Nursing Care Plan

Nursing Care Plan for Urethral Stricture

Nursing Care Plan , Nursing Care Plan for Urethral Stricture

Definition of Urethral Stricture

A urethral stricture is a narrowing of a section of the urethra. It causes a blocked or reduced flow of urine which can lead to complications.

Symptoms and signs

Symptoms of urethral stricture is a typical small stream of urine and branched irritation and other symptoms of infection such as frequency, urgency, dysuria, sometimes with infiltrates, abces and fistula. Symptoms are retained urine.

Physical Examination

Anamnese

To find the absence of symptoms and signs of urethral stricture also to look for causes of urethral stricture.

General and local examination

To check on the patient also to change in urethral fibrosis, infiltrates, abscesses or fistulas.

Examination Support

Laboratory: urea, creatinine, to see the renal physiology. Radiological Diagnosis must be made with urethrography. Retrograde urethrography to see the anterior urethra. Antegrade urethrography to see the posterior urethra. Bipoler urethrography is a combination of antegrade and retrograde urethrography examinations. With this examination can be expected in addition to the diagnosis of urethral strictures can be also determined the length of urethral stricture are important for therapy planning / operations.

Basic Concepts of Nursing Care

In nursing care is carried out by using the nursing process. The nursing process is a form of dynamic problem-solving process in an effort to improve and maintain optimal patient through a systematic approach to help patients. Nursing theories and concepts are implemented in an integrated manner in which organized phases which include:

Assessment, Nursing Diagnosis, Interventions, Implementation, Evaluation.

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Nursing Care Plan for Thyroid Cancer

Nursing Care Plan , Nursing Care Plan for Thyroid Cancer

Thyroid cancer is a disease in which malignant (cancer) cells form in the tissues of the thyroid gland.

The thyroid is a gland at the base of the throat near the trachea (windpipe). It is shaped like a butterfly, with a right lobe and a left lobe. The isthmus, a thin piece of tissue, connects the two lobes. A healthy thyroid is a little larger than a quarter. It usually cannot be felt through the skin. The thyroid uses iodine, a mineral found in some foods and in iodized salt, to help make several hormones. Thyroid hormones do the following:

Control heart rate, body temperature, and how quickly food is changed into energy (metabolism).
Control the amount of calcium in the blood.

There are four main types of thyroid cancer:

Papillary thyroid cancer: The most common type of thyroid cancer.
Follicular thyroid cancer. Hürthle cell carcinoma is a form of follicular thyroid cancer and is treated the same way.
Medullary thyroid cancer.
Anaplastic thyroid cancer.

Possible signs of thyroid cancer include a swelling or lump in the neck.

Thyroid cancer may not cause early symptoms. It is sometimes found during a routine physical exam. Symptoms may occur as the tumor gets bigger. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

A lump in the neck.
Trouble breathing.
Trouble swallowing.
Hoarseness.

More :

Nursing Management for Thyroid Cancer: Preoperative, Intraoperative and Postoperative

Nursing Care Plan for Cataract

Cataracts , Nursing Care Plan

Cataract

A cataract is a clouding of the lens in your eye. It affects your vision. Cataracts are very common in older people. By age 80, more than half of all people in the United States either have a cataract or have had cataract surgery.

Common symptoms are

Blurry vision
Colors that seem faded
Glare
Not being able to see well at night
Double vision
Frequent prescription changes in your eye wear

Cataracts usually develop slowly. New glasses, brighter lighting, anti-glare sunglasses or magnifying lenses can help at first. Surgery is also an option. It involves removing the cloudy lens and replacing it with an artificial lens. Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataracts.

NIH: National Eye Institute

Cataract Symptoms

Having cataracts is often compared to looking through a foggy windshield of a car or through the dirty lens of a camera. Cataracts may cause a variety of complaints and visual changes, including blurred vision, difficulty with glare (often with bright sun or automobile headlights while driving at night), dulled color vision, increased nearsightedness accompanied by frequent changes in eyeglass prescription, and occasionally double vision in one eye. Some people notice a phenomenon called "second sight" in which one's reading vision improves as a result of their increased nearsightedness from swelling of the cataract. A change in glasses may help initially once vision begins to change from cataracts; however, as cataracts continue to progress and opacify, vision becomes cloudy and stronger glasses or contact lenses will no longer improve sight.

Cataracts are usually gradual and usually not painful or associated with any eye redness or other symptoms unless they become extremely advanced. Rapid and/or painful changes in vision are suspicious for other eye diseases and should be evaluated by an eye-care professional.

Cataract Exams and Tests

To detect a cataract, the eye-care provider examines your lens. A comprehensive eye examination usually includes the following:

Visual acuity test: An eye chart test is used to measure your reading and distance vision.
Refraction: Your eye doctor should determine if glasses would improve your vision.
Glare testing: Vision may be significantly altered in certain lighting conditions and normal in others; in these circumstances, your doctor may check your glare symptoms with a variety of different potential lighting sources.
Potential acuity testing: This helps the ophthalmologist get an idea of what your vision would be like after removal of the cataract. Think of this as the eye's vision potential if the cataract was not present.
Contrast sensitivity testing: This checks for your ability to differentiate different shades of gray, which is often this limited by cataracts.
Tonometry: a standard test to measure fluid pressure inside the eye (Increased pressure may be a sign of glaucoma.)
Pupil dilation: The pupil is enlarged with eye drops so that the ophthalmologist can further examine the lens and retina. This is important to determine if there are other conditions which may ultimately limit your vision besides cataracts.

Source : http://www.emedicinehealth.com/cataracts/page6_em.htm#Exams and Tests

Nursing Care Plan for Cataract

Data Analysis

1. Objective data: patient's eye's lens appears cloudy. Both pupils appear to look gray.

Subjective data: patients complaining blurred vision / dim and decreased visual acuity and glare, the patient is difficult to see at night.

Changes in sensory reception or sense organ of vision status.

Impaired sensory perception (visual)

2. Objective data: patient looks anxious.

Subjective data: the patient says with a nervous illness.

Changes in health status.

Anxiety

3. Objective data: -

Subjective data: patient revealed not know much about the illness.

Not familiar with information sources

Lack of knowledge.

4. Objective data: patients seem to lack confidence

Subjective data: the patient says embarrassed by the disease

Impaired self-image

Low self esteem

Nursing Diagnosis for Cataract

1. Impaired sensory perception (visual) related to Changes in sensory reception or sense organ of vision status.

2. Anxiety related to changes in health status.

3. Lack of knowledge related to Not familiar with the sources of information.

4. Low self esteem, related to, Impaired self-image

Nursing Care Plan for Nausea and Vomiting

Nausea , Nursing Care Plan

Nausea

Nausea is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, preceded vomiting. A person can suffer nausea without vomiting. Some common causes of nausea are motion sickness, gastroenteritis (stomach infection) or food poisoning, side effects of many medications including cancer chemotherapy, or morning sickness in early pregnancy. Medications taken to prevent nausea are called antiemetics and include diphenhydramine, metoclopramide and ondansetron. Nausea may also be caused by stress and depression.

Vomiting

Vomiting (known medically as emesis and informally as throwing up and a number of other terms) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure. The feeling that one is about to vomit is called nausea, which usually precedes, but does not always lead to, vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting, and, in severe cases where dehydration develops, intravenous fluid may need to be administered to replace fluid volume.

Vomiting is different from regurgitation, although the two terms are often used interchangeably. Regurgitation is the return of undigested food back up the esophagus to the mouth, without the force and displeasure associated with vomiting. The causes of vomiting and regurgitation are generally different.
en.wikipedia

How is nausea or vomiting treated?

Symptomatic treatment may occur while the underlying illness is being investigated because ideally, nausea and vomiting should resolve when the cause of the symptoms resolves.

Nausea and vomiting are often made worse when the patient is dehydrated, resulting in a vicious cycle. The nausea makes it difficult to drink fluid, making the dehydration worse, which then increases the nausea. Intravenous fluids may be provided to correct this issue.

There are a variety of anti-nausea medications (antiemetics) that may be prescribed. They can be administered in different ways depending upon the patient's ability to take them. Medications are available by pill, liquid, or tablets that dissolve on or under the tongue, by intravenous or intramuscular injection, or by rectal suppository.

Common medications used to control nausea and vomiting include promethazine (Phenergan), prochlorperazine (Compazine), droperidol (Inapsine) metoclopramide (Reglan), and ondansetron (Zofran). The decision as to which medication to use will depend on the specific situation.
www.medicinenet.com

Nursing Diagnosis and Intervention Nursing Care Plan for Nausea and Vomiting

Nursing Diagnosis: Fluid and electrolyte deficit related to excessive fluid output.

Purpose: devisit fluid and electrolyte resolved

Expected outcomes: The signs of dehydration do not exist, the mucosa of the mouth and lips moist, fluid balance.

Nursing Intervention:

Observation of vital signs.
Observation for signs of dehydration.
Measure infut and output of fluid (fluid balance).
Provide and encourage families to provide drinking a lot of approximately 2000 - 2500 cc per day.
Collaboration with physicians in the provision of therafi fluid, electrolyte laboratory tests.
Collaboration with a team of nutrition in low-sodium fluids.

Nursing Diagnosis: Risk for Fluid Volume Deficit related to a sense of nausea and vomiting

Purpose: Maintaining the balance of fluid volume.

Expected outcomes: The client does not nausea and vomiting.

Nursing Intervention:

Monitor vital signs.
Rational: This is an early indicator of hypovolemia.
Monitor intake and urine output and concentration.
Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one suggestive of dehydration and require increased fluids.
Give fluid little by little but often.
Rationale: To minimize loss of fluid.
The risk of infection associated with an inadequate defense of the body, characterized by: body temperature above normal. Respiratory frequency increased.

Nursing Care Plan for Gastritis

Gastritis , Nursing Care Plan

Gastritis

Gastritis occurs when the lining of the stomach becomes inflamed or swollen.

Gastritis can last for only a short time (acute gastritis), or linger for months to years (chronic gastritis)

Symptoms
Many people with gastritis do not have any symptoms.

Symptoms you may notice are:

Loss of appetite
Nausea and vomiting
Pain in the upper part of the belly or abdomen

If gastritis is causing bleeding from the lining of the stomach, symptoms may include:

Black stools
Vomiting blood or coffee-ground like material

Gastritis is diagnosed through one or more medical tests:

Upper gastrointestinal endoscopy. The doctor eases an endoscope, a thin tube containing a tiny camera, through your mouth (or occasionally nose) and down into your stomach to look at the stomach lining. The doctor will check for inflammation and may remove a tiny sample of tissue for tests. This procedure to remove a tissue sample is called a biopsy.
Blood test. The doctor may check your red blood cell count to see whether you have anemia, which means that you do not have enough red blood cells. Anemia can be caused by bleeding from the stomach.
Stool test. This test checks for the presence of blood in your stool, a sign of bleeding.

Treating Gastritis

1. Conservatives on state of acute
If severe disease, patients need to be treated and given fluids per infusion.

Bed rest
Fasting, nasogastric tube pairs
Analgesics, antibiotics

2. When conservative treatment fails or there is a progressive toxemia cholecystectomy needs to be done. It is necessary to prevent the occurrence of complications (gangrene, perforation, empyema, pancreatitis dam kalangitis)
Cholecystectomy should be done also in the repeated attacks

Nursing Care Plan for Gastritis

Nursing Diagnosis Acute Pain related to obstruction / spasm of the duct, the inflammatory process and tissue ischemia.

Nursing Interventions for Gastritis

Observe and record the location and character of pain (persistent, intermittent, colicky)
Record the response to pain
Increase bed rest, let the patient make a comfortable position.
Control the temperature of the environment
Encourage use of relaxation techniques

Collaboration:

Anticholinergics: Atropine, Propentelin (Pro-banthine)

Sedatives: Phenobarbital

Narcotics: meperidine hydrochloride

Monoktanoin

Relaxation of smooth muscle

Nursing Diagnosis Imbalanced nutrition less than body requirements related to obstruction of bile flow

Nursing Interventions for Gastritis

Assess abdominal distension

Calculate the calorific intake, keep the comments about the appetite to a minimum.

Provide a pleasant atmosphere at mealtime

Ambulation and activities corresponding increase tolerance

Collaboration:

Add the appropriate diet tolerance, high fiber, low fat

Provide an overview of bile

Supervise laboratory examination

Give local nutritional support as needed

http://nanda-nursinginterventions.blogspot.com/

Nursing Care Plan for Congestive Heart Failure

Congestive Heart Failure , Nursing Care Plan

Heart failure (HF) often called congestive heart failure (CHF) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. Heart failure can cause a number of symptoms including shortness of breath, leg swelling, and exercise intolerance. The condition is diagnosed with echocardiography and blood tests. Treatment commonly consists of lifestyle measures (such as smoking cessation, light exercise including breathing protocols, decreased salt intake and other dietary changes) and medications, and sometimes devices or even surgery.

Common causes of heart failure include myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy. The term "heart failure" is sometimes incorrectly used to describe other cardiac-related illnesses, such as myocardial infarction (heart attack) or cardiac arrest, which can cause heart failure but are not equivalent to heart failure.

The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness.

An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. The person's ability to exercise may also diminish. Patients may not even sense this decrease and they may subconsciously reduce their activities to accommodate this limitation.
As the body becomes overloaded with fluid from congestive heart failure, swelling (edema) of the ankles and legs or abdomen may be noticed. This can be referred to as "right sided heart failure" as failure of the right sided heart chambers to pump venous blood to the lungs to acquire oxygen results in buildup of this fluid in gravity-dependent areas such as in the legs. The most common cause of this is longstanding failure of the left heart, which may lead to secondary failure of the right heart. Right-sided heart failure can also be caused by severe lung disease (referred to as "cor pulmonale"), or by intrinsic disease of the right heart muscle (less common)
In addition, fluid may accumulate in the lungs, thereby causing shortness of breath, particularly during exercise and when lying flat. In some instances, patients are awakened at night, gasping for air.
Some may be unable to sleep unless sitting upright.
The extra fluid in the body may cause increased urination, particularly at night.
Accumulation of fluid in the liver and intestines may cause nausea, abdominal pain, and decreased appetite.

Nursing Assessment for Congestive Heart Failure

a. Identity

b. Food or liquid
Symptoms:

Loss of appetite
Nausea and vomiting
Swelling of the extremities
Diit high salt or fat, sugar and caffeine

c. Elimination
Symptoms:

Decreased urination, dark urine
Urination at night
Diarrhea or constipation

d. Activity / rest
Symptoms:

Fatigue or tiredness constantly throughout the day
Insomnia
Chest pain with activity

e. Circulation
Symptoms:

History of hypertension
Cardiac surgery
Anemia
Endocarditis

f. Ego integrity
Symptoms:

Anxiety, worry and fear
Stress-related illnesses

g. Comfort
Symptoms:

Chest pain, acute or chronic angina
Muscle pain

h. Respiratory
Symptoms:

Dyspnea on exertion, while sitting or sleeping with multiple pillows

i. Social interaction
Symptoms:

Decreased participation in usual social activities

j. Security
Symptoms:

Changes in mental function
Loss of strength or muscle tone
skin blisters

Nursing Diagnosis for Congestive Heart Failure

Decreased cardiac output related to

Changes in myocardial contractility or inotropic changes.
Changes in frequency, rhythm, cardiac conduction.
Structural changes. (eg, valve abnormalities, ventricular aneurysm)

Activity intolerance related to

Weakness, fatigue.
Changes in vital signs, presence of dysritmia.
Dyspnea.
Pale.
Sweating.

Excess fluid volume related to

The decline in glomerular filtration rate (decrease in cardiac output) or increased production of ADH and sodium and water retention.

Risk for impaired skin integrity related to

Bed rest.
Edema, decreased tissue perfusion.

Nursing Care Plan for Non-Hodgkin's Lymphoma

Non-Hodgkin's lymphoma , Nursing Care Plan

Non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma is cancer of the lymphoid tissue, which includes the lymph nodes, spleen, and other organs of the immune system.

Causes

White blood cells called lymphocytes are found in lymph tissues. They help prevent infections. Most lymphomas start in a type of white blood cells called B lymphocytes, or B cells.
For most patients, the cause of this cancer is unknown. However, lymphomas may develop in people with weakened immune systems. For example, the risk of lymphoma increases after an organ transplant or in people with HIV infection.

There are many different types of non-Hodgkin's lymphoma. It is classified according to how fast the cancer spreads.

The cancer may be low grade (slow growing), intermediate grade, or high grade (fast growing). Burkitt's tumor is an example of a high-grade lymphoma. Follicular lymphoma is a low-grade lymphoma
The cancer is further sub-classified by how the cells look under the microscope, for example, if there are certain proteins or genetic markers present.

According to the American Cancer Society, a person has a 1 in 50 chance of developing non-Hodgkin's lymphoma. Most of the time, this cancer affects adults. However, children can get some forms of lymphoma. High-risk groups include those who have received an organ transplant or who have a weakened immune system.
This type of cancer is slightly more common in men than in women.

Signs and symptoms of NHL include the following:

Swollen, painless lymph nodes in the neck, armpits, or groin
Unexplained weight loss
Fever
Night sweats
Coughing, trouble breathing, or chest pain
Weakness and tiredness that don't go away (fatigue)
Abdominal pain or swelling, or a feeling of fullness in the abdomen
Itching of the skin

Treatment
Treatment depends on:

The type of lymphoma
The stage of the cancer when you are first diagnosed
Your age and overall health
Symptoms, including weight loss, fever, and night sweats
Radiation therapy may be used for disease that is confined to one body area.

Chemotherapy is the main type of treatment. Most often,multiple different drugs are used in combination together.

Another drug, called rituximab (Rituxan), is often used to treat B-cell non-Hodgkin's lymphoma.

Radioimmunotherapy may be used in some cases. This involves linking a radioactive substance to an antibody that targets the cancerous cells and injecting the substance into the body.

People with lymphoma that returns after treatment or does not respond to treatment may receive high-dose chemotherapy followed by an autologous bone marrow transplant (using stem cells from yourself).

Additional treatments depend on other symptoms. They may include:

Transfusion of blood products, such as platelets or red blood cells
Antibiotics to fight infection, especially if a fever occurs

Nursing Care Plan for Non-Hodgkin's Lymphoma

Priority Nursing

Providing physical and psychological support for diagnostic tests and treatment programs.
Preventing complications
Eliminate pain
Provides information about the disease / prognosis and treatment needs

Purpose

Complications prevented / decreased
Receive real situation.
Pain relief / control
The disease process / prognosis, possible complications and treatment programs understand.

Nursing Diagnosis Nursing Care Plan for Non-Hodgkin's Lymphoma

Ineffective Breathing Pattern
Ineffective Airway Clearance

Risk factors include
Tracheobronchial obstruction, mediastinal node enlargement or edema and airway path (Hodgkin's and non-Hodgkin's), superior vena cava syndrome (non-Hodgkin's)

Possible evidenced by
(not applicable, the existence of signs and symptoms make the actual diagnosis)

Expected Result / Patient Evaluation Criteria will
Maintaining Normal Breathing Pattern / Effective Free Dyspnea, cyanosis or Signs Other Respiratory distress

Nursing Care Plan for Diabetic Gangrene

Diabetic Gangrene , Nursing Care Plan

Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies (necrosis). This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death. Diabetes and long-term smoking increase the risk of suffering from gangrene.

There are different types of gangrene with different symptoms, such as dry gangrene, wet gangrene, gas gangrene, internal gangrene and necrotising fasciitis. Treatment options include debridement (or, in severe cases, amputation) of the affected body parts, antibiotics, vascular surgery, maggot therapy or hyperbaric oxygen therapy.

Nursing Care Plan for Diabetic Gangrene

Nursing diagnosis that appear in diabetic foot gangrene patients are as follows:

Impaired tissue perfusion related to the weakening / decreased blood flow to the area of gangrene due to obstruction of blood vessels.

Objective:

Maintain peripheral circulation remain normal.

Results Criteria:

Palpable peripheral pulses were strong and regular
The color of the skin around the wound is pale / cyanotic
The skin around the wound felt warm.
Edema does not occur and injuries from getting worse.
Improved sensory and motor

Nursing Interventions for Diabetic Gangrene

Teach the patient to mobilize
Rational: the mobilization improves blood circulation.

Teach about the factors that can increase blood flow:
Elevate the legs slightly lower than the heart (elevation position at rest), avoid tight bandage, avoid using a pillow, behind the knees and so on.
Rational: to increase blood flow through so that does not happen edema.

Teach about the modification of risk factors such as:
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and drug use vasoconstriction.
Rationale: High cholesterol can accelerate the occurrence of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.

Cooperation with other health team in the provision of vasodilators, regular blood sugar checks and oxygen therapy (HBO).
Rational: vasodilator administration will increase the dilation of blood vessels so that tissue perfusion can be improved, while the regular blood sugar checks can be up to date and state of the patient, to improve the oxygenation of the HBO ulcer / gangrene.

Nursing Care Plan for Impaired Verbal Communication

Impaired Verbal Communication , 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

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.

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).

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.

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

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.

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.

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.

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

Nursing Care Plan , 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.

Etiology of Pleural Effusion

Various causes of pleural effusion are:

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

Signs and Symptoms of Pleural Effusion

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

Examination Support

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.

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

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.

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:

Ineffective airway clearance related to weakness and poor cough effort.

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

Activity intolerance related to general weakness.

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

Nursing Care Plan for Pulmonary Embolism

Nursing Care Plan , 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.

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 , Nursing Care Plan

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.
who.int

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 , Nursing Care Plan

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.

nhlbi.nih.gov

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.

Nursing Care Plan for Empyema

Empyema , Nursing Care Plan

Nursing Care Plan for Empyema

Empyema

Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space).

Symptoms

Chest pain, which worsens when you breathe in deeply (pleurisy)
Dry cough
Excessive sweating, especially night sweats
Fever and chills
General discomfort, uneasiness, or ill feeling (malaise)
Shortness of breath
Weight loss (unintentional)

Nursing Diagnosis of Empyema 1:

Ineffective airway clearance related to bronchus spsame, increased production of secretions, weakness

Nursing Intervention and Rational:

Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds
R /: To determine the presence of airway obstruction, the degree yan tachipneu found the process of acute infection.

Assess the frequency of respiratory
R /: The process of acute infection (tachipnea)

Nursing diagnosis of empyema 2:

Impaired Gas Exchange related to airway obstruction secondary to the buildup of secretions, Bronchospasme

Nursing Intervention and Rational:

Assess the frequency and depth of breathing, note the use of auxiliary respiratory muscles and an inability to speak due to shortness
R /: Evaluation of the degree of respiratory distress or failure and chronic disease processes.

Help clients to find a position that facilitates breathing, with the head higher
R /: Supply of oxygen can be updated, in order to practice breathing lungs do not collapse.

Nursing diagnosis of empyema 3:

Imbalanced Nutrition, Less Than Body Requirements related to Shortness of breath, anorexia, nausea, vomiting, drug effects, weakness

Nursing Intervention and Rational:

Obserasi intake and output / 8 hours. The amount of food consumed each day and measuring body weight each day
R /: Identifying the lack of progress / storage of the expected goal

Create a fun atmosphere, an environment free of odor during meal times:

Perform mouth care before and after meals
Clean environment in which the presentation of food
Avoid use of foul-smelling fragrances
Perform chest physiotherapy and nebulizer at least one hour before meals
Provide a place to dispose of tissues / secretions cough

R /: The smells and sights that are not pleasant during the meal can lead to anorexia. The drugs are given soon after a meal can trigger nausea and vomiting.

Nursing Care Plan for Perinatal Asphyxia

Nursing Care Plan , Nursing Care Plan for Perinatal Asphyxia

NCP - Nursing Care Plan for Perinatal Asphyxia

Perinatal asphyxia or neonatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. Hypoxic damage can occur to most of the infant's organs (heart, lungs, liver, gut, kidneys), but brain damage is of most concern and perhaps the least likely to quickly or completely heal. In the more pronounced cases, an infant will survive, but with damage to the brain manifested as either mental, such as developmental delay or intellectual disability, or physical, such as spasticity — in fact, spastic diplegia and the other forms of cerebral palsy almost always feature asphyxiation during the birth process as a major, if not defining, factor.

Nursing Assessment for Perinatal Asphyxia

Physical Examination

Respiratory system
- Low Apgar scores
- Breathing shallow, irregular, tachypnea
- Snoring, breathing nostrils, retracted suplasternal / substernal, cyanosis
- Baby does not breathe / breath over 30 x

Cardiovascular system
- Optimal pulse, rapid or irregular may be within the normal range (120-160 x / min)
- Heart rate more than 100

Integument system
- Presence of cyanosis / pallor - indication of gravity hypoksia
- Pitting edema of the hands and feet
Digestive system
- Weak reflexes
- Lethargy
- Small stomach capacity
Muskoloskeletas system
- Decreased muscle tone
- Edema, weak reflexes, there are no lines on the soles of the feet most / all of the palm.

Nursing Diagnosis Nursing Care Plan for Perinatal Asphyxia

Ineffective Breathing Pattern related to immaturity of the respiratory organs

Risk of hypothermia related to systems that have not been mature thermoregulasi

Imbalanced Nutrition, Less Than Body Requirements related to weak sucking reflex

Nursing Care Plan for Cerebral Palsy (CP)

Cerebral Palsy , Nursing Care Plan

NCP - Nursing Care Plan for Cerebral Palsy (CP)

Cerebral palsy (CP) is an umbrella term for a group of disorders affecting body movement, balance, and posture. Loosely translated, cerebral palsy means “brain paralysis.” Cerebral palsy is caused by abnormal development or damage in one or more parts of the brain that control muscle tone and motor activity (movement). The resulting impairments first appear early in life, usually in infancy or early childhood. Infants with cerebral palsy are usually slow to reach developmental milestones such as rolling over, sitting, crawling, and walking.

Treatment

Treatment for cerebral palsy is a lifelong multi-dimensional process focused on the maintenance of associated conditions. In order to be diagnosed with cerebral palsy the damage that occurred to the brain must be non-progressive and not disease like in nature. The manifestation of that damage will change as the brain and body develop, but the actual damage to the brain will not increase. Treatment in the life of cerebral palsy is the constant focus on preventing the damage in the brain from prohibiting healthy development on all levels. The brain, up to about the age of 8, is not concrete in its development. It has the ability to re-organize and re-route many signal paths that may have been affected by the initial trauma; the earlier it has help in doing this the more successful it will be. Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents caring for someone with this disability. They can all be useful at all stages of this disability and are vital in a person with cerebral palsy's ability to function and live more effectively. In general, the earlier treatment begins the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. The earliest proven intervention occurs during the infant's recovery in the neonatal intensive care unit (NICU). Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepienes, baclofen and intrathecal phenol/baclofen); hyperbaric oxygen; the use of Botox to relax contracting muscles; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesizers. For instance, the use of a standing frame can help reduce spasticity and improve range of motion for people with CP who use wheelchairs. Nevertheless, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Non-speaking people with CP are often successful availing themselves of augmentative and alternative communication systems such as Blissymbols. Constraint-induced movement therapy (CIMT) has shown promising evidence in helping individuals with neurological disorders that have lost most of the use of an extremity. Research has proven the positive benefits of CIMT for people who have had a stroke and traumatic brain injury. However, later studies have addressed the application of CIMT for children with CP challenged with hemiparesis, that show a significant benefit in constraint induced movement therapy for children with cerebral palsy who are challenged with hemiparesis.wikipedia

Nursing Diagnosis Nursing Care Plan for Cerebral Palsy (CP)

Risk for Injury related to disturbances in motor function
Imbalanced Nutrition, Less Than Body Requirements related to difficulty swallowing and increased activity
Activity Intolerance related to disorders of movement and posture that is not progressive
Ineffective Tissue Perfusion related to cerebral edema that change / stop the blood flow of arterial / venous
Risk for Infection related to suppression of inflammatory response (due to - drugs)
Knowledge Deficit related to home care and therapeutic needs

Nursing Care Plan for Peptic Ulcer

Nursing Care Plan , Nursing Care Plan for Peptic Ulcer

A peptic ulcer is a sore in the lining of your stomach or your duodenum, the first part of your small intestine. A burning stomach pain is the most common symptom. The pain :

May come and go for a few days or weeks
May bother you more when your stomach is empty
Usually goes away after you eat

Peptic ulcers happen when the acids that help you digest food damage the walls of the stomach or duodenum. The most common cause is infection with a bacterium called Helicobacter pylori. Another cause is the long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) such as aspirin and ibuprofen. Stress and spicy foods do not cause ulcers, but can make them worse.

Nursing Assessment Nursing Care Plan for Peptic Ulcer

Assess for chronic use of certain medications (such as aspirin, steroids).
Collect information of complaints that brought client to the hospital.
Obtain history of onset and progression of symptoms.
Obtain information of diet, use of alcohol and tobacco, ingestion of irritating foods, previous diseases or infections of GI tract, emotional stress.
Assess connection of pain attacks to meals, certain drugs, ingestion of coffee, alcohol.
Perform complete physical assessment including weight, vital signs, signs of GI bleeding, and acute abdomen.
Assess diagnostic tests and procedures for abnormal values

Nursing Diagnosis for Peptic Ulcer

Acute Pain related to irritation of the mucosa and muscle spasms.
Anxiety related to the nature and management of long-term illness
Imbalanced Nutrition: Less than Body Requirements related to pain associated with food.
Knowledge deficient the prevention, symptoms and treatment of conditions related to inadequate information.

Nursing Intervention Nursing Care Plan for Peptic Ulcer

Goals :

Reduce or completely eliminate contributing factors.
Assist with stress management.
Promote adequate nutrition.
Prevent avoidable injury.
Then surgical intervention prescribed, prevent postoperative complications.
Relief or diminish symptoms.
Decreased anxiety with increased knowledge of disease, it treatment, way of prevention and follow-up.

Nursing Interventions

Assess, report , and record signs and symptoms and reactions to treatment.
Monitor fluids input and output closely.
Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics, sedatives as prescribed, monitor for side effects.
Monitor client’s vital signs and signs of possible GI bleeding or perforation closely.
Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values.
Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation.
Provide prescribed diet – avoid irritating foods, coffee, etc.
Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation.
For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome.
Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation.
Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

Nursing Care Plan for Delusional Disorders

Delusional Disorder , Nursing Care Plan

NCP For Delusional Disorders

Delusional Disorder

Delusional disorder is an illness characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms, according to the Diagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). It defines delusions as false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person's culture or subculture.

Nonbizarre refers to the fact that this type of delusion is about situations that could occur in real life, such as being followed, being loved, having an infection, and being deceived by one's spouse.

Delusional disorder is on a spectrum between more severe psychosis and overvalued ideas. Bizarre delusions represent the manifestations of more severe types of psychotic illnesses (eg, schizophrenia) and "are clearly implausible, not understandable, and not derived from ordinary life experiences".

On the other end of the spectrum, making a distinction between a delusion and an overvalued idea is important, the latter representing an unreasonable belief that is not firmly held. Additionally, personal beliefs should be evaluated with great respect to complexity of cultural and religious differences: some cultures have widely accepted beliefs that may be considered delusional in other cultures.

Unfortunately, patients with delusional disorder do not have good insight into their pathological experiences. Interestingly, despite significant delusions, many other psychosocial abilities remain intact, as if the delusions are circumscribed. Indeed, this is one of the key differences between delusional disorder and other primary psychotic disorders. However, the individual may rarely seek psychiatric help, remain isolated, and often present to internists, surgeons, dermatologists, policemen, and lawyers rather than psychiatrists. Despite this, their prognosis, while not good, is not as bad as other more severe disorders.

Current Diagnosis Criteria

DSM-IV-TR defines delusional disorder with the following criteria:

A: Nonbizarre delusions (ie, involving situations that occur in real life, such as being followed, poisoned, infected, loved at distance, deceived by spouse or lover, or having a disease) occurring for at least 1 month's duration.
B: Criterion A for schizophrenia has never been met (ie, patients do not have simultaneous hallucinations, disorganized speech, negative symptoms such as affective flattening, or grossly disorganized behavior). Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.
C: Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
E: The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.

Subtypes are defined as erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified.
emedicine.medscape.com

Diagnoses for Delusional Disorders

Anxiety
Disabled family coping
Disturbed personal identity
Disturbed sensory perception (visual, auditory)
Disturbed thought processes
Fear
Imbalanced nutrition: Less than body requirements
Impaired home maintenance
Impaired social interaction
Ineffective coping
Powerlessness
Risk for injury
Risk for other-directed violence
Risk for self-directed violence
Social isolation

Key outcomes for Delusional Disorders

The patient will consider alternative interpretations of a situation without becoming hostile or anxious.
The patient and his family will participate in care and prescribed therapies.

The patient will identify internal and external factors that trigger delusional episodes.
The patient will maintain functioning to the fullest extent possible within the limitations of his visual or auditoryimpairment.
The patient will remain oriented to person, place, time, and situation.
The patient will express all fears and concerns.
The patient will show no signs of malnutrition.
The patient will recognize symptoms and comply with medication regimen.
The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
The patient will demonstrate adaptive coping behaviors.
The patient will identify and perform activities that decrease delusions.
The patient will remain free from injury.
The patient won't harm others.
The patient won't harm self.
The patient will maintain family and peer relationships.

Interventions for Delusional Disorders

In dealing with the patient, be direct, straightforward, and dependable. Whenever possible, elicit his feedback. Move slowly, with a matter-of-fact manner, and respond without anger or defensiveness to his hostile remarks.
Accept the patient's delusional system. Don't attempt to argue with him about what's real.
Respect the patient's privacy and space needs. Avoid touching him unnecessarily.
Take steps to reduce social isolation, if the patient allows. Gradually increase social contacts after he has become comfortable with the staff.
Watch for refusal of medication or food, resulting from the patient's irrational fear of poisoning.
Monitor the patient carefully for adverse effects of neuroleptic drugs: drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome.

http://ncp-blog.blogspot.com/2010/11/ncp-for-delusional-disorders.html

Nursing Care Plan for Bowel Incontinence

Bowel Incontinence , Nursing Care Plan for Bowel Incontinence

Definition:

Change in normal bowel habits characterized by involuntary passage of stool.

Related Factors:

Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)

Defining Characteristics:

Constant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognizes rectal fullness but reports inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate, red perianal skin

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Bowel Continence
Bowel Elimination

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Bowel Incontinence Care
Bowel Training
Bowel Incontinence Care: Encopresis

Client Outcomes

Regular, complete evacuation of fecal contents from the rectal vault
Defecates soft-formed stool
Decreased or absence of bowel incontinence incidences
Intact skin in the perianal/perineal area
Demonstrates the ability to isolate, contract, and relax pelvic muscles , Increases pelvic muscle strength .

Nursing Care Plan for Deficient Knowledge

Deficient Knowledge , Nursing Care Plan for Deficient Knowledge

NANDA Definition: Absence or deficiency of cognitive information related to specific topic

Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, beliefs); and psychomotor domain (physical skills or procedures). The nurse must decide with the learner what to teach, when to teach, and how to teach the mutually agreed-on content. Adult learning principles guide the teaching-learning process. Information should be made available when the patient wants and needs it, at the pace the patient determines, and using the teaching strategy the patient deems most effective. Many factors influence patient education, including age, cognitive level, developmental stage, physical limitations (e.g., visual, hearing, balance, hand coordination, strength), the primary disease process and other comorbidities, and sociocultural factors. Older patients need more time for teaching, and may have sensory-perceptual deficits and/or cognitive changes that may require a modification in teaching techniques. Certain ethnic and religious groups hold unique beliefs and health practices that must be considered when designing a teaching plan. These practices may vary from "home remedies" (e.g., special soups, poultices) and alternative therapies (e.g., massage, biofeedback, energy healing, macrobiotics, or megavitamins in place of prescribed medications) to reliance on an elder in the family to coordinate the plan of care. Patients with low literacy skills will require educational programs that include more simplified treatment regimens, simplified teaching tools (e.g., cartoons, lower readability levels), a slower presentation pace, and techniques for cueing patients to initiate certain behaviors (e.g., pill schedule posted on refrigerator, timer for taking medications).

Although the acute hospital setting provides challenges for patient education because of the high acuity and emotional stress inherent in this environment, the home setting can be similarly challenging because of the high expectations for patients or caregivers to self-manage complex procedures such as IV therapy, dialysis, or even ventilator care in the home. Caregivers are often overwhelmed by the responsibility delegated to them by the health care professionals. Many have their own health problems, and may be unable to perform all the behaviors assigned to them because of visual limitations, generalized weakness, or feelings of inadequacy or exhaustion.

Deficient Knowledge This care plan describes adult learning principles that can be incorporated into a teaching plan for use in any health care setting.

Defining Characteristics:

Questioning members of health care team
Verbalizing inaccurate information
Inaccurate follow-through of instruction
Denial of need to learn
Incorrect task performance
Expressing frustration or confusion when performing task
Lack of recall

Related Factors:

New condition, procedure, treatment
Complexity of treatment
Cognitive/physical limitation
Misinterpretation of information
Decreased motivation to learn
Emotional state affecting learning (anxiety, denial, or depression)
Unfamiliarity with information resources

Expected Outcomes

Patient demonstrates motivation to learn.
Patient identifies perceived learning needs.
Patient verbalizes understanding of desired content, and/or performs desired skill.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Knowledge (Specify Type)
Information Processing

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Learning Facilitation
Teaching: Individual

Ongoing Assessment

Determine who will be the learner: patient, family, significant other, or caregiver. Many elderly or terminal patients may view themselves as dependent on their caregiver, and therefore will not want to be part of the educational process.
Assess motivation and willingness of patient and care-givers to learn. Adults must see a need or purpose for learning. Some patients are ready to learn soon after they are diagnosed; others cope better by denying or delaying the need for instruction. Learning also requires energy, which patients may not be ready to use. Patients also have a right to refuse educational services.
Assess ability to learn or perform desired health-related care. Cognitive impairments need to be identified so an appropriate teaching plan can be designed. For example, the Mini-Mental Status Test can be used to identify memory problems that would interfere with learning. Physical limitations such as impaired hearing or vision, or poor hand coordination can likewise compromise learning and must be considered when designing the educational approach. Patients with decreased lens accommodation may require bolder, larger fonts or magnifying mirrors for written material.
Identify priority of learning needs within the overall plan of care. Adults learn material that is important to them.
Question patient regarding previous experience and health teaching. Adults bring many life experiences to each learning session. Adults learn best when teaching builds on previous knowledge or experience.
Identify any existing misconceptions regarding material to be taught. This provides an important starting point in education.
Determine cultural influences on health teaching. Providing a climate of acceptance allows patients to be themselves and to hold their own beliefs as appropriate.
Determine patient’s learning style, especially if patient has learned and retained new information in the past. Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method will facilitate success in mastery of knowledge.
Determine patient or caregiver’s self-efficacy to learn and apply new knowledge. Self-efficacy refers to one’s confidence in his or her ability to perform a behavior. A first step in teaching may be to foster increased self-efficacy in the learner’s ability to learn the desired information or skills.

Therapeutic Interventions

Provide physical comfort for the learner. This allows patient to concentrate on what is being discussed or demonstrated. According to Maslow’s theory, basic physiological needs must be addressed before patient education.
Provide a quiet atmosphere without interruption. This allows patient to concentrate more completely.
Provide an atmosphere of respect, openness, trust, and collaboration. This is especially important when providing education to patients with different values and beliefs about health and illness.
Establish objectives and goals for learning at the beginning of the session. This allows learner to know what will be discussed and expected during the session. Adults tend to focus on here-and-now, problem-centered education.
Allow learner to identify what is most important to him or her. This clarifies learner expectations and helps the nurse match the information to be presented to the individual’s needs. Adult learning is problem-oriented. Determine priorities (i.e., what the patient needs to know now versus later). Patients may want to focus only on self-care techniques that facilitate discharge from the hospital or enhance survival at home (e.g., how to take medications, emergency side effects, suctioning a tracheal tube) and are less interested in specifics of the disease process.
Explore attitudes and feelings about changes. This assists the nurse in understanding how learner may respond to the information and possibly how successful the patient may be with the expected changes.
Allow for and support self-directed, self-designed learning. Adults learn when they feel they are personally involved in the learning process. Patients know what difficulties will be encountered in their own environments, and must be encouraged to approach learning activities from their priority needs.
Assist the learner in integrating information into daily life. This helps learner make adjustments in daily life that will result in the desired change in behavior (or learning).
Allow adequate time for integration that is in direct conflict with existing values or beliefs. Information that is in direct conflict with what is already held to be true forces a reevaluation of the old material and is thus integrated more slowly.
Give clear, thorough explanations and demonstrations.
Provide information using various mediums (e.g., explanations, discussions, demonstrations, pictures, written instructions, computer-assisted programs, and videotapes). Different people take in information in different ways. Match the learning style with the educational approach.
Ensure that required supplies or equipment are available so that the environment is conducive to learning. This is especially important when teaching in the home setting.
When presenting material, move from familiar, simple, and concrete information to less familiar, complex, or more abstract concepts. This provides patient with the opportunity to understand new material in relation to familiar material.
* Focus teaching sessions on a single concept or idea. This allows the learner to concentrate more completely on material being discussed. Highly anxious and elderly patients have reduced short-term memory and benefit from mastery of one concept at a time.
Pace the instruction and keep sessions short. This prevents fatigue. Learning requires energy.
Encourage questions. Learners often feel shy or embarrassed about asking questions and often want permission to ask them.
* Allow learner to practice new skills; provide immediate feedback on performance. This allows patient to use new information immediately, thus enhancing retention. Immediate feedback allows learner to make corrections rather than practicing the skill incorrectly.
Encourage repetition of information or new skill. This assists in remembering.
Provide positive, constructive reinforcement of learning. A positive approach allows learner to feel good about learning accomplishments, gain confidence, and maintain self-esteem while correcting mistakes. Incorporate rewards into the learning process.
Document progress of teaching and learning. This allows additional teaching to be based on what the learner has completed, thus enhancing the learner’s self-efficacy and encouraging most cost-effective teaching.

Education/Continuity of Care

Provide instruction for specific topics.
Explore community resources.
Refer patient to support groups as needed. These allow patient to interact with others who have similar problems or learning needs.
Include significant others whenever possible. This encourages ongoing support for patient.

Nursing Care Plan for Gastroenteritis

Gastroenteritis , Nursing Care Plan

Gastroenteritis

Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Diarrhea, crampy abdominal pain, nausea, and vomiting are the most common symptoms.

Viral infection is the most common cause of gastroenteritis but bacteria, parasites, and food-borne illness (such as shellfish) can be the offending agent.

Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have "food poisoning," and they may indeed have a food-borne illness. Many people also refer to gastroenteritis as "stomach flu," although influenza has nothing to do with the condition.

Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water.

The severity of infectious gastroenteritis depends on the immune system's ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as you vomit and experience diarrhea.
Most people recover easily from a short bout with vomiting and diarrhea by drinking fluids and easing back into a normal diet. But for others, such as infants and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored.

Symptoms

By definition, gastroenteritis affects both the stomach and the intestines, resulting in both vomiting and diarrhea.

Common symptoms may include:

Low grade fever to 100°F (37.7°C)
Nausea with or without vomiting
Mild-to-moderate diarrhea:
Crampy painful abdominal bloating

More serious symptoms

Blood in vomit or stool
Vomiting more than 48 hours
Fever higher than 101°F (40°C)
Swollen abdomen or abdominal pain
Dehydration - weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of sweat and tears are characteristic findings.

Nursing Diagnosis

Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.
Imbalanced Nutrition, Less Than Body Requirements related to nausea and vomiting.

Intervention

Diagnosis 1

Imbalanced Nutrition, Less Than Body Requirements related to nausea and vomiting.

Purpose :
Nutritional needs disturbances resolved

Outcomes :

Clients increased nutritional intake, low dietary portion 1 provided, nausea, vomiting does not exist.

Intervention:

Examine patterns of clients and nutritional changes. Measure client weight. Examine factors cause the fulfillment of nutritional disorders. Perform physical examination of the abdomen (palpation, percussion, and auscultation). Give your diet in warm conditions and the small but frequent portions. Collaboration with the team in determining diet nutrition clients.

Diagnosis 2

Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.

Purpose :
Fluid and electrolyte Devisit resolved

Outcomes:Signs of dehydration are not there, mouth and lip mucosa moist, well-balanced fluid exchange

Intervention

Observation of vital signs. Observation of signs of dehydration. Measure the liquid infut and output (balanc ccairan). Provide and encourage families to provide a lot of drinking more or less 2000 - 2500 cc per day. Collaboration with physicians in providing therafi fluid, electrolyte lab tests. Collaboration with a team of nutrition in low-sodium fluids.

Nursing Care Plan for Anorexia Nervosa

Anorexia Nervosa , Nursing Care Plan

NCP For Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600-800 calories per day, but there are extreme cases of complete self-starvation. It is a serious mental illness with a high incidence of comorbidity and the highest mortality rate of any psychiatric disorder.

Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, it can affect men and women of any age, race, and socioeconomic and cultural background. Anorexia nervosa occurs in females 10 times more than in males.
(wikipedia)

Nursing Care Plan for Anorexia Nervosa
NCP for Anorexia Nervosa

Assessment and collection of data

record inadequate nutrition
record the weight loss of 15% below normal, or more
examine skin turgor
leg muscle strength
amenorrhea
electrolyte imbalance
dental erosion

Examination information:

anemia
electrolyte imbalance
electrocardiogram

Nursing diagnosis, planning, and implementation
Imbalances nutrition: less than body requirements related to inadequate intake, vomiting

Expected outcome : diet according to individual body weight.

monitoring of patient weight
monitoring vital signs and laboratory
increase patient confidence
give eat little but often

Body image disorders associated with psychosocial and cognitive changes

Expected outcome: patients verbally expressed satisfaction with the body.

review and document verbal and nonverbal responses
listen to patients and bring to reality
monitor the expression of negative patient and document patient's verbal and nonverbal
examine the need referral to counseling and social services
give an award verbally

Evaluation

Patients receive the appropriate weight
patients satisfied with her body
patients to assess the positive effect in the body.

Source : http://ncp-blog.blogspot.com/2011/03/ncp-for-anorexia-nervosa.html

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