Nursing Care Plan

Alteration in Bowel Elimination: Constipation

Definition:

A situation where an individual experience or a higher risk of static in the large intestine, resulting in a rare bowel movements, hard, dry stools.

Related Factors:

Pathophysiology
Related to innervation disorders, pelvic floor muscles are weak, and immobilization:
Spinal cord lesions
Spinal cord injury
Dementia
Cerebrovascular injury (CSV, stroke)
Neurological Disease
Related to a reduced metabolic rate:
Obesity
Diabetic neuropathic
Uremia
Hypothyroidism
Hyperparathyroidism
Related to decreased peristalsis:
Hypoxia (cardiac, pulmonary)
Action
Related to side effects (specific):
Aluminum antacids
Aspirin anesthetic
Iron Fenotiasine
Barium Calcium
Anticholinergics Diuretics
Narcotics Agents antiparkinson
Situational
Related to decreased peristaltis
Immobilization
Gestation
Stress
Lack of exercise
Related to elimination pattern ketitakteraturan
Dealing with fear of pain
Related to fluid intake takadekuat

Major Data

• Frequency decreased
• Stool hard, dry
• Straining at stool issue
• Abdominal distension

Minor Data

• Pressure on the rectal
• Headache, decreased appetite
• Abdominal pain

Expected Outcomes Nursing Care Plan for Alteration in Bowel Elimination : Constipation

Individuals will:

1. Describe the therapeutic program defecation
2. reported or showed increased bowel elimination
3. explain the rationale of intervention

Nursing Intervention Nursing Care Plan for Alteration in Bowel Elimination : Constipation

Teach the importance of balance diet

• Review the list of foods that contain lots of bulk
  • Fresh fruits skinned
  • Chaff
  • Nuts
  • Bread and cereals
  • Fruits and vegetables are cooked
  • Fruit juice
• Includes nearly 800 grams of fruit and vegetables every day for normal defecation
• Gradually increase fiber foods
• Suggest 2 liters of fluid intake (8-10 glasses) unless there are contraindications
• Recommend drinking a glass of warm water 30 minutes before breakfast which can stimulate spending feces.
• Set a regular time of elimination
• Assist individuals to normal position rather squat to allow optimum use of abdominal muscles and the effects of gravity.
• Teach how to memasase lightly on the bottom of the abdomen while on the toilet
• If there is hardening of the stool, put the warm mineral oil and let stand for 20-30 minutes. Use gloves lubricated with a good, hard stools resolve and dispose of floating-fractions. Keep track of vagal stimulation (dizziness, weak pulse)
• Explain the dangers of the use of laxatives and enemas.

Nursing Care Plan for Imbalanced Nutrition Less than Body Requirements

Definition

A situation where individuals who are at risk of weight loss associated with inadequate input, or metabolism of nutrients is not adequate for metabolic needs.

Related Factors:

Pathophysiology
Related to an increased calorie needs and difficulty in digesting sufficient calories
Burn
Infection
Dependence of chemicals
Cancer
Trauma
Related to dysphagia
Cerebrovascular injury
Amiotrofik lateral sclerosis
Cerebral palsy
Parkinson's
Abnormalities neurovaskuler
Muscular dystrophy
Related to decreased absorption of nutrients
Crohn's Disease
Cystic Fibrosis
Lactose Intolerance
Related to decreased desire to eat
Decreased level of consciousness
Related to vomiting is stimulated alone, refusing to eat
Anorexia nervosa
Related to a reluctance to eat for fear of poisoning
Paranoid behavior
Related to anorexia, excessive physical agitation
Bipolar disorder
Related to anorexia and diarrhea
Protozoan infection
Related to vomiting, anorexia, gastrointestinal damage
Pancreatitis
Related to anorexia, fat and protein metabolism damage, and damage to storage of vitamin
Cirrhosis
Action
Related to an increased need for protein and vitamins for healing wounds
Surgery
Medications
Reconstruction of oral surgery
Wire jaw
Radiation Therapy
Related to inadequate absorption as the effect of
Colchicine
Piremetamin
Antacids
Neomycin
Para-Aminosalicylic Acid
Related to decreased oral input, mouth discomfort, nausea, vomiting
Radiation Therapy
Chemotherapy
Tonsillectomy
Situational (Personal, environmental)
Related to decreased desire to eat
Anorexia
Depression
Stress
Social isolation
Nausea and vomiting
allergy
Related to less knowledge of adequate nutrition
Related to the inability to chew
Damage to teeth or no teeth
Installation of false teeth are not strong
Maturisional
Related to inadequat input
Lack of emotional stimulation / sensory
Lack of knowledge about caregivers
Related to malabsorption, diet restriction, and anorexia
Celiac disease
Lactose Intolerance
Cystic Fibrosis
Related to difficulties to suck (infant) and dysphagia
Cerebral palsy
Cleft lip or palate
Related to inadequate swallowing, fatigue, and dyspnea
Congenital heart disease
Prematurity


Nursing Care Plan for Imbalanced Nutrition Less than Body Requirements

Major Data

• Reported inadequate food input is less than the recommended food inputs with or without weight loss
• Metabolic needs of actual or risk of excessive nutrient inputs.

Minor Data

• Weight loss of 10% -20% or more below ideal body weight for height
• Triceps skin folds, arm circumference was less than 60% of the standard measurement
• Muscle weakness and tenderness
• Sensitive mental stimulation and mental disorder
• Decrease in serum albumun

Expected Outcomes Nursing Care Plan for Imbalanced Nutrition Less than Body Requirements

Individuals will:

1. Improving the oral input
2. Explain the factors that cause if known
3. Explain the rationale and treatment procedures

Nursing Intervention Nursing Care Plan for Imbalanced Nutrition Less than Body Requirements

1. Determine daily calorie needs are realistic and adequate. Consultation on nutrition expert.
2. Weigh the body weight every day, monitor the results of laboratory examination.
3. Explain the importance of adequate nutrition.
4. Teach individuals to use flavorings to help improve the taste and smell of food (lemon, mint, clove, cinnamon, rosemary)
5. Give encouragement of individuals to eat with others (food served in the family room or group)
6. Plan maintenance procedures have an unpleasant or painful not done before eating.
7. Give a fun, relaxed atmosphere (not visible potty, do not busy)
8. Adjust the treatment plan to reduce or eliminate odors that cause wanted to vomit or procedure performed near the time of eating.
9. Teach or assist individuals to rest before eating.
10. Teach individuals to avoid the smell of fried food-eating, coffee-cooked if possible.
11. Maintain oral hygiene before and after chewing.
12. Offer to eat small portions but frequently to reduce feelings of tension in the stomach (six times per day with little food)
13. Set to get the nutrients protein / high calorie, which is presented to individuals when they want to eat. (Eg, if the chemotherapy is done early morning and serve meals in the evening before eating).
14. Instruct individuals who experience decreased appetite for:
    • Eating dry foods waking.
    • Eating salty foods if there are no restrictions.
    • Avoid foods that are too sweet, fattening, greasy.
    • Try to drink clear, warm.
    • Sip through a straw.
    • Eat whenever tolerated.
    • Eat small meals low in fat and eat more often.
15. Try commercial supplements are available in many forms (powder, pudding, liquid)
16. If individuals experiencing eating disorders (Townsend, 1994)
    • Set goals with the client's input, doctors and nutritionists.
    • Talk about the benefits of compliance and the consequences of disobedience.
    • If the input of food that must be rejected, remind the doctor.
    • Sitting accompany individuals during the meal, limit the time to eat up to 30 minutes.
    • Observe at least 1 hour before. Accompany client when to the bathroom.
    • Weigh the client body when he woke up and after the first micturition.
    • Give encouragement to repair, but do not focus the conversation on food or way of eating.
    • Along the improvement of individual, explore issues of self-image, weigh again, and watched over.
17. For individuals who are hyperactive
    • Provide food and beverages that are high in protein, high calorie.
    • Offer more frequent smaller meals. Avoid foods that contain no calories (eg, soda)
    • Take a stroll along individual when given little food.

Source : Nanda Nursing Interventions

Nursing Care Plan for Imbalanced Nutrition More than Body Requirements


Definition :

A situation where an individual experiencing or at risk of weight gain associated with the input that exceeds the metabolic needs.


Related Factors:

Pathophysiology
Related to changes in the pattern of satisfaction
Drugs (corticosteroids, antihistamines)
Radiation (decreased sense of taste and smell)
Situational (Personal, environmental)
Related to the risk of weight gain more than 25-39 pounds during pregnancy
Related to lack of basic nutrition knowledge
Maturisional
(The adult / elderly)
Related to the decline in activity patterns and a decrease in metabolic demand.


Major Data

• Being overweight (10% higher than the ideal body standards)
• Obesity (20% higher than the ideal body standards)
• Triceps skinfolds greater than 15 mm in men, and 25 mm in women

Minor Data

• Reported a diet of unwanted
• Input exceeds the metabolic needs
• Monotonous activity pattern

Expected Outcomes Nursing Care Plan for Imbalanced Nutrition More than Body Requirements

Individuals will :

1. Have increased the use of activity with weight loss.
2. Explain the relationship between activity with weight.
3. Identifying eating patterns that support weight gain
4. Weight loss

Nursing Intervention Nursing Care Plan for Imbalanced Nutrition More than Body Requirements

1. Increase awareness of individuals about the type / amount of food consumed
   
   • Instruct the individual to keep a diet diary for one week.
     • What, when, where, and why eat?
     • Will do anything else (eg, watching TV, dinner preparation)
     • Emotions just before eating
     • The presence of another person
   • Review the diary with the individual's diet to show a pattern (eg, time, place, people, emotions, food)
   • Review of food items of high and low in calories.
2. Assist individuals to set realistic goals (eg, by lowering the oral input of 500 calories will cause weight loss 1-2 pounds per week)
3. Teach the techniques of behavior modification
   • Eat only a special place at home (eg, table)
   • Do not eat while doing other activities such as reading or watching TV, eating only when seated.
   • Drinking 240 cc of water before eating.
   • Use a small plate, so portions look more.
   • Prepare small portions, just enough to eat and the excess residual removed.
   • Do not ever eat from plates of others.
   • Eat slowly and chew thoroughly.
   • Put cutlery and wait 15 seconds between bites.
   • Eating low-calorie snack that need to chew to satisfy the needs of oral (carrots, celery, apples)
   • Reduce calorie fluids, drinking diet sodas or water.
4. Plan a daily walking program and gradually increase speed and distance running.
   • Start with 500 m to 1 km / day; add 100m / week.
   • Increase slowly
   • Avoid holding or pushing too hard and being too tired.
   • Stop immediately if the following signs occur:
     • Sense of tightness or chest pain.
     • Very difficult to breathe.
     • Pain was floated.
     • Dizziness.
     • Loss of muscle control.
     • Nausea.
   • Set a regular time of day to exercise, with the aim of 3-5 times a week with a duration of 15-45 minutes and with a frequency of 80% of cardiac stress tests or rough count (170 x / min for 20-29 years of age; 160 x / min for age 30-39 years; 150 x / min for 40-49 years of age; 140 x / min for ages 50-59 years).

Nursing Care Plan for Imbalanced Nutrition Less than Body Requirements

Ineffective Thermoregulation

Definition:

Circumstances where an individual experiencing or at risk of inability to maintain normal body temperature effectively with any discrepancies or changes in external factors.

Related Factors:
Situational (Personal, environmental)
Related to fluctuations in environmental temperature
Related to objects that are wet and cold (clothing, bedding)
Related to a wet body surface
Related to clothing that is not compliant with the weather
Related to limited regulation of metabolic compensation
Elderly
Newborns

Expected Outcomes Nursing Care Plan for Ineffective Thermoregulation

Babies will

• Having a temperature between 36.4 to 37.5 º C.

Parents will

• Explain the techniques to avoid heat loss at home.

Nursng Intervention Nursing Care Plan for Ineffective Thermoregulation

1. Reduce or eliminate the sources of heat loss in infants
   • Evaporation
     • When a shower, prepare a warm environment.
     • Wash and dry each section to reduce evaporation
     • Limit the time of contact with clothing or a wet blanket
   • Convection
     • Avoid the flow of air (air conditioning, ceiling fan, open vent)
   • Conduction
     • Warm all the goods for care (stethoscope, scales, hand care givers, clothes, bed linen)
   • Radiation
     • Reduce the objects that absorb heat (metal)
     • Place the baby swing bed away from the wall (outside) or window if possible.
2. Monitor the baby's body temperature
   • If the temperature is below normal
     • Use with two blankets
     • Wear headgear
     • Assess the environmental sources for heat loss
     • If hypothermia settled more than 1 hour, refer to the more expert.
     • Review of the complications of cold stress, hypoxia, respiratory acidosis, hypoglycemia, fluid and electrolyte imbalance, weight loss.
   • If the temperature is above normal
     • Remove the blanket
     • Remove the headgear, when worn
     • Assess the environmental temperature again
     • If the temperature hyperthermia settled more than 1 hour, report the physician.
3. Teach caregivers why babies are vulnerable to temperature (hot and cold)
   • Demonstrate how to save heat during the bath.
   • Instruct that do not need to routinely measure the temperature at home.
   • Teach to measure the temperature if the baby is hot, sore, or sensitive excitatory.
   • Teach the elderly why they are vulnerable to heat and cold weather.
   • Refer to the hypothermia and hyperthermia for prevention.

Hyperthermia

Definition:

Circumstances where an individual experiencing or at risk of increased body temperature continuously above 37.8 per oral or per-rectal 38.8 ° C because of the increased vulnerability to external factors.

Nursing Care Plan for Hyperthermia

Related Factors:

Related to decrease the ability to sweat : (Special Treatment)

• Situational
• Exposure to heat (sun)
• Clothing that does not comply with the climate

Related to a decrease in circulation:

• Extreme weight loss
• Dehydration
• Insufficiency hydration for heavy activity
• Maturisional

Related to temperature regulation is not effective:

• Newborns
• Premature Babies
• Elderly

Major Data:

Higher temperature 37.8 orally or 38.8 º C per rectal

Minor Data:

• Skin redness
• Warm to the touch
• Respiratory frequency increased
• Tachycardia
• Goosebumps
• Dehydration
• Pain or illness-specific or general (eg, headache, fatigue)
• Malaise / fatigue / weakness
• Loss of appetite

Expected Outcomes

Individuals will:

1. Identifying risk factors to hyperthermia.
2. Connecting method of prevention of hyperthermia.
3. Maintaining body temperature within normal limits.

Nursing Intervention Nursing Care Plan for Hyperthermia

1. Teach clients the importance of maintaining adequate fluid intake (at least 2000 ml / day unless there are contraindications to heart or kidney disease) to prevent dehydration
2. Monitor input and output.
3. Assess whether clothing or bedcovers too warm for the environment or activities planned.
4. Teach the importance of increased fluid intake during hot weather and exercise
5. Explain why the children and the elderly at higher risk of hyperthermia.
6. Explain the need to avoid alcohol, caffeine, and eat lots and heavy food during hot weather.
7. Explain the importance of wearing baggy clothes, thin and absorbs sweat
8. Teach early signs of hyperthermia or heat stroke: Skin redness, fatigue, headache, loss of appetite.

Nursing Care Plan for Ineffective Thermoregulation

Hypothermia

Hypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as 35.0 °C (95.0 °F). Body temperature is usually maintained near a constant level of 36.5–37.5 °C (98–100 °F) through biologic homeostasis or thermoregulation. If exposed to cold and the internal mechanisms are unable to replenish the heat that is being lost, a drop in core temperature occurs. As body temperature decreases, characteristic symptoms occur such as shivering and mental confusion.




Nursing Care Plan for Hypothermia

Related Factors:

• Situational (Personal, environmental)
• Heat, rain, wind
• Clothing that does not comply with the climate
• Decrease in circulation:
• Extreme weight loss
• Consuming alcohol
• Dehydration
• Inactivity
• Maturisional
• Ineffective temperature regulation:
• Newborns
• Elderly

Major Data:

• Temperatures below 35.5 º C per rectal
• Cold skin
• Pallor (medium)
• Shivering (mild)

Minor Data:

• Mental disorder / sleepy / restless
• Decrease in pulse and respiration
• Kakeksia / malnutrition

Expected Outcomes

Individuals will:

1. Identifying risk factors of hypothermia.
2. Connecting method of maintaining warmth / heat loss prevention.
3. Maintain body temperature within normal limits.

Nursing Intervention Nursing Care Plan for Hypothermia

1. Teach clients to reduce exposure to the cold environment of the old.
2. Explain to family members that neonates, infants and the elderly are more susceptible to heat loss.
3. Teach early signs of hypothermia: skin cold, pale, shivering.
4. Explain the need to drink 8-10 glasses of water every day
5. Explain the need to avoid alcohol on the very cold weather.
6. Teach them to put on extra clothing.

Nursing Care Plan for Hyperthermia

Definition : Impaired Gas Exchange

Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.

Related Factors:

• Altered oxygen supply
• Alveolar-capillary membrane changes
• Altered blood flow
• Altered oxygen-carrying capacity of blood

Nursing Care Plan for Impaired Gas Exchange

Major Data

Dyspnea when performing activities

Minor data

• Confusion / agitation.
• The tendency to take a three-point position (sitting, one hand on each knee, leaning forward).
• Breathing with the lips with a long expiratory phase.
• Lethargy and fatigue.
• Increased pulmonary vascular resistance.
• Decrease in gastric motility.
• Decrease in oxygen content, decreased O2 saturation, PCO2 decreased as shown by the results of blood gas analysis.
• Cyanosis.

Nursing Care Plan for Impaired Gas Exchange

Nursing Care Plan for Hypothermia