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Thursday, May 5, 2011

Nursing Interventions for Imbalanced Nutrition Less than Body Requirements

Imbalanced Nutrition Less than Body Requirements

NANDA Definition: Intake of nutrients insufficient to meet metabolic needs

Adequate nutrition is necessary to meet the body’s demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and self-constructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive impairments causing them to forget to eat, physical limitations that interfere with preparing food, deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and interferes with digestion, and social isolation and boredom that cause a lack of interest in eating. This care plan addresses general concerns related to nutritional deficits for the hospital or home setting.

Nursing Intervention for Imbalanced Nutrition Less than Body Requirements
  1. Determine daily calorie needs are realistic and adequate. Consultation on nutrition expert.
  2. Weigh the body weight every day, monitor the results of laboratory examination.
  3. Explain the importance of adequate nutrition.
  4. Teach individuals to use flavorings to help improve the taste and smell of food (lemon, mint, clove, cinnamon, rosemary)
  5. Give encouragement of individuals to eat with others (food served in the family room or group)
  6. Plan maintenance procedures have an unpleasant or painful not done before eating.
  7. Give a fun, relaxed atmosphere (not visible potty, do not busy)
  8. Adjust the treatment plan to reduce or eliminate odors that cause wanted to vomit or procedure performed near the time of eating.
  9. Teach or assist individuals to rest before eating.
  10. Teach individuals to avoid the smell of fried food-eating, coffee-cooked if possible.
  11. Maintain oral hygiene before and after chewing.
  12. Offer to eat small portions but frequently to reduce feelings of tension in the stomach (six times per day with little food)
  13. Set to get the nutrients protein / high calorie, which is presented to individuals when they want to eat. (Eg, if the chemotherapy is done early morning and serve meals in the evening before eating).
  14. Instruct individuals who experience decreased appetite for:
    • Eating dry foods waking.
    • Eating salty foods if there are no restrictions.
    • Avoid foods that are too sweet, fattening, greasy.
    • Try to drink clear, warm.
    • Sip through a straw.
    • Eat whenever tolerated.
    • Eat small meals low in fat and eat more often.
  15. Try commercial supplements are available in many forms (powder, pudding, liquid)
  16. If individuals experiencing eating disorders (Townsend, 1994)
    • Set goals with the client's input, doctors and nutritionists.
    • Talk about the benefits of compliance and the consequences of disobedience.
    • If the input of food that must be rejected, remind the doctor.
    • Sitting accompany individuals during the meal, limit the time to eat up to 30 minutes.
    • Observe at least 1 hour before. Accompany client when to the bathroom.
    • Weigh the client body when he woke up and after the first micturition.
    • Give encouragement to repair, but do not focus the conversation on food or way of eating.
    • Along the improvement of individual, explore issues of self-image, weigh again, and watched over.
  17. For individuals who are hyperactive
    • Provide food and beverages that are high in protein, high calorie.
    • Offer more frequent smaller meals. Avoid foods that contain no calories (eg, soda)
    • Take a stroll along individual when given little food.

Nursing Interventions for Pain

Nursing Interventions for Pain

Pain is a feeling triggered in the nervous system. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen or chest or you may feel pain all over, such as when your muscles ache from the flu.

Pain can be helpful in diagnosing a problem. Without pain, you might seriously hurt yourself without knowing it, or you might not realize you have a medical problem that needs treatment. Once you take care of the problem, pain usually goes away. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain. Sometimes chronic pain is due to an ongoing cause, such as cancer or arthritis. Sometimes the cause is unknown.

Fortunately, there are many ways to treat pain. Treatment varies depending on the cause of pain. Pain relievers, acupuncture and sometimes surgery are helpful.

Nursing Interventions for Pain

  1. Increase knowledge
    • Explain the causes of pain to the individual, if known.
    • Linking how long the pain will last, if known.
    • Explain diagnostic tests and procedures in detail with a connecting discomfort and sensation will be felt, and the estimated duration of pain occur.
  2. Provide accurate information to reduce fear.
  3. Connect your acceptance of individual response to pain.
    • Recognizing the existence of pain.
    • Listen with full attention on the pain.
    • Shows that the pain you are because you want to understand better (not to determine if the pain is really there).
  4. Assess the family to know the concept of error handling or painful.
  5. Discuss the reasons why individuals may experience an increase or decrease in pain (eg, increasing fatigue pain, distraction reduce pain).
    • Give encouragement to family members telling each other personally feel concerned.
    • Assess whether painful family dispute and discuss the impact on individuals who experience pain.
    • Encourage families to continue to give attention to pain, although not shown.
  6. Provide opportunities for individuals to rest during the day and time of uninterrupted sleep at night.
  7. Talk with individuals and families use distraction therapy, along with other methods to reduce pain.
  8. Teach methods of distraction for acute pain, with regular breathing.
  9. Teach noninvasive pain reduction
  10. Give individuals the optimal reduction of pain with analgesics.
  11. After granting a reduction of pain, returned 30 minutes later to assess its effectiveness.
  12. Provide accurate information to correct errors on a family concept (eg, addiction, hesitant about the pain).
  13. Give the individual the opportunity to talk about fear, anger, and frustration in place, difficulty understanding the situation.
  14. Give encouragement of individuals to talk about the pain experience.

Sunday, May 1, 2011

Nursing Intervention for Diabetes

Nursing Intervention for Diabetes

Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (ADA], Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003.

Nursing Intervention for Diabetes

Nursing Diagnosis

Impaired nutrition: less than body requirements related to the reduction of oral input, anorexia, nausea, increased metabolism of protein, fat.

Nursing Intervention

Objective :
The patient's nutritional needs are met

Result Criteria :
Patients can digest the amount of calories or nutrients appropriate
Stable weight or additions to the range usually

Intervention :

  • Weigh the body weight per day or according to the indication.
  • Determine the diet and eating patterns of patients and compare it with foods that can be spent on patients.
  • Auscultation bowel sounds, record the existence of abdominal pain / abdominal bloating, nausea, vomit that has not had time to digest food, maintain a state of fasting according to the indication.
  • Give the liquid diet containing foods (nutrients) and the electrolyte immediately if the patient has to tolerate it orally.
  • Involve the patient's family at this meal digestion according to the indication.
  • Observation of the signs of hypoglycemia, such as changes in level of consciousness, skin moist / cold, rapid pulse, hunger, sensitive to stimuli, anxiety, headaches.
  • Collaboration examination of blood sugar.
  • Collaboration of insulin treatment.
  • Collaboration with dietitians.

Source :

Nursing Interventions for Pneumonia

Pneumonia, acute infection of the lung parenchyma, interstitial lung tissue in which fluid and blood cells escape into the alveoli. that often impairs gas exchange. Pneumonia classified in several ways.

Based on microbiological etiology origin:
  • Viral
  • Bacterial
  • Fungal
  • Protozoa
  • Mycobacterium
  • Mycoplasmal
  • Rickettsial
Based in location, pneumonia can be classified:

Bronchopneumonia, Bronchopneumonia involves distal airways and alveoli
Lobular pneumonia or lobar pneumonia. In this pneumonia involves part of a lobe; and lobar pneumonia, an entire lobe

The infection is also classified as one of three types:

Primary pneumonia

Primary pneumonia results directly from inhalation or aspiration of a pathogen, such as bacteria or a virus; it includes pneumococcal and viral pneumonia.

Secondary pneumonia

Secondary pneumonia may follow initial lung damage from a noxious chemical or other insult (superinfection) or may result from hematogenous spread of bacteria from a distant area.

Aspiration pneumonia

Aspiration pneumonia results from inhalation of foreign matter, such as stomach contents vomitus or food particles, into the bronchi. It’s more likely to occur in elderly or debilitated patients, those receiving nasogastric tube feedings, higher prevalence those with an impaired gag reflex, poor oral hygiene, or a decreased level of consciousness.

Nursing Interventions for Pneumonia

Intervention and Rationale:
I. Assess for:
  • Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
  • Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
  • Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.
II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.
  • ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.
III. Administer:
  • Oxygen therapy via cannula - maintain optimal oxygen level.
  • Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
  • Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
  • Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.
IV. Perform or Provide:
  • Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
  • Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
  • Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
  • Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
  • Postural drainage and percussion PRN - mobilizes secretion.
  • Suction secretions if cough ineffective - removal if unable to bring up secretions.
  • Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.