Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process

Copyright 2018 wolters kluwer all rights reserved

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Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Implementation #2 Monitoring and managing patient needs: o Self-care deficit syndrome Assist when there is depression: no physical or emotional energy to perform self-care activities Minimize injury risk: safe environment, assist in changing positions, assist in activities of daily living, encourage self-care, give positive feedback, write behavioral records at periodic intervals, frequency depends on hospital, unit guidelines Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Implementation #3 Monitoring and managing patient needs (cont.) o Disturbed sleep pattern: promote sleep, promote wakefulness during day, shut drapes at night, keep them open during the day, help patient reorient to daytime/nighttime o Imbalanced nutrition: Less than body requirements: Monitor fluid/dietary intake, monitor weight loss/gain, good oral hygiene, frequent sips of fluids, sugarless gum Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Implementation #4 Monitoring and managing patient needs (cont.) o Strict dietary control: foods containing tyramine not to be eaten for patients on MAOIs, no food from outside o Risk for suicide: Well-supervised environment; wait for therapeutic effect; report expressions of guilt, hopelessness, helplessness, insomnia, weight loss, direct/indirect threats of suicide; care while swallowing Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Implementation #5 Monitoring and managing patient need (cont.) o Acute pain: Drugs: trazodone, priapism impotence, prolonged, inappropriate penile erection, injection of alpha-adrenergic stimulants, surgical intervention Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Implementation #6 Educating the patient and family o Managing reactions; patients continue proper drug regimen; evaluate ability to take responsibility of drugs; explain adverse reactions o Teaching plan: inform primary health care provider, dentist; dizziness: rise slowly out of bed, chair; help changing positions; relieve dry mouth: frequent sips of water, sucking hard candy, chewing gum Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Implementation #7 Educating the patient and family (cont.) o Teaching plan: report unusual changes, physical effects; avoid prolonged exposure to sunlight or sunlamps; male patients: if experiencing prolonged, inappropriate, painful erections, stop drug, notify primary health care provider o Remember to take lithium with food or immediately after meals to avoid stomach upset. Drink at least 10 large glasses of fluid each day and add extra salt to food if permissible. 25 26 27 28 29 30
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