SUFFOLK COUNTY COMMUNITY COLLEGE

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					                                                      SCHOOL OF NURSING


                                                          COURSE OUTLINE
                                                            ADDENDUM




          Level II Course Title: Adult Health Nursing II                   Catalog No.: NUR240

          Credits: 8                                                       Lecture & Clinical




Revised 6/06, 12/06, 7/07, 8/07, 6/16/08,12/08, 6/09,11/09DP
                                                          TABLE OF CONTENTS
                                                                                                                                                 PAGE

NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT REQUIRE HOME CARE ........1
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT RESPIRATORY
FUNCTION ...................................................................................................................................................5
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT HEMATOLOGICAL
FUNCTION ...................................................................................................................................................7
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
MUSCULOSKELETAL FUNCTION ...........................................................................................................9
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT ENDOCRINE
FUNCTION .................................................................................................................................................11
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
GASTROINTESTINAL/HEPATOBILIARY FUNCTION ........................................................................13
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT MALE & FEMALE
ORGAN REPRODUCTIVE FUNCTION ...................................................................................................16
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT URINARY AND
RENAL FUNCTION ...................................................................................................................................18
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT NEUROLOGICAL
FUNCTION .................................................................................................................................................20
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS RESULTING FROM BURNS,
DISASTER AND SHOCK STATES ...........................................................................................................23




                                                                              i
  NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT REQUIRE
                         HOME CARE
BEHAVIORAL OBJECTIVES COURSE CONTENT                                     CORRELATED LEARNINGS
ASSESSMENT                          ASSESSMENT                           ASSESSMENT
1. Assesses the needs of a client 1. Utilizing the nursing process       Review articles pertaining to
   requiring Home Care                 to identify client needs          Home Care
2. Assesses the client’s level of2.    Stressors affecting care in the
   knowledge                           home
                                    3. Safety issues in the home
                                       environment
                                    4. Identify family and other
                                       support systems
                                 5.    Describe the role of the nurse
                                       in home care

DIAGNOSIS                           DIAGNOSIS                            DIAGNOSIS
Formulate nursing diagnoses         Risk for Injury                      Analyze Data and Formulate
based on a biopsychosocial          Impaired Home Maintenance R/T        Diagnoses
assessment of clients in the Home   Impaired Cognitive, Emotional or
Care Setting                        Psychomotor Functioning
                                    Impaired Home Maintenance R/T
                                    Inadequate Support Systems
                                    Care Giver Role Strain

PLANNING                            PLANNING                             PLANNING
1. Proposes alternate nursing       1. Formulates nursing diagnosis      1. Identify areas of care that can
   measures to assist the client       based on assessment data             be delegated
   in adapting to changes in        2. Determines expected               2. Participates in developing a
   levels of physical and              outcomes for individual              teaching plan
   psychological functioning in        clients and families
   the home care setting
2. Plans nursing measures that
   allow for prevention/or early
   detection of complications
3. Formulates a teaching plan
   for a home care client

IMPLEMENTATION                      IMPLEMENTATION                       IMPLEMENTATION
1. Implements measures to           1. Adaptations to maximize 1.        1. Incorporates the client’s values
   promote optimal client              functioning in the home care          and preferences in medical
   functioning in the home care        setting                               decision making and goal
   setting                          2. Maintaining a safe therapeutic        setting.
2. Promotes adaptation by              environment.                      2. Reinforce health teaching with
   manipulating the environment     3. Applying principles of            client and or family members.
   to maintain optimal level of        asepsis.                          3. Assist the nurse to coordinate
   independence                     4. Importance of                     discharge planning.
                                       interdisciplinary team            4. Utilization of written Home
                                       functions.                        Care/Discharge Plan clinical
                                                                         assignment.
                                                      1
BEHAVIORAL OBJECTIVES               COURSE CONTENT                       CORRELATED LEARNINGS
                                    5. Effective communication
                                       strategies for dealing with the
                                       client and care givers in the
                                       home.

EVALUATION                          EVALUATION                           EVALUATION
1. Evaluates the effectiveness of   1. Outcome criteria for:             1. Reports and records
   nursing action designed to:         a. Self-care in the home             significant changes in client
   a. maintain current level of        b. Home maintenance                  status
       functioning                                                       2. Evaluates progress based on
   b. prevent complications                                                 outcome criteria for an
   c. improve level of                                                      individual client in the home
       functioning                                                          setting
2.Evaluates the effectiveness                                            3. Evaluates the effectiveness of
   of client teaching                                                       teaching
                                                                         4. Illustrate with examples how
                                                                            home care objectives were
                                                                            met.
                                                                         5. Summarize a journal article
                                                                            related to home care nursing.




                                                      2
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT CARDIAC AND
     PERIPHERAL VASCULAR FUNCTION

BEHAVIORAL OBJECTIVES                 COURSE CONTENT                       CORRELATED LEARNINGS
ASSESSMENT                            ASSESSMENT                           ASSESSMENT
1. Assesses the client’s              1. Stressors affecting circulation   1. Performs a circulatory
   circulatory status.                   a. Internal/External                  assessment
   a. Assesses the effects of         2. Assessment criteria for           2. Diagnostic tests:
      alterations in circulation on      alteration in circulation             CBC, cardiac isoenzymes,
      physical and psychological      3. Effect of stressors:                 troponin, APTT, prothrombin
      adaptation                         a. Acute coronary syndrome:           time, INR, homocystine
   b. Assesses client’s level of               1. angina                       levels, BNP, C Reactive
      knowledge                                2. MI                           Protein, EKG, chest X-ray,
                                               3. Cardiogenic Shock            cardiac catheterization,
                                               4. CHF                           hemodynamic monitoring,
                                               5. pulmonary edema               CVP, radionuclide studies,
                                         b. Life threatening                   arteriograms, venograms
                                             dysrythmias                   3. Analyzes information from
                                         c. Emboli, DVT,                       cardiac assessment and
                                         d. Coagulation therapy                diagnostic tests
                                            Heparin, Coumadin, HIT         4. Formulates, revises or
                                         e. Peripheral vascular disease        concurs with nursing
                                         f. Aneurysm                           diagnosis

DIAGNOSIS                             DIAGNOSIS                            DIAGNOSIS
Formulate nursing diagnoses           Common Nursing Diagnoses for         Analyze Data and Formulate
based on a biopsychosocial            these disorders include:             Diagnoses
assessment of clients with              Impaired Gas Exchange
Cardiovascular and Peripheral           Decreased Cardiac Output
Dysfunction.                            Ineffective Tissue Perfusion
                                        Activity Intolerance
                                        Ineffective Therapeutic
                                         Management
                                        PC Dysrythmias

PLANNING                            PLANNING                               PLANNING
1. Proposes alternate nursing       1. Formulates nursing diagnosis        1. Plans nursing care for a client
   measures to assist the client in     based on assessment data              with an alteration in
   adapting to changes in levels 2. Determines expected                       circulatory function
   of physical and psychological       outcomes for individual             2. Participates in developing a
   functioning.                        clients                                teaching plan for a client with
2. Plans nursing measures that                                                impaired circulatory function
   allow for prevention/or early                                           3. Incorporates homecare needs
   detection of complications                                                 as indicated.
3. 3. Formulates a teaching
   plan for a client within
   alteration in circulatory
   function



                                                       3
BEHAVIORAL OBJECTIVES               COURSE CONTENT                 CORRELATED LEARNINGS
IMPLEMENTATION                      IMPLEMENTATION                 IMPLEMENTATION
1. Implements measures to           1. Adaptations to maximize     1. Implements a plan of care for
   promote optimal client              function                       a client with circulatory
   functioning in an individual        a. Emergency treatment         problems. Implements a
   with a circulatory deficit          b. Sequential compression      teaching plan for a client with
2. Initiates appropriate actions          devices                     a circulatory problem
   for persons experiencing a          c. Diet therapy             2. Implements the following
   cardiac related emergency           d. Drug therapy                skills:
3. Promotes adaptation by           2. Surgery                        a. Apical and radial pulses
   manipulating the environment        a. Revascularization           b. Peripheral vascular
   to maintain optimal level of        b. Angioplasty                     assessment
   independence                        c. Valve replacement
                                       d. Transplantation
                                    3. Teaching Needs for Self-
                                       Care:
                                       a. Drug/diet therapy
                                       b. Planned exercises
                                       c. Stress reduction
                                       d. Foot Care
                                       e. Weight control
                                       f. Community agencies
                                       g. Rehabilitation program

EVALUATION                          EVALUATION                     EVALUATION
1. Evaluates the effectiveness      2. Outcome criteria for:       1. Reports and records
   of nursing action designed to:      a. Cardiovascular              significant changes in
     a.         maintain current          adaptation                  cardiovascular status
         level of                      b. Self-care                2. Evaluates progress based on
         functioning                                                  outcome criteria for an
     b. prevent complication                                          individual client with a
     c. improve level of                                              circulatory dysfunction
         functioning                                               3. Evaluates the effectiveness of
2. Evaluates clients response                                         teaching for a client with a
    to drug, diet and activity                                        circulatory deficit
    regimen
   2. Evaluates the
        effectiveness
    of client teaching for a
    client with a circulatory
     deficit




                                                    4
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
                   RESPIRATORY FUNCTION
BEHAVIORAL OBJECTIVES              COURSE CONTENT                    CORRELATED LEARNINGS
ASSESSMENT                         ASSESSMENT                        ASSESSMENT
1. Assesses the client's           1. Stressors affecting            1. Performs a respiratory
   respiratory status for             respiratory status                assessment
   presence of stressors that      2. Assesses for alterations in:   2. Diagnostic Tests:
   precipitate respiratory               Rate and character of            Lung Scan
   dysfunction                           respirations; pain;              X-rays
2. Assess the effects of                 characteristics of               Bronchoscopy
   alterations in respiration on         breathing; skin color;           Thoracentesis
   physical and psychological            hemoptysis                       Biopsy
   adaptation                      3. Effects of stressors                Blood Gases
3. Assesses client’s level of         a. Cancer of the lung               Pulmonary Function Tests
   knowledge                          b. Respiratory Failure and          Sputum Analysis
                                         ARDS                        3. Formulates, revises, or
                                      c. Chest Trauma-                  concurs with nursing
                                          Pneumothorax,                 diagnosis
                                          Hemothorax
                                      d. Pulmonary Embolism

DIAGNOSIS                          DIAGNOSIS                         DIAGNOSIS
Formulate nursing diagnoses        Common Nursing Diagnoses for      Analyze Data and Formulate
based on a biopsychosocial         these disorders include:          Diagnoses
assessment of clients with          Impaired Gas Exchange
Respiratory Dysfunction             Acute Confusion RT hypoxia
                                    Ineffective Airway Clearance
                                    Ineffective Breathing Patterns
                                    Impaired Verbal Communication

PLANNING                           PLANNING                          PLANNING
1. Proposes alternate nursing      1. Formulates nursing diagnoses   1. Participates in developing a
   care measures to assist the        based on assessment data          teaching plan for a client with
   client in adapting to changes   2. Determines expected               respiratory problem
   in physical and                    outcomes for individual        2. Plans nursing care for a client
   psychological functioning          clients                           with respiratory dysfunction
2. Formulates a teaching plan                                        3. Reviews established
   for self-care for client with                                        protocols for assisting with
   respiratory dysfunction                                              respiratory procedures i.e.
3. Proposes alterations in                                              Thoracentesis
   nursing care to prevent                                           4. Incorporates home care needs
   respiratory infections                                               as indicated




                                                    5
BEHAVIORAL OBJECTIVES             COURSE CONTENT                    CORRELATED LEARNINGS
IMPLEMENTATION                    IMPLEMENTATION                    IMPLEMENTATION
1. Utilizes the nursing process   1. Mechanical ventilation         1. Implements a plan of care for
   with minimal assistance to     2. Chest drainage                    client with respiratory
   maintain/improve the           3. Suctioning                        problem
   client’s current status        4. Diet management                2. Implements teaching plan for
                                  5. Drug Management                   a client with a respiratory
                                  6. Teaching needs for self-care      problem
                                  7. Surgery                        3. Assists client with
                                     a. Thoracotomy                    preventative or prescribed
                                     b. Lobe resections and            breathing exercises
                                        pneumonectomy               4. Implements the following
                                                                       skills:
                                                                        a. endotracheal suctioning
                                                                        b. maintain water seal
                                                                            drainage system
                                                                        c. Safety aspects for a
                                                                            ventilated client

EVALUATION                        EVALUATION                        EVALUATION
1. Evaluates effectiveness of     1. Outcome criteria for:          1. Reports and records
   respiratory therapy               a. Respiratory adaptations        significant changes in
2. Evaluates effectiveness of        b. Self-care                      respiratory status
   nursing actions designed to:                                     2. Evaluates outcome criteria
   a. maintain or improve                                              for individual clients with
       current level of                                                respiratory problem
       functioning                                                  3. Evaluates effectiveness of
   b. prevent complications                                            client teaching for a client
3. Evaluates the effectiveness                                         with respiratory dysfunction
   of client teaching with
   respiratory problems




                                                  6
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
                  HEMATOLOGICAL FUNCTION
BEHAVIORAL OBJECTIVES               COURSE CONTENT                        CORRELATED LEARNINGS
ASSESSMENT                          ASSESSMENT                            ASSESSMENT
1. Assess the client’s              1. Pathophysiology of                 1. Assess stressors for client with
    hematological status and           hematologic dysfunctions              anemia, or bleeding
    stressors that precipitate      2. Assess circulatory changes:           dysfunction.
    hematological dysfunction          vital signs, bleeding, blood       2. Reviews diagnostic tests:
2. Assess the effects of               count, color, diet, petechiae,        CBC, sed rate, WBC with
    alterations in hematological       infections, sensory changes in        differential UA
    function                           extremities
3. Assess laboratory findings for   3. Effects of stressors and client
    client with blood dyscrasia        adaptation:
4. Assess client’s level of            Polycythemia vera
   knowledge                           Chronic Myelocytic Leukemia
                                       Chronic Lymphocytic
                                            Leukemia
                                       HIT
                                       DIC

DIAGNOSIS                           DIAGNOSIS                             DIAGNOSIS
Formulate nursing diagnoses         Common Nursing Diagnoses for          Analyze Data and Formulate
based on a biopsychosocial          these disorders include:              Diagnoses
assessment of clients with           Risk for Infection
Hematological Dysfunction            Fatigue
                                     Risk for Injury
                                     Impaired Oral Mucous
                                       Membranes
                                     Imbalanced Nutrition
                                     Anxiety

PLANNING                            PLANNING                              PLANNING
1. Identify outcomes for            1. Develops approaches to             1. Participates in developing a
   prevention of illness and           nursing care based on                 teaching plan including
   adaptation of client with           assessment of individual              sensitivity to cultural and
   hematological dysfunction           status.                               spiritual diversity
2. Develop a plan of care that      2. Identify and prioritize nursing    2. Plans nursing care that
   prioritizes nursing diagnoses       diagnoses                             enhances and/or maintains
   based upon subjective and        3. Develop a plan of care that           optimal functioning and
   objective assessment.               prioritizes nursing diagnoses         quality of life.
3. Plan nursing interventions for      based upon subjective and
   a client with anemia                objective assessment.
                                    4. Determine client outcomes
                                       appropriately and on an
                                       individual basis.
                                    5. Develop a plan of care based
                                       on client’s variables including
                                       personal, spiritual and cultural
                                       diversity.
                                                      7
BEHAVIORAL OBJECTIVES              COURSE CONTENT                      CORRELATED LEARNINGS
IMPLEMENTATION                     IMPLEMENTATION                      IMPLEMENTATION
1. Implements therapeutic          1. Measure to increase adaptation   1. Communicates ideas
   nursing interventions that         to stressors:                       effectively with clients and
   optimize adaptation for the        a. therapeutic nutrition            other members of health care
   client with leukemia.              b. pharmacologic                    team.
2. Discuss client’s role in                management                  2. Demonstrates skill in:
   medical and surgical               c. oxygen therapy                   a. therapeutic nutrition
   management of blood                d. blood transfusion                b. management of bleeding
   dysfunction.                            observation                    c. observations with
3. Teach client about diagnostic      e. activity exercises                    chemotherapy and
   studies used to detect             f. positioning                           radiation
   hematological dysfunction.         g. bone marrow aspiration        3. Reviews protocols for bone
4. Teach client basic principles      h. bone marrow transplant           marrow aspiration and
   of effective nutrition             i. chemotherapy                     splenectomy.
                                      j. splenectomy                   4. Provides supportive assistance
                                      k. prevention of infection          in dealing with stressors and
                                      l. biopsychosocial support          adaptation.
                                      m. teaching measures to          5. Carries out protective isolation
                                           include diet, medication,      procedures.
                                           safety, rest & exercise     6. Provides discharge planning
                                                                          and community referrals.

EVALUATION                         EVALUATION                          EVALUATION
1. Evaluate outcomes utilizing     1. Outcome criteria for:            1. Evaluate client’s
   outcome criteria developed in      a. Hematological adaptation         understanding and adaptation
   the planning phase of care.        b. Self-care                        to nursing interventions.




                                                   8
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
                 MUSCULOSKELETAL FUNCTION

BEHAVIORAL OBJECTIVES               COURSE CONTENT                    CORRELATED LEARNINGS
ASSESSMENT                          ASSESSMENT                        ASSESSMENT
1. Assess the client’s              1. Stressors affecting mobility   1. Assesses problems of a client
   musculoskeletal status and       2. Musculoskeletal assessment        with an alteration in mobility
   stressors that precipitate       3. Effects of stress on           2. Diagnostic tests
   musculoskeletal dysfunction         musculoskeletal systems           Arthrocentesis
2. Assess the effects of               a. Musculoskeletal trauma         Arthroscopy
   alterations in musculoskeletal      b. Osteomyelitis,                 Bone Scan, Tomogram
   dysfunction                             Osteoporosis                  Calcium, Phosphorous,
3. Assess laboratory findings for      c. Gout                            Alkaline
   client with musculoskeletal         d. Osteoarthritis                 Phosphatase
   dysfunction                         e. Rheumatoid arthritis           Uric Acid, Sed Rate
4. Assess client’s level of            f. Systemic lupus                 Serology tests associated
   knowledge                               erythematosus                  with joint disease
                                       g. Herniated Disc              3. Formulates, revises or
                                       h. Fractures                      concurs with nursing
                                                                         diagnosis

DIAGNOSIS                           DIAGNOSIS                         DIAGNOSIS
Formulate nursing diagnoses         Common Nursing Diagnoses for      Analyze Data and Formulate
based on a biopsychosocial          these disorders include:          Diagnoses
assessment of clients with            Risk for Peripheral
                                      Neurovascular dysfunction
                                      Acute Pain
                                      Chronic Pain
                                      Disturbed Body Image
                                      Impaired Physical Mobility
                                      PC Compartment Syndrome
                                      PC Thromboembolism
                                      PC Delayed Healing or Non
                                       Union

PLANNING                            PLANNING                          PLANNING
1. Proposes alterations in          1. Formulates nursing             1. Plans nursing care for a
   nursing care to meet the            diagnoses based on                client with a musculoskeletal
   needs of the immobilized            assessment data                   problem
   client and to maintain optimal   2. Determine expected             2. Reviews established
   levels of mobility.                 outcomes for individual           protocols for assisting a
2. Reorders nursing priorities in      clients                           client in a cast or in traction,
   accordance with changing                                              or a knee immobilizer
   therapeutic response.                                              3. Develops a teaching plan for
3. Formulates a teaching plan to                                         use of ambulatory aids
   prepare the client with a
   motor problem to function at
   his maximal level of
   independence
                                                    9
BEHAVIORAL OBJECTIVES                COURSE CONTENT                    CORRELATED LEARNINGS
IMPLEMENTATION                       IMPLEMENTATION                    IMPLEMENTATION
1. Manipulates the                   1. Adaptation to Maximize         1. Implements a plan of care for
   environment to protect the           Function                          a client with a
   immobilized client from              a. Cast care, pin care            Musculoskeletal problem i.e.
   further injury or impairment         b. Traction, types and            reinforcing physical therapy
2. Selects appropriate First Aid            maintenance                   program
   measures for emergency               c. Measures to prevent joint   2. Implements a teaching plan
   treatment of musculoskeletal             degeneration                  for a client with a
   injuries                             d. Diet/Drug management           musculoskeletal problem
3. Revises approaches to                e. First Aid and Positioning   3. Implements the following
   nursing action in response to            for hip fractures             skills:
   increasing muscle spasm           2. Teaching Needs for Self-          a. Teach use of ambulatory
4. Applies principles from the          care                                  aids
   natural sciences to maintain         a. Diet and Drug therapy          b. Apply splints, braces
   traction apparatus                   b. Planned exercise               c. Maintain traction
5. Manipulates the                      c. Use of ambulatory aids         d. Give cast care, pin care
   environment to maintain a            d. Home adaptations for           e. Teach use of self-help
   proper balance between rest              independence                      devices
   and activity in inflammatory         e. Community agencies          4. Implements neurovascular
   or degenerative joint             3. Surgery                           assessment
   conditions                           a. Total hip replacement,
                                            knee replacement
                                        b. Open reduction of
                                            fractures
                                        c. Amputations

EVALUATION                           EVALUATION                     EVALUATION
1. Evaluates the effectiveness of    1. Outcome criteria for:       1. Reports and records
   nursing care and rehabilitation      a. Motor-Safety adaptations    significant changes in motor
   measures.                            b. Self-care                   function
                                                                    2. Evaluates outcome criteria
                                                                       for a client with a specific
                                                                       motor problem
                                                                    3. Evaluates the effectiveness
                                                                       of an established plan of care
                                                                       for a client with a
                                                                       musculoskeletal problem




                                                    10
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
                    ENDOCRINE FUNCTION

BEHAVIORAL OBJECTIVES                  COURSE CONTENT                      CORRELATED LEARNINGS
ASSESSMENT                             ASSESSMENT                          ASSESSMENT
Assess the client’s regulatory         Assess for:                         Nursing history
status.                                Parameters of regulatory function   Related diagnostic tests
Assess factors that precipitate        Mechanisms                          Formulates, revises or concurs
regulatory dysfunction                 External                            with nursing diagnoses, care map
Assess alterations in the client’s     Interference
current ability to cope with stress.   Hyperfunction or
analyze laboratory findings in         Hypofunction of endocrine
clients with hormone imbalances.       glands: pituitary, thyroid,
States effects of these findings on    adrenals and parathyroid
the plan of nursing care.
Assess client’s level of
knowledge

DIAGNOSIS                              DIAGNOSIS                           DIAGNOSIS
Formulate nursing diagnoses            Common Nursing Diagnoses for        Analyze Data and Formulate
based on a biopsychosocial             these disorders include:            Diagnoses
assessment of clients with               Disturbed Body Image
Endocrine Dysfunction                    Sexual Dysfunction
                                         Activity Intolerance
                                         PC Fluid and Electrolyte
                                          Imbalance
                                         Decreased Cardiac Output
                                         Disturbed Thought Processes

PLANNING                               PLANNING                            PLANNING
Proposes alterations in nursing        Formulate nursing diagnoses or      Participates in developing a
care to decrease stress in             care map based on assessment        teaching plan for a client with a
individual clients                     data                                regulatory problem
Plans nursing actions to restore       Determine expected outcomes for     Plans nursing care for a client
optimal level of adaptation when       individual clients                  with a regulatory problem
a hormonal deficiency or excess                                            Incorporate homecare needs as
exists                                                                     indicated
Proposes nursing measures that
encourage prevention or early
detection of complications in
clients with regulatory problems
Formulates a teaching plan for
self-care for a client who has a
regulatory problem or has
undergone endocrine surgery




                                                       11
BEHAVIORAL OBJECTIVES              COURSE CONTENT                    CORRELATED LEARNINGS
IMPLEMENTATION                     IMPLEMENTATION                    IMPLEMENTATION
1. Decrease external stressors     1. Adaptations to achieve         1. Implements a plan of care for
   that interfere with the            homeostasis                       a client with a regulatory
   client’s ability to cope with      a. Hormone Replacement            problem.
   deficiencies in regulatory               Steroids                 2. Plans nursing care for a
   mechanisms.                        b. Diet Therapy                   client with a regulatory
2. Implements measures to             c. Emergency Treatment            problem.
   promote optimal client             d. Fluid and electrolyte
   functioning when a                     balance
   hormonal deficiency/excess      2. Teaching Needs for Self care
   exists.                            a. Stress Management
3. Promotes adaptation by             b. Manifestations of
   encouraging optimal levels             hormone
   of independence in clients             deficiency/excess
   with regulatory problems.          c. Monitoring effects of
4. Teaches comprehensive self             hormone therapy
   management to assist clients       d. Diet therapy
   adapting to endocrine              e. Measures to prevent
   dysfunction.                           infection and fatigue
                                      f. Community Agencies
                                   3. Surgery
                                      a. Subtotal and Total
                                          Thryoidectomy
                                      b. Adrenalectomy
                                      c. Parathyroidectomy
                                   4. Irradiation therapy

EVALUATION                         EVALUATION                        EVALUATION
1. Evaluates effectiveness of      1. Outcome criteria for:          1. Reports and records
   hormone replacement                a. regulatory adaptations         significant changes in
   therapy                            b. self-care                      regulatory status
2. Evaluates effectiveness of                                        2. Evaluates outcome criteria
   nursing actions designed to:                                         for individual client with
   a. maintain or improve                                               regulatory problems
       current level of                                                 receiving hormone
       functioning                                                      replacement therapy
   b. prevent complications                                          3. Uses established outcome
3. Evaluates the effectiveness                                          criteria to evaluate
   of client teaching for a                                             effectiveness of client
   client with a regulatory                                             teaching for a client with
   problem                                                              endocrine dysfunction




                                                  12
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
           GASTROINTESTINAL/HEPATOBILIARY FUNCTION

BEHAVIORAL OBJECTIVES                COURSE CONTENT                      CORRELATED LEARNINGS
ASSESSMENT                           ASSESSMENT                          ASSESSMENT
1. Assess the client’s               1. Stressors affecting              1. Nursing history
   gastrointestinal and                 Nutritional/Metabolic            2. Diagnostic tests: X-rays,
   Hepatobiliary status and             patterns of G.I. Hepatobiliary      ERCP imaging studies,
   stressors that precipitate           functioning.                        sonogram, CBC and bleeding
   gastrointestinal or               2. Assesses for alteration of          studies, electrolytes, serum
   Hepatobiliary dysfunction            G.I./Hepatobiliary function         enzymes.
2. Assess the effects of                in: weight, dietary patterns,    3. Selects appropriate nursing
   alterations in gastrointestinal      alcohol use, bowel habits,          diagnosis for a client with
   or Hepatobiliary dysfunction         pain, nausea, vomiting,             gastrointestinal or
3. Assess laboratory findings           distension, anorexia, skin          hepatobiliary dysfunction
   for client with                      turgor, jaundice, ascites
   gastrointestinal or                  pruritis, bleeding, pernicious
   Hepatobiliary dysfunction            anemia etc.
4. Assess client’s level of          3. Effects of stressors:
   knowledge                            a. GERD
                                        b. Ulcers
                                        c. Inflammatory bowel
                                            disease
                                        d. Irritable Bowel
                                            Syndrome
                                        e. Peritonitis
                                        f. Intestinal obstruction
                                        g. Hernias (self-study)
                                        h. Hepatitis and cirrhosis
                                        i. Pancreatitis and
                                            cholecystitis
                                        j. Cancer
                                        k. Bariatric Surgery

DIAGNOSIS                            DIAGNOSIS                        DIAGNOSIS
Formulate nursing diagnoses          Common Nursing Diagnoses for     Analyze Data and Formulate
based on a biopsychosocial           these disorders include:         Diagnoses
assessment of clients with            Risk for Hemorrhage
Gastrointestinal/Hepatobiliary        Risk for Deficient Fluid Volume
Dysfunction                           Acute or Chronic Pain
                                      Fluid and Electrolyte Imbalance
                                      Imbalanced Nutrition
                                      Ineffective Therapeutic Regimen
                                             Management
                                      Disturbed Body Image
                                      Constipation


                                                     13
BEHAVIORAL OBJECTIVES              COURSE CONTENT                      CORRELATED LEARNINGS
                                   Diarrhea
                                    Excess Fluid Volume
                                    PC Hemorrhage
                                    PC Porto-Systemic
                                    Encephalopathy
                                    Acute Pain
                                    Imbalanced Nutrition
                                    Impaired Skin Integrity
                                    PC Drug Toxicity
                                    Disturbed Body Image
                                    PC Fluid and electrolyte
                                          Imbalance
                                    PC Hyperglycemia

PLANNING                           PLANNING                            PLANNING
1. Proposes alternate nursing      1. Formulates nursing               1. Plans nursing care for a client
   measures to assist the client      diagnoses based on                  with an alteration in G.I. or
   in adapting to changes in          assessment data.                    Hepatobiliary function
   levels of physical and          2. Determines expected              2. Participates in developing a
   psychological functioning.         outcomes for individual             teaching plan for a client
2. Plans nursing measures that        clients                             with an alteration in G.I. or
   allow for prevention and/or                                            Hepatobiliary function
   early detection of                                                  3. Incorporates homecare needs
   complications                                                          as indicated
3. Formulates a teaching plan
   for a client having an
   alteration in G.I or
   Hepatobiliary function

IMPLEMENTATION                     IMPLEMENTATION                      IMPLEMENTATION
1. Selects nursing measures to     1. Adaptations to maintain          1. Implements a plan of care for
   maintain or improve the            function:                           a client with a
   clients nutritional status         a. Drug Therapy                     gastrointestinal/hepatobiliary
2. Discusses principles of diet       b. Diet therapy                     problem
   management for a client            c. Colostomy, ileostomy,         2. Implements a teaching plan
   with an alteration in G.I.            and Koch pouch care              for a client with an alteration
   function                           d. Care of esophageal,              in G.I. function
                                          nasogastric and intestinal   3. Implements the following
                                          tubes, T-tubes                  skills:
                                      e. Measures to prevent              a. Tube feedings
                                          Hepatitis                       b. Ostomy care
                                      f. Stress reduction                 c. Maintenance of
                                                                              nasogastric tubes and G.I.
                                                                              suction




                                                    14
BEHAVIORAL OBJECTIVES             COURSE CONTENT                     CORRELATED LEARNINGS
                                  2. Surgery:
                                     a. Gastrectomy
                                     b. Bariatric Surgery
                                     c. Bowel resection,
                                        colostomy, ileostomy
                                     d. Herniorraphy (self study)
                                     e. Cholecystectomy
                                     f. Shunt procedures
                                  3. Teaching needs for self-care:
                                     a. Drug/diet therapy
                                     b. Ostomy care
                                     c. Measures to decrease
                                        stress
                                     d. Community agencies

EVALUATION                         EVALUATION                        EVALUATION
1. Evaluates the effectiveness     1. Outcome criteria for:          1. Reports and records
   of nursing action designed          a. Gastrointestinal or           significant changes in fluid
   to:                                    Hepatobiliary adaptation      and nutritional status
   a. Improve or maintain              b. Self-care                  2. Evaluates progress based on
       current level of                                                 outcome criteria for an
       functioning.                                                     individual client with an
   b. Prevent complications                                             alteration in G.I.or
2. Evaluates the effectiveness                                          Hepatobiliary function
   of client teaching for a client                                   3. Evaluates the effectiveness of
   with an alteration in G.I. or                                        client teaching for a client
   Hepatobiliary functioning                                            with an alteration in G.I. or
                                                                        Hepatobiliary function




                                                  15
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
          MALE & FEMALE ORGAN REPRODUCTIVE FUNCTION
BEHAVIORAL OBJECTIVES              COURSE CONTENT                    CORRELATED LEARNINGS
ASSESSMENT                         ASSESSMENT                        ASSESSMENT
1. Assesses the client’s           1. Stressors affecting            1. Diagnostic tests
   reproductive organ status          sexual/reproductive states        a. Gynecological exam
2. Assesses                        2. Assesses for alterations in       b. Pap Smear
   sexual/reproductive patterns       male and female                   c. MRI-CT of pelvis,
   in the presence of stressors       reproductive organ function:          abdomen, bones
   that precipitate reproductive      Cervical cancer, uterine/         d. Cervical, endometrial,
   dysfunction                           endometrial cancer,                vaginal biopsy
3. Assesses the efforts of               ovarian cancer                 e. colposcopy
   alterations in sexuality and       Prostatic Hypertrophy             f. D & C
   reproduction in physical and       Prostate and Testicular           g. cystoscopy
   psychological adaptation              Cancer                         h. sigmoidoscopy
4. Assesses the clients level of                                        i. endoscopy
   knowledge related too                                                j. CA125 Antigen level
   reproductive organ function                                          k. ultra sonography
                                                                        l. PSA, Prostatic Alkaline
                                                                            Phosphatase
                                                                        m. Alfa-feto Protein
                                                                     2. Analyzes alterations in male
                                                                        and female sexual/
                                                                        reproductive function
                                                                     3. Selects appropriate Nursing
                                                                        DX for client with
                                                                        deterioration in male and
                                                                        female sexual/reproduction

DIAGNOSIS                          DIAGNOSIS                         DIAGNOSIS
Formulate nursing diagnoses        Common Nursing Diagnoses for      Analyze Data and Formulate
based on a biopsychosocial         these disorders include:          Diagnoses
assessment of clients with Male      Body Image Disturbance
and Female Reproductive              PC Hemorrhage
Dysfunction                          PC Metastasis
                                     PC Urinary Incontinence
                                     PC Sexual Dysfunction
                                     Anticipatory Grieving

PLANNING                           PLANNING                          PLANNING
1. Plans nursing care to assist    1. Formulates nursing             1. Plans nursing care for a
   clients in dealing with            diagnosis based on                client with alterations in male
   female sexual/reproductive         assessment data                   or female
   concerns                        2. Determines expected               sexual/reproductive function
2. Proposes alternate nursing         outcomes for individual        2. Formulates a teaching plan
   care measures to assist            clients                           for the male and female
   clients in adopting changes                                          client with a
   in physical and                                                      sexual/reproductive
                                                                        organ dysfunction
                                                   16
BEHAVIORAL OBJECTIVES               COURSE CONTENT                   CORRELATED LEARNINGS
   psychological functioning                                         3. Reviews established protocol
3. Formulates a teaching plan                                           for clients receiving
   for prevention and                                                   chemotherapy, Radiation and
   management in a client with                                          surgical interventions
   female sexual/reproductive                                        4. Incorporates home care needs
   dysfunction                                                          as indicated

IMPLEMENTATION                   IMPLEMENTATION                      IMPLEMENTATION
1. Utilizes the nursing process  1. Adaptations to maintain          1. Implements a plan of care for
   to maintain/improve the          function                            a client with cervical, uterine
   clients current                  a. testosterone sparing             or ovarian cancer
   sexual/reproductive status          drugs                         2. Implements a plan of care for
2. Manipulates the environment      b. androgen deprivation             a client experiencing
   to manipulate alterations in        drugs                            hysterectomy or
   sexual/reproductive patterns     c. Chemotherapy                     oophorectomy, or pelvic
3. Teaches principles of            d. Radiation therapy                exenteration
   prevention and management        e. Prevent complications of      3. Implements a teaching plan
   of cervical and uterine             therapy                          for a client with a
   cancer and management of         f. Relieve pain                     sexual/reproductive organ
   ovarian cancer                                                       dysfunction
4. Instructs the client in self-                                     4. Implements a plan of care for
   care following interventions                                         a client with prostate or
   for cervical, uterine and                                            testicular cancer
   ovarian cancer                                                    5. Implements the following
5. Discusses problems of                                                skills:
   sexuality in clients who have                                          Care of continuous bladder
   undergone prostrate surgery.                                           irrigation

EVALUATION                          EVALUATION                       EVALUATION
1. Evaluates the effectiveness      1. Outcome Criteria for:         1. Reports and records
    of nursing actions designed        a. Adaptations in sexuality      significant changes in
    to:                                   and reproduction              sexual/reproductive patterns
    a. prevent complications           b. Adaptations to body        2. Develops outcome criteria for
    b. maintain or improve                image                         a client with a female
        current level of               c. Self care                     sexual/reproductive problem
        functioning                                                  3. Evaluates effectiveness of
   Evaluates the effectiveness of                                       teaching for clients with
   client teaching for a client                                         male or female sexual/
   with female sexual/                                                  reproductive problems
   reproductive dysfunction




                                                   17
     NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
                   URINARY AND RENAL FUNCTION
BEHAVIORAL OBJECTIVES               COURSE CONTENT                    CORRELATED LEARNINGS
ASSESSMENT                          ASSESSMENT                        ASSESSMENT
1. Assesses the client’s            1. Stressors affecting            1. Diagnostic tests
   genitourinary status.               elimination                       Blood chemistry
2. Assesses elimination/sexual      2. Assesses for alterations in:      Clearance studies
   reproductive patterns for             elimination, pain, gastro-      Bacteriologic studies
   presence of stressors that            intestinal symptoms, fluid      Radiologic studies
   precipitate genitourinary             balance, vital signs,           Angiogram
   dysfunction.                          emotional changes, Sexual       Cystoscopy
3. Assess the effects of                 dysfunction.                    Needle biopsy
   alterations in genitourinary        Effects of stress:             2. Analyzes alterations in
   function on physical and            a. Polycystic kidney disease      elimination
   psychological adaptation.           b. Renal calculi               3. Selects appropriate nursing
4. Assesses the client’s level of      c. Renal failure                  diagnosis for a client with an
   knowledge                           d. Dialysis                       alteration in elimination
                                       e. Transplantation
                                       f. Cancer
                                       g. Urinary Diversions

DIAGNOSIS                           DIAGNOSIS                         DIAGNOSIS
Formulate nursing diagnoses         Common Nursing Diagnoses for      Analyze Data and Formulate
based on a biopsychosocial          these disorders include           Diagnoses
assessment of clients with           Acute Pain
Urinary and Renal Dysfunction        PC Fluid and Electrolyte
                                            Imbalances
                                     PC Septic Shock
                                     Activity Intolerance
                                     Imbalanced Nutrition
                                     Disturbed Thought Process
                                     PC Metabolic Acidosis

PLANNING                            PLANNING                          PLANNING
1. Plans nursing care to assist     1. Formulate nursing diagnosis    1. Plans nursing care for a client
   clients in dealing with             based on assessment data          with alterations in urinary
   elimination concerns             2. Determines expected               elimination
2. Proposes alternate nursing          outcomes for individual        2. Formulates a plan for
   care measures to assist             Clients                           teaching for the client with an
   clients in adapting to                                                elimination impairment
   changes in physical and                                            3. Reviews established protocol
   psychological functioning                                             for clients receiving chemo
                                                                         and peritoneal dialysis
3.   Formulates a teaching plan                                       4. Incorporates homecare needs
     for prevention and                                                  as indicated
     management in a client with
     elimination dysfunction


                                                   18
BEHAVIORAL OBJECTIVES COURSE CONTENT                                 CORRELATED LEARNINGS
IMPLEMENTATION                   IMPLEMENTATION                      IMPLEMENTATION
1. Utilizes the nursing process  1. Adaptations to maintain          1. Implements a plan of care
   to maintain/improve the          function:                           for a client in renal failure
   client’s current elimination     a. Maintenance of fluid          2. Implements a plan of care
   status                              balance                          for a client having urinary
2. Manipulates the environment      b. Drug therapy:                    tract surgery or prostrate
   to prevent alterations in           electrolyte & vitamin            surgery
   elimination                         replacement                   3. Implements a teaching plan
3. Teaches principles of               diuretics                        for a client with an
   prevention and management           immunosuppressants               elimination problem
   to the client with a urinary     c. Minimize and manage           4. Implements the following
   tract infection or renal            complications of venous          skills:
   calculi                             access devices.                  a. Participation in care of
4. Instructs the client in self-    d. Diet therapy                          client undergoing
   care following urinary                                                    dialysis
   diversion                                                            b. Urinary diversion care

EVALUATION                         EVALUATION                        EVALUATION
1. Evaluates the effectiveness     1. Outcome criteria for:          1. Reports and records
   of nursing actions designed a.       Adaptations in elimination      significant changes in
   to:                         b.       stressors.                      elimination
                      b. Self-care
   a. prevent complications                                          2. Develops outcome criteria
   b. maintain or improve                                               for a client with a
        current level of                                                elimination problem
        functioning                                                  3. Evaluates effectiveness of
   Evaluates the effectiveness                                          teaching for clients with
   of client teaching for a client                                      sexual/elimination
   with elimination/sexual                                              problems
   problems




                                                  19
   NURSING MANAGEMENT OF CLIENTS WITH STRESSORS THAT AFFECT
                  NEUROLOGICAL FUNCTION
BEHAVIORAL OBJECTIVES               COURSE CONTENT                         CORRELATED LEARNINGS
ASSESSMENT                          ASSESSMENT                             ASSESSMENT
   1. Assesses the client’s         Stressors affecting cognitive-         1. Nursing history
      Neurological status           perceptual :                           2. Diagnostic Tests:
   2. Assesses cognitive-           1. Assesses for alterations in             X-rays/Cat scan, MRI, MRA
      perceptual patterns for            neurological status i.e.: level       Brain scan
      presence of stressors that         of consciousness, pupillary           Cerebral Angiography
      precipitate neurological           response, vital signs, motor          EEG
      dysfunction.                       and sensory functions,                Lumbar Puncture
   3. Assesses the effects of            mental status, speech,                Electromyograph, Nuclear
      alterations in neurological        headache, vomiting,                     Magnetic Resonance
      function on physical and           incontinence                          Positron Emission
      psychological adaptation      2. Effects of stressors                      Tomography
   4. Assesses the client’s level         a. Increasing intracranial       3. Analyzes the neurological
      of knowledge                           pressure                         Assessment- Glasgow Coma
                                         b. Altered level of                     Scale
                                             consciousness                 4. Selects appropriate nursing
                                         c. Neurological trauma:              diagnosis for a client with a
                                             head injury, spinal cord         neurological problem
                                             injury, ruptured
                                             intervertebral disc
                                         d. Cerebrovascular accident
                                         e. Degenerative Neurologic
                                             Disorders: Parkinson’s
                                             Disease, Myasthenia
                                             Gravis, Huntington’s
                                             Disease, Multiple
                                             Sclerosis, ALS, Gullian
                                             Barre
                                         f. Neurologic Tumors

DIAGNOSIS                           DIAGNOSIS                              DIAGNOSIS
Formulate nursing diagnoses         Common Nursing Diagnoses for           Analyze Data and Formulate
based on a biopsychosocial          these disorders include:               Diagnoses
assessment of clients with           Chronic Confusion
Neurologic Dysfunction               Risk for Injury
                                     Compromised Family Coping
                                     Impaired verbal Communication
                                     Disturbed Sensory Perception
                                     Unilateral Neglect
                                     Impaired Swallowing




                                                      20
BEHAVIORAL OBJECTIVES              COURSE CONTENT                   CORRELATED LEARNINGS
                                    PC Aspiration
                                    PC Seizures
                                    Impaired Physical Mobility
                                    Total Urinary Incontinence
                                    Bowel Incontinence
                                    PC Increased Intracranial
                                     Pressure
                                    Ineffective Airway Clearance
                                    Sexual Dysfunction
                                    PC Autonomic Dysreflexia
                                    Self Care Deficit
                                    Powerlessness

PLANNING                           PLANNING                         PLANNING
1. Proposes alternate nursing      1. Formulates nursing            1. Formulates a plan for the care
   care measures to assist the        diagnoses based on               of a client with a neurological
   client in adapting to changes      assessment data                  deficit
   in physical and                 2. Determines expected           2. Plans nursing care for a client
   psychological functioning          outcomes for individual          who is unconscious
2. Plans nursing care to prevent      clients                       3. Plans nursing care that
   complications of immobility                                         enables a client to
3. Formulates a teaching plan                                          maintain/restore or improve
   to assist the client with a                                         levels of
   neurological deficit to                                             physical/psychological
   perform A.D.L. with                                                 functioning
   maximal independent
   functioning

IMPLEMENTATION                   IMPLEMENTATION                     IMPLEMENTATION
1. Utilizes the nursing process  1. Adaptations to maximize         1. Implements a teaching plan
   to maintain/improve the          function                           for a client with a
   client’s current neurological    a. Positioning and use of          neurological problem
   functioning                         supportive devices           2. Implements a plan of care for
2. Manipulates the environment      b. Range of motion and             a client with a change in level
   to prevent complications of         other exercises                 of physical and/or
   immobility                       c. Use of ambulatory aids          psychological functioning
3. Implements care for the          d. Bowel and bladder            3. Assists client with exercise
   unconscious client                  training                        positioning, ambulatory
4. Teaches principles of            e. Inducing hypothermia         4. Implements the following:
   adaptation in A.D.L. to the      f. Halo Cast                       a. Neurological assessment
   client with a neurological       g. Diet/Drug therapy               b. Correct use of ambulatory
   deficit                          h. Support of psychological           aids
   Utilizes supportive devices         adaptation to long-term
   effectively to maintain             problems
   correct alignment in the         i. Emergency management
   client with alterations in          of head and spine injuries
   neurological functioning            j. CVA & stroke
                                           protocol


                                                  21
BEHAVIORAL OBJECTIVES             COURSE CONTENT                  CORRELATED LEARNINGS
                                  2. Cranial and Spinal Surgery
                                     a. Craniotomy
                                     b. Laminectomy
                                     c. Microdiscectomy

EVALUATION                        EVALUATION                      EVALUATION
1. Evaluates effectiveness of     1. Outcome criteria for:        1. Reports and records
   nursing actions designed to:      a. Neurological adaptation      significant changes in
   a. Maintain current level         b. Self-care                    neurological functioning
      of functioning                                              2. Evaluates progress based on
   b. Prevent complications                                          outcome criteria for a client
      improve level of                                               with a neurological problem
      functioning                                                 3. Evaluates effectiveness of
   c. Evaluates effectiveness                                        client- teaching for client
      of client teaching for                                         with neurological problems
      a client with
      neurological problem




                                                 22
NURSING MANAGEMENT OF CLIENTS WITH STRESSORS RESULTING FROM
             BURNS, DISASTER AND SHOCK STATES
BEHAVIORAL                     COURSE CONTENT                                 CORRELATED
OBJECTIVES                                                                    LEARNINGS
ASSESSMENT                     ASSESSMENT                                     ASSESSMENT
1. Assesses the client’s       1. Stressors affecting the recovery of         1. Diagnostic tests
   status in response to          clients experiencing burns, shock states       Trauma Workup
   stressors as a result of       and disasters                                   CBC
   burn injuries, shock        2. Assesses for alterations in: vital signs,       BS
   states and disasters.          intake and output, pain, lab values, burn       UA
2. Assesses airway,               areas,                                          ABG’S
   respiratory, circulatory,      triage categories.                              BUN, Creatinine
   elimination and             3. Effects of stressors:                           Electrolytes
   metabolic status.                   a. Burns                                   Culture &Sensitivity
3. Assesses the client for             b. Shock states                        2. Assesses fluid
   risk factors implicated             c. Disasters                              replacement
   in burn injuries, shock                     1. radiology                      Requirements to prevent
   states and disasters                        2. biologic                       and treat shock states
4. Assesses the burn area                      3. chemical                       and disasters
   various methods                                                            3. Formulates appropriate
5. Assesses the impact of                                                        nursing diagnosis for a
   physical and emotional                                                        client experiencing
   stress on clients                                                             burns, shock states and
   experiencing burns,                                                           disasters
   shock states and
   disasters
6. Assess for
   epidemiological
   clustering of disaster
   events
7. Assesses client’s level
   of knowledge related to
   burns, shock states and
   disasters

DIAGNOSIS                    DIAGNOSIS                                        DIAGNOSIS
Formulate nursing diagnoses Common Nursing Diagnoses for these                Analyze Data and Formulate
based on a biopsychosocial   disorders include:                               Diagnoses
assessment of clients with    Fluid and Electrolyte Imbalance
Burns/Shock States/Disasters   Acute Pain
                              Deficient Fluid Volume
                              Decreased Cardiac Output
                              Ineffective Tissue Perfusion
                              Ineffective Breathing Pattern
                              Ineffective Thermoregulation
                              Risk for Infection Transmission
                              Coping Ineffective Community
                              Risk for Post Trauma Syndrome
                              Powerlessness
                                                    23
BEHAVIORAL OBJECTIVES               COURSE CONTENT                      CORRELATED LEARNINGS
                                     Social Isolation
                                     Spiritual Distress

PLANNING                            PLANNING                            PLANNING
1. Proposes alternate nursing       1. Formulates nursing               1. Plans nursing care for a
    care to assist the client in         diagnoses based on                client/group experiencing
    adapting to changes in               assessment data                   burns, shock states and
    physical and psychological      Determines expected outcomes           disasters
    functioning                     for individual clients and groups   2. Reviews established practices
2. Plans nursing actions:           2. Internal/External disaster          for wound care of various
    a. to preserve joint mobility           plans                          types of burns
    b. to prevent spread of                                             3. Reviews established practices
        infection                                                          for care of clients in shock
    c. for early detection of                                              states and disasters
        shock and fluid overload                                        4. Develops a teaching plan for
3. Formulates a teaching plan to                                           self care
   prepare the client with burns
   or injuries from shock states
   or disasters to function at
   maximal level of
   independence

IMPLEMENTATION                      IMPLEMENTATION                      IMPLEMENTATION
  1. Implements a plan of care      1. Provides measures to prevent     1. Implements a plan of care for
     for a client with burn             and treat complications of         a client with burn injuries,
     injuries, shock states and         burns, shock states and            shock states and disasters
     disasters                          disasters                       2. Implements the following
  2. Promotes adaptation by         2. Adaptation to maintain              skills:
     encouraging optimal                function:                          a. wound care
     levels of independence             a. positioning                     b. fluid resuscitation
  3. Selects measures to                b. ROM                             c. system assessment
     promote and                        c. physical therapy                d. pain control
     maintain client’s              3. Airway maintenance and O2           e. therapeutic
     nutritional status                 administration                          communication
                                    4. Pain Management                     f. Isolation Precautions
                                    5. Fluid resuscitation to prevent               biologic
                                        and treat shock states, burns               radiologic
                                        and disasters                               chemical
                                    6. Decontamination
                                    7. Surgical Interventions
                                        a. Debridement
                                        b. Tissue Grafting
                                    8. Wound care, Sterile
                                        dressings
                                    9. Therapeutic Communication
                                    10. Drug/Diet Therapy
                                    11. Rehabilitation Program



                                                     24
BEHAVIORAL OBJECTIVES             COURSE CONTENT                CORRELATED LEARNINGS
EVALUATION                        EVALUATION                    EVALUATION
1. Evaluates effectiveness of     1. Outcome criteria for:      1. Reports and records
   nursing actions designed to:      a. self care                  significant changes
   a. Prevent complications          b. coping strategies       2. Evaluates progress based on
   b. Improve level of               c. response to treatment      outcome criteria
      functioning                                               3. Evaluates effectiveness of
    c. Determine effectiveness                                     client teaching
       of client teaching




                                                 25

				
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