Hemodialysis Nursing Care Plan

Nursing Care Plan - Hemodialysis

Bronchial Asthma Nursing Care Plan

Asthma Nursing Care Plan - Ineffective Breathing Pattern by jamieboyRN

  Bronchial Asthma triggers may include:

• Tobacco smoke
• Infections such as colds, flu, or pneumonia
• Allergens such as food, pollen, mold, dust mites, and pet dander
• Exercise
• Air pollution and toxins
• Weather, especially extreme changes in temperature
• Drugs (such as aspirin, NSAID, and beta-blockers)
• Food additives (such as MSG)
• Emotional stress and anxiety
• Singing, laughing, or crying
• Smoking, perfumes, or sprays
• Acid reflux

Post Op Surgery - Nursing Care Plan

Pain related to post surgical incision as manifested by a pain scale of 6

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Risk for infection related to post surgical incision

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acute pain related to post surgical procedure

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Angina Pectoris Nursing Care Plan

The classic symptom of coronary artery disease (CAD) is angina—pain caused by loss of oxygen and nutrients to the myocardial tissue because of inadequate coronary blood flow. In most but not all patients presenting with angina, CAD symptoms are caused by significant atherosclerosis. Unstable angina is sometimes grouped with MI under the diagnosis of acute coronary syndrome. Angina has three major forms: (1) stable (precipitated by effort, of short duration, and easily relieved), (2) unstable (longer lasting, more severe, may not be relieved by rest/nitroglycerin; may also be new onset of pain with exertion or recent acceleration in severity of pain), and (3) variant (chest pain at rest with ECG changes due to coronary artery spasm). The AHCPR guidelines of May 1994 state that unstable angina is a transitory syndrome that causes significant disability and death in the United States.

CARE SETTING
Patients judged to be at intermediate or high likelihood of significant CAD are often hospitalized for further evaluation and therapeutic intervention. Classification of angina (provided by Canadian Cardiovascular Society Classification [CCSC]) aids in determining the risk of adverse outcomes for patients with unstable angina and, therefore, level of treatment needs. Class III angina is identified as occurring if the patient walks less than two blocks and normal activity is markedly limited, and class IV angina occurs at rest or with minimal activity and level of activity is severely limited. These two classes may require inpatient evaluation/therapeutic adjustments.

NURSING PRIORITIES

1. Relieve/control pain.
2. Prevent/minimize development of myocardial complications.
3. Provide information about disease process/prognosis and treatment.
4. Support patient/SO in initiating necessary lifestyle/behavioral changes.

 DISCHARGE GOALS

1. Achieves desired activity level; meets self-care needs with minimal or no pain.
2. Free of complications.
3. Disease process/prognosis and therapeutic regimen understood.
4. Participating in treatment program, behavioral changes.
5. Plan in place to meet needs after discharge.

Desired Outcomes

1. Report/display decreased episodes of dyspnea, angina, and dysrhythmias.
2. Demonstrate increased activity tolerance.
3. Participate in behaviors/activities that reduce the workload of the heart.

Nursing intervention with rationale:

1.Maintain bed/chair rest in position of comfort during acute episodes.
Rationale: Decreases oxygen consumption/demand, reducing myocardial workload and risk of decompensation.
2. Monitor vital signs (e.g., heart rate, BP) and cardiac rhythm.
Rationale: Tachycardia may be present because of pain, anxiety, hypoxemia, and reduced cardiac output. Changes may also occur in BP (hypertension or hypotension) because of cardiac response. ECG changes reflecting ischemia/dysrhythmias indicate need for additional evaluation and therapeutic intervention.
3. Auscultate breath sounds and heart sounds. Listen for murmurs.
Rationale: S3, S4, or crackles can occur with cardiac decompensation or some medications (especially beta-blockers). Development of murmurs may reveal a valvular cause for chest pain (e.g., aortic stenosis, mitral stenosis) or papillary muscle rupture.
4. Provide for adequate rest periods. Assist with/perform self-care activities, as indicated.
Rationale: Conserves energy, reduces cardiac workload.
5. Stress importance of avoiding straining/ bearing down, especially during defecation.
Rationale: Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, both of which may impair cardiac output.
6. Encourage immediate reporting of pain for prompt administration of medications as indicated.
Rationale: Timely interventions can reduce oxygen consumption and myocardial workload and may prevent/minimize cardiac complications.
7. Monitor for and document effects of/adverse response to medications, noting BP, heart rate, and rhythm (especially when giving combination of calcium antagonists, betablockers, and nitrates).
Rationale: Desired effect is to decrease myocardial oxygen demand by decreasing ventricular stress. Drugs with negative inotropic properties can decrease perfusion to an already ischemic myocardium. Combination of nitrates and betablockers may have cumulative effect on cardiac output.
8. Assess for signs and symptoms of heart failure.
Rationale: Angina is only a symptom of underlying pathology causing myocardial ischemia. Disease may compromise cardiac function to point of decompensation.
9. Administer supplemental oxygen as needed.
Rationale: Increases oxygen available for myocardial uptake to improve contractility, reduce ischemia, and reduce lactic acid levels.
10. Administer medications as indicated: Calcium channel blockers, e.g., diltiazem (Cardizem), nifedipine (Procardia), verapamil (Calan), bepridil (Vascor), amlodipine (Norvasc), felodipine (Plendil), isradipine (DynaCirc).
Rationale: Although differing in mode of action, calcium channel blockers play a major role in preventing and terminating ischemia induced by coronary artery spasm and in reducing vascular resistance, thereby decreasing BP and cardiac workload.

Angina Pectoris Nursing Care Plan

Free Nursing Care Plans

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Pregnancy Induced Hypertension Nursing Care Plan

Pregnancy Induced Hypertension Nursing Care Plan

Hypertension Nursing Care Plan

Hypertension refers to a state where a person’s blood pressure remains at an elevated level at all times. This condition is formally known as arterial hypertension and is popularly called high blood pressure.

2 types of hypertension: 

1. Primary Hypertension – when a patient’s chronically elevated blood pressure does not have a specific medical cause that can be identified 
2. Secondary Hypertension – When high blood pressure is caused by other health conditions like tumors of the adrenal gland, kidney disease of other problems. 

Hypertension is a dangerous condition because it can lead to serious complications. Chronically elevated blood pressure increases the risk of developing heart failure, heart attacks, arterial aneurysm and strokes. Many cases of chronic renal failure have been linked to high blood pressure.

Signs and Symptoms:
Undiagnosed high blood pressure can lead to many physical problems including damage to major organs over a period of time. The symptoms of hypertension, if ignored, can lead to deterioration in kidney / liver function and cardiac problems. Hypertension can also damage vision, cause strokes and more.
Common Hypertension Symptoms to be aware of. 

1. Recurrent / persistent headaches 
2. Vision problems including blurring of vision 
3. Giddiness 
4. Convulsions 
5. Tremors in the hands or other body parts 
6. Walking difficulties (formally called ataxia)

Myocardial Infarction Nursing Care Plan

Nursing Care Plan for Myocardial Infarction

NCP Myocardial Infarction

Risk for Infection Nursing Care Plan

Nursing Diagnosis: Risk for Infection
Universal Precautions; Standard Precautions; CDC Guidelines; OSHA
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Immune Status
* Knowledge: Infection Control

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Infection Control
* Infection Protection

NANDA Definition: At increased risk for being invaded by pathogenic organisms

Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Being malnourished, having inadequate resources for sanitary living conditions, and lacking knowledge about disease transmission place individuals at risk for infection. Health care workers, to protect themselves and others from disease transmission, must understand how to take precautions to prevent transmission. Because identification of infected individuals is not always apparent, standard precautions recommended by the Centers for Disease Control and Prevention (CDC) are widely practiced. In addition, the Occupational Safety and Health Administration (OSHA) has set forth the Blood Borne Pathogens Standard, developed to protect workers and the public from infection. Ease and increase in world travel has also increased opportunities for transmission of disease from abroad. Infections prolong healing, and can result in death if untreated. Antimicrobials are used to treat infections when susceptibility is present. Organisms may become resistant to antimicrobials, requiring multiple antimicrobial therapy. There are organisms for which no antimicrobial is effective, such as the human immunodeficiency virus (HIV).

* Risk Factors: Inadequate primary defenses: broken skin, injured tissue, body fluid stasis
* Inadequate secondary defenses: immunosuppression, leukopenia
* Malnutrition
* Intubation
* Indwelling catheters, drains
* Intravenous (IV) devices
* Invasive procedures
* Rupture of amniotic membranes
* Chronic disease
* Failure to avoid pathogens (exposure)
* Inadequate acquired immunity

* Expected Outcomes Patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.
* Infection is recognized early to allow for prompt treatment.

Ongoing Assessment

* Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; in-dwelling catheters (Foley, peritoneal); wound drainage tubes (T-tubes, Penrose, Jackson-Pratt); endotracheal or tracheostomy tubes; venous or arterial access devices; and orthopedic fixator pins. Each of these examples represent a break in the body’s normal first lines of defense.
* Monitor white blood count (WBC). Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3. Very low WBC (neutropenia <1000 mm3) indicates severe risk for infection because patient does not have sufficient WBCs to fight infection. NOTE: In elderly patients, infection may be present without an increased WBC.
* Monitor the following for signs of infection:
o Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture.
o Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia.
o Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.
o Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.
* Assess nutritional status, including weight, history of weight loss, and serum albumin. Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection.
* In pregnant patients, assess intactness of amniotic membranes. Prolonged rupture of amniotic membranes before delivery places the mother and infant at increased risk for infection.
* Assess for exposure to individuals with active infections.
* Assess for history of drug use or treatment modalities that may cause immunosuppression. Antineoplastic agents and corticosteroids reduce immunocompetence.
* Assess immunization status. Elderly patients and those not raised in the United States may not have completed immunizations, and therefore not have sufficient acquired immunocompetence.

Therapeutic Interventions

* Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access management.
* Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing.
* Limit visitors. This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. The most common modes of transmission are by direct contact (touching) and by droplet (airborne).
* Encourage intake of protein- and calorie-rich foods. This maintains optimal nutritional status.
* Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
* Encourage coughing and deep breathing; consider use of incentive spirometer. These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
* Administer or teach use of antimicrobial (antibiotic) drugs as ordered. Antimicrobial drugs include antibacterial, antifungal, antiparasitic, and antiviral agents. All of these agents are either toxic to the pathogen or retard the pathogen’s growth. Ideally, the selection of the drug is based on cultures from the infected area; this is often impossible or impractical, and in these cases, empirical management usually is undertaken with a broad-spectrum drug.
* Place patient in protective isolation if patient is at very high risk. Protective isolation is established if white blood cell counts indicate neutropenia (<500 to 1000 mm3). Institutional protocols may vary.
* Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.

Education/Continuity of Care

* Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care. Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks.
* Teach patient the importance of avoiding contact with those who have infections or colds.
* Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or colds.
* Teach patient, family, and caregivers the purpose and proper technique for maintaining isolation.
* Teach patient to take antibiotics as prescribed. Most antibiotics work best when a constant blood level is maintained; a constant blood level is maintained when medications are taken as prescribed. The absorption of some antibiotics is hindered by certain foods; patient should be instructed accordingly.
* Teach patient and caregiver the signs and symptoms of infection, and when to report these to the physician or nurse.
* Demonstrate and allow return demonstration of all high-risk procedures that patient or caregiver will do after discharge, such as dressing changes, peripheral or central IV site care, peritoneal dialysis, self-catheterization (may use clean technique). Bladder infection is more related to overdistended bladder resulting from infrequent catheterization than to use of clean versus sterile technique.

Anorexia Nervosa Nursing Care Plans

Anorexia nervosa is an eating disorder that causes people to obsess about their weight and the food they eat. People with anorexia nervosa attempt to maintain a weight that’s far below normal for their age and height. To prevent weight gain or to continue losing weight, people with anorexia nervosa may starve themselves or exercise excessively.

Anorexia nervosa is a disease that affects all organ systems, principally the cardiovascular and endocrine systems. However, complications can also involve other systems, including the GI, renal, reproductive, neurologic, orofacial, dermatologic, and hematologic symptoms.

A typical case of anorexia nervosa involves a young person (teenager or young adult) who is mildly overweight or of normal weight and who begins a diet and exercise plan to lose weight. As she loses weight and receives initial positive reinforcement for this behavior (eg, compliments by peers on her appearance), the reward is high and causes an inability to stop this behavior once an ideal weight is achieved.

ETIOLOGICAL THEORIES

Psychodynamics

The individual reflects a developmental arrest in the very early childhood years. The tasks of trust, autonomy, and separation-individuation are unfulfilled, and the individual remains in the dependent position. Ego development is retarded. Symptoms are often associated with a perceived loss of control in some aspect of life and may center on fears of sexual maturity/intimacy. Although these disorders affect women primarily, approximately 5% to 10% of those afflicted are men. Additionally, eating disorders are often associated with depression, anxiety, phobias, and cognitive problems.
Biological

These disorders may be caused by neuroendocrine abnormalities within the hypothalamus. Symptoms are linked to various chemical disturbances normally regulated by the hypothalamus. Furthermore, a physiological defect may make it difficult for the individual to interpret sensations of hunger and fullness.

Family Dynamics

Issues of control become the overriding factors in the family of the client with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. There is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.

NURSING PRIORITIES

1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist client to develop realistic body image/improve self-esteem.
4. Provide support/involve SO, if available, in treatment program to client/SO.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment.

DISCHARGE GOALS

1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.

Nursing diagnosis of Anorexia Nervosa and Bulimia Nervosa: NUTRITION: altered, less than body requirements may be related to inadequate food intake; self-induced vomiting and chronic/excessive laxative use possibly evidenced by body weight 15% (or more) below expected (anorexia), or may be within normal range (bulimia, binge-eating), pale conjunctiva and mucous membranes; poor skin turgor/muscle tone, edema, excessive loss of hair; increased growth of body hair (lanugo), amenorrhea, hypothermia, bradycardia, cardiac irregularities, hypotension, electrolyte imbalances.

Desired Outcome:

1. Verbalize understanding of nutritional needs.
2. Establish a dietary pattern with caloric intake adequate to regain/maintain appropriate weight.
3. Demonstrate weight gain toward expected goal range.

Nursing intervention with rationale:

1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Malnutrition is a mood-altering condition leading to depression and agitation and affecting cognitive functioning/decision-making. Improved nutritional status enhances thinking ability, and psychological work can begin.
2. Involve client with team in setting up/carrying out program of behavior modification. Provide reward for weight gain as individually determined; ignore loss.
Rationale: Provides structured eating stimulation while allowing client some control in choices. Behavior modification may be effective only in mild cases or for short-term weight gain. Note: Combination of cognitive-behavioral approach is preferred for treating bulimia.
3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion and/or comment. Promote pleasant environment and record intake.
Rationale: Client detects urgency and reacts to pressure. Any comment that might be seen as coercion provides focus on food. When staff member responds consistently, client can begin to trust her or his responses. The single area in which client has exercised power and control is food/eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.
4. Provide smaller meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Client may feel bloated for 3–6 weeks while body readjusts to food intake.
5. Make selective menu available and allow client to control choices, as much as possible.
Rationale: Client who gains self-confidence and feels in control of environment is more likely to eat preferred foods.
6. Be alert to choices of low-calorie foods/beverages; hoarding food; disposing of food in various places such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
7. Maintain a regular weighing schedule, such as Monday/Friday before breakfast in same attire, on same scale, and graph results.
Rationale: Provides accurate ongoing record of weight loss/gain. Also diminishes obsessing about changes in weight.
8. Weigh with back to scale (depending on program protocols).
Rationale: Although some programs prefer client to see the results of weighing, this approach can force the issue of trust in client who usually does not trust others.
9. Consult with dietitian/nutritional therapy team.
Rationale: Helpful in determining individual dietary needs and appropriate sources. Note: Insufficient calorie and protein intake can lower resistance to infection and cause constipation, hallucinations, and liver damage.
10. Transfer to acute medical setting for nutritional therapy, when condition is life-threatening.
Rationale: The underlying problem cannot be cured without improved nutritional status. Hospitalization provides a controlled environment in which food intake, vomiting/elimination, medications, and activities can be monitored. It also separates the client from SO(s) and provides exposure to others with the same problem, creating an atmosphere for sharing.

Nursing Diagnoses

1. Imbalanced Nutrition: Less Than Body Requirements

Common Related Factors	Defining Characteristics
Severe fear of obesity Severely distorted self-concept, self-esteem, and/or body image Absence of physical conditions that would explain weight loss or prevent weight gain	Body weight 15% to 29% or more below ideal weight for height Self-restricted calorie intake despite hunger Obsession with food, calories, weight, and control issues
Common Expected Outcomes Patient stops losing weight. Patient begins to gain weight. Patient recognizes eating disorder.	NOC Outcomes Nutritional Status: Food and Fluid Intake; Weight Control NIC Interventions Eating Disorders Management; Weight Gain Assistance; Nutritional Therapy

Ongoing Assessment

Actions/Interventions	Rationale
Record the patient’s weight and height on intake. Weigh regularly, maintaining standard conditions (i.e., same scale, same time of day, patient wearing similar clothes).	This ensures accurate record of weight changes.
Weigh the patient in a matter-of-fact manner without discussion.	This reduces risk of acting-out behaviors. Weight gain is only one aspect of the total therapeutic program; other critical factors include nutritional adequacy, behaviors related to eating, appropriate use of exercise, and development of a healthy body image.
Obtain weight history, including initial motivation for weight loss or food restrictions.	Clinical anorexia can follow ordinary weight loss dieting.
Conduct a nutritional assessment:	It is critical that the health care provider openly discuss and have an understanding of the complex food and weight-related behaviors of the patient so that appropriate supports can be integrated into the treatment plan.
Assess the patient’s beliefs and fears about food and weight gain	Excessive focus on food and weight can be a maladaptive method of coping with stress.
Knowledge about nutrition and sources of information	This information provides the basis for an individualized teaching plan about maintaining adequate nutritional intake.
Behaviors used to reduce calorie intake (dieting), to increase energy output (exercising), and generally to lose weight (vomiting, purging, and laxative abuse)	This provides data on patient thinking and thought distortions.
Assess cardiovascular, metabolic, renal, gastric, hematological, and endocrine system functioning.	Assessment provides data on the severity of malnutrition.
Monitor intake (i.e., daily food plans that track eating trends along with emotional states and triggering events). Record intake and output for the hospitalized patient.	These data help determine the patient’s actual caloric intake and eating behaviors.

Therapeutic Interventions

Actions/Interventions	Rationale
Prescribe appropriate nutrition and total calories per day to relieve acute starvation.	A gradual refeeding prescription ensures steady weight gain and reduces risk of medical complications.
Supervise all activities immediately before and after meals; maintain supervision consistency.	This decreases opportunity to engage in compensatory activities to reduce calorie intake.
Provide food and meals without comment.	This helps separate emotional behaviors from eating behaviors.
Set limits on all exercise but allow daily activity.	Preventing all forms of exercise may induce severe anxiety.
Assure the patient that treatment is not designed to produce obesity.	Patients have an overwhelming fear of weight gain and obesity.
Acknowledge any anger, sadness, or feeling of loss that the patient may have toward treatment.	This helps provide external emotional controls that have not yet been internalized by the patient.
Provide supplemental feedings and nutrition as indicated.	Nutritional supplements may be necessary if the patient is malnourished. Tube or parenteral feedings may be necessary if the patient is unable to allow herself or himself oral feedings.

2. Disturbed Body Image

Common Related Factors	Defining Characteristics
Difficulty coping with development and maturation Inability to achieve unreasonable personal goals Alexithymia (channeling uncomfortable feelings into behaviors such as self-starvation)	Distorted views of one’s body weight and shape for age Negative feelings about self and body Self-loathing (impulsive or obsessive) Intense fear of gaining or not being able to lose weight
Common Expected Outcomes Patient identifies positive thoughts and feelings regarding body and self. Patient identifies a direct means of coping with problems.	NOC Outcome Body Image NIC Interventions Self-Awareness Enhancement; Body Image Enhancement

Ongoing Assessment

Actions/Interventions	Rationale
Explore the patient’s understanding of his or her physical body, especially as it relates to maturation. Assess to what degree the patient’s negative body image and negative self-concept are related to overwhelming anxiety.	Patients with anorexia have a distorted body image.
Assess to what degree culture, religion, race, and gender influence the patient’s negative views of self.	Cultural and social norms about body size and shape may influence the patient’s thinking and feelings about his or her body image.
Determine the family or patient’s perceptions regarding psychological and physical changes brought about by anorexia.	These data need to be compared to the patient’s thinking prior to the onset of anorexia.
Obtain the patient’s assessment of personal strengths and weaknesses.	Patients learn they have the ability to handle day-to-day stress.
Assess the patient’s ability to identify “here and now” emotional states and precipitating events that trigger negative behaviors.	The patient may not be aware of the relationship between feelings and eating behaviors.

Therapeutic Interventions

Actions/Interventions	Rationale
Encourage reexamination of positive and negative self-perceptions.	The patient needs to develop a realistic understanding of his or her body image.
Encourage the patient to identify the differences between “real people” and celebrities.	Patients often use media reports of celebrities as a guide for their eating behaviors.
Encourage recognition, expression, and acceptance of unpleasant feelings.	Patients with anorexia have a need for control in multiple areas of their lives. Mastery over food may have become a method for reducing tensions.
Help the patient develop a realistic, acceptable perception of body image and food.	Patients must understand the complex health problems associated with anorexia.
Refer the patient to individual counseling and a support group for eating disorders.	Multiple approaches are needed to achieve long-term changes in behavior. Groups that come together for mutual support and guidance can provide long-term assistance.

Acute Pain Nursing Diagnosis

Acute Pain NCP

2 Diabetic Retinopathy Nursing Care Plans

Diabetic retinopathy is retinopathy (damage to the retina) caused by complications of diabetes mellitus, which can eventually lead to blindness. It is an ocular manifestation of systemic disease which affects up to 80% of all patients who have had diabetes for 10 years or more. Despite these intimidating statistics, research indicates that at least 90% of these new cases could be reduced if there was proper and vigilant treatment and monitoring of the eyes.

Altered Sensory Perception

In poorly controlled DM, microcirculatory changes occur rapidly wherein the lining of the retinal blood vessels that supply the retina is blocked within the retina. Visual impairment occurs as a result of this    ischemia which significantly alter the visual perception of the patient.

Assessment	Nursing Diagnosis	Objectives	Nursing Interventions	Rationale	Expected Outcome
s> the pt. may be verbalize: -change in sensory acuity o> -lethargy -dependency on significant others -bilateral blindness -change in usual response to stimuli -poor concentration - change in behavior pattern	Altered sensory perception (visual) r/t micro vascular destruction 2° DM	Short term: after 1-2 hrs. of NI, the pt. will demonstrate behaviors to prevent accidents that can result due to visual impartment. Long term: After 2-3 days of NI. The pt. will be free of injury caused by the sensory alterarion.	>establish rapport >monitor and assess V.S >assess pt’s general physical condition >listen and respect clients expression of dependency >reorient to time, place, and staff and events as necessary >explain procedures / expected sensations and outcomes >minimize discussion of negatives within clients hearing >provide rest periods >arrange bed, personal articles and food trays >instruct SO not to leave the client unattended >provide safety measures >position door s and furniture’s so they are out of travel path >administer antidiabetic medications as needed	>to gain pt’s. trust and cooperation >to obtain baseline data >to note for any abnormality >to encourage verbalization of feelings >enhances pt’s. well being and sense of importance. >to promote participation >pt may misinterpret and believe references are to himself / herself >to conserve energy >enhances safety >to prevent injury >to aid in maintaining balance >to treat underlying condition.	The pt shall have demonstrated behaviors to prevent accident / injures. The pt shall have been free of injury caused by the alteration

Risk For Falls

Retina is the most metabolically active structure per weight of tissue in the body. Thus the retina is an inevitable target for micro vascular damage in diabetes mellitus. Diabetic retinopathy appears to be a response to retinal ischemia resulting from blood vessel changes and RBC aggregation. It is the leading cause of blindness. In the case of the pt. retinopathy become a chronic complication that lead to blindness. Blindness increase the pt’s susceptibly to falling that may cause physical harm. This impartment in eyesight may to inability to recognize danger.

Assessment	Nursing Diagnosis	Objectives	Nursing Interventions	Rationale	Expected Outcome
s> the patient may verbalize: -weakness -imbalance of stance and posture o> -elderly -needs  assistance in performing ADLs -dependent to significant others -decrease Hgb concentration -bilateral blindness -(+) homans sign on both legs - with  limited ROM -faintness when turning -decrease lower extremely strength -difficulty c̄ gait	Risk for falls r/t eyesight impairment (blindness)	Short term: After 1-2 hrs of NI, the pt will be able to demonstrate behaviors to reduce and protect  self from injury. Long term: After 2-3 days of NI, the pt will be free of injury from mechanical sources	>establish rapport >monitor and assess V.S >assess pts general physical condition >evaluate client’s cognitive status >provide information regarding clients dse  condition (s) that may result in increase risk of falls. >review medication regimen and how it affects clients. Instruct in monitoring of side effect. >ensure safety precautions >instruct the S.O not to leave the unattended . >instruct pt. to ask for assistance during ambulation/ transfer >administer due to meds	>to gain pts trust and cooperation >to obtain  baseline >to note any abnormality >affects ability to perceive own limitation and risk for falling >to instill awareness on the need to promote safety. >use of pain medication may contribute to weakness and confusion; multiple medications and combinations  may contribute to dizziness or loss of balance > to prevent falls >to treat underlying medical condition	The pt shall have demonstrated behaviors to protect self from injury The pt shall have been free for injury.

CVA Nursing Care Plan

CVA Nursing Care Plan

Aplastic Anemia Nursing Care Plan

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:

• 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
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.

Risk for Infection

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	Nursing Inter­ventions	Rationale	Expected Outcome
S = O O = 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 r/t inadequate secondary defenses 2 Aplastic Anemia	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 rapport 2.       Monitor vital signs, especially temp. 3.       Stress proper hand washing techniques by all caregivers between therapies 4.       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 anxiety 2.  to obtain baseline data; also, fever is usually the initial sign of infection 3.       hand washing is the primary measure against nosocomial infections/ cross contamination 4.       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 infection Long 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.

Fracture Nursing Care Plans

Fracture Nursing Care Plans

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Chronic Obstructive Pulmonary Disease Bronchitis) Nursing Care Plans

6 Pleural Effusion Nursing Care Plans

6 Pleural Effusion Nursing Care Plans

6 More Bronchopneumonia Nursing Care Plans

6 More Broncho Pneumonia Nursing Care Plans

Hypertensive Emergency Nursing Care Plan

A hypertensive emergency is severe hypertension (high blood pressure) with acute impairment of an organ system (especially the central nervous system, cardiovascular system and/or the renal system) and the possibility of irreversible organ-damage. In case of a hypertensive emergency, the blood pressure should be lowered aggressively over minutes to hours with an antihypertensive agent.

Several classes of antihypertensive agents are recommended and the choice for the antihypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patient’s usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous sodium nitroprusside injection which has an almost immediate antihypertensive effect is suitable but in many cases not readily available. In less urgent cases, oral agents like captopril, clonidine, labetalol, prazosin, which all have a delayed onset of action by several minutes compared to sodium nitroprusside, can also be used.

Decreased Cardiac Output

Hypertension is defined as a condition wherein there is an increase in BP beyond the normal range. Hypertensive emergency is used for BPs above 160/100mmHg. With hypertension, the blood vessels constrict. When blood vessels are constricted, there is a decrease in blood volume, decrease in cardiac output and increase in BP as blood passes through the narrowed lumen of the vessels.

Assessment	Nursing Diagnosis	Objectives	Nursing Interventions	Rationale	Expected Outcome
S> (none) O> The pt. Manifested: > dysrrhythmias > prolonged capillary refill > cold clammy skin > dyspnea > variations in BP > restlessness > BP of 190/150 The pt. May manifest	Decreased cardiac output r/t altered stroke volume secondary to hypertensive emergency	Short Term: After 6 hours of NI, the pt will manifest hemodynamic stability (BP, CO, UO, PR) pt shall also verbalize understanding of the disease process & risk factors Long Term: After 4 days of NI, the pt will participate in activities that decrease blood pressure	Establish Rapport Monitor Vital Signs History Taking Assess patient’s condition Review lab data Review ECG strip Monitor BP, PR frequently Provide information on test procedures Explain dietary restrictions Encourage rest & reposition client q2 Encourage relaxation techniques Provide PM care Encourage to increase activity level as tolerated Teach home BP reading & monitoring Administer anti hypertensives	To gain pt’s trust To obtain baseline data To determine contributing factors To determine present condition For comparison with normal values To determine alterations in electrical activity of the heart To note response to activity To gain pt’s participation & decrease anxiety level To inform patient of contributing factors To decrease stress and promote venous return To alleviate anxiety & stress To promote hygiene & comfort To maintain functional ability To detect change in VS & seek timely intervention To decrease BP within normal ranges	The pt shall have manifested hemodynamic stability (BP, CO, UO, PR) pt shall have also verbalized understanding of the disease process & risk factors. The pt shall have participated in activities that decrease blood pressure

Dengue Hemorrhagic Fever Nursing Care Plans

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