Question

Complete a CARE PLAN for a client after a disaster.

The six steps of the nursing process required

1- assessment

2- diagnosis

3- outcome identification

4- planning

5- implementation

6- Evaluation

Nursing diagnose approved by NANDA International http://www.nanda.org/ Include a list of all references used to support your answer.

Answer 1

CARE PLAN for a client after a disaster

Client Assessment

Data depend on specific injuries incurred and presence of chronic conditions (refer to specific plans of care for appropriate data, such as burns, multiple trauma, cardiac and respiratory conditions, and so forth) and timing of presentation for care.

Nursing Priorities

1. Prevent or treat life-threatening conditions.

2. Prevent further injury and spread of infection.

3. Support efforts to cope with situation.

4. Facilitate integration of event.

5. Assist community in recovery process and preparing for future occurrences.

Discharge Goals

1. Free of preventable complications.

2. Anxiety reduced to a manageable level.

3. Beginning to cope effectively with situation.

4. Plan in place to meet needs after discharge.

5. Community preparedness enhanced.

1. NURSING DIAGNOSIS: Risk for Injury—Trauma, Suffocation, or Poisoning

Risk Factors May Include

• Biological—immunization level of community, presence of microorganism
• Chemical—contact with chemical pollutants, poisonous agents
• Exposure to open flame or flammable material
• Acceleration and deceleration forces
• Contamination of food or water

Possibly Evidenced By

• (Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client/Caregivers Will

• Physical Injury Severity
  • Minimize degree of and prevent further injury.
• Personal Safety Behavior
  • Verbalize understanding of condition and specific needs.
  • Identify interventions appropriate to situation.
  • Demonstrate behaviors necessary to protect self from further injury.
  • Accept responsibility for own care and follow up as individually able.

ACTIONS/INTERVENTIONS	RATIONALE
Acquire information about nature of emergency, accident, or disaster. Prepare area and equipment; check and restock supplies.	Identifies basic resource needs and helps to prepare staff for appropriate level of response based on customary injuries and healthcare needs usually associated with specific event. Assists in providing safe medical and nursing care in anticipa- tion of emergency need.
Assist in prioritizing (triaging) clients for treatment, including de- contamination. Monitor for and treat life-threatening injuries.   Determine primary needs and specific complaints of client. Check for medical alert tag. Obtain additional medical information, including preexisting conditions, allergies, and current medication.	Promotes efficient care of those who can be medically treated and maximizes use of resources. Note: In routine emergency situations, the goal is to do the best for each individual. How- ever, in a disaster, the focus of treatment shifts to do the greatest good for the greatest number. Information necessary for triaging to appropriate services. Note: Pediatric clients are better able to compensate during early hypovolemic shock than adults, creating a false impression of normalcy (American Academy of Pediatrics [AAP], 2006). Provides for assessment and treatment of conditions that might not be evident initially.
Determine client’s developmental level, decision-making ability,level of cognition, and competence. Evaluate individual’s response to event, mood, coping abilities, and personal vulnerability. Ascertain knowledge of needs and injury prevention and motivation to prevent further injury. Discuss importance of self-monitoring of conditions and emotions that can contribute to occurrence of injury— shock state, ignoring basic needs, fatigue, anger, and irritability. Note socioeconomic status and availability and use of resources.	Affects treatment plan regarding issues of informed consent, self-care, client teaching, and discharge. People react to traumatic situations in many ways and may ex- hibit a wide range of responses—from no visible response to wild emotions. This may result in carelessness or increased risk-taking without considerations of consequences or inabil- ity to act on own behalf, including protecting self. Indicator of need for information and assistance with making positive changes, promoting safety and sense of security. Recognizing these factors and dealing with them appropriately,including seeking support and assistance, can reduce individual risks. May determine ability to access help for identified problems.
Collaborative Work with other agencies, such as law enforcement, fire depart- ment, Red Cross, and ambulance and EMTs, as indicated. Follow prearranged roles when participating in a community disaster plan. Triage: Emergency Care Identify and manage life-threatening situations—airway problems, bleeding, and diminished consciousness. Obtain and assist with diagnostic studies, as indicated. Provide therapeutic interventions as individually appropriate. (Refer to specific CPs; e.g., Burns, Fractures, Crainocere- bral Trauma, Myocardial Infarction, Chronic Obstructive Pulmonary Disease [COPD], Ventilatory Assistance	During a disaster, many people are involved with care of victims. Most communities have disaster plans in which nurses will participate. Stabilization of medical condition is necessary before proceeding with additional therapies. Note: Children are at greater risk than adults when exposed to chemical agents/poisonous gases because of (1) higher minute volume, (2) increased skin permeability, (3) greater body surface to weight ratio, (4) less intravascular volume increasing risk of hypovolemic shock, (5) shorter stature increasing exposure to greatest gas vapor density at ground level (Foltin, 2006). Choice of studies is dependent on
Provide written instructions and list of resources for later review. Identify community resources, including shelter, neighbors, friends, and government agencies available for assistance. Refer to other resources, as indicated, such as counseling	individual situation and availability of resources. Specific needs of client and the level of care available at a particular site determine response. Client and significant other(s) (SO[s]) are generally not able to assimilate information at time of crisis and may need rein- forcement or want additional information. May need assistance or ongoing monitoring postdischarge to deal with self-care needs as well as safe housing and other life requirements. Note: Release of client without active support increases personal risk because of possibility of unrecognized or subacute injury or delayed psychological response.Immediate “debriefing” or counseling is beneficial for dealing with crisis to enhance ability to meet own needs.

1. NURSING DIAGNOSIS:- Risk for Infection

1. Risk Factors May Include

Increased environmental exposure, inadequate acquired immunity, inadequate vaccination

Inadequate primary defenses—broken skin, tissue destruction, invasive procedures

Chronic disease, malnutrition

1. Possibly Evidenced By

(Not applicable; presence of signs and symptoms establishes an vactual   diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

1. Risk Control

Verbalize understanding of individual exposure and risk factor(s).

Identify interventions to prevent and reduce risk of infection.

1. Infection Severity

Be free of or demonstrate resolution of infection.

1. NURSING DIAGNOSIS: [severe/panic] Anxiety

May Be Related To

Situational crisis; exposure to toxins

Threat to health status; threat of death

Interpersonal transmission (e.g., of concerns or fears)

Unconscious conflict about essential values, beliefs

Unmet needs

Possibly Evidenced By

Reports concerns due to change in life events

Distressed, apprehensive, irritability, worried, focus on self, fear

Scanning, vigilance, restlessness

Cardiovascular excitation; changes in vital signs

Impaired attention; difficulty concentrating; rumination

Desired Outcomes/Evaluation Criteria—Client Will

Anxiety Self-Control

Acknowledge and discuss feelings.

Verbalize accurate knowledge of current situation and potential outcomes.

Identify healthy ways to successfully deal with stress.

Report anxiety is reduced to a manageable level.

Demonstrate problem-solving skills appropriate for individual situation.

Use resources and support systems effectively

1. NURSING DIAGNOSIS: Spiritual Distress

May Be Related To

Natural disasters; environmental/life changes

Anxiety; stress; depression

Separated support system; loss

Possibly Evidenced By

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Spiritual Health

Verbalize increased sense of self-concept and hope for future.

Discuss beliefs and values about spiritual issues.

Verbalize acceptance of self as being worthy.

Actions/interventions

Spiritual Support

Independent

1. Determine client’s religious or spiritual orientation, current involvement, and presence of conflicts.
2. Establish environment that promotes free expression of feelings and concerns. Provide calm, peaceful setting when possible.
3. Listen to client’s and SO’s reports or expressions of anger, concern, alienation from God, and/or belief that situation is a punishment for wrongdoing.
4. Note sense of futility, feelings of hopelessness and helplessness, and lack of motivation to help self.
5. Listen to expressions of inability to find meaning in life or reason for living. Evaluate for suicidal ideation.
6. Determine support systems available to client and SO(s).
7. Ask how you can be most helpful. Convey acceptance of client’s spiritual beliefs and concerns.
8. Make time for nonjudgmental discussion of philosophical is- sues or questions about spiritual impact of events and current situation.
9. Discuss difference between grief and guilt and help client to identify and deal with each, assuming responsibility for own actions and expressing awareness of the consequences of acting out of false guilt.
10. Use therapeutic communication skills of reflection and active-listening.
11. Discuss use of, and provide opportunities for, client and SO to experience meditation, prayer, and forgiveness. Provide information that anger with God is a normal part of the grieving process.
12. Assist client to develop goals for dealing with life situation.

Collaborative

1. Identify and refer to resources that can be helpful, such as pas- toral or parish nurse, religious counselor, crisis counselor, psychotherapy, and Alcoholics or Narcotics Anonymous.
2. Encourage participation in support groups.

5. NURSING DIAGNOSIS: risk for Post-Trauma Syndrome

Risk Factors May Include

Events outside the range of usual human experience

Serious threat or injury to self or loved ones, witnessing violent death or tragic events

Disasters; destruction of one’s home or community; epidemics

Exaggerated sense of responsibility and survivor’s role in the event

Possibly Evidenced By

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client/Caregivers Will

Personal Resiliency

Express own feelings and reactions openly, avoiding projection.

Demonstrate ability to deal with emotional reactions in an individually appropriate manner.

Anxiety Level

Report absence of physical manifestations such as pain, nightmares, flashbacks, or fatigue

associated with the event.

Actions/interventions

Crisis Intervention

Independent

1. Determine involvement in event— survivor, SO, and family, rescue or aid worker, healthcare provider, or family member of responder.
2. Evaluate life factors and stressors currently or recently occur- ring, such as displacement from home due to catastrophic event—illness, injury, natural disaster, or terrorist attack.
3. Identify how client’s past experiences may affect current situation.
4. Listen for comments of taking on responsibility such as “I should have been more careful . . . or gone back to get her.”
5. Identify client’s current coping mechanisms.
6. Determine availability and usefulness of client’s support systems—family, social, and community.
7. Provide information about signs and symptoms of post-trauma response, especially if individual is involved in a high-risk occupation.
8. Identify and discuss client’s strengths as well as vulnerabilities.
9. Evaluate individual’s perceptions of events and personal sig- nificance, for example, a rescue worker trained to provide lifesaving assistance but recovering only dead bodies.
10. Provide emotional and physical presence by sitting with client and SO and offering solace.
11. Encourage expression of feelings. Note whether feelings expressed appear congruent with events experienced.
12. Note presence of nightmares, reliving the incident, loss of appetite, irritability, numbness and crying, and family or relationship disruption.
13. Provide a calm, safe environment.
14. Encourage and assist client in learning stress management techniques.

Collaborative

1. Recommend participation in debriefing sessions that may be provided following major disaster events.
2. Identify employment and community resource groups.
3. Administer medications, as indicated, such as the following: Antipsychotics, for example, phenothiazines such as chlorpromazine (Thorazine) and haloperidol (Haldol) Carbamazepine (Tegretol)
4. All those concerned with a traumatic event are at risk for emo- tional trauma and have needs related to their situation and involvement in the event. Note: Close involvement with victims or survivors affects individual responses and may prolong emotional suffering.
5. Affects client’s reaction to current event and is basis for planning care and identifying appropriate supports and resources.
6. Indicators of “survivor’s guilt” and blaming self for actions that can delay recovery and impair general well-being.
7. Noting positive or negative skills provides direction for care.
8. Family and others close to the client may also be at risk and require assistance to cope with the trauma.
9. Awareness of these factors helps individual identify need for assistance when they occur.
10. Provides information to build on for coping with traumatic experience.
11. Events that trigger feelings of despair and hopelessness may be more difficult to deal with and require long-term interventions.
12. Strengthens coping abilities.
13. It is important to talk about the incident repeatedly. Incongruen- cies may indicate deeper conflict and can impede resolution.
14. These responses are normal in the early postincident time frame. If prolonged and persistent, they may indicate needfor more intensive therapy.
15. Helps client deal with the disruption in personal life.
16. Promotes relaxation and helps individual exercise control overself and what has happened.
17. Dealing with the stresses promptly may facilitate recovery from event and prevent exacerbation.
18. Provides opportunity for ongoing support to deal with recurrent feelings related to the trauma.
19. Low doses may be used for reduction of psychotic symptoms when loss of contact with reality occurs, usually for clientswith especially disturbing flashbacks.
20. Used to alleviate intrusive recollections and flashbacks, impul- sivity, and violent behavior.

References-

1. http://www.nanda.org/
2. Doenges, Moorhouse & Murr. Nursing care plans. Guideline for individualizing client care across life span, 9^th edn