Nursing Care Plan

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Nursing Care Plan for Impaired Verbal Communication

Impaired verbal communication is defined as decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.

Related to :
  • Physiologic conditions
  • Alteration of central nervous system
  • Impaired neurologic development or dysfunction
  • Disturbance in attachment/bonding with the parent/caregiver

Characterized by :
  • Language delay or total absence of language
  • Immature grammatic structure; pronoun reversal; inability to name objects
  • Stereotyped or repetitive use of language (echolalia, idiosyncratic words, inappropriate high-pitched squealing/giggling, repetitive phrases, sing-song speech quality)
  • Lack of response to communication attempts by others

Outcome :
  • Communicate in words/gestures that are understood by others

Interventions and Rationales
  1. Use one-on-one interactions to engage the client in nonverbal play.
    R/: The nurse enters the client’s world in a nonthreatening interaction to form a trusting relationship.

  2. Recognize subtle cues indicating the client is paying attention or attempting to communicate.
    R/: Cues are often difficult to recognize (glancing out of the corner of the eye).

  3. Describe for the client what is happening, and put into words what the client might be experiencing.
    R/: Naming objects and describing actions, thoughts, and feelings helps the client to use symbolic language.

  4. Encourage vocalizations with sound games and songs.
    R/: Children learn through play and enjoyable activities.

  5. Identify desired behaviors and reward them (e.g., hugs,treats,tokens,points,or food).
    R/: Behaviors that are rewarded will increase in frequency. Desire for food is a powerful incentive in modifying behavior.

  6. Use names frequently, and encourage the use of correct pronouns (e.g., I,me,he). R: Problems with self-identification and pronoun reversal are common.

  7. Encourage verbal communication with peers during play activities using role modeling, feedback, and reinforcement.
    R/: Play is the normal medium for learning in a child’s development.

  8. Increase verbal interaction with parents and siblings by teaching them how to facilitate language development.
    R/: Play is the normal medium for learning in a child’s development.

Nursing Care Plan for Pleural Effusion

Pleural effusion

Pleural effusion is excess fluid that accumulates in the pleura, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during respiration.

Pleural Effusion
Etiology of Pleural Effusion

Various causes of pleural effusion are:
  1. Neoplasms, such as bronchogenic and metastatic neoplasms.
  2. Cardiovascular, such as congestive heart failure, pulmonary embolus and pericarditis.
  3. Diseases of the abdomen, such as pancreatitis, ascites, abscess and Meigs syndrome.
  4. Infections caused by bacteria, viruses, fungi, and parasites microbacterial.
  5. Trauma
  6. Other causes such as systemic lupus erythematosus, rheumatoid arthritis, nephrotic sindroms and uremia.

Signs and Symptoms of Pleural Effusion
  1. Cough
  2. Dyspnea varies
  3. Complaints of chest pain (pleuritic pain)
  4. In severe effusions occur protrusion intercostal space.
  5. Chest movement was reduced and delayed on the part of the experience effusion.
  6. Percussion dims above pleural effusion.
  7. Egofoni close above the depressed pulmonary effusion.
  8. Diminished breath sounds over the pleural effusion.
  9. Fremitus focal and touch reduced.
  10. Clubbing is a sign of a real physical bronchogenic carcinoma, bronchiectasis, pulmonary abscess and tuberculosis.

Examination Support
  1. Thoracic radiograph
    In the photo seen the loss of thoracic kostofrenikus corner and you will see a curved surface if the amount of fluid is more than 300 cc. The shift of the mediastinum are occasionally found.

  2. Thoracic CT scan
    Important in detecting abnormalities of the trachea and branch configuration of the main bronchus, determine the lesions in the pleura and in general reveal the nature and degree of abnormality found in the shadow of the lung and other thoracic tissues

  3. Ultrasound
    Ultrasound can help detect pleural fluid that arise and are often used in guiding the insertion of needles to take on torakosentesis pleural fluid.

  4. Thoracocentesis


Physical Examination

On physical examination obtained dull percussion, vocals fremitus decline or even disappear asymmetric, noisy breathing also decreased or disappeared. Respiratory movements decreased or asymmetric, occurred in the lower lung, which had pleural effusion. Physical examination was greatly assisted by radiological examination which showed clearly that phrenic costalis picture disappears and the liquid boundary curve.


Nursing diagnoses for Pleural Effusion, that may arise:
  1. Ineffective airway clearance related to weakness and poor cough effort.

  2. Impaired gas exchange related to the reduced effectiveness of the surface of the lung and atalektasis.

  3. Activity intolerance related to general weakness.

  4. Imbalanced Nutrition, Less Than Body Requirements characterized by weakness, dyspnea and anorexia.

Nursing Care Plan for Pulmonary Embolism

Pulmonary embolism (PE)

A pulmonary embolism is a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a deep vein thrombosis that breaks loose and travels through the bloodstream to the lung. Pulmonary embolism is a serious condition that can cause
  • Permanent damage to the affected lung
  • Low oxygen levels in your blood
  • Damage to other organs in your body from not getting enough oxygen
If a clot is large, or if there are many clots, pulmonary embolism can cause death.



Pulmonary Embolism
Signs and Symptoms
  • dyspnoea - suddenly and there is at 90% of cases
  • pleuritic chest pain
  • haemoptisis
  • fainting
  • tachycardia more than 100/menit
  • tachipnoe more than 20/menit
  • fever

Threat Signs of Life:
Symptoms of Pulmonary embolism:
  • severe dyspnea
  • chest pain
  • increased venous pressure
  • there is evidence of right heart failure
  • hypotension
  • shock

Assessment for Pulmonary Embolism

Assessment of the ABCD approach

Airway
  • Assess and maintain airway
  • Perform head tilt, chin lift if necessary
  • Use this tool to the airway if necessary
  • Consider referring to the anesthesiologist to do intubation if unable to maintain airway

Breathing
  • Assess oxygen saturation using pulse oximeter, to retain more than 92% saturation.
  • Give high-flow oxygen via non re-breath mask.
  • Consider getting a breathing using bag-valve-mask ventilation
  • Make checks to assess arterial blood gas PaO2 and PaCO2
  • Assess breathing
  • Perform examination of respiratory system
  • Listen to the sound of the pleura
  • Make checks thoracic images - may be normal, but look for:
  • Evidence of a wedge shaped shadow (infarct)
  • Linear atelectasis
  • Effuse pleural
  • Hemidiaphragm increased
  • If the clinical signs show the presence of pulmonary embolism, ventilation perfusion scan done (VQ) or CT pulmonary angiogram (CTPA) in accordance with local policy

Circulation
  • Assess heart rate and rhythm, the possibility of sound gallops
  • Assess increased JVP
  • Record blood pressure
  • ECG examination may show:
  • Sinus tachycardia
  • The existence of S1 Q3 T3
  • Right bundle branch block (RBBB)
  • Right axis deviation (RAD)
  • P pulmonale
  • Perform IV access
  • Perform a complete blood

Disability
  • Assess level of consciousness by using AVPU
  • Decreased awareness of incoming patients showed early signs of extreme conditions and require immediate medical attention and requires treatment in the ICU.

Exposure
  • Always examine the possibility of using a test Pulmonary embolism, if the patient is stable and health history examinations do other physical examination.
  • Do not forget to check for signs of DVT

Risk Factors of Pulmonary embolism
  • DVT exist in 50% of patients
  • Previous surgery
  • Previous trauma
  • Immobilization for various reasons
  • Malignancy
  • Patients taking oral contraceptives
  • Patients received hormone therapy
  • Long gestation
  • Obesity
  • Patients get Estregen Selective Receptor Modulator therapy (SERM)
  • Hyperviskositas Syndrome
  • Childbed
  • Nephrotic syndrome
  • Antithrombin III deficiency
  • Deficiencies of protein C and S
  • Lupus anticoagulant

Nursing Care Plan for Pulmonary Embolism

Nursing Care Plan for Meningitis

Meningitis is inflammation of the meninges, the covering of the brain and spinal cord. It is most often caused by infection (bacterial, viral, or fungal), but can also be produced by chemical irritation, subarachnoid haemorrhage, cancer and other conditions.
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Signs of meningitis as follows :
  • fever
  • headache
  • stiff neck
  • photophobia and vomiting
  • confused (possible)
Septicemia patients usually do not show the existence of neurologic failure, but patients showed the existence of:
  • circulatory changes
  • decreased peripheral perfusion
  • tachycardia
  • tachypnoe
  • hypotension
  • ptechie as an indication of the patients had bacteremia by meningococcal


Assessment

Always use the ABCDE approach to assessment


Airway
  • Make sure the airway clearance
  • Prepare tools to facilitate the airway if necessary
  • If there is a decrease in respiratory function immediately contact an anesthesiologist and treated in the ICU

Breathing
  • Assess respiratory rate - less than 8 or over 30 is a significant sign.
  • Assess oxygen saturation
  • Perform blood gas
  • Give oxygen
  • Chest auscultation
  • Make checks thoracic photo

Circulation
  • Assess heart rate - more than 100 or less than 40 x / min is a significant sign
  • Monitoring blood pressure
  • Check the capillary refill time
  • Attach infusion using a large cannula
  • Replace catheter
  • Check the laboratory for complete blood, urine, electrolyte
  • Perform blood cultures
  • Perform a throat swab for culture and sensitivity
  • Record the temperature

Disability
  • Assess level of consciousness by using AVPU
  • Obserasi focal neurological signs

Exposure
  • Assess the ptechie


Sign of the threat to life

If the patient shows signs of distress showing patients should be brought immediately to the ICU as for the sign as follows:
  • Redness more
  • CRT more than 4 seconds
  • Oliguria
  • Breathing is less than 8 or more than 30 per minute
  • Heart rate less than 40 or more than 140 times per minute
  • Signs of impairment of consciousness
  • Focal neurology
  • Convulsions
  • Bradycardia and hypertension
  • Papiloedema

Nursing Care Plan for Meningitis

Nursing Care Plan for COPD

COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.

COPD Nursing Care Plan


Assessment

Airway
  • Assess and maintain airway
  • Do the head tilt, chin lift if necessary
  • Use the help of the airway if necessary
  • Consider to be referring to the anesthesiologist

Breathing
  • Assess oxygen saturation using pulse oximeter
  • Do inspection arterial blood gases to assess pH, PaCO2 and PaO2
  • If the arterial pH less than 7.2, more profitable patients using non-invasive ventilation (NIV) and references must be made in accordance with local policy
  • Control of oxygen therapy to maintain oxygen saturation over 92%
  • Strictly monitoring PaCO2
  • Record the temperature
  • Make checks for signs of:
    • cyanosis
    • clubbing
    • pursed lip breathing
    • movement symmetry
    • intercostal retractions
    • tracheal deviation
  • Listen to the:
    • wheezing
    • crackles
    • decrease in airflow
    • silent chest
  • Make checks to see piston :
    • pneumothorax
    • consolidation
    • signs of heart failure
  • If there is evidence of an infection usually caused by bacterial pathogens including :
    • streptococcus pneumoniae
    • haemophilus influenzae
    • moraxella catarrhalis

Circulation
  • assess heart rate and rhythm
  • record blood pressure
  • check ECG
  • do intake output, and do a complete blood
  • pairing IV access
  • fluid restriction did

Disability
  • Assess the level of consciousness by using AVPU
  • Patients showed a decrease in consciousness needed medical help immediately and treated in ICU.

Exposure
  • If the patient is stable and health history examinations do other physical examination.