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Monday, February 27, 2012

Nursing Interventions Risk for Fluid Volume Deficit related to Appendicitis


Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital out patient center, or home setting.

The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment paramount to prevent potentially life-threatening hypovolemic shock. Older clients are more like to develop fluid imbalances.

Nursing Interventions Risk for Fluid Volume Deficit related to Appendicitis

Nursing Diagnosis Fluid Volume Deficit related to nausea, vomiting, and fasting

characterized by:
  • Lips dry.
  • The mouth chapped.
  • Blood pressure decreased.
  • Rapid pulse.
  • Nausea and vomiting.
  • A cold sweat.
  • Thirst.
Objectives: The client will maintain body fluid balance by the following criteria:
  • Normal blood pressure.
  • Lips are not dry.
  • Normal pulse.
  • Clients do not complain of thirst.
  • Intake and output balance.

Risk for Fluid Volume Deficit related to Appendicitis

Nursing Interventions Risk for Fluid Volume Deficit for Appendicitis :

1.) Record intake and output.
To find out the balance of fluids in the body that are needed for daily metabolism.

2.) Monitor skin turgor.
To find out the less interstitial fluid / loss can lead to loss of skin elasticity.

3.) Observed temperature and mucous membranes.
Dry mucous membranes which is an indicator of dehydration.

4.) Monitoring of urine.
The reduced amount of urine as indicators of reduced fluid in the body.

Nursing Interventions for Risk for Infection

Risk for Infection

Definition: At increased risk for being invaded by pathogenic organisms

Risk Factors:

Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease.

Nursing Interventions for Risk for Infection

1. Monitor the following for signs of infection:
  • 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.
  • 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.
  • Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.
  • Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.

2. 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.

3. 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.

4. 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.

5. Assess for history of drug use or treatment modalities that may cause immunosuppression. Antineoplastic agents and corticosteroids reduce immunocompetence.

6. 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.

7. 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.


Sunday, February 26, 2012

Nursing Interventions for Activity Intolerance

Activity Intolerance

Activity Intolerance Definition : Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Related Factors:
  • Generalized weakness
  • Deconditioned state
  • Sedentary lifestyle
  • Insufficient sleep or rest periods
  • Depression or lack of motivation
  • Prolonged bed rest
  • Imposed activity restriction
  • Imbalance between oxygen supply and demand
  • Pain
  • Side effects of medications

Nursing Interventions for Activity Intolerance

1. Assess patient's level of mobility. This aids in defining what patient is capable of, which is necessary before setting realistic goals.

2. Assess nutritional status. Adequate energy reserves are required for activity.

3. Assess potential for physical injury with activity. Injury may be related to falls or overexertion.

4. Assess patient's cardiopulmonary status before activity using the following measures:
  • Heart rate Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting (e.g., climbing four flights of stairs versus shoveling snow).
  • Orthostatic BP changes Elderly patients are more prone to drops in blood pressure with position changes.
  • Need for oxygen with increased activity Portable pulse oximetry can be used to assess for oxygen desaturation. Supplemental oxygen may help compensate for the increased oxygen demands.
  • How Valsalva maneuver affects heart rate when patient moves in bed Valsalva maneuver, which requires breath holding and bearing down, can cause bradycardia and related reduced cardiac output.
5. Assess need for ambulation aids: bracing, cane, walker, equipment modification for activities of daily living (ADLs). Some aids may require more energy expenditure for patients who have reduced upper arm strength (e.g., walking with crutches). Adequate assessment of energy requirements is indicated.

6. Determine patient's perception of causes of fatigue or activity intolerance. These may be temporary or permanent, physical or psychological. Assessment guides treatment.
Monitor patient's sleep pattern and amount of sleep achieved over past few days. Difficulties sleeping need to be addressed before activity progression can be achieved.

Saturday, February 25, 2012

Symptoms of Heart Diseases

Here are some early indication of heart disease symptoms:

Symptoms of Heart Diseases

1. Leg cramps during walking

Leg cramps during exercise might be caused by dehydration. It is important to drink a lot of fluid during exercise. Leg cramps occur when the muscle suddenly and forcefully contracts. The most common muscles to contract in this manner are muscles that cross two joints. Leg cramps during walking might be an indication of heart disease caused by arteries in your leg being clogged up by cholesterol in result of not enough oxygen being delivered to the cells in your leg.

2. Chest pain

Chest pain is caused by blood vessels in the heart temporarily being blocked up. It is also caused by inadequate oxygen supply to the heart muscle or coronary . The persistence of chest pain would be an early indication of heart diseases.

3. Shortness of breath

Shortness of breath (dyspnea) is the major symptom of the left ventricular insufficiency. People with shortness of breath are four times more likely to die from a heart disease related cause than individuals without any symptoms.

4. Headaches

People see sparkling zigzag lines or loss of vision before a migraine attack may be at particular risk of future cardiovascular problems. Generally headaches do not cause heart diseases but a sudden, explosive onset of great pain might be.

5. Dizziness

Dizziness can have many causes including low blood count, low iron in the blood stream and other blood disorders, dehydration, and viral illnesses. Since there are many different conditions that can produce these symptoms, anybody experiencing episodes of severe headaches or dizziness ought to be checked by your doctor.

6. Palpitations

Palpitations is an extremely common symptom of heart disease. Palpitations are skips in the heart beats and irregular heart beats.

7. Loss of consciousness

It is a common symptom, most people pass out at least once in their lives. However, sometimes loss of consciousness indicates a dangerous or even life-threatening condition such as heart disease so when loss of consciousness occurs it is important to figure out the cause.

There are many more symptoms such as fatigue, memory defects, and changes in skin tone and temperature.

Symptoms of Heart Diseases

Acute Pain related to Urinary Tract Infection

Urinary Tract Infection (UTI) is one of the infections that are very common both in men and women. Pains that are unbearable and discomfort go along with urinary tract infection. Urinary tract infection is caused by bacteria particularly E. coli that enter the urinary tract, urethra and bladder.

Some symptoms of these are frequent urge to eliminate urine, blood in the urine, pains in the abdomen, and pain every time the patient urinate. Urinary tract infection recovery time differ as its seriousness does.

Generally, these kinds of infections are caused by bacteria from outside the body getting a foothold in the urinary tract. Poor hygiene and sexual intercourse are among the leading ways that these bacteria get in.

Irritants such as catheters can increase the chances of getting a UTI by wearing away at the protective layers of tissue in the urinary tract itself.

Home based or over the counter urinary tract infection remedies include:
  • Drink lots of water. This will help flush the system and reduce the bacteria level to the point that your immune system can handle it.
  • Avoid sugar, which will help to feed the bacteria.
  • Unsweetened cranberry juice is a proven urinary tract infection remedy. Chemicals in the juice help prevent the bacteria from finding a purchase on the urinary tract walls.
  • Orange juice and other acidic fruit juices help by increasing the acid content of the urine, which will further inhibit bacterial growth.

Nursing Diagnosis Acute Pain related to Urinary Tract Infection

Results Criteria:
  • Patients report no pain during urination.
  • There is no tension Bladder
  • The patient appeared calm
  • Calm expression
Nursing Interventions Acute Pain related to Urinary Tract Infection:

1. Assess the intensity, location, and factors that aggravate or relieve pain.
Rational: Pain is a great sign of infection

2. Provide adequate rest periods and activity levels that can be tolerant.
Rationale: Clients can rest in peace and to relax the muscles

3. Encourage drinking lots of 2-3 liters if no contraindications
Rational: To assist clients in urination

4. Give analgesics according to the therapy program.
Rational: Analgesic block the path of pain

Gastritis Nursing Diagnosis and Nursing Interventions

1. Gastritis Nursing Diagnosis : Pain (acute / chronic)

Pain (acute / chronic) associated with inflammation or irritation of the gastric mucosa due to increased gastric acid.

Nursing Interventions for Pain - Gastritis:
  • Assess the patient's general condition
  • Assess vital signs
  • Assess pain scale
  • Provide a quiet environment and comfortable
  • Teach relaxation techniques

2. Gastritis Nursing Diagnosis : Imbalanced Nutrition Less Than Body Requirements

Imbalanced Nutrition Less Than Body Requirements related to anorexia, vomiting, and irregularities in body perception.

Nursing Interventions for Imbalanced Nutrition Less Than Body Requirements - Gastritis
  • Allow clients to choose foods (low-calorie foods are not allowed)
  • Make mealtime structure with a time limit (eg 40 minutes)
  • Eliminate distractions (eg conversation, watching television) during mealtimes
  • Specify the time to eat, serve food, and eating time limit; inform the client that if the food is not eaten during the time that has been provided, will be the replacement of other feeding methods.
  • When food is not eaten, do feeding through a tube, NGT to order in this state do not give offerings to the client.
  • Perform a replacement feeding method each time the client refuses to eat by mouth.
  • Keep your attention during the meal if the client refuses to eat.
Evaluation Criteria
  • Client expressed understanding of nutritional needs.
  • Receive adequate caloric intake to maintain normal body weight.
  • Following the return of a normal diet.

3. Gartitis Nursing Diagnosis - Fluid Volume Deficit

Nursing Interventions for Fluid Volume Deficit - Gastritis

  • Monitor input and output; keep records in the nurse's office, and observations with as simple as possible.
  • Monitor the administration of fluids with electrolytes to order; accompany the client when the bath to prevent the emptying of intravenous fluids.
  • Monitor vital signs as needed.
Evaluation Criteria
  • Clients are required to demonstrate adequate hydration.
  • Balance between input and output.

4. Gastritis Nursing Diagnosis - Knowledge Deficit

Knowledge deficit and information related to the conditions and lack of coping skills

Nursing Diagnosis for Knowledge deficit - Gastritis
  • Guidelines emphasize nutrition and how to cope with a diet when away from home.
  • Discuss with the client the importance of reviewing the needs of calories every 2 to 4 weeks.
  • Encourage the use of stress management techniques.
  • Increase peogram regular practice.
  • Encourage follow-up care visits with physicians and counselors.
Evaluation Criteria
  • Clients expressed the importance of lifestyle changes to maintain a normal weight.
  • Clients seeking counseling resources to help make changes.
  • Clients trying to maintain weight.