Typhoid Fever - 5 Nursing Diagnosis and Interventions

Nursing Care Plan for Typhoid Fever : Nursing Diagnosis and Interventions

1. Activity intolerance related to mandatory bed rest.

Intervention:
1) Provide assistance to meet their daily needs such as food, drink, change clothes and watch oral hygiene, hair, genetalia, and nails.
Rationale: To provide assistance to the client to avoid the onset of complications associated with the movement who violate program bedrest.

2) Involve the family in the fulfillment of ADL.
Rationale: Participation family is very important to facilitate the nursing process and prevent further complications.

3) Explain the purpose of bed rest to prevent complications and speed up the healing process.
Rationale: Rest decrease intestinal mobility also decreases the rate of metabolism and infection.


2. Risk for fluid volume deficit related to the intake is less, nausea, vomiting / excessive spending, diarrhea, body heat.

Intervention:
1) Monitor the status of hydration (moisture of mucous membranes, skin turgor, adequate pulse, blood pressure orthostatic) if needed.
Rationale: Changes in hydration status, mucous membranes, skin turgor describe the severity of dehydration.

2) Monitor vital signs
Rationale: Changes in vital signs to describe the general state of the client.

3) Monitor the input of food / liquid and count daily calorie intake.
Rationale: Provides guidelines to replace fluids.

4) Encourage the family to help patients eat.
Rationale: Family as the driving fluid needs of clients.

5) Collaborate with other medical team for IV fluid administration.
Rationale: Giving IV fluids to meet fluid needs.


3. Imbalanced Nutrition, Less Than Body Requirements
related to less intake due to nausea, vomiting, anorexia, or diarrhea due to excessive output.

Intervention:
1) Monitor the amount of nutrients and calories.
Rationale: Knowing the cause of the less intake so as to determine appropriate and effective intervention.

2) Monitor the weight loss.
Rational: Cleanliness nutrients can be known through increased weight 500 g / week.

3) Monitor the environment during the meal.
Rationale: A comfortable environment can reduce stress and more conducive to eating.

4) Monitor nausea and vomiting.
Rationale: Nausea and vomiting affect nutrition.

5) Involve the family in the client's nutritional needs.
Rationale: Increasing the role of the family in nutrition to accelerate the healing process.

6) Instruct the patient to enhance the protein and vitamin C.
Rationale: Protein and vitamin C to meet nutritional needs.

7) Provide food selected.
Rational: To assist in fulfilling the nutritional needs.

8) Collaboration with a nutritionist to determine the amount of calories and nutrients it needs patients.
Rationale: Helps in the healing process.


4. Acute pain related to inflammation of the small intestine.

Intervention:
1) Assess the level of pain, location, duration, intensity and characteristics of pain.
Rationale: Changes in the characteristics of the pain may indicate the spread of diseases / complications occur.

2) Review the factors that increase pain and decrease pain.
Rational: It can pinpoint the factors that trigger or aggravate (such as stress, food intolerance) or identify the occurrence of complications, as well as help in making the diagnosis and therapeutic needs.

3) Give warm compresses on the area of pain.
Rationale: For the pain disappeared.

4) Collaborate with other medical team in the delivery of analgesics.
Rational: Analgesic can help reduce pain.


5. Knowledge Deficit: conditions of disease, treatment and prognosis needs related to lack of information or inadequate information.

Intervention:
1) Assess the extent of knowledge of the client's family about his illness.
Rationale: Knowing the mother's knowledge about the disease typhoid fever.

2) Give health education about the disease and treatment of clients.
Rationale: In order for the client's mother found out about the disease typhoid fever, causes, signs and symptoms, as well as the care and treatment of typhoid fever.

3) Give the family an opportunity to ask if there is not yet understood.
Rationale: In order to understand more about the family disease.

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Nursing Diagnosis and Interventions for Menstruation Disorders - Dysmenorrhea

Nursing Diagnosis for Dysmenorrhea

Dysmenorrhea is defined as a condition of severe uterine pain during menstruation. All women experience an irregular period once in awhile during their child bearing years. Some women may experience periodic pains during or prior to, or after menstrual periods in the lower abdomen as resulting of over production of certain hormones in the prostaglandins family.

Primary dysmenorrhea is due to disordered or too much prostaglandin production through the secretory endometrium of the uterus within the absence of a structural lesion.

Dysmenorrhea (painful menstruation) can also include symptoms such as headache, fatigue, bloating, and even nausea, vomiting, and/or diarrhea.

Dysmenorrhea can be treated with a variety of drugs, including pain relievers, sedatives, antispasmodics, prostaglandin inhibitors, and oral contraceptives.


Nursing Diagnosis and Interventions for Menstruation Disorders - Dysmenorrhea

1. Acute Pain related to increased uterine contractility, hypersensitivity
2. Imbalanced Nutrition Less Than Body Requirements related to the nausea, vomiting.
3. Ineffective individual coping related to emotional excess.

Nursing Interventions for Dysmenorrhea

1. Acute Pain related to increased uterine contractility, hypersensitivity.

Goal: pain reduced client

Nursing Interventions:
1. Warm the abdomen.
Rational: may cause vasodilation and reduce the spasmodic contractions of the uterus.

2. Massage the abdominal area that feels pain.
Rational: reduce pain due to the stimulus of therapeutic touch.

3. Perform light exercise
Rational: it can improve blood flow to the uterus and muscle tone.

4. Perform relaxation techniques.
Rational: reduce the pressure to get relaxed.

5. Give the natural diuresis (vitamin) sleep and rest.
Rational: reduce congestion.

2. Ineffective individual coping related to emotional excess.

Nursing Interventions:
1. Assess client's understanding of her illness.
Rational: maternal anxiety of the pain will be greatly influenced by knowledge.

2. Determine the additional stress that accompanies it.
Rational: stress can impair the autonomic nervous response, so it is feared to increase the pain.

3. Provide an opportunity to discuss how the pain.

4. Help clients identify coping skills during the period covered.
Rational: the use of behavior management techniques can help clients adapt to the pain they experienced.

5. Give the period of sleep or rest.
Rational: the pain and fatigue due to spending a lot of body fluids tends to be a problem that must mean a lot of the body tends to be significant problems that must be addressed immediately.

6. Push the skills of stress, such as relaxation techniques, visualization, guidance, imagination and deep breathing exercises.
Rational: it can reduce pain and distract the client to pain.

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2 Nursing Diagnosis Interventions for Anemia

Nursing Care Plan for Anemia

Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.

There are several types and classifications of anaemia. This is a condition in which the body lacks the amount of red blood cells to keep up with the body's demand for oxygen.

Symptoms of Anemia

According to John Hopkins Point-of-Care Information Technology Center, (The John Hokins POC-IT Center), the most common causes of anemia include:

• dizziness,
• weakness and fatigue,
• shortness of breath with activity,
• dizziness,
• occasional chest pains, and
• cold, clammy skin.
  

Having nerve pain may also point to the presence of this problem.

Causes of Anemia

There are several causes of anemia, which include:

• Iron deficiency
• Kidney disease
• Pregnancy
• Poor nutrition
• Deficiency of vitamin B12 known as pernicious anemia
• Sickle cell anemia
• Thalassemia
• Alcohol
• Bone marrow related anemia
• Aplastic anemia
• Hemolytic anemia
• Active bleeding, eg. heavy bleeding during menstration.

Treatments of Anemia

Once the doctor determines the cause he or she will initiate a treatment program for you. Here are some causes along with their treatment protocol. Blood Loss: the source of the bleeding will be determined and stopped. For example you may be given a blood transfusion and iron to build up your red blood cell count. Iron Deficiency: If you have inadequate iron levels you most likely will be prescribed iron supplements.

Do not do this on your own but under the care of a physician because consuming too much iron can be dangerous. Red blood cell destruction: Known as hemolytic anemia, there are various causes for it. So the treatment would of course depend on the cause. Follow up care: You need to stay under your doctor's care and have repeated blood work done to determine if the anemia has gone away. Your response to the treatments prescribed will determine what the next steps are to take. The hopeful outcome is that you have overcome your anemia.

If not, with continued care over time you should be able to do so. Before doing any dietary or lifestyle changes always consult with your health care provider, particularly if you have been diagnosed with a disease or are taking any prescription medication.

2 Diagnosis Nursing Interventions for Anemia

1. Ineffective Tissue Perfusion

Objectives:

• Adequate tissue perfusion

Nursing Intervention for Anemia :

• Monitor vital signs, capillary refill, skin color, mucous membranes.
• Exalt the position of head of in bed
• Examine and document the presence of pain.
• Observation of a delay in verbal response, confusion, or restlessness
• Observe and document the presence of the cold.
• Maintain the ambient temperature to keep warm the body needs.
• Provide oxygen as needed.

2. Activity Intolerance

Objectives:

• Tolerant of activity

Nursing Intervention:

• Assess the capability of doing the activity
• Monitor vital signs during and after activity, and noted a physiological response to activity (increased heart rate increased blood pressure, or rapid breathing).
• Provide information to the patient or family to stop doing activities if teladi symptoms of increased heart rate, increased blood pressure, rapid breathing, dizziness or fatigue).
• Provide support to perform their daily activities according to the ability of the child.
• Creating a schedule of activities involving other health team.

Related Articles :
Nursing Diagnosis for Anemia
Nursing Intervention for Anemia
Nursing Care Plan for Anemia
Management of Anemia
NCP for Anemia
Ineffective Tissue perfusion related to Anemia
Nanda Anemia

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3 Nursing Diagnosis and Interventions for Hepatitis

Hepatitis is a class of diseases That impact the liver. Hepatitis can cause inflammations of the liver and can cause its function to diminish. When this Happens liver scarring can occur, the which is known as cirrhosis, and in severe cases, cancer can develop. Hepatitis can be attributed to Certain types of medication, toxins, alcohol, hereditary conditions, viruses, and autoimmune disorders. Hepatitis can be classified as viral or non viral.

There are five types of viral hepatitis to play, and each has Their Own transmission methods, effects, and symptoms. These five types are categorized, A, B, C, D, and E. The most common of these types are A, B, and C.

In the viral hepatitis and non viral forms may show mild, moderate, or severe symptoms. Some Patients may not show any symptoms at all. Fatigue is usually the only symptom in very mild cases. Other symptoms include: jaundice, headaches, fever, joint pain, muscle aches, a lack of appetite, pale stools, dark urine the color of tea, vomiting, nausea, abdominal pain, diarrhea, drowsiness, circulatory problems, and dizziness.

3 Nursing Diagnosis and Interventions for Hepatitis

1. Nursing Diagnosis: Acute Pain related to swelling of the liver is inflamed.

Expected outcomes :

• Showed signs of physical pain and pain behavior (do not wince in pain, cry intensity and location)

Nursing Interventions for Acute Pain - Nursing Care Plan for Hepatitis:

• Collaboration with patients, to determine the method can be used for pain intensity.
• Indicate the client's acceptance of the client's response to pain
  • Acknowledge the pain.
  • Listen attentively to the client about pain expression.
• Provide accurate information and explain the causes of pain, how long the pain will end, if known.
• Discuss with your doctor the use of analgesics that do not contain hepatotoxic effects.

2. Nursing Diagnosis : Ineffective Breathing Pattern related to intra-abdominal fluid collections, ascites decreased lung expansion and accumulation of secretions.

Expected outcomes :

• Adequate breathing pattern

Nursing Interventions for Ineffective Breathing Pattern - Nursing Care Plan for Hepatitis:

• Monitor the frequency, depth and respiratory effort
• Auscultation of breath sounds additional
• Give the semi-Fowler position
• Give a deep breath and coughing exercises effective
• Give oxygen as needed

3. Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements related to failure to meet the metabolic needs of entry: anorexia, nausea / vomiting and disturbances of digestion absorption and metabolism: a decrease in peristalsis (visceral reflex), retained bile.

Expected outcomes :

• The patient will show behavioral changes in lifestyle to improve / maintain appropriate weight.
• Patients will show improvement with a goal weight and value-free laboratory signs of malnutrition.

Nursing Interventions Imbalanced Nutrition Less Than Body Requirements - Nursing Care Plan for Hepatitis

• Monitor the inclusion of diet / calories. Give a little meal in the frequency often, and offer the greatest breakfast.
• Provide oral care before meals.
• Encourage eating in an upright sitting position.
• Encourage intake of orange juice, beverage and candy carbonate heavy throughout the day.
• Consult an expert on diet, nutrition support teams to provide appropriate dietary needs of patients, with the input of fat and protein as tolerated.
• Keep an eye on blood glucose.
• Give extra food / nutrient total support when needed.

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Nursing Diagnosis and Interventions for Jaundice

Jaundice is a yellow discoloration of the skin, the mucous membrane and the white of the eyes. Jaundice is most commonly found in babies and newborns. Jaundice newborn is an infant with a condition caused by the extensive amount of bilirubin in blood.

Jaundice newborn represents a large group of newborns, approximately 60% of full term (physiological or normal jaundice) and 90% of premature babies (jaundice of prematurity). There is also breastfeeding jaundice which occurs when a newborn is not getting enough milk to drink.

There are a number of possible causes for jaundice in babies and newborns. The most common cause is over-feeding with breast milk. Since the baby's liver is too small, it can rarely cope with the enzymes, present in the milk, especially if the baby is overfed. Other causes include diseases, anemia, or a physical defect in the liver.

Newborn jaundice usually lasts 10 -14 days and it retreats in reverse to the development process, legs looking normal first leaving the little face colored the longest. This process can last up to one month in the premature babies. The same may occur in the breast- fed babies, where the substances contained in mother's milk cause slower development of the enzymes responsible for the digestion of the bilirubin. This condition is called breast milk jaundice and it may take up to 12 weeks to improve.


Nursing Diagnosis for Jaundice and Nursing Intervention for Jaundice

1. Deficient Fluid Volume related to inadequate fluid intake, photo-therapy, and diarrhea.

Goal:
Adequate neonatal body fluids

Intervention:

• Record the number and quality of stools,
• Monitor skin turgor,
• Monitor intake output,
• Give water between breast-feeding or give bottle.

2. Hyperthermia related to the effects of phototherapy

Goal:
The stability of the baby's body temperature can be maintained

Intervention:

• Give a neutral ambient temperature,
• Keep the temperature between 35.5 ° - 37 ° C,
• Check vital signs every 2 hours.

3. Impaired skin integrity related to hyperbilirubinemia and diarrhea

Goal:
The integrity of the baby's skin can be maintained

Intervention:

• Assess skin color every 8 hours,
• Monitor direct and indirect bilirubin,
• Change position every two hours,
• Massage the area that stands out,
• Keep skin clean and moisture.

4. Anxiety related to medical therapy given to the baby.

Goal:
Parents know about treatment, symptoms can be identified to deliver the health care team.

Intervention:

• Review knowledge of the client's family,
• Give the cause of yellow health education, therapy and treatment process.
• Give health education on infant care to home.
  

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Nursing Interventions for Urinary Tract Infection (UTI)

Nursing Diagnosis for Urinary Tract Infection (UTI) :

1. Impaired Urinary Elimination
2. Knowledge Deficit

Nursing Interventions for Urinary Tract Infection (UTI) :

1. Impaired Urinary Elimination related to mechanical obstruction of the bladder or other urinary tract structures.

Expected outcomes are:

• Improved elimination pattern, not the signs urinary disorders (urgency, oliguri, dysuria)

Nursing Interventions Impaired Urinary Elimination of UTI :

a. Monitor input and output characteristics of the urine.
Rational: provides information about renal function and presence of complications

b. Determine the patient's voiding patterns
c. Encourage increased fluid intake
Rationale: increased hydration will flush the bacteria.

d. Review the full bladder complaints
Rational: urinary retention may occur causing tissue distension (bladder / kidney)

e. Observations of changes in mental status:, behavior or level of consciousness
Rational: the accumulation of residual uremic and electrolyte imbalance can be toxic to the central nervous system

f. Unless contraindicated: reposition the patient every two hours
Rational: To prevent static urine

g. Collaboration:
- Monitor laboratory tests: electrolytes, creatinine
Rational: control of renal dysfunction
- Take action to keep the urine acid: increase input berry juice and give medicines to increase urine aam.
Rational: aam urine inhibit the growth of germs. Increased input juice may affect the treatment of urinary tract infections.

2. Knowledge Deficit: about condition, prognosis, and treatment needs related to the lack of sources of information.

Expected outcomes are:

• Expressed understanding of the condition, diagnostic examination, treatment plan, self-care and preventive measures.

Nursing Interventions Knowledge Deficit of UTI :

a. The review process of the disease and hope that will come
Rational: provides basic knowledge which the patient can make an informed choice.

b. Provide information on: sources of infection, measures to prevent the spread, explain the administration of antibiotics, diagnostic examination: objectives, a brief overview, preparation required prior to inspection, examination after treatment.
Rational: knowledge of what is expected to reduce anxiety and help develop client adherence to therapeutic plan.

c. Make sure the patient, or the people closest to have written agreements for continued treatment and written instructions for care after the examination
Rational: verbal instructions can be easily forgotten.

d. Instruct patient to use a given drug, drink as much as approximately eight glasses a day, especially berry juices.
Rationale: Patients often discontinue their medication, if the signs of the disease subsided. Fluids to help flush the kidneys. Pyruvic acid from berry juice helps to maintain the state of the urine acid and prevent bacterial growth.

e. Provide the opportunity for patients to express feelings and concerns about the treatment plan.
Rational: To detect the signal indicative of the possibility of non-compliance and help to develop a therapeutic plan acceptance.

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4 Nursing Diagnosis Interventions for Hypertension

Nursing Diagnosis for Hypertension - Nursing Care Plan for Hypertension

1. Risk for decreased cardiac output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy.

Purpose: afterload is not increased, there was no vasoconstriction, and myocardial ischemia does not occur.

Expected outcomes:

• Maintaining blood pressure within an acceptable range.
• Showed stable cardiac rhythm and frequency.
• Participate in activities that lower blood pressure.

Nursing interventions:

• Monitor and measure blood pressure in both hands, using a cuff and proper techniques in terms of measuring blood pressure.
• Auscultation of breath sounds and heart tone. Observe skin color, moisture, temperature and capillary refill time.
• Note the presence, quality of the central and peripheral pulses.
• Maintain restrictions on activities such as rest in bed or chair.
• Assist in performing self-care activities as needed.
• Provide a quiet environment, convenient, and therapeutic and reduce activity. Note the general edema.
• Monitor response to medication to control blood pressure. Give fluid and dietary sodium restriction as indicated.
• Medical collaboration in the provision of drugs as indicated.

2. Acute pain: headache related to increased cerebral vascular pressure.

Purpose: The pressure does not increase cerebral vascular

Expected Outcomes: Patients revealed the absence of headache and looked comfortable.

Nursing interventions:

• Maintain bed rest, quiet neighborhood, a little light.
• Limit of patients in the activity.
• Minimize disruption and environmental stimuli.
• Give a fun action according to indications such as ice packs, the position of comfort, relaxation techniques, counseling imagination, avoid constipation.
• Medical collaboration in providing analgesic and sedative drugs.

3. Ineffective Tissue Perfusion: cerebral, renal, cardiac related to impaired circulation.

Purpose: The circulation of the body is not impaired.

Expected outcomes :

• Patients demonstrating an improved tissue perfusion as indicated by: blood pressure within acceptable limits, no complaints of headache, dizziness, laboratory values ​​within normal limits.
• Stable vital signs.
• Urine output 30 ml / min.

Nursing interventions:

• Maintain bed rest, elevate the head position in bed patients.
• Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if it is available.
• Measure the input and discharge.
• Observe the sudden hypotension.
• Ambulation within your means and avoid fatigue in patients.
• Monitor electrolytes, creatinine according to medical advice.
• Maintain fluids and medications according to medical advice.

4. Knowledge deficit related to lack of information about the disease process and self-care.

Purpose : patients are met in terms of information about hypertension.

Expected outcomes :

• Patients can express their knowledge and skills of the management of early treatment of hypertension.
• Reported the use of drugs according to medical advice.

Nursing interventions:

• Describe the nature of the disease and the purpose of the procedure and the treatment of hypertension.
• Explain the importance of a peaceful environment and theraupetik, and management of stressors.
• Discuss the importance of maintaining a stable weight.
• Discuss the need for low-calorie diet, low in sodium to order.
• Discuss the importance of avoiding fatigue in the activity.
• Explain the need to avoid constipation in the bowel movement.
• Explain penetingnya maintain proper fluid intake, amount allowed, restrictions such as caffeinated coffee, tea and alcohol.
• Discuss the symptoms of relapse or progression of complications reported to the doctor: headache, dizziness, fainting, nausea and vomiting.
• Talk about drugs: the name, dosage, time of administration, purpose and side effects or toxic effects.
• Explain the need to avoid drug-free, without a doctor's examination.

Related Articles : Nursing Care Plan for Hypertension
Hypertension Diet
Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions
Nursing Management of Hypertension
Pathophysiology of Hypertension
Nanda Nursing Diagnosis for Hypertension

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2 Nursing Care Plan for Rheumatic Heart Disease - Assessment, Diagnosis and Interventions

Nursing assessment is done in providing nursing care in rheumatic heart disease beginning to collect data on the following matters:

• About heart function.
• Nutritional status of patients.
• Tolerance to the activities and attitudes of patients toward limiting the activities undertaken.
• Disturbances in sleep patterns.
• Level of discomfort felt by rheumatic fever patients.
• Ability of the patient in terms of troubleshooting.
• Knowledge of patients and families will be suffered by rheumatic heart disease.

Assessment of the above are generally aware of what is known by the patient and the family of rheumatic heart disease. Now the next step in the assessment in terms of nursing as one of the nursing process. Next examined the nursing care in rheumatic heart disease are:

• History of rheumatic heart disease.
• Monitor cardiac complications in the event.
• Auscultation of heart sounds, usually typical in patients with rheumatic heart was weakened heart sounds with the rhythm of galloping diastole.
• Assessment of the patient's vital signs.
• Assessment of pain.
• Assessment of the presence of markers of inflammation in the joints.
• Assessment of the presence of lesions on the skin.

Nursing Care Plan for Rheumatic Heart Disease

Next is the nursing diagnosis of rheumatic heart disease. Some nursing diagnoses that may arise in providing nursing care in rheumatic heart disease, among which are:

1. Decreased cardiac output related to valvular stenosis

Goals to be achieved is to increase cardiac output.

Expected outcomes are:

• Patients showed reduced levels of dyspnoe experienced.
• Patients participating in participating in the activity and demonstrate increased tolerance.

Nursing interventions:

• Monitor vital signs such as: blood pressure, apical pulse and peripheral pulse.
• Monitor cardiac rhythm and frequency.
• Semifowler bed rest in a position that is 45 degrees.
• Encourage the patient to stress management techniques (quiet environment, meditation).
• Bantu patient activity as indicated when the patient is able.
• Medical collaboration in terms of oxygen delivery and therapy.

2. Activity intolerance related to decreased cardiac output, oxygen supply and demand imbalance.

Goals to be achieved is an optimal patient can tolerate the activity does.

Expected outcomes are:

• Verbal response to reduced fatigue
• Conducting activities within the limits of his ability (pulse activity should not be more than 90X/mnt, no chest pain).

Nursing interventions:

• Energy saving during the acute patients.
• Maintain bed rest until the results of laboratory and clinical status of patients improved.
• In line with the good general condition, monitor the gradual increase in the level of activity undertaken.
• Teach to participate in activities of daily necessities.
• Create a schedule of activities and also the breaks.

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3 Nursing Diagnosis and Interventions for Bladder Cancer

1. Nursing Diagnosis for Bladder Cancer: Risk for infection related to inadequate defenses, secondary and immune system (the effect of chemotherapy / radiation), malnutrition, invasive procedures.

Goals:

• Patients are able to identify and participate in infection prevention measures.
• Showed no signs of infection and wound healing normally takes place.

Nursing Interventions for Bladder Cancer:

• Wash hands before taking action. Visitors are also encouraged to do the same.
• Maintain a good personal hygine
• Monitor the temperature
• Examine all the systems to look for signs of infection
• Avoid / limit invasive procedures and maintain aseptic procedures
• Collaborative
• Give antibiotics when indicated.

2. Nursing Diagnosis for Bladder Cancer: Risk for Sexual Dysfunction related to deficit of knowledge / skills about alternative responses to health transition, decreased function / structure, the effects of treatment.

Goals:

• Patients may express its understanding of the effects of cancer and treatment on sexuality.
• Maintaining sexual activity within your limits

Nursing Interventions for Bladder Cancer:

• Discuss with patients and families about sexuality and the reaction process and its relationship with disease
• Give advise on the effect of treatment on sexuality
• Give privacy to the patient and her partner. Knock before entering.

3. Nursing Diagnosis for Bladder Cancer: Risk for Impaired Skin Integrity related to the effects of radiation and chemotherapy, immunologic deficits, decreased nutrient intake and anemia.

Goals:

• Patients can identify interventions related to specific conditions
• Participate in the prevention of complications and accelerated healing

Nursing Interventions for Bladder Cancer:

• Assess the integrity of the skin to see any side effects of cancer therapy, wound healing observed.
• Instruct patient not to scratch the itch
• Change the position of the patient on a regular basis
• Give advise patients to avoid the use of skin creams, oils, powders without medical advice

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Nursing Interventions for Self-Care Deficit - Bathing / Hygiene

Self-Care Deficit - Bathing / Hygiene

Definition

Circumstances where individuals have failed to implement or complete ability bathing / hygiene activities.

Data:

Lack of ability to bathe themselves (including washing the whole body, combing hair, brushing teeth, doing skin care and nails as well as the use of makeup)

• Can not or no desire to wash the body or body parts.
• Can not use the source water.
• Inability to feel the need for hygiene measures.

Lack of ability to wear his own clothes (including underwear routine or special clothing, not the clothes the night)

• Failure of the ability to use or release of clothes.
• Inability to fasten clothing.
• Inability to dress themselves satisfactorily.

Expected outcomes are:

Individuals will
1. Identifying the love of self-care activities.
2. Demonstrated that optimal hygiene in care after assistance is given.
3. Participate in physical and or verbal self-care activities

• Carry out the shower activity at its optimal level.
• Reported satisfaction with the achievements despite the limitations.
• Connecting a feeling of comfort and satisfaction with the cleanliness of the body.
• Demonstrate ability to use adaptive assistive devices.
• Describe the factors that cause of the lack of ability to bathe.

Nursing Interventions for Self-Care Deficit - Bathing / Hygiene:

1. Encourage individuals to use corrective lenses or assistive devices are prescribed.

2. Keep the temperature warm bath; make sure the preferred water temperature of the individual.

3. Provide privacy for bathing routine.

4. Give all toiletries in a convenient boundary.

5. Provide security in the bathroom (eg, the floor is not slippery, handle bars, bells).

6. If the individual is able to physically push using the bath or shower, depending on the hospital facilities in preparation for return home.

7. Provide adaptive equipment if needed

• Seat or no back seat while bathing
• The holder of spongy long reach back or lower extremities
• Place the handle on the bathroom wall
• Board to move to a bath seat
• Pad or mat that is not slippery
• Dishwashing gloves with pockets for soap
• Toothbrush that has been adapted
• Shavers
• Shower spray handle

8. To individual eyesight deficiencies

• Place toiletries in the most appropriate location for the individual
• Keep the call bell within easy reach
• Give the same degree of privacy
• Verbally inform yourself before entering or leaving the bath
• Observation of the individual's ability to put all toiletries
• Observation of the individual's ability to perform oral care, brushing her hair.
• Provide a place to clean clothing that is easily accessible.

9. For individuals with missing limbs or pain

• Bathe in the early morning or before bed at night.
• Encourage individuals to use the mirror over the bath to observe the area of ​​skin that have paralise
• Encourage individuals who experience limb amputation to observe the integrity of the skin is left for good.
• Give only some supervision or assistance needed to learn to re-use or adaptation of limb defects

10. For individuals with cognitive decline

• Give time to bathe consistent routine as part of a structured program to help reduce anxiety
• Keep instructions simple and avoid distractions; orientation purposes of toiletries.
• If the individual is unable to bathe the whole body, allow individuals to bathe a part of her body until it is; give positive feedback on the success
• Monitoring activities carried out until the individual can safely perform tasks that are not supported
• Encourage attention to the task, but be wary of fatigue that may increase anxiety

11. Ensure that the shower facilities available at home and help in determining if there are different needs for adaptation.

12. refer to the occupational therapy or social services to assist in obtaining necessary equipment.

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Nursing Interventions for Fluid Volume Excess

Excess Fluid Volume

Definition:

Circumstances where an individual experiencing or at risk of excess intracellular or interstitial fluid.

Major data

• edema
• tighten skin, shiny

Minor data

• more inputs than outputs
• shortness of breath
• weight gain

Expected outcomes are:

Individuals will:

1. Reveal the causative factors and prevention methods edema.
2. showed a decrease of peripheral and sacral edema.

Nursing Interventions for Fluid Volume Excess

1. Assess input and diet habits that can support the retention of fluids

2. Encourage individuals to reduce salt intake

3. Teach individuals to

• Read labels for sodium content
• Avoid foods that are fun, canned, and frozen foods.
• Cook without using salt and spices to add flavor (lemon, basil, mint)
• Use vinegar to taste salt substitute soup, stew, etc.

4. Review of the evidence depends on the venostatis.

5. Keep the limb is edematous as high above the heart if possible (unless there are contraindications by heart failure)

6. Instruct the individual to avoid made ​​of jersey pants / girdle, knee-high pants, and crossed the lower leg and remained elevated leg exercises whenever possible.

7. To inadequate drainage:

• Keep the limb elevated on pillows
• Measure blood pressure in the arm that does not hurt
• Do not give injections or intravenous fluids to enter the arms are sore.
• Protect your arm is sore, from injury.
• Encourage individuals to avoid strong detergents, carrying heavy bags, smoke, injuring the epidermis or nodule on the nail, reaching into a hot oven, use a jewelry or watches, or using a headband.
• Warn people to see a doctor if the arms become red, swollen, or other hardware of the ordinary.

8. Protect the arm edema, from injury.

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Nursing Intervention and Implementation of Low Back Pain

Lower back pain is one of the leading reasons people in the United States visit their doctors. It will inhibit the lives of millions of Americans this year. In fact, an average four out of five adults will experience low back pain at some point in their lives. So the question, "What is causing my lower back pain?" is not uncommon.

Three categories of lower back pain

Your lower back pain will fall into one of three categories, which your doctor bases on your description of the pain.

1. Axial lower back pain - mechanical or simple back pain

2. Radicular lower back pain - sciatica

3. Lower back pain with referred pain



Nursing Intervention and Implementation of Low Back Pain

1. Relieve pain
To reduce pain nurses can encourage patients to bed rest and changing sleeping position is determined, to improve lumbar flexion. Patients are taught to control and adjust the pain, which is done through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and the imagination (imagine the fun things by focusing on it).
Gently massage the soft tissue is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given a drug nurse should assess the patient's response to each drug.

2. Improve physical mobility
Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once the back pain is reduced, self-care activities may be done with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. The twist and sway should be avoided. Patients are encouraged to switch the activity of lying, sitting and walking around for a long time. Nurses should encourage patients to comply with appropriate training program established, training is just not effective.

3. Improve proper body mechanics
Patients must be taught how to sit, stand, lie down and lift items correctly.

4. Health education
Patients must be taught how to sit, stand, lie down and lifting objects properly

5. Improve the performance of the role
Responsibilities associated with the role may have changed since the onset of lower back pain. Once the pain healed, patients can return to his role of responsibility again. However, if the activity is impacting on the bottom of my back pain again, it may be difficult to return to the original liability without bearing the risk of chronic low back pain with disability and depression caused.

6. Changing nutrition and weight loss
Weight loss through the adjustment of feeding can prevent recurrence of back pain, by means of the rational nutrition plan that includes changes in eating habits to maintain a desirable weight.

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Nursing Interventions for Schizophrenia

Nursing Interventions for Schizophrenia

Goal:

1. Set realistic goals with clients.
2. Set the desired outcomes for clients with schizophrenia.
3. Set the desired criteria for the families that have family members with schizophrenia.

Nursing Interventions for Schizophrenia

1. Clients who withdrew and isolation

• Use a self-therapeutic.
• Perform a planned interaction, brief, frequent, and not demanding.
• Plan simple activities one-on-one.
• Maintain consistency and honesty in interactions.
• Gradually encourage clients to interact with their peers in a non-threatening situation
• Provide social skills training.
• Perform a variety of actions to improve self-esteem.

2. Clients show regressive behavior or unfair

• Do approach, it is strange behavior (do not reinforce this behavior).
• Treat the client as an adult, even though the client regresses.
• Monitor the client's diet, and give support and assistance when necessary.
• Assist the client in terms of hygiene and dress up, only when the client can not do it alone.
• Be careful with the touch because it can be considered a threat
• Create a regular schedule of activities of daily living.
• Give a simple choice of two things for clients who experience ambivalence.

3. Clients with no clear pattern of communication

• Keep your own communication to keep it clear and unambiguous.
• Maintain consistency of your verbal and nonverbal communication.
• Clarification of any meaning ambiguous or not clearly related to client communication

4. Clients who are suspicious and rude

• Form professional relationships; too friendly to bet the threat.
• Be careful with the touch because it can be considered a threat.
• Give as much control and autonomy to the client within the therapeutic limits.
• Create a sense of trust through brief interactions that communicate caring and respect.
• Describe any treatment, medication and laboratory tests before the start.
• Do not focus or strengthen the suspicion or delusional ideas.
• Identify and provide a response to the underlying emotional needs of suspicion or delusional
• Intervene when the client shows signs of increasing anxiety and potentially express an unconscious behavior.
• Be careful to not behave in a way that could be misinterpreted kilen.

5. Clients with hallucinations or delusions

• Do not focus on hallucinations or delusions. Perform an interrupt to initiate interaction with the client's hallucinatory one-on-one based on reality.
• Tell them that you do not agree with the perception of the client, but the validation that you believe that the hallucinations are real to the client.
• Do not argue with the client about the hallucinations or delusions.
• Respond to the feelings that are communicated to the client when he was having hallucinations or delusions.
• Switch and the client focus on a structured activity or task-based reality.
• Move the client to a more quiet, less stimulating.
• Wait until the client does not have hallucinations or delusions before starting the counseling session about it.
• Explain that hallucinations or delusions are symptoms of psychiatric disorders.
• Say that the anxiety or increased stimulus from the environment, to stimulate the onset of hallucinations.
• Help clients to control hallucinations by focusing on reality and take medication as prescribed.
• If hallucinations persist, Bantu clients ignore it and continue acting remedy properly despite a hallucination.
• Teach a variety of cognitive strategies and tell the client to use self talk ("voices that makes no sense") and the cessation of the mind ("I will not think about it").

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Nursing Diagnosis and Interventions for Cerebral Palsy

Cerebral Palsy is a condition lasting damage to brain tissue and not progressive, occurring in a young (since birth) and hinder normal brain development with clinical manifestations may change throughout life and showed abnormalities in the attitude and movement, accompanied by neurological abnormalities in the form of spastic paralysis, ganglia disorders, basal, cereblum and mental disorders.

Nursing Diagnosis for Cerebral Palsy

a. Risk for injury r/t spasms, uncontrolled movements and seizures

b. Impaired Physical mobility r/t spasms and muscle weakness.

c. Changes in growth and development r/t neuromuscular disorders.

d. Impaired verbal communicationr/t difficulty in articulation.

e. Risk for aspiration r/t neuromuscular disorders

f. Changes in thought processes r/th cerebral injury, learning disabilities.

g. Self-care Deficit r/t muscle spasms, increased activity, cognitive changes.

h. Deficient Knowledge r/t home care and therapeutic needs.

Goal :
a. Children will always be safe and free from injury.
b. Children will have a maximum movement ability and not have contractures.
c. Children will explore how to learn and participate with other children in doing some activities.
d. Children will express their needs and develop a body weight within normal limits.
e. Children do not have aspirations.
f. The child will demonstrate an appropriate level of learning ability.
g. Daily needs of the child tetpenuhi.
h. Parents / family demonstrate understanding of the needs of child care that is characterized by taking an active role in child care.
i. Children do not show a marked impairment of skin integrity with intact skin.


Nursing Interventions for Cerebral Palsy

a. The increasing need for security and prevent injury

1) avoid children from harmful objects, for example can be dropped.
2) watch the children during activity.
3) give the kids a break when tired.
4) use safety equipment when necessary.
5) when a seizure; install a safety device in the mouth so that the tongue is not bitten.
6) do suction.
7) the provision of anti-seizure in the event of a seizure.

b. Improve the physical mobility

1) examine the movement of the joints and muscle tone.
2) do physical therapy.
3) do repositioning every 2 hours.
4) evaluation of the needs of special equipment for eating, writing and reading and activities.
5) teach the use of a walker.
6) teach how to sit, crawl in young children, walking, and others.
7) teaches how to reach for objects.
8) taught to move the limbs.
9) teach appropriate ROM.
10) provide a rest period.

c. Increases the need rumbuh flowers in the optimum level

1) examine the growth and development.
2) teaching for early intervention with therapeutic recreation and school activities.
3) Provide appropriate activities, withdrawal and can be done by a child

d. Improve communication

1) examine the response to communication.
2) use the cards / pictures / whiteboards to facilitate communication.
3) Involve the family in training a child to communicate.
4) refer to a speech therapist.
5) teach and assess non-verbal meaning.
6) trained in the use of the lips, mouth and tongue.

e. Improve the nutritional status needs

1) examine the diet of children.
2) Weigh weight every day.
3) provide adequate nutrition and food preferences, lots of protein, minerals and vitamins.
4) Give extra foods that contain lots of calories.
5) Help your child meet their daily needs with the ability

f. Prevent the occurrence of aspiration

1) do immediately when there is suction secretions.
2) provide an upright position or semi-sitting while eating and drinking.
3) examine the pattern of breathing

g. Increase the need for intellectual

1) review the child's level of understanding.
2) teach in understanding conversations with verbal or non verbal.
3) teach writing using whiteboards or other devices that can be used according to the ability of parents and children.
4) teaching reading and writing according to his needs

h. Meet the daily needs

1) examine the level of children's ability to meet daily needs.
2) assist in meeting the needs; eating and drinking, elimination, personal hygiene, dress, play activities.
3) Involve families and for children who are cooperative in meeting their daily needs.

i. Enhance the knowledge and the role of parents in meeting child care needs

1) examine the level of parental knowledge.
2) teach parents to express their feelings about the child's condition.
3) teach parents in meeting child care needs.
4) teach about the conditions experienced by children and are related to physical therapy and exercise needs.
5) emphasize that parents and families have an important role in helping meet the needs.
6) explain the importance of play and socialization needs of others.

j. Prevent to impaired skin integrity

1) examine the area that is attached ancillary equipment.
2) use a skin lotion to prevent dry skin.
3) do the massage in a depressed area.
4) provide a comfortable position and provide support with pillows.
5) ensure that ancillary equipment or dressing appropriately and fixed.

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Nursing Interventions Risk for Fluid Volume Deficit related to Appendicitis

Definition

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.

Nursing Interventions Risk for Fluid Volume Deficit for Appendicitis :

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

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

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

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

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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.

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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.

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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.

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Nursing Interventions for Ineffective Airway Clearance

Nursing Interventions for Ineffective Airway Clearance

Nursing Priority

NO.1 To maintain adequate, patent airway:

1. Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways.
2. Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions.
3. Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).
4. Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea.
5. Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway.
6. Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated.
7. Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.
8. Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs.
9. Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to identify causative/precipitating factors.
10. Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
11. Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.

Nursing Priority

NO.2 To mobilize secretions:

1. Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.
2. Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.)
3. Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.
4. Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.
5. Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort.
6. Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.
7. Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).
8. Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions.
9. Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)
10. Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.

Nursing Priority

NO.3 To assess changes, note complications:

1. Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways.
2. Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress.
3. Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.
4. Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
5. Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client’s decision making about medication regimen and response to any given medication.
6. Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention.
7. Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.

Nursing Priority

NO.4 To promote wellness (Teaching/Discharge Considerations):

1. Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs.
2. Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount.
3. Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection.
4. Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called “huffing”] or respiratory muscle strength training, chest percussion), if indicated.
5. Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia.
6. Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).
7. Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways.
8. Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function.
9. Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular Dystrophy Association).
10. Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)

Nursing Interventions for Ineffective Airway Clearance

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Nursing Interventions for Risk for Injury

Risk for Injury

NANDA Definition:

The risk of injury as a result of the interaction of environmental conditions with individual adaptive response and defense sources.

Related To :
[Substance intoxication]
[Substance withdrawal]
[Disorientation]
[Seizures]
[Hallucinations]
[Psychomotor agitation]
[Unstable vital signs]
[Delirium]
[Flashbacks]
[Panic level of anxiety]

Goals

• Short-Term Goal : Client’s condition will stabilize within 72 hours.
• Long-Term Goal : Client will not experience physical injury.

Nursing Intervention for Risk for Injury

1. Maintain a closed central IV system using Luer-Lok connections and taping of all connections. Rationale: Inadvertent disconnection of central IV system can result in lethal air emboli.
2. Administer appropriate TPN solution via peripheral or central venous route, including peripherally inserted central catheter (PICC) lines and tunneled catheters. Rationale: Solutions containing high concentrations of dextrose more than 10% must be delivered via a central vein because they result in chemical phlebitis when delivered through small peripheral veins.
3. Monitor for potential drug and nutrient interactions. Rationale: Various interactions are possible, such as digoxin in conjunction with diuretic therapy, which can cause hypomagnesemia; hypokalemia may result from chronic use of laxatives, mineralocorticoid steroids, diuretics, or amphotericin.
4. Assess catheter for signs of displacement out of central venous position: extended length of catheter on skin surface, leaking of IV solution onto dressing, client complaints of neck arm pain, tenderness at catheter site, or swelling of extremity on side of catheter insertion. Rationale: Central venous catheter tip may slip out of superior vena cava and migrate into smaller innominate and jugular veins, causing a chemical thrombophlebitis. Incidence of subclavian or superior vena cava thrombosis is increased with extended use of central venous catheters.
5. Inspect peripheral TPN catheter site routinely and change sites at least every other day or per protocol. Rationale: Peripheral TPN solutions, although less hyperosmolar, can still irritate small veins and cause phlebitis. Peripheral venous access is often limited in malnourished clients, but site should still be changed if signs of irritation develop.
6. Investigate reports of severe chest pain or coughing in clients with central line. Turn client to left side in Trendelenburg position, if indicated, and notify physician. Rationale: Suggests presence of air embolus requiring immediate intervention to displace air into apex of heart away from the pulmonary artery.
7. Maintain an occlusive dressing on catheter insertion sites for 24 hours after subclavian catheter is removed. Rationale: Extended catheter use may result in development of catheter skin tract. Once the catheter is removed, air embolus is still a potential risk until skin tract has sealed.

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