Nursing Care Plans

Nursing Diagnosis Disturbed Sleep pattern

2010-06-24T01:56:00.000-07:00

Nursing care Plans Disturbed Sleep pattern. NANDA Nursing Diagnosis Definition Disturbed Sleep pattern Time-limited disruption of sleep

Disturbed Sleep pattern Characteristics:

Prolonged awakenings, sleep maintenance insomnia, self-induced impairment of normal pattern, sleep onset more than 30 minutes, early morning insomnia, awakening earlier or later than desired, verbal complaints of difficulty falling asleep, verbal complaints of not feeling well-rested, increased proportion of Stage 1 sleep, dissatisfaction with sleep, less than age-normed total sleep time, three or more nighttime awakenings, decreased proportion of Stages 3 and 4 sleep, decreased ability to function

Related Factors:

Daytime activity pattern, Thinking about home, Body temperature, Temperament, Dietary, Childhood onset, Inadequate sleep hygiene, Sustained use of antisleep agents, Circadian asynchrony, Frequently changing sleep-wake schedule, Depression, Loneliness, Frequent travel across time zones, daylight/darkness exposure, grief, anticipation, shift work, delayed or advanced sleep phase syndrome, loss of sleep partner, life change, preoccupation with trying to sleep, periodic gender-related hormonal shifts, biochemical agents, fear, separation from significant others; social schedule inconsistent with chronotype, aging-related sleep shifts, anxiety, medications, fear of insomnia, maladaptive conditioned wakefulness, fatigue, boredom

Nursing Outcomes Nursing care Plans Disturbed Sleep pattern

Sleep
Rest
Well-Being
Psychosocial Adjustment: Life Change
Quality of Life
Pain Level
Comfort Level

Client Outcomes

Wakes up less frequently during night
Awakens refreshed and is not fatigued during day
Falls asleep without difficulty
Verbalizes plan to implement bedtime routines

NIC Interventions (Nursing Interventions Classification)

Sleep Enhancement

Nursing Interventions nursing care Plans Disturbed Sleep pattern

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.

Client/Family Teaching for Disturbed Sleep pattern

Teach the following guidelines for good sleep hygiene to improve sleep habits: Go to bed only when sleepy, When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy, Use the bed only for sleeping not for reading or snoozing in front of the television, Avoid afternoon and evening naps, Get up at the same time every morning, Recognize that not everyone needs 8 hours of sleep, Move the alarm clock away from the bed if it is a source of distraction.
Encourage client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals before bedtime.
Advise client to avoid use of alcohol or hypnotics to induce sleep.
Ask client to keep a sleep diary for several weeks.
Teach relaxation techniques, pain relief measures, or the use of imagery before sleep.
Teach client need for increased exercise.
Encourage client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts.

Nursing Diagnosis Disturbed Body Image

2010-06-19T08:44:00.000-07:00

NANDA Nursing diagnosis Definition Confusion in mental picture of one's physical self Defining Characteristics: Nonverbal response to actual or perceived change in structure and/or function; verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function; verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function; behaviours of avoidance, monitoring, or acknowledgment of one's body

Objective

Missing body part; actual change in structure or function; avoidance of looking at or touching body part; intentional or unintentional hiding or overexposure of body part; trauma to non-functioning part; change in social involvement; change in ability to estimate spatial relationship of body to environment

Subjective

Change in lifestyle; fear of rejection or reaction by others; focus on past strength, function, or appearance; negative feelings about body; feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)

• Body Image

• Child Development: 2 Years

• Child Development: 3 Years

• Child Development: 4 Years

• Child Development: 5 Years

• Child Development: Middle Childhood (6-11 Years)

• Child Development: Adolescence (12-17 Years)

• Distorted Thought Control

• Grief Resolution

• Psychosocial Adjustment: Life Change

• Self-Esteem

Client Outcomes

States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
Calls body part or loss by appropriate name
Looks at and touches changed or missing body part
Cares for changed or nonfunctioning part without inflicting trauma
Returns to previous social involvement
Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)

Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image.
Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis
Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle.
Identify clients at risk for body image disturbance (e.g. body builders, cancer survivors).
Clients should not be rushed into sharing their feelings.
Do not ask clients to explore feelings unless they have indicated a need to do so.
Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs.
Encourage client to purchase clothes that are attractive and that de-emphasize their disability.
Allow client and others gradual exposure to the body change.
Encourage client to discuss interpersonal and social conflicts that may arise.
Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths.
Help client accept help from others; provide a list of appropriate community resources.
Help client describe self-ideal, identify self-criticisms, and be accepting of self.
Encourage client to write a narrative description of their changes.
Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure.
Encourage client to continue same personal care routine that was followed before the change in body image.
Focus on remaining abilities. Have client make a list of strengths.

Home health Care Interventions

Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
Assess family/caregiver level of acceptance of client's body changes.
Be accepting of changes in all interactions with client and family/caregivers.
Help client to see new or changing roles in family.
Refer to medical social services for level of acceptance and possible financial impact of changes.
Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty.
Teach family and client complications of medical condition and when to contact physician.
Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities.
If appropriate, provide home health aide support to help the client and family through ADL transition.
Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures.
Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations.

Nursing Diagnosis Fatigue

2010-06-18T11:14:00.000-07:00

Nursing Definition for Nursing Diagnosis Fatigue An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level

Characteristics: Inability to restore energy even after sleep; lack of energy or inability to maintain usual level of physical activity; increase in rest requirements; tired; inability to maintain usual routines; verbalization of an unremitting and overwhelming lack of energy; lethargic or listless; perceived need for additional energy to accomplish routine tasks; increase in physical complaints; compromised concentration; disinterest in surroundings, introspection; decreased performance; compromised libido; drowsy; feelings of guilt for not keeping up with responsibilities

Related Factors:

Boring lifestyle; stress; anxiety; depression

Humidity; lights; noise; temperature

Negative life events; occupation

Sleep deprivation; pregnancy; poor physical condition; disease states (cancer, HIV, multiple sclerosis); increased physical exertion; malnutrition; anemia

NOC Outcomes (Nursing Outcomes Classification)
• Endurance
• Concentration
• Energy Conservation
• Nutritional Status: Energy

Client Outcomes

Verbalizes increased energy and improved well-being
Explains energy conservation plan to offset fatigue

NIC Interventions (Nursing Interventions Classification)
Energy Management

Nursing Interventions

Assess severity of fatigue on a scale of 0 to 10; assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, mood, and usual pattern of activity.
Evaluate adequacy of nutrition and sleep. Encourage the client to get adequate rest. Refer to Imbalanced Nutrition: less than body requirements or Disturbed Sleep pattern if appropriate.
Determine with help from the primary care practitioner whether there is a physiological or psychological cause of fatigue that could be treated, such as anemia, electrolyte imbalance, hypothyroidism, depression, or medication effect.
Work with the physician to determine if the client has chronic fatigue syndrome.
Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope.
Encourage client to keep a journal of activities, symptoms of fatigue, and feelings.
Assist client with ADLs as necessary; encourage independence without causing exhaustion.
Help client set small, easily achieved short-term goals such as writing two sentences in a journal daily or walking to the end of the hallway twice daily.
With physician's approval, refer to physical therapy for carefully monitored aerobic exercise program.
Refer client to diagnosis-appropriate support groups such as National Chronic Fatigue Syndrome Association or Multiple Sclerosis Association.
Help client identify essential and nonessential tasks and determine what can be delegated.
Give client permission to limit social and role demands if needed (e.g., switch to part-time employment, hire cleaning service).
Refer client to occupational therapy to learn new energy-conserving ways to perform tasks.
If client is very weak, refer to physical therapy for prescription and use of a mobility aid such as a walker.
Identify recent losses; monitor for depression as a possible contributing factor to fatigue.
Review medications for side effects. Certain medications (e.g., beta-blockers, antihistamines, pain medications) may cause fatigue in the elderly.

Home Care Interventions

Assess client's history and current patterns of fatigue as they relate to the home environment. Fatigue may be more pronounced in specific settings for physical or psychological reason.
Assess home for environmental and behavioral triggers of increased fatigue
When assisting client with adapting to home and daily patterns, avoid activities of high energy output. Refer to occupational therapy to accomplish this if necessary.
Assist client with identifying or creating a safe, restful place within the home that can be used routinely (e.g., a room with familiar, nonthreatening, or nonfrightening belongings).

Client/Family Teaching

Share information about fatigue and how to live with it, including need for positive self-talk.
Teach strategies for energy conservation
Teach client to carry a pocket calendar, make lists of required activities, and post reminders around the house.
Teach the importance of following a healthy lifestyle with adequate nutrition and rest, pain relief, and appropriate exercise to decrease fatigue.
Teach stress-reduction techniques such as controlled breathing, imagery, and use of music. See Anxiety care plan if appropriate; anxiety is correlated with increased fatigue.

Nursing outcomes, interventions and Patient teaching for Alzheimer's disease

2009-05-07T10:35:00.000-07:00

Alzheimer's disease (AD) is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception. Many scientists believe that Alzheimer's disease results from an increase in the production or accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.

Nursing outcomes Nursing Care Plans for Alzheimer's Disease

Patient will:

Perform bathing and hygiene needs.
Maintain a regular bowel elimination pattern.
Use support systems and develop adequate coping behaviors.
Oriented to time, person, place, and situation to the fullest extent possible.
Perform dressing and grooming needs within the confines of the disease process.
Consume daily calorie requirements.
Show no signs of malnutrition.
Effectively communicate needs verbally or through the use of alternative means of communication.
Use support systems and develop adequate coping behaviors.
Free from signs and symptoms of infection.
Perform toileting needs within the confines of the disease process.

Nursing interventions for patient Alzheimer's disease

Establish an effective communication system with the patient and his family to help them adjust to the patient's altered cognitive abilities.
Provide emotional support to the patient and his family. Encourage them to talk about their concerns. Listen carefully to them, and answer their questions honestly and completely.
Because the patient may misperceive his environment, use a soft tone and a slow, calm manner when speaking to him.
Allow the patient sufficient time to answer your questions because his thought processes are slow, impairing his ability to communicate verbally.
Administer ordered medications to the patient and note their effects.
If the patient has trouble swallowing, check with a pharmacist to see if tablets can be crushed or capsules can be opened and mixed with a semi-soft food.
Protect the patient from injury by providing a safe, structured environment. Provide rest periods between activities because these patients tire easily.
Encourage the patient to exercise, as ordered, to help maintain mobility.
Encourage patient independence, and allow ample time for the patient to perform tasks.
Encourage sufficient fluid intake and adequate nutrition. Provide assistance with menu selection, and allow the patient to feed himself as much as he can. Provide a well-balanced diet with adequate fiber. Avoid stimulants, such as coffee, tea, cola, and chocolate. Give the patient semisolid foods if he has dysphagia. Insert and care for a nasogastric tube or a gastrostomy tube for feeding as ordered.
Because the patient may be disoriented or neuromuscular functioning may be impaired, take the patient to the bathroom at least every 2 hours, and make sure he knows the location of the bathroom.
Assist the patient with hygiene and dressing as necessary. Many patients with Alzheimer's disease are incapable of performing these tasks.

Family And Patient Teaching For Patient Alzheimer's Disease

Teach the patient's family about the disease. Explain that the cause of the disease is unknown. Review the signs and symptoms of the disease with them. Be sure to explain that the disease progresses but at an unpredictable rate and that patients eventually suffer complete memory loss and total physical deterioration. (See Teaching patients about Alzheimer's disease.)
Review the diagnostic tests that are to be performed and treatment the patient requires.
Advise family members to provide the patient with exercise. Suggest physical activities, such as walking or light housework, that occupy and satisfy the patient.
Stress the importance of diet. Instruct family members to limit the number of foods on the patient's plate so he doesn't have to make decisions. If the patient has coordination problems, tell family members to cut his food and to provide finger foods, such as fruit and sandwiches. Suggest using plates with rim guards, easy-grip utensils, and cups with lids and spouts.
Encourage family members to allow the patient as much independence as possible while ensuring his and others' safety. Tell them to create a routine for all the patient's activities, which helps them avoid confusion. If the patient becomes belligerent, advise family members to remain calm and try to distract him.
Refer family members to support groups such as the Alzheimer's Association. Set up an appointment with the social service department to help family members assess their needs.

Nursing interventions and Patient teaching for mesothelioma

2009-05-06T07:31:00.000-07:00

Nursing interventions for mesothelioma patient

Listen to the patient's fears and concerns. Give clear, concise explanations of all procedures and actions, and remain with him during periods of severe anxiety. Encourage him to identify actions that promote comfort. Then be sure to perform them and to encourage the patient and family to help. Include the patient in decisions related to his care whenever possible.
Administer ordered pain medication as required. Monitor and document the medication's effectiveness.
Perform comfort measures, such as repositioning and relaxation techniques.
Monitor respiratory status. Provide oxygen as ordered, and assist the patient to a comfortable position (Fowler's position, for example) that allows for maximal chest expansion to relieve respiratory distress.
If mobility decreases, turn the patient frequently. Provide skin care, particularly over bony prominences. Encourage him to be as active as possible.
Prevent infection. Adhere to strict aseptic technique when suctioning the patient, changing dressings or I.V. tubing, and performing any type of invasive procedure. Monitor body temperature and white blood cell count closely.
Monitor I.V. fluid intake to avoid circulatory overload and pulmonary congestion.
Watch for treatment complications by observing and listening to the patient. Also monitor laboratory studies and vital signs. Perform appropriate nursing measures to prevent or alleviate complications. Report complications.

Patient teaching for mesothelioma patient

Show the patient how to perform relaxation techniques. Also demonstrate breathing and positioning variations to ease the dyspnea associated with progressive disease.
Explain all procedures and treatments. Schedule time to answer the patient's questions.
Teach the patient measures (such as increasing fluid intake) to minimize adverse effects of treatment.
When appropriate, teach the patient and family procedures to maximize breathing and prevent the complications of immobility.
Explain how to practice meticulous hand washing and aseptic techniques to avoid infection.
Refer the patient to the social services department, support groups, and community or professional mental health resources to help him and family cope with terminal illness.

Nursing care plans NANDA Nursing Diagnosis: Disturbed Sensory perception

2009-03-21T05:44:00.000-07:00

NANDA Nursing Diagnosis Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Defining Characteristics: Poor concentration, auditory distortions, change in usual response to stimuli, restlessness, reported or measured change in sensory acuity, irritability, disoriented in time, in place, or with people; change in problem-solving abilities; change in behavior pattern; altered communication patterns; hallucinations; visual distortions

NOC Outcomes

Body Image
Cognitive Orientation
Sensory Function: Vision
Vision Compensation Behavior
Cognitive Orientation
Communication: Receptive Ability
Distorted Thought Control
Hearing Compensation Behavio

Client Outcomes

Demonstrates understanding by a verbal, written, or signed response
Demonstrates relaxed body movements and facial expressions
Explains plan to modify lifestyle to accommodate visual or hearing impairment
Remains free of physical harm resulting from decreased balance or a loss of vision, hearing, or tactile sensation
Maintains contact with appropriate community resources

NIC Interventions

Communication Enhancement: Hearing Deficit
Cognitive Stimulation
Environmental Management

Nursing Interventions and Rationales

Nursing care plans for Dermatophytosis (tinea)

2009-03-14T19:12:00.000-07:00

Nursing care plans for Dermatophytosis

Dermatophytosis (tinea) is a group of superficial fungal infections usually classified according to their anatomic location. Dermatophytosis may affect the scalp (tinea capitis), the bearded skin of the face (tinea barbae), the body (tinea corporis, occurring mainly in children), the groin (tinea cruris, or jock itch), the nails (tinea unguium, also called onychomycosis), and the feet (tinea pedis, or athlete's foot). These disorders vary from mild inflammations to acute vesicular reactions.

Tinea infections are prevalent in the United States and are usually more common in males than in females. Although remissions and exacerbations are common, with effective treatment, the cure rate is very high. About 20% of infected people develop chronic conditions.

Causes

Tinea infections result from dermatophytes (fungi) of the genera Trichophyton, Microsporum, and Epidermophyton. Transmission can occur directly through contact with infected lesions or indirectly through contact with contaminated articles, such as shoes, towels, or shower stalls. Some cases come from contact with contaminated animals or soil. Warm weather, humidity, and tight clothing encourage fungus growth

Complications

Hair or nail loss and secondary bacterial or candidal infections, resulting in inflammation, itching, tenderness, and maceration, are common complications of tinea infections.

Assessment Nursing care plans for Dermatophytosis

Tinea lesions vary in appearance and duration. Inspection of the patient with tinea capitis may expose small, spreading papules on the scalp that may progress to inflamed, pus-filled lesions (kerions). Patchy hair loss with scaling may be visible. Tinea barbae appears as pustular folliculitis in the bearded area.

In patients with tinea corporis, inspection and palpation reveal flat skin lesions at any site except the scalp, bearded skin, or feet. These lesions may be dry and scaly or moist and crusty; as they enlarge, their centers heal, producing the classic ring-shaped appearance. In patients with tinea cruris, inspection and palpation find raised, sharply defined, itchy red lesions in the groin that may extend to the buttocks, inner thighs, and external genitalia. Tinea unguium starts at the tip of one or more toenails (fingernail infection is less common). Inspection reveals gradual thickening, discoloration, and crumbling of the nail, with accumulation of subungual debris. Eventually, the nail may be completely destroyed.

Diagnoses Nursing care plans for Dermatophytosis (tinea)

Acute pain
Deficient knowledge (skin care regimen)
Disturbed body image
Impaired skin integrity
Risk for infection

Key outcomes Diagnoses Nursing care plans for Dermatophytosis (tinea)

patient will report feelings of increased comfort.
patient and his family will demonstrate the appropriate skin care regimen.
patient will voice feelings about his changed body image.
patient will exhibit improved or healed wounds or lesions.
patient will avoid or minimize the risk of secondary infection.

Nursing interventions Patient teaching Base On NANDA nursing Diagnosis here

Nursing care plans for Disturbed Body Image

2009-03-06T19:15:00.000-08:00

Nursing Diagnosis : Disturbed Body Image
Nursing care plans for Disturbed Body Image
NANDA Definition: Confusion in mental picture of one's physical self

Defining Characteristics: Nonverbal response to actual or perceived change in structure and or function, verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function, erbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function, behaviors of avoidance, monitoring, or acknowledgment of one's body

Objective
Missing body part; actual change in structure or function; avoidance of looking at or touching body part, intentional or unintentional hiding or overexposure of body part; trauma to nonfunctioning part; change in social involvement, change in ability to estimate spatial relationship of body to environment

Subjective
Change in lifestyle, fear of rejection or reaction by others, focus on past strength, function, or appearance, negative feelings about body, feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Body Image
• Child Development: 2 Years
• Child Development: 3 Years
• Child Development: 4 Years
• Child Development: 5 Years
• Child Development: Middle Childhood (6-11 Years)
• Child Development: Adolescence (12-17 Years)
• Distorted Thought Control
• Grief Resolution
• Psychosocial Adjustment: Life Change
• Self-Esteem

Client Outcomes
• States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
• Calls body part or loss by appropriate name
• Looks at and touches changed or missing body part
• Cares for changed or nonfunctioning part without inflicting trauma
• Returns to previous social involvement
• Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Nursing Interventions and Rationales

Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image The five BII subscales-General Appearance, Body Competence, Others' Reaction to Appearance, Value of Appearance, and Body Parts-exhibited moderate to high internal reliability and concurrent validity.
Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis. Clients are in shock during acute phase, and their own value system must be considered. Clients deal better with change over time.
Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle. Changes in body image cause anxiety. People in this situation use a variety of unconscious coping mechanisms to deal with their altered body image (ABI). Defense mechanisms are normal, unless they are used so much that they interfere with rather than improve self-esteem.
Identify clients at risk for body image disturbance (e.g., body builders, cancer survivors). The results of one study suggest that male body builders are at risk for body image disturbance and the associated psychological characteristics that have been commonly reported among eating disorder patients. These psychological characteristics also appear to predict steroid use in this group of males. Steroid users reported an elevated drive to put on muscle mass in the form of bulk.
Clients should not be rushed into sharing their feelings. Feelings associated with complicated and emotionally powerful issues involving an altered body image take time to work through and express.
Do not ask clients to explore feelings unless they have indicated a need to do so. Patients reported keeping their feelings to themselves as a frequently used coping strategy.
Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs. Emphasizing strengths promotes a positive self-image. Planning for an event such as hair loss helps to decrease the anxiety associated with a sudden change in appearance.
Encourage client to purchase clothes that are attractive and that de-emphasize their disability. Individuals with osteoporosis are not usually disabled but may perceive themselves as unattractive and experience social isolation as a result of ill-fitting clothes that accentuate the physical changes.
Allow client and others gradual exposure to the body change. Begin by having the client touch the affected area; then use a mirror to look at it. Go to a hospital shop with a nurse or support person and discuss feelings associated with the reaction of others to the body change. Part of the rehabilitation process is graded exposure-the client moves from a protected to an unprotected environment with the support of the nurse.
Encourage client to discuss interpersonal and social conflicts that may arise. A good perception of body image is best achieved within a supportive social framework. Clients with an active social support network are likely to make better progress. Changes in physical appearance and function associated with disease processes need to be integrated into the interaction that occurs between patients and lay caregivers.
Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths. It is important for clients to be involved in their own care. If they have received information about their altered body image, treatment, and rehabilitation, they will be able to make their own choices. Consequently they will be more likely to come to terms with and adapt to their ABI. Healthy adaptation to body image exists when the person is able to maximize ability despite disability .
Help client accept help from others; provide a list of appropriate community resources (e.g., Reach to Recovery, Ostomy Association). Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning.
Help client describe self-ideal, identify self-criticisms, and be accepting of self. The perception of self-image involves knowing the self and what is important and valued. Disability causes individuals to live as changed human beings whether they are willing to or not.
Encourage client to write a narrative description of their changes. An analysis based on the grounded theory method revealed that one's experience of coping or adjustment to a disability is represented as narratives about himself or herself. Each person with TBI reconstructed certain self-narratives when coping with their changed self-images and daily lives.
Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure. Nurses must be aware of their nonverbal behavior; clients often become acutely aware of nurses' feelings as a result of the nurses' facial expressions, tone of voice, touch, or other behaviors.
Encourage client to continue same personal care routine that was followed before the change in body image. It is preferable that this care be completed in the bathroom and not in bed. This routine gives the client privacy and also prevents the client from settling into an "invalid" role. Research has shown that women who resume familiar routines and habits heal better and suffer less depression than those who settle into the role of patient.

Geriatric

Focus on remaining abilities. Have client make a list of strengths. Results from unstructured interviews with women aged 61 to 92 regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the "naturalness" of the aging process. Motivation and self-worth are increased in the elderly by highlighting their capabilities. Even a severely disabled client is usually capable of accomplishing some tasks. Normal changes in body image occur as a result of the aging process.

Multicultural

Assess for the influence of cultural beliefs, norms, and values on the client's body image. The client's body image may be based on cultural perceptions, as well as influences from the larger social context.
Validate the client's feelings with regard to the impact of health status on disturbances in body image. Validation lets the client know that the nurse has heard and understands what was said and promotes the nurse-client relationship.
Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. Body image disturbances are pervasive across western cultures and appear to increase in other cultures with acculturation to western ideals.

Home Care Interventions

Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
Assess family/caregiver level of acceptance of client's body changes.
Be accepting of changes in all interactions with client and family and caregivers. Acceptance promotes trust.
Help client to see new or changing roles in family. Point out ways in which the community can help support client and family strengths.
Refer to medical social services for level of acceptance and possible financial impact of changes. Clients and caregivers may see the nurse's visit as being solely involved with physiological issues such as dressing, especially under managed care systems. Social worker visits can support the client or caregivers with dedicated time and can help the nurse be supportive and adapt interventions to promote acceptance. The nurse or social worker can introduce or reinforce use of community resources.
Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty looking at or touching changed body part. The quicker the involvement in self-care, the greater the chances for permanent acceptance and positive self-esteem.
Teach family and client complications of medical condition and when to contact physician.
Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities. The quicker the reinvolvement in daily living activities and self-care, the greater the chances for permanent acceptance and positive self-esteem.
If appropriate, provide home health aide support to help the client and family through ADL transition.
Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures, assist with transfer/ambulation safety, or obtain use of a prosthetic device in the home setting.
Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations (e.g., client with ostomy). Good nutrition and sleep patterns promote faster healing and better coping.
Assist family with obtaining needed supplies. Cost of ostomy supplies and adaptive equipment can be an added stressor for the client. Community resources can assist.

Client/Family Teaching

Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site). Patient teaching by ET nurses may alleviate problems associated with altered body image in relation to the presence of an ostomy.
Inform client of available community support groups; offer to make initial phone call. Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning.
Refer client to counseling for help adjusting to body change. Counseling is important for a client who is trying to create a new body ideal or work through a grief process.
Provide printed material and didactic information for significant others. Some significant others prefer to receive didactic material rather than vent their feelings as a way of showing support.
Encourage significant others to offer support. Social support from significant others enhances both emotional and physical health.
Direct social support as follows: instruct regarding practical care, encourage appraisal support, encourage self-esteem support, and encourage sense of belonging. The preceding are four categories of support recognized in the body-image care model. Clients with an active social support network are likely to make better progress than those without support.
Refer to an interdisciplinary team clients with ostomies who are having difficulty with personal acceptance, personal and social body-image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications Many clinical studies have found patients with ostomies to be a group facing multiple adjustment demands. One of these demands is coping with a significant change in body image. At the Medical College of Wisconsin, a team approach has been initiated; the ET nurse, the psychologist, and the surgeon deal with body image concerns together. The multidisciplinary approach has been demonstrated to be successful in facilitating adaptation to an altered body image.

Nursing Care Plans for Diarrhea

2009-03-06T07:48:00.000-08:00

Nursing Diagnosis: Diarrhea
Nursing care plans for Diarrhea
NANDA Definition: Passage of loose, unformed stools

Defining Characteristics: Hyperactive bowel sounds, at least three loose liquid stools per day, urgency, abdominal pain, cramping

Related Factors:
Psychological
High stress levels and anxiety
Situational
Alcohol abuse, toxins, laxative abuse, radiation, tube feedings , adverse effects of medications, contaminants, travel
Physiological
Inflammation, malabsorption, infectious processes, irritation, parasites

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Bowel Elimination
• Electrolyte and Acid-Base Balance
• Fluid Balance
• Hydration
• Treatment Behavior: Illness or Injury

Client Outcomes
• Defecates formed, soft stool every day to every third day
• Maintains a rectal area free of irritation
• States relief from cramping and less or no diarrhea
• Explains cause of diarrhea and rationale for treatment
• Maintains good skin turgor and weight at usual level
• Contains stool appropriately (if previously incontinent)

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Diarrhea Management

Nursing Interventions and Rationales Nursing Care Plans for Diarrhea

Assess pattern of defecation or have client keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen. Assessment of defecation pattern will help direct treatment.
Identify cause of diarrhea if possible (e.g., viral, rotavirus, human immunodeficiency virus/HIV), food, medication effect, radiation therapy, protein malnutrition, laxative abuse, stress). Identification of the underlying cause is imperative because the treatment and expected outcome depend on it. If the onset of diarrhea is sudden with no obvious cause, a colonoscopy is recommended to rule out colon cancer. When reviewing medication, assess for medications that increase peristalsis, such as metoclopramide. HIV infection is also commonly associated with diarrhea.
If client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic therapy, consider possibility of Clostridium difficile infection. difficile infection and pseudomembranous colitis have become increasingly common because of the frequent use of broad-spectrum antibiotics.
Use Standard Precautions when caring for clients with diarrhea to prevent spread of infectious diarrhea; use gloves and handwashing. Clostridium difficile has been shown to be contagious and at times epidemic. One study of medical patients demonstrated that more than 30% developed nosocomial diarrhea after admission to a nursing unit, and the majority of cases were caused by Clostridium difficile. Clostridium difficile is spread by direct or indirect contact, placing other clients at risk for infection.
Obtain stool specimens as ordered to either rule out or diagnose an infectious process (e.g., ova and parasites, Clostridium difficile infection, bacterial cultures).
If client has infectious diarrhea, avoid using medications that slow peristalsis. If an infectious process is occurring, such as Clostridium difficile infection or food poisoning, medication to slow down peristalsis should generally not be given. The increase in gut motility helps eliminate the causative factor, and use of antidiarrheal medication could result in a toxic megacolon.
Observe and record number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output. Documentation of output provides a baseline and helps direct replacement fluid therapy.
Inspect, palpate, percuss, and auscultate abdomen; note whether bowel sounds are frequent.
Assess for dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock. Severe diarrhea can cause deficient fluid volume with extreme weakness and cause death in the very young, the chronically ill, and the elderly.
Observe for symptoms of sodium and potassium loss (e.g., weakness, abdominal or leg cramping, dysrhythmia). Note results of electrolyte laboratory studies. Stool contains electrolytes; excessive diarrhea causes electrolyte abnormalities that can be especially harmful to clients with existing medical conditions.
Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure specific gravity of urine if possible. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume.
Weigh client daily and note decreased weight. An accurate daily weight is an important indicator of fluid balance in the body.
Give clear fluids as tolerated, serving at lukewarm temperature.
For children with diarrhea, give oral rehydration therapy liquids (Pedialyte) as directed by physician. Oral rehydration therapy is effective for treating mild to moderate dehydration in children with diarrhea and may help prevent the need for hospitalization with administration of IVs.
If diarrhea is associated with cancer or cancer treatment, once infectious cause of diarrhea is ruled out, provide medications as ordered to stop diarrhea. The loss of proteins, electroytes, and water from diarrhea in a cancer client can lead to rapid deterioration and possibly fatal dehydration.
If diarrhea is chronic and there is evidence of malnutrition, consult with primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals. A hydrolyzed formula contains protein that is partially broken down to small peptides or amino acids for people who cannot digest nutrients.
Encourage client to eat small, frequent meals and to consume foods that normally cause constipation and are easy to digest . Encourage client to avoid milk products, foods high in fiber, and caffeine. Bland, starchy foods are initially recommended when starting to eat solid food again.
Provide a readily available bedpan, commode, or bathroom.
Maintain perirectal skin integrity. Cleanse with a mild cleansing agent (perineal skin cleanser). Apply protective ointment prn. If skin is still excoriated and desquamated, apply a wound hydrogel. Avoid the use of rectal Foley catheters. Moisture-barrier ointments protect the skin from excoriation. Rectal Foley catheters can cause rectal necrosis, sphincter damage, or rupture, and the nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care.
If client is receiving a tube feeding, do not assume it is the cause of diarrhea. Perform a complete assessment to rule out other causes such as medication effects, sorbitol in medications, or an infection. Research has shown that tube feedings do not usually cause diarrhea. Howeve, sorbitol in medication has been linked to diarrhea.
If client is receiving a tube feeding , suggest formulas that contain a bulking agent such as Jevity. Note rate of infusion, and prevent contamination of feeding by rinsing container every 8 hours and replacing it every 24 hours. Rapid administration of tube feeding and contaminated feedings have been associated with diarrhea. Bulking agents are useful in tube feedings to prevent diarrhea.

Geriatric

Evaluate medications client is taking. Recognize that many medications can result in diarrhea, including digitalis, propranolol, ACE inhibitors, Hx-receptor antagonists, NSAIDS, anticholinergic agents, oral hypoglycemia agents, antibiotics, and others. A drug-associated cause should always be considered when treating diarrhea in the older person; many drugs can result in diarrhea.
Monitor client closely to detect whether an impaction is causing diarrhea; remove impaction as ordered. Impactions are more common in the elderly than in younger clients. It is very important that the client be checked for impaction before being given any antidiarrheal medication.
Seek medical attention if diarrhea is severe or persists for more than 24 hours, or if client has symptoms of dehydration or electrolyte disturbances such as lassitude, weakness, or prostration. Elderly clients can dehydrate rapidly. The greatest concern for elderly clients with severe diarrhea is hypokalemia. Hypokalemia is treatable but when missed can be fatal.
Provide emotional support for clients who are having trouble controlling unpredictable episodes of diarrhea. Diarrhea can be a great source of embarrassment to the elderly and can lead to social isolation and a feeling of powerlessness.

Home Care Interventions Nursing Care Plans for Diarrhea

Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling.
Assess for methods of handling soiled laundry if client is bedbound or has been incontinent. Instruct or reinforce Standard Precautions with family and bloodborne pathogen precautions with agency caregivers. The Bloodborne Pathogen Regulations of the Occupational Safety and Health Administration (OSHA) identify legal guidelines for caregivers.
When assessing medication history, include over-the-counter drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix over-the-counter medications when self-treating. Mixing over-the-counter medications can further irritate the gastrointestinal system, intensifying the diarrhea or causing nausea and vomiting.

Client and Family Teaching Nursing Care Plans for Diarrhea

Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract.
Teach appropriate method of taking ordered antidiarrheal medications; explain side effects.
Explain how to prevent the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food).
Help client to determine stressors and set up an appropriate stress reduction Care plans .
Teach signs and symptoms of dehydration and electrolyte imbalance.

Nursing Care Plans for Deficient Knowledge

2009-03-02T22:36:00.000-08:00

Nursing care plans with Nursing Diagnosis: Deficient Knowledge

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

Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors: Lack of exposure; lack of recall; information misinterpretation; cognitive limitation; lack of interest in learning; unfamiliarity with information resources

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
· Knowledge of: Diet
· Disease Process
· Energy Conservation
· Health Behaviors
· Health Resources
· Infection Control
· Medication
· Personal Safety
· Prescribed Activity
· Substance Use Control
· Treatment Procedures
· Treatment Regimen

Client Outcomes
· Explains disease state, recognizes need for medications, understands treatments
· Explains how to incorporate new health regimen into lifestyle
· States an ability to deal with health situation and remain in control of life
· Demonstrates how to perform procedures satisfactorily
· Lists resources that can be used for more information or support after discharge

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
· Teaching: Disease Process
· Teaching: Individual
· Teaching: Infant Care

Nursing Interventions and Rationales

Observe client's ability and readiness to learn (e.g., mental acuity, ability to see or hear, no existing pain, emotional readiness, absence of language or cultural barriers). Education in self-care must take into account physical, sensory, mobility, sexual, and psychosocial changes related to age.
Assess barriers to learning (e.g., perceived change in lifestyle, financial concerns, cultural patterns, lack of acceptance by peers or coworkers). The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.
Determine client's previous knowledge of or skills related to his or her diagnosis and the influence on willingness to learn. New information is assimilated into previous assumptions and facts and may involve negotiating, transforming, or stalling.
Involve clients in writing specific outcomes for the teaching session, such as identifying what is most important to learn from their viewpoint and lifestyle. Objectives put the content into focus, provide a forum for evaluation outcomes, and ensure continuity. Client involvement improves compliance with health regimen and makes teaching and learning a partnership.
When teaching, build on client's literacy skills. In patients with low literacy skills, materials should be short and have culturally sensitive illustrations.
Present material that is most significant to client first, such as how to give injections or change dressings; present additional material once client's most pressing educational needs have been met. Information building begins with explaining simple concepts and moves on to explanations of complex application situations.
Determine client's understanding of common medical terminology, such as "empty stomach," "emesis," and "palpation." Clients are expected to read and understand labels on medicine containers, appointment slips, and informed consents, yet an estimated 40 million adults are functionally illiterate.
Evaluate the readability of the material in pamphlets or written instructions. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability and comprehension of instruction, poor communication, and increased physical limitations.
Use visual aids such as diagrams, pictures, videotapes, audiotapes, and interactive Internet web sites. Verbal reinforcement of personalized, written instructions appears to be the best tested intervention. Computer-generated, personalized instructions improved adherence when compared with handwritten instructions. This evidence-based study suggested leaflets as a useful resource for information provision.
Provide preadmission self-instruction materials to prepare client for postoperative exercises. Providing clients with preadmission information about exercises has been shown to increase positive feelings and the ability to perform prescribed exercises.
Identify the primary family support person; be aware of that person's ability to learn and incorporate needed changes.
Assess willingness of family to incorporate new information, immunizations, medical/dental care, and diet/behavior modifications in support of the client. Attention needs to be directed at family adjustment factors. For example, women recovering from alcohol abuse are at risk for relapse if their spouse continues to drink alcohol, and modification of eating patterns plus social and partnership support have had more success than modification alone.
Help client identify community resources for continuing information and support. Learning occurs through imitation, so persons who are currently involved in lifestyle changes can help the client anticipate adjustment issues. Community resources can offer financial and educational support. For example, role modeling and skill training have been used to monitor symptoms and solve asthma problems.
Evaluate client's learning through return demonstrations, verbalizations, or the application of skills to new situations. Presenting information along with with examples of how to apply the information has been found more successful than providing information alone in a home care setting.

Geriatric Nursing Care Plans

Adapt the teaching process for the physical constraints of the aging process (e.g., speak clearly, use a variety of audio-visual-psychomotor methods, provide examples, and allow time for client to repeat and review). Adults are capable of learning at any age. Age modifies but does not inhibit learning. Older adults need practice to use new technology.
Ensure that the client uses necessary reading aids (e.g., glasses, magnifying lenses, large-print text) or hearing aids. Visual and hearing deficits require amplification or clarification of sensory input.
Use printed material, videotapes, lists, diagrams, and Internet addresses that the client can refer to at another time. These methods provide a reference that can be used in a less stressful setting, decreasing barriers to learning. This study demonstrated the effectiveness of printed material and a web-based format for education. The web-based format demonstrated two additional benefits when compared with printed material: increased social support and decreased anxiety.
Assess client's previous knowledge and resistance or blocks to incorporating new information into the current lifestyle. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.
Repeat and reinforce information during several brief sessions. Understanding past information is essential to acquiring new knowledge. Brief sessions focus attention on essential information.
Discuss healthy lifestyle changes that promote wellness for the older adult. It is never too late to stop smoking, lose weight, or modify dietary intake of fats and alcohol. Quality vs. quantity of life may be the key issue in teaching self-care health habits.
Evaluate readability of the material. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability, comprehension of instruction, poor communication, and increased physical limitations.
Consider health education programs using television and newspapers. There was a significant increase in stroke knowledge (52% more likely to know a risk factor and 35% know a symptom, p = 0.032) following this health education program as demonstrated through a telephone pretest and posttes.

Multicultural Nursing Care Plans Interventions and Rationales

Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes.
Assess for the influence of cultural beliefs, norms, and values on the client's knowledge base. The client's knowledge base may be influenced by cultural perceptions.
Use a neutral indirect style when addressing areas where improvement is needed when working with Native American clients. Using indirect statements such as "I had a client who tried 'X' and it seemed to work very well" will help avoid resentment from the client.
Validate the client's feelings and concerns related to previous learning experiences. Validation lets the client know the nurse has heard and understands what was said.
Approach individuals of color with respect, warmth, and professional courtesy. Instances of disrespect and lack of caring have special significance for individuals of color.

Home Care Interventions

Because home care is an intermittent model of care having a goal of safety and optimal wellness of the client between visits, the importance of teaching (by nurse) and learning (by client) should not be understated. All of the previously mentioned interventions are applicable to the home setting.
Select a space and time for teaching in which client and/or caregiver can focus on information to be learned. The home setting provides many distractions that may impair the ability of the client to learn.
Consider the complexity of material or behaviors to be learned. Adjust care plan and respective teaching and learning experiences accordingly to build client confidence in ability to learn (and change). Confidence in ability to learn and change is part of readiness to learn.
Assess for specific areas of learning that have the potential for strong emotional responses by the client or family/caregiver. Allow time for expression of feelings and encourage acceptance of need for learning. An individual's perception of barriers and benefits has consistently been most predictive of subsequent behavior. Clinicians should develop interventions that increase benefits and decrease barriers.
Document client's and caregivers' responses to learning. Clear documentation supports continuity in the learning experience

Nursing Care Plans With Nursing Diagnosis: Deficient Fluid volume

2009-02-28T05:52:00.000-08:00

Nursing Diagnosis: Deficient Fluid volume

NANDA Definition for Deficient Fluid volume: Decreased intravascular, interstitial, and or intracellular fluid

Defining Characteristics Deficient Fluid volume : Decreased urine output, increased urine concentration, weakness, sudden weight loss, decreased venous filling, increased body temperature, decreased pulse volume or pressure, change in mental state, elevated hematocrit, decreased skin or tongue turgor; dry skin/mucous membranes, thirst, increased pulse rate, decreased blood pressure.

Related Factors: Active fluid volume loss; failure of regulatory mechanisms

NOC Outcomes (Nursing Outcomes Classification): Suggested NOC Labels
· Fluid Balance
· Hydration
· Nutritional Status: Food and Fluid Intake

Client Outcomes
· Maintains urine output more than 1300 ml/day (or at least 30 ml/hr)
· Maintains normal blood pressure, pulse, and body temperature
· Maintains elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, time
· Explains measures that can be taken to treat or prevent fluid volume loss
· Describes symptoms that indicate the need to consult with health care provider

NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels
· Fluid Management
· Hypovolemia Management
· Shock Management: Volume

Nursing Interventions and Rationales

Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, diuretic therapy). Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss.
Watch for early signs of hypovolemia, including weakness, muscle cramps, and postural hypotension. Late signs include oliguria; abdominal or chest pain; cyanosis; cold, clammy skin; and confusion.
Monitor total fluid intake and output every 8 hours and every hour for the unstable client.
Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine. Monitoring for trends for 2 to 3 days gives a more valid picture of the client's hydration status than monitoring for a shorter period. Dark-colored urine with increasing specific gravity reflects increased urine concentration.
Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh client on same scale with same type of clothing at same time of day, preferably before breakfast. Body weight changes reflect changes in body fluid volume. A 1-pound weight loss reflects a fluid loss of about 500 cc.
Monitor vital signs of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client and every 4 hours for the stable client. Observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume, and increased or decreased body temperature. A decreasd pulse pressure is an earlier indicator of shock than is the systolic blood pressure. Decreased intravascular volume results in hypotension and decreased tissue oxygenation. The temperature will be decreased as a result of decreased metabolism, or it may be increased if there is infection or hypernatremia present.
Check orthostatic blood pressures with client lying, sitting, and standing. A 15 mm Hg drop when upright or an increase of 15 beats/minute in the pulse rate are seen with deficient fluid volume.
Monitor for inelastic skin turgor, thirst, dry tongue and mucous membranes, longitudinal tongue furrows, speech difficulty, dry skin, sunken eyeballs, weakness, and confusion. Tongue dryness, longitudinal tongue furrows, dryness of the mucous membranes of the mouth, upper body muscle weakness, thirst, confusion, speech difficulty, and sunkenness of eyes are symptoms of deficient fluid volume.
Provide frequent oral hygiene, at least twice a day. Oral hygiene decreases unpleasant tastes in the mouth and allows the client to respond to the sensation of thirst.
Provide fresh water and oral fluids preferred by client, provide prescribed diet; offer snacks, instruct significant other to assist client with feedings as appropriate. The oral route is preferred for maintaining fluid balance. Distributing the intake over the entire 24 hour period and providing snacks and preferred beverages increases the likelihood that the client will maintain the prescribed oral intake.
Provide free water with tube feedings as appropriate. This provides water for replacement of intravascular or intracellular volume as necessary. Tube feeding has been found to increase the risk for dehydration.
Institute measures to rest the bowel when client is vomiting or has diarrhea,. Hydrate client with ordered IV solutions if prescribed. The most common cause of deficient fluid volume is gastrointestinal loss of fluid. At times it is preferable to allow the gastrointestinal system to rest before resuming oral intake.
Provide oral replacement therapy as ordered with a glucose-electrolyte solution when client has acute diarrhea or nausea or vomiting. Provide small, frequent quantities of slightly chilled solutions. Maintenance of oral intake stabilizes the ability of the intestines to digest and absorb nutrients; glucose-electrolyte solutions increase net fluid absorption while correcting deficient fluid volume.
Administer antidiarrheals and antiemetics as appropriate. The gastrointestinal tract is a common site for fluid loss. The goal is to stop the loss that results from vomiting or diarrhea.
If client requires IV fluid replacement, maintain patent IV access, set an appropriate IV infusion flow rate, and administer at a constant flow rate as ordered. Isotonic IV fluids such as 0.9% N/S or lactated ringers allow replacement of intravascular volume.
Assist with ambulation if client has postural hypotension. Postural hypotension can cause dizziness, which places the client at higher risk for injury.
Promote skin integrity (e.g., monitor areas for breakdown, ensure frequent weight shifts, prevent shearing, promote adequate nutrition). Deficient fluid volume decreases tissue oxygenation, which makes the skin more vulnerable to breakdown.

Critically ill Nursing Care Plans

Monitor central venous pressure, right atrial pressure, and pulmonary wedge pressure for decreases. Hemodynamic parameters are sensitive indicators of intravascular fluid volume, and hemodynamic measurements are especially needed in the client with cardiac or renal problems.
Monitor serum and urine osmolality, serum sodium, blood urea nitrogen (BUN)/creatinine ratio, and hematocrit for elevations. These are all measures of concentration and will be elevated with decreased intravascular volume.
When ordered, initiate a fluid challenge of crystalloids for replacement of intravascular volume; monitor client's response to prescribed fluid therapy and fluid challenge, especially noting vital signs, urine output, and lung sounds. A fluid challenge can help the client with deficient fluid volume regain intravascular volume quickly, but the client must be carefully observed to ensure that he or she does not go into fluid volume overload. In trauma clients, if there is no clinical improvement after 2 L of crystalloids, then generally a blood transfusion should be iniated.
Position client flat with legs elevated when hypotensive, if not contraindicated. This position enhances venous return, thus contributing to the maintenance of cardiac output.
If trauma client, monitor lactic acid levels as ordered, along with watching for signs of fluid deficit and shock. Increased lactic acid levels can help identify occult hypoperfusion, which results in decreased survival and increased incidence of respiratory complications and multiple organ failure in trauma clients.
Consult physician if signs and symptoms of deficient fluid volume persist or worsen. Prolonged deficient fluid volume increases the risk for development of complications, including shock, multiple organ failure, and death.

Nursing Care Plans for Geriatric

Monitor elderly clients for deficient fluid volume carefully, noting new onset of weakness, dizziness, or dry mouth with longitudinal furrows. The elderly are predisposed to deficient fluid volume because of decreased fluid in body, decreased thirst sensation, and decreased ability to concentrate urine.
Check skin turgor of elderly client on the forehead or sternum; also look for the presence of longitudinal furrows on the tongue and dry mucous membranes. Elderly people commonly have decreased skin turgor from normal age-related loss of elasticity; therefore checking skin turgor on the arm is not reflective of fluid volume (Bennett, 2000). The presence of longitudinal furrows or dry mucous membranes is a good indication of dehydration in the elderly.
Encourage fluid intake by offering fluids regularly to cognitively impaired clients. The elderly have a decreased thirst sensation (Metheny, 2000), and short-term memory loss may impede the client's memory of fluid intake.
Incorporate regular hydration into daily routines Integration of hydration into regular routines increases the chance that the client will meet the daily fluid requirements.
Monitor elderly clients for excess fluid volume during the treatment of deficient fluid volume: listen to lung sounds, watch for edema, and note vital signs. The elderly client has a decreased ability to adapt to rapid increases in intravascular volume and can quickly develop heart failure.

Home Care Interventions

Determine if it is appropriate to intervene for defecient fluid volume or allow the client to die comfortably without fluids as desired. Deficient fluid volume may be a symptom of impending death in terminally ill clients. The deficit may result in a mild euphoria, and a more comfortable death.
Teach family members how to monitor output in the home. Instruct them to monitor both intake and output. An accurate measure of fluid intake and output is an important indicator of client fluid status.
When weighing client, use same scale each day. Be sure scale is on a flat surface. Do not weigh client with scale placed on any kind of rug. Use bed or chair scales for clients who are unable to stand. An accurate daily weight is an excellent reflection of fluid balance.
Teach family about complications of deficient fluid volume and when to call physician.
If the client is receiving IV fluids, there must be a responsible caregiver in the home. Teach caregiver about administration of fluids, complications of IV administration, and when to call for assistance. Assist caregiver with administration for as long as necessary to maintain client safety. Administration of IV fluids in the home is a high-technology procedure and requires sufficient professional support to ensure safety of the client.
Identify an emergency plan, including when to call help. Some complications of deficient fluid volume cannot be reversed in the home and are life-threatening. Clients progressing toward hypovolemic shock will need emergency care.

Client and Family Teaching

Instruct client to avoid rapid position changes, especially from supine to sitting or standing.
Teach client and family about appropriate diet and fluid intake.
Teach client and family how to measure and record intake and output accurately.
Teach client and family about measures instituted to treat hypovolemia and to prevent or treat fluid volume loss.
Instruct client and family about signs of deficient fluid volume that indicate they should contact health care provider.

Nursing Care Plans for Decreased Cardiac output

2009-02-27T18:39:00.000-08:00

Nursing Diagnosis: Decreased Cardiac output
Nursing Care Plans for Decreased Cardiac output
NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body

Defining Characteristics: Altered heart rate/rhythm: arrhythmias (tachycardia, bradycardia); palpitations; EKG changes; altered preload: jugular vein distention; fatigue; edema; murmurs; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); weight gain; altered afterload: cold/clammy skin; shortness of breath/dyspnea; oliguria; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR); increased/decreased pulmonary vascular resistance (PVR); skin color changes; altered contractility: crackles; cough; orthopnea/paroxysmal nocturnal dyspnea; cardiac output less than 4 L/min; cardiac index less than 2.5 L/min; decreased ejection fraction, stroke volume index (SVI), left ventricular stroke work index (LVSWI); S3 or S4 sounds; behavioral/emotional: anxiety ; restlessness

Related Factors: Myocardial infarction or ischemia, valvular disease, cardiomyopathy, serious dysrhythmia, ventricular damage, altered preload or afterload, pericarditis, sepsis, congenital heart defects , vagal stimulation, stress, anaphylaxis, cardiac tamponade

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Cardiac Pump Effectiveness
• Circulatory Status
• Tissue Perfusion: Abdominal Organs
• Tissue Perfusion: Peripheral
• Vital Signs Status

Client Outcomes

Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain
Remains free of side effects from the medications used to achieve adequate cardiac output
Explains actions and precautions to take for cardiac disease

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Cardiac Care: Acute
• Circulatory Care

Nursing Interventions and Rationales

Monitor for symptoms of heart failure and decreased cardiac output, including diminished quality of peripheral pulses, cool skin and extremities, increased respiratory rate, presence of paroxysmal nocturnal dyspnea or orthopnea, increased heart rate, neck vein distention, decreased level of consciousness, and presence of edema. As these symptoms of heart failure progress, cardiac output declines.
Listen to heart sounds; note rate, rhythm, presence of S3, S4, and lung sounds. The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate onset of heart failure. If client develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea.
Observe for confusion , restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output.
Observe for chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factors. Chest pain/discomfort is generally indicative of an inadequate blood supply to the heart, which can compromise cardiac output. Clients with heart failure can continue to have chest pain with angina or can reinfarct.
If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician. These actions can increase oxygen delivery to the coronary arteries and improve client prognosis.
Place on cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation. Atrial fibrillation is common in heart failure.
Monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. Hemodynamic parameters give a good indication of cardiac function.
Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, maintaining adequate perfusion of the body.
Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
Note results of EKG and chest Xray. EKG can reveal previous MI,or evidence of left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension . Xray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette found in dilated cardiomyopathy or large pericardial effusion.
Results of diagnostic imaging studies such as echocardiogram, radionuclide imaging or dobutamine stress echocardiography. The echocardiogram is the most important imaging tool for evaluation patients with symptoms of heart failure because overall systolic function and chamber size can be evaluated quickly. In addition, global versus regional left ventricular function, valvular abnormalities, and diastolic function can be defined, assisting in differential diagnosis. An ejection fraction in a healthy heart is approximately 50%. Most patients experiencing heart failure have an ejection fraction of less than 40%.
Watch laboratory data closely, especially arterial blood gases and electrolytes, including potassium. Client may be receiving cardiac glycosides and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use.
Monitor lab work such as complete blood count, sodium level, and serum creatinine. Routine blood work can provide insight into the etiology of heart failure and extent of decompensation. A low serum sodium level often is observed with advanced heart failure and can bea poor prognostic sign. Serum creatinine levels will elevate in clients with severe heart failure because of decreased perfusion to the kidneys.Creatinine may also elevate because of ACE inhibitors.
Administer oxygen as needed per physician's order.
Place client in semi-Fowler's position or position of comfort. Elevating the head of the bed may decrease the work of breathing, and also decrease venous return and preload.
Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin converting enzyme (ACE) inhibitors, digoxin, and beta-blockers such as carvedilol. Notify physician if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered.
During acute events, ensure client remains on bed rest or maintains activity level that does not compromise cardiac output. In severe heart failure, restriction of activity often facilitates temporary recompensation.
Gradually increase activity when client's condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity intolerance .
Serve small sodium-restricted, low-cholesterol meals. Give only small amounts of caffeine-containing beverages, if no resulting dysrhythmia. Sodium-restricted diets help decrease fluid volume excess. Low-cholesterol diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. One cup of caffeinated coffee has generally not been found to have any significant effect (Schneider, 1987; Powell, 1993).
Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity can cause constipation. Straining when defecating that results in the Valsalva maneuver can lead to dysrhythmia, decreased cardiac function, and sometimes death.
Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client.
Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest periods decrease oxygen consumption.
Weigh client at same time daily. An accurate daily weight is a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids.
Assess for presence of anxiety; see interventions for Anxiety to facilitate reduction of anxiety in clients and family.
Consider using music to decrease anxiety and improve cardiac function. Music has been shown to reduce heart rate, blood pressure, anxiety, and cardiac complications.
Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.
Refer to heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. Exercise can help many patients with heart failure. Whereas rest was commonly recommended a few years ago, it has become clear that inactivity can worsen the skeletal muscle myopathy in these patients.A carefully monitored exercise program can improve both functional capacity, and left ventricular function. Exercise based cardiac rehabilitation programs apppear to be effective in reducing cardiac deaths, but the evidence base is weakened by poor quality trials.

Geriatric Care Plans

Observe for atypical pain; the elderly often have jaw pain instead of chest pain or may have silent myocardial infarctions with symptoms of dyspnea or fatigue. The elderly have altered pain pathways and often do not experience the usual chest pain of cardiac patients.
Observe for syncope, dizziness, palpitations, or feelings of weakness associated with a irregular heart rhythm. Dysrhythmias are common in the elderly.
Observe for side effects from cardiac medications. The elderly have difficulty with metabolism and excretion of medications due to decreased function of the liver and kidneys; therefore toxic side effects are more common.

Home Care Interventions for Decreased Cardiac output

Begin discharge planning as soon as possible with case manager or social worker to assess home support systems and the need for community or home health services. These may be to assist with home care, assistance with meal perparations, housekeeping, personal care, transportation to doctor visits, or emotional support. Clients often need help upon discharge. The existing social support network needs to be assessed and assistance provided as needed to meet client needs and to keep the support persons from being overwhelmed. Being discharged to home without adequate support has been shown to be related to readmission of elderly patients.
Assess or refer to case manager or social worker to evaluate client ability to pay for prescriptions. The cost of drugs may be a factor to fill prescriptions and adhere to a treatment plan.
Continue to monitor client for exacerbation of heart failure when discharged home. Transition to home can create increased stress and physiological instability related to diagnosis.
Assess client for understanding and compliance with medical regimen, including medications, activity level, and diet.
Instruct family and client about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor. Early recognition of symptoms facilitates early problem solving and prompt treatment. Clients with heart failure need intensive guideline gased education about these topics to help prevent readmission to the hospital.
Identify emergency plan, including use of CPR. Decreased cardiac output can be life threatening.
Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Transition to the home setting can cause risk factors such as inappropriate diet to reemerge.
Refer to physical therapy for strengthening exercises if client is not involved in cardiac rehabilitation.
Refer to medical social services as necessary for counseling about the impact of severe or chronic cardiac disease. Social workers can assist the client and family with acceptance of life changes.

Client/Family Teaching

Teach symptoms of heart failure and appropriate actions to take if client becomes symptomatic.
Teach importance of smoking cessation and avoidance of alcohol intake. Clients who continue to smoke increase their chance of dying by at least 50%, and alcohol depresses heart contractility. Smoking cessation advice and counsel given by nurses can be effective, and should be available to clients to help stop smoking.
Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques).
Explain necessary restrictions, including consumption of a sodium-restricted diet, guidelines on fluid intake, and the avoidance of Valsalva's maneuver. Teach the importance of pacing activities, work simplification techniques, and the need to rest between activities to prevent becoming overly fatigued. Sodium retentiion leading to fluid overload is a common cause of hospital readmission.
Assist client in understanding the need for and how to incorporate lifestyle changes. Refer to cardiac rehabilitation for assistance with coping and adjustment. Psychoeducational programs including information on stress management and health education have been shown to reduce long term mortality and recurrence of myocardial infarction in heart patients.
Teach client actions, side effects, and importance of consistently taking cardiovascular medications. Medications can prolong the lives of heart failure clients but often are not taken, resulting in hospital readmissions.
Provide client/family with advance directive information to consider. Allow client to give advance directions about medical care or designates who should make medical decisions if he or she should lose decision-making capacity.
Instruct client on importance of getting a pneumonia shot and yearly flu shots as prescribed by physician. Clients with decreased cardiac output are considered higher risk for complications or death if they do not get immunization injections.
Instruct client/family on the need to weigh daily and keep a weight log. Ask if client has a scale at home; if not, assist in getting one. Instruct on establishing baseline weight on own scale when gets home. Weighing daily is an essential aspect of self-management. A scale is necessary. Scales vary and the client needs to establish a baseline weight on their home scale.
Provide specific written materials and self care plan for client/caregivers to use for reference. Consult dietitian or assist client in understanding the need for a sodium-restricted diet. Provide alternatives for salt such as spices, herbs, lemon juice, or vinegar. Although the initial elimination of salt from the diet is very difficult for a person use to its taste, the taste of salt can be unlearned. The above can enhance the taste appeal of food while the preference for salt is changing.
Instruct family regarding cardiopulmonary resuscitation.

Nursing care plans For Constipation

2009-02-27T07:02:00.000-08:00

Nursing Diagnosis: Constipation
Nursing care plans For Diagnosis Constipation
NANDA Definition: A decrease in a person's normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Defining Characteristics: Change in bowel pattern; bright red blood with stool; presence of soft paste-like stool in rectum; distended abdomen; dark, black, or tarry stool; increased abdominal pressure; percussed abdominal dullness; pain with defecation; decreased volume of stool; straining with defecation; decreased frequency; dry, hard, formed stool; palpable rectal mass; feeling of rectal fullness or pressure; abdominal pain; unable to pass stool; anorexia; headache; change in abdominal growing (borborygmi); indigestion; atypical presentation in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); severe flatus; generalized fatigue; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or without palpable muscle resistance; nausea and/or vomiting; oozing liquid stool

Related Factors:
Functional Recent environmental changes; habitual denial or ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting, abdominal muscle weakness
Psychological Depression; emotional stress; mental confusion
Pharmacological Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal antiinflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
Mechanical Rectal abscess or ulcer; pregnancy; rectal anal fissures; tumors; megacolon (Hirschsprung's disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity
Physiological Poor eating habits; decreased motility of gastrointestinal tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods and eating patterns; dehydration

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
· Bowel Elimination
· Hydration
Client Outcomes
· Maintains passage of soft, formed stool every 1 to 3 days without straining
· States relief from discomfort of constipation
· Identifies measures that prevent or treat constipation

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
· Constipation/Impaction Management

Nursing Interventions and Rationales

Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; alterations in perianal sensation; present bowel regimen. There often are multiple reasons for constipation; the first step is assessment of usual patterns of bowel elimination.
Have the client or family keep a diary of bowel habits including time of day; usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation. A diary of bowel habits is valuable in treatment of constipation.
Review client's current medications. Many medications affect normal bowel function, including opiates, antidepressants, antihypertensives, anticholinergics, diuretics, anticonvulsants, antacids containing aluminum, iron supplements, and muscle relaxants.
Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with constipation the abdomen is often distended with a palpable colon.
Check for impaction; perform digital removal per physician's order. If impaction is present, use cleansing regimen until you obtain a very soft stool. If using an enema, the client must be able to bodily retain the fluid. If the client has poor sphincter tone, use a cone tip irrigating bag to assist the client in retaining the fluids. This also decreases the amount of fluid necessary for cleansing.
Provide privacy for defecation. Assist the client to the bathroom and close the door if possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber to diet gradually. Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea. A daily fiber intake of 25 g can increase frequency of stools in clients with constipation. Dietary supplements of fiber in the form of bran or wheat fiber are helpful for women experiencing constipation with pregnancy.
Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve. Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation.
Encourage client to be out of bed as soon as possible, and to own activities of daily living (ADLs) as able. Encourage exercises such as turning and changing positions in bed, lifting their hips off the bed, doing range of motion exercises, alternating lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching arms away from body, and pulling in the abdomen while taking deep breaths. Activity, even minimal, increases peristalsis, which is necessary to prevent constipation.
At each meal, sprinkle bran over client's food as allowed by client and prescribed diet. Ensure that client receives adequate fluid (1500 ml/day) along with bran. The number of bowel movements is increased and the use of laxatives is decreased in a client who eats wheat bran. A study done on institutionalized elderly male clients with chronic constipation demonstrated that with bran use, clients were able to discontinue use of oral laxatives.
Initiate a regular schedule for defecation, using the client's normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex. A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur. Hot liquids can stimulate peristasis and result in defecation.
Emphasize to the client the necessary ingredients for a normal bowel regimen (e.g., fluid, fiber, activity, and regular schedule for defecation). Help client onto bedside commode or toilet with client's hips flexed and feet flat. Have client deep breathe through mouth to encourage relaxation of the pelvic floor muscle and use the abdominal muscles to help evacuation.
Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided. Soapsuds enemas can cause damage to the colonic mucosa. The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown.
For the stable neurological client, consider use of a bowel routine of Therevac enema or suppositories every other day, or performing digital stimulation with physician's permission. For persistent constipation, refer to physician for evaluation. Use of the Therevac SB mini-enema was found to cut time needed for bowel care by as much as one hour or more as compared with use of suppositories.

Geriatric

Explain the importance of fiber intake, fluid intake, and activity for soft, formed stool. Fiber intake, fluid intake, and activity are often decreased in elderly clients. Increasing fiber and fluids can effectively prevent constipation in the elderly.
Determine client's perception of normal bowel elimination; promote adherence to a regular schedule. Misconceptions regarding the frequency of bowel movements can lead to anxiety and overuse of laxatives.
Explain Valsalva's maneuver and the reason it should be avoided. Valsalva’s maneuver can cause bradycardia and even death in cardiac patients.
Respond quickly to client's call for help with toileting.
Avoid regular use of enemas in the elderly. Enemas can cause fluid and electrolyte imbalances ( and damage to the colonic mucosa.
Use opioids cautiously. If ordered, use stool softeners and bran mixtures to prevent constipation. Use of opioids can cause constipation.
Position client on toilet or commode and place a small footstool under the feet. Placing a small footstool under the feet increases intraabdominal pressure and makes defecation easier for an elderly client with weak abdominal muscles.

Home Care Interventions

Put client in bathroom to toilet when possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
Carefully monitor bowel patterns of clients under pain management with opioids. Introduce a bowel management program at first sign of constipation. Constipation is a major problem for terminally ill or hospice clients who may need very high doses of opioids for pain management.
When using a bowel program, establish a pattern that is very regular and allows client to be part of family unit. Regularity of program promotes psychological and/or physiological "readiness" to evacuate. Families of home care clients often cannot proceed with normal daily activities until bowel programs are complete.

Client/Family Teaching Nursing care plans For Constipation

Instruct client on normal bowel function and the necessity of fluid, fiber, and activity in a bowel program.
Encourage client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice. Most cases of constipation are mechanical and result from habitual neglect of impulses that signal appropriate time for defecation. This results in accumulation of a large, dry fecal mass.
Encourage client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if used regularly.
If not contraindicated, teach client how to do bent-leg sit-ups to increase abdominal tone; also encourage client to contract abdominal muscles frequently throughout the day. Help client develop a daily exercise program to increase peristalsis.

Nursing Care Plans For Chronic Pain

2009-02-27T02:47:00.000-08:00

Nursing Diagnosis: Chronic Pain

Nursing Care Plans For Chronic Pain
NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does, an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring, without an anticipated or predictable end and a duration >6 months; a state in which an individual experiences pain that persists for a month beyond the usual course of an acute illness or a reasonable duration for an injury to heal, is associated with a chronic pathologic process, or recurs at intervals for months or years.

Defining Characteristics:
Subjective
Pain is always subjective and cannot be proved or disproved. The client's report of pain is the most reliable indicator of pain. Clients with cognitive abilities who can speak or point should use a pain rating scale (eg 0 to 10) to identify their current level of pain intensity and determine a comfort/function goal .
Objective
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report. However, observable responses to pain are helpful in its assessment, especially in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite or the inability to ambulate, perform activities of daily living (ADLs), work, or sleep. Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, and increase or decrease in respiratory rate and depth may be present but are usually not present with chronic pain that is relatively stable. Clients with chronic, cancer, or nonmalignant pain may experience threats to self-image; a perceived lack of options for coping; and worsening helplessness, anxiety, and depression. Chronic pain may affect almost every aspect of the client's daily life, including concentration, work, and relationships.

Related Factors: Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Pain Level
• Pain Control
• Comfort Level
• Pain: Disruptive Effects

Client Outcomes

Uses pain rating scale to identify current level of pain intensity, determines a comfort/function goal, and maintains a pain diary.
Describes the total plan for drug and nondrug pain relief, including how to safely and effectively take medicines and integrate nondrug therapies.
Demonstrates ability to pace self, taking rest breaks before they are needed.
Functions on an acceptable ability level with minimal interference from pain and medication side effects

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Pain Management, Analgesic Administration

Nursing Interventions and Rationales

Determine whether client is experiencing pain at time of initial interview. If so, intervene at that time to provide pain relief. The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient.
Ask client to describe past and current experiences with pain and effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses, and how he or she expresses pain. A number of concerns (barriers) may affect client's willingness to report pain and use analgesics.
Describe the adverse effects of unrelieved pain. Numerous pathophysiological and psychological morbidity factors may be associated with pain.
Tell client to report pain location, intensity, and quality when experiencing pain. The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals.
Ask client to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain. Systematic tracking of pain appears to be an important factor in improving pain management.
Determine client's current medication use. To aid in planning pain treatment, obtain a medication history
Explore need for medications from the three classes of analgesics: opioids, and adjuvant medications. For chronic neuropathic pain, consider adjuvant medications that are analgesic, such as anticonvulsants and antidepressants. Some types of pain respond to non-opioid drugs alone. However, if pain is not responding, consider increasing the dosage or adding an opioid. At any level of pain, analgesic adjuvants may be useful. Analgesic combinations may enhance pain relief.
The oral route is preferred. If client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral or another noninvasive route as smoothly as possible. The least invasive route of administration capable of providing adequate pain control is recommended. The oral route is the most preferred because it is the most convenient and cost effective. Avoid the intramuscular (IM) route because of unreliable absorption, pain, and inconvenience.
Obtain a prescription to administer a non-opioid, unless contraindicated, around the clock (ATC). NSAIDs act mainly in the periphery to inhibit the initiation of pain signals. The analgesic regimen should include a non-opioid drug ATC, even if pain is severe enough to require the addition of an opioid .
For persistent cancer pain, obtain a prescription to administer opioid analgesics. When pain persists or increases, an opioid such as codeine or hydrocodone should be added to the non-opioid. If this is not effective, switch to morphine or other single-entity opioids.
Establish ATC dosing and administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level. A PRN order for a supplementary opioid dose between regular doses is an essential backup.
Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Always obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation. Because there is great individual variation in the development of opioid-induced side effects, they should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis.
Explain pain management approach that has been ordered, including therapies, medication administration, side effects, and complications. One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role client needs to play in pain control.
Discuss client's fears of undertreated pain, addiction, and overdose. A number of concerns may affect patients' willingness to report pain and use analgesics. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan. Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction.
Review client's pain diary, flow sheet, and medication records to determine overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., one week). Systematic tracking of pain appears to be an important factor in improving pain management.
Obtain prescriptions to increase or decrease analgesic doses when indicated. Base prescriptions on the client's report of pain severity and the comfort/function goal and response to previous dose in terms of relief, side effects, and ability to perform the daily activities and the prescribed therapeutic regimen. Opioid doses should be adjusted individually to achieve pain relief with an acceptable level of adverse effects.
If opioid dose is increased, monitor sedation and respiratory status for a brief time. Patients receiving long-term opioid therapy generally develop tolerance to the respiratory depressant effects of these agents.
In addition to the use of analgesics, support the client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore clients' sense of self-control, personal efficacy, and active participation in their own care.
Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions.
Plan care activities around periods of greatest comfort whenever possible. Pain diminishes activity.
Ask clients to describe their appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments directed toward improving these functions. Because there is great individual variation in the development of opioid-induced side effects, clinicians should monitor and, if development is inevitable, prophylactically treat them.
Explore appropriate resources for management of pain on a long-term basis. Most patients with cancer or chronic nonmalignant pain are treated for pain in outpatient and home care settings. Plans should be made to ensure ongoing assessment of the pain and the effectiveness of treatments in these settings
If client has progressive cancer pain, assist client and family with handling issues related to death and dying. Peer support groups and pastoral counseling may increase the client's and family's coping skills and provide needed support.
If client has chronic nonmalignant pain, assist client and family with minimizing effects of pain on interpersonal relationships and daily activities such as work and recreation. Pain reduces clients' options to exercise control, diminishes psychological well-being, and makes them feel helpless and vulnerable. Therefore clinicians should support active client involvement in effective and practical methods to manage pain.

Geriatric

Always take an elderly client's reports of pain seriously and ensure that the pain is relieved. In spite of what many professionals and clients believe, pain is not an expected part of normal aging.
When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale and written materials.
Handle client's body gently. Allow client to move at own speed.
Use NSAIDs with caution and avoid ATC NSAID dosing. Opioids ATC are preferable to chronic NSAID administration in the elderly client because of an increased risk for NSAID adverse effects.
Use acetaminophen and NSAIDs with low side effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid). Watch for side effects such as GI disturbances and bleeding problems. Elderly clients are at increased risk for gastric and renal toxicity from NSAIDs.
Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium). A higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation.
In an elderly client, avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet). Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency

Home Care Interventions

Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary. Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management.
Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval. Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated.
Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased). The cognitive effects of opioids usually subside within a week of initial dosing or dose increases. The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment.
Collaborate with health care team on an ongoing basis (including client and family) to determine optimal pain control profile. Identify the most effective interventions and the medication administration routes most acceptable to the family and client. Success in pain control is partially dependent on the acceptability of the suggested intervention. Acceptability promotes compliance. Dosages vary among routes and will need to be adjusted accordingly to avoid breakthrough or transitional pain.
If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration. Some routes of medication administration require special conditions and procedures to be safe and accurate.
Assess knowledge base of client and family for highly technological medication administration including the use of PCA pump. Teach as necessary. Appropriate instruction in the home increases the accuracy and safety of medication administration.
Support the client and family in the use of opioid analgesics. Well-intentioned friends and family may create added stress by expressing judgment or fears regarding the use of opioid analgesics.

Client And Family Teaching

To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.
Provide written materials regarding pain control, such as the Agency for Health Care Policy and Research pamphlet, Managing Cancer Pain: Patient Guide.
Discuss the various discomforts encompassed by the word pain and ask clients to give examples of pain they have experienced. Explain the pain assessment process and the purpose of the pain rating scale that will be used. Teach clients to use the pain rating scale to rate the intensity of current or past pain. Ask them to set a pain relief goal by selecting a pain rating on the scale; if pain goes above this level, they should take action that decreases pain or notify a member of the health care team.
Discuss the total plan for drug and nondrug treatment, including the medication plan for ATC administration and supplemental doses, the maintenance of a pain diary, and the use of supplies and equipment.
Reinforce the importance of taking pain medications to keep pain under control.
Reinforce that taking opioids for pain relief is not an addiction.
Explain to clients with chronic neuropathic pain the process of taking adjuvant analgesics (e.g., tricyclic antidepressants); a low dose is used initially and is increased gradually. Emphasize that pain relief is delayed and the drugs must be taken daily. Reassure the client that although the medicine is an antidepressant, it is used for analgesia and not depression. Comparable teaching should take place when an anticonvulsant is prescribed for analgesia.
Emphasize to clients with chronic nonmalignant pain the importance of participating in therapeutic regimens other than medication (e.g., physical therapy, group therapy).
Emphasize to clients the importance of pacing themselves and taking rest breaks before they are needed.
Demonstrate the use of appropriate nonpharmacological approaches for controlling pain.

Nursing Care Plans For Chronic Confusion

2009-02-26T18:36:00.000-08:00

Nursing Diagnosis: Chronic Confusion

Nursing Care Plans For Chronic Confusion
NANDA Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by a decreased ability to interpret environmental stimuli and a decreased capacity for intellectual thought processes, which manifest as disturbances of memory, orientation, and behavior

Defining Characteristics: Altered interpretation/response to stimuli; clinical evidence of organic impairment; altered personality; impaired memory (short and long term); impaired socialization; no change in level of consciousness
Related Factors: Multi-infarct dementia; Korsakoff's psychosis; head injury; Alzheimer's disease; cerebrovascular accident

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Cognitive Orientation
• Information Processing
• Memory
• Neurological Status: Consciousness

Client Outcomes
• Remains content and free from harm
• Functions at maximal cognitive level
• Participates in activities of daily living at the maximum of functional ability

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Dementia Management
• Environmental Management
• Reality Orientation
• Surveillance: Safety

Nursing Interventions and Rationales

Determine client's cognitive level using a screening tool such as the Mini Mental State Exam (MMSE). Using a standard evaluation tool such as the MMSE can help determine the client's abilities and assist with planning appropriate nursing interventions.
Gather information about client pre-dementia functioning, including social situation, physical condition, and psychological functioning. Knowing the client's background can help the nurse identify agenda behavior and use validation therapy, which will provide guidance for reminiscence. Background information may help the nurse to understand client’s behavior if client becomes delusional and hallucinates.
Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior. As much as 50% of clients with dementia have depressive symptoms.
Ensure that client is in a safe environment by removing potential hazards such as sharp objects and harmful liquids. Clients with dementia lose the ability to make good judgments and can easily harm self or others.
Place an identification bracelet on client. Clients with dementia wander and can become lost; identification bracelets increase client safety.
Avoid exposing client to unfamiliar situations and people as much as possible. Maintain continuity of caregivers. Maintain routines of care through established mealtimes, bathing, and sleeping schedules. Send familiar person with client when client goes for diagnostic testing or into unfamiliar environments. Situational anxiety associated with environmental, interpersonal, or structural change can escalate into agitated behavior.
Keep environment quiet and nonstimulating; avoid using buzzers and alarms if possible. Minimize sights and sounds that have a high potential for misinterpretation such as buzzers, alarms, and overhead paging systems. Sensory overload can result in agitated behavior in a client with dementia. Misinterpretation of the environment can also contribute to agitation.
Begin each interaction with client by identifying self and calling client by name. Approach client with a caring, loving, and accepting attitude and speak calmly and slowly. Dementia clients can sense feelings of compassion. A calm, slow manner projects a feeling of comfort to the client.
Touch client gently, stroking hand or arm in a soothing fashion if acceptable in client's culture.
Give one simple direction at a time and repeat as necessary. Use verbal and physical prompts, and model the desired action if needed and possible. People with dementia need time to assimilate and interpret your directions. If you rephrase your question, you give them something new to process, increasing their confusion.
Break down self-care tasks into simple steps. Dementia clients are unable to follow complex commands; breaking down an activity into simple steps makes completing the activity more feasible.
Keep questions simple; yes or no questions are often preferable to open-ended questions. Use positive statements and actions and avoid negative communication. Negative feedback leads to increased confusion and agitation. It is more effective to go along with the client and then redirect as necessary.
If eating in the dining room causes increased agitation, let client leave and eat in a quieter environment with a smaller number of people. The noise and confusion in a large dining room can be overwhelming for a dementia client and can result in agitated behavior. It is preferable to have dementia clients eat in small groups.
Provide finger food if patient has difficulty using eating utensils or if unable to sit to eat. Feeding oneself is a complex task and may prove challenging for someone with significant dementia.
Provide boundaries by placing red or yellow tape on the floor or by using a stop sign. Boundaries help the client identify safe areas; older clients can more easily see red and yellow than other colors.
Assess the etiology of wandering before or rather than attempting to control the wandering. Wandering indicates a problem and need for intervention; therefore the reason for the wandering behavior needs to be determined.
Write client's name in large block letters in the room and on client's clothing and possessions. Use symbols rather than words to identify areas such as the bathroom or kitchen.
Limit visitors to two and provide them with guidelines on appropriate topics to discuss and how to best communicate with client.
Set up scheduled quiet periods in a recliner or room. Use blankets and other environmental cues to define rest periods. Quiet times allow the client's anxiety and building tension levels to decrease. Fatigue has been associated with the onset of increased confusion and agitation.
Provide quiet activities, such as listening to classical or religious music, or other cues that promote relaxation in the afternoon or early evening. An increase in confusion and agitation, referred to as sundowning syndrome, may occur in the late afternoon and early evening. Quiet activities can provide a calming environment.
Provide simple activities for the client, such as folding washcloths and sorting or stacking activities. Avoid misleading and frightening stimuli, which may include television, mirrors, and pictures of people or animals. Repetitive activities give the client with dementia a positive outlet for behavior. Dementia clients see, hear, and perceive a different world than other people. They may not recognize themselves in the mirror and be afraid of the stranger they see so close to them.
Consider using doll therapy. Ask family members to bring a large, safe doll or stuffed animal such as a teddy bear. Doll therapy can be soothing to some dementia clients.
If client becomes increasingly confused and agitated, perform the following steps:

Monitor client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation. An acute change in behavior is a medical emergency and should be evaluated. Many physiological factors can result in increased agitation of clients with dementia.
Monitor for psychological causes, including changes in environment, caregiver, and routine; demands to perform beyond capacity; and multiple competing stimuli. It is important for the nurse to recognize precipitating events and subsequent behavior to prevent furthers incidents of agitation.
Avoid confrontations with the client; allow client to dissipate energy by performing repetitive tasks or by pacing.

If client is delusional or hallucinating , do not confront him or her with reality. Use validation therapy to verbally reflect back the emotions that the client appears to be experiencing. Use statements such as, "It must be frightening to see a fire at the end of your bed," "I can see that you are afraid," "I will stay with you," or "Can you tell me more about what is going on right now?" Orienting the client to reality can increase agitation; validation therapy conveys empathy and understanding and can help determine the internal stimulus that is creating the change in behavior. In one study, training in validation therapy for staff resulted in decreased doses of psychotherapeutic medications and incidences of behavior problems.
Decrease stimuli in the environment (turn off Radio, take client to a quiet place). Institute activities associated with pleasant emotions, such as playing soft music the client likes, looking through a photo album, providing favorite food, or using simulated presence therapy. Decreasing stimuli can decrease agitation. Reassuring activities, such as simulated presence therapy wherein client listens to a tape of a loved one's phone conversation, can help bring about pleasant emotions that soothe the client.
Avoid using restraints if at all possible. Restraints are not benign interventions and should be used sparingly and judiciously only when alternatives to manage the behaviors have been tried and been unsuccessful. Side effects include falls, increased confusion , deconditioning, and incontinence.
Use prn or low dose regular dosing of psychotropic or antianxiety drugs only as a last resort. They are effective in managing symptoms of psychosis and aggressive behavior. Start with the lowest possible dose. Psychotropic drugs such as haloperidol (Haldol) and resperidone (Risperdol) may decrease client function and have side effects that need to be monitored.
Avoid use of anticholinergic medications such as Benadryl. Anticholinergic medications have a high side effect profile that includes disorientation, urinary retention, and excessive drowsiness (Nurses Drug Hand book). The anticholinergic side effects outweigh the antihistaminic effects.
For predictable difficult times, such as during bathing and grooming, try the following:

Massage the client's hands lovingly or use therapeutic touch to relax the client. Hand massage and therapeutic touch have been shown to induce relaxation that may allow care activities to take place without difficulty.
Use positive behavioral reinforcement for each of the small steps involved in bathing, such as praising client for walking toward the shower, sitting in the shower chair, and removing items of clothing. Positive behavioral reinforcement for desired behavior is effective for clients with dementia. Consider a towel bath if shower or tub bathing is too stressful for client.
Treat the client with the utmost respect and give individualized care. Treating confused clients with respect and individualizing care can decrease aggression and increase nursing staff satisfaction.

For early dementia clients with primarily symptoms of memory loss, see care plan for Impaired Memory. For clients with self-care deficits, see appropriate care plan (Feeding Self-care deficit, Dressing/grooming Self-care deficit, Toileting Self-care deficit).

Geriatric
• Most of the preceding interventions apply to the geriatric client.
• Use reminiscence and life review therapeutic interventions; ask questions about client's work, child rearing,

Multicultural

Assess for the influence of cultural beliefs, norms, and values on the family or caregiver understanding of chronic confusion or dementia. What the family considers normal and abnormal health behavior may be based on cultural perceptions.
Inform client family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia . An understanding of dementia behavior will enable the client family/caregiver to provide the client with a safe environment.
Refer family to social services or other supportive services to assist with meeting the demands of caregiving for the client with dementia. Black caregivers of dementia clients may evidence less desire than others to institutionalize their family members and are more likely to report unmet service needs . Families of dementia clients may report restricted social activity.
Encourage family to make use of support groups or other service programs. Studies indicate that some minority families of clients with dementia may use few support programs even though these programs could have a positive impact on caregiver well-being.
Validate the family members’ feelings with regard to the impact of client behavior on family lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship.

Home Care Interventions

Keeping the client as independent as possible is important. However, because community-based care is usually less structured than institutional care, in the home setting, the goal of maintaining safety for the client takes on primary importance.
Provide support to family of client with chronic and disabling condition.
If client will require extensive supervision on an ongoing basis, evaluate client for day care programs. Refer family to medical social services to assist with this process if necessary. Day care programs provide safe, structured care for the client and respite for the family. Respite care for caregivers is an essential part of successful long-term care for a confused client.
Encourage family to include client in family activities when possible. Reinforce use of therapeutic communication guidelines and sensitivity to the number of people present. These steps help the client maintain dignity and lead to familiar socialization of the client.
Assess family caregivers for caregiver burden. Caring for a loved one with a dementing process is highly stressful. Respite care is a necessary component to the overall care plan.

Client/Family Teaching

Recommend that the family develop a memory aid wallet or booklet for client that contains pictures and text that chronicle the client's life. Using memory aids such as wallets or booklets helps dementia clients make more factual statements and stay on topic, and it decreases the number of confused, erroneous, and repetitive statements.
Teach family how to converse with a memory-impaired person. Guidelines include the following:

Ask client to have a conversation with you.
Guide conversation to specific, nonthreatening topics and redirect the conversation back on topic when client begins to ramble.
Reassure and help out when the client gets stuck or cannot find the right words.
Smile and act interested in what client is saying even if unsure what it means.
Thank client for talking.
Avoid quizzing client or asking a lot of specific questions.
Avoid correcting or contradicting something that was stated even if it is wrong.

Teach family how to set up environment and use care techniques/interventions listed so that client will experience a progressively lowered stress threshold. Alzheimer's clients are unable to deal with stress; decreasing stress can decrease confusion and changes in behavior.
Discuss with the family what to expect as the dementia progresses .
Counsel the family about resources available with regard to end-of-life decisions and legal concerns.
Inform family that as dementia progresses, hospice care may be available in the terminal stages in the home to help the caregiver. Hospice services in the late stages of dementia can help support the family with nursing services and visitation by primary care provider, home health aides, social services, volunteer visitors, and a spiritual counselor if desired as the client is dying.

Nursing Care Plans For Bowel incontinence

2009-02-26T17:35:00.000-08:00

Nursing Diagnosis: Bowel incontinence
Nursing Care Plans For Bowel incontinence

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

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

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

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
• Bowel Continence
• Bowel Elimination

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

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Bowel Incontinence Care
• Bowel Training
• Bowel Incontinence Care: Encopresis

Nursing Interventions and Rationales

In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, and aggravating and alleviating factors. Unless questioned directly, patients are unlikely to report the presence of fecal incontinence. The nursing history determines the patterns of stool elimination to characterize involuntary stool loss and the likely etiology of the incontinence .
Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual acuity). A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of functional status on stool elimination patterns and incontinence.
Complete an assessment of cognitive function. Dementia, acute confusion, and mental retardation are risk factors for fecal incontinence.
Document patterns of stool elimination and incontinent episodes via a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. This document is used to confirm the verbal history and to assist in determining the likely etiology of stool incontinence. It also serves as a baseline to evaluate treatment efficacy.
Identify the probable causes of fecal incontinence. Fecal incontinence is frequently multifactorial; therefore identification of the probable etiology of fecal incontinence is necessary to select a treatment plan likely to control or eliminate the condition.
Improve access to toileting:

o Identify usual toileting patterns among persons in the acute care or long term care facility and plan opportunities for toileting accordingly.
o Provide assistance with toileting for patients with limited access or impaired functional status.
o Institute a prompted toileting program for persons with impaired cognitive status.
o Provide adequate privacy for toileting.
o Respond promptly to requests for assistance with toileting.

• For the client with intermittent episodes of fecal incontinence related to acute changes in stool consistency, begin a bowel reeducation program consisting of:
o Cleansing the bowel of impacted stool if indicated.
o Normalizing stool consistency by adequate intake of fluids and dietary or supplemental fiber.
o Establishing a regular routine of fecal elimination based on established patterns of bowel elimination

Begin a prompted defecation program for the adult with dementia, mental retardation, or related learning disabilities. Prompted urine and fecal elimination programs have been shown to reduce or eliminate incontinence in the long term care facility and community settings.
Begin a scheduled stimulation defecation program, including the following steps, for persons with neurological conditions causing fecal incontinence:

o Before beginning the program, cleanse the bowel of impacted fecal material.
o Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
o Whenever feasible, determine a regular schedule for bowel elimination based on previous patterns of bowel elimination.
o Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may be used.
The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material.

Begin a pelvic floor reeducation or muscle exercise program for persons with sphincter incompetence or pseudodyssynergia of the pelvic muscles, or refer persons with fecal incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, including biofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with fecal incontinence related to sphincter or pelvic floor muscle dysfunction.
Begin a pelvic muscle biofeedback program among patients with urgency to defecate and fecal incontinence related to recurrent diarrhea. Pelvic muscle reeducation, including biofeedback, can reduce uncontrolled loss of stool among persons who experience urgency and diarrhea as provacative factors for fecal incontinence. Reducing the incidence of diarrhea can help to reduce bowel incontinence.
Cleanse the perineal and perianal skin following each episode of fecal incontinence. When incontinence is frequent, use an incontinence cleansing product specifically designed for this purpose. Frequent cleaning with soap and water may compromise perianal skin integrity and enhance the irritation produced by fecal leakage.
Apply mineral oil or a petroleum based ointment to the perianal skin when frequent episodes of fecal incontinence occur. These products form a moisture and chemical barrier to the perianal skin that may prevent or reduce the severity of compromised skin integrity with severe fecal incontinence.
Assist the patient to select and apply a containment device for occasional episodes of fecal incontinence. A fecal containment device will prevent soiling of clothing and reduce odors in the patient with uncontrolled stool loss.
Teach the caregivers of the patient with frequent episodes of fecal incontinence and limited mobility to regularly monitor the sacrum and perineal area for pressure ulcerations. Limited mobility, particularly when combined with fecal incontinence, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary incontinence reduces this risk.
Consult the physician concerning the use of an anal continence plug for the patient with frequent stool loss. The anal continence plug is a device that can reduce or eliminate persistent liquid or solid stool incontinence in selected patients.
Apply a fecal pouch to the patient with frequent stool loss, particularly when fecal incontinence produces altered perianal skin integrity. Fecal pouches contain stool loss, reduce odor, and protect the perianal skin from chemical irritation resulting from contact with stool.
Consult the physician concerning the use of a rectal tube for the patient with severe fecal incontinence. A large-sized French indwelling catheter has been used for fecal containment when incontinence is severe and perianal skin integrity significantly compromised. The safety of this technique remains unknown.

Geriatric

Evaluate elderly client for established or acute fecal incontinence when client enters the acute or long term care facility; intervene as indicated. The rate of fecal incontinence among patients in acute care facilities is as high as 3%; in long term care facilities the rate is as high as 50%.
To evaluate cognitive status in the elderly person, use a NEECHAM confusion scale to identify acute cognitive changes, a Folstein Mini-Mental Status Examination, or other tool as indicated. Acute or established dementia increases the risk of fecal incontinence among elderly persons.

Home Care Interventions

Assess and teach a bowel management program to support continence.
Provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease. Avoidance of complicated maneuvers increases the chance of success in toileting programs and decreases the client's risk for embarrassing incontinent episodes.
Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Careful planning can both help client retain dignity and maintain integrity of family patterns.
If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. If necessary, refer the client to physical therapy services to learn side transfers and to build strength for transfers.
If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care.

Client and Family Teaching

Teach the client and family to perform a bowel reeducation program; scheduled, stimulated program; or other strategies to manage fecal incontinence.
Teach the client and family about common dietary sources of fiber, as well as supplemental fiber or bulking agents as indicated.
Teach nursing colleagues and nonprofessional care providers the importance of providing toileting opportunities and adequate privacy for the patient in an acute or long term care facility.
Refer to nursing diagnoses Diarrhea and Constipation for detailed management of these related conditions.

Nursing Care Plan For Pregnancy Induced Hypertension (PIH) Preeclampsia and Eclampsia

2009-02-26T06:22:00.000-08:00

Pregnancy-induced hypertension (PIH) is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It typically occurs in nulliparous women and may be nonconvulsive or convulsive. Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7% of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups.

Eclampsia, the convulsive form, occurs between 24 weeks' gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease. About 5% of women with preeclampsia develop eclampsia; of these, about 15% die of eclampsia or its complications. Fetal mortality is high because of the increased incidence of premature delivery PIH and its complications are the most common cause of maternal death in developed countries.

Cause of Preeclampsia
The cause of preeclampsia is unknown, it is often called the “DISEASE OF THEORIES” because many causes have been proposed, yet none has been well established. than how does preeclampsia occur Experts believe that decreased levels of prostaglandins and a decreased resistance to angiotensin II lead to a generalized arterial vasospasm that then causes endothelial damage. The brain, liver, kidney, and blood are particularly susceptible to multiple dysfunctions. Several risk factors have been identified that may predispose a woman to developing preeclampsia: nulliparity; familial history; multiple gestation; patient history of diabetes mellitus, chronic hypertension, renal disease, trophoblastic disease, and malnutrition.

Complications
Generalized arteriolar vasoconstriction is thought to produce decreased blood flow through the placenta and maternal organs. This decrease can result in intrauterine growth retardation, placental infarcts, and abruptio placentae. Hemolysis, elevated liver enzyme levels, and a low platelet count characterize severe eclampsia. A unique form of coagulopathy is also associated with this disorder. Other possible complications include stillbirth of the neonate, seizures, coma, premature labor, renal failure, and hepatic damage in the mother.

Assessment Nursing care Plans For Pregnancy Induced Hypertension
A patient with mild preeclampsia typically reports a sudden weight gain of more than 3 lb (1.4 kg) per week during the second trimester or more than 1 lb (0.5 kg) per week during the third trimester.
The patient's history reveals hypertension, as evidenced by elevated blood pressure readings: 140 mm Hg or more systolic, or an increase of 30 mm Hg or more above the patient's normal systolic pressure, measured on two occasions, 6 hours apart; and 90 mm Hg or more diastolic, or an increase of 15 mm Hg or more above the patient's normal diastolic pressure, measured on two occasions, 6 hours apart.
Inspection reveals generalized edema, especially of the face. Palpation may reveal pitting edema of the legs and feet. Deep tendon reflexes may indicate hyperreflexia.
As preeclampsia worsens, the patient may demonstrate oliguria (urine output of 400 ml/day or less), blurred vision caused by retinal arteriolar spasms, epigastric pain or heartburn, irritability, and emotional tension. She may complain of a severe frontal headache.
In a patient with severe preeclampsia, blood pressure readings increase to 160/110 mm Hg or higher on two occasions, 6 hours apart, during bed rest. Also, ophthalmoscopic examination may reveal vascular spasm, papilledema, retinal edema or detachment, and arteriovenous nicking or hemorrhage.
Preeclampsia can suddenly progress to eclampsia with the onset of seizures. The patient with eclampsia may appear to cease breathing, then suddenly take a deep, stertorous breath and resume breathing. The patient may then lapse into a coma, lasting a few minutes to several hours. Awakening from the coma, the patient may have no memory of the seizure. Mild eclampsia may involve more than one seizure; severe eclampsia, up to 20 seizures.
Physical examination findings in a patient with eclampsia are similar to those of a patient with preeclampsia but more severe. Systolic blood pressure may increase to 180 mm Hg and even to 200 mm Hg. Inspection may reveal marked edema, but some patients exhibit no visible edema.

Diagnostic tests
Blood Hematocrit
Renal Function
Serum uric acid
Creatinine
Creatinine clearance
BUN
Coagulation Platelets
Fibrin degradation products

Nursing diagnoses Nursing Care Plan For Pregnancy Induced Hypertension

Activity intolerance
Anxiety
Disturbed sensory perception (visual)
Disturbed thought processes
Excess fluid volume
Fear
Impaired urinary elimination
Ineffective coping
Ineffective tissue perfusion: Cerebral, peripheral
Risk for injury

Key outcomes

The patient will be able to perform activities of daily living without excessive fatigue.
The patient will identify strategies to reduce anxiety.
The patient will maintain optimal functioning within the confines of the visual impairment.
The patient will maintain orientation to environment.
The patient's fluid volume will remain within normal parameters.
The patient will verbalize fears and concerns.
The patient's urine output will remain within normal limits.
The patient will demonstrate adaptive coping behaviors.
The patient will exhibit signs of adequate cerebral and peripheral perfusion.
The patient will avoid complications

Nursing interventions, Rationales And Patient teaching
Related to nursing diagnosis

Nursing Management Of Preeclampsia

Nursing Care Plans For Bathing hygiene Self care deficit

2009-02-25T00:10:00.000-08:00

Nursing Diagnosis: Bathing hygiene Self care deficit

NANDA Definition: Impaired ability to perform or complete bathing/hygiene activities for oneself

Defining Characteristics: Inability to: wash body or body parts; obtain or get to water source; regulate temperature or flow of bath water; get bath supplies; dry body; get in and out of bathroom

Impaired physical mobility-functional level classification:

Completely independent
Requires use of equipment or device
Requires help from another person for assistance, supervision, or teaching
Requires help from another person and equipment or device
Dependent does not participate in activity

Related Factors: Decreased or lack of motivation; weakness and tiredness; severe anxiety; inability to perceive body part or spatial relationship; perceptual or cognitive impairment; pain; neuromuscular impairment; musculoskeletal impairment; environmental barriers

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Self-Care: Activities of Daily Living (ADLs)

• Self-Care: Bathing

• Self-Care: Hygiene

Client Outcomes

• Remains free of body odor and maintains intact skin

• States satisfaction with ability to use adaptive devices to bathe

• Bathes with assistance of caregiver as needed without anxiety

• Explains and uses methods to bathe safely and with minimal difficulty

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Bathing

• Self-Care Assistance: Bathing/Hygiene

Nursing Interventions and Rationales

Assess client's ability to bathe self through direct observation (in usual bathing setting only) and from client/caregiver report, noting specific deficits and their causes. Use of observation of function and report of function provide complementary assessment data for goal and intervention planning .
If in a typical bathing setting for the client, assess via direct observation using physical performance tests for ADLs. Observation of bathing performed in an atypical bathing setting may result in false data for which use of a physical performance test compensates to provide more accurate ability data .
Ask client for input on bathing habits and cultural bathing preferences. Creating opportunities for guiding personal care honors long-standing routines, increases control, prevents learned helplessness, and preserves self-esteem. Cultural preferences are respected.
Develop a bathing care plan based on client's own history of bathing practices that addresses skin needs, self-care needs, client response to bathing and equipment needs. Bathing is a healing rite and should not be routinely scheduled with a task focus. It should be a comforting experience for the client that enhances health..
Individualize bathing by identifying function of bath , frequency required to achieve function, and best bathing form to meet client preferences, preserve client dignity, make bathing a soothing experience, and reduce client aggression. Individualized bathing produces a more positive bathing experience and preserves client dignity. Client aggression is increased with shower and tub bathing. Towel bathing increases privacy and eliminates need to move client to central bathing area; therefore it is a more soothing experience than either showering or tub bathing.
Request referrals for occupational and physical therapy. Collaboration and correlation of activities with interdisciplinary team members increases the client's mastery of self-care tasks.
Plan activities to prevent fatigue during bathing and seat client with feet supported. Energy conservation increases activity tolerance and promotes self-care.
Provide medication for pain 45 minutes before bathing if needed. Pain relief promotes participation in self-care.
Consider environmental and human factors that may limit bathing ability, such as bending to get into tub, reaching required for bathing items, grasping force needed for faucets, and lifting of self. Adapt environment by placing items within easy reach, lowering faucets, and using a handheld shower. Environmental factors affect task performance. Function can be improved based on engineering principles that adapt environmental factors to the meet the client's capabilities.
Use any necessary adaptive bathing equipment. Adaptive devices extend the client's reach, increase speed and safety, and decrease exertion.
Provide privacy: have only one caregiver providing bathing assistance, encourage a traffic-free bathing area, and post privacy signs. The client perceives less privacy if more than one caregiver participates or if bathing takes place in a central bathing area in a high-traffic location that allows staff to enter freely during care .
Keep client warmly covered. Clients, especially elderly clients, who are prone to hypothermia may experience evaporative cooling during and after bathing, which produces an unpleasant cold sensation .
Allow client to participate as able in bathing. Smile and provide praise for accomplishments in a relaxed manner. The client's expenditure of energy provides the caregiver the opportunity to convey respect for a well-done task, which increases the client's self-esteem. Smiling and being relaxed are associated with a calm, functional client response.
Inspect skin condition during bathing. Observation of skin allows detection of skin problems.
Use or encourage caregiver to use an unhurried, caring touch. The basic human need of touch offers reassurance and comfort.
If client is bathing alone, place assistance call light within reach. A readily available signaling device promotes safety and provides reassurance for the client.

Geriatric

Provide same type of bathrobe and bathing articles, such as scented dusting powder and bath oil, that client used previously. Use of sensory channels to stimulate memory may help foster understanding of bathing and self-care.
Assess for grieving resulting from loss of function. Grief resulting from loss of function can inhibit relearning of self-care.
Arrange bathing environment to promote sensory comfort: reduce noise of voices and water and decrease glare from tiles, white walls, and artificial lights. Noise discomfort can result from high-echo tiled walls, loud voices, and running water. Glare can cause visual discomfort, especially in clients with visual changes or cataracts.
When bathing a cognitively impaired client, have all bathing items ready for client's needs before bathing begins. Injury often occurs when cognitively impaired client is left alone to obtain forgotten items
Bathe elderly clients before bedtime to improve sleep. An evening bath helps elderly clients sleep better
Bathe cognitively impaired clients before bedtime. Bathing a cognitively impaired client in the evening helps improve symptoms of dementia.
Limit bathing to once or twice a week; provide a partial bath at other times. Frequent bathing promotes skin dryness. Reducing frequency of bathing decreases aggressive behavior in cognitively impaired clients.
Allow client or caregiver adequate time to complete the bathing activity. Significant aging increases the time required to complete a task; therefore elderly individuals with a self-care deficit require more time to complete a task.
Avoid soap or use only mild soap on genital and axillary areas; rinse well. Soap can alter skin pH and thus skin defenses, and it may increase skin dryness that results from decreased oil and perspiration production in the elderly.
Use tepid water: test water temperature before use with a thermometer. Hot water promotes skin dryness and may burn a client with decreased sensation.
Use a gentle touch when bathing; avoid vigorous scrubbing motions. Aging skin is thinner, more fragile, and less able to withstand mechanical friction than younger skin.
Add hydrating bath oils to tub bath water 15 minutes after client immerses in water. Client's skin is coated with oil rather than being hydrated if bath oil is placed in water before client's skin is moistened with water

Home Care Interventions

Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with bathing and hygiene. Support by home health aides preserves the energy of the client and provides respite for caregivers.
Cue cognitively impaired clients in steps of hygiene. Cognitively impaired clients can successfully participate in many activities with cueing, and participation in self-care can enhance their self-esteem.
Respect the preference of terminally ill clients to refuse or limit hygiene care. Maintaining hygiene, even with assistance, may require excessive energy demands from terminally ill clients. Pain on touch or movement may be intractable and not resolved by medication.
If a terminally ill client requests hygiene care, make an extra effort to meet request and provide care when client and family will most benefit. When desired, improved hygiene greatly boosts the morale of terminally ill clients.
Maintain temperature of home at a comfortable level when providing hygiene care to terminally ill clients. Terminally ill clients may have difficulty with thermoregulation, which will add to the energy demand or decrease comfort during hygiene care.

Client And Family Teaching

Teach client and family how to use adaptive devices for bathing, and teach bathing techniques that promote safety . Adaptive devices can provide independence, safety, and speed.
Teach client and family an individualized bathing routine that includes a schedule, privacy, skin inspection, soap or lubricant, and chill prevention. Teaching methods to meet client's needs increases the client's satisfaction with the bathing experience.

Source Nursing Diagnosis : A Guide To Planning Care

Nursing Care Plans for Adult Failure to thrive

2009-02-24T23:48:00.000-08:00

Nursing Diagnosis: Adult Failure to thrive
NANDA Definition: Progressive functional deterioration of a physical and cognitive nature with remarkably diminished ability to live with multisystem diseases, cope with ensuing problems, and manage care

Defining Characteristics: Anorexia-does not eat meals when offered; states does not have an appetite, is not hungry, or "I don't want to eat"; inadequate nutritional intake-eating less than body requirements; consumption of minimal to no food at most meals (i.e., consumes less than 75% of normal requirements); weight loss (from baseline weight)-5% unintentional weight loss in 1 month or 10% unintentional weight loss in 6 months; physical decline (decline in bodily function) — evidence of fatigue, dehydration, incontinence of bowel and bladder; frequent exacerbations of chronic health problems (e.g. pneumonia, urinary tract infections); cognitive decline (decline in mental processing) as evidenced by problems with responding appropriately to environmental stimuli, demonstrated difficulty in reasoning, decision making, judgment, memory, and concentration; decreased perception; decreased social skills; social withdrawal-noticeable decrease from usual past behavior in attempts to form or participate in cooperative and interdependent relationships (e.g., decreased verbal communication with staff, family, friends); decreased participation in ADLs that the older person once enjoyed; self-care deficit-no longer looks after or takes charge of physical cleanliness or appearance; difficulty performing simple self-care tasks; neglect of home environment and/or financial responsibilities; apathy as evidenced by lack of observable feeling or emotion in terms of normal ADLs and environment; altered mood state-expresses feelings of sadness, being low in spirit; expresses loss of interest in pleasurable outlets such as food, sex, work, friends, family, hobbies, or entertainment; verbalizes desire for death

Related Factors: Depression; apathy; fatigue

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Physical Aging Status
• Psychosocial Adjustment: Life Change
• Will to Live
Client Outcomes
• Resumes highest level of functioning possible
• Consumes adequate dietary intake for weight and height
• Maintains usual weight
• Has adequate fluid intake with no signs of dehydration
• Participates in ADLs
• Participates in social interactions
• Maintains clean personal and home environment
• Expresses feelings associated with losses
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Mood Management
• Self-Care Assistance

Nursing Interventions and Rationales

Elderly clients who have failure to thrive (FTT) should be evaluated by review of the patient's ADLs, cognitive function, and mood; a targeted history and physical examination; and selected laboratory studies. Early recognition and management of FTT can reduce the risk of further functional deterioration, hospitalization, or nursing home placement
Assess possible causes for adult FTT and treat any underlying problems such as depression, malnutrition, and illnesses that are caused by physical and cognitive changes. The characteristics of FTT in the elderly are malnutrition (undernutrition), loss of physical and cognitive function, and depression . Malnutrition is a frequent condition, both widely represented in the geriatric population and underestimated in diagnostic and therapeutic work-up, and is known to affect health status and life expectancy of elderly people. An initial clinical assessment that combines multiple and varied sources of information is recommended to evaluate patients with suspected dementia .
Assess for signs of fatigue and sensory changes that may indicate an infection is present that may be related to undetected diabetes mellitus. Older adults may never exhibit the classic signs of polyuria, polydipsia, polyphagia, and weight loss; instead they may develop an infection and complain of fatigue and sensory changes .
Assess for all etiologies including depression using a geriatric depression scale. Be alert for depression in clients newly admitted to nursing homes. The geriatric depressions scale is recommended to determine the presence of depression. Depression in newly admitted nursing home residents is a frequently overlooked area of nursing concern. New depression may be the first sign of impending cognitive dysfunction .
Note if the client is irritable and is blaming others. Recent findings in nursing research support the presence of these behaviors as symptomatic of depression.
Provide cognitive therapy for clients who are identified as depressed. Reinforce their value as a person and provide reality as to "who they really are." Clients who are depressed can be helped by examining "who they are" as compared to "who they believe they are" .
Instill hope and encourage the expression of positive thoughts. The findings from this study of 1002 older disabled women suggest that positive emotions can protect older persons against adverse health outcomes. Of the women studied, 351 were described as emotionally vital, and among the women without a specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking 1/4 mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression because protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed .
Monitor elderly client's weight and note any unexplained weight loss. The FTT of an elderly client is usually accompanied by weight loss that occurs without immediate explanation.
Play soothing music during mealtimes to increase the amount of food eaten. One study suggested that dinner music, particularly soothing music, can reduce irritability, fear, panic, and depressed mood and can stimulate the appetite of demented patients in a nursing home. In this study the patients were less irritable, anxious, and depressed during the periods when music was playing.
Note changes in the elderly client's appetite and assess for depression. Depression can lead to FTT by two routes: a direct path of decreased appetite as a symptom of depression and an indirect path of increasing disability as an effect of depression.
Offer comfort foods and happy hour: foods associated with bygone years, intended to trigger recollections of pleasant childhood experiences and feelings of caring and healing, and a "happy hour" beverage, presented in a social milieu. These are two approaches that have demonstrated effectiveness in stimulating oral intake in the FTT client.
Provide appropriate nutrition for the client whose obesity may be affecting physical performance and thus has limited ability to perform ADLs, which leads to functional dependence. Malnutrition includes obesity (overnutrition); obesity among older persons is defined as being (30% above ideal body weight. Obesity may contribute to the previously mentioned problems.
Encourage clients to reminiscence about past experiences. Reminiscing helps to foster social relatedness. A standard reminiscence interview and one that focused on successfully met challenges reduced state anxiety and enhanced coping self-efficacy.
Encourage clients to pray if they wish. Various studies have discovered that various groups of people have used prayer for managing their symptoms of aging or illness .
Encourage elderly clients to interact with others on a regular basis. Have them participate in activities for seniors in their community. FTT of an elderly client is usually accompanied by social withdrawal
Help clients to participate in activities by assessing motivation and helping them to identify reasons to participate such as better mobility, more independence, feelings of well-being. Motivation has been identified as an important factor in the older adult's ability to perform functional activities .
Provide physical touch for clients. Touch their hand or arm when speaking with them; offer hugs with permission. Touch helps with integration and fosters social relatedness. Tactile stimulation benefits the older adult's psychological well-being.
Administer therapeutic touch (TT). Results of this study of (n = 16) patients in the advanced stages of dementia of the Alzheimer's type (DAT), showed that discomfort levels decreased significantly after five therapeutic touch sessions, becoming significantly lower than levels in the control group (n = 10)
Refer to care plans for Imbalanced Nutrition: less than body requirements, Hopelessness, and Disturbed Energy field.

Multicultural

Assess for the influence of cultural beliefs, norms, and values on the family's or caregiver's understanding of FTT. What the family considers normal and abnormal health behavior may be based on cultural perceptions .
Validate the family's feelings and concerns related to the FTT symptoms. Validation lets the family know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship.

Home Care Interventions

Assess and track areas of decreased functioning resulting from failure to thrive. Ensure that all symptomatology is considered for necessary action. Clients may change response to stressors/needs with changes in environment or interventions.
Give permission for role activity changes. Negotiate and clarify role expectations and reevaluate as necessary. Failure to thrive may require an extended period of recovery. Chronic illness often requires role changes to preserve a functional unit. Comfort level with role activities supports continued recovery.
Provide support for family/caregivers. Support for caregivers decreases caregiver burden.
Refer to medical social services or mental health counseling and/or community support groups. If necessary, contract with client to attend sessions. Counseling support can increase coping ability; group participation provides support and offers new problem-solving strategies to the client.
Refer to home health aide services for assistance with ADLs throughout the duration of decreased participation. Maintaining ADLs and the integrity of the environment prevents further decline in status of those areas and decreases frustration as the client recovers and resumes responsibility for them. Client/Family Teaching .
If adult FTT is related to dementia, help the caregiver to understand the diagnosis and help to identify needs that the caregiver will have to assist client with, such as nutrition, maintenance of adequate fluid intake, toileting, self-care, and safety. When the etiology of adult FTT is dementia, the caregiver needs to be educated on how to handle .
Instruct the family on the use of verbal cues to encourage eating, such as "Pick up your spoon; use the spoon to scoop up the pudding; now put the spoon with the pudding in your mouth." Verbal cueing is effective for improving nutritional status.
Discuss the possibility with the physician of a drug holiday when the etiology is delirium. Delirium may resolve with a drug holiday .
Provide referral for evaluation of hearing and appropriate hearing aids.
Refer for psychotherapy and possible medication if the etiology is depression. Treatment of the etiology is necessary; the previously mentioned are treatments that may be used for depression .

OSTEOPOROSIS

2009-02-24T03:30:00.000-08:00

In osteoporosis, a metabolic bone disorder, the rate of bone resorption accelerates, while the rate of bone formation decelerates. The result is decreased bone mass. Bones affected by this disease lose calcium and phosphate and become porous, brittle, and abnormally vulnerable to fracture. Osteoporosis may be primary or secondary to an underlying disease.

Osteoporosis is often called the 'silent disease' is often also called porous bone at the time porous bone often occur without significant complaints. Osteoporosis is a disease with a marked reduction in bone mass, so that the bones become fragile and the risk of a fracture increases. In normal conditions, we also experienced bone porous followed by the formation of bone cells in the bone is porous. On osteoporosis, bone porous happen excessive and not followed the process enough so that the formation of the bones thin and become more fragile.

Osteoporosis (porous bone) is often called the 'silent disease' or the bone thief. This is because at the time bone porous often occur without any real complaints. To know new people with osteoporosis after the condition is quite severe by the body that crookback or broken bones. It is very important for us to know the risk factors of osteporosis, so that we can be vigilant and make efforts to prevention.

Type Of Osteoporosis

There are 2 types of Osteoporosis, Osteoporosis, namely primary and secondary. Osteoporosis Primary Osteoporosis is a kind of unknown cause.While Osteoporosis Secondary Osteoporosis is caused by other diseases, such as Hiperparatiroidisme, Hipertiroidisme, Diabetes Mellitus Type 1, Cushing syndrome, the use of drugs kortikosteroid in long time (usually used by people with Asthma), diuretik drugs (usually used by people with hypertension), antikonvulsan drugs (anti-spastic), and others. Osteoporosis can occur secondary to the age of 40 years or younger, depending on the condition that the disease affects.

Osteoporosis risk factors:
Osteoporosis risk factors that can not be changed:

Women. Risk of osteoporosis in women more than men because, generally smaller bone mass and the menopause.
Age. Risk of osteoporosis increases each time the addition of 1,4-1,8 age 10 years.
Asian and Caucasus higher risk for osteoporosis than the African race.
Genetic factors. There is a history osteoporosis or fracture in the age more than 50 years in the family is also the occurrence of osteoporosis risk factors.
Some chronic diseases such as diabetes (diabetes), liver disease, kidney, chronic diarrhea and increase the risk of osteoporosis.

Osteoporosis risk factors that can be changed:

Smoking habits and consumption of alcoholic beverages increase the risk of osteoporosis.
Feed calcium and vitamin D that is less important risk factor in osteoporosis.
Weigh less and less exercise (sports) higher risk of osteoporosis.
The use of drugs such as steroid, anti-convulsive drugs (Phenobarbital & Phenytoin), antasida containing aluminum, metotreksat, siklosporin A risk factor is the cause of osteoporosis because of extraction of calcium from the bones in the number of lots.

Depression and Osteoporosis

Some research proves, there is a close relationship between depression and osteoporosis. Reciprocal nature of the relationship back. The failure of people with osteoporosis choose coping mechanism in the face of rational keterbatasannya, will trigger the occurrence of depression. Conversely, the more often someone experiencing stress and depression, disregulasi will trigger the body's hormones, especially cortisol is bad for the osteophenia and osteoporosis.

Osteoporosis examination

To see the level of bone density and to detect Osteoporosis, can be done in a way to measure bone density using a tool called a Densitometer X-ray Absorptiometry. These two types, namely SXA (Single X-ray Absorptiomety) and DEXA (Dual Energy X-ray Absorptiometry).

In addition to bone density examination, currently available laboratory examination to determine bone activity Remodelling the examination or CTx C-Telopeptide and N-Mid Osteocalcin. CTx or C-Telopeptide is the result of the disintegration of the bones is released into the blood so that it can be used to assess the process of crushing bones. While the N-Mid Osteocalcin is a protein which faction was formed by Osteoblas and a role in the process of bone formation.

By doing inspections or CTx C-Telopeptide and N-Mid Osteocalcin the activity can be Remodelling bone, and when the results of the examination showed abnormal results or imbalance occurs Remodelling the bones need to caution risk the occurrence of Osteoporosis or other bone disease possibility. In addition, the examination can also be used to monitor osteoporosis treatment, especially CTx treatment is used to monitor oral anti resorpsi treatment.

Rheumatoid Arthritis

2009-02-23T23:32:00.000-08:00

Rheumatoid Arthritis (RA)

This is thought to be an auto-immune disease in which the body attacks its own cartilage and joint linings, causing inflammation, swelling, pain and loss of function. The main symptom is inflammation of the synovial membrane. If left untreated the membrane thickens, the synovial fluid increases, and the resulting pressure causes pain and tenderness. The membrane then produces abnormal granulation tissue (pannus) which adheres to the surface of articular cartilage allowing fibrous tissue to adhere to the exposed bone ends. The tissue ossifies and fuses the joint so that it becomes fixed. The range of motion of the joint is greatly restricted. The growth of the membrane causes joint distortion. It is this which gives the clinical appearance of RA. Removal of the pannus reduces its growth, helps to prevent deformities, and improves joint function. Ligaments and tendons also become inflamed, leading to shortening, stiffening and scarring, resulting in contractures and subluxation (partial dislocation) of the joint.

OSTEOARTHRITIS
Osteoarthritis is the most common form of arthritis. It causes deterioration of the joint cartilage and formation of reactive new bone at the margins and subchondral areas of the joints. This chronic degeneration results from a breakdown of chondrocytes, most often in the hips and knees.
Osteoarthritis occurs equally in both sexes, after age 40, with the earliest symptoms occurring in middle age and progressing with advancing age.
Depending on the site and severity of joint involvement, disability can range from minor limitation of the fingers to near immobility in people with hip or knee disease. Progression rates vary; joints may remain stable for years in the early stage of deterioration.

Causes
Primary osteoarthritis, a normal part of aging, may result from metabolic, genetic, chemical, and mechanical factors.

Nursing diagnoses

Acute pain
Anxiety
Disturbed body image
Disturbed sleep pattern
Dressing or grooming self-care deficit
Impaired physical mobility
Ineffective coping
Chronic pain, related to joint inflammation
Impaired home maintenance, related to fatigue
Activity intolerance, related to the effects of inflammation
Deficient knowledge: Therapeutic regimen

EXPECTED OUTCOMES
• Verbalize effective pain management strategies.
• Use assistive devices to minimize joint stress with ADLs.
• Verbalize a plan to reduce responsibilities for home maintenance.
• Express a willingness to plan rest breaks during the day.
• Demonstrate understanding of the prescribed therapeutic regimen and its importance for both short- and long-term benefit.

PLANNING AND IMPLEMENTATION
• Teach techniques for relieving pain and morning stiffness, including:
• Performing ROM exercises in shower or bathtub
• Applying local heat with paraffin dip or compress; using cold packs as needed
• Teach techniques to minimize joint stress while performing ADLs.
• Provide Arthritis Foundation literature and information.
• Discuss ways to delegate household tasks to other family members.
• Provide information about the disease process and its manifestations,
prescribed medications with desired and adverse effects,
and the importance of balancing rest and activity.

Hypertension

2009-02-21T03:37:00.000-08:00

Hypertension Definition:
Conceptual Definition about Hypertension, There Is clinical evidence shows a continuous relationship between blood pressure level and cardiovascular risk, the definition of hypertension still remains largely arbitrary. Many have attempted to numerically define this quantitative threshold, the real threshold level for hypertension is flexible, depending in large part on the total cardiovascular risk profile of an individual subject.

Operational Definition, Identify hypertension individuals are a systolic blood pressure of more than 140 mmHg or a diastolic blood pressure of more than 90 mmHg.

Classification of Hypertension
Classification of Hypertension According to Disease Evolution:
1. Malignant Hypertension
2. Benign Hypertension

Classification of Hypertension According to Blood Pressure Levels:
1. Normality of 24 h Ambulatory Blood Pressure Values
2. Normality of Home Blood Pressure Values
Definitions and classification of blood pressure levels
Optimal                                              Systolic less 120         Diastolic less than 80
Normal Systolic 120–129       Diastolic 80–84
High normal                                        Systolic 130–139          Diastolic 85–89
Grade 1 hypertension (mild)                Systolic 140–159      Diastolic 90–99
Grade 2 hypertension (moderate)        Systolic 160–179        Diastolic 100–109
Grade 3 hypertension (severe)            Systolic more 180        Diastolic more than 110
Isolated systolic hypertension              Systolic more than 140 Diastolic less 90

Classification According to Etiology of Hypertension
90–95% of hypertension cases, the etiological factors that are responsible for the blood pressure increase remain unknown. Secondary forms of hypertension are relatively rare diseases; their prevalence amounts to 5–10% of all cases of hypertension

Classification of Hypertension According to Global Cardiovascular Risk Profile

Assessment of Hypertension

Nursing Care Plans For Acute Confusion

2009-02-17T07:52:00.000-08:00

Nursing Care Plans Diagnosis: Acute Confusion

NANDA Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle

Defining Characteristics: Lack of motivation to initiate and/or follow through with goal-directed or purposeful behavior; fluctuation in psychomotor activity; misperceptions; fluctuation in cognition; increased agitation or restlessness; fluctuation in level of consciousness; fluctuation in sleep-wake cycle; hallucinations

Related Factors: 60 years of age; dementia; alcohol abuse; abuse; delirium; uncontrolled pain; multiple morbidities and medications

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Distorted Thought Control
• Information Processing
• Memory
• Neurological Status: Consciousness
• Safety Behavior: Personal
• Sleep
Client Outcomes
• Cognitive status restored to baseline
• Obtains adequate amount of sleep
• Demonstrates appropriate motor behavior
• Maintains functional capacity

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Delusion Management
Nursing Interventions and Rationales
• Assess client’s behavior and cognition systematically and continually throughout the day and night as appropriate. Rapid onset and fluctuating course are hallmarks of delirium. The Confusion Assessment Method is sensitive, specific, reliable, and easy to use.. Nurses play a vital role in assessing acute confusion because they provide 24- hours-a-day care and see the client in a variety of circumstances. Delirium always involves acute change in mental status; therefore knowledge of the client’s baseline mental status is key in assessing delirium.
• Perform an accurate mental status exam that includes the following:
o Overall appearance, manner, and attitude
o Behavior observations and level of psychomotor behavior
o Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by client)
o Insight and judgment
o Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking)
o Attention
Abnormal attention is an important diagnostic feature of delirium. Delirium is a state of mind, while agitation is a behavioral manifestation. Some clients may be delirious without agitation and may actually have withdrawn behavior. This is a hypoactive form of delirium. Some clients have a mixed hypoactive/hyperactive type of delirium .
• Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects). Such alterations may be contributing to confusion and must be corrected. Medications are considered the most common cause of delirium in the ICU.
• Treat underlying causes of delirium in collaboration with the health care team: Establish/maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, body temperature, oxygenation (if patients experience low oxygen saturation treat with supplemental oxygen), blood glucose levels, blood pressure.
• Communicate client status, cognition, and behavioral manifestations to all necessary providers. Monitor for any trending of these. Recognize that client’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as client preference for caregivers. Careful monitoring may allow for various symptoms to be related to various causes and interventions.
• Lab results should be closely monitored and physiological support provided as appropriate. Once acute confusion has been identified, it is vital to recognize and treat the associated underlying causes .
• Establish or maintain elimination patterns. Disruption of elimination may be a cause for confusion. Changes in elimination patterns may also be a symptom of acute confusion. Prompt response to requests for assistance with elimination in addition to timed voids may assist in maintaining regular elimination, orientation, and patient safety.
• Plan care that allows for appropriate sleep-wake cycle. Disruptions in usual sleep and activity patterns should be minimized as those clients with nocturnal exacerbations endure more complications from delirium.
• Review medication. Medication is one of the most important modifiable factors that can cause delirium, especially use of anticholinergics, antipsychotics, and hypnosedatives .
• Decrease caffeine intake. Decreasing caffeine intake helps to reduce agitation and restlessness .
• Modulate sensory exposure and establish a calm environment. Extraneous lights and noise can give rise to agitation, especially if misperceived. Sensory overload or sensory deprivation can result in increased confusion. Clients with a hyperactive form of delirium often have increased irritability and startle responses and may be acutely sensitive to light and sound.
• Manipulate the environment to make it as familiar to the patient as possible. Use a large clock and calendar. Encourage visits by family and friends. Place familiar objects in sight. An environment that is familiar provides orienting clues, maintains an appropriate balance of sensory stimulation, and secures safety .
• Identify self by name at each contact; call patient by his or her preferred name. Appropriate communication techniques for clients at risk for confusion .
• Use orientation techniques. However, if client becomes distressed or argumentative about what is real, do not argue with the client. Rather, explore the emotion behind the client’s non–reality-based statements.
• Offer reassurance to the client and use therapeutic communication at frequent intervals. Client reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety .
• Provide supportive nursing care. Delirious patients are unable to care for themselves as a result of their confusion. Their care and safety needs must be anticipated by the nurse.
• Identify, evaluate, and treat pain quickly (see care plan for Acute Pain). Untreated pain is a potential cause for delirium.
Geriatric
• Mobilize client as soon as possible; provide active and passive range of motion. Older clients who had a low level of physical activity before injury are at a particular risk for acute confusion .
• Provide sufficient medication to relieve pain. Older clients may give inaccurate pain histories; underreport symptoms; not want to bother the nurse; and exhibit restlessness, agitation, or increased confusion .
• Because anxiety and sensory impairment decrease the older client's ability to integrate new information, explain hospital routines and procedures slowly and in simple terms, repeating information as necessary .
• Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes). Continuity of care helps decrease the disorienting effects of hospitalization (Matthiesen et al, 1994).
• If clients know that they are not thinking clearly, acknowledge the concern. Confusion is very frightening .
• Do not use the intercom to answer a call light. The intercom may be frightening to an older confused client .
• Keep client's sleep-wake cycle as normal as possible (e.g., avoid letting client take daytime naps, avoid waking clients at night, give sedatives but not diuretics at bedtime, provide pain relief and backrubs). Acute confusion is accompanied by disruption of the sleep-wake cycle.
• Maintain normal sleep/wake patterns (treat with bright light for 2 hours in the early evening). This facilitates normal sleep/wake patterns .
Home Care Interventions
• Monitor for acute changes in cognition and behavior. An acute change in cognition and behavior is the classic presentation of delirium. It should be considered a medical emergency.
Client/Family Teaching
• Teach family to recognize signs of early confusion and seek medical help. Early intervention prevents long-term complications.

Nursing Care Plans For Impaired Oral mucous membrane

2009-02-17T07:43:00.000-08:00

Nursing Care Plans Diagnosis: Impaired Oral mucous membrane

Definition: Disruptions of the lips and soft tissues of the oral cavity

Defining Characteristics: Purulent drainage or exudates; gingival recession, pockets deeper than 4 mm; enlarged tonsils beyond what is developmentally appropriate; smooth atrophic, sensitive tongue; geographic tongue; mucosal denudation; presence of pathogens; difficult speech; self-report of bad taste; gingival or mucosal pallor; oral pain/discomfort; xerostomia (dry mouth); vesicles, nodules, or papules; white patches/plaques, spongy patches, or white curd-like exudate; oral lesions or ulcers; halitosis; edema; hyperemia; desquamation; coated tongue; stomatitis; self-report of difficult eating or swallowing; self-report of diminished or absent taste; bleeding; macroplasia; gingival hyperplasia; fissures, cheilitis; red or bluish masses .

Related Factors: Chemotherapy; chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); depression; immunosuppression; aging-related loss of connective, adipose, or bone tissue; barriers to professional care; cleft lip or palate; medication side effects; lack of or decreased salivation; chemical trauma (e.g., acidic foods, drugs, noxious agents, alcohol); pathological conditions—oral cavity (radiation to head or neck); NPO for more than 24 hours; mouth breathing; malnutrition or vitamin deficiency; dehydration; infection; ineffective oral hygiene; mechanical (e.g., ill-fitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); decreased platelets; immunocompromised; impaired salivation; radiation therapy; barriers to oral self-care; diminished hormone levels (women); stress; loss of supportive structures

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Oral Health
• Tissue Integrity: Skin and Mucous Membranes
Client Outcomes
• Maintains intact, moist oral mucous membranes that are free of ulceration and debris
• Describes or demonstrates measures to regain or maintain intact oral mucous membranes
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Oral Health Restoration

Nursing Interventions and Rationales
• Inspect oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Refer to a physician or specialist as appropriate. Oral inspection can reveal signs of oral disease, symptoms of systemic disease, drug side effects, or trauma of the oral cavity.
• Assess for mechanical agents such as ill-fitting dentures or chemical agents such as frequent exposure to tobacco that could cause or increase trauma to oral mucous membranes. Irritative and causative agents for stomatitis should be eliminated .
• Monitor client's nutritional and fluid status to determine if adequate. Refer to the care plan for Deficient Fluid volume or Imbalanced Nutrition: less than body requirements if applicable. Dehydration and malnutrition predispose clients to impaired oral mucous membranes.
• Encourage fluid intake up to 3000 ml per day if not contraindicated by client's medical condition (Rhodes, McDaniel, Johnson, 1995). Fluids help increase moisture in the mouth, which protects the mucous membranes from damage and helps the healing process.
• Determine client's mental status. If client is unable to care for self, oral hygiene must be provided by nursing personnel. The nursing diagnosis Bathing/Hygiene Self-care deficit is then also applicable.
• Determine client's usual method of oral care and address any concerns regarding oral hygiene. Whenever possible, build on client's existing knowledge base and current practices to develop an individualized plan of care.
• If client does not have a bleeding disorder and is able to swallow, encourage to brush teeth with a soft pediatric-sized toothbrush using a fluoride-containing toothpaste after every meal and to floss teeth daily. The toothbrush is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling periodontal disease.
• Use tap water or normal saline to provide oral care; do not use commercial mouthwashes containing alcohol or hydrogen peroxide. Also, do not use lemon-glycerin swabs. Alcohol dries the oral mucous membranes Hydrogen peroxide can damage oral mucosa and is extremely foul tasting to clients (Tombes, Gallucci, 1993; Winslow, 1994). Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel.
• Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous client. Do not use to clean the teeth or else the platelet count is very low, and the client is prone to bleeding gums. Studies have shown that foam sticks are probably not effective for removing plaque from teeth. However, they are useful for cleaning the mouth of the edentulous client.
• If client's oral cavity is dry, the keep inside of the mouth moist with frequent sips of water and salt water rinses (1/2 tsp salt in 8 oz of warm water) or artificial saliva. Moisture promotes the cleansing effect of saliva and helps avert mucosal drying, which can result in erosions, fissures, or lesions. Sodium chloride rinses have been shown to be effective for the prevention and treatment of stomatitis.
• Keep lips well lubricated using petroleum jelly or a similar product .
• For clients with stomatitis, increase frequency of oral care up to every hour while awake if necessary. Increasing the frequency of oral care has been shown to be effectively decrease stomatitis.
• Provide scrupulous oral care to critically ill clients. Cultures of the teeth of critically ill clients have yielded significant bacterial colonization, which can cause nosocomial pneumonia.
• If mouth is severely inflamed and it is painful to swallow, contact the physician for a topical anesthetic agent or analgesic order. Modification of oral intake (e.g., soft or liquid diet) may also be necessary to prevent friction trauma. The nursing diagnosis Imbalanced Nutrition: less than body requirements may apply.
• If whitish plaques are present in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red base that bleeds, suspect a fungal infection and contact the physician for follow-up. Oral candidiasis (moniliasis) is extremely common secondary to antibiotic therapy, steroid therapy, HIV infection, diabetes, or immunosuppressive drugs and should be treated with oral or systemic antifungal agents.
• If client is unable to swallow, keep suction nearby when providing oral care.
• Refer to Impaired Dentition if the client has problems with the teeth.
Geriatric
• Carefully observe oral cavity and lips for abnormal lesions such as white or red patches, masses, ulcerations with an indurated margin, or a raised granular lesion. Malignant lesions are more common in elderly persons than in younger persons (especially if there is a history of smoking or alcohol use), and many elderly persons rarely visit a dentist.
• Ensure that dentures are removed and scrubbed at least once daily, removed and rinsed thoroughly after every meal, and removed and kept in an appropriate solution at night. This is an evidence-based protocol for denture care. Denture plaque-containing candidiasis can cause denture-induced stomatitis, which is more common with unhealthy lifestyles and poor oral hygiene than otherwise .
Home health Care Interventions
• Instruct client to avoid alcohol- or hydrogen peroxide-based commercial products for mouth care and to avoid other irritants to the oral cavity (e.g., tobacco, spicy foods). Oral irritants can further damage the oral mucosa and increase the client's discomfort.
• Instruct client in ways to soothe the oral cavity.
• If client often breathes by mouth, add humidity to room unless contraindicated.
• If necessary, refer for home health aide services to support family in oral care and observation of the oral cavity.
Client/Family Teaching
• Teach client how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and healing.
• Teach how to implement a personal plan of oral hygiene including a schedule of care. Encouragement and reinforcement of oral care are important to oral outcomes.

Nursing Care Plans For Ineffective Health maintenance

2009-02-17T07:21:00.000-08:00

Nursing Diagnosis: Ineffective Health maintenance

NANDA Definition: The inability to identify, manage, or seek out help to maintain health

Defining Characteristics: History of lack of health-seeking behavior; reported or observed lack of equipment, financial, and/or other resources; reported or observed impairment of personal support systems; expressed interest in improving health behaviors; demonstrated lack of knowledge regarding basic health practices; demonstrated lack of adaptive behaviors to internal and external environmental changes; reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas

Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills); lack of or significant alteration in communication skills (written, verbal, or gestural); unachieved developmental tasks; lack of material resources; dysfunctional grieving; disabling spiritual distress; inability to make deliberate and thoughtful judgments; ineffective coping

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Health Beliefs: Perceived Resources

• Health-Promoting Behavior, Health-Seeking Behavior

Client Outcomes

• Discusses fear of or blocks to implementing a health regimen

• Follows mutually agreed upon health care maintenance plan

• Meets goals for health care maintenance

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Health System Guidance

• Support System Enhancement

• Health Education

Nursing Interventions and Rationales

• Assess client's feelings, values, and reasons for not following prescribed plan of care. See Related Factors. A factor to assess when examining client responsibility is the level of dissatisfaction with current lifestyle and readiness for change.

• Assess for family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen. Responsiveness to clients enables the nurse to gain an understanding of clients' lives and to cultivate their connections to a responsive community, encouraging clients to not get into "receiving" behaviors.

• Help client determine how to arrange a daily schedule that incorporates the new health care regimen (e.g., taking pills before meals).

• Refer client to social services for financial assistance if needed. Information-seeking behavior is a strategy that many people use as a means of coping with and reducing stress when coping with an illness such as cancer .

• Identify support groups related to the disease process (e.g., Reach to Recovery for a woman who has had a mastectomy).

• Help client to choose healthy lifestyle and to have appropriate diagnostic screening tests. This study identified that women who adopt a healthy lifestyle and practice preventive healthy behaviors can reduce the risks of some cancers and other diseases such as heart disease and sexually transmitted infections.

• Identify complementary healing modalities such as herbal remedies, acupuncture, healing touch, yoga, or cultural shamans that the client uses in addition to or instead of the prescribed allopathic regimen. Expenditures for alternative medicine professional services have increased 45% since 1990. Total visits to alternative medical practitioners exceeded total visits to all U.S. primary care practitioners. A widening recognition of the mind-body-spirit connection in western medicine has resulted in a growing interest in ancient health practices such as yoga .

• Refer client to community agencies for appropriate follow-up care (e.g., day treatment or adult day health program). Increased social support has been related to a reduction in mortality rates and incidences of physical and mental illness. This study showed a positive response when using a community youth setting, such as the girl scouts, to prevent disordered eating behaviors.

• Obtain or design educational material that is appropriate for the client; use pictures if possible. Verbal reinforcement of personalized written instructions appears to be the best intervention. In one study, the use of computer-generated, personalized instructions improved adherence when compared with the use of handwritten instructions .

• Ensure that follow-up appointments are scheduled before the client is discharged; discuss a way to ensure that appointments are kept. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.

Geriatric

• Assess sensory deficits and psychomotor skills in terms of client's ability to comply with a health program. Barriers to health promotion in people with chronic illness were fatigue, time, safety, and lack of accessible facilities.

• Discuss "symptoms of daily living" in addition to the major illness. Older adults are unlikely to report day-to-day symptoms such as headaches because they do not view them as illness. However, these day-to-day complaints may foretell more serious problems.

• Recognize resistance to change in lifelong patterns of personal health care. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.

• Discuss with client realistic goals for changes in health maintenance. The focus of a chronic illness may be care rather than cure. In this study of 86 people, the oldest old may have increased optimism but decreased satisfaction. They have a sense of realism about the tasks of aging and have a present-focused orientation .

• Consider the age of the client when suggesting screening for disease. Even assuming that the mortality reduction with screening persists in the elderly, 80% of the benefit is achieved before 80 years of age for colon cancer, before 75 years of age for breast cancer, and before 65 years of age for cervical cancer. The small benefit of screening in the elderly may be outweighed by the harms: anxiety, additional testing, and unnecessary treatment .

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on the client's ability to modify health behavior. What the client considers normal and abnormal health behavior may be based on cultural perceptions .

• Discuss with the client those aspects of their health behavior/lifestyle that will remain unchanged by their health status. Aspects of the client's life that are meaningful and valuable to him or her should be understood and preserved without change.

• Negotiate with the client regarding the aspects of health behavior that will need to be modified. Give and take with the client will lead to culturally congruent care .

• Assess the role of fatalism on the client's ability to modify health behavior Fatalistic perspectives involve the belief in some African-American and Latino populations that you cannot control your own fate and influence health behaviors .

• Validate the client's feelings regarding the impact of health status on current lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship .

Home Care Interventions

• Provide aids to assist with compliance (e.g., prepare medication schedules and put a week's medication in daily containers).

• Provide sufficient outside supports (e.g., written notices, calendars, planned ride shares) to assist with follow-through of the agreed-upon actions. Cues play a significant role in stimulating completion of desired health actions.

• Establish a written contract with client to follow the agreed-upon health care regimen. Written agreements reinforce the verbal agreement and serve as a reference.

• Meet with client following the proposed actions to review the contract and determine the next course of action. Do this until the client is able to initiate and follow through independently. Successful completion of contracts promotes improved self-esteem and positive coping.

Client/Family Teaching

• Provide family with lists of addresses for information to be obtained from the Internet. (Most libraries have Internet access with printing capabilities.) Internet-based technologies have emerged as potentially powerful tools to enable meaningful communication and proactive partnership in care for various medical conditions . A study of 469 Internet postings of patients with implantable defibrillators showed that they used the Internet for practical information seeking and support in coping.

• Have client and family demonstrate at least twice any procedures to be done at home. Practice of a procedure exposes problems, enhances skill levels, and promotes confidence in new behaviors.

• Explain nonthreatening material before introducing more anxiety-producing possible side effects of the disease or medical regimen. An individual's perception of barriers and benefits has consistently been most predictive of subsequent behavior .

Nursing Care Plans For Risk for Infection

2009-02-16T05:06:00.001-08:00

Nursing Diagnosis: Risk for Infection

NANDA Definition: At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.
Risk Factors: Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Immune Status
• Knowledge: Infection Control
• Risk Control
• Risk Detection
Client Outcomes
• Remains free from symptoms of infection
• States symptoms of infection of which to be aware
• Demonstrates appropriate care of infection-prone site
• Maintains white blood cell count and differential within normal limits
• Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Infection Control
• Infection Protection
Nursing Interventions and Rationales
• Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. With the onset of infection the immune system is activated and signs of infection appear.
• Assess temperature of neutropenic clients every 4 hours; report a single temperature of >38.5° C or three temperatures of >38° C in 24 hours. Neutropenic clients do not produce an adequate inflammatory response; therefore fever is usually the first and often the only sign of infection (Wujcik, 1993).
• Use an electronic or mercury thermometer to assess temperature. When temperature values have important consequences for treatment decisions, use mercury or electronic thermometers with established accuracy (Erickson et al, 1996).
• Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). Laboratory values are correlated with client's history and physical examination to provide a global view of the client's immune function and nutritional status and develop an appropriate plan of care for the diagnosis (Lehmann, 1991).
• Remove the granulocytopenic client from areas exposed to construction dust so that the client won't inhale fungal spores. Remove all plants and flowers from client's room. Aspergillus, an organism that can cause fungal pneumonia, is commonly found in soil, water, and decomposing vegetation. This fungus can enter the hospital through an unfiltered air system, in dust stirred up during construction, or in food or ornamental plants (Carlianno, 1999).
• Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes. Preventive skin assessment protocol, including documentation, assists in the prevention of skin breakdown. Intact skin is nature's first line of defense against microorganisms entering the body (Kovach, 1995).
• Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces. Maintaining supple, moist skin is the best method of keeping skin intact. Dry skin can lead to inflammation, excoriations, and possible infection episodes (Kovach, 1995) (see Risk for impaired Skin integrity).
• Encourage a balanced diet, emphasizing proteins to feed the immune system. Immune function is affected by protein intake (especially arginine); the balance between omega-6 and omega-3 fatty acid intake; and adequate amounts of vitamins A, C, and E and the minerals zinc and iron. A deficiency of these nutrients puts the client at an increased risk of infection (Lehmann, 1991).
• Use strategies to prevent nosocomial pneumonia: assess lung sounds, sputum, and redness or drainage around stoma sites; use sterile water rather than tap water for mouth care of immunosuppressed clients; provide a clean manual resuscitation bag for each client; use sterile technique when suctioning; suction secretions above tracheal tube before suctioning; drain accumulated condensation in ventilator tubing into a fluid trap or other collection device before repositioning the client; assess patency and placement of nasogastric tubes; elevate the head of the client to (30° to prevent gastric reflux of organisms in the lung; institute feeding as soon as possible; assess for signs of feeding intolerance—no bowel sounds, abdominal distension, increased residual, emesis. Hospital-acquired pneumonia is the second most common nosocomial infection but has the highest mortality (30%) and morbidity rates. The strategies listed are used to prevent nosocomial pneumonia (Tasota et al, 1998).Once treatment for pneumonia has begun, it must continue for 48 to 72 hours, the minimum time to evaluate a clinical response (Ruiz et al, 2000).
• Encourage fluid intake. Fluid intake helps thin secretions and replace fluid lost during fever (Carlianno, 1999).
• Encourage adequate rest to bolster the immune system. Chronic disease and physical and emotional stress increase the client's need for rest (Potter, Perry, 1993).
• Use proper hand washing techniques before and after giving care to client and any time hands become soiled, even if gloves are worn: Wet hands under running water; dispense a minimum of 3 to 5 ml of soap or detergent and thoroughly distribute it over all areas of both hands; vigorously wash all surfaces of hands and fingers for at least 10 to 15 seconds, including backs of hands and fingers and under nails; rinse to remove soap, and thoroughly dry hands; use a dry paper towel to turn the faucet off. Consistent and meticulous hand washing remains the most important contributing factor related to reduction of the frequency of nosocomial infections in the intensive care unit (ICU). Hand washing significantly decreases the number of pathogens on the skin and contributes to decreases in client's morbidity and mortality (Tasota et al, 1998). Ensure that all hospital staff members follow precautions to prevent the spread of infection. In this study, a high percentage of staff did not wash hands at appropriate times (Chandra, Milind, 2001). When soap is used, the mechanical action of washing and drying removes most of the transient bacteria. Hands should remain in contact with the cleanser for 10 seconds, but 20 to 30 seconds is ideal (Gould, 1994a). Rinsing hands with tap water and drying them with towels can reduce methicillin-resistant Staphylococcus aureus (MRSA) contamination by 95% (Sarver-Steffensen, 1999).
• Hands should be thoroughly dried with paper towels after washing. Bacterial transfer occurs more readily between wet surfaces than dry ones (Marples, Towers, 1979). More microorganisms were removed with paper towels than with linen. After use of hot-air dryers, fecal organisms have been recovered from hands, and bacterial counts are significantly higher than when paper towels are used (Gould, 1994b).
• Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance except sweat. Use goggles, gloves, and gowns when appropriate. Wearing gloves does not obviate the need for scrupulous hand washing. The purpose of wearing gloves is either to protect the hands from becoming contaminated with dirt and microorganisms or to prevent the transfer of organisms that are already present on the hands (Smock, Shiel, 1994). The first and most important tier of the new Centers for Disease Control and Prevention (CDC) guidelines is Standard Precautions. Because client examination and medical history cannot reliably identify every client with blood-borne pathogens, Standard Precautions apply to all clients. You must assume all clients are carrying blood-borne pathogens such as human immunodeficiency virus (HIV) or Hepatitis B or C (HBV or HCV). Standard Precautions exceed Universal Precautions. Transmission of blood-borne pathogens takes place by parenteral, mucous membrane, or nonintact skin exposure to blood and other body substances. You must take precautions whenever contact is likely with blood, mucous membranes, nonintact skin, or any body substance except sweat (Medcom). This study indicates that when risk for infection is high, powder-free gloves should be considered because powder may promote wound infection (Dave, Wilcox, Kellett, 1999).
• Follow Transmission-Based Precautions for airborne-, droplet-, and contact-transmitted microorganisms:
o Airborne: Isolate the client in a room with monitored negative air pressure, with the room door closed, and the client remaining in the room. Always wear appropriate respiratory protection when you enter the room. For tuberculosis, you should wear an approved particulate respirator mask. Limit the movement and transport of the client from the room to essential purposes only. If at all possible, have the client wear a surgical mask during transport.
o Droplet: Keep the client in a private room, if possible. If not possible, maintain a spatial separation of 3 feet from other beds or visitors. The door may remain open. You should wear a mask when you must come within 3 feet of the client. Some hospitals may choose to implement a mask requirement for droplet precautions for anyone entering the room. Limit transport to essential purposes, and have the client wear a mask if possible.
o Transmission: Place the client in a private room if possible or with someone who has an active infection from the same microorganism. Wear clean, nonsterile gloves when entering the room. When providing care, change gloves after contact with any infective material such as wound drainage. Remove the gloves and wash your hands before leaving the room and take care not to touch any potentially infectious items or surfaces on the way out. Wear a gown if you anticipate your clothing may have substantial contact with the client or other potentially infectious items. Remove the gown before leaving the room. Limit the transport of the client to essential purposes and take care that the client does not contact other environmental surfaces along the way. Dedicate the use of noncritical client care equipment to a single client. If use of common equipment is unavoidable, adequately clean and disinfect equipment before use with other clients.
Standard Precautions are based on the likely routes of transmission of pathogens. The second tier of the new CDC guidelines is Transmission-Based Precautions. This replaces many old categories of isolation precautions and disease-specific precautions with three simpler sets of precautions. These three sets of precautions are designed to prevent airborne transmission, droplet transmission, and contact transmission (Medcom).
• Sterile technique must be used when inserting urinary catheters. Catheters must be cared for at least every shift. The genitourinary (GU) track is the most common site of nosocomial infections in the acute care setting. Catheterization and instrumentation of the urinary tract are implicated as precipitating factors in approximately 80% of cases (Tasota et al, 1998).
• Use careful technique when changing and emptying urinary catheter bags; avoid cross-contamination. Clients are most at risk for cross-infection during bag changing and emptying (Platt et al, 1983; Crow et al, 1993; Roe, 1993).
• Use alternatives to indwelling catheters whenever possible (external catheters, incontinence pads, bladder control techniques). The GU track is the most common site of nosocomial infections in the acute care setting. Catheterization and instrumentation of the urinary tract are implicated as precipitating factors in approximately 80% of cases (Tasota et al, 1998).
• Provide well-designed site care for all peripheral, central venous, and arterial catheters: standardize insertion technique; select catheters with as few lumens as necessary; avoid use of femoral catheters in clients with fecal or urinary incontinence; use aseptic technique for insertion and care; stabilize cannula and tubing; maintain a sterile occlusive dressing (change every 72 hours per hospital policy); label insertion sites and all tubing with date and time of insertion, inspect every 8 hours for signs of infection, record and report; replace peripheral catheters per hospital policy (usually every 48 to 72 hours); when fever of unknown origin develops, obtain culture. More than 40% of bloodstream infections in ICUs are associated with short-term use of central venous catheters. Strict aseptic technique should be maintained. The risk of infection associated with use of triple-lumen catheters is as much as three times greater than the risk associated with single-lumen catheters. Clients with unexplained fever and signs of localized infection most likely have a catheter-related infection. The catheter should be removed and samples obtained for microbial culture (Tasota et al, 1998). Care in selection of site and catheter is important. The shortest catheter and smallest size should be used when possible. Accommodate the need to replace catheters before they occlude (Schmid, 2000).
• Use careful sterile technique wherever there is a loss of skin integrity. Use of sterile technique prevents infection in at-risk clients (Wujcik, 1993).
• Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perineal care performed by either nurse or client. Hygienic care is important to prevent infection in at-risk clients (Wujcik, 1993).
• Recommend responsible use of antibiotics; use antibiotics sparingly. Clients infected with resistant strains of bacteria are more likely than control clients to have received previous antimicrobials, and hospital areas that have the highest prevalence of resistance also have the highest rates of antibiotic use. For these reasons, programs to prevent or control the development of resistant organisms often focus on the overuse or inappropriate use of antibiotics, for example, by restriction of widely used broad-spectrum antibiotics (e.g., third-generation cephalosporins) and vancomycin. Other approaches are to rotate antibiotics used for empiric therapy and to use combinations of drugs from different classes (Weber, Raasch, Rutala, 1999). Widespread use of certain antibiotics, particularly third-generation cephalosporins, has been shown to foster development of generalized beta-lactam resistance in previously susceptible bacterial populations. Reduction in the use of these agents (as well as imipenem and vancomycin) and concomitant increases in the use of extended-spectrum penicillins and combination therapy with aminoglycosides have been shown to restore bacterial susceptibility (Yates, 1999).
Geriatric
• Recognize that geriatric clients may be seriously infected but have less obvious symptoms. The immune system declines with aging. The elderly may present with atypical manifestations of infections (Madhaven, 1994).
• Suspect pneumonia when the client has symptoms of fatigue or confusion. The only early indicators of pneumonia in an elderly client may be confusion and fatigue. An elderly client with pneumonia may not have such classic signs and symptoms as fever, cough, or an increased white blood cell (WBC) count, or lung consolidation may be masked by chronic pulmonary disease. Among all age groups, the elderly are at greatest risk because aging can impair normal pulmonary defense mechanisms. Once an older client develops pneumonia, his or her risk takes on deadly dimensions. Clients >65 years of age are five times more likely than those in any other age group to die of a bacterial nosocomial pneumonia (Calianno, 1999).
• Most clients develop nosocomial pneumonia by either aspirating contaminated substances or inhaling airborne particles. Refer to care plan for Risk for Aspiration.
• Foot care other than simple toenail cutting should be performed by a podiatrist.
• Observe and report if client has a low-grade temperature or new onset of confusion. The elderly can have infections with low-grade fevers. Be suspicious of any temperature rise or sudden confusion—these symptoms may be the only signs of infection (Madhaven, 1994).
• During the peak of the influenza epidemic, limit visits by relatives and friends. Hospital- and nursing home-acquired influenza A virus infection leads to high mortality in the elderly (Madhaven, 1994).
• Recommend that the geriatric client receive an annual influenza immunization and one-time pneumococcal vaccine. Among the many infections to which the aged are susceptible, pneumonia and influenza combined are responsible for the greatest mortality (Madhaven, 1994). Oseltamivir prophylaxis was very effective in protecting nursing home residents from ILI and in halting an outbreak of influenza B. A comparable nursing home in this study that did not use this treatment had double the cases (Parker, Loewen, Skowronski, 2001).
• Recognize that chronically ill geriatric clients have an increased susceptibility to infection; practice meticulous care of all invasive sites.

Home Care Interventions
• Assess home care environment for appropriate disposal of used dressing materials. Used dressing materials may contain or be a primary medium for growth of pathogens.
• Role model all preventive behaviors in care of client (e.g., Universal Precautions). Do not visit client when you are ill. Demonstration is a more effective teaching strategy than verbalization.
• Maintain the cleanliness of all irrigation and cleansing solutions. Change solutions when cleanliness has not been maintained—do not wait to finish bottle. Solutions exposed to contaminants provide a medium for growth of pathogens.
• Assess and teach clients about current medications and therapies that promote susceptibility to infection: corticosteroids, immunosuppressants, chemotherapeutic agents, and radiation therapy. Knowledge of risk factors promotes vigilance in assessment, prompt reporting, and early treatment.
• Assess client for knowledge of infections that have been drug resistant.
• Instruct client to complete any course of prophylactic antibiotic therapy unless experiencing adverse side effects. Prophylactic antibiotic therapy decreases the risk of infection.
Client/Family Teaching
• Teach client and family the symptoms of infection that should be promptly reported to a primary medical caregiver (e.g., redness; warmth; swelling; tenderness or pain; new onset of drainage or change in drainage from wound; increase in body temperature; hepatitis B virus [HBV]/acquired immunodeficiency syndrome [AIDS] symptoms: malaise, abdominal pain, vomiting or diarrhea, enlarged glands, rash; tuberculosis symptoms: cough, night sweats, dyspnea, changes in sputum, changes in breath sounds; insulin-dependent diabetes mellitus [IDDM] symptoms: sores or wounds that do not heal). A high prevalence of HBV/AIDS, an increasing incidence of tuberculosis, and the general risk of diabetes are related to increased rate of infection.
• Encourage high-risk persons, including health care workers, to have influenza vaccinations. Vaccinations help to prevent viral nosocomial pneumonia (Carlianno, 1999).
• Assess whether client and family know how to read a thermometer; provide instructions if necessary. Chemical dot thermometers are easy to use and decrease risk of infection. Clients need to know that the instructions should be followed carefully and that electronic or mercury thermometers may be the best choice for accuracy. Chemical dot thermometers may underestimate the oral temperature by (0.4° C in about 50% of adults, thus lacking the sensitivity to screen for fever and providing many false readings. Conversely, they may overestimate axillary temperature by (0.4° C in about 50% of adults and some young children, thus lacking the specificity to rule out fever and providing many false-positive readings (Erickson et al, 1996).
• Instruct client and family about the need for good nutrition (especially protein) and proper rest to bolster immune function.
• If client has AIDS, discuss the continued need to practice safe sex, avoid unsterile needle use, and maintain a healthy lifestyle to prevent infection.
• Refer client and family to social services and community resources to obtain support in maintaining a lifestyle that increases immune function (e.g., adequate nutrition and rest, freedom from excessive stress).

Nursing Care Plans For Anxiety

2009-02-16T04:56:00.000-08:00

Nursing Diagnosis: Anxiety

NANDA Definition: Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.

Defining Characteristics:
Behavioral
Diminished productivity; scanning and vigilance; poor eye contact; restlessness; glancing about; extraneous movement (e.g., foot shuffling, hand/arm movements); expressed concerns resulting from change in life events; insomnia; fidgeting
Affective
Regretful; irritability; anguish; scared; jittery; overexcited; painful and persistent increased helplessness; rattled; uncertainty; increased wariness; focus on self; feelings of inadequacy; fearful; distressed; apprehension; anxious
Physiological
Voice quivering
Objective
Trembling/hand tremors; insomnia
Subjective
Shakiness; worried; regretful
Physiological-sympathetic
Increased pulse; increased blood pressure; increased tension; cardiovascular excitation; heart pounding; superficial vasoconstriction; respiratory difficulties; increased respiration; increased perspiration; facial flushing; facial tension; pupil dilation; anorexia; dry mouth; weakness; increased reflexes; twitching
Physiological-Parasympathetic
Decreased pulse; decreased blood pressure; abdominal pain; nausea; diarrhea; urinary urgency; urinary hesitancy; urinary frequency; tingling in extremities; fatigue; faintness; sleep disturbance
Cognitive
Blocking of thoughts; confusion; preoccupation; forgetfulness; rumination; impaired attention; decreased perceptual field; fear of nonspecific consequences; tendency to blame others; difficulty concentrating; diminished ability to problem solve; diminished learning ability; awareness of physiological symptoms

Related Factors: Unconscious conflict regarding essential values or life goals; threat to self-concept; threat of death; threat to or change in health status, environment, interaction patterns; situational or maturational crises; interpersonal transmission of contagion; unmet needs

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Anxiety Control
• Aggression Control
• Coping
• Impulse Control
Client Outcomes
• Identifies and verbalizes symptoms of anxiety
• Identifies, verbalizes, and demonstrates techniques to control anxiety
• Verbalizes absence of or decrease in subjective distress
• Has vital signs that reflect baseline or decreased sympathetic stimulation
• Has posture, facial expressions, gestures, and activity levels that reflect decreased distress
• Demonstrates improved concentration and accuracy of thoughts
• Identifies and verbalizes anxiety precipitants, conflicts, and threats
• Demonstrates return of basic problem-solving skills
• Demonstrates increased external focus
• Demonstrates some ability to reassure self
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Anxiety Reduction
Nursing Interventions and Rationales
• Assess client's level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonverbal expressions of anxiety). Validate observations by asking client, "Are you feeling anxious now?" Anxiety is a highly individualized, normal physical and psychological response to internal or external life events (Badger, 1994).
• Use presence, touch (with permission), verbalization, and demeanor to remind clients that they are not alone and to encourage expression or clarification of needs, concerns, unknowns, and questions. Being supportive and approachable encourages communication (Olson, Sneed, 1995).
• Accept client's defenses; do not confront, argue, or debate. If defenses are not threatened, the client may feel safe enough to look at behavior (Rose, Conn, Rodeman, 1994).
• Allow and reinforce client's personal reaction to or expression of pain, discomfort, or threats to well-being (e.g., talking, crying, walking, other physical or nonverbal expressions). Talking or otherwise expressing feelings sometimes reduces anxiety (Johnson, 1972).
• Help client identify precipitants of anxiety that may indicate interventions. Gaining insight enables the client to reevaluate the threat or identify new ways to deal with it (Damrosch, 1991).
• If the situational response is rational, use empathy to encourage client to interpret the anxiety symptoms as normal. Anxiety is a normal response to actual or perceived danger (Peplau, 1963).
• If irrational thoughts or fears are present, offer client accurate information and encourage him or her to talk about the meaning of the events contributing to the anxiety. This study shows that during diagnosis and management of cancer, highlighting the importance of the meaning of events to an individual is an important factor in making people anxious. Acknowledgment of this meaning may help to reduce anxiety (Stark, House, 2000).
• Encourage the client to use positive self-talk such as "Anxiety won't kill me," "I can do this one step at a time," "Right now I need to breathe and stretch," "I don't have to be perfect." Cognitive therapies focus on changing behaviors and feelings by changing thoughts. Replacing negative self-statements with positive self-statements helps to decrease anxiety (Fishel, 1998).
• Avoid excessive reassurance; this may reinforce undue worry. Reassurance is not helpful for the anxious individual (Garvin, Huston, Baker, 1992).
• Intervene when possible to remove sources of anxiety. Anxiety is a normal response to actual or perceived danger; if the threat is removed, the response will stop.
• Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate client's understanding. With preadmission patient education, patients experience less anxiety and emotional distress and have increased coping skills because they know what to expect (Review, 2000). Uncertainty and lack of predictability contribute to anxiety (Garvin, Huston, Baker, 1992).
• Explore coping skills previously used by client to relieve anxiety; reinforce these skills and explore other outlets. Methods of coping with anxiety that have been successful in the past are likely to be helpful again. Listening to clients and helping them to sort through their fears and expectations encourages them to take charge of their lives (Fishel, 1998).
• Provide backrubs for clients to decrease anxiety. In one study the dependent variable, anxiety, was measured prior to back massage, immediately following, and 10 minutes later on four consecutive evenings. There was a statistically significant difference in the mean anxiety (STAI) score between the back massage group and the no intervention group (Fraser, Kerr, 1993). In a discussion of the results of a systematic review of 22 articles examining the effect of massage on relaxation, comfort, and sleep, the most consistent effect of massage was reduction in anxiety. Out of 10 original research studies, 8 reported that massage significantly decreased anxiety or perception of tension (Richards, Gibson, Overton-McCoy, 2000).
• Provide massage before procedures to decrease anxiety. In one study parents performed massage on their hospitalized preschoolers and school-age children before venous puncture. The results obtained indicate that massage had a significant effect on nonverbal reactions, especially those related to muscular relaxation (Garcia, Horta, Farias, 1997).
• Use therapeutic touch and healing touch techniques. Various techniques that involve intention to heal, laying on of hands, clearing the energy field surrounding the body, and transfer of healing energy from the environment through the healer to the subject can reduce anxiety (Fishel, 1998). In a recent study, anxiety was significantly reduced in a therapeutic touch placebo condition. Healing touch may be one of the most useful nursing interventions available to reduce anxiety (Gagne and Toye in Fishel, 1998).
• Provide clients with a means to listen to music of their choice. Provide a quiet place and encourage clients to listen for 20 minutes. Music is a simple, inexpensive, esthetically pleasing means of alleviating anxiety. When allowed to participate in decision-making regarding their care, patients can regain a partial sense of control. As patient advocates, nurses should take advantage of the therapeutic effect of music by incorporating it into their plan of care (Evans, Rubio, 1994). Immediately and 1 hour after listening to music for 20 minutes in a quiet environment, reductions in heart rate, respiratory rate, and myocardial oxygen demand were significantly greater in the experimental group of patients with myocardial infarction than in the control group (White, 1999).
• For the client experiencing preoperative anxiety, provide music of their choice for listening. A study indicates that music combined with preoperative instruction can be more beneficial than preoperative instruction alone for reducing the anxiety of ambulatory surgery patients. Patients who listened to their choice of music before surgery in addition to receiving preoperative instruction had significantly lower heart rates than patients in the control group who received only preoperative instruction (Augustin, Hains, 1996).
• Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients. A study of perioperative clients has shown that interacting with animals reduces blood pressure and cholesterol, decreases anxiety, and improves a person's sense of well-being ( Miller, Ingram, 2000).
• Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety. Withdrawal from these substances is characterized by anxiety (Badger, 1994).
• Identify and limit, discontinue, or be aware of the use of any stimulants such as caffeine, nicotine, theophylline, terbutaline sulfate, amphetamines, and cocaine. Many substances cause or potentiate anxiety symptoms.
Geriatric
• Monitor client for depression. Use appropriate interventions and referrals. Anxiety often accompanies or masks depression in elderly adults.
• Provide a protective and safe environment. Use consistent caregivers and maintain the accustomed environmental structure. Elderly clients tend to have more perceptual impairments and adapt to changes with more difficulty than younger clients, especially during illness (Halm, Alpen, 1993).
• Observe for adverse changes if antianxiety drugs are taken. Age renders clients more sensitive to both the clinical and toxic effects of many agents.
• Provide a quiet environment with diversion. Excessive noise increases anxiety; involvement in a quiet activity can be soothing to the elderly.
Multicultural
• Assess for the presence of culture-bound anxiety states. The context in which anxiety is experienced, its meaning, and responses to it are culturally mediated. The following culture-bound syndromes are related to anxiety: Susto-Latin America, Nervios-Latin America, Dhat-Asia, Koro-Southeast Asia, Kayak angst-Eskimo, Taijin kyousho-Japan, Nervous breakdown-African Americans (Kavanagh, 1999; Charron, 1998).
• Assess for the influence of cultural beliefs, norms, and values on the client's perspective of a stressful situation. What the client considers stressful may be based on cultural perceptions (Leininger, 1996).
• In the culturally diverse client identify how anxiety is manifested. Anxiety is manifested differently from culture to culture through cognitive to somatic symptoms (Charron, 1998).
• Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety. Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998).
Client/Family Teaching
• Teach client and family the symptoms of anxiety. If client and family can identify anxious responses, they can intervene earlier than otherwise (Reider, 1994). Information is empowering and reduces anxiety (Fishel, 1998).
• Because intensive care unit (ICU) stays are increasingly shorter, provide written teaching information that is readily available to clients when they are transferred out. Time constraints have become a barrier to effective teaching. A pamphlet (available in Spanish and English) has been developed to ease the move for patients, families, and critical care and medical nurses from a medical ICU (MICU) to a general floor. Reading this pamphlet has helped to reduce symptoms of anxiety (Maillet, Pata, Grossman, 1993).
• Help client to define anxiety levels (from "easily tolerated" to "intolerable") and select appropriate interventions. Mild anxiety enhances learning and adaptation, but moderate to severe anxiety may impede or immobilize progress (Peplau, 1963).
• Consider referral for the prescription of antianxiety medications for clients who have panic disorder (PD) associated with anxiety. PD may be treated with drugs, psychosocial intervention, or both. In a recent study, the combination of imipramine and cognitive-behavioral therapy appeared to confer limited advantage acutely but more substantial advantage by the end of maintenance (Barlow et al, 2000).
• Teach client techniques to self-manage anxiety. Mental health interventions during hospitalization should emphasize teaching patients to manage their own anxiety instead of directly intervening to reduce current levels of anxiety (Rose, Conn, Rodeman, 1994).
• Teach client to identify and use distraction or diversion tactics when possible. Early interruption of the anxious response prevents escalation.
• Teach client to allow anxious thoughts and feelings to be present until they dissipate. Allowing and even devoting time and energy to a thought, purposefully and repetitively, reduces associated anxiety (Beck, Emery, 1985).
• Teach progressive muscle relaxation techniques. In one study, a significant reduction in anxiety level was obtained by using progressive muscle relaxation interventions (Weber, 1996).
• Teach relaxation breathing for occasional use: client should breathe in through nose, fill slowly from abdomen upward while thinking "re," and then breathe out through mouth, from chest downward, and think "lax." Anxiety management training effectively treats both specific and generalized anxiety (Fishel, 1998).
• Teach client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of procedure. Use of guided imagery has been useful for reducing anxiety (Weber, 1996).
• Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude. Health and well-being are influenced by how well-defined and met needs are in areas of safety, diet, exercise, sleep, work, pleasure, and social belonging. Exercise is an excellent means of decreasing anxiety (Fishel, 1998). Results of cross-sectional and longitudinal studies seem to indicate that aerobic exercise training has antidepressant and anxiolytic effects and protects against harmful consequences of stress (Salmon, 2000).
• Teach use of appropriate community resources in emergency situations (e.g., suicidal thoughts), such as hotlines, emergency rooms, law enforcement, and judicial systems. The method of suicide prevention found to be most effective is a systematic, direct-screening procedure that has a high potential for institutionalization (Shaffer, Craft, 1999).
• Encourage use of appropriate community resources: family, friends, neighbors, self-help and support groups, volunteer agencies, churches, clubs and centers for recreation, and other persons with similar interests. One of the most reassuring elements of care includes access to the family (Fishel, 1998). Vicarious experience provided through dyadic support is effective in helping patients undergoing cardiac surgery to cope with surgical anxiety and in improving self-efficacy expectations and self-reported activity after surgery (Parent, Fortin, 2000).
• Provide family members with information to help them to distinguish between a panic attack and serious physical illness symptoms. Instruct family members to consult a health care professional if they have questions. Education on managing anxiety disorders must include family members because they are the ones usually called upon to take the client for emergency care. Family members can be expert informants because of their familiarity with the client's history and symptoms (Fishel, 1998).

Nursing Care Plans For Deficient Knowledge

2009-02-16T04:53:00.000-08:00

Nursing Diagnosis: Deficient Knowledge

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

Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors: Lack of exposure; lack of recall; information misinterpretation; cognitive limitation; lack of interest in learning; unfamiliarity with information resources

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Knowledge of: Diet
• Disease Process
• Energy Conservation
• Health Behaviors
• Health Resources
• Infection Control
• Medication
• Personal Safety
• Prescribed Activity
• Substance Use Control
• Treatment Procedure(s)
• Treatment Regimen

Client Outcomes
• Explains disease state, recognizes need for medications, understands treatments
• Explains how to incorporate new health regimen into lifestyle
• States an ability to deal with health situation and remain in control of life
• Demonstrates how to perform procedure(s) satisfactorily
• Lists resources that can be used for more information or support after discharge

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Teaching: Disease Process
• Teaching: Individual
• Teaching: Infant Care
Nursing Interventions and Rationales
• Observe client's ability and readiness to learn (e.g., mental acuity, ability to see or hear, no existing pain, emotional readiness, absence of language or cultural barriers). Education in self-care must take into account physical, sensory, mobility, sexual, and psychosocial changes related to age (Bohny, 1997).
• Assess barriers to learning (e.g., perceived change in lifestyle, financial concerns, cultural patterns, lack of acceptance by peers or coworkers). The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences (Bohny, 1997).
• Determine client's previous knowledge of or skills related to his or her diagnosis and the influence on willingness to learn. New information is assimilated into previous assumptions and facts and may involve negotiating, transforming, or stalling.
• Involve clients in writing specific outcomes for the teaching session, such as identifying what is most important to learn from their viewpoint and lifestyle. Objectives put the content into focus, provide a forum for evaluation outcomes, and ensure continuity. Client involvement improves compliance with health regimen and makes teaching and learning a partnership.
• When teaching, build on client's literacy skills. In patients with low literacy skills, materials should be short and have culturally sensitive illustrations (Mayeaux et al, 1996). The National Adult Literacy Survey reported that 44 million Americans could not read or write well enough to meet the needs of everyday living and working (Quirk, 2000).
• Present material that is most significant to client first, such as how to give injections or change dressings; present additional material once client's most pressing educational needs have been met. Information building begins with explaining simple concepts and moves on to explanations of complex application situations.
• Determine client's understanding of common medical terminology, such as "empty stomach," "emesis," and "palpation." Clients are expected to read and understand labels on medicine containers, appointment slips, and informed consents, yet an estimated 40 million adults are functionally illiterate (Williams et al, 1995).
• Evaluate the readability of the material in pamphlets or written instructions. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability and comprehension of instruction, poor communication, and increased physical limitations (Hayes, 1998).
• Use visual aids such as diagrams, pictures, videotapes, audiotapes, and interactive Internet web sites. Verbal reinforcement of personalized, written instructions appears to be the best tested intervention. Computer-generated, personalized instructions improved adherence when compared with handwritten instructions (Hayes, 1998). This evidence-based study suggested leaflets as a useful resource for information provision (Kubba, 2000).
• Provide preadmission self-instruction materials to prepare client for postoperative exercises. Providing clients with preadmission information about exercises has been shown to increase positive feelings and the ability to perform prescribed exercises (Rice et al, 1992).
• Identify the primary family support person; be aware of that person's ability to learn and incorporate needed changes.
• Assess willingness of family to incorporate new information, immunizations, medical/dental care, and diet/behavior modifications in support of the client. Attention needs to be directed at family adjustment factors. For example, women recovering from alcohol abuse are at risk for relapse if their spouse continues to drink alcohol (Murphy, 1993), and modification of eating patterns plus social and partnership support have had more success than modification alone (Keller et al, 1997).
• Help client identify community resources for continuing information and support. Learning occurs through imitation, so persons who are currently involved in lifestyle changes can help the client anticipate adjustment issues. Community resources can offer financial and educational support. For example, role modeling and skill training have been used to monitor symptoms and solve asthma problems (Bartholomew et al, 2000).
• Evaluate client's learning through return demonstrations, verbalizations, or the application of skills to new situations. Presenting information along with with examples of how to apply the information has been found more successful than providing information alone in a home care setting (Duffy, 1997).
Geriatric
• Adapt the teaching process for the physical constraints of the aging process (e.g., speak clearly, use a variety of audio-visual-psychomotor methods, provide examples, and allow time for client to repeat and review). Adults are capable of learning at any age. Age modifies but does not inhibit learning (Dellasega et al, 1994). Older adults need practice to use new technology (Westerman, Davies, 2000).
• Ensure that the client uses necessary reading aids (e.g., glasses, magnifying lenses, large-print text) or hearing aids. Visual and hearing deficits require amplification or clarification of sensory input.
• Use printed material, videotapes, lists, diagrams, and Internet addresses that the client can refer to at another time. These methods provide a reference that can be used in a less stressful setting, decreasing barriers to learning. This study demonstrated the effectiveness of printed material and a web-based format for education. The web-based format demonstrated two additional benefits when compared with printed material: increased social support and decreased anxiety (Scherrer et al, 2000).
• Assess client's previous knowledge and resistance or blocks to incorporating new information into the current lifestyle. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences (Bohny, 1997).
• Repeat and reinforce information during several brief sessions. Understanding past information is essential to acquiring new knowledge. Brief sessions focus attention on essential information.
• Discuss healthy lifestyle changes that promote wellness for the older adult. It is never too late to stop smoking, lose weight, or modify dietary intake of fats and alcohol. Quality vs. quantity of life may be the key issue in teaching self-care health habits (Walker, 1992).
• Evaluate readability of the material. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability, comprehension of instruction, poor communication, and increased physical limitations (Hayes, 1998).
• Consider health education programs using television and newspapers. There was a significant increase in stroke knowledge (52% more likely to know a risk factor and 35% know a symptom, p = 0.032) following this health education program as demonstrated through a telephone pretest and posttest (Becker et al, 2001).

Multicultural
• Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D'Avanzo et al, 2001).
• Assess for the influence of cultural beliefs, norms, and values on the client's knowledge base. The client's knowledge base may be influenced by cultural perceptions (Leininger, 1996).
• Use a neutral indirect style when addressing areas where improvement is needed when working with Native American clients. Using indirect statements such as "I had a client who tried 'X' and it seemed to work very well" will help avoid resentment from the client (Seiderman et al, 1996).
• Validate the client's feelings and concerns related to previous learning experiences. Validation lets the client know the nurse has heard and understands what was said. (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
• Approach individuals of color with respect, warmth, and professional courtesy. Instances of disrespect and lack of caring have special significance for individuals of color (D'Avanzo et al, 2001).

Home Care Interventions
• NOTE: Because home care is an intermittent model of care having a goal of safety and optimal wellness of the client between visits, the importance of teaching (by nurse) and learning (by client) should not be understated. All of the previously mentioned interventions are applicable to the home setting.
• Select a space and time for teaching in which client and/or caregiver can focus on information to be learned. The home setting provides many distractions that may impair the ability of the client to learn.
• Consider the complexity of material or behaviors to be learned. Adjust care plan and respective teaching and learning experiences accordingly to build client confidence in ability to learn (and change). Confidence in ability to learn and change is part of readiness to learn.
• Assess for specific areas of learning that have the potential for strong emotional responses by the client or family/caregiver. Allow time for expression of feelings and encourage acceptance of need for learning. An individual's perception of barriers and benefits has consistently been most predictive of subsequent behavior. Clinicians should develop interventions that increase benefits and decrease barriers (Fenn, 1998).
• Document client's and caregivers' responses to learning. Clear documentation supports continuity in the learning experience

Nursing Care Plans For Excess Fluid volume

2009-02-13T05:55:00.000-08:00

Nursing Diagnosis: Excess Fluid volume

NANDA Definition: Increased isotonic fluid retention

Defining Characteristics: Jugular vein distention; decreased hemoglobin and hematocrit; weight gain over short period; changes in respiratory pattern, dyspnea or shortness of breath; orthopnea; abnormal breath sounds (rales or crackles); pulmonary congestion; pleural effusion; intake exceeds output; S3 heart sound; change in mental status; restlessness; anxiety; blood pressure changes; pulmonary artery pressure changes; increased central venous pressure; oliguria; azotemia; specific gravity changes; altered electrolytes; edema, may progress to anascara; positive hepatojugular reflex

Related Factors: Compromised regulatory mechanism; excess fluid intake; excess sodium intake

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Electrolyte and Acid-Base Balance
• Fluid Balance
• Hydration
Client Outcomes
• Remains free of edema, effusion, anascara; weight appropriate for client
• Maintains clear lung sounds; no evidence of dyspnea or orthopnea
• Remains free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm
• Maintains normal central venous pressure, pulmonary capillary wedge pressure, cardiac output, and vital signs
• Maintains urine output within 500 ml of intake and normal urine osmolality and specific gravity
• Remains free of restlessness, anxiety, or confusion
• Explains measures that can be taken to treat or prevent excess fluid volume, especially fluid and dietary restrictions and medications
• Describes symptoms that indicate the need to consult with health care provider
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Fluid Management
• Fluid Monitoring
Nursing Interventions and Rationales
• Monitor location and extent of edema; use a millimeter tape in the same area at the same time each day to measure edema in extremities. Heart failure and renal failure are usually associated with dependent edema because of increased hydrostatic pressure; dependent edema will cause swelling in the legs and feet of ambulatory clients and the presacral region of clients on bed rest. Dependent edema was found to demonstrate the greatest sensitivity as a defining characteristic for excess fluid volume (Rios et al, 1991). Generalized edema (e.g., in the upper extremities and eyelids) is associated with decreased oncotic pressure as a result of nephrotic syndrome. Measuring the extremity with a millimeter tape is more accurate than using the 1 to 4 scale (Metheny, 2000).
• Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast. Body weight changes reflect changes in body fluid volume. Clinically it is extremely important to get an accurate body weight of a client with fluid imbalance (Metheny, 2000).
• Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. Pulmonary edema results from excessive shifting of fluid from the vascular space into the pulmonary interstitial space and alveoli. Pulmonary edema can interfere with the oxygen-carbon dioxide exchange at the alveolar-capillary membrane (Metheny, 2000), resulting in dyspnea and orthopnea.
• With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in the upright position; assess for positive hepatojugular reflex. Increased intravascular volume results in jugular vein distention, even in a client in the upright position, and also a positive hepatojugular reflex.
• Monitor central venous pressure, mean arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output; note and report trends indicating increasing pressures over time. Increased vascular volume with decreased cardiac contractility increases intravascular pressures, which are reflected in hemodynamic parameters. Over time, this increased pressure can result in uncompensated heart failure.
• Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea. Monitor for gallop rhythms. If signs of heart failure are present, see nursing care plan for Decreased Cardiac output. Heart failure results in decreased cardiac output and decreased blood pressure. Tissue hypoxia stimulates increased heart and respiratory rates.
• Monitor serum osmolality, serum sodium, blood urea nitrogen (BUN)/creatinine ratio, and hematocrit for decreases. These are all measures of concentration and will decrease (except in the presence of renal failure) with increased intravascular volume. In clients with renal failure the BUN will increase because of decreased renal excretion.
• Monitor intake and output; note trends reflecting decreasing urine output in relation to fluid intake. Accurately measuring intake and output is very important for the client with fluid volume overload.
• Monitor client's behavior for restlessness, anxiety, or confusion; use safety precautions if symptoms are present. When excess fluid volume compromises cardiac output, the client will experience tissue hypoxia. Cerebral tissue is extremely sensitive to hypoxia, and the client may demonstrate restlessness and anxiety before any physiological alterations occur. When the excess fluid volume results in hyponatremia, the cerebral function will also be altered because of cerebral edema (Fauci et al, 1998).
• Monitor for the development of conditions that increase the client's risk for excess fluid volume. Common causes are heart failure, renal failure, and liver failure, all of which result in decreased glomerular filtration rate and fluid retention. Other causes are increased intake of oral or IV fluids in excess of the client's cardiac and renal reserve levels, increased levels of antidiuretic hormone, or movement of fluid from the interstitial space to the intravascular space (Fauci et al, 1998). Early detection allows the institution of specific treatment measures before the client develops pulmonary edema.
• Provide a restricted-sodium diet as appropriate if ordered. Restricting the sodium in the diet will favor the renal excretion of excess fluid. Take care to avoid hyponatremia. Decreasing sodium can be more important that restricting fluid intake (Fauci et al, 1998).
• Monitor serum albumin level and provide protein intake as appropriate. Serum albumin is the main contributor to serum oncotic pressure, which favors the movement of fluid from the interstitial space into the intravascular space. When serum albumin is low, peripheral edema may be severe.
• Administer prescribed loop, thiazide, and/or potassium-sparing diuretics as appropriate; these may be given intravenously or orally. Therapeutic responses to diuretic therapy include natriuresis, diuresis, elimination of edema, vasodilation, reduction of cardiac filling pressures, decreased renal vasculature resistance, and increased renal blood flow (Cody, Kubo, Pickworth, 1994; DePriest, 1997).
• Monitor for side effects of diuretic therapy: orthostatic hypotension (especially if client is also receiving angiotensin-converting enzyme [ACE] inhibitors) and electrolyte and metabolic imbalances (hyponatremia, hypocalcemia, hypomagnesemia, hyperuricemia, and metabolic alkalosis). In clients receiving loop or thiazide diuretics, observe for hypokalemia. Observe for hyperkalemia in clients receiving a potassium-sparing diuretic, especially with the concurrent administration of an ACE inhibitor. The blood pressure reduction in response to ACE inhibitors is greater in the presence of sodium depletion and diuretic therapy. The incidence of electrolyte and metabolic imbalances ranges from 14% to 60%; the most common is hypokalemia (Cody, Kubo, Pickworth, 1994).
• Implement fluid restriction as ordered, especially when serum sodium is low; include all routes of intake. Schedule fluids around the clock, and include the type of fluids preferred by the client. Fluid restriction may decrease intravascular volume and myocardial workload. Overzealous fluid restriction should not be used because hypovolemia can worsen heart failure. In one study, instituting fluid restriction, distributing fluids over a 24-hour period, and using a fluid restriction when the client had hyponatremia all had high intervention content validity scores for the fluid management intervention label (Cullen, 1992). Client involvement in planning will enhance participation in the necessary fluid restriction.
• Maintain the rate of all IV infusions carefully. This is done to prevent inadvertant exacerbation of excess fluid volume.
• Turn clients with dependent edema frequently (i.e., at least every 2 hours). Edematous tissue is vulnerable to ischemia and pressure ulcers (Cullen, 1992).
• Provide for scheduled rest periods. Bed rest can induce diuresis related to diminished peripheral venous pooling, resulting in increased intravascular volume and glomerular filtration rate (Metheny, 2000).
• Promote a positive body image and good self-esteem. Visible edema may alter the client's body image (Cullen, 1992). See the care plan for Disturbed Body image.
• Consult with physician if signs and symptoms of excess fluid volume persist or worsen. Because excess fluid volume can result in pulmonary edema, it must be treated promptly and aggressively (Fauci et al, 1998).
Geriatric

• Recognize that the presence of risk factors for excess fluid volume is particularly serious in the elderly. Decreased cardiac output and stroke volume are normal aging changes that increase the risk for excess fluid volume (Metheny, 2000).
Home Care Interventions
• Assess client and family knowledge of disease process causing excess fluid volume. Teach about disease process and complications of excess fluid volume, including when to contact physician. Knowledge of disease and complications promotes early detection of and intervention for pending problems.
• Assess client and family knowledge and compliance with medical regimen, including medications, diet, rest, and exercise. Assist family with integrating restrictions into daily living. Knowledge promotes compliance. Assistance with integration of cultural values, especially those related to foods, with medical regimen promotes compliance and decreased risk of complications.
• If client is confined to bed rest or has difficulty reclining, follow previously mentioned positioning recommendations.
• Teach and reinforce knowledge of medications. Instruct client not to use over-the-counter medications (e.g., diet medications) without first consulting the physician. Instruct client to make primary physician aware of medications ordered by other physicians. There is potential for undesirable interaction among multiple medications, especially when use of over-the-counter and other prescribed medications is not monitored.
• Identify emergency plan for rapidly developing or critical levels of excess fluid volume when diuresing is not safe at home. When out of control, excess fluid volume can be life threatening.
• Teach about signs and symptoms of both excess and deficient fluid volume and when to call physician. Fluid volume balance can change rapidly with aggressive treatment.
Client/Family Teaching
• Describe signs and symptoms of excess fluid volume and actions to take if they occur. Teach the importance of fluid and sodium restrictions. Help client and family to devise a schedule for intake of fluids throughout entire day. Refer to dietitian concerning implementation of low-sodium diet.
• Teach how to take diuretics correctly: take one dose in the morning and second dose (if taken) no later than 4 PM. Adjust potassium intake as appropriate for potassium-losing or potassium-sparing diuretics. Note the appearance of side effects such as weakness, dizziness, muscle cramps, numbness and tingling, confusion, hearing impairment, palpitations or irregular heartbeat, and postural hypotension. Emphasise the need to consult with health care provider before taking over-the-counter medications (Byers, Goshorn, 1995; Dunbar, Jacobson, Deaton, 1998).

Nursing Care Plans For Acute Pain

2009-02-13T05:46:00.000-08:00

Nursing Diagnosis: Acute Pain

NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of <6 months (NANDA)Defining Characteristics: Subjective Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999). Objective Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.Related Factors: Actual or potential tissue damage (mechanical [e.g., incision or tumor growth], thermal [e.g., burn], or chemical [e.g., toxic substance]) NOC Outcomes (Nursing Outcomes ClassificationSuggested NOC Labels • Pain Level, Pain Control, Comfort Level • Pain: Disruptive Effects Client Outcomes • Uses a pain rating scale to identify current level of pain intensity and determines a comfort/function goal (if client has cognitive abilities) • Describes how unrelieved pain will be managed • Reports that the pain management regimen relieves pain to a satisfactory level with acceptable or manageable side effects • Performs activities of recovery with a reported acceptable level of pain (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team) • States an ability to obtain sufficient amounts of rest and sleep • Describes a nonpharmacological method that can be used to control pain NIC Interventions (Nursing Interventions Classification)Suggested NIC Labels • Conscious Sedation • Patient-Controlled Analgesia (PCA) Assistance Nursing Interventions and Rationales• Determine whether client is experiencing pain at the time of the initial interview. If so, intervene at that time to provide pain relief. The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000). • Ask client to describe past experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects, typical coping responses, and how he or she expresss pain. A number of concerns (barriers) may affect patients' willingness to report pain and use analgesics (Ward et al, 1993). • Describe adverse effects of unrelieved pain. Numerous pathophysiological and psychological morbidity factors may be associated with pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994). • Tell client to report location, intensity (using a pain rating scale), and quality when experiencing pain. The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000). • Determine client's current medication use. To aid in planning pain treatment, obtain a medication history (Acute Pain Management Guideline Panel, 1992). • Explore the need for both opioid (narcotic) and non-opioid analgesics. Pharmacological interventions are the cornerstone of pain management (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999). • Obtain a prescription to administer a non-opioid (acetaminophen, Cox-2 inhibitor, or a nonsteroidal antiinflammatory drug [NSAID]), unless contraindicated, around the clock (ATC). NSAIDs act mainly in the periphery to inhibit the initiation of pain impulses (Dahl, Kehlet, 1991). Unless contraindicated, all patients with acute pain should receive a non-opioid ATC (Acute Pain Management Guideline Panel, 1992). The analgesic regimen should include a non-opioid, even if pain is severe enough to require the addition of an opioid (Jacox et al, 1994; McCaffery, Pasero, 1999). • Obtain a prescription to administer opioid analgesia if indicated, especially for severe pain. Opioid analgesics are indicated for the treatment of moderate to severe pain (Jacox et al, 1994; McCaffery, Pasero, 1999). • Administer opioids orally or intravenously, not intramuscularly. Use a preventive approach to keep pain at or below an acceptable level. Provide PCA and intraspinal routes of administration when appropriate and available. The least invasive route of administration capable of providing adequate pain control is recommended. The intramuscular (IM) route is avoided because of unreliable absorption, pain, and inconvenience. The intravenous (IV) route is preferred for rapid control of severe pain. For ongoing pain, give analgesia ATC. PRN dosing is appropriate for intermittent pain (Jacox et al, 1994; McCaffery, Pasero, 1999). • Discuss client's fears of undertreated pain, overdose, and addiction. A number of concerns may affect clients' willingness to report pain and use opioid analgesics (Ward et al, 1993). Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (Jacox et al, 1994; McCaffery, Pasero, 1999). Addiction is extremely unlikely after patients use opioids for acute pain (Acute Pain Management Guideline Panel, 1992). • When opioids are administered, assess pain intensity, sedation, and respiratory status at regular intervals. Opioids may cause respiratory depression because they reduce the responsiveness of carbon dioxide chemoreceptors located in the respiratory centers of the brain. Because even more opioid is required to produce respiratory depression than is required to produce sedation, patients with clinically significant respiratory depression are usually also sedated. Respiratory depression can be prevented by assessing sedation and decreasing the opioid dose when the patient is arousable but has difficulty staying awake (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994). • Review client's flow sheet and medication records to determine overall degree of pain relief, side effects, and analgesic requirements during the past 24 hours. Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000). • Administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level. A PRN order for supplementary opioid doses between regular doses is an essential backup (American Pain Society, 1999). • Obtain prescriptions to increase or decrease opioid doses as needed; base prescriptions on client's report of pain severity and response to the previous dose in terms of relief, side effects, and ability to perform the activities of recovery. Increase or decrease the dose of opioid based on assessment of the patient's response. Patients' responses, and therefore their requirements, vary widely, so it is less important to focus on the amount given than on the response (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994). • When client is able to tolerate oral analgesics, obtain a prescription to change to the oral route; use an equianalgesic chart to determine initial dose. (See Appendix E for an equianalgesic chart.) The oral route is preferred because it is the most convenient and cost-effective (Jacox et al, 1994). Use of equianalgesic doses when switching from one opioid or route of administration to another will help to prevent loss of pain control from underdosing and side effects from overdosing (McCaffery, Pasero, 1999). • In addition to use of analgesics, support client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore the clients' sense of self-control, personal efficacy, and active participation in own care (Jacox et al, 1994). • Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Acute Pain Management Guideline Panel, 1992). • Plan care activities around periods of greatest comfort whenever possible. Pain diminishes activity (Jacox et al, 1994; McCaffery, Pasero, 1999). • Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation. Because there is great individual variation in the development of opioid-induced side effects, these side effects should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999). Geriatric • Always take the elderly client's reports of pain seriously and ensure that the pain is relieved. In spite of what many professionals and clients believe, pain is not an expected part of normal aging (McCaffery, Pasero, 1999). • When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale (use enlarged scale) and written materials. • Handle client's body gently. Allow client to move at own speed. • Use acetaminophen and NSAIDs with low side-effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid), and watch for side effects, such as GI disturbances and bleeding problems. Elderly people are at increased risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute Pain Management Guideline Panel, 1992). • Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium). The higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation (American Pain Society, 1999; Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999). • Use opioids with caution in the elderly client. The elderly are more sensitive to the analgesic effects of opioid drugs because they experience a higher peak effect and a longer duration of pain relief. Reduce the initial recommended adult starting opioid dose by 25% to 50%, especially if the client is frail and debilitated; then increase the dose if safe and necessary (Acute Pain Management Guideline Panel, 1992). • Avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet), in elderly clients. Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999). Multicultural • Assess pain in a culturally diverse client using a self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain rating scale. Have scale translated into client's native language if necessary.. Inadequate pain management is widespread, especially among minority groups, and a major reason is the failure to assess pain properly. The more cultural differences between patient and nurse, the more difficult it is for the nurse to assess and treat pain. Self-report of pain is the single most reliable indicator of pain, regardless of culture (McCaffery, 1999; McCaffery, Pasero, 1999). • Administer analgesics on a preventive basis to keep pain ratings at or below an acceptable level. Regardless of the patient's cultural background, pain rated at (4 on a 0 to 10 pain rating scale interferes significantly with daily function. Perceived quality of life appears to be comparable across cultures, with pain ratings of >6 interfering markedly with a person's ability to enjoy life (McCaffery, 1999; McCaffery, Pasero, 1999).
• Assess for the influence of cultural beliefs, norms, and values on the client's perception and experience of pain. The client's experience of pain may be based on cultural perceptions (Leininger, 1996).
• Assess for the role of fatalism on the client's beliefs regarding their current state of comfort. Fatalistic perspectives in some African-American and Latino populations involve the belief that you cannot control your own fate and influence your health behaviors (Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).
• Incorporate folk health care practices and beliefs into care whenever possible. Incorporating folk health care beliefs and practices into pain management care increased compliance with the treatment plan (Juarez, Ferrell, Borneman, 1998).
• Use a family-centered approach when working with Latino, Asian American, African-American, and Native American clients. Involving family in pain management care increased compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).
• Use culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the client. Culturally diverse clients may express pain differently than clients from the majority culture. The Oucher scale has African-American and Hispanic versions and is used to assess pain in children (Beyer, Denyes, Villarruel, 1992).
• Ensure that directions for medications are available in the client's language of choice and are understood by client and caregiver. Bilingual instructions for medications increased compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).
• Validate the client's feelings and emotions regarding current health status. Validation lets the client know the nurse has heard and understands what was said, and it promotes the nurse-client relationship. (Stuart, Laraia, 2001;Giger, Davidhizer, 1995).
Home Care Interventions
• Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary. Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management (Humphrey, 1994).
• Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval. Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated (Jacox et al, 1994).
• Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased). The cognitive effects of opioids usually subside within a week of initial dosing or dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment (Sjogren et al, 2000).
• If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration. Some routes of medication administration require special conditions and procedures to be safe and accurate (McCaffery, Pasero, 1999).
• Assess knowledge base of client and family for highly technological medication administration. Teach as necessary. Be sure clients know when, how, and who to contact if analgesia is unsatisfactory. Appropriate instruction in the home increases the accuracy and safety of medication administration (McCaffery, Pasero, 1999).
Client/Family Teaching
• NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.
• Provide written materials on pain control such as the Agency for Health Care Policy and Research (AHCPR) pamphlet, Pain Control: Patient Guide.
• Discuss the various discomforts encompassed by the word pain, and ask client to give examples of previously experienced pain. Explain pain assessment process and purpose of the pain rating scale.
• Teach client to use the pain rating scale to rate intensity of past or current pain. Ask client to set a comfort/function goal by selecting a pain level on the rating scale that makes it easy to perform recovery activities (e.g., turn, cough, deep breathe). If pain is above this level, client should take action that decreases pain or notify a member of the health care team. (See Appendix E for information on teaching clients to use the pain rating scale.)
• Demonstrate medication administration and use of supplies and equipment. If PCA is ordered, determine client's ability to press appropriate button. Remind client and staff that the PCA button is for patient-only use.
• Reinforce importance of taking pain medications to keep pain under control.
• Reinforce that taking opioids for pain relief is not addiction and that addiction is very unlikely to occur.
• Demonstrate use of appropriate nonpharmacological approaches for controlling pain, such as heat, cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music, and television.

Free Nursing Care Plans Based On Nursing Diagnosis

2009-02-12T06:21:00.001-08:00

Nursing care plans based on nursing diagnosis

Nursing Diagnosis: Acute Pain
Nursing Diagnosis: Excess Fluid volume
Nursing Diagnosis: Deficient Knowledge
Nursing Diagnosis: Activity intolerance
Nursing Diagnosis: Anxiety
Nursing Diagnosis: Risk for Infection
Nursing Diagnosis: Ineffective Health maintenance
Nursing Diagnosis: Imbalanced Nutrition: less than body requirements
Nursing Diagnosis: Impaired Oral mucous membrane
Nursing Diagnosis: Activity intolerance
Nursing Diagnosis: Acute Confusion
Nursing Diagnosis: Acute Pain
Nursing Diagnosis: Adult Failure to thrive
Nursing Diagnosis: Anxiety
Nursing Diagnosis: Bathing/hygiene Self-care deficit
Nursing Diagnosis: Bowel incontinence
Nursing Diagnosis: Chronic Confusion
Nursing Diagnosis: Chronic Pain
Nursing Diagnosis: Constipation
Nursing Diagnosis: Decreased Cardiac output
Nursing Diagnosis: Deficient Fluid volume
Nursing Diagnosis: Deficient Knowledge
Nursing Diagnosis: Diarrhea
Nursing Diagnosis: Disturbed Body Image
Nursing Diagnosis: Disturbed Sensory perception specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory
Nursing Diagnosis: Disturbed Sleep pattern
Nursing Diagnosis: Dysfunctional Grieving
Nursing Diagnosis: Excess Fluid volume
Nursing Diagnosis: Fatigue
Nursing Diagnosis: Fear
Nursing Diagnosis: Feeding Self-care deficit
Nursing Diagnosis: Functional urinary Incontinence
Nursing Diagnosis: Hopelessness
Nursing Diagnosis: Impaired Comfort—pruritis
Nursing Diagnosis: Impaired Gas exchange
Nursing Diagnosis: Impaired Oral mucous membrane
Nursing Diagnosis: Impaired Parenting
Nursing Diagnosis: Impaired Physical Mobility
Nursing Diagnosis: Impaired Skin integrity
Nursing Diagnosis: Impaired Swallowing
Nursing Diagnosis: Impaired Tissue integrity
Nursing Diagnosis: Ineffective Airway clearance
Nursing Diagnosis: Ineffective Breastfeeding
Nursing Diagnosis: Ineffective Coping
Nursing Diagnosis: Ineffective Health maintenance
Nursing Diagnosis: Ineffective Therapeutic regimen management
Nursing Diagnosis: Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral
Nursing Diagnosis: Latex Allergy response
Nursing Diagnosis: Imbalanced Nutrition: more than body requirements
Nursing Diagnosis: Nausea
Nursing Diagnosis: Fear
Nursing Diagnosis: Imbalanced Nutrition: less than body requirements
Nursing Diagnosis: Risk for Aspiration
Nursing Diagnosis: Risk for Falls
Nursing Diagnosis: Risk for Infection
Nursing Diagnosis: Risk for Injury
Nursing Diagnosis: Risk for situational low Self-esteem
Nursing Diagnosis: Risk for Suicide
Nursing Diagnosis: Spiritual distress
Nursing Diagnosis: Total urinary Incontinence
Nursing Diagnosis: Urinary retention
Nursing Diagnosis: Wandering

List of complete all Nursing Diagnoses
Activity Intolerance
Activity Intolerance, Risk for
Airway Clearance, Ineffective
Anxiety
Anxiety, Death
Aspiration, Risk for
Attachment, Parent/Infant/Child, Risk for
Impaired
Autonomic Dysreflexia
Autonomic Dysreflexia, Risk for
Blood Glucose, Risk for Unstable
Body Image, Disturbed
Body Temperature: Imbalanced, Risk for
Bowel Incontinence
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Breathing Pattern, Ineffective
Cardiac Output, Decreased
Caregiver Role Strain
Caregiver Role Strain, Risk for
Comfort, Readiness for Enhanced
Communication: Impaired, Verbal
Communication, Readiness for Enhanced
Confusion, Acute
Confusion, Acute, Risk for
Confusion, Chronic
Constipation
Constipation, Perceived
Constipation, Risk for
Contamination
Contamination, Risk for
Coping: Community, Ineffective
Coping: Community, Readiness for Enhanced
Coping, Defensive
Coping: Family, Compromised
Coping: Family, Disabled
Coping: Family, Readiness for Enhanced
Coping (Individual), Readiness for Enhanced
Coping, Ineffective
Decisional Conflict
Decision Making, Readiness for Enhanced
Denial, Ineffective
Dentition, Impaired
Development: Delayed, Risk for
Diarrhea
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Energy Field, Disturbed
Environmental Interpretation Syndrome, Impaired
Failure to Thrive, Adult
Falls, Risk for
Family Processes, Dysfunctional: Alcoholism
Family Processes, Interrupted
Family Processes, Readiness for Enhanced
Fatigue
Fear
Fluid Balance, Readiness for Enhanced
Fluid Volume, Deficient
Fluid Volume, Deficient, Risk for
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Gas Exchange, Impaired
Grieving
Grieving, Complicated
Grieving, Risk for Complicated
Growth, Disproportionate, Risk for
Growth and Development, Delayed
Health Behavior, Risk-Prone
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Home Maintenance, Impaired
Hope, Readiness for Enhanced
Hopelessness
Human Dignity, Risk for Compromised
Hyperthermia
Hypothermia
Immunization Status, Readiness for Enhanced
Infant Behavior, Disorganized
Infant Behavior: Disorganized, Risk for
Infant Behavior: Organized, Readiness for
Enhanced
Infant Feeding Pattern, Ineffective
Infection, Risk for
Injury, Risk for
Insomnia
Intracranial Adaptive Capacity, Decreased
Knowledge, Deficient (Specify)
Knowledge (Specify), Readiness for Enhanced
Latex Allergy Response
Latex Allergy Response, Risk for
Liver Function, Impaired, Risk for
Loneliness, Risk for
Memory, Impaired
Mobility: Bed, Impaired
Mobility: Physical, Impaired
Mobility: Wheelchair, Impaired
Moral Distress
Nausea
Neurovascular Dysfunction: Peripheral, Risk for
Noncompliance (Specify)
Nutrition, Imbalanced: Less than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements, Risk for
Nutrition, Readiness for Enhanced
Oral Mucous Membrane, Impaired
Pain, Acute
Pain, Chronic
Parenting, Impaired
Parenting, Readiness for Enhanced
Parenting, Risk for Impaired
Perioperative Positioning Injury, Risk for
Personal Identity, Disturbed
Poisoning, Risk for
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
Power, Readiness for Enhanced
Powerlessness
Powerlessness, Risk for
Protection, Ineffective
Rape-Trauma Syndrome
Rape-Trauma Syndrome: Compound Reaction
Rape-Trauma Syndrome: Silent Reaction
Religiosity, Impaired
Religiosity, Readiness for Enhanced
Religiosity, Risk for Impaired
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Conflict, Parental
Role Performance, Ineffective
Sedentary Lifestyle
Self-Care, Readiness for Enhanced
Self-Care Deficit: Bathing/Hygiene
Self-Care Deficit: Dressing/Grooming
Self-Care Deficit: Feeding
Self-Care Deficit: Toileting
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Risk for Situational Low
Self-Mutilation
Self-Mutilation, Risk for
Sensory Perception, Disturbed (Specify: Auditory,
Gustatory, Kinesthetic, Olfactory Tactile,
Visual)
Sexual Dysfunction
Sexuality Pattern, Ineffective
Skin Integrity, Impaired
Skin Integrity, Risk for Impaired
Sleep Deprivation
Sleep, Readiness for Enhanced
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Spontaneous Ventilation, Impaired
Stress, Overload
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for
Suicide, Risk for
Surgical Recovery, Delayed
Swallowing, Impaired
Therapeutic Regimen Management: Community,
Ineffective
Therapeutic Regimen Management, Effective
Therapeutic Regimen Management: Family,
Ineffective
Therapeutic Regimen Management, Ineffective
Therapeutic Regimen Management, Readiness for
Enhanced
Thermoregulation, Ineffective
Thought Processes, Disturbed
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective (Specify: Cerebral, Cardiopulmonary, Gastrointestinal, Renal)
Tissue Perfusion, Ineffective, Peripheral
Transfer Ability, Impaired
Trauma, Risk for
Unilateral Neglect
Urinary Elimination, Impaired
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence, Functional
Urinary Incontinence, Overflow
Urinary Incontinence, Reflex
Urinary Incontinence, Stress
Urinary Incontinence, Total
Urinary Incontinence, Urge
Urinary Incontinence, Risk for Urge
Urinary Retention
Ventilatory Weaning Response, Dysfunctional
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
Walking, Impaired
Wandering

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Nursing Care Plans For Activity Intolerance

2009-02-12T03:25:00.000-08:00

Nursing Diagnosis: Activity intolerance

NANDA Definition:
Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Defining Characteristics:
Verbal report of fatigue or weakness, abnormal heart rate or blood pressure response to activity, exertional discomfort or dyspnea, electrocardiographic changes reflecting dysrhythmias or ischemia

Related Factors:
Bed rest or immobility; generalized weakness; sedentary lifestyle; imbalance between oxygen supply and demand

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Endurance
• Energy Conservation
• Activity Tolerance
• Self-Care: Activities of Daily Living (ADLs)

Client Outcomes
• Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate; maintains monitor patterns (rhythm and ST segment) within normal limits
• States symptoms of adverse effects of exercise and reports onset of symptoms immediately
• Maintains normal skin color and skin is warm and dry with activity
• Verbalizes an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms
• Expresses an understanding of the need to balance rest and activity
• Demonstrates increased activity tolerance

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Energy Management
• Activity Therapy

Nursing Interventions and Rationales
• Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a disease can help direct appropriate interventions.
• Assess client daily for appropriateness of activity and bed rest orders. Inappropriate prolonged bed rest orders may contribute to activity intolerance. A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).
• Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily. The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).
• If appropriate, gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation. Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998).
• Ensure that clients change position slowly. Consider using a chair-bed (stretcher-chair) for clients who cannot get out of bed. Monitor for symptoms of activity intolerance. Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993).
• When getting clients up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not define orthostatic intolerance (Winslow, Lane, Woods, 1995).
• Perform range-of-motion exercises if client is unable to tolerate activity. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994).
• Refer client to physical therapy to help increase activity levels and strength.
• Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (ACSM, 1995):
o Excessive fatigue
o Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency
o Onset of angina with exercise
o Palpitations
o Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced left bundle block, second- or third-degree atrioventricular block, frequent premature ventricular contractions)
o Exercise hypotension (drop in systolic blood pressure of more than 10 mm Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia)
o Excessive rise in blood pressure (systolic greater than 220 mm Hg or diastolic greater than 110 mm Hg); NOTE: these are upper limits; activity may be stopped before reaching these values
o Inappropriate bradycardia (drop in heart rate greater than 10 beats/min) with no change or increase in workload
o Increased heart rate above the prescribed limit
• Instruct client to stop activity immediately and report to physician if experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort, tightness, or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (McGoon, 1993). The client should be evaluated before resuming activity (Thompson, 1988).
• Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).
• Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998).
• Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing. The loss of functional ability that accompanies disease often leads to continence problems. The cause may not be the person's bladder instability but his or her ability to get to the toilet quickly (Nazarko, 1997).
• Assess for constipation. Impaired mobility is associated with increased risk of bowel dysfunction, including constipation. Constipation increases the risk of urinary tract infection and urge incontinence (Nazarko, 1997).
• Consider dietitian referral to assess nutritional needs related to activity intolerance. Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999).
• Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications. Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients with coronary heart disease and heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes (Wenger et al, 1995).
• Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity. Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993).
• Monitor a chronic obstructive pulmonary disease (COPD) client's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, and skin tone changes such as pallor and cyanosis.
• Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing. Training clients with COPD to slow their respiratory rate with a prolonged exhalation (with or without pursed lips) helps control dyspnea and results in improved ventilation, increased tidal volume, decreased respiratory rate, and a reduced alveolar-arterial oxygen difference. This breathing pattern not only helps relieve dyspnea but can improve the ability to exercise and carry out ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993).
• Provide emotional support and encouragement to client to gradually increase activity. Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
• Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994).
• Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
• Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can increase mobility by helping the client overcome limitations.
• Use a walking belt when ambulating a client who is unsteady. With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.
• Work with client to set mutual goals that increase activity levels.

Geriatric
• Slow the pace of care. Allow client extra time to carry out activities.
• Encourage families to help/allow elder to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary. Encouraging activity not only enhances good functioning of the body's systems but also promotes a sense of worth by providing an opportunity for productivity (Eliopoulous, 1997).
• When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting. Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991).

Home Care Interventions
• Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services.
• Assess the home environment for factors that precipitate decreased activity tolerance: presence of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive activity patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and activity of daily living patterns. Clients and families often estimate energy requirements inaccurately during hospitalization because of the availability of support.
• Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events).
• Provide client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity. Social isolation can contribute to activity intolerance.
• Discuss the importance of sexual activity as part of daily living. Instruct the client in adaptive techniques to conserve energy during sexual interactions. Families may make unsafe choices for sexual activity or place added stress on themselves trying to cope with this issue without proper support or teaching.
• Instruct the client and family in the importance of maintaining proper nutrition and rest for energy conservation and rehabilitation.
• Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living.
• Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for hospice patients. Evaluate intermittently. Assessments ensure the safety and appropriate use of these supports.
• Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated. Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).
• Be aware of increased risk of bone fracture even after muscle strength is normalized, especially in osteopenic-prone individuals such as estrogen-deficient women and the elderly. Reduction in weight bearing muscle activity during bed rest invariably produces significant changes in calcium balance and, in weeks, changes in bone mass (Bloomfield, 1997)
• Allow terminally ill clients and their families to guide care. Control by the client or family promotes effective coping.
• Provide increased attention to comfort and dignity of the terminally ill client in care planning. For example, oxygen may be more valuable as a support to the client's psychological comfort than as a booster of oxygen saturation.

Client/Family Teaching
• Instruct client on rationale and techniques for avoiding activity intolerance.
• Teach client to use controlled breathing techniques with activity.
• Teach client the importance and method of coughing, clearing secretions.
• Instruct client in the use of relaxation techniques during activity.
• Help client with energy conservation and work simplification techniques in ADLs.
• Teach client the importance of proper nutrition.
• Describe to client the symptoms of activity intolerance, including which symptoms to report to the physician.
• Explain to client how to use assistive devices or medications before or during activity.
• Help client set up an activity log to record exercise and exercise tolerance.

Free Nursing Care Plans for Pneumonia

2009-02-12T02:53:00.001-08:00

PNEUMONIA
Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood
cells escape into the alveoli. More than 3 million people in the United States are diagnosed each year with pneumonia. The disease process begins with an infection in the alveolar spaces. As the organism multiplies, the alveolar spaces fill with fluid, white blood cells, and cellular debris from phagocytosis of the infectious agent. The infection spreads from the alveolus and can involve the distal airways (bronchopneumonia), part of a lobe (lobular pneumonia), or an entire lung (lobar pneumonia).

Nursing Diagnosis:
Imbalanced Nutrition: less than body requirements

NANDA Definition:
Intake of nutrients insufficient to meet metabolic needs

Defining Characteristics:
Body weight 20% under ideal weight; pale conjunctival and mucus membranes; weakness of muscles required for swallowing or mastication; sore, inflamed buccal cavity; satiety immediately after ingesting food; reported or evidence of lack of food; reported inadequate food intake less than RDA (Recommended Dietary Allowance); reported altered taste sensation; perceived inability to ingest food; misconceptions; loss of weight with adequate food intake; aversion to eating; abdominal cramping; poor muscle tone; abdominal pain with or without pathology; lack of interest in food; capillary fragility; diarrhea and/or steatorrhea; excessive loss of hair; hyperactive bowel sounds; lack of information; misinformation

Related Factors:
Inability to ingest or digest food or absorb nutrients because of biological, psychological, or economic factors

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
• Nutritional Status
• Nutritional Status: Food and Fluid Intake
• Nutritional Status: Nutrient Intake
• Weight Control

Client Outcomes
• Progressively gains weight toward desired goal
• Weight is within normal range for height and age
• Recognizes factors contributing to underweight
• Identifies nutritional requirements
• Consumes adequate nourishment
• Free of signs of malnutrition

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Nutrition Management
• Eating Disorders Management
• Electrolyte Management: Hypophosphatemia
• Enteral Tube Feeding
• Feeding
• Nutrition Therapy
• Nutritional Counseling
• Nutritional Monitoring
• Swallowing Therapy
• Weight Gain Assistance
• Weight Management

Nursing Interventions and Rationales
• Determine healthy body weight for age and height. Refer to dietitian for complete nutrition assessment if 10% under healthy body weight or if rapidly losing weight. Legal intervention may be necessary. Early diagnosis and a holistic team treatment of eating disorders are desirable. Of women who ran 15 to 30 miles per week, 20% to 25% had increased risk of eating disorders (Estok, Rudy, 1996). In the developed world, protein-calorie malnutrition (PCM) most often accompanies a disease process. Surveys of hospitalized children in this country revealed that 20% to 40% had PCM (Baker, 1997). Over the short term, patients involuntarily committed for treatment of eating disorders progressed as well as those seeking treatment voluntarily (Watson, Bowers, Andersen, 2000).
• Compare usual food intake to USDA Food Pyramid, noting slighted or omitted food groups. Milk consumption has decreased among children while intake of fruit juices and carbonated beverages has increased. A higher incidence of bone fractures in teenage girls has been associated with a greater consumption of carbonated beverages (Wyshak, 2000). Possibly also related is the substitution of soda for milk. Omission of entire food groups increases risk of deficiencies.
• If client is a vegetarian, evaluate if obtaining sufficient amounts of vitamin B12 and iron. Strict vegetarians may be at particular risk for vitamin B12 and iron deficiencies. Special care should be taken when implementing vegetarian diets for pregnant women, infants, children, and the elderly. A dietitian can usually furnish a balanced vegetarian diet (with adequate substitutes for omitted foods) for inpatients and can provide instruction for outpatients.
• Assess client's ability to obtain and use essential nutrients. Cases of vitamin D deficiency rickets have been reported among dark-skinned infants and toddlers who were exclusively breast fed and were not given supplemental vitamin D. The children resided in northern (Fitzpatrick et al, 2000), mid-south (Kreiter et al, 2000), and southern (Shah et al, 2000) states, indicating that the presence of natural sunlight does not eliminate the risk of disease.
• Observe client's ability to eat (time involved, motor skills, visual acuity, ability to swallow various textures). Poor vision was associated with lower protein and energy (calorie) intakes in home care clients independent of other medical conditions (Payette et al, 1995).
NOTE: If client is unable to feed self, refer to Nursing Interventions and Rationales for Feeding Self-care deficit. If client has difficulty swallowing, refer to Nursing Interventions and Rationales for Impaired Swallowing.
• If client lacks endurance, schedule rest periods before meals and open packages and cut up food for client. Nursing assistance with activities of daily living (ADLs) will conserve the client's energy for activities the client values. Clients who take longer than 1 hour to complete a meal may require assistance (Evans, 1992).
• Evaluate client's laboratory studies (serum albumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, vitamins, and minerals). An abnormal value in a single diagnostic study may have many possible causes, but serum albumin less than 3.2 g/dl was shown to be highly predictive of mortality in hospitals, and serum cholesterol of less than 156 mg/dl was the best predictor of mortality in nursing homes (Morley, 1997).
• Maintain a high index of suspicion of malnutrition as a contributing factor in infections. Impaired immunity is a critical adjunct factor in malnutrition-associated infections in all age groups in all populations of the world (Chandra, 1997).
• Be alert for food-nutrient-drug interactions. Individuals at greatest risk are those who are malnourished, consume alcohol, receiving many drugs long term for chronic diseases, or take medications with meals or through a feeding tube (Lutz, Przytulski, 2001). Case reports still appear in medical journals describing scurvy in persons with alcoholism (Garg, Draganescu, Albornoz, 1998).
• Assess for recent changes in physiological status that may interfere with nutrition. The consequences of malnutrition can lead to a further decline in the patient's condition that then becomes self-perpetuating if not recognized and treated. Extreme cases of malnutrition can lead to septicemia, organ failure, and death (Arrowsmith, 1997). Diarrhea in patients receiving warfarin has been suggested as possibly causing lower intake and/or malabsorption of vitamin K (Black, 1994; Smith, Aljazairi, Fuller, 1999).
• If the client is pregnant, ensure that she is receiving adequate amounts of folic acid by eating a balanced diet and taking prenatal vitamins as ordered. All women of childbearing potential are urged to consume 400 (g of synthetic folic acid from fortified foods or supplements in addition to food folate from a varied diet (National Academy of Sciences, 1998).
• Observe client's relationship to food. Attempt to separate physical from psychological causes for eating difficulty. It may be difficult to tell if the problem is physical or psychological. Refusing to eat may be the only way the client can express some control, and it may also be a symptom of depression (Evans, 1992).
• Provide companionship at mealtime to encourage nutritional intake. Mealtime usually is a time for social interaction; often clients will eat more food if other people are present at mealtimes.
• Consider six small nutrient-dense meals vs. three larger meals daily to reduce the feeling of fullness. Eating small, frequent meals reduces the sensation of fullness and decreases the stimulus to vomit (Love, Seaton, 1991).
• Weigh client weekly under same conditions.
• Monitor food intake; specify proportion of served food that is eaten (25%, 50%); consult with dietitian for actual calorie count.
• Monitor state of oral cavity (gums, tongue, mucosa, teeth).
• Provide good oral hygiene before and after meals. Good oral hygiene enhances appetite; the condition of the oral mucosa is critical to the ability to eat. The oral mucosa must be moist, with adequate saliva production to facilitate and aid in the digestion of food (Evans, 1992).
• If a client has anorexia and dry mouth from medication side effects, offer sips of fluids throughout the day. Although artificial salivas are available, more often than not clients preferred water to the more expensive products (Ganley, 1995).
• Determine relationship of eating and other events to onset of nausea, vomiting, diarrhea, or abdominal pain.
• Determine time of day when the client's appetite is the greatest. Offer highest calorie meal at that time. Clients with liver disease often have their largest appetite at breakfast time.
• Offer small volumes of light liquids as an appetizer before meals. Small volumes of liquids (up to 240 mL) stimulate the gastrointestinal tract, which enhances peristalsis and motility (Rogers-Seidel, 1991).
• Administer antiemetics as ordered before meals. Antiemetics are more effective when given before nausea occurs.
• Prepare the client for meals. Clear unsightly supplies and excretions. Avoid invasive procedures before meals. A pleasant environment helps promote intake.
• If food odors trigger nausea, remove food covers away from client's bedside. Trapped odors diffuse into air away from client.
• If vomiting is a problem, discourage consumption of favorite foods. If favorite foods are consumed and then vomited, the client may later reject them.
• Work with client to develop a plan for increased activity. Immobility leads to negative nitrogen balance that fosters anorexia.
• If client is anemic, offer foods rich in iron and vitamins B12, C, and folic acid. Heme iron in meat, fish, and poultry is absorbed more readily than nonheme iron in plants. Vitamin C increases the solubility of iron. Vitamin B12 and folic acid are necessary for erythropoiesis.
• If the client is lactose intolerant (genetically or following diarrhea), suggest cheeses (natural or processed) with less lactose than fluid milk. Encourage client to identify the extent of the intolerance. When lactose intake is limited to the equivalent of 240 ml of milk or less a day, symptoms are likely to be negligible and the use of lactose-digestive aids unnecessary (Suarez. Savaiano, Levitt, 1995).
• For the agitated client, offer finger foods (sandwiches, fresh fruit) and fluids that can be ingested while pacing. If a client cannot be still, food can be consumed while he or she is in motion.
Geriatric
• Assess for protein-energy malnutrition. Protein-energy malnutrition in older persons is rarely recognized and even more rarely treated appropriately (Morley, 1997). Clients in institutions are susceptible to protein-calorie malnutrition (PCM) or protein-energy malnutrition when they are unable to feed themselves. When followed for 6 months in a long-care hospital, 84% of patients had an intake below estimated energy expenditure and 30% were below estimated basal metabolic rate (BMR) (Elmstahl et al, 1997). Patients admitted to a geriatric rehabilitation unit had an average of four nutritional problems. The primary nutrition problem was protein-energy malnutrition, which was associated with an increased length of stay (Keller, 1997). Nutritional risk independently increased the likelihood of death in cognitively impaired older adults (Keller, Ostbye, 2000).
• Interpret laboratory findings cautiously. Compromised kidney function makes reliance on urine samples for nutrient analyses less reliable in the elderly than in younger persons.
• Offer high protein supplements based on individual needs and capabilities. Give client a choice of supplements to increase personal control. If client is unwilling to drink a glass of liquid supplement, offer 30 ml per hour in a medication cup and serve it like medicine. Patients with decreased kidney function may not be able to excrete the waste products from protein metabolism. Often the elderly will take medications when they will not take food. The supplement is then served as a medicine.
• Offer liquid energy supplements. Energy supplementation has been shown to produce weight gain and reduce falls in frail elderly living in the community. It also has been shown to decrease mortality in hospitalized older persons and to decrease morbidity and mortality in hip fracture patients. When given liquid preloads 60 minutes before the next meal, older persons consistently ate a greater total energy load (Morley, 1997). Inadequate kilocaloric intake has been correlated with increased mortality in the elderly (Elmstahl et al, 1997; Incalzi et al, 1996).
• Unless medically contraindicated, permit self-selected seasonings and foods. Older persons rate flavor as the most important determinant of their food choice. Ability to taste declines in most but not all aging clients. Usually salt receptors are most affected and sweet receptors least affected. Blindfolded older subjects have about one half the ability of younger subjects to recognize blended foods, which predominantly results from a decline in olfactory sense (Morley, 1997). In hospitalized patients permitted their preferred food, ice cream, ad libitum, protein-energy malnutrition was reversed (Winograd, Brown, 1990).
• Play relaxing dinner music during mealtime. On a nursing home ward for demented patients, the patients ate more calmly and spent more time with dinner when music was played (Ragneskog et al, 1996). Selections with a slow tempo, at or below the human heart rate, have usually been used to dampen environmental noises that might otherwise startle clients. Fewer incidents of agitated behaviors occurred during the weeks that music was played compared with weeks without music (Denney, 1997).
• Assess components of bone health: calcium intake, vitamin D status, and regular exercise. The Adequate Intake (AI) for calcium for adults aged 19 to 50 years is 1000 mg. For those >50 years of age the amount is 1200 mg (National Academy of Sciences, 1998). Milk and milk products are the best animal sources of calcium, followed by sardines, clams, oysters, and salmon. In milk, calcium is combined with lactose, which increases absorption (although only 28% of the available calcium in milk is absorbed). Besides lactose, another advantageous component in milk is the protein the osteoblasts need to rebuild the bone matrix. In sum, milk is such an important source of calcium that it is virtually impossible to obtain adequate dietary calcium without milk or dairy products (Lutz, Przytulski, 2001). In the absence of adequate exposure to sunlight, the AI for vitamin D is set at 5 mg/day for persons 31 to 50 years of age, 10 mg for those 51 to 70 years of age, and 15 mg for persons (71 years of age (National Academy of Sciences, 1998). An 80-year-old person requires almost twice as much time in the sun to produce the same amount of vitamin D as a 20-year-old person does (Ryan, Eleazer, Egbert, 1995). Even among institutionalized elderly, prevalence of vitamin D deficiency showed significant seasonal variation (Liu et al, 1997). The USDA Modified Food Guide Pyramid for People Over 70 Years of Age specifies calcium, vitamin D, and vitamin B12 supplementation (Russell, Rasmussen, Lichtenstein, 1999). Exercise not only increases bone density but also increases muscle mass and improves balance (Nelson et al, 1994).
• Instruct in wise use of supplements. Milk-alkali syndrome has occurred in women ingesting 4 to 12 g of calcium carbonate daily (Beall, Scofield, 1995).
• Consider social factors that may interfere with nutrition (e.g., lack of transportation, inadequate income, lack of social support). Nutritional deficiencies are seen in at least one third of the elderly in industrialized countries (Chandra, 1997). In most surveys, poverty was found to be the major social cause of food insecurity and weight loss, but friendship networks play an important role in maintaining adequate food intake (Morley, 1997).
• Assess for psychological factors that impact nutrition. Watch for signs of depression. In persons with depression, 90% of the elderly lose weight, compared with 60% of younger persons (Morley, 1997).
• Consider the effects of medications on food intake. Appetite-stimulating drugs may have a role in some cases. The side effects of drugs are a major cause of weight loss in older persons (Morley, 1997). Compared with a placebo, megestrol acetate improved appetite and promoted weight gain in geriatric patients (Yeh et al, 2000).
• Provide appropriate food textures for chewing ease. Insert dentures (if needed) before meals. Assess fit of dentures. Refer for dental consultation if needed. The bony structure of jaws changes over time, requiring adjustment of dentures. The most common feeding difficulties among geriatric rehabilitation clients involved dentures (lack of or ill fitting) and oral infections (Keller, 1997).
NOTE: If client unable to feed self, refer to Nursing Interventions and Rationales for Feeding Self-care deficit.
Multicultural
• Assess for dietary intake of essential nutrients. Studies have shown that black women have calcium intakes of (75% of the RDA (Zablah et al, 1999). Hispanics with type II diabetes also often have inadequate protein nutritional status (Castenada, Bermudez, Tucker, 2000). Mexican-American women have a higher prevalence of iron deficiency anemia than non-Hispanic white females (Frith-Terhune et al, 2000). Rural black men had low caloric intakes coupled with high fat intakes but nutrient deficiencies (Vitolins et al, 2000).
• Assess for the influence of cultural beliefs, norms, and values on the client's nutritional knowledge. What the client considers normal dietary practices may be based on cultural perceptions (Leininger, 1996).
• Discuss with the client those aspects of their diet that will remain unchanged. Aspects of the client's life that are meaningful and valuable to them should be understood and preserved without change (Leininger, 1996).
• Negotiate with the client regarding the aspects of his or her diet that will need to be modified. Give and take with the client will lead to culturally congruent care (Leininger, 1996).
• Validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on ability to obtain nutritious food. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995)

Client/Family Teaching
• Help client/family identify area to change that will make the greatest contribution to improved nutrition. Change is difficult. Multiple changes may be overwhelming.
• Build on the strengths in the client's/family's food habits. Adapt changes to their current practices. Accepting the client's/family's preferences shows respect for their culture.
• Select appropriate teaching aids for the client's/family's background.
• Implement instructional follow-up to answer client's/family's questions.
• Suggest community resources as suitable (food sources, counseling, Meals on Wheels, Senior Centers).
Teach client and family how to manage tube feedings or parenteral therapy at home.

Nursing Care Plans For Hypertension

2009-02-11T08:48:00.000-08:00

Nursing Care Plans For Patient With Hypertension

Hypertension is an intermittent or sustained elevation of diastolic or systolic blood pressure. Serial blood pressure measurements are used to classify hypertension:

Prehypertension: systolic blood pressure greater than 120 but less than 140 mm Hg or diastolic blood pressure greater than 80 but less than 90 mm Hg
Stage 1 hypertension: systolic blood pressure greater than 139 but less than 160 mm Hg or diastolic blood pressure greater than 89 but less than 100 mm Hg
Stage 2 hypertension: systolic blood pressure greater than 159 mm Hg or diastolic blood pressure greater than 99 mm Hg

Aside from characteristic high blood pressure, hypertension is classified according to its cause, severity, and type. The two major types are essential (also called primary or idiopathic) hypertension, the most common (90% to 95% of cases), and secondary hypertension, which results from renal disease or another identifiable cause. Malignant hypertension is a severe, fulminant form of hypertension that commonly arises from both types.

Causes

The cause of essential hypertension is unknown. however, it is known that the disease is associated with risk factors such as genetic predisposition, stress, obesity, and a high-sodium diet. Secondary hypertension results from underlying disorders that impair blood pressure regulation, particularly renal, endocrine, vascular, and neurological disorders; hypertensive disease of pregnancy (formerly known as toxemia); and use of estrogen-containing oral contraceptives.

Genetic Gender, ethnic/racial, and life span considerations, Hypertension is a complex disease combining the effects of multiple genes and environmental factors. Over 100 candidate genes may increase susceptibility to hypertension, and there may be many more. Genes have been located for several syndromes that include hypertension as a feature (Liddle’s syndrome, glucocorticoid-remediable aldosteronism, the syndrome of apparent mineralocorticoid excess), but genetic causes of primary hypertension have been elusive. The degree of risk for hypertension that can be attributed to genetics varies from 15% to 70% depending on the ethnicity of populations studied and the contributions of environmental factors.

African Americans and elderly people are most prone to hypertension and its complications. The prevalence and incidence of hypertension is increased by 50% in African Americans as compared with whites and Hispanics/Latinos.

Complications

Hypertension is a major cause of stroke, cardiac disease, and renal failure. Complications occur late in the disease and can attack any organ system. Cardiac complications include coronary artery disease, angina, myocardial infarction, heart failure, arrhythmias, and sudden death. Neurologic complications include cerebral infarctions and hypertensive encephalopathy.

Assessment Nursing Care Plans For Hypertension

In many cases, the hypertensive patient has no symptoms, flushing of the face may be present. In later stages, a fundoscopic examination of the retina may reveal hemorrhage, fluid accumulation, and narrowed arterioles. Palpate peripheral pulses; note pulsus alternans (alternating strength of the pulse) and bounding arterial pulses. An atrial gallop (S4 heart sound) on auscultation is suggestive of hypertensio

Inspection may reveal peripheral edema in late stages when heart failure is present. Ophthalmoscopic evaluation may reveal hemorrhages, exudates, and papilledema in late stages if hypertensive retinopathy is present.

Using a correctly sized blood pressure cuff, measure blood pressure in both arms three times 3 to 5 minutes apart while the patient is at rest in the sitting, standing, and lying positions. Three readings above 140/90 mm Hg indicate hypertension. Hypertension should not be diagnosed on the basis of one reading unless it is greater than 210/120 mm Hg.

Diagnostic tests Nursing Care Plans For Hypertension
The following tests may be used to find predisposing factors and help identify the cause of hypertension:

Blood urea nitrogen
Serum creatinine
Total cholesterol
Triglycerides
Electrocardiogram
Electrocardiography may show left ventricular hypertrophy or ischemia, and chest X-rays may show cardiomegaly.
Ophthalmoscopy reveals arteriovenous nicking and, in patients with hypertensive encephalopathy, edema.

Treatment

The long-term goal of care is to limit organ damage. The primary goal is to reduce the blood pressure to less than 140/90. In prehypertension, if the patient has no more than one cardiac risk factor and no organ damage, a trial of nonpharmacologic management is usually initiated with regular follow-up for 6 months. Conservative medical management stresses diet, exercise, and changes in lifestyles. Since weight loss can result in a drop of 10 mm Hg in both systolic and diastolic blood pressure, patients are encouraged to reach a weight within 15% of their ideal body weight. Patients are placed on a low-sodium, low-cholesterol diet; reducing sodium intake by 2 g a day can lower systolic readings by 2.2 mm Hg. Advise patients to cease smoking and to reduce alcohol intake to one glass of wine or beer per day. Recommend an aerobic exercise regimen that builds up to 20 to 30 minutes three times a week. When these changes are not effective, drug therapy, along with these recommendations, becomes necessary.

Treatment for a patient with secondary hypertension includes correcting the underlying cause and controlling hypertensive effects. Severely elevated blood pressure (hypertensive crisis) may be refractory to medications and may be fatal. Hypertensive emergencies require parenteral administration of a vasodilator or an adrenergic inhibitor or oral administration of a selected drug (such as nifedipine, captopril, clonidine, or labetalol), to rapidly reduce blood pressure.

Diagnoses Nursing Care Plans For Hypertension

Deficient knowledge
Fatigue
Ineffective coping
Ineffective tissue perfusion: Cardiopulmonary
Noncompliance: Therapeutic regimen
Risk for injury

Key outcomes Nursing Care Plans For Hypertension
Knowledge: Diet, Disease process, Health behaviors, Medication, Prescribed activity, Treatment regime

Patient will identify appropriate food choices.
Patient will express that he has more energy.
Patient will demonstrate adaptive coping behaviors.
Patient will maintain adequate cardiac output and hemodynamic stability.
Patient will comply with his therapy regimen.
Patient will remain free from complications.

Discharge and home healthcare Patient teaching Nursing Care Plans For Hypertension:

Teach the patient to use a self-monitoring blood pressure cuff and to record the reading at least twice weekly in a journal for review by the physician at every office 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.

Make sure that the patient understands the need to control risk factors through medication therapy, dietary modifications, exercise guidelines, stress-reduction methods, and follow-up care.

Suggest stress-reduction groups, dietary changes, and an exercise program, particularly aerobic walking, to improve cardiac status and reduce obesity and serum cholesterol levels, Encourage a change in dietary habits.

Explain which signs and symptoms indicate a need to contact the physician. These symptoms include headache, blurred vision, dizziness, sleepiness, confusion, and changes in sexual performance. If the patient experiences altered sexual performance after starting a medication, encourage her or him to notify the physician immediately to have the medicationchanged rather than just stopping it without consultation.

Nursing Care Plans For Cataract

2009-02-10T07:10:00.000-08:00

Nursing Care Plans For Patient With Cataract

Cataracts are the leading cause of preventable blindness among adults in the United States. The incidence of cataracts in the United States is 1.2 to 6.0 cases per 10,000 people. A cataract is defined as opacity of the normally transparent lens that distorts the image projected on the retina. The lens opacity reduces visual acuity. As the eye ages, the lens loses water and increases in size and density, causing compression of lens fibers. A cataract then forms as oxygen uptake is reduced, water content decreases, calcium content increases, and soluble protein becomes insoluble. Over time, compression of lens fibers causes a painless, progressive loss of transparency that is often bilateral. The rate of cataract formation in each eye is seldom identical. Without surgery, a cataract can lead to blindness.

Cataract a common cause of gradual vision loss is opacity of the lens or the lens capsule of the eye. The clouded lens blocks light shining through the cornea. This block, in turn, blurs the image cast onto the retina. As a result, the brain interprets a hazy image. Cataracts commonly affect both eyes, but each cataract progresses independently. Exceptions are traumatic cataracts, which are usually unilateral, and congenital cataracts, which may remain stationary. Cataracts are most prevalent in people older than age 70. Surgery restores vision in about 95% of patients.

CAUSES

Cataracts have several causes and may be age-related, present at birth, or formed as a result of trauma or exposure to a toxic substance, Cataracts are classified by the cause:

Senile cataracts develop in elderly people
Congenital cataracts occur in neonates from inborn errors of metabolism or from maternal rubella infection during the first trimester
Traumatic cataracts develop after a foreign body injures the lens with sufficient force to allow aqueous or vitreous humor to enter the lens capsule
Complicated cataracts occur secondary to uveitis, glaucoma, retinitis pigmentosa, or retinal detachment
Toxic cataracts result from drug or chemical toxicity with prednisone, ergot alkaloids, naphthalene, and phenothiazines.

Genetic Considerations; Epidemiological studies indicate that cataracts have strong genetic components. Several loci have been identified for an autosomal dominant form of cataracts. Congenital cataracts occur with galactosemia and these can appear within just a few days of birth. The specific genetic contributions of the more common age-associated cataracts are still unclear. Ethnicity and race have no known effect on the risk of cataracts.

Complications

Complications may include retinal disorders, pupillary block, adhesions, acute glaucoma, macular edema, and retinal detachment. Following extracapsular cataract extraction, the posterior capsule may become opacified. This condition, called a secondary membrane or after-cataract, occurs when subcapsular lens epithelial cells regenerate lens fibers, which obstruct vision. After-cataract is treated by yttrium-aluminum-garnet (YAG) laser treatment to the affected tissue. Without surgery, a cataract eventually causes complete vision loss.

Assessment Nursing Care Plans For Cataract

Typically, the patient complains of painless, gradual vision loss. He may also report a blinding glare from headlights when he drives at night, poor reading vision, and an annoying glare and poor vision in bright sunlight. If he has a central opacity, the patient may report seeing better in dim light than in bright light, because this cataract is nuclear and, as the pupil dilates, the patient can see around the opacity.

Physical examination. Cataract formation causes blurred vision, a loss measured by Use of the snellen chart. Color perception of blue, green, and purple is reported as varying Shades of gray. If the cataract is advanced, shining a penlight on the pupil reveals the white area Behind the pupil. A dark area in the normally homogeneous red reflex confirms the diagnosis.

Treatment

Surgical lens extraction

Diagnoses that may occur in Nursing Care Plans For Cataract

Anxiety
Deficient knowledge (diagnosis and treatment)
Disturbed sensory perception: Visual
Risk for infection
Risk for injury

Key outcomes Nursing Care Plans For Cataract

patient and his family will voice their feelings and concerns.
patient will verbalize understanding of the disease and treatment.
patient will regain normal visual functioning.
patient will show no signs or symptoms of infection.
patient will avoid injury
Body image; Safety behavior: Personal; Safety behavior: Fall prevention; Safety behavior: Home physical environment; Anxiety control; Neurological status; Rest; Sleep

Interventions Nursing Care Plans For Cataract

Postoperatively, monitor the patient until he recovers from the effects of the anesthetic. Keep the side rails of the bed up, monitor vital signs, and assist him with early ambulation.
Apply an eye shield or eye patch postoperatively as ordered
Communication enhancement: Visual deficit; Activity therapy; Cognitive stimulation; Environmental management; Fall prevention; Surveillance: Safety

Nursing Care Plans For Cataract Home Health:

Caution him to avoid activities that increase intraocular pressure, such as straining with coughing, bowel movements, or lifting
Clients fitted with cataract eyeglasses need information about altered spatial perception. The eyeglasses should be first used when the patient is seated, until the patient adjusts to the distortion. Instruct the client to look through the center of the corrective lenses and to turn the head, rather than only the eyes, when looking to the side. Clear vision is possible only through the center of the lens. Hand-eye coordination movements must be practiced with assistance and relearned because of the altered spatial perceptions.
Teach the patient or family member how to instill ophthalmic ointment or drops.
Driving, sports, and machine operation can be resumed when permission is granted by the eye surgeon.
If the patient has increased eye discharge, sharp eye pain , or deterioration in vision, instruct him to immediately notify the physician.

Nursing Care Plans For Obsessive–Compulsive Disorder

2009-02-09T20:38:00.000-08:00

Nursing Care Plans For Patient With Obsessive–Compulsive Disorder

Obsessive–Compulsive Disorder

This disorder is characterized by involuntary recurring thoughts or images that the individual is unable to ignore and by recurring impulse to perform a seemingly purposeless activity. These obsessions and compulsions serve to prevent extreme anxiety on the part of the individual.

Patients with obsessive-compulsive disorder are prone to abuse alcohol, anxiolytics, or other substances in an attempt to relieve their anxiety. In addition, other anxiety disorders and major depression commonly coexist with obsessive-compulsive disorder. Obsessive-compulsive disorder is typically a chronic condition with remissions and flare-ups. Mild forms of the disorder are relatively common in the population at large.

Causes

The cause of obsessive-compulsive disorder is unknown. Some studies suggest the possibility of brain lesions, but the most useful research and clinical studies base an explanation on psychological theories. Several studies have shown brain abnormalities, such as decreased caudal size and decreased white matter, but results are inconsistent and remain under investigation. In addition, major depression, organic brain syndrome, and schizophrenia may contribute to the onset of obsessive-compulsive disorder.

Assessment Nursing Care Plans For Obsessive Compulsive Disorder

The psychiatric history of a patient with this disorder may reveal the presence of obsessive thoughts, words, or mental images that persistently and involuntarily invade the consciousness. Common obsessions include thoughts of violence (such as stabbing, shooting, maiming, or hitting), thoughts of contamination (images of dirt, germs, or stool), repetitive doubts and worries about a tragic event, and repeating or counting images, words, or objects in the environment. The patient recognizes that the obsessions are a product of his own mind and that they interfere with normal daily activities but feels powerless to stop them.

The patient's history may also reveal the presence of compulsions irrational and recurring impulses to repeat a certain behavior. Common compulsions include repetitive touching, sometimes combined with counting; doing and undoing (for instance, opening and closing doors or rearranging things); washing (especially hands); and checking (to be sure no tragedy has occurred since the last time he checked). In all cases, obsessive-compulsive behaviors and activities consume more than 1 hour of the patient's time per day. The activities are done to alleviate anxiety triggered by the patient's core fear.

During the assessment interview, determine the patient's personality type. The obsessional personality usually is rigid and conscientious and has great aspirations. He exhibits a formal, reserved manner, with precise and careful movements and posture; he takes responsibility seriously and finds decision-making difficult. He lacks creativity and the ability to find alternate solutions to his problems.Also evaluate the impact of obsessive-compulsive phenomena on the patient's normal routine. He'll typically report moderate to severe impairment of social and occupational functioning.

Diagnoses Nursing Care Plans For Obsessive Compulsive Disorder

Anxiety
Chronic low self-esteem
Fear
Ineffective coping
Ineffective role performance
Impaired social interaction
Risk for injury
Social isolation

Key outcomes Nursing Care Plans For Obsessive–Compulsive Disorder

The patient will express feelings of anxiety as they occur.
The patient will develop self-esteem.
The patient will express fears and concerns.
The patient will demonstrate effective social interaction skills.
The patient will cope with stress without excessive obsessive-compulsive behavior.
The patient will reduce the amount of time spent each day on obsessing and ritualizing.
Ritualistic behavior won't produce harmful effects.
The patient will maintain family and peer relationships
Client is able to maintain anxiety at level in which problemsolving can be accomplished.
Client is able to verbalize signs and symptoms of escalating anxiety.
Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level.

Interventions Nursing Care Plans For Obsessive–Compulsive Disorder

Approach the patient unhurriedly.
Provide an accepting atmosphere; don't show shock, amusement, or criticism of the ritualistic behavior.
Allow the patient time to carry out the ritualistic behavior (unless it's dangerous) until he can be distracted into some other activity. Blocking this behavior raises anxiety to an intolerable level.
Keep the patient's physical health in mind. For example, compulsive hand washing may cause skin breakdown, and rituals or preoccupations may cause inadequate food and fluid intake and exhaustion. Provide for basic needs, such as rest, nutrition, and grooming, if the patient becomes involved in ritualistic thoughts and behaviors to the point of self-neglect.
Let the patient know you're aware of his behavior. For example, you might say, I noticed you've made your bed three times today; that must be very tiring for you. Help the patient explore feelings associated with the behavior. For example, ask him, What do you think about while you are performing your chores?
Make reasonable demands, and set reasonable limits; make their purpose clear. Avoid creating situations that increase frustration and provoke anger, which may interfere with treatment.
Explore patterns leading to the behavior or recurring problems.
Listen attentively, offering feedback.
Encourage the use of appropriate defense mechanisms to relieve loneliness and isolation.
Engage the patient in activities to create positive accomplishments and raise his self-esteem and confidence.
Encourage active diversional resources, such as whistling or humming a tune, to divert attention from the unwanted thoughts and to promote a pleasurable experience.
Assist the patient with new ways to solve problems and to develop more effective coping skills by setting limits on unacceptable behavior (for example, by limiting the number of times per day he may indulge in obsessive behavior). Gradually shorten the time allowed. Help him focus on other feelings or problems for the remainder of the time.
Identify insight and improved behavior (reduced compulsive behavior and fewer obsessive thoughts). Evaluate behavioral changes by your own and the patient's reports.
Identify disturbing topics of conversation that reflect underlying anxiety or terror.
Observe when interventions don't work; reevaluate and recommend alternative strategies.
Monitor effects of pharmacologic therapy.

Nursing Care Plans For Atrial Septal Defect

2009-02-08T21:38:00.000-08:00

Nursing Care Plans For Patient With Atrial Septal Defect

In patients with an atrial septal defect, an opening between the left atrium and the right atrium allows blood to shunt between the chambers. Because atrial pressure normally is slightly higher in the left atrium than in the right, blood typically shunts from left to right. The pressure difference may force large amounts of blood through the defect during diastole. If the hole is more than 1/8 (1 cm) in diameter, the atria act as a single chamber.

Most infants with an atrial septal defect have no significant left-to-right shunt and no symptoms because during diastole, blood flows toward the ventricular chamber (usually the right), which has thinner, more compliant walls.

Symptoms of left-to-right shunt typically develop in adolescents and young adults because the left ventricle becomes thicker over the years from increased left ventricular end-diastolic pressure. This increased ventricular resistance forces blood through the defect rather than into the ventricles.

An atrial septal defect is found in about 10% of children who have congenital heart disease and who have lived past their first birthday. It's almost twice as common in females as in males and has a strong familial tendency.

Although an atrial septal defect is benign during infancy and childhood, delayed development of signs and symptoms and complications makes it one of the most common congenital heart defects diagnosed in adolescence and adulthood. Although the prognosis is excellent in asymptomatic people, it's poor in those with cyanosis caused by large, untreated defects.

Causes

The cause of an atrial septal defect is unknown. In this disorder, left-to-right shunt results in right ventricular volume overload, which affects the right atrium, right ventricle, and pulmonary arteries. Eventually, the right atrium enlarges and the right ventricle dilates to accommodate the increased blood volume.

Complications

In some adult patients, fixed (irreversible) pulmonary hypertension causes the shunt to reverse direction; unoxygenated blood enters the systemic circulation, causing cyanosis. Right and left ventricular hypertrophies become significant. Atrial arrhythmias, heart failure, and emboli may occur.

Children with an atrial septal defect seldom develop heart failure, pulmonary hypertension, infective endocarditis, or other complications.

Assessment Nursing Care Plans For Atrial Septal Defect

Small defects typically go undetected in a preschooler, although the child may have a history of fatigue, shortness of breath after extreme exertion, and frequent respiratory tract infections.

A large defect may retard a child's growth. Cyanosis may develop, especially if right ventricular outflow is obstructed. Inspection of the jugular vein may reveal a strong pulse preceded by a systolic collapse. Inspection of the chest wall may reveal left chest prominence. An impulse may be palpable in that area.

In children, auscultation may reveal an early to midsystolic murmur, superficial in quality, heard at the second or third left intercostal space. If the patient has a large shunt the result of increased tricuspid valve flow a low-pitched diastolic murmur at the lower left sternal border can be heard. The murmur becomes more pronounced on inspiration. The intensity of the murmur is a rough indicator of left-to-right shunt size, but its low pitch can make it difficult to hear.

The most diagnostic sounds are a fixed, widely split S1 (caused by delayed closure of the pulmonic valve) and a systolic click or late systolic murmur at the apex (resulting from mitral valve prolapse, which occasionally affects older children with atrial septal defects).

Adult patients with atrial septal defect complain of more pronounced symptoms, such as fatigue and exertional dyspnea. Symptoms may become severe enough to sharply limit the patient's activities, especially after age 40.

If the patient has a large, uncorrected defect and fixed pulmonary hypertension, auscultation reveals an accentuated S2 and, possibly, a pulmonary ejection click and an audible S4. The patient becomes cyanotic and develops clubbed nails; severe pulmonary vascular disease may lead to syncope and hemoptysis.

Diagnostic tests Nursing Care Plans For Atrial Septal Defect

Chest X-rays show an enlarged right atrium and right ventricle, a prominent pulmonary artery, and increased pulmonary vascular markings. The sinus venosus defect is characterized by an absent right superior vena cava shadow and entrance of the horizontal pulmonary vein into the upper right cardiac shadow.

Electrocardiography results may be normal but usually show right-axis deviation, a prolonged PR interval, varying degrees of right bundle-branch block, right ventricular hypertrophy, atrial fibrillation (particularly in severe cases after age 30) and, in patients with ostium primum, left-axis deviation.

Echocardiography shows volume overload on the right side of the heart and is used to measure right ventricular enlargement. It also may be used to locate the defect and estimate the size and direction of the shunt. (Other causes of right ventricular enlargement must be ruled out.)

Cardiac catheterization can be used to confirm an atrial septal defect by demonstrating that right atrial blood is more oxygenated than superior vena caval blood, which indicates a left-to-right shunt. Catheterization also can be used to help determine the degree of shunting and pulmonary vascular disease. Pulmonary artery systolic pressures are usually positive. Dye injection shows the defect's size and location, the location of pulmonary venous drainage, and atrioventricular valve competence. Cardiac catheterization is performed only if inconsistencies in the clinical data exist or if significant pulmonary hypertension is suspected.

Treatment

Operative repair is advised for patients with uncomplicated atrial septal defect and evidence of significant left-to-right shunting. Ideally, this is performed when the patient is between ages 2 and 4. Operative repair shouldn't be performed on a patient with a small defect and trivial left-to-right shunt. Because an atrial septal defect seldom produces complications in infants and toddlers, surgery may be delayed until they reach preschool or early school age. A large defect may need immediate surgical closure with sutures or a patch graft. Alternatively, placement of an atrial occluder during cardiac catheterization is becoming a more common intervention than open-heart surgery.

Diagnoses Nursing Care Plans For Atrial Septal Defect

Activity intolerance
Decreased cardiac output
Deficient knowledge (diagnosis and treatment)
Fatigue
Impaired gas exchange
Risk for infection

Key outcomes Nursing Care Plans For Atrial Septal Defect

The patient will carry out activities of daily living without weakness or fatigue.
The patient will maintain hemodynamic stability, and cardiac output will remain adequate.
The patient or her parents will verbalize understanding of the atrial septal defect and plans for treatment.
The patient will report that she has more energy.
The patient will maintain adequate ventilation and oxygenation.
The patient will remain free from signs and symptoms of infection.

Interventions Nursing Care Plans For Atrial Septal Defect
Encourage the child to engage in any activity she can tolerate. Living as normally as possible is important to avoid illness-dependent behavior patterns.

After surgery

Closely monitor vital signs, central venous and intra-arterial pressures, and intake and output.
Watch for atrial arrhythmias.
Give an antibiotic and an analgesic, as ordered.
Provide range-of-motion exercises and coughing and deep-breathing exercises.

Nursing Care Plans For Delusional Disorders

2009-02-08T19:52:00.000-08:00

Nursing Care Plans For Patient With Delusional Disorders

DELUSIONAL DISORDERS

According to the DSM-IV-TR, delusional disorders are characterized by false beliefs with a plausible basis in reality. Formerly referred to as paranoid disorders, delusional disorders are known to involve erotomanic, grandiose, jealous, or somatic themes as well as persecutory delusions. Some patients experience several types of delusions; other patients experience unspecified delusions that have no dominant theme.

Delusional disorders commonly begin in middle or late adulthood, usually between ages 40 and 55, but they can occur at a younger age. These uncommon illnesses affect less than 1% of the population; the incidence is about equal in males and women. Typically chronic, these disorders often interfere with social and marital relationships but seldom impair intellectual or occupational functioning significantly.

Causes

Delusional disorders of later life strongly suggest a hereditary predisposition. At least one study has linked the development of delusional disorders to inferiority feelings in the family. Some researchers suggest that delusional disorders are the product of specific early childhood experiences with an authoritarian family structure. Others hold that anyone with a sensitive personality is particularly vulnerable to developing a delusional disorder.

Certain medical conditions are known to exaggerate the risks of delusional disorders: head injury, chronic alcoholism, deafness, and aging. Predisposing factors linked to aging include isolation, lack of stimulating interpersonal relationships, physical illness, and diminished hearing and vision. In addition, severe stress (such as a move to a foreign country) may precipitate a delusional disorder.

Assessment Nursing Care Plans For Delusional Disorders

The psychiatric history of a delusional patient may be unremarkable, aside from behavior related to his delusions. He's likely to report problems with social and marital relationships, including depressive symptoms or sexual dysfunction. In fact, about one-third of delusional patients are widowed, divorced, or separated at the time of first admission. Others describe a life marked by social isolation or hostility. Such patients may deny feeling lonely, relentlessly criticizing or placing unreasonable demands on others.

Also watch for nonverbal cues, indicating suspiciousness or mistrust, such as excessive vigilance or obvious apprehension on entering the room. During questions, the patient may listen intently, reacting defensively to imagined slights or insults. He may sit at the edge of his seat or fold his arms as if to shield himself. If he carries papers or money, he may clutch them firmly.

Diagnostic Nursing Care Plans For Delusional Disorders
Psychiatric examination confirms the presence of the following diagnostic criteria in the DSM-IV-TR:

Nonbizarre delusions of at least 1 month's duration are present, involving real-life situations, such as being followed, poisoned, infected, loved at a distance, or deceived by one's spouse or lover.
Auditory or visual hallucinations, if present, aren't prominent.
Apart from the delusion or its ramifications, behavior isn't obviously odd or bizarre, and the patient isn't markedly impaired functionally.
If a major depressive or manic syndrome has been present during the delusional disturbance, the total duration of all episodes of the mood syndrome has been brief relative to the total duration of the delusional disturbance.
The patient has never met diagnostic criteria for schizophrenia (presence of characteristic psychotic symptoms in the active phase for at least 1 week), and it can't be established that an organic factor initiated and maintained the disturbance.
In addition, blood and urine tests, psychological tests, and a neurologic evaluation rule out organic causes of the delusions, such as amphetamine-induced psychoses and Alzheimer's disease. Endocrine function tests are performed to rule out hyperadrenalism, pernicious anemia, and thyroid disorders such as â€œmyxedemic madness

Treatment

Effective treatment of delusional disorders, consisting of a combination of drug therapy and psychotherapy, must correct the behavior and mood disturbances that result from the patient's mistaken belief system. Treatment may also include mobilizing a support system for the isolated, aged patient.

Drug treatment with antipsychotic agents is similar to that used in schizophrenic disorders. Antipsychotics appear to work by blocking postsynaptic dopamine receptors. These drugs reduce the incidence of psychotic symptoms, such as hallucinations and delusions, and relieve anxiety and agitation. Other psychiatric drugs, such as antidepressants and anxiolytics, may be prescribed to control associated symptoms.

High-potency antipsychotics include fluphenazine, haloperidol, thiothixene, and trifluoperazine. Loxapine, molindone, and perphenazine are intermediate in potency, and chlorpromazine and thioridazine are low-potency agents. Haloperidol and fluphenazine are depot formulations that are implanted I.M. to release the drug gradually over a 30-day period, improving compliance.

Clozapine, which differs chemically from other antipsychotic drugs, may be prescribed for severely ill patients who fail to respond to standard neuroleptic treatment. This agent effectively controls a wider range of psychotic symptoms without the usual adverse effects.

However, clozapine can cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, and seizures, as well as agranulocytosis, a potentially fatal blood disorder characterized by a low white blood cell count and pronounced neutropenia. Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If caught in the early stages, the disorder is reversible.

Diagnoses that may occur in Nursing Care Plans For Delusional Disorders

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

Key outcomes Nursing Care Plans For Delusional Disorders

The patient will consider alternative interpretations of a situation without becoming hostile or anxious.
The patient and his family will participate in care and prescribed therapies.
The patient will identify internal and external factors that trigger delusional episodes.
The patient will maintain functioning to the fullest extent possible within the limitations of his visual or auditory impairment.
The patient will remain oriented to person, place, time, and situation.
The patient will express all fears and concerns.
The patient will show no signs of malnutrition.
The patient will recognize symptoms and comply with medication regimen.
The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
The patient will demonstrate adaptive coping behaviors.
The patient will identify and perform activities that decrease delusions.
The patient will remain free from injury.
The patient won't harm others.
The patient won't harm self.
The patient will maintain family and peer relationships.

Interventions Nursing Care Plans For Delusional Disorders

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

Patient teaching Nursing Care Plans For Delusional Disorders

If the patient is taking clozapine, stress the importance of returning weekly to the hospital or outpatient setting to have his blood monitored.
Emphasize the importance of complying with the prescribed medication treatment. Instruct the patient to report any adverse effects instead of stopping the drug. If he's taking a slow-release formulation, be sure he understands when to return to the physician for his next dose.
Involve family members in treatment. Teach them how to recognize an impending relapse, and suggest ways to manage symptoms. These include tension, nervousness, insomnia, decreased concentration ability, and loss of interest.