I. Infectious and Communicable Disease Problems (35%)
This area focuses on the nursing care of patients with infections of body
systems such as acquired immunodeficiency syndrome (AIDS),
cytomegalic inclusion disease, encephalitis, epiglottitis, gram-negative
sepsis, hepatitis, herpes viruses (including varicella), human
immunodeficiency virus (HIV), infectious gastroenteritis, Legionnaires'
disease, Lyme disease, meningitis, mononucleosis, mumps, otitis media,
pertussis (whooping cough), rabies, rheumatic fever, rubella, rubeola
(measles), salmonella, sexually transmitted diseases (STDs),
shingellosis, urinary tract infection, and tuberculosis.
A. Theoretical framework - basis for care
1. Types of infectious and communicable disease
a. Diseases transmitted via the blood and body fluids (for example:
AIDS, hepatitis type B)
b. Diseases transmitted via respiratory secretions (for example:
tuberculosis, mononucleosis, streptococcal infections, rubeola [measles],
varicella, Haemophilus influenza)
c. Diseases transmitted via the body drainage and secretions (for
example: conjunctivitis, nosocomial infections, staphylococcal infections,
herpes simplex, STDs)
d. Diseases transmitted via the gastrointestinal tract (for example:
infectious diarrhea, salmonella, shingellosis, hepatitis type A, helminthic
diseases)
2. Clinical manifestations of infectious and communicable
diseases
a. Altered respiratory functioning (for example: increased secretions,
presence of abnormal breath sounds, cough, dyspnea, tachypnea)
e. Altered vital signs (for example: fever, tachycardia)
f. Alterations in comfort (for example: pain, fatigue, anorexia, insomnia)
g. Alterations in mental status (for example: confusion, slowed thought
processes)
3. Factors influencing the patient's response to infections and
communicable diseases
a. Age and physiological factors (for example: active and passive
immunity)
b. Psychological factors (for example: stress, cognitive ability)
c. Socioeconomic and cultural factors (for example: health practices.
lifestyle, nutritional status, environmental factors, substance abuse)
d. Presence of other illness (for example: patient with diabetes, patient
with leukemia, patients receiving immunosuppressive drugs, patient
receiving antibiotic therapy, patient with an opportunistic infection)
e. Causative agent (for example: bacteria, viruses, other pathogens)
f. Site of infectious or communicable disease
g. Extent or severity of involvement (for example: local vs. systemic
infection)
4. Theoretical basis for interventions related to infectious and
communicable diseases
b. Immunizations (for example: mumps, measles, rubella (MMR);
diphtheria, pertussis, tetanus (DPT); Haemophilus b, polio, hepatitis B
vaccine)
c. Preventive measures (for example: tuberculosis screening, health
teaching, sex education, proper nutrition, universal precautions, body
substance isolation)
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, nutritional status, medications, past illnesses, health
habits, family history, allergies, occupation, social habits,
previous exposure to causative agents)
2) Assess factors influencing the patient's response to infectious
and communicable diseases (see IA3)
3. Obtain objective data related to the patient's infectious and
communicable disease problem (for example: determine clinical
manifestations, altered vital signs, alterations in the integument)
4) Review laboratory and other diagnostic data (for example:
complete blood count [CBC], rubella titers, VDRL, sputum for acid-
fast bacilli, culture and sensitivity reports, Mantoux test,
sedimentation rate, diagnostic radiology and imaging modalities,
serum screening for hepatitis viruses, human immunodeficiency
virus [HIV])
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: risk for
infection related to decreased immune response; risk for infection
related to presence of indwelling catheter; risk for social isolation
related to environmental stimuli; impaired skin integrity related to
pruritus; knowledge deficit: unprotected sexual practices)
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 be afebrile, patient will verbalize preventive
measures, patient's skin will remain intact)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to the health
problem in planning the patient care (for example: stress reduction
measures, age-related factors, immune status [see IA3])
b. Plan nursing measures on the basis of established priorities to
achieve the expected outcomes (for example: monitor hydration status,
alleviate skin discomfort, provide protective isolation)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to control the spread of the causative organism
*for example: universal precautions, isolation techniques, personal
protective equipment, protective barrier techniques, body substance
isolation, environmental considerations)
b. Use nursing measures to promote, maintain, or restore physiological
functioning (for example: provide adequate fluids for a patient with
infectious gastroenteritis, provide skin care for a patient with varicella,
establish a rest schedule for a patient with mononucleosis, make dietary
adjustments for altered elimination patterns)
c. Use nursing measures to minimize patient discomfort (for example:
provide a sitz bath for a patient with vaginitis, provide skin care for a
patient with pruritus, provide a cool, nonstimulating environment for a
patient with meningitis)
d. Use nursing measures specific to prescribed medications (for
example: assess vital signs prior to the administration of analgesics,
monitor temperature following the administration of antipyretics, assess
for allergies prior to the administration of antibiotics, administer
urinary analgesics to relieve dysuria, apply skin preparations to relive
itching, administer antiviral agents to inhibit infection, monitor for
adverse reactions)
e. Use nursing measures to assist the patient and/or significant others to
cope with the health problem (for example: use therapeudic
communication techniques with the patient and/or family, refer the
patient with AIDS to a support group, make referrals to community
health agencies for patients with tuberculosis)
f. Provide information and instruction (for example: emphasize the need
for protective asepsis, instruct the patient about the need for proper
nutrition, instruct the patient with an STD about prophylactic measures,
provide instruction about hygienic practices, instruct parents about the
need for their child to complete the course of antibiotic therapy, advise
the patient with hepatitis type B to refrain from donating blood)
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 relative to
the expected outcomes (for example: decrease in wound drainage,
decrease in pain to otitis media, effects of antipyretic medication,
condition of the skin, alterations in the patient's condition, patient
verbalizes the intention to practice safe sex, patient verbalizes
knowledge of the route of transmission, patient with tuberculosis
adheres to medication regimen)
II. Tissue Trauma (30%)
This area focuses on the nursing care of patients with all types of tissue
trauma. Tissue trauma includes such problems as burns, accidents,
ulcers, inflammatory disease, and accidental poisoning, as well as
surgical intervention.
A. Theoretical framework - basis for care
1. Types of tissue trauma
a. Physical/mechanical/degenerative (for example: soft tissue trauma,
accidents, falls, hiatal hernia, pressure ulcers, traumatic amputation, bee
stings, animal bites)
b. Thermal (for example: burns, frostbite)
c. Chemical (for example: medications, poisons, toxins, burns)
b. Preoperative care (for example: types of anesthesia, preoperative
teaching, premedications)
c. Intraoperative care (for example: anesthesia, blood and fluid
replacement, positioning)
d. Postoperative care (for example: comfort management, immediate
assessment of the patient postoperatively, routine care, wound care,
physical activity, diet)
e. Emergency interventions (for example: first aid measures, antidotes,
splints)
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, nutritional status, medications, recent injuries, past
illnesses, health habits, family history, occupation)
2) Assess factors influencing the patient's response to tissue
trauma (see IIA3)
3) Obtain objective data related to the patient's tissue trauma
problem (for example: clinical manifestations, activity tolerance,
altered vital signs, cardiopulmonary assessment, behavioral
response, extent of tissue trauma)
4) Review laboratory and other diagnostic data (for example:
central venous pressure readings, vital signs, endoscopic
procedures, diagnostic imaging modalities, serum electrolytes,
serum albumin, CBC, liver enzymes)
b. Synthesize assessment data (see IIBIa[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: risk for
infection related to break in skin integrity; altered peripheral tissue
perfusion related to thrombus formation)
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 verbalize diminished pain, patient will comply
with diet and fluid regimen)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to tissue trauma
(see IIA3) in planning patient care (for example: consider cultural
dietary restrictions for the patient with Crohn's disease, plan pain
management for the patient with a history of substance abuse)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: monitor fluid
and electrolyte balance for a patient with burns)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to control the extent of tissue trauma (for
example: provide skin care for the patient with an ileostomy, use
surgical asepsis when changing a burn dressing)
b. Use nursing measures to minimize patient discomfort (for example:
provide skin care to T-tube drainage site, provide diversional activities
for the patient postoperatively)
c. Use nursing measures to promote fluid, electrolyte, and nutritional
balance (for example: offer small, frequent feedings for the patient
following a gastrectomy; monitor intake and output for the patient with
burns, report alterations in the patient's condition)
d. Use nursing measures to assist the patient and/or significant others
to cope (for example: refer the patient with an ileostomy to a self-help
group, use therapeutic communication to encourage patient to verbalize
feelings regarding changes in body image)
e. Use nursing measures specific to prescribed medications (for example:
monitor the electrolyte status of the patient receiving potassium
supplements, monitor vital signs prior to the administration of
analgesics, monitor the elimination pattern of a patient receiving
lactulose [Cephulac])
f. use nursing measures to provide information and instruction (for
example: reinforce crutch walking for a patient with an amputation,
provide preoperative and postoperative instructions, provide
instruction regarding endoscopic procedures)
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 relative to
the expected outcomes (for example: condition of the skin around a
surgically created opening, patient verbalizes relief of pain following the
administration of a narcotic analgesic, record body weight and urine
output for the patient with burns, report alterations on the patient's
condition)
b. Revise the patient's plan of care as necessary (for example: assess the
effectiveness of the ostomy device, increase frequency of coughing and
deep-breathing exercises for the patient postoperatively)
III. Neurological, Sensory, and Musculoskeletal Dysfunctions (35%)
This area focuses on the nursing care of patients with problem affecting
the neurological system, such as cerebrovascular accidents, multiple
sclerosis, Parkinson's disease, myasthenia gravis, brain tumors, spinal
cord injuries, seizure disorders, and head trauma. Sensory dysfunction
include such problems as glaucoma, Meniere's disease, otosclerosis,
and cataracts. Musculoskeletal dysfunction includes such problems as
rheumatoid arthritis, joint replacement, degenerative joint disease,
contractures, fractures, scoliosis, gout, slipped femoral epiphysis, and
lumbar disc disease.
A. Theoretical framework - basis for care
1. Types of neurological, sensory, and musculoskeletal
dysfunctions
e. Preoperative and postoperative care (for example: craniotomy, open
reduction with internal fixation of the fracture, cataract removal,
iridectomy, lens implantation, laminectomy)
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, nutritional status, medications, history of trauma,
family history, onset of symptoms, occupation)
2) Assess factors influencing the patient's response to
neurological, sensory, and musculoskeletal dysfunction (see IIIA3)
3) Obtain objective data related to the patient's neurological,
sensory, and musculoskeletal dysfunction (for example: clinical
manifestations, altered vital signs, Glasgow coma scale, reflexes,
behavioral responses, range of motion)
4) Review laboratory and other diagnostic data (for example:
cerebrospinal fluid results, diagnostic imaging modalities,
hemoglobin and hematocrit in the patient postoperatively,
sedimentation rate)
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: impaired
physical mobility related to muscular weakness; impaired verbal
communication related to altered speech patterns; activity intolerance
related to weakness; diversional activity deficit related to prolonged
bed rest; ineffective individual coping related to mood swings)
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's skin will remain intact, patient will be able to
communicate needs, patient will be free of injury)
3. Planning - formulate specific strategies to achieve the
expected outcomes
a. Consider factors influencing the patient's response to neuromuscular,
sensory, and musculoskeletal dysfunction in planning patient care (see
IIIA3)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (for example: monitor
traction devices, reinforce crutch-walking instruction)
4. Implementation - carry out nursing plans designed to move
the patient toward the expected outcomes
a. Use nursing measures to protect the patient (for example: assist a
patient who is visually impaired to ambulate, provide abductor devices
for a patient following hip replacement, prevent fluid overload in a
patient who is on fluid restriction, provide safety measures for a patient
with seizures)
b. Use nursing measures to promote, maintain, or restore the patient's
neurological, sensory, or musculoskeletal functioning and/or prevent
complications (for example: perform passive range-or-motion exercise
for a patient with paralysis, maintain skeletal traction for a patient with
a fractured femur, elevate the casted extremity, administer prescribed
eyedrops to a patient with glaucoma)
c. Use nursing measures to minimize patient discomfort (for example:
assist with mechanical devices, administer anti-inflammatory
medications to the patient with arthritis, promote or limit activity,
apply heat and cold treatments)
d. Use nursing measures specific to prescribed medications (for
example: administer antiseizure medications on a regular schedule to
control seizure activity, monitor the bowel movements of a patient
receiving stool softeners, emphasize the need to adhere to steroid
therapy, monitor body weight for a patient who is receiving
corticosteroids)
e. Use nursing measures to assist the patient and/or significant others to
cope with the health problem (for example: refer a patient with
multiple sclerosis to a support group, suggest that the significant others
of a patient with myasthenia gravis learn cardiopulmonary resuscitation
techniques)
f. Provide information and instruction (for example: provide information
to patients undergoing diagnostic tests such as angiograms, EEGs, CAT
scans, magnetic resonance imaging [MIR], and lumbar punctures;
instruct the patient about the medication regimen; instruct the patient
regarding the use of community resources; instruct the patient
regarding the use of assistive devices; emphasize the need for follow-up
care; reinforce rehabilitation instruction)
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 relative to
the expected outcomes (for example: patient is free from pain, patient
verbalizes the need for follow-up care, patient verbalizes the need to
take medication at the prescribed time, alterations in the patient's
condition)
b. Revise the patient's plan of care as necessary (for example: increase
observation to q15 minutes for a patient with increased intracranial
pressure, revise the exercise schedule for a patient in traction)
