusion, changes in sleep rhythm, urinary tract infection,
difficulty urinating, pneumonia)
Therapeutic
- Place it on the
bedTherapeutic, if available
- Position as
comfortable as possible
- Keep sheets dry,
clean and unwrinkled
- Install
siderails, if necessary
- Position the bed
close to the nurse station, if necessary
- Close the bed
table position
- Provide active
or passive motion exercises
- Maintain patient
hygiene
- Facilitate the
fulfillment of daily needs
- Give
antiembolism stockings, if necessary
- Change position
every 2 hours
Education
- Explain the purpose
of bed rest
Tracheostomy
Treatment 1.01023
Definition
Identify and
maintain airway clearance and capacity and prevent complications from
tracheostomy.
Action
Observation
- Monitor for
secretions, soiled, damp dressings, or signs and symptoms of airway obstruction
requiring suctioning
- Monitor for
signs of inflammation, infection, edema, or discolored secretions in the stoma
Therapeutic
- Position
Serni-Fowler
- Put on sterile
gloves, gown and eye protection
- Perform
tracheostomy suctioning, as indicated
- Remove soiled
dressing, remove gloves and wash hands
- Prepare a
sterile dressing change set
- Put on sterile
gloves
- Remove the
oxygen hose, if attached
- Remove the inner
cannula with the non-dominant hand
- Clean the stoma
and surrounding skin with gauze and/or cotton swab
- Dry the skin
around the stoma with sterile gauze
- Untie the dirty
tracheostomy
- Put a sterile
dressing and tie on the tracheostomy
Education
- Explain the
procedure of action
- Teach signs and
symptoms that need to be reported (eg signs and symptoms of stoma infection)
Traction Treatment
1.05182
Definition
Identify and treat
patients with traction on to immobilize and stabilize body parts.
Action
Observation
- Monitor
self-care ability when traction is applied
- Monitor external
fixation device Monitor pen insertion (pin)
- Monitor for
signs of damage to skin integrity or bony prominences
- Monitor
circulation, movement, and sensation in the injured extremity
- Monitor for
complications of immobilization
Therapeutic
- Position the
body in the proper alignment
- Maintain a
proper lying position in bed
- Ensure proper
traction load
- Make sure the
ropes and pulleys are free from hanging
- Ensure that the
rope pull and the load remain along the axis of the fracture bone
- Secure the
traction load when moving the patient
- Perform pin
insertion area care
- Perform skin
care on friction areas
- Attach a
trapezoid to move in bed, if available
Education
- Advise
maintenance of braces, as needed
- Advise external
fixation device maintenance, as needed
- Advise the
importance of adequate nutrition for bone healing
Urostomy Treatment
1.04167
Definition
Identify and treat
the health of patients undergoing urostomy and prevent complications.
Action
Observation
- Check general
condition (eg consciousness, vital signs)
- Check the
condition of the urostomy (eg timing of urostomy, type of urostomy, urostomy
characteristics, complications, urine characteristics)
- Check the
patient's ability and knowledge of urostomy
Therapeutic
- Prepare
equipment, materials and action room, if necessary
- Prepare the
patient: maintain privacy and free the urostomy area from clothing
- Perform
irrigation urostomy every 4-6 hours to prevent mucus buildup that can block the
flow of urine
- Use 50-60 cc
NacI 0.9% or aquadest for irrigation
- Apply aseptic
technique and patient safety during urostomy care
- Free the
urostomy from the previous bag
- Clean the stoma
with warm clean water and soap
- Measure stoma
with measurement guide
- Prepare a new
plate and stoma bag
- Use paste or
powder as needed
- Install a new
stoma bag and plate and buckle, if necessary
Education
- Explain the
procedure to be carried out
- Teach how to
care for a stoma
- Describe the
signs of worsening urostomy and bladder distension
Collaboration
- Collaboration in
case of herniation, atrophy, or worsening of the stoma
Home Planning
1.12465
Definition
Facilitate the
planning of the needs of the patient from entering the hospital until after
leaving the hospital.
Action
Observation
- Identify indications
for patient discharge
- Identify the
patient's readiness to go home
- Identify health
education topics needed by patients
- Monitor patient
and family response to health education
Therapeutic
- Provide health
education to patients and families
- Prepare patients
and families to get information about referral services, if they will be
referred
- Prepare the
transportation that will be used for the return
- Make sure the
patient gets to the destination safely
Education
- Explain the
follow-up care and subsequent treatment
- Teach how to do
self-care at home
- Advise healthy
living behavior while at home
- Encourage family
to provide independent care support
Collaboration
- Coordinate
discharge planning proposals to other health teams
Surgical
Preparation 1.14573
Definition
Identify and
prepare patients for surgical procedures and prevent complications and
worsening of surgical procedures.
Action
Observation
- Identification
of the patient's general condition (eg consciousness, hemodynamics, consumption
of anticoagulants, type of surgery, type of anesthesia, comorbidities [such as
DM, hypertension, heart disease, COPD, asthma). knowledge of surgery,
psychological readiness)
- Monitor blood
pressure, pulse, respiration, body temperature, weight, ECG
- Monitor blood
sugar levels
Therapeutic
- Take blood
samples for blood chemistry tests (eg, complete blood count, kidney function,
liver function)
- Facilitation of
supporting examinations (eg chest X-ray, x-ray examination)
- Fasting for at
least 6 hours before surgery
- Free the area of
skin to be operated on from hair or body hair
- Bathe with
antiseptic liquid (eg, 2% chlorhexidine) at least 1 hour and maximum at night
before surgery
- Ensure the
completeness of preoperative documents (eg approval letter for surgery,
radiology results, laboratory results)
- Transfer to the
operating room with a suitable transfer device (eg wheelchair, bed)
Education
- Explain the
procedure, time and duration of the operation
- Explain fasting
time and administration of premedication (if any)
- Practice
effective coughing techniques
- Practice
postoperative pain reduction techniques
- Advise stop
anticoagulant drugs
- Teach how to
bathe with antiseptic
Collaboration
- Collaborative
administration of drugs before surgery (eg antibiotics, antihypertensives,
antidiabetics), as indicated
- Coordination
with nutrition workers regarding fasting schedule and patient's diet
- Collaboration
with the surgeon if there is an increase in body temperature, hyperglycemia,
hypoglycemia or worsening of the condition
- Coordination
with operating room nurses
Preparation for
Ultrasonography (USG) Examination 1.14574
Definition
Identify and
prepare tests to determine fetal development and provide information that is
accurate and non-invasive, painless, and safe.
Action
Observation
- Identification
of indications for inspection
- Identify
knowledge of inspection procedures
- Monitor inspection
results
Therapeutic
- Prepare
equipment
- Prepare the
patient physically and emotionally
- Discuss the
results of the examination with the medical team
- Schedule
re-examinations or additional procedures, if necessary
Education
- Explain the purpose
and procedure of the examination
- Recommend
fasting for at least 8 hours, if necessary
First Aid 1.02080
Definition
Provide basic and
immediate treatment in emergency conditions both with tools and without tools.
Action
Observation
- Identification
of rescuer, patient and environmental safety
- Identify the
patient's response to AVPU (alert, verbal, pain, unresponsive)
- Monitor vital
signs
- Monitor wound
characteristics (eg drainage, color, size, odor)
Therapeutic
- Ask for help, if
necessary
- Perform RICE
(rest, ice, compression, elevation) on extremity muscle injuries
- Perform bleeding
cessation (eg pressure, pressure dressing, positioning)
- Clean the skin
from toxins or chemicals that stick with soap and running water
- Remove the sting
from the skin
- Remove insect
bites from the skin using tweezers or a suitable tool
Education
- Teach wound care
techniques
Collaboration
- Collaborative
administration of drugs (eg prophylactic antibiotics, vaccines, antihistamines,
anti-inflammatory and analgesics), if necessary
Lactation Massage
1.03134
Definition
Increase milk
production by triggering the oxytocin hormone through massage.
Action
Observation
- Monitor the
condition of mammae and nipples
- Identify the
mother's desire to breastfeed
- Identification
of mother's knowledge about breastfeeding
Therapeutic
- Position the
mother comfortably
- Massage from
head, neck, shoulders, back and breasts
- Gently massage
- Massage in a
circle (butterfly stroke)
- Massage regularly
every day
- Support mothers
to increase self-confidence in breastfeeding by giving praise to the mother's
positive behavior
- Involve husband
and family
Education
- Explain the
purpose and procedure of action
- Explain the
benefits of the action.
Family
Anticipation Promotion 1.12466
Definition
Increase the
family's readiness to prevent the development or crisis situation due to health
problems.
Action
Observation
- Identify
possible crisis situations or developmental problems and their impact on the
lives of patients and families
- Identify
problem-solving methods that families often use
Therapeutic
- Facilitate in
deciding strategies for solving problems faced by the family
- Involve all
family members in anticipating health problems, if possible
- Make regular
visits to family, if necessary
- Make a schedule
of activities with your family related to the health problems you are facing
Education
- Explain normal
development and behavior to family
Collaboration
- Cooperation with
other relevant health workers, if necessary
Exclusive
Breastfeeding Promotion 1.03135
Definition
Improve mother's
ability to exclusively breastfeed (0-6 months).
Action
Observation
- Identification
of lactation needs for mothers in antenatal, intranatal and postnatal
Therapeutic
- Facilitation of
mothers doing IMD (early initiation of breastfeeding)
- Facilitate
mothers for joining or rooming in
- Use a spoon and
a cup if the baby can't breastfeed
- Support
breastfeeding mothers by accompanying mothers during breastfeeding activities
- Discuss with
family about exclusive breastfeeding
- Prepare
breastfeeding classes in the prenatal period at least 2 times and the
postpartum period at least 4 times
Education
- Explain the
benefits of breastfeeding for mother and baby
- Explain the
importance of breastfeeding at night to maintain and increase milk production
- Explain the
signs that the baby is getting enough breast milk (eg weight gain, urination
more than 10 times/day, urine color is not concentrated)
- Explain the
benefits of joining (rooming in)
- Encourage
mothers to breastfeed as soon as possible after giving birth
- Advise the
mother to provide nutrition to the baby only with breast milk
- Encourage the
mother to breastfeed as often as possible after birth according to the baby's
needs
- Advise the
mother to maintain milk production by expressing, even if the mother or baby
are separated
Weight Promotion
1.03136
Definition
Facilitates weight
gain.
Action
Observation
- Identify
possible causes of underweight
- Monitor for
nausea and vomiting
- Monitor the
number of calories consumed daily
- Weight monitor
- Monitor albumin,
lymphocytes, and serum electrolytes
Therapeutic
- Provide oral
care before feeding, if necessary
- Provide the
right food according to the patient's condition (eg food with a smooth texture,
blended food, liquid food given via NGT or gastrostomy, total parenteral
nutrition as indicated)
- Serve food
attractively
- Give
supplements, if necessary
- Give praise to
the patient / family for the improvement achieved
Education
- Explain the type
of food that is highly nutritious, but still affordable
- Explain the
increase in caloric intake needed
Body Image
Promotion I.09305
Definition
Increase the improvement
of changes in perception of the patient's physical.
Action
Observation
- Identification
of expected body image based on developmental stage
- Identification
of culture, religion, gender, and age related to body image
- Identify changes
in body image that result in social isolation
- Monitor the
frequency of self-critical statements
- Monitor whether
the patient can see the body parts that have changed
Trapeutic
- Discuss changes
in the body and its functions
- Discuss the
difference between physical appearance and self-esteem
- Discuss changes
due to puberty, pregnancy, and aging
- Discuss
stressful conditions that affect body image (eg wounds, illness, surgery)
- Discuss how to
develop realistic body image expectations
- Discuss the
perception of patients and families about changes in body image
Education
- Explain to
family about body image treatment
- Encourage the
use of self-image against body image
- Encourage use of
assistive devices (eg clothing, wigs, cosmetics)
- Encourage
participation in support groups (eg peer groups)
- Train your own
body functions
- Practice
self-improvement (eg dressing up)
- Practice
self-disclosure to other people and groups.
Family Support
Promotion I.13488
Definition
increase the
participation of family members in emotional and physical care.
Action
Observation
- Identify the
family's physical, emotional and educational resources
- Identify the
needs and expectations of family members
- Identify
perceptions of the situation, triggers events, feelings and behavior of the
patient
- Identify other
family member situational stressors
- Identify
physical symptoms due to stress (eg nausea, vomiting, disability)
Trapeutic
- Provide a
comfortable environment
- Facilities for
care and treatment programs for family members
- Discuss family
members who will be involved in the treatment
- Discuss
abilities and family planning in care
- Discuss types of
home care
- Discuss how to
overcome difficulties in treatment
- Support family
members to maintain or maintain family relationships
- Respect the
decisions the family needs
- Appreciate the
mechanism of care used by the family
Education
- Explain to the
family about the care and treatment the patient is undergoing
- Encourage the
family to be assertive
- Encourage
increasing positive aspects of the patient's situation
Social Support
Promotion I.13489
Definition
Improve the
ability to interact with other people.
Action
Observation
- Identify
strengths and weaknesses in relationships
Therapeutic
- Maintain
patience and honesty in relationship development
- Give positive
feedback on the activities carried out
- Motivation to
participate in individual, group and social activities
- Motivation to
maintain verbal communication
- Motivation to do
outdoor activities and new environments (eg sightseeing, shopping)
- Discuss the
planning of upcoming activities
Education
- Encourage
interaction with others who have the same interests and goals
- Encourage use of
assistive devices (eg glasses and hearing aids)
- Suggest sharing
problems with others
- Advise to
respect others
- Advise to
express anger appropriately
- Advise planning
of special activities
- Practice
improving the abilities you have
- Practice role
playing in communication skills
Collaboration
- Refer to skill
group, if necessary
Spiritual Support
Promotion I.09306
Definition
Promotes a sense
of balance and connection with a greater power.
Action
Observation
- Identify beliefs
with meaning and purpose in life, as needed
- Identify spiritual
perspectives, as needed
Therapeutic
- Treat patients
with dignity and respect
- Show openness,
empathy and willingness to listen to the patient's feelings
- Ensure that
nurses are always there and supportive
- Use
classification techniques to help assess confidence, if necessary
- Facilitate the
proper expression and easing of anger
- Motivation to
review past lives and focus on things that give spiritual strength
- Motivation to
interact with family members, friends, and others
- Encouragement of
privacy and quiet time for spiritual activity
- Motivation for
participation in support groups
- Motivation to
express feelings (eg loneliness, helplessness, anxiety)
- Motivate the use
of spiritual resources, if necessary
- Schedule a
spiritual guide visit, if necessary
Education
- Suggest
remembering vivid memories
- Advise to pray
- Encourage use of
spiritual media (eg television, books)
- Suggest
relaxation methods (eg deep breathing techniques, guided imagination,
meditation)
PromotionEducationLactation in Community I.112467
Definition
Efforts to improve
breastfeeding behavior in the community throughEducation.
Action
Observation
- Identify
breastfeeding behavior in the community
- Identification
of breastfeeding support groups or health cadres
- Monitor baby's
weight every 2 weeks or every 1 month
Therapeutic
- Form
breastfeeding support groups and trained cadres, if not yet available
- Socialize to
pregnant women about breastfeeding at least 2 times
- Involve husband,
family and surrounding community to support breastfeeding mothers
Education
- There is
counseling about the benefits, position, placement, and problems during
breastfeeding by health workers or cadres or breastfeeding support groups
- Advise cadres to
visit postpartum mothers for less than 2 weeks
- Advise cadres to
accompany mothers during exclusive breastfeeding (6 months)
- Advise the
mother to give complementary foods to breast milk after 6 months to 2 years
- Recommend
expressing breast milk at least 1 month before the mother returns to work
- Advise how to
store breast milk properly
Fecal Elimination
Promotion I.04168
Definition
Supports formal
affective discharge
Action
Observation
- Identification
of faecal elimination problems (eg constipation, incontinence, bowel sounds,
schibala, reflex ability to defecate, neurological disorders)
- Identification
of foods and/or drugs that may interfere with faecal elimination
- Perform rectal
examination, if necessary
Therapeutic
- Do abdominal
messages
Education
- Describe foods
that support normal faecal elimination (eg high in fiber and sufficient water)
- Recommend
drinking warm water after eating
Collaboration
- Collaboration of
laxatives, if necessary
- Refer to
rehabilitation nurse
Urine Elimination
Promotion I.04169
Definition
Facilitates normal
urine output.
Action
Observation
- Identify
problems and factors related to urine elimination
- Check for signs
and symptoms of urinary retention or urinary incontinence
Therapeutic
- Facilitation of
urination before the procedure
- Facilitate
measuring fluid intake and urine output
- Provide modality
therapy for strengthening the pelvic muscles / voiding
- Give drinking
water 8 glasses per day, if there are no contraindications
Education
- Teach about the signs
of urination and the right time to urinate
Hope Promotion
I.09307
Definition
Increases
confidence in the ability to initiate and sustain action.
Action
Observation
- Identify patient
and family expectations in life achievement
Therapeutic
- Realize that the
conditions experienced have an important value
- Guide the recall
of pleasant memories
- Involve patients
actively in treatment
- Develop plans
that involve the achievement of simple to complex goals
- Provide
opportunities for patients and families to be involved with group support
- Create an
environment that makes it easy to practice spiritual needs
Education
- Suggest
expressing feelings about the situation realistically
- Encourage
maintaining a relationship (eg mentioning the name of a loved one)
- Advise maintain
relationshipTherapeuticwith other people
- Practice setting
goals according to expectations
- Practice how to
develop spiritual self
- Practice how to
reminisce and enjoy the past (eg achievements.experiences)
Self-Esteem
Promotion I.09308
Definition
Increase the
assessment of feelings/perceptions of oneself or one's abilities.
Action
Observation
- Identification
of culture, religion, race, gender, and age on self-esteem
- Monitor self-deprecating
verbalization
- Monitor the
level of self-esteem at any time, as needed
Therapeutic
- Motivation to
engage in positive verbalization for yourself
- Motivation to
accept new challenges or things
- Discuss
statements about self-esteem
- Discuss belief
in self-assessment
- Discuss
experiences that increase self-esteem
- Discuss negative
self-perceptions
- Discuss reasons
for self-criticism or guilt
- Discuss setting
realistic goals to achieve higher self-esteem
- Discuss with
family to set clear expectations and boundaries
- Give positive
feedback on improving achieving goals
- Facilitation of
self-esteem-enhancing environments and activities
Education
- Explain to the
family the importance of support in the development of the patient's positive
self-concept
- Advise to
identify the strengths you have
- Encourage
maintaining eye contact when communicating with others
- Encourage
opening up to negative criticism
- Recommend
evaluating behavior
- Teach how to
deal with bullying
- Practice
increasing responsibility for yourself
- Practice
positive self-statement/ability
- Practice
positive thinking and behaving
- Practice
increasing confidence in the ability to handle situations
Positive
Relationship Promotion I.09309
Definition
Increase
interactions between two or more people that are mutually beneficial and are
characterized by appropriate reciprocity.
Action
Observation
- Identify
barriers to relationship building
Therapeutic
- Discuss the
advantages of interacting with others
- Discuss the
disadvantages of not interacting with other people
- Discuss with the
family the problems felt in caring for the patient
- Create an
atmosphere that supports relationship improvement
- Give praise
fairly if you succeed in building a relationship
- Give examples of
adaptive behavior in building relationships
- Avoid conflicts
with patient/family values
-Education
- Teach how to
introduce gradually (eg with 1 person or family member, ith 2-3 people, with
4-5 people, more than 5 people)
- Suggest to
include a schedule of talking with other people into the daily activity
schedule
- Practice
speaking while doing daily activities
- Explain to the
family about the meaning, signs and symptoms, and the process of barriers to
build relationships.
- Explain to the
family how to care for the patient
- Explain to the
family household activities that can involve the patient talking (eating,
praying together)
- Advise the
family to help the patient according to schedule
- Train the family
how to guide the patient to speak and give praise
Driving Safety
Promotion I.14575
Definition
Facilitate
individuals, families, and communities to increase awareness of behaviors to
reduce the risk of motor vehicle accidents.
Action
Observation
- Identify
knowledge about driving safety
- Identification
of user safety needs (eg passenger condition)
- Identification
of individuals and groups at high risk for vehicle injury
- Identification
of safety hazards in the environment
- Monitor the use
of child restraint chairs and seats
Therapeutic
- Eliminate
hazards in the environment around the vehicle
- Provide
literature on how to improve vehicle safety
- Make sure the
driver does not start the vehicle until all passengers are safely seated
- Parents' motivation
is an example of the role of using seat belts
- Give praise to
the use of vehicles that are good and correct
- Support the
government in enforcing driving safety regulations
Education
- Explain the
risks associated with motorized vehicles or non-motorized vehicle users
- Information
about driving regulations on the highway
- Explain the
importance of using proper protective equipment to reduce the risk of injury
(eg car seats, seats, belts, helmets)
- Explain the
importance of always wearing a seat belt
- Explain the use
of a comfortable seat belt and man
- Explain the
importance of choosing an age-appropriate bicycle and adjusting it periodically
as the child grows
- Explain wearing
a helmet
- Explain the
importance of wearing protective shoes and clothing when riding a bicycle or
motorbike
- Information on
high-risk groups about behaviors that may lead to driving (eg drinking alcohol,
risky behavior, disobeying the law)
- Recommend for
parents to bring a child safety seat when traveling (eg airplane, train, bus)
- Teach how to use
the safety seat
- Teach parents to
secure babies in child safety seats and children under 13 years in the back
seats of cars
Collaboration
- Collaboration
with community institutions in driving safety education efforts (eg schools,
police and health services)
Hygiene Promotion
I.11358
Definition
Identify and
facilitate improvement of personal and environmental hygiene status.
Action
Observation
- Identification
of the patient's general condition (eg physical and mental abilities)
- Identification
of independence in making efforts to clean oneself and the environment
- Identify
knowledge about the importance of hygiene efforts
Therapeutic
- Consider the
culture in carrying out cleaning efforts
- Consider the characteristics
of the patient and the community to perform hygiene efforts (eg age,
socio-economic, education)
- Facilities to
carry out personal hygiene efforts as needed
- Motivation of
family and community participation in hygiene promotion efforts
- Give praise for
efforts to promote cleanliness
Education
- explain the
benefits of hygiene for health
Promotion of
medication adherence
Definition
Improving
disciplinary behavior in carrying out nursing/treatment action programs agreed
with health workers to obtain effective results
Action
Observation
- Identify the
level of understanding of the disease, complications and recommended treatment
- Identify changes
in health conditions that have just been experienced by tarapeutik
- Provide written
information about the patient's treatment schedule
- Involve the
family as a drug taking supervisor
- Arrange
medication taking schedule By adjusting the patient's daily activities if
possible
Education
- Explain the
importance of following treatment according to the program
- Explain the
consequences that may occur if you do not comply with treatment
- Explain the
strategy of obtaining medication continuously
- Advise to
provide instructions for drug use
- Teach strategies
to maintain or improve medication adherence
Promotion of
exercise program compliance
Definition
Facilitates
regular physical activity to maintain or progress to a higher level of fitness
and health
Action
Observation
- Identify
knowledge about physical exercise
- Identify
previous sports experience
- Identify
motivation to start or continue an exercise program
- Identify
barriers to exercise
- Identify the
availability of positive role models to maintain the training program
- Monitor response
to exercise program
- Monitor
compliance with the therapeutic training program
- Motivation
expresses feelings about sport or the need for exercise
- Motivation to
start or continue sports
- Facilitate
developing training programs according to needs
- Set short-term
and long-term goals for the exercise program with the patient
- Schedule
exercise programs together with patients
- Involve family
in planning exercise program
- Determine the
frequency, duration and intensity of the exercise program
- Graph the
progress of the training process to provide motivation and complianceEducation
- Explain the
benefits of exercise for health
- Recommend
warming up and cooling down during exercise
- Teach
appropriate types of exercises
- Teach techniques
to avoid injury during sports
- Teach proper
breathing techniques to maximize oxygen absorption during exercise
Confidence
promotion
Definition
Increase
confidence in ability to design and carry out required activities
Action
Observation
- Identify
inappropriate verbal and nonverbal expressions
- Identify
potential problems experienced by tarapeutik
- Use active listening
techniques about (SWOT) and what matters (SMART)
- Discuss plans to
achieve the expected goals
- Discuss
self-change plans
- Motivation to
think positively and be committed to achieving goals
- Make and choose
priority decisions to solve problems
- Keep personal
notes in determining achievements and enjoy each achievement
- Discuss
solutions in dealing with problems
- Discuss how to
handle unexpected situations effectively
- Motivation to
stay calm when facing problems with the abilities you have
- Motivate the
effectiveness of decisions made in influencing or improving judgments
- Involve family
members in achieving goals
Education
- Recommend
evaluating how to solve the problem
- Teach problem
solving and difficult situations (e.g. life threatening)Collaboration
- Collaboration
with specialist nursing teams in modifying interventions
Self awareness
promotion
Definition
Increase
understanding and explore thoughts, feelings, motivations and behaviors
Action
Observation
- Identify current
emotional state
- Identify
responses shown in various therapeutic situations
- Discuss values
that contribute to self-concept
- Discuss about
behavioral thoughts or responses to kodidi
- Discuss the
impact of disease on self-concept
- Express denial
about reality
- Motivation in
improving learning ability
Education
- Advise about
thoughts and feelings about yourself
- Advise realize that
everyone is unique
- Encourage
expressing feelings (eg angry or depressed)
- Suggest asking
for help from others, as needed
- Recommend
changing your view of yourself as a Victim
- Advise to
identify feelings of guilt
- Encourage
identifying situations that trigger anxiety
- Recommend
re-evaluating negative perceptions about yourself
- Encourage in
self-expression with peer groups
- Teach how to
make life priorities
- Practice your
positive self-abilities
Oral health
promotion
Definition
Increase patient
knowledge and ability to maintain and improve oral and dental health
Action
Observation
- Identification
of the patient's general condition (eg age, oral health)
- Identify
potential dental and oral problems (eg how to brush your teeth, eating habits
that damage teeth)
Tarapeutik
- Use toothpaste
that contains fluoride
- Choose an
age-appropriate toothbrush
- Immediately
clean children's teeth that have erupted
Education
- Explain the
development of teeth according to age
- Recommend avoiding
sweet and sticky foods
- Recommend to
check your teeth every 6 months
- Teach how to
brush your teeth properly (from gums to teeth)
Collaboration
- Collaboration on
regular cleaning of plaque/tartar
Promotion of
readiness to receive information
Definition
Increase patient
readiness in receiving information about health conditions
Action
Observation
- Identify the
information to be conveyed
- Identify
understanding of current health conditions
- Identify
readiness to receive information
Tarapeutik
- Strengthen the
potential of patients and families to receive information
- Involve decision
makers in the family to receive information
- Facilitate
recognizing body conditions that require nursing services
- First convey
good (positive) information before conveying bad (negative) information
regarding the patient's condition
- Provide a
contact number that can be contacted if the patient needs assistance
- Record the
patient's identity and contact number to improve or follow up the patient's
condition
- Facilitate
access to services when needed
Education
- Provide
information in the form of flowcharts, leaflets or pictures to make it easier
for patients to get health information
- Instruct the
family to accompany the patient during the progressive or terminal acute phase
if possible
Promotion of
family integrity
Definition
Increase the
patient's knowledge and ability to maintain and improve family cohesion and
integrity
Action
Observation
- Identify the
family's understanding of the problem
- Identification
of priority conflicts between family members
- Identification
of family coupling mechanism
- Monitor
relationships between family members
Tarapeutik
- Respect family
privacy
- Facilitate
family visits
- Facilitating
family decision making and problem solving
Education
- Inform the
patient's condition regularly to the family
- Encourage family
members to maintain family harmony
Collaboration
- Refer for family
therapy if necessary
Effective
communication promotion
Definition
Improve patient
communication skills for health decision making
Action
Observation
- Identify the
priority of the communication method used according to ability
- Clearly identify
the source of the message (who should say it)
Tarapeutik
- Facilitation of
clearly expressing message content
- Facilitate the
delivery of a logical message structure
- Support patients
and families using effective communication
Education
- Explain the need
for effective communication
- Teach formulating
messages correctly
Speech Deficit
Communication Promotion
Definition
Using additional
communication techniques in individuals with speech disorders
Action
Observation
- Monitor the
speed of pressure, quantity, volume, and speech diction
- Identify
emotional and physical behavior as a form of communication
Tarapeutik
- Use alternative
communication methods (e.g. writing, blinking eyes, communication board with
pictures and letters, hand signals and computer)
- Adjust
communication style to needs (eg stand in front of patient listen carefully,
show one idea or thought at a time, speak slowly while avoiding shouting, use
written communication, or ask family for help to understand patient's speech)
- Modify the
environment to minimize help
- Repeat what was
said
- Provide
psychological support
- Use a
spokesperson, if necessary
Education
- Advise speak
slowly
- Teach patient
and family cognitive, anatomical, and physiological processes related to speech
ability
Collaboration
- Refer to speech
pathologist or therapist
Promotion of
Communication Hearing Deficit
Definition
Using additional
communication techniques in hearing-impaired individuals
Action
Observation
- Check hearing
ability
- Monitor
excessive cerumen accumulation
- Identify the
patient's preferred method of communication (eg oral, written, lip movements,
sign language)
Tarapeutik
- Use simple
language
- Use sign
language, if necessary
- Verify what the
patient says or writes
- Facilitate use
of hearing aids
- Dealing with
patients directly during communication
- Avoid smoking,
chewing food or chewing gum, and covering your mouth when talking
- Avoid noise when
communicating more than 1 meter from the patient
- Perform ear
irrigation, if necessary
- Maintain ear
cleanliness
Education
- Suggest
conveying messages with gestures
- Teach how to
clean serumen properly
Visual deficit
communication promotion
Definition
Using additional
communication techniques in visually impaired individuals
Action
Observation
- Check your
eyesight
- Monitor the
impact of visual disturbances (eg risk of injury, depression, anxiety, ability
to perform daily activities)
Tarapeutik
- Facilitate
increased stimulation of other senses (eg, aroma, taste, texture, food)
- Make sure your glasses
or contact lenses work properly
- Provide
sufficient lighting
- Give readings in
capital letters
- Avoid
structuring the environment without notifying
- Provide
assistive devices (eg clock, telephone)
- Facilitate
reading letters, newspapers or other information media
- Use light and
contrasting colors in the environment
- Provide a
magnifying glass, if necessary
Education
- Explain the
environment to the patient
- Teach families
how to help patients communicate
Collaboration
- Refer the
patient to a therapist, if necessary
Coping Promotion
Definition
Increase cognitive
and behavioral efforts to assess and respond to stressors and/or the ability to
use available resources
Action
Observation
- Identify short
and long term activities according to goals
- Identify the
capabilities possessed
- Identify
available resources to meet objectives
- Identify
understanding of the disease process
- Identify the
impact of the situation on roles and relationships
- Identify problem
solving methods
- Identify needs
and desires for social support
Tarapeutik
- Discuss the role
changes experienced
- Use a calm and
reassuring approach
- Discuss reasons
for self-criticism
- Discuss to
clarify misunderstandings and evaluate own behavior
- Discuss the
consequences of not using guilt and shame
- Discuss the
risks that pose a danger to yourself
- Facilitate in
obtaining the required information
- Provide
realistic choices regarding certain aspects of treatment
- Motivation to
set realistic expectations
- Review
capabilities in decision experience
- Avoid making
decisions when the patient is under pressure
- Motivation to
engage in social activities
- Motivation to
identify available support systems
- Accompany when
grieving (eg chronic illness, disability)
- Introduce people
or groups who have had the same experience
- Support the
proper use of defense mechanisms
- Reduce
threatening environmental stimuli
Education
- Encourage
relationships that have the same interests and goals
- Encourage the
use of spiritual resources, if necessary
- Encourage
expressing feelings and perceptions
- Get the family
involved
- Suggest making
more specific goals
- Teach how to
solve problems constructively
- Practice using
relaxation techniques
- Practice social
skills, as needed
- Practice
developing objective assessment
Lactation
Promotion
Definition
Increase exclusive
breastfeeding coverage and continue up to 2 years
Action
- Identify
lactation needs for mother and baby
Tarapeutik
- Facilitate
mothers when doing IMD
- Facilitate
mothers for joining or rooming in
- Use spoons and
cups when baby can't suckle
- Accompany the
mother during breastfeeding activities, if necessary
Education
- Explain the
importance of breastfeeding up to 2 years
- Explain the
benefits of joining or rooming in
- Recommend
breastfeeding at least 2 times during pregnancy, and after giving birth 3-4
times
- Hold a classEducationabout the benefits and portions
of breastfeeding in the prenatal period and the postpartum period
- Advise mother to
maintain milk production by expressing breast milk
- Advise the
mother to provide nutrition to the baby only with exclusive breastfeeding for 6
months and continued until 2 years
- Advise the
mother to give complementary foods to breast milk after 6 months
- Encourage the
mother to breastfeed as often as possible immediately after birth according to
the needs of the baby.
Action
Observation
- Identify
lactation needs for mother and babyTherapeutic
- Facilitate
mothers when doing IMD
- Facilitate
mothers for joining or rooming in
- Use spoons and
cups when baby can't suckle
- Accompany the
mother during breastfeeding, if necessary
Education
- Explain the
importance of breastfeeding up to 2 years
- Explain the
benefits of joining or rooming in
- Recommend
breastfeeding at least 2 times during pregnancy, and after giving birth 3-4
times
- Hold a classEducationabout the benefits and positions
of breastfeeding in the prenatal and postpartum periods
- Advise mother to
maintain milk production by expressing breast milk
- Advise the
mother to provide nutrition to the baby only with exclusive breastfeeding for 6
months and continued until 2 years
- Advise the
mother to give complementary foods to breast milk after 6 months
- Encourage the
mother to breastfeed as often as possible immediately after birth according to
the baby's needs
Facilitates
regular physical activity to maintain or improve to a higher level of fitness
and health.
Observation
- Identify health
beliefs about physical exercise
- Identify
previous sports experience
- Identify
individual motivations for starting or continuing an exercise program
- Identify
barriers to exercise
- Monitor
compliance with the exercise program
- Monitor response
to exercise program
Therapeutic
- Motivation to
express feelings about exercise/need to exercise
- Motivation to
start or continue sports
- Facilitation in
identifying positive role models to maintain the exercise program
- Facilitation in
developing appropriate training programs to meet needs
- Facility} in
setting short and long term goals of latin program
- Facilitation in
scheduling regular weekly training periods
- Facilitation in
maintaining the progress of the fatihan program
- Perform sports
activities with the patient, if necessary
- Involve family
in planning and maintaining exercise program
- Give positive
feedback on every effort made by the patient
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
breathing techniques to maximize oxygen absorption during physical exercise
Collaboration
- Collaboration
with medical rehabilitation or exercise physiologist, if necessary
Health Literacy
Promotion
- Improve the
health of individuals, families, groups, and communities to obtain, manage and
understand health-related information.
Action
Observation
- Identify health
literacy status at first contact
- Identify the
patient's learning styleTherapeutic
- Create a
supportive environment so the patient does not feel embarrassed and/or
stigmatized
- Use appropriate
and clear communication techniques:
- Use
easy-to-understand language
- Use simple
language
- Use
communication techniques that pay attention to aspects of culture, age and
gender
- Provide an
interpreter, if necessary:
- Prepare the information
that will be given both verbally and non-verbally
- Use the right
strategy in delivering information
- Use a variety of
tools to communicate
- Facilitate to
ask questions and clarify unclear informationEducation
- Suggest asking
if there is information that is not clear.
Definition
Facilitates the
use of posture and movement in activities of daily living to prevent fatigue
and musculoskelotal strain or injury.
Action
Observation:
- Identify
commitment to learning and using proper posture
- Identify
understanding of body mechanics and exercise (eg demonstrating proper technique
during exercise activities):
- Monitor the
improvement of posture or body mechanics
Therapeutic.K
- Facilitate in
demonstrating the right sleeping position
- Facilitation in
identifying appropriate posture exercises
- Facilitate in
choosing warm-up activities before starting exercise or work that is not done
routinely,
- Facilitation in
doing flexion exercises to facilitate back mobility, as indicated:
EducationI
- Describe spinal
structure and function and optimal posture for movement and use of the body:
- Explain the need
for proper posture to prevent fatigue, strain, or injury
- Explain possible
causes of muscle or joint pain:
- Inform the
frequency and number of repetitions for each exercise:
- Recommend
avoiding sleeping in the prone position
- Advise to avoid
sitting in the same position for the same period
- Advise to move
the feet first then the body when turning to walk from a standing position
- Teach how to use
posture and body mechanics to prevent injury during physical activity.
- Teach how to
change the load from one leg to the other when standing:
- Teach the use of
mattresses/chairs or pillows, if necessary:
Collaboration: :
- Collaboration
with physiotherapists in developing a body mechanics promotion plan, if
Need
Parenting
Promotion
Facilitate
parents, family members and/or caregivers in providing support and
comprehensive care
for families experiencing or at risk of experiencing problems
health.
Action
Observation
- Identification
of high-risk families in the follow-up program
- Monitor
children's health status and child immunization status
Erapeutik
- Support mothers
to receive and carry out pre-natal care regularly and as early as possible
- Make home visits
according to the level of risk
- Facilitate
parents in having realistic expectations according to the child's ability level
and development
- Facilitate
parents in accepting role transitions
- Provide the
necessary anticipatory guidance according to the child's developmental age
- Facilitate
parents in identifying the baby's unique temperament
- Improve
parent-child interaction and set an example
- Facilitating
parents in getting support, and participating in the role of group programs
- Facilitate
parents in developing and maintaining a social support system
- Provide media to
develop parenting skills
- Facilitate
parents to develop social and coping skills
- Facilitation of
arranging child care, if necessary
- Facilitate the use
of contraception
Education
- Teach parents to
respond to baby's cues
Health Effort
Behavior Promotion
definition
Increase changes
in patient/client behavior so that they have the willingness and ability to
conducive to
overall health both for the environment and the surrounding community.
Action
Observation
- Identify health
behavior that can be improved
Therapeutic.
- Provide a
supportive environment for health
Indonesian
Minister of Nursing Intervention Standards
- Orientation of
health services that can be utilized:
Education
- Advise delivery
assisted by health workers
- Suggest
exclusive breastfeeding babies:
- Recommend
weighing toddlers every month:
- Recommend using
clean water
- Recommend
washing hands with clean water and soap
- Recommend using
healthy latrines:
- Recommend
eradicating larvae at home once a week:
- Encourage eating
vegetables and fruit every day'
- Encourage
physical activity every day:
- Recommend not
smoking in the house:
CHILDREN
DEVELOPMENT PROMOTION
Definition
Enhance and
facilitate the ability of parents/caregivers to optimize
gross motor, fine
motor, language, cognitive, social and emotional development in children
preschool and
school age. :
Action
Observation:
- Identification
of children's special needs and children' adaptability
Therapeutic,
- Facilitate
children's relationships with peers:
- Support children
to interact with other children:
- Support children
to express their feelings positively
- Support children
in dreaming or fantasizing appropriately
- Support
children's participation in school, extracurricular and community activities
- Provide
children' age appropriate toys
- Sing with
children the songs that children like
- Read
stories/fairy tales to children
- Discuss with the
youth their goals and expectations
- Provide
opportunities and tools for drawing, painting and coloring
- Provide toys in
the form of puzzles and maze : :
Education,
- Explain the
names of objects in the surrounding environment.
- Teach caregivers
developmental milestones and established behavior
- Teach
cooperative attitude, not competition among children
- Teach children
how to ask for help from other children, if necessary
- Teach assertive
techniques to children and adolescents
- Demonstrate developmental-enhancing
activities in caregiversCollaboration
- Refer for
counseling, if necessary
Promotion of Youth
Development
Promotes physical,
cognitive, social and emotional development from childhood to adolescence.
Action
Observation
- Identify the
stages of adolescent development
Therapeutic
- Provide
adolescent health guidance and counseling for adolescents and their
families/parents/caregivers
- Improve personal
hygiene and appearance
- Support
participation in safe sports on a regular basis
- Facilitate
decision-making abilities
- Support
communication skills
- Support
assertive attitude skills
- Facilitate a
sense of responsibility to self and others
- Support
nonviolent response in resolving conflict
- Support
development and maintain social relationships
- Support
extracurricular activities
Education
- Describe the
normal development of adolescents
- Teach to
recognize health problems and disorders in adolescence (eg anemia, dental
problems, abnormal sexual maturity, alcohol, smoking,
substance abuse,
impaired body image, low self-esteem)
- Teach drug,
alcohol and cigarette abuse prevention strategies
Collaboration
- Refer for
counseling or hypnotherapy if necessary
Adhesion Promotion
Definition
Increase and
maintain attachment or lactation appropriately.
Action
Observation
- Monitor
breastfeeding activities
- Identify the
baby's ability to suck and swallow breast milk
- Identification
of the mother's breast (eg swelling, sore nipples, mastitis, breast tenderness)
- Monitor
attachment while breastfeeding (e.g. lower areola smaller than upper areola,
baby's mouth is wide open, baby's lips are turned outward and baby's chin is
pressed against mother's breast)
therapy
- Avoid holding
baby's head
- Discuss with the
mother problems during the breastfeeding process
Education
- Teach the mother
to support the whole body of the baby
- Instruct the
mother to remove the upper clothes so that the baby can touch the mother's
breast
- Encourage the
baby to approach the mother's breast from the bottom
- Instruct the
mother to hold the breast using her finger like the letter "C" at the
12-6 or 3-9 o'clock position when pointing to the baby's mouth
- Advise
breastfeeding mothers to wait for the baby's mouth to open wide so that the
lower areeola can enter completely
- Teach mothers to
recognize signs that the baby is ready to breastfeed
Family Effective
Process Promotion
Definition
Take action to
maintain and improve processes in the family
Action
Observation
- Identify the
type of family process
- Identify
problems or disturbances in the family process
- Identify the
need for self-care at home for the client and keep adapting to the family's
lifestyle
therapy
- Maintain ongoing
interactions with family members
- Motivate family
members to do activities together such as eating together, discussing with
family
- Facilities for
family members to visit the hospital
- Schedule
self-care activities at home to reduce disruption to family routines
Education
- Explain strategies
to restore normal family life to family members
- Discuss social
support from around the family
- practice time
management family if home care is needed
Resilience
Promotion
Definition .
Increase the
development, use, strengthening and for the factors that the family will use in
dealing with stressors.
Action
Observe
- Facilitate
family support and involvement
- Develop family
routines and traditions (eg recreation, eating together)
- Ensure that the
family as a source of means and support
- Facilitate
family communication
- Involve family
in community activities (eg volunteering)
- Agree on the
family/community model in general behavior
- Involve the
community in youth programs
- Facilitation of
Development of Environmental resources
- Motivation to
pursue the desired achievement
- Motivation to
achieve positive health porfaku
- Motivation to
develop friendships
- Motivation to
develop social awareness
- Motivate
youth/family/community in developing self-confidenceEducation
- Encourage the
family to be involved in the activities of other family members
- Advise the
family to provide a conducive learning atmosphere
- Encourage the
family to appreciate the achievements achieved
- Advise
family/community to respect health
- Advise the
family in determining age-appropriate expectations
- Advise to follow
available and affordable programs
- Latin assertive
skills in making decisions and socializing
SUPPORT SYSTEM
PROMOTION
Definition
Increase the
provision of assistance to patients with family, friends, and the community.
Action
Observation
- Identify the
psychological response to the situation and the availability of a support
system
- Identify
resources for caregiver availability
- Monitor current
family situation and support system
Therapeutic
- Provide support
and caring in service
- Motivation to
participate in social and community activities
- Motivation to
build relationships with parties who have the same needs
- Get the family
involved. Important people and friends in care
Education
- Describe the
barriers to the support system
- Available social
network information
- Inform the
support system level (eg family, friends and community)
- Encourage family
to be involved in treatment
Collaboration
- Refer to
self-help groups
- Collaboration
with community-based prevention or treatment programs, if necessary
PROMOTION
SOCIALIZATION
Definition
Improve the
ability to interact with others
Action
Observation
- Identify the
ability to interact with other people.
- Identify
barriers to interacting with other people
Therapeutic
- Motivation
increases engagement in a relationship
- Motivation of
patience in developing a relationship
- Motivation to
participate in new activities and group activities
- Motivation to
interact outside the environment (e.g. travel, to the bookstore)
- Discuss
strengths and limitations in communicating with others
- Discuss the
planning of future activities
- Give positive
feedback in self-care
- Give positive
feedback on every ability upgrade
Education
- Encourage
interacting with others gradually
- Encourage
participation in social and community activities
- Recommend
sharing experiences with others
- Advise to
increase self-honesty and respect the rights of others
- Encourage use of
assistive devices (eg glasses and hearing aids)
- Suggest small
group planning for special activities
- Practice role
playing to improve communication skills
- Practice
expressing anger appropriately
Promotion of Skin
to Skin Engineering I.14577
Definition
Increase skin
contact between mother and baby directly so that the baby can breastfeed
Action
Observation
- baby breathing
monitor
- Monitor vital
signs and bleeding after delivery
Therapeutic
- Give mothers the
opportunity to join or rooming-in
- Give a semi-Fowler
position after being in the post partum care room
- Undress baby,
put on baby diaper and hat
- Place the baby
in the prone position between the mother's breasts
- Provide warmth
by covering the baby's back
- Give the baby
the opportunity to suckle until it's finished without interruption
- Put the baby
next to the mother or place the baby crib next to the mother's bed
Therapeutic
- Advise mother to
take off the top clothes
- Advise mother to
clean the sweat on the chest
- Advise to give breastfeeding
opportunities for more than 1 hour or until the baby shows signs of being ready
to breastfeed
Anxiety Reduction
I.09314
Definition
Minimizing
individual conditions and subjective experiences of objects that are not clear
and specific due to anticipation of danger that allows individuals to take
action to deal with threats.
Action
Observation
- Identify when
anxiety levels change (eg, condition, time of day, stressor)
- Identify
decision-making abilities
- Monitor for
signs of anxiety (verbal and non-verbal)
Therapeutic
- Create
atmosphereTherapeuticto cultivate
trust
- Accompany the
patient to reduce anxiety, if possible
- Understand
situations that create anxiety
- Listen
attentively
- Use a calm and
reassuring approach
- Place personal
items that provide comfort
- Motivation to
identify situations that trigger anxiety
- Discuss
realistic planning of upcoming events
Education
- Describe the
procedure, including the sensations that may be experienced
- Inform factually
about diagnosis, treatment, and prognosis
- Instruct the
family to stay with the patient, if necessary
- Advise
non-competitive activities, as needed
- Encourage
expressing feelings and perceptions
- Practice
diversion activities to reduce tension
- Practice proper
use of self-defense mechanisms
- Practice
relaxation techniques
Collaboration
- Collaboration in
the administration of anxiety drugs, if necessary
RegulationTemperature
I.14578
Definition
Maintain body
temperature within normal range
Action
Observation
- Monitor baby's
temperature until stable (36.5⁰C – 37.5⁰C)
- Monitor the
child's body temperature every 2 hours, if necessary
- Monitor blood
pressure, respiratory rate and pulse
- Monitor skin
color and temperature
- Monitor and
record signs and symptoms of hypothermia or hyperthermia
Therapeutic
- Install a
continuous temperature monitor, if necessary
- Increase fluid
intake and adequate nutrition
- Swaddle the baby
immediately after birth to prevent loss of breath
- Put LBW babies
in plastic immediately after birth (eg polyethylene, polyurethane)
- Use a baby hat
to prevent heat loss in newborns
- Place the
newborn under a radiant warmer
- Maintain
incubator humidity of 50% or more to reduce heat loss due to an evaporation
- Set the
temperature of the incubator as needed
- Warm up
materials that will be in contact with the baby (eg blankets, swaddles,
stethoscope)
- Avoid placing
the baby near an open window or in an area with air conditioning or fans
- Use heating
mats, warm blankets, and heaters to raise body temperature, if necessary
- Use cooling
mattresses, water circulating blankets, ice packs or gel pads and intravascular
cooling catheterization to lower body temperature
- Adjust the
ambient temperature to the patient's needs
Education
- Explain how to
prevent heat exhaustion and heat stroke
- Explain how to
prevent hypothermia due to exposure to cold air
- Demonstrate the
kangaroo method of care (PMK) for LBW babies
Collaboration
- Collaborative
administration of antipyretics, if necessary
Cardiac
rehabilitation I.02081
Definition
Managing the
recovery period of cardiac function after experiencing a disturbance that
results in an imbalance in myocardial oxygen demand and supply, and minimizing
the incidence of attacks, risk behaviors and psychosocial impacts.
Action
Observation
- Monitor activity
tolerance level
- Check for
exercise contraindications (tachycardia >120/minute, BP >180 mmHg, BP
>110 mmHg, orthostatic hypotension >20 mmHg, angina, dyspnea, ECG
ischemia, not grade 2 and 3 atrioventricular, ventricular tachycardia)
- Perform anxiety
and depression screening, if necessary
Therapeutic
- Facilitate
patients undergoing phase 1 exercise (inpatient)
- Facilitate
patients undergoing phase 2 exercise (outpatient)
- Facilitate
patients undergoing phase 3 exercise (maintanance)
- Facilitate
patients undergoing phase 4 (long term) exercise
Education
- Describe the
series of phases of cardiac rehabilitation
- Advise to
undergo exercise according to tolerance
- Instruct patient
and family to modify risk factors (eg, exercise, diet, smoking cessation,
weight loss)
- Instruct patient
and family to adhere to health control schedule
Drug
Reconciliation I.14579
Definition
Identifying the
suitability of the treatment program with the drug received by the patient to
prevent medication errors
Action
Observation
- Identification
of drugs that are currently and will be used by the patient, (eg drug name,
dose, frequency, route, drug started, changed, continued, and stopped, history
of allergies, drug side effects that have occurred)
Therapeutic
- Complications of
drug data that have been and will be used
- Communicating
with patients and or their families or nurses regarding changes in therapy that
occur
Education
Collaboration
- Consult the
medical if you find a discrepancy
- Collaboration
with pharmacists who are responsible for the drug information provided
Cognitive
Restructuring I.06027
Definition
Facilitates
changing dispersed mindsets, seeing oneself and the world realistically
Action
Observation
- Identify
erroneous interpretations of the causes of perceived stress
Therapeutic
- Replace
erroneous interpretations with interpretations based on reality
- Create an
alternative perspective or solution to the situation
- Facilitation of
accepting the reality of self-statements that evoke emotions (arousal)
- Define the
distorted thoughts experienced (eg, overgeneralization, magnification,
personalization)
- Label emotional
changes (eg, anger, anxiety, hopelessness)
- Support belief
systems to see situations in a different way
Education
- Teach to
identify stressors that cause stress (eg, situations, events, interactions with
other people)
- Discuss
disabilities that lead to irrational self-statements
- Discuss belief
systems that affect health status
- Discuss
illustrative statements to see the situation from a different point of view
- Practice
accepting reality and self-statements that cause stress
- Practice
expressing the emotions you feel (eg, anger, anxiety, hopelessness)
- Practice turning
irrational self-statements into rational ones
- Train against
distorted perceptions or thoughts
Fluid
Resuscitation I.03139
Definition
Give intravenous
fluids quickly as indicated
Action
Observation
- Identification
of shock class for estimation of blood loss
- Monitor
hemodynamic status
- Monitor oxygen
status
- Monitor body
fluid output (eg, urine, nasogastric fluids, chest tube fluids)
- Monitor the
value of BUN, creinine, total protein, and albumin, if necessary
- Monitor for
signs and symptoms of pulmonary edema
Therapeutic
- Install a large
IV line (eg number 14 or 16)
- Give 1-2 L of
crystalloid fluid infusion in adults
- Give crystalloid
fluid infusion 20 ml/kg body weight in children
- Do cross matchine
products
Collaboration
- Collaborative
determination of the type and amount of fluid (eg, crystalloid, colloid)
- Collaboration of
blood product distribution
Fetal
Resuscitation I.02082
Definition
Provide prompt and
appropriate action to maintain placental perfusion to the fetus.
Action
Observation
- Monitor fetal
heart rate
- Monitor for
signs of abnormal fetal heart rate (eg, bradycardia, tachycardia,
decelerations, slow decelerations, prolonged decelerations and sinusoidal
patterns)
- Monitor maternal
and fetal vital signs
Therapeutic
- Use universal
precautions
- Reposition
mother to lateral position
- Give oxygen 6-8
L, as needed
- Give IV fluid
boluses, as indicated
- Calm mom and
family
- Provide left
lateral position during the 2nd stage of labor to improve placental position
- Anticipate labor
conditions immediately
Education
- Explain the
purpose and procedure of fetal resuscitation
- Inform the
action to be taken to increase fetal oxygenation
Collaboration
- Collaborative
administration of oxytocin induction, as indicated
- Collaborative
administration of tocolytics to reduce contractions, as indicated
- Collaborative
amnioinfusion, as indicated
Cardiopulmonary
Resuscitation I.02083
Definition
Provide first aid
in conditions of stopping breathing and hanging with chest compression
techniques and breathing assistance
Action
Observation
- Identification
of rescuer, environment and patient safety
- Identify the
patient's response (eg, calling the patient, patting the patient on the
shoulder)
- Monitor carotid
pulse during breaths every 2 minutes or 5 cycles of CPR
Therapeutic
- Wear personal
protective equipment
- Activate the
emergency medical system or shout for help
- Position the
patient supine on a flat and hard place
- Adjust the
position of the rescuer kneeling beside the victim
- Feel the carotid
pulse in <10 seconds
- Give rescue
breathing if there is a pulse but no breath
- Chest
compressions 30 times combined with assisted breathing (ventilation) 2 times if
there is no pulse and no breath
- Compression with
the heel of the palm stacked on top of the other palm perpendicular to the
mid-chest (lower half of the sternum)
- Compression with
a compression depth of 5 – 6 cm at a speed of 100 – 120 times/minute
- Clear and open
airway with head tilt Chin lift or jaw thrust (if cervical injury is suspected)
- Provide
breathing assistance using a bag valve mask using the EC-clamp technique
- Combine
compressions and ventilation for 2 minutes or as many as 5 cycles
- Stop CPR if
there are signs of life, a more skilled helper arrives, signs of biological
death are found, DO NOT RESUCITATION (DNR)
Education
- Explain the
purpose and procedure of the action to the family or patient introduction
Collaboration
- Medical team
collaboration for advanced life support
Neonatal
Resuscitation I.02084
Definition
Provide adequate
ventilation and circulation to maintain the life of the newborn
Action
Observation
- Perform initial
assessments (eg, is the baby full term, is the baby crying or breathing,
whether the baby's muscle tone is good)
- Periodically
monitor respiration, heart rate, and oxygenation
Therapeutic
- Place the
newborn under a warm heat emitter
- Perform initial
stabilization steps, (eg, provide warmth, clear the airway if necessary with a
rubber ball suction, dry the baby, provide tactile stimulation by rubbing the
baby's back or soles of the baby's feet, adjust the baby's position by placing
a cloth roll on the baby's shoulder.
- Give positive
pressure ventilation (VTP) if the baby still has acne apnea and has difficulty
breathing
- Ensure the
attachment of the mask without covering the chin, mouth and nose.
- Provide
ventilation with a respiratory rate of 40-60 times per minute to achieve and
maintain a heart rate of more than 100 per minute
- Perform chest
compressions and ventilation in a 3:1 ratio if the heart rate is less than 60
per minute after adequate ventilation with oxygen for 30 seconds
- Give 90
compressions and 30 ventilations per minute
- Give epinephrine
and/or volume-boosting fluids according to protocol
- Insert
orogastric catheter if ventilation is given for more than 2 minutes
- Stop
resuscitation if no heartbeat is detected for 10 minutes
Education
- Explain the
purpose and procedure to parents with communication methodTherapeutic
Collaboration
- Collaborative
endotracheal intubation if mask ventilation is ineffective and takes a long
time
Reference I.12473
Definition
Arrange further
treatment by delegating duties and responsibilities for examination and patient
care to other health or health workers
Action
Observation
- Identification
of referral indications (eg, need for further treatment, facilities not
available, request from patient or family)
- Check the
patient's condition prior to referral (eg, general condition, vital signs,
consciousness)
therapeutic
- Get patient and
or family consent (informed consent)
- Provide
opportunities for patients and families to ask questions and get related
answers (eg, purpose of referral, benefits of referral, risks of not being
referred, referral procedure, time and duration of referral)
- Contact the
health service that is the referral destination who will receive the patient
- Ensure that
information about the patient is known and recorded by health workers at the
health service for referral purposes
- Complete and
send the necessary files (eg, referral forms, photocopies of medical records,
results of supporting examinations, health insurance files)
- Ensure that the
referred patient is wearing an identification bracelet
- Perform
emergency treatment before referral, if necessary
- Provide means of
transportation to make referrals safely and on time
- Complete
resuscitation equipment and tools or materials that may be needed during the
referral process (eg complete oxygen cylinders, emergency kits)
Education
- Explain the
purpose and procedure of referral
- Inform the plan
of referring to patients and families
- Inform health
services that are referred to (eg indications for referral, patient condition,
interventions that have been carried out, intervention plans that have not been
carried out)
Referral to
Pregnancy Lactation Class l.03140
Definition
Delegating health
services for pregnant women in preparation for breastfeeding to breastfeeding
classes/clinics, lactation/lactation corners, to get counseling, information
andEducationfrom a breastfeeding counselor at
least 1-2 pregnancies.
Action
Observation
- Identification
of maternal gestational age (32 weeks)
- Identify the
mother's motivation and need for breastfeeding
- Identification
of information about breastfeeding that has been obtained
Therapeutic
- Discuss the
importance of breastfeeding classes during pregnancy
- Discuss breast
changes during pregnancy
- Refer to breastfeeding
class services during pregnancy
Education
- Explain the
purpose and procedure of referral
- Advise mother to
getEducationand breastfeeding counseling at
least 1-2 times during pregnancy
Collaboration
- Collaboration
with a lactation counselor
Referral to
Postpartum Lactation Class l.03141
Definition
Delegating health
services for breastfeeding mothers to breastfeeding classes/lactation
clinics/lactation corners, to get counseling, information andEducationand breastfeeding counselor
Action
Observation
- Identify the
mother's ability to breastfeed
- Check baby's
weight defense
- Check primitive
reflexes (rooting, sucking and swallowing)
- Check the
condition of the mother's breasts (eg type of nipple, swelling, blisters /
sores on the nipple, nipple pain and mastitis)
- Check the
mother's psychological condition and family support
- Check the
position and placement when the mother is breastfeeding
- Check the use of
formula milk
- Check the
mother's skills when expressing breast milk
- Check how to
store breast milk
Therapeutic
- Discuss the
importance of breastfeeding classes in the postpartum period
Education
- Explain the
purpose and procedure of referral
- Recommend
visiting health services (eg lactation clinic, lactation corner, breastfeeding
class)
Collaboration
- Refer to
breastfeeding class services in the postpartum period
Referral to
Breastfeeding Support Group I.03142
Definition
Delegating health
services for pregnant and lactating women in preparing and maintaining
breastfeeding in order to obtain counseling, information andEducationso that mothers receive
breastfeeding support while in the treatment room or community.
Action
Observation
- Identification
of the mother's gestational age
- Identify the
mother's motivation and need for breastfeeding
- Identify the
information that has been obtained about breastfeeding
- Identify the
support received during pregnancy, labor and postpartum
- Identify
breastfeeding support groups willing to facilitate
- Discuss the
importance of relying on breastfeeding support groups
- Motivate mothers
to join breastfeeding support groups
- Refer to a breastfeeding
support group
Education
- Explain the
purpose and procedure of referral
- Recommend
visiting a breastfeeding support groupCollaboration
- Collaboration
with breastfeeding counselors and mothers who are successful in breastfeeding
executives
Referral to
Community Service l.12474
Definition
Develop further
management of health and nursing services to a more complete source of health
services for individuals, families and groups in the community.
Action
Observation
- Identify sources
of health services in the community
- Identify health
problems of individuals, families and community groups.
Therapeutic
- Facilitate the
referral process, if necessary
- Facilitation of
deciding which health services can be referred to
- Facilitation of
individuals, families and groups preparing the referral process (eg
administration, health information/data)
- Provide accurate
information to the intended service institution
- Facilitate the
follow-up process in the community after referral
- Complete the documentation
process
Referral to Family
Planning Services 1.07231
Definition
Develop further
management of the family member's pregnancy planning program to family planning
service institutions.
Action
Observation
- Identify the
family's need for a pregnancy planning program
- Identify the
potential and sources of family strength
- Identify whether
the role and function of family health is going well
Therapeutic
- Discuss with the
family, especially the head of the family about the family planning program
- Agree on time
with the patient and family for the initial meeting of the family planning
program
- Give individuals
the opportunity to share their problems
- Family
facilitation to identify the appropriate type of family planning
- Facilitate
patients and families to agree on the choice of family planning programs
- Provide
reinforcement for patient and family decisions
- Explain the
purpose, benefits and procedures of family planning to all family members
Referral to
Enterostoma Nurse 1.04170
to
Definition
DoCollaborationwith enterostoma nurses in
the management of patients with stoma.
Action
Observation
- Identification
of the patient's condition (e.g. stoma creation plan, abnormal stoma)
- Prepare a resume
of the patient's condition (eg disorders of the colon or urethra, occupation of
the patient, type and timing of stoma insertion, stoma problems)
- Write clearly
the type of handler that is expected from the enterostoma nurse
Education
- Explain the
purpose and procedure of referral
Collaboration
- Collaboration
with enterostoma nurse for further intervention
Referral to Group
Support Therapy
Definition
Delegation of
individual nursing services to group health service sources in the community
Action
Observation
- Identify sources
of health support in the community
- Identification
of individual needs
- Monitor the
final results of the therapy program
Therapeutic
- Facilitation of
deciding to join a group therapy program
- Motivation to
adjust to the support group
- Facilitation of
following the therapy program according to the stages until it is completed
- Provide
reinforcement for individual achievements in the group
- Make
modifications and follow-up programs
Education
- Explain the
purpose and procedure of referral
Referral to Family
Therapy
Definition
Delegating
individual therapy program services in the family to undergo family therapy.
Action
Observation
- Identify the
patient's problems in the family
- Identify the
potential and sources of family strength
- Identify whether
the role and function of family health is going well
Therapeutic
- Discuss plans to
involve all family members in the therapy program
- Discuss with the
head of the family about the health problems experienced
- Agree on time with
patient and family for initial therapy meeting
- Give individuals
the opportunity to share their problems
- Family
facilitation to identify the appropriate therapy model
- Facilitate
patients and families to agree on therapeutic options and implementation
strategies
- Provide
reinforcement for individuals and families
Education
- Explain the
purpose of the benefits and the process of therapy to all family members
exclusion
Definition
Separating
patients in a special room with close supervision
Action
Observation
- Identify medical
history
- Identify a
history of harmful behavior to self and others
- Monitor safety
while in the exclusion room
Therapeutic
- Designate one
nursing staff member to communicate and direct other staff
- Contracts to control
behavior
- Support the
fulfillment of basic needs (eg nutrition, elimination, hydration, and hygiene)
- Avoid using
objects that can hurt yourself or others
- Create a
comfortable and low-stimulus environment
- Apply physical
restraint or restriction of movement, if necessary
Education
- Explain goals
and procedures to patients and families in easy-to-understand language
- Practice
controlling behavior, if necessary
Collaboration
- Collaborative
administration of drugs for anxiety or agitation, as indicated
Infant Screening
Before Discharge 1.10343
Definition
Detecting an
abnormality/disease that is not clinically clear by using a number of tests,
examinations or procedures
Action
Observation
- Identify the
readiness of the baby and family for discharge
Therapeutic
- Do a baby growth
and development screening
- Perform hearing
screening with hearing loss tests otoaustic emissions (OAE), auditory brain
stem response (ABR)
- Perform pulse
oximetry examination to identify infants who have critical congenital heart
disease
- Perform
congenital hypothyroid screening, if necessary
Education
- Explain to
parents about the purpose and procedure of screening
- Teach observing
and assessing baby's behavior related to baby's hearing ability
- Inform parents
of the importance of following up on screening results
Nutrition
screening 1.03143
Definition
Early detection of
patients who are at risk of malnutrition with a fast process to prevent a
decrease in nutritional status
Action
Observation
- Identification
of nutritional status within 1x24 hours after the patient enters the hospital
Therapeutic
- Use a valid and
reliable screening instrument
- Perform
re-screening after one week, if the nutritional screening shows the risk of
malnutrition
Education
- Explain the
purpose and procedure of nutrition screening
- Inform the
results of nutrition screening
Collaboration
- Collaboration
with nutritionists to carry out further examinations, if nutrition screening
shows the risk of being malnourished
- Collaboration
with nutritionists to carry out standardized nutritional care processes, if
nutrition screening shows a risk of being malnourished
Screening l.14580
Definition
Early detection of
the possibility of having cancer so that treatment can be done as soon as
possible
Action
Observation
- Identification
of the patient's initial condition (eg anamnesis of complaints, age, gender,
family history of cancer, exposure to carcinogens
Therapeutic
- Perform a
physical examination of the breast, cervix, prostate, lungs or organs that may
be affected by cancer
- Facilitation to
carry out supporting examinations for cancer detection in both women and men
Education
- Explain the
procedure and purpose of early detection of cancer
- Explain the
supporting examination procedures
- Recommend
regular cancer detection
Health screening
l.14581
Definition
Early detection of
the risk of health problems by history taking, physical examination, and other
procedures.
Action
Observation
- Identification
of target population health screening
Therapeutic
- Perform health
screening informed consent
- Provide access
to screening services (eg time and place)
- Schedule health
screening time
- Use valid and
accurate screening instruments
- Provide a comfortable
environment during health screening procedures
- Take a history
of medical history, risk factors, and medication, if necessary
- Perform a
physical examination, as indicated
Education
- Explain the
purpose and procedure of health screening
- Inform health
screening results
Collaboration
- Refer for
further diagnostic tests (eg Pap smear, mammography, prostate, ecg), if
necessary
Persecution/Persecution
Screening l.14582
Definition
Detect early
causes of suffering, pain, and death on purpose
Action
Observation
- Identify any
physical complaints (eg bleeding, injury, injury)
- Identification
of behavioral and psychological changes
- Identify the
presence of a self-concept (eg presence of low self-esteem)
- Identification
of any history of violence (eg perpetrator, victim, witness)
- Identify the
intensity and frequency of abuse experienced
- Identify
feelings during the screening process (eg feeling guilty, angry, sad)
- Identify the
coping used
- Identify the
closest support
Therapeutic
- Provide a
comfortable, safe and private environment
- Pay attention to
basic and psychological needs
- Show respect and
empathy for everything that is expressed (eg, verbal, nonverbal)
- Avoid stigma
- Do a physical
examination
Education
- Explain the
purpose and procedure of screening
Collaboration
- Collaborative
investigations (eg laboratory, forensics)
- Refer to related
services, if necessary
Substance Abuse
Screening I. 09316
Definition
Detect early use
of substances that are not in accordance with medical indications so that it
can lead to addiction and death.
Action
Observation
- Identification
of reason and circumstances at admission (eg withdrawal, overdose,
intoxication)
- Identification
of medical history/therapy
- Identification
of history of substance use problems (eg hospitalization, medical/mental
complications, criminal behavior)
- Identify
conditions that cause stress (eg events, environment)
- Identification
of trigger factors for substance reuse
- Identification
of recent substance use (eg type, route of administration, dose and time)
- Identify social
relationships and barriers (eg close/trusted people, group activities)
- Identification
of self-concept (eg self-image, identity, role, ideal self, self-esteem)
- Identify spiritual
and religious aspects (eg values, beliefs, worship activities)
- Identify the
coping mechanisms used before and now
- Identification
of the causes and effects of substance use
- Identify ways to
overcome the suggestions used and their effectiveness
- Identify the
support system used and available
Therapeutic
- Provide a
comfortable, safe and private environment
- Pay attention to
basic and psychological needs
- Give an attitude
of respect and empathy for all that is expressed (eg verbal, nonverbal)
- Do a physical
examination
Education
- Explain the
purpose and procedure of screening
Collaboration
- Collaboration
investigations (eg blood, urine, MRI)
- Refer to related
services, if necessary
Infant and Toddler
Development Screening I. 10344
Definition
Early detection of
the risk of misplaced development of children under five years of age.
Action
Observation
- Identification
of infant/toddler developmental stages with valid and trusted instruments (eg
KPSP, Denver II)
Therapeutic
- Perform
screening according to the age standards that have been set
- Provide a
comfortable, safe and private environment
- Pay attention to
basic and psychological needs
- Show respect and
empathy for everything that is said (eg verbal, nonverbal)
- Avoid stigma
- Do a physical
examination
Education
- Explain to
parents the purpose and procedure of screening
- Inform parents
of the results of the screening
Tuberculosis I
screening. 01024
Definition
Early detection of
the risk of tuberculosis health problems by history taking, physical
examination, and other procedures.
Action
Observation
- Identification
of the target population for tuberculosis screening (risk groups)
Therapeutic
- Perform informed
consent for tuberculosis screening
- Provide access
to tuberculosis screening services (eg time and place)
- Schedule
tuberculosis screening time
- Use a valid and
accurate tuberculosis screening instrument (eg signs and symptoms, AFB, chest
X-ray)
- Provide a
comfortable environment during the tuberculosis screening procedure
- Take a history
of medical history, risk factors, and treatment, if necessary
- Perform physical
examination as indicated
Education
- Explain the
purpose and procedure of tuberculosis screening
- Inform health
results
Airway Stability
I.01025
Definition
Maintain a patent
airway either without an instrument or with an assisted airway.
Action
Observation
- Identify the
size and type of oropharyngeal or nasopharyngeal tube
- Monitor airway
sounds after airway tube is inserted (eg, shortness of breath, snoring)
- Monitor for
complications of airway tube insertion
- Monitor chest
wall symmetry
- Monitor oxygen
saturation (SpO2) and CO2
Therapeutic
- Use personal
protective equipment (eg gloves, goggles, mask)
- Position the
patient's head as needed
- Perform oral and
oropharyngeal suction
- Insert
oro/nasopharyngeal tube correctly
- Make sure the
oro/nasopharyngeal tube reaches the base of the tongue and keeps the tongue
from falling back
- Fixation of oro/nasopharyngeal
tube in the right way
- Replace the
oro/nasopharyngeal tube according to the procedure
- Insert the
laryngeal mask airway (LMA) correctly
- Ensure insertion
of endotracheal tube and tracheostomy only by a competent medical team
- Facilitate the
insertion of the endotracheal tube by preparing the necessary intubation
equipment and emergency equipment
- Give 100% oxygen
for 3-5 minutes, as needed
- Half intubated
chest auscultation
- Inflate
endotracheal/tracheostomy cuff
- Mark the endotracheal
tube on the lips or mouth
- Verify the
position of the tube using a chest x-ray, make sure the trachea is 2-4 cm above
the carina
Education
- Explain the
purpose and procedure of airway stabilization
Collaboration
- Collaborative
selection of the size and type of endotracheal tube or tracheostomy tube with
high volume, low pressure cuff
Cognitive
Stimulation I.06208
Definition
Increase
environmental awareness and understanding by utilizing stimulus planning.
Action
Observation
- Identify limited
cognitive abilities
Therapeutic
- Support the
environment in stimulating through various contacts
- Do it gradually
and repeatedly if there are changes or new things
- Provide calendar
- Orient the time,
place and person
- Show sensitivity
in treatment by responding
- Provide
opportunities to be responsible for tasks and work
- Engage in arts
and cultural activities actively
- Engage in
multi-stimulation programs to improve cognitive abilities (eg singing,
listening to music, listening to murattals, creative activities, social
interactions, or problem solving)
- Give opportunity
to give opinion
- Plan sensory
stimulation activities
- Give rest time
- Put personal
items and photos in the patient's room
Education
- Advise to
interact with other people
- Encourage
re-expressing thoughts to stimulate memory
- Suggest to do
activities to improve ability and learning
- Encourage use of
memory aids (eg to-do lists, schedules and reminders)
- Recommend
repeating the information obtained
Surveillance I.
14582
Definition
Collects,
interprets, and synthesizes patient data for continuous and sustainable
clinical decision making.
Action
Observation
- Identify the
patient's health risks
- Identify the
patient's normal behavior and routine
- Identify the
patient's perception of his health status
- Identify initial
conditions that require an immediate response (eg changes in vital signs, slow
or fast heart rate, low or high blood pressure, difficulty breathing, changes
in level of consciousness, repeated or prolonged seizures, chest pain, changes
in mental status)
- Check for signs,
symptoms or current problems
- Monitor the
patient's ability to perform self-care activities
- Monitor
neurological status
- Monitor behavior
patterns
- Monitor
cognitive abilities
- Monitor
emotional state
- Monitor vital
signs
- Monitor coping
strategies used by patients and families
- Monitor changes
in sleep patterns
- Monitor skin in
high-risk patients
- Monitor for
signs and symptoms of fluid and electrolyte imbalance
- Monitor network
pervus
- Monitor for
signs of infection, if necessary
- Monitor
nutritional status
- Monitor
gastrointestinal function
- Monitor
elimination pattern
- Monitor bleeding
tendencies in high-risk patients
Therapeutic
- Activate the
quick reaction team, if necessary
- Set the
frequency of data collection and interpretation
- Determine the
patient's condition is unstable or critically stable (eg. Patients requiring
frequent neurologic assessments, patients having cardiac dysrhythmias, patients
receiving continuous drug infusions)
- Facility of
obtaining diagnostic tests, if necessary
- Interpret
diagnostic test results, if necessary
- Retrieve and
analyze laboratory data
- Involve patient
and family in monitoring activities, if necessary
- Record the type
and amount of drainage and notify the doctor of any significant changes
- Compare the
current status with the previous status to detect improvement and worsening of
the patient's condition
- Analyze multiple
medical programs and ensure their safety and accuracy
- Provide the
right environment as desired (e.g. matching nurse competencies with patient
care needs, ratio with nurses, providing adequate complementary staff, ensuring
continuity of care)
Education
- Explain the results
of diagnostic tests to patients and families
Collaboration
- Collaboration
with the medical team, if necessary
- Collaboration
with the medical team to carry out invasive hemodynamic monitoring, if
necessary
- Collaboration
with the medical team to carry out ICP monitoring
Security and
safety surveillance I. 14584
Definition
Collects,
interprets, and synthesizes safety data and patient safety risk factors for
continuous and sustainable clinical decision making.
Action
Observation
- Identify hazards
that threaten patient safety, if any
- Identify
information about the patient's normal behavior and routine
- Identify
perceptions about safety
- Check for signs,
symptoms or current problems
- Monitor the patient's
ability to perform self-care activities
- Monitor
neurological status
- Monitor behavior
patterns
- Monitor
cognitive abilities
- Monitor
emotional state
- Monitor vital
signs, as needed
- Monitor for
signs and symptoms of fluid-electrolyte imbalance
- Monitor bleeding
tendencies in high-risk patients
Therapeutic
- Set the
frequency of data collection and interpretation
- Determine the
patient's condition is unstable or critically stable (eg. Patients requiring
frequent neurologic examinations, patients having cardiac dysrhythmias,
patients receiving continuous intravenous infusion of drugs such as
nitroglycerin or insulin)
- Facilities for
obtaining diagnostic tests, if necessary
- Interpretation
of diagnostic test results, if necessary
- Compare this
status with the previous status to detect improvement and worsening of the
patient's condition
- Prioritize
actions based on the patient's condition
- Analyze multiple
medical programs and ensure their safety and accuracy
- Provide the
right environment as desired (eg matching nurse competence with patient care
needs, ratio with nurses, providing adequate support, ensuring continuity of
care)
Education
- Encourage the
family to be involved in maintaining patient safety, if necessary
Collaboration
- Collaboration
with the medical team, if necessary
- Collaboration
with the medical team to carry out invasive hemodynamic monitoring, if
necessary
- Collaboration
with the medical about conditions related to the therapy program, if necessary
Advanced pregnancy
surveillance I. 07232
Definition
Collect,
interpret, and synthesize data on pregnant women with a history of trauma or
injury that threatens pregnancy or pregnant women with a history of problematic
pregnancies
Action
Observation
- Identification
of risks that threaten pregnancy (eg history of falls, trauma, infection of the
birth canal, consumption of drugs, age more than 35 years and less than 20
years, malnutrition, obstructive disease)
- Identify
behaviors and routines that could threaten the patient's pregnancy (eg extreme
sports, climbing or descending stairs, smoking, alcoholism)
- Identify
critical stable or unstable conditions (eg fetal distress, bleeding, anemia,
hypertension, PROM, preeclampsia/eclampsia)
- Check her
current pregnancy signs, symptoms or problems
Therapeutic
- Set the
frequency of collection and interpretation of pregnancy-related data (eg
maternal weight, FHR, estimated fetal weight, fetal movement, gestational age, fundal
height)
- Facilities for
pregnant women to obtain information on early detection of dangerous signs and
symptoms of pregnancy (eg bleeding, high blood pressure, signs of anemia and
results of diagnostic tests)
- Interpret
diagnostic results, if necessary
- Provide a safe
and comfortable environment for pregnant women
Education
- Advise to share
his perception of risky pregnancy
Collaboration
- Collaborate on
medical programs for pregnant women and ensure their safety and accuracy
Community Surveillance
I. 14584
Definition
Collect,
interpret, and synthesize data that is sustainable for decision making in the
community.
Action
Observation
- Identification
of public health data reporting purposes and procedures
- Collect data
related to health events in the community
- Set frequency
and data analysis collection
Therapeutic
- Report mechanism
data using existing standard reporting
- Follow up
reports to relevant agencies to ensure the accuracy and usefulness of
information
- Engage actively
in program development in the community (eg health education, government policy
and advocacy skills) related to community data collection and reporting
- Use previous
reports to identify the need for additional data collection, analysis and interpretation
Education
- Teach (Family
and community) to recognize the importance of follow-up treatment of infectious
diseases
Collaboration
- Collaboration
with other parties in the collection, analysis, and reporting of public health
data
Distraction Techniques
I. 14584
Definition
Divert attention
or negative emotions and thoughts towards unwanted sensations.
Action
Observation
- Identify the
desired choice of distraction technique
Therapeutic
- Use distraction
techniques (eg reading books, watching television, therapy activities, reading
stories, singing)
Education
- Explain the
benefits and types of distraction for the five senses (eg music, calculations,
television, reading, video/games)
- Recommend using
techniques according to energy level, ability, age, developmental level
- Suggest making a
list of fun activities
- Recommend
practicing distraction techniques
Guided Imagination
Technique I. 08247
Definition
Forming
imagination with all senses through cognitive processing by changing objects, places,
events or situations to promote relaxation, increase comfort and relieve pain.
Action
Observation
- Identify the
problem experienced
- Monitor response
to emotional changes
Therapeutic
- Provide a quiet
and comfortable room
Education
- Suggest
imagining a place you have been or would like to visit (eg mountains, beaches)
- Encourage
imagining visiting the place visited is in good health, together with loved
ones or loved ones in a comfortable atmosphere
Muscle
strengthening exercise technique I.05184
Definition
facilitates
regular resistive muscle training to maintain or increase muscle strength.
Action
Observation
- identify risks
- identification
of muscle fitness level using the exercise field or test laboratory (eg maximum
lift, flat count per unit time)
- identification
of type and duration of heating/cooling activity
- monitor the
effectiveness of the exercise.
Therapeutic
- do the exercises
according to the specified program
- the facility
sets realistic short-term and long-term goals in determining the exercise plan.
- Facilities to
get the resources needed in the home/work environment
- The facility
develops an exercise program appropriate to the level of muscle fitness,
musculoskeletal constraints, functional health goals, exercise equipment
resources, and social support
- The facility of
changing the program or developing other strategies to prevent him from getting
bored and dropping out of practice.
- Give written
instructions on the guidelines and forms of motion for each muscle movement.
Education
- Describe muscle
function, exercise physiology, and consequences of muscle disuse.
- Collaboration
with other healthcare teams (eg activity therapist, exercise physiologist,
occupational therapist, recreational therapist, physical therapist) in
planning, teaching, and monitoring muscle training programs.
Joint
strengthening exercise technique L.05185
Definition
Using active or
passive body movement techniques to maintain or
restore improves
joint flexibility
Action
Observation
- Identify
limitation of joint function and motion
- Monitor the
location and nature of discomfort or pain during movement/activity
Therapeutic
- Perform pain
control before starting the exercise
- Provide optimal
body position for passive or active joint movement
- Facility to
schedule active and passive range of motion exercises
- Regular joint
movement facilities within the limits of pain, endurance, and joint mobility
- Provide positive
reinforcement to do the exercises together
Education
- Explain to the
patient / family the purpose and plan of exercise together
- Encourage
sitting in bed, on the side of the bed (bouncing) or chair, as tolerated
- Teach doing
active and passive range of motion exercises systematically
- Suggest
visualizing gestures before starting the movement
- Encourage
ambulation, as tolerated
Collaboration
- Collaboration
with physiotherapists in developing and implementing exercise programs.
Calming technique
I.08248
Definition
Relaxation
technique by forming individual imagination by using all senses through
cognitive processing to reduce stress.
Action
Observation
- Identify the
problem experienced
Therapeutic
- Make a contract
with the patient
- Create a quiet
and comfortable room
Education
- Recommend
listening to soft music or music you like
- Encourage
prayer, dhikr, reading the holy book, worship according to the religion adhered
to
- Suggest doing
calming techniques until the feeling calms down.
Activity therapy
I.05186
Definition
Using certain
physical, cognitive, social, and spiritual activities to restore engagement,
frequency, or duration of individual or group activity.
Action
Observation
- Identification
of activity level deficit
- Identify the
ability to participate in certain activities
- Identify
resources for the desired activity
- Identify
strategies to increase participation in activities
- Identify the
meaning of routine activities (eg work) and free time
- Monitor
emotional, physical, social, and spiritual responses to activities
Therapeutic
- facilities focus
on ability, not a natural deficit
- agreed on a
commitment to increase the frequency and range of activities
- facilitation of
choosing activities and setting consistent activity goals according to
physical, psychological and social abilities
- coordinating the
selection of activities according to age
- facilitate the
meaning of the selected activity
- transportation
facilities to attend activities, if appropriate
- patient and
family facilities in adjusting the environment to coordinate the selected
activities
- facilities for
routine physical activity (eg ambulation, mobilization and self-care) as needed
- substitute
activity facilities when experiencing limited time, energy or motion
- gross motor
activity facilities for hyperactive patients
- increase
physical activity to maintain weight, if appropriate
- facilities for
motor activity to relax muscles
- facility
activities with implicit and emotional memory components (eg special religious
activities) for dementia patients, where appropriate.
- Engage in
non-competitive, structured and active group play
- Facilities for
developing self-motivation and strengthening
- Patient and
family facilities monitor their own progress towards achieving goals
- Schedule
activities in daily routine
- Provide positive
reinforcement for participation in activities
Education
- Explain the
method of daily activities, if necessary
- Teach how to do
the chosen activity
- Encourage
physical, social, spiritual and cognitive activities to maintain function and
health
- Encourage
involvement in group activities or therapy, if appropriate
- Encourage
families to provide positive reinforcement for participation in activities
Collaboration
- Collaboration
with occupational therapists in planning and monitoring activity programs where
appropriate
- Refer to
community activity centers or programs, if necessary
Acupressure
therapy I.06209
Definition
Using pressure
techniques on specific points to reduce pain, promote relaxation, prevent or
reduce nausea.
Action
Observation
- Check for
contraindications (eg contusions, abdominal tissue, infection, heart disease
and young children)
- Check
psychological comfort level by touch
- Check sensitive
places for finger pressure
- Identify the
results you want to achieve
Therapeutic
- Determine
acupuncture points, according to the results achieved
- Pay attention to
verbal or nonverbal cues to determine the desired location
- Stimulate
acupressure points with fingers or thumbs with adequate pressure force
- Press your
finger or wrist to reduce nausea
- Press the tense
muscle until it relaxes or the pain decreases, about 15-20 seconds
- Apply pressure
to both extremities
- Do acupressure
every day for the first week to treat pain
- Referred to
tailoring therapy to etiology, location, and symptoms, if necessary
Education
- Advise to relax
- Teach family or
loved ones to do acupressure independently
Collaboration
- Collaboration
with certified therapists
-
Acupuncture
therapy I.06210
Definition
Using the needle
insertion method at certain precise points on the body surface
Action
Observation
- Check medical
history and physical assessment as needed
- Check the risk
of acupuncture
Therapeutic
- Observe patient
safety procedures (hand washing, skin preparation, work environment
preparation, equipment preparation, needle expiration, waste management, blood
management)
- Give the
appropriate position and open the area to be treated, as needed
- Determine
acupuncture points
- Perform
acupuncture as indicated (location, size, needle, number of needles used)
- Manage the side
effects of acupuncture (eg pain, hematoma, fainting, broken needles, bent,
stuck, infection)
Education
- Explain
acupuncture procedures, indications, contraindications, and possible side
effects
Collaboration
- Collaboration
with certified therapists
Animal assisted
therapy I.09317
Definition
Using animals to
simulate health restoration, distraction and relaxation.
Action
Observation
- Identification
of patient acceptance of animals as agents
- Identification
of allergies in animals
- Do a physical
examination
Therapeutic
- Set standards
for screening, training and care of animals in therapy programs, if necessary
- Follow the
regulations of the health department regarding the use of animals as
therapeutic agents
- Develop protocol
guidelines outlining the response to trauma or injury from contact with animals
- Prepare animals
(eg dog, cat, horse, snake, turtle, rabbit, experiment, bird)
- Facilities for
patients to hold, pet, watch and express emotions to animals
- Motivation to
play with therapy
- Motivation to
feed or care for animals
- Provide
opportunities to reminisce and share experiences of caring for other
pets/animals
Education
- Explain the
purpose and reasons for owning an animal
Cupping therapy
I.02085
Definition
Using the skin
suction method with negative pressure on certain parts to remove toxins or
oxides in the body.
Action
Observation
- Check medical
history
- Identification
of contraindications to cupping therapy (eg consumption of blood retailers
[inspiration, aspirin]
- Do a physical
examination
Therapeutic
- Determine the
freezing point
- Determine the
type of cupping that will be done (eg dry or wet cupping)
- Make the patient
as comfortable as possible
- Undress in the
area to be cupped
- Put on gloves
and other personal protective equipment
- Disinfect the
area to be cupped with an alcohol swab or alcohol swab
- Rub the skin
with herbal oil to increase blood circulation (eg olive oil)
- Do the shovel
with enough pull
- Make an incision
on the area that has been dry cupping
- Do the shoveling
again after the cut
- Perform cupping
for no more than 5 minutes to avoid tissue hypoxia
- Open the hood
and clean the collected blood
- Clean the area
where the cupping has been done
- Avoid cupping in
the eye area, nose, mouth areola mammae, genitals, near large blood vessels,
varicose veins and wound tissue.
- Perform
sterilization on cupping tools that have been used
Education
- Explain the
purpose and procedure of cupping therapy
- Advise fasting
before cupping, if necessary
- It is
recommended not to take a bath 2-3 hours after cupping
Storytelling therapy
I.10345
Definition
Using narrative
stories such as fairy tales, myths, legends with certain improvisations to
remedy physical and psychological problems
Action
Observation
- Identify the
child's readiness
- Identify
children's interest in stories
- Identify the
theme you like
- Identify the
child's expressions and responses
Therapeutic
- Provide a
comfortable environment
- Establish
intimacy with children and family
- Start telling
stories from simple things to complex things
- Focus on the
child
- Ask the child
for feedback
- Provide positive
reinforcement feedback
- Document the
process and therapy
Education
- Explain the
purpose of the reaction
Play therapy
I.10346
Definition
Using toys or
media to facilitate children in communicating perceptions.
Action
Observation
- Identify the
child's feelings expressed during play
- Monitor the use
of children's play equipment
- Monitor the
child's response to therapy
- Monitor the
child's anxiety level during therapy
Therapeutic
- Create a
comfortable and safe environment
- Allow sufficient
time to allow effective play sessions
- Arrange playing
sessions to facilitate the desired result
- Set limits for
training sessionsTherapeutic
- Provide safe,
appropriate creative, efficient play equipment, equipment that stimulates child
development, which can encourage the expression of children's knowledge and
feelings
- Motivate
children to share feelings, knowledge, and perceptions
- Communicate
acceptance of feelings, both positive and negative, expressed through play
- Continue regular
play sessions to build trust and reduce fear of unfamiliar equipment or
maintenance
- Document
observations made during play sessions
Education
- Explain the
purpose of playing for children and parents
- Explain playing procedures
to children and parents in easy-to-understand language
Biofeedback
therapy I.09318
Definition
Facilitates
self-control of physiological responses by using a biofeedback monitor.
Action
Observation
- Check medical
history
- Identify
abilities and abilities to use biofeedback treatments
- Identification
of receptivity to therapy
- Identification
of the biofeedback device to be used (eg thermal feedback: electrodermal or
galvanic skin response, electromyographic feedback, respiratory biofeedback,
electroencephalographic biofeedback)
- Identify
specific health conditions that require therapy
Therapeutic
- Arrange the
therapy room so that the patient does not touch any conductive marks
- Install
instrument devices as needed
- Set baseline
physiological response threshold to compare therapeutic effects
- Operate the
biofeedback device
- Facilitate
learning to modify the body's response to cues on the monitor
- Provide progress
feedback after each therapy session
Education
- Explain the
procedure for using the device
- Explain the
purpose of using feedback
- Inform the time,
frequency, duration and place, therapy with patients/families
- Teach to check
the instrument is functioning properly before use
- Inform the
results of therapy to strengthen the response to therapy
Diversional
therapy
Definition
Use leisure or
recreational activities to promote feelings of well-being.
Action
Observation
- Identification
of readiness and ability to receive information
- Identify hobbies
and usual activities
Therapeutic
- Provide health
education materials and media
- Schedule health
education as agreed
- Give opportunity
to ask questions
Education
- Suggest to
prepare a quiet and comfortable room
- Recommend
running hobbies and activities you usually do
- Recommend
watching television, reading books, and other entertainment
- Advise to do
activities that can reduce attention (eg dhikr, worship, singing in groups,
simple games playing card puzzles)
Hypnosis Therapy
I.09320
Definition
Facilitates the
attainment of full concentration to create changes in sensations, thoughts, or
behavior.
Action
Observation
- Identify the
history of problems experienced
- Identify the
purpose of the hypnosis technique
- Identify
acceptance to use hypnosis
Therapeutic
- Create a
trusting relationship.
- Provide a
comfortable, quiet and distraction-free environment.
- Sitting language
that is easy to understand.
- Target
effectively.
- Facilitate
identifying appropriate hypnosis techniques (eg hand to face movements,
escalation techniques, fractionation).
- Avoid guessing
what they are thinking.
- Facilitate the
use of all senses during the therapy process.
- Give positive
feedback after each sessionEducation.
- Encourage deep
breaths to intensify relaxation.
Humor Therapy
I.09321
Definition
Use humor to make
it easier to build relationships, reduce tension and anger, or deal with
feelings of witnessing.
Family Therapy
I.09322
Definition
Using family
members to move the family to a more productive way of life.
Action
Observation
- Identification
of family health history.
- Identification
of family communication patterns.
- Identify ways
families solve problems.
- Identification
of decision making in the family.
- Identify the
occurrence of abuse in the family.
- Identification
of family strengths/resources.
- Identify the
role of each family member in the family system.
- Identification
of specification breakdowns related to role expectations.
- Identification
of substance abuse in family members.
- Identification
of intermediaries in the family.
- Identification
of dissatisfaction and/or conflict occurs.
- Identify current
or future events that threaten the family.
- Identification
of needs and expectations in the family.
- Monitor adverse
response to therapy.
Therapeutic
- Facilitate
family strategy.
- Facilitate
strategies to reduce stress.
- Facilitate
family systems strategy, if appropriate.
- Discuss the best
ways to deal with behavioral dysfunction in the family.
- Discuss family
boundaries.
- Discuss
constructive problem solving strategies.
- Discuss the
treatment plan with the family.
- Discuss ways to
cultivate new behaviors.
- Plan a strategy
to stop therapy.
Education
- Recommendations
to communicate more effectively.
- Suggestions for
members to prioritize and choose family problems.
- Suggestion that
all family members participate in household chores together (eg eating
together).
- Suggestions for
changing the way you relate to other family members.
Therapeutic
- Set normal
environment (eg using clock, calendar, fumitur).
- Facilitate open
communication between patients, nurses, and other staff.
- Involve in
decisions about self-care.
- Write down
behavioral expectations and agreements, if appropriate.
- Support formal
and informal group activities to improve sharing, cooperation, compromise, and
leadership skills.
- Ensure staff
fulfill appointments and monitor patients.
- Minimize
restrictions that reduce privacy or self-control (autonomy).
- Facilitation of
using the telephone.
- Provide a
comfortable environment for visits by family and other friends.
- Provide books,
magazines, arts, and crafts according to background, cultural recreation and
education needs.
- Limit the number
of psychotic patients who have not been treated during control.
Education
- Advise to use
own objects
Collaboration
- Coordinate
reduction or adjustment of drug dose, as indicated
Murattal Therapy
I.08249
Definition
Using the media of
the Koran (either by listening or reading) to help increase specific growth in
the body both physiologically and psychologically.
Action
Observation
- Identify aspects
to be changed or maintained (eg attitude, physiological, psychological)
- Identify aspects
to be focused on in therapy (eg stimulation, relaxation, concentration, pain
reduction)
- Identify the
type of therapy used based on the patient's condition and ability (listening or
reading the Qur'an)
- Identify the
media used (eg speakers, earphones, cellphones)
- Identify the
duration and duration of administration according to the patient's condition.
- Monitor focused
changes.
Therapeutic
- Position in a
comfortable position and environment.
- Limit external
stimuli during therapy (eg lights, sounds, visitors, telephone calls)
- Make sure the
volume used in accordance with the wishes of the patient.
- Play preset
recordings.
- Accompany during
reading the Qur'an, if necessary.
Education
- Explain the
purpose and benefits of therapy.
Behavioral
Cognitive Therapy I.09323
Definition
Using techniques
of thinking, feeling and behaving about an event to restore self-awareness.
Action
Observation
- Identify a
thorough diagnostic history
- Identification
of symptoms, environmental, cultural, biological factors that influence.
- Identify
problems that cause distorted thoughts and negative perceptions.
- Identify
underlying assumptions, beliefs or schemas of thought patterns and distorted
thoughts.
- Identify
alternative methods of solving problems (eg mind correction process)
- Monitor
abilities that have been trained.
Therapeutic
- Create
relationshipsTherapeuticand effective
collaborative (patient-nurse).
- Analysis of
experienced thought distortion (eg labeling, overgeneralization,
personalization).
- Make monitoring
observations of thoughts and behavior.
- Make activity
assignments at home in the therapy process.
- Turn mistaken
thoughts into systematic.
- Make report
cards / daily activity notes and share.
- Provide positive
reinforcement of the abilities you have.
Education
- Describe the
problem experienced (eg anxiety, trauma syndrome)
- Describe the
strategies and processes of behavioral thought therapy.
- Discuss the
wrong thoughts experienced.
- Discuss
self-monitoring in understanding the condition during therapy.
- Discuss the
daily activity plan related to the therapy given.
- Practice
relaxation techniques (eg breathing, progressive muscle training).
- Practice mind
restructuring with the ABC method (Actual, Belief, Consequence) by countering /
fighting wrong thinking patterns.
- Practice mind
restructuring with the ABCD method (disputing, effects)
- Practice
individual coping skills.
- Practice using
the principle of FEAR (Feling frightened, expecting bad things to happen,
attitude, and action, result and reward) at the age of children.
Collaboration
- Collaboration in
the provision of therapy (eg psychopharmaceuticals, ECT)
Leech Therapy
I.02087
Definition
Using leeches to
remove excess implanted tissue that mixes with venous blood.
Action
Observation
- Monitor daily
hemoglobin and hematocrit levels, if necessary.
- Monitor the size
of the leech until it enlarges (10-25 minutes) until it comes off on its own
Therapeutic
- Use universal
precautions.
- Use leech
therapy in areas with adequate arterial blood flow.
- Use leeches for
one patient only.
- Clean the bite
marks with a sterile cloth and dry.
- Limit the
location with a cloth or towel so the leeches don't move.
- Apply 5%
dextrose at the site of therapy.
- Place the leech
carefully with tweezers.
- Ensure that the
anterior and posterior ends are attached to the treatment area
- Remove leeches
that do not fall with alcohol.
- Clean the
therapy area with hydrogen peroxide and sterile water every 1-2 hours.
Education
- Inform the leech
to issue a local anesthetic.
- Inform the
action does not require local anesthesia, because the implanted tissue has few
active nerves.
- Inform that the
leech secretes hirudin, an anticoagulant, so that blood will flow from the
wound up to 50 ml for 24 to 48 hours after the leech is removed
- Inform that
leeches are therapeutic.
- Advise not to
touch or release the leech manually.
Collaboration
- Collaboration of
antibiotics, if necessary.
Action
Observation
- Identify the
type of humor desired.
- Identify the
patient's typical response to humor (eg laughing or smiling)
- Identify
situations and conditions for using humor.
- Monitor response
and discontinue humor strategies if ineffective.
Therapeutic
- Avoid sensitive
content
- Show an attitude
of respect for the humor that is done.
- Respond
positively to humor efforts made.
Education
- Discuss the
advantages of laughing.
- Recommend using
humor therapy media (eg funny games, cartoons, jokes, videos, tapes, books)
Intravenous
Therapy l.02086
Definition
Administer and
monitor fluids and/or drugs intravenously.
Action
Observation
- Identification
of indications for intravenous therapy.
- Check the type,
amount, expiration date, type of solution, and damage to the container.
- Check IV patency
before administering drugs or fluids.
- Monitor IV flow
and catheter insertion site during therapy.
- Monitor for
signs and symptoms of fluid overload.
- Monitor
potassium values below 200 mEq/24 hours in adults.
- Monitor for
signs and symptoms of local infectious fleebitis
Therapeutic
- Maintain aseptic
technique.
- Do the five
right before giving fluids or drugs (drug, dose, patient, route, and time.)
- Give via
induction pump, if necessary
- Give fluids at
room temperature, unless there are other indications.
- Give drugs
through IV, infusion tube and other equipment every 48-72 hours.
- Perform
treatment of the IV catheter insertion area.
- Perform hose
rinsing after administration of concentrated solution.
- Document the
therapy given.
Education
- Explain the
purpose and steps of the procedure.
Group Therapy
l.13500
Definition
Use groups with
similar problems to provide emotional and behavioral support, practice new
behaviors, and share health information.
Action
Observation
- Identify the
group's topics, goals and processes.
- Monitor the
active involvement of each group member.
Therapeutic
- Form groups of 5
to 12 members.
- Determine a
suitable time and place for group meetings.
- Create a
comfortable atmosphere.
- Use a written
contract, if necessary.
- Create a
motivational climate for the group process.
- Start and end
activities on time.
- Adjust the seat
according to the method used.
- Agree on group
norms.
- Provide
appropriate directions and information.
- Avoid
unproductive group interactions.
- Guide the group
through the stages of group development.
- Direct group
members to be actively involved.
Education
- Encourage a
variety of feelings, knowledge, and experiences.
- Encourage mutual
help in groups.
- Practice
responsibility and self-control in groups.
Collaboration
- Refer to another
specialist nurse,
- Anjur decides
attention / thoughts on the chanting of the verses of the Qur''an.
Music Therapy
l.08250
Definition
Using music to
help change behavior, feelings, or body physiology.
Action
Observation
- Identification
of growth or physiology to be achieved (eg relaxation, stimulation,
concentration, pain relief)
- Identification
of interest in music.
- Identify the
music you like.
Therapeutic
- Choose the music
you like.
- Position in a
comfortable position.
- Limit external
stimuli during therapy (eg lights, visitor sounds, telephone calls)
- Provide music
therapy equipment
- Adjust sound
volume accordingly.indication
- Give music
therapy as indicated.
- Avoid giving
music therapy for a long time.
- Avoid giving
music therapy during acute head injury.
Education
- Explain the
goals and procedures of music therapy.
- Advise relax
while listening to music.
Oxygen Therapy
Definition
Provide
supplemental oxygen to prevent and treat tissue oxygen deprivation conditions.
Swallowing Therapy
l.03144
Definition
Restore the
ability to swallow to prevent complications due to swallowing disorders.
Action
Observation
- Monitor for
signs and symptoms of aspiration.
- Monitor tongue
movement when eating, drinking
- Monitor for
signs of fatigue when eating, drinking, and swallowing
Therapeutic
- Provide a
comfortable environment.
- Maintain patient
privacy.
- Use assistive
devices, if necessary.
- Avoid using
straws.
- Sit down.
- Give lollipops
to increase tongue power.
- Facilitate
placing food behind the mouth.
- Provide oral
care, as needed.
Education
- Inform the
benefits of swallowing therapy to patients and families.
- Encourage
opening and closing the mouth when giving food.
- Advise not to
talk while eating.
Collaboration
- Collaboration
with other health professionals in providing therapy (eg occupational
therapists, speech pathologists, and nutritionists) in managing the patient's
rehabilitation program.
Mileu Therapy
l.09324
Definition
Using people,
resources, and/or events in the immediate environment to improve or optimize
psychosocial functioning.
Action
Observation
- Identify the
contribution of environmental factors to behavior.
- Identify the
needs of others other than the patient's needs.
- Identify the
resources needed to fulfill self-care.
- Monitor behavior
that may annoy or harm others.
Action
Observation
Oxygen Flow Rate
Monitor
Monitor the
Position of Oxygen Therapy Equipment
-Monitor the flow
of oxygen periodically and make sure the given fraction is sufficient
-Monitor the
effectiveness of oxygen therapy (eg, oximetry, blood gas analysis) if necessary
-Monitor the
ability to release oxygen while eating
-Monitor for signs
of hypoventilation
-Monitor signs and
symptoms of oxygen toxicity and atelectasis
-Monitor the level
of anxiety due to oxygen therapy
-Monitor Nasal Mucosal
Integrity Due to Oxygen Installation
Therapeutic
-Clean the
secretions in the mouth, nose, and trachea, if necessary
-Maintain patent
airway
-Prepare and Set
Up Oxygen Delivery Equipment
-Give Additional
Oxygen If Needed
-Keep giving
oxygen while the patient is being transported
-Use the
appropriate oxygen device according to the patient's level of mobility
Education
--Teach Patients
And Families How To Use Oxygen At Home
Collaboration
-CollaborationDetermination of Oxygen
Dosage
-CollaborationThe use of oxygen during
activity and or sleep
Heat Exposure
Therapy
Definition
Stimulates the
skin and underlying tissue with heat to reduce pain and other discomfort.
Action
Observation
-Identification of
Contradictory Use of Therapy (eg Decreased or Absent Sensation, Decreased
Circulation)
-Therapeutic
Device Temperature Monitor
-Monitor skin
condition during therapy
-Monitor general
condition, comfort and safety during therapy
-Monitor the
patient's response to therapy
Therapeutic
-Choose a
stimulation method that is comfortable and easy to obtain (eg, hot water
bottle, electric heat pillow, paraffin wax, lamp)
-Choose an
appropriate stimulation location
-Wrap the Therapy
Tool Using a Cloth
-Use a damp cloth
around the therapy area
-Determine the
duration of therapy according to the patient's response
-Avoid doing
therapy in areas receiving radiation therapy
Education
-Teach How to
Prevent Network Damage
-Teach how to
adjust the temperature independently
Smoking Cessation
Therapy
Definition
Using nicotine
substances and psychosocial interventions for smoking cessation.
Action
Observation
-Identify Current
Smoking Status And Smoking History
-Identify Reasons
to Quit Smoking
-Identification of
readiness to quit smoking
-Identify Changes
in Psychosocial Aspects (eg Positive and Negative Feelings of Smoking) That
Affect Smoking Behavior
--Monitor For 2
Years After Quitting If Possible
Therapeutic
-Reassure if the
withdrawal symptoms of nicotine are temporary
-Motivation to
determine the date of quitting smoking
-Facilitate
Choosing the Best Method To Quit Smoking
-Manage Nicotine
Stopping Therapy
-Make a note about
the causes and effects of smoking
-Facilitation in
developing a smoking cessation plan related to psychosocial aspects that
influence smoking behavior
-Facilitation to
develop practical methods for resisting the urge to smoke (eg, making friends
with friends who don't smoke, smoking less frequently, relaxation exercises)
-Use Non-Smoking
Role Models
-Provide Positive
Reinforcement To Maintain A Smoke-Free Lifestyle (E.g. Celebrating Quit Smoking
Day, Reward Yourself After Being Smoking-Free At 1 Week, 1 Month, 6 Months;
Save Money That Usually To Buy Cigarettes And Buy A Special Gift For himself)
-Promote a
Smoke-Free Environmental Policy
-Involve in a quit
smoking support group
Education
-Explain the
Benefits of Quitting Smoking Consistently
-Describe the
physical symptoms of nicotine withdrawal (eg Headache, Dizziness, Nausea,
Irritability and Insomnia)
-Explain the
Self-Help Method to Quit Smoking
-Describe the
Specific Management Strategy Plan and Overcome Problems Due to Quitting Smoking
-Teach to
recognize signs of recurrence of the desire to smoke (eg, being around other
people who smoke, often visiting smoking areas)
-Teach How to
Overcome Failure (eg Convince Not "Failure", But Learning And
Identifying Relapses)
-Information of
Nicotine Substitutes(Ex. Nicotine Patches,Chewing Gum,Nose Sprays,Inhalers)
-Inform that dry
mouth, cough, itchy throat, and feeling of tightness are symptoms that may
occur after quitting smoking
-Use Nicotine
Patches Or Chewing Gum
-Recommend Trying
to Quit Smoking, If Relapse
Collaboration
-Refer to group
programs or individual therapists, if appropriate
-Refer to National
And Local Organizational Resources For Smoking Quitting Support
Massage Therapy
Definition
Provides Skin And
Tissue Stimulation With Various Movement Techniques And Hand Pressure To
Relieve Pain, Promote Relaxation, Improve Circulation, And / Or Stimulate
Growth And Development In Babies And Children.
Action
Observation
-Identification of
contradictions in massage therapy (eg, decreased platelet count, impaired skin
integrity, deep vein thrombosis, lesion area, redness or inflammation, tumors,
and hypersensitivity to touch)
-Identification of
Willingness and Acceptance of Massage
-Monitor Response
to Massage
Therapeutic
-Set Time Period
For Massage
-Select the area
of the body to be massaged
-Wash Hands With
Warm Water
-Prepare a Warm,
Comfortable and Privacy Environment
-Open the area to
be massaged as needed
-Cover areas that
are not exposed (e.g. with blankets, sheets, bath towels)
-Use Lotion Or Oil
To Reduce Friction (Note The Contradictions Of Using Certain Lotions Or Oils
For Each Individual)
-Do the massage
slowly
-Do a massage with
the right technique
Education
-Explain the
purpose and procedure of therapy
-Advise Relax
During Massage
-Recommend resting
after massage
Substance Abuse
Therapy (Substance Detoxification)
Definition
Using Medical And
PsychotherapyTherapeuticFor Treatment of
Dysfunction Due to Substance Abuse or Addiction.
Action
Observation
-Check Substance
Use During Medication(E.g. Urine Skinning And Breath Analysis)
-Check for
communicable diseases (eg HIV/AIDS, hepatitis B and C and tuberculosis), refer
if any
-Identify and
treat family or social relationship dysfunction (eg dependence on others,
disability)
Therapeutic
-Build a Trusting
Relationship
-Perform Symptom
Management During the Detoxification Period
-Consider the
presence of comorbidities, or psychiatric disorders or medical comorbidities
-Involve in
psychotherapy as indicated (eg, cognitive therapy, motivational therapy, counseling,
family support, family therapy, or group support)
-Facilitate
Resocialization and Rebuilding Relationships
-Facilitate
Developing Self-Esteem (eg Reinforcing Positive Efforts)
-Involve the
family in planning and treatment activities (eg, Drug Addicts/Drug Users
Rehabilitation Group, BNN Rehabilitation Program)
Education
-Describe symptoms
or behaviors that may increase the likelihood of relapse (eg, fatigue,
depression, lying)
-Describe the
effects of the substances used (eg, physical, psychological, and social)
-Explain the
importance of not using substances
-Discuss Relapse
Prevention Plans (E.g. Create Behavior Contracts, Identify Resources for Coping
With Stressful Situations)
-Advise Accepting
Responsibility or Dysfunction and Handling Related to Drug Use
-Encourage
Families to Participate in Recovery Efforts
-Advise Evaluating
Substance Use Progress By Making Personal Notes
-Advise stress
management (eg exercise, meditation and relaxation therapy)
-Teach Family
About Substance Use Disorders And Associated Dysfunctions
Collaboration
-CollaborationAdministration of Drug
Substances (eg Disulfiram, Amprospic Acid, Methadone, Naltrexone, Nicotine
Patches Or Chewing Gum Or Buprenorphine) As Indicated
-Coordinate And
Facilitate Group Confrontation Strategies To Cope With Substance Use And
Defense In Substance Drug Use
-Refer to
multidisciplinary programs (e.g. Shelters, Detoxification Programs, or
Community Care) if appropriate
Recreational
Therapy
Definition
Using Recreation
To Improve Relaxation And Social Skills
no
Observation
-Check for a
Mobility Deficit
-Check Physical
And Mental Ability To Participate In Recreational Activities
-Identify the
Meaning of Recreational Activities
-Identify the
goals of recreational activities (eg reduce anxiety and stimulate development)
-Examine
Emotional, Physical, And Social Responses To Recreational Activities
Therapeutic
-Involve in
Recreational Activity Planning
-Choose
recreational activities according to physical, psychological, and social
abilities
-Plan Recreational
Activities According to Age and Ability (eg Happy Shopping, Beach Visits,
Plantations)
-Facilitation of
Required Resources for Recreational Activities
-Provide Safe
Recreation Equipment
-Transportation to
Recreational Facilities
-Preparation of
Safety Risk Precautions
-Give Supervision
of Recreational Sessions, If Appropriate
-Give Positive
Reinforcement to Active Participation in Activities
Education
-Explain the
purpose and procedure of therapy
-Explain the
Benefits of Stimulation Through Sensory Modalities in Recreation
Relaxation Therapy
Definition
Using stretching
techniques to reduce signs and symptoms of discomfort such as pain, muscle
tension, or anxiety
Action
Observation
-Identify
Decreased Energy Levels, Inability to Concentrate, Or Other Symptoms That
Impair Cognitive Ability
-Identify
Relaxation Techniques That Have Been Effectively Used
-Identify
Willingness, Ability, and Use of Prior Techniques
-Check muscle
tension, pulse rate, blood pressure, and temperature before and after exercise
-Monitor Response
to Relaxation Therapy
Therapeutic
-Create a quiet
and undisturbed environment with comfortable lighting and room temperature, if
possible
-Provide Written
Information About Preparation and Relaxation Technique Procedures
-Use Loose Clothes
-Use Soft Voice
Tone With Slow And Rhythmic Rhythm
-Use relaxation as
a supporting strategy with analgesics or other medical measures, if appropriate
Education
-Describe the
goals, benefits, limitations and types of relaxation available (eg music,
meditation, deep breathing, progressive muscle relaxation)
-Describe in
detail the chosen relaxation intervention
-Recommend taking
a comfortable position
-Advise relax and
feel the sensation of relaxation
-Recommend often
repeating or practicing the chosen technique
-Demonstrate and
Practice Relaxation Techniques (E.g. Deep Breathing, Stretching, Or Guided
Imagination)
Progressive Muscle
Relaxation Therapy
Definition
Uses Muscle
Tension And Stretching Techniques To Relieve Muscle Tension, Anxiety, Pain And
Improve Comfort, Concentration And Wellness
Action
Observation
-Identify a quiet
and comfortable place
-Monitor regularly
to ensure muscles relax
-Monitor for
indicators of non-relaxation (eg presence of movement, heavy breathing)
Therapeutic
-set the
environment so that there is no interference during therapy
-provide a
reclined position in a chair or other comfortable position
-stop relaxation
session gradually
-give time to
express feelings about therapy
Education
-Recommend wearing
comfortable clothes that are not cramped
-Recommend doing
jaw muscle relaxation
- Suggest to tense
the muscles for 5 to 10 seconds, then recommend relaxing the muscles for 10-20
seconds, 8 to 16 times each.
-Recommend tensing
the leg muscles for no more than 5 seconds to avoid cramps
-Advise focus on
the sensation of muscle tension
-Advise focus on
relaxed muscle sensations
-Encourage deep
and slow breathing
-Advise practice
between regular sessions with nurses
Remedial Therapy
Definition
Using adjustment
of children's learning and therapy techniques based on the style and interests
of children who have difficulty in mastering optimal thinking skills and basic
cognitive abilities
Action
Observation
- Identification
of Specific Learning Problems (eg Reading Difficulties, Sequence Disorders,
Letter Perception)
-Identify
Abilities and Disabilities/Difficulties Experiencing (eg Cognitive Abilities,
Gross Motor, Fine Motor, Language And Communication, Social Interaction,
Self-Ability, Vision, Hearing, And Oral Muscles)
-Identify Academic
And Non-Academic Needs
Therapeutic
-Plan The Method
To Use By Combining Visual Stimulus And Learning Methods Using Aids As Teaching
Media (eg Cards, Arranging Objects Based on Color and Size, Arranging Blocks)
-Prepare Learning
Aids (eg Pictures, Posters, Balls, Toy Blocks)
-Give the Lesson
Questions That Have Been Given)
-Convey the
material for easy understanding
-Summary of
lessons that have been given together with students/students
-Give Assignments
To Evaluate
-Assign One Task
At A Time Use Communication Methods That Stimulate The Senses (Ex. Typing)
-Create Structured
Routines That Kids Can Complete
-Avoid focusing on
what you can't do, but on what you can do
Education
-Explain the
purpose and procedure of remedial therapy
-Advise to avoid
always following the child's wishes
-Advise Avoid
Multitasking
Reminiscent
Therapy
Definition
Using The Ability
To Recall Past Events, Feelings, And Thoughts To Facilitate Relaxation, Quality
Of Life, Or Adaptation To Current Circumstances.
Action
Observation
- Identify
Meaningful Memories Through Body Language, Facial Expressions, And Tone of Voice
Identify Themes For Each Session (E.g. Work Routines)
-Identify the
Right Number of Participants for Reminiscens Therapy in Groups
Therapeutic
-Use comfortable
clothes
-Limit the length
of the session according to your attention span, response and willingness to
continue
-Determine the
Most Effective Reminiscent Method (eg, Autobiography, Journal, Life Event
Review, Notes, Open Discussion, and Story Telling)
-Use Effective
Listening Techniques
-Use Visual Aids
(e.g. Music for Audio Stimulation, Photo Albums for Visual Stimulation, Perfume
For Olfactory Stimulation) To Facilitate Sensory Stimulation of Memories –
-Use direct and
open-ended questions about past events
-Use Photo Albums
To Stimulate Memories –
-Use Communication
Skills (e.g. Focusing, Reflecting, And Re-expressing, to develop relationships)
- Use direct
questions to refocus on life events, if necessary
-Keep focusing on
the process rather than the end product each session
-Provide support
and empathy for participants Facilitate to overcome bad, painful or negative
memories
- Facilitating the
family on the benefits of reminiscent therapy
-give immediate
positive feedback
-Give
reinforcement to previous coping skills
-Discuss the
affective qualities that accompany memories in an empathetic way
Education
-Encourage to
express positive and negative feelings towards memories verbally
- Suggest writing
past events
-Suggest writing a
letter to an old relative or friend
Methadone
Maintenance Therapy
Definition
Using methadone is
accompanied by psychosocial intervention for patients with opioid dependence
according to the diagnostic criteria of the III Multiple Classification
Guidelines for Diagnostic Mental Disorders (PPDGJ-III).
Action
Observation
-Do screening
according to inclusion criteria undergoing the Methadone Maintenance Therapy
Program (PTRM)
-Monitor for signs
of toxicity or withdrawal symptoms for 45 minutes after administration of the
initial dose –
-Monitor the dose
every day on a regular basis, according to indications
-Monitor social
influence in dose adjustment (eg behavioral and emotional stability)
-Do a
comprehensive re-screening if they express their desire to go back to PTRM
Therapeutic
-make decisions
for indications of MMT Plan therapy (initiation, stabilization and maintenance)
-Estimate the
appropriate drug dose for opiate addiction
-Do the
recommended initial dose, as indicated
-Give methadone in
liquid form and dilute it to 100cc with a syrup solution
- Ask to
immediately swallow methadone in front of the nurse
- Give me a glass
of water
- Make sure
methadone has been swallowed by asking to name or say something else
- Sign the
document having received the dose of methadone on that day
- Administer a
stabilizing dose, as indicated
- Perform
maintenance dosing, as indicated
- Discontinue
methadone as indicated (eg stable, at least 6 months heroin free, adequate life
support)
- Decrease
gradually with a maximum dose of 10% every 2 weeks.
- Make drop-out
decisions with the criteria of 7 consecutive days of stopping taking drugs
without information on whereabouts
- Conduct
counseling to minimize drop-out
Education
- Teach patients
and families about MMT
Collaboration
- Collaboration of
dose modification for subsequent administration if there is intoxication or
severe withdrawal symptoms
- Collaboration
with the medical team to assess dose increase/decrease at least once a week for
the first month, then at least every month
- Collaboration
with the medical team, if you are still using heroin to increase the dose
Using pictures or
other art forms to facilitate communication and/or healing.
Observation
- Identification
of art-based activity forms
- Identify the art
media to be used, (e.g. pictures [photos, human drawings, family pictures,
photo journals, media journals], graphics [time, body maps], artifacts [masks,
statues])
- Identify the
artwork
- Identify
self-concept through human images
- Monitor
engagement during the art creation process, including verbal and nonverbal
behavior
Therapeutic
- Provide art
equipment according to the level of development and therapeutic goals
- Provide a quiet
environment free of distractions
- Limit completion
time
- Record the patient's
interpretation of the drawing or artistic creation
- Copy/document
archival artwork, as needed
- Discuss the
meaning of the artwork created, combine patient assessment with literature
- Discuss progress
according to the level of development
- Avoid discussing
the meaning of the artwork before it's finished
Education
- Recommend
realistic or artistic drawing
- Suggest to
describe the process and results of making works of art
- Encourage using
paintings or drawings as a medium for telling stories about the effects of
stressors (eg divorce, abuse)
Collaboration
- Refer as
indicated (eg social worker, art therapy)
Using the hands on
the body or specific body parts to focus, direct, and modulate the energy field
in the healing effort.
Observation
- Identify the
desire to intervene
- Identify the
goal of the desired touch therapy
- Monitor
relaxation response and other expected changes
Therapeutic
- Create a
comfortable environment without distraction
- Position sitting
or supine comfortably
- Focus on inner
strength
- Focus on
intention to facilitate healing
- Think of the
patient as a unit and facilitate an open and balanced flow of patient energy
- Place palms
facing the patient 3 to 5 inches from the body
- Focus on intent
facilitates symmetry and healing in disturbed areas
- Move your hands
slowly and steadily as much as possible, from head to toe
- Very gentle
downward movement of the hand through the patient's energy field
- Pay attention to
the overall pattern of energy flow, especially the affected area, which may be
felt through the hands (eg changes in temperature, tingling, or other
sensations of subtle movement)
Education
-recommend resting
for 20 minutes or more after treatment
Recover physical
and psychological disorders that occur as a result of trauma to children
Observation
- Identify trauma
and its meaning in children
therapeutic
- Use
developmentally appropriate language to ask questions about taruma
- Use relaxation
and desensitization procedures to facilitate the child's depiction of events
- Disruption of
trust, security and the right to access with caution
- Use art and play
to support the expression of feelings
- Involve parents
or caregivers in therapy
- Facilitate
parents to cope with their own emotional stress on trauma
- Avoid involving
parents in dealing with their own emotional distress over the trauma
Education
- Explain the
purpose and procedure of therapy
- Describe the
child's response to trauma
Using
communication methodsTherapeuticby
focusing on emotional content.
Observation
- Identify stages
of cognitive impairment (eg malorientation, time confusion, repetition, or
vegetation)
- Monitor and
reflect gestures
Therapeutic
- Avoid using
validation strategies if confusion is caused by acute, reversible causes, or
vegetation stage
- Listen with
empathy
- Refrain from
correcting or contradicting the patient's perceptions and experiences
- Ask
non-threatening factual questions (eg who?, what?, when?, how?)
- Avoid asking
“why?”
- Repeat
questions, repeat key words, according to the tone of speech
- Maintain eye
contact
- Use supportive
touch (eg gentle touch to cheek, shoulder, arm or hand)
- Use the
patient's language and communication style (eg auditory, visual, kinesthetic)
- Engage in
activities as needed
Education
- Encourage
expressing emotions according to experience (eg love, fear, sadness)
- Recommend
singing and playing familiar music
- Encourage
reminiscing about previous events to identify coping methods that have been
used before
Installing a
tourniquet to minimize the potential for patient injury
Observation
- Identify the
integrity of the skin to which the tourniquet cuff will be applied
- Identify the
functions of regulators and measuring devices with calibration
- Identify the
size of the tourniquet that fits the extremity
- Tourniquet
pressure monitor
- Monitor
peripheral pulse
Therapeutic
- Protect skin and
cuff from liquid
- Set the
tourniquet pressure 50 mmHg higher than the systolic blood pressure in the
upper extremities, or as indicated
- Adjust
tourniquet pressure 100 mmHg higher than systolic blood pressure in the lower
extremities, or as indicated
- Apply pressure
for 60 minutes on the upper extremity, or as indicated
- Apply pressure
for 90 minutes on the lower extremities, or as indicated
- Allow 15 minutes
of deflation of the cuff
Education
- Advise to report
changes in sensation (eg tingling, numbness and cramping)
Provides
stimulation to the skin and underlying tissue with a controlled, low-voltage
electric current.
Observation
- Identify the
stimulation area
- Monitor skin
irritation at the electrode site every 12 hours
Therapeutic
- Make sure the
TENS equipment battery is full
- Avoid using TENS
in patients with pacemakers
- Use disposable
electrodes
- Attach the wires
to the electrodes and the TENS unit is connected properly
- Define and set
the amplitudeTherapeutic, rate and pulse
width
- Discontinue use
if it cannot be tolerated
- Customize the
place and location to achieve the desired response
Education
- Explain the TENS
procedure to the patient and family
- Inform the
sensation that will be felt when the TENS unit is activated
Patient Transfer
I.14587
Definition
Prepare and transfer
patients to other rooms (e.g. ward, ICU, operating room, diagnostic examination
room) effectively and safely
Action
Observation
- Check the
general condition of the patient
- Check the
readiness of the equipment to be used (eg oxygen, emergency kit)
- Inform the
designated room nurse via internal telephone that the patient is ready to be
delivered
- Monitor the
patient's condition during the transfer process
Therapeutic
- Complete the
transfer form
- Transfer the
patient to the designated room using an appropriate transfer device (eg safe,
wheelchair)
- Include
patient's nursing and medical records
- Perform
ventilation support (bagging) if the patient is using an ETT and is not
attached to a transport ventilator
- Transfer the
patient from the gurney/wheelchair to the bed in the designated room
- Perform the
handover of the patient with the designated room nurse
Education
- Explain the
patient's condition to the family
- Inform the
patient or family that they will be escorted to the room
Prepare and
administer blood or plasma products via a transfusion set.
Observation
- Identify the
transfusion plan
- Monitor vital
signs before, during and after transfusion (blood pressure, temperature, pulse
and respiratory rate)
- Monitor for
signs of fluid overload (eg, dyspnea, tachycardia, cyanosis, elevated blood
pressure, headache, convulsions)
- Monitor
transfusion reactions
Therapeutic
- Do a double
check on the blood label (blood type, rhesus, expiration date, serial number,
number, and patient identity)
- Install
intravenous access if not already installed
- Check the
patency of intravenous access, phlebitis and signs of local infection
- Give 0.9% NaCl
50-100 ml before transfusion is done
- Adjust the flow
rate of transfusion according to blood products 10-15 ml/KgBW in 2-4 hours
- Give a
transfusion within a maximum of 4 hours
- Stop the
transfusion if there is a transfusion reaction
- Document the
date, time, blood count, duration and transfusion response
Education
- Explain the
purpose and procedure of transfusion
- Describe the
signs and symptoms of a transfusion reaction that need to be reported (eg
itching, shortness of breath, dizziness, and/or chest pain)
Prioritize care
according to the level of emergency.
Observation
- Identify the
nature of the problem, circumstance or accident
- Identify
critical patients from the location first
- Identification
of injuries/injury
- Identify the
main complaint of the patient
- Identify the
patient's medical history
- Carry out
primary survey, if necessary
- Perform
secondary system survey of all body systems, if necessary
Therapeutic
- Prepare room and
equipment for triage
- Consider
available resources
- Call the right
officer
- Treat
life-threatening injuries
Establish pre- and
post-disaster patient care priorities for emergency care while allocating
needed resources.
Observation
- Identify the
nature of the problem, emergency, accident or disaster
- Identify
critical patients from the location first
- Identification
of injuries/injury
- Identify the
main complaint of the patient
- Identify the
patient's medical history
- Carry out
primary survey, if necessary
- Perform
secondary system survey of all body systems, if necessary
Therapeutic
- Prepare room and
equipment for triage
- Consider
available resources
- Call the right
officer
- Participate in
prioritizing patients for treatment
- Treat
life-threatening injuries
- Provide first
aid, if necessary
Determine the
nature and urgency of the problem and provide brief directions on required
treatment by telephone
Observation
- Ask the purpose
of the call (eg conditions, symptoms, medical conditions, past medical history,
and current medications)
- Ask about the
complaints/symptoms experienced
Therapeutic
- Introduce
yourself beforehand by stating your name, position and agency, mentioning the
call being recorded
- Show a desire to
help (eg How can I help?)
- Speak directly
to the patient, if possible
- Use standard
operating procedure guidelines in prioritizing problems
- Prioritize
problems based on the most threatening conditions
- Provide first
aid instructions or emergency instructions (eg CPR or delivery instructions),
according to standard operating procedures
- Provide clear
directions for transportation to hospital, if necessary
- Provide referral
and/or intervention options
- Document any
assessments, suggestions, instructions, or other information provided to the
patient, in accordance with standard operating procedures
Education
- Inform about
self-medicating and self-care agents
Carry out
laboratory tests at the patient's bedside
Observation
- Check reagent
expiration date
Therapeutic
- Practice
universal precautions
- Perform sampling
in accordance with standard operating procedures
- Perform bedside
specimen testing
- Make sure the
reagent has been calibrated
- Make sure the
checks are carried out in accordance with the right time
- Label the
specimens taken
- Store reagents
according to storage instructions
- Do documentation
of inspection results
- Report the
results of laboratory tests to other health workers, if necessary
Education
- Explain the
procedure to the patient and or family
- Inform the
patient of laboratory test results, if necessary
Yoga I.08253
Definition
Provides
stimulation to improve health, comfort and relaxation through a series of
breathing techniques and certain movements
Action
Observation
- Identify
tolerances for choices
- Identify types
of yoga exercises and movements, as needed
- Check vital
signs before and after exercise
Therapeutic
- Do yoga
movements (eg Bidalasana/cat stretch, janu sirsana, lying twist, nadi shodan)
- Set the
frequency of doing yoga, according to ability
Education
- Explain the
purpose and reasons for the exercise
- Recommend doing
yoga in groups of 5-8 people
- Demonstrate yoga
movements
CHAPTER V IDHS LINK –SIKI
Main Intervention
Anxiety Reduction
Relaxation Therapy
More Weight
Main Intervention
Nutrition Counseling Promotion of Physical Exercise
Weight Management
Mourn
Main Intervention
Grieving Process Support
Ineffective airway clearance
Main Intervention
Effective Cough Exercises Respiratory
Monitoring
Airway Management
Community Health Deficit
Main Intervention
Community Health Development Promotion of
Health Effort Behavior
Nutritional Deficit
Main Intervention
Weight Promotion Nutrition Management
Knowledge Deficit
Main Intervention
EducationHealth
Self Care Deficit
Main Intervention
Self Care Support Self Care Support: Dress
Self-Care Support: CHAPTER/BAB Self-Care
Support: Eating/Drinking
Self Care Support: Decorated Self Care
Support: Bath
Diarrhea
Main Intervention
Fluid Monitoring Diarrhea Management
Gastrointestinal Motility Dysfunction
Main Intervention
Infection Control Nutrition Management
Sexual Dysfunction
Main Intervention
EducationSexuality
Sexuality Counseling
Baby Behavior Disorganization
Main Intervention
Baby Care
Autonomic Dysrflexia
Main Intervention
Dysrflexia Management
Spiritual Distress
Main Intervention
Coping Promotion Spiritual Support
Body Image Disorder
Main Intervention
Body Image Promotion Coping Promotion
Urinary Elimination Disorder
Main Intervention
Self-Care Support: CHAPTER/BAB Urine
Elimination Management
Self-Identity Disorder
Main Intervention
Coping Promotion Reality Orientation
Self Awareness Promotion
Impaired Skin/Tissue Integrity
Main Intervention
Skin Integrity Treatment Wound Care
Social Interaction Disorder
Main Intervention
Behavior Modification Social Skills Promotion
Socialization
Verbal Communication Disorder
Main Intervention
Communication Promotion: Talking Deficit
Communication Promotion: Visual Deficit
Communication Promotion: Hearing Deficit
Memory Disorder
Main Intervention
Reality Oriented Memory Exercise
Swallowing disorders
Main intervention
Self-care support: eating/drinking aspiration
prevention
Impaired physical mobility
Main intervention
Ambulation support mobilization support
mobilization support
impaired physical mobility
Main intervention
Weaning of mechanical ventilation respiratory
monitoring
Sensory perception disorder
Main intervention
Chemical restraint hallucinations management
Minimize stimulation
Impaired gas exchange
Main intervention
Oxygen therapy respiration monitoring
Sleep disorder
Main intervention
Sleep supportEducationactivity/rest
Disruption of family processes
Main intervention
Family therapy family coping support
Promotion of effective family processes
Disturbance of comfort
Main intervention
Relaxation therapy pain management
Position setting
Spontaneous circulation disorders
Main intervention
Defibrillation management
cardiopulmonary resuscitation
Fluid resuscitation
Developmental disorders
Main intervention
Developmental care promotion of adolescent
development
Promotion of child development
Impaired spontaneous ventilation
Main intervention
Respiratory monitoring ventilation support
Chronic low self-esteem
Main intervention
Coping promotion behavior management
Self esteem promotion
Situational low self-esteem
Main intervention
Coping promotion behavior management
Self esteem promotion
hyperthermia
main intervention
temperature regulation hyperthermia
management
Hypervolemia
Main intervention
Management of hypervolemia fluid monitoring
hypothermia
Main intervention
Heat exposure therapy hypothermia management
Hypovolemia
Main intervention
Management of hypovolemia management of
hypovolemic shock
Neonatal jaundice
Main intervention
Neonatal phototherapy baby care
Fecal incontinence
Main intervention
Fecal elimination exercises for fecal
incontinence treatment
Urinary incontinence persists
Main intervention
Urinary catheterization for urinary
incontinence
Excessive Urinary Incontinence
Main Intervention
Urine Catheterization Treatment Medication
Functional Urinary Incontinence
Main Intervention
Urine Catheterization Treatment Medication
Reflex urinary incontinence
Main Intervention
Urine Catheterization Urine Incontinence
Treatment
Stress Urinary Incontinence
Main Intervention
Pelvic Muscle Exercise Urine Incontinence
Treatment
Urgency Urinary Incontinence
Main Intervention
Urinary Incontinence Treatment
Activity Intolerance
Main Intervention
Activity Therapy Energy Management
Social isolation
Main Intervention
Activity Therapy Socialization Promotion
Fatigue
Main Intervention
EducationEnergy
Management Activities / Rest
Despair
Main Intervention
Emotional Support
Hope Promotion
Coping Promotion
Readiness to Increase Urine Elimination
Main Intervention
Urine Elimination Management
Self Care Support : BAB/BAK
Treatment Program Compliance Support
EducationToilet
Training
Pelvic Muscle Exercises
Fluid Management
Medication Management
Uterine Prolapse Management
Fluid Monitoring
Urine Catheter Treatment
Urine Elimination Promotion
Self-Esteem Promotion
Self Awareness Promotion
Readiness Improved Fluid Balance
Main Intervention
Fluid Management Fluid Monitoring
Readiness Improved Fluid Balance
Main Intervention
Self-Esteem Promotion
Self Awareness Promotion Coping Promotion
Readiness to Improve Family Coping
Main Intervention
Family Coping Support
Family Engagement
Coping Promotion
Community Coping Enhancement Readiness
Main Intervention
Support Support Group Promotion Support
System
Readiness to Improve Health Management
Main Intervention
Anticipatory Guidance
EducationHealth
EducationDisease
Risk Identification
Behavior Management
Joint Goal Setting
Increased Readiness to Be a Parent
Main Intervention
Family Anticipation Promotion
Parenting Promotion
Increased Readiness to Be a Parent
Main Intervention
EducationNutrition
Nutrition Counseling
Readiness to Increase Knowledge
Main Intervention
EducationHealth
Information Reception Readiness Promotion
Readiness to Improve Family Process
Main Intervention
Family Supplies Promotion
Family Effective Process Promotion
Improved Sleep Readiness
Main Intervention
Sleep Support
EducationActivity / Rest
Childbirth Readiness
Main Intervention
EducationLabor
EducationLabor
Comfort Care
Childbirth Care
High Risk Maternity Care
Pre-C-section Care Exclusive Breastfeeding
Promotion
Lactation Promotion
Adhesion Promotion
Skin to Skin Engineering Promotion
Fetal Resuscitation
The Tensions of the Caregiver Role
Main Intervention
EducationOn
Nanny
Parenting Promotion
helplessness
Main Intervention
Hope Promotion
Coping Promotion
Family Coping Disability
Main Intervention
Family Coping Support
Coping Promotion
Post Partum Discomfort
Main Intervention
Pain Management
Relaxation Therapy
Acute Confusion
Main Intervention
• Delirium Management
• Hallucinations Management
• Substance Abuse Management
Chronic Confusion
Main Intervention
Delirium Management
Dementia Management
Validation Therapy
Constipation
Main Intervention
Fecal Elimination Management
Constipation Management
Defensive Coping
Main Intervention
Self-Esteem Promotion
Self Awareness Promotion
Coping Promotion
Ineffective Community Coping
Main Intervention
EducationHealth
Community Environmental Management
Community Health Development
Ineffective Coping
Main Intervention
Decision Making Support
Role Appearance Support
Coping Promotion
Ineffective Family Health Management
Main Intervention
Family Coping Support
Family Support Planning Care
Family Discussion Coordination
Family Assistance
Ineffective Health Management
Main Intervention
Decision Making Support
Self-responsibility Support
EducationHealth
Family Engagement
Effective Breastfeeding
Main Intervention
Lactation Counseling
Exclusive Breastfeeding Promotion
Lactation Promotion
Ineffective Breastfeeding
Main Intervention
EducationBreast-feed
Lactation Counseling
Nausea
Main Intervention
Nausea Management
Vomiting Management
Acute Pain
Main Intervention
Pain Management
Analgesic Administration
Chronic Pain
Main Intervention
Pain Management
Comfort Care
Relaxation Therapy
Childbirth Pain
Main Intervention
Pain Management
Position Setting
Relaxation Therapy
Obesity
Main Intervention
EducationEffective
Weight
Weight Management
Ineffective Health Care
Main Intervention
EducationHealth
Positive Behavior Contract
Joint Goal Setting
Health Effort Behavior Promotion
Ineffective Role Appearance
Main Intervention
Role Appearance Support
Achieving the Role of Being a Parent
Main Intervention
Family Anticipation Promotion
Parenting Promotion
Decreased Cardiac Output
Main Intervention
Acute Cardiac Care
Decreased Intracranial Adaptive Capacity
Main Intervention
Management of Increased Intracranial Pressure
Intracranial Pressure Monitoring
Decrease in Family Coping
Main Intervention
Family Coping Support Coping Promotion
Disclaimer Ineffective
Main Intervention
Self Awareness Promotion Coping Promotion
Ineffective Peripheral Perfusion
Main Intervention
Preferred Sensation Management Circulation
Treatment
Violent Behavior
Main Intervention
Environmental Safety Management Angry Control
Management
Behavior Management Mood Management
Health Behaviors Tend to be Risky
Main Intervention
Behavior Modification Health Effort Behavior
Promotion
Postoperative Recovery Delay
Main Intervention
Pain Management Self Care Support
Wound Care Nutritional Management
Ineffective Breathing Pattern
Main Intervention
Airway Management Respiration Monitoring
Ineffective Sexual Pattern
Main Intervention
EducationSexuality
Sexuality Counseling
Urine Retention
Main Intervention
Urine Catheterization
Allergy Risk
Main Intervention
EducationAllergic
Reactions Allergy Prevention
Aspiration Risk
Main Intervention
Aspiration Prevention Airway Management
Risk of Overweight
Main Intervention
EducationNutrition
Counseling Diet
Suicide Risk
Main Intervention
Suicide Prevention Mood Management
Injury Risk
Main Intervention
Environmental Safety Management Injury
Prevention
Risk of Injury to Mother
Main Intervention
Injury Prevention High Risk Pregnancy Care
High Risk Maternity Care
Risk of Injury to the Fetus
Main Intervention
Fetal Heart Rate Monitoring Fetal Movement
Measurement
Injury Prevention
Risk of Nutritional Deficit
Main Intervention
Eating Disorder Management Nutrition
Management
Gastrointestinal Motility Dysfunction Risk
Main Intervention
EducationInfection
Control Diet
Peripheral Neurovascular Dysfunction Risk
Main Intervention
Peripheral Sensation Management Positioning
Risk of Sexual Dysfunction
Main Intervention
EducationSexuality
Sexuality Counseling
Baby Behavioral Disorganization Risk
Main Intervention
EducationBaby
Safety Baby Care
Spiritual Distress Risk
Main Intervention
Spiritual Development Support Promotion
Spiritual Support
Risk of Impaired Skin/Tissue Integrity
Main Intervention
Skin Integrity Care
Developmental Disorder Risk
Main Intervention
Promotion of Child Development Promotion of
Youth Development
Risk of Attachment Disorder
Main Intervention
Family Integrity Promotion Attachment
Promotion
Risk of Growth Disturbance
Main Intervention
Nutrition Management Health Screening
Risk of Impaired Spontaneous Circulation
Main Intervention
First Aid Acute Cardiac Care
Risk of Chronic Low Self-Esteem
Main Intervention
Promotion of Self-Esteem Promotion of
Socialization
Coping Promotion
Situational Low Self-Esteem Risk
Main Intervention
Support Appearance Role Self Awareness
Promotion
Self-Esteem Promotion Coping Promotion
Hypothermia Risk
Main Intervention
Management of Hypothermia Temperature
Regulation
Perioperative Hypothermia Risk
Main Intervention
Management of Hypothermia Invasive
Hemodynamic Monitoring
Risk of Hypovolemia
Main Intervention
Management of Hypovolemia Fluid Monitoring
Neonatal Jaundice Risk
Main Intervention
Baby Care Neonatal Care
Infection Risk
Main Intervention
Immunization/Vaccination Management Infection
Prevention
Urinary Urinary Incontinence Risk
Main Intervention
Urine Elimination Management
Activity Intolerance Risk
Main Intervention
Energy Management Physical Exercise Promotion
Fall Risk
Main Intervention
Fall Prevention Environmental Safety
Management
Risk of Unwanted Pregnancy
Main Intervention
EducationFamily
Planning Unwanted Pregnancy Management
Powerlessness Risk
Main Intervention
Hope Promotion Coping Promotion
Risk of Fluid Imbalance
Main Intervention
Fluid Management Fluid Monitoring
Risk of Electrolyte Imbalance
Main Intervention
Electrolyte Monitoring
Risk of instability of Blood Glucose Level
Main Intervention
Management of Hyperglycemia Management of Hypoglycemia
Bleeding Risk
Main Intervention
Bleeding Prevention
Risk of Ineffective Gastrointestinal
Perfusion
Main Intervention
Prevention of Bleeding Nutrition Counseling
Risk of Ineffective Myocardial Perfusion
Main Intervention
Emboli Prevention Arrhythmia Management
Cardiogenic Shock Management Cardiac Care
Risk of Ineffective Peripheral Perfusion
Main Intervention
Shock Prevention Circulation Treatment
Risk of Ineffective Renal Perfusion
Main Intervention
Prevention of Shock Control of Bleeding
Risk of Ineffective Cerebral Perfusion
Main Intervention
Management of Increased Intracranial Pressure
Intracranial Pressure Monitoring
Risk of Violent Behavior
Main Intervention
Prevention of Violent Behavior Coping
Promotion
Risk of Delayed Postoperative Recovery
Main Intervention
Nutrition Management Mobilization Support
EducationBleeding
Prevention Pain Management
EducationNutrition
Risk of Ineffective Parenting Process
Main Intervention
Family Wholeness Promotion Attachment
Promotion
Shock Risk
Main Intervention
Fluid Monitoring Shock Prevention
Risk of Ineffective Thermoregulation
Main Intervention
EducationBody
Temperature MeasurementEducationthermoregulation
Post Traumatic Syndrome
Main Intervention
Anxiety Reduction Grieving Process Support
Ineffective Thermoregulation
Main Intervention
Temperature Regulation
delusion
Main Intervention
Management of Reality Oriented Delusions
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