Nurseslabs » hyperthermia

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

5 Benign Febrile Convulsions Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:36 +0000

A febrile seizure is a convulsion in a child triggered by a fever. Such convulsions occur without any underlying brain or spinal cord infection or other neurological cause. According to studies, about 3-5% of otherwise healthy children between the ages of 9 months and 5 years will have a seizure caused by a fever. Toddlers are most commonly affected. Most occur well within the first 24 hours of an illness, not necessarily when the fever is highest.

The first febrile seizure is one of life’s most frightening moments for parents. Most parents are afraid that their child will die or have brain damage. Thankfully, simple febrile seizures are harmless. There is no evidence that simple febrile seizures cause death, brain damage, mental retardation, a decrease in IQ, or learning difficulties. (www.nlm.com) However, a very small percentage of children go on to develop other seizure disorders such as epilepsy later in life.

Read our Benign Febrile Convulsions Nursing Care Plans

1. Hyperthermia - Benign Febrile Convulsions Nursing Care Plans

Benign Febrile Convulsion is a convulsion triggered by a rise in body temperature. Fever is not an illness and is an important part of the body’s defense against infection. Antigens or microorganisms cause inflammation and the release of pyrogens which is a substance that induces fever.

Assessment

Planning

Nursing Interventions

Rationale

Expected Outcome

Subjective:

Objective:

the patient manifested:

febrile temp = 39°C
flushed skin and warm to touch
Convulsion
RR = 34 bpm

the patient may manifest:

high fever
weakness

Short term:

After 4 hours of nursing interventions, the patient’s temperature will decrease from 39°C to normal range of 36.5°C to 37°C.

Long Term:

After 2 days of nursing interventions, the patient will be able to be free of complications and maintain core temperature within normal range.

Assess underlying condition and body temperature.
Monitor and recorded vital signs.
Remove unnecessary clothing that could only aggravate heat.
Promote adequate rest periods.
Provide TSB
Advise to increase fluid intake.
Loosen clothing.
Administer IV fluids at prescribed rate. Monitor regulation rate frequently.
Administer antipyretics as ordered.

To obtain baseline date.
To note for progress and evaluate effects of hyperthermia.
To decrease or totally diminish pain.
Reduces metabolic demands or oxygen.
To promote surface cooling.
To help decrease body temperature.
To provide proper ventilation and promote release of heat through evaporation.
To promote fluid management.
Antipyretics lower core temperature.

Short term:

The patient’s temperature shall have decreased from 39°C to normal range of 36.5°C to 37°C.

Long Term:

The patient shall have been able to be free of complications and maintain core temperature within normal range.

5 Benign Febrile Convulsions Nursing Care Plans Original source at: Nurseslabs

6 Bronchopneumonia Nursing Care Plans

Nurseslabs — Sat, 21 Jan 2012 09:16:19 +0000

Pneumonia is the inflammation of the lung caused by bacteria in which the air sacs become filled with inflammatory cells and the lung becomes solid. The symptoms include those of any infection (fever, malaise, headache, etc.,) together with cough and chest pain.

It is estimated that, worldwide, some 4 million children under five years of age, die each year from acute respiratory infection (ARI) with the most of these deaths caused by pneumonia in developing countries.

In 1989, when the program for Control Acute Respiratory Infections (CARI) of the Philippines was launched, the death toll from pneumonia among children under the age of five years was 25,000. The latest statistics (2006) disclosed that almost 60 out of 1000 children under five children suffer from pneumonia and five in every 11,000 die from the disease. The Department of Health believes that if health workers used a standard method of detecting and managing ARI’s specially pneumonia, infant deaths could be cut by half, saving 50,000 lives a year. Pneumonia can be categorized by type of infiltrate: lobar pneumonia and bronchopneumonia.

View our gallery of nursing care plans

1. Ineffective Airway Clearance

NDx: Ineffective airway clearance r/t accumulation of tracheobronchial secretions

Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways.

Assessment

Planning

Nursing Interventions

Rationale

Expected Outcome

Restlessness with nasal flaring
With rales on both lung fields
warm, flushed skin
minimal colorless nasal secretions
tachypnea AEB RR=53bpm
DOB
tachycardia
irritability
chest indrawing
cough
cyanosis
noisy breathing
pallor
changes in RR and rhythm
risk for infection
orthopnea
tachypnea

SHORT TERM:After 3-4 hours of NI, pt.’s SO will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and RR improve

LONG TERM:

After 2-3 days of NI, pt. will be able to establish and maintain airway patency.

Monitor and record vital signs
Assess patient’s condition.
Elevate head of bed and encourage frequent position changes.
Keep back dry and loosen clothing
Auscultate breath sounds and assess air movement
Monitor child for feeding intolerance and abdominal distention
Instruct the SO to provide an increased fluid intake for the child
Instruct the SO to provide
adequate rest periods for the child
Give expectorants and bronchodilators as ordered.
Administer oxygen therapy and other medications as ordered.

To obtain baseline data
To know the patient’s general condition
To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation
To promote comfort and adequate ventilation
To ascertain status and to note progress
To avoid compromising the airway
To help liquefy the secretions
Rest will prevent fatigue and decrease oxygen demands for metabolic demands
To further mobilize secretions
To clear airway when secretions are blocking the airway
indicated to increase oxygen saturation.

SHORT TERM:

After 3-4 hours of NI, pt. shall have demonstrated improve airway clearance AEB reduction of congestion with breath sounds clear and RR improve

LONG TERM:

After 2-3 days of NI, pt. shall have established and maintained airway patency.

6 Bronchopneumonia Nursing Care Plans Original source at: Nurseslabs

5 Pneumonia Nursing Care Plans

Nurseslabs — Thu, 12 Jan 2012 14:49:32 +0000

Pneumonia is an inflammatory illness of the lung. It is often described as lung parenchyma or alveolar inflammation leading to abnormal alveolar filling with fluid. Pneumonia can result from a variety of causes, including infection with microorganisms like bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.

Incidences of Pneumonia

Pneumonia is a common illness in all parts of the world in all age groups. Majority of deaths occur in the newborn period in children, with over two million deaths a year worldwide.

The World Health Organization estimates that one out of three newborn infant deaths is due to pneumonia.
It kills more children than any other illness, accounting for 19% of all under-five deaths.
According to the National Statistical Coordination Board of the Philippines, there are 776,562 of pneumonia in the country in 2004 alone. This could be an implication that pneumonia is one of the leading causes of morbidity and mortality in the country.
World Health Organization notes Invasive Pneumococcal Disease deaths at 1.6 million people each year.
Of these, 700,000 to one million are children under five years old and over 90 percent of these deaths occur in developing countries.
Pneumonia is a top killer in India,China,Nigeria,Pakistan,Bangladesh,Indonesia, and Brazil.

Additional & Updated Nursing Care Plans for Pneumonia

1. Ineffective Airway Clearance

NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia.

The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

ASSESSMENT

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

With unproductive cough
With wheezes and crackles auscultated on left lower lungfield.
Presence of clear watery discharge from her nose
Restlessness
Irritability

Short Term: After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved. Long Term:

After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.

Establish rapport to patient and SO
Assess patient’s condition
Monitor and record V/S
Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds
Assist patient to change position every 30 minutes
Elevate head of bed and align head in the middle
Provide health teachings regarding effective coughing and deep breathing exercise.
Encourage to increase fluid intake.
Encourage steam inhalation
Administer meds as ordered

To gain the trust and cooperation
To know and determine patient’s needs
To establish base line data
To identify areas of consolidation and determine possible bronchospasm or obstruction.
To mobilize secretions
To facilitate breathing
To expel the mucous
To liquefy secretions
To moisten secretions and alleviate congestion
To reduce bronchospasm and mobilize secretion

Short Term: After 3-4 hours of nursing interventions, the patient’s respiration shall have improved and difficulty of breathing shall have been relieved.

Long Term:

After 3 – 4 days of nursing interventions, the patient will have been able to maintain a patent airway.

5 Pneumonia Nursing Care Plans Original source at: Nurseslabs

Acute Pyelonephritis Nursing Care Plans

Nurseslabs — Mon, 09 Jan 2012 17:01:24 +0000

Kidney infection (pyelonephritis) is a specific type of urinary tract infection (UTI) that generally begins in your urethra or bladder and travels up into your kidneys. A kidney infection requires prompt medical attention. If not treated properly, a kidney infection can permanently damage your kidneys or spread to your bloodstream and cause a life-threatening infection. Kidney infection treatment usually includes antibiotics and often requires hospitalization (Mayo Clinic).

This post contains 4 nursing care plans regarding acute pyelonephritis.

Ineffective Renal Tissue Perfusion

Capillaries are an integral part of the nephrons which are responsible for oxygenation. When the nephrons are destroyed or impaired such as in the progress of a renal disease like Pyelonephritis, there will be progressive decline in kidney perfusion. This hypoperfusion affects the kidney’s production of erythropoietin factor responsible for the production of RBC. A decreased in RBC levelproduction will then result to decreased oxygen supply to the kidney

Hyperthermia

In response to infection, inflammatory mediators and neutrophils are activated which will travel to the infected area via increased blood flow and chemotaxis. WBCs, particularly neutrophils, migrate into the site to perform phagocytosis. Neutrophils immediately die after performing their function, and release pyrogens. Pyrogens stimulate fever by increasing heat production and conservation. Fever stimulates immune system activity and kills microorganisms

Acute Pain

As the chemical mediators are released in response to infection, increased renal blood flow and infiltration of WBCs occur in the infected area. These stretch the renal capsule which irritates the nerve endings in the area, causing the activation of pain receptors. The location of the pain is attributed to the retroperitoneal anatomic site of the kidney.

Impaired Urinary Elimination

The entry of microorganisms in the urinary tract triggers the defenses built in our urinary system. One of these is an increase in urine production. The urine flow flushes / washes away microorganisms present in the tract. When the bladder detects the microbes, bladder wall irritation occurs. The bladder contracts its smooth muscles to eradicate the pathogens along with the urine.

Acute Pyelonephritis Nursing Care Plans Original source at: Nurseslabs

2 Dengue Hemorrhagic Fever Nursing Care Plans

Nurseslabs — Wed, 21 Dec 2011 17:07:56 +0000

Dengue is transmitted by the bite of an Aedesmosquito infected with any one of the four dengue viruses. It occurs in tropical and sub-tropical areas of the world. Symptoms appear 3—14 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.

Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs (e.g. Ibuprofen) is not recommended.

Dengue hemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication, affecting mainly children. Early clinical diagnosis and careful clinical management by experienced physicians and nurses increase survival of patients.

Read the two Dengue Hemorrhagic Fever Nursing Care Plans below

1. Ineffective Tissue Perfusion - Dengue Hemorrhagic Fever Nursing Care Plans

NDx: Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1

A mosquito which carries the dengue virus is called Aedes aegypti. The said mosquito comes in contact with a person and bites the person. The dengue virus will flow through the blood stream and destroys blood components. Patients with dengue often has decreased WBC, platelet & haemoglobin count. Hemoglobin count is used to measure oxygen carrying capacity of the blood. Hemoglobin carries oxygen. Therefore, if there is decreased haemoglobin, there is also decreased oxygen that reaches the different tissues of the body.

Assessment

Objectives

Nursing Interventions

Rationale

Expected Outcome

Subjective: (none)Objective:

Decreased WBC
Decreased platelet
Decreased HgB
Decreased capillary refill time
Dysrhythmias
Altered LOC
Fever
Chills
Diaphoresis

Short Term:After 4 hours of NI, the pt will demonstrate behaviours to improve circulation.

Long Term:

After 4 days of NI, the pt will demonstrate increased perfusion as appropriate

Establish Rapport
Monitor Vital Signs
Assess patient’s condition
Note customary baseline data
Determine presence of dysrhythmias
Perform blanch test
Check for Homan’s sign
Note presence of bleeding
Elevate HOB
Encourage quiet & restful atmosphere
Instruct to avoid tiring activities
Encourage light ambulation
Encourage use of relaxation techniques
Administer medications

To gain pt’s trust
To obtain baseline data
To assess contributing factors
For comparison with current findings
To identify alterations from normal
To identify / determine adequate perfusion
To determine presence of thrombus formation
To determine risk of anemia
To promote circulation
To promote comfort & decrease tissue O₂ demand
To decrease cardiac workload
To enhance venous return
To decrease tension and anxiety level
To treat underlying cause

The pt shall have demonstrated behaviours to improve circulationThe pt shall have demonstrated increased perfusion as appropriate

2. Hyperthermia - Dengue Hemorrhagic Fever Nursing Care Plans

NDx: Hyperthermia

When a person comes in contact with a mosquito, Aedes aegypti, the dengue virus flows through the blood stream. As the compensatory mechanism of the body, it will raise its temperature to allow the immune system to work better and to deteriorate the condition of the invaders thus causing hyperthermia.

Assessment

Objectives

Nursing Interventions

Rationale

Expected Outcome

S> (none)O>

Temp of 39.8 or higher
Flushed skin
Skin warm to touch
Chills
Increased RR
Tachycardia
Convulsions
Sweating

Short Term:After 4 hours of NI, pt’s temperature will decrease from 39.8 to 37.

Long Term:

After 3 days of NI, the pt will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention

Establish Rapport
Monitor Vital Signs
Assess neurologic response, note LOC & orientation, reaction to stimuli, papillary reactions & presence of seizures
Note presence / absence of sweating
Wrap extremities with bath towels
Provide TSB q 15 minutes
Apply local ice packs in axilla
Instruct client to have bed rest
Instruct client to increase OFI
Administer replacement fluids
Administer antipyretics
Reassess temperature q 15 minutes

To gain pt’s trust
To obtain baseline data
To evaluate effects & extent of hyperthermia
To monitor heat & fluid loss
To minimize shivering
To reduce body temperature
To reduce body temperature in areas of high blood flow
To reduce metabolic demands / oxygen consumption
To prevent dehydration
To support circulating blood volume and tissue perfusion
To restore normal body temperature
To determine effectiveness of interventions done

The pt shall have a decreased body temperature from 39.8 to 37The pt shall have identified underlying factors and importance of treatment as well as s/sx requiring further evaluation or intervention

2 Dengue Hemorrhagic Fever Nursing Care Plans Original source at: Nurseslabs

5 Neonatal Sepsis Nursing Care Plans

Nurseslabs — Sat, 12 Nov 2011 12:37:34 +0000

Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs in a neonate. Here are 5 Neonatal Sepsis Nursing Care Plans.

Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum.

Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early- onset sepsis and most often appears in the first 24 hours of life.

The infection is often acquired from the mother. This can be cause by a bacteria or infection acquired by the mother during her pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24 hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital for an extended period of time.

Signs and symptoms of Neonatal Sepsis includes but is not limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Possible complications are disability and worst is death of the neonate.

This post has 5 Neonatal Sepsis Nursing Care Plans

1. Hyperthermia - Neonatal Sepsis Nursing Care Plans

NDx: Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia

Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) and increased heat production which results to fever.

Assessment

Planning

Intervention

Rationale

Expected Outcome

Subjective:

May manifest:

Irritability
Weakness

Objective:

The patient may manifest one or more of the following:

Temperature above normal level (36 ^oC)
Skin warm to touch
Presence of tachycardia (above 160 bpm)
Presence of tachypnea (above 60 bpm)
WBC elevated

Short-term:

After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level

Long Term:

After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

Independent

1. Monitor neonate’s condition.

2. Monitor Vital signs

3. Provide TSB

Interdependent

4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants

Dependent

5. Administer Anti-pyretics as ordered

1. To determine the need for intervention and the effectiveness of therapy.

2. To have a baseline data

3. Helps in lowering down the temperature

4. this would prevent the spread of pathogens to the infant from equipment

5. aids in lowering down temperature

The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

5 Neonatal Sepsis Nursing Care Plans Original source at: Nurseslabs

8 TAHBSO Nursing Care Plans

Nurseslabs — Mon, 31 Oct 2011 06:17:08 +0000

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately.

View the surgical procedure for TAHBSO

Post-operative nursing care for patients who underwent TAHBSO would include:

Determines patient’s immediate response to surgical intervention.
Monitor patient’s physiologic status.
Assess patient’s pain level and administers appropriate pain relief measures.
Maintains patient’s safety(airway, circulation, prevention of injury)
Administer medication, fluid and blood component therapy, if prescribed.
Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy.

This post includes several nursing care plans for post-TAHBSO patients.

1 Acute Pain

NDx: Acute pain secondary to surgical operation

Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain.

Assessment

Planning

Nursing
Interventions

Rationale

Evaluation

Subjective: The patient may verbalized:“My incision hurts”Objective: The patient manifested

irritability
impaired physical mobility
disturbed sleep pattern
facial mask
diaphoresis
restlessness
facial grimaces

Short term:After 4 hours of nursing interventions, the patient’s pain scale will decrease 10/10 to 5/10Long term:After 1 day of nursing interventions, patient’s pain will diminish and perform activities like side movement and leg bending

Establish rapport
Emphasize ordered diet
Monitor vital signs
Provide comfort measures
Encourage deep breathing
Provide safety measure
Develop communicationreview procedures/expectations and tell client when treatment will hurt
Administer analgesics as indicated to maximal dosage as needed

To gain trust
To encourage patient not to eat untolerated food
To obtain baseline data
To satisfy the confinement of patient
To inhibit pain
To prevent from injury
To alter pain and diminish emotional stress
To reduce concern of unknown and associated muscle tension & To maintain acceptable level of pain.

Short term:The patient’s pain scale decreased 10/10 to 5/10Long term:The patient’s pain diminished and performed activities like side movements and leg bending

8 TAHBSO Nursing Care Plans Original source at: Nurseslabs