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

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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

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Nursing Diagnosis Nursing Intervention For Anaemia Client

Anaemia is a term that indicates a low red blood cell count and hemoglobin and hematocrit levels below normal.
Anaemia is reduced to below the normal value of red blood cells, hemoglobin quality and volume of packed red bloods cells (hematocrit) per 100 ml of blood (Price, 2006: 256).
Thus, anemia is not a diagnosis or disease, but is a reflection of state of a disease or disorder of the body functions and changes the fundamental patotisiologis anemnesis described through a thorough, physical examination and laboratory information.


Nursing Diagnosis for Anaemia

• Risk of infection related to an inadequate defense, the secondary (decrease in hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response depressed)).
• Imbalanced nutrition: Less than body requirements related to the failure to digest or inability to digest the food / nutrient absorption necessary for the formation of red blood cells.
• Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
• Ineffective tissue perfusion related to decreased cellular components required for the delivery of oxygen / nutrients to the cells.
• Risk for impaired skin integrity related to circulatory and neurological changes.
• Constipation or diarrhea related to decreased dietary inputs; changes in the digestive process; the side effects of drug therapy.
• Deficient knowledge related to lack of exposure / recall; incorrect interpretation of information; do not know the source of information.

Nursing Intervention For Anaemia Client

• Assess the level of client activity
• Rational: To know the client and the activities undertaken to determine the next intervention.
• Put the tools needed client
• Rational: To assist clients in meeting their needs.
• Assist patients in active and passive exercises
• Rational: To improve the circulation of tissue.
• Assist patients in meeting the needs of daily activities
• Rational: With the help of nurses and families to meet client needs.
• Provide quiet environment
• Rationale: Increasing the rest to reduce strain the heart and lungs.

Reference

Nursing Intervention

Nursing

Nursing Care Plan , Nursing Dignosis , Nursing Intervention

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STANDARDIZED NURSING CARE PLAN For Anxiety(PSYCHIATRY)

Mental disorders that cause nervousness, fear, apprehension, and worrying. These disorders affect how we feel and behave, and they can manifest real physical symptoms. Mild anxiety is vague and unsettling, while severe anxiety can be extremely debilitating, having a serious impact on daily life.

Patient/Client Nursing Assessment:
Objective Data:

• Patient’s mood anxious.
• Irritable
• Agitated
• Restless.
• Shaking legs, pacing
• Worried facial expression
• Startle response
• Fragmented sleep pattern
• Sweating palms
•  Rapid speech
• Altered vital signs
•  Crying, absent insight
•  Aggressive behaviour
•  Panic
•  Fearful
•  Hypervegalance
•  Indegestion, heart burn
•  appetite,nausea vomiting,dirrhea.

Subjective Data:

• Patients Verbalize: increased muscle tension
• Feel difficulty concentrating
• Frequent sensation of tingling.
• Feeling of gabrahut, fear.
• Others:

Nursing Diagnosis
Anxiety related to:

• Hallucinations
• Fear of open,
• public places and
• crowd
• Fear of close space
• Multiple life stress
• PTSD
• Threat to self
• Others: 

Goal/Expected Outcome
S.T.G.(Short Term Goal)

• Able to express anxiety by 1-2 days and its cause
• Learning skills to control anxiety by 3-4 days
• Express feelings of relaxation by the help of meds & utilization of learned skills by one week

L.T.G.(Long Term Goal)

• By the time of discharge patient will be able to free or control his anxiety by using effective coping skills at his/her
• Anxiety will be at the scale of ______
• Other:

Nursing Intervention Statements

• Assess patient anxiety level.As Per Scale
•  Approach the patient in calm manner.
•  Help the patient to identify factors those make him tense anxious.
• Encourage him to share his stressors and acknowledge feelings
• Teach deep breathing exercises,muscle relaxation, guided imagery
• Reduce environmental stimulation.
• Help the patient identify support person at home, safe place.
• Arrange small group activities
• Teach diversonal activities e.g.drawing, painting, arts & craft Involve family in patients care
• Administer anti-anxiety drugs as PRN & regular basis as per order

Nursing Care Plan , Nursing Dignosis , Nursing Intervention , nursing Plan For Anxiety

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SELF-CARE DEFICIT:FEEDING HYGIENE DRESSING / GROOMING TOILETING Nursing Dignosis intervention

Nursing Assessment

• Evaluate each of the activities of
• daily living using the following
• coding scale
•  Completely independence
•  Require use of assistive device
•  Needs minimal help
•  Need assistance and/or some
•  Need total supervision
•  Needs total assistance
•  Self feeding deficit
•  Self bathing deficit
•  Self dressing deficit
•  Self toileting deficit
•  Instrumental self care deficit
•  Others

Nursing Diagnosis

• Self care deficit:
• Feeding
• Hygiene
• Dressing / grooming
• Toileting
• Related to
• In-tolerance to activity:
• decreased strength and
• endurance
• Neuromuscular impairment
• Musculo skeletalimpairment
• Depression; severe anxiety
• Pain, discomfort
• Perceptual or cognitive
• impairment
• Fatigue
• Aging

Others

Goal/Expected Outcome

• Patient will look neat and clean q shift
• Patient will be able to performs self care activities within level of own ability
• Patient will participate independently in her (his self care by
• Other

Nursing Intervention Statements

• Assess causative or contributing
• factors to self care deficit
• Identify degree of individualimpairment according to scale.
• Determine individual strengths and ability to participate in each self care activities
• Promote optimal participation of patient in care activities
• Provide privacy during activities of daily living.
• Provide hygiene care i.e. sponge bath q day
• Give mouth care q--
• Give eye care q--
• Give perineal / Foleys care q ____
• Give hair wash twice a week
• Assist in feeding as required
• Assist in toileting
• Others

Nursing Care Plan , Nursing Dignosis , Nursing Intervention

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Sleep Pattern Disturbance Nursing Assessment Dignosis and Intervention

Assessment Nursing
Objective Data:

•  Look tired/ fatigue
•  Agitation
•  Mood alteration
•  Not sleeping ______ hrs
•  Always sleeping
•  Socialization extreme
•  Isolation
•  Alert / Active
•  Passive / confuse
•  Restlessness
•  Others

Subjective Data:

• Insomnia
• Excessive sleep / inability to stay
• a walker
• Disturb sleep
• Not feeling rested after sleep
• Headache
• Heavy feeling at eyesight
• Wakefulness
• Night mares
• Others

Nursing Diagnosis
disturbances related
to:

• Frequent awakening secondary to impaired O2 transportation
• Impaired elimination (bladder or bowel)
• Excessive day time sleep due to medication
• Environmentalchange

Goal/Expected Outcome

• Patient verbalizes
• feeling of rested after sleep.
• Patient will follow sleeping 6-8 hrs at night.
• Pt. will maintain normal (6-8 hrs) continuous sleeping pattern with no any disturbance.
• Others:

Nursing Intervention Statements

• Establish sleep cycle where pt sleeps
• at night and awake during day with
• brief rest periods as needed
• Engage the client in ADL
• Provide quiet environment as pt.needs
• Encourage relaxation prior to bed time.
• Encourage use of pre-sleep routines e.g. hot bath, warm milk, stretching.
• Provide opportunities for fresh air and good ventilation.
• Organize procedures to minimize disturbances
• Limit amount and length of day time sleep
• Limit intake of caffeinated drinks
• Administer medication as indicated

Nursing Care Plan , Nursing Dignosis , Nursing Intervention , Sleep Pattern Disturbance

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What is Hypopituitarism? How do Nursing Care of Hypopituitarism

Hypopituitarism results when the pituitary gland is unable to secrete a normal amount of pituitary hormones. Primary causes are pituitary tumors, inadequate blood supply to the pituitary gland, infection, radiation therapy, or surgical removal of a portion of the pituitary gland. Secondary causes affect the hypothalamus, which regulates the pituitary gland.

PROGNOSIS

Patients require life-long treatment and can expect a normal life span.

SIGNS AND SYMPTOMS

• Fatigue caused by a decreased production of ACTH

• Lethargy and diminished cognition caused by a decreased production of

TSH

• Sensitivity to cold due to low TSH, which stimulates thyroid hormone

• Decreased appetite due to TSH deficiency

• Infertility due to luteinizing hormone (LH) and follicle-stimulating hormone

(FSH) production

• Short stature due to diminished secretion of growth hormone

• Infertility, amenorrhea caused by decreased production of FSH and LH

TEST RESULTS

• Decreased ACTH usually due to a lesion of the pituitary.

• TSH deficiency due to a mass, trauma, surgery, or idiopathic.

• Decreased prolactin due to a mass, causing diminished or lack of prolactin from the anterior pituitary.

• Presence of a pituitary tumor shown on MRI.

TREATMENT

• Administer replacement hormones (estrogen, testosterone, corticosteroids,growth hormone, and thyroid hormone).

• Surgical removal of the pituitary tumor if it exists.

NURSING DIAGNOSES

• Disturbed body image related to illness

• Sexual dysfunction related to disease

NURSING INTERVENTION

• Monitor weight daily because antidiuertic hormone (ADH) and adrenocortiocotropic hormone (ACTH), from the pituitary, regulate fluid retention and excretion in the body.

• Monitor intake and output to ensure the balance is equal due to hormone regulation.

• Explain to the patient:

• The need to take medication for the rest of the patient’s life.

• The need for frequent laboratory tests.

Hypopituitarism , Nursing Dignosis , Nursing Intervention

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What is Acute Pain?Acute Pain Nursing Dignosis And Intervention

Acute pain usually points to an aberration or an illness. It is differentiated from chronic pain by the duration, usually less than 4 to 6 months.Pain nerves are stimulated by pressure, cuts, heat, cold, stabs, surgery, and so on.Other causes include fractures, burns, and bruises.

PROGNOSIS

Acute pain is usually able to be managed and terminated in less than 4 to 6 months.

SIGNS AND SYMPTOMS

• Intense sharp pain (severe)

• Fleeting, momentary, or ongoing

• Cramping, spasmotic

INTERPRETING TEST RESULTS

• Ultrasound.• X-rays.• CT scans.• MRI.

TREATMENTS

• Surgery.• Delivery of child.• Anesthesia.• Analgesics:• acetaminophen

• aspirin • COX-2 inhibitors• NSAIDs:• celecoxib • diclofenac • flurbiprofen

• ibuprofen • indomethacin • ketorolac

• nabumetone • naproxen • hydromorphone

• levorphanol • meperidine• methadone

• morphine• oxycodone • Antispasmotics.

• Muscle relaxers.• Neuropathic pain relievers:

• tricyclic antidepressants:

• amitriptyline • desipramine

• nontricyclic antidepressants:

• bupropion • anticonvulsants:

• carbamazapine • clonazepam

• gabapentin • pregabalin

• Anxiolytics.• Steroids.

• Heat/cold.• Transcutaneous electrical nerve stimulator (TENS) unit.

• Epidural injection.

NURSING DIAGNOSES

• Acute pain • Powerlessness

NURSING INTERVENTIONS

• Cold or hot packs.• Massage.• Physical therapy.• Acupuncture.• Biofeedback.• Chiropractic• Meditation.

• Support groups.• Prayer.• Explain to the patient:

• Diagnoses.• Tests and treatments.• Use of pain medication, timing, and side effects.

• Use of alternative therapies.• Opioids: codeine • hydrocodone

Acute Pain , Nursing Dignosis , Nursing Intervention

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What Is Bronchiectasis?and Nursing Care Plan

Bronchi and bronchioles become abnormally and permanently dilated, caused by infection and inflammation. This results in excessive production of mucous that obstructs the bronchi. There is some obstruction of the airways and a chronic infection. The changes within the lung can be localized or generalized. The lung may develop areas of atelectasis where thick mucous obstructs the smaller airways, making the mucous difficult to expel. This results in inflammation and infection of the airways and leads to bronchiectasis.

PROGNOSIS

Early diagnosis and appropriate treatment of infections are essential for management. Postural drainage and chest physical therapy aid in movement of mucous from the airways. The difficulty in breathing is caused by excess mucus similar to patients with Chronic Obstructive Pulmonary Disease (COPD) (emphysema or chronic bronchitis).

SIGNS AND SYMPTOMS

• Difficult breathing (dyspnea) due to the mucous production and irritation

within the airways.

• Productive, foul-smelling odorous cough, due to thick, difficult-to-expel,tenacious mucous, often with bacterial colonization.

• Cough may be worse when lying down.

• Recurrent bronchial infections.

• Hemoptysis (blood-tinged or bloody mucous).

• Loss of weight because patients are not eating well, due to respiratory

changes and foul-smelling mucous with cough. Increased respiratory effort requires more calories to meet normal requirements.

• Crackles or rhonchi on inspiration due to mucous build-up.

• Anemia of chronic disease.

• Cyanosis.

• Clubbing of the fingers.

TEST RESULTS

• Culture and sensitivity of sputum to identify bacteria and appropriate antibiotics.

• Shadows in affected area of the lungs on the chest x-ray.

• CT scan or high-resolution CT will show areas of bronchiectasis.

• Decreased lung vital capacity on pulmonary function test.

TREATMENT

Treatment is focused on getting enough oxygen to meet current needs of the patient,

expel mucous, and treat infections.

• Supplemental oxygen to help meet body’s needs.

• Postural drainage to assist with drainage of secretions.

• Chest PT to loosen secretions.

• Remove excessive secretions during a bronchoscopy.

• Administer bronchodilators to help keep airways open:

• albuterol, levalbuterol

• Administer antibiotics to treat infection:

• selected based on the results of a culture and sensitivity study

NURSING DIAGNOSES

• Ineffective airway clearance

• Imbalanced nutrition: less than what the body requires

• Impaired gas exchange

NURSING INTERVENTION

• Monitor respiratory rate, effort, breath sounds, skin color, and use of accessory muscles.

• Perform chest percussion to help loosen secretions.

• Explain to the patient:

• That family member can perform chest PT.

• How to do postural drainage.

• How to administer oxygen.

• How to properly administer medications.

Bronchiectasis , Nursing Dignosis , Nursing Intervention

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Nursing Care Plan(intervention) for the Client/Patient of Sleep Disorder

• Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care.
• Determine current level of anxiety, if client is anxious.
• Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite.
• Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications.
• Provide measures to take before bedtime to assist with sleep.
• Provide pain relief shortly before bedtime and position client comfortably for sleep.
• Keep environment quiet.
• Do a careful history of all medications including over-the-counter medications and alcohol intake.
• If client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for evaluation.
• Evaluate client for presence of depression or anxiety.
• Encourage social activities.
• Suggest light reading or TV viewing that does not excite as an evening activity.
• Increase daytime physical activity. Encourage walking as client is able.
• Avoid use of hypnotics and alcohol to sleep.
• Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible.
• Use soothing sound generators with sounds of the ocean, rainfall, or waterfall to induce sleep, or use "white noise" such as a fan to block out other sounds.
• Determine if client has a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems.
• Observe elimination patterns. Have client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning.
• If client continues to have insomnia despite developing good sleep hygiene habits, refer to a sleep clinic for further evaluation.

Nursing Care Plan , Nursing Intervention

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Nursing Interventions For The Altreration in Nutrition Less Than Body Requirement

Nursing Diagnosis for  The Altreration in Nutrition Less Than Body Requirement

• High Risk for or
• Actual
• Alteration in nutrition less than body requirement related to:
• NPO
• Dyspnea
• Dysphaagia
• Nausea/vomiting/anorexia/diarrhea
• Fatigue
• Medication side effect
• Decrease/Absent gut sounds.
• Increase gut sound.
• Impaired digestion.
• Decrease absorption of nutrient.
• Inability to chew,swallow/suck.

Nursing Interventions

• Assess previous nutritional intake
• Monitor Weight as Indicated
• Ascultate bowel sounds
• Maintain intravenous therapy as per Physician's/Doctor's order.
• Maintain oral hygiene by giving mouth care at least.
• Check vital signs as per doctor's order.
• Monitor Electrolytes as needed and replace as per physician's/doctor's order.
• Monitor intake and output.
• Provide with adequate calories as per body needs prefer his/her/ likes/dislikes.
• Provide odorless environment.
• Control pain and nausea before meal by administering the drugs as ordered.
• Encourage small frequent meals
• Consults the dietician if ordered/needed.
• Restrict liquids with meal provide one hour before or after.
• Monitor abdominal girth if needed.
• Monitor and document NG aspiration and stool frequency to evaluate tolerance of diet.

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Nursing Intervention Diagnosis Symptoms of Anxiety

Anxiety is a word that describes feelings of worry, nervousness, fear, apprehension, concern or restlessness.

Some Kind Of Sign and Symptoms Anxiety

• Diarrhoea
• Headache
• Backache
• Heart palpitations
• Tense muscles
• Trembling
• Churning stomach
• Sweating/flushing
• Nausea
• Numbness or "pins and needles" in arms, hands or legs

Nursing Diagnosis for Anxiety Patient/client

• Anxiety related to:
• Hospitalization
• Unfamiliar environment and routine
• Insufficient knowledge of condition,healthstatus,diagnostic tests,treatment.
• Poor progress
• Procedure/surgery/pain
• Other

Nursing Intervention for Anxiety Patient/client

• Assess patient's level of anxiety/shift on a scale of mild to severe.
• Introduce yourself and other member of the health team orient patient to room,(call bell,cardiac monitor,IMED etc)
• Explain unit's policies and routines.
• Determine patient's knowladge of his/her condition,its prognosis and treatment measures.
• Reinforce and supplement the physican's explanation as necessary.
• Explain any scheduled diagnostic tests or procedure.
• Provide reassurance and comfort.Speed time with the patient,encourage sharing of feelings and concerns.
• Listen attentively and convey empathy and understanding.
• Correct any misconceptions and inaccurate information the patient may express.
• Allow close relatives to visit patient frequently.
• other

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Nursing Diagnosis Intervention Ineffective Breathing Pattern

Nursing Diagnosis Ineffective Breathing Pattern
Ineffective breathing pattern related to:

• Neuromuscular
• Musculo-skeletal impairment.
• Anxiety.
• Pain
• Decreased energy/fatigue.
• surfactant deficiency.
• decrease lung compliance
• Presence of Meconium in respiratory tract

Nursing Intervention Ineffective Breathing Pattern

• Assess respiratory rate
• Asess SPO2
• Note type of breathing pattern
• Auscultate breath sounds
• Administer oxygen as ordered
• Suction airway
• Elevate head of the bed
• Perform insensitive spirometer
• Provide comfort for relief of pain,if pain is a factor.
• Medication with analgesics as needed
• Monitor series of chest X-ray/ABG's
• Document patient's response to nursing action/treatment regimen
• Consider use of paper bags as means of Rebreathing Expired air if indicated.
• Give Bronchodilator as ordered
• Perform chest physiotherapy
• Encourage deep breathing and coughing exercise
• other 

Nursing Dignosis , Nursing Intervention

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Nursing Diagnostic( Interventions) for Effected in Liver Abscess

Nursing Assessment Nursing Care Plan for Liver abscess
Signs and symptoms of liver abscess depend on the degree of involvement. Some patients are acutely ill; in others, the abscess is recognized only at autopsy, after death from another illness.
With a pyogenic abscess, the onset of symptoms is usually sudden; with an amebic abscess, it's more insidious. Common signs and symptoms include abdominal pain, weight loss, fever, chills, diaphoresis, nausea, vomiting, and anemia. Symptoms of right pleural effusion, such as dyspnea and pleural pain, develop if the abscess extends through the diaphragm. Liver damage may cause jaundice.
The patient may report right abdominal and shoulder pain, chills, fever, diaphoresis, nausea, vomiting, and weight loss. If the abscess extends through the diaphragm, he may complain of dyspnea and chest pain (symptoms of pleural effusion); if he has developed anemia, he may report fatigue. Inspection may disclose jaundice, a sign of liver damage. On palpation, the liver may feel enlarged, indicating hepatic disease.

Diagnostic Tests For Liver Abscess

• Ultrasonography and
• Computed tomography scan
• Blood cultures and percutaneous liver aspiration, Liver biopsy
• Urinalysis
• Stool

Nursing diagnosis Nursing Care Plan for Liver abscess

• Impaired Liver Function
• Acute pain
• Deficient knowledge (diagnosis and treatment)
• Imbalanced nutrition: Less than body requirements
• Risk for impaired skin integrity
• Risk for infection

Nursing Key outcomes Nursing Care Plan for Liver abscess

• Be free of signs of liver failure as evidenced by liver function studies within normal limits (WNL) and absence of jaundice, hepatic enlargement, or altered mental status
• The patient will express feelings of comfort.
• The patient and family will express an understanding of the disease process and treatment regimen.
• The patient will achieve adequate caloric and nutritional intake.
• The patient's skin integrity will remain intact.
• The patient will remain free from signs and symptoms of infection.

Nursing interventions Nursing Care Plan for Liver abscess

• Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain. Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
• Teaching: Individual Planning, implementation, and evaluation of a teaching about Liver abscess. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
• Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
• Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity. Pressure Management: Minimizing pressure to body parts. Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them
• Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents. Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

Sources:
Nurse Thought

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What is Simple Goiter Symptoms and Nursing Dignosis Intervention

A lack of iodine in the patient’s diet (endemic, simple goiter) causes the thyroid gland to become enlarged. This is seen less today because iodine is added to table salt. The thyroid gland can also become enlarged by ingesting large amounts of goitrogenic drugs or goitrogenic foods that decrease production of thyroxine,
such as strawberries, cabbage, peanuts, peas, peaches, and spinach. This results in sporadic simple goiter. A simple goiter is not caused by inflammation or neoplasm.
PROGNOSIS:Prognosis is good if treated and patients go on to live normal lives.
SIGNS AND SYMPTOMS
• Difficulty in swallowing (dysphagia) due to a large thyroid pressing on the esophagus
• Enlarged thyroid gland
• Respiratory distress from the large gland, causing pressure on the trachea
• A tight feeling in the throat from a large gland
• Coughing
TEST RESULTS
• Decreased or normal serum T4 level caused by an underactive thyroid.
• Increased serum TSH, by the pituitary gland, attempting to stimulate or shut off production of the thyroid in making thyroid hormone.
• RAIU uptake normal or increased—a radioactive isotope is injected into a vein. A scan of the thyroid is done to visualize the thyroid more completely.
• Ultrasound enables sound waves to bounce off the gland, giving the size and location of any nodules.
TREATMENT
• If increased TSH, administer hormone replacement with levothyroxine (T4),dessicated thyroid, or liothyronine (T3).
• If the thyroid gland is overactive, then administer small doses of Lugol’s solution or potassium iodide solution.
• If the simple goiter cannot be reduced through medication, then a thyroidectomy is performed during which all or part of the thyroid is removed.
NURSING DIAGNOSES
• Imbalanced nutrition: less than what body requires; related to inadequate intake in relation to metabolic needs
• Fatigue related to sleep deprivation
• Hyperthermia related to increased metabolic rate

NURSING INTERVENTION
• Avoid goitrogenic foods or drugs in sporadic goiter since they make thyroid hormone production.
• Use iodized salt to prevent and treat endemic goiter, since the thyroid needs iodine to make thyroid hormone.
• Explain to patient:
• The need for life-long thyroid replacement after thyroidectomy and radioactive iodine.
• The need for intermittent lab work to monitor the thyroid.
• Visits to the primary care practitioner to monitor size of thyroid gland.

Endocrine System , Nursing Care Plan , Nursing Dignosis , Nursing Intervention

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What is Hyperthyroidism (Graves Disease) ? Treatment Nursing Diagnosis and Intervention

PROGNOSIS of Hyperthyroidism
The prognosis is good if the cause of hyperthyroidism is treated; however, hyperthyroidism is a chronic disease. Signs such as bulging eyes (exophthalmos) are not reversible. Furthermore, thyroid surgery may result in complications.
SIGNS AND SYMPTOMS of Hyperthyroidism
• Enlarged thyroid gland (goiter) caused by tumor
• Protrusion of the eyeballs (exophthalmos) due to lymphocytic infiltration which pushes out the eyeball
• Sweating (diaphoresis); excess thyroid hormone raises the metabolic rate
• Increased appetite due to increased metabolism
• Nervousness due to high levels of thyroid hormone
• Weight loss due to increased metabolism
• Menstrual changes due to elevated levels of thyroid hormone
TEST RESULTS of Hyperthyroidism
• Increased serum T3.
• Increased serum T4.
• Increased TRH and TSH if pituitary gland is the cause of hyperthyroidism.
• Presence of antibodies if cause is Graves’ disease.
• Thyroid scan reveals enlarged thyroid.
TREATMENT of Hyperthyroidism
• For mild cases and for young patients, administer antithyroid medication such as propylthiouracil and methimazole to block synthesis of T3 and T4.
• For Graves’ disease and for patients 50 years of age or older, radioactive iodine therapy is used to decrease production of thyroid hormones. Administer Lugol’s solution, SSKI, or potassium iodide.
• For severe cases where the size of the thyroid gland interferes with swallowing or breathing, the thyroid gland is surgically reduced in size or removed.
• Administer beta blockers such as propranolol until hyperthyroidism diminishes to decrease sympathetic activity and control tachycardia, tremors, and anxiety.
NURSING DIAGNOSES of Hyperthyroidism
• Imbalanced nutrition: less than what body requires related to inadequate intake in relation to metabolic needs
• Fatigue related to sleep deprivation
• Hyperthermia related to increased metabolic rate

NURSING INTERVENTION of Hyperthyroidism
• Monitor vital signs.
• Provide cool environment.
• Protect the patient’s eyes with dark glasses and artificial tears if the patient has exophthalmos.
• Provide a diet high in carbohydrates, protein, calories, vitamins, and minerals.
• Monitor for laryngeal edema following surgery (hoarseness or inability to clearly speak).
• Keep oxygen, suction, and a tracheotomy set near bed in case the neck swells and breathing is impaired.
• Keep calcium gluconate near the patient’s bed following surgery. This is the treatment for tetany and is used to maintain the serum calcium level in normal range.
• Place the patient in a semi-Fowler’s position to decrease tension on the neck following surgery.
• Support the patient’s head and neck with pillows.
• Monitor for muscle spasms and tremors (tetany) caused by manipulation of the parathyroid glands during surgery.
• Check for Trousseau’s sign (inflate blood pressure cuff on the arm and muscles contract).
• Check for Chvostek’s sign (tapping of the facial nerve causes twitching of the facial muscles). Both this sign and Trousseau’s sign are positive when the parathyroid glands have been manipulated during thyroid surgery, in which case they secrete too much phosphorus and not enough calcium. Since muscles, i.e. the heart, need calcium for work, a low calcium level may cause muscle spasms which are easily detected by Chvostek’s sign and Trousseau’s sign. The treatment is IV calcium, administered quickly.
• Check drainage and hemorrhage from incision line; red flags are frank hemorrhage and purulent, foul smelling drainage.
• Monitor for signs of hypocalcemia (tingling of hands and fingers).

Endocrine System , Nursing Care Plan , Nursing Dignosis , Nursing Intervention

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