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