I. Cardiovascular/Pulmonary Problems (50%)
II. Abnormal Cellular Growth (25%)
III. Needs of the Childbearing Family (25%)
I. Cardiovascular/Pulmonary Problems (50%)
This area focuses on the nursing care of patients with problems such as
respiratory failure, croup, asthma, smoke inhalation, chronic obstructive
pulmonary disease (COPD), atelectasis, pneumonia, pulmonary edema,
peripheral vascular disease, hypertension, myocardial infarction (MI),
congestive heart failure (CHF), shock, anemias.
A. Theoretical framework - basis for care
1. Types of cardiovascular/pulmonary problems
a. Problems of intake and supply
1) Depression of respiratory center (for example: drugs, pH
imbalances, respiratory failure)
d. Preoperative and postoperative care (for example: thoracic surgery,
angioplasty, coronary artery bypass graft, peripheral vascular surgery,
abdominal aneurysm)
e. Health instruction (for example: rationale for breathing exercises,
stress management, instruction relative to diagnostic and laboratory
tests, preventive measures for health maintenance, perioperative
instructions)
B Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective
symptoms, diet, medications, past illnesses, health habits, family
history, allergies, occupation)
2) Assess factors influencing the patient's response to
cardiovascular/pulmonary problems (for example: stress in
patient's daily life, dietary patterns [see IA3])
3) Obtain objective data related to the patient's
cardiovascular/pulmonary problems (for example: determine
clinical manifestation, altered vital signs, capillary refill,
peripheral pulses, breath sounds)
4) Review laboratory and other diagnostic data (for example: blood
gases, electrolyte levels, stress tests, pulse oximetry, complete
blood count, cardiac enzymes, pulmonary function test,
bronchoscopy, thoracentesis, cardiac catheterization,
electrocardiogram, theophylline levels)
b. Synthesize assessment data (see IB1a]1-4] above)
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: acute
pain [chest] related to coronary spasm; noncompliance related to
negative side effects of antihypertensive drug therapy; ineffective
airway clearance related to bronchial edema)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for
example: patient will state that discomfort is relieved, patient's blood
pressure will be within designated limits, patient will verbalize that
respirations are less labored)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to
cardiovascular/pulmonary problems in planning patient care [see IA3]
(foe example: plan care of patient post-MI to include ethnic dietary
patterns, plan to discuss resumption of patient's sexual activities)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: monitor breath
sounds, encourage fluid intake to loosen secretions, provide rest to
decrease myocardial oxygen demand)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to maintain a patent airway (for example:
provide suctioning, provide tracheotomy care, encourage coughing and
deep breathing)
b. Use nursing measures to increase oxygen supply (for example:
positioning, administration of oxygen, instruction in breathing exercises
and use of an inhaler, administration of blood, management of
mechanical ventilation, management of chest drainage apparatus,
position for postural drainage, provide a humidified croupette for a
child with croup)
c. Use nursing measures to reduce cell demand for oxygen (for example:
provide rest and comfort, manipulate the environment to reduce
anxiety)
d. Use nursing measures to prevent complications of
cardiovascular/pulmonary problems (for example: encourage coughing
and deep breathing, apply antiembolic stockings, administer humidified
oxygen, encourage ambulation, position chest drainage tubes, apply
intermittent compression devices)
e. Use nursing measures specific to prescribed medications (see IA4a)
(for example: take blood pressure prior to the administration of an
antihypertensive agent, check prothrombin times prior to the
administration of a long-acting anticoagulant, administer intramuscular
iron preparations via Z-track, determine the pulse rate prior to the
administration of cardiac glycosides)
f. Use measures to assist the patient and/or significant others to cope
with the health problem (for example: refer the patient to a local
support group, discuss lifestyle changes to reduce stress)
g. Provide information and instruction (for example: instruct the patient
regarding breathing techniques, instruct the patient about the use and
side effects of medications, instruct the patient about risk factors for
cardiovascular/pulmonary problems, discuss the avoidance of allergens
for a child with asthma)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the patient's response to nursing actions (for
example: chart changes in color and amount of sputum, chart changes in
breath sounds, chart absence of redness and swelling in a patient with
thrombophlebitis, report that patient verbalizes lack of pain relief
following the administration of nitroglycerin)
b. Revise the patient's plan of care as necessary (for example: encourage
additional fluid intake to increase production of sputum, provide
diversional activity for the patient with an MI who is experiencing
boredom and restlessness)
II. Abnormal Cellular Growth (25%)
This area focuses on the nursing care of patients with problems such as
fibroids; pyloric stenosis; cancer of the liver, prostate, breast, lung, and
uterus; Wilms' tumor; leukemias; sarcomas; and lymphomas.
A. Theoretical framework - basis for care
1. Types of abnormal cellular growth
a. Problems resulting from benign abnormal cellular growth (for
example: fibroids, gestational trophoblastic disease [hydatidiform mole],
fibrocystic disease of the breast)
b. Problems resulting from hypertrophy (for example: pyloric stenosis,
prostatic hypertrophy)
c. Problems resulting from malignant abnormal cellular growth (for
example: cancer of the skin, stomach, intestines, liver, prostate, breast,
uterus, lungs, bladder: Wilms' tumor; neuroblastoma; leukemia;
sarcomas; lymphomas)
2. Clinical manifestations of abnormal cellular growth
a. Alteration in size
b. Alteration in rate of growth
c. Altered function of involved cells
d. Local and systemic effects resulting form altered size, altered rate of
growth, and altered function of involved cells (for example: metastasis,
pressure on vital organs, pain)
e. Behavioral changes (for example: confusion, slurred speech, altered
mentation)
3. Factors influencing the patient's response to abnormal
cellular growth
a. Age and physiological factors
b. Psychological factors
c. Socioeconomic and cultural factors (for example: lifestyle, family
history, occupation, health practices)
d. Nutritional status
e. Presence of other illness
f. Site of abnormal cell growth (for example: local vs. distant)
g. Degree of involvement (for example: benign vs. malignant, acute vs.
chronic)
4. Theoretical basis for interventions related to abnormal
cellular growth
a. Medications (for example: antineoplastic agents, steroids, analgesics,
hormonal therapy)
b. Other treatment modalities (for example: chemotherapy, radiation
therapy, surgical intervention, immunotherapy, bone marrow
transplant)
c. Preoperative and postoperative care (for example: laryngectomy,
mastectomy, prostatectomy, colostomy, ileal conduit)
d. Health instruction (for example: risk factors, warning signs,
prevention, breast self-examination, testicular self-examination)
B. Nursing care related to theoretical framework
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: subjective
symptoms, diet, medications, health habits, family history,
allergies, occupation)
2) Assess factors influencing the patient's response to abnormal
cell growth (for example: weight loss, occupation, [seeIIA3])
3)Obtain objective data related to the patient's abnormal cellular
growth (for example: determine clinical manifestations, weight
changes, presence of mass, abdominal distention)
4) Review laboratory and other diagnostic data (for example:
biopsy, scan, blood studies, vital signs, complete blood count [CBC],
uric acid, calcium, acid phosphatase, prostate-specific antigen
[PSA], magnetic resonance imaging [MRI])
b. Synthesize assessment data (see IIB1a[1-4])
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify the psychological and physiological ramifications of
treatment modalities on the patient and family (for example: consider
the effects of alopecia, stomatitis, osteoporosis, erythema, bone marrow
depression, pancytopenia, nausea and vomiting, bone marrow
transplant, depressed mood, body image)
b. Identify actual or potential nursing diagnoses (for example: impaired
oral mucous membranes related to immunosuppression secondary to
chemotherapy; altered nutrition: less than body requirements related to
difficulty swallowing; ineffective individual coping related to denial
secondary to diagnosis of cancer)
c. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
d. Establish expected outcomes (patient-centered goals) of nursing care
(for example: patient will state coping mechanisms to be utilized,
patient's mouth will be free of ulcers)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to abnormal cell
growth and involve the patient's family in planning individualized
patient care (for example: consider role changes, sexuality, changes in
body image, changes in lifestyle)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: provide a low-
residue diet for a patient receiving radiation therapy, provide a
mechanically soft diet for the patient with stomatitis, provide play
therapy for a child with leukemia)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Provide instruction in the prevention and detection of abnormal
cellular growth (for example: instruct patients concerning breast and
testicular self-examination, the seven danger signals of cancer,
carcinogenic factors, screening and diagnostic testing, preventive
dietary measures)
b. Use nursing measures to provide patient comfort (for example:
imaging, meditation, medications, patient-controlled analgesia [PCA],
intraspinal analgesics, positioning, mouth care, skin care)
c. Use nursing measures to promote optimal nutrition (for example:
offer small frequent feedings, continuous enteral feedings, total
parenteral nutrition [TPN])
d. Use nursing measures to promote elimination (for example: manage
altered elimination routes such as ileo-conduit or colostomy, instruct the
patient regarding self-care, monitor urinary drainage in a patient
following a transurethral prostatectomy)
e. Use nursing measures to promote safety (for example: prevention of
infection and hemorrhage; minimize side effects of treatment modalities
by providing skin care, mouth care, and protective isolation)
f. Use nursing measures to provide spiritual and emotional support
g. Use nursing measures specific to prescribed medications (for example:
monitor platelet count with antineoplastic agents, monitor fluid balance
for a patient receiving steroids, monitor for side effects of medications)
h. Use nursing measures to provide information and instruction (for
example: provide referrals to self-help groups, reinforce patient's
knowledge about prosthetic devices, emphasize conception control for a
patient following removal of a gestational trophoblastic neoplasm
[hydatidiform mole])
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the patient's response to nursing actions (for
example: record daily weight for a patient on total parenteral nutrition,
report skin breakdown for a patient undergoing radiation therapy, chart
intake and output for an infant with pyloric stenosis)
b. Revise the plan of care (for example: increase fluid intake when
hematuria is noted in a patient on chemotherapy)
III. Needs of the Childbearing Family (25%)
This area focuses on the nursing care of the childbearing family. Health
care needs and problems that occur during the antepartal, intrapartal,
postpartal, and neonatal periods are included.
3) Psychosocial changes in the expectant family (for example:
emotional responses, role transition, alterations in sexuality,
differences based on age and culture)
4) Health maintenance (for example: calculation of date of
conception; obstetrical history; lab tests such as serology for
syphilis, smear for gonorrhea, test for chlamydia, herpes, Pap
smear; patient education regarding nutrition, activities of daily
living [ADLs], and symptoms to be reported)
1) Process of labour (for example: stages and phases of labour,
fetal presentation and positions)
2) Complications of labour (for example: fetal malposition, pattern
of late decelerations, primary and secondary inertia, premature
rupture of membranes, prolapsed cord)
3) Medical interventions (for example: amniotomy, episiotomy,
induction of labour, forceps, cesarean section)
e. Physiology of the neonate: normal transition to extrauterine life (for
example: respiratory changes, circulatory changes, temperature
regulation, newborn reflexes, GI/GU function)
f. Nutritional needs of the neonate
g. Complications of the neonate (for example: prematurity, postmaturity,
large of small for gestation, respiratory distress syndrome, hemolytic
disease, infection, fetal alcohol syndrome, hypoglycemia)
B. Nursing care related to theoretical framework - the childbearing
woman
1. Assessment - gather and synthesize data about the
patient's functional health patterns
a. Gather assessment data
1) Obtain the patient's health history (for example: obstetric-
gynecologic history, expected date of delivery, history of
bleeding, substance abuse, fetal movement patterns)
2) Assess factors influencing the patient's response to
childbearing (for example: preparation for childbirth, cultural
factors, socioeconomic status, patient age, lifestyle, psychological
factors, nutrition, bonding)
3) Obtain objective data (for example: fetal heart rate, fetal
movement, weight gain, amount and colour of lochia, colour of
amniotic fluid, location and contraction of the fundus)
4) Review laboratory and other diagnostic data (for example:
sonogram, fetal heart monitor, amniocentesis, estriol levels,
alpha-fetoprotein level, nonstress test, stress test)
b. Synthesize assessment data (see IIIB1a [1-4] above)
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example: fluid
volume deficit related to inadequate fluid intake during labour;
impaired skin integrity related to episiotomy; urinary retention related
to urethral trauma; knowledge deficit: care of the perineum)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's developmental level)
c. Establish expected outcomes (patient-centered goals) for care (for
example: patient will correctly demonstrate childbearing exercises,
patient will perform care of perineum correctly)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to childbearing
(see IIIB1a[2]) and involve the patient's family in planning patient care
(for example: plan sibling visits, consider low socioeconomic status,
consider ethnicity, consider patient age)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: provide
feedback on the progress of labour to reduce anxiety, monitor the
patient for urinary retention)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to enhance positive outcomes for the
childbearing family (for example: provide instructions regarding the
effects of nutrition, lifestyle, drugs, medications, and infections;
manipulate the environment to foster rest, nutrition, and reduction of
stress)
b. Use nursing measures to promote optimal fetoplacental blood flow
(for example: position to prevent vena caval syndrome, monitor fetal
heart rate during labour and delivery)
c. Use nursing measures to ensure a safe environment (for example:
safety measures for the patient with preeclampsia, maintain bed rest
prior to fetal engagement)
d. Use nursing measures to facilitate the progress of labour (for
example: positioning, coaching, encourage ambulation)
e. Use nursing measures to facilitate involution and healing (for
example: episiotomy care, nipple care, fundal massage)
f. Use nursing measures to provide emotional support (for example:
assist with role transition, foster bonding)
g. Use nursing measures to ensure optimal nutrition (for example:
provide instruction regarding antepartal weight gain, provide postpartal
dietary instruction)
h. Use nursing measures to relieve patient discomfort (for example:
instruction in breathing patterns, application of heat and cold)
I. Use nursing measures specific to prescribed medications during the
childbearing cycle (for example: monitor uterine contractions for a
patient receiving oxytocin [Pitocin]; keep calcium gluconate at the
bedside of a patient receiving magnesium sulfate; check the blood
pressure of a patient receiving ergonovine maleate; monitor the blood
pressure of a patient receiving anesthesia)
j. Use nursing measures to assist the patient in making educated choices
throughout the childbearing cycle (for example: birthing options, family
planning)
k. Provide information and instruction (for example: home health care,
signs and symptoms of impaired involution, self-care needs, infant care,
referrals)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the patient's response to nursing actions (for
example: chart colour and amount of lochia, condition of nipples,
condition of episiotomy; report tetanic contractions)
b. Revise the plan of care (for example: coach the patient in progressive
levels of breathing during labour, monitor vital signs with increased
frequency as labour progresses)
C. Nursing care related to theoretical framework - the fetus/neonate
1. Assessment - gather and synthesize data about the
patient's health status in relation to the patient's functional
health patterns
a. Gather assessment data
1) Obtain the fetus/neonate's health history (for example: length
of labour, type of delivery, exposure to teratogens, maternal
history of substance abuse)
2) Obtain objective data related to the fetus/neonate's health status
(for example: vital signs, Apgar score, reflexes, condition of
umbilical cord stump, hyperexcitability, high-pitched cry)
3) Review laboratory and other diagnostic data (for example: tests
for fetal maturity, bilirubin, Coombs' test, screening for
phenylketonuria [PKU], galactosemia, and hypothyroidism)
b. Synthesize assessment data (see IIIC1a [1-3])
2. Analysis - identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify actual or potential nursing diagnoses (for example:
ineffective breast-feeding related to poor sucking reflex; ineffective
thermoregulation related to newborn transition to the extrauterine
environment)
b. Set priorities (for example: based on Maslow's hierarchy of needs,
based on the patient's development level)
c. Establish expected outcomes (patient-centered goals) for care (for
example: axillary temperature will be stable, mother will use the
rooting mechanism to initiate feeding, circumcision will show no signs of
infection)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Plan for anticipated needs of the fetus/neonate on the basis of
established priorities (for example: plan to facilitate bonding)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: swaddle the
neonate to promote security and maintain body temperature, provide a
dark quiet environment for a neonate with drug addiction, increase
fluid volume for a neonate who is undergoing phototherapy)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to ensure a safe environment (for example:
provide warmth for the neonate, encourage rest, cover the eyes of a
neonate undergoing phototherapy, complete newborn identification
procedure)
b. Use nursing measures to increase the fetus/neonate's oxygen supply
(for example; suction the neonate's airway, administer oxygen at no
more than 60%)
c. Use nursing measures to ensure optimal nutrition (for example: assist
with neonate feeding, facilitate breast-feeding)
d. Use nursing measures to relieve fetal/neonate discomfort (for
example: provide a quiet environment for the neonate with drug
addiction, care of circumcision site)
e. Use nursing measures to provide emotional support (for example:
foster bonding)
f. Use nursing measures specific to prescribed medication (for example:
administer prophylactic eyedrops, administer vitamin K)
g. Use nursing measures to facilitate healing (for example: cord care,
circumcision care)
h. Use nursing measures to maintain physiological stability (for
example: care during phototherapy,, positioning, maintain cord clamp)
5. Evaluation - appraise the effectiveness of the nursing
interventions relative to the nursing diagnosis and the
expected outcomes
a. Assess and report the fetus/neonate's response to nursing actions (for
example: chart daily weight, chart colour and consistency of stool, chart
response to feeding and bonding, report elevated bilirubin levels)
b. Revise the plan of care (for example: provide fluid in response to
temperature elevation, refer mother to a home health care agency if the
neonate's weight gain is poor)
