Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Nursing Diagnosis and Interventions   September 19, 2013

Atheroscleros is when the inside of the arteries are thickened, hardened and stiffened, causing the space for blood flow to be narrowed or closed. This will decrease the oxygen supply to local or distant tissues.

Atherosclerosis is a disease of the arterial blood vessels (arteries), in which the walls of the blood vessels become thickened and hardened by "plaques." The plaques are composed of cholesterol and other lipids, inflammatory cells, and calcium deposits.

Cause:

• Coronary Artery Disease -loss of blood to areas of the heart
• Stroke -loss of blood to areas of the brain
• Peripheral Vascular Disease -characterized by leg pain with walking

Symptoms depend on which arteries are affected. For example:

• Coronary (heart) arteries-may cause symptoms of heart disease, such as chest pain
• Arteries in the brain-may cause symptoms of a stroke such as weakness or dizziness
• Arteries in the lower extremities-may cause pain in the legs or feet and trouble walking

Ineffective Tissue perfusion : peripheral

Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Defining Characteristics:

• Edema;
• positive Hoeman's sign;
• altered skin characteristics (hair, nails, moisture);
• weak or absent pulses;
• skin discolorations;
• skin temperature changes;
• altered sensations;
• diminished arterial pulsations;
• skin color pale on elevation, color does not return on lowering the leg;
• slow healing of lesions; cold extremities;
• dependent, blue, or purple skin color

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue perfusion : peripheral related to circulation disorders.

Goal: demonstrate improved perfusion

Outcomes: a peripheral pulse, skin color and temperature is normal, the increase behaviors that increase tissue perfusion.

Nursing Interventions and Rational:

1. Observation of the affected part of skin color.
R /: Skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; skin changes (colorless, shiny / tense).
R /: These changes indicate progress or chronic process.

3. View and examine the skin for ulceration, lesions, areas of gangrene.
R /: Lesions can occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue.

4. Push the right nutrients and vitamins.
R /: The balance of a good diet includes protein and adequate hydration, necessary for healing.

5. Monitior signs of tissue perfusion adequacy.
R /: To know the early signs of impaired perfusion.

6. Encourage the patient performs the exercises, or exercises gradually extremities.
R /: For circulation.

Risk for Infection related to Premature Rupture of Membranes

Risk for Infection related to Premature Rupture of Membranes

Risk for Infection   September 18, 2013

Nursing Care  Plan for Premature Rupture of Membranes

Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins. If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes (PPROM).

PROM occurs in about 8 to 10 percent of all pregnancies. PPROM (before 37 weeks) accounts for one fourth to one third of all preterm births.

The management of PPROM is among the most controversial issues in perinatal medicine. Points of contention include:

• Expectant management versus intervention
• Use of tocolytics
• Duration of administration of antibiotic prophylaxis
• Timing of administration of antenatal corticosteroids
• Methods of testing for maternal/fetal infection
• Timing of delivery.

Risk Factors and Causes:

Certain types of infections appear to be able to cause preterm PROM, and in rare cases procedures such as amniocentesis can cause PROM, but researchers do not believe there is a single cause of the condition. The following are some known risk factors:

• Lower socioeconomic status
• history of PPROM
• bleeding during pregnancy
• Smoking
• Prior preterm birth
• Sexually transmitted diseases
• Multiple pregnancy
• Polyhydramnios

The following are the most common symptoms of PROM. However, each woman may experience symptoms differently. Symptoms may include:

• Leaking or a gush of watery fluid from the vagina
• Constant wetness in underwear

If you notice any symptoms of PROM, be sure to call your doctor as soon as possible. The symptoms of PROM may resemble other medical conditions. Consult your doctor for a diagnosis.


Nursing Diagnosis for Premature Rupture of Membranes : Risk for Infection related to invasive procedures, recurrent vaginal examination, and amniotic membrane rupture.

Goal: maternal infection does not occur

Expected outcomes: Mother states / shows are free of any signs of infection.

Nursing Interventions for Premature Rupture of Membranes:

1. Perform initial vaginal examination, when the contraction pattern repeat, or maternal behavior indicates progress.
R /: Repeated vaginal examinations play a role in the incidence of ascending tract infections.

2. Monitor temperature, pulse, respiration, and white blood cells as indicated.
R /: Within 4 hours after membrane rupture, chorioamnionitis incidence increased progressively in accordance with the time indicated by vital signs.

3. Give prophylactic antibiotics when indicated.
R /: Antibiotic may protect against the development of chorioamnionitis in women at risk.

Disturbed Sleep Pattern related to Alzheimer's Disease

Disturbed Sleep Pattern related to Alzheimer's Disease

Nursing Diagnosis and Interventions   September 17, 2013

Nursing Care Plan for Alzheimer's Disease - Nursing Diagnosis : Disturbed Sleep Pattern

Alzheimer's disease is the most common form of dementia. Dementia is a group of symptoms associated with a decline in the way the brain functions, affecting the memory and the way behave. There is no cure for the disease, which worsens as it progresses, and eventually leads to death. Early symptoms are often mistakenly thought to be 'age-related' concerns, or manifestations of stress. In the early stages, the most common symptom is difficulty in remembering recent events.

As the disease advances, symptoms can include confusion, irritability, aggression, mood swings, trouble with language, and long-term memory loss. As the sufferer declines they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. Since the disease is different for each individual, predicting how it will affect the person is difficult. AD develops for an unknown and variable amount of time before becoming fully apparent, and it can progress undiagnosed for years.

The cause and progression of Alzheimer's disease are not well understood. Research indicates that the disease is associated with plaques and tangles in the brain. There are no available treatments that stop or reverse the progression of the disease.

Because AD cannot be cured and is degenerative, the sufferer relies on others for assistance. The role of the main caregiver is often taken by the spouse or a close relative. Alzheimer's disease is known for placing a great burden on caregivers; the pressures can be wide-ranging, involving social, psychological, physical, and economic elements of the caregiver's life. In developed countries, AD is one of the most costly diseases to society.

Disturbed Sleep Pattern

Time-limited disruption of sleep (natural periodic suspension of consciousness)

Defining Characteristics:

• Prolonged awakenings;
• sleep maintenance insomnia;
• self-induced impairment of normal pattern;
• sleep onset >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 (e.g., hyporesponsiveness, excess sleepiness, decreased motivation);
• decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional lability, agitation and impulsivity, atypical polysomnographic features);
• decreased ability to function

Nursing Diagnosis for Alzheimer's Disease : Disturbed Sleep Pattern related to changes in sensory

Goal: changes in sleep patterns can be resolved client

Outcomes:

• No changes in behavior and appearance (restless).
• Able to create adequate sleep patterns with a decrease of the mind hovering (daydreaming).
• Able to determine the cause of inadequate sleep.

Nursing Interventions:

1. Provide a comfortable environment for improving sleep (turn off the lights, ventilation adequate space, suitable temperature, avoid noise).
R /: Constraints on cortical reticular information will be reduced during sleep, improving the automatic response, thus increasing cardiovascular response to noise during sleep.

2. Encourage exercise during the day and lower mental activity / physical in the afternoon.
R /: Physical activity and mental fatigue that lead to long can increase confusion, which is programmed activities without excessive stimulation increased sleep time.

3. Give afternoon snacks, warm milk, bath, and massage the patient's back.
R /: Improve relaxation with drowsiness.

4. Lower the number of drinks the afternoon. Voiding before bed.
R /: Reduce the need for up to urinate during the night.

5. Encourage clients to listen to soft music.
R /: Lowering the sensory stimulation by blocking other sounds from the surrounding environment that would inhibit sleep.

Acute Pain related to Atherosclerosis

Acute Pain related to Atherosclerosis

Nursing Diagnosis and Interventions   September 17, 2013

Nursing Care Plan for Atherosclerosis - Nursing Diagnosis : Acute Pain

Atherosclerosis is an inflammation in human blood vessels, which caused accumulation of atheromatous plaque.

Atherosclerosis (also known as arteriosclerotic vascular disease or ASVD) is a specific form of arteriosclerosis in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol and triglyceride.

Atherosclerosis is a chronic disease that remains asymptomatic for decades. Atherosclerotic lesions, or atherosclerotic plaques are separated into two broad categories: Stable and unstable (also called vulnerable).

Clinically, atherosclerosis is typically associated with men over the age of 45. Sub-clinically, the disease begins to appear at early childhood, and perhaps even at birth. Noticeable signs can begin developing at puberty. Though symptoms are rarely exhibited in children, early screening of children for cardiovascular diseases could be beneficial to both the child and his/her relatives.


Acute Pain

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 less than 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.


Nursing Diagnosis for Atherosclerosis : Acute Pain related to impaired ability of blood vessels to supply oxygen to the tissues.

Having given nursing care, is expected to decrease pain, with outcomes: patient states; chest pain disappear or be in control, the patient does not seem grimace, demonstrate relaxation techniques.

Nursing Intervention

1. Monitor the characteristics of pain through verbal response, and hemodynamics (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
R /: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the picture of pain experienced by patients include: place, intensity, duration, quality, and distribution.
R /: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other diseases, so we get accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
R /: Helps reduce external stimuli that can add to the tranquility so that the patient can rest and the heart does not work too hard.

4. Teach relaxation techniques with a deep breath
R /: Helps relieve pain experienced by the patient psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
R /: They can cause respiratory depression and hypotension.

Ineffective Breathing Pattern related to Pleural Effusion

Ineffective Breathing Pattern related to Pleural Effusion

Pulmonary Nursing   September 16, 2013

Nursing Care Plan for Pleural Effusion - Nursing Diagnosis : Ineffective Breathing Pattern

Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura.

Some of the more common causes are:

• Congestive heart failure
• Pneumonia
• Liver disease (cirrhosis)
• End-stage renal disease
• Nephrotic syndrome
• Cancer
• Pulmonary embolism
• Lupus and other autoimmune conditions

Other less common causes of pleural effusion include:

• Tuberculosis
• Autoimmune disease
• Bleeding (due to chest trauma)
• Chylothorax (due to trauma)
• Rare chest and abdominal infections
• Asbestos pleural effusion (due to exposure to asbestos)
• Meig’s syndrome (due to a benign ovarian tumor)
• Ovarian hyperstimulation syndrome

Symptoms of pleural effusion include:

• Chest pain
• Dry, nonproductive cough
• Dyspnea (shortness of breath, or difficult, labored breathing)
• Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect)

Ineffective Breathing Pattern

Definition : Inspiration and/or expiration that does not provide adequate ventilation

Defining Characteristics :

• Accessory muscle use
• Abnormal heart rate response to activity
• Altered respiratory rate or depth or both
• Assumption of 3-point position
• Decreased minute ventilation
• Decreased vital capacity
• Decreased tidal volume
• Dyspnea
• Nasal flaring
• Prolonged expiratory phase
• Pursed lip breathing

Nursing Diagnosis for Pleural Effusion : Ineffective Breathing Pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, inflammatory process.

Possibility evidenced by:

• dyspnoea, 
• tachypnea, 
• respiratory depth changes, 
• use of accessory muscles, 
• impaired development of the chest, 
• cyanosis, 
• abnormal blood gas analysis.

Goal: Effective breathing pattern

Outcomes:

• Showed normal breathing pattern / effective with normal blood gas analysis.
• Free cyanosis and signs of hypoxia symptoms.

Nursing Intervention:

1. Identify the etiology or trigger factor.
2. Evaluation of respiratory function (rapid breathing, cyanosis, changes in vital signs).
3. Auscultation of breath sounds.
4. Note the position of the trachea and chest development, review fremitus.
5. Maintain a comfortable position is usually the head of the bed elevated.
6. Give oxygen via cannula / mask
7. When the chest tube is installed:
   • check the vacuum controller, liquid limit.
   • Observation of air bubbles bottle container.
   • Hose clamp on the bottom of the drainage in the event of a leak.
   • Keep an eye on the ebb and flow of water reservoir.
   • Note the character / number of chest tube drainage.

Deficient Knowledge related to Herniated Nucleus Pulposus

Deficient Knowledge related to Herniated Nucleus Pulposus

Nursing Diagnosis and Interventions   September 16, 2013

Nursing Care Plan for Herniated Nucleus Pulposus - Nursing Diagnosis : Deficient Knowledge

Definition
A herniated disc is a fragment of the disc nucleus which is pushed out of the outer disc margin, into the spinal canal through a tear or "rupture." In the herniated disc's new position, it presses on spinal nerves, producing pain down the accompanying leg. This produces a sharp, severe pain down the entire leg and into the foot. The spinal canal has limited space which is inadequate for the spinal nerve and the displaced herniated disc fragment.

The compression and subsequent inflammation is directly responsible for the pain one feels down the leg, termed "sciatica." The direct compression of the nerve may produce weakness in the leg or foot in a specific patter, depending upon which spinal nerve is compressed.

A herniated disc is a definite displaced fragment of nucleus pushed out through a tear in the outer layer of the disc (annulus). For a disc to become herniated, it typically is in an early stage of degeneration.


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 Herniated Nucleus Pulposus : Deficient Knowledge : about the condition, prognosis and actions related to misinformation, misinterpretation, given the lack of information, not to know the sources of information.

Goal: The Client acknowledges, understands, about the condition, prognosis and actions to be taken.

Outcomes:

• Clients can express understanding of the condition, prognosis and action.
• Doing back lifestyle changes.
• Participate in the rule action.

Nursing Interventions:

1). Describe the process of disease and prognosis as well as restrictions on activities such as driving a vehicle in avoiding long periods of time.

2). Provide information about a variety of things as well as instruct patients to make changes "body dynamics" without the help and also do exercises including information about its own body mechanics to stand, lift and use of ancillary shoes.

3). Discuss the treatment and some side effects.

4). Suggest to use the board / mat hard. Small pillows were a little flat in the bottom of the neck, side sleeping position with knees flexed avoid prone.

5). Discuss dietary needs.

6). Avoid the use of heating preformance long time.

7). Refer back to the use of a soft neck collar.

8). Suggest to conduct regular medical evaluation.

9). Provide information about signs that need to be reported at the next evaluation as puncture pain, loss of sensation / ability to walk.

10). Assess the likelihood to alternative treatments such as chemonucleolysis, surgical intervention.