NURSING PLANNING NURSING RATIONALE

CUES DIAGNOSIS INTERVENTIONS

S: reports of Pain, Acute/Chronic After 2 hours of > Investigate > Helpful in

pain/discomfort. related to distention of thorough Nursing care reports of pain, determining pain
tissues by accumulation the patient will be able noting location and management needs
of fluid/ inflammatory to verbalize methods intensity (scale of and
O: process. that provide relief of 0–10). Note effectiveness of
> fatigue pain. precipitating program
> red, swollen, hot factors and
joints nonverbal pain
> with guarded/ cues.
protective behavior > Soft/sagging
> facial mask grimace > mattress, large
> limited movement Recommend/provid pillows prevent
> irritability e firm mattress or maintenance
bed board, small of proper body
pillow. alignment, placing
stress on affected
joints.

> Rests painful

joints and
> Place/monitor use maintains neutral
of pillows, position. Note: use
sandbags, of splints can
splints, braces decrease pain and
may reduce
damage to joint;
however, prolonged
inactivity can result
in loss of joint
mobility/function.
> Encourage
frequent changes > Prevents general
of position. Assist fatigue and joint
patient to stiffness. stabilizes
move in bed, joint, decreasing
supporting affected joint movement and
joints above and associated pain.
below, avoiding
jerky movements.
> Heat promotes
muscle relaxation
> Recommend that and mobility,
patient take warm decreases
bath or shower on pain, and relieves
arising and/or at morning stiffness.
bedtime. Apply Sensitivity to heat
warm, moist may be diminished
compresses and dermal injury
to affected joints may occur.
several times a
day. Monitor water
temperature of
compress. > To prevent fatigue

> Promotes
> Encourage adequate
rest periods relaxation, provides
sense of control,
> Encourage use of and may
stress management enhance coping
techniques, e.g., abilities
progressive
relaxation,
biofeedback,
visualization,
guided
imagery, self-
hypnosis, and
controlled > Refocuses
breathing. Provide attention, provides
therapeutic touch. stimulation, and
enhances
> Involve in self-esteem and
diversional feelings of general
activities well-being
appropriate for
individual > Cold may relieve pain
situation and swelling during
acute episodes.

> Apply ice or cold

packs when indicated.
Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a
person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by
prompt recognition of the problem and notification of the emergency medical system (EMS), followed by early
CPR, defibrillation(which delivers a brief electric shock to the heart in attempt to get the heart to beat normally),
and advanced cardiac life support measures.

CPR must be performed within four to six minutes after cessation of breathing so as to prevent brain damage
ordeath. It is a two-part procedure that involves rescue breathing and external chest compressions. To provide
oxygen to a person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate blood through
the heart to vital organs by external chest compressions. Mouth-to-mouth breathing and external chest
compression should be performed together, but if the rescuer is not strong enough to do both, the external
chest compressions should be done. This is more effective than no resuscitation attempt, as is CPR that is
performed "poorly."

When performed by a bystander, CPR is designed to support and maintain breathing and circulation until
emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in
conjunction with other basic and advanced life support measures.

According to the American Heart Association, early CPR and defibrillation combined with early advanced
emergency care can increase survival rates for people with a type of abnormal heart beat called ventricular
fibrillation by as much as 40%. CPR by bystanders may prolong life during deadly ventricular fibrillation, giving
emergency medical service personnel time to arrive.

However, many CPR attempts are not ultimately successful in restoring a person to a good quality of life. Often,
there is brain damage even if the heart starts beating again. CPR is therefore not generally recommended for
the chronically or terminally ill or frail elderly. For these people, it represents a traumatic and not a peaceful end
of life.

Each year, CPR helps save thousands of lives in the United States. More than five million Americans annually
receive training in CPR through American Heart Association and American Red Cross courses. In addition to
courses taught by instructors, the American Heart Association also has an interactive video called Learning
System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same
way, but use different terms. These organizations recommend that family members or other people who live
with people who are at risk for respiratory or cardiac arrest be trained in CPR. A hand-held device called a CPR
Prompt is available to walk people trained in CPR through the procedure, using American Heart Association
guidelines. CPR has been practiced for more than 40 years.

Performing CPR

The basic procedure for CPR is the same for all people, with a few modifications for infants and children to
account for their smaller size.

PERFORMING CPR ON AN ADULT. The first step is to call the emergency medical system for help by telephoning
911; then to begin CPR, following these steps:

• The rescuer opens a person's airway by placing the head face up, with the forehead tilted back and the
chin lifted. The rescuer checks again for breathing (three to five seconds), then begins rescue breathing
(mouth-to-mouth artificial respiration), pinching the nostrils shut while holding the chin in the other
hand. The rescuer's mouth is placed against the unconscious person's mouth with the lips making a tight
 seal, then gently exhales for about one to one and a half seconds. The rescuer breaks away for a
moment and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
• After two breaths, the rescuer checks the unconscious person's pulse by moving the hand that was
under the person's chin to the artery in the neck (carotid artery). If the unconscious person has a
heartbeat, the rescuer continues rescue breathing until help arrives or the person

• begins breathing without assistance. If the unconscious person is breathing, the rescuer turns the
person onto his or her side.
• If there is no heartbeat, the rescuer performs chest compressions. The rescuer kneels next to the
unconscious person, placing the heel of one hand in the spot on the lower chest where the two halves of
the rib cage come together. The rescuer puts one hand on top of the other on the person's chest and
interlocks the fingers. The arms are straightened, the rescuer's shoulders are positioned directly above
the hands on the unconscious person's chest. The hands are pressed down, using only the palms, so
that the person's breastbone sinks in about1.5–2 inches. The rescuer releases pressure without
removing the hands, then repeats about 15 times per 10–15 second intervals.
• The rescuer tilts the unconscious person's head and returns to rescue breathing for one or two quick
breaths. Then breathing and chest compressions are alternated for one minute before checking for a
pulse. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the unconscious person
is breathing but has no pulse, the chest compressions are continued. If the unconscious person has a
pulse but is not breathing, rescue breathing is continued.
• For children over the age of eight, the rescuer performs CPR exactly as for an adult.

PERFORMING CPR ON AN INFANT OR CHILD UNDER THE AGE OF EIGHT. The procedures outlined above are
followed with these differences:

• The rescuer administers CPR for one minute, then calls for help.
• The rescuer makes a seal around the child's mouth or infant's nose and mouth to give gentle breaths.
The rescuer delivers 20 rescue breaths per minute, taking 1.5–2 seconds for each breath.
• Chest compressions are given with only one hand for a child and with two or three fingers for an infant.
The breastbone is depressed only 1–1.5 in (2.5–3.8 cm) for a child and 0.5–1 in (1.3–2.5 cm) for an
infant, and the rescuer gives at least 100 chest compressions per minute.

New developments in CPR

Some new ways of performing CPR have been tried. Active compression-decompression resuscitation,
abdominal compression done in between chest compressions, and chest compression using a pneumatic vest
have all been tested but none are currently recommended for routine use.

The active compression-decompression device was developed to improve blood flow from the heart, but clinical
studies have found no significant difference in survival between standard and active compression-
decompression CPR. Interposed abdominal counterpulsation, which requires two or more rescuers, one
compressing the chest and the other compressing the abdomen, was developed to improve pressure and
therefore blood flow. It has been shown in a small study to improve survival but more data is needed. A
pneumatic vest, which circles the chest of an unconscious person and compresses it, increases pressure within
the chest during external chest compression. The vest has been shown to improve survival in a preliminary
study but more data is necessary for a full assessment.