February 2012 | Nursing Care Plan

What is Deep Vein Thrombosis?Nursing Care Diagnosis and Intervention

What is Deep Vein Thrombosis?
Thrombophlebitis, or the formation of a clot within the vein, commonly occurs within the deep veins in the legs, and may also occur in the arms. Initially platelets and white cells clump together, sticking to the inside of the vessel wall. As blood flows over the area, other cells may deposit onto the area, making the thrombus larger. Compression of blood flow, which will increase the venous pressure or sluggishness of the blood flow, can increase the risk of clot formation. Immobility,obesity, or hormonal changes such as pregnancy can all contribute to increased risk.

Nursing Diagnosis Deep Vein Thrombosis
• Risk for acute pain
• Impaired physical mobility

Nursing Intervention for Deep Vein Thrombosis
• Monitor vital signs .
• Monitor for signs of pulmonary embolism, shortness of breath, chest pain,
tachycardia (rapid heart rate), tachypnea (rapid respirations), and diaphoresis
(sweating).
• Monitor for signs of bleeding or bruising.
• Avoid massaging the area to lessen the possibility of dislodging the clot.
• Intermittent warm, moist soaks. Assess skin between changes.
• Follow weight-dosed heparin protocol.
• Monitor lab results: PT, PTT, INR, and CBC with platelets.
• Low molecular weight heparin (enoxaparin, dalteparin).
• Warfarin orally.
• Instruct patient to:
• Report signs of bleeding or bruising to physician, nurse practitioner, or
physician assistant.
• Avoid injury.
• Use of electric razor and soft toothbrush; avoid flossing between teeth.
• Diet restrictions, and to check with health care provider or pharmacist
about interactions of any medications, if on warfarin as outpatient.
Sources
Medical-Surgical Nursing Demystified

What is Myocarditis?Nursing Care Diagnosis and Intervention

What is Myocarditis?
Myocarditis is an inflammation of the heart muscle or myocardium. In general, myocarditis caused by infectious diseases, but can be as a result of allergic reactions to drugs and toxic effects of chemicals radiation.

Symptoms of Myocarditis

Malaise
Rash
Fever
Variable symptom severity
Chest pain
Arrhythmia
Breathlessness
Acute heart failure - see also symptoms of heart failure
Eosinophilia
Chest discomfort
Heart palpitations
Heartbeat irregularity
Abnormal heart electrical activity test results
Increased heart enzymes
Enlarged heart
Increased heart rate

Nursing Diagnosis of Myocarditis Client

Risk for Infection
Ineffective Peripheral Tissue Perfusion
Activity Intolerance
Acute Pain
Risk of Decreased Cardiac Output
Knowledge Deficit

Nursing Intervention Myocarditis client
Temporarily limit the patient’s activities to decrease stress on the heart.
• Provide bedside commode.
• Monitor for:
• Difficulty breathing (dyspnea) because fluid overload.
• Heart rate >100 beats per minute (tachycardia) because infection or inflammation
may increase the heart rate.
• No competitive sports.
• Return to normal activities slowly once physician approves.

Sources
Medical-Surgical Nursing Demystified

Nursing care Myocarditis , Nursing Diagnosis Myocarditis , Nursing Intervention

What is Pulmonary Embolism?Nursing Care Diagnosis and Intervention

What is Pulmonary Embolism?
Blood flow is obstructed in the lungs caused by thrombus (blood clot), air, or fat emboli that become stuck in an artery, causing impaired gas exchange. Patients may be predisposed to clot formation, have pooling of blood, or damage to vessel walls, or take certain medications that increase the risk of thrombus formation.
Thrombus are commonly found in vessels in lower extremities. When a thrombus loosens and travels in the peripheral circulation, it is called an embolus. The embolus travels through the right side of the heart and is sent to the lungs where it lodges in one of the arteries. Depending on the size of the artery that the embolus lodges in, a section of lung will have no blood supply and alveolar function will suffer. As blood supply to an area of the lung diminishes, alveoli collapse,causing atelectasis.

Nursing Diagnosis for Pulmonary Embolism Client
• Anxiety
• Impaired gas exchange
• Ineffective tissue perfusion

Nursing Intervention for Pulmonary Embolism Client
• Monitor arterial blood gas for changes and decrease in oxygenation.
• Monitor pulse oximetry for oxygen saturation.
• Place patient in high Fowler’s position.
• Monitor cardiovascular status for heart rate, rhythm, heart sounds, and pulse deficit.
• Have the patient perform turning, coughing, and deep-breathing exercises to enhance air movement.
• Monitor respiration for rate, effort, use of accessory muscles, skin color, and lung sounds.

Explain to the patient:
• To avoid sitting and standing for too long to decrease chance of clot
formation.
• Not to cross legs to avoid constriction of vessels in the lower extremities,decreasing the chances of clot formation.
• That pulmonary embolism is an adverse effect from using hormonal contraceptives and a different form of birth control needs to be used in the future
• How to identify side effects from using anticoagulants, such as bleeding or bruising.
.

Sources
Medical-Surgical Nursing (Demystified)

Nirsing Diagnosis Pulmonary Embolism , Nursing care Pulmonary Embolism , Nursing Intervention Pulmonary Embolism

Nursing Intervention A Client with Typhoid fever

Nursing Intervention A Client with Typhoid fever
Typhoid fever carry the bacteria in their bloodstream and intestinal tract and can spread the infection directly to other people by contaminating food or water.

What are the signs and symptoms of typhoid fever?
If you have typhoid fever you may have the following symptoms:

• constant fever up to 104°
• diarrhea
• constipation
• stomach pain
• headache
• malaise
• nonproductive cough
• slow heart rate (bradycardia)
• anorexia

Nursing Assessment for Typhoid fever

Health History Now
Why patients enter the hospital and what the major complaints of patients, so it can be

enforced priority nursing issues that may arise.

Previous Health History
Does the patient had been ill and treated with the same disease.
Family Health History
Does anyone in the family of patients, the sick like a patient.
Psychosocial History
Intrapersonal: the feeling felt client (anxious / sad)
Interpersonal: relationship with other people.
Patterns of health function
The pattern of nutrition and metabolism.
Usually the client is reduced appetite due to a disruption in the small intestine.
Rest and sleep patterns
During the pain patients feel unable to rest because the patient felt pain in her

stomach, nausea, vomiting, sometimes diarrhea.

Physical examination
Awareness and patient's general condition
Patient awareness of the need to study the unconscious - not conscious (composmentiscoma) to assess the severity of the patient's disease prognosis.

Vital Signs and physical examination Head to foot
Blood pressure, pulse, respiration, temperature which is a measure of the general
condition of patient / patient's condition and includes examination from head to toe by using
the principles of inspection, auscultation, palpation, percussion), in addition to body weight
were also aware of any decline weight because of the increased nutritional deficiencies that
occur, so it can be calculated nutritional needs required.

Nursing Diagnosis for Typhoid fever
The increase in body temperature associated with the infection process of salmonella thypii

Nursing Intervention for Typhoid fever
Objectives : Normal body temperature
Intervention :

Observation of the client's body temperature
Rational: to know the changes in body temperature.
Encourage the family to put on clothing that can absorb sweat like cotton
Rational: to maintain body hygiene
Collaboration with physicians in the provision of anti piretik
Rational: to reduce the heat to the drug

Give an explanation of the importance of fluid requirements in patients and families.
Observation of input and output of fluid.
Instruct the patient to drink plenty of 2.5 liters / 24 hours.
Observation drip infusion.
Collaboration with physicians to fluid therapy (oral / parenteral).

Sources
http://nanda-nursing.blogspot.com/2011/01/nursing-diagnosis-and-nursing_17.html

Nursing Care Typhoid fever , Nursing Diagnosis Typhoid fever , Nursing Intervention Typhoid fever

About Liver Functions and Nursing Intervention for Liver Cancer Client

The liver has many functions. Some of the functions are: to produce substances that break down fats, convert glucose to glycogen, produce urea (the main substance of urine), make certain amino acids (the building blocks of proteins), filter harmful substances from the blood (such as alcohol), storage of vitamins and minerals (vitamins A, D, K and B12) and maintain a proper level or glucose in the blood. The liver is also responsible for producing cholesterol. It produces about 80% of the cholesterol in your body.

Nursing Intervention for Liver Cancer Client

Explain the treatments to the patient and his family, including adverse reactions the patient may experience.
Give analgesics as ordered and encourage the patient to identify care measures that promote comfort.
Prepare the patient for surgery, if indicated.
Provide comprehensive care and emotional assistance.
Monitor the patient for fluid retention and ascites.
Monitor respiratory function.
Provide patient with a special diet that restricts sodium, fluids, and protein and that prohibits alcohol.
To increase venous return and prevent edema, elevate the patient’s legs whenever possible.
Keep the patient’s fever down.
Provide meticulous skin care.
Turn the patient frequently and keep his skin clean to prevent pressure ulcers.

Sources:
http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing-interventions-for-liver-cancer.html
http://www.mamashealth.com/organs/liver.asp

nursing care Liver Cancer , Nursing Diagnosis Liver Cancer , Nursing Intervention Liver Cancer

What is Fractures?Nursing Care Diagnosis and Intervention

A fracture is the separation of bone. The degree of the separation depends on the strength of the bone and energy of events that caused the fracture.
Fractures are classified in four categories:
Complete: The bone separates into two distinct parts.
Incomplete: The bone does not separate into two distinct parts.
Closed (simple): The bone does not break the skin.
Open (compound): The bone breaks the skin.
There are three types of fractures:
Hairline: An incomplete fracture.
Greenstick: An incomplete fracture where the bone is partially broken resulting in the bone bending like a broken green stick.
Comminuted: A complete fracture where the bone is broken into several fragments.

Symptoms of Fracture

Crepitus
Reduced range of motion
Unable to bear weight on the injured bone
Pain
Deformity
Edema

Nursing Diagnosis of Fracture

Increased risk of hypovolemia and shock related to trauma and bleeding.
Increased risk of bone inflammation related to open fracture.
Increased risk of fat embolism related to fracture of the long bones.
Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation.
Pain and immobility , related to diagnosis of fracture.
Increased risk of respiratory, cardiovascular, bowel, and skin complications related to a long period of immobility.
Anxiety related to the symptoms of disease and fear of the unknown.

Nursing Intervention of Fracture

Provide fracture fixation to prevent following injury of tissues.
Observe signs of fat embolism (especially during first 48 hours after the fracture).
Monitor fluids input and output continuously, insert IV catheter, urinary catheter.
Monitor client’s vital signs.
Monitor client’s laboratory tests results for abnormal values.
Provide emergency care if requires (hemostasis, respiratory care, prevention of shock).
Provide care to client with cast (observe signs of circulatory impairment – change in skin color and temperature, diminished distal pulses, pain and swelling of the extremity; protect the cast from damage).
Provide care to client in traction (check the weights are hanging freely, observe skin for irritation and site of skeletal traction insertion for signs of infection; use aseptic technique when cleaning the site of insertion).
Administer IV therapy, analgesics, antibiotics, and other medications as prescribed.
Prepare client and his family for surgical intervention if required.
For client after surgical intervention provide routine postoperative care and teach about possible postoperative complications.
In case of hip fracture and hip replacement maintain the adduction of the affected extremity.
Teach the client appropriate crutch-walking techniques .
Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation.
Instruct client regarding fracture healing process, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.
Provide respiratory exercises to prevent lung complications.
Observe for signs of thrombophlebitis, report immediately.
Provide appropriate skin care to prevent pressure sores.
Encourage fluid intake and high-protein, high-vitamin, high-calcium diet.

Nursing Diagnosis Fractures , Nursing Intervention , nursingcare Fractures

General Postoprative Nursing Care Implications

a. Monitor vital signs as ordered.
b. Report elevated temperature and rapid/weak pulse immediately to supervisor (infection).
c. Report lowered blood pressure and increased pulse to supervisor (hypovolemic shock).
d. Administer analgesics as ordered.
e. Apply all nursing implications related to the patient receiving analgesics whether narcotic or nonnarcotic, to include the following.
(1) Check each medication order against the doctor's order.
(2) Prepare the medications (check labels, accurately calculate dosages, observe proper asepsis techniques with needles and syringes).
(3) Check the patient's identification wristband to ensure positive identification before administering medications.
(4) Administer the medications. Offer each drug separately if administering more than one drug at the same time.
(5) Remain with the patient and see that the medication is taken. Never leave medications at the bedside for the patient to take later.
(6) Document the medications given as soon as possible.
f. Administer IV fluids as ordered. Maintain and monitor all IV sites. Follow SOP for infection control.
g. Participate with the health team in the patient's nutrition therapy.
h. Apply all nursing implications related to the patient diets (serving, recording intake, and food tolerance).
i. Coordinate with team leader for "take-home" wound care supplies and prescriptions for self-administration.
j. Prepare the patient and the family for disposition (transfer, return to duty, discharge). Supply the patient or family member with written instructions for:
(1) Wound care.
(2) Medications.
(3) Making outpatient appointments.
(4) An emergency, including the phone numbers for doctors and/or clinics.
k. Document the patient's disposition in the nurse's notes in accordance with unit

Sources
U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL FORT SAM HOUSTON, TEXAS 78234-6100

FON , Nursing Education Post operative Care , Postopative Nursing Care

What is Leukemia?Nursing Care and Intervention

Leukemia, the most common cancer in childhood, is a group of cancer diseases of blood-forming tissues such as the bone marrow and lymphatic system.
The problem in leukemia is the production of an excessive number of immature (still in the stem, or “blast,” stage) white blood cells (WBCs). Crowding from these excessive immature cells compromises the production of other cells in the bone marrow. The leukemias are categorized by subtype into two major classifications: acute lymphoid leukemia (ALL)/blast stem leukemia,the most common type in children, and acute myelogenous leukemia (AML),most frequent in adults and the most common form of leukemia overall. The primary difference is the type of leukocyte (WBC) involved. In ALL, the immature WBCs are lymphocytes, and in AML the WBCs involved are cells from the myeloid line, primarily granulocytes or monocytes.

Nursing Interventions of Leukemia in Children

Reinforce physician’s explanation of diagnosis and treatment plan.
Maintain contact after discharge and between remissions to encourage
follow-up care and respond to questions or provide emotional support.
Provide antiemetic and appetite stimulant to increase nutritional intake.
Offer foods after antiemetic takes effect to reduce nausea and maximize
caloric intake.
Explain procedure at child’s level of understanding including what will
be seen, felt, heard, and smelled; use drawings when appropriate.
Allow to eat any food that is tolerated; avoid forcing food during nausea
episode.
Rinse mouth to remove unpleasant taste sensation.

Sources:
Pediatric Nursing Demystified (Demystified Nursing)

nursing care Leukemia , Nursing Intervention Leukemia , Pediatric Nursing

What is Stomatitis?Nursing Care and Nursing Intevention

Stomatitis, inflammation of the oral mucosa, including the cheek, lip,tongue, palate, and floor of the mouth, may be infectious or noninfectious.The most common form in children is aphthous stomatitis, or canker sore,which has an unknown origin or may be associated with trauma such as injury with toothbrush, biting of the cheek, or abrasion by braces.

Symptoms of Stomatitis

Mouth inflammation
Sore mouth
Mouth ulcers
Sore oral membranes
Oral membrane ulcers
Bad breath
Oral bleeding
Blood in saliva

Nursing Intervention of Stomatitis Children
Pain relief
• Administer topical agents and analgesics for pain relief.
• Provide medication before meals to promote adequate nutrition intake.
• Provide straw for drinking to avoid painful lesions.
• Perform mouth care with soft toothbrush, foam applicator, or cloth for comfort.
Teach the client and parents:
• Prevention of spread through careful handwashing and teaching to keep fingers out of mouth and avoid touching body with contaminated hands.
• All objects placed in the mouth of the infected child should be washed thoroughly or discarded.
• Use restraint as needed to prevent self-contamination by younger child.
• Keep immunocompromised persons, infants, and other young children
away from infected child to avoid exposure.
• Inform parents and older children that type 1 HSV is not the herpes commonly associated with sexual activity, to avoid assumptions that the child is sexually active.

Sources
Pediatric Nursing Demystified (Demystified Nursing)
http://www.rightdiagnosis.com/s/stomatitis/symptoms.htm

nursing care Stomatitis , Nursing Intervention Stomatitis , Pediatric Nursing

What is Food poisoning(gastroenteritis)?Nursing Care Diagnosis and Intervention

Food poisoning comes from eating food or drinking water that is the contaminated with a virus, bacterium, parasite, or chemical that causes illness. It is also called gastroenteritis.

Symptoms of Food poisoning(gastroenteritis)
The major clinical manifestations are diarrhea of varying degrees and abdominal pain and cramping. Associated clinical manifestations are nausea, vomiting, fever anorexia, distention, tenesmus, and borborygmi.

Nursing Diagnosis for Food poisoning(gastroenteritis)

Imbalanced Nutrition: Less than Body Requirements due to insufficient intake and excessive output;
Risk for Deficient Fluid Volume (if Diarrhea does not occur or intake of fluids is insufficient but does not have any signs of dehydration);
and Hyperthermia RT inflammatory process.
manifestations of gastroenteritis is abdominal pain

Nursing Care Plan For Food poisoning(gastroenteritis) Client

Monitor the patient’s fluids status carefully.
Plan care to allow uninterrupted rest periods for the patient.
If the patient is nauseated, advise him to avoid quick movements, which can increase the severity of nausea.
If the patient can tolerate oral fluids, replace lost fluids and electrolytes with broth, ginger, ale, and lemonade, as tolerated.
Assess vital signs at least every 4 hours, weigh him daily, and record intake and output.
Teach the patient about gastroenteritis, describing its symptoms and varied causes.
Teach the patient the proper preventive measures
If dehydration occurs, administer oral and I.V. fluids as ordered.
To ease anal irritation caused by diarrhea, clean the area carefully and apply repellent cream, such as petroleum jelly.
Wash hand thoroughly after giving care to avoid spreading of infection, and use standard precaution whenever handling vomitus or stools.

Sources
Bjorklund, Ruth. Food Borne Illnesses New York : Marshall Cavendish Benchmark, 2006.
Scott, Elizabeth and Paul Sockett. How to Prevent Food Poisoning: A Practical Guide to Safe Cooking, Eating, and Food HandlingNew York: Wiley, 2001.

nursing care Food poisoning(gastroenteritis) , Nursing Diagnosis Food poisoning(gastroenteritis) , Nursing Intervention Food poisoning(gastroenteritis)

What is Glaucoma?Nursing Care Primary Nursing Diagnosis and Intervention

Glaucoma is an acute or chronic condition in which there is an increase of intraocular pressure (IOP), which leads to damage of the retina and optic nerve, with resulting visual field loss.

Cause of Glaucoma
Glaucoma causes include elevated eye pressure (called intraocular pressure or IOP) due to the eye’s inability to drain fluid efficiently.

Symptoms of Glaucoma

Severe eye or brow pain
Headache
Nausea
Vomiting
Redness of the eye
Decreased or blurred vision
Seeing colored rainbows or halos

Primary Nursing Daignosis
Sensory and perceptual alterations (visual) related to nerve fiber destruction caused by increased IOP

Nursing Intervention for Glaucoma Client

Monitor blood pressure, pulse, and respiration every 4 hours.
Monitor the degree of eye pain every 30 minutes during the acute phase.
Monitor input and output every 8 hours while receiving intravenous osmotic agent.
Monitor visual acuity at any time before hatching ophthalmic agents.
Give appropriate instructions optalmic agent for glaucoma. Inform your doctor if :
        hypotension
        urinary output of less than 240 ml / hour
        No loss of pain in the eye within 30 minutes of drug therapy
        Decrease in constant visual acuity.
Prepare patients for surgery
Maintain bed rest in semi-Fowler position. Prevent increase in IOP :
    Instruct to avoid coughing, sneezing, straining, or placing the head below the pelvic
    Provide quiet environment and avoid light.
    Give anlgetic prescription and evaluation of its effectiveness.

nursing care Glaucoma , nursing diagnosis Glaucoma , nursing intervention Glaucoma

Nursing Diagnosis and intervention Tuberculosis Clients

Tuberculosis is a infective disease that spread through person to person tuberculosis is airborne disease caused by the Mycobacterium tuberculosis.

Nursing Diagnosis for tuberculosis Clients

Risk for infection
fatigue
impaired gas exchange
imbalanced nutrition
ineffective health maintenance

Nursing Intervention for tuberculosis Client

Take the Patient is isolation to prevent and spreading tuberculosis risk for infection to other person
Always wear N-95 Mask for Nursing care and Therapy purpose nurses paramedical staff and vistors
Place the Patient in a negative pressure room and in a isolation room
Take standrad precuation providing direct care to the patien.
Give Appropriate Diet and take diet plan for nutritionest.
Monitor Patient nutrition need.
To take coughing adiqat
Teach the tuberculosis patient to stay in well ventilated areas and limit contact to other people
Give ATT Drug and other medication as prescribed
Be alert for signs of drug reaction.
Give postion in a high fowlers to reduce maximum difficulty of breathing
To maintain rest periods so the tuberculosis patient can have energy to breathe

nursing care Tuberculosis , nursing diagnosis Tuberculosis , nursing intervention Tuberculosis

What is Hemorrhoids?Nursing Care Diagnosis And Intervention

What is Hemorrhoids?
Hemorrhoids are a common, generally insignificant swelling and distension of veins in the anorectal region. They become significant when they bleed or cause pain or itching.
Hemorrhoids develop when increased intra-abdominal pressure produces increased systemic
and portal venous pressure, thus causing increased pressure in the anorectal veins. The arterioles in the anorectal area send blood directly to the swollen anorectal veins, further increasing the pressure. Recurrent and repeated increased pressure causes the distended veins to separate from the surrounding smooth muscle and leads to their prolapse (enlarged internal hemorrhoids that actually protrude through the anus).

Causes of Hemorrhoids Clients
heart failure; anorectal infections; anal intercourse; alcoholism; pregnancy; colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or hepatitisconstipation, diarrhea, coughing, sneezing, or vomiting and loss of muscle tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids

Nursing Diagnosis for Hemorrhoids Clients

Pain (acute or chronic) related to rectal swelling and prolapse
Constipation related to ignore the urge to defecate due to pain during defecation
Anxiety related to plan surgery
Acute pain related to irritation, pressure and rectal sensitivity in the area / anal and anorectal disease secondary to postoperative spasm of the sphincter.
Impaired Urinary Elimination related to the fear of postoperative pain.
Risk for infection related to inadequate primary defenses.
Deficient knowledge related to the lack of information about home care.

Nursing Intervention for Hemorrhoids Client

Administer local anesthetic as prescribed.
As needed, provide warm sitz baths or cold compresses to reduce local pain, swelling, and information.
Check for signs and symptoms of anal infection, such as increases pain and foul smelling anal drainage.
Teach the patient about hemorrhoidal development, predisposing factors, and tests.
Encourage the patient to eat high fiber diet to promote regular bowel movement.
Emphasize the need for good anal hygiene. Caution against vigorous wiping with washcloths and using harsh soaps.
Encourage the use of medicated astringent pads and toilet paper without dyes or perfumes.
Prepare the patient for surgery if necessary
Provide the patient with high fiber diet and encourage adequate fluid intake and exercise to prevent constipation.
Monitor the patient’s pain level and the effectiveness of the prescribed medications.

Sources
http://nursingfile.com/nursing-care-plan/nursing-interventions/nursing-interventions-for-hemorrhoids.html
http://blog-nursingcareplan.blogspot.com/2012/02/nursing-care-plan-for-hemorrhoids.html

nursing care Hemorrhoids , nursing diagnosis Hemorrhoids , nursing intervention Hemorrhoids

What is Tetanus?Nursing Care Diagnosis And Intervention

What is Tetanus?
Tetanus, or lockjaw, is a preventable but often fatal disorder that is caused by the bacterium Clostridium tetani, a spore-forming anaerobe. The bacterium exists in spore form in an aerobic environment until it is exposed to an anaerobic environment. The organism then changes to the vegetative form, multiplies, and produces neurotoxins.

Symptoms of Tetanus

Stiffness of your abdominal muscles
Painful body spasms
Fever
Sweating
Spasms and stiffness in your jaw muscles
Stiffness of your neck muscles
Difficulty swallowing
Elevated blood pressure
Rapid heart rate

Nursing Assessment for Tetanus Client
History of present illness: a severe injury, burns and inadequate immunization.
Respiratory System: dyspnea, cyanosis and asphyxia due to respiratory muscle contraction.
Cardiovascular System : dysrhythmias, tachycardia, hypertension and bleeding, initially the body temperature 38-40 ° C or febrile up to the terminal 43-44 ° C.
Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.
Urinary System l: urinary retention (bladder distension and urine output does not exist / oliguria)
Digestive System: constipation due to no bowel movements.
Integument and muskuloskletal System: pain, tingling at the site of injury, sweating, initially trismus, muscle spasms face with increasing contraction eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.
If this continues there will be the status of general convulsions and seizures.

Nursing Diagnosis for Tetanus

Increased body temperature (hyperthermia) related to the effects of toxins (bacteremia)
Changes in nutrition, less than body requirements related to the mastication muscle stiffness
Disturbed interpersonal relationships related to speech difficulties
Impaired daily needs related to the condition of weak and frequent seizures
The risk of fluid and electrolyte imbalances related to intake of less and oliguria
Risk of injury related to frequent seizures
Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasms.
Lack of rest requirements related to frequent seizures.
Breathing pattern disorders related to impaired airway due to spasm of respiratory muscles
Lack of knowledge of the client and family about tetanus disease related to lack of information.

Nursing Intervention for Tetanus Client

Protect the client from injury.
Provide comfort measures.
Monitor client for signs of arrythmias.
Prevent client from having spasms by:
Controlling the environment
Avoiding stress, pain, coughing, or flatus to occur to the patient
Avoid touching, turning, and jarring the bed of the client
The nurse should organize the activity of the client. Provision of cluster care is a must. cluster care is doing all nursing measures in one setting. Gentle nursing care is also required. The nurse should also turn the client to prevent respiratory problems.
Maintain adequate airway and ventilation.
Maintain an intravenous line.

Sources
http://www.nursingcare101.com/tetanus
http://nursing-careplans.blogspot.com/2011/04/nursing-care-plan-for-tetanus.html
http://www.mayoclinic.com/health/tetanus/DS00227/DSECTION=symptoms

nursing care Tetanus , Nursing Diagnosis Tetanus , Nursing Intervention Tetanus

What is Ventricular Tachycardia?Nursing Care Diagnosis and Intervention

What is Ventricular Tachycardia?
Abnormal electrical impulses within the ventricles cause the heart to contract more than 160 beats per minute. This results in inadequate filling of the ventricles with blood between beats; subsequently, less blood is pumped throughout the body than during normal contractions.
Ventricular tachycardia (called “V tach”) often occurs after acute myocardial infarction and in cardiomyopathy, CAD, mitral valve prolapse, and other myocardial disease.
Ventricular tachycardia occurs in people with underlying heart abnormalities. In those who have had a heart attack, for example, the scar from the heart attack causes the electrical abnormalities that create the tachycardia.

Symptoms of Ventricular Tachycardia

Palpitations, an uncomfortable awareness of the heart beating rapidly or irregularly.
Dizziness or lightheadedness.
Shortness of breath.
Chest pain, or angina.
Near-fainting or fainting (syncope).
Weak pulse or no pulse.

Nursing Diagnosis of Ventricular Tachycardia
• Decreased cardiac output
• Impaired gas exchange
• Ineffective tissue perfusion

Nursing Intervention of Ventricular Tachycardia
• Explain to the patient the necessity of follow-up.
• Call the physician if the patient experiences dizziness.
• The importance of regular examinations.
• Begin CPR if pulse is absent.
• Prepare to administer medication per physician’s order or protocol.

nursing care Ventricular Tachycardia , nursing Diagnosis Ventricular Tachycardia , Nursing Intervention Ventricular Tachycardia

What is Pulmonary edema? Nursing Diagnosis and Intervention

What is Pulmonary edema?
Fluid builds up in the lungs as a result of ineffective pumping of blood by the heart as a result of left-sided heart failure, AMI, worsening of heart failure, or volume overload. The patient experiences hypoxia, which is insufficient oxygen supply to tissues, caused by decreased oxygenation of the blood. Several noncardiac issues may lead to pulmonary embolism.

Causes of Pulmonary edema

High blood pressure
Diabetes
Coronary or valvular heart disease
Obesity
Being at high altitude
Central nervous system injury
Infection
Hanta virus
Inhaling toxins

Symptoms of Pulmonary edema

Extreme shortness of breath or difficulty breathing (dyspnea) that worsens when lying down
A feeling of suffocating or drowning
Wheezing or gasping for breath
Anxiety, restlessness or a sense of apprehension
A cough that produces frothy sputum that may be tinged with blood
Excessive sweating
Pale skin
Chest pain, if pulmonary edema is caused by heart disease
A rapid, irregular heartbeat (palpitations)

Nursing Diagnosis of Pulmonary edema
• Anxiety
• Excess fluid volume
• Impaired gas exchange

Nursing Intervention of Pulmonary edema

Place the patient in full Fowler’s position to enhance air exchange and diaphragmatic movement, sitting with legs dangling over sides of bed.
• Monitor cardiovascular function for changes in heart sounds, extra sounds,murmurs.
• Monitor respirations for changes in lung sounds, chest expansion.
Decrease sodium in diet.
• Sleep with head elevated i.e. three pillows, or blocks under head of bed frame.
Check oxygen saturation (pulse oximetry).
• Record fluid intake and output.
• Weigh the patient daily. Call physician if patient gains 2 lbs daily.
• Call physician if BUN and creatinine increase.
• Record characteristics of sputum.
Sources
Read more: http://www.umm.edu/altmed/articles/pulmonary-edema-000137.htm#ixzz1mvDrSppF
Medical-Surgical Nursing Demystified

nursing care Pulmonary edema , nursing diagnosis Pulmonary edema , nursing intervention Pulmonary edema

Nursing Management Scabies Nursing Diagnosis And Intervention

Scabies are mites which burrow into the skin and set up an intense itching in the infested person. Transmission is by prolonged close body contact and the mites may be easily passed on among children. A lotion is applied externally to the entire body from the neck down. One or two applications will usually kill the mites and eggs.

Nursing Diagnosis of SCABIES
Risk of infection related to damaged skin tissue and invasive procedures

Nursing Interventions of SCABIES

Instruct patient to apply the cream at bedtime, from neck down to toes, covering the entire body.
Advise patient to report any skin irritation.
Suggest the family members and other close contact of the patient be checked for possible symptoms and be treated if necessary.
If patient is hospitalized, practice good handwashing technique, or use gloves while performing nursing procedure.
Terminal disinfection should be carried out after discharge of patient.

Nursing Goal of SCABIES

Layer of the skin looks normal
A good skin integrity can be maintained (sensation, elasticity, temperature)
No cuts or lesions on the skin
Able to protect skin and keep skin moist and natural treatments

Sources:
http://www.stdservices.on.net/std/#SCABIES
http://nursingcrib.com/communicable-diseases/what-is-scabies/

Nursing Care Plan Scabies , Nursing Diagnosis Scabies , Nursing Intervention Scabies

Nursing Care Acute Respiratory Failure Diagnosis and Intervention

Nursing Assessment Acute Respiratory Failure

Obtain history from the client as to the onset and progression of symptoms.
Assess respirations for dyspnea and pain that increases with inspiration.
Assess for headache, confusion, restlessness, and increased heart rate.
Assess sputum for quantity and characteristics.

Nursing Diagnosis Acute Respiratory Failure
• Ineffective breathing pattern
. Fatigue related to oxygen deprivation.
. Fear related to air hunger and mechanical ventilation.
• Ineffective airway clearance
• Anxiety

Nursing Goal Acute Respiratory Failure

Prevent avoidable injury.
Maintain effective airway clearance and gas exchange.
Increase comfort.
Reduce anxiety.
Maintain adequate nutritional status.
Increase understanding of the disease process, its treatment, and prevention

Nursing Intervention Acute Respiratory Failure
• Monitor respiratory status for rate, effort, use of accessory muscles, sputum
production, and breath sounds.
• Monitor pulse oximetry to check oxygen saturation levels.
• Monitor sputum for changes in color and amount.
• Monitor vital signs for changes.
• Place patient in high Fowler’s or semi-Fowler’s position on bedrest to ease
respiratory effort by allowing optimal diaphragmatic excursion.
• Monitor ventilator settings if appropriate.
• Change patient position every 2 hours to decrease chance of skin breakdown.
• Monitor intake and output of fluids to check for balance.
• Explain to the patient:
• The importance of doing coughing and deep-breathing exercises to fully
expand lungs and enhance the expelling of mucous.
• How to identify the signs of respiratory distress.
.Provide emotional support to the client and family members.
.Provide teaching in order to provide sufficient care at home and to prevent future incidence.

Nursing Evaluation Acute Respiratory Failure

Maintains adequate gas exchange.
Alleviation of pain and discomfort.
Maintains adequate airway clearance and effective breathing patterns.
Maintains adequate nutritional status.
Absence of infection and complications.

Nursing Assessment Acute Respiratory Failure , Nursing Care plan Acute Respiratory Failure , Nursing Diagnosis Acute Respiratory Failure

What is Cardiomyopathy?Nursing Diagnosis and Intervention

What is Cardiomyopathy?
The middle layer of the heart wall that contains cardiac muscle (myocardium) weakens and stretches, causing the heart to lose its pumping strength and become enlarged. The heart remains functional; however, contractions are weak, resulting in decreased cardiac output. Most are idiopathic and not related to the major causes of heart disease. The three types of cardiomyopathy are:
1. Dilated cardiomyopathy (common): The heart muscle thins and enlarges,which leads to congestive heart failure. Progressive hypertrophy and dilatation result in problems with pumping action of ventricles.
2. Hypertrophic cardiomyopathy: The ventricular heart muscle thickens, resulting in outflow obstruction or restriction. There is some blood flow present.
3. Restrictive cardiomyopathy (rare): The heart muscle becomes stiff and restricts blood from filling ventricles, usually as a result of amyloidosis, radiation,or myocardial fibrosis after open-heart surgery.

Nursing Goal for Cardiomyopathy

Patient alert and oriented
Skin warm and dry
Pulses strong and equal bilaterally
Absence of life-threatening dysrythmias
Urine output 30 ml/hr
CVP 2 to 6 mm Hg
Capillary refill < 3 sec
BP 90 to 120 mm Hg
Pulse pressure 30 to 40 mm Hg

HR 60 to 100 beats/min

Nursing Assessment Cardiomyopathy

Obtain vital signs every 15 minutes during acute phase.
Assess the patient for changes in neurological function hourly and as clinically indicated.
Assess for skin warmth, color, and capillary refill time.
Assess for chest discomfort because myocardial ischemia may result from poor perfusion.
Assess heart and lung sounds to evaluate the degree in heart failure.

NURSING DIAGNOSES for Cardiomyopathy
• Activity intolerance
• Impaired gas exchange
• Decreased cardiac output

NURSING INTERVENTION for Cardiomyopathy
• Place patient in a semi-Fowler’s position for comfort, which eases respiratory
effort.
• Record intake and output of fluids.
• Monitor vital signs to assess for increased respiratory rate, arrythmias.
• Monitor electrocardiogram to look for changes from previous tracing.
• Explain to the patient: fluids restriction may be necessary as heart failure is
a concurrent disease with dilated cardiomyopathy.
• Record daily weight and call physician if weight increases 3 lbs (1.4 kg).
• No smoking or drinking alcohol.
• No straining during bowel movements.
• Increase exercise.
Sources:
http://nursingcrib.com/critical-care-and-emergency-nursing/cardiomyopathy/
Medical-Surgical Nursing Demystified

Nursing Care Cardiomyopathy , Nursing Diagnosis Cardiomyopathy , Nursing Intervention Cardiomyopathy

What is Abdominal Pain?Nursing Care and Nursing Intervention

Abdominal Pain is a condition.Abdominal pain is pain that is felt in the abdomen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (such as the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity. Organs of the abdomen include the stomach, small intestine, colon, liver, gallbladder, spleen, and pancreas

Nursing Assessment for Abdominal Pain Client
General:
Anorexia and malaise, fever, tachycardia, diaphoresis, pale, abdominal rigidity, failure to issue a rectal feces or flatus, increased bowel sounds (early obstruction), decreased bowel sounds (advanced), retention of urination and leukocytosis.
Specific:

Small intestine
Weight, such as cramping abdominal pain, distension increased
mild distension
Nausea
Vomiting: at the beginning containing food is not digested and kim; water and then vomit contains bile, black and faecal
Dehydration
Colon
mild abdominal discomfort
severe distension
Vomiting latent faecal
latent Dehydration: acidosis rarely

Nursing Diagnosis and Nursing Intervention for Abdominal Pain Nursing Care Plan - Acute Pain

Pain related to distention, rigidity
Goal: pain is resolved or controlled
Criteria for outcome: patients revealed a decrease discomfort; expressed pain at tolerable levels, indicating relaxed.

Intervention for Abdominal Pain Client

Maintain bed rest in a comfortable position, do not support the knee.
Assess the location, weight and type of pain
Assess effectiveness and monitor side effects anlgesik; avoid morphine
Provide a planned rest period.
Review and recommend doing lathan active or passive range of motion every 4 hours.
Change positions frequently and give her back rubbing and skin care.
Auscultation bowel sounds; kekauan or notice increasing pain; give enema slowly when ordered.
Give and recommend alternative pain relief measures.

Sources:

http://nursing-care-plan-nanda.blogspot.com/2011/04/abdominal-pain-nursing-care-plan-acute.html

http://www.medicinenet.com/abdominal_pain/article.htm

Nursing Assessment Abdominal Pain , Nursing Care Plan Abdominal Pain , Nursing Intervention Abdominal Pain

Nursing Care Bladder Cancer Diagnosis and Intervention

Bladder cancer is the second most common urological cancer after prostate cancer

Sympotoms of Bladder Cancer

blood in your urine
Needing to strain (bear down)
pain in the Bladder

Nursing Diagnosis for Bladder Cancer
Risk for altered urinary elimination related to the obstruction of urinary flow

Aphysical assessment of the Bladder Cancer Client/Petient

assessment of the patient's ability and any assistance they need to accomplish their ADLs (activities of daily living) with the disease
data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. This includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. If this information is not known, then you need to research and find it.

Nursing Intervention for Bladder Cancer

To relieve discomfort administer ordered analgesics for pain as necessary.
Implement comfort measures and provide distractions that will enable the patient to relax.
As appropriate, implement measures to prevent or alleviate complications of treatment.
Monitor the patient’s intake and output. Question him regularly about changes in his urine elimination pattern to detect changes in his condition.
Observe the patient’s urine for signs of hematuria (reddish tint to gross bloodiness).
Monitor the patient’s laboratory tests, such as changes in white blood cell differential, indicating possible bone marrow suppression from chemotherapy.
If the patient is being given intravesical chemotherapy, watch closely for myelosuppression, chemical cystitis, and skin rash.
Encourage the patient to express feelings and concerns about the extent of the cancer.
Instruct the patient and the family about the types of treatment that are being planned for him.
Teach the patient and family to recognize and to manage adverse effects of chemotherapy.
Stress the importance of notifying the doctor if the patient develops signs and symptoms of urinary tract infection or other sudden changes in his condition.

Sources:
ADAM for images
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Handbook for Brunner & Suddarth’s, Textbook of Medical-SurgicalNursing, 11th ed

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Nursing Plan Client with Liver Disorders (Hepatitis and Liver Cirrhosis)

Nursing Assessment Client with Liver Disorders (Hepatitis and Liver Cirrhosis)

1. Assess for history of hemotransfusion, previous contact with person, infected by hepatitis A, resent sexual contact with person, probably infected by hepatitis B or C .
2. Assess for history of previous liver diseases, presence of genetic and metabolic diseases, affecting liver (such as cystic fibrosis, etc.), toxic influence on liver (such as alcohol intake, etc.) , presence of long-term bile obstruction states.
3. Collect information of complaints that brought client to the hospital (jaundice, abdominal pain, nausea, vomiting, bowel disturbances, fever, appetite changes, neurological changes, changes in color of urine and stool, etc.) .
4. Obtain history of onset and progression of symptoms.
5. Perform complete physical assessment including vital signs, signs of liver damage, jaundice, bowel dysfunction, encephalopathy, ascites, etc.
6. Assess diagnostic tests and procedures for abnormal values.

Nursing Diagnosis Client with Liver Disorders (Hepatitis and Liver Cirrhosis)

1. Increased risk of dehydration, electrolytes and metabolic disturbances, related to liver damage.
2. Intolerance to certain kinds of foods, related to liver damage.
3. Increased risk of secondary infections due to impaired immune state, related to liver dysfunction.
4. Increased risk of hematological complications, related to liver dysfunction.
5. Increased risk of metabolic and toxic disturbances, related to liver insufficiency.
6. Presence of risk of hemocirculatory complications and portal hypertension (ascites, esophageal varices, etc.) due to impaired liver function.
7. Changes in neurological state (encephalopathy) due to liver insufficiency.
8. Weakness and fatigue, related to diagnosis of hepatitis or liver cirrhosis, alterations in skin integrity.
9. Appetite changes and weight loss due to symptoms of the disease.
10. Anxiety related to the symptoms of disease and fear of the unknown.

Nursing Plan and Interventions Client with Liver Disorders (Hepatitis and Liver Cirrhosis)
Goals
1. Prevent further infections.
2. Promote adequate nutrition and fluid intake.
3. Prevent avoidable injury, changes in electrolytes and metabolic state of the client.
4. Maintain enteric isolation precautions.
5. Prevent possible hemorrhage and neurological complications.
6. Prevent alteration in skin integrity.
7. Then surgical intervention prescribed, prevent postoperative complications.
8. Relief symptoms of liver damage, weakness and fatigue.
9. Decreased anxiety with increased knowledge of disease, it treatment, way of prevention and follow-up.

Interventions for Client with Liver Disorders (Hepatitis and Liver Cirrhosis)

1. Assess, report , and record signs and symptoms and reactions to treatment.
2. Monitor fluids input and output closely, observe signs of dehydration, secondary infections, neurological disturbances, edemas (ascites), jaundice intensity, skin integrity daily.
3. Provide adequate diet with high proteins, carbohydrates and vitamins (carefully in client with encephalopathy).
4. Observe feces and urine for color and frequency.
5. Administer antibiotics, antiemetics, vitamins A,C, K, steroids and other medications as prescribed, monitor for side effects.
6. Monitor client’s vital signs and signs of possible dehydration closely.
7. Monitor client’s laboratory tests results (CBC, electrolytes, liver enzymes, billirubin levels, serological tests for HAV, HBV, HCV) for abnormal values.
8. Provide prescribed diet, rest and comfort measures.
9. Administer IV therapy and electrolytes replacement as prescribed.
10. Monitor for signs of possible bleeding.
11. Prepare client for paracentesis if required.
12. Provide emotional support to client and his family, explain all procedures to decrease anxiety and to obtain cooperation.
13. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

Evaluation Client with Liver Disorders (Hepatitis and Liver Cirrhosis)

1. Reports increased comfort, decreased anxiety.
2. Reducing of ascites and edema.
3. Reduced weakness and fatigue in client.
4. Maintains stable vital signs, fluid and metabolic balance, nutritional state.
5. Maintain skin integrity.
6. Laboratory tests results shows no abnormalities.
7. Shows no hematological or neurological complications.
8. Demonstration of understanding of disease progress, diagnostic and treatment procedures, prevention, and need for follow-up.

Nursing Care Plan Liver Disorders , Nursing Diagnosis Liver Disorders , Nursing interventio Liver Disorders

What is Renal Failure?Nursing Care Diagnosis and Intervention

What is Renal Failure?
Loss of renal function
May be acute or chronic
The acute renal failure is an abrupt reduction in renal functions associated with oligurea (less than 400/day),fatigue,anorexia,nausea and vomiting

Causes of Acute Renal Failure
The most common cause of acute renal failure is impaired renal blood flow
Renal vasoconstriction and vascular disease (hypertension)
Urinary tract obstruction

Clinical manifestations

Oligurea (less than 400ml/day)
Anuria(less than 50/day)
Fatigue
Anorexia
Nausea
Vomiting
Increase creatinine and urea level in serum

Nursing diagnoses for Renal failure

fluid volume excess related to decrease urine out put and retention of sodium and water
Altered nutrition ,less than body requirements related to anorexia nausea and vomiting
Activity intolerance related to fatigue and retention of waste products
Knowledge deficit about diabetes self care and control of disease process

Nursing Intervention for Renal Failure client

Daily weigh
Assess intake and out put
Assess skin turgor and presence of edema
Assess neck vain for distention
Assess BP and P and respiratory rate and rhythm to provide base line data
Assess fluid used to take medication
Assist patient to cope with her disease
Provide preference food or palatable to patient
Count calories
Assess for anorexia ,vomiting, nausea
Assess for patient understanding of dietary restriction
Encourage in take of protein with high biologic value
Lower sodium intake

nursing care for Renal Failure , Nursing Diagnosis For Renal Failure , Nursing intervention for Renal Failure

Nursing Care Bed Sore Pressure Sores and Diagnosis

An injuries to skin and underlying tissues that result from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks.

Stages of Bed Sore pressure sores

reddened or darkened skin that will not turn white when firmly pressed
partial skin loss that may appear as an abrasion, blister or shallow crater
full skin loss extending to underlying tissue
full skin loss extending beyond the underlying tissue to muscle and bone

Nursing Diagnosis for Bed Sore (Pressure Sores)Patient:

Impaired Wheelchair Mobility
Impaired Physical Mobility
All the Self-Care Deficits
Impaired Bed Mobility
Ineffective Protection
Risk for Trauma (if restraints are being used)
Chronic Pain
Risk for Impaired Skin Integrity
Risk for Infection
Impaired Comfort

Nursing Care For Bed sore (pressure sores)Patient.

Keep the patient's skin moisturized
Use of Water Filled Mattresses or Sheep Skin Pads
Clean the pressure sore by irrigating the wound with a saline solution (available from drug stores) or other cleaning solution recommended by a health care professional.
Remove all dead tissue and scabs. A health professional can recommend the best approach, depending on the severity of the pressure sore.
Pat the wound dry.
Bandage the wound with a dressing that keeps the pressure sore moist while keeping surrounding tissues dry.
Use pillows and padded protectors to support arms, legs and vulnerable areas.
Change the position of a bed-bound person every two hours. Handle and move carefully to avoid skin tears and scrapes.
Change the position of a chair-bound person hourly.
Use of foam wedges to prevent skin contact between legs or ankle bones
Clean skin with warm water and minimal friction. Apply lotion often.
Avoid direct pressure to bony areas such as ankles and hips.
Discourage the bed-bound or chair-bound person from sitting with the head elevated more than 30 degrees, except for short periods of time.
Check and change bed linens as often as necessary
Use continence management products if necessary to reduce exposure to moisture

Sources
http://www.mayoclinic.com
http://allnurses.com
http://www.howtocare.com

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