Nursing Care Plans

NCP Nursing Care Plan For Hepatitis B

2011-08-13T21:15:00.003+07:00

Image Courtesy Of chop.edu

Hepatitis B is irritation and swelling (inflammation) of the liver due to infection with the hepatitis B virus (HBV).Other types of viral hepatitis include:

Hepatitis A
Hepatitis C
Hepatitis D

Causes, Incidence, And Risk Factors for Hepatitis BHepatitis B infection can be spread through having contact with the blood, semen, vaginal fluids, and other body fluids of someone who already has a hepatitis B infection.Infection can be spread through:

Blood transfusions (not common in the United States)
Direct contact with blood in health care settings
Sexual contact with an infected person
Tattoo or acupuncture with unclean needles or instruments
Shared needles during drug use
Shared personal items (such as toothbrushes, razors, and nail clippers) with an infected person.

The hepatitis B virus can be passed to an infant during childbirth if the mother is infected.

Risk factors for hepatitis B infection include:

Being born, or having parents who were born in regions with high infection rates (including Asia, Africa, and the Caribbean)
Being infected with HIV
Being on hemodialysis
Having multiple sex partners
Men having sex with men

Most of the damage from the hepatitis B virus occurs because of the way the body responds to the infection. When the body's immune system detects the infection, it sends out special cells to fight it off. However, these disease-fighting cells can lead to liver inflammation.

Complications for Hepatitis Bhere is a much higher rate of hepatocellular carcinoma in people who have chronic hepatitis B than in the general population.

Other complications may include:

Chronic persistent hepatitis
Cirrhosis
Fulminant hepatitis, which can lead to liver failure and possibly death

Nursing Assessment NCP Nursing Care Plan for Hepatitis B

Patient history. Question the patient about potential sources of transmission and risks: a history of blood dyscrasias, multiple blood or blood product transfusions, alcohol or drug abuse (sharing of needles), exposure to hepatotoxic chemicals or medications, and travel to third world countries or areas where the sanitation is poor. Since HAV transmission occurs in association with daycare centers, among male homosexuals, and among household contacts of persons with acute cases, inquire into these areas. Also ask about recent meals, because hepatitis A occasionally occurs from contaminated food or improper sewage treatment. Determine the patient’s occupation; teratogen exposure may cause a nonviral hepatitis.

Diagnostic tests for Viral hepatitis

Antibody to HBsAg (Anti-HBs) -- a positive result means you have either had hepatitis B in the past, or have received a hepatitis B vaccine
Antibody to hepatitis B core antigen (Anti-HBc) -- a positive result means you had a recent infection or an infection in the past
Hepatitis B surface antigen (HBsAg) -- a positive result means you have an active infection
Hepatitis E surface antigen (HBeAg) -- a positive result means you have a hepatitis B infection and are more likely to spread the infection to others through sexual contact or sharing needles

Nursing diagnosis NCP Nursing Care Plan for Hepatitis B

• Activity intolerance

• Anxiety

• Deficient knowledge (diagnosis and treatment)

• Fear

• Imbalanced nutrition: Less than body requirements

• Risk for infection

• Risk for injury

Nursing Key outcomes NCP Nursing Care Plan for Hepatitis B

The patient will perform activities of daily living within the confines of the disease process, Extent of active management of energy to initiate and sustain activity.
The patient will identify strategies to reduce anxiety, Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source.
The patient and family will express an understanding of the disease process and treatment regimen Ability to acquire, organize, and use information. Verbalize understanding of condition/disease process and treatment.
The patient will discuss fears and concerns, Acknowledge and discuss fears, recognizing healthy versus unhealthy fears.
The patient will achieve adequate caloric and nutritional intake, Display normalization of laboratory values and be free of signs of malnutrition.
The patient will remain free from signs and symptoms of infection, patient will Identify interventions to prevent/reduce risk of infection.
The patient will avoid complications, Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Nursing interventions NCP Nursing Care Plan for Hepatitis B

Activity Therapy: Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s (or group’s) activity. Energy Management: Regulating energy use to treat or prevent fatigue and optimize function. Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
Teaching Individual about disease, diagnosis and treatment. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement: Intensifying a patient’s sense of physical and psychological safety. Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
Infection Protection: Prevention and early detection of infection in a patient at risk. Infection Control: Minimizing the acquisition and transmission of infectious agents. Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Surveillance: Safety: Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety. Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group. Environmental Management Manipulation of the patient’s surroundings for therapeutic benefit

NCP Nursing Care Plan for Hydrocephalus

2011-05-30T07:46:00.000+07:00

NCP Nursing Care Plan for Hydrocephalus. Hydrocephalus is an excessive accumulation of cerebrospinal fluid (CSF) in the ventricular spaces of the brain. Result from obstruction in CSF flow (noncommunicating hydrocephalus) or from faulty absorption of CSF (communicating hydrocephalus). It's most common in neonates but can also occur in adults as a result of injury or disease. In infants, hydrocephalus enlarges the head; in both infants and adults, resulting compression can damage brain tissue. With early detection and surgical intervention, the prognosis improves but remains guarded. Even after surgery, such complications as developmental delay, impaired motor function, and vision loss can persist. Without surgery, the prognosis is poor: Mortality may result from increased intracranial pressure (ICP) in people of all ages; infants may also die prematurely of infection and malnutrition.

Characteristics of hydrocephalus in infants, changes characteristic of hydrocephalus include marked enlargement of the head; distended scalp veins; thin, shiny, and fragile-looking scalp skin; and underdeveloped neck muscles.

Causes for Hydrocephalus

Hydrocephalus may result from an obstruction in CSF flow (noncommunicating hydrocephalus) or from faulty absorption of CSF (communicating hydrocephalus). In noncommunicating hydrocephalus, the obstruction occurs most frequently between the third and fourth ventricles and at the aqueduct of Sylvius. It can also occur at the outlets of the fourth ventricle (foramina of Luschka and Magendie) or, rarely, at the foramen of Monro. This obstruction may result from faulty fetal development (myelomeningocele, congenital arachnoid cysts), infection (syphilis, granulomatous diseases, meningitis), tumor, cerebral aneurysm, or a blood clot. In communicating hydrocephalus, faulty reabsorption of CSF may result from surgery to repair a myelomeningocele, adhesions between meninges at the base of the brain, or meningeal hemorrhage.

Complications for Hydrocephalus

Potential complications of hydrocephalus include:

Mental retardation,
Impaired motor function, and vision loss.
Death may result from increased intracranial pressure (ICP) in people of all ages
In infants may also die of infection and malnutrition.

Nursing Assessment Nursing Care Plan for Hydrocephalus

The patient's history may reveal the cause of hydrocephalus, infection (syphilis, granulomatous diseases, meningitis), tumor, cerebral aneurysm, In severe hydrocephalus, the infant's parents may report irritability, anorexia, episodes of projectile vomiting, and a high-pitched, shrill cry. Inspection may reveal depression of the roof of the eye orbit, displacement of the eyes downward, and prominent sclera (sunset sign).

Physical examination: a focus area of the head

Inspection In an infant may reveal an enlarged head that is clearly disproportionate to the infant's growth, an unmistakable sign of hydrocephalus. Neurologic examination may demonstrate abnormal muscle tone of the legs.

In adults and older children with a fused cranium, the patient history may uncover signs of increased ICP, including frontal headaches, nausea, and vomiting that may be projectile. If the patient or parents report that these symptoms cause wakening or occur on awakening, hydrocephalus should be suspected. The patient may also report diplopia and restlessness. Neurologic examination may detect a decreased level of consciousness, ataxia, and impaired intellect. Neurologic impairment may also cause incontinence.

Diagnostic tests for Hydrocephalus

Skull X-ray.
Angiography,
Computed tomography scanning, and magnetic resonance imaging

Nursing diagnosis Nursing Care Plan for Hydrocephalus

Common nursing diagnosis found in Nursing Care Plan for Hydrocephalus

Acute pain
Anxiety
Delayed growth and development
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Ineffective tissue perfusion: Cerebral.
Interrupted family processes.
Infant Behavior, risk for disorganized.
Risk for infection

Nursing Key outcomes Nursing Care Plan for Hydrocephalus

The patient will exhibit no signs of pain or agitation.
Family members will identify measures to reduce anxiety.
The patient will achieve age-appropriate growth, behaviors, and skills to the fullest extent possible.
The patient will show no signs of malnutrition.
The patient will maintain adequate ventilation and oxygenation.
The patient will maintain and improve current level of consciousness (LOC).
Family members will verbalize the effect of the patient's condition on their daily life.
The patient will remain free from signs of seizure activity.
The patient will remain free from signs and symptoms of infection.

Nursing Interventions Nursing Care Plan for Hydrocephalus

Pain Management, Analgesic Administration, Environmental Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient: Use of pharmacologic agents to reduce or eliminate pain: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger, Calming Technique: Reducing anxiety in patient experiencing acute distress
Developmental Enhancement, Nutritional Monitoring, Developmental Care: Child/Adolescent Facilitating or teaching parents/caregivers to facilitate the optimal gross motor, fine motor, language, cognitive, social, and emotional growth of preschool and school-age children/of individuals during the transition from childhood to adulthood; Collection and analysis of patient data to prevent or minimize malnourishment; Structuring the environment and providing care in response to the behavioral cues and states of the preterm infant
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids; Weight Gain Assistance: Facilitating gain of body weight
Respiratory Monitoring, Oxygen Therapy, Airway Management; Collection and analysis of patient data to ensure airway patency and adequate gas exchange; Administration of oxygen and monitoring of Facilitation of patency of air passages
Cerebral Perfusion Promotion of adequate perfusion and limitation of complications for a patient experiencing or at risk for inadequate cerebral perfusion
Family Process Maintenance, Family Integrity Promotion, Normalization Promotion: Minimization of family process disruption effects, Facilitating family participation in the emotional and physical care of the patient, Assisting parents and other family members of children with chronic diseases or disabilities in providing normal life experiences for their children and families
Developmental Care: Structuring the environment and providing care in response to the behavioral cues and states of the preterm infant. Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk, Minimizing the acquisition and transmission of infectious agents, Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan for Liver abscess

2011-05-23T10:23:00.000+07:00

NCP Nursing Care Plan for Liver abscess. Liver abscess is a relatively uncommon but life-threatening disorder that occurs when bacteria or protozoa destroy hepatic tissue. The damage produces a cavity, which fills with infectious organisms, liquefied hepatic cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver.

A liver abscess occurs when bacteria or protozoa destroy hepatic tissue, producing a cavity, which fills with infectious organisms, liquefied liver cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver. Liver abscess carries a mortality of 10% to 20%, despite treatment. Liver abscess affects both sexes and all age-groups, although it's slightly more prevalent in hospitalized children (because of a high rate of immunosuppression) and in females (most commonly those between ages 40 and 60).

Causes for Liver abscess

Underlying causes of liver abscess include benign or malignant biliary obstruction along with cholangitis, extrahepatic abdominal sepsis, and trauma or surgery

Certain illnesses or conditions may also lead to abscess development; these include cholecystitis, colon cancer, diverticulitis, peritonitis, regional enteritis, infective endocarditis, pelvic inflammatory disease, pneumonia, trauma, and septicemia.

Nursing Assessment Nursing Care Plan for Liver abscess

Signs and symptoms of liver abscess depend on the degree of involvement. Some patients are acutely ill; in others, the abscess is recognized only at autopsy, after death from another illness.

With a pyogenic abscess, the onset of symptoms is usually sudden; with an amebic abscess, it's more insidious. Common signs and symptoms include abdominal pain, weight loss, fever, chills, diaphoresis, nausea, vomiting, and anemia. Symptoms of right pleural effusion, such as dyspnea and pleural pain, develop if the abscess extends through the diaphragm. Liver damage may cause jaundice.

The patient may report right abdominal and shoulder pain, chills, fever, diaphoresis, nausea, vomiting, and weight loss. If the abscess extends through the diaphragm, he may complain of dyspnea and chest pain (symptoms of pleural effusion); if he has developed anemia, he may report fatigue. Inspection may disclose jaundice, a sign of liver damage. On palpation, the liver may feel enlarged, indicating hepatic disease.

Diagnostic Tests For Liver Abscess

Ultrasonography and
Computed tomography scan
Blood cultures and percutaneous liver aspiration, Liver biopsy
Urinalysis
Stool

Nursing diagnosis Nursing Care Plan for Liver abscess

Impaired Liver Function
Acute pain
Deficient knowledge (diagnosis and treatment)
Imbalanced nutrition: Less than body requirements
Risk for impaired skin integrity
Risk for infection

Nursing Key outcomes Nursing Care Plan for Liver abscess

Be free of signs of liver failure as evidenced by liver function studies within normal limits (WNL) and absence of jaundice, hepatic enlargement, or altered mental status
The patient will express feelings of comfort.
The patient and family will express an understanding of the disease process and treatment regimen.
The patient will achieve adequate caloric and nutritional intake.
The patient's skin integrity will remain intact.
The patient will remain free from signs and symptoms of infection.

Nursing interventions Nursing Care Plan for Liver abscess

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain. Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Teaching: Individual Planning, implementation, and evaluation of a teaching about Liver abscess. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity. Pressure Management: Minimizing pressure to body parts. Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them
Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents. Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan For Colorectal Cancer

2011-05-19T10:15:00.000+07:00

Image courtesy of cancer.osu.edu

NCP Nursing Care Plan for Colorectal Cancer, Colorectal cancer accounts for about 15% of all malignancies and for about 11% of cancer mortality in both men and women living in the United States. It is the third most common cause of death from cancer among men and women, combined. Malignant tumors of the colon or rectum are almost always adenocarcinomas. About half of these are sessile lesions of the rectosigmoid area; the rest are polypoid lesions.

Colorectal cancer tends to progress slowly and remains localized for a long time. Consequently, it's potentially curable in 75% of patients. With early diagnosis, the 5-year survival rate is 50%. It is potentially curable in 75% of patients if an early diagnosis allows resection before nodal involvement

Causes For Colorectal Cancer

The cause of colorectal cancer is largely unknown; however there is much evidence to suggest that incidence increases with age. Risk factors include a family history of colorectal cancer and a personal history of past colorectal cancer, ulcerative colitis, Crohn’s disease, or adenomatous colon polyps. Other factors that magnify the risk of developing colorectal cancer include obesity, diabetes mellitus, alcohol usage, night shift work, and physical inactivity. It has been strongly suggested that diets high in fat and refined carbohydrates play a role in the development of colorectal cancer.

Complications For Colorectal Cancer

As the tumor grows and encroaches on the abdominal organs, abdominal distention and intestinal obstruction occur. Anemia may develop if rectal bleeding isn't treated

Nursing Assessment Nursing Care Plan For Colorectal Cancer

Signs and symptoms depend on the tumor's location. If it develops on the colon's right side, the patient probably won't have signs and symptoms in the early stages because the stool is still in liquid form in that part of the colon. He may have a history of black, tarry stools, however, and report anemia, abdominal aching, pressure, and dull cramps. As the disease progresses, he may complain of weakness, diarrhea, obstipation, anorexia, weight loss, and vomiting.

Patient History. Seek information about the patient’s usual dietary intake, family history, and the presence of the other major risk factors for colorectal cancer. A change in bowel pattern (diarrhea or constipation) and the presence of blood in the stool are early symptoms and might cause the patient to seek medical attention. Patients may report that the urge to have a bowel movement does not go away with defecation. Cramping, weakness, and fatigue are also reported. As the tumor progresses, symptoms develop that are related to the location of the tumor within the colon. When the tumor is in the right colon, the patient may complain of vague cramping or aching abdominal pain and report symptoms of anorexia, nausea, vomiting, weight loss, and tarrycolored stools. A partial or complete bowel obstruction is often the first manifestation of a tumor in the transverse colon. Tumors in the left colon can cause a feeling of fullness or cramping, constipation or altered bowel habits, acute abdominal pain, bowel obstruction, and bright red bloody stools. In addition, rectal tumors can cause stools to be decreased in caliber, or “pencil-like.” Depending on the tumor size, rectal fullness and a dull, aching perineal or sacral pain may be reported; however, pain is often a late symptom.

Physical Examination. Inspect, auscultate, and palpate the abdomen. Note the presence of any distension, ascites, visible masses, or enlarged veins (a late sign due to portal hypertension and metastatic liver involvement). Bowel sounds may be high-pitched, decreased, or absent in the presence of a bowel obstruction. An abdominal mass may be palpated when tumors of the ascending, transverse, and descending colon have become large. Note the size, location, shape, and tenderness related to any identified mass. Percuss the abdomen to determine the presence of liver enlargement and pain. A rectal tumor can be easily palpated as the physician performs a digital rectal exam.

Diagnostic tests For Colorectal Cancer

Several tests support a diagnosis of colorectal cancer. Digital rectal examination can detect almost 15% of colorectal cancers. Specifically, it can detect suspicious rectal and perianal lesions. Fecal occult blood test can detect blood in stools, a warning sign of rectal cancer.

Digital examination.
Hemoccult test (guaiac).
Proctoscopy or sigmoidoscopy.
Colonoscopy permits visual inspection (and photographs) of the colon up to the ileocecal valve and gives access for polypectomies and biopsies of suspected lesions.
Computed tomography scan.
Barium X-ray. Barium examination should follow endoscopy or excretory urography because the barium sulfate interferes with these tests.
Carcinoembryonic antigen, although not specific or sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastasis or recurrence.

Nursing diagnosis Nursing Care Plan For Colorectal Cancer

Acute pain
Anxiety
Constipation
Deficient fluid volume
Diarrhea
Fear
Imbalanced nutrition: Less than body requirements
Risk for infection

Nursing Key outcomes Nursing Care plan for Colorectal Cancer

The patient will express that he feels less pain.
The patient will express feeling less anxious.
The patient will have soft, formed stools that are easy to pass.
The patient's fluid volume will be maintained within normal range.
The patient will resume a regular elimination pattern.
The patient will verbalize fears and concerns relating to his diagnosis and condition.
The patient won't experience further weight loss.
The patient won't exhibit signs or symptoms of infection.

Nursing interventions Nursing Care Plan for Colorectal Cancer

Pain Management, Analgesic Administration, Environmental Comfort Management, Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient, Use of pharmacologic agents to reduce or eliminate pain, Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress.
Constipation/Impaction Management: Prevention and alleviation of constipation/impaction. Bowel Management: Establishment and maintenance of a regular pattern of bowel elimination.
Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Diarrhea Management: Management and alleviation of diarrhea. Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance. Perineal Care: Maintenance of perineal skin integrity and relief of perineal discomfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement: Intensifying a patient’s sense of physical and psychological safety Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
Infection Protection: Prevention and early detection of infection in a patient at risk Infection Control: Minimizing the acquisition and transmission of infectious agents. Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan For Nonviral Hepatitis

2011-05-02T08:22:00.000+07:00

NCP Nursing Care Plans For Nonviral Hepatitis. Hepatitis can be caused by bacteria, by hepatotoxic agents (drugs, alcohol, industrial chemicals), or most commonly, by a virus. In Non viral hepatitis Classified as toxic or drug-induced (idiosyncratic) hepatitis, nonviral hepatitis is an inflammation of the liver. Most patients recover from this illness, although a few develop fulminating hepatitis or cirrhosis

Causes For Nonviral Hepatitis

Alcohol overuse
Direct hepatotoxicity hepatocellular damage and necrosis usually caused by toxins
Cholestatic reactions
Metabolic and autoimmune disorders
Infectious agents

Complications For Nonviral Hepatitis

Complications may include cirrhosis, hepatitis, and liver failure.

Nursing Assessment Nursing Care Plan For Nonviral Hepatitis

Patient history of alcohol use or recent infection. His medication history may include one implicated in causing the disorder, as stated above.

Clinical features of toxic and drug-induced hepatitis vary with the severity of the liver damage and the causative agent. In most patients, symptoms resemble those of viral hepatitis: anorexia, nausea, vomiting, jaundice, dark urine, hepatomegaly, possibly abdominal pain, clay-colored stools, and pruritus with the cholestatic form of hepatitis.

Diagnostic tests For Nonviral Hepatitis

Diagnostic findings include elevations in serum aspartate aminotransferase, alanine aminotransferase, both total and direct bilirubin (with cholestasis), and alkaline phosphatase levels; white blood cell (WBC) count; and eosinophil count (possible in the drug-induced type).

Liver function tests
Liver scan: May be indicated for differential diagnosis, to identify underlying chronic liver disease, or for evaluating organ function.
Liver biopsy: Considered if diagnosis is uncertain or if clinical course is atypical or unduly prolonged.
Urinalysis: Checks the urine for bilirubin for the nonjaundiced client with suspected viral hepatitis.

Nursing diagnosis Nursing Care Plan For Nonviral Hepatitis

Acute pain
Activity intolerance
Anxiety
Deficient knowledge (diagnosis and treatment)
Fear
Imbalanced nutrition: Less than body requirements
Risk for infection
Risk for injury

Nursing Key outcomes NCP Nursing Care Plan For Nonviral Hepatitis

Pain Level Control: Severity of reported or demonstrated pain, Personal actions to control pain, Report pain is relieved/controlled. Demonstrate use of relaxation skills and diversional activities as indicated for individual situation
The patient will perform activities of daily living within the confines of the disease process, Extent of active management of energy to initate and sustain activity.
The patient will identify strategies to reduce anxiety, Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source.
The patient and family will express an understanding of the disease process and treatment regimen Ability to acquire, organize, and use information. Verbalize understanding of condition/disease process and treatment.
The patient will discuss fears and concerns, Acknowledge and discuss fears, recognizing healthy versus unhealthy fears.
The patient will achieve adequate caloric and nutritional intake, Display normalization of laboratory values and be free of signs of malnutrition.
The patient will remain free from signs and symptoms of infection, patient will Identify interventions to prevent/reduce risk of infection.
The patient will avoid complications, Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Nursing interventions NCP Nursing Care Plan For Nonviral Hepatitis

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain. Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Activity Therapy: Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s (or group’s) activity. Energy Management: Regulating energy use to treat or prevent fatigue and optimize function. Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
Teaching Individual about disease, diagnosis and treatment. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement: Intensifying a patient’s sense of physical and psychological safety. Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
Infection Protection: Prevention and early detection of infection in a patient at risk. Infection Control: Minimizing the acquisition and transmission of infectious agents. Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Surveillance: Safety: Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety. Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group. Environmental Management Manipulation of the patient’s surroundings for therapeutic benefit

NCP Nursing Care Plan for Viral hepatitis

2011-04-26T10:43:00.000+07:00

Image courtesy Of umm.edu

NCP Nursing Care Plan for Viral hepatitis. Hepatitis is a widespread inflammation of the liver that results in degeneration and necrosis of liver cells. Viral hepatitis is a fairly common systemic disease. It's marked by hepatic cell destruction, necrosis, and autolysis, leading to anorexia, jaundice, and hepatomegaly. In most patients, hepatic cells eventually regenerate with little or no residual damage, allowing recovery. However, old age and serious underlying disorders make complications more likely. The prognosis is poor if edema and hepatic encephalopathy develop

Types Of Viral Hepatitis

The most common types are Hepatitis A, Hepatitis B, and Hepatitis C.

Type A (infectious or short-incubation hepatitis) is raising among people with immunosuppression. It's usually self-limiting and without a chronic form. About 40% of cases in the United States result from hepatitis A virus. Primarily transmitted by the fecal-oral route, by either person-to-person contact or consumption of contaminated food or water. Although viremia occurs early in infection and can persist for several weeks after onset of symptoms, bloodborne transmission of Hepatitis A virus HAV is uncommon. Hepatitis A virus HAV occasionally might be detected in saliva in experimentally infected animals, but transmission by saliva has not been demonstrated.
Type B (serum or long-incubation hepatitis) is also increasing among HIV-positive individuals. Hepatitis B is considered a sexually transmitted disease because of its high incidence and rate of transmission by this route. Hepatitis B is caused by infection with the Hepatitis B virus (HBV). The incubation period from the time of exposure to onset of symptoms is 6 weeks to 6 months. HBV is found in highest concentrations in blood and in lower concentrations in other body fluids (e.g., semen, vaginal secretions, and wound exudates). HBV infection can be self-limited or chronic.
Type C accounts for about 20% of all viral hepatitis cases and is primarily transmitted through blood and body fluids or obtained during tattooing. is most efficiently transmitted through large or repeated Percutaneous exposure to infected blood (e.g., through transfusion of blood from unscreened donors or through use of injecting drugs). Although much less frequent, occupational, perinatal, and sexual exposures also can result in transmission of HCV.
Type D (delta hepatitis) is responsible for about 50% of all cases of fulminant hepatitis, which has a high mortality. Developing in 1% of patients, fulminant hepatitis causes unremitting liver failure with encephalopathy. It progresses to coma and commonly leads to death within 2 weeks. Hepatitis D virus which is an RNA virus structurally unrelated to the Hepatitis A, B, or C viruses. Hepatitis D, which can be acute or chronic, is uncommon in the United States. Hepatitis D virus HDV is an incomplete virus that requires the helper function of HBV to replicate and only occurs among people who are infected with the Hepatitis B virus. Hepatitis D virus is transmitted through Percutaneous or mucosal contact with infectious blood and can be acquired either as a coinfection with HBV or as superinfection in persons with HBV infection. There is no vaccine for Hepatitis D, but it can be prevented in persons who are not already HBV-infected by Hepatitis B vaccination.
Type E (formerly grouped with type C under the name non-A, non-B hepatitis) occurs primarily in people who have recently returned from an endemic area (such as India, Africa, Asia, or Central America); it's more common in young adults and more severe in pregnant females. Hepatitis E is a serious liver disease caused by the Hepatitis E virus (HEV) that usually results in an acute infection. It does not lead to a chronic infection. While rare in the United States, Hepatitis E is common in many parts of the world. Transmission: Ingestion of fecal matter, even in microscopic amounts; outbreaks are usually associated with contaminated water supply in countries with poor sanitation
Some older books and websites list additional hepatitis viruses. These are virus-like agents transmitted in blood that were once suspected of causing hepatitis but do not: Hepatitis G. Transfusion transmitted virus (TTV)

Causes for Viral hepatitis

The six major forms of viral hepatitis A, B, C, D, and E

Complications for Viral hepatitis

Life-threatening fulminant hepatitis the most feared complication develops in about 1% of patients, causing unremitting liver failure with encephalopathy

Complications may be specific to the type of hepatitis:

Chronic active hepatitis may occur as a late complication of hepatitis B. During the prodromal stage of acute hepatitis B, a syndrome resembling serum sickness, characterized by arthralgia or arthritis, rash, and angioedema, may occur. This syndrome can lead to misdiagnosis of hepatitis B as rheumatoid arthritis or lupus erythematosus. Primary liver cancer may develop after infection with hepatitis B or C.
Type D hepatitis can cause a mild or asymptomatic form of type B hepatitis to flare into severe, progressive chronic active hepatitis and cirrhosis.
Other complications include a syndrome that resembles serum sickness (muscle and joint pain, rash, angioedema), as well as cirrhosis, pancreatitis, myocarditis, Aplastic anemia, or peripheral neuropathy.

Nursing Assessment NCP Nursing Care Plan for Viral hepatitis

Diagnostic tests for Viral hepatitis

Viral hepatitis serologies
Liver function tests
Liver scan: May be indicated for differential diagnosis, to identify underlying chronic liver disease, or for evaluating organ function.
Liver biopsy: Considered if diagnosis is uncertain or if clinical course is atypical or unduly prolonged.
Urinalysis: Checks the urine for bilirubin for the nonjaundiced client with suspected viral hepatitis.

Nursing diagnosis NCP Nursing Care Plan for Viral hepatitis

Activity intolerance
Anxiety
Deficient knowledge (diagnosis and treatment)
Fear
Imbalanced nutrition: Less than body requirements
Risk for infection
Risk for injury

Nursing Key outcomes NCP Nursing Care Plan for Viral hepatitis

The patient will perform activities of daily living within the confines of the disease process, Extent of active management of energy to initate and sustain activity.
The patient will identify strategies to reduce anxiety, Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source.
The patient and family will express an understanding of the disease process and treatment regimen Ability to acquire, organize, and use information. Verbalize understanding of condition/disease process and treatment.
The patient will discuss fears and concerns, Acknowledge and discuss fears, recognizing healthy versus unhealthy fears.
The patient will achieve adequate caloric and nutritional intake, Display normalization of laboratory values and be free of signs of malnutrition.
The patient will remain free from signs and symptoms of infection, patient will Identify interventions to prevent/reduce risk of infection.
The patient will avoid complications, Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Nursing interventions NCP Nursing Care Plan for Viral hepatitis

Activity Therapy: Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s (or group’s) activity. Energy Management: Regulating energy use to treat or prevent fatigue and optimize function. Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
Teaching Individual about disease, diagnosis and treatment. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement: Intensifying a patient’s sense of physical and psychological safety. Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
Infection Protection: Prevention and early detection of infection in a patient at risk. Infection Control: Minimizing the acquisition and transmission of infectious agents. Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Surveillance: Safety: Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety. Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group. Environmental Management Manipulation of the patient’s surroundings for therapeutic benefit

NCP Nursing Care Plans for Intestinal Obstruction

2011-04-23T09:07:00.000+07:00

Image Courtesy of umm.edu

NCP Nursing Care Plans for Intestinal Obstruction. Intestinal obstruction is the partial or complete blockage of the lumen of the small or large bowel. Intestinal obstruction occurs when a blockage obstructs the normal flow of contents through the intestinal tract. It's commonly a medical emergency. Complete obstruction in any part of the bowel, if untreated, can cause death within hours from shock and vascular collapse. Intestinal obstruction is most likely after abdominal surgery or in people with congenital bowel deformities.

Causes for Intestinal Obstruction

The two major types of intestinal obstruction are mechanical and neurogenic or nonmechanical.

Intestinal obstruction results from mechanical or nonmechanical (neurogenic) blockage of the lumen.

Mechanical obstruction include adhesions and strangulated hernias (Mechanical obstruction usually associated with small-bowel obstruction) chronic, severe constipation or fecal impaction, carcinomas (usually associated with large-bowel obstruction) foreign bodies, such as fruit pits, gallstones, and worms; compression of the bowel wall from stenosis; intussusception; volvulus of the sigmoid or cecum, tumors and atresia.
Nonmechanical obstruction usually results from paralytic ileus, the most common of all intestinal obstructions. Paralytic ileus is a physiological form of intestinal obstruction that usually develops in the small bowel after abdominal surgery. Other nonmechanical causes of obstruction include electrolyte imbalances, toxicity, such as that associated with uremia or generalized infection; neurogenic abnormalities such as spinal cord lesions; and thrombosis or embolism of mesenteric vessels.

Complications for Intestinal Obstruction

Intestinal obstruction can lead to perforation, peritonitis, septicemia, secondary infection, metabolic alkalosis or acidosis, hypovolemia or septic shock and, if untreated, death.

Nursing Assessment Nursing Care Plans for Intestinal Obstruction

Investigation of the patient's history often reveals predisposing factors, such as surgery (especially abdominal surgery), radiation therapy, and gallstones. The history may also disclose certain illnesses that can lead to obstruction, such as Crohn's disease, diverticular disease, and ulcerative colitis. Family history may reveal colorectal cancer in one or more relatives. Hiccups are a common complaint in all types of bowel obstruction. Other specific assessment findings depend on the cause of obstruction mechanical or nonmechanical and its location in the bowel

Diagnostic tests for Intestinal Obstruction

Various tests help to establish the diagnosis and pinpoint complications. For example,

Abdominal X-rays.
Barium enema In large-bowel obstruction reveals a distended, air-filled colon or a closed loop of sigmoid with extreme distention
Serum sodium, chloride, and potassium levels may decrease because of vomiting.
White blood cell counts may be normal or slightly elevated if necrosis, peritonitis, or strangulation occurs. Serum amylase level may increase, possibly from irritation of the pancreas by a bowel loop.
Hemoglobin concentration and hematocrit may increase, indicating dehydration.
Sigmoidoscopy, colonoscopy, or a barium enema may be used to help determine the cause of obstruction.

Nursing diagnosis Nursing Care Plans for Intestinal Obstruction

Acute pain
Constipation
Deficient fluid volume
Imbalanced nutrition: Less than body requirements
Ineffective tissue perfusion: GI

Nursing Key outcomes Nursing Care Plans for Intestinal Obstruction

The patient will express feelings of comfort, Report pain is relieved/controlled, Verbalize methods that provide relief.
The patient's bowel function will return to normal, Participate in bowel program as indicated.
The patient's fluid volume will remain within normal parameters, Maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, good skin turgor.
The patient will maintain adequate caloric intake. Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.
The patient will exhibit signs of adequate GI perfusion.

Nursing interventions Nursing Care Plans for Intestinal Obstruction

Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Comfort Management Manipulation of the patient’s surroundings for promotion of optimal comfort
Constipation/Impaction Management: Prevention and alleviation of constipation/impaction. Bowel Management: Establishment and maintenance of a regular pattern of bowel elimination
Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance Facilitating gain of body weight.
Fluid/Electrolyte Management Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels. Gastrointestinal Intubation: Insertion of a tube into the gastrointestinal tract

NCP Nursing Care Plan for Irritable Bowel Syndrome

2011-04-08T06:35:00.000+07:00

NCP Nursing Care Plan for Irritable Bowel Syndrome. Irritable bowel syndrome (IBS), sometimes called spastic, spastic colitis, mucous colitis. Is a common condition marked by chronic or periodic diarrhea alternating with constipation. It's accompanied by straining and abdominal cramps. Although people with IBS have a gastrointestinal (GI) tract that appears normal, colonic smooth muscle function is often abnormal. The autonomic nervous system, which innervates the large bowel, fails to provide the normal contractions interspaced with relaxations that propel stool smoothly forward. Excessive spasm and peristalsis lead to constipation or diarrhea, or both. Generally patients with IBS have either diarrhea or constipation predominant syndrome. Irritable bowel syndrome occurs mostly in females, with symptoms first emerging before age 40.

Causes for Irritable Bowel Syndrome

Although the precise etiology is unclear, irritable bowel syndrome involves a change in bowel motility, reflecting an abnormality in the neuromuscular control of intestinal smooth muscle.

Contributing or aggravating factors include anxiety and stress. Irritable bowel syndrome may also result from dietary factors, such as fiber, fruits, coffee, alcohol, and foods that are cold, highly seasoned, or laxative in nature. Other possible triggers include hormones, laxative abuse, and allergy to certain foods or drugs.

Complications for Irritable Bowel Syndrome

Irritable bowel syndrome is associated with a higher-than-normal incidence of diverticulitis and colon cancer. Although complications are usually few, the disorder may lead to chronic inflammatory bowel disease.

Nursing Assessment NCP Nursing Care Plan for Irritable Bowel Syndrome

Patient reports a history of chronic constipation, diarrhea, or both. investigate possible contributing psychological factors such as a recent stressful life change that may have triggered or aggravated symptoms.
Inspection, the patient may seem anxious and fatigued, but otherwise normal. Auscultation may reveal normal bowel sounds. Palpation typically discloses a relaxed abdomen. Occasionally, percussion reveals tympany over a gas-filled bowel.
Auscultation of the abdomen, normal bowel sounds may be heard, although they may be quiet during constipation. Tympanic sounds may be heard over loops of filled bowel. Although palpation often discloses a relaxed abdomen, it may reveal diffuse tenderness, which becomes worse if the sigmoid colon is palpable. The patient may have pain on rectal examination but does not usually experience rectal bleeding.

Diagnostic tests for Irritable Bowel Syndrome

No definitive test exists to confirm irritable bowel syndrome, the diagnosis typically involves studies to rule out other, more serious disorders, such as diverticulitis or colon cancer. The most frequently performed tests include barium enema, stool examination and Flexible sigmoidoscopy or colonoscopy

Nursing diagnosis NCP Nursing Care Plan for Irritable Bowel Syndrome

Acute pain
Constipation
Deficient knowledge (diagnosis and treatment)
Diarrhea
Disturbed body image
Ineffective coping

Nursing Key outcomes Nursing Care Plan for Irritable Bowel Syndrome

Nursing outcomes Nursing Care Plan for Irritable Bowel Syndrome, patient will;

Express feelings of comfort.
Patient's stool will be soft and will pass easily.
Express an understanding of the disease process and treatment regimen.
Bowel function will return to normal.
Express positive feelings about herself.
Demonstrate adaptive coping behaviors.

Nursing interventions NCP Nursing Care Plan for Irritable Bowel Syndrome

Usually Patient isn't hospitalized; nursing interventions focus on patient teaching and home health care guidance.

Teach to the patient about disease and treatment plan, prescribed drugs, reviewing their desired effects and possible adverse reactions. Diagnostic tests. Review all pretest guidelines. Explain that diagnostic tests can't specifically diagnose irritable bowel syndrome but do rule out other disorders.
Help the patient to implement lifestyle changes that reduce stress
Remind the patient about regular exercise, Discourage smoking, Explain the need for regular physical examinations

NCP Nursing Care Plan for Dislocated Or Fractured Jaw

2011-04-07T07:46:00.000+07:00

Image Courtesy Of scripps.org

NCP Nursing Care Plan for Dislocated or Fractured Jaw. Dislocation and subluxation are terms used to describe the anatomic displacement of a bone from its normal position in the joint. Dislocation is the complete separation of the bone from the articular surfaces of the joint, whereas subluxation is only a partial displacement in the joint. Both dislocations and subluxations refer to the position of the distal bone in relation to its proximal articulation. Displacement of the temporomandibular joint results in a dislocated jaw. A break in one or both of the two maxillae (upper jawbones) or the mandible (lower jawbone) constitutes a fractured jaw. Treatment usually restores jaw alignment and function.

Causes for Dislocated or Fractured Jaw

Simple dislocations or fractures are usually caused by a manual blow along the jawline as may occur in cases of child, spouse, or elder abuse; more serious compound fractures frequently result from motor vehicle accidents.

Complications for Dislocated or Fractured Jaw

Infection can be a serious complication of a fractured jaw. A fracture can cause a large sublingual hematoma, which may compromise the airway. Injury can also traumatize the nerves that innervate the jaw and face.

Complications may include:

• Airway blockage

• Bleeding

• Breathing blood or food into the lungs

• Difficulty eating (temporary)

• Difficulty talking (temporary)

• Infection of the jaw or face

• Jaw joint (TMJ) pain and other problems

• Problems aligning the teeth

Nursing Assessment Nursing Care Plan for Dislocated or Fractured Jaw

Patient's history reveals an injury to the jaw, and he reports mandibular pain beginning right after the injury. Patient may report Bite that feels "off" or crooked, Difficulty speaking, Drooling because of inability to close the mouth, Inability to close the mouth, Jaw that may protrude forward, Pain in the face or jaw, located in front of the ear on the affected side, and gets worse with movement, Teeth that aren't normally aligned
Inspection reveals malocclusion (the most obvious sign of dislocation or fracture), swelling, ecchymosed, loss of function, and asymmetry.
Palpation of the injured area reveals pain and swelling. During palpation, note whether the patient experiences any altered sensation. A mandibular fracture that damages the alveolar nerve produces paresthesia or anesthesia of the chin and lower lip.

Diagnostic tests For Dislocated or Fractured Jaw

X-rays usually most accurate confirm the diagnosis

Nursing diagnosis Nursing Care Plan for Dislocated or Fractured Jaw

Acute pain
Ineffective airway clearance
Anxiety
Disturbed body image
Imbalanced nutrition: Less than body requirements
Impaired verbal communication
Risk for aspiration
Risk for deficient fluid volume
Risk for infection

Nursing Key outcomes Nursing Care Plan for Dislocated or Fractured Jaw

Nursing outcomes Nursing Care Plan for Dislocated or Fractured Jaw, Patient will:

Express feelings of comfort and relief of pain.
Demonstrate methods (coughing, suctioning) to maintain a patent airway.
Express that he feels less anxious.
Express positive feelings about self.
Have no further weight loss.
Use an alternative method of communication if unable to communicate with language.
Avoid aspiration.
Fluid volume will remain adequate.
Exhibit no signs or symptoms of infection.

Nursing interventions Nursing Care Plan for Dislocated or Fractured Jaw

Pain Management, Analgesic Administration, and Environmental Management Comfort: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Use of pharmacologic agents to reduce or eliminate pain. Manipulation of the patient’s surroundings for promotion of optimal comfort
Respiratory Monitoring, Airway Management: Facilitation of patency of air passages. Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
Body Image Enhancement: Improving a patient’s conscious and unconscious perceptions and attitudes toward patient body. Self-Esteem Enhancement: Assisting a patient to increase patient personal judgment of self-worth
Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance Facilitating gain of body weight. Eating impairment Management
Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech. Active Listening Attending closely to and attaching significance to a patient’s verbal and nonverbal messages
Aspiration Precautions Prevention or minimization of risk factors in the patient at risk for aspiration
Fluid Monitoring, Hemodynamic Regulation, Bleeding Precautions: Collection and analysis of patient data to regulate fluid balance, Optimization of heart rate, preload, afterload, and contractility, Reduction of stimuli that may indicate bleeding or hemorrhage in at-risk patients
Infection Protection, Infection Control, infection Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plans for Cerebral Palsy

2011-04-06T08:08:00.000+07:00

NCP Nursing Care Plans for Cerebral Palsy. Cerebral palsy the most common crippling disease in children includes several neuromuscular disorders resulting from prenatal, perinatal, or postnatal central nervous system damage. Cerebral palsy, a disorder that affects motor skills, muscle tone, and muscle movement, is a disorder which is most commonly due to damage during prenatal, perinatal, and postnatal periods during the pregnancy process. Although nonprogressive, these disorders may become more obvious as an affected infant grows older.

Types of cerebral palsy:

Spastic cerebral palsy (affecting about 70% of children with cerebral palsy)
Athetoid cerebral palsy (affecting about 20%)
Ataxic cerebral palsy (affecting about 10%)
Mixed cerebral palsy

Incidence of cerebral palsy is highest in premature neonates and in those who are small for gestational age. Cerebral palsy is slightly more common in boys than in girls and occurs more commonly in whites.

Causes for Cerebral Palsy

About 40% of all cases, the cause for cerebral palsy is unknown. The most prevalent cause of cerebral palsy is prenatal factors. Cerebral palsy usually stems from conditions that result in cerebral anoxia, hemorrhage, or other damage. Conditions that cause these problems can occur before, during, or after birth.

Prenatal causes include Rhesus (Rh) factor or ABO blood type incompatibility, maternal infection (especially rubella in the first trimester), maternal diabetes, irradiation, anoxia, toxemia, malnutrition, abnormal placental attachment, and isoimmunization.
During parturition, conditions that can cause cerebral palsy include trauma during delivery, depressed maternal vital signs from general or spinal anesthesia, asphyxia from the cord wrapping around the neck, prematurity, prolonged or unusually rapid labor, and multiple births
Postnatal causes include infections, such as meningitis and encephalitis, head trauma, poisoning, and any condition that results in cerebral thrombus or embolus.

Complications for Cerebral Palsy

• Cerebral palsy may produce complicating conditions, including

• Seizure disorders

• Language and perceptual deficits speech, vision, and hearing problems

• Mental retardation

• Dental problems

• Respiratory difficulties, such as poor swallowing and gag reflexes.

Nursing Assessment Nursing Care Plans for Cerebral Palsy

The patient's history and physical examination findings, including results of the neurologic assessment, confirm the diagnosis of cerebral palsy.

Patient history, maternal history often reveals the possible cause of cerebral palsy. Patients who have mixed forms of the disorder may display a combination of clinical findings
Generally, inspection reveals a child with retarded growth and development. If you observe the patient eating, you may notice that he has difficulty chewing and swallowing. Other findings vary depending on the type of cerebral palsy.
Neurologic examination may reveal hyperactive deep tendon reflexes and increased stretch reflexes, rapid alternating muscle contraction and relaxation, and weakness. Muscle contraction in response to manipulation with a tendency toward contractures also occurs.

Diagnostic tests for Cerebral Palsy

Appropriate tests are performed to diagnose conditions associated with cerebral palsy and to determine the degree of visual, auditory, and mental impairment.

Brain scans; Magnetic resonance imaging (MRI), Cranial ultrasound, Computerized tomography (CT)
Electroencephalogram (EEG)
Vision impairment tests
Hearing impairment tests
Speech delays or impairments tests
Intellectual disabilities or mental retardation tests
Other developmental delays tests

Nursing diagnosis Nursing Care Plans for Cerebral Palsy

Chronic low self-esteem
Compromised family coping
Deficient knowledge (diagnosis and treatment)
Delayed growth and development
Disturbed body image
Disturbed sensory perception: Visual, hearing
Imbalanced nutrition: Less than body requirements
Impaired physical mobility
Impaired swallowing
Interrupted family processes
Risk for impaired parenting
Risk for impaired skin integrity

Nursing Key outcomes Nursing Care Plans for Cerebral Palsy

Nursing Key outcomes Nursing Care Plans for Cerebral Palsy, Patient will:

Verbalize feelings related to self-esteem.
Develop adequate coping mechanisms.
Demonstrate knowledge of the condition and the treatment plan.
Achieve age-appropriate growth, behaviors, and skills to the fullest extent possible.
Express positive feelings about himself.
Maintain optimal functioning within the limits of the visual or hearing impairment.
Remain oriented to person, place, time, and situation.
Consume adequate daily calories as required.
Maintain joint mobility and ROM.
Swallow without pain or aspiration.
Family members will discuss how the patient's condition has affected the family's daily life.
The parents will identify realistic goals according to the abilities of the child.
Skin will show no signs of breakdown.

Nursing interventions Nursing Care Plans for Cerebral Palsy

Self-Esteem Enhancement, Emotional Support, Body Image Enhancement: Assisting a patient to increase his/her personal judgment of self-worth. Provision of reassurance, acceptance, and encouragement during times of stress. Improving a patient’s conscious and unconscious perceptions and attitudes toward body
Family Involvement Promotion, Family Support, Family Mobilization: Facilitating family participation in the emotional and physical care of the patient. Promotion of family values, interests, and goals. Utilization of family strengths to influence patient’s health in a positive direction
Teaching Individual Planning, implementation, and evaluation of a teaching program designed to address a patient’s diagnosis and treatment. Learning Facilitation Promoting the ability to process and comprehend information Learning Readiness Enhancement Improving the ability and willingness to receive information.
Developmental Enhancement Child, Developmental Care: Facilitating or teaching parents/caregivers to facilitate the optimal gross motor, fine motor, language, cognitive, social, and emotional growth of preschool and school-age children/of individuals during the transition from childhood to adulthood Structuring the environment and providing care in response to the behavioral cues and states of the preterm infant. Nutritional Monitoring: Collection and analysis of patient data to prevent or minimize malnourishment
Self-Esteem Enhancement Assisting a patient to increase personal judgment of self-worth
Communication Enhancement, Environmental Management: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision, Manipulation of the patient’s surroundings for therapeutic benefit
Nutrition Management, Weight Gain Assistance, Eating Disorders Management: Assisting with or providing a balanced dietary intake of foods and fluids, Facilitating gain of body weight.
Exercise Therapy: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement.
Swallowing Therapy, Aspiration Precautions: Facilitating swallowing and preventing complications of impaired swallowing. Prevention or minimization of risk factors in the patient at risk for aspiration
Family Process Maintenance, Family Integrity Promotion, Normalization Promotion: Minimization of family process disruption effects. Facilitating family participation in the emotional and physical care of the patient. Assisting parents and other family members of children with chronic diseases or disabilities in providing normal life experiences for their children and families
Skin Surveillance, Pressure Management, Pressure Ulcer Prevention: Collection and analysis of patient data to maintain skin and mucous membrane integrity. Minimizing pressure to body parts. Prevention of pressure ulcers for a patient at high risk for developing them

NCP Nursing Care Plans for Cerebral Contusion

2011-04-05T08:34:00.000+07:00

Image Courtesy Of neurosurgery.ufl.edu

NCP Nursing Care Plans for Cerebral Contusion. Cerebral Contusion is a Head injury that More serious than a concussion, a cerebral contusion is an ecchymosed of brain tissue that results from a severe blow to the head. When the head is abruptly brought to a stop against a solid object, the brain continues to move for an instant, hitting the inside the now stationary skull. The soft brain is easily contused and lacerated by the hard bony ridges at the base of the skull or by the tentorium cerebelli and falx cerebri. A contusion disrupts normal nerve functions in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death.

Causes Cerebral Contusion

Acceleration-deceleration or coup countercoup injuries

Complications for Cerebral Contusion

When injuries cause the brain to strike against bony prominences inside the skull (especially to the sphenoidal ridges), intracranial hemorrhage or hematoma can occur. The patient may also suffer tentorial herniation. Residual headache and vertigo may complicate recovery. Secondary effects, such as cerebral edema, may accompany serious contusions, resulting in increased intracranial pressure (ICP) and herniation.

Nursing Assessment Nursing care plans for Cerebral Contusion

The patient's history reveals a severe traumatic impact to the head, commonly against a blunt surface such as a car dashboard. Signs and symptoms vary, depending on the location of the contusion and the extent of damage. A period of unconsciousness, possibly lasting 6 hours or more, may follow the trauma. An unconscious patient may appear pale and motionless, whereas a conscious patient may appear drowsy or easily disturbed by any form of stimulation, such as noise or light. A conscious patient may become agitated or violent. Assessment of an unconscious patient may reveal below-normal blood pressure and temperature. His pulse rate may be within normal levels but feeble, and his respirations may be shallow. In a conscious patient, temperature, pulse rate, and respiratory status vary, depending on his physical and emotional status.

• Inspection may reveal severe scalp wounds, labored respirations and, possibly, involuntary evacuation of the bowels and bladder. Palpation may disclose less obvious head injuries such as hematoma. On palpation, the unconscious patient's skin will feel cold.

• Neurologic findings may include hemiparesis, decorticate or decerebrate posturing, and unequal pupillary response. With effort, you may be able to temporarily rouse an unconscious patient. If you're performing a neurologic examination after the acute stage of the injury, you may find that the patient has returned to a relatively alert state, perhaps with temporary aphasia, slight hemiparesis, or unilateral numbness.

Diagnostic tests for Cerebral Contusion

Cerebral angiography outlines vasculature, and a
Computed tomography (CT) scan CT scan
MRI (magnetic resonance imaging)

Nursing diagnosis Nursing care plans for Cerebral Contusion

Common Nursing diagnosis found in Nursing care plans for Cerebral Contusion

Acute pain
Anxiety
Ineffective cerebral tissue Perfusion
Disturbed sensory perception: Kinesthetic, tactile
Disturbed thought processes
Impaired verbal communication
Ineffective coping
Risk for deficient fluid volume
Risk for infection
Risk for injury
Risk for post trauma syndrome

Nursing Interventions Nursing Care Plans for Cerebral Contusion

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique Reducing anxiety in patient experiencing acute distress
Neurologic Monitoring, Cerebral Perfusion Promotion. Administer supplemental oxygen via appropriate route, such as mechanical ventilator and mask, to maintain appropriate O2 saturation, as indicated.
Communication Enhancement, Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids. Environmental Management Manipulation of the patient’s surroundings for therapeutic benefit. Peripheral Sensation Management Prevention or minimization of injury or discomfort in the patient with altered sensation
Communication Enhancement Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech. Active Listening Attending closely to and attaching significance to a patient’s verbal and nonverbal messages
Coping Enhancement, Decision-Making Support, Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Providing information and support for a person who is making a decision regarding healthcare
Fluid Monitoring, Hemodynamic Regulation, and Bleeding Precautions: Collection and analysis of patient data to regulate fluid balance. Optimization of heart rate, preload, afterload, and contractility. Reduction of stimuli that may indicate bleeding or hemorrhage in at-risk patients
Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk, Minimizing the acquisition and transmission of infectious agents, Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Safety Surveillance, Risk Identification, Safety Environmental Management: Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety. Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group. Manipulation of the patient’s surroundings for therapeutic benefit
Crisis Intervention, Coping Enhancement, Support System Enhancement: Use of short-term counseling to help the patient cope with a crisis and resume a state of functioning comparable to or better than the pre-crisis state, Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles. Facilitation of support to patient by family, friends, and community

NCP Nursing Care Plans For Aplastic Anemia

2011-04-04T06:34:00.000+07:00

Image courtesy of umm.edu

NCP Nursing Care Plans For Aplastic Anemia. Aplastic, or hypoplastic, anemia is a bone marrow failure that is characterized by a decrease in all formed elements of peripheral blood and its bone marrow. If all elements are suppressed resulting in loss of production of healthy erythrocytes, platelets, and granulocytes the condition is known as pancytopenia. Onset is often insidious and may become chronic; however, onset may be rapid and overwhelming when the cause is a myelotoxin. Aplastic and hypoplastic anemia are potentially fatal, commonly used interchangeably with other terms for bone marrow failure, aplastic anemia correctly refer to pancytopenia resulting from the decreased functional capacity of a hypoplastic, fatty bone marrow. These disorders usually produce fatal bleeding or infection, particularly when they're idiopathic.

Causes For Aplastic Anemia

Injury or damage to the stem cells that inhibit red blood cell (RBC) production.

Complications For Aplastic Anemia

Life-threatening hemorrhage from the mucous membranes is the most common complication of aplastic or hypoplastic anemias because affected patients develop alloimmunization, which can make platelet transfusions ineffective. Immunosuppression can lead to secondary opportunistic infections.

Nursing Assessment Nursing Care Plans For Anemia

The patient's history may not help to establish disease onset because the symptoms usually develop insidiously. The patient may report signs and symptoms of anemia (progressive weakness and fatigue, shortness of breath, and headache) or signs of thrombocytopenia (easy bruising and bleeding, especially from the mucous membranes [nose, gums, rectum, vagina]).

Inspection may reveal pallor if the patient is anemic, and ecchymosis, petechiae, or retinal bleeding if thrombocytopenia is present. You may note alterations in the level of consciousness and weakness if bleeding into the central nervous system has occurred.

Auscultation may reveal bibasilar crackles, tachycardia, and a gallop murmur if severe anemia results in heart failure.

The patient may also have signs and symptoms of an opportunistic infection (most commonly, a bacterial infection). Fever, oral and rectal ulcers, and sore throat may indicate the presence of an infection but without characteristic inflammation due to leukopenia.

Diagnostic tests For Aplastic Anemia

Complete blood count
Serum iron; coagulation tests; bone marrow biopsy; hemoglobin electrophoresis;
transaminase; bilirubin; lactic dehydrogenase; blood urea nitrogen; creatinine;
hepatitis testing; peripheral smear.

Nursing diagnosis Nursing Care Plans For Aplastic Anemia

Activity intolerance
Acute pain
Fatigue
Fear
Impaired oral mucous membrane
Ineffective thermoregulation
Risk for deficient fluid volume
Risk for infection

Nursing outcomes Nursing Care Plans For Aplastic Anemia

Nursing Key outcomes Nursing Care Plans For Aplastic Anemia, Patient will;

State the need to increase activity level gradually and the importance of rest periods.
Express feelings of comfort and decreased pain.
Identify measures to prevent or reduce fatigue.
Verbalize fears and concerns.
Oral mucous membranes will remain intact.
Maintain a normal body temperature.
Maintain adequate fluid balance.
Free from signs and symptoms of infection

Nursing interventions Nursing Care Plans For Aplastic Anemia

To identify causative/precipitating factors. Assist client to deal with contributing factors and manage activities within individual limits. Activity Therapy Prescription of and assistance with specific physical, cognitive, social and spiritual activities to increase the range, frequency, or duration of an individual’s or group are activity. Energy Management Regulating energy use to treat or prevent fatigue and optimize function
Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Manipulation of the patient’s surroundings for promotion of optimal comfort
Energy Management regulating energy use to treat or prevent fatigue and optimize function. Exercise Promotion Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health. Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids
Anxiety Reduction Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement Intensifying a patient’s sense of physical and psychological safety. Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Oral Health Restoration, Oral Health Maintenance, Promotion of healing for a patient who has an oral mucosa or dental lesion. Maintenance and promotion of oral hygiene and dental health for the patient at risk for developing oral or dental lesions. Promotion of oral hygiene and dental care for a patient with normal oral and dental health
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range. Fever Treatment Management of a patient with hyperpyrexia caused by nonenvironmental factors
Fluid Monitoring Hemodynamic Regulation Bleeding Precautions Collection and analysis of patient data to regulate fluid balance Optimization of heart rate, preload, afterload, and contractility Reduction of stimuli that may indicate bleeding or hemorrhage in at risk patients
Infection Protection Infection Control and Surveillance Prevention and early detection of infection in a patient at risk, Minimizing the acquisition and transmission of infectious agents, Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan For Urinary Tract Infections (UTIs)

2011-04-03T08:29:00.000+07:00

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NCP Nursing Care Plan For Urinary Tract Infections (UTIs). Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra the two forms of lower urinary tract infection (UTI) are cystitis (infection of the bladder) and urethritis (infection of the urethra). Urinary tract infection (UTI) more common in females than in males. UTI is prevalent in girls. In adult males and in children, lower UTIs typically are associated with anatomic or physiologic abnormalities and therefore need close evaluation. Most UTIs respond eadily to treatment, but recurrence and resistant bacteria flare-up during therapy are possible.

Urinary reflux is one reason that bacteria spread in the urinary tract. Vesicourethral reflux occurs when pressure increases in the bladder from coughing or sneezing and pushes urine into the urethra. When pressure returns to normal, the urine moves back into the bladder, taking with it bacteria from the urethra. In vesicoureteral reflux, urine flows backward from the bladder into one or both of the ureters, carrying bacteria from the bladder to the ureters and widening the infection. If they are left untreated, UTIs can lead to chronic infections, pyelonephritis, and even Systemic sepsis and septic shock. If infection reaches the kidneys, permanent renal damage can occur, which leads to acute and chronic renal failure.

Causes for Urinary tract infection (UTI)

Most lower UTIs result from ascending infection by a single gram-negative, enteric bacterium, such as Escherichia coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, and Serratia. In a patient with neurogenic bladder, an indwelling urinary catheter, or a fistula between the intestine and bladder, a lower UTI may result from simultaneous infection with multiple pathogens.

Studies suggest that infection results from a breakdown in local defense mechanisms in the bladder that allows bacteria to invade the bladder mucosa and multiply. These bacteria can't be readily eliminated by normal urination.

The pathogen's resistance to the prescribed antimicrobial therapy usually causes bacterial flare-up during treatment. Even a small number of bacteria in a midstream urine specimen obtained during treatment casts doubt on the effectiveness of treatment.

In almost all patients, recurrent lower UTIs result from reinfection by the same organism or by some new pathogen. In the remaining patients, recurrence reflects persistent infection, usually from renal calculi, chronic bacterial prostatitis, or a structural anomaly that is a source of infection. The high incidence of lower UTI among females probably occurs because natural anatomic features that facilitate Urinary tract infection (UTI).

Complications for Urinary tract infections (UTIs)

If untreated, chronic UTI can seriously damage the urinary tract lining. Infection of adjacent organs and structures (for example, pyelonephritis) may also occur. When this happens, the prognosis is poor.

Nursing Assessment Nursing care plans for Urinary tract infections (UTIs)

Patients History. The patient with a UTI has a variety of symptoms that range from mild to severe. The typical complaint is of one or more of the following: frequency, burning, urgency, nocturia, blood or pus in the urine, and suprapubic fullness. The patient may complain of urinary urgency and frequency, dysuria, bladder cramps or spasms, itching, a feeling of warmth during urination, nocturia. Other complaints include low back pain, malaise, nausea, vomiting, pain or tenderness over the bladder, chills, and flank pain. Inflammation of the bladder wall also causes hematuria and fever. Ask the patient about risk factors, including recent catheterization of the urinary tract, pregnancy or recent childbirth, neurological problems, volume depletion, frequent sexual activity, and presence of a sexually transmitted infection (STI).

Physical Examination. Physical examination is often unremarkable in the patient with a UTI, although some patients have costovertebral angle tenderness in cases of pyelonephritis. On occasion, the patient has fever, chills, and signs of a systemic infection. Inspect the urine to determine its color, clarity, odor, and character. Surveillance for STIs is recommended as part of the examination.

Diagnostic tests Urinary tract infections (UTIs).

Several tests are used to diagnose lower UTIs:

Leukocyte esterase dip test
Clean-catch urinalysis.
Clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.
Sensitivity testing is used to determine the appropriate antimicrobial drug.
Stained smear of urethral discharge can be used to rule out sexually transmitted disease.
Voiding cystourethrography or excretory urography

Nursing diagnosis Nursing care plans for Urinary tract infections (UTIs).

Acute pain
Deficient knowledge (prevention)
Disturbed sleep pattern
Impaired urinary elimination
Risk for infection
Risk for injury
Sexual dysfunction

Nursing Key outcomes nursing care plans for Urinary tract infections (UTIs)

The patients will:

Report increased comfort.
Identify risk factors that exacerbate the disease process or condition and modify his lifestyle accordingly.
Verbalize feeling well rested after undisturbed periods of sleep.
Remain free from signs or symptoms of infection.
Avoid or minimize complications.
Reestablish sexual activity at the preillness level.
Patient and family will demonstrate skill in managing elimination problem.

Nursing interventions Nursing care plans for Urinary tract infections (UTIs)

Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Comfort Manipulation of the patient’s surroundings forpromotion of optimal comfort
Teaching the patient of a teaching program about UTIs, how to prevent recurrent lower UTIs, and therapy.
Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information
Sleep Enhancement to Facilitation of regular sleep/wake cycles. Simple Relaxation Therapy Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety. Environmental Management Manipulation of the patient’s surroundings for therapeutic benefit
Urinary Elimination Management Maintenance of an optimum urinary elimination pattern. Urinary Catheterization Insertion of a catheter into the bladder for temporary or permanent drainage of urine. Perineal Care Maintenance of perineal skin integrity and relief of perineal discomfort
Infection Protection to Prevention and early detection of infection in a patient at risk. Infection Control Minimizing the acquisition and transmission of infectious agents. Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Risk Identification Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group. Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety
Sexual Counseling Use of an interactive helping process focusing on the need to make adjustments to sexual practice or to coping with a sexual event/disorder. Teaching/Assisting individuals to understand physical and psychosocial dimensions of sexual growth and development

NCP Nursing Care Plan For Anaphylaxis Shock

2011-04-02T05:08:00.000+07:00

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NCP Nursing Care Plan for Anaphylaxis Shock. Anaphylaxis is a dramatic, acute atopic reaction marked by the sudden onset of rapidly progressive urticaria and respiratory distress. A severe reaction may initiate vascular collapse, leading to systemic shock and, possibly, death. Anaphylactic shock, or anaphylaxis, is an immediate, life-threatening allergic reaction that is caused by a systemic antigen-antibody immune response to a foreign substance (antigen) introduced into the body.

Causes for Anaphylaxis Shock

Anaphylaxis can result from a variety of causes, but it most commonly occurs in response to food, medications, and insect bites. Anaphylactic reactions result from systemic exposure to sensitizing drugs or other specific antigens.

Complications for Anaphylaxis Shock

Untreated anaphylaxis can cause respiratory obstruction, systemic vascular collapse, and death minutes to hours after the first symptoms.

Nursing Assessment Nursing Care Plan for Anaphylaxis Shock

The patient, a relative, or another responsible person may report the patient's exposure to an antigen. Immediately after exposure, the patient may complain of a feeling of impending doom or fright and exhibit apprehension, restlessness, cyanosis, cool and clammy skin, erythema, edema, tachypnea, weakness, sweating, sneezing, dyspnea, nasal pruritus, and urticaria.

Patient History: Obtain information about any recent food intake, medication ingestion, outdoor activities and exposure to insects, or known allergies. Symptoms usually begin within 5 to 30 minutes, and the earlier the signs and symptoms begin the more severe the reaction. Often the signs and symptoms begin with skin and respiratory involvement

Physical examination: Note any hives, which appear as well-defined areas of redness with raised borders and blanched centers. On inspection, the patient's skin may display well-circumscribed, discrete cutaneous wheals with erythematous, raised, serpiginous borders and blanched centers. Angioedema may cause the patient to complain of a lump in his throat, or you may hear hoarseness or stridor. Wheezing, dyspnea, and complaints of chest tightness suggest bronchial obstruction. They are early signs of impending, potentially fatal respiratory failure.

Auscultate the patient’s blood pressure with a high suspicion for hypotension. Auscultate the patient’s heart to identify cardiac dysrhythmias, which may precipitate vascular collapse. Palpate the patient’s extremities for signs of cardiovascular com

Diagnostic tests for Anaphylaxis Shock

Usually No tests are required

Nursing diagnosis Nursing Care Plan for Anaphylaxis Shock

Common nursing diagnosis found in nursing care plan for patient with Anaphylaxis

• Acute confusion

• Acute pain

• Anxiety

• Decreased cardiac output

• Deficient fluid volume

• Deficient knowledge (avoidance strategies)

• Impaired gas exchange

• Impaired skin integrity

• Ineffective airway clearance

• Ineffective breathing pattern

Nursing outcomes for Anaphylaxis Shock

Nursing outcomes Nursing Care Plan for Anaphylaxis, patient will:

Reoriented to the situation and his surroundings.
Express feelings of comfort and decreased pain.
Verbalize measures to reduce his anxiety level.
Cardiac output and heart rate will remain within normal range, and his pulses will remain palpable.
Maintain an adequate fluid volume.
Verbalize measures to avoid allergens.
Ventilation and oxygenation will remain adequate.
Wounds or lesions will heal without complications.
Maintain a patent airway.
Maintain a respiratory rate within five breaths of baseline.

Nursing interventions Nursing Care Plan For Anaphylaxis Shock

Delirium Management Provision of a safe and therapeutic environment for the patient who is experiencing an acute confusional state. Reality Orientation Promotions of patient’s awareness of personal identity, time, and environment. Surveillance Safety Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety
Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental and Comfort Management Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Provision of a modified environment for the patient who is experiencing a chronic confusional state. Calming Technique to Reducing anxiety in patient experiencing acute distress
Hemodynamic Regulation Optimization of heart rate, preload, after load, and contractility. Cardiac Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function. Circulatory Care Mechanical Assist Devices Temporary support of the circulation through the use of mechanical devices or pumps
Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded. Shock Management Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Teaching Individual Planning, implementation, and evaluation of a teaching program designed to address a patient’s particular needs. Learning Facilitation to promoting the ability to process and comprehend information. Learning Readiness Enhancement to Improving the ability and willingness to receive information
Respiratory Monitoring to Collection and analysis of patient data to ensure airway patency and adequate gas exchange. Oxygen Therapy Administration of oxygen and monitoring of its effectiveness. Airway Management Facilitation of patency of air passages
Wound Care Prevention of wound complications and promotion of wound healing Cleansing, monitoring, and promotion of healing in a wound.
Airway Management Facilitation of patency of air passages. Respiratory Monitoring Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Ventilation Assistance: Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs

NCP Nursing Care Plans for Burns Injury

2011-03-25T07:22:00.000+07:00

NCP Nursing Care Plans for Burns Injury. A major burn is a devastating injury, requiring painful treatment and a long period of rehabilitation. Burns have a catastrophic effect on people in terms of human life, suffering, disability, and financial loss. Burns can be fatal, permanently disfiguring, and incapacitating, both emotionally and physically. Infections are a major cause of morbidity and mortality in seriously burned patients. The skin injury from burns has six different mechanisms of injury: scalds, contact burns, fire, chemical, electrical, and radiation.

Causes for Burns Injury

Thermal burns, the most common type, result from preventable accidents occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkali, or vesicants. Electrical burns commonly occur after contact with faulty electrical wiring or high-voltage power lines. Friction, or abrasion, burns happen when the skin is rubbed harshly against a coarse surface. Sunburn follows excessive exposure to sunlight and improper use of tanning lights.

Complications for Burns Injury

Leading causes of death in burn patients are respiratory complications and sepsis.

Other possible complications include:

Hypovolemic shock
Anemia
Malnutrition
Multisystem organ dysfunction.

Nursing Assessment Nursing Care Plans for Burns Injury

Patient history. Obtain a complete description of the burn injury, including the time, the situation, the burning agent, and the actions of witnesses. The time of injury is extremely important since any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit specific information about the location of the accident, since closed-space injuries are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people who are involved with the child. The injury may be suspect if there is a delay in seeking health care, if there are burns that are not consistent with the story, or if there are bruises at different stages of healing. Note whether the description of the injury changes or differs among family or household members.

Basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine burn severity. First, determine the depth of tissue damage. A partial-thickness burn damages the epidermis and part of the dermis; a full-thickness burn also affects the subcutaneous tissue. The more traditional method is to gauge burns by degree. Most burns include a combination of degrees and thicknesses

RULE OF NINES

The “rule of nines” is a practical technique used to estimate the extent of TBSA total body surface area involved in a burn. The technique divides the major anatomic areas of the body into percentages: in adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portions of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patient’s palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patient’s response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and outpu

Nursing diagnosis Nursing Care Plans for Burns Injury

Impaired gas exchange
Ineffective airway clearance
Acute pain
Decreased cardiac output
Deficient fluid volume
Ineffective tissue perfusion: Peripheral
Hypothermia
Impaired skin integrity
Impaired physical mobility
Disturbed body image
Risk for infection

Nursing outcomes Nursing Care Plans for Burns Injury

Nursing Key outcomes Nursing Care Plans for Burns Injury, Patient will:

Ventilation will remain adequate.
Airway will remain patent
Achieve pain relief with analgesia or other measures.
Maintain adequate cardiac output.
Fluid volume will remain within the acceptable range.
Exhibit signs of adequate peripheral perfusion
Communicate understanding of special dietary needs.
Maintain normal body temperature.
Wounds and incisions will appear clean, pink, and free of purulent drainage.
Attain the highest degree of mobility possible within the confines of the injury.
Express positive feelings about self.
Express that he feels less anxious.
Demonstrate effective coping mechanisms.
Remain free from signs and symptoms of infection.
Express his feelings and fears about the traumatic event.

Nursing interventions Nursing Care Plans for Burns Injury

Provide immediate, aggressive burn treatment to increase the patient's chance for survival.
Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring
Airway Management Facilitation of patency of air passages
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Manipulation of the patient’s surroundings for promotion of optimal comfort
Hemodynamic Regulation Optimization of heart rate, preload, afterload, and contractility. Circulatory Care Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps
Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management Reduction in extracellular and/or intracellular fluid volume. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Fluid/Electrolyte Management Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels. Circulatory Care Arterial/Venous Insufficiency: Promotion of arterial/venous circulation
Hypothermia Treatment Rewarming and surveillance of a patient whose core body temperature is below 35C. Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
Wound Care Prevention of wound complications and promotion of wound healing
Exercise Therapy Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement
Body Image Enhancement improving a patient’s conscious and unconscious perceptions and attitudes toward his/her body. Self Esteem Enhancement Assisting a patient to increase his/her personal judgment of self worth.
Infection Protection Prevention and early detection of infection in a patient at risk. Infection Control Minimizing the acquisition and transmission of infectious agents. Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan for Abdominal Trauma

2011-03-23T10:52:00.000+07:00

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NCP Nursing Care Plan for Abdominal Trauma. Blunt and penetrating abdominal injuries may damage major blood vessels and internal organs. Intra-abdominal trauma is usually not a single organ system injury; as more organs are injured, the risks of organ dysfunction and death climb. Such injuries are potentially fatal; the prognosis depends on the extent of injury and the organ damaged but is improved by prompt diagnosis and surgical repair.

Blunt injuries occur when there is no break in the skin; they often occur as multiple injuries. In blunt injuries, the spleen and liver are the most commonly injured organs. Injury occurs from compression, concussive forces that cause tears and hematomas to the solid organs such as the liver, and deceleration forces.

Penetrating injuries are those associated with foreign bodies set into motion. The foreign object penetrates the organ and dissipates energy into the organ and surrounding areas. The most commonly involved abdominal organs with penetrating trauma include the intestines, liver, and spleen.

Causes for Abdominal Trauma

Blunt (nonpenetrating) abdominal injuries usually result from motor vehicle accidents, fights, falls from heights, and sports accidents. Penetrating abdominal injuries usually result from stabbings and gunshots.

Complications for Abdominal Trauma

The abdominal cavity contains solid, gas filled, fluid filled, and encapsulated organs. These organs are at greater risk for injury than are other organs of the body because they have few bony structures to protect them. Immediate life threatening complications include hemorrhage and hypovolemic shock. Later complications include infection and dysfunction of major organs, such as the liver, spleen, pancreas, and kidneys.

Nursing Assessment Nursing Care Plan for Abdominal Trauma

The patient's history reveals an accidental or forcibly inflicted abdominal injury. Symptoms vary with the degree of injury and the organs damaged. History of the mechanism of injury by including a detailed report from the pre-hospital professionals, witnesses, or significant others. The patient with a blunt or penetrating abdominal injury typically is in obvious discomfort or pain.
Inspection pinpoints the type of abdominal injury and helps determine its severity. Depending on the severity of the injury, the patient may be pale, cyanotic, or dyspneic. Inspection of the patient with a blunt abdominal injury may also reveal bruises, abrasions, contusions and, possibly, distention, For a patient with a penetrating abdominal injury, inspection reveals the type of wound and associated blood loss. Internal bleeding caused by this type of trauma may be further determined by diagnostic tests. Gunshots usually produce both entrance and exit wounds, with variable blood loss, pain, and tenderness. The patient may also exhibit pallor, cyanosis, tachycardia, shortness of breath, and hypotension.
Palpation may reveal the extent of pain and tenderness and, in blunt abdominal injuries, abdominal splinting or rigidity. Rib fractures commonly accompany blunt abdominal injuries.
Auscultation may disclose tachycardia, decreased breath sounds, absent or decreased bowel sounds, or bowel sounds in the chest. Auscultate all four abdominal quadrants for 2 minutes per quadrant to determine the presence of bowel sounds. Although the absence of bowel sounds can indicate underlying bleeding, their absence does not always indicate injury

If the patient is hemorrhaging from a critical abdominal injury, he or she may be profoundly hypotensive with the symptoms of hypovolemic shock.

Diagnostic tests for Abdominal Trauma

Abdominal and Chest X-rays
Computed tomography (CT) scan
Focused abdominal sonogram fortrauma
Arterial blood gas analysis evaluates respiratory status
Excretory urography and cystourethrography show renal and urinary tract damage

Nursing diagnosis Nursing Care Plan for Abdominal Trauma

Common nursing diagnosis found in Nursing Care For Abdominal Trauma

Acute pain
Decreased cardiac output
Deficient fluid volume
Impaired gas exchange
Ineffective tissue perfusion: Renal, cardiopulmonary, gastrointestinal
Imbalanced nutrition: Less than body requirements
Impaired skin integrity
Anxiety
Risk for infection
Risk for post trauma syndrome

Nursing outcomes Nursing Care Plan for Abdominal Trauma

Nursing Key Outcome Nursing care Plan For Abdominal Trauma, Patient Will:

Express feelings of comfort and relief of pain.
Express that he feels less anxious.
Show signs of adequate cardiac output.
Fluid volume will remain within acceptable range.
Express understanding of special dietary needs.
Maintain adequate ventilation.
Regain skin integrity.
Develop effective coping mechanisms.
Show signs of adequate cardiopulmonary, renal, and gastrointestinal perfusion.
Exhibit no further signs or symptoms of infection.
Express his feelings and fears about the traumatic event.

Nursing interventions Nursing Care Plan for Abdominal Trauma

Provide emergency care, as needed, to support the patient's vital functions, maintain airway and breathing.
Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain
Environmental Management Comfort Manipulation of the patient’s surroundings for promotion of optimal comfort
Hemodynamic Regulation Optimization of heart rate, preload, afterload, and contractility
Cardiac Care Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care Mechanical Assist Devices Temporary support of the circulation through the use of mechanical devices or pumps
Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded
Shock Management Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Respiratory Monitoring Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy Administration of oxygen and monitoring of its effectiveness
Airway Management Facilitation of patency of air passages
Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids
Wound Care Prevention of wound complications and promotion of wound healing, Wound Site Care Cleansing, monitoring, and promotion of healing in a wound
Pressure Ulcer Care Facilitation of healing in pressure ulcers
Anxiety Reduction Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger, Calming Technique: Reducing anxiety in patient experiencing acute distress
Infection Protection Prevention and early detection of infection in a patient at risk
Infection Control Minimizing the acquisition and transmission of infectious agents
Infection Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and role, Identify supportive persons for client

NCP Nursing Care Plan for Abdominal Aortic Aneurysm

2011-03-22T09:11:00.001+07:00

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NCP Nursing Care Plan for Abdominal Aortic Aneurysm. Abdominal aortic aneurysm (AAA) is a localized outpouching abnormal dilation in the arterial wall that generally occurs in the aorta between the renal arteries and the iliac branches. Nearly 98% of all abdominal aneurysms are located in the infrarenal aorta. These aneurysms can be fusiform (spindle shaped) or saccular (pouchlike) and develop slowly.

First, a focal weakness in the muscular layer of the aorta (tunica media), resulting from degenerative changes, allows the inner layer (tunica intima) and outer layer (tunica adventitia) to stretch outward (often caused by plaque and cholesterol deposits) and degenerative changes occur. The inner and outer layers of the arterial wall are stretched, and as the pulsatile force of the blood rushes through the aorta, the vessel wall becomes increasingly weak, and the aneurysm enlarges. Abdominal aneurysms can be fatal. More than half of people with untreated aneurysms die of aneurysm rupture within 2 years.

Causes for Abdominal Aortic Aneurysm

The most common cause of Abdominal Aortic Aneurysm is atherosclerosis or arteriosclerosis; the rest, from cystic medial necrosis, trauma, syphilis, and other infections.

Complications for Abdominal Aortic Aneurysm

Hemorrhage and shock from aneurysmal rupture

Nursing Assessment Nursing Care Plan for Abdominal Aortic Aneurysm

Patient History most of abdominal aortic aneurysm are asymptomatic and are found incidentally. When the aorta enlarges and compresses the surrounding structures, patient complaints may include flank and back pain, epigastric discomfort, or altered bowel elimination. The pain may be deep and steady with no change if the patient shifts position. If the patient reports severe back and abdominal pain, rupture of the abdominal aortic aneurysm may be imminent
Inspection of the patient with an intact abdominal aneurysm usually reveals no significant findings. However, if the patient isn't obese, you may notice a pulsating mass in the periumbilical area. If the aneurysm has ruptured, you may notice signs of hypovolemic shock, such as skin mottling, decreased level of consciousness, diaphoresis, and oliguria. The abdomen may appear distended and an ecchymosis or hematoma may be present in the abdominal, flank, or groin area
Palpation of the abdomen may disclose some tenderness over the affected area. A pulsatile mass may be felt; however, avoid deep palpation to locate the mass because this may cause the aneurysm to rupture. Palpation of the peripheral pulses may reveal absent pulses distal to a ruptured aneurysm

Watch for signs that may indicate impending aneurysm rupture. Note subtle changes such as a change in the characteristics and quality of peripheral pulses, changes in neurological status, and changes in vital signs such as a drop in blood pressure, increased pulse, and increased respirations. An abdominal aneurysm can impair flow to the lower extremities and cause what are known as the five Ps of ischemia: pain, pallor, pulselessness, paresthesias, and paralysis

Diagnostic tests for Abdominal Aortic Aneurysm

• Abdominal ultrasonography or echocardiography

• Anteroposterior and lateral X-rays of the abdomen

• Computed tomography scan

• Aortography

Nursing diagnosis Nursing Care Plan for Abdominal Aortic Aneurysm

Common nursing diagnosis found in Nursing Care Plan for Abdominal Aortic Aneurysm

Deficient fluid volume
Acute pain
Anxiety
Decreased cardiac output
Impaired gas exchange
Impaired physical mobility
Impaired skin integrity
Ineffective tissue perfusion: Renal, cardiopulmonary
Risk for fluid volume deficit related to hemorrhage

Nursing outcomes Nursing Care Plan for Abdominal Aortic Aneurysm

Nursing Key outcome NCP Nursing Care Plan for Abdominal Aortic Aneurysm, Patient Will:

Express feelings of increasing comfort and decreased pain.
Verbalize strategies to reduce his anxiety level.
Maintain adequate cardiac output.
Maintain adequate fluid volume.
Maintain adequate ventilation and oxygenation.
Maintain joint mobility and muscle strength.
Patient's skin will remain intact.
Pulses will remain palpable distal to the aneurysm site.
Maintain adequate urine output (output will be equivalent to intake).

Nursing interventions Nursing Care Plan for Abdominal Aortic Aneurysm

Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications
Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Calming Technique: Reducing anxiety in patient experiencing acute distress
Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness

NCP Nursing Care Plan For Gout Gouty Arthritis

2011-03-22T09:11:00.000+07:00

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NCP Nursing Care Plan For Gout Gouty Arthritis, Gout also known as gouty arthritis is a metabolic disease marked by monosodium urate deposits that cause red, swollen, and acutely painful joints. Gout can affect any joint but mostly affects those in the feet, especially the great toe, ankle, and midfoot. Which cause painfully arthritic joints. It can strike any joint but favors those in the feet and legs. Primary gout usually occurs in men older than age 30 and in postmenopausal women. Secondary gout occurs in older people.

Gout follows an intermittent course and commonly leaves patients free from symptoms for years between attacks, serum urate levels rise but produce no symptoms. Gout can lead to chronic disability or incapacitation and, rarely, severe hypertension and progressive renal disease.

Gout develops in four stages: asymptomatic, acute, intercritical, and chronic:

asymptomatic ,serum urate levels rise but produce no symptoms
Acute Stage, first acute attack strikes suddenly and peaks quickly. involves only one or a few joints.
Intercritical, Symptom-free intervals between gout attacks
Chronic polyarticular gout sets in. This final, unremitting stage of the disease (also known as tophaceous gout) is marked by persistent painful polyarthritis. An increased concentration of uric acid leads to urate deposits called tophi in cartilage, synovial membranes, tendons, and soft tissue. Tophi form in the fingers, hands, knees, feet, ulnar sides of the forearms, pinna of the ear, Achilles tendon and, rarely, in such internal organs as the kidneys and myocardium. Renal involvement may adversely affect renal function.

Causes For Gout Gouty Arthritis

Although the exact cause of primary gout remains unknown, it seems linked to a genetic defect in purine metabolism, which causes overproduction of uric acid (hyperuricemia), retention of uric acid, or both.

Nursing Assessment Nursing Care Plan For Gout Gouty Arthritis

Patient history may reveal that the patient has a sedentary lifestyle and a history of hypertension and renal calculi. He may report waking during the night with pain in his great toe or another location in the foot. He may complain that initially moderate pain has grown intense so that eventually he can't bear the weight of bedsheets or the vibrations of a person walking across the room. He may report accompanying chills and a mild fever.
Inspection typically reveals a swollen, dusky red or purple joint with limited movement. You may also notice tophi, especially in the outer ears, hands, and feet. Late in the chronic stage of gout, the skin over the tophi may ulcerate and release a chalky white exudate or pus. Chronic inflammation and tophaceous deposits prompt secondary joint degeneration. Erosions, deformity, and disability may develop.
Palpation may reveal warmth over the joint and extreme tenderness. The vital signs assessment may disclose fever and hypertension. If the patient has a fever, possible occult infection must be investigated.

Diagnostic tests For Gout Gouty Arthritis

Needle aspiration of synovial fluid

X-rays

Nursing diagnosis Nursing Care Plan For Gout Gouty Arthritis

Common Nursing diagnosis found in Nursing Care Plan For Gout Gouty Arthritis

Activity intolerance
Acute pain
Anxiety
Deficient knowledge (diagnosis and treatment)
Disturbed sleep pattern
Impaired physical mobility
Risk for injury

Nursing Key outcomes Nursing Care Plan For Gout Gouty Arthritis

Nursing key outcome Nursing Care Plan For Gout Gouty Arthritis, patient will:

Express feelings of comfort and decreased pain
Activities of daily living within the confines of the disease.
Identify strategies to reduce anxiety.
Demonstrate knowledge of the condition and treatment regimen.
Verbalize feeling well rested.
Maintain joint mobility and range of motion.
Express adequate coping skills.
Remain free from complications.

Nursing interventions Nursing Care Plan For Gout Gouty Arthritis

Activity Therapy: Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s (or group’s) activity
Energy Management: Regulating energy use to treat or prevent fatigue and optimize function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Calming Technique: Reducing anxiety in patient experiencing acute distress
Teaching Individual: Planning, implementation, and evaluation of a teaching program designed to address a patient’s particular needs
Learning Facilitation: Promoting the ability to process and comprehend information
Learning Readiness Enhancement: Improving the ability and willingness to receive
Sleep Enhancement: Facilitation of regular sleep/wake cycles
Simple Relaxation Therapy: Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety
Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
Exercise Therapy: [specify]: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement.
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient
Traction/Immobilization Care: Management of a patient who has traction and/or a stabilizing device to immobilize and stabilize a body part
Risk Identification: Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group
Environmental Management: Safety: Manipulation of the patient’s surroundings for therapeutic benefit

NCP Nursing Care Plans for Stroke Cerebrovascular Accident

2011-03-19T08:35:00.000+07:00

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NCP Nursing Care Plans for Stroke Cerebrovascular Accident. Stroke Also known as brain attack or a Cerebrovascular accident, Cerebrovascular accident (CVA), or “stroke,” is the interruption of normal blood flow in one or more of the blood vessels that supply the brain. Stroke interrupts or diminishes oxygen supply and commonly causes serious damage or necrosis in brain tissues. The sooner circulation returns to normal after stroke, the better chances are for complete recovery. About half of those who survive stroke remain permanently disabled and experience a recurrence within weeks, months, or years. A CVA is an acute neurological injury that occurs because of changes in the blood vessels of the brain. The changes can be intrinsic to the vessel (atherosclerosis, inflammation, arterial dissection, dilation of the vessel, weakening of the vessel, obstruction of the vessel) or extrinsic, such as when an embolism travels from the heart. Although reduced blood flow interferes with brain function, the brain can remain viable with decreased blood flow for long periods of time. However, total cessation of blood flow produces irreversible brain infarction within 3 minutes. Once the blood flow stops, toxins released by damaged neurons, cerebral edema, and alterations in local blood flow contribute to neuron dysfunction and death.

Causes for Stroke Cerebrovascular Accident

Major causes of stroke include cerebral thrombosis, embolism, and hemorrhage.

Thrombosis is the most common cause of stroke in middle-age and elderly people.
Embolism, the second most common cause of stroke, can occur at any age, especially among patients with a history of rheumatic heart disease, endocarditis, posttraumatic valvular disease, or myocardial fibrillation and other cardiac arrhythmias.
Hemorrhage, the third most common cause of stroke, may also occur suddenly at any age. Such hemorrhage results from chronic hypertension or aneurysms, which cause sudden, rupture of a cerebral artery.

Factors that increase the risk of stroke include:

• History of TIAs

• Heart disease

• Atherosclerosis

• Hypertension

• Arrhythmias

• Rheumatic heart disease

• Diabetes mellitus

• Gout

• Postural hypotension

• Cardiac enlargement

• Smoking

• And a family history of cerebrovascular disease

Complications for Stroke Cerebrovascular Accident

Among the many possible complications of stroke are unstable blood pressure from loss of vasomotor control, fluid imbalances, malnutrition, infections such as pneumonia, and sensory impairment, including vision problems. Altered level of consciousness (LOC), aspiration, contractures, and pulmonary emboli also may occur.

Nursing Assessment Nursing Care Plans for Stroke Cerebrovascular Accident

Patient history. Determine if the patient has experienced an inability to recognize familiar objects or persons through sensory stimuli or any memory loss. Elicit a history of speech difficulties such as an inability to understand language or express language aphasia, poorly articulated speech dysarthria, or any other form of speech impairment (dysphasia), lost the ability to comprehend written words (alexia), read written words (dyslexia), or write (agraphia). History of visual difficulties such as diplopia, defective vision, or blindness in the right or left halves of the visual fields of both eyes , lack of depth perception, color blindness, blindness, blurring on the affected side, or drooping eyelids (ptosis).

Neurologic examination identifies most of the physical findings associated with stroke. These may include unconsciousness or changes in LOC, such as a decreased attention span, difficulties with comprehension, forgetfulness, and a lack of motivation. If conscious, the patient may exhibit anxiety along with communication and mobility difficulties.

Inspection may reveal related urinary incontinence.

Diagnostic tests for Stroke Cerebrovascular Accident

Computed tomography scan.
Magnetic resonance imaging.
Electrocardiogram.
Carotid duplex may detect carotid artery stenosis.
Angiography.
EEG helps to localize the damaged area.

Nursing Diagnosis Nursing care plan for Stroke Cerebrovascular Accident

Diagnosis of stroke is based on observation of clinical features, a history of risk factors, and the results of diagnostic tests, Nursing Diagnosis for Stroke Cerebrovascular Accident:

Anxiety
Self-Care Deficit: bathing/hygiene, dressing/grooming, feeding, toileting
Disturbed sensory perception: Tactile
Impaired gas exchange
Impaired physical mobility
Impaired verbal communication
Ineffective airway clearance
Ineffective tissue perfusion: Cerebral
Powerlessness
Risk for aspiration
Risk for disuse syndrome
Risk for impaired skin integrity
Risk for infection
Risk for injury
Situational low self-esteem
Toileting self-care deficit
Total urinary incontinence

Nursing Outcomes Nursing Care Plan For Stroke Cerebrovascular Accident

Nursing Outcomes Nursing Care Plan For Stroke Cerebrovascular Accident patient will:

Identify strategies to reduce anxiety.
Perform bathing and hygiene needs to the fullest extent possible.
Report signs and symptoms of impaired sensation.
Perform dressing and grooming needs to the fullest extent possible.
Maintain adequate ventilation and oxygenation.
Achieve the maximum mobility possible within the confines of the condition.
Effectively communicate needs verbally or through an alternative means of communication.
Maintain a patent airway.
Exhibit signs of adequate cerebral perfusion.
Express feelings of control over health and well-being.
Free from signs of aspiration.
Maintain joint mobility and range of motion (ROM).
Maintain intact skin with no signs of breakdown.
Remain free from signs or symptoms of infection.
Free from injury.
Verbalize feelings regarding self-esteem.
Perform toileting needs to the fullest extent possible.
Identify strategies to reduce incontinent episodes.

Nursing Interventions Nursing care plan for Stroke Cerebrovascular Accident

Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Provision of a modified environment for the patient who is experiencing a confusional state
Calming Technique: Reducing anxiety in patient experiencing acute distress
Self-Care Assistance: Assisting another to perform activities of daily living
Bathing: Cleaning of the body for the purpose of relaxation, cleanliness, and healing
Hair/Nail Care: Promotion of neat, clean, attractive hair/nails and prevention of skin lesions related to improper care of nails
Feeding: Providing nutritional intake for patient who is unable to feed self
Bowel/Urinary Elimination Management: Establishment and maintenance of a regular pattern of bowel elimination/Maintenance of an optimum urinary elimination pattern
Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
Peripheral Sensation Management: Prevention or minimization of injury or discomfort in the patient with altered sensation
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages

NCP Nursing Care Plan for Acute Respiratory Failure

2011-03-18T07:44:00.002+07:00

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NCP Nursing Care Plan for Acute Respiratory Failure. When the lungs can't adequately maintain arterial oxygenation or eliminate carbon dioxide (CO2), acute respiratory failure occurs. If not checked and treated, the condition leads to tissue hypoxia. In patients with essentially normal lung tissue, acute respiratory failure usually produces a partial pressure of arterial CO2 (PaCO2) greater than 50 mm Hg and a partial pressure of arterial oxygen (PaO2) less than 50 mm Hg.

These limits, however, don't apply to patients with chronic obstructive pulmonary disease COPD.

Causes for Acute Respiratory Failure

Acute respiratory failure may develop from COPD, Other causes of acute respiratory failure include:

Central nervous system depression due to head trauma or injudicious use of sedatives, opioids, tranquilizers, or oxygen
Cardiovascular disorders (myocardial infarction, heart failure, or pulmonary emboli)
Airway irritants, such as smoke or fumes
Endocrine or metabolic disorders, such as myxedema or metabolic acidosis
Thoracic abnormalities, such as chest trauma, pneumothorax, or thoracic or abdominal surgery
Noncompliance with prescribed bronchodilator or corticosteroid therapy.

Complications for Acute Respiratory Failure

Tissue hypoxia,
Metabolic acidosis.
Respiratory and cardiac arrest.

Nursing Assessment Nursing Care Plan for Acute Respiratory Failure

Inspection, note cyanosis of the oral mucosa, lips, and nail beds; nasal flaring; and ashen skin. You may observe the patient yawning and using accessory muscles to breathe. He may appear restless, anxious, depressed, lethargic, agitated, or confused. Additionally, he usually exhibits tachypnea, which signals impending respiratory failure.
Palpation may reveal cold, clammy skin and asymmetrical chest movement, which suggests pneumothorax. If tactile fremitus is present, notice that it decreases over an obstructed bronchi or pleural effusion but increases over consolidated lung tissue.
Percussion especially in patients with COPD reveals hyperresonance. If acute respiratory failure results from atelectasis or pneumonia, percussion usually produces a dull or flat sound.
Auscultation typically discloses diminished breath sounds. In patients with pneumothorax, breath sounds may be absent. In other cases of respiratory failure, you may hear such adventitious breath sounds as wheezes and rhonchi . If you hear crackles, suspect pulmonary edema as the cause of respiratory failure.

Diagnostic tests for Acute Respiratory Failure

ABG analysis
Chest X-rays
Electrocardiography (ECG)
Pulse oximetry.
Blood tests such as a white blood cell count low hematocrit and decreased hemoglobin levels signal blood loss, which indicates decreased oxygen-carrying capacity.
Serum electrolyte
Pulmonary artery
Blood culture and sputum culture to identify the pathogen.

Nursing diagnosis Nursing Care Plan for Acute Respiratory Failure

Common Nursing diagnosis found in patient with Acute Respiratory Failure

Anxiety
Decreased cardiac output
Fatigue
Fear
Impaired gas exchange
Impaired physical mobility
Impaired verbal communication
Ineffective airway clearance
Ineffective coping
Ineffective tissue perfusion: Cardiopulmonary
Risk for impaired skin integrity
Risk for infection

Nursing outcomes Nursing Care Plan for Acute Respiratory Failure

Patient will :

Express feelings of reduced anxiety.
Remain hemodynamically stable.
Verbalize the importance of balancing activity with adequate rest periods.
Discuss fears or concerns.
Maintain adequate ventilation and oxygenation
Maintain joint range-of-motion and muscle strength.
Use alternate means of communication.
Maintain a patent airway.
Use support systems to assist with coping.
Maintain adequate cardiopulmonary perfusion.
Maintain skin integrity.
Remain free from signs or symptoms of infection.

Nursing Interventions Nursing Care Plan for Acute Respiratory Failure

Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Calming Technique: Reducing anxiety in patient experiencing acute distress
Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps
Energy Management: Regulating energy use to treat or prevent fatigue and optimize function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Security Enhancement: Intensifying a patient’s sense of physical and psychological safety
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Exercise Therapy: [specify]: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement, etc.
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient
Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech
Communication Enhancement: Hearing Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing
Active Listening: Attending closely to and attaching significance to a patient’s verbal and nonverbal messages
Airway Management: Facilitation of patency of air passages
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Cough Enhancement: Promotion of deep inhalation by the patient with subsequent generation of high intrathoracic pressures and compression of underlying lung parenchyma for the forceful expulsion of air
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Decision-Making Support: Providing information and support for a person who is making a decision regarding healthcare
Fluid/Electrolyte Management: Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels
Cerebral Perfusion Promotion: Promotion of adequate perfusion and limitation of complications for a patient experiencing or at risk for inadequate cerebral perfusion
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care: Arterial/Venous Insufficiency: Promotion of arterial/venous circulation
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity
Pressure Management: Minimizing pressure to body parts
Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them
Infection Protection: Prevention and early detection of infection in a patient at risk
Infection Control: Minimizing the acquisition and transmission of infectious agents
Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan For Encephalitis

2011-03-18T07:44:00.001+07:00

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NCP Nursing Care Plan For Encephalitis. Encephalitis is a severe inflammation of the brain characterized by intense lymphocytic infiltration of brain tissues and the leptomeninges. This process causes cerebral edema, degeneration of the brain's ganglion cells, and diffuse nerve cell destruction. Viruses transmitted by arthropods are arboviruses (arthropod-borne). Transmission by means other than arthropod bites may occur through ingestion of infected goat's milk and accidental injection or inhalation of the virus. Eastern equine encephalitis may produce permanent neurologic damage and is commonly fatal.

Causes For Encephalitis

Encephalitis usually results from infection frequently caused by enteroviruses (coxsackievirus, poliovirus, and echovirus). Other causes include herpesvirus, mumps virus, adenoviruses, and demyelinating diseases after measles, varicella, rubella, or vaccination

Complications For Encephalitis

Potential complications associated with viral encephalitis include:

• Bronchial pneumonia,

• Urine retention

• Urinary tract infection

• Pressure ulcers.

• Coma.

• Epilepsy, parkinsonism, and mental deterioration may also occur

Nursing Assessment Nursing Care Plan For Encephalitis

Depending on the severity of the disease, all forms of viral encephalitis have similar clinical features. The severity of arbovirus encephalitis may range from subclinical to rapidly fatal necrotizing disease. Herpes encephalitis also produces signs and symptoms that vary from subclinical to acute and often fatal fulminating disease.

Patient History. Obtain a history of recent illnesses, which may include an upper respiratory infection or a minor systemic illness that caused headache, muscle ache, malaise, sore throat, and runny nose. Note if the patient has other sites of infection, such as a recent skull fracture or head injury, middle ear infection, or sinus infection. Ask if the patient has had a recent immunization, exposure to mumps or hsv, animal bites, recent travel, or exposure to epidemic outbreaks or mononucleosis. Ask if a child has been playing in a rural area where exposure to ticks or mosquitoes was possible

Neurologic examination, The patient appears acutely ill with an altered mental status that may range from mild confusion to delirium and coma. Tremors, cranial nerve palsies, exaggerated deep tendon reflexes, absent superficial reflexes, and paresis or paralysis of the extremities. The patient may complain of a stiff neck when the head is bent forward.Vital signs usually reveal fever.

Diagnostic tests For Encephalitis

The following tests help establish a diagnosis.

Blood analysis or,
Rarely, cerebrospinal fluid (CSF) analysis
Serologic studies in herpes encephalitis.
Lumbar puncture CSF analysis
EEG.
Computed tomography scanning
Magnetic resonance imaging.

Nursing diagnosis Nursing Care Plan For Encephalitis

Acute pain
Anxiety
Disturbed thought processes
Hyperthermia
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Impaired physical mobility
Risk for deficient fluid volume
Risk for impaired skin integrity

Nursing outcomes Nursing Care Plan For Encephalitis

Nursing outcomes Nursing Care Plan For Encephalitis The patient will:

Express feelings of comfort and relief of pain.
Identify strategies to reduce anxiety.
Remain oriented to person, place, time, and situation.
Exhibit fluid balance within normal limits.
Consume adequate daily calories as required
Maintain adequate ventilation and oxygenation.
Maintain joint mobility and muscle strength.
Exhibit temperature within normal limits.
Maintain intact skin with no signs of breakdown.

Nursing interventions Nursing Care Plan For Encephalitis

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Provision of a modified environment for the patient who is experiencing a chronic confusional state
Calming Technique: Reducing anxiety in patient experiencing acute distress
Delusion Management: Promoting the comfort, safety, and reality orientation of a patient experiencing false, fixed beliefs that have little or no basis in reality
Environmental Management: Safety: Manipulation of the patient’s surroundings for therapeutic benefit
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
Fever Treatment: Management of a patient with hyperpyrexia caused by nonenvironmental factors
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Weight Gain Assistance: Facilitating gain of body weight
Eating Disorders Management: Prevention and treatment of severe diet restrictions and over exercising or binging and purging of foods and fluids
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Exercise Therapy: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement
Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance
Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity
Pessure Management: Minimizing pressure to body parts
Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them

NCP Nursing Care Plans For Sudden Infant Death Syndrome SIDS

2011-03-18T07:43:00.000+07:00

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NCP Nursing Care Plans For Sudden Infant Death Syndrome SIDS. Sudden infant death syndrome (SIDS), also known as crib death, is the third leading cause of death among apparently healthy infants between ages 1 month to 1 year. In 2002, SIDS caused 2,295 infant deaths, accounting for 8.2% of total infant deaths that year. Most deaths occur between ages 1 and 4 months, with incidence declining rapidly between ages of 4 to 12 months.

About 60% of victims are male infants who die in their sleep, without warning, sound, or struggle. The incidence is slightly higher in preterm infants, Inuit infants, disadvantaged black infants, infants born to mothers younger than age 20, and infants of multiple births.

Causes For Sudden Infant Death Syndrome SIDS

At one time, SIDS was attributed to abuse or accidental suffocation during sleep. On postmortem examination, some SIDS-diagnosed infants show changes indicating chronic hypoxia, hypoxemia, and large-airway obstruction, leading researchers to suspect more than one cause.

Two leading hypotheses are the hypoxemia theory and the apnea theory. The hypoxemia theory suggests that SIDS occurs because of damage to the respiratory control center in the brain from chronic hypoxemia. The apnea theory holds that the SIDS victim experiences prolonged periods of sleep apnea and eventually dies during an episode.

Another proposed cause involves Clostridium botulinum toxin, which has been linked to a few SIDS deaths. A disproved theory is an association between SIDS and diphtheria, tetanus, and pertussis vaccines. And, although bottle-feeding and advanced parental age don't cause the syndrome, breast-fed infants are at decreased risk for SIDS

Nursing Assessment Nursing Care Plans For Sudden Infant Death Syndrome SIDS

The patient history supplied by the parents may reveal that they found the infant wedged in a crib corner or with blankets wrapped around his head. Despite such findings, autopsy results rule out suffocation as the cause of death. The history may also note frothy, blood-tinged sputum found around the infant's mouth or on the crib sheets. However, autopsy findings show a patent airway, ruling out aspiration of vomitus as the cause of death.

Typically, the parents report that the infant didn't cry and showed no signs of disturbed sleep. Reports of the infant found in a peculiar position or tangled in his blankets suggest movement before death, possibly from terminal spasm. Occasionally, the history may reveal a respiratory tract infection.

Documentation of events before discovery of the infant's death should be part of the history. Often, bruising, possible fractured ribs, and the appearance of blood in the infant's mouth, nose, or ears from internal bleeding may be confused with abuse. Although this possibility shouldn't be dismissed, never assume that abuse caused the infant's death without obtaining further information. Avoid assessment questions that may suggest parental responsibility for the death.

Depending on how long the infant has been dead, inspection may reveal an infant with mottled complexion and extremely cyanotic lips and fingertips. You may also see pooled blood in the legs and feet. These markings may be mistaken for bruises. The infant's diaper may be wet and full of stools.

Diagnostic tests For Sudden Infant Death Syndrome SIDS

Diagnosis of SIDS requires an autopsy to rule out other causes of death. Characteristic histologic findings on autopsy include small or normal adrenal glands and petechiae over the visceral surfaces of the pleura, within the thymus (which is enlarged), and in the epicardium. Autopsy also reveals well-preserved lymphoid structures; signs of chronic hypoxemia such as increased pulmonary artery smooth muscle; edematous, congestive lungs fully expanded; liquid (not clotted) blood in the heart; and stomach curd inside the trachea

Nursing Diagnosis Nursing Care Plans For Sudden Infant Death Syndrome SIDS

Dysfunctional grieving
Fear
Hopelessness
Interrupted family processes
Spiritual distress

Nursing Outcomes Nursing Care Plans For Sudden Infant Death Syndrome SIDS

Family members will seek appropriate support persons for assistance.
Family members will use available support systems to assist in coping with fear.
Family members will identify feelings of hopelessness regarding the current situation.
Family members will share feelings about the event.
Family members will verbalize measures to prevent SIDS.
Family members will use effective coping strategies to ease spiritual discomfort.

Nursing Interventions NCP Nursing Care Plans For Sudden Infant Death Syndrome SIDS

Grief Work Facilitation: Assistance with the resolution of a significant loss
Grief Work Facilitation: Perinatal Death: Assistance with the resolution of a perinatal loss
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Security Enhancement: Intensifying a patient’s sense of physical and psychological safety
Hope Instillation: Facilitation of the development of a positive outlook in a given situation
Emotional Support: Provision of reassurance, acceptance, and encouragement during times of stress
Family Process Maintenance: Minimization of family process disruption effects
Family Integrity Promotion: Facilitating family participation in the emotional and physical care of the patient
Normalization Promotion: Assisting parents and other family members of children with chronic diseases or disabilities in providing normal life experiences for their children and families
Spiritual Support: Assisting the patient to feel balance and connection with a greater power
Grief Work Facilitation: Assistance with the resolution of a significant loss

NCP Nursing Care Plan for Acute Respiratory Distress Syndrome ARDS

2011-03-17T07:09:00.000+07:00

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NCP Nursing Care Plan for Acute respiratory distress syndrome ARDS. Acute respiratory distress syndrome (ARDS) is a form of pulmonary edema that causes acute respiratory failure. Also known as shock, stiff, white, wet, or Da Nang lung. It may follow direct or indirect lung injury. ARDS results from increased permeability of the alveolocapillary membrane. Fluid accumulates in the lung interstitium, alveolar spaces, and small airways, causing the lung to stiffen. Effective ventilation is thus impaired, prohibiting adequate oxygenation of pulmonary capillary blood. Severe ARDS can cause intractable and fatal hypoxemia; however, patients who recover may have little or no permanent lung damage.

Causes for Acute respiratory distress syndrome ARDS

Trauma is the most common cause of ARDS, possibly because trauma-related factors, such as fat emboli, sepsis, shock, pulmonary contusions, and multiple transfusions, increase the likelihood of microemboli developing.

ARDS can result from any one of several respiratory and nonrespiratory causes:

Aspiration of gastric contents
Sepsis (primarily gram-negative), trauma (lung contusion, head injury, long bone fracture with fat emboli), or oxygen toxicity
Viral, bacterial, or fungal pneumonia or microemboli (fat or air emboli or disseminated intravascular coagulation)
Anaphylaxis, drug overdose (barbiturates, glutethimide, narcotics) or blood transfusion
Smoke or chemical inhalation (nitrous oxide, chlorine, ammonia)
Pancreatitis, hypertransfusion, cardiopulmonary bypass
Near drowning.
Less common causes of ards include coronary artery bypass grafting, hemodialysis, leukemia, acute miliary tuberculosis, pancreatitis, thrombotic thrombocytopenic purpura, uremia, and venous air embolism.

Nursing Assessment Nursing Care Plan for Acute respiratory distress syndrome (ARDS)

ARDS initially produces rapid, shallow breathing and dyspnea within hours to days of the initial injury (sometimes after the patient's condition appears stable). Hypoxemia develops, causing an increased drive for ventilation. Because of the effort required to expand the stiff lung, intercostal and suprasternal retractions result. Fluid accumulation may produce crackles and rhonchi, and worsening hypoxemia causes restlessness, apprehension, mental sluggishness, motor dysfunction, and tachycardia (possibly with transient increased arterial blood pressure).

Severe ARDS causes overwhelming hypoxemia, which, if uncorrected, results in hypotension, decreasing urine output, respiratory and metabolic acidosis and, eventually, ventricular fibrillation or standstill.

In stage I, the patient may complain of dyspnea, especially on exertion. Respiratory and pulse rates are normal to high. Auscultation may reveal diminished breath sounds.
In stage II, respiratory distress becomes more apparent. The patient may use accessory muscles to breathe and appear pallid, anxious, and restless. He may have a dry cough with thick, frothy sputum and bloody, sticky secretions. Palpation may disclose cool, clammy skin. Tachycardia and tachypnea may accompany elevated blood pressure. He may have a change or decrease in mental status. Auscultation may reveal basilar crackles. (Stage II signs and symptoms may be incorrectly attributed to other causes such as multiple traumas.)
In stage III, the patient struggles to breathe. Vital signs reveal tachypnea (more than 30 breaths/minute), tachycardia with arrhythmias (usually premature ventricular contractions), and a labile blood pressure. Inspection may reveal a productive cough and pale, cyanotic skin. He may demonstrate a change or decrease in mental status. Auscultation may disclose crackles and rhonchi. The patient needs intubation and ventilation.
In stage IV, the patient has acute respiratory failure with severe hypoxia. His mental status is deteriorating, and he may become comatose. His skin appears pale and cyanotic. Spontaneous respirations aren't evident. Bradycardia with arrhythmias accompanies hypotension. Metabolic acidosis and respiratory acidosis develop. When ARDS reaches this stage, the patient is at high risk for fibrosis. Pulmonary damage becomes life-threatening.

Diagnostic tests for Acute respiratory distress syndrome ARDS

Arterial blood gas (ABG) analysis.

Serial chest X-rays.

Nursing diagnosis for Acute respiratory distress syndrome ARDS

Common Nursing diagnosis found in patient with Acute respiratory distress syndrome ARDS

Anxiety
Decreased cardiac output
Fatigue
Fear
Impaired gas exchange
Impaired physical mobility
Impaired verbal communication
Ineffective airway clearance
Ineffective coping
Ineffective tissue perfusion: Cardiopulmonary
Risk for impaired skin integrity
Risk for infection

Nursing outcomes Nursing Care Plan for Acute respiratory distress syndrome (ARDS)

The patient will express feelings of reduced anxiety.
The patient will remain hemodynamically stable.
The patient will verbalize the importance of balancing activity with adequate rest periods.
The patient will discuss fears or concerns.
The patient will maintain adequate ventilation and oxygenation
The patient will maintain joint range-of-motion and muscle strength.
The patient will use alternate means of communication.
The patient will maintain a patent airway.
The patient will use support systems to assist with coping.
The patient will maintain adequate cardiopulmonary perfusion.
The patient will maintain skin integrity.
The patient will remain free from signs or symptoms of infection.

Nursing Interventions Nursing Care Plan for Acute respiratory distress syndrome ARDS

Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Calming Technique: Reducing anxiety in patient experiencing acute distress
Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps
Energy Management: Regulating energy use to treat or prevent fatigue and optimize function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Security Enhancement: Intensifying a patient’s sense of physical and psychological safety
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Exercise Therapy: [specify]: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement, etc.
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient
Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech
Communication Enhancement: Hearing Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing
Active Listening: Attending closely to and attaching significance to a patient’s verbal and nonverbal messages
Airway Management: Facilitation of patency of air passages
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Cough Enhancement: Promotion of deep inhalation by the patient with subsequent generation of high intrathoracic pressures and compression of underlying lung parenchyma for the forceful expulsion of air
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Decision-Making Support: Providing information and support for a person who is making a decision regarding healthcare
Fluid/Electrolyte Management: Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels
Cerebral Perfusion Promotion: Promotion of adequate perfusion and limitation of complications for a patient experiencing or at risk for inadequate cerebral perfusion
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care: Arterial/Venous Insufficiency: Promotion of arterial/venous circulation
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity
Pressure Management: Minimizing pressure to body parts
Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them
Infection Protection: Prevention and early detection of infection in a patient at risk
Infection Control: Minimizing the acquisition and transmission of infectious agents
Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plans For Meningococcal Infections

2011-03-17T06:42:00.002+07:00

NCP Nursing Care Plans For Meningococcal Infections. Two major meningococcal infections, meningitis and meningococcemia, are caused by the gram-negative bacteria Neisseria meningitidis, which also causes primary pneumonia, purulent conjunctivitis, endocarditis, sinusitis, and genital infection. Meningococcemia occurs as simple bacteremia, fulminating meningococcemia and, rarely, chronic meningococcemia. It commonly accompanies meningitis. Meningococcal infections may occur sporadically or in epidemics; particularly virulent infections may be fatal within a matter of hours.

Causes For Meningococcal Infections

Neisseria meningitidis has seven serogroups (A, B, C, D, X, Y, and Z

Complications For Meningococcal Infections

Respiratory failure that requires mechanical ventilation. If severe
Disseminated intravascular coagulation (DIC) develops,
Hemorrhage GI tract, and urinary tract, as well as tissue ischemia.
Septic arthritis, pericarditis, or endophthalmitis.
Aspiration of the organism can cause meningococcal pneumonia.
Meningococcal infections may progress very rapidly, causing neurologic deterioration and even death.

Nursing Assessment Nursing Care Plans For Meningococcal Infections

Features of meningococcal bacteremia include sudden spiking fever, headache, sore throat, cough, chills, myalgia , arthralgia, tachycardia, tachypnea, mild hypotension, and a petechial, nodular, or maculopapular rash. Headache and stiff neck can also occur as the infection extends to the meninges.

Characteristics of the rare chronic meningococcemia include intermittent fever, rash, joint pain, and an enlarged spleen.

Diagnostic tests For Meningococcal Infections

• Blood culture,

• Cerebrospinal Fluid CSF culture

Nursing diagnosis Nursing Care Plans For Meningococcal Infections

Acute pain
Hyperthermia
Decreased cardiac output
Impaired skin integrity
Ineffective breathing pattern
Ineffective tissue perfusion: Cardiopulmonary

Nursing outcomes Nursing Care Plans For Meningococcal Infections

The patient will express feelings of comfort and relief from pain.
The patient will maintain adequate cardiac output.
The patient will remain a febrile.
The patient's skin will remain warm, dry, and intact.
The patient will exhibit healed or improved lesions or wounds.
The patient's ventilation will remain adequate.
The patient will maintain collateral circulation.
The patient will remain hemodynamically stable.

Nursing interventions Nursing Care Plans For Meningococcal Infections

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
Fever Treatment: Management of a patient with hyperpyrexia caused by non environmental factors
Malignant Hyperthermia Precautions: Prevention or reduction of hyper metabolic response to pharmacological agents
Hemodynamic Regulation: Optimization of heart rate, preload, after load, and contractility
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity
Pressure Management: Minimizing pressure to body parts
Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them
Ventilation Assistance: Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs
Airway Management: Facilitation of patency of air passages
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Fluid/Electrolyte Management: Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels
Cerebral Perfusion Promotion: Promotion of adequate perfusion and limitation of complications for a patient experiencing or at risk for inadequate cerebral perfusion
Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Gastrointestinal Intubation: Insertion of a tube into the gastrointestinal tract Circulatory Care: Arterial/Venous Insufficiency: Promotion of arterial/venous circulation

NCP Nursing Care Plans for Meningitis

2011-03-17T06:42:00.001+07:00

Image courtesy of sitemaker.umich.edu

NCP Nursing Care Plans for Meningitis. In meningitis, the brain and the spinal cord meninges become inflamed. Such inflammation may involve all three meningeal membranes: the dura mater, arachnoid membrane, and pia mater. For most patients, meningitis follows the onset of respiratory symptoms: In about 50% of patients, it develops over 1 to 7 days; in about 20% of patients, over 1 to 3 weeks. In about 25% of patients, meningitis is unheralded by respiratory symptoms; it has a sudden onset, causing serious illness within 24 hours.

Causes for Meningitis

Meningitis can be caused by bacteria, viruses, protozoa, or fungi. It most commonly results from bacterial infection, usually due to Neisseria meningitides, Haemophilus influenzae, Streptococcus pneumoniae, or Escherichia coli. Occasionally the causative organism can't be determined.

Complications for Meningitis

Potential complications of meningitis include:

Visual impairment
Optic neuritis
Cranial nerve palsies
Deafness
Personality change
Headache
Paresis or paralysis
Endocarditis
Coma
Vasculitis
Cerebral infarction
Children may develop sensory hearing loss, epilepsy, mental retardation, hydrocephalus, or subdural effusions.

Nursing assessment Nursing Care Plans for Meningitis

The cardinal signs of meningitis are those of infection and increased intracranial pressure (ICP).

The patient history may detail headache, stiff neck and back, malaise, photophobia, chills and, sometimes, vomiting, twitching, and seizures.

Patient history varies according to which form of meningitis the patient has: acute or subacute. For the subacute form, the patient or family may describe vague, mild symptoms such as irritability, loss of appetite, and headaches. With an acute infection, there may be reports of a headache that became progressively worse, with accompanying vomiting, disorientation, or delirium. The patient may also note an increased sensitivity to light (photophobia), chills, fever, and even seizure activity. Frequently the patient or family describes a recent upper respiratory or other type of infection. A patient with pneumococcal meningitis may have had a recent ear, sinus, or lung infection or endocarditis.
Physical Assesment findings vary, depending on the severity of the meningitis. You may note opisthotonus, (a spasm in which the back and extremities arch backward so that the body rests on the head and heels), a sign of meningeal irritation. In meningococcal meningitis, you may see a petechial, purpuric, or ecchymotic rash on the lower part of the body. Neurologic examination may uncover other indications of meningeal irritation, including positive Brudzinski's and Kernig's signs and exaggerated and symmetrical deep tendon reflexes. It may also reveal altered LOC, ranging from confusion or delirium to deep stupor or coma. Vision testing may reveal diplopia and other visual problems. Ophthalmoscopic examination may show papilledema (another sign of increased ICP), but this is rare.

Diagnostic tests for Meningitis

Lumbar puncture cerebrospinal fluid (CSF)
Chest X-rays
White blood cell count
Computed tomography scanning.

Nursing diagnoses Nursing Care Plans for Meningitis

Common nursing diagnosis found in nursing Care Plans for meningitis

Acute pain
Anxiety
Hyperthermia
Impaired gas exchange
Risk for deficient fluid volume
Risk for impaired skin integrity

Nursing outcomes Nursing Care Plans for Meningitis

The patient will express feelings of comfort and relief of pain.
The patient will identify strategies to reduce anxiety.
The patient will exhibit temperature within normal range.
The patient will maintain adequate ventilation and oxygenation.
The patient will maintain fluid volume within normal range.
The patient's skin integrity will remain intact.

Nursing interventions Nursing Care Plans for Meningitis

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
Calming Technique: Reducing anxiety in patient experiencing acute distress
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
Fever Treatment: Management of a patient with hyperpyrexia caused by non environmental factors
Malignant Hyperthermia Precautions: Prevention or reduction of hyper metabolic response to pharmacological agents.
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance
Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity
Pressure Management: Minimizing pressure to body parts
Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them

NCP Nursing Care Plan For Asthma

2011-03-17T06:42:00.000+07:00

image courtesy of students.cis.uab.edu

NCP Nursing Care Plan For Asthma. Asthma is a growing health problem, the number of children with asthma has increased markedly, unfortunately, and approximately 75% of children with asthma continue to have chronic problems in adulthood. Asthma is a reversible lung disease that may resolve spontaneously or with treatment, asthma is characterized by obstruction or narrowing of the airways, which are typically inflamed and hyperresponsive to various stimuli. Signs of asthma range from mild wheezing and Dyspnea to life-threatening respiratory failure. Symptoms of bronchial airway obstruction may persist between acute episodes.

Hyper-reactivity leads to airway obstruction due to acute onset of muscle spasm in the smooth muscle of the tracheobronchial tree, thereby leading to a narrowed lumen. In addition to muscle spasm, there is swelling of the mucosa, which leads to edema. Lastly, the mucous glands increase in number, hypertrophy, and secrete thick mucus.

In asthma, the total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) increase, but the hallmark of airway obstruction is a reduction in ratio of the forced expiratory volume in 1 second (FEV1) and the FEV1 to the forced vital capacity (FVC).

Although asthma can result from infections (especially viral) and inhaled irritants, it often is the result of an allergic response. An allergen (antigen) is introduced to the body, and sensitizing antibodies such as immunoglobulin E (IgE) are formed. IgE antibodies bind to tissue mast cells and basophils in the mucosa of the bronchioles, lung tissue, and nasopharynx. An antigen-antibody reaction releases primary mediator substances such as histamine and slow-reacting substance of anaphylaxis (SRS-A) and others. These mediators cause contraction of the smooth muscle and tissue edema. In addition, goblet cells secrete a thick mucus into the airways that causes obstruction.

Extrinsic and intrinsic asthma

For many asthmatics, intrinsic and extrinsic asthma coexist. Intrinsic asthma results from all other causes except allergies, such as infections (especially viral), inhaled irritants, and other causes or etiologies. The parasympathetic nervous system becomes stimulated, which increases bronchomotor tone, resulting in bronchoconstriction.

Asthma that results from sensitivity to specific external allergens is referred to as extrinsic (atopic). In those cases where the allergen isn't obvious, asthma is referred to as intrinsic (nonatopic). Allergens that cause extrinsic asthma include pollen, animal dander, house dust or mold, kapok or feather pillows, food additives containing sulfites, and any other sensitizing substance.

Extrinsic asthma usually begins in childhood and is accompanied by other manifestations of atopy (type I, immunoglobulin [Ig] E–mediated allergy), such as eczema and allergic rhinitis.

With intrinsic asthma, no extrinsic allergen can be identified. Most cases are preceded by a severe respiratory tract infection. Irritants, emotional stress, fatigue, exposure to noxious fumes, and endocrine, temperature, and humidity changes may aggravate intrinsic asthma attacks.

Asthma Causes and Treatment

Asthma also called chronic reactive airway disease, chronic inflammatory disorder episodic exacerbations of reversible inflammation and hyperreactivity and variable constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Asthma that results from sensitivity to specific external allergens is known as extrinsic. In cases in which the allergen isn't obvious, asthma is referred to as intrinsic.

Extrinsic asthma Allergens include pollen, animal dander, house dust or mold, kapok or feather pillows, food additives containing sulfites, Genetic and environmental: household substances (such as dust mites, pets, cockroaches, mold), pollen, foods, latex, emotional upheaval, air pollution, cold weather, exercise, chemicals, medications, viral infections and any other sensitizing substance.

Extrinsic asthma usually begins in childhood and is accompanied by other manifestations such as eczema and allergic rhinitis. In patients with intrinsic (nonatopic) asthma, no extrinsic allergen can be identified. Most cases are preceded by a severe respiratory tract infection. Irritants, emotional stress, fatigue, and exposure to noxious fumes, as well as endocrine changes and changes in temperature and humidity, may aggravate intrinsic asthma attacks. In many patients with asthma, intrinsic and extrinsic asthma coexist.

Exercise may also provoke an asthma attack. In patients with exercise-induced asthma, bronchospasm may follow heat and moisture loss in the upper airways.

Treatment for Asthma

Treatment of acute asthma aims to decrease bronchoconstriction, reduce bronchial airway edema, and increase pulmonary ventilation. After an acute episode, treatment focuses on avoiding or removing precipitating factors, such as environmental allergens or irritants.

Drug therapy is most effective when begun soon after the onset of symptoms. A patient who doesn't respond to this treatment, whose airways remain obstructed, and who has increasing respiratory difficulty is at risk for status asthmaticus and may require mechanical ventilation.

Nursing Diagnosis Asthma

Nursing Assessment for patients with asthma. An asthma attack may begin dramatically, with simultaneous onset of many severe symptoms, or insidiously, with gradually increasing respiratory distress. It typically includes progressively worsening shortness of breath, cough, wheezing, and chest tightness or some combination of these signs and symptoms.

Patients history, obtain history of allergies thorough description of the response to allergens or other irritants. The patient may describe a sudden onset of symptoms after exposure, with a sense of suffocation. Symptoms include dyspnea, wheezing, and a cough and also chest tightness, restlessness, anxiety, and a prolonged expiratory phase. Ask if the patient has experienced a recent viral infection.

Physical examination. severe shortness of breath can hardly speak, patients use their accessory muscles for breathing. Some patients have an increased anteroposterior thoracic diameter. If the patient has marked, color changes such as pallor or cyanosis or becomes confused, restless, or lethargic, increased risk of respiratory failure.

Percussion of the lungs usually produces hyper-resonance, and palpation may reveal vocal fremitus.
Auscultation high-pitched inspiratory and expiratory wheezes, prolonged expiratory phase of respiration. A rapid heart rate, mild systolic hypertension, and a paradoxic pulse may also be present.

Diagnostic test for asthma

Pulmonary function tests
Pulse oximetry.
Arterial blood gas (ABG) analysis.
Complete blood count.
Chest X-rays.
Peak Expiratory Flow Rates (PEFR)

Nursing diagnosis for Asthma

Impaired gas exchange related to Altered oxygen supply obstruction of airways by secretions, bronchospasm, air-trapping Alveoli destruction
Ineffective airway clearance related to obstruction from narrowed lumen and thick mucus
imbalanced Nutrition: Less than Body Requirements related to Dyspnea, sputum production Medication side effects; anorexia, nausea or vomiting
Fatigue
Ineffective breathing pattern
Anxiety
Deficient knowledge (treatment regimen, self-care, and discharge needs)
Fear

Nursing Care Plans for Asthma

Common nursing diagnosis found in Nursing Care Plans for Asthma; Impaired gas exchange, Ineffective airway clearance, imbalanced Nutrition: Less than Body Requirements, Fatigue, Ineffective breathing pattern, Anxiety, Deficient knowledge (treatment regimen, self-care, and discharge needs), Fear

Sample Nursing care plans for Asthma

NURSING DIAGNOSIS	INTERVENTIONS	RATIONALE	EVALUATION
ineffective Airway Clearance R/T Bronchospasm Increased production of secretions, retained secretions, thick, viscous secretions Decreased energy or fatigue	· Evaluate respiratory rate/depth and breath sounds. · Assist client to maintain a comfortable position. · Keep environmental free from sources of allergen such as dust, smoke, and feather pillows to a minimum according to individual situation. · Encourage/instruct in deep-breathing and directed coughing exercises	· Tachypnea is usually present to some degree and may be pronounced during respiratory stress. · facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing · Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. · To maximize cough effort, lung expansion and drainage, and reduce pain impairment.	· Respiratory Status: Airway Patency · Maintain patent airway with breath sounds clear or clearing. · Demonstrate behaviors to improve or maintain clear airway.
impaired Gas Exchange R/T Altered oxygen supply, obstruction of airways by secretions, bronchospasm	· monitor skin and mucous membrane color. · Monitor vital signs · Encourage adequate rest and limit activities to within client tolerance. · Monitor and graph serial ABGs and pulse oximetry. · Administer medications as indicated	· Duskiness and central cyanosis indicate advanced hypoxemia · Increased PaCO2 signals impending respiratory failure for asthmatics.	· Demonstrate improved ventilation · Demonstrate adequate oxygenation of tissues by ABGs within client’s normal limits · absence of symptoms of respiratory distress

Patient Teaching Discharge and Home Healthcare Guidelines For Asthma

To prevent asthma attacks, teach patients the triggers that can precipitate an attack. Teach the patient and family the correct use of medications, including the dosage, route, action, and side Effects. In rare instances, asthma can lead to respiratory failure (status asthmaticus) if patients are not treated immediately or are unresponsive to treatment. Explain that any Dyspnea unrelieved by medications, and accompanied by wheezing and accessory muscle use, needs prompt attention from a healthcare provider.

Patient Teaching Discharge and Home Healthcare Guidelines:

• Teach the patient and his family to avoid known allergens and irritants.

• Teach the patient about his medications, drug interactions, including proper dosages, administration instructions, and adverse effects.

• Teach the patient how to use a metered-dose inhaler.

• Explain how to use a peak flow meter to measure the degree of airway obstruction, If the patient has moderate to severe asthma. Tell him to keep a record and Explain the importance of calling the physician at once if the peak flow drops suddenly

• If the patient develops a fever above 100° F (37.8° C), chest pain, shortness of breath without coughing or exercising, or uncontrollable coughing. Tell the patient to notify the physician

• Teach the patient and his family an uncontrollable asthma attack requires immediate attention.

• Teach the patient diaphragmatic and effective coughing techniques.

• Urge him to Increase fluid intake to help loosen secretions and maintain hydration.

• Teach the patient and his family important of Regular medical follow-up care, when to notify healthcare professional of changes in condition, and periodic spirometry testing, chest x-rays, and sputum cultures.

NCP Nursing Care Plans for Croup

2011-03-15T07:24:00.001+07:00

Image courtesy of ncbi.nlm.nih.gov

NCP Nursing Care Plans for Croup. A severe inflammation and obstruction of the upper airway, croup can occur as acute laryngotracheobronchitis, laryngitis, and acute spasmodic laryngitis. It must always be distinguished from epiglottitis. Croup is a childhood disease affecting boys more commonly than girls typically between age 3 months and 3 years that usually occurs during the winter.

Croup usually occurs in the winter as acute laryngotracheobronchitis, laryngitis, or acute spasmodic laryngitis. It must be distinguished from epiglottiditis. Usually mild and self-limiting, acute laryngotracheobronchitis appears mostly in children ages 3 months to 3 years. Acute spasmodic laryngitis affects children between ages 1 and 3, particularly those with allergies and a family history of croup. Overall, up to 15% of patients have a family history of croup. Recovery is usually complete.

Causes for Croup

Parainfluenza viruses, adenoviruses, respiratory syncytial virus, influenza viruses, measles viruses, and bacteria (pertussis and diphtheria)

Complications for Croup

Airway obstruction, respiratory failure, and dehydration are complications of croup. Latent complications are ear infection and pneumonia.

Nursing Assessment Nursing Care Plans for Croup

Recent upper respiratory tract infection preceding croup.

• inspection, you may observe the use of accessory muscles with nasal flaring during breathing. You typically hear the child's sharp, barklike cough and hoarse or muffled vocal sounds. As croup progresses, the patient may display further upper airway obstruction with severely compromised ventilation. (See How croup affects the upper airways.)

• Auscultation may disclose inspiratory stridor and diminished breath sounds. These signs and symptoms may last for only a few hours, or they may persist for 1 to 2 days.

• In laryngotracheobronchitis, the patient may complain of fever and breathing problems that occur more often at night. Typically, the child becomes frightened because he can't breathe out (because inflammation causes edema in the bronchi and bronchioles).

Nursing diagnosis Nursing Care Plans for Croup

Anxiety
Deficient knowledge (home care)
Disabled family coping
Fear
Hyperthermia
Impaired gas exchange
Ineffective airway clearance

Nursing outcomes Nursing Care Plans for Croup

Patient and family will verbalize strategies to reduce anxiety.
Patient and family will demonstrate an understanding of what has been taught.
Patient and family will Verbalize understanding of condition/disease process and treatment
Patient and family will use available support systems to assist with coping.
Family Coping: Family actions to manage stressors that tax family resources
Patient and family will verbalize fears and concerns.
The patient's temperature will be within normal range.
The patient will maintain adequate ventilation and oxygenation.
The patient will maintain a patent airway.

Nursing Interventions Nursing Care Plans for Croup

Anxiety Control: Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source
Coping: Actions to manage stressors that tax an individual’s resources
Teaching: Individual Planning, implementation, and evaluation of a teaching program designed to address a patient’s particular needs
Learning Facilitation: Promoting the ability to process and comprehend information
Learning Readiness Enhancement: Improving the ability and willingness to receive information
Family Therapy: Assisting family members to move their family toward a more productive way of living
Family Support: Promotion of family values, interests, and goals
Family Involvement Promotion: Facilitating family participation in the emotional and physical care of the patient
Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
Fever Treatment: Management of a patient with hyperpyrexia caused by nonenvironmental factors
Malignant Hyperthermia Precautions: Prevention or reduction of hypermetabolic response to pharmacological agents used during surgery
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Cough Enhancement: Promotion of deep inhalation by the patient with subsequent generation of high intrathoracic pressures and compression of underlying lung parenchyma for the forceful expulsion of air

Patient teaching discharge and home health guidance for patient with Croup

If the patient is hospitalized, advise the parents that he may be placed in a cool-mist tent to provide high humidity.
Explain that the hospitalized child may require hydration with I.V. fluids if he can't be hydrated orally.
Warn parents that ear infections and pneumonia may complicate croup.
Urge the parents to seek immediate medical attention if the patient has an earache, productive cough, high fever, or increased shortness of breath.

NCP Nursing Care Plans for Tuberculosis

2011-03-15T07:24:00.000+07:00

image Courtesy of commons.wikimedia.org

NCP Nursing Care Plans for Tuberculosis. Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, an aerobic acid-fast bacillus. Although it is most frequently a pulmonary disease, more than 15% of patients experience extra pulmonary TB that can infect the meninges, kidneys, bones, or other tissues. Pulmonary TB can range from a small infection of bronchopneumonia to diffuse intense inflammation, necrosis, pleural effusion, and extensive fibrosis. An acute or chronic infection caused by Mycobacterium tuberculosis, tuberculosis (TB) is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation. People living in crowded, poorly ventilated conditions are most likely to become infected.

In patients with strains that are sensitive to the usual antitubercular agents, the prognosis is excellent with correct treatment. However, in those with strains that are resistant to two or more of the major antitubercular agents, mortality is 50%. Tuberculosis (TB) is an acute or chronic infection characterized by pulmonary infiltrates and by the formation of granulomas with caseation, fibrosis, and cavitation. The incidence of TB has been increasing in the United States secondary to homelessness, drug abuse, and human immunodeficiency virus infection. Globally, TB is the leading infectious cause of morbidity and mortality, generating 8 to 10 million new cases each year.

The disease is twice as common in males as in females and four times as common in nonwhites as in whites. Incidence is highest in people who live in crowded, poorly ventilated, unsanitary conditions, such as prisons, tenement houses, and homeless shelters. The typical newly diagnosed patient with TB is a single, homeless, nonwhite man. With proper treatment, the prognosis is usually excellent. However, mortality is 50% in strains of TB resistant to two or more of the major antitubercular agents.

Causes for Tuberculosis

TB results from exposure to Mycobacterium tuberculosis. A person's risk of contracting TB increases if he has frequent contact with people who have the disease, if he lives in crowded or unsanitary living conditions, or if he has poor nutrition. There has been an increase of incidence of TB in the United States due to the increase of human immunodeficiency virus infection, the increasing number of homeless individuals (poor environment and poor nutrition), and the appearance of drug-resistant strains of TB.

Complications for Tuberculosis

TB can cause massive pulmonary tissue damage, with inflammation and tissue necrosis eventually leading to respiratory failure. Bronchopleural fistulas can develop from lung tissue damage, resulting in pneumothorax. The disease can also lead to hemorrhage, pleural effusion, and pneumonia. Small mycobacterial foci can infect other body organs, including the kidneys and the central nervous and skeletal systems. The patient also might develop complications such as liver involvement from drug therapy.

Nursing Assessment Care Plans for Tuberculosis

Ask patients about a previous history of TB or Hodgkin’s disease, diabetes mellitus, leukemia, gastrectomy, silicosis (a disease resulting from inhalation of quartz dust), and immunosuppressive disorders. A history of corticosteroid or immunosuppressive drug therapy can also increase the likelihood of TB infection. Determine if the patient has had recent contact with a newly diagnosed TB patient or has resided in any type of long-term facility. Take an occupational history as well to determine if the patient is a healthcare worker and therefore at risk. The patient with a primary infection after an incubation period of 4 to 8 weeks is usually asymptomatic but may complain of weakness and fatigue, anorexia and weight loss, low-grade fever, and night sweats. The patient with reactivated TB may report chest pain and a cough that produces blood or mucopurulent or blood-tinged sputum. He may also have a low-grade fever.

Auscultation detects crepitant rales, bronchial breath sounds, wheezes, and whispered pectoriloquy.
Chest percussion detects a dullness over the affected area, indicating consolidation or pleural fluid.

Diagnostic test for Tuberculosis

Several of these tests may be necessary to distinguish TB from other diseases that may mimic it, such as lung carcinoma, lung abscess, pneumoconiosis, and bronchiectasis.

Chest X-ray shows nodular lesions, patchy infiltrates (mainly in upper lobes), cavity formation, scar tissue, and calcium deposits; however, it may not be able to distinguish active from inactive TB.
Tuberculin skin test detects TB infection. Intermediate-strength purified protein derivative or 5 tuberculin units (0.1 ml) are injected intracutaneously on the forearm.
sputum smears and cultures to identify M. tuberculosis.

Nursing diagnoses Care Plans for Tuberculosis

Common nursing diagnosis found in Nursing diagnoses Care Plans for Tuberculosis

Fatigue
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Ineffective airway clearance
Ineffective coping
Ineffective therapeutic regimen management
Risk for injury

Nursing outcomes Care Plans for Tuberculosis

The patient will identify measures to prevent or reduce fatigue.
The patient will consume adequate daily calories as required.
The patient will maintain adequate ventilation and oxygenation.
The patient will maintain a patent airway.
The patient will use support systems to assist with coping.
The patient will express an understanding of the illness and comply with treatment modalities.
The patient will remain free from complications.

Nursing Interventions Care Plans for Tuberculosis

Energy Management: Regulating energy use to treat or prevent fatigue and optimize function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Weight Gain Assistance: Facilitating gain of body weight
Eating Disorders Management: Prevention and treatment of severe diet restrictions and over exercising or binging and purging of foods and fluids
Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Cough Enhancement: Promotion of deep inhalation by the patient with subsequent generation of high intrathoracic pressures and compression of underlying lungparenchyma for the forceful expulsion of air
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Decision-Making Support: Providing information and support for a person who is making a decision regarding healthcare
Impulse Control Training: Assisting the patient to mediate impulsive behavior through application of problem-solving strategies to social and interpersonal situations
Self-Modification Assistance: Reinforcement of self-directed change initiated by the patient to achieve personally important goals
Health System Guidance: Facilitating a patient’s location and use of appropriate health services
Patient Contracting: Negotiating an agreement with a patient that reinforces a specific behavior change
Surveillance: Safety: Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety
Risk Identification: Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group
Environmental Management: Safety: Manipulation of the patient’s surroundings for therapeutic benefit

Patient Teaching discharge and Home Health Guidance for Patient with Tuberculosis

Patient teaching discharge and home healthcare guidelines for Patient with Pulmonary Tuberculosis. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to abstain from alcohol while on INH, and refer for eye examination after starting, then every month while taking, ethambutol. Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel.

Patient Teaching & Home Health Guidance for Patient with Pulmonary Tuberculosis

Improve ventilation in the home by opening windows in room of affected person, and keeping bedroom door closed as much as possible.
Instruct patient to cover mouth with fresh tissue when coughing or sneezing and to dispose of tissues promptly in plastic bags.
Discuss Tuberculosis TB testing of people residing with patient.
Investigate living conditions, availability of transportation, financial status, alcohol and drug abuse, and motivation, which may affect compliance with follow-up and treatment. Initiate referrals to a social worker for interventions in these areas.
Report new cases of Tuberculosis TB to public health department for screening of close contacts and monitoring.
Review possible complications: hemorrhage, pleurisy, symptoms of recurrence (persistent cough, fever, or Hemoptysis).
Instruct patient on avoidance of job-related exposure to excessive amounts of silicone (working in foundry, rock quarry, sand blasting), which increases risk of reactivation.
Encourage patient to report at specified intervals for bacteriologic (smear) examination of sputum to monitor therapeutic response and compliance.
Instruct patient in basic hygiene practices and investigate living conditions. Crowded, poorly ventilated conditions contribute to development and spread of Tuberculosis TB.
Encourage regular symptom screening and follow-up chest X-rays for rest of life to evaluate for recurrence.
Show the patient and family how to perform postural drainage and chest percussion. Also teach the patient coughing and deep-breathing exercises. Instruct him to maintain each position for 10 minutes and then to perform percussion and cough.
Instruct patient on prophylaxis with isoniazid for people infected with the tubercle bacillus without active disease to prevent disease from occurring, or to people at high risk of becoming infected.
Educate asymptomatic people about PPD testing and treatment of latent Tuberculosis TB for positive results, based on risk grouping.

NCP Nursing Care Plans For Amebiasis

2011-03-15T07:22:00.000+07:00

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NCP Nursing Care Plans For Amebiasis. Also called amoebic dysentery, Amebiasis can take the form of either an acute or a chronic protozoal infection. Extraintestinal Amebiasis can induce hepatic abscess and infection of the lungs, pleural cavity, pericardium, peritoneum and, rarely, the brain. Amebiasis occurs worldwide; about 90% of infections are asymptomatic and the rest produce symptoms ranging from amoebic dysentery to abscesses of the liver and other organs. It's the third most common cause of death from paralytic disease, after schistosomiasis and malaria. It's most common in the tropics, subtropics, and other areas with poor sanitation and health practices.

Causes For Amebiasis

Amebiasis is caused by Entamoeba histolytica. This protozoan has two stages: during the cystic stage, it can survive outside the body; during the trophozoite stage, it can't

Complications For Amebiasis

Amebiasis can cause chronic, recurrent episodes of diarrhea and abdominal pain, ameboma, megacolon, intussusception, extraintestinal abscesses, and intestinal stricture, hemorrhage, or perforation. Rarely, it causes a brain abscess, which is usually fatal

Nursing Assessment Nursing Care Plans For Amebiasis

The patient may have a history of recent travel to an area with poor sanitation, sexual practices involving oral-anal contact, eating or drinking suspect food or water, or institutionalization.

The patient's signs and symptoms vary with the severity of the infestation, from no symptoms or mild diarrhea to fulminating dysentery.

If the patient has acute amebiasis, he may complain of chills and abdominal cramping; profuse, bloody diarrhea with tenesmus; and diffuse abdominal tenderness (caused by extensive rectosigmoid ulcers). He also develops a sudden high fever, with a temperature of 104Â° to 105Â° F (40Â° to 40.5Â° C).

A patient with chronic amebiasis may report intermittent diarrhea that lasts for 1 to 4 weeks and recurs several times a year. Such diarrhea produces 4 to 8 (or, in severe diarrhea, up to 18) foul-smelling mucous- and blood-tinged stools daily. The patient may also report vague abdominal cramps and, possibly, weight loss. Any fever he has is mild.

Inspection may reveal perianal ulceration and systemic signs of dehydration or anemia. Palpation may reveal diffuse abdominal tenderness and hepatomegaly. Auscultation of the abdomen may disclose hyperactive bowel sounds, particularly in the lower quadrants, when the patient has acute diarrhea.

Nursing diagnosis Nursing Care Plans For Amebiasis

Common nursing diagnosis found in Nursing Care Plans For Amebiasis:

• Acute pain

• Deficient fluid volume

• Diarrhea

• Fatigue

• Hyperthermia

• Imbalanced nutrition: Less than body requirements

• Impaired skin integrity

• Risk for infection

Nursing outcomes Nursing Care Plans For Amebiasis

Nursing outcomes patient will:

• The patient will express feelings of comfort and relief from pain.

• The patient's electrolyte levels will stay within normal range.

• The patient's elimination pattern will return to normal.

• The patient will report an increased energy level.

• The patient will remain afebrile.

• The patient will experience no further weight loss.

• The patient will avoid skin breakdown or infection.

• The patient will experience no further signs or symptoms of infection.

Nursing Interventions Nursing Care Plans For Amebiasis

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded
Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Diarrhea Management: Management and alleviation of diarrhea
Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance
Perineal Care: Maintenance of perineal skin integrity and relief of perineal discomfort
Energy Management: Regulating energy use to treat or prevent fatigue and optimize function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range.
Fever Treatment: Management of a patient with hyperpyrexia caused by nonenvironmental factors.
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Weight Gain Assistance: Facilitating gain of body weight
Eating Disorders Management: Prevention and treatment of severe diet restrictions and over exercising or binging and purging of foods and fluids
Pressure Ulcer Care: Facilitation of healing in pressure ulcers
Infection Protection: Prevention and early detection of infection in a patient at risk
Infection Control: Minimizing the acquisition and transmission of infectious agents
Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

Patient Teaching discharge and Home Health Guidance for Patient with Amebiasis

Teach the patient about amebicide therapy, including precautions he should take and adverse effects of the medication
Encourage the patient to return for follow-up appointments at scheduled intervals.
Teach the patient and his family how to handle infectious material and about the need for careful hand washing.
Advise travelers to endemic areas and campers to boil untreated or contaminated water to prevent the disease.

NCP Nursing Care Plans for Common Cold

2011-03-14T09:58:00.000+07:00

NCP Nursing Care Plans for Common Cold. The common cold is an acute, usually afebrile, viral infection that causes inflammation of the upper respiratory tract. It's the most common infectious disease and is more prevalent in children, adolescent boys, and females. In temperate climates, it occurs more often in the colder months; in the tropics, during the rainy season.

Causes for Common Cold

About 90% of colds stem from a viral infection of the upper respiratory tract passages and consequent mucous membrane inflammation. The most common causative agent is the rhinovirus; however, some colds result from Mycoplasma. Other offenders include coronaviruses, myxoviruses, adenoviruses, coxsackieviruses, and echoviruses.

Complications for Common Cold

Secondary bacterial infection may occur, causing sinusitis, otitis media, pharyngitis, or lower respiratory tract infection

Nursing Assessment Nursing Care Plans for Common Cold

Assess patient’s exposure to others with the common cold. Patient usually complains of nasal congestion, headache, and burning, watery eyes. He may also report chills, myalgia, arthralgia, malaise, lethargy, and a hacking, nonproductive, or nocturnal cough. Most patients are afebrile, although fever may occur, especially in children.Clinical features develop more fully as the cold progresses. By the second day (in addition to initial symptoms), the patient may report a copious nasal discharge that often irritates the nose, adding to his discomfort. About 3 days after onset, major symptoms diminish, but congestion often persists for a week. Reinfection (with productive cough) is common, but complications are rare.

• Inspection may reveal a reddened nose and eyes and nasal discharge. The nasal and pharyngeal mucous membranes may exhibit increased erythema, and the patient's voice may have a nasal quality. The skin around the nose may be excoriated because of frequent nose blowing.

Nursing diagnosis Nursing Care Plans for Common Cold

Common nursing diagnosis found in Nursing Care Plans for Common Cold

Acute pain
Fatigue
Hyperthermia
Ineffective airway clearance
Ineffective breathing pattern
Risk for infection

Nursing outcomes Nursing Care Plans for Common Cold

The patient will be free from pain.
The patient will report increased energy.
The patient will remain afebrile.
The patient will expectorate sputum effectively.
The patient will express feelings of comfort in maintaining air exchange.
The patient will experience no further signs or symptoms of infection.

Nursing Interventions Nursing Care Plans for Common Cold

Pain Management
Administer analgesics, as indicated
Energy Management: Regulating energy use to treat or prevent fatigue and optimize function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
Temperature Regulation: Attaining and/or maintaining body temperature within a normal range.
Fever Treatment: Management of a patient with hyperpyrexia caused by nonenvironmental factors.
Malignant Hyperthermia Precautions: Prevention or reduction of hypermetabolic response to pharmacological agents used during surgery
Maintain airway patency.
Expectorate/clear secretions readily.
Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange
Infection Protection: Prevention and early detection of infection in a patient at risk
Infection Control: Minimizing the acquisition and transmission of infectious agents
Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan for Thyroid Cancer

2011-03-14T09:22:00.000+07:00

Thyroid Cancer, Cancer of the thyroid is a malignant neoplasm of the thyroid gland.

Pathophysiology and etiology of thyroid cancer

Although Thyroid cancer occurs in all age groups Incidence increases with age. The average age at time of diagnosis is 45. There appears to be an association between external radiation to the head and neck in infancy and childhood, and subsequent development of thyroid carcinoma. (Between 1949 and 1960, radiation therapy was commonly given to shrink enlarged tonsil and adenoid tissue, to treat acne, or to reduce an enlarged thymus.) People who have goiters have an increased risk for developing thyroid cancer. The incidence among such patients is 10–15 percent. A lack of iodine in the diet may lead to thyroid cancer. Because iodine is added to salt in the United States, thyroid cancer is rarely caused by iodine deficiencies in this country. Thyroid cancer may also have a genetic basis. Some researchers have found that an alteration in the RET gene may be transmitted from a parent to a child, causing medullary thyroid cancer. If several people in a family are diagnosed with thyroid cancer, other members may wish to be tested for a mutation of the RET gene. This syndrome, when present, is also called familial medullary thyroid cancer or Multiple Endocrine Neoplasia, type 2 (MEN 2). Individuals who have MEN 2 syndrome are also at risk for developing other types of cancer.

Types characteristics of thyroid cancers

Papillary adenocarcinoma (Most common and least aggressive, Asymptomatic nodule in a normal gland, Starts in childhood or early adult life, remains localized, Metastasizes along the lymphatics if untreated, More aggressive in the elderly, Growth is slow, and spread is confined to lymph nodes that surround thyroid area, Cure rate is excellent after removal of involved areas). Papillary carcinoma accounts for half of all thyroid cancers in adults; it's most common in young adult females and metastasizes slowly. It's the least virulent form of thyroid cancer. Follicular carcinoma is less common but more likely to recur and metastasize to the regional nodes and through blood vessels into the bones, liver, and lungs.
Follicular adenocarcinoma ( Appears after 40 years of age, Encapsulated; feels elastic or rubbery on palpation, Spreads through the bloodstream to bone, liver, and lung, Prognosis is not as favorable as for papillary adenocarcinoma, Brief encouraging response may occur with irradiation, Progression of disease is rapid; high mortality )
Medullary (Appears after 50 years of age, Occurs as part of multiple endocrine neoplasia MEN), Hormone-producing tumor causing endocrine dysfunction symptoms, Metastasizes by lymphatics and bloodstream, Moderate survival rate, inheritable type of thyroid malignancy, which can be detected early by a radioimmunoassay for calcitonin )
Anaplastic (50% of anaplastic thyroid carcinomas occur in patients older than 60 years, Hard, irregular mass that grows quickly and spreads by direct invasion to adjacent tissues, May be painful and tender, Survival for patients with anaplastic cancer is usually less than 6 months, The most aggressive and lethal solid tumor found in humans, Least common of all thyroid cancers, Usually fatal within months of diagnosis)
Thyroid lymphoma (Appears after age 40 years, May have history of goiter, hoarseness, Dyspnea, pain, and pressure, Good prognosis )

Complications For Thyroid Cancers

Untreated thyroid carcinoma can be fatal.
Hemorrhage
Hematoma formation
Edema of the glottis
Injury to the recurrent laryngeal nerve
Hypothyroidism occurs in 5% of patients in first postoperative year; increases at rate of 2% to 3% per year.
Hypoparathyroidism occurs in about 4% of patients and is usually mild and transient; requires calcium supplements I.V. and orally when more severe.

Clinical Manifestations for Thyroid Cancers

On palpation of the thyroid, there may be a firm, irregular, fixed, painless mass or nodule.
The occurrence of signs and symptoms of hyperthyroidism is rare.

Symptoms of Thyroid Cancer

As with many other forms of cancer, most people in the early stages of thyroid cancer have no symptoms or signs of disease. When symptoms or signs occur, they may include the following:
Hoarseness
A lump near the Adam’s apple of the neck
Swollen lymph nodes in the neck or nearby
Dysphagia (difficulty swallowing)
Pain in the neck or throat
Medullary carcinoma of the thyroid secretes CALCITONIN and thus can cause symptoms due to the presence of this hormone, such as flushing, nausea, and diarrhea. In addition, medullary carcinoma of the thyroid is often inherited. Family members can be screened by measuring their calcitonin levels or by looking for abnormal chromosomes, such as RET.
Anaplastic carcinoma typically presents in older men as a very hard mass in the neck. It is often incurable at the time of diagnosis, as it does not concentrate iodine, and thus radioactive iodine (RAI) therapy cannot be used. It is poorly responsive, if at all, to chemotherapy and external radiation therapy.

Nursing Diagnosis for Thyroid Cancer

Nursing Diagnosis for Thyroid Cancer. Nursing care plan for Thyroid Cancer begins with a detailed assessment as soon as the patient is admitted. In the Assessment phase, information is obtained the patient in a direct and structured manner through observation, interviews and examination. Initial interview includes an evaluation of mental status. Even when the initial assessment is complete, each encounter with the patient involves a continuing assessment .The ongoing assessment involves what patient is saying or doing at that moment.

Focused Nursing Assessment for Thyroid Cancer

Explore patient's feelings and concerns regarding the diagnosis, treatment, and prognosis. The first indication of disease may be a painless nodule discovered incidentally or detected during physical examination.If the tumor grows large enough to destroy the thyroid gland.

Patient’s history may include sensitivity to cold and mental apathy (hypothyroidism). If the tumor triggers excess thyroid hormone production, the patient may report sensitivity to heat, restlessness, and overactivity (hyperthyroidism). The patient may also complain of diarrhea, dysphagia, anorexia, irritability, and ear pain. When speaking with the patient, you may hear hoarseness and vocal stridor.

On inspection, you may detect a disfiguring thyroid mass, especially if the patient is in the later stages of anaplastic thyroid cancer. (See Anaplastic thyroid cancer.)

Palpation may disclose a hard nodule in an enlarged thyroid gland or palpable lymph nodes with thyroid enlargement.

By auscultation, you may discover bruits if thyroid enlargement results from an increase in TSH, which increases thyroid vascularity.

Diagnostic Evaluation

A thyroid scan with 99mTc will detect a cold nodule with little uptake
FNA biopsy
Surgical exploration
ultrasound
MRI
CT scans
Thyroid scans
Radioactive
Iodine uptake studies
Thyroid suppression tests

Nursing Diagnosis for Patient with Thyroid Cancer

Commong Nursing Diagnosis That Could Be Found In Patient With Thyroid Cancer:

Fear/Anxiety [specify level]
Acute/chronic Pain
Risk for ineffective Airway Clearance
Impaired verbal Communication
Risk for Injury, [tetany, thyroid storm]
Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs

Nursing Care Plan for Thyroid Cancer

Nursing Care Plan for Thyroid Cancer. Common Nursing Diagnosis That Could Be Found In Nursing Care Plan Patient With Thyroid Cancer: Fear/Anxiety, Acute/chronic Pain, Risk for ineffective Airway Clearance, Impaired verbal Communication, Risk for Injury (tetany because of thyroid storm), Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs

Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer

Nursing Diagnosis Fear/Anxiety

Could be related to:

Situational crisis cancer Thyroid Cancer
Threat to, or change in, health, socioeconomic status, role functioning, interaction patterns
Threat of death
Separation from family hospitalization, treatments, diagnostic procedures, diagnosis of chronic/life-threatening condition

Nursing Outcomes Evaluation Criteria, Client Will:

Fear or Anxiety Self Control: Display appropriate range of feelings and lessened fear. Appear relaxed and report anxiety is reduced to a manageable level. Demonstrate use of effective coping mechanisms and active participation in treatment regimen.

Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety:

Review client’s and significant other’s (SO’s) previous experience with cancer. Determine what the doctor has told client and what conclusion client has reached. Rationale Clarifies client’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer.
Ascertain client/SO(s) perception of what is occurring and how this affects life. Rationale Fear is a natural reaction to frightening events and how client views the event will determine how he or she will react
Encourage client to share thoughts and feelings. Rationale Provides opportunity to examine realistic fears and misconceptions about diagnosis.
Provide open environment in which client feels safe to discuss feelings or to refrain from talking. Rationale Helps client feel accepted in present condition without feeling judged and promotes sense of dignity and control.
Be alert to signs of denial/depression. Indicates need for specific interventions to identify and deal with problems. Rationale Client may deny problems until unable to deal with situation. Depression may accompany problems associated with fear that interfere with daily activities
Maintain frequent contact with client. Talk with and touch client, as appropriate. Rationale Provides assurance that the client is not alone or rejected; conveys respect for and acceptance of the person, fostering trust.
Be aware of effects of isolation on client when required by immunosuppression or radiation implant. Limit use of isolation clothing, as possible. Rationale Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety, fear, and alienation.
Assist client and SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears. Rationale Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control and coping strategies are available.
Provide accurate, consistent information regarding diagnosis and prognosis. Avoid arguing about client’s perceptions of situation. Rationale Can reduce anxiety and enable client to make decisions and choices based on realities.
Explain the recommended treatment, its purpose, and potential side effects. Help client prepare for treatments. Rationale The goal of cancer treatment is to destroy malignant cells while minimizing damage to normal ones. Treatment may include curative, preventive, or palliative surgery as well as chemotherapy, internal or external radiation, or newer, organ-specific treatments such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral progenitor cell transplant may be recommended for some types of cancer.
Note ineffective coping such as poor social interactions, helplessness, giving up everyday functions, and usual sources of gratification. Rationale Identifies individual problems and provides support for client and SO in using effective coping skills.
Administer anti-anxiety medications, such as lorazepam (Ativan) or alprazolam (Xanax), as indicated. Rationale May be useful for brief periods of time to help client handle feelings of anxiety related to diagnosis or situation during periods of high stress, to assist client with diagnostic procedures, such as lying still during scan, and/or to minimize nausea.
Refer to additional resources for counseling and support as needed. Rationale May be useful from time to time to assist client and SO in dealing with anxiety.

Nursing Diagnosis Acute/Chronic Pain

Related to: Disease process compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation, metastasis to bones. Side effects of various cancer therapy agents

Nursing Outcomes Evaluation Criteria Client Will

• Report maximal pain relief or control with minimal interference with activities of daily living (ADLs).

• Follow prescribed pharmacological regimen.

• Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain

Determine pain history, for example, location of pain, frequency, duration, and intensity using a rating scale (scale of 0–10), or verbal rating scale “no pain” to “excruciating pain”; and relief measures used. Believe client’s report. Rationale Information provides baseline data to evaluate need for, and effectiveness of, interventions. Pain of more than 6 months’ duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention.
Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client about what to expect. Rationale A wide range of discomforts are common such as incisional pain, burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer.
Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV. Rationale Promotes relaxation and helps refocus attention.
Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck. Rationale Prevents hyperextension of the neck
Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch. Rationale Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain.
Provide cutaneous stimulation, such as heat and cold packs, or massage. Rationale May decrease inflammation, muscle spasms, reducing associated pain.
Be aware of barriers to cancer pain management related to client, as well as the healthcare system. Rationale Clients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; belief that pain has meaning, such as “God wills it,” they should overcome it; or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities.
Evaluate pain relief at regular intervals. Adjust medication regimen as necessary. Inform client and SO of the expected therapeutic effects and discuss management of side effects. Rationale Goal is maximum pain control with minimum interference with ADLs.
Develop individualized pain management plan with the client and physician. Provide written copy of plan to client, family and SO, and care providers. Rationale An organized plan beginning with the simplest dosage schedules and least invasive modalities improves chance for pain control. Particularly with chronic pain, client and SO must be active participant in pain management and all care providers need to be consistent.
Refer to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, as indicated. Rationale May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain.

Nursing Diagnosis Risk for Ineffective Airway Clearance

Related to Tracheal obstruction, swelling, bleeding, laryngeal spasms.

Nursing Outcomes Evaluation Criteria

• Client Will Maintain patent airway, with aspiration prevented.

Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance

Monitor respiratory rate, depth, and work of breathing. Rationale Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.
Auscultate breath sounds, noting presence of rhonchi. Rationale Rhonchi may indicate airway obstruction and accumulation of copious thick secretions.
Assess for Dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice. Rationale Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention.
Keep head of bed elevated 30 to 45 degrees. Caution client to avoid bending neck; support head with pillows in the immediate postoperative period. Rationale Enhances breathing and reduces likelihood of tension on surgical wound.
Assist with repositioning, deep breathing exercises, and coughing, as indicated. Rationale Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions.
Investigate reports of difficulty swallowing and drooling of oral secretions. Rationale May indicate edema and sequestered bleeding in tissues surrounding operative site.
Keep tracheostomy tray at bedside. Rationale Compromised airway may create a life-threatening situation requiring emergency procedure.
Provide steam inhalation, humidify room air. Rationale Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.
Assist with and prepare for procedures, such as: Tracheostomy Rationale although rare, tracheostomy may be necessary to obtain airway if obstructed by edema of glottis or hemorrhage.

Nursing Diagnosis Impaired Verbal Communication

Related to: Vocal cord injury, laryngeal nerve damage. Tissue edema; pain and discomfort

Nursing Outcomes Evaluation Criteria

Client Will Establish method of communication in which needs can be understood.

Nursing Interventions and Rationale:

Assess speech periodically and encourage voice rest. Rationale Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and or compression of the trachea.
Keep communication simple. Ask yes and no questions. Rationale Reduces demand for response; promotes voice rest.
Provide alternative methods of communication as appropriate—slate board, letter and picture board. Place intravenous (IV) line to minimize interference with written communication. Rationale Facilitates expression of needs.
Anticipate needs as much as possible. Visit client frequently. Rationale Reduces anxiety and client’s need to communicate.
Post notice of client’s voice limitations at central station and answer call light promptly. Rationale Prevents client from straining voice to make needs known and summon assistance.
Maintain quiet environment. Rationale Enhances ability to hear whispered communication and reduces necessity for client to raise and strain voice to be heard.

Nursing Diagnosis Risk For Injury

Related to: tetany, thyroid storm. Chemical imbalance, such as with hypocalcemia, increased release of thyroid hormones, excessive central nervous system (CNS). Stimulation

Nursing Outcomes Evaluation Criteria Client Will Demonstrate absence of injury with complications minimized or controlled.

Nursing Interventions And Rationale

Monitor vital signs, noting elevated temperature, tachycardia (140 to 200 beats/minute), dysrhythmias, respiratory distress, and cyanosis—developing pulmonary edema or heart failure (HF). Rationale : Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm.
Evaluate reflexes periodically. Observe for neuromuscular irritability—twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, and seizure activity. Rationale : Hypocalcemia with tetany (usually transient) may occur 1 to 7 days postoperatively and indicates hypoparathyroidism, which can occur because of inadvertent trauma to and partial to total removal of parathyroid gland(s) during surgery.
Keep side rails raised and padded, bed in low position, and airway at bedside. Avoid use of restraints. Rationale Reduces potential for injury if seizures occur. (Refer to CP: Seizure Disorders, ND: risk for Trauma/Suffocation.)
Monitor serum calcium levels. Rationale : Clients with levels less than 7.5 mg/100 mL generally require replacement therapy.
Administer medications, as indicated, for example: IV calcium (gluconate or chloride) Phosphate-binding agents, Sedativesm Anticonvulsants Rationale : Corrects deficiency, which is usually temporary but may be permanent. Note: Use with caution in clients taking digoxin because calcium increases cardiac sensitivity to digoxin, potentiating risk of toxicity. Helpful in lowering elevated phosphorus levels associated with hypocalcemia. Promotes rest, reducing exogenous stimulation. Controls seizure activity associated with thyroid storm until corrective therapy is successful.

Nursing Diagnosis Deficient Knowledge Regarding Condition, Prognosis, Treatment, Self-Care, And Discharge Needs

Related to: Lack of exposure and recall; misinterpretation, Unfamiliarity with information resources

Nursing Outcomes Evaluation Criteria

• Client Will Verbalize understanding of surgical procedure and prognosis and potential complications.

• Verbalize understanding of therapeutic needs.

• Participate in treatment regimen.

• Initiate necessary lifestyle changes.

Nursing Interventions and Rationale

Review surgical procedure and future expectations. Rationale Provides knowledge base from which client can make informed decisions.
Discuss need for well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt. Rationale Promotes healing and helps client regain and maintain appropriate weight. Use of iodized salt is often sufficient to meet iodine needs unless salt is restricted for other healthcare problems, such as with HF.
Identify foods high in calcium, such as dairy products, and vitamin D, such as fortified dairy products, egg yolks, and liver. Rationale Maximizes supply and absorption of calcium if parathyroid function is impaired.
Encourage progressive general exercise program. Rationale In clients with subtotal thyroidectomy, exercise can stimulate the thyroid gland and production of hormones, facilitating recovery of general well-being.
Review postoperative exercises to be instituted after incision heals flexion, extension, rotation, and lateral movement of head and neck. Rationale Regular range-of-motion (ROM) exercises strengthen neck muscles and enhance circulation and healing process.
Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts. Rationale Effects of hyperthyroidism usually subside completely, but it takes some time for the body to recover.
Instruct in incision care cleansing and dressing application. Rationale Enables client to provide competent self-care. Note: Neck incisions heal rapidly and are watertight within 24 to 36 hours.
Recommend the use of loose-fitting scarves to cover scar, avoiding the use of jewelry. Rationale Covers the incision without aggravating healing or precipitating infections of suture line.
Discuss possibility of change in voice. Rationale Normal surgical area swelling and vocal cord dysfunction can cause changes in pitch and quality of voice, which may be temporary or permanent.
Review drug therapy and the necessity of continuing even when feeling well. Rationale If thyroid hormone replacement is needed because of surgical removal of gland, client needs to understand rationale for replacement therapy and consequences of failure to routinely take medication.
Identify signs and symptoms requiring medical evaluation: fever, chills, continued and purulent wound drainage, erythema, gaps in wound edges, sudden weight loss, intolerance to heat, nausea and vomiting, diarrhea, insomnia, weight gain, fatigue, intolerance to cold, constipation, and drowsiness. Rationale Early recognition of developing complications, such as infection, hyperthyroidism, or hypothyroidism, may prevent progression to life-threatening situation.
Stress necessity of continued medical follow-up. Rationale Provides opportunity for evaluating effectiveness of therapy and prevention of complications.

Patient Teaching Thyroid Cancer

Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer:

Happy Holidays everyone!

2010-12-24T09:43:00.000+07:00

Happy Holidays everyone!

Happy Holidays and Best wishes for a happy and prosperous New Year.

Wishing you a very happy holidays from Nurse Thought

Nursing Diagnosis Impaired Skin integrity

2010-09-07T22:53:00.001+07:00

Nursing Diagnosis Impaired Skin integrity
Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis).

Related Factors:
External:
Hyperthermia, hypothermia, chemical substance, mechanical factors (e.g. friction, shearing forces, pressure, restraint), physical immobilization, humidity, extremes in age, moisture, radiation, medications
Internal:
Altered metabolic state, altered nutritional state (e.g. obesity, emaciation), altered circulation, altered sensation, altered pigmentation, skeletal prominence, developmental factors, immunological deficit, alterations in skin turgor (change in elasticity), altered fluid status.

Suggested Nursing Outcomes

Tissue Integrity: Skin and Mucous Membranes
Wound Healing: Primary Intention
Wound Healing: Secondary Intention

Client Outcomes

Regains integrity of skin surface
Reports any altered sensation or pain at site of skin impairment
Demonstrates understanding of plan to heal skin and prevent reinjury
Describes measures to protect and heal the skin and to care for any skin lesion

Suggested Nursing Interventions

Incision Site Care
Pressure Ulcer Care
Skin Care: Topical Treatments
Skin Surveillance Wound Care

Nursing Interventions and Rationales

Nursing Interventions

Rationales

· Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear)

· Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection.

· Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently .

· For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors.

· Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours

· Evaluate for use of specialty mattresses, beds

· Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudates

· Avoid massaging around the site of skin impairment and over bony prominences.

· Assess client's nutritional status

· Prior assessment of wound etiology is critical for proper identification of nursing interventions.

· Systematic inspection can identify impending problems early.

· A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown.

· Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

· To reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed.

· Massage may lead to deep-tissue trauma

· Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing

Home Care Interventions Client and Family Teaching

Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing
Teach client to use a topical treatment that is matched to the client, wound, and setting.
If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours
Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury

Nursing Diagnosis Impaired Gas exchange

2010-07-06T11:00:00.000+07:00

Nursing Diagnosis Impaired Gas exchange Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Visual disturbances, decreased carbon dioxide, dyspnea, abnormal arterial blood gases, hypoxia, irritability, somnolence, restlessness, hypercapnia, tachycardia, cyanosis, abnormal skin color, hypoxemia, hypercarbia, headache on awakening, abnormal rate rhythm depth of breathing, diaphoresis, abnormal arterial pH, abnormal nasal flaring

Nursing Outcomes

Respiratory Status: Gas Exchange
Respiratory Status: Ventilation
Tissue Perfusion: Pulmonary
Vital Signs Status
Electrolyte and Acid-Base Balance

Client Outcomes

Demonstrates improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters
Maintains clear lung fields and remains free of signs of respiratory distress
Verbalizes understanding of oxygen and other therapeutic interventions

Nursing Interventions

Airway Management
Oxygen Therapy
Respiratory Monitoring
Acid-Base Management
Monitor respiratory Auscultate breath sounds, rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns, oxygen saturation using pulse oximeter. Note blood gas results as available continuously
Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and extreme lethargy.
Observe for cyanosis sign
coach the client to slow respiratory rate, Demonstrate and encourage the client to use pursed-lip breathing
Position client with head of bed elevated, in a semi-Fowler's position, If client has unilateral lung disease, alternate semi-Fowler's position with lateral position. If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position
Administer oxygen
If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation.
Encourage client to stop smoking

Nursing Diagnosis Ineffective Airway clearance

2010-07-01T10:56:00.000+07:00

Nursing Diagnosis Ineffective Airway clearance Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Dyspnea, diminished breath sounds, orthopnea, adventitious breath sounds crackles, wheezes, cough, ineffective or absent sputum production, cyanosis, difficulty vocalizing, wide-eyed, changes in respiratory rate and rhythm, restlessness

Related Factors:

Environmental, Smoking, smoke inhalation, second-hand smoke, Obstructed Airway, Airway spasm, retained secretions, excessive mucus, presence of artificial airway, foreign body in airway, secretions in bronchi, exudates in alveoli, Physiological, Neuromuscular dysfunction, hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways

Nursing Outcomes
• Respiratory Status: Ventilation
• Respiratory Status: Airway Patency
• Respiratory Status: Gas Exchange
• Aspiration Control

• Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea
• Maintains a patent airway at all times
• Relates methods to enhance secretion removal
• Relates the significance of changes in sputum to include color, character, amount, and odor
• Identifies and avoids specific factors that inhibit effective airway clearance

Nursing Interventions
• Airway Management
• Airway Suctioning
• Cough Enhancement

Monitor respiratory, including patterns, rate, depth, and effort, Breath sounds.
Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours)
If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position
Teach client to deep breath and perform controlled coughing.
Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary.
Observe sputum, noting color, odor, and volume
Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side every 2 hours
Encourage increased fluid.
Administer oxygen as ordered.
Administer medications such as bronchodilators or inhaled steroids as ordered.
Provide Chest physical therapy: postural drainage, percussion, and vibration as ordered.
Refer for physical therapy or respiratory therapy for further treatment.
Monitor blood gas values and pulse oxygen saturation levels.
If the client has COPD, consider helping the client use the huff cough technique

Nursing Diagnosis Risk for Infection

2010-06-27T00:26:00.000+07:00

Nursing Diagnosis Risk for Infection: At increased risk for being invaded by pathogenic organisms

Risk Factors

Invasive procedures
Insufficient knowledge regarding avoidance of exposure to pathogens
Trauma, Tissue destruction and increased environmental exposure, Rupture of amniotic membranes
Pharmaceutical agents (e.g. Immunosuppressant)
Malnutrition
Increased environmental exposure to pathogens
Inadequate acquired immunity
Inadequate secondary defences (e.g. decreased haemoglobin)
Chronic disease

Nursing Outcomes

Immune Status
Knowledge: Infection Control
Risk Control
Risk Detection

Client Outcomes

Remains free from symptoms of infection
States symptoms of infection of which to be aware
Demonstrates appropriate care of infection.
Maintains white blood cell count and differential within normal limits
Demonstrates appropriate hygienic measures such as hand washing, oral care, and perinea care

Nursing Interventions
Infection Control
Infection Protection

Observe and report signs of Infection.
Assess temperature, Use an electronic or mercury thermometer to assess temperature.
Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures).
Assess skin for colour, moisture, texture, and turgor (elasticity).
Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces.
Encourage a balanced diet, emphasizing proteins to feed the immune system.
Prevent nosocomial pneumonia.
Encourage fluid intake and adequate rest to bolster the immune system.
Before and after giving care to client use Proper hand washing techniques.
Use goggles, gloves, and gowns when appropriate Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance.
Transmission Based Precautions for

• Airborne
• Droplet
• Contact transmitted

Sterile technique on catheterize.
Use careful technique when changing and emptying urinary catheter bags; avoid cross contamination.
Use careful sterile technique wherever there is a loss of skin integrity.
Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perinea care.
Antibiotics.

Nursing Care Plans Attention Deficit Hyperactivity Disorder (ADHD)

2009-08-29T23:01:00.000+07:00

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Attention-deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention or hyperactivity impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development (APA, 2000). The patient with attention deficit hyperactivity disorder has difficulty focusing his attention, engaging in quiet passive activities, or both. Some patients have an attention deficit without hyperactivity; they're less likely to be diagnosed and receive treatment. Although attention deficit hyperactivity disorder is present at birth, diagnosis before age 4 or 5 is difficult unless the child exhibits severe symptoms. Some patients, however, aren't diagnosed until they reach adulthood. Males are three times more likely to be affected than females. The presence of other psychiatric disorders also needs to be determined, this disorder occurs in roughly 3% to 5% of school-age children.

Causes for Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder is thought to be a physiologic brain disorder with a familial tendency. Some studies indicate that it may result from altered neurotransmitter levels in the brain. Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD

Complications for Attention Deficit Hyperactivity Disorder (ADHD)

Emotional and social complications can result from the child's impulsive behavior, inattentiveness, and disorganization in school. Hyperactivity can also lead to poor nutrition.

Assessment Nursing Care Plans Attention Deficit Hyperactivity Disorder (ADHD)

The patient is usually characterized as a fidgeted and a daydreamer. He may also be described as inattentive and lazy. The parents may state that their child is intelligent but that his school or work performance is sporadic. They may also report that he has a tendency to jump quickly from one partly completed project, thought, or task to another. If the child is younger, the parents may note that he has difficulty waiting in line, remaining in his seat, waiting his turn, or concentrating on one activity long enough to complete it. An older child or an adult may be described as impulsive and easily distracted by irrelevant thoughts, sights, or sounds. He may also be characterized as emotionally labile, inattentive, or prone to daydreaming. His disorganization becomes apparent when, for example, he has difficulty meeting deadlines and keeping track of school or work tools and materials.

Difficulties in performing age-appropriate tasks
Highly distractible
Extremely limited attention span
Shifts from one uncompleted activity to another
Impulsivity, or deficit in inhibitory control, is common
Difficulty forming satisfactory interpersonal relationships
Disruptive and intrusive behaviors inhibit acceptable social interaction
Difficulty complying with social norms
Some children with ADHD are very aggressive or oppositional. Others exhibit more regressive and immature behaviors.
Low frustration tolerance and outbursts of temper are common.
Boundless energy, exhibiting excessive levels of activity, restlessness, and fidgeting
Often described as “perpetual motion machines,” continuously running, jumping, wiggling, or squirming
They experience a greater than average number of accidents, from minor mishaps to more serious incidents that may lead to physical injury or the destruction of property.

Predisposing Factors for Attention Deficit Hyperactivity Disorder (ADHD)

The patient with attention deficit hyperactivity disorder has difficulty focusing his attention, engaging in quiet passive activities, or both. Some patients have an attention deficit without hyperactivity; they're less likely to be diagnosed and receive treatment. Although attention deficit hyperactivity disorder is present at birth, diagnosis before age 4 or 5 is difficult unless the child exhibits severe symptoms. Some patients, however, aren't diagnosed until they reach adulthood. Attention deficit hyperactivity disorder is thought to be a physiologic brain disorder with a familial tendency. Some studies indicate that it may result from altered neurotransmitter levels in the brain. Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD

Predisposing Factors for Attention Deficit Hyperactivity Disorder (ADHD)
Physiological

Genetics. A number of studies have indicated that hereditary factors may be implicated in the predisposition to ADHD. Siblings of hyperactive children are more likely than normal children to have the disorder.

Biochemical. Abnormal levels of the neurotransmitters dopamine, norepinephrine, and possibly serotonin have been suggested as a causative factor.

Prenatal, Perinatal, and Postnatal Factors. Maternal smoking during pregnancy has been linked to ADHD . Premature birth, fetal distress, precipitated or prolonged labor, and perinatal asphyxia have also been implicated. Postnatal factors include cerebral palsy, epilepsy, and other central nervous system abnormalities resulting from trauma, infections, or other neurological disorders.

Psychosocial
Environmental Influences: Disorganized or chaotic environments or a disruption in family equilibrium may predispose some individuals to ADHD. A high degree of psychosocial stress, maternal mental disorder, paternal criminality, low socioeconomic status, and foster care have been implicated.
Nursing diagnosis Nursing Care Plans Attention Deficit Hyperactivity Disorder (ADHD)

Common Nursing Diagnosis and Interventions found on Nursing Care Plans Attention Deficit Hyperactivity Disorder (ADHD)

Risk for self directed or other directed violence
Defensive coping
Impaired social interaction
Ineffective coping
Low self esteem
Noncompliance
Anxiety (moderate to severe)
Compromised family coping
Imbalanced nutrition: Less than body requirements
Ineffective family therapeutic regimen management
Interrupted family processes
Risk for impaired parenting

Key outcomes nursing diagnosis Nursing Care Plans Attention Deficit Hyperactivity Disorder (ADHD)

The patient and his family will report concern about difficulties in social interactions.
The patient and his family will communicate understanding of special dietary needs.
The patient will demonstrate effective social interaction skills.
The patient and his family will comply with the prescribed treatment regimen.
The patient's family will discuss the impact of the patient's illness and feelings about it with a health care professional.
The parents will utilize support groups and other community resources.
The patient will acknowledge and respond to efforts by others to establish communication.

Nursing interventions for ADHD

Set realistic expectations and limits because the patient with attention deficit hyperactivity disorder is easily frustrated
Always remain calm and consistent with the child.
Keep all your instructions to the child short and simple.
Provide praise and rewards whenever possible.
Provide the patient with diversional activities suited to his short attention span.
Help the parents and other family members develop planning and organizing systems to help them cope more effectively with the child's short attention span.

Nursing diagnosis Risk for self directed or other-directed violence

Observe client’s behavior frequently.
Observe for suicidal behaviors: Verbal statements, such as “ statement going to kill myself”
Determine suicidal intent and available means. Ask how where and when you plan to kill yourself
Obtain contract from client not to harm self and agreeing to seek out staff when ideation occurs.
Help client to recognize when anger occurs and to accept those feelings
Act as a role model for appropriate expression of angry feelings.
Give positive reinforcement.

Nursing diagnosis Defensive coping

Encourage client to recognize and verbalize feelings of inadequacy and need for acceptance from others and to recognize how these feelings provoke defensive behaviors
Provide immediate, fact, nonthreatening feedback for unacceptable behaviors
Help client identify situations that provoke defensiveness
Practice with role play for appropriate responses
Give positive feedback for acceptable behaviors
Evaluate and discuss with client the effectiveness of the new behaviors and any modifications for improvement

Nursing diagnosis Impaired social interaction

Develop trust relationship
Give to the client’s constructive criticism and positive reinforcement for client’s efforts
Give Positive feedback to client
Provide group situations for client

Nursing diagnosis Ineffective coping

Provide safe environment for continuous large muscle movement, If client is hyperactive
Provide large motoric activities
Do not debate, argue, rationalize, or bargain with the client.
Explore with client and discus alternative ways of handling frustration that would be most suited for client

Nursing diagnosis Low self esteem

Nursing diagnosis Anxiety

Establish a trusting relationship
Maintain an atmosphere of calmness
Offer support during times of elevated anxiety, Use of touch is comforting for some clients
When anxiety diminishes, help client to recognize specific events that preceded onset of anxiety.
Provide help to client to recognize signs of escalating anxiety
On escalating anxiety provide tranquilizing medication, as ordered

Nursing diagnosis Compromised family coping

Nursing diagnosis Imbalanced nutrition: Less than body requirements

Nursing diagnosis Ineffective family therapeutic regimen management

Nursing diagnosis Interrupted family processes

Nursing diagnosis Risk for impaired parenting

Patient teaching Nursing Care Plans Attention Deficit Hyperactivity Disorder (ADHD)

Make certain that the parents fully understand the child's prescribed medication regimen.
Teach the patient and family about any adverse reactions that may occur, emphasizing those that may require immediate medical attention.
Encourage the parents to provide the child with nutritious snacks such as fruit to supplement his dietary intake.
Refer the parents to appropriate support groups.

Nursing Care Plan for Abortion

2009-08-12T22:53:00.000+07:00

In nursing care plan for abortion definitions for Abortion is: Spontaneous abortion, miscarriage, or induced abortions, the products of conception are expelled from the uterus before fetal viability and gestation of less than 20 weeks is achieved.

Causes for Abortion
It’s May result from fetal, placental, or maternal factors:

Fetal factors usually include defective embryologic development resulting from abnormal chromosome division (the most common cause of fetal death), faulty implantation of fertilized ovum, and failure of the endometrium to accept the fertilized ovum, usually cause such abortions between 9 and 12 weeks of gestation
Placental factors usually include premature separation of the normally implanted placenta, abnormal placental implantation, and abnormal platelet function. Usually cause abortion around the 14th week of gestation.
Maternal factors usually include maternal infection, severe malnutrition, and abnormalities of the reproductive organs. usually cause abortion between 11 and 19 weeks of gestation

Other maternal factors include endocrine problems, such as thyroid gland dysfunction or lowered estriol secretion, trauma, including any type of surgery that necessitates manipulation of the pelvic organs, blood group incompatibility and Rh isoimmunization, and recreational drug use and environmental toxins.

Therapeutic abortion is performed to preserve the mother's mental or physical health in cases of unplanned pregnancy, or medical conditions, such as cardiac dysfunction or fetal abnormality.

Complications that may happen in Nursing Care Plan for Abortion

Infections in case of the products of conception aren't completely expelled
Hemorrhage
Anemia
Coagulation defects such as disseminated intravascular coagulation

Assessment Nursing Care Plan for Abortion

Pink discharge for several days or a scant brown discharge for several weeks
Cramps and increased vaginal bleeding
If any contents remain, cramps and bleeding continue.

Assess the patient’s emotional status, as well as that of the baby’s father and other family members. Often this hospital admission is the first one for the patient, and it may cause anxiety and fear

Diagnostic tests Nursing Care Plan for Abortion

HCG in the blood or urine confirms
Decreased HCG level
Laboratory test results reflect a decreased hemoglobin level
Ultrasound examination; absence of fetal heart sounds

Nursing diagnosis
Primary Nursing Diagnosis found in Nursing Care Plan for Abortion
Anticipatory grieving related to an unexpected pregnancy outcome
Common nursing diagnosis found in Nursing Care Plan for Abortion

Anxiety
Disabled family coping
Dysfunctional grieving
Hopelessness
Powerlessness
Risk for infection

Nursing outcomes, Interventions, and Patient teaching Nursing Care Plan for Abortion