Saturday, September 7, 2013

Decreased Cardiac output related to Hypertension

Nursing Care Plan for Hypertension - Nursing Diagnosis : Decreased Cardiac output



Hypertension is the term used to describe high blood pressure.

Blood pressure is a measurement of the force against the walls of your arteries as your heart pumps blood through your body.

Blood pressure readings are usually given as two numbers -- for example, 120 over 80 (written as 120/80 mmHg). One or both of these numbers can be too high.

The top number is called the systolic blood pressure, and the bottom number is called the diastolic blood pressure.
  • Normal blood pressure is when your blood pressure is lower than 120/80 mmHg most of the time.
  • High blood pressure (hypertension) is when your blood pressure is 140/90 mmHg or above most of the time.
  • If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.(nlm.nih.gov)

Decreased Cardiac output

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;
  • S3 or S4 sounds;
  • behavioral/emotional: anxiety;
  • restlessness

Nursing Diagnosis for Hypertension : Decreased Cardiac output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy

Goal: Clients want to participate in activities that lower blood pressure / cardiac workload

Outcomes:
  • Blood pressure within an acceptable range of individuals.
  • Rhythm and heart rate stabilized in the normal range.

Hypertension Nursing Interventions and Rational :


1. Monitor your blood pressure . Measure in both arms / thighs for initial evaluation . Use the proper cuff size and accurate technique .
R / : Comparison of pressure gives a more complete picture of the involvement / field of vascular problems.

2 . Note the presence , quality of central and peripheral pulses .
R / : pulse on the carotid , jugular , radial and femoral probably observed / palpable . Pulse in the legs may be decreased , reflecting the effect of vasoconstriction ( increased SVR ) and venous congestion .

3 . Auscultation of the heart tone , and breath sounds .
R / : S4 commonly heard in patients with severe hypertension due to atrial hypertrophy ( increase in volume / pressure atrium ) . Development S3 , showed ventricular hypertrophy and malfunction . Cracles existence , wheezing may indicate pulmonary congestion secondary to the occurrence or chronic heart failure .

4 . Observe skin color , moisture , temperature , and capillary refill time .
R / : The pale , cool , moist skin and slow capillary refill time may be related to vasoconstriction or reflect decompensation / decrease in cardiac output .

5. Note the general edema / specific.
R /: May indicate heart failure, kidney or vascular damage.

6. Provide a quiet, comfortable, reduce, activity / environment commotion, limit the number of visitors and length of stay.
R /: Helps to reduce sympathetic stimulation; increase relaxation.

7. Maintain restrictions on activities, such as, resting in bed / chair; schedule rest periods without interruption; aids patients perform self-care activities as needed.
R /: Reduce stress and tension that affect blood pressure and hypertensive disease course.

8. Perform actions that comfortable, such as., Back and neck massage, elevating the head of the bed.
R /: Reduce discomfort and can reduce sympathetic stimulation.

9. Encourage relaxation techniques, manual imagination, vision activities.
R /: to reduce stress design, create a calming effect, so it will decrease blood pressure.

10. Monitor response to medication to control blood pressure.
R /: response to drug therapy "stepped" (which consisted of diuretics, sympathetic inhibitors, and vasodilators) depends on the individual and synergistic effects of the drug. Because of these side effects, it is important to use the drug in the least amount and lowest doses.

Friday, September 6, 2013

Deficient Knowledge related to Laparotomy

Nursing Care Plan for Laparotomy - Nursing Diagnosis : Deficient Knowledge


A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as celiotomy. (wikipedia)

Deficient Knowledge

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)


Nursing Diagnosis for Laparotomy : Deficient Knowledgerelated to lack of information, do not know the source of information.

Outcomes:
  • Reveals an understanding of the disease process and treatment.

Interventions and Rational :

1. Review the procedure and postoperative expectations.
R /: To provide basic knowledge of where the patient can make an informed choice.

2. Discuss the importance of adequate fluid intake, dietary needs.
R /: Increases healing and normalization of bowel.

3. Demonstrate belutan wound care or appropriate.
R /: Increases healing, reduce the risk of infection, providing an opportunity to observe the wound.

4. Revisit gastrotomi hose care when the patient is discharged with this tool.
R /: Increase the independence, improve self-care skills.

5. Identify signs that require medical evaluation, fever settled, swelling, erythema, artau opening the wound edges, change drainage characteristics.
R /: Early recognition of complications and immediate intervention can prevent progression of the situation serious, life-threatening.

6. Encourage gradual increase in activity in accordance tolernsi and balance with adequate rest periods.
R /: Prevent fatigue, stimulate circulation and normalizing organ function, improve healing.

Anxiety related to Laparotomy

Nursing Care Plan for Laparotomy - Nursing Diagnosis : Anxiety


A laparotomy is a surgical incision (cut) into the abdominal cavity. This operation is performed to examine the abdominal organs and aid diagnosis of any problems, including abdominal pain. In many cases, the problem – once identified – can be fixed during the laparotomy. In other cases, a second operation is required. Another name for laparotomy is abdominal exploration.

Anxiety

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


Nursing Diagnosis for Laparotomy : Anxiety related to surgical procedure, preoperative procedures.

Outcomes:
  • Patients will demonstrate the ability focus on new knowledge and skills.
  • Identification of symptoms as an indicator of anxiety itself.
  • Showed no aggressive behavior.
  • Communicating and handling negative feelings appropriately.
  • Relaxed and comfortable in the move.

Interventions and Rational :
1. Monitor patient's signs and symptoms of anxiety while nursing assessment.
R /: Assessment of patients with anxiety conditions carefully allows nurses to make nursing priorities.

2. Focus discussion on stressors that affect the condition of the patient.
R /: Focus discussion facilitates the ability of the patient to express fears and feelings are felt and build a therapeutic relationship.

3. Discuss the patient's perception will be a surgical procedure, the fear associated with the operation.
R /: Discussion will make the patient's perception and fear to express themselves and explore self-knowledge.

4. Provide information procedure before surgery, the patient's illness and surgery preparation
R /: Measures to increase knowledge and anxiety reduction.

Followers