Nurseslabs » activity intolerance

Activity Intolerance — Pneumonia Nursing Care Plans

Nurseslabs — Tue, 27 Mar 2012 13:32:37 +0000

Nursing Diagnosis: Activity intolerance

May be related to

Imbalance between oxygen supply and demand
General weakness
Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea

Possibly evidenced by

Verbal reports of weakness, fatigue, exhaustion
Exertional dyspnea, tachypnea
Tachycardia in response to activity
Development/worsening of pallor/cyanosis

Desired Outcomes

Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.

Nursing Interventions	Rationale
Evaluate patient’s response to activity. Note reports of dyspnea, increased weakness/fatigue, and changes in vital signs during and after activities.	Establishes patient’s capabilities/needs and facilitates choice of interventions.
Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.	Reduces stress and excess stimulation, promoting rest
Explain importance of rest in treatment plan and necessity for balancing activities with rest.	Bedrest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual patient response to activity and resolution of respiratory insufficiency.
Assist patient to assume comfortable position for rest/sleep.	Patient may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on overbed table with pillow support.
Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase. and demand.	Minimizes exhaustion and helps balance oxygen supply and demand.

Activity Intolerance — Pneumonia Nursing Care Plans Original source at: Nurseslabs

Activity Intolerance — Nursing Diagnosis

Nurseslabs — Tue, 28 Feb 2012 15:21:28 +0000

NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

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 — Activity Intolerance

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 — Activity Intolerance

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 — Activity Intolerance

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 for Activity Intolerance

Client can perform the activity without complications

Nursing Interventions for Activity Intolerance

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

NANDA Nursing Diagnosis List

bobbyRN — Mon, 20 Feb 2012 15:08:18 +0000

Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by the nurses in the nursing process to provide more comprehensive assessment of the client.

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

Health Perception and Management Pattern

Contamination
Disturbed energy field
Effective therapeutic regimen management
Health-seeking behaviors
Ineffective community therapeutic regimen management
Ineffective family therapeutic regimen management
Ineffective health maintenance
Ineffective protection
Ineffective therapeutic regimen management
Noncompliance
Readiness for enhanced immunization status
Readiness for enhanced therapeutic regimen management
Risk for contamination
Risk for falls
Risk for infection
Risk for injury (trauma)
Risk for perioperative positioning injury
Risk for poisoning
Risk for suffocation

Nutritional-Metabolic Pattern

Adult failure to thrive
Deficient blood volume
Effective breastfeeding
Excess fluid volume
Hyperthermia
Hypothermia
Imbalanced nutrition: more than body requirements
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: risk for more than body requirements
Impaired dentition
Impaired oral mucous membrane
Impaired skin integrity
Impaired swallowing
Impaired tissue integrity (specify type)
Ineffective breastfeeding
Ineffective infant feeding pattern
Ineffective thermoregulation
Interrupted breastfeeding
Latex allergy response
Nausea
Readiness for enhanced fluid balance
Readiness for enhanced nutrition
Risk for aspiration
Risk for deficient fluid volume
Risk for imbalanced fluid volume
Risk for imbalanced body temperature
Risk for latex allergy response
Risk for impaired liver function
Risk for impaired skin integrity
Risk for unstable blood glucose

Elimination Pattern

Bowel incontinence
Constipation
Diarrhea
Functional urinary incontinence
Impaired urinary elimination
Overflow urinary incontinence
Perceived constipation
Readiness for enhanced urinary elimination
Reflex urinary incontinence
Risk for constipation
Risk for urge urinary incontinence
Stress urinary incontinence
Total urinary incontinence
Urge urinary incontinence
Urinary retention

Activity-Exercise Pattern

Activity intolerance (specify)
Autonomic dysreflexia
Decreased cardiac output
Decreased intracranial adaptive capacity
Deficient diversional activity
Delayed growth and development
Delayed surgical recovery
Disorganized infant behavior
Dysfunctional ventilatory weaning response
Fatigue
Impaired spontaneous ventilation
Impaired bed mobility
Impaired gas exchange
Impaired home maintenance
Impaired physical mobility
Impaired transfer ability
Impaired walking
Impaired wheelchair mobility
Ineffective airway clearance
Ineffective breathing pattern
Ineffective tissue perfusion (specify)
Readiness for enhanced organized infant behavior
Risk for disproportionate growth
Risk for activity intolerance
Risk for autonomic dysreflexia
Risk for disuse syndrome
Risk for peripheral neurovascular dysfunction
Risk for sudden infant death syndrome
Sedentary lifestyle
Self-care deficit (specify: bathing/hygiene, dressing/grooming, feeding, toileting)
Wandering

Sleep-Rest Pattern

Insomnia
Readiness for enhanced sleep
Sleep deprivation

Cognitive-Perceptual Pattern

Acute confusion
Acute pain
Chronic confusion
Chronic pain
Decisional conflict (specify)
Deficient knowledge (specify)
Disturbed sensory perception (specify)
Disturbed thought process
Impaired environmental interpretation syndrome
Impaired memory
Readiness for enhanced comfort
Readiness for enhanced decision making
Readiness for enhanced knowledge
Risk for acute confusion
Unilateral neglect

Self-Perception and Self-Conception Pattern

Anxiety
Chronic low self-esteem
Death anxiety
Disturbed body image
Disturbed personal identity
Fear
Hopelessness
Powerlessness
Readiness for enhanced hope
Readiness for enhanced power
Readiness for enhanced self-concept
Risk for compromised human dignity
Risk for loneliness
Risk for self-directed violence
Risk for powerlessness
Risk for situational low self-esteem
Situational low self-esteem

Role-Relationship Pattern

Caregiver role strain
Chronic sorrow
Dysfunctional family process: alcoholism
Impaired parenting
Impaired social interaction
Impaired verbal communication
Ineffective role performance
Interrupted family process
Parental role conflict
Readiness for enhanced communication
Readiness for enhanced family processes
Readiness for enhanced parenting
Relocation stress syndrome
Risk for caregiver role strain
Risk for complicated grieving
Risk for impaired parent/child attachment
Risk for impaired parenting
Risk for relocation stress syndrome
Risk for other-directed violence
Social dysfunction

Sexuality-Reproductive

Ineffective sexuality pattern
Rape-trauma syndrome
Rape-trauma syndrome: compound reaction
Rape-trauma syndrime: silent reaction
Sexual dysfunction

Coping-Stress Tolerance Pattern

Compound family coping
Defensive coping
Disabled family coping
Ineffective community coping
Ineffective coping
Ineffective denial
Post-trauma syndrome
Readiness for enhanced community coping
Readiness for enhanced coping
Readiness for enhanced family coping
Risk for self-mutilation
Risk for suicide
Risk for post-trauma syndrome
Risk-prone health behaviors
Self-mutilation
Stress overload

Value-Belief Pattern

Impaired religiosity
Moral distress
Readiness for enhanced religiosity
Readiness for enhanced spiritual well-being
Risk for impaired religiosity
Risk for spiritual distress
Spiritual distress

These were modified by Marjory Gordon on 2007, with permission.

NANDA Nursing Diagnosis List Original source at: Nurseslabs

8 Cholecystectomy Nursing Care Plans

Nurseslabs — Thu, 16 Feb 2012 09:20:35 +0000

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.

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.

Below we have 8 Cholecystectomy Nursing Care Plans

1 Preoperative Problem: Acute Pain

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.

Acute Pain-Cholecystectomy

2 Preoperative Problem: Fear

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

Fear-Cholecystectomy

3 Ineffective Breathing Pattern

Respirations may be increased as a result of pain or as an initial compensatory mechanism. however, increased work of breathing may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve.

Ineffective Breathing Pattern-Cholecystectomy

4 Risk for Aspiration

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.

Risk for Aspiration-Cholecystectomy

5 Post Operative Acute Pain

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.

Post Operative Acute Pain

6 Activity Intolerance

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.

Activity Intolerance-Cholecystectomy

7 Impaired Physical Mobility

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.

Impaired Physical Mobility-Cholecystectomy

8 Risk for Infection

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.

Risk for Infection-Cholecystectomy

8 Cholecystectomy Nursing Care Plans Original source at: Nurseslabs

5 Bronchial Asthma Nursing Care Plans

Nurseslabs — Sat, 11 Feb 2012 08:31:55 +0000

Bronchial asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways.
Bronchial asthma is the more correct name for the common form of 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 - Bronchial Asthma Nursing Care Plans

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

5 Coronary Artery Disease Nursing Care Plans

Nurseslabs — Fri, 03 Feb 2012 18:19:49 +0000

Coronary artery disease (CAD) is a condition in which plaque builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow. When your coronary arteries are narrowed or blocked, oxygen-rich blood can’t reach your heart muscle. This can cause angina or a heart attack. Without quick treatment, a heart attack can lead to serious problems and even death.

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.

Here are 5 Coronary Artery Disease Nursing Care Plans

1. Decreased Cardiac Output - Coronary Artery Disease Nursing Care Plans

NDx: Decreased cardiac output r/t increased vascular resistance

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.

Assessment

Planning

Nursing interventions

Rationale

Expected outcome

S= ∅

O=The patient may manifest:

restlessness
increased bp
cold clammy skin
decreased peripheral pulses

Short term:

After 2-3 hours of nursing interventions, the patient will verbalize understanding of disease process.

Long term:

After two days of nursing interventions the patient will participate in activities to decrease in the heart’s workload

assess patient’s condition
monitor and record vital signs
encourage patient to verbalize concerns
encourage patient to change position every two hours
encourage patient to do relaxation techniques
encourage patient to engage in divertional activities such as chatting with family and friends.
reinforced low salt and low fat diet

to determine possible prolems
for baseline data
to make client express his feelings
to improve venous return
to reduce stress
to divert attention and help patient lessen experienced pain and anxiety
to prevent further complications of the disease

Short term:

The patient shall have verbalizedUnderstanding of disease process.

Long term:

The patient shall have participated in activities to decrease in the heart’s workload

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

10 Congestive Heart Failure Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:53 +0000

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself; instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

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).

Here are 10 Congestive Heart Failure Nursing Care Plans

1. Decreased Cardiac Output - Congestive Heart Failure Nursing Care Plans

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

NDx: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

Assessment

Planning

Nursing Interventions

Rationale

Evaluation

Subjective:(none)

Objectives:

The patient manifested the following:

with pale conjunctiva, nail beds and buccal mucosa
irregular rhythm of pulse
bradycardic
pulse rate of 34 beats/min
generalized weakness

Short Term:After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.

Long Term:

After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

Assess for abnormal heart and lung sounds.
Monitor blood pressure and pulse
Assess mental status and level of consciousness.
Assess patient’s skin temperature and peripheral pulses.
Monitor results of laboratory and diagnostic tests.
Monitor oxygen saturation and ABGs.
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
Implement strategies to treat fluid and electrolyte imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
Encourage periods of rest and assist with all activities.
Assist the patient in assuming a high Fowler’s position.
Teach patient the pathophysiology of disease, medications
Reposition patient every 2 hours
Instruct patient to get adequate bed rest and sleep
Instruct the SO not to leave the client unattended
Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.

Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
Results of the test provide clues to the status of the disease and response to treatments.
Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
Decreases the risk for development of cardiac output due to imbalances.
Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
Reduces cardiac workload and minimizes myocardial oxygen consumption.
Allows for better chest expansion, thereby improving pulmonary capacity.
Provides the patient with needed information for management of disease and for compliance.
To prevent occurrence of bed sores
To promote relaxation to the body
To ensure safety and reduce risk for falls that may lead to injury

Short Term:After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.

Long Term:

After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

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

14 Mastectomy Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:47 +0000

Mastectomy is the surgical removal of the breast which is usually a surgical management for patients with breast cancer. This is done to prevent the metastasize of the cancer cells. Breast cancer is the most common malignancy experienced by women. Breast cancer is the uncontrolled growth of breast cells.

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 - Mastectomy Nursing Care Plans

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.

NDx: Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue

Assessment

Objectives

Nursing Interventions

Rationale

Desired Outcomes

S: ØO:The patient may manifest:

edema
muscle weakness
altered mobility
sensory and perceptual disturbances due to anesthesia
Apprehension, restlessness
thirst; cold , moist, pale skin
increase in pulse rate, respiration rate
drop in temperature
decrease in urinary output

Short term:After 3-4 hours of nurse-patient interaction, the patient will verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.

Long Term:

After 3-4 days of nurse-patient interaction, the patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Establish pt. Rapport
Monitor vital signs frequently.
Access mood, coping abilities and personality styles
Identify interventions and safety devices
Encourage participation in self-help programs, such as assertiveness training, positive self image
Provide bibliotherapyand written resources
Assist client during periods of ambulation
Walk client’s unaffected side
Instruct the client to keep the shoulders level and the muscle relaxed when walking

To gain trust and cooperation of the pt.
VS could indicate possible bleeding
That may result in carelessness and increased risk-taking without consequences.
To promte safe physical environment and individual safety
To enhance self-esteem and sense of self-worth
For later review and self-pced learning
The nurse supports the client when or if client loose balance
The lient is more likely to drift toward the side of the body that is heavier
Clients tend to accommodate for the change in the center of gravity by leaning to the side

Short term:The patient shall verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.

Long Term:

The patient shall demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

14 Mastectomy Nursing Care Plans Original source at: Nurseslabs

14 Cerebrovascular Accident Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:40 +0000

Cerebrovascular accident is the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. It is also known as stroke. CVA can be ischemic or hemorrhagic. Hemorrhagic strokes results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue. The two types of hemorrhagic strokes are intracerebral hemorrhage or subarachnoid hemorrhage. Hemorrhagic strokes have the slowest recovery of all types of stroke.

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.

Check out the updated version 8 Stroke Nursing Care Plans here

1. Ineffective Cerebral Tissue Perfusion - Cerebrovascular Accident Nursing Care Plans

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

4 Diabetes Mellitus Nursing Care Plans

Nurseslabs — Fri, 06 Jan 2012 23:00:18 +0000

This post contains nursing care plans for Diabetes Mellitus.

Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid metabolism. The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia), resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, or both. Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.

Other Diabetes Mellitus Nursing Care Plans

Here are 4 Diabetes Mellitus Nursing Care Plans

1. Deficient Fluid Volume - Diabetes Mellitus Nursing Care Plans

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.

Nursing Diagnosis: Deficient Fluid Volume r/t intracellular DHN 2° the DM II

Assessment

Planning

Nursing
Interventions

Rationale

Evaluation

Subjective: (none)Objective:

elevated temperature of 38.4°C/axilla
increased urine output.
sweating of the skin
thirst
exhaustion
weight loss
dry skin or mucous membrane

Short Term:After 3° of NI, patient shall have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.

Long Term:

After 2 days of NI, the patient shall have maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs.

Establish rapport
Take and record vital signs
Monitor the temperature
Assess skin turgor and mucous membranes for signs of dehydration
Encourage the patient to increase fluid intake
Administer IVF as ordered by the Doctor
Administer anti-pyretic as prescribed by the Doctor.

Friendly relationship with patient and to be able to each other’s concern
To obtain baseline data
To monitor changes in temperature
Dry skin and mucous membranes are signs of dehydration
To replace fluid loss and prevent dehydration
To replace electrolytes and fluid loss
To decrease body temperature and will have less occurrence of dehydration.

Short Term:After 3° of NI, patient will have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.

Long Term:

After 2 days of NI, the patient will have maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs

4 Diabetes Mellitus Nursing Care Plans Original source at: Nurseslabs