Textbook of Medical-Surgical Nursing 3e

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Chapter 2   Thoughtful practice

Plan of Nurs ing Care Example of an individualised plan of nursing care

CHART 2-8

Mr John Lee, a 50-year-old management consultant, was admitted to the nursing unit from his doctor’s office. A routine physical examination 3 months previously had revealed essential hypertension with BP 170/110 and decreased urine creatinine clearance. During the subsequent 3 months the blood pressure elevation did not respond to diet therapy. Mr Lee admitted that he had not been successful in adhering to the low-sodium, low-cholesterol weight-reduction diet that had been prescribed for him. He stated, ‘My life is just too busy—I work all hours of the day and night.’ He indicated that in addition to his work he and his wife share the responsibility for raising their two teenage daughters. He drinks five to seven cups of coffee daily and drinks alcohol only at social occasions. Admission physical examination revealed BP 194/112, P 96, R 20, T 37 8 C, height 175 cm, weight 95 kg, and slight oedema of the ankles and feet. Mr Lee stated that his feet are ‘always puffy at night.’ There were several darkened areas (2 cm in diameter) on the anterior lower legs bilaterally. A brief hospitalisation was planned for thorough evaluation and initiation of therapy. The doctor’s orders on admission included activity as desired; Lasix, 40 mg bd; monitor vital signs every 4 hours while awake; and 6,300 kJ, 1 g sodium, low-cholesterol diet. nursing diagnosis : Ineffective health maintenance related to hypertension, stress, obesity, and caffeine intake Ineffective coping related to role responsibilities at work and home Non-compliance with dietary regime related to knowledge deficit and lifestyle

collaborative problems : Ischaemic ulcers of lower legs goals : Immediate: Gradual decrease in blood pressure Intermediate: Initiation of lifestyle alterations to decrease stress Long-term: Alteration of lifestyle to reduce emotional and environmental stressors

Compliance with dietary regime Absence of ischaemic leg ulcers

Nursing interventions 1. Monitor BP lying, sitting, and standing every 4 h

Expected outcomes Experiences no further increase in BP

Outcomes BP range of 162/112–138/98 since admission No variation greater than 5 mm Hg in systolic or diastolic pressures with postural changes No variation between right and left arms Maximum BP from 24 h after admission to time of discharge: 138/98 Intake: 1850 mL Output: 1685 mL Minimal oedema of feet late in evening Rests in bed 1 h in morning and 2 h in afternoon; disconnects telephone during rest periods Awake at intervals during night: 8 h of uninterrupted sleep at night after ­initiation of 20 mg Temazepam at bedtime Wife and daughters visit 2 h in evening: patient calm and relaxed after visits Wife and daughters aware of need to decrease stress: they consult with patient about regular family activities Accurately described relationship between stress and hypertension

2. Monitor fluid status: a. FBC b. Peripheral oedema 3. Promote atmosphere conducive to physical and mental rest: a. Encourage alternation of rest and activity

Urinary output adequate in relation to oral intake No evidence of peripheral oedema

Alternates periods of rest and activity

b. Encourage limitation of visitors and interactions that are stress- producing

Limits visitors to family in the evenings

Avoids stress-producing interactions

4. Assist patient to identify barriers to behaviour changes and to develop strategies to alter lifestyle to decrease stress: a. Discuss relationship between emotional stress and physiological functioning b. Encourage patient to identify stress- producing stimuli

Describes stress as a precursor to alteration in physiological functioning

Identifies lifestyle factors that produce stress

Identified the following stressors: Self-imposed demands of job; unwillingness to refer clients

Identifies lifestyle adjustments necessary to reduce stress

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