CAD is the most common type of heart disease. Lifestyle changes, medicines, and/or medical procedures can effectively prevent or treat CAD in most people. Other names for Coronary Artery Disease are Atherosclerosis, Coronary heart disease, Hardening of the arteries, Heart disease, Ischemic heart disease, and Narrowing of the arteries.

1 Decreased Cardiac Output

Cad causes narrowing of blood vessels. This condition leads to intense pressure exerted on the walls of the blood vessels. The body’s compensatory mechanism is to increase the work load of the heart and thus the patient has decreased cardiac output.

5 Coronary Artery Disease Nursing Care Plans Original source at: Nurseslabs

Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum hemorrhage (vaginal bleeding). It affects approximately 0.5% of all labors.

Read our Placenta Previa Nursing Care Plans below

1 Deficient Fluid Volume

Fluid volume deficit is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active Blood Loss or Hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death.

3 Placenta Previa Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/3-placenta-previa-nursing-care-plans/feed/ 0 http://nurseslabs.com/10-chronic-obstructive-pulmonary-disease-bronchitis-nursing-care-plans/ http://nurseslabs.com/10-chronic-obstructive-pulmonary-disease-bronchitis-nursing-care-plans/#comments Tue, 24 Jan 2012 17:32:54 +0000 NursesLabs http://nurseslabs.com/?p=985 Chronic Obstructive Bronchitis is an inflammation of the bronchi (chronic obstructive bronchitis) causes increase mucus production and chronic cough.

10 Chronic Obstructive Pulmonary Disease: Bronchitis Nursing Care Plans Original source at: Nurseslabs

]]> Chronic Obstructive Bronchitis is an inflammation of the bronchi (chronic obstructive bronchitis) causes increase mucus production and chronic cough. The clinical manifestations of Chronic Bronchitis continue for at least 3 months of the year for 2 consecutive years. Chronic bronchitis is also known the blue bloater. It is characterized by the following:

• An increase in the size and number of submucous glands in the large bronchi which causes increase mucus production
• An increased number of globlet cells, which also secrete mucus
• Impaired ciliary function, which reduces mucus clearance

1 Ineffective Airway Clearance

COPD is an inflammatory response to the offending microorganism. The defense mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile respiratory tract, as a result inflammation develops. The inflammation and increased secretions make it difficult to maintain a patent airway.

Assessment	Nursing Diagnosis	Planning	Nursing Inter­ventions	Rationale	Expected Outcome
S:ÆO: The may patient manifest the ffg.:>with wheezes/crackles upon auscultation on the BLF >with subcostal retraction >with nasal flaring >presence of non-productive cough >increase RR above normal range	Ineffective airway clearance related to retained and excessive secretions and ineffective coughing	Short term:After 4-5 hours of nursing interventions the patient will demonstrate effective clearing of secretions.Long term:After 2 days of nursing interventions, the patient will maintain effective airway clearance.	>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S>Position head midline with flexion on appropriate for age/condition >Elevate HOB >Observe S/Sx of infections >Auscultate breath sounds & assess air mov’t >Instruct the patient to increase fluid intake >Demonstrate effective coughing and deep-breathing techniques. >Keep back dry >Turn the patient q 2 hours >Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage. >Administer bronchodilators if prescribed.	>To gain trust and active participation>To know the condition of the pt>To have a baseline data.>To gain or maintain open airway >To decrease pressure on the diaphragm and enhancing drainage >To identify infectious process >To ascertain status & note progress >To help to liquefy secretions. >To maximize effort >To prevent further complications >To prevent possible aspirations >These techniques will prevent possible aspirations and prevent any untoward complications >More aggressive measures to maintain airway patency.	Short term:The patient shall have demonstrated effective clearing of secretions.Long term:The patient shall have maintained effective airway clearance.

2 Ineffective Breathing Pattern

The presence of microorganisms in the lungs causes body to increase the secretory activity of goblet cells to get rid of the invading organism but the mechanism is not enough which allows the stasis of mucus secretion leading to ineffective breathing pattern.

Assessment	Nursing Dx	Planning	NursingInter­ventions	Rationale	Expected Outcome
S: Reports of dyspneaO:  The patient may manifest the manifest the ffg.:> with wheezes /crackles upon auscultation on BLF> increase RR above normal range >presence of productive cough >use of accessory muscle when breathing >presence of nasal flaring and retractions	Ineffective breathing pattern related to retained mucus secretions	Short term:After 4-5 hours of nursing interventions the patient will improve breathing pattern.Long term:After 2 days of nursing interventions the patient will maintain a respiratory rate within normal limits.	>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S especially RR>Provide rest periods >Place pt in semi-fowlers position >Increase fluid intake >Keep patient back dry >Change position every 2 hours >Perform CPT >Place a pillow when the client is sleeping >Instruct  how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate >Maintain a patent airway, suctioning of secretions may be done as ordered >Provide respiratory support. Oxygen inhalation is provided per doctor’s order >Administer prescribed cough suppressants and analgesics and be cautious, however, because opioids may depress respirations more than desired.	>To gain trust and active participation>To know the condition of the pt>To have a baseline data.>To reduce fatigue and obtain rest >To have a maximum lung expansion >To liquefy secretions >To avoid stasis of secretions and avoid further complication >To facilitate secretion mov’t and drainage >To loosen secretion >To provide adequate lung expansion while sleeping. >To promote physiological ease of maximal inspiration >To remove secretions that  obstructs the airway >To aid in relieving patient from dyspnea >To promote deeper respirations and cough	Short term:The patient shall have improved breathing pattern.Long term:The patient shall have maintained a respiratory rate within normal limits.

3 Impaired Gas Exchange

The disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection leading to inflammation and accumulation of secretions. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively.

Assessment	Nursing Dx	Planning	NursingInter­ventions	Rationale	Expected Outcome
S:ÆO: The patient may manifest the ffg.:>Appearance of bluish extremities when in cough (cyanosis), lips>Lethargy >Restlessness >Hypercapnea >Hypoxemia >Abnormal rate, rhythm, depth of breathing >Diaphoresis	Impaired gas exchange related to altered oxygen	Short term:After 4-5 hours of nursing interventions the patient will improve ventilation and adequate oxygenation of tissuesLong term:After 2 days of nursing interventions the patient will minimize or totally be free of symptoms of respiratory distress.	>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S>Monitor level of consciousness or mental status >Assist the client into the High-Fowlers position >Increase patient’s fluid intake >Encourage expectoration >Encourage frequent position changes >Encourage adequate rest & limit activities to within client tolerance >Promote calm/restful environments >Administer supplemental oxygen judiciously as indicated >Administer meds as indicated such as bronchodilators	>To gain trustand active participation>To know the condition of the pt>To have a baseline data. >Restlessness, anxiety, confusion, somnolence are common manifestation of hypoxia and hypoxemia. >The upright position allows full lung excursion and enhances air exchange >To help liquefy secretions >To eliminate thick, tenacious, copious secretions which contribute for the impairment of gas exchange. >To promote drainage of secretions >Helps limit oxygen needs/consumption >To correct/improve existing deficiencies >May correct or prevent worsening of hypoxia. >To treat the underlying condition	Short term:The patient shall have improved ventilation and adequate oxygenation of tissuesLong term:The patient shall have minimized or totally be free of symptoms of respiratory distress.

4 Sleep Pattern Disturbance

COPD patients need a comfortable position such as the High-Fowler’s position during sleeping in order to promote lung expansion. Lying flat on bed promotes the occurrence of DOB and makes the patient uncomfortable due to the impaired alveolar ventilation which the body processes at night can’t be controlled

Assessment	Nursing Dx	Planning	NursingInter­ventions	Rationale	Expected Outcome
S:ÆO: The patient may manifest the ffg.:>irritability>restlessness >lethargy >changes in posture >difficulty of breathing which worsens at night	Sleep pattern disturbance related to difficulty of breathing	Short term:After 4-5 hours of nursing interventions the patient will identify individually appropriate interventions to promote sleep.Long term:After 2 days of nursing interventions, the patient will be able to report improvements in sleep/rest pattern.	>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S>Monitor level of consciousness or mental status >Promote comfort measures such as back rub and change in position as necessary >Observe provision of emotional support >Provide quiet environment. >Increase patient’s fluid intake >Encourage expectoration >Limit the fluid intake in evening if nocturia is a problem >Obtain feedback from SO regarding usual bedtime, rituals/routines >Provide safety for patient sleep time safety >Recommend midmorning nap if one required >Administer pain medication as ordered.	>To gain trust and active participation>To know the condition of the pt>To have a baseline data>Restlessness, anxiety, confusion, somnolence are common manifestation of hypoxia and hypoxemia. >To provide non pharmagcologic management >Lack of knowledge and problems, relationships may create tension. Interfering with sleep routines based on adult schedules may not meet child’s needs. >To promote an environment conducive to sleep. >To help liquefy secretions >To eliminate thick, tenacious, copious secretions which contribute for the DOB >To reduce need for nighttime elimination >To determine usual sleep patterns & provide comparative baseline >To promote comfort/safety >Napping esp. in the afternoon can disrupt normal sleep pattern >To relieve discomfort and take maximum advantage of sedative effect	Short term:The patient shall have identified individually appropriate interventions to promote sleepLong term:The patient shall have reported improvements in pt.’s sleep/rest

5 Risk for Spread of Infection

Once the bacteria, virus, or fungus enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight the infection. Disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection

Assessment	Nursing Dx	Planning	NursingInter­ventions	Rationale	Expected Outcome
S:ÆO: The patient may manifest:>Body temperature above normal range>dehydration >increase WBC count >presence of increase mucus production	Risk for spread of infection related to stasis of secretions and decreased ciliary action.	Short term:After 4-5 hours of nursing interventions the patient will identify interventions  to prevent and/or reduce the risk of infectionLong term:After 2 days of nursing interventions the patient will have minimize or totally be free from the risk of infection.	>Establish rapport to the pt. and SO>Assess the patient condition>Monitor & record V/S>Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake >Turn the patient q 2 hours >Encourage increase fluid intake >Stress the importance of handwashing to SO’s >Teach the SO’s how to care for and clean respiratory equipment >Teach the SO’s the manifestations of pulmonary infections (change in color of sputum, fever, chills) , self-care and when to call the physician >Recommend rinsing mouth with water >Administer antimicrobial such as cefuroxime as indicated.	>To gain trust and active participation>To know the condition of the pt>To have a baseline data and fever may be present because of infection and/or dehydration>These activities promote mobilization and expectoration of secretions to reduce the risk of developing pulmonary infection. >To facilitate secretion mov’t and drainage >To liquefy secretions >Handwashing is the primary defense against the spread of infection >Water in respiratory equipment is a common source of bacterial growth >Early recognition of manifestations can lead to a rapid diagnosis. >To prevent risk of oral candidiasis. >Given prophylactically to reduce any possible complications	Short term:The shall have identified interventions to prevent and/or reduce the risk of infectionLong term:The patient shall have minimized or totally be free from the risk of infection.

Other nursing diagnoses:

• 6 High risk for suffocation
• 7 High risk for aspiration
• 8 Anxiety RT acute breathing difficulties
• 9 Activity Intolerance RT inadequate oxygenation
• 10 Imbalanced Nutrition: Less than body requirements RT reduced appetite and dyspnea (for empysema)

Once the bacteria, virus, or fungus enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight the infection. Disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection

10 Chronic Obstructive Pulmonary Disease: Bronchitis Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/10-chronic-obstructive-pulmonary-disease-bronchitis-nursing-care-plans/feed/ 1 http://nurseslabs.com/risk-for-impaired-skin-integrity-diabetes-insipidus-nursing-care-plans/ http://nurseslabs.com/risk-for-impaired-skin-integrity-diabetes-insipidus-nursing-care-plans/#comments Tue, 24 Jan 2012 17:32:54 +0000 NursesLabs http://nurseslabs.com/?p=2256 Common Risk Factor Urinary frequency with high volume output and the potential for incontinence Common Expected Outcomes Patient’s skin remains intact. NOC Outcomes Tissue Integrity: Skin and Mucous Membranes; Risk Control; Risk Detection NIC Interventions Skin Surveillance; Skin Care: Topical Treatments Ongoing Assessment Inspect skin; document condition and changes in status. Early detection and intervention [...]

Risk for Impaired Skin Integrity | Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

]]> Common Risk Factor

• Urinary frequency with high volume output and the potential for incontinence

Common Expected Outcomes

• Patient’s skin remains intact.

NOC Outcomes

NIC Interventions

• Skin Surveillance;
• Skin Care: Topical Treatments

Ongoing Assessment

1. Inspect skin; document condition and changes in status. Early detection and intervention may prevent occurrence or progression of impaired skin integrity. Fluid loss from polyuria contributes to decreased skin turgor and dryness.
2. Assess for continence or incontinence. Evaluate need for an indwelling urinary catheter. Excessive moisture on the skin increases the risk of skin breakdown.
3. Assess other factors that may risk the patient’s skin integrity (e.g., immobility, nutritional status, altered mental status). Excessive moisture from urinary incontinence can add to the risk for skin breakdown from other sources.

Therapeutic Actions

1. Provide easy access to the bathroom, urinal, or bedpan. Both polyuria and polydipsia disrupt the patient’s normal activities (including sleep). Easy access to void will decrease inconvenience and frustration.
2. Use skin barriers as needed. These prevent redness or excoriation from urinary frequency.
3. Keep bed linen clean, dry, and wrinkle-free. This prevents shearing forces.

Risk for Impaired Skin Integrity | Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

• Intake exceeds nutritional and caloric needs (wide fluctuations in weight within a discrete period of time in response to binging and purging)

Defining Characteristics

• Unhealthy eating pattern
• Episodic binge eating
• Eating in response to cues (i.e., conflict, social situation)
• Eating in response to emotions (i.e., anxiety, depression)
• Wide weight fluctuations within a short period of time

Common Expected Outcomes

• Patient is able to stabilize weight without bingeing and purging.
• Patient is able to stabilize eating behavior.

NOC Outcome

NIC Interventions

Ongoing Assessment

1. Obtain accurate history of weight changes. Many patients with bulimia have histories of struggles with the balance of food consumed and nutritional needs.
2. Obtain accurate food history, including daily intake and number and types of weight loss diets used in the past. Many patients have experienced unsuccessful attempts at severely restrictive dieting followed by secret consumption of large amounts of food.
3. Determine type and frequency of binge-purge behavior with associated feeling states. Purging (vomiting, laxatives, diuretics, or exercise) may result in weight fluctuations greater than 10 pounds within 1 to 2 days. It is critical that the therapist obtain a clear picture of maladaptive behaviors so that therapeutic measures can be integrated into the individual treatment plan.
4. Weigh the patient routinely, without comment and using a matter-of-fact manner, no more than twice per week. Weighing too often reinforces the patient’s preoccupation with weight. A standardized method of weighing the patient will improve the value of recording patient weights.

Therapeutic Interventions

1. Devise a food plan that specifies total daily calories (³1600 kcal/day) and includes all food groups, with three meals plus a light evening snack. Adequate intake alleviates effects of starvation (e.g., sleeplessness or waking during the night) and decreases preoccupation with thoughts of food and relapse.
2. Provide accurate information about nutrition, metabolic functioning, and role of deprivation in triggering binges. Knowledge serves to correct faulty ideas.
3. Provide healthy interactions immediately before, during, and after meals. Healthy social interactions encourage normal eating and interfere with the potential impulse to vomit. Interactions can be provided by a friend or family member or by staff if the patient is hospitalized.
4. Encourage healthy physical activity. Discourage excessive exercise as a method of coping with binge eating. Balanced activity promotes feelings of well-being and self-control.
5. Continually assess potential for purging behavior, particularly in response to weight changes. If bingeing is suspected, address it directly. Use observation and supervision only as necessary. Early assessment helps interrupt compulsive bingeing and purging behaviors.

Imbalanced Nutrition: More Than Body Requirements | Bulimia NCP Original source at: Nurseslabs

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure (Joyce M. Black, 2008).

1. Decreased Cardiac Output

The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness

10 Congestive Heart Failure Nursing Care Plans Original source at: Nurseslabs

Outcomes: Infection Severity, Immune Status (NOC). Client will remain free of infection as evidenced by temperature remaining within normal limits. Client will verbalize interventions that prevent infection.

Evaluation: The client will remain free of infection or seek treatment promptly if manifestations of infection appear. The client will verbalize methods that minimize this condition from occurring.

Sources: Black, J. M. (2009). Medical Surgical Nursing: Clinical Management and Positive Outcomes. Singapore: Elsevier.

Chemotherapy: Risk For Infection RT Leukopenia Original source at: Nurseslabs

Dermatitis is a common condition that usually isn’t life-threatening or contagious. But, it can make you feel uncomfortable and self-conscious. A combination of self-care steps and medications can help you treat dermatitis.

1. Impaired Skin Integrity

Ongoing Assessment

Therapeutic Actions

4 Dermatitis Nursing Care Plans Original source at: Nurseslabs

The nursing goal for a patient who underwent mastectomy can be: pain management, counseling due to disturbed body image, and preventing infection due to surgical incision.

This post contains 14 nursing care plans for patients who underwent mastectomy.

1. Risk for Injury

Areas involving the neck are considered to be the most vascularized parts of a person’s body. We all know that the most common complication of a surgery is excessive bleeding or hemorrhage, this was brought about by excessive blood loss intra or post operatively.

14 Mastectomy Nursing Care Plans Original source at: Nurseslabs

It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or “bedwetting”).

Urine output is increased because it is not concentrated normally.

Consequently, instead of being a yellow color, the urine is pale, colorless or watery in appearance and the measured concentration (osmolality or specific gravity) is low (1).

1. Deficient Fluid Volume

3 Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs