Palawan State University

College of Nursing and Health Sciences

Health Assessment Tool - Adult
Related Learning Experience

Student Name__LIANA S. CERVANTES___ Date__OCT.17,2019___

Area/ Ward___EMERGENCY ROOM____

Client Initial P.S Age73 Y/O DOB_06-48-51_ Gender F Upper Quadrants

WT_45 KILOS_ HT_150 cm_ Admission Date_Oct.16,2019_ Description_Radiating Pain_
Allergies_NONE_ Medicated? YES: Metoclopramide
Admission Diagnosis / Current Diagnosis
UPPER GASTRO INTESTINAL BLEEDING (UGIB)
Growth and (Actual Stage)
Development LATE ADULTHOOD/MATURITY:
Assessment Time: Ego Integrity vs. Despair
Date: 8:00 A.M-10:00 AM Patient_ 73 years old - Ego Integrity vs.
OCT.17,2019 Despair _

Vital Signs T 35.6 Celsius Alteration in Present

HR 83 bmp (Thready pulse) S/P/C R/T_Gastrointestinal/Abdominal Pain/
RR 15 cpm (On Assisted Ventilation Discomfort
Endotracheal Intubation) Cellular Integrity Cool , Cold and Dry
BP 60 PALPATORY
Skin T: 35.6 Celsius
Temperature
Sensory/ Awake, confused and weak
Perception/ Color/ Turgor Pale & Tenting
Cognition
Edema None
Mood Anxious

Behavior Cooperative but Lethargic Mucus Pale & Dry

Speech/ Primary BEFORE ENDO. INTUBATION: 8: 00 Membranes (-) Lesions
Language A.M Rash / Lesion / None
(+)Dysarthria but Appropriate Wound
(+)impaired hearing
Primary Language:_Cebuano_ Alteration in None
Present Skin Integrity
Related to:
* Dyspnea
Oxygenation BEFORE ENDO.INTUBATION: 8: 00 A.M
*Altered perceptions
(+) dyspneic , Nasal flaring, Grunting &
* Sensory challenge involving hearing
Respiratory Irregular
or vision
Effort DURING INTUBATION:
Regular with RR or !5cpm/minute
Pupils (L) mm :N/A
Lung Sounds Decreased
Post-op due to Glaucoma & Cataract
Diminished Vesicular Lung sound
(R) 4mm & Nonreactive O2 therapy/ O2 O2 therapy:
saturation Endotracheal Intubation with
Pain BEFORE ENDO.INTUBATION: 8: 00
Mechanical/Assited Ventilation via Bag
A.M
Valve Mask
Score_10 _
LPM: 4 Liters Per Minute
Location Abdomenal Area: Both L & R

`PALAWAN STATE UNIVERSITY

 O2 Sat 95% (PNSS/ Normal Saline) 1L
@200ml/hour 5gtts/min
Cough/ Non-productive
Respiratory Treatments_O2 Therapy_ *5% Dextrose in Lactated Ringer’s
Treatments Solution (D5LR) 250 cc + 2ampules
Impaired Gas Present R/T: Dopamine
Exchange *Blood Loss @30gtts/min
*Low levels of hemoglobin
*Pain *5% Dextrose in Lactated Ringer’s
Oxygen_4LPM Bag Valve Mask__ Solution (D5LR) 250 cc + 2ampules
Nor-epinephrine @15gtts/min
Cardiovascular: Irregular, Very Weak, thready Pulse
APICAL *8:00 AM HR: 112bpm
*8:02 AM HR: 135 bpm Elimination (+) IFC with Urine output of 50cc
*9:00 AM HR: 83 bpm *Tea-colored Indwelling Foley Catheter
Output.
Extremities:
Capillary Refill R/L brachial > 5seconds
R/L radial > 5seconds Mobility Impaired Mobility
R/L dorsalis pedis > 5seconds
R/L posterior tibial > 5seconds Muscle tone and strength (+) weakness & limitations
Monitors O2 saturation 95% Gait, fall risk During Admission:
Assisted Ventilator via BVM Nonambulatory: Confined
to Bed Bed
*Transferred at Medical Ward:
Alarm parameters are verified and ON
*Prior To admission:
Tissue Perfusion Present R/T: Ambulatory with Full Range
*Hypoventilation of Motion but unsteady
*Hypovolemia (According to SO)

Functional ability During Admission:

Total assistance
Abdomen / LBM
DIET: N/A Firm, Rigid, Flat, (+) Tenderness *PTA: Independent
BM: Continent
Casts / Assistance devices Cane
Bowel sounds (+) RLQ (+) RUQ (+) LUQ (+) LLQ
Alteration in Mobility Present R/T:
+hyperactive
*Pain
NGT (+)Nasogastric Tube (Open to Drain) *Total Body Weakness
*Dark Read /tea-colored NGT Output

Nutrition Parenteral Nutrition Student Nurse Signature over Printed Name.

Present R/T:
*Inability to absorb or metabolize
foods
*Inability to digest foods
LIANA S. CERVANTES
*Inability to ingest foods
*Unwillingness to eat

GU Indwelling Foley Catheter

IVF *0.9% Sodium Chloride Solution

`PALAWAN STATE UNIVERSITY

STATE AND PRIORITIZE THREE (3) NURSING DIAGNOSES

1. Impaired Gas Exchange related to low level of Hemoglobin or blood loss secondary to Upper Gastrointestinal Bleeding
2. Deficient Fluid Volume may be related to Active fluid volume loss secondary to Upper Gastrointestinal Bleeding.
3. Decreased Cardiac Output related to Alterations in heart rate and rhythm and Late uncompensated hypovolemic shock
secondary to UGIB.

NURSES NOTES:

9:50 AM for Endotracheal Intubation BP: 60 Palpatory .

HR: 83 bpm (Thready Pulse) .
RR: on Assisted Ventilation Endotracheal Intubation
GCS 10(E4V2M4) .

D- Relatives consented for Endotracheal Intubation

A-Informed Dr.J; Materials Prepared; Written Consent secured for intubation; IFC (Indwelling Foley Catheter) & NGT (Nasogastric
Tube) Insertion attended; Assistive Bag-Valve Endotracheal Ventilation device; Carry-out Doctor’s Orders; For Follow -Up Blood
@ Lab; NGT inserted & open to drain dark red in color NGT Output ; tea-colored Indwelling Foley Catheter Output .

R- Endorsed with patient linen; GCS 8 (E4V1M3); On continuous Bag-Valve Endotracheal Ventilation with O2 at
15cpm; with Nasogastric Tube (NGT) open to drain -Dark Red in color; with Indwelling Foley Catheter with urine bag
with output at 50cc.

LABORATORY WORKS AND DIAGNOSTIC TESTS

TEST RESULTS NORMAL DATES REASON WHY TEST WAS ORDERED

VALUES FOR YOUR CLIENT

Complete Blood
HEMATOLOG Count: Date Received: Patient has chief complaints of He
Y OCT.17,2019 12:16 Hemopthesis with fever that is why pla
Hemoglobin 92 g/L 120-160 AM Hematology was ordered in order tha
Hematocrit 26.0 36-57 to find out if the cause is a blood- pro
Date Reported: related disorder or any infection nu
Red Blood Cells 2.7 4.0-5.5 OCT.17,2019 12:35 issues. Ou
AM The Hematology Result can also sho
MCV 95.9 RNP show how much blood components com
Date Printed: do the patient still has and how Ha
MCH 33.6 RNP
OCT.17,2019 12:35 much was already lost. en

`PALAWAN STATE UNIVERSITY

 MCHC 35.0 RNP AM tre
for
RDW-3D 49.2 RNP

RDW-CV 14.1 RNP

Platelet Count 14 150-450

WBC 11.8 5.0-10.0

Differential
Count:

Segmenters 66.3 50-70

Lymphocytes 26.0 25-40

Monocytes 4.7 3-6

Eosinophils 0.7 2-4

Basophils 0.3 0-1

Miscellaneous:

77.0
RBS

Blood Typing “B” Rh (D) +

LABORATORY WORKS AND DIAGNOSTIC TESTS

REASON WHY TEST WAS ORDERED FOR

TEST RESULTS DIAGNOSIS DATES YOUR CLIENT

(ECG) HR: 135 bpm Sinus Tachy Date Received: Patient has a very weak radial pulsation
ElectroCardioGra OCT.17,2019 8:02 AM tachycardiac heart rate with a 60 Palpato
m P: 77ms Abnormal Q wave BP that is why ECG was performed in ord
(I,III, aV1,V1) Date Reported: to check and record the electrical activity
PR: 141 ms OCT.17,2019 8:02 AM the client’s heart rhythm, to see if client s
Inferior Myocardial has poor blood flow to her heart mus
QRS: 90 ms Infarction Date Printed: known as ischemia and diagnose a he
OCT.17,2019 8:02 AM attack.
QT/QTC: 289/434 ms Low Voltage ECG was also used to
(Limb Lead) check on things that are abnormal with t
P/QRST/T: 71/84/72 client, such as thickened heart muscle a
significant electrolyte abnormalities l
RV5/SVI : high potassium or high or low calcium.
0.253/0.209 mV

`PALAWAN STATE UNIVERSITY

 TEST RESULTS NORMAL DATES REASON WHY TEST WAS ORDERED FOR YOUR CLIENT N
VALUES

URINALYSIS None Yet None Yet Requested A urinalysis is a test of the client’s urine. A urinalysis is used to Urinal
On: detect and manage a wide range of disorders, such as urinary tract importa
Oct.17.2019 infections, kidney disease and diabetes. liver func
order t
A urinalysis involves checking the appearance, concentration and render ca
content of urine. Abnormal urinalysis results may point to a disease
or illness.

TEST RESULTS NORMAL DATES REASON WHY TEST WAS NURSING SIGNIFIC
VALUES ORDERED FOR YOUR CLIENT

FECALYSIS None Yet None Yet Requested Fecalysis is used in diagnosing Fecalysis helps nurses initiate a plan of care
On: disorders related to patient’s from such blood problems. This test also he
Oct.17.2019 Upper gastrointestinal (GI) Watch Out For and Evaluate the effectiven
bleeding or medication therapy intestinal malabsorption or pancreatic insuffi
that results in bleeding.

MEDICATION SHEET

DATE: October 17,2018 STUDENT: Liana S. Cervantes

PATIENT NAME: Client PS ALLERGIES: None

CLIENT
DOSE/
SPECIFIC MAJOR SIDE DRUG/DRUG OR DRUG/ DIET
DRUG NAMES MECHANISM OF ACTION ROUTE/
INDICATIONS EFFECTS AND CONTRADICT
SAFE
DOSAGE

BRAND: It is used to An immediate precursor of 250/200 mL Cardiovascular: DRUG INTERACTIONS:

INTROPIN, DOPASTAT, treat heart norepinephrine, dopamine @15cc/hr Ventricular Tricyclic antidepressants may p
REVIMINE failure (weak stimulates dopaminergic, arrhythmia, atrial pressor response to adrenergic
heart). beta-adrenergic, and 30gtts/min fibrillation (at effects of dopamine are antago
GENERIC: It is used to alpha-adrenergic very high doses), adrenergic blocking agents, suc
DOPAMINE treat low receptors of the ectopic beats, and metroprolol.
blood sympathetic nervous tachycardia,
CLASSIFICATION: pressure. system. The main effects anginal pain, CONTRAINDICATIONS:
Pharmacologic produced are dose- palpitation, Hypersensitivity to dopamine,
classification: dependent. It has a direct cardiac pheochromocytoma, ventricula
ADRENERGIC stimulating effect on beta1 conduction uncorrected tachyarrhythmias
receptors (in I.V. doses of abnormalities,
Therapeutic 2 to 10 mcg/ kg/minute) widened QRS
classification: and little or no effect on complex,
VASOPRESSOR, beta2 receptors. In I.V. bradycardia,
INOTROPIC DRUG doses of 0.5 to 2 hypotension,
mcg/kg/minute it acts on hypertension,

`PALAWAN STATE UNIVERSITY

 dopaminergic receptors, vasoconstriction
Pregnancy risk causing vasodilation in the
category C renal, mesenteric, Respiratory:
coronary, and Dyspnea
intracerebral vascular
beds; in I.V. doses of more Gastrointestinal:
than 10 mcg/kg/minute, it Nausea, vomiting
stimulates alpha
receptors. Metabolic/nutriti
Low to moderate doses onal: Azotemia
result in cardiac
stimulation (positive Central nervous
inotropic effects) and system:
renal and mesenteric Headache,
vasodilation anxiety
(dopaminergic response).
High doses result in Endocrine:
increased peripheral Piloerection
resistance and renal
vasoconstriction. Ocular: Increased
intraocular
pressure; dilated
pupils

Gangrene of
extremities has
occurred when
high doses were
administered for
prolonged
periods or in
patients with
occlusive vascular
disease receiving
low doses of
dopamine
hydrochloride

BRAND: DRUG INTERACTIONS:

LEVOPHED Produces •Stimulates alpha – IVF Infusion •Anxiety,
vasoconstricti adrenergic receptors 15-20gtts dizziness, •Use with cyclopropane or halo
GENERIC: on and located mainly in blood headache, anesthesia, cardiac glycosides,
myocardial vessels, causing *0.5 – 1 mcg insomnia, local use of cocaine may result
NOREPINEPHRINE stimulation, constriction of both initially, restlessness, myocardial irritation ability
which may be capacitance and resistance followed by tremor, weakness •Use wit MAO inhibitors, meth
CLASSIFICATION: required after vessels maintenanc •Dyspnea doxapram or tricyclic antidepre
VASOPRESSOR adequate fluid •Also has minor beta – e infusion of •Arrhythmias, result in severe hypertension
replacement adrenergic activity - 12 bradycardia, •Alpha- adrenergic blockers an
in the (myocardial simulation) mcg/min chest pain response
treatment of •Therapeutic Effects: titrated by hypertension •Beta blockers my exaggerate h
severe Increased BP. Increased BP response •Decreased urine block cardiac stimulation
hypotension cardiac output. output, renal •Concurrent use with ergot alk
and shock. failure (ergotamine, ergonovine, meth
•Hyperglycemia oxytocin) may result in enhance
•Metabolic vasoconstriction and hypertens
acidosis
•Phlebitis at IV CONTRAINDICATIONS:
site

`PALAWAN STATE UNIVERSITY

 •Fever Vascular, mesenteric or periphe
Hypoxia, Hypercabia, Hypotens
hypovolemia (without appropr
replacement), Hypersensitivity

DRUG INTERACTIONS:
BRAND: Short-term Gastric acid-pump 40mg TID Diarrhea, nausea, Omeprazole potentially can inc
PRILOSEC treatment of inhibitor: Suppresses q12H fatigue, concentrations in blood of diaz
active gastric acid secretion by constipation, warfarin (Coumadin), andphen
GENERIC: duodenal specific inhibition of the vomiting, by decreasing the elimination o
OMEPRAZOLE ulcer; First- hydrogen-potassium ATP flatulence, acid the liver. The absorption of cer
line therapy in as enzyme system at the regurgitation, be affected by stomach acidity.
CLASSIFICATION: treatment of secretory surface of the taste perversion, omeprazole as well as other PP
PROTON PUMP heartburn or gastric parietal cells; arthralgia, absorption and concentration i
INHIBITORS (PPI) symptoms of blocks the final step of myalgia, urticaria, ketoconazole (Nizoral) and incr
gastroesophag acid production. dry mouth, absorption and concentration i
eal reflux dizziness, digoxin (Lanoxin). This may red
disease headache, effectiveness of ketoconazole o
(GERD); Short- paraesthesia, digoxin toxicity
term abdominal pain,
treatment of skin rashes, CONTRAINDICATIONS:
active benign weakness, back Contraindicated with
gastric ulcer; pain, upper hypersensitivity to omeprazole
GERD, severe respiratory components;Use cautiously wit
erosive infection, cough. pregnancy,lactation.
esophagitis,
poorly Potentially Fatal:
responsive Anaphylaxis
symptomatic
GERD;

Long-term
therapy:
Treatment of
pathologic
hypersecretor
y conditions
(Zollinger-
Ellison
syndrome,
multiple
adenomas,
systemic
mastocytosis);
Eradication of
H. pylori
With
amoxicillin or
metronidazole
.

BRAND: General: Tranexamic acid Tablet: CNS: Dizziness DRUG INTERACTIONS:

CYKLOKAPRON, Treatment of competitively inhibits 500mg drug-drug: concurrent use of cl
HEMOSTAN, LYSTEDA excessive activation of plasminogen EENT: Visual complexes may ↑ the risk of th
bleeding (via binding to the kringle abnormalities complications (give tranexamic
GENERIC: resulting from domain), thereby reducing following clotting factor replace
TRAMEXAMIC systemic or conversion of plasminogen CV: Hypotension,

`PALAWAN STATE UNIVERSITY

 ACID local to plasmin (fibrinolysin), thromboembolis
hyperfibrinoly an enzyme that degrades m, thrombosis CONTRAINDICATIONS:
CLASSIFICATION: sis fibrin clots, fibrinogen, and > Hypersensitivity
PHARMACOLOGIC: other plasma proteins, GI: Diarrhea, > Active Intravascular Clotting
ANTIFIBRINOLYTIC Prophylaxis in including the procoagulant nausea, vomiting > Acquired defective color visio
patients with factors V and VIII > Subarachnoid Hemorrhage
THERAPEUTIC: coagulopathy
HEMOSTATIC AGENT undergoing A: 100% bioavailable with Precautions:
surgical IV administration Use cautiously with renal impa
PREGNANCY CATEGORY
RISK: B procedures D: Penetrates readily into hematuria originating in the up
joint fluid and synovial tract; and conditions associated
membranes thrombus formation
M and E: 95% excreted
unchanged in urine

Onset: Unknown
Peak: Unknown
Duration: 7-8hours
Drug Half-Life: 6 hours

BRAND: Relief of Stimulates motility of Dosages CNS: DRUG INTERACTIONS:

REGLAN, MAXOLON symptoms of upper GI tract without 10-15 mg PO Restlessness, - Decreased absorption of digo
acute and stimulating gastric, billiary, up to 4 drowsiness, stomach
GENERIC: reccurent or pancreatic secretions; times/day fatigue, lassitude, - Increased toxic and immunosu
METOCLOPROMIDE diabetic appears to sensitize 30 minutes insomnia, effects of cyclosporine
gastroparesis tissues to action of before each extrapyramidal - Increased neuromuscular bloc
CLASSIFICATION: - Short-term acetylcholine; relaxes meal and at reactions, succinylcholine
Pharmacologic Class therapy for pyloric sphincter, which, bedtime for parinsonism-like
DOPAMINERGIC adults with when combined with 2-8 weeks reactions, CONTRAINDICATIONS:
BLOCKER symptomatic effects on motility, akathisia, Concentrations
GERD who fail accelerates gastric dystonia, - Allergy to metoclopramide
Therapeutic Class to respond to emptying and intestinal myoclonus, - GI hemorrhage
ANTIEMETIC conventional transit; little effect on dizziness, anxiety - Mechanical obstruction or pe
GI STIMULANT therapy gallbladder or colon - Pheochromocytoma
- Prevention motility; increases lower CV: Transient - Epilepsy
Pregnancy Risk Factor of nausea and esophageal sphincter hypertension
B vomiting pressure; has sedative Precaution
associated properties; induces GI: Nausea, - Previously detected breast ca
with release of prolactin. diarrhea - Lactation
emetogenic - Pregnancy
cancer Pharmacokinetics - Fluid overload
chemotherapy D: Crosses placenta; - Renal impairment
- Prophylaxis enters breast milk
of M: Hepatic
postoperative E: Urine
nausea and
vomiting Drug Half Life
when 5-6 hours
nasogastric
suction is
undesirable
- Facilitation
of small-bowel
intubation
when tube
does not pass
the pylorus

`PALAWAN STATE UNIVERSITY

 with
conventional
maneuvers
- Stimulation
of gastric
emptying and
intestinal
transit of
barium when
delayed
emptying
interferes
with
radiologic
examination
of the
stomach or
small intestine
- Unlabeled
uses:
Improvement
of lactation;
treatment of
nausea and
vomiting of a
variety of
etiologies:
hyperemesis
gravidarum,
gastric ulcer,
anorexia
nervosa

CLIENT INITIALS: __P. S__ DATE: OCTOBER NURSING CARE PLAN MA

`PALAWAN STATE UNIVERSITY

17,2019 PRIORITY CONCEPT:
__Exchanging
NURSING DIAGNOSIS: Impaired Gas Exchange
__Communicatin
RELATED TO: low level of Hemoglobin or blood loss Oxygenation
__Relating
SECONDARY TO: Upper Gastrointestinal Bleeding

Assessment Planning Goal Implementation Rationale Evaluation

Pertinent Data Patient will: Nurse Will: Why: What Happened

Subjective: Short Term Goals / Assess respirations: Rapid, shallow breathing and Written consent secured
“Hirap ko maghinga kay Outcomes: quality, rate, pattern, hypoventilation affect gas and intubation was
skit tyan ko” as weakly Patient will have depth and breathing exchange by affecting CO2 performed, patient was
verbalized by the patient effective oxygen effort. levels. Flaring of the nostrils, the Assistive Bag-Valve
therapy. dyspnea, use of accessory Mask with endotrachea
Objective: muscles, tachypnea and /or intubation ventilation.
Vital Signs: apnea are all signs of severe Patient exhibits no
T : 35.6 Celsius distress that require dyspnea,
HR: 112 bmp immediate intervention. Has a heart rate of 83
(Thready pulse) Patient will be awake bpm and respiratory rat
RR: 35 cpm and alert. Absence of ventilation, of 15 cpm via BVM ETV
BP: 60 PALPATORY Assess for life- asymmetric breath sounds, SaO2 via pulse oximetry
O2 SAT: 76% Patient will maintain threatening problems. dyspnea with accessory 95%..
o2 sat of 95-100%. muscle use, dullness on chest Appropriate injury speci
Lab Result: percussion and gross chest treatment has been
Hemoglobin 92 g/L Long Term Goal wall instability (i.e. flail chest started.
(Normal Val.120-160g/L) Patient will maintain or sucking chest wound) all
optimal gas exchange require immediate attention.
Hematocrit 26.0
(Normal Val. 36-57 g/L) Monitor vital signs.
Absence of lung sounds, JVD
Red Blood Cells 2.7 g/L and / or tracheal deviation
(Normal Val. 4.0-5.5 g/L) could signify a Pneumothorax
or Hemothorax.
Nasal Cannula @1-3 Lpm
Dyspnea Assess for changes in
Anxiety orientation and behavior. Tachycardia, restlessness,
Weakness diaphoresis, headache,
Restlessness lethargy and confusion are all
Confusion signs of hypoxemia.
Irritability Initially with hypoxia and
Cool and clammy skin hypercapnia blood pressure
Paleness or Pallor (BP), heart rate and
respiratory rate all increase.
As the condition becomes
more severe BP may drop,
heart rate continues to be
rapid with arrhythmias and
respiratory failure may ensue.
Restlessness is an early sign of
hypoxia. Mentation gets
worse as hypoxia increases
due to lack of blood supply to
the brain.

`PALAWAN STATE UNIVERSITY

 Monitor ABGs.

Increasing PaCO2 and

decreasing PaO2 are signs of
respiratory failure.
Place the patient on
continuous pulse
oximetry. Pulse oximetry is useful in
detecting changes in
oxygenation. Oxygen
saturation should be
maintained at 90% or greater.

Assess skin color for

development of cyanosis, Lack of oxygen delivery to the
especially circumoral tissues will result in cyanosis.
cyanosis. Cyanosis needs treated
immediately as it is a late
development in hypoxia.

Provide supplemental
oxygen, via 100% O2 non- Early supplemental oxygen is
rebreather mask. essential in all trauma
patients since early mortality
is associated with inadequate
delivery of oxygenated blood
to the brain and vital organs.

Prepare the patient for

intubation and assist with Early intubation and
the pumping of bag-valve mechanical ventilation are
mask @ RR of necessary to maintain
15cpm/min. adequate oxygenation and
ventilation, prior to full
decompensation of the
patient.
Check and monitor IVF
drop rates and
Administer medications Treatment needs to focus on
as prescribed Treat the the underlying problem that
underlying injuries with leads to the respiratory
appropriate failure.
interventions.

 If the Client goal was/ was not met, briefly describe why and what steps would be taken next:
TEACHING CARE PLAN FOR PRIMARY CARE PROVIDER OR SOs

KNOWLEDGE DEFICIT/
LEARNING NEED GOAL AND PLAN FOR TEACHING

Knowledge in use of GOAL:

`PALAWAN STATE UNIVERSITY

mechanical ventilation or Bag-
Valve Mask Endotracheal
Ventilation and the care
involve.
The Significant others demonstrate knowledge of mechanical ventilation and care involved.
PLAN:
1. Assess the client’s perception and understanding of mechanical ventilation.
This information provides an important starting point in education.
2. Assess the client’s readiness and ability to learn.
Educational interventions must be designed to meet the learning limitations, motivation, and needs
client. Clients in acute care may not be able to take in much information because of fatigue, pain, se
overload, hypoxemia, and the like.
3. Encourage the client or significant others to express feelings and ask questions.
Questions facilitate open communication between the client and health care professionals and allow
verification of understanding and the opportunity to correct misconceptions.
4. Explain the importance of frequent assessment of vital signs, auscultation of breath sounds, ventila
checks.
This information also helps reduce anxiety by providing a basis for actions.
5. Explain to the client the reason for the inability to talk while intubated. Explain alternative efforts fo
communicating.
The endotracheal tube passes through the vocal cords and attempts to talk can cause more trauma
cords. However, clients must understand how to use supplementary methods for communication su
paper, pen, pictures.
6. Explain that the client will not be able to eat or drink while intubated but assure him or her that alte
measures (IV fluids, gastric feedings, or hyperalimentation) will be taken to provide nourishment.
The risk for aspiration is high if the client eats or drinks while intubated. In long-term care settings, c
be allowed to eat and drink after a swallow evaluation.
7. Explain that alarms may periodically sound off, which may be normal, and that the staff will be in cl
proximity.
Explaining expected events can help reduce anxiety.
8. Explain the need for suctioning as needed.
This information can help reduce anxiety associated with the procedure.
9. Teach significant others the proper way of pumping the Assistive Bag-Valve Mask without hyper or
ventilating the patient.
Too much or too little can cause serious complications to patient that is why knowledge on how to p
in a breath-like pattern is important for the SOs to know. A preferred RR of 12-15 cpm or one pump
five seconds is the most suitable rate.
10. Explain the weaning process and explain that extubation demonstrates adequate respiratory functi
decrease in pulmonary secretions.
This information aids the client in maintaining some control.
11. If long-term ventilation is anticipated, discuss or plan for long-term ventilator care management an
appropriate referrals: long-term ventilator facilitates versus home care management.
Continuity of care is facilitated through the use of specialty resources.
`PALAWAN STATE UNIVERSITY
`PALAWAN STATE UNIVERSITY