Tuesday, September 10, 2013

Disturbed Sensory Perception (visual) related to Glaucoma

Nursing Care Plan for Glaucoma - Nursing Diagnosis : Disturbed Sensory Perception (visual)

Glaucoma is a group of eye disorders leading to progressive damage to the optic nerve, and is characterized by loss of nerve tissue resulting in loss of vision. The optic nerve is a bundle of about one million individual nerve fibers and transmits the visual signals from the eye to the brain. The most common form of glaucoma, primary open-angle glaucoma, is associated with an increase in the fluid pressure inside the eye. This increase in pressure may cause progressive damage to the optic nerve and loss of nerve fibers. Vision loss may result. Advanced glaucoma may even cause blindness. Not everyone with high eye pressure will develop glaucoma, and many people with normal eye pressure will develop glaucoma. When the pressure inside an eye is too high for that particular optic nerve, whatever that pressure measurement may be, glaucoma will develop.

Glaucoma is the leading cause of blindness among Hispanics.

There are many types of glaucoma and many theories about the causes of glaucoma. The exact cause is unknown. Although the disease is usually associated with an increase in the fluid pressure inside the eye, other theories include lack of adequate blood supply to the nerve.

Disturbed Sensory Perception

Disturbed Sensory Perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)

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

Nursing Diagnosis for Glaucoma : Disturbed Sensory Perception (visual) related to impaired sensory reception: impaired organ status.

Goal: The use of optimum vision.

Outcomes:
  • Maintain visual acuity field without further loss.
Nursing Interventions :


1. Make sure the degree or type of vision loss.
R /: Affect and the patient's expectations of future intervention options.

2. Encourage the patient to express feelings of loss / likely loss of vision.
R /: While early intervention to prevent blindness, patients face the possibility of experience or experience partial or total vision loss. Although vision loss has occurred can not be repaired (although with treatment), deprived of further preventable.

3. Show giving eye drops, droplets counting example, follow a schedule, not one dose.
R /: Controlling IOP, prevent further vision loss.

Deficient Fluid Volume related to Diabetic Ketoacidosis

Nursing Care Plan for Diabetic Ketoacidosis - Nursing Diagnosis : Deficient Fluid Volume

Diabetic ketoacidosis is a state of emergency or acute Type I diabetes, is caused by the increased acidity of the body of ketone bodies due to deficiency or insulin deficiency, characterized by hyperglycemia, acidosis, and ketones due to a lack of insulin (Stillwell, 1992).

Diabetic ketoacidosis is often the first sign of type 1 diabetes in people who do not yet have other symptoms. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin, or surgery can lead to diabetic ketoacidosis in people with type 1 diabetes.

Most cases of diabetic ketoacidosis occur in people with type 1 diabetes, although it can also be a complication of type 2 diabetes.

Symptoms of diabetic ketoacidosis include:
  • Deep, rapid breathing
  • Dry skin and mouth
  • Flushed face
  • Fruity smelling breath
  • Nausea and vomiting
  • Stomach pain

Deficient Fluid Volume

Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)

Defining Characteristics:
  • Decreased urine output;
  • increased urine concentration;
  • weakness;
  • sudden weight loss (except in third-spacing);
  • decreased venous filling;
  • increased body temperature;
  • decreased pulse volume/pressure;
  • change in mental state;
  • elevated hematocrit;
  • decreased skin/tongue turgor;
  • dry skin/mucous membranes;
  • thirst;
  • increased pulse rate;
  • decreased blood pressure


Nursing Diagnosis for Diabetic Ketoacidosis : Deficient Fluid Volume related to excessive secretion of fluid (osmotic diuresis) due to hyperglycemia

Outcomes:
  • Vital signs within normal limits
  • Peripheral pulse can be palpated
  • Skin turgor and capillary refill good
  • Balance urine output
  • Normal electrolyte levels

Nursing Intervention:
  • Observation of input and output of fluids every hour.
  • Observation drip infusion.
  • Monitor vital signs and level of consciousness every 15 minutes, if stable continue for every hour.
  • Observation of skin turgor, mucous membranes, acral, capillary refill
  • Monitor results of laboratory tests: hematocrit, BUN / creatinine, blood osmolarity, sodium, potassium.
  • EKG monitor.
  • CVP monitoring (when used).
  • Collaboration with other health team:
  • Parenteral fluid administration : Giving insulin therapy, Catheter urine, CVP installation if possible

Monday, September 9, 2013

Impaired Physical Mobility related to Herniated Nucleus Pulposus

Nursing Care Plan for Herniated Nucleus Pulposus - Nursing Diagnosis : Impaired Physical Mobility

HNP, or a herniated nucleus pulposus, is the more medically oriented term for what most people refer to as a “herniated disc.” The nucleus pulposus is the gel-like inner material found within the thick, outer wall of each intervertebral disc, which are soft, sponge-like bodies responsible for providing support and flexibility along the entire length of the spine. Due to the gradual deterioration of these discs over time as part of the natural aging process, these discs develop a tear and the nucleus pulposus can push through the disc wall and extrude into the spinal canal – a condition known as a herniated nucleus pulposus.


Impaired Physical Mobility

A limitation in independent, purposeful physical movement of the body or of one or more extremities

Defining Characteristics:
  • Postural instability during performance of routine activities of daily living (ADLs);
  • limited ability to perform gross motor skills;
  • limited ability to perform fine motor skills;
  • uncoordinated or jerky movements;
  • limited range of motion;
  • difficulty turning;
  • decreased reaction time;
  • movement-induced shortness of breath;
  • gait changes (e.g., decreased walking speed, difficulty initiating gait, small steps, shuffles feet, exaggerated lateral postural sway);
  • engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on preillness/predisability);
  • slowed movement;
  • movement-induced tremor


Nursing Diagnosis for Herniated Nucleus Pulposus : Impaired Physical Mobility
related to pain and discomfort, muscle spasm restrictive therapy. For example: bed rest, neurovascular damage.
Goal: No impairment of physical mobility.

Outcomes:
  • Clients expressed understanding of the situation / risk factors and individualized treatment rules.
  • Demonstrate behavioral techniques.
  • Maintain or improve the strength and function of body parts affected and or compensation.

Nursing Intervention:
  1. Provide protective measures as indicated by the specific situation.
  2. Note the emotional response / behavior on immobilization. Provide appropriate activities with patients.
  3. Follow the activities / procedures with rest methods. Instruct the patient to participate in regular daily activities within individual limitations.
  4. Help the patient to perform range of motion exercises active or passive.
  5. Instruct the patient to train the lower leg / knee. Value of the edema, erytema the lower extremities.
  6. Assist patients in performing activities of progressive ambulation.
  7. Demonstrate the use of auxiliary equipment such as a walker, cane.
  8. Provide good skin care, massage pressure points after each change of position. Check the state of the skin under the brace, with a specific time period.

Urinary Retention related to Benign Prostatic Hyperplasia (BPH)

Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.

BPH involves hyperplasia (an increase in the number of cells) rather than hypertrophy (a growth in the size of individual cells), but the two terms are often used interchangeably, even amongst urologists.

Urinary retention

Incomplete emptying of the bladder

Defining Characteristics:

Measured urinary residual >150 to 200 ml or 25% of total bladder capacity;
obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying);
irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia);
overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)


Nursing Care Plan for Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis : Urinary Retention related to mechanical obstruction, enlarged prostate, decompensated detrusor muscle.

Goal:
  • Urination by a considerable amount, with no palpable bladder.
  • Shows post-voiding residual of less than 50 ml in the absence of droplets / excess flow.

BPH Nursing Intervention and Rational:

1. Encourage clients to urinate every 2 to 4 hours.
R /: Minimizing excessive retention of urine in the bladder.

2. Observation of the flow of urine. Note the size of the force.
R /: Useful for evaluating obstruction and intervention options.

3. Supervise and record time, the number of each micturition. Note the decrease in spending and changes in urine specific gravity.
R /: Urinary retention increases the pressure in the upper urinary tract that can affect the kidneys.

4. Encourage drinking water to 3000 ml / day.
R /: Increased flow of fluid to maintain renal perfusion and kidney cleanse, bladder from bacterial growth.

5. Perform catheterization and perianal care.
R /: Reduce the risk of ascending infection.

Sunday, September 8, 2013

Acute Pain related to Gastritis

Nursing Care Plan for gastritis - Nursing Diagnosis : Acute Pain

Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter pylori, chronic bile reflux, and stress; certain autoimmune disorders can cause gastritis as well. The most common symptom is abdominal upset or pain. (wikipedia)

Acute Pain

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 less than less than 6 months.

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.


Nursing Diagnosis for Gastritis : Acute Pain related to inflammation of the mucosal lining of the stomach (gastric)

Goal: Pain is reduced with no inflammation or irritation of the gastric mucosa

Outcomes:

  • Pain scale is reduced
  • Do not feel pain in the epigastric.
  • Not grimace (no abdominal tenderness)

Gastritis Nursing Interventions and Rational:

1. Record complaints of pain, including the location, duration, intensity (scale of 0-10)
R /: Pain is not always there, but if there is to be compared with the previous patient's symptoms of pain, which can help diagnose the etiology and occurrence of bleeding complications.

2. Review the factors that increase or decrease pain.
R /: Assist in making diagnoses and treatment needs.

3. Give food a little but often as an indication for patients.
R /: Food has the effect of neutralizing acid, also destroy the gastric contents. Eating little to prevent distension.

4. Assistive range of motion exercises active / passive.
R /: Reduce joint stiffness, pain minimize discomfort.

5. Provide frequent oral care and comfort measures (back massage, change of positions).
R /: Bad breath due to retained secretions, causing no appetite and can increase nausea. Gingivitis and dental problems can be improved.

6. Give medications as indicated.
R /: Lowering the acidity of gastric absorption or by neutralizing chemical.

Gastritis - Definition, Classification, Pathophysiology and Prevention

Risk for Impaired Skin integrity related to Diarrhea

Diarrhea is a condition that is classified as the appearance of loose, watery stools and/or a frequent need to go to the bathroom.

Diarrhea may be related to a viral or bacterial infection and is sometimes the result of food poisoning. The condition commonly known as traveler’s diarrhea occurs when you’ve been exposed to bacteria or parasites while on vacation to developing countries. (healthline.com)


Impaired Skin integrity

Altered epidermis and/or dermis

Defining Characteristics:
  • Invasion of body structures;
  • destruction of skin layers (dermis);
  • disruption of skin surface (epidermis)


Nursing Care Plan for Diarrhea - Nursing Diagnosis : Risk for Impaired Skin integrity :perianal related to increased frequency of bowel movements (diarrhea)

Goal: Impaired skin integrity is resolved

Outcomes:
  • Integrity of the skin returns to normal
  • No irritation

Interventions and Rational :

1. Assess skin damage / irritation every bowel movement.
R /: Knowing how much damage.

2. Discuss and explain the importance of keeping the beds.
R /: Environmental cleanliness and beds, can reduce the irritation and infection.

3. Demonstrate and involve families in caring for perianal (when wet, and dressed down as well as the base).
R /: Humid temperatures accelerate the irritation.

4. Adjust the position or sitting with 2-3 hour intervals.
R /: Position adjustment can help improve comfort.

Deficient Fluid Volume related to Diarrhea

Nursing Care Plan for Diarrhea - Nursing Diagnosis : Deficient Fluid Volume


Diarrhea is the condition of having three or more loose or liquid bowel movements per day. The most common cause is gastroenteritis.

Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person.

Deficient Fluid Volume

Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)

Defining Characteristics:
  • Decreased urine output;
  • increased urine concentration;
  • weakness;
  • sudden weight loss (except in third-spacing);
  • decreased venous filling;
  • increased body temperature;
  • decreased pulse volume/pressure;
  • change in mental state;
  • elevated hematocrit;
  • decreased skin/tongue turgor;
  • dry skin/mucous membranes;
  • thirst;
  • increased pulse rate;
  • decreased blood pressure


Nursing Diagnosis for Diarrhea : Deficient Fluid Volume related to frequent bowel movements

Goal:
  • Fluid balance can be maintained within normal limits.
  • Maintain adequate fluid volume.
  • Fluid and electrolyte deficits can be resolved.

Outcomes:
  • Mucous membranes moist
  • Good skin turgor
  • Input and output balanced

Diarrhea Nursing Interventions and Rational :

1. Observation of vital signs
R /: hypotension, tachycardia, fever may indicate a response to and / or the effects of fluid loss.

2. Observation for signs of dehydration.
Rapid population feces through the intestine reducing the absorption of low circulating volume of water causes mucous membrane dryness and thirst. Concentrated urine specific gravity has increased.

3. Appropriate laboratory examination program; electrolytes, hematocrit, pH, serum albumin.
R /: Determine the need and effectiveness of replacement therapy.
Give medications as indicated: Anti-diarrhea

4. Provision of appropriate fluid and electrolyte therapy program.
R /: Maintaining bowel rest will require replacement to correct fluid loss / anemia.

5. Administration of drugs as indicated.

Followers