NURSING CARE PLAN IN PATIENT WITH MULTIPLE BONE AND PULMONARY

METASTASIS SRINAGARIND HOSPITAL KHON KAEN

279 731 Advanced Nursing Practice in Selected Areas of Interest 1 (Adult 1)
Presented to:
Assoc Prof. Dr. Earmporn Thongkrajai

Meida Laely Ramdani

565060129-2

Master of Nursing Science Program

Faculty of Nursing, Khon Kaen University
First Semester, Academic Year 2014

CLIENT ASSESMENT WITH MULTIPLE BONE METASTASIS IN ACCIDENT AND

EMERGENCY WARD 2, SRINAGARIND HOSPITAL KHON KAEN
A. HEALTH HISTORY
Assessment at 28 August 2014
1. Client Profile
Mrs. N. is a 27 years old, She lives with her husband and 2 doughters in Nong Khai. The
first doughter is 2 years old and the second doughter is 8 month. The Major reason for
seeking health care in Srinagarind Hospital is severe pain in her low back (right hip)
especially in the right side. She arrived at Srinagarind Hospital at 21 August 2014, with
the major reason severe pain in her hip and low back bone. She feel severe pain at least 5
month ago. At present her blood pressure: 127/73, Pulse rate 105 perminute, respiratory
rate: 20 perminute and temperature: 38.39 0C. Laboratory record: Hb : 7 , Haematocrit:
24.4 (normal: ), RBC: 60,400 (Normal: ), Platelet: 686. 000 (normal: ), Neutrofil: 92
(normal: ), Basofil 3 (Normal: ), Monocyte: 3 (normal: ), WBC: 3 (normal: )
2. Treatment/Medication
Before she wents to Srinagarind hospital, she cames to the many doctor which is closer
from her house. But the result after the medication was same, the pain was not relieve yet
and still severe.
3. Past illnesses/Hospitalizations
She never hospitalized before. The sickness is started from April in this year. She said
that before she gots sickness in her lower back bone, she was very often bleeding on her
vaginal, and after coitus the bleeding was occur. This cases she felts about 5 months ago.
4. Allergies
She said that she does not have any allergy from foods, drinks, or drugs.
5. Developmental History
She has 2 sisters and she is the second. She grew up with the family who very love her.
Her parentss home is far from her home, but she often visit to her parents, and sometime
her parents visited to her home. She has 2 doughters and husband who very love her, live
together in a home. She did not get the sickness like this before.

6. Health Perception/Health Management Pattern

Before she gots shick, 5 years ago rated at 9, but now the rate is 3: sefere pain, and not
good. She could not doing the daily activities as usual. Understand that she has disease,

and the kind of the disease. If she got sick she went to the doctor or health care services.
Pain is very severe and she expect that she will get sick for a long time after hospitalized.
7. Nutritional/metabolic
Height: 158 cm
Weight: 50 kg
Ideal body weight: 20 (normal)
She loss her weight 6 kg/4 month
Usual eating pattern: before sick she has a good appetite, eat three times a day, and eat
some snack. But during sick, if she feel severe pain she do not want to eat. Sometime if
she feel anxiety about her sickness she has not appetite. She has a braces in her teeth.
Does not wear dentures. Nails hard and smooth, normal skin turgor, no dehydration signs.
No recent hair loss or change in texture. She used hair color, and the color is reddish.
8. Elimination Pattern
Bowel habits: she said that I dont have problem with bowel pattern, before sick and
hospitalized I have at least once bowel movement a day (soft and brown), no mucus, no
blood, or tarry stool, no rectal bleeding. But since I hospitalized once bowel movement 2
days.
Bladder habits: before sick 2-5 a day and since she is sick 2-5 a day.
9. Activity Exercise Pattern
States she arises at 06.00, does her chores around the house, cooking, bathing to her child
doughters and eats breakfast with her husband and feeding the daughters. Has no regular
exercise regimen, just take a rilex time with her douhgters. She never doing the exercise
after she gots married and has a baby.
10. Sexuality Reproductive Pattern
Obstetric history: gravida 2, para 2, abortion 0
Two doughter the still toddler, living together in her house.
11. Sleep/Rest Pattern
Before sick, goes to bed at 10.00 pm and awaken at 06.00. But now, she has problem with
her sleep pattern because discomfort in her severe pain in her lower back bone. Sometime
sleep only 2-3 hour in the night, and she tried to sleep again but could not. She has dark
circle under eyes, and looked pale. She sleep with one pillow, and use soft pillow to prop
her right leg, to make it comfort and relieve the pain.
12. Sensory/Perceptual Pattern
Vision: she has not any problem in her eyes, still clear to see. No discharge, redness
or trauma to eyes.

Hearing: she has not problem in her ears. She does not wear any hearing aids. Does

not ask for question to be repeated at normal healing level.

Smell: states she has no decrease in smell. No allergies, nosebleeds, or discharge
Touch: The pain area feel comfort and feel better if some one touch and give the soft

massase in the back area and her right leg.

Pain: admit pain in her lower hip and lower extremity, and the right side more severe
than the left side. I feel very pain if I move my body. I can not walk, I just lye down

in the bed. I need some one to help me if I want to sit, I can not do it by my self.
13. Cognitive Pattern
Speech clear without stutter. Word choice appropriate to education and culture. She

can speaks English well and fluently. Follows verbal cues

Examines ideas clearly and concisely. Recalls past events without difficulty, oriented

to time, place, and person, and communicative.

She dont have a problem in her cognition.
14. Role/relationship Pattern
Married for 3 years. Lives with husband and her 2 little doughters, the first one 2 years
old, and the second one is 8 month. Her husband very loves her, and take care of her and
their doughters. When she is hospitalized, her husband take care of the doughter at home.
Now, she is very miss her doughter, and she was crie when she told to the nurse. Pain is
very severe and she expect that she will get sick for a long time after hospitalized. And
she can not take care of her doughter and serves her husband completely. So that she has
plan if she can not take care of her doughter by her self, her mother will take care of
them. And she already offering for her husband, if she can not serves completely as a
wife, he can seeking other women to be his new wife and get married, but her husband
will not.
15. Value Belief Pattern
Religious orientation is Budhist.
16. Coping/Stress Tolerance Pattern
She states that I am very stress, I do not know what will I do now and after this, I will
get sick and severe pain for a long time. I can not doing anything. If I am up to 35 years
old is okay if I get sick like this, but I am 27 years old, I am a younger mother, I have two
babies, I have a husband and she cried when she told to the nurse.
B. GENERAL PHYISICAL ASSESMENT
General physical survey

Height: 158 cm , Weight: 50 kg Ideal body weight: 20 (normal), she loss her weigh 6

kg/4 months.
Body Temperature: 38.39 0C, pulse 105 perminute, respiratory rate 20 x/mnt Blood
pressure: 127/73 mmHg, client attentive and cooperative. Lying down, on supine,
sometime semi fowler if she got tired and the right leg prop with pillow. Sometime
her face shown like holding pain, gramicing, and hold the pain area. Feel severe pain

in her right hip and low back bone, scale of the pain is 9.
17. Assesment of Skin, Hair and Nails
Skin: dark brown color, consistent throughout the body. Temperature warm on hands,
arm, leg, and the back. Skin smooth, no dehydration sign, sometime itching because

sweating, and the skin wet. No edema

Hair: She has a long black hair, and thick. She used hair color, and the color is reddish.

No recent hair loss or change in texture.

Nails: fingernails short, thick and clear. No clubbing or Beaus lines. Normal Capillary
refill (<3 second)

18. Assesment of Head and Neck

Head symmetrically rounded, neck with full ROM, and nontender. No scars, masses or
pulsation. Trachea midline. Carotid pulse -2 + bilaterally without bruits, can rise
eyebrow, and smile (CN VII intact)
19. Assesment of Eye and ear
Normal eye: equal size and shape bilaterally. No swelling, redness, or thickening.
Ear: Color of the skin ear consisten with color of skin on face. No lumps or lesions.
Nontender bilateraly. Mastoid process palpation no pain. Do not has problem in her
ear.
20. Assesment of Nose and Sinuses
Nasal septum: midline without bleeding or perforation, no inflammation on skin
lessions. Frontal and maxillary sinuses non-tender bilateraly.
21. Assesment of Mouth and Pharynx
Do not find any problems in mouth and pharynx.
Lips moist, sometime dry, no lesion or ulcerations. Hard palate smooth without
lessions and masses.
Tongue midline when protruded, no fasciculation intact, no masses or lesions.
She uses bracec in her teeth.
22. Assesment of Heart
5

 No visible pulsation, heaves, lifts, or vibrations.

S1, S2 sounds, heard no splitting sounds, murmurs, gallops, or rubs.
23. Assesment of Pharipheral Vascular system
Arms: equal in size and symmetry, warm and dry to touch bilateraly, no edema or

lesions.
Radial pulse 122 perminute, and regular
Amplitude of radial and brachial pulse 1+ bilateraly.
Epitrohlear nodes unpalpable
Capillary refill time < 3 second
Legs: equal in size and symmetry, warm in right leg.

24. Assesment of Thorax and Lungs

No visible pulsation or lesion present. No use of accessory muscles of respiration, no
nasal faring, tenderness, or masses
Respiration 22 perminute and regular. Neither cough nor adventitious sounds.
Tactile fremitus equale bilateraly.
Toenails soft. Capillary refile < 3 seconds
25. Assesment of Breast
Breast symmetrical in size. No masses, lesions, tenderness on palpation bilateraly. No
dimpling or inverted nipples.
26. Assesment of Abdomen
Abdomen:, have a stretch mark.
Umbilicus midline without swelling or discoloration.
Sometime feel vomiting.
Bowel sounds presents in all four quadrants.
27. Genitourinary Assesment
Public hairs sparse. Vaginal bleeding, after coital bleeding, abnormal discharge in her
vagina.
28. Musculosceletal Assesment
Patient can not walk, can not sit by herself, upper extremity have full range of motion,

but in lower extremity is not. The left leg can to move but in right side is not.
Lower extremities: in rights leg is warm to touch, complaint of radiating pain in all of

her right leg and right hip joint, the scale is 9.

The left side of her hip has insition wound because had been operation procedure 3
days ago (25 August 2014).
6

 Caseas bone at right acetabular + pelvis

No abnormal soft tissue lesion (after biopsy)
29. Neurologycal Assesment
Neurological status: oriented to time, place, person, and events.
Facial expression correlates with state of health and topic being discussed (appears
somewhat sad, happy, anxious)
Speech clear and coherent
Questions anwered appropriately
Long-term and short-term memory intact
Cooperative throughout interview, vocabulary correlates to educational level.
Asked appropriet question relevant to illness and answered all question posed.
CN I-XII intact and integrated
C. SUPPORTED ASSESMENT
1. MRI of Thoracic Spine, at 09 June 2014
Finding:
S/P T4 laminectomy
The studt reveals normal thoracolumbar curve. Normal marrow signal intensity of
remaining thoracic vertebral body is seen. The vertebral dises, vertebral endplates are
within normal limits. No evidence of spinal cord intensity change, spinal cord
compression or verve root compression is detected. No intradural collection/abscess is
noted.
The remaining vertebral dises and vertebral ebdplate are unremarkable.
The conus medullaris is at L1 level with normal apperarance. A 4.6 x 1.1 cm
rimenhancing lesion at surgical subcutaneous back tissue is noted.
Impression: no evidence of intradural or epidural abscess/collection.
No evidence of spinal cord intensity change, compression or nerve root compression.
A 4.6 x 1.1 cm rim enhancing lesion at surgical sub cutaneous back tissue, psor operative
change/seroma.
2. MRI of Lumbosacral Spine, at
History: low back pain.
Finding:
The study reveals decrease normal lumbar lordotic curve. Minimal marginal
osteophytes at L1-L3 are seen. No collapse vertebral body or bony destruction is
detected. There is decrase normal high S1 on T2W of L1/2 disc; some degree of
dehydrating disc. Mild narrowing L1/2 intervertebal disc space is found. No vertebral
subluxation is observed.
Bulging L1/2 disc causes narrowing spinal canal without nerve root compression.
Mild bulging L2/3 disc causes mild narrowing spinal canal without nerve root
compression.
7

Small Schmorls nodes at upper L2, L3 vertebral bodies.

No facet joint or ligamentum flavum hypertrophy.
Top of conus medullaris terminates at L1 level.
Visible mass at cervix (4.8 x 4.3 cm) with intermediate S1 on T1W and high S1 on T2W.
Impression:
Bulging L1/2, L2/3 disc cause mild lumbar stenosis without nerve root

compression.
Schmorls nodes at L2, L3.
A 4.8x4.3 cm mass at cervix; Ca cervix cannot be exluded---please correlated

withtissue pathology.
3. Laboratory summary
Routine Hematology
No
.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

No.
1.
2.
3.
4.
5.
6.
7.

Test

20/08/2014

21/8/2014

27/08/2014

28/8/2014

30/08/2014

Hb
Hct
Wbc
Plt.
PMN
Lympho
Mono
Eos
Baso
Aniso
Poikilo
Polychro
Target
Microcyte
Macrocyte
Hypochromia
Retic count
PT
PTT
Other (LNR)

6.5
27.1
42.920
698.000
42.8
5.5
2.1
0.2
0.1
2+
Few

8.6
27.1
72.940
673k
91.8
4.6
3.5
0.1
0.1
2+

8.9
28.2
46.200
622k
64
27
11
6
6
few

4.7
24.4
60.400
686k
9.2
3
2
0
0

Few
2+

8.1
25.2
57.000
557k
84
8
5
0
0
1+
Few
Few
Few
1+

1+

2+

Test
BUN
Cr
Na
K
HCO3
Cl
Ca

Normal
5.8 19.1 mg/dL
0.5 - 1.5 mg/dL
130 - 147 mEq/L
3.4 - 4.7 mEq/L
20.6 -28.2 mEq/L
96-107 mEq/L
8.4-10.2 mg/dL

1+
few
2+
few
2.88

14.9
26.8
1.4

20/08/2014
6.9
0.7
138
3.6
22.5
98
8.8

8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

PO4
Chol
Tot Prot
Alb
Glob
DB
TB
ALT
AST
Alk phos
CK
Mg

2.5 4.6 mg/dL

127 262 mg/dL
6.5 8.8 g/dL
3.8 5.4 g/dL
2.6 3.4 g/dL
0 0.5 mg/dL
0.25 1.5 mg/dL
4 36 U/L
12 32 U/L
42 121 U/L
25 200 U/L
1.6 2.6 mg/dL

3.0
172
7.1
3.4
4.0
0.1
0.3
7
11
123
17
1.9

URINALYSIS
TEST
Sp gr
PH
Albumin
Glucose
Ketone
Blood
Bile
Urobile
RBC
WBC
Epi.sq

21/8
1.007
6.5
2+
50 100
5 10
0-1

23/8
1.007
7.0

30/8
1.009
7
-

0-1

Normal

4. CLINICAL HYSTORY (date of report: 29 August 2014):

Patient present with abnormal uterine bleeding., PV found exophytic mass at 1 oclock
with contact bleeding with history of chronic hip pain, investigastion found osteolytic
lesion at right acetabulum.
CLINICAL DIAGNOSIS: servical mass with vaginal bleeding and osteolytic lesion at
right acetabulum
PATHOLOGY DIAGNOSIS:
Cervix, biopsy: Squamous cell carcinoma, large cell, non-keratinized
GROSS EXAMINATION: received in formalin are three pleces of firm white tissue
measuring 1,2x1x0.5 cm. all are submitted as 1A5.
MICROSCOPIC EXAMINATION:

Section reveal sheets of malignancy cells showing marked pleomorphic nuclei, prominent
nucleoli, scant to moderate amount eosinophilic cytoplasm with identifiable intercellularbridge, numerous mitoses are noted/
Clinical Summary Departemen Orthopaedi (Attend: 5 Sept 2014)
Case cancer servix with bone metastases have fever since admit 21 August 2014, Body
temperature: 38, 39 0C.
D. MEDICATION
No
.

Type of Drugs

1.
2.
3.

4.
5.

Dose

1st week
Morphin
Morphin
Pre operation for biopsy:
NPO AMN 5% DN/2
Cefatoxim
Cbc
Reticoal
Morphin 2 mg (v)parenteral for BTP
Nurontin
Paracetamol

Note

2 mg
3 mg (v)

every 4 hour
(24/8/14)

1000 ml
1 gr

300 mg

DATA ANALYZE :
No. Medical Record:
Age: 27 years old

No
.
1.

Oredered & Selected data

SD:
client states feel severe pain in right hip
and lower, back bone, the scale of pain was

Problem
Chronic pain

Etiology
Disease process: multiple
bone metastase

10

9, and quantity of pain is very often

OD:
Pulse rate: 122/minute, Temperature: 39
0
C, Blood Pressure: 132/80 mmHg.
Facial mask of pain
Heat in area of pain
MRI of lumbosacral:
Decrease normal lumbarlordotic cureve.
Minimal marginal osteophytes at L1-L2
Comppresiion: bulging L1/L2 disc causes
narrowing spinal canal without nerve root
compression, Mild bulging L2/3 dis causes
mild narrowing spinal canal without nerve
root compression, small schmorls nodes
at L2 L3
A 4,8x4,3 cm mass at cervix; Ca cervix
cannot be exluded
Guarded position
2.

3.

4.

5.

SD:
Client states sometime I unappetite if severe
pain arises, loss body weight 6 kg/4
month
OD:
Albumin : 3.4 g/dL (normal: 3.8 5.4 g/dL)
Patient lye down and look weak
BMI: 20 (normal)
SD:
client states:
last night I slept only 2 hours, I tried to sleep
again but could not. If I feel pain, I could not
sleep
OD:
Dark circle under eyes and look concave in
around eye
Looked pale
Pulse rate: 122 perminute
S:
Client states I can not walk, I can not sit by
my self,
O:
Patient inability to reposition self in
bed
Patient can not to move from supine
to prone
Patient can not to move from supine
to sitting.

Risk for Inadequate

Nutrition: less then
body requirements

Nausea and vomiting,

disease process and
treatment

Sleep pattern,
Disturbance

Severe Pain

Bed Mobility
impaired

Impaired physical mobility

S:
Client states I can not moving my left leg,

Physical mobility
Impaired

Severe pain, imflamantory

join disease (bone metastase

11

6.

and my lower extremity, and very pain if I

moving
O:
Facial mask of pain
Data from gynecologi depeartement:
cancer
Radiology test:
S:
Client states: I got bleeding after having sex
with my husband

from cancer cervix)

Sexual dysfunction

Pain, Vaginal bleeding, post

coital bleeding,

Activity Intolerance

Chronic disease: multiple

bone metastases (right
acetabular, Right proximal
femur, inferior pubic
ramus), pain

Hyperthermia

Infection Process

Hopelesness

Prolonged pain, discomfort

and weakness; impaired
functional abilities
(walking), prolonged
treatments

Parenting,
impaired risk

Chronic illness,

Self esteem
disturbed

Loss of Body Function,

disfigurement

O:

7.

Post coital bleeding

Vaginal bleeding
Cancer servix

S:
Cient states: I can not move the body by my
self
O:

8.

S: OD:

9.

10.

The patient lie down

Body Temperaure 38,4 0C

Tachycardia: Pulse: 122 perminute
Warm to touch
Specific aches and pains

S:
Clients states I dont know what will I do
after I get sick like this
O:
Client Lie in the bed
Client Cry when she told to the nurse
servical mass with vaginal bleeding
and osteolytic lesion at right
acetabulum

S: she states I have 2 doughters, the first one

is 2 years old and the secend one is 8 month, I
love them very much, I am worry if I can not
to be a good mother, and I can not take care of
them completely
O:
She cry when she told to the the nurse
11. S:
Client states I am to young to get disease like
this, I am 27 years old and I have a husband
and 2 little brother , I worry if I can not to be

12

a good wife and good mother

O:
Client Cry
The face look sad
Can not move her right leg because
very pain
12.

13.

1.
2.
3.
4.

S:
Client states I can not walk, I can not sit by
my self, I can not to wearing my chlotes and
my older sister help me to do everything for
me
O:
Her sister helps her if she needs
something
S:
Client states sometime I feel itching, because
I sweating and feel to hot
O:
Touch warm
Body temperature 38,4 oC
The clothes is wet

Self care deficit:

Bathing, Dressing,
instrumental,
toileting

Chronic pain, vhronic

illness (cancer servix with
multiple bone metastases)

Skin Integrity,
impaired (risk for
impaired)

Long bed rest and

Hyperthermia

Nursing Diagnosis appropriate with the priority

Chronic pain related to Disease process: multiple bone metastase
Hyperthermia related to Infection Process and disease prosess
Sleep pattern disturbed related to Severe Pain
Risk for Inadequate Nutrition: less then body requirements related to nausea and

vomiting, disease process and treatment

5. Physical mobility Impaired Severe pain related to inflamantory join disease (bone
metastases from cancer cervix)
6. Activity Intolerance related to chronic disease: multiple bone metastases (right
acetabular, Right proximal femur, inferior pubic ramus), chronic pain
7. Self care deficit: Bathing, Dressing, instrumental, toileting related to chronic pain,
chronic illness (cancer servix with multiple bone metastases)

8. Sexual dysfunction related to pain, vaginal bleeding, post coital bleeding,

9. Parenting, impaired related to chronic illness
10. Hopelesness related to prolonged pain, discomfort and weakness; impaired functional
abilities (walking), prolonged treatments.
11. Skin Integrity, impaired (risk for impaired) related to long bedrest and hyperthermia
12. Self esteem related to Loss Body Function disfigurement
13

NURSING CARE PLAN

No.

Nursing Diagnosis

NOC

1.

Severe chronic pain

related to disease
process: multiple
bone metastases

Goals:
The person will relate improvement
of pain and increased daily activities
as evidenced by (specify).
Indicators:
o Relate that others validate that their
pain exists.
o Practice selected noninvasive painrelief measures.
o Communicate improvement in pain
verbally, by pain assessment scale,

NIC
1.

2.

Assess for Factors that Decrease Pain

Tolerance:
Disbelief from others Uncertainty of
prognosis
Fear (e.g., of addiction or loss of
control)
Reduce or Eliminate Factors that
Increase Pain.
Establish a supportive accepting
relationship: a) Acknowledge the pain.,
b) Listen attentively to clients

14

or by behavior (specify).
o Maintain usual family role and
relationships throughout pain
experience, as evidenced by
(specify).

3.

4.

5.
6.
7.

discussion of pain, c) Convey that you

are assessing pain because you want to
understand it better (not determine if it
really exists.
Assess
the
family
for
any
misconceptions about pain or its
treatment: a) Explain the concept of
pain as an individual experience. b)
Discuss factors related to increased pain
and options to manage. c) Encourage
family members to share their concerns
privately (
Determine with Client and Family the
Effects of Chronic Pain on the Persons
Life
Discuss with client and family the
therapeutic uses of distraction, along
with other methods of pain relief.
Emphasize that the degree to which a
person can be distracted from the pain is
not at all related to the existence or
intensity of the pain.
Explain that distraction usually increases
pain tolerance and decreases pain
intensity; however, after the distraction
ceases, the person may have an
increased awareness of pain and fatigue.
Vary the environment if possible.
Encourage family to personalize the
room with flowers, plants, and pictures.
Provide music, videos, and video games.
Consult with a recreational therapist for
appropriate tasks.
Collaborate with Client about Possible
Methods to Reduce Pain Intensity.
Clients willingness (motivation) and
ability to participate
Preference
Support of significant others for method
Contraindications (allergy, health
problem)
Methods cost, complexity, precautions,
and convenience (i.e: Hot water bottle)
Collaborate with Client to Initiate
Appropriate
Nonpharmaceutical
Pain-Relief
Measures.
Provide Pain Relief with Prescribed

15

2.

Hyperthermia
related to Infection
Process and disease
prosess

3.

Sleep
pattern
disturbed related to
Severe Pain

4.

Risk for Inadequate

Nutrition: less then
body requirements
related to nausea
and
vomiting,
disease process and
treatment

Analgesics.
Use oral route when feasible,
intravenous or rectal routes if needed
with permission.
Avoid intermuscular routes due to erratic
absorption and unnecessary pain.
Assess vital signs, especially respiratory
rate, before administration.
Consult with pharmacist for possible
adverse interactions with other
medications (e.g., muscle relaxants,
tranquilizers).
Understand pain therapies, including the
peak and duration of selected routes of
administration of opioid therapy.

5.
255Impaired physical
555Mobility related to
555severe pain and
555inflammatory joint
5. disease (hip join
555acetabular, L1 /L2)
222

6. Sleep disturbances

Goal:

Goal: The client will report an

optimal balance of rest.
Indicators:
o Describe factors that prevent or

Position in alignment to prevent

complications:
Use a foot board
Avoid prolonged sitting or lying in the same
position
Use a small pillow when in fowler position
Place pillow to support the leg from groin to
foot, and use a pillow to flex the shoulder
and elbow slightly. Support the lower foot
in dorsal flexion with a towel roll or
special boot.
Have the client keep a sleepwake
diary for one month to include
bedtime, arising time, difficulty getting
sleep, number of awakenings (reason),
and naps

16

inhibit sleep.
Identify techniques to induce
sleep.

Evaluate if there is a physiologic

condition or medication that is
interfering with sleep. Refer to related
factors under Pathophysiologic and
Treatment-Related. Refer to the
primary care provider for
management.
Evaluate if a psychological state is
interfering with sleep. Refer to
Situation-Related Factors. Refer to
Mental Health Professions.
Determine if the lifestyle or life events
are interfering with sleep. Refer to
other nursing diagnoses if
appropriate: Grieving, Stress Overload,
Ineffective Coping, or Risk-Prone
Health Behavior.

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