E
Risk for Electrolyte Imbalance
Risk Factors
Diarrhea; endocrine dysfunction; fluid imbalance (e.g., dehydration, water intoxication); impaired regulatory mechanisms (e.g., diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone); renal dysfunction; treatment-related side effects (e.g., medications, drains); vomiting
Client Outcomes
Client Will (Specify Time Frame)
• Maintain a normal sinus heart rhythm with a regular rate
• Maintain an absence of muscle cramping
• Maintain normal serum potassium, sodium, calcium, and phosphorus
Nursing Interventions
Monitor vital signs at least three times a day, or more frequently as needed. Notify provider of significant deviation from baseline.
Monitor cardiac rate and rhythm. Report changes to provider.
• Monitor intake and output and daily weights.
• Monitor for abdominal distention and discomfort.
• Monitor the client’s respiratory status and muscle strength.
• Assess cardiac status and neurological alterations.
Review laboratory data as ordered and report deviations to provider.
• Review the client’s medical and surgical history for possible causes of altered electrolytes.
Complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Notify the provider for any increase in pain or discomfort or if comfort measures are not effective.
Monitor the effects of ordered medications such as diuretics and heart medications.
Administer parenteral fluids as ordered and monitor their effects.
Client/Family Teaching and Discharge Planning
• Teach client/family the signs of low potassium and the risk factors.
• Teach client/family signs of high potassium and the risk factors.
• Teach client/family the signs of low sodium and the risk factors.
• Teach client/family the signs of high sodium and the risk factors.
• Teach client/family the importance of hydration during exercise.
• Teach client/family the warning signs of dehydration.
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of.
Instruct the client to report any adverse medication side effects to his/her provider.
Disturbed Energy Field
Disruption of the flow of energy surrounding a person’s being results in disharmony of the body, mind, and/or spirit
Defining Characteristics
Perceptions of changes in patterns of energy flow around the body, such as movement (i.e., tingling, wave, spike, bulge) or lack of movement (i.e., congestion, density, hole, diminished flow); sounds (i.e., tone, words); temperature change (i.e., warmth, coolness); and/or visual changes (i.e., image, color)
Related Factors (r/t)
Client Outcomes
Client Will (Specify Time Frame)
• State increased ability to cope
• Demonstrate evidence of physical relaxation (e.g., decreased blood pressure, pulse, respiration rate, muscle tension)
Nursing Interventions
• Consider using Therapeutic Touch (TT) and/or Healing Touch (HT) for clients with anxiety, tension, pain, or other conditions that indicate a disruption in the flow of energy.
• Consider HT treatments for clients with psychological depression.
• Administer TT and/or HT as described in the following discussion (may also include Reiki practice).
• Refer to care plans for Anxiety, Acute Pain, and Chronic Pain.
Guidelines for Therapeutic Touch and Healing Touch
• TT and HT may be practiced by anyone with the requisite preparation, desire, and commitment.
• Those who are not licensed health care professionals may practice TT and HT within their families, religious or spiritual community, and with friends.
• NOTE: Nurses who are not trained in TT or HT should consider spending quiet time with clients listening to their concerns.
• TT is conducted according to the standards for its practice.
• HT is conducted according to the code of ethics and standards of practice developed by Healing Touch International, Inc.
• Administer TT and HT according to the guidelines established by the prospective therapies and programs.
• Assess for the influence of cultural beliefs, norms, and values on the client’s sense of disharmony of mind and spirit.
• Assess for the presence of specific culture-bound syndromes that may manifest as disturbances in energy or spirit.
• Validate the client’s feelings and concerns related to sense of disharmony or energy disturbance.
• See Guidelines for TT and HT.
• Help the client and family accept TT and HT as healing interventions.
• Assist the family with providing an appropriate space in which TT and/or HT can be administered.
Consider complementary therapies such as Therapeutic Touch for clients in community mental health programs.
In the presence of a psychiatric disorder, refer for psychiatric home health care services for client reassurance and implementation of therapeutic regimen.
Client/Family Teaching and Discharge Planning
• Teach the TT and/or specific HT technique to clients and family members.
• Teach that when working with the very young, old, or ill, or in the head area, TT should be gentle and used only for short periods.
• Teach the client how to use guided imagery.
• Consider the use of progressive muscle relaxation, autogenic training, relaxation response, biofeedback, emotional freedom technique, guided imagery, diaphragmatic breathing, transcendental meditation, cognitive-behavioral therapy, mindfulness-based stress reduction, and emotional freedom technique.
Impaired Environmental Interpretation Syndrome
Consistent lack of orientation to person, place, time, or circumstances over more than 3 to 6 months, necessitating a protective environment
Risk for dry Eye
At risk for eye discomfort or damage to the cornea and conjunctiva due to reduced quantity or quality of tears to moisten the eye
Risk Factors
Aging; autoimmune diseases (rheumatoid arthritis, diabetes mellitus, thyroid disease, gout, osteoporosis, etc.); contact lenses; environmental factors (air conditioning, excessive wind, sunlight exposure, air pollution, low humidity); female gender; history of allergy; hormones; lifestyle (e.g., smoking, caffeine use, prolonged reading); mechanical ventilation therapy; neurological lesions with sensory or motor reflex loss (lagophthalmos, lack of spontaneous blink reflex due to decreased consciousness and other medical conditions); ocular surface damage; place of living; treatment-related side effects (e.g., pharmaceutical agents such as angiotensin-converting enzyme inhibitors, antihistamines, diuretics, steroids, antidepressants, tranquilizers, analgesics, sedatives, neuromuscular blockage agents; surgical operations); vitamin A deficiency
Client Outcomes
Client Will (Specify Time Frame)
• Experience comfort of the eyes without itching or burning of the eyes, and a feeling of dryness
• Demonstrate how to place drops in the eyes if drops are ordered
Nursing Interventions
• Watch for symptoms of dry eyes, which include blurring of vision, heaviness of eyelids, irritation and gritty sensation, light sensitivity, pain, decreased vision, redness of eyes, reflex tears, stinging and ocular discomfort.
If symptoms are present, refer client to an ophthalmologist for diagnosis and treatment.
Apply warm compresses over the closed eyes if ordered.
• Review medications that the client is taking for possible initiation of dry eye.
Watch for symptoms of blepharitis including crusting and irritation at the base of the lashes and adjacent redness of the eyelid which may accompany dry eye and refer for treatment as needed.
Client/Family Teaching and Discharge Planning
• Teach clients that the following activities such as watching television, computer use, and driving are associated with decreased blinking that can cause dry eye.
• Teach clients methods to decrease problems with dry eye including the following:
Avoiding spending long periods of time in dry and windy or hot dry weather
Avoiding spending time in air-conditioned rooms or smoky environments
Protecting eyes from wind and dust
Teach client to consult with physician regarding use of omega-3 supplements to decrease dry eye.
• Teach client using eye drops how to self-administer eye drops, and to keep drops in the refrigerator.
• Warn clients with dry eyes that driving at night can be dangerous.