Saturday, November 28, 2009

Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function: 

11 Gordon’s Functional Health Patterns 

  1. Health Perception Health Management Pattern 
  2. Nutritional Metabolic Pattern 
  3. Elimination Pattern 
  4. Activity Exercise Pattern 
  5. Sleep Rest Pattern 
  6. Cognitive-Perceptual Pattern 
  7. Self-Perception-Self-Concept Pattern 
  8. Role-Relationship Pattern 
  9. Sexuality-Reproductive 
  10. Coping-Stress Tolerance Pattern 
  11. Value-Belief Pattern 

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use. 

  • Contamination
  • Disturbed energy field 
  • Effective therapeutic regimen management
  • Health-seeking behaviors (specify) 
  • Ineffective community therapeutic regimen management 
  • Ineffective family therapeutic regimen management 
  • Ineffective health maintenance 
  • Ineffective protection 
  • Ineffective therapeutic regimen management 
  • Noncompliance (ineffective Adherence) 
  • Readiness for enhanced immunization status 
  • Readiness for enhanced therapeutic regimen management 
  • Risk for contamination 
  • Risk for infection 
  • Risk for injury 
  • Risk for perioperative positioning injury 
  • Risk for poisoning 
  • Risk for sudden infant death syndrome 
  • Risk for suffocation 
  • Risk for trauma 
  • Risk-prone health behavior 

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system. 

  • Adult failure to thrive 
  • Deficient fluid volume: [isotonic] 
  • Deficient fluid volume: hyper/hypotonic 
  • Effective breastfeeding [Learning Need] 
  • Excess fluid volume 
  • Hyperthermia 
  • Hypothermia 
  • Imbalanced nutrition: more than body requirements 
  • Imbalanced nutrition: less than body requirements 
  • Imbalanced nutrition: risk for more than body requirements 
  • Impaired dentition 
  • Impaired oral mucous membrane 
  • Impaired skin integrity 
  • Impaired swallowing 
  • Impaired tissue integrity 
  • Ineffective breastfeeding 
  • Ineffective infant feeding pattern 
  • Ineffective thermoregulation 
  • Interrupted breastfeeding 
  • Latex allergy response 
  • Nausea 
  • Readiness for enhanced fluid balance 
  • Readiness for enhanced nutrition 
  • Risk for aspiration 
  • Risk for deficient fluid volume 
  • Risk for imbalanced fluid volume 
  • Risk for imbalanced body temperature 
  • Risk for impaired liver function 
  • Risk for impaired skin integrity 
  • Risk for latex allergy response 
  • Risk for unstable blood glucose 

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin). 

  • Bowel incontinence 
  • Constipation 
  • Diarrhea 
  • Functional urinary incontinence 
  • Impaired urinary elimination 
  • Overflow urinary incontinence 
  • Perceived constipation 
  • Readiness for enhanced urinary elimination
  • Reflex urinary incontinence 
  • Risk for constipation 
  • Risk for urge urinary incontinence 
  • Stress urinary incontinence 
  • Total urinary incontinence 
  • Urge urinary incontinence 
  • [acute/chronic] Urinary retention 

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. 

  • Activity intolerance 
  • Autonomic dysreflexia 
  • Decreased cardiac output 
  • Decreased intracranial adaptive capacity 
  • Deficient diversonal activity 
  • Delayed growth and development 
  • Delayed surgical recovery 
  • Disorganized infant behavior 
  • Dysfunctional ventilatory weaning response 
  • Fatigue 
  • Impaired spontaneous ventilation 
  • Impaired bed mobility 
  • Impaired gas exchange 
  • Impaired home maintenance 
  • Impaired physical mobility 
  • Impaired transfer ability 
  • Impaired walking 
  • Impaired wheelchair mobility 
  • Ineffective airway clearance 
  • Ineffective breathing pattern 
  • Ineffective tissue perfusion 
  • Readiness for enhanced organized infant behavior 
  • Readiness for enhanced self care 
  • Risk for delayed development 
  • Risk for disorganized infant behavior 
  • Risk for disproportionate growth 
  • Risk for activity intolerance 
  • Risk for autonomic dysreflexia 
  • Risk for disuse syndrome 
  • Sedentary lifestyle 
  • Self-care deficit 
  • Wandering 

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input. 

  • Acute confusion 
  • Acute pain 
  • Chronic confusion 
  • Chronic pain 
  • Decisional conflict 
  • Deficient knowledge 
  • Disturbed sensory perception 
  • Disturbed thought processes 
  • Impaired environmental interpretation syndrome 
  • Impaired memory 
  • Readiness for enhanced comfort 
  • Readiness for enhanced decision making 
  • Readiness for enhanced knowledge 
  • Risk for acute confusion 
  • Unilateral neglect 

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation. 

  • Insomnia 
  • Readiness for enhanced sleep 
  • Sleep deprivation 

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth. 

  • Anxiety 
  • disturbed Body image 
  • Chronic low self-esteem 
  • Death anxiety 
  • Disturbed personal identity 
  • Fear 
  • Hopelessness 
  • Powerlessness 
  • Readiness for enhanced hope 
  • Readiness for enhanced power 
  • Readiness for enhanced self-concept 
  • Risk for compromised human dignity 
  • Risk for loneliness 
  • Risk for powerlessness 
  • Risk for situational low self-esteem 
  • Risk for [/actual] other-directed violence Risk for [actual/] self-directed violence 
  • Situational low self-esteem 

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships. 

  • Caregiver role strain 
  • Chronic sorrow 
  • Complicated grieving 
  • Dysfunctional family processes: alcoholism (substance abuse) 
  • Grieving 
  • Impaired social interaction 
  • Impaired verbal communication 
  • Ineffective role performance 
  • Interrupted family processes 
  • Parental role conflict 
  • Readiness for enhanced communication 
  • Readiness for enhanced family processes 
  • Readiness for enhanced parenting 
  • Relocation stress syndrome 
  • Risk for caregiver role strain 
  • Risk for complicated grieving 
  • Risk for impaired parent/infant/child attachment 
  • Risk for relocation stress syndrome 
  • Social isolation 

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions. 

  • Ineffective sexuality patterns 
  • Rape-trauma syndrome 
  • Sexual dysfunction 

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies. 

  • Compromised family coping 
  • Defensive coping 
  • Disabled family coping 
  • Impaired adjustment 
  • Ineffective community coping 
  • Ineffective coping 
  • Ineffective denial Post-trauma syndrome 
  • Readiness for enhanced community coping 
  • Readiness for enhanced coping 
  • Readiness for enhanced family coping 
  • Risk for self-mutilation 
  • Risk for suicide 
  • Risk for post-trauma syndrome 
  • Self-mutilation 
  • Stress overload 

Value-Belief Pattern it’s focused on the person’s values and beliefs. 

  • Impaired religiosity 
  • Moral distress 
  • Readiness for enhanced religiosity 
  • Readiness for enhanced spiritual well-being 
  • Risk for impaired religiosity 
  • Risk for spiritual distress Spiritual distress

Friday, November 27, 2009

Pain Nursing Management
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Merskey & Bogduk). Pain is “an unpleasant sensory and emotional experience associatedwith actual or potential damage or described in terms of such damage; ef pain is always subjective” (International Association for the Study of Pain, 1979). Pain is categorized according to its duration, location, and etiology. Three basic categories of pain are generally recognized: acute pain, chronic (nonmalignant) pain, and cancer-related pain. 
One view explain that pain is a sense similar to vision or hearing, a component of the sensory that warns us of impending damage, gives accurate information to the brain about injuries, and helps us to heal. The inclusion of pain in The Senses: a Comprehensive Reference, alongside vision, hearing, or olfaction shows that this view is persuasive. But there has always been an alternative interpretation of pain. Pain is seen as a trigger of emotional states, a behavioral drive, and a highly effective learning tool. Aristotle, who was the originator of this view, made it very clear: there are only five senses – vision, hearing, touch, taste, and smell. Pain and pleasure are not senses but passions of the soul. 

Acute Pain 
For purposes of definition, acute pain can be described as lasting from seconds to 6 months. However, the 6-month time frame has been criticized (Brook) as inaccurate since many acute injuries heal within a few weeks and most heal by 6 weeks. Usually of recent onset and commonly associated with a specific injury, acute pain indicates that damage or injury has occurred. Pain is significant in that it draws attention to its existence and teaches the person to avoid similar potentially painful situations. If no lasting damage occurs and no systemic disease exists, acute pain usually decreases along with healing. 
In a situation where healing is expected in 3 weeks and the patient continues to suffer pain, it should be considered chronic and treated with interventions used for chronic pain. Waiting for the full 6-month time frame in this example could cause needless suffering. Unrelieved acute pain can affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems. The stress response (neuroendocrine response to stress) that occurs with trauma also occurs with other causes of severe pain. The stress response generally consists of increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids. 

Chronic (nonmalignant) Pain 
Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Chronic pain may be defined as pain that lasts for 6 months or longer, although 6 months is an arbitrary period for differentiating between acute and chronic pain. An episode of pain may assume the characteristics of chronic pain before 6 months have elapsed, or some types of pain may remain primarily acute in nature for longer than 6 months. 
Suppression of the immune function associated with chronic pain may promote tumor growth. Also, chronic pain often results in depression and disability. Although health care providers express concern about the large quantities of opioid medications required to relieve chronic pain in some patients, it is safe to use large doses of these medications to control progressive chronic pain. 

Cancer-Related Pain 
Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that after fear of dying, it is the second most common fear of newly diagnosed cancer patients (Lema). 
Pain in the patient suffering from cancer can be directly associated with the cancer (eg, bony infiltration with tumor cells or nerve compression), a result of cancer treatment (eg, surgery or radiation), or not associated with the cancer (eg, trauma). Most pain associated with cancer, however, is a direct result of tumor involvement. 

Pathophysiology of Pain 
The sensory experience of pain depends on the interaction between the nervous system and the environment. The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous systems. 

Peripheral Nervous System 
A number of algogenic (pain-causing) substances that affect the sensitivity of nociceptors are released into the extracellular tissue as a result of tissue damage. Histamine, bradykinin, acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain. The transmission of pain is also referred to as nociception. Prostaglandins are chemical substances thought to increase the sensitivity of pain receptors by enhancing the painprovoking effect of bradykinin. These chemical mediators also cause vasodilation and increased vascular permeability, resulting in redness, warmth, and swelling of the injured area. 
Once nociception is initiated, the nociceptive action potentials are transmitted by the peripheral nervous system (Porth, 2002). The first-order neurons travel from the periphery (skin, cornea, visceral organs) to the spinal cord via the dorsal horn. There are two main types of fibers involved in the transmission of nociception. Smaller, myelinated Ad (A delta) fibers transmit nociception rapidly, which produces the initial “fast pain.” Type C fibers are larger, unmyelinated fibers that transmit what is called second pain. This type of pain has dull, aching, or burning qualities that last longer than the initial fast pain. The type and concentration of nerve fibers to transmit pain vary by tissue type. 
The same noxious stimulus produces hyperalgesia, and the person reports greater pain than was felt at the first stimulus. For this reason, it is important to treat patients with analgesic agents when they first feel the pain. Patients require less medication and experience more effective pain relief if analgesia is administered before the patient becomes sensitized to the pain. Chemicals that reduce or inhibit the transmission or perception of pain include endorphins and enkephalins. These morphinelike neurotransmitters are endogenous (produced by the body). Endorphins and enkephalins are found in heavy concentrations in the central nervous system, particularly the spinal and medullary dorsal horn, the periaqueductal gray matter, hypothalamus, and amygdala. 

Central Nervous System 
After tissue injury occurs, nociception (the neurologic transmission of pain impulses) to the spinal cord via the Ad and C fibers continues. The fibers enter the dorsal horn, which is divided into laminae based on cell type. The laminae II cell type is commonly referred to as the substantia gelatinosa. In the substantia gelatinosa are projections that relay nociception to other parts of the spinal cord. 
Nociception continues from the spinal cord to the reticular formation, thalamus, limbic system, and cerebral cortex. Here nociception is localized and its characteristics become apparent to the person, including the intensity. The involvement of the reticular formation, limbic, and reticular activating systems is responsible for the individual variations in the perception of noxious stimuli. Individuals may report the same stimulus differently based on their anxiety, past experiences, and expectations. This is a result of the conscious perception of pain. 
The interconnections between the descending neuronal system and the ascending sensory tract are called inhibitory interneuronal fibers. These fibers contain enkephalin and are primarily activated through the activity of non-nociceptor peripheral fibers (fibers that normally do not transmit painful or noxious stimuli) in the same receptor field as the pain receptor, and descending fibers, grouped together in a system called descending control. 
The enkephalins and endorphins are thought to inhibit pain impulses by stimulating the inhibitory interneuronal fibers, which in turn reduce the transmission of noxious impulses via the ascending system (Puig & Montes). 
The noxious impulses are influenced by a “gating mechanism.” Melzack and Wall proposed that stimulation of the large-diameter fibers inhibits the transmission of pain, thus “closing the gate.” Conversely, when smaller fibers are stimulated, the gate is opened. The gating mechanism is influenced by nerve impulses that descend from the brain. 

Factors Influencing the Pain Response 
Pain experience is influenced by a number of factors, including; past experiences with pain, anxiety, culture, age, gender, and expectations about pain relief. These factors may increase or decrease the person’s perception of pain, increase or decrease tolerance for pain, and affect the responses to pain. 

Pharmacologic Interventions: 

  • Approaches for Using Analgesic Agents
  • Local Anesthetic Agents 
  • Opioid Analgesic Agents 
  • Nonsteroidal Anti-inflammatory Drugs 
  • Tricyclic Antidepressant Agents and Anticonvulsant Medications 
  • Routes of Administration; Parenteral, Oral, Rectal,Transdermal, Transmucosal, Intraspinal and Epidural 

Nonpharmacologic Interventions : 

  • Cutaneous Stimulation and Massage 
  • Ice and Heat Therapies 
  • Transcutaneous Electrical Nerve Stimulation 
  • Distraction 
  • Relaxation Techniques 
  • Guided Imagery 
  • Hypnosis 

Nursing Management of Pain 

The factors to consider in a complete pain assessment are the intensity, timing, location, quality, personal meaning, aggravating and alleviating factors, and pain behaviors. The pain assessment begins by observing the patient carefully, noting the patient’s overall posture and presence or absence of overt pain behaviors and asking the person to describe, in his or her own words, the specifics of the pain. The words used to describe the pain may point toward the etiology. 
Instruments for assessing the perception of pain: Pain Intensity Scales 
Simple Descriptive Pain Intensity Scale 

  • 0: No pain 
  • 1: Mild pain 
  • 2: Moderate pain 
  • 3: Severe pain 
  • 4: Very severe pain 
  • 5: Worst possible pain

0 – 10 Numeric Pain Intensity Scale 
Visual Analog Scale (VAS) 

  1. No pain 
  2. Pain as bad as it could possibly be 

Nurses Role in Pain Management: 

  • Identifying Goals for Pain nursing management 
  • Establishing the Nurse–Patient Relationship and Teaching 
  • Providing Physical Care 
  • Managing Anxiety Related to Pain

• Reports relief that pain is accepted as real
and that he or she will receive assistance in
pain relief
• Reports lower intensity of pain and discomfort after interventions implemented
• Reports less disruption from pain and discomfort after use of intervention
• Uses pain medication as prescribed
• Identifies effective pain relief strategies
• Demonstrates use of new strategies to relieve pain and reports their effectiveness
• Experiences minimal side effects of analgesia without interruption to treat side effects
• Increases interactions with family and friends
1. Reassure patient that you know pain is real and will assist him or her in dealing with it.
2. Use pain assessment scale to identify intensity of pain.
3. Assess and record pain and its characteristics: location, quality, frequency, and duration.
4. Administer balanced analgesics as prescribed to promote optimal pain relief.
5. Read minister pain assessment scale.
6. Document severity of patient’s pain on chart.
7. Obtain additional prescriptions as needed.
8. Identify and encourage patient to use strategies that have been successful with previous pain.
9. Teach patient additional strategies to relieve pain and discomfort: distraction, relaxation, cutaneous stimulation, etc.
10. Instruct patient and family about potential side effects of analgesics and their prevention and management.
1. Achieves pain relief
a. Rates pain at a lower intensity (on a scale of 0 to 10)
after intervention
b. Rates pain at a lower intensity for longer periods
2. Patient or family administers prescribed analgesic medications correctly
a. States correct dose of medication
b. Administers correct dose using correct procedure
c. Identifies side effects of medication
d. Describes actions taken to prevent or correct side effects
3. Uses nonpharmacologic pain strategies as recommended
a. Reports practice of nonpharmacologic strategies
b. Describes expected outcomes of nonpharmacologic
4. Reports minimal effects of pain and minimal side effects of
a. Participates in activities important to recovery (eg, drinking
fluids, coughing, ambulating)
b. Participates in activities important to self and to family
(eg, family activities, interpersonal relationships, parenting,
social interaction, recreation, work)
c. Reports adequate sleep and absence of fatigue and

Sunday, November 22, 2009

Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH
Nursing care plans, Pregnancy Induced Hypertension (PIH) is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It typically occurs in Nulliparity women and may be nonconvulsive or convulsive.Preeclampsia continues to have a massive impact on maternal and prenatal morbidity/mortality 
Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7% of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups. The classic diagnostic triad included hypertension, proteinuria, and edema. Recently, the National High Blood Pressure Education Working Group recommended eliminating edema as a diagnostic criterion because it is too frequent an observation during normal pregnancy to be useful in diagnosing preeclampsia 
Eclampsia, preeclampsia with seizures, the occurrence of seizures defines eclampsia. It is a manifestation of severe central nervous system involvement. The convulsive form occurs between 24 weeks’ gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease. 

Severe Preeclampsia
Mild Preeclampsia
·      Blood pressure >160 mm Hg systolic or >110 mm Hg diastolic on two occasions at least 6 hours apart while the patient is on bed rest 
·      Proteinuria of 5 g or higher in 24-hour urine specimen or 3+ or greater on two random urine samples collected at least 4 hours apart
·      Oliguria < 500 mL in 24 hours
·      Cerebral or visual disturbances
·      Pulmonary edema or cyanosis
·      Epigastrica or right upper quadrant pain
·      Impaired liver function
·      Thrombocytopenia
·      Fetal growth restriction
·       Blood pressure  > 140/90 mm Hg but  < 160/110 mm Hg on two occasions at least 6 hours apart while the patient is on bed rest

·       Proteinuria > 300 mg/24 h but < 5 g/24 h

·       Asymptomatic

Cause of preeclampsia
The cause of preeclampsia is unknown, it is often called the “disease of theories” because many causes have been proposed, yet none has been well established. Geographic, ethnic, racial, nutritional, immunologic, and familial factors may contribute to preexisting vascular disease, which, in turn, may contribute to its occurrence. Age is also a factor. Adolescents and primiparas older than age 35 are at higher risk for preeclampsia. However, a growing body of evidence suggests that maternal vascular endothelial injury plays a central role in the disorder. Other theories include a long list of potential toxic sources, such as autolysis of placental infarcts, autointoxication, uremia, maternal sensitization to total proteins, and pyelonephritis.

Risk Factors for Preeclampsia
  • Age less than 20 years or more than 35 years 
  • Nulliparity 
  • Multiple gestation 
  • Hydatidiform mole 
  • Diabetes mellitus 
  • Thyroid disease 
  • Chronic hypertension 
  • Renal disease 
  • Collagen vascular disease 
  • Antiphospholipid syndrome 
  • Family history of preeclampsia 
Complications of Preeclampsia
Generalized arteriolar vasoconstriction is thought to produce decreased blood flow through the placenta and maternal organs. This decrease can result in:
  • Intrauterine growth retardation (or restriction), 
  • Placental infarcts, and 
  • Abruptio placentae. 
Other possible complications include
  • Stillbirth of the neonate, 
  • Seizures, 
  • Coma, 
  • Premature labor, 
  • Renal failure 
  • Hepatic damage in the mother. 
Treatment for Preeclampsia
Early recognition is the key to Preeclampsia treatment. Therapy for patients with preeclampsia is intended to halt the progress of the disorder specifically, the early effects of eclampsia, such as seizures, residual hypertension, and renal shutdown, and to ensure fetal survival. Some physicians advocate the prompt inducement of labor, especially if the patient is near term; others follow a more conservative approach. Therapy may include:
  • Complete bed res. 
  • An antihypertensive, such as methyldopa or hydralazine 
  • Magnesium sulfate to promote diuresis, and reduce blood pressure. 
Nursing diagnosis
Common nursing diagnosis found in Nursing care plans Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH
  • Activity intolerance 
  • Disturbed sensory perception (visual) 
  • Disturbed thought processes 
  • Excess fluid volume 
  • Fear 
  • Impaired urinary elimination 
  • Ineffective coping 
  • Ineffective tissue perfusion: Cerebral, peripheral 
  • Excess Fluid Volume related to pathophysiologic changes of gestational hypertension and increased risk of fluid overload 
  • Ineffective Tissue Perfusion: Fetal Cardiac and Cerebral related to altered placental blood flow caused by vasospasm and thrombosis 
  • Risk for Injury related to seizures or to prolonged bed rest or other therapeutic regimens 
  • Anxiety related to diagnosis and concern for self and fetus 
  • Decreased Cardiac Output related to decreased preload or antihypertensive therapy

Nursing outcome nursing interventions, Nursing care plans Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH

  • Control I.V. fluid intake using a continuous infusion pump. 
  • Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/hour. 
  • Monitor hematocrit levels to evaluate intravascular fluid status.
  • Monitor vital signs every hour. 
  • Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate). 
  • Position on side to promote placental perfusion. 
  • Monitor fetal activity. 
  • Evaluate NST to determine fetal status. 
  • Increase protein intake to replace protein lost through kidneys. 
  • Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain. 
  • Instruct to lie down on left side if symptoms are present. 
  • Keep the environment quiet and as calm as possible. 
  • If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. 
  • If patient is hospitalized, have oxygen and suction setup, along with a tongue blade and emergency medications, immediately available for treatment of seizures. 
  • Assess DTRs and clonus every 2 hours. Increase frequency of assessment as indicated by patient's condition. 

Evaluation: Expected Outcomes

  • No evidence of pulmonary edema; urine output adequate 
  • FHR within normal range; reactivity present 
  • No seizure activity 
  • Expresses concern for self and the fetus 
  • Maintaining bed rest and pursuing diversional activities 
  • BP and other vital parameters stable

Friday, November 20, 2009

Nursing care plans for Hypertension; hypertension, high blood pressure, is the most common of all health problems in adults and is the leading risk factor for cardiovascular disorders. Hypertension is a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more. 
There are two kinds of hypertension; they are primary hypertension, meaning that the reason for the elevation in blood pressure cannot be identified. Also known as essential hypertension. These terms mean simply that the hypertension is of unknown origin. In some patients with primary hypertension, there is a strong hereditary tendency. 
And, Secondary hypertension or malignant hypertension is the term used to signify high blood pressure from an identified cause. The elevation of blood pressure results from some other disorder Such as kidney disease, renal artery stenosis. 

Cause for Hypertension
Although the precise cause for most cases of hypertension cannot be identified, it is understood that hypertension is a multifactorial condition. Because hypertension is a sign, it is most likely to have many causes, just like fever has many causes. For hypertension to occur there must be a change in one or more factors affecting peripheral resistance or cardiac output. In addition, there must also be a problem with the control systems that monitor or regulate pressure. 
  1. Primary hypertension or essential hypertension (90% to 95% of Cases) Precise cause unknown 
  2. Secondary Hypertension or malignant hypertension causes by: 
  • RENAL: Acute glomerulonephritis, Chronic renal disease, Polycystic disease, Renal artery stenosis, Renal vasculitis,Renin-producing tumors. 
  • CARDIOVASCULAR: Coarctation of aorta, Increased intravascular volume, Increased cardiac output, Rigidity of the aorta 
  • ENDOCRINE: Adrenocortical hyperfunction, Exogenous hormones e.g (glucocorticoids, estrogen including pregnancy-induced and oral contraceptives), Pheochromocytoma, Hypothyroidism, Hyperthyroidism, Pregnancy-induced 
  • NEUROLOGIC: Psychogenic, Increased intracranial pressure, Sleep apnea, Acute stress, including surgery 
Complications for Hypertension
Hypertension is a major cause of stroke, cardiac disease, and renal failure. Complications occur late in the disease and can attack any organ system.

Cardiac complications include
  • Coronary artery disease 
  • Angina 
  • Myocardial infarction
  •  Heart failure 
  • Arrhythmias 
  • Sudden death. 
Neurologic complications:
  • Cerebral infarctions
  • Hypertensive encephalopathy can cause blindness. 
  • Renovascular hypertension can lead to renal failure. 
Treatment of Hypertension
Although essential hypertension has no cure, drug therapy and diet and lifestyle modifications can control it. Current guidelines for treating hypertension recommend, as a first step, lifestyle modifications that are aimed at increasing physical activity and weight loss in most patients. Unfortunately, many patients are unable to lose weight, and pharmacological treatment with antihypertensive drugs must be initiated. 
Two general classes of drugs are used to treat hypertension: 
  • Vasodilator drugs that increase renal blood flow 
  • Natriuretic or diuretic drugs that decrease tubular reabsorption of salt and water. 
Nursing Assessment Nursing care plans for Hypertension
  • Nursing History Family history of high Blood Pressure 
  • Previous episodes of high Blood Pressure 
  • Dietary habits and salt intake 
  • Target organ disease or other disease processes that may place the patient in a high-risk group diabetes, CAD, kidney disease 
  • Cigarette smoking Episodes of headache, weakness, muscle cramp, tingling, palpitations, sweating, vision disturbances 
  • Medication that could elevate Blood Pressure: Hormonal contraceptives, steroids NSAIDs Nasal decongestants, appetite suppressants, tricyclic antidepressants 
  • Other disease processes, such as gout, migraines, asthma, heart failure, and benign prostatic hyperplasia, which may be helped or worsened by particular hypertension drugs. 

Physical Examination
  • Auscultate heart rate and palpate peripheral pulses; determine respirations. 
  • If skilled in doing so, perform funduscopic examination of the eyes for the purpose of noting vascular changes. Look for edema, spasm, and hemorrhage of the eye vessels. Refer to ophthalmologist for definitive diagnosis. 
  • Examine the heart for a shift of the point of maximal impulse to the left, which occurs in heart enlargement. 
  • Auscultate for bruits over peripheral arteries to determine the presence of atherosclerosis, which may be manifested as obstructed blood flow. 
  • Determine mentation status by asking patient about memory, ability to concentrate, and ability to perform simple mathematical calculations. 
  • Blood Pressure Determination, Auscultate and record precisely the systolic and diastolic. 
Nursing Diagnoses Nursing care plans for Hypertension
  • Common nursing diagnosis found in patient with hypertension 
  • Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease process 
  • Ineffective Therapeutic Regimen Management related to medication adverse effects and difficult lifestyle adjustments 
  • Deficient knowledge (lifestyle modifications) 
  • Fatigue 
  • Ineffective coping 
  • Ineffective tissue perfusion: Cardiopulmonary 
  • Noncompliance: Therapeutic regimen 
  • Risk for injury 
Nursing outcome nursing interventions and patients teaching Nursing care plans for Hypertension Key outcomes nursing care plans for Hypertension Patient will:

  • Remain free from complications. 
  • Identify appropriate food choices. 
  • Express that he has more energy. 
  • Maintain adequate cardiac output and hemodynamic stability. 
  • Demonstrate adaptive coping behaviors 
  • Comply with his therapy regimen. 
  • Demonstrates increased knowledge about high blood pressure , medication effects, and prescribed therapeutic activities 
  • Takes medications, keeps follow-up appointments 

Nursing Interventions nursing care plans for Hypertension
Nursing Interventions nursing care plans for Hypertension with nursing diagnosis; Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease process 
Nursing Interventions Providing Basic Education:

  • Explain the meaning of high blood pressure, risk factors, and Explain the influences of high blood pressure on the cardiovascular, cerebral, and renal systems. 
  • Stresses that Hypertension can never be total cure, only control, of essential hypertension; emphasize the consequences of uncontrolled hypertension. 
  • Stress the fact that there may be no correlation between high blood pressure and symptoms; the patient cannot tell by the way he feels whether blood pressure is normal or elevated. 
  • Have the patient recognize that hypertension is chronic and requires persistent therapy and periodic evaluation. 
  • Present a coordinated and complementary plan of guidance. Inform the patient of the meaning of the various diagnostic and therapeutic activities to minimize anxiety and to obtain cooperation. Solicit the assistance of the patient’s spouse, family, and friends provide information regarding the total treatment plan. Be aware of the dietary plan developed for this particular patient. 
  • Explain the pharmacologic control of hypertension. Explain that the drugs used for effective control of elevated blood pressure will likely produce adverse effects. Warn the patient of the possibility that orthostatic hypotension may occur initially with some drug therapy: Instruct the patient to get up slowly to offset the feeling of dizziness, Encourage the patient to sit or lie down immediately if he feels faint Alert the patient to expect initial effects, such as anorexia, lightheadedness, and fatigue, with many medications. Inform the patient that the goal of treatment is to control blood pressure, reduce the possibility of complications, and use the minimum number of drugs with the lowest dosage necessary to accomplish this. 
  • Educate the patient to be aware of serious adverse effects and report them immediately so that adjustments can be made in individual pharmacotherapy. 
  • Note that dosages are individualized; therefore, they may need to be adjusted because it is often impossible to predict reactions. 
  • Warn the patient on vasodilating drugs to use caution in certain circumstances that produce vasodilation a hot bath, hot weather, febrile illness, consumption of alcohol which may exacerbate blood pressure reduction. 
  • Warn patients that blood pressure is often decreased when circulating blood volume is reduced as in dehydration, diarrhea, and hemorrhage so blood pressure should be monitored closely and treatment adjusted.

Tuesday, November 10, 2009

The nursing process
Nursing Process 
The nursing process is a problem solving process consists of elements assessment, planning, implementation, and evaluation. Many a priori assumptions have been identified and studied concern the nursing process approach to patient care that includes decision making as a characteristic of the process. These assumptions are that the nursing process is a holistic, scientific, individualized, problem-solving approach with an emphasis on diagnosing. 
Shore (1988) described the nursing process as “combining the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method.” 
The nursing process is used by nurses every day to help patients improve their health and assist doctors in treating patients. Nursing requires the use of this process day in and day out. The process is based on theories and practices taught in nursing school. It is a form of problem solving. The nursing process is made up of a series of stages that are used to achieve the objective – the health improvement of the patient. The nursing process can stop at any stage as deemed necessary or can repeat as needed. This process is inclusive of physical health as well as the emotional aspects of patient health. 
Nursing knowledge is used throughout the process to formulate changes in approach to the patient’s changing condition. During the process, nurses use this knowledge to identify problems and changes that are occurring to the patient. Caring for a patient requires the nurse to communicate with the patient to determine how they are feeling and gain the results of implemented care from the patient. 

Phases of the nursing process include:

  • Assessment of the patient’s needs 
  • Diagnosis of human response needs that nurses can deal with 
  • Planning of patient’s care 
  • Implementation of care 
  • Evaluation of the success of the implemented care 
Nursing Process diagram Nursing Process diagram
Nursing Process diagram Nursing Process diagram

Nursing Assessment
Assessment is widely recognized as the first step in the nursing process. Nurses use assessment to determine patients actual and potential needs, the assistance patients require, and the desired outcomes to evaluate the care provided. Process includes using communication and physical assessment skills to establish a relationship and to gather needed information. The important content will vary with the patient but generally includes physical assessment, other diagnostic data, and assessment of the meaning of the health experience, quality of life, symptoms, and cultural factors that may affect health. Communication is essential in assessment, and is both the means for nurses and patients to influence each other and the process that leads to therapeutic and supportive influences on patients’ health. Patients’ successful communication of their needs to nurses is vital to individualized care. Individualized patient care has been found to produce more favorable outcomes and to reduce the cost of health care (Attree, 2001). 
Physical assessment skills are routinely included in nursing curricula. They include (a) a general survey of patients’ appearance and behaviors; (b) assessment of vital signs, temperature, pulse, respiration rates, and blood pressure; (c) assessment of height and weight; and (d) physical examination to assess patients’ structures, organs, and body systems. Physical assessment can be complete, assessing all of the persons’ organs and body systems, or modified to focus only on areas suggested by the persons’ health history or symptoms. Effective assessment is the essential basis for providing effective nursing care. 

Nursing Diagnosis
Nursing diagnosis is the second step in the nursing process. It is the judgment made about the meaning of a cluster of signs and symptoms (defining characteristics) found in the nursing assessment of the patient. Without a nursing diagnosis, a nurse is left rudderless to determine what goals should be set for the patient, what outcomes are desired, or what interventions to choose to meet the goals and resolve the nursing diagnosis. 
NANDA, International (2003) defines a nursing diagnosis as a “clinical judgment about individual, family, or community responses to actual or potential health conditions/problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”. There are three types of nursing diagnoses: actual, risk, and wellness. 
An actual nursing diagnosis is a human response to health conditions/problems/life processes that exist in individuals, families, or communities. An actual nursing diagnosis is “supported by defining characteristics (manifestations, signs, symptoms) that cluster in patterns of related cues or inferences” (NANDA). 
A risk nursing diagnosis describes a human response that may develop in vulnerable individuals, families, or communities. It is “supported by risk factors that contribute to increased vulnerability” (NANDA). 
A wellness nursing diagnosis describes a human response that indicates a readiness for enhancement in levels of wellness in the individual, family, or community (NANDA). 
The end product is the client diagnostic statement that combines the specific client need with the related factors or risk factors (etiology), and defining characteristics (or cues) as appropriate. 

Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions. These actions are documented as the plan of care. 
An intervention is defined as “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes” (Dochterman & Bulechek, 2004). 
The Nursing Interventions Classification (NIC) is a comprehensive standardized classification of interventions that nurses perform. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice care, to primary care) and all specialties (from critical care to ambulatory care and long-term care). NIC is recognized by the American Nurses Association (ANA).

Nursing Outcomes Classification
The definition of a nursing-sensitive patient outcome is an individual, family or community state, behavior, or perception that is measured along a continuum in response to a nursing intervention(s). Each outcome has an associated group of indicators that are used to determine patient status in relation to the outcome. (Moorhead, Johnson, & Maas, 2004).
The Nursing Outcomes Classification (NOC) is a comprehensive, research-based standard ized classification of patient/client, family, and community outcomes developed to evaluate the effects of nursing interventions across the continuum of care. An outcome is stated as a variable concept representing an individual, family, or community condition that is measurable along a continuum and responsive to nursing interventions. The outcomes in the classification are grouped into seven domains: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge and Behavior, Perceived Health, Family Health, and Community Health. Within each domain are several classes that contain the outcomes specific to that class. The Nursing Outcomes Classification is the most comprehensive classification of nursing-sensitive patient outcomes currently available for nurses to use with individuals, families, and communities across the care continuum and in specialty practice.

Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions. Legal and ethical concerns related to interventions also must be considered. Before implementing the interventions in Nursing care Plans, the nurse needs to understand the reason for doing each Nursing intervention, its expected effect, and any potential hazards that can occur. The nurse must also be sure that the interventions are 

  1. Consistent with the established plan of care
  2. Implemented in a safe and appropriate manner, 
  3. Evaluated for effectiveness, and 
  4. Documented in a timely manner. 

Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated. This is done by direct observation of the client, interviewing the client/significant other, and/or reviewing the client’s health record. 
Evaluation is an ongoing process, a constant measuring and monitoring of the client status to determine:

  • appropriateness of nursing actions
  • the need to revise interventions
  • development of new client needs
  • the need for referral to other resources, and
  • the need to rearrange priorities to meet changing demands of care. 

To effectively use the nursing process, the nurse must possess, and be able to apply, certain skills. Particularly important is a thorough knowledge of science and theory, as applied not only in nursing but also in other related disciplines, such as medicine and psychology.
Acute respiratory distress syndrome (ARDS) is an acute and persistent lung disease characterized by an arterial hypoxemia (PaO2/FiO2<200 mmHg), resistant to oxygen therapy and bilateral infiltrates on chest X ray’ (Lucangelo et al). Brunner and Suddarth defined ARDS is a clinical syndrome characterized by a sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia refractory to oxygen supplementation, and reduced lung compliance. These signs occur in the absence of left-sided heart failure. Patients with ARDS usually require mechanical ventilation with a higher-than normal airway pressure.

Pathophysiology of Acute Respiratory Distress Syndrome ARDS
Inflammatory damage to the alveoli, either by locally produced pro-inflammatory mediators, or remotely produced and arriving via the pulmonary artery. The change in pulmonary capillary permeability allows fluid and protein leakage into the alveolar spaces with pulmonary infiltrates. The alveolar surfactant is diluted with loss of its stabilizing effect, resulting in diffuse alveolar collapse and stiff lungs.

Sunday, November 8, 2009

Acute Respiratory Distress Syndrome (ARDS)
Acute Respiratory Distress Syndrome (ARDS)
Acute respiratory distress syndrome (ARDS) is an acute and persistent lung disease characterized by an arterial hypoxemia (PaO2/FiO2<200 mmHg), resistant to oxygen therapy and bilateral infiltrates on chest X ray’ (Lucangelo et al).  Brunner and Suddarth defined ARDS is a clinical syndrome characterized by a sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia refractory to oxygen supplementation, and reduced lung compliance. These signs occur in the absence of left-sided heart failure. Patients with ARDS usually require mechanical ventilation with a higher than normal airway pressure.

Pathophysiology For ARDS
Inflammatory damage to the alveoli, either by locally produced Pro- inflammatory mediators, or remotely produced and arriving via the pulmonary artery. The change in pulmonary capillary permeability allows fluid and protein leakage into the alveolar spaces with pulmonary infiltrates. The alveolar surfactant is diluted with loss of its stabilizing effect, resulting in diffuse alveolar collapse and stiff lungs.

Causes For ARDS
There are many causes of pro-inflammatory mediator release sufficient to cause ARDS, and there may be more than one present. Common causes in order of prevalence:

  • Sepsis/pneumonia; secondary risk factors for developing ARDS, when septic, are alcoholism and cigarette smoking
  • Gastric aspiration (even if on a proton pump inhibitor, indicating that a low pH is not the only damaging component)
  • Trauma/burns, via sepsis, lung trauma, smoke inhalation, fat emboli, and possibly direct effects of large amounts of necrotic tissue.

Nursing Assessment Nursing Care Plans for Acute Respiratory Distress Syndrome (ARDS)
ARDS showed that, in patients with ALI (acute lung injury), elevated levels of PAI-1 (plasminogen activator inhibitor-1)  in pulmonary oedema fluid and in plasma are associated with a higher mortality rate and fewer days of assisted ventilation. Recently, Ware LB et al. showed that protein C levels were lower in ALI/ARDS patients than in normal subjects and were associated with worse clinical outcomes, including death, fewer ventilator-free days, and more non-pulmonary organ failures, even when only those patients without sepsis were analyzed. Levels of thrombomodulin in the pulmonary edema fluid of patients with ALI/ARDS were more than ten-fold higher than in normal plasma and two-fold higher than in ALI/ARDS plasma. Higher thrombomodulin levels in edema fluid were associated with worse clinical outcomes. Decreasing circulating protein C and increased circulating thrombomodulin are markers of the pro-thrombotic, anti fibrinolytic state. Intercostal retractions and crackles, as the fluid begins to leak into the alveolar interstitial space, are evident on physical examination.
A diagnosis of ARDS may be made based on the following criteria: a history of systemic or pulmonary risk factors, acute onset of respiratory distress, bilateral pulmonary infiltrates, clinical absence of left-sided heart failure, and a ratio of partial pressure of oxygen of arterial blood to fraction of inspired oxygen (PaO2/FiO2) less than 200 mm Hg (severe refractory hypoxemia)
Nursing diagnosis Nursing Care Plans for Acute Respiratory Distress Syndrome (ARDS)

Common nursing diagnosis found in Nursing Care Plans for Acute Respiratory Distress Syndrome (ARDS)

  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Activity intolerance
  • Anxiety (specify level: mild, moderate, severe, panic)
  • Disturbed gas exchange
  • Risk for aspiration

Nursing interventions Nursing Care Plans for Acute Respiratory Distress Syndrome (ARDS)
Common nursing diagnosis fond in Nursing Care Plans for Acute Respiratory Distress Syndrome ARDS is; Ineffective airway clearance, Ineffective breathing pattern, Activity intolerance, Anxiety (specify level: mild, moderate, severe, panic), Disturbed gas exchange, Risk for aspiration
Below is Nursing interventions Nursing Care Plans for Acute Respiratory Distress Syndrome (ARDS) with Nursing diagnosis Ineffective airway clearance

Nursing Outcome
Nursing Interventions
Ineffective airway clearance
       Maintain airway patency.
       Expectorate/clear secretions readily.
       Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
       Verbalize understanding of cause(s) and therapeutic management regimen.
       Demonstrate behaviors to improve or maintain clear airway.
       Identify potential complications and how to initiate appropriate preventive or corrective actions.
       Position head midline with flexion appropriate for age/condition to open or maintain open airway in at-rest or compromised individual.
       Assist with appropriate testing (e.g. pulmonary function/ sleep studies) to identify causative/precipitating factors.
       Suction nasal/tracheal/oral porn to clear airway when secretions are blocking airway.
       Elevate head of the bed/change position every 2 hours to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments (pulmonary toilet).
       Monitor infant/child for feeding intolerance, abdominal distention, and emotional stressors that may compromise airway.
       Insert oral airway as appropriate to maintain anatomic position of tongue and natural airway.
       Assist with procedures (tracheotomy) to clear and maintain open airway.
       Keep environment allergen free (e.g., dust, feather pillows, smoke) according to individual situation.
       Encourage deep-breathing and coughing exercises; splint chest/incision to maximize effort.
       Administer analgesics to improve cough when pain is inhibiting effort. (Caution: Overmedication can depress respirations and cough effort.) Monitor for signs/symptoms of congestive heart failure (crackles, edema, weight gain).
       Encourage/provide warm versus cold liquids as appropriate.
       Provide supplemental humidification, if needed (ultrasonic nebulizer, room humidifier).
       Perform/assist client with postural drainage and percussion as indicated if not contraindicated by condition, such as asthma.
       Assist with respiratory treatments (intermittent positive pressure breathing—IPPB, incentive spirometer).
       Support reduction/cessation of smoking to improve lung function.
       Discourage use of oil-based products around nose to prevent aspiration into lungs.
       An auscultative breath sounds and assesses air movement to ascertain status and note progress.
       Monitor vital signs, noting blood pressure/pulse changes.
       Observe for signs of respiratory distress (increased rate, restlessness/ anxiety, use of accessory muscles for breathing).
       Evaluate changes in sleep pattern, noting insomnia or daytime somnolence.
       Document response to drug therapy and/or development of adverse side effects or interactions with antimicrobials, steroids, expectorants, bronchodilators.
       Observe for signs/symptoms of infection (e.g., increased dyspnea with onset of fever, change in sputum color, amount, or character) to identify infectious process/promote timely intervention.
       Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy.
       Monitor/document serial chest x-rays/ABGs/pulse oximetry readings.
       Observe for improvement in symptoms.

        Client’s response to interventions/teaching and actions performed.
        Attainment/progress toward desired outcome(s).
·       Modifications to care plan.