Niagara County Community College Date

Nursing Education Name

Medical Diagnosis: ORIF L femur (MVA), alcohol abuse, heroin dependence, hepatitis
C
Surgical Procedure & date: N/A
Patient Initials: M.S. Age: 25Y Room: N/A Eriksons Developmental Stage: Intimacy Vs Isolation
B. Theoretical Need w/ Rationale C. Theoretical Nursing Approach D. Scientific Rationale for Approach
A. Brief Description of Pathophysiology Including Signs & Symptoms: Substance abuse can be defined as using a drug or substance that is
inconsistent with medical or social norms and despite its negative consequences. The DSM-IV-TR distinguishes substance abuse from
independence for medical diagnoses purposes. Abuse creates problems in social, vocational and legal areas of a person's life where
dependence includes problems associated with addiction including withdrawal, tolerance and unsuccessful attempts to quit substance. The
clinical course of treatment remains the same once withdrawal and detoxification have occurred, so the terms abuse and dependence are used
interchangeably at times. Alcoholism is one the America's greatest epidemics, effecting over 43% of families, reportedly. It is mainly studied
due to its ready availability and is only really studied on those who are seeking help. Alcoholism usually begins when the patient is between
15-17 years of age. They will have their first experience of intoxication, however the signs of dependence usually do not become apparent until
the patient reaches the age of late teens, and it becomes a significant hindrance to their life by mid-twenties to mid-thirties. This first sign of
alcoholic difficulties is as evidenced by an alcoholic related break up of a significant relationship, withdrawal, and arrest for public intoxication or
driving, early alcohol related health problems and difficulties functioning at school or work. The later courses of alcoholism results in periods of
abstinence, where the patient sets up limits to drinking (i.e. only beer, certain times) and this usually occurs after a life altering event has taken
place (arrest, family loss). Alcoholism is characterized by periods of remission and relapse, 60-70% of patients who attempted remission
remained sober after the first year, however most relapse in the second year. The exact cause of substance dependence is unknown however
many factors are known to be linked. These include: Biologic, children of alcoholic parents are more likely to develop alcoholism and drug
dependence, in part this is contributed to environmental factors, and part hereditary. This is supported by twin studies raised in separate
households. Neurochemical research conducted primarily on animals indicates stimulation of dopamine pathways, increasing euphoric feeling.
This creates a reinforced positive system. Some analysts believe that children of alcoholics are more likely to become alcoholics is due to
environment not facilitating coping mechanisms. Other factors to consider are cultural, social, and economic and peer behaviors.
Signs and symptoms of alcohol withdrawal begin 4-12 hours after cessation, including headache, nausea, vomiting, sweating, increased HR/BP,
insomnia, anxiety and untreated or progressing signs include anxiety, coarse hand tremors and seizures.
DSM-IV-TR diagnostic criteria for substance abuse: denial of problems, minimizes use of substance, rationalization, blaming others for problems,
anxiety, irritability, impulsive, feelings of guilt or sadness, poor judgment, limited insight, low self-esteem, ineffective coping strategies, difficulty expressing
genuine feelings, impaired role performance, strained interpersonal relationships, physical problems, sleep disturbances, inadequate nutrition.
Opioid addiction is a popular drug abused due to desensitizing the user's psychological and physiological pain, creating a sense of euphoria and
wellbeing. This class of drugs includes medically prescribed analgesics such as morphine, and illicit drugs, such as heroin. The user spends a lot of
time and illegal activity attempting to obtain drug, and medical professionals may write their own prescription to fill.
Signs and symptoms of opioid intoxication develops soon after euphoric feeling development; apathy, lethargy, listlessness, impaired judgment,
psychomotor retardation, agitation, constricted pupils, drowsiness, slurred speech, impaired attention and memory. Severe intoxication, or OD can cause
respiratory distress, coma, unconsciousness and death. Naloxone is given every few hours until serum levels drop below nontoxic to reverse all opioid
effects.
Signs of Withdrawal include anxiety, aching back and legs, opioid cravings. Progressing sx: nausea and vomiting, dysphoria, lacrimation, rhinorrhea,
sweating, diarrhea, yawning, fever, insomnia. These symptoms cause a significant amount of stress to the body, methadone can be used to decrease
symptoms. Heroin symptoms present 6-24 hours, peak 2-3 days.
Hepatitis C, caused by a virus, producing liver inflammation. The defining characteristics between the various forms of viral hepatitis is by the antigens
produced in serum blood work. HCV is an RNA virus primarily transmitted percutaneously, including among I.V. drug users.
Signs and symptoms include acute and chronic phases. Acute symptoms anorexia, nausea, vomiting, RUQ discomfort, constipation or diarrhea,
decreased sense of taste and smell, malaise, headache, fever, arthralgia, uticaria, hepatomegaly, splenomeglay, weight loss, jaundice, pruritus, dark
urine, bilirubinemia, light stools, fatigue. Chronic hepatitis: malaise, easily fatigued, hepatomegaly, myalgias/arthralgias, elevated liver enzymes.
ORIF procedure (open reduction internal fixation- surgery needed) surgical incision on lateral side to fix a potentially infected bone/broken bone,
secondary to MVA.

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B. Theoretical Need w/ Rationale
B. Theoretical Need w/ Rationale
1) Safety and Security R/T Altered mental
status secondary to illicit and alcohol drug use
Poor judgment and coping mechanisms
Cognitive Impairment
Lack or recall or memory
Risk for cardiovascular damage/failure
Left leg fracture/ORIF procedure
Developmental Considerations:
This age group is focused on finding
independence and niche in world while also
finding love and belonging, a sense of belonging
and focusing on a significant other and new
family. Activities may put client at higher physical
risk taking.
CBC w/ diff
Hgb 13.2-17.3g/dL
Hct 39-50%
RBC 80-100fL
WBC 4-11ul
platelet 150-400ul
neutrophils (40-60%), lymphocytes (20-40%),
monocytes (4-8%), eosinophils (1-3%), Basophils (0-
1%), bands (0-5%)
PT/INR
1-14sec, 25-35 sec, 0.8-1.2sec.
C. Theoretical Nursing Approach
C. Theoretical Nursing Approach
Assess for substance abuse history including
type of substance, amount and route upon
floor admission.
Assess patient's cognition of behavioral and
psychological effects of substance abuse Q shift
Collaborate with health care team to discuss
client's rehabilitation/12 step program eligibility
prior to discharge
Monitor patient for signs and symptoms of
alcohol/heroin dependence or withdrawal Q
shift
Health teach client the risks of I.V. drug use and
other risks with alcohol abuse Q shift or PRN
Preform and record random toxicology screens
as ordered
Identify the patient's behavior using ego defense
mechanisms to explain reasons of continued
substance abuse Q shift PRN
Spend time with patient, being sure to maintain
TCT Q shift
Preform neuro assessment Q shift or as ordered
D. Scientific Rationale for Approach
D. Scientific Rationale for Approach
This information provides background of client to
provide personal and effective teaching plan
for client. Client's habits may have changed
over time so using facility guided tools for
assessment is crucial to have full knowledge.
Many patients are accurate and informed
regarding the consequences of substance abuse,
but continue their habits. Ask patient first time
experienced being intoxicated.
These programs are effective in teaching client
specific coping mechanisms the patient can
use in their day-to- day routine, while providing
a sense of community and second chances.
Medications used during hospitalization help
decrease withdrawal symptoms such as
methadone and naltrexone. Signs of
symptoms, or cravings may continue to persist.
Risks of I.V. use include HIV/AIDS transmission,
CV and blood borne diseases. The toxic effect
of alcohol involves cirrhosis of the liver and
mental alterations.
As per facility/protocol/patient orders, support
and reward client for compliance.
Identified ego defense mechanisms, Projection
involves shifting blame from self, to forces
greater than. This stops patient from healing.
Patients who suffer from feelings of
worthlessness require a nonjudgmental
environment as negative feelings reduce
chance of full and lifelong recovery.
By assessing patient's pupil response,
cranial/facial nerve functioning, patent's
balance and gait, speech, affect and
cognition, the health care team may provide
most accurate treatment course.
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B. Theoretical Need w/ Rationale C. Theoretical Nursing Approach
Monitor patient's LOC and gait prior to and after
administration of narcotic medication Q shift
LFTs Monitor and assess any past or current medical
ALT 0.7-55U/L history pertinent to current hospitalization
AST 0.8-48U/L
Maintain seizure precautions and bed rest orders
ALP 0.45-115U/L at all times as ordered
Albumin 3.5-5 g/dl
Total protein 6-8.3mg/dl
GGT 0.9-48U/L Assist patient with ambulation and ADL set up as
needed Q shift
LD 122-222U/L
Monitor for signs and symptoms of worsening
hepatitis C Q shift
Monitor and assess patient for onset of tremors
Q shift
Monitor post op incision site and I.V. site for signs
and symptoms of infection Q shift or PRN
Provide safe environment for client Q shift
Monitor labs CBC w/ diff as ordered
Health teach patient appropriate mobility
techniques post op ORIF as needed
D. Scientific Rationale for Approach
Monitor patient's LOC prior to administration to
ensure coherency and ability to tolerate CNS
depressant. Monitor patient's ability to walk
and be left alone after administration of
medication.
Cognition improves as the body maintains health
and declines when underlying conditions are
not being addressed.
Alcohol withdrawal induced seizures may occur,
plan of care to include padded railings, no tight or
constrictive clothing, every 15 minute safety
checks.
Post medication administration, side effects
include light headedness, dizziness and
drowsiness. This increases risk for falls and
injury. S/P ORIF also decreases patient's
mobility.
Signs of worsening symptoms include yellowing
of skin, nail beds and sclera, pain to RUQ,
anorexia or bowel elimination changes as
inflammation continues to impact hepatic-
biliary system.
Monitor for hands and arms extended and spread
apart with rigid tremors are a sign of
progressing alcohol withdrawal.
Post op incision may become infected with
maltreatment/neglect to incision site.
Sporadic and jerk like motions can cause the
I.V. to tear.
Remove objects that can cause harm: sharp
objects, loose rugs and furniture, plastic bags
and kitchen utensils.
CBC with differential helps reflect any potential
blood loss, anemia and infection occurring
before symptoms present.
Not bending at hips, past 90 degrees and sitting
devices allow proper hip alignment for better
healing and decreased risk of further injury.
Maintain LLE abduction.
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B. Theoretical Need w/ Rationale
2) Self Esteem R/T Feelings of apathy
Lack of resources
Lack of insight
Perpetually low self-esteem state
Potential current state of denial
Failure to progress or maintain sobriety
Current hospitalization and immobility
Developmental Considerations:
This age group is most greatly focused with
where they fit in the world. Hospitalization and
loss of autonomy will decrease patient's level of
self-confidence.
C. Theoretical Nursing Approach
Monitor labs LFTs as ordered Q shift
Assess and record patient's use of denial,
rationalization and blame to sustain habit Q
shift
Be supportive towards patient's growing
awareness of substance abuse behaviors as
needed
Health teach patient and provide accurate
information regarding substance abuse as
needed
Encourage patient to attend behavioral therapy
sessions as available Q day
Health teach patient current use of Lorazepam
and methadone Q medication administration or
as needed
Provide physical assistance and set reminders for
patent as needed
D. Scientific Rationale for Approach
Liver function tests determine the livers
functionality. Imbalances can result from
hepatitis progression or complication to
medications given.
Excusing one's behavior, shifting blame to
another situation/individual or failure to
acknowledge the substance abuse even exists
are ways to avoid feelings of guilt and
responsibility through use of ego defense
mechanisms. This hinders the patient's ability to
successfully cope with original problems.
Positive support encourages patient to continue
seeking help through positive reinforcement.
Insight is the first step in recovery.
It is critical patients have accurate and
appropriate information when being treated for
substance dependence. The client's
understanding of withdrawal and detoxification
being the first steps to recovery are essential
to maintain sobriety.
Cognitive-behavioral therapies motivate patents
and prepare them to recognize and cope with
triggers and situations of cravings. AA provide
guidelines to help enable an alcohol free life in
the community.
Lorazepam labeled uses include management of
anxiety disorders, short term relief of anxiety,
pre-anesthetic medication, and management of
status epilepticus.
Methadone labeled uses include relief of severe
pain, for temporary relief and maintenance
treatment for federally approved programs for
narcotic abstinence syndrome.
The patient may feel overstimulated and out of control
with responsibilities due to short attention span.
The nurse can assist client by using short and
concise methods.
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B. Theoretical Need w/ Rationale
3) Nutrition R/T medication side effects including
nausea and vomiting
Inadequate resources
Potential financial troubles, limited income or
misused money
Physical symptoms of physiological withdrawal
Developmental Considerations:
Specific food likes and dislikes and eating routines are
not uncommon at this age. Lack of routine or lower
socioeconomic status may decrease patient's food
choices
C. Theoretical Nursing Approach
Use consensual validation and seeking clarification
while speaking to client
Promote leisurely activities involving the arts Q
day
Encourage patient to voice concerns and long
term goals Q shift and prior to discharge
Refer patient to community services and social
work home visits prior to discharge
Assess patients nutritional status Q shift or upon
admission
Assess and record patients skin turgor Q shift
Provide the patient several options when ready to
eat Q meal time
Monitor patient for nausea and vomiting Q shift or
as needed
Weigh patient Q week
Offer high protein and high calorie diet
D. Scientific Rationale for Approach
Forms of therapeutic communication, which allows the
nurse to convey reality in a nonjudgmental and non-
aggressive tone. Ex. Is it that you mean.. or I
don't understand what you mean by that.
By collaborating with therapists and social work,
the client can express feelings and find self-
satisfaction in finishing self-fulfilling project,
increasing awareness of coping strategies.
By patient keeping voice heard, increases
feelings of self-worth and preservation.
Personal goals should collaborate with health
care team's goals.
Community services to assist with medication
administration, doctors visits, and social work
to assist with finances during recovery phase.
This decreases stress to further promote
psychological healing.
By assessing general integument condition,
mucous membranes and activity level, the nurse
is able to determine if patients nutrition is
adequate.
Skin turgor is indicative of peripheral tissue
hydration. Normal turgor is brisk/instant.
Allowing the patient the choice of meals, the less
risk of agitation or noncompliance and refusal
to eat
A common side effect of medications prescribed,
can be adjusted with medications, times of
dosage and use of anti-emetic.
Patient with compromised liver function and drug
dependence can cause a decreased weight
secondary to altered protein and fat
metabolism and general anorexia.
High protein, calorie and green leafy vegetables
provide necessary required nutrition for
patients who may be experiencing anorexia
and decreased ability to obtain healthy
groceries.
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B. Theoretical Need w/ Rationale
CMP Alkaline 44-147IU/L, ALT 8-
37 IU/L, AST 10-34IU/L, BUN 7-
20mg/dl, Calcium 8.5-10.2mg/dl, Chloride
96-106 meq/l, CO2 23-29meq/l, Creatinine
0.6-1.3mg/dl, Glucose 70-
100mg/dl, Potassium 3.7-5.2
meq/l, Sodium 135-145meq/l, Total
Bilirubin 0.3-1.9mg/dl, Total protein 6-
8.3mg/dl.)
C. Theoretical Nursing Approach
Monitor attitudes towards eating and food
Provide companionship for patient during meal
times
Provide liquid nutritional supplements in between
meals Q shift
Monitor labs CMP as ordered Q shift
Discourage patient from drinking carbonated or
caffeinated beverages Q shift or PRN
Health teach patient to report sensation of
nausea prior to meal time Q shift
Assist patient to remain sober from alcohol
Administer medication thiamine 100mg PO Q
day
Nursing record patient's diet history and risk for vit
B deficiency, develop a diet and teaching plan
prior to discharge (1479)
Thiamine deficiency noted in alcoholics due to
alcohol properties metabolizing vit B
complexes
D. Scientific Rationale for Approach
Many psychological factors partake in addiction
and decreased appetite. The two are
interlinked more often than not. Collaborate
with social work to address patients financial
and housing situation to better nutritional
intake at home.
Attention and social aspects of eating is
important in appetite
These supplements can be used to increase
calories and protein without interfering with
voluntary food intake, that may be
compromised currently (secondary to
substance withdrawal, medication adverse
effects)
CMP labs indicate fluid and electrolyte balance.
Imbalances may indicate poor/inadequate
nutrition or a physical ailment occurring.
Caffeine and carbonated beverages can irritate
and increase surface space in stomach,
decreasing patients appetite.
Administer anti-emetic 30 minutes prior to meal
time to decrease potential nausea, increasing
food tolerance and nutritional intake
Alcohol provides empty calories and damages
liver. Positive reinforcement will encourage
patient to remain sober.
Vitamin B1 replacement.
Side Effects- feelings of warmth, weakness, sweating,
restless, tight throat, cyanosis, pulmonary edema,
GI hemorrhage, uticaria.
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B. Theoretical Need w/ Rationale
4) Sleep, Rest and Activity R/T acute pain secondary
to MVA, ORIF and potentially hepatic RUQ discomfort
Impaired mobility secondary to s/p LLE ORIF
Activity intolerance secondary to heroin use and
Cardiovascular damage
Hospitalization and
Physical and psychological symptoms of substance
withdrawal, affecting sleep patterns and comfort.
C. Theoretical Nursing Approach
Administer medication Folic acid 2mg PO Q day
Nursing- Obtain careful history of diet, including
drug and alcohol intake prior to therapy, monitor
for patients on phenytoin for sub therapeutic
plasma levels, monitor for therapeutic effects
(666)
Administer medication Magnesium sulfate 1
Gm in 50ml NS IV solution Q 6 hours
Nursing- Monitor serum labs periodically, monitor
BP and HR closely during IV administration,
monitor respiratory rate closely and urinary
output. (Pg 916)
Magnesium therapy due to increase free fatty acids
with ETOH withdrawal, magnesium deficiency.
Preform pain assessment Q 4 hours or PRN
Assess for probable cause of pain with Q pain
assessment
Monitor patients response and coping to pain
experienced Q shift
Health teach patient to disclose all illicit and
prescription drug use for appropriate dosing of
medications during hospitalization
D. Scientific Rationale for Approach
Vitamin B9, supplement, essential for nucleoprotein
synthesis, and maintenance of erythropoiesis.
Leads to megaloblast formation and arrest of bone
marrow maturation.
Side Effects- rash, irritability, difficulty sleeping,
malaise, confusion, fever.
Saline cathartic, electrolyte replacement,
Anti consultant. Acts as a CNS depressant and
retains water in the small intestine producing
more water content of feces and distends colon.
Side Effects- flushing, sweating, extreme thirst,
muscle weakness, decreased or absent reflexes,
hypothermia, depressed cardiac function.
Utilizing (quality, severity/scale, location, onset,
duration and precipitating or relieving factors)
PQRST, is the first step in planning care
appropriately to plan care reducing pain.
Different etiological factors present differently and
respond differently to medication and nursing
interventions. Hepatic pain may represent as
dull and persistent ache to RUQ. LLE post-
operative pain is better managed with PRN
analgesics and position change.
A patient with a history of substance abuse can
have an increased medication tolerance,
requiring an increased dose or more health
teaching regarding non pharmacological
measures. Patients ability to cope with current
pain and situation is indicative of likelihood of
full sober recovery.
Increased drug use can create a broader drug
tolerance, so the medication used in acute pain
sustained after MVA, is less effective.
8
B. Theoretical Need w/ Rationale C. Theoretical Nursing Approach
Monitor patients objective symptoms of pain
Developmental Considerations: prior to and after medication administration
This age group is focused on socialization and
meeting new people, going to new places and
experiencing new things. Lifestyle at this age is active
and may not be inclined to sleep as long as
recommended.
Health teach patient non-pharmacological
techniques to decrease pain as needed Q shift
Assess patients readiness to adapt new lifestyle
choices and coping mechanisms into daily
routine Q shift
Evaluate what pain means to individual client as
needed
Engage patient in one to one activities with nurse Q
shift
Engage patient in solitary games, during rest times
Cluster care during patient rest periods and
D. Scientific Rationale for Approach
Objective symptoms include increased heart rate,
BP, RR and temperature. Agitation,
restlessness and irritability may all also be
signs of pain intolerance. Assess level of pain
prior to administration to compare therapeutic
effects. Monitor objective signs after
administration to ensure medication
intervention is effective.
Non-pharmacological techniques to reduce pain
include deep breathing, turning and
positioning, mind distracting activities, ice and
heat therapy. This gives the patient additional
coping strategies after discharge.
Utilizing ego defense mechanisms such as
resistance, rationalization, intellectualization,
dissociation, conversion and denial may all be
seen when patient is attempting to protect the
ego from accepting realities of being addicted.
A client with substance abuse may have a
lowered pain tolerance and expect a total
elimination of pain, while others may be
satisfied with a decrease in pain experienced.
Managing clients personal pain management
goals furthers chances of remaining sober with
appropriate pain management and coping
techniques.
The nurse patient relationship is a controlled,
professional and approachable relationship that the
patient can find comfort and routine with. Utilizing
large muscle groups to alleviate tension
As the patient heals from S/P ORIF, bed rest is
ordered and can create boredom and feelings
of stirring. Mind intensive and age/cognitive
appropriate games are a good activity so
patient does not focus on pain or hospital stay.
Clustering care during HS and periods of patient
rest/alone time decreases mental stress
experienced by patient and promotes rest.
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B. Theoretical Need w/ Rationale C. Theoretical Nursing Approach
Administer medication Ativan
Nursing- supervise ambulation, CBCs, LFTs
( )
Administer medication Methadone
Nursing- assess pain using PQRS 1-2 hours
after administration, monitor for signs of
withdrawal, measure VS prior to
administration, monitor for signs of
dependence, monitor bowel elimination
pattern, may increase serum amylase and
lipase levels, monitor for toxicity/overdose.
(Davis Pdf)
5) Elimination R/T constipation and diarrhea Assess usual pattern of elimination and compare
secondary to medication side effects with current pattern Q shift
Inadequate hydration and nutrition
Cardiovascular compensation, potential anemia
Evaluate dietary habits, prior to and during
Post-anesthetic adverse effect: constipation, hospitalization Q shift
decreased motility, appetite
Developmental Considerations: Preform abdominal assessment via IAPP as
Easy and regular GI motility, peristalsis and elimination needed
is expected with this age group
Urinalysis Color/Odor amber/yellow and
odorless/aromatic
Protein 0-trace Assist patient to and for privacy of elimination Q
24 hr pro <150mg/day shift
Glucose/ketones none
Bilirubin none
Encourage an increase in fiber to diet Q day
Specific Gravity 1.003-1.03
Osmolality 300-1300 mOsm/kg
ph 4-8 Monitor void and BM for color and consistency
RBCs 0-4/hpf changes
D. Scientific Rationale for Approach
Lorazepam- anxiolytic, sedative-hynotic,
benzodiazepine
Side Effects- amnesia, drowsiness, weakness,
depression, hyper/potension nausea, vomiting,
abdominal distention.
Opioid analgesic
Side Effects- confusion, sedation, dizziness,
dysphoria, euphoria, floating feeling, blurred
vision, headache, unusual dreams, diploplia,
miosis, respiratory depression, torsades de
pointes, decreased HR/BP, prolonged QT,
nausea, vomiting, constipation, urinary retention,
flushing, sweating, physical dependence,
psychological tolerance
Medications such as methadone decreased GI
motility, increasing risk for constipation. By
comparing the two patterns, the patient is able
to determine if there has been a change.
Dietary increase, decrease or change in quality
of food will typically reflect through bowel and
urine elimination.
Symmetrical, no scars, positive bowel sounds x4
quadrants, tympany and soft, non-distended and
non-tender abdomen are normal findings. No
changes are expected at this time. Potential
RUQ d/t hepatitis. Preform assessment at time of
new symptom or complaint.
Patient may feel weak or dizzy secondary to
medications, privacy is essential to maintain
patient dignity and cooperation. Assist with
bed pan during bed rest orders as needed.
Raw fruits, vegetables and whole grains passes
through GI system well, absorbing water from
large colon and facilitating BM easier.
Darkened urine and light colored stool is
indicative of worsening Hepatitis C as
hyperbilirubinemia occurs.
1
B. Theoretical Need w/ Rationale
WBCs 0-5/hpf
Casts/Cultures none (Lewis
GFR >60
BUN 6-20mg/dL
6) Oxygen R/T post op ORIF, decreased blood
supply to LLE
Post-anesthetic respiratory depression
Medication adverse effects- respiratory
depression, cough
I.V. site 100ml/hr D5 NS
Developmental Considerations:
Easy and regular respirations, healthy and functioning
cardiovascular system expected. Adult and matured
functioning without wear and tear of aging process.
C. Theoretical Nursing Approach
Monitor labs urinalysis, creatinine clearance,
specific gravity and GFR/BUN as ordered Q
shift
Monitor and record I+O Q shift
Monitor vital signs Q 4 hours
Perform Lung assessment Q 4 hours utilizing IPPA
Monitor patient for signs of pallor and cyanosis in face
and extremities Q shift
Assess LLE for sensation, peripheral pulses,
cyanosis/pallor and
Health teach patient to cough and deep breathe
Q shift or as needed
Assist patient with turning and positioning Q 2-3
hours as needed
D. Scientific Rationale for Approach
These labs indicate renal, hepatic and GI
function. Abnormal levels to be addressed.
Medications such as methadone can cause
urinary retention. Tally intake including I.V.
fluid and all output including emesis (adverse
drug effects, withdrawal, post-anesthesia) and
void to assure numbers are equal.
Vital signs reflect physiology of body,
cardiovascular system and coping/tolerance
the body has against external world. Report
fever, increased or decreased RR, HR and BP
as these are indicative of drug toxicity or
withdrawal.
Utilizing the steps inspection, palpation, percussion
and auscultation, the nurse has a full and
comprehensive understanding of the patient's lung
status. Use this method with any new complain
offered, cough present, etc.
A sign of decreased peripheral oxygenation.
On the post- operative peripheral extremity, there
is responsive inflammation to tissues, increasing
blood flow but ultimately with compromised
circulation. Ensuring patient has tactile
sensation, a dorsal pulse and appropriate color
and temperature promotes good healing.
As patient remains on bed rest, lung secretions
may sit in airway tract for longer periods of
time. Health teach patient to breathe in deeply,
and somewhat forcibly cough to exhale. This
procedure removes any stagnate mucous in
airway, promoting clear lungs.
Continued bed rest, acute post-operative pain
and depressed affect can contribute to
increased sleeping or lack of motivation to
better ones self. Turning in bed helps promote
lung clearing and peripheral circulation.
1
B. Theoretical Need w/ Rationale
7) Love and Belonging R/T Poor self-concept,
ineffective coping
Separation from family
Euphoric and depressive feelings secondary to
substance use
Manipulative and irrational behavior, recent MVA
Family dynamics affected by substance abuse
Hepatitis C diagnosis and lifestyle restrictions
Developmental Considerations:
This is this age group's highest concern. Forced
separations with loved ones due to syndrome
process or hospitalization can be emotionally
taxing
C. Theoretical Nursing Approach
Monitor patients peripheral extremities to
address any potential cardiovascular damage
Q shift or upon admission
Monitor patient for change in LOC Q shift
Assess patient for signs and symptoms of
anemia Q shift
Establish theoretic nurse to client relationship Q
beginning of shift and throughout patient admission
Involve family and friends of client in plan of care Q
shift
Health teach patient rehabilitation programs and
options in and near community prior to discharge
Assess patients readiness to learn and provide
initial information on substance abuse
Maintain use of TCT with each interaction with
client
Monitor close personal relationships client has
with hospital visits
D. Scientific Rationale for Approach
If past heroin use was administered
intravenously, circulatory collapse may have
occurred in certain areas of the body from
repetitive toxic exposure. Assess heart on
ECG or rhythm to address any cardiac
abnormalities.
LOC change is sometimes the first sign of
hypoxia. Post-anesthesia, current medication
use and withdrawal symptoms can depress
respiratory rate.
Alcohol abuse destroys RBC quantity in blood,
while poor nutrition typically coincides with
substance abuse, decreasing any nutritional
value for body.
By establishing and providing a professional and calm
environment, met to meet the client's needs to
establish trust.
During care plan meetings, the health care team is
able to communicate any familial dynamics that
may be a concern for the patient, other support
members for the patient may be a great source of
patient's behavioral patterns for the staff to know.
Drug rehabilitation programs in WNY include Horizon
health services, McAuly residence, and
Reflections recovery center provide dynamic,
interpersonal therapies inpatient and outpatient to
suit each clients needs, increasing chance of full
recovery.
If the patient is experiencing acute withdrawal, it
is an inappropriate teaching time. After
detoxification, address patient in a non-
demanding fashion.
TCT uses non-judgmental and professional tone
to address patients intimate details of life, so
the nurse can objectively and therapeutically
assist patient in recovery
Relationships that cause patient strain can cause
stress and relapse.
1
B. Theoretical Need w/ Rationale C. Theoretical Nursing Approach
Interview patient if there is a history of substance
abuse in family
Refer patient to specialist or therapist prior to
discharge
D. Scientific Rationale for Approach
Substance abuse is more common within family
dynamics due to biological and environmental
factors.
Referring patient to appropriate therapist
(regarding age, past experiences and
substance use) will benefit patient only if
appropriately suited for individual needs.

Works Cited

Shiela L. Videbeck, Psychiatric-Mental Health Nursing, 5 th edition, 2011, Lippincott Williams and Wilkins

Wislon, Shannon, Shields, Nurses Drug Guide, 2012, Pearson

Davis PDF, EA Davis Company 2015