Nurseslabs » risk for injury

Risk for Injury — Liver Cirrhosis Nursing Care Plans

Nurseslabs — Tue, 01 May 2012 15:26:37 +0000

NURSING DIAGNOSIS: Injury, risk for [hemorrhage]

Risk factors may include

Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and release of thromboplastin)
Portal hypertension, development of esophageal varices

Desired Outcomes

Maintain homestasis with absence of bleeding
Demonstrate behaviors to reduce risk of bleeding.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Assess for signs/symptoms of GI bleeding; e.g., check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus.	The GI tract (esopahgus and rectum) is the most usual source of bleeding because of its mucosal fragility and alterations in hemostasis associated with cirrhosis.
Observe for presence of petechiae, ecchymosis, bleeding from one or more sites.	Subacute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.
Monitor pulse, BP (and CVP if available).	An increased pulse with decreased BP and CVP can indicate loss of circulating blood volume, requiring further evaluation.
Note changes in mentation/level of consciousness.	Changes may indicate decreased cerebral perfusion secondary to hypovolemia, hypoxemia.
Avoid rectal temperature; be gentle with GI tube insertions.	Rectal and esophageal vessels are most vulnerable to rupture.
Encourage use of soft toothbrush, electric razor, avoiding straining for stool, forceful nose blowing, and so forth.	In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.
Use small needles for injections. Apply pressure to small bleeding/venipuncture sites for longer than usual.	Minimizes damage to tissues, reducing risk of bleeding/hematoma.
Recommend avoidance of aspirin-containing products.	Prolongs coagulation, potentiating risk of hemorrhage.
Monitor Hb/Hct and clotting factors.	Indicators of anemia, active bleeding, or impending complications (e.g., DIC).
Administer medications as indicated: Supplemental vitamins (e.g., vitamins K, D, and C); Stool softeners.	Promotes prothrombin synthesis and coagulation if liver is functional. Vitamin C deficiencies increase susceptibility of GI system to irritation/bleeding. Prevents straining for stool with resultant increase in intra-abdominal pressure and risk of vascular rupture/hemorrhage.
Provide gastric lavage with room temperature/cool saline solution or water as indicated.	In presence of acute bleeding, evacuation of blood from GI tract reduces ammonia production and risk of hepatic encephalopathy.
Assist with insertion/maintenance of GI/esophageal tube (e.g., Sengstaken-Blakemore tube).	Temporarily controls bleeding of esophageal varices when control by other means (e.g., lavage) and hemodynamic stability cannot be achieved.
Prepare for surgical procedures, e.g., direct ligation (banding) or varices, esophagogastric resection, splenorenal-portacaval anastomosis.	May be needed to control active hemorrhage or to decrease portal and collateral blood vessel pressure to minimize risk of recurrence of bleeding.

Risk for Injury — Liver Cirrhosis Nursing Care Plans Original source at: Nurseslabs

Risk for Injury — Alcohol Withdrawal Nursing Care Plans

Nurseslabs — Tue, 27 Mar 2012 11:30:13 +0000

Nursing Diagnosis: Risk for Injury

Risk factors may include

Cessation of alcohol intake with varied autonomic nervous system responses to the system’s suddenly altered state
Involuntary clonic/tonic muscle activity (seizures)
Equilibrium/balancing difficulties, reduced muscle and hand/eye coordination

Desired Outcomes

Demonstrate absence of untoward effects of withdrawal.
Experience no physical injury.

Nursing Interventions	Rationale
Identify stage of AWS (alchohol withdrawal syndrome); i.e., stage I is associated with signs/symptoms of hyperactivity (e.g., tremors, sleeplessness, nausea/ vomiting, diaphoresis, tachycardia, hypertension). Stage II is manifested by increased hyperactivity plus hallucinations and/or seizure activity. Stage III symptoms include DTs and extreme autonomic hyperactivity with profound confusion, anxiety, insomnia, fever.	Prompt recognition and intervention may halt progression of symptoms and enhance recovery/improve prognosis. In addition, recurrence/progression of symptoms indicates need for changes in drug therapy/more intense treatment to prevent death.
Monitor/document seizure activity. Maintain patent airway. Provide environmental safety, e.g., padded side rails, bed in low position.	Grand mal seizures are most common and may be related to decreased magnesium levels, hypoglycemia, elevated blood alcohol, or history of head trauma/preexisting seizure disorder. Note: In absence of history of/other pathology causing seizures, they usually stop spontaneously, requiring only symptomatic treatment. Note: Antiepileptic drugs are not indicated for alcohol withdrawal seizures.
Check deep-tendon reflexes. Assess gait, if possible.	Reflexes may be depressed, absent, or hyperactive. Peripheral neuropathies are common, especially in malnourished patient. Ataxia (gait disturbance) is associated with Wernicke’s syndrome (thiamine deficiency) and cerebellar degeneration.
Assist with ambulation and self-care activities as needed.	Prevents falls with resultant injury.
Provide for environmental safety when indicated.	May be required when equilibrium, hand/eye coordination problems exist.
Administer medications as indicated e.g.: Benzodiazepines (BZDs), e.g., chlordiazepoxide (Librium), diazepam (Valium), clonazepam (Klonopin), oxazepam (Serax), clorazepate (Tranxene); Haloperidol (Haldol); Thiamine; Magnesium sulfate.	BZDs are commonly used to control neuronal hyperactivity because of their minimal respiratory and cardiac depression and anticonvulsant properties. Studies have also shown that these drugs can prevent progression to more severe states of withdrawal. IV/PO administration is preferred route because IM absorption is unpredictable. Muscle-relaxant qualities are particularly helpful to patient in controlling “the shakes,” trembling, and ataxic quality of movements. Patient may initially require large doses to achieve desired effect, and then drugs may be tapered and discontinued, usually within 96 hr. Note: These agents are used cautiously in patients with known hepatic disease because they are metabolized by the liver, although Serax has a shorter half-life. May be used in conjunction with BZDs for patients experiencing hallucinations. Thiamine deficiency (common in alcohol abuse) may lead to neuritis, Wernecke’s syndrome, and/or Korsakoff’s psychosis. Reduces tremors and seizure activity by decreasing neuromuscular excitability.

Risk for Injury — Alcohol Withdrawal Nursing Care Plans Original source at: Nurseslabs

Risk for Injury — AIDS Nursing Care Plans

Nurseslabs — Mon, 26 Mar 2012 00:57:41 +0000

Nursing Diagnosis: Risk for Injury (Hemorrhage)

Risk factors may include

Abnormal blood profile: decreased vitamin K absorption, alteration in hepatic function, presence of autoimmune antiplatelet antibodies, malignancies (KS), and/or circulating endotoxins (sepsis)

Desired Outcomes

Display homeostasis as evidenced by absence of bleeding.

Nursing Interventions	Rationale
Avoid injections, rectal temperatures/rectal tubes. Administer rectal suppositories with caution.	Protects patient from procedure-related causes of bleeding; i.e., insertion of thermometers, rectal tubes can damage or tear rectal mucosa. Note: Some medications need to be given via suppository, so caution is advised.
Maintain a safe environment; e.g., keep all necessary objects and call bell within patient’s reach and keep bed in low position.	Reduces accidental injury, which could result in bleeding.
Maintain bedrest/chair rest when platelets are below 10,000 or as individually appropriate. Assess medication regimen.	Reduces possibility of injury, although activity needs to be maintained. May need to discontinue or reduce dosage of a drug. Note: Patient can have a surprisingly low platelet count without bleeding.
Hematest body fluids, e.g., urine, stool, vomitus, for occult blood.	Prompt detection of bleeding/initiation of therapy may prevent critical hemorrhage.
Observe for/report epistaxis, hemoptysis, hematuria, nonmenstrual vaginal bleeding, or oozing from lesions/body orifices/IV insertion sites.	Spontaneous bleeding may indicate development of DIC or immune thrombocytopenia, necessitating further evaluation and prompt intervention.
Monitor for changes in vital signs and skin color, e.g., BP, pulse, respirations, skin pallor/discoloration.	Presence of bleeding/hemorrhage may lead to circulatory failure/shock.
Evaluate change in level of consciousness.	May reflect cerebral bleeding.
Review laboratory studies, e.g., PT, aPTT, clotting time, platelets, Hb/Hct.	Detects alterations in clotting capability; identifies therapy needs. Note: Many individuals (up to 80%) display platelet count below 50,000 and may be asymptomatic, necessitating regular monitoring.
Administer blood products as indicated.	Transfusions may be required in the event of persistent/massive spontaneous bleeding.
Avoid use of aspirin products/NSAIDs, especially in presence of gastric lesions.	These medications reduce platelet aggregation, impairing/prolonging the coagulation process, and may cause further gastric irritation, increasing risk of bleeding.

Risk for Injury — AIDS Nursing Care Plans 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

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

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