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

1 Ineffective Airway Clearance

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

2 Ineffective Breathing Pattern

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

3 Impaired Gas Exchange

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

4 Sleep Pattern Disturbance

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

5 Risk for Spread of Infection

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

Other nursing diagnoses:

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

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

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

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

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

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

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

1. Impaired Skin Integrity

Ongoing Assessment

Therapeutic Actions

4 Dermatitis Nursing Care Plans Original source at: Nurseslabs

The 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/cholecystectomy-nursing-care-plans/ http://nurseslabs.com/cholecystectomy-nursing-care-plans/#comments Tue, 24 Jan 2012 17:32:35 +0000 NursesLabs http://nurseslabs.com/?p=708 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 [...]

7 Cholecystectomy Nursing Care Plans Original source at: Nurseslabs

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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

]]> http://nurseslabs.com/cholecystectomy-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/aplastic-anemia-nursing-care-plans/ http://nurseslabs.com/aplastic-anemia-nursing-care-plans/#comments Thu, 12 Jan 2012 14:49:28 +0000 NursesLabs http://nurseslabs.com/?p=1193 Aplastic anemia is a condition where bone marrow does not produce sufficient new cells to replenish blood cells. The condition, per its name, involves both aplasia and anemia. Read the nursing care plan for Aplastic Anemia.

4 Aplastic Anemia Nursing Care Plans Original source at: Nurseslabs

]]> Aplastic anemia is a condition where bone marrow does not produce sufficient new cells to replenish blood cells. The condition, per its name, involves both aplasia and anemia. Typically, anemia refers to low red blood cell counts, but aplastic anemia patients have lower counts of all three blood cell types: red blood cells, white blood cells, and platelets, termed pancytopenia.

Signs and Symptoms of Aplastic Anemia

• Anemia with malaise, pallor and associated symptoms such as palpitations
• Thrombocytopenia (low platelet counts), leading to increased risk of hemorrhage, bruising and petechiae
• Leukopenia (low white blood cell count), leading to increased risk of infection
• Reticulocytopenia (low reticulocyte counts)

Causes of Aplastic Anemia

In many cases, the etiology is considered to be idiopathic (cannot be determined), but one known cause is an autoimmune disorder in which white blood cells attack the bone marrow.

Aplastic Anemia Nursing Care Plans

Risk for infection related to decreased resistance and increased susceptibilitysecondary to leukopenia

Aplastic anemia is characterized by the depression of hemato-poietic activity in bone marrow affecting all blood cells.  In effect, serum level of RBC, WBC and Platelets are depleted.  Apparently, WBCs or leukocytes are the ones responsible in acting against foreign microorganisms that invade the body. Such event of a depleted leukocytes can highly predisposes the individual to acquire various secondary infec-tions since the body is said to be immuno-compromised.  Thus, a nursing diagnosis of risk for infection was derived.

Assessment	Nursing Dx	Planning	NursingInter­ventions	Rationale	Expected Outcome
S = OO = the client manifested the ff. s/sx: weakness easy fatigability dryness of lips bloodstained gums and teeth with untrimmed and dirty fingernails with limited range of motion lab values suggest a decreased in WBC count, neutrophils, hematocrit, hemoglobin and thrombocytes = the client may further manifest: -hyperthermia -flushed skin -irritability -restlessness -various signs of different systemic infection such as: Resp: Cough, colds, adventitious breath sounds Skin: rashes, itchiness, wounds, untimely wound healing GI: nausea, vomiting, abdominal discomfort GU: dysuria, abnormal discharges and other associated symptoms	Risk for infection related to decreased resistance and increased susceptibilitysecondary to leukopenia	Short term:After 4 hours of NI, the client will identify interven-tions to reduce/ prevent risk for infection.Long term:After 3 days of NI, the client will display techniques and lifestyle changes conducive for her health promotion and disease prevention and she will be free from signs of potential infection.	1.       Maintain established rapport2.       Monitor vital signs, especially temp.3.       Stress proper hand washing techniques by all caregivers between therapies4.       Monitor visitors/ caregivers of the client.  Instruct SO to limit visitors especially those with known contagious illnesses. 5.       Maintain aseptic/sterile techniques as much as possible 6.Advise the use of facial mask when going outside the client’s room 7.       Encouraged early ambulation, deep breathing and turning exercises as indicated. 8. Provide regular catheter/ perineal care as indicated 9.       Reinforce teachings about diet.  Avoid raw meats, fruits and vegetables.  Consume prescribed nutritionally adequate menus. 10.    Enforce strict bed rest.  Provide the client her favorite books as necessary. 11. Review to the client and SO about the nature of the disease and the interventions needed. 12.    Instruct the client to report significant changes that she may experience typical to a presence of infection. 13. Refer to other members of the health care team.	1. to gain trust & relieve anxiety2.  to obtain baseline data; also, fever is usually the initial sign of infection3.       hand washing is the primary measure against nosocomial infections/ cross contamination4.       prevents unwanted exposure of the client to other communicable diseases 5.  to avoid cross contamination 6. reverse isolation is an important for clients who are immuno-suppressed 7. simple exercises helps tone body built and strengthen the body system. 8.  to prevent growth  of microorganisms 9.  to provide an optimum nutrition to meet daily needs of client; raw food can contain microorganisms that may precipitate infection 10.    client is in great need of staying on her room to avoid potential exposure to pathogenic elements 11.  helps alleviate anxiety; can also foster cooperation and compliance to prescribed therapeutics 12. to intervene with such events accordingly 13.    promotes inter-disciplinary care rendered to the client	Short term:The client shall have identified interventions to reduce/prevent risk for infectionLong term:The client shall have displayed techniques and lifestyle changes conducive for her health promotion and disease prevention and have been free form signs of potential infection.

Other Possible Nursing Diagnoses for Aplastic Anemia

• Activity intolerance RT insufficient oxygen secondary to diminished red blood cell count
• Risk for impaired oral mucus membrane RT tissue hypoxia and vulnerability
• Risk for ineffective therapeutic regimen management RT insufficient knowledge of causes, prevention and signs and symptoms of complications

References

• Wikipedia: Aplastic Anemia

4 Aplastic Anemia Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/aplastic-anemia-nursing-care-plans/feed/ 4 http://nurseslabs.com/nanda-nursing-diagnosis-list/ http://nurseslabs.com/nanda-nursing-diagnosis-list/#comments Thu, 12 Jan 2012 09:30:32 +0000 bobbyRN http://nurseslabs.com/?p=4578 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 [...]

NANDA Nursing Diagnosis List Original source at: Nurseslabs

]]> 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

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

Nutritional-Metabolic Pattern

1. Adult failure to thrive
2. Deficient blood volume
3. Effective breastfeeding
4. Excess fluid volume
5. Hyperthermia
6. Hypothermia
7. Imbalanced nutrition: more than body requirements
8. Imbalanced nutrition: less than body requirements
9. Imbalanced nutrition: risk for more than body requirements
10. Impaired dentition
11. Impaired oral mucous membrane
12. Impaired skin integrity
13. Impaired swallowing
14. Impaired tissue integrity (specify type)
15. Ineffective breastfeeding
16. Ineffective infant feeding pattern
17. Ineffective thermoregulation
18. Interrupted breastfeeding
19. Latex allergy response
20. Nausea
21. Readiness for enhanced fluid balance
22. Readiness for enhanced nutrition
23. Risk for aspiration
24. Risk for deficient fluid volume
25. Risk for imbalanced fluid volume
26. Risk for imbalanced body temperature
27. Risk for latex allergy response
28. Risk for impaired liver function
29. Risk for impaired skin integrity
30. Risk for unstable blood glucose

Elimination Pattern

1. Bowel incontinence
2. Constipation
3. Diarrhea
4. Functional urinary incontinence
5. Impaired urinary elimination
6. Overflow urinary incontinence
7. Perceived constipation
8. Readiness for enhanced urinary elimination
9. Reflex urinary incontinence
10. Risk for constipation
11. Risk for urge urinary incontinence
12. Stress urinary incontinence
13. Total urinary incontinence
14. Urge urinary incontinence
15. Urinary retention

Activity-Exercise Pattern

1. Activity intolerance (specify)
2. Autonomic dysreflexia
3. Decreased cardiac output
4. Decreased intracranial adaptive capacity
5. Deficient diversional activity
6. Delayed growth and development
7. Delayed surgical recovery
8. Disorganized infant behavior
9. Dysfunctional ventilatory weaning response
10. Fatigue
11. Impaired spontaneous ventilation
12. Impaired bed mobility
13. Impaired gas exchange
14. Impaired home maintenance
15. Impaired physical mobility
16. Impaired transfer ability
17. Impaired walking
18. Impaired wheelchair mobility
19. Ineffective airway clearance
20. Ineffective breathing pattern
21. Ineffective tissue perfusion (specify)
22. Readiness for enhanced organized infant behavior
23. Risk for disproportionate growth
24. Risk for activity intolerance
25. Risk for autonomic dysreflexia
26. Risk for disuse syndrome
27. Risk for peripheral neurovascular dysfunction
28. Risk for sudden infant death syndrome
29. Sedentary lifestyle
30. Self-care deficit (specify: bathing/hygiene, dressing/grooming, feeding, toileting)
31. Wandering

Sleep-Rest Pattern

1. Insomnia
2. Readiness for enhanced sleep
3. Sleep deprivation

Cognitive-Perceptual Pattern

1. Acute confusion
2. Acute pain
3. Chronic confusion
4. Chronic pain
5. Decisional conflict (specify)
6. Deficient knowledge (specify)
7. Disturbed sensory perception (specify)
8. Disturbed thought process
9. Impaired environmental interpretation syndrome
10. Impaired memory
11. Readiness for enhanced comfort
12. Readiness for enhanced decision making
13. Readiness for enhanced knowledge
14. Risk for acute confusion
15. Unilateral neglect

Self-Perception and Self-Conception Pattern

1. Anxiety
2. Chronic low self-esteem
3. Death anxiety
4. Disturbed body image
5. Disturbed personal identity
6. Fear
7. Hopelessness
8. Powerlessness
9. Readiness for enhanced hope
10. Readiness for enhanced power
11. Readiness for enhanced self-concept
12. Risk for compromised human dignity
13. Risk for loneliness
14. Risk for self-directed violence
15. Risk for powerlessness
16. Risk for situational low self-esteem
17. Situational low self-esteem

Role-Relationship Pattern

1. Caregiver role strain
2. Chronic sorrow
3. Dysfunctional family process: alcoholism
4. Impaired parenting
5. Impaired social interaction
6. Impaired verbal communication
7. Ineffective role performance
8. Interrupted family process
9. Parental role conflict
10. Readiness for enhanced communication
11. Readiness for enhanced family processes
12. Readiness for enhanced parenting
13. Relocation stress syndrome
14. Risk for caregiver role strain
15. Risk for complicated grieving
16. Risk for impaired parent/child attachment
17. Risk for impaired parenting
18. Risk for relocation stress syndrome
19. Risk for other-directed violence
20. Social dysfunction

Sexuality-Reproductive

1. Ineffective sexuality pattern
2. Rape-trauma syndrome
3. Rape-trauma syndrome: compound reaction
4. Rape-trauma syndrime: silent reaction
5. Sexual dysfunction

Coping-Stress Tolerance Pattern

1. Compound family coping
2. Defensive coping
3. Disabled family coping
4. Ineffective community coping
5. Ineffective coping
6. Ineffective denial
7. Post-trauma syndrome
8. Readiness for enhanced community coping
9. Readiness for enhanced coping
10. Readiness for enhanced family coping
11. Risk for self-mutilation
12. Risk for suicide
13. Risk for post-trauma syndrome
14. Risk-prone health behaviors
15. Self-mutilation
16. Stress overload

Value-Belief Pattern

1. Impaired religiosity
2. Moral distress
3. Readiness for enhanced religiosity
4. Readiness for enhanced spiritual well-being
5. Risk for impaired religiosity
6. Risk for spiritual distress
7. Spiritual distress

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

NANDA Nursing Diagnosis List Original source at: Nurseslabs

]]> http://nurseslabs.com/nanda-nursing-diagnosis-list/feed/ 0 http://nurseslabs.com/4-diabetes-mellitus-nursing-care-plans/ http://nurseslabs.com/4-diabetes-mellitus-nursing-care-plans/#comments Fri, 06 Jan 2012 23:00:18 +0000 NursesLabs http://nurseslabs.com/?p=737 Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid metabolism. Here you view 4 Diabetes Mellitus Nursing Care Plans

4 Diabetes Mellitus Nursing Care Plans Original source at: Nurseslabs

]]> 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.

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.

Assessment	Nursing Diagnosis	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	Deficient Fluid Volume r/t intracellular DHN 2° the DM II	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 rapportTake and record vital signsMonitor the temperatureAssess skin turgor and mucous membranes for signs of dehydrationEncourage 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 concernTo obtain baseline dataTo monitor changes in temperatureDry skin and mucous membranes are signs of dehydrationTo 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

]]> http://nurseslabs.com/4-diabetes-mellitus-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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