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

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

The nursing goal for patients with stroke can be towards maintaining effective tissue perfusion, preventing further complications, and enhancing coping. This is a nursing care plan for patients with hemorrhagic stroke.

1 Ineffective Cerebral Tissue Perfusion

The presence of partial blockage of the blood vessel can be multifactorial. These can be due to vaso constriction, platelet adherence on rough surface, fat accumulation and therefore decreases elasticity of vessel wall leading to alteration of blood perfusion with the initiation of the clotting sequence. This may later lead to the development of thrombus which can be loosened and dislodged in some areas of the brain such as mid cerebral carotid artery that may lead to alteration of blood perfusion and further develop to cerebral infarct.

NCP- CVA- Ineffective- Tissue- Perfusion

14 Cerebrovascular Accident Nursing Care Plans Original source at: Nurseslabs

A cholecystectomy consists of excising the gallbladder from the posterior liver wall and ligating the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through a right upper paramedian or upper midline incision if necessary, the common duct may be explored through this incision. When stones are suspected in the common duct, operative cholangiography may be performed (if it has not been ordered preoperatively). The surgeon may dilate the common duct if it is already dilated as a result of a pathologic process. Dilation facilitates stone removal. The surgeon passes a thin instrument into the duct to collect the stones, either whole or after crushing them.

After exploring the common duct, the surgeon usually inserts a T0tube to ensure adequate bile drainage during duct healing (choledochostomy). The T-tube also provides a route for postoperative cholangiography or stone dissolution, when appropriate.

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A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of a stone in the common bile duct and when the client’s physique does not allow access to the gallbladder. Occasionally, when a client is very obese, the gallbladder is not retrievable via laparoscopic instruments. Further, a surgeon may have difficulty accessing the gallbladder in an adult with a small frame and may need to perform the conventional open cholecystectomy.

1 Acute Pain Cholecystectomy Nursing Care Plan

The flow of bile in the gall bladder is obstructed due to the presence of stones. When the bladder releases bile, it contracts and there is spasm, thus it cannot adequately release bile due to the stone, it stimulates the release of cytokines resulting to pain.

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2 Fear RT Outcome of Surgery Cholecystectomy Nursing Care Plan

Undergoing open cholecystectomy, the patient may perceive threat like the outcome of the surgery that is consciously recognized by the client as danger

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3 Risk for Aspiration Cholecystectomy Nursing Care Plan

Prior to any surgical invasion, general anesthesia is induced. It relaxes the muscles of the body and depresses the sensation of pain, thus the gag and swallowing reflex is temporarily suppressed that may lead to aspiration.

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4 Post-Op Acute Pain Cholecystectomy Nursing Care Plan

In performing cholecystectomy, surgical incision is done. By which, the incision causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. This irritation will send signal to the cortex and thalamus of the brain thus producing pain perception.

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5 Impaired Physical Mobility Cholecystectomy Nursing Care Plan

Presence of surgical incision procedures causes the pt. to be reluctant in doing movements such as ROM, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation.

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6 Activity Intolerance Cholecystectomy Nursing Care Plan

Post-op pt. usually is under bed rest for few days that may hinder them to their usual activity. Presence of surgical incision procedures causes the pt. to be reluctant in doing personal activities, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation.

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7 Risk for Infection Cholecystectomy Nursing Care Plan

The patient is at risk of acquiring infection due to the break in the continuity of the first line defense which is the skin. The patient shall have undergone cholecystectomy, thus there is an incision and suture made in the abdomen. If there is a breakage in the skin, the pathogens will easily invade the body’s system thus increasing risk for infection.

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7 Cholecystectomy Nursing Care Plans Original source at: Nurseslabs

Below contains the list of nursing diagnoses approved by NANDA-I.

Health Perception and Management Pattern

1. Contamination
2. Disturbed energy field
3. Effective therapeutic regimen management
4. Health-seeking behaviors
5. Ineffective community therapeutic regimen management
6. Ineffective family therapeutic regimen management
7. Ineffective health maintenance
8. Ineffective protection
9. Ineffective therapeutic regimen management
10. Noncompliance
11. Readiness for enhanced immunization status
12. Readiness for enhanced therapeutic regimen management
13. Risk for contamination
14. Risk for falls
15. Risk for infection
16. Risk for injury (trauma)
17. Risk for perioperative positioning injury
18. Risk for poisoning
19. Risk for suffocation

NANDA Nursing Diagnosis List Original source at: Nurseslabs

NANDA Definition

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity.

Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Defining Characteristics:

• Verbal report of fatigue or weakness
• Inability to begin or perform activity
• Abnormal heart rate or blood pressure (BP) response to activity
• Exertional discomfort or dyspnea

Related Factors:

• Generalized weakness
• Deconditioned state
• Sedentary lifestyle
• Insufficient sleep or rest periods
• Depression or lack of motivation
• Prolonged bed rest
• Imposed activity restriction
• Imbalance between oxygen supply and demand
• Pain
• Side effects of medications

Expected Outcomes

• Patient maintains activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.
• Patient verbalizes and uses energy-conservation techniques.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Activity Tolerance
• Energy Conservation
• Knowledge: Treatment Regimen

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Energy Management
• Teaching: Prescribed Activity/Exercise

Nursing Goal

Client can perform the activity without complications

Nursing Intervention:

• Assess the influence of activity on wound condition and general body condition
  R: Activity stimulate increased vascularization and the pulsation of the reproductive organs, but can affect postoperative wound conditions and reduced energy.
• Help clients to meet the needs of everyday activities
  R: Resting client optimally.
• Help clients to act in accordance with the capability / condition of the client
  R: Optimizing conditions for the client, on abortion imminens, rest is absolutely indispensable.
• Evaluate the development of the client’s ability to do activities
  R: Assessing the client’s general condition.

Activity Intolerance Nursing Diagnosis Original source at: Nurseslabs

Here you view 4 Diabetes Mellitus Nursing Care Plans

1. Deficient Fluid Volume

Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.

4 Diabetes Mellitus Nursing Care Plans Original source at: Nurseslabs

Causes of pleural effusion can be grouped into four major categories:

• Increased systemic hydrostatic pressure (e.g., heart failure)
• Reduced capillary oncotic pressure (e.g., liver or renal failure)
• Increased capillary permeability (e.g., infection or trauma)
• Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)

1 Ineffective Breathing Pattern

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

6 Pleural Effusion Nursing Care Plans Original source at: Nurseslabs

Bronchial asthma

What do you think is the nursing goal for patient’s with bronchial asthma, and what is that one-most nursing diagnosis that pops to your head when you hear asthma?

This post contains 5 bronchial asthma nursing care plans. 

1 Ineffective Airway Clearance

The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstriction, increased vascular permeability leading to fluid leakage from the lung vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.

Asthma- Ineffective- Airway- Clearance

5 Bronchial Asthma Nursing Care Plans Original source at: Nurseslabs

Nursing goal for a patient with Rectal CA can be towards managing pain, managing symptoms, and patient education.

Acute Pain

The patient has colorectal cancer and one of its symptoms is abdominal pain. The pain is a subjective unpleasant sensation resulting from stimulation of sensory nerve endings by injury, or other harmful factors. Pain is activated when a pt’s pain threshold is reached. Pain threshold is the point at which a stimulus activates pain receptors to produce a feeling of pain. Pain usually accompanies inflammation. It results from the synthesis of prostaglandins, which are hormones produced during the inflammatory process.

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Constipation

Due to decrease physical activity of patient, the movement of feces through the large intestine is slow, thus, the patient manifest difficulty or decreased frequency in defecation. And also there is a presence of blockage in the intestines forming bulk and therefore the stool cannot pass through. (Ed notes: also there is painful and straining-like passage of stool)

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Impaired Bed Mobility

Abdominal cramping because of colorectal cancer there is a blockage of stool and formation of masse It starts from the synthesis of prostaglandins, which are hormones produced during the inflammatory process. The pain is triggered when the patient is moving so the response of the patient  he/she will not move to prevent initiation of pain.

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Activity Intolerance

Activity intolerance is brought about by the weakness. Weakness is caused by cancer, cancer cells get the nutrients that normal cell needs. In this situation normal cell lack nutrients so they cannot perform their functions. There will energy that the body can use so instead of doing daily activities the patient will just take rest.

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Self-Care Deficit

Restriction on the physical mobility of the client has resulted to a decreased ability for selfcare.  Specifically for this client, he has been unable to perform activities like bathing (and other measures of grooming), dressing up and attend to toileting needs by herself, thus, there is selfcare deficit. Weakness that is brought by cancer normal cells are lacking in nutrients. That the body needs in order to perform activities of daily living.

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Knowledge Deficit

They cannot understand diagnostic procedures that’s why doctors and nurses must explain medical procedures to the patient level of understanding. And also they lack knowledge about the surgery. The affected colon must be remove as what the doctor decides.

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Risk for Impaired Skin Integrity

Prolonged physical immobilization may cause pressure ulcers. Pressure ulcers may be caused by inadequate blood supply and as a result of  reperfusion injury when blood reenters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas

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Conclusion

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Source:

• eMedicine: Rectal Adenocarcinoma

Rectal Adenocarcinoma Nursing Care Plans Original source at: Nurseslabs