Showing posts with label Nursing Care Plan. Show all posts

Ineffective Tissue perfusion related to Diabetic Foot Ulcers

Nursing Care Plan for Diabetic Foot Ulcers

Ulcers are open sores on the skin or mucous membrane surface and the ulcer is extensive tissue death and accompanied invasive saprophyte bacteria. The existence of the saprophyte bacteria cause ulcers smelling, diabetic ulcers is also one of the symptoms and the clinical course of the disease diabetes mellitus with peripheral neuropathy. (Andyagreeni, 2010).

Diabetic ulcers are chronic complications of diabetes mellitus as a major cause of morbidity, mortality and disability in patients with diabetes. High LDL levels play an important role for the occurrence of diabetic ulcers through the formation of atherosclerotic plaque in the walls of blood vessels, (zaidah 2005).

Diabetic foot ulcers are the complications associated with morbidity from diabetes mellitus. Diabetic foot ulcers are serious complications due to diabetes. (Andyagreeni, 2010).

Nursing Care Plan for Diabetic Foot Ulcers

Nursing Diagnosis : Ineffective Tissue perfusion related to weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels.

Goal: maintain peripheral circulation remained normal.

Expected outcomes:

Palpable peripheral pulses were strong and regular.
The color of the skin around the wound; not pale / cyanosis.
The skin around the wound felt warm.
Edema does not occur and the wound is not getting worse.
Sensory and motor improves.

Interventions:

1. Instruct the patient to mobilize.
Rational: the mobilization improves blood circulation.

2. Teach about the factors that can increase blood flow: Elevate the patient's leg is slightly lower than the heart (elevation position at rest), avoid crossing legs, avoid tight bandage, avoid the use of cushions, behind the knees and so on.
Rational: increase blood flow back so there is no edema.

3. Teach about the modification of risk factors such as:
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and drug use vasoconstriction.
Rational: high cholesterol can accelerate the onset of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.

4. Cooperation with other health care team in the delivery of vasodilators, checks blood sugar regularly and oxygen therapy.
Rational: vasodilator administration will increase the dilation of blood vessels and tissue perfusion can be improved, while the regular blood sugar checks can track the progress and state of the patient.

Nursing Care Plan for Acute Psychotic

Definition of Acute Psychotic

Psychotic is mental disorder characterized by the inability of the individual to assess what actually happened, for example, there are hallucinations, delusions or chaotic behavior / weird.

Clinical Manifestations

The behavior exhibited by the patient are:

Hearing voices no source.
Belief or fear that weird / absurd.
Confusion or disorientation.
Changes in behavior ; be strange or scary as aloof, heightened scrutiny, threatening themselves, other people or the environment, to talk and laugh and get angry or hit for no reason.

Brief psychotic disorder symptoms always include at least one major psychotic symptoms, usually with sudden onset, but not always incorporate the overall pattern of symptoms found in schizophrenia. Some clinicians have observed that affective symptoms, confusion and concentration problems may be more often found in a brief psychotic disorder rather than a chronic psychotic disorder. Symptoms characteristic for brief psychotic disorder is an emotional change, clothing or bizarre behavior, yelling screaming or silent, and impaired memory for recent events occurred. Some of these symptoms are found in disorders that direct and clear diagnosis of delirium requires a complete organic inspection, although the result may be negative.

Mental status examination is usually present with severe psychotic agitation that may be associated with bizarre behavior, uncooperative, aggressive physical or verbal, irregular speak, shout or silence, labile mood or depression, suicide, kill thoughts or behavior, anxiety, hallucinations, delusions, disorientation, impaired attention, impaired concentration, memory impairment, and poor insight.

As in acute psychiatric patients, a history which is necessary to make the diagnosis may not be obtained only from the patient. Despite the presence of psychotic symptoms may be obvious, information on prodromal symptoms, previous episodes of a mood disorder, and a history of ingestion of a recently psychotomimetic substances may not be obtained from clinical interviews alone. In addition, clinical may not be able to obtain accurate information about the presence or absence of precipitating stressor.

The most obvious example is the originator of stresos major life events that can cause significant emotional anger in each person. The event is the death of a close family member and a heavy vehicle accidents. Some argue that the severity of clinical events should be considered in relation to the patient's life. Although this view has a reason, but it may expand the definition to include precipitating stressor events that are not associated with psychotic episodes. Other clinicians argue that stressors may be a sequence of events that cause stress are, rather than single events that give rise to stress the obvious. But the sum of the degree of stress caused by the sequence of events requires a degree of clinical judgment almost impossible.

Diagnosis

For a definite diagnosis of symptoms of acute psychotic disorders are as follows :

Hallucinations (false sensory perceptions or imagined : for instance, no one heard a sound source or see something that no object).
Delusions (strongly held idea that a real one and can not be accepted by social groups of patients, such as patients believe that they are poisoned by a neighbor, receiving messages from the television, or was observed / supervised by someone else).
Agitation or bizarre behavior.
Talks strange or chaotic (disorganization).
Unstable emotional state and extreme (irritable).

Nursing Care Plan for Acute Psychotic

Maintaining patient safety and care of individuals, things to do :

Family or friends should accompany the patient.
Basic needs of patients are met (eg, eating, drinking, elimination, and hygiene).
Be careful that the patient does not get injured.

Counseling patients and families :

Help families identify aspects of the law relating to psychiatric treatment include: patient rights, obligations and responsibilities of the family in the treatment of patients.
Assist patients and families to reduce the stress and contact with the stressor.
Motivation of patients to perform activities of daily living after symptoms improve.

Nursing Care Plan for Crohn's Disease

Crohn's disease is an autoimmune disease characterized by inflammation of any part of the digestive tract starts from mouth to anus. Crohn's disease typically affects the ileum, the lower part of the small intestine. This condition occurs when the immune system reacts abnormally, attack bacteria, food, and other substances improperly, which causes the accumulation of white blood cells in the lining of the intestine.

Cause of Crohn 's disease is unknown. The study focused on three possible causes, namely :
1. Immune system dysfunction
2. Infection
3. Food

Although not found the presence of autoantibodies, regional enteritis is thought to be a hypersensitivity reaction or may be caused by an unknown infectious agent. These theories put forward because of the granulomatous lesions similar to lesions found in fungi and pulmonary tuberculosis. There are some interesting similarities between regional enteritis and ulcerative colitis. Both are inflammatory diseases, although the lesions is different. Both of these diseases have manifestations outside the digestive tract ; uveitis, arthritis and skin lesions were identical.

Crohn's disease that attacks the digestive system can cause a variety of complications, one of which is certainly disorders of the gut or digestive system. Crohn 's disease can cause a thickening or swelling of the intestinal wall, and this can cause blockage in the intestines. Finally, disturbed digestive system, intestines can not absorb nutrients from food, such as protein, vitamins, calories, and minerals.

Other complications that may arise as a result of Crohn 's disease is osteoporosis, anemia can cause fatigue, impaired liver function, cancer of the colon, toxic megacolon, kidney stone disease, or arthritis.

The main symptoms are diarrhea, abdominal pain, and weight loss . Often obtained malaise, loss of appetite, nausea, vomiting, and there may be subfebrile fever. Occur suddenly, can resemble obstruction and appendicitis. At regional enteritis, the onset of symptoms is usually hidden, with persistent abdominal pain and diarrhea that does not go away with defecation. Diarrhea occurred in 90 % of patients. Scar tissue and granuloma formation affects the ability of the intestine to transport the products of digestion upper intestine, through the lumen constriction, resulting in a cramping abdominal pain. Because the intestinal peristaltic stimulated by food, cramping pain occurs after eating. To avoid this cramping pain, patients tend to limit food intake, reducing the amount and types of food so that the normal nutritional needs are not met. The result is weight loss, malnutrition, and anemia secondary. In addition, the formation of ulcers in the lining membrane of the intestine and the place of inflammation, discharge will produce a constant irritant to the colon that are drawn from the thin intestine, swollen, which causes chronic diarrhea. Nutritional deficiencies may occur due to impaired absorption. The result is that the individual be thin because of inadequate food intake and fluid lost continuously. In some patients, inflamed bowel can be perforated and anal abscess formation, and intra-abdominal. Fever and leukocytosis. Abscesses, fistulas, and fissures are common. Clinical course and symptoms vary. In some patients there were periods of remission and exacerbation, while others follow the weight causes illness. Symptoms extends throughout the gastrointestinal tract and generally include joint problems (arthritis), skin lesions (erythema nodosum), ocular disorders (conjunctivitis), and oral ulcers.

Nursing Diagnosis for Crohn's Disease

1. Pain related to irritable initestinal, abdominal cramps and surgical response.
2. Fluid and Electrolyte imbalances related to discharge of excessive vomiting.
3. Imbalanced Nutrition Less Than Body Requirements related to the inadequate nutritional intake secondary to pain, stomach and intestinal inconveniences.
4. Risk for infection related to post- surgical wound.
5. Anxiety related to the prognosis of the disease and surgical plan.

Nursing Care Plan for Chickenpox

Nursing Diagnosis for Chickenpox

Chickenpox is an infectious disease caused by the varicella-zoster virus infection. The disease is transmitted aerogen.

Incubation time

When exposed to the plague within 2 to 3 weeks. this can be characterized by the body feels hot but not fever.

Symptoms

Initially, patients may feel a slight fever, runny nose, quickly feel tired, lethargic, and weak. These symptoms are typical for a viral infection. In more severe cases, you can also get joint pain, headache and dizziness. A few days later occurred the redness of the skin that is small for the first time found around the chest and abdomen or buttocks, followed arise member and facial movements.

Redness of the skin is then turned into the eject containing liquid with a thin wall. This rash may feel a bit of pain or itching that can be accidentally hit. If recoil is left then immediately dried up scab and it will be missed and leave spots on darker skin (hyperpigmentation). These spots will gradually fade until some time later, they will not leave the container again.

Another case where the eject chickenpox is broken. Krusta soon to be formed over the dry longer. These conditions facilitate bacterial infection occurs on former scratch now. after drying container will eliminate chickenpox earlier in containers. Especially if patients are adults or young adults, the former will be more difficult chickenpox disappear.

Quarantine time

For 5 days after the rash appears and until all starting blisters have scab. During quarantine sufferers should still shower as usual, because of the germs that are on the skin will be menginfeksi skin is exposed to chicken pox. To avoid any potential loss of confidential scar should avoid breakage eject chickenpox. When drying the body after a bath should not rub with the towel too hard. To avoid irritation, should be given containing menthol powder talk to reduce friction that occurs on the skin so that the skin is more irritated. For having sensitive skin can also use the powder salycil talk that does not contain bulbs. Make sure you are always consuming nutritious food to accelerate the healing process itself. Consumption of fruits that contain vitamin C such as guava and red tomato juice can be made.

Prevention

Immunizations are available for children older than 12 months. Vaccination is also recommended for people over the age of 12 years who do not have immunity, or those who have never been exposed to this disease, because adults affected with this disease, usually more severe and can sometimes be unconscious. For those who were over the age of 50 years should be vaccinated again.

Nursing Diagnosis

Hypertermia related to the disease.
Impaired Skin Integrity related to mechanical factors (eg stress, tear, friction)
Disturbed Body Image related to lesions on the skin.
Deficient Knowledge: about the condition and treatment needs.
Risk for Infection related to damage skin tissue.

Sample of Nursing Care Plan for Wandering

Wandering Definitions:

Moving from place to place without a fixed plan; roaming; rambling: wandering tourists.

Related factors:

Cognitive impairment (disorientation, difficulty remembering and memory).
Emotional (depression).
Excessive stimuli from the environment.
Lasts all day.

Objective data:
A woman, 62-year-old was found wandering, not be able to remember the people (neighbors, saleswoman) and the events that happened in the previous weeks.

Subjective data:
The patient reported that the stress because she was arguing with her husband. She said that she did not plan wandering. Only instinctively move from one place to another.

NOC

1. Safe Wandering
Definition: Safe, socially acceptable with no visible that cognitively impaired.

Indicators:

The patient is able to move without hurting themselves (1-5).
The Patient were able to demonstrate that the activity has a goal (1-5).
The patient wants to go home (1-5).

2. Acute confusion level
Definition: The severity of disturbances in consciousness and cognition that develops in a short period of time.

Indicators:

Patients did not experience disorientation place (1-5)
Patients did not experience disorientation people (1-5)
Patients experienced a decline in memory impairment (1-5)

3. Memory
Definition:
The ability to restore cognitive function and reported previously stored information.

Indicators:

Given the close information accurately (1-5)
Given the information just accurately (1-5)
Given the information that the information is accurate (1-5)

NIC

1. Reality Orientation
Definition: introduce / increase patient awareness regarding personal identity, time and the environment.

Activities:

Using a consistent approach when interacting with patients.
Inform patients about the people, places and times as needed.
Preventing patients frustrated by giving questions related to orientation can not afford missed.
Provide a physical environment that remains and planned daily routine.
Approach the patient with slowly and from the front.
Using a calm approach and not rush when interacting with patients.
Speak slowly, clearly and corresponding volume in patients.

2. Medication Management
Definition: Facilitation of safe and effective use of prescription and over the counter drugs.

Activities:

Determine and regulate the drug is needed in accordance with the protocol.
Monitor the effectiveness of treatment modalities.
Monitor patient adherence to treatment regimens.

3. Family Involvement Promotion
Definition: Facilitating family participation in the emotional and physical care of patients.

Activities:

Identification with family members about the patient's difficulty coping.
Inform family members about the factors that may increase the patient's condition.
Encourage family members to keep or maintain a good relationship with the family.

Nursing Care Plan for Mastoiditis

Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear.

Causes of Mastoiditis

Acute mastoiditis:

Haemophilus influenzae.
Streptococcus pneumoniae.
Streptococcus pyogenes.
Moraxella catarrhalis.
Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus infection (MRSA).

Chronic mastoiditis:

Staphylococcus aureus, including MRSA.
Infection is often polymicrobial.
Gram-negative organisms such as Escherichia coli, Proteus, or Pseudomonas.
Anaerobic bacteria: Peptostreptococcus species, anaerobic Gram-negative bacilli (ie, pigmented Prevotella, Porphyromonas, and Bacteroides species) and Fusobacterium species.
Mycobacterium tuberculosis, nontuberculous mycobacteria, and Mycobacterium bovis are rare causes.

Symptoms of Mastoiditis

Ear pain or discomfort
Drainage from the ear
Headache
Fever, may be high or suddenly increase
Redness of the ear or behind the ear
Hearing loss
Swelling behind ear, may cause ear to stick out

Nursing Diagnosis for Mastoiditis

Acute pain related to inflammation process.
Disturbed Sensory perception related to obstruction, infection of the middle ear or auditory nerve damage.
Anxiety related to the inability to communicate.
Risk for injury related to vertigo and a decrease in body balance

Nursing Care Plan for Cerebral Palsy

Assessment

Assess the mother's pregnancy history
Assess history of childbirth
Identification of children who are at risk
Assess the child irritable, difficulty in eating / swallowing, delayed development of normal children, the development of less movement, abnormal posture, lack of movement development, abnormal posture, persistent infant reflexes, ataxic, lack of muscle tone.
Monitor response to child's play
Assess intellectual functioning
No muscle coordination when performing movement (loss of balance)
Stiff muscles and exaggerated reflexes (spasticas)
Difficulty chewing, swallowing and sucking, and difficulty speaking.
body shaking
Difficulty moving exactly like menulus or pressing a button.
Children with cerebral palsy may have additional problems, including the following: seizures, problems with vision and hearing as well as in speaking, there are learning disabilities and behavioral disorders, mental retardation, problems related to respiratory problems, problems in defecation and waste little water, and there are re-shape abnormalities such as scoliosis.
Past medical history: premature birth, and birth trauma.
History of present illness: muscle weakness, mental retardation, severe disorders-hypotonia, Throwing / Suction eating, impaired speech / voice, visual and hearing.

Subjective data :

Parents say that when pregnant mothers experienced tooplasmosis, their children's growth rather late.
Parents say son can not walk seendiri, can not feed themselves, can not brush your teeth with help.
Parents also say that children can not do the things kids his age do.
Parents feel the burden of caring for their children and embarrassed by her condition. Parents worried about their future.

Objective data :

Test results showed the body feel warm.
Sweat a lot
There are involuntary movements (not coordinated)
posture opistotonik
Children difficulty to eat
Often ceguken, and irritabel.

Nursing Care Plan for Cerebral Palsy - Nursing Diagnosis

Hypertermia
Risk for injury
Imbalanced Nutrition, Less Than Body Requirements
Impaired verbal communication
Activity intolerance
Delayed growth and development
Knowledge deficit
Ineffective breathing pattern

Nursing Care Plans: Diagnoses, Interventions, and Outcomes

The bestselling nursing care planning book on the market, Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8th Edition covers the most common medical-surgical nursing diagnoses and clinical problems seen in adults. It includes 217 care plans, each reflecting the latest evidence and best practice guidelines. NEW to this edition are 13 new care plans and two new chapters including care plans that address health promotion and risk factor management along with basic nursing concepts that apply to multiple body systems. Written by expert nursing educators Meg Gulanick and Judith Myers, this reference functions as two books in one, with 147 disorder-specific and health management nursing care plans and 70 nursing diagnosis care plans to use as starting points in creating individualized care plans.

Read More : Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e

217 care plans --- more than in any other nursing care planning book.
70 nursing diagnosis care plans include the most common/important NANDA-I nursing diagnoses, providing the building blocks for you to create your own individualized care plans for your own patients.
147 disorders and health promotion care plans cover virtually every common medical-surgical condition, organized by body system.
Prioritized care planning guidance organizes care plans from actual to risk diagnoses, from general to specific interventions, and from independent to collaborative interventions.
Nursing diagnosis care plans format includes a definition and explanation of the diagnosis, related factors, defining characteristics, expected outcomes, related NOC outcomes and NIC interventions, ongoing assessment, therapeutic interventions, and education/continuity of care.
Disorders care plans format includes synonyms for the disorder (for easier cross referencing), an explanation of the diagnosis, common related factors, defining characteristics, expected outcomes, NOC outcomes and NIC interventions, ongoing assessment, and therapeutic interventions.
Icons differentiate independent and collaborative nursing interventions.
Student resources on the Evolve companion website include 36 of the book's care plans - 5 nursing diagnosis care plans and 31 disorders care plans.
Three NEW nursing diagnosis care plans include Risk for Electrolyte Imbalance, Risk for Unstable Blood Glucose Level, and Risk for Bleeding.
Six NEW health promotion/risk factor management care plans include Readiness for Engaging in a Regular Physical Activity Program, Readiness for Enhanced Nutrition, Readiness for Enhanced Sleep, Readiness for Smoking Cessation, Readiness for Managing Stress, and Readiness for Weight Management.
Four NEW disorders care plans include Surgical Experience: Preoperative and Postoperative Care, Atrial Fibrillation, Bariatric Surgery, and Gastroenteritis.
NEW Health Promotion and Risk Factor Management Care Plans chapter emphasizes the importance of preventive care and teaching for self-management.
NEW Basic Nursing Concepts Care Plans chapter focuses on concepts that apply to disorders found in multiple body systems.
UPDATED care plans ensure consistency with the latest U.S. National Patient Safety Goals and other evidence-based national treatment guidelines.
The latest NANDA-I taxonomy keeps you current with 2012-2014 NANDA-I nursing diagnoses, related factors, and defining characteristics.
Enhanced rationales include explanations for nursing interventions to help you better understand what the nurse does and why.

Risk for Injury - Nursing Care Plan Meningitis

Nursing Diagnosis for Meningitis: Risk for Injury related to general weakness.

The expected outcomes / evaluation criteria pediatric patients: No seizures or comorbidities or other injury.

intervention
a. Monitor the spasms / twitching of the hands, feet and mouth or other facial muscles.
Rational: reflecting on the CNS in general irritation that require immediate evaluation and possible intervention to prevent complications.

b. Provide security for patients by providing assistance on the bed and keep the barrier remained in place and attach the plastic artificial airway or soft rolls and a suction bulb.
Rationale: protect patients when seizures. Note; enter the airway assistance / soft rolls if only jaw relaxation, not forced to enter as his teeth shut and soft tissue will be damaged.

c. Maintain bed rest during the acute phase. Move. Moving with the help of corresponding improvement in the situation.
Rational: reducing the risk of falls / trauma case vertigo, syncope or ataxia.

d. Give medication as indicated as phenytoin (Dilantin), diazepam, phenobarbital.
Rational: an indication for the treatment and prevention of seizures. Records: Phenobarbital may cause respiratory and sedative defresi and mask the signs / symptoms of increased ICP.

Risk for Infection - Nursing Care Plan for Appendicitis

Nursing Diagnosis Interventions for Appendicitis: Risk for Infection

Risk factors include:

Inadequate primary defense, perforation / rupture of the appendix; peritonitis; abscess formation.
Invasive procedures, surgical incisions.

Intervention:

Independent:

Monitor vital signs noticed fever, chills, sweating, mental changes, increased abdominal pain.
Do a good hand washing and aseptic wound care. Provide complete care.
See incision and bandage. Write down the characteristics and wound drainage / drain (if included), the erythema.
Provide appropriate information, be honest with the patient / parent close.

Collaboration

Take for example the drainage when indicated.
Give antibiotics, are as indicated.

Impaired Physical Mobility Nursing Care Plan Scoliosis

Impaired Physical Mobility Nanda Definition: a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in the which an individual has a Limitation in independent, purposeful physical movement of the body or of one or more extremities.

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (eg, as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability Continues to grow. And with shorter hospital stays, Patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, affecting balance and gait changes can significantly compromise the mobility of elderly Patients. Mobility is paramount if elderly Patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly Patients are also at Increased risk for the complications of immobility. Nursing goals are to maintain functional ability, Prevent additional impairment of physical activity, and Ensure a safe environment.

Nursing Diagnosis for Scoliosis: Impaired Physical Mobility related to postural imbalance.

Purpose : Increase physical mobility

Plan of action
1. Assess the level of physical mobility.
Rational: Influencing choice / control the effectiveness of interventions.

2. Increase activity if pain is reduced.
Rationale: Provides the opportunity to release energy.

3. Teaching aids and active joint range of motion exercises.
Rationale: Increases muscle strength and circulation.

4. Involve the family in performing self-care.
Rational: The family that cooperate to relieve the officer, and provide comfort to patients.

Nursing Care Plan for Acute Otitis Media

Nursing Diagnosis for Acute Otitis Media and Nursing Interventions for Acute Otitis Media

Nursing Assessment for Acute Otitis Media

Assess the presence of pain behaviors: verbal and non-verbal.
Assess the increase in temperature (an indication of the infection process).
Assess the presence of enlarged lymph nodes in the neck area.
Assess nutritional status and adequacy of fluid intake of calories.
Assess the possibility of deafness.

Nursing Diagnosis for Acute Otitis Media

Acute Pain related to inflammation of the middle ear tissue.
Disturbed Sensory Perception: auditory conductive disorder related to the sound of the organ.

Nursing Interventions for Acute Otitis Media

1. Acute Pain related to inflammation of the middle ear tissue.

Purpose: The reduction in pain.

Intervention:

Assess the level of intensity of the client and client's coping mechanisms.
Give analgesics as indicated.
Distract the patient by using relaxation techniques: distraction, guided imagination, touching, etc..

2. Disturbed Sensory Perception: auditory conductive disorder related to the sound of the organ.

Purpose: to improve communication

Intervention:

Reduce noise in the client environment.
Looking at the client when speaking.
Speaking clearly and firmly on the client without the need to shout.
Provide good lighting when the client relies on the lips.
Using the signs of non-verbal (eg facial expressions, pointing, or body movement) and other communications.
Instruct family or the people closest to the client on how techniques of effective communication so that they can interact with clients.
If the client wants, the client can use hearing aids.

Nursing Care Plan for Osteomyelitis

Nursing Care Plan for Osteomyelitis : Nursing Diagnosis for Osteomyelitis and Nursing Interventions for Osteomyelitis

Osteomyelitis is an infection of the bone. It can be caused by a variety of microbial agents (most common in staphylococcus aureus) and situations, including:

An open injury to the bone, such as an open fracture with the bone ends piercing the skin.
An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood (bacteremia, sepsis).
A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria.
Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.
A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

Symptoms of osteomyelitis

The symptoms of osteomyelitis can include:

Pain and/or tenderness in the infected area
Swelling and warmth in the infected area
Fever
Nausea, secondarily from being ill with infection
General discomfort, uneasiness, or ill feeling
Drainage of pus through the skin

Additional symptoms that may be associated with this disease include:

Excessive sweating
Chills
Lower back pain (if the spine is involved)
Swelling of the ankles, feet, and legs
Changes in gait (walking pattern that is a painful, yielding a limp)

Nursing Diagnosis for Osteomyelitis

Acute pain related to inflammation and swelling
Impaired Physical Mobility related to pain and limitation of the load weight
Risk for Infection

Targets to be achieved:

Pain is reduced
Improvement of physical mobility within the limits of therapeutic
Infection control

Nursing interventions for Osteomyelitis

1. Immobilization of the affected area with a splint to reduce pain and muscle spasms.

2. Joints above and below the affected area should be made so that still can be moved according to the range yet gently. The wound itself is sometimes very painful and must be handled carefully and slowly.

3. Elevate the affected area to reduce swelling and discomfort.

4. Monitor the affected extremity neurovascular status.

5. Do pain management techniques such as massage, distraction, relaxation, hypnosis to reduce pain perception and collaboration with medical for providing analgesic.

6. Protect your bones by means of immobilization and avoid stress on the bone because bones become weak due to the infection process.

Reference : http://my.clevelandclinic.org/disorders/osteomyelitis/hic_osteomyelitis.aspx

Diabetes Mellitus Nursing Care Plan - 10 Nursing Diagnosis

Diabetes mellitus is a disease caused by defective carbohydrate metabolism and characterized by abnormally large amounts of sugar in the blood and urine. Diabetes mellitus is usually classified into two types. Type I or "insulin-dependent" diabetes mellitus (IDDM), formerly called juvenile-onset diabetes, which occurs in children and young adults has been implicated as one of the autoimmune diseases. Type II or "non-insulin-dependent" diabetes mellitus (NIDDM), formerly called adult-onset diabetes is found in persons over 40 years old and progresses slowly.

Detection of Type II diabetes in the absence of symptoms starts with the measurement of the glucose levels in urine. If a high level is detected, the amount of blood sugar is measured after an overnight fast. A high value indicates diabetes, and those with a normal level then undergo an oral glucose tolerance test in which the amount of glucose in the blood is measured after ingestion of a large amount of sugar.

10 Nursing Diagnosis for Diabetes Mellitus

1. Imbalanced Nutrition: Less/More than Body Requirements

2. Ineffective Tissue Perfusion: Renal, cardiopulmonary, peripheral

3. Impaired Urinary Elimination

4. Disturbed sensory perception: Visual, tactile

5. Activity Intolerance

6. Ineffective Coping

7. Sexual Dysfunction

8. Fear

9. Deficient Knowledge

10. Risk for Impaired Skin Integrity

Source : http://nursing-diagnosis-nanda.blogspot.com/2012/05/10-nanda-nursing-diagnosis-for-diabetes.html

Nursing Care Plan for Rheumatoid Arthritis - Diagnosis and Interventions

Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
Source : medicinenet.com

Nursing Diagnosis for Rheumatoid Arthritis

Acute Pain / Chronic related to tissue distension by fluid accumulation / inflammation, joint destruction.
Impaired physical mobility related to skeletal deformities, pain, discomfort, activity intolerance, decreased muscle strength.

Nursing Interventions for Rheumatoid Arthritis
Acute Pain / Chronic Pain related to tissue distension by fluid accumulation / inflammation, joint destruction.

Goal :

Pain is reduced / lost

Expected results :

Indicates no pain
Looks relaxed, to sleep / rest and participate in activities based on ability.
Following program prescribed pharmacologic
Combining the skills of relaxation and entertainment activity in the pain control program.

Nursing Intervention :

Assess pain, note the location and intensity (scale 0-10). Write down the factors that accelerate and signs of pain non-verbal.
R / Assist in determining the need for pain management and program effectiveness.
Give a hard mattress, small pillows, elevate the bed linen as needed.
R / soft mattress, large pillows, will prevent the maintenance of proper body alignment, placing stress on joints that hurt. Bed linen elevation decrease the pressure on painful joints.
Instruct to frequently change positions. Helps to move in bed, prop a pain in the joints above and below, avoid jerky movements.
R / Prevent the occurrence of general fatigue and joint stiffness. Stabilize joints, reduce the movement / pain in the joints.
Instruct the patient to a warm bath or shower at the time awake. Monitor the water temperature, water bath, and so forth.
R / Heat enhance muscle relaxation, and mobility, reduce pain and stiffness in the morning release. Sensitivity to heat, can be removed and dermal wound can be healed.
Give a massage
R / enhance relaxation / reduce pain
Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, guidelines imagination, self hypnosis, and breathing control.
R / Increase relaxation, provide a sense of control and may improve coping abilities.
Engage in activities of entertainment that is suitable for individual situations.
R / Focusing attention back, provide stimulation, and increased self-confidence and feeling healthy.
Give the drug prior to activity / exercise that is planned as directed.
R / Increase relaxation, reduce muscle tension / spasm, making it easier to participate in therapy.
Collaboration: Provide drugs according to doctor's instructions.
R / as anti-inflammatory and mild analgesic effect in reducing stiffness and increasing mobility.
Give the ice-cold compress if needed.
R / The cold can relieve pain and swelling during the acute period.

Source : http://nanda-nursing.blogspot.com/2011/03/nursing-diagnosis-for-rheumatoid.html

Nursing Diagnosis - Care Plan for Impaired Physical Mobility

Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.
Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.
Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.
Impaired physical mobility – Related factors arising from within the person include pain or fear of discomfort, anxiety or depression, and physical limitations due to neuromuscular or musculoskeletal impairment. External factors include enforced rest for therapeutic purposes, as in the case of immobilization of a fractured limb. The human body is designed for motion; hence, any restriction of movement will take its toll on every major anatomic system.
Defining Characteristics:

Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation
Reluctance to attempt movement
Limited range of motion (ROM)
Decreased muscle endurance, strength, control, or mass
Imposed restrictions of movement including mechanical, medical protocol, and impaired coordination
Inability to perform action as instructed

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Ambulation: Walking
Joint Movement: Active
Mobility Level

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Exercise Therapy: Ambulation
Joint Mobility
Fall Precautions
Positioning
Bed Rest Care

Expected Outcomes

Patient performs physical activity independently or with assistive devices as needed.
Patient is free of complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, and normal bowel pattern.

Source : http://nursing-interventions.com/nursing-diagnosis-for-impaired-physical-mobility

Nursing Diagnosis - Care Plan for Acute Pain

Nursing Diagnosis for Acute Pain

Definition: 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 less than 6 months
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.
Defining Characteristics
Patient reports pain
Guarding behavior, protecting body part
Self-focused
Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
Facial mask of pain
Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)
Related Factors:
Postoperative pain
Cardiovascular pain
Musculoskeletal pain
Obstetrical pain
Pain resulting from medical problems
Pain resulting from diagnostic procedures or medical treatments
Pain resulting from trauma
Pain resulting from emotional, psychological, spiritual, or cultural distress
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
Comfort Level
Medication Response
Pain Control
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
Analgesic Administration
Conscious Sedation
Pain Management
Patient-Controlled Analgesia Assistance
Expected Outcomes
Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.

Source : http://nursing-interventions.com/nanda-acute-pain-nic-noc

Nursing Care Plan for COPD

Anemia

Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.

The word anemia is taken from a Greek word meaning lack of blood as hemoglobin deficiency prevails in the blood. Hemoglobin present inside the red blood cells normally carries oxygen from lungs to the tissues and anemia causes hypoxia in organs.

Anemia can be mild, moderate, or severe, and this condition can be caused by many different factors. In this condition your body does not have an adequate number of red blood cells present, and if the condition is severe it can lead to serious complications or even be fatal in some cases.

Anemia signs and symptoms are:
1. Paleness
2. Headache
3. Irritability

Symptoms of more severe iron deficiency anaemia include:
1. Dyspnea
2. Rapid heartbeat
3. Brittle hair and nails

Nursing Diagnosis for Anemia

1. Ineffective Tissue Perfusion related to decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.

2. Fatigue related to an imbalance between oxygen supply (delivery) and demand.

3. Risk for infection related to inadequate secondary defenses.

4. Anxiety related to change in health status.

http://blog-nursingcareplan.blogspot.com/2011/04/nursing-care-plan-for-anemia.html

Hyperthermia : Nursing Care Plan - Nursing Diagnosis and Nursing Interventions

Hyperthermia

Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death.

The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.

Hyperthermia can be created artificially by drugs or medical devices. Hyperthermia therapy may be used to treat some kinds of cancer and other conditions, most commonly in conjunction with radiotherapy.

Hyperthermia differs from fever in the mechanism that causes the elevated body temperatures: a fever is caused by a change in the body's temperature set-point.

The opposite of hyperthermia is hypothermia, which occurs when an organism's temperature drops below that required for normal metabolism. Hypothermia is caused by prolonged exposure to low temperatures and is also a medical emergency requiring immediate treatment.

Signs and symptoms

Hot, dry skin is a typical sign of hyperthermia. The skin may become red and hot as blood vessels dilate in an attempt to increase heat dissipation, sometimes leading to swollen lips. An inability to cool the body through perspiration causes the skin to feel dry.

Other signs and symptoms vary depending on the cause. The dehydration associated with heat stroke can produce nausea, vomiting, headaches, and low blood pressure. This can lead to fainting or dizziness, especially if the person stands suddenly.

In the case of severe heat stroke, the person may become confused or hostile, and may seem intoxicated. Heart rate and respiration rate will increase (tachycardia and tachypnea) as blood pressure drops and the heart attempts to supply enough oxygen to the body. The decrease in blood pressure can then cause blood vessels to contract, resulting in a pale or bluish skin color in advanced cases of heat stroke. Some victims, especially young children, may have seizures. Eventually, as body organs begin to fail, unconsciousness and coma will result.

Hyperthermia

Related To :

Infection
Inflammation
Dehydration
CNS Pathology
Exposure to heat/sun
Impaired physical environment
Vigorous activity

Evidenced by :

Temperature over 37.8 C (100 F) orally, or 38.8 C (101 F) rectally.
Malaise/weakness
Loss of appetite
Tachycardia
Shivering/goose pimples
Dehydration
Flushed skin/li>
Warm to touch
Increased respiratory rate

Goal : The patient will : Maintian normal body temperature.

Nursing Interventions :

Administer antipyretics per physician's order.
Remove excess clothing or blankets.
Assess possible etiology of increased temperature.
Encourage fluids when indicated.
Assess temperature q ___ hours.
Provide air condition/fan if appropriate.

NCP for Anemia

Nursing Care Plan for Anemia

Definition of Anemia

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal. The normal level of hemoglobin is generally different in males and females. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the source and the laboratory reference used.

Anemia Symptoms

Clinical symptoms that appear to reflect dysfunction of various systems in the body such as decrease in physical performance, impaired neurologic (nerve), which is manifested in changes in behavior, anorexia (emaciated body), and abnormal cognitive development in children. Often, too, growth abnormality, epithelial dysfunction, and reduced gastric acidity.

An easy way to know anemia with 5 signs: weak, tired, lethargic, tired, negligent. If it appears five of these symptoms, we can be sure a person has anemia. Another symptom is the appearance of sclera (white color on the lower eyelid).

Anemia can cause fatigue, weakness, lack of energy and the head was floating. If the anemia gets worse, can cause a stroke or heart attack.
Source : http://signssymptoms.blogspot.com/2011/04/anemia-symptoms.html

Nursing Assessment for Anemia
Assessment of patients with anemia (Doenges, 1999) include :

Activity / rest
Symptoms :
fatigue, weakness, general malaise. Lost productivity: a reduction in enthusiasm for work. Low exercise tolerance. The need for sleep and rest more.
Signs :
tachycardia / takipnae; dyspnea during work or rest. Lethargy, withdrawn, apathetic, lethargic, and less interested in its surroundings. Muscle weakness, and decreased strength. Ataxia, the body is not upright. Shoulders down, slumped posture, slow, and other signs that indicate fatigue.
Circulation
Symptoms :
A history of chronic blood loss, such as chronic gastrointestinal bleeding, heavy menstruation, angina, CHF (due to excessive cardiac work). History of chronic infective endocarditis. Palpitations (tachycardia compensation).
Signs :
Blood pressure: systolic to diastolic steady improvement, and widening pulse pressure, postural hypotension. Dysrhythmias: ECG abnormality, ST segment depression and T wave leveling or depression; tachycardia. The sound of the heart: systolic murmur. Extremity (color): pale skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and the base of the nail. (Note: in black patients, white may appear to be grayish). Leather like waxy, pale or bright lemon yellow. Sclera: blue or pearly white. Slow capillary filling (decreased blood flow to the capillary and vasoconstriction compensation) nails: easily broken, shaped like a spoon (koilonikia). Hair: dry, easily breaking, thinning, gray hair grow prematurely.
Integrity ego
Symptoms :
Religious beliefs / cultural influence treatment options, such as refusal of blood transfusions.
Signs :
depression.
Elimination
Symptoms :
A history of pyelonephritis, kidney failure. Flatulen, malabsorption syndrome. Hematemesis, stool with fresh blood, melena. Diarrhea or constipation. Decrease in urine output.
Signs :
Abdominal distension.
Food / fluid
Symptoms :
Decreased dietary input. Painful mouth or tongue, difficulty swallowing (pharyngeal ulcers). Nausea / vomiting, dyspepsia, anorexia. The presence of weight loss. Never satisfied to chew or sensitive to ice, dirt, corn flour, paint, clay, and so forth.
Signs :
Tongue looks red meat / subtle deficiency of folic acid and vitamin B12. Dry mucous membranes, pale. Skin turgor: ugly, dry, looks shriveled / lost elasticity. Stomatitis and glositis (deficiency status). Lips: selitis, such as inflammatory lips with the corner of his mouth cracked.
Neurosensori
Symptoms :
Headache, throbbing, vertigo, tinnitus, inability to concentrate. Insomnia, decreased vision, and shadows on the eyes. Weakness, poor balance, unsteady legs, paresthesias hands / feet; klaudikasi. The sensation of being cold.
Signs :
Sensitive to stimuli, anxiety, depression tend to sleep, apathy. Mental: not able to respond, slow and shallow. Ophthalmic: hemoragis retina. Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia, decreased sense of vibration, and position, positive Romberg sign, paralysis.
Pain / comfort
Symptoms: abdominal pain, headache
Breathing
Symptoms :
A history of tuberculosis, lung abscess. Short of breath at rest and activity.
Signs :
Tachypnoea, orthopnea, and dyspnea.
Security
Symptoms :
A history of work exposure to chemicals,. History of exposure to radiation, either to treatment or accident. History of cancer, cancer therapy. Not tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor wound healing, frequent infections.
Signs :
A low fever, chills, night sweats, general lymphadenopathy. Ptekie and ekimosis(aplastic).
Sexuality
Symptoms :
Changes in menstrual flow, such as menorrhagia or amenorrhea. Lost libido (male and female). Imppoten.
Signs :
Pale vaginal walls.

Source : http://ncp-blog.blogspot.com/2011/05/ncp-for-anemia.html

Nursing Diagnosis Intervention