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 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.

See all our nursing care plans here

1 Hyperthermia

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.

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

]]> http://nurseslabs.com/5-benign-febrile-convulsions-nursing-care-plans/feed/ 0 http://nurseslabs.com/more-bronchopneumonia-nursing-care-plans/ http://nurseslabs.com/more-bronchopneumonia-nursing-care-plans/#comments Sat, 21 Jan 2012 09:16:19 +0000 NursesLabs http://nurseslabs.com/?p=819 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 [...]

6 More Bronchopneumonia Nursing Care Plans Original source at: Nurseslabs

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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 Clearnace

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	Nursing Diagnosis	Planning	Nursing Interventions	Rationale	Expected Outcome
S>(none) O> >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	Ineffective airway clearance r/t accumulation of tracheobronchial secretions	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 More Bronchopneumonia Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/more-bronchopneumonia-nursing-care-plans/feed/ 2 http://nurseslabs.com/pneumonia-nursing-care-plans/ http://nurseslabs.com/pneumonia-nursing-care-plans/#comments Thu, 12 Jan 2012 14:49:32 +0000 NursesLabs http://nurseslabs.com/?p=237 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.

5 Pneumonia Nursing Care Plans Original source at: Nurseslabs

]]> 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

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.

 

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Signs and Symptoms of Pneumonia [From Wikipedia

1 Ineffective Airway Clearance

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	NURSING DIAGNOSIS	OBJECTIVES	NURSING INTERVENTIONS	RATIONALE	EXPECTED OUTCOMES
S> Ø   O> Patient manifested the ff:   - with unproductive cough -with wheezes and crackles auscultated on left lower lungfield. - presence of clear watery discharge from her nose   > Patient may manifest the ff: - restlessness - irritability	Ineffective airway clearance related to presence of secretions secondary to pneumonia.	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

]]> http://nurseslabs.com/pneumonia-nursing-care-plans/feed/ 0 http://nurseslabs.com/acute-pyelonephritis-nursing-care-plans/ http://nurseslabs.com/acute-pyelonephritis-nursing-care-plans/#comments Mon, 09 Jan 2012 17:01:24 +0000 NursesLabs http://nurseslabs.com/?p=309 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 [...]

Acute Pyelonephritis Nursing Care Plans Original source at: Nurseslabs

]]> 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.

 

Conclusion

Nursing goal should be towards preventing further infection, managing pain, and establishing effective urinary elimination. Hope you’ve found this post useful, if you do, please subscribe and enter your email address below, or you can also drop a comment, thanks for reading!

Acute Pyelonephritis Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/acute-pyelonephritis-nursing-care-plans/feed/ 2 http://nurseslabs.com/2-dengue-hemorrhagic-fever-nursing-care-plans/ http://nurseslabs.com/2-dengue-hemorrhagic-fever-nursing-care-plans/#comments Wed, 21 Dec 2011 17:07:56 +0000 NursesLabs http://nurseslabs.com/?p=751 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 [...]

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

]]> 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 haemorrhagic 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.

Ineffective Tissue Perfusion

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	Nursing Diagnosis	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	Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1	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 circulation The pt shall have demonstrated increased perfusion as appropriate

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	Nursing Diagnosis	Objectives	Nursing Interventions	Rationale	Expected Outcome
S> (none) O> > Temp of 39.8 > Flushed skin > Skin warm to touch > Chills The pt. May manifest > Increased RR > Tachycardia > Convulsions > Sweating	Hyperthermia	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 37 The pt shall have identified underlying factors and importance of treatment as well as s/sx requiring further evaluation or intervention

Source: WHO> Dengue

Image Source: (1) (2)

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

]]> http://nurseslabs.com/2-dengue-hemorrhagic-fever-nursing-care-plans/feed/ 4 http://nurseslabs.com/neonatal-sepsis-nursing-care-plans/ http://nurseslabs.com/neonatal-sepsis-nursing-care-plans/#comments Sat, 12 Nov 2011 12:37:34 +0000 NursesLabs http://nurseslabs.com/?p=726 Neonatal sepsis nursing care plans, nursing management, interventions, drugs, surgical management, responsibilities of nurses.

5 Neonatal Sepsis Nursing Care Plans Original source at: Nurseslabs

]]> Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs in a neonate.  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.

This post has 5 neonatal sepsis nursing care plans

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.

1 Hyperthermia

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	Nursing Diagnosis	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	Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia	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 levelLong Term:After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.	Independent1.  Monitor neonate’s condition.2.  Monitor Vital signs3.  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 data3.  Helps in lowering down the temperature4. 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

]]> http://nurseslabs.com/neonatal-sepsis-nursing-care-plans/feed/ 0 http://nurseslabs.com/tahbso-nursing-care-plans/ http://nurseslabs.com/tahbso-nursing-care-plans/#comments Mon, 31 Oct 2011 06:17:08 +0000 NursesLabs http://nurseslabs.com/?p=397 Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, ovaries, fallopian tubes and cervix. View the Nursing Care Plans for TAHBSO

8 TAHBSO Nursing Care Plans Original source at: Nurseslabs

]]> 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:

1. Determines patient’s immediate response to surgical intervention.
2. Monitor patient’s physiologic status.
3. Assess patient’s pain level and administers appropriate pain relief measures.
4. Maintains patient’s safety(airway, circulation, prevention of injury)
5. Administer medication, fluid and blood component therapy, if prescribed.
6. 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

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	Nursing Diagnosis	Planning	Nursing Interventions	Rationale	Evaluation
Subjective: The patient may verbalized:“My incision is hurts”Objective: The patient manifested : -irritability -impaired physical mobility -disturbed sleep pattern -facial mask -diaphoresis -restlessness -facial grimaces	Acute pain secondary to surgical operation	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 rapportEmphasize ordered dietMonitor vital signsProvide comfort measure Encourage deep breathingProvide safety measure Develop communication review procedures/expectations and tell client when treatment will hurt Administer analgesics as indicated to maximal dosage as needed	To gain trustTo encourage patient not to eat untolerated foodTo obtain baseline dataTo satisfy the confinement of patientTo 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

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