Nursing care plans


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Nursing care plans

  1. 1. Advance Medical – Surgical Nrsg. II0
  2. 2. a.) Enumerate the diff. problems involving each system assigned and describe each.b.) Select one problem in each system and make a NCP using format: Nursing Dx. – Objectives of care – Nrsg. Intervention - RationaleGroup I1. Eye Problems  Disorders of the eyelids and lacrimal ducts are commonly apparent on examination. Such disorders are caused by a range of factors, from infection to congenital deformity. They include blepharitis, chalazion, dacryocystitis, orbital cellulitis, ptosis, and stye.  Conjunctival disorders typically cause obvious inflammation. Although some are self-limiting, others may lead to blindness if left untreated.  Some corneal disorders, such as abrasions, may be mild and seldom cause complications. Others, such as keratitis, can lead to blindness if untreated.  Disorders of the uveal tract, retina, and lens may be acute or chronic and may cause visual disturbances or even vision loss. They include age-related macular degeneration, cataract, retinal detachment, retinitis pigmentosa, uveitis, and vascular retinopathies.  Miscellaneous disorders include extraocular motor nerve palsies, glaucoma, and strabismus. Glaucoma Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleGlaucoma is a group  Acute pain  The patient will express  For the patient with angle-closure glaucoma, give medications, as ordered, andof disorders  Anxiety feelings of comfort. prepare him physically and psychologically for laser iridotomy or surgery.characterized by high  Disturbed  The patient will identify  Remember to administer cycloplegic eyedrops in the affected eye only. In theintraocular pressure sensory strategies to reduce anxiety. unaffected eye, these drops may precipitate an attack of angle-closure glaucoma and(IOP) that damages perception: threaten the patients residual vision.the optic nerve. Visual  The patient will regain normalGlaucoma may occur  Fear visual functioning.  After trabeculectomy, give medications, as ordered, to dilate the pupil. Also apply aas a primary or  Risk for injury  The patient and family will topical corticosteroid, as ordered, to reduce inflammation.congenital disease or express their feelings and  After surgery, protect the affected eye by applying an eye patch and shield,secondary to other concerns. positioning the patient on his back or unaffected side, and following general safetycauses, such as injury, measures.  The patient will avoid injury.
  3. 3. infection, surgery, or  Administer pain medication as ordered.prolonged topicalcorticosteroid use.  Encourage ambulation immediately after surgery.  Encourage the patient to express any concerns he may have about having a chronic condition.  Stress the importance of strictly adhering to the prescribed drug therapy to maintain low IOP and prevent optic disk changes that cause vision loss.  Explain all procedures and treatments, especially surgery, to help reduce the patients anxiety.  Inform the patient that lost vision cant be restored but that treatment can usually prevent further loss.  Instruct the patients family how to modify his environment for safety. For example, suggest keeping pathways clear and reorienting the patient to room layouts, if necessary.  Teach the patient signs and symptoms that require immediate medical attention, such as sudden vision change or eye pain.  Discuss the importance of glaucoma screening for early detection and prevention. Point out that all people older than age 35, especially those with a family history of glaucoma, should have an annual tonometric examination.2. Throat Problems  Throat disorders, characterized by a sore throat, dysphagia, hoarseness, and airway obstruction, may be caused by bacterial, fungal, or viral infections; an aneurysm; surgical trauma; cancer; smoking; and overuse of the vocal cords. These disorders include juvenile angiofibroma, laryngitis, pharyngitis, tonsillitis, vocal cord nodules and polyps, and vocal cord paralysis. Pharyngitis Nursing Diagnoses Objectives of Care Nursing Interventions and RationalePharyngitis, the most  Acute pain  The patient will express  Administer an analgesic and warm saline gargles as ordered and as appropriate.
  4. 4. common throat  Fatigue feelings of comfort.  Encourage the patient to drink plenty of fluids (up to 2½ qt [2.5 L] per day). Monitordisorder, is an acute or  Imbalanced  The patient will verbalize the intake and output scrupulously, and watch for signs of dehydration (cracked lips, drychronic inflammation nutrition: Less importance of adequate rest mucous membranes, low urine output, poor skin turgor). Provide meticulous mouthof the pharynx. Its than body periods. care to prevent dry lips and oral pyoderma and maintain a restful environment.widespread among requirementsadults who live or  Impaired oral  The patient will take in an  Obtain throat cultures, and administer an antibiotic as in dusty or dry mucous adequate number of calories  Maintain a restful environment, especially if the patient is febrile, to conserve energy.environments, use membrane every day.their voices  Risk for deficient  The  Encourage a soft, light diet with plenty of liquids to combat the commonly patients mucousexcessively, habitually fluid volume experienced anorexia. An antiemetic can be given before eating if ordered. membranes will remain intact.use tobacco or  Examine the skin twice a day for possible drug sensitivity rashes or for rashesalcohol, or suffer from  The patients fluid volume will indicating a communicable disease.chronic sinusitis, remain within normal range.persistent coughs, or  Administer an antitussive, as ordered, if the patient has a cough.allergies.  Administer an analgesic as ordered.Uncomplicated  If the patient has acute bacterial pharyngitis, emphasize the importance of completingpharyngitis usually the full course of antibiotic therapy. Tell him to call the physician if he experiences anysubsides in 3 to 10 adverse reactions.days.  Advise the patient with chronic pharyngitis how to minimize sources of throat irritation in the environment, by using a bedside humidifier, for example. Refer him to a self-help group, if appropriate, to stop smoking.  Inform the patient and his family that in the case of a positive streptococcal infection, all of his family should undergo throat cultures, regardless of the presence or absence of symptoms. Individuals with positive cultures require penicillin therapy.  Teach the patient to avoid using irritatants, such as alcohol, which may exacerbate symptoms.3. Problems that involve Immune System  Characterized by a harmful reaction to extrinsic materials or allergens, allergic disorders include allergic rhinitis, anaphylaxis, asthma, atopic dermatitis, blood transfusion reaction, latex allergy, and urticaria and angioedema.
  5. 5.  Autoimmune disorders are marked by an abnormal immune response to oneself. Autoimmunity leads to a sequence of tissue reactions and damage that may produce diffuse, systemic signs and symptoms. Among the autoimmune disorders are ankylosing spondylitis, fibromyalgia syndrome, Goodpastures syndrome, graft rejection syndrome, juvenile rheumatoid arthritis, lupus erythematosus, polymyositis and dermatomyositis, Reiters syndrome, rheumatoid arthritis, scleroderma, SjÃgrens syndrome, and vasculitis.Lupus erythematosus Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleLupus erythematosus  Acute pain  The patient will express  Continually assess the patient for signs and symptoms of organ involvement, whileis a chronic  Constipation feelings of comfort and offering encouragement, emotional support, and thorough patient teaching.inflammatory  Decreased decreased pain.  Monitor the patient for hypertension, weight gain, and other signs of renalautoimmune disorder cardiac output  The patient will pass soft, involvement.that affects the  Diarrhea regular stool withoutconnective tissues.  Disturbed body  Evaluate the patient for possible neurologic damage signaled by personality changes, straining.Lupus erythematosus image paranoid or psychotic behavior, depression, ptosis, and diplopia.takes two forms:  Fatigue  The patient will maintain  Check urine, stools, and GI secretions for blood. Check the scalp for hair loss and thediscoid lupus  Imbalanced adequate cardiac output. skin and mucous membranes for petechiae, bleeding, ulceration, pallor, and bruising.erythematosus (DLE) nutrition: Less  The patient will resume aand systemic lupus than body  Provide a balanced diet. Foods high in protein, vitamins, and iron help maintain normal bowel eliminationerythematosus (SLE). requirements optimum nutrition and prevent anemia. Renal involvement may mandate a low- pattern.DLE affects only the  Impaired oral sodium, low-protein diet. Provide bland, cool foods if the patient has a sore; SLE affects mucous  The patient will verbalize  Urge the patient to get plenty of rest. Schedule diagnostic tests and procedures tomultiple organs membrane feelings about a changed body allow adequate rest.(including the skin)  Impaired physical image.and can be fatal. mobility  Describe all tests and procedures to the patient. Explain that several blood samples  The patient will express  Impaired skin are needed initially and then periodically to monitor progress. feelings of increased energy. integrity  Apply heat packs to relieve joint pain and stiffness. Encourage regular exercise to  Impaired tissue  The patient will show no signs maintain full range of motion and to prevent contractures. integrity of malnutrition.  Explain to the patient the expected benefit of prescribed medications, and watch for  Impaired urinary  The patients oral mucous adverse effects, especially when administering high doses of corticosteroids or elimination membrane will remain intact. NSAIDs.  Ineffective  The patient will maintain joint breathing  Institute seizure precautions if you suspect CNS involvement. mobility and range of motion. pattern
  6. 6.  Risk for infection  The patient will maintain skin  Warm and protect the patients hands and feet if she has Raynauds phenomenon. Risk for integrity. peripheral  If musculoskeletal involvement compromises the patients mobility, arrange for a neurovascular  The site of impaired tissue will physical therapy and occupational therapy consultation. dysfunction have reduced pain, redness,  Support the patients self-image. Offer female patients helpful tips. Suggest and swelling. hypoallergenic cosmetics. As needed, refer her to a hairdresser who specializes in  The patient will maintain fluid scalp disorders. Offer male patients similar advice, suggesting hypoallergenic hair care balance; intake will equal and shaving products. output.  Teach range-of-motion exercises and body alignment and postural techniques.  The patient will maintain a  Be sure the patient understands ways to avoid infection. Direct her to avoid crowds respiratory rate within five and people with known infections. breaths of baseline.  Advise the patient to notify the physician if fever, cough, or rash occurs or if chest,  The patient will remain free abdominal, muscle, or joint pain worsens. from signs and symptoms of infection.  Teach the importance of eating a balanced diet and the restrictions associated with medications.  The patient will report alterations in sensation or  Teach the patient and her family about prescribed medications. Include such pain in the extremities. information as adverse effects, whether the medication needs to be taken with food, and correct administration techniques.  Teach the importance of good skin care, avoiding dryness and the use of irritating soaps, hair dryers, hair coloring, and permanent wave solutions.  Encourage exercise, such as aerobics, swimming, walking, bicycling, and range-of- motion exercises.  Stress the importance of keeping regular follow-up appointments and contacting the physician if flare-ups occur.  Instruct the photosensitive patient to wear protective clothing (hat, sunglasses, long- sleeved shirts or sweaters, and slacks) and to use a sunscreen when outdoors.  Teach the patient to perform meticulous mouth care to relieve discomfort and prevent infection.  Because SLE usually affects women of childbearing age, questions associated with
  7. 7. pregnancy commonly arise. The best evidence available indicates that a woman with SLE can have a safe, successful pregnancy if she sustains no serious renal or neurologic impairment. Advise her to seek additional medical care from a rheumatologist during her pregnancy. As indicated, explain that her physicians may order low-dose aspirin to reduce the risk of thrombosis during pregnancy.  Warn the patient against trying unproven miracle drugs to relieve arthritis symptoms.  Refer the patient to the Lupus Foundation of America and the Arthritis Foundation, as necessary.Group II1. Musculoskeletal Problems  Arising before or at birth, congenital disorders of the musculoskeletal system include clubfoot, developmental dysplasia of the hip, muscular dystrophy, and osteogenesis imperfecta.  Joint disorders, which attack the bodys centers of mobility, are painful and disabling. Causes of joint disorders may range from chronic conditions to acute infections. No matter what the cause, they all need a team treatment approach that emphasizes patient participation. This includes gout, neurogenic arthropathy, osteoarthritis, and septic arthritis.  Disorders affecting bone structure and function include hallux valgus, herniated disk, kyphosis, Legg-Calv´-Perthes disease, Osgood-Schlatter disease, osteomyelitis, osteoporosis, Pagets disease, and scoliosis.  Diseases that affect the skeletal muscles and connective tissues invariably cause discomfort and restrict movement. Common among these disorders are Achilles tendon contracture, carpal tunnel syndrome, rhabdomyolysis, tendinitis and bursitis, and torticollis. Herniated disk Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleA herniated disk (also  Activity  The patient will perform  Assess the patients pain. With the patient and the physician, plan a pain-controlknown as a herniated intolerance activities without excessive regimen using such methods as relaxation, transcutaneous electrical nervenucleus pulposus or a  Anxiety fatigue or pain. stimulation, distraction, heat or ice application, traction, bracing, or positioning inruptured or slipped  Chronic pain addition to analgesics and muscle relaxants. Give pain medications as ordered and  The patient will identifydisk) occurs when all  Dressing or assess the patients response. strategies to reduce anxiety.or part of the nucleus grooming self-  Offer supportive care, careful patient teaching, and encouragement to help thepulposus, an care deficit  The patient will express
  8. 8. intervertebral disks  Fear feelings of comfort and patient cope with the discomfort and frustration of chronic back pain and impairedgelatinous center,  Impaired physical decreased pain. mobility. Include the patient and his family in all phases of his care.extrudes through the mobility  The patient will perform  Encourage the patient to verbalize his concerns about his disorder. Answer questionsdisks weakened or  Risk for injury activities of daily living within the patient has as honestly as you can.torn outer ring (anulus the confines of the disorder.fibrosus). The  Encourage the patient to perform as much self-care as his immobility and pain allow.resultant pressure on  The patient will discuss fears Provide him with adequate time to perform these activities at his own pace.spinal nerve roots or and concerns.  Help the patient identify and perform activities that promote rest and relaxation.on the spinal cord  The patient will achieve theitself causes back pain  If the patient is to undergo myelography, question him carefully about allergies to highest level of mobilityand other symptoms iodides, iodine-containing substances, or seafood because such allergies may indicate possible within the confines ofof nerve root sensitivity to a radiopaque contrast agent used in the test. Monitor intake and output. the disease.irritation. Watch for seizures and an allergic reaction.  The patient will demonstrate  If the patient is in traction, ensure that the pelvic straps are properly positioned and methods to prevent injury to that the weights are suspended. Periodically remove the traction to inspect skin. Also himself. remember to monitor for deep vein thrombosis.  After laminectomy, microdiskectomy, or spinal fusion, enforce bed rest as ordered. If the patient has a blood drainage system (Hemovac) in use, check the tubing frequently for patency and a secure vacuum seal. Empty the system at the end of each shift as ordered, and record the amount and color of drainage. Report colorless moisture on dressings (possible cerebrospinal fluid leakage) or excessive drainage immediately. Check the neurovascular status of the patients legs (color, motion, temperature, and sensation).  Monitor vital signs, and check for bowel sounds and abdominal distention. Use the logrolling technique to turn the patient. Administer analgesics as ordered, especially about 30 minutes before initial attempts to sit or walk. Assist the patient during his first attempt to walk. Provide a straight-backed chair, and allow him to sit in it briefly.  Teach the patient about treatments, which may include bed rest and pelvic traction; heat application to the area to decrease pain; an exercise program; medications to decrease pain, inflammation, and muscle spasms; and surgery.  Before myelography, reinforce previous explanations of the need for this test, and tell the patient to expect some pain. Assure him that hell receive a sedative before the
  9. 9. test, if needed, to keep him as calm and comfortable as possible. After the test, urge the patient to remain in bed with his head elevated (especially if metrizamide was used) and to drink plenty of fluids.  If surgery is required, explain all preoperative and postoperative procedures and treatments to the patient and his family.  Prepare the patient for discharge.2. Breast Problems  Some breast disorders, such as mastitis, result from infection and usually affect lactating women. Others, such as galactorrhea, result from hormonal dysfunction unrelated to lactation. Mastitis Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleParenchymatous  Acute pain  The patient will express  Give an analgesic as needed.inflammation of the  Ineffective feelings of comfort.  Provide comfort measures such as warm soaks.mammary glands, or breast-feeding  The patient will resumemastitis, occurs  Risk for impaired  Use meticulous hand-washing technique and provide good skin care. breast-feeding with no furtherpostpartum in about skin integrity  Tell the patient to take the antibiotic exactly as prescribed, even if her symptoms complications.1% of lactating  Risk for infection subside.women, mainly in  The patients skin integrity willprimiparas who are remain intact.  Reassure the mother that breast-feeding wont harm her infant because hes thebreast-feeding. It source of the infection. If only one breast is affected, advise the patient to offer the  The patient will remain freeoccurs occasionally in infant that breast first to promote complete emptying and prevent clogged ducts. from signs and symptoms ofnonlactating women However, if an open abscess develops, she must stop breast-feeding with this breast infection.and rarely in men. The and use a breast pump until the abscess heals. She should continue to breast-feed onprognosis is good. the unaffected side.  Show how to position the infant properly to prevent cracked nipples.  Stress the importance of emptying the breasts completely, because milk stasis can cause infection and mastitis.  Teach the patient to alternate feeding positions and to rotate pressure areas on the
  10. 10. nipples.  Remind the patient to position the infant properly on the breast with the entire areola in his mouth.  Advise the patient to expose sore nipples to the air as often as possible.  Teach the patient proper hand-washing technique and personal hygiene.  Instruct the patient to get plenty of rest and consume sufficient fluids and a balanced diet to enhance breast-feeding.  Suggest applying a warm, wet towel to the affected breast or taking a warm shower to relax and improve breast-feeding.3. Reproductive Health Problems  Common gynecologic complaints may arise from menstrual problems, such as premenstrual syndrome, and infections, such as vulvovaginitis and pelvic inflammatory disease. Hormonal dysfunction can lead to other gynecologic disorders such as endometriosis and infertility. The development of benign tumors can account for such disorders as ovarian cysts and uterine leiomyomas.  Male reproductive disorders affect the testes, prostate, and epididymis. Examples of male reproductive disorders include benign prostatic hyperplasia, epididymitis, male infertility, prostatitis, testicular torsion, and undescended testes. Pelvic inflammatory Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale disease  The patient will expressPelvic inflammatory  Acute pain  After establishing that the patient has no drug allergies, administer an antibiotic and feelings of comfort.disease (PID) is an  Anxiety an analgesic as ordered.  The patient will identifyumbrella term that  Deficient fluid strategies to reduce anxiety.  Monitor vital signs for fever and fluid intake and output for signs of dehydration.refers to any acute, volume  The patients fluid volume will Watch for abdominal rigidity and distention, possible signs of developing peritonitis.subacute, recurrent,  Ineffective remain within normal  Provide frequent perineal care if vaginal drainage occurs.or chronic infection of coping parameters.the oviducts and  Ineffective  Use meticulous hand-washing technique; institute wound and skin precautions, if  The patient will demonstrateovaries, with adjacent sexuality necessary. adaptive coping behaviors.tissue involvement. It patterns  The patient will express  Encourage the patient to discuss her feelings. Also, offer emotional support, and helpincludes inflammation  Risk of infection
  11. 11. of the cervix feelings about her current her develop effective coping strategies.(cervicitis), uterus condition.  To prevent recurrence, encourage compliance with treatment and explain the disease(endometritis),  The patient will remain free and its severity.fallopian tubes from signs and symptoms of(salpingitis), and infection.  Stress the need for the patients sexual partner to be examined and, if necessary,ovaries (oophoritis), treated for infection.which can extend to  Discuss the use of condoms to prevent the spread of sexually transmitted diseases.the connective tissuelying between the  Because PID may cause dyspareunia, advise the patient to check with her physicianbroad ligaments about sexual activity.(parametritis).  To prevent infection after minor gynecologic procedures, such as dilatation and curettage, tell the patient to immediately report fever, increased vaginal discharge, or pain. After such procedures, instruct her to avoid douching or having intercourse for at least 7 days.Group III1. Urinary system (Prostate) Problems  Congenital renal disorders are present at birth but may not cause signs and symptoms until much later in life. These disorders include medullary sponge kidney and polycystic kidney disease.  Acute renal disorders have a sudden onset. They include acute poststreptococcal glomerulonephritis, acute pyelonephritis, acute renal failure, acute tubular necrosis, renal calculi, and renal vein thrombosis.  Chronic renal disorders develop slowly and persist for a long time. They include chronic glomerulonephritis, chronic renal failure, cystinuria, hydronephrosis, nephrotic syndrome, renal tubular acidosis, and renovascular hypertension.  Lower urinary tract disorders include congenital anomalies of the ureter, bladder, and urethra; lower urinary tract infection; neurogenic bladder; and vesicoureteral reflux. Benign prostatic Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale hyperplasiaAlthough most males  Acute pain  The patient will express  Prepare the patient for diagnostic tests and surgery as appropriate.over age 50 have  Impaired urinary feelings of comfort.
  12. 12. some prostatic elimination  The patient and family will  Monitor and record the patients vital signs, intake and output, and daily weight.enlargement, in  Risk for infection demonstrate skill in managing Watch closely for signs of postobstructive diuresis (such as increased urine output andbenign prostatic  Risk for injury the urinary elimination hypotension), which may lead to dehydration, lowered blood volume, shock,hyperplasia (BPH) the  Sexual problem. electrolyte losses, and anuria.prostate gland dysfunctionenlarges sufficiently to  Urinary retention  The patient will remain free  Administer antibiotics as ordered for UTI, urethral procedures that involvecompress the urethra from signs or symptoms of instruments, and cystoscopy.and cause some overt infection.  If urine retention occurs, try to insert an indwelling urinary catheter. If the catheterurinary obstruction.  The patient will minimize cant be passed transurethrally, assist with suprapubic cystostomy. Watch for rapidBPH begins with complications. bladder decompression.changes inperiurethral glandular  The patient will express  Avoid giving a patient with BPH decongestants, tranquilizers, alcohol, antidepressants,tissue. As the prostate feelings about potential or or anticholinergics because these drugs can worsen the obstruction.enlarges, it may actual changes in sexual After prostatic surgeryextend into the activity.bladder and obstruct  Maintain the patients comfort, and watch for and prevent postoperative  The patient will regain abilityurine outflow by complications. Observe for signs of shock and hemorrhage. Check the catheter to completely evacuate thecompressing or frequently (every 15 minutes for the first 2 to 3 hours) for patency and urine color; bladder.distorting the prostatic check the dressings for bleeding.urethra. BPH may also  Postoperatively, many urologists insert a three-way catheter and establish continuouscause a diverticulum bladder irrigation. Keep the solution flowing at a rate sufficient to maintain patencymusculature that and ensure that returns are clear and light pink. Watch for fluid overload fromretains urine when the absorption of the irrigating fluid into the systemic circulation. If a regular catheter isrest of the bladder used, observe it closely. If drainage stops because of clots, irrigate the catheter asempties. Depending ordered, usually with 80 to 100 ml of normal saline solution, while maintaining asepticon the size of the technique.enlarged prostate, the  Administer belladonna and opium suppositories or other anticholinergics, as ordered,age and health of the to relieve bladder spasms that can occur after transurethral resection.patient, and theextent of the  Make the patient comfortable after an open procedure: Administer suppositoriesobstruction, BPH may (except after perineal prostatectomy), and give analgesics to control incisional treated surgically Change dressings frequently.or symptomatically.  Continue infusing I.V. fluids until the patient can drink enough on his own (2 to 3 qt [2 to 3 L]/day) to maintain adequate hydration.
  13. 13.  Administer stool softeners and laxatives, as ordered, to prevent straining. Dont check for fecal impaction because a rectal examination can cause bleeding.2. Biliary & Pancreatic Problems  Diseases of the gallbladder and biliary tract are common and often painful conditions that usually require surgery and may be life-threatening. They are often associated with inflammation and deposition of calculi.  Acute or chronic inflammation is commonly associated with disorders of the stomach, intestines, and pancreas. In addition, ulceration, herniation, or the development of diverticula may damage the GI mucosa lining the stomach and intestines. Pancreatitis Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleInflammation of the  Acute pain  The patient will express  Assess the patients level of pain. As ordered, administer meperidine or otherpancreas, or  Deficient fluid feelings of comfort. analgesics. Evaluate and document effectiveness of pain medications; watch forpancreatitis, occurs in volume adverse reactions.  The patients fluid volume willacute and chronic  Disturbed body remain within normal  Maintain the NG tube for drainage or suctioning.forms. Its associated image parameters.with biliary tract  Hopelessness  Restrict the patient to bed rest, and provide a quiet and restful environment.disease, alcoholism,  Imbalanced  The patient will express  Place the patient in a comfortable position that also allows maximal chest expansion,trauma, and certain nutrition: Less positive feelings about such as Fowlers position.drugs, and it can be than body himself.idiopathic. Acute requirements  Assess pulmonary status at least every 4 hours to detect early signs of respiratory  The patient will participate inpancreatitis generally  Ineffective complications. decisions about care.resolves clinically and breathing  Monitor fluid and electrolyte balance and report any abnormalities. Maintain anhistologically but is pattern  The patient will achieve accurate record of intake and output. Weigh the patient daily and record his weight.serious in nature and  Risk for impaired adequate caloric andhas a 10% mortality. skin integrity nutritional intake.  Evaluate the patients present nutritional status and metabolic requirements.Chronic pancreatitis  Risk for injury  The patients breathing  Provide I.V. fluids and parenteral nutrition as ordered. As soon as the patient cancauses irreversible pattern will remain within five tolerate it, provide a diet high in carbohydrates, low in protein, and low in fat.tissue damage and breaths of baseline.  Monitor serum glucose levels and administer insulin as ordered.tends to progress tosignificant loss of  The patients skin integrity will  Dont confuse thirst due to hyperglycemia (indicated by serum glucose levels up to
  14. 14. pancreatic function. remain intact. 350 mg/dl and glucose and acetone in the urine) with dry mouth due to NG intubation and anticholinergics.  The patient will avoid complications.  If the patient has chronic pancreatitis, allow him to express feelings of anger, depression, and sadness related to his condition, and help him to cope with these feelings. Encourage him to use appropriate physical outlets to express his emotions, such as pounding a punching bag and throwing pillows.  Counsel the patient to contact a self-help group, such as Alcoholics Anonymous, if needed.  Emphasize the importance of avoiding factors that precipitate acute pancreatitis, especially alcohol.  Refer the patient and family members to the dietitian. Stress the need for a diet high in carbohydrates and low in protein and fats. Caution the patient to avoid beverages with caffeine and irritating foods.  Point out the need to comply with pancreatic enzyme replacement therapy. Instruct the patient to take the enzymes with meals or snacks to help digest food and to promote fat and protein absorption. Advise him to watch for and report any of the following signs and symptoms: fatty, frothy, foul-smelling stools; abdominal distention; cramping; and skin excoriation.3. Problems of sexually transmitted diseases  Sexually transmitted diseases (STDs) are some of the most common infections in the United States. STDs include chancroid, chlamydial infections, genital warts, gonorrhea, herpes simplex virus, syphilis, and trichomoniasis. Gonorrhea Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleGonorrhea is a  Acute pain  The patient will remain free  Before treatment, determine if the patient has any drug sensitivities. Duringcommon sexually  Ineffective sexual from pain. treatment, watch closely for signs of a drug reaction.transmitted disease patterns  The patient will voice his  Use standard precautions when obtaining specimens for laboratory examination andthat usually starts as  Risk for infection
  15. 15. an infection of the  Situational low feelings about potential or when caring for the patient. Carefully place all soiled articles in containers, andgenitourinary tract, self-esteem actual changes in sexual dispose of them according to facility policy.especially the urethra activity.  Monitor the patient for complications.and cervix. It also can  The patient will state infectionbegin in the rectum,  Isolate the patient with an eye infection. risk factors.pharynx, or eyes. Left  If the patient has gonococcal arthritis, apply moist heat to ease pain in affected joints.untreated, gonorrhea  The patient will identify signs Administer analgesics as ordered.spreads through the and symptoms of infection.blood to the joints,  If the physician or laboratory hasnt already done so, report all cases of gonorrhea to  The patient will experience notendons, meninges, the local public health authorities so that they can follow up with the patients sexual further signs or symptoms ofand endocardium; in partners. Examine and test all people exposed to gonorrhea. infection.females, it also can  Report all cases of gonorrhea in children to child abuse authorities.lead to chronic pelvic  The patient will expressinflammatory disease concern about self-concept,  Routinely instill prophylactic medications, according to facility protocol, in the eyes of(PID) and sterility. esteem, and body image. all neonates on admission to the nursery. Check the neonate of an infected mother for any signs of infection. Obtain specimens for culture from his eyes, pharynx, and rectum.  Urge the patient to inform all sexual partners of the infection so that they can seek treatment. To prevent gonorrhea, provide the following patient teaching:  Tell the patient to avoid sexual contact until cultures prove negative and infection is eradicated.  Advise the partner of an infected person to receive treatment even if the partner doesnt have a positive culture. Recommend that the partner avoid sexual contact with anyone until treatment is complete because reinfection is extremely common.  Counsel the patient and all sexual partners to be tested for human immunodeficiency virus and hepatitis B infection.  Instruct the patient to be careful when coming into contact with any bodily discharges to avoid contaminating the eyes.  Tell the patient to take anti-infective drugs for the length of time prescribed.  To prevent reinfection, tell the patient to avoid sexual contact with anyone suspected
  16. 16. of being infected, to use condoms during intercourse, to wash genitalia with soap and water before and after intercourse, and to avoid sharing washcloths or using douches.  Advise the patient to return for follow-up testing.Group IV1. HIV and Aids infection  Immunodeficiency disorders are caused by an absent or a depressed immune response and manifest in various forms. Immunodeficiency disorders include acquired immunodeficiency syndrome, chronic fatigue and immune dysfunction syndrome, chronic mucocutaneous candidiasis, common variable immunodeficiency, complement deficiencies, DiGeorge syndrome, selective IgA deficiency, and severe combined immunodeficiency disease. Acquired immunodeficiency Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale syndromeCurrently one of the  Activity  The patient will verbalize the  Recognize that a diagnosis of AIDS is profoundly distressing because of the diseasesmost widely publicized intolerance importance of balancing social impact and the discouraging prognosis. The patient may lose his job anddiseases, acquired  Disturbed body activity, as tolerated, with financial security as well as the support of family and friends. Coping with an alteredimmunodeficiency image rest. body image, the emotional burden of serious illness, and the threat of death maysyndrome (AIDS) is  Fatigue overwhelm the patient.marked by progressive  The patient will verbalize  Hopelessnessfailure of the immune feelings about a changed body  Monitor the patient for fever, noting any pattern, and for signs of skin breakdown,  Hyperthermiasystem. Although its image. cough, sore throat, and diarrhea. Assess him for swollen, tender lymph nodes, and  Imbalancedcharacterized by check laboratory values regularly. nutrition: Less  The patient will express thatgradual destruction of he has more energy.  Avoid glycerine swabs for mucous membranes. Try normal saline or bicarbonate than bodycell-mediated (T-cell) mouthwash for daily oral rinsing. requirements  The patient will makeimmunity, it also  Impaired oral decisions on his own behalf.  Record the patients caloric intake.affects humoral mucousimmunity and even  The patient will maintain a  Ensure adequate fluid intake during episodes of diarrhea. membraneautoimmunity normal body temperature.  Impaired skin  Provide meticulous skin care, especially if the patient is debilitated.because of the central integrity  The patient will maintainrole of the CD4+ T  Encourage the patient to maintain as much physical activity as he can tolerate. Make  Impaired tissue current weight or achievelymphocyte in sure his schedule includes time for both exercise and rest. integrity
  17. 17. immune reactions.  Ineffective ideal weight.  If the patient develops Kaposis sarcoma, monitor the progression of lesions.The resultant coping  The patients oral mucousimmunodeficiency  Ineffective health  Monitor opportunistic infections or signs of disease progression, and treat infections membranes will remain intact.makes the patient maintenance as ordered.susceptible to  Ineffective  The patients wounds and  Combination antiretroviral therapy is used to maximally suppress HIV replication,opportunistic protection lesions will heal without thereby improving survival. Poor drug compliance may lead to resistance andinfections, unusual  Ineffective complications. treatment failure. Patients must understand that medication regimens must becancers, and other sexuality  The site of impaired tissue will followed closely and may be required for many years, if not throughout life.abnormalities that patterns have reduced redness,define AIDS.  Interrupted  Urge the patient to inform potential sexual partners and health care workers that he swelling, and pain. family processes has HIV infection.  Noncompliance  The patient will use support  Teach the patient how to identify the signs of impending infection, and stress the (treatment systems to assist with coping. importance of seeking immediate medical attention. regimen)  The patient will perform  Powerlessness  Involve the patient with hospice care early in treatment so he can establish a health maintenance activities  Risk for deficient relationship. according to the level of his fluid volume ability.  If the patient develops AIDS dementia in stages, help him understand the progression  Risk for infection of this symptom.  Social isolation  The patient will demonstrate use of protective measures,  Keep in mind that cultures that traditionally rely on extended family, churches, and including conserving energy, ministers for social and emotional support, such as Blacks and Hispanics, may feel maintaining a balanced diet, particularly isolated if theyre reluctant to disclose their HIV illness to anyone other and getting plenty of rest. than immediate family. With several major support systems unavailable to them, they may need support and assistance in tapping their internal resources as well as in using  The patient will voice feelings other external resources that may be available to them. about changes in sexual identity. Health care workers and the public are advised to use precautions in all situations that risk exposure to blood, body fluids, and secretions. Diligently practicing  The family will state ways to standard precautions can prevent the inadvertent transmission of acquired support and assist the patient. immunodeficiency syndrome (AIDS), hepatitis B, and other infectious diseases that are  The patient will comply with transmitted by similar routes. In addition: the treatment regimen.  Educate the patient and his family, sexual partners, and friends about disease  The patient will express transmission and prevention of extending the disease to others. feelings of control over his  Inform the patient not to donate blood, blood products, organs, tissue, or sperm. condition and situation.
  18. 18.  The patient will maintain  If the patient uses I.V. drugs, caution him not to share needles. adequate fluid balance.  Inform the patient that high-risk sexual practices for AIDS transmission are those that  The patient will experience no exchange body fluids, such as vaginal or anal intercourse without a condom. fever, chills, or other signs or  Discuss safer sexual practices, such as hugging, petting, mutual masturbation, and symptoms of illness. protected sexual intercourse. Abstaining is also the most protective method of not  The patient will maintain peer transmitting the disease. and family relationships.  Advise female patients of childbearing age to avoid pregnancy. Explain that an infant may become infected before birth, during delivery, or during breast-feeding.2. Cancer  Cancers in the head, neck, and spine are among the deadliest and most disfiguring. Involvement of speech and sense organs, as well as the central nervous system, can have an enormous impact on the patients quality of life.  The lung and breast are the most common sites for thoracic cancer. Although rare, soft-tissue sarcomas may also develop in the chest region.  Cancers in the abdominal and pelvic region of the body can obstruct the affected organ or disrupt its secretory or absorptive functions and obstruct the flow of GI contents.  Besides their impact on physiologic function, cancers of the reproductive system have profound implications for the patients body image and self-esteem.  Cancer in bone, skin, and soft tissue can be just as serious as cancer in some major organs. Both primary malignant tumors and metastatic lesions may afflict these structures.  When cancer affects the circulatory systems, the entire body may become rapidly involved in the disease. Esophageal cancer Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleEsophageal cancer is  Acute pain  The patient will express  Monitor the patients nutritional and fluid status, and provide him with high-calorie,most common in  Anxiety feelings of comfort and high-protein foods. If hes having trouble swallowing solids, puree or liquefy his food,males older than age  Deficient fluid decreased pain. and offer a commercially available nutritional supplement. As ordered, provide tube60 and is nearly volume feedings, and prepare him for supplementary parenteral nutrition.  The patient will express thatalways fatal. The  Fatigue he feels less anxious.  To prevent food aspiration, place the patient in Fowlers position for meals and allowdisease occurs  Fear plenty of time to eat. If he regurgitates food after eating, provide mouth care.worldwide, but  Imbalanced  The patient will maintain fluid
  19. 19. incidence varies nutrition: Less volumes within normal range.  If the patient has a gastrostomy tube, give food slowly—by gravity—in prescribedgeographically. It is than body  The patient will express that amounts (usually 200 to 500 ml). Offer him something to chew before each feeding.most commonly found requirements he has more energy. This promotes gastric secretions and provides some semblance of normal Japan, Russia,  ImpairedChina, the Middle swallowing  The patient will express  Administer ordered analgesics for pain relief as necessary. Provide comfort measures,East, and the Transkei  Risk for concerns and fears related to such as repositioning and distractions.region of South Africa. aspiration his diagnosis and condition.  After surgery, monitor the patients vital signs, fluid and electrolyte balance, and  Risk for infection  The patient will maintain intake and output. Immediately report unexpected changes in the patients condition. weight within an acceptable Monitor him for such complications as infection, fistula formation, pneumonia, range. empyema, and malnutrition.  The patient will swallow  If an anastomosis to the esophagus was performed, position the patient flat on his without coughing or choking. back to prevent tension on the suture line. Watch for signs of an anastomotic leak.   If the patient had a prosthetic tube inserted, make sure it doesnt become blocked or The patient wont aspirate. dislodged. This could cause a perforation of the mediastinum or precipitate tumor  The patient will show no erosion. evidence of infection.  After radiation therapy, monitor the patient for such complications as esophageal perforation, pneumonitis and fibrosis of the lungs, and myelitis of the spinal cord.  After chemotherapy, take steps to decrease adverse effects, such as providing normal saline mouthwash to help prevent mouth ulcers. Allow the patient plenty of rest, and administer medications as ordered to reduce adverse effects.  Protect the patient from infection.  Throughout therapy, answer the patients questions and tell him what to expect from surgery and other therapies. Listen to his fears and concerns, and stay with him during periods of severe anxiety.  Encourage the patient to identify actions and care measures that promote his comfort and relaxation. Try to perform these measures, and encourage the patient and family to do so as well.  Whenever possible, include the patient in care decisions.  Explain the procedures the patient is to undergo after surgery—closed chest drainage, nasogastric suctioning, and placement of gastrostomy tubes.
  20. 20.  If appropriate, instruct family members in gastrostomy tube care. This includes checking tube patency before each feeding, providing skin care around the tube, and keeping the patient upright during and after feeding.  Stress the need to maintain adequate nutrition. Ask a dietitian to instruct the patient and family. If the patient has difficulty swallowing solids, instruct him to puree or liquefy his food and to follow a high-calorie, high-protein diet to minimize weight loss. Also, recommend that he add a commercially available, high-calorie supplement to his diet.  Encourage the patient to follow as normal a routine as possible after recovery from surgery and during radiation therapy and chemotherapy. Tell him that this will help him maintain a sense of control and reduce the complications associated with immobility.  Advise the patient to rest between activities and to stop activity that tires him or causes pain.Group V1. Cardiovascular Disorders  Abnormalities during fetal development may cause structural defects of the heart and great arteries. These defects may increase pulmonary blood flow (such as atrial septal defect, patent ductus arteriosus, and ventricular septal defect), obstruct the flow of blood out of the heart (such as coarctation of the aorta), cause a mixing of oxygenated and deoxygenated blood in the heart or great vessels (such as transposition of the great arteries), or decrease pulmonary blood flow (such as Tetralogy of Fallot).  Valvular heart disease  Acquired inflammatory heart disease  Degenerative cardiovascular disorders  Vascular disorders can affect the arteries, the veins, or both types of vessels. Arterial disorders include aneurysms, which result from a weakening of the arterial wall; arterial occlusive disease, which commonly results from atherosclerotic narrowing of the arterys lumen; and Raynauds disease, which may be linked to immunologic dysfunction. Thrombophlebitis, a venous disorder, results from inflammation or occlusion of the affected vessel. Hypertension Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale
  21. 21. Hypertension is an  Deficient  The patient will identify  If a patient is hospitalized with hypertension, find out if he was taking his prescribedintermittent or knowledge appropriate food choices. antihypertensive. If he wasnt, ask why. If he cant afford the medication, refer him tosustained elevation of (lifestyle the appropriate social service department.  The patient will express thatdiastolic or systolic modifications) he has more energy.  When routine blood pressure screening reveals elevated pressure, make sure theblood pressure. Serial Fatigue sphygmomanometer cuff size is appropriate for the patients upper armblood pressure  Ineffective  The patient will demonstrate circumference. Take the pressure in both arms in lying, sitting, and standing positions.measurements are coping adaptive coping behaviors. Ask the patient if he smoked, drank a beverage containing caffeine, or wasused to classify  Ineffective tissue  The patient will maintain emotionally upset before the test. Advise him to return for blood pressure testing athypertension: perfusion: adequate cardiac output and frequent and regular intervals. Cardiopulmonary hemodynamic stability. Prehypertension:  Noncompliance:  To help identify hypertension and prevent untreated hypertension, participate in systolic blood  The patient will comply with Therapeutic public education programs dealing with hypertension and ways to reduce risk factors. pressure greater his therapy regimen. regimen Encourage public participation in blood pressure screening programs. Routinely than 120 but less  Risk for injury  The patient will remain free screen all patients, especially those at risk (blacks and those with family histories of than 140 mm Hg from complications. hypertension, stroke, or heart attack). or diastolic blood pressure greater  Teach the patient to use a self-monitoring blood pressure cuff and to record the than 80 but less reading at least twice weekly in a journal for review by the physician at every office than 90 mm Hg appointment. Tell the patient to take his blood pressure at the same hour each time with relatively the same type of activity preceding the measurement. Stage 1 hypertension:  Tell the patient and family to keep a record of drugs used in the past, noting especially systolic blood which ones are or arent effective. Suggest recording this information on a card so the pressure greater patient can show it to his physician. than 139 but less  To encourage compliance with antihypertensive therapy, suggest establishing a daily than 160 mm Hg routine for taking medication. Warn the patient that uncontrolled hypertension may or diastolic blood cause stroke and heart attack. Tell him to report any adverse reactions to prescribed pressure greater drugs. Advise him to avoid high-sodium antacids and over-the-counter cold and sinus than 89 but less medications containing harmful vasoconstrictors. than 100 mm Hg  Help the patient examine and modify his lifestyle. Suggest stress-reduction groups, Stage 2 dietary changes, and an exercise program, particularly aerobic walking, to improve hypertension: cardiac status and reduce obesity and serum cholesterol levels. systolic blood pressure greater  Encourage a change in dietary habits. Help the obese patient plan a reducing diet. Tell him to avoid high-sodium foods (such as pickles, potato chips, canned soups, and cold
  22. 22. than 159 mm Hg cuts), table salt, and foods high in cholesterol and saturated fat. or diastolic blood pressure greater than 99 mm Hg2. Pulmonary Disorders  Pediatric disorders include croup, a severe inflammation of the upper airway, and epiglottiditis, an acute inflammation of the epiglottis that affects mainly young children. They also include respiratory distress syndrome, which is marked by widespread alveolar collapse and occurs mainly in premature infants, and sudden infant death syndrome, which strikes apparently healthy infants.  Acute respiratory disorders require prompt treatment and nursing care. They range from acute respiratory distress syndrome to sarcoidosis.  Several factors can lead to chronic respiratory disorders. For instance, a genetic defect leads to cystic fibrosis, whereas damage to the bronchial wall results in bronchiectasis. Environmental factors cause chronic obstructive pulmonary disease, infection causes pulmonary tuberculosis, and occupational hazards lead to such disorders as asbestosis, berylliosis, coal workers pneumoconiosis, and silicosis. Atelectasis Nursing Diagnoses Objectives of Care Nursing Interventions and RationaleIn atelectasis, alveolar  Acute pain  The patient will express  Encourage the patient recovering from surgery (or other patients at high risk forclusters (lobules) or  Anxiety feelings of comfort, either atelectasis) to perform coughing and deep-breathing exercises every 1 to 2 hours. Tolung segments that  Deficient verbally or through behavior. minimize pain during these exercises, hold a pillow tightly over the patients incisionalexpand incompletely knowledge area. Teach the patient how to do this for himself. Gently reposition the patient often,  The patient will use supportmay produce a partial (prevention) and help him walk as soon as possible. Administer adequate analgesics to control systems to assist with anxiety.or complete lung  Fear pain.collapse. This  Impaired gas  The patient will express an  Monitor mechanical ventilation. Maintain tidal volume at 10 to 15 ml/kg of thephenomenon exchange understanding of techniques patients body weight to ensure adequate lung expansion. Use the sigh mechanism oneffectively removes  Ineffective to prevent atelectasis, such as the ventilator, if appropriate, to intermittently increase tidal volume at the rate of 3certain regions of the airway clearance incentive spirometry and deep to 4 sighs/hour.lung from gas  Ineffective This allows breathing  Monitor pulse oximetry for decreases in oxygenation.  The patient will discuss fearsunoxygenated blood pattern and concerns.  Help the patient use an incentive spirometer to encourage deep pass unchanged  Risk for infectionthrough these regions  The patient will maintain  Humidify inspired air, and encourage adequate fluid intake to mobilize secretions. Useand produces hypoxia. adequate ventilation and postural drainage and chest percussion to remove secretions.
  23. 23. oxygenation.  For the intubated or uncooperative patient, provide suctioning as needed. Administer The patient will maintain a sedatives with care because these medications depress respirations and the cough patent airway. reflex. They also suppress sighs. Keep in mind that the patient is able to cooperate minimally (or not at all) with treatment if he has pain. The patient will maintain a respiratory rate within five  Assess breath sounds and respiratory status frequently. Report changes immediately. breaths of baseline.  Offer ample reassurance and emotional support because the patients limited The patient will remain free breathing capacity may frighten him. from signs and symptoms of  Teach the patient how to use the spirometer. Urge him to use it every 1 to 2 hours. infection.  Show the patient and family members how to perform postural drainage and percussion. Instruct the patient to maintain each position for 10 minutes and then perform chest percussion. Let him know when to cough. Teach coughing and deep- breathing exercises to promote ventilation and mobilize secretions.  Encourage the patient to stop smoking, lose weight, or both, if needed. Refer him to appropriate support groups for help.  Demonstrate comfort measures to promote relaxation and conserve energy. Advise the patient and family members to alternate periods of rest and activity to promote energy and prevent fatigue.