Cerebral Contusion is a Head injury that More serious than a concussion, a cerebral contusion is an ecchymosed of brain tissue that results from a severe blow to the head. When the head is abruptly brought to a stop against a solid object, the brain continues to move for an instant, hitting the inside the now stationary skull. The soft brain is easily contused and lacerated by the hard bony ridges at the base of the skull or by the tentorium cerebelli and falx cerebri. A contusion disrupts normal nerve functions in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death.

Causes For  Cerebral Contusion

Cerebral contusion can happen to anyone, at any time. The most common causes of contusion include a blow to the head from a motor vehicle crash, fall or assault. People at higher risk are those who have difficulty walking and fall often, those who are active in high impact contact sports. It is also seen in child, spouse, and elder abuse. A cerebral contusion results from acceleration-deceleration or coup countercoup injuries. Contusions may correspond to the site of impact or develop opposite the impact (“coup” contusions- contre coup” contusions). Cerebral contusion that occur directly beneath the site of impact (coup) when the brain rebounds against the skull from the force of a blow (a beating with a blunt instrument, for example), when the force of the blow drives the brain against the opposite side of the skull (counter coup), or when the head is hurled forward and stopped abruptly (as in a motor vehicle accident when the driver’s head strikes the windshield). The brain continues moving, slaps against the skull (acceleration), and then rebounds (deceleration). A cerebral contusion can be distinguished from a cerebral infarct because, in the infarct, the superficial cortex is usually preserved, whereas in the contusion, it is the first to be damaged.

Complications for Cerebral Contusion

When injuries cause the brain to strike against bony prominences inside the skull (especially to the sphenoidal ridges), intracranial hemorrhage or hematoma can occur. The patient may also suffer tentorial herniation. Residual headache and vertigo may complicate recovery. Secondary effects, such as cerebral edema, may accompany serious contusions, resulting in increased intracranial pressure (ICP) and herniation.

Treatment for Cerebral Contusion

Contusions usually involve the surface of the brain, especially the crowns of gyri, and are more frequent in the orbital surfaces of the frontal lobes and the tips of the temporal lobes. Acute contusions show hemorrhagic necrosis and brain swelling. Gradually, macrophages remove necrotic brain tissue and blood. Eventually, the contusion evolves into a yellowish plaque characterized by loss and atrophy of brain tissue, glial scarring, hemosiderin deposition, and loss of axons in the underlying white matter.  Immediate treatment may include establishing a patent airway and, if necessary, tracheotomy or endotracheal intubation. Treatment may also consist of careful administration of I.V. fluids I.V. mannitol to reduce ICP, and restricted fluid intake to decrease intracerebral edema. Dexamethasone may be given I.M. or I.V. for several days to control cerebral edema. An intracranial hemorrhage may require a craniotomy to locate and control bleeding and to aspirate blood. Epidural and subdural hematomas usually are drained by aspiration through burr holes in the skull. Increased ICP which can occur in hemorrhage, hematoma, and tentorial herniation may be controlled with mannitol I.V, steroids, or diuretics, but emergency surgery is usually required.

NCP Nursing care plans for Cerebral Contusion

NCP Nursing care plans for Cerebral Contusion. Common nursing diagnosis found in nursing care plan for patient with Cerebral Contusion:  Acute pain, Anxiety, ineffective cerebral tissue Perfusion, Disturbed sensory perception: Kinesthetic, tactile, disturbed thought processes, impaired verbal communication, Ineffective coping, Risk for deficient fluid volume, Risk for infection, Risk for injury, Risk for post trauma syndrome

Nursing Diagnosis for Cerebral Contusion

Nursing Diagnosis For Cerebral Contusion determine from the data that nurses collect from nursing assessment and from diagnostic test. If patient unconscious nursing assessment obtained from family, friends, and emergency personnel, if necessary

Nursing Assessment Nursing care plans for Cerebral Contusion

The patient’s history reveals a severe traumatic impact to the head, commonly against a blunt surface such as a car dashboard. Signs and symptoms vary, depending on the location of the contusion and the extent of damage. A period of unconsciousness, possibly lasting 6 hours or more, may follow the trauma. An unconscious patient may appear pale and motionless, whereas a conscious patient may appear drowsy or easily disturbed by any form of stimulation, such as noise or light. A conscious patient may become agitated or violent. Assessment of an unconscious patient may reveal below-normal blood pressure and temperature. His pulse rate may be within normal levels but feeble, and his respirations may be shallow. In a conscious patient, temperature, pulse rate, and respiratory status vary, depending on his physical and emotional status.

• Inspection may reveal severe scalp wounds, labored respirations and, possibly, involuntary evacuation of the bowels and bladder. Palpation may disclose less obvious head injuries such as hematoma. On palpation, the unconscious patient’s skin will feel cold.
• Neurologic findings may include hemiparesis, decorticate or decerebrate posturing, and unequal pupillary response. With effort, you may be able to temporarily rouse an unconscious patient. If you’re performing a neurologic examination after the acute stage of the injury, you may find that the patient has returned to a relatively alert state, perhaps with temporary aphasia, slight hemiparesis, or unilateral numbness.

Diagnostic tests for Cerebral Contusion

• Cerebral angiography outlines vasculature, and a
• Computed tomography (CT) scan CT scan
• MRI (magnetic resonance imaging)

Nursing diagnosis Nursing care plans for Cerebral Contusion

Common Nursing diagnosis found in Nursing care plans for Cerebral Contusion

• Acute pain
• Anxiety
• Decreased intracranial adaptive capacity
• Disturbed sensory perception: Kinesthetic, tactile
• Disturbed thought processes
• Impaired verbal communication
• Ineffective coping
• Risk for deficient fluid volume
• Risk for infection
• Risk for injury
• Risk for post trauma syndrome

Nursing Intervention and Rationale Nursing Care Plan for Cerebral Contusion

Nursing diagnosis acute pain

Related factors injuring agents (Cerebral Contusion)

Nursing Interventions:

• Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
• Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
• Environmental Management Manipulation of the patient’s surroundings for promotion of optimal comfort

Nursing diagnosis Anxiety

Related to Threat to or change in health status progressive debilitating disease, illness, interaction patterns, role function/status

Nursing Interventions:

• Anxiety Reduction minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
• Provision of a modified environment for the patient who is experiencing a confusional state
• Calming Technique: Reducing anxiety in patient experiencing acute distress

Nursing diagnosis Ineffective cerebral tissue Perfusion

Related to Interruption of blood flow by space-occupying lesions (hemorrhage, hematoma), cerebral edema

Nursing Interventions

• Neurologic Monitoring
• Cerebral Perfusion Promotion
• Collaborative oxygen, Prepare for surgical intervention, such as craniotomy or insertion of ventricular drain or ICP pressure monitor, if indicated, and transfer to higher level of care.

Nursing diagnosis Disturbed sensory perception: Kinesthetic, tactile

Related to Altered sensory reception, transmission, and/or integration: Neurologic disease, trauma

Nursing Interventions

• Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision
• Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
• Peripheral Sensation Management: Prevention or minimization of injury or discomfort in the patient with altered sensation

Nursing diagnosis Disturbed thought processes

Nursing diagnosis Impaired verbal communication

Related to decrease in circulation to brain, Cerebral Contusion

Nursing Interventions:

• Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech
• Communication Enhancement: Hearing Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing
• Active Listening: Attending closely to and attaching significance to a patient’s verbal and nonverbal messages

Nursing diagnosis Ineffective coping

Related to Impairment of nervous system cognitive, sensory, perceptual impairment, memory loss, Severe/chronic pain.

Nursing Interventions:

• Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
• Decision-Making Support Providing information and support for a person who is making a decision regarding healthcare
• Impulse Control Training Assisting the patient to mediate impulsive behavior through application of problem-solving strategies to social and interpersonal situations

Nursing diagnosis Risk for deficient fluid volume

Nursing Interventions:

• Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance
• Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
• Bleeding Precautions: Reduction of stimuli that may indicate bleeding or hemorrhage in at-risk patients

Nursing diagnosis Risk for infection

Risk factor inadequate primary defenses broken skin, traumatized tissue

Nursing Interventions:

• Infection Protection Prevention and early detection of infection in a patient at risk
• Infection Control Minimizing the acquisition and transmission of infectious agents
• Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

Nursing diagnosis Risk for injury

Nursing Interventions:

• Safety Behavior: Personal: Individual or caregiver efforts to control behaviors that might cause physical injury
• Risk Actions to eliminate or reduce actual, personal, and modifiable health threats
• Safety Status: Physical Injury: Severity of injuries from accidents and trauma

Nursing diagnosis Risk for post trauma syndrome

Risk factors, serious injury or threat to self, criminal victimization. Tragic occurrence involving violent and/or multiple deaths; disasters; epidemics

Nursing Interventions:

• Crisis Intervention Use of short-term counseling to help the patient cope with a crisis and resume a state of functioning comparable to or better than the pre-crisis state
• Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
• Support System Enhancement Facilitation of support to patient by family, friends, and community

 Patient Teaching And Home Healthcare Guidance For Patient With Cerebral Contusion

Patient teaching and home healthcare guidance for patient with Cerebral Contusion be sure the patient understands all medications, including the dosage, route, action, adverse effects, and the need for routine laboratory monitoring for convulsants. Teach the patient and caregiver the signs and symptoms that necessitate a return to the hospital. Teach the patient to recognize the symptoms and signs of post injury syndrome, which may last for several weeks. Explain that mild cognitive changes do not always resolve immediately. Provide the patient and significant others with information about the trauma clinic and the phone number of a clinical nurse specialist in case referrals are needed. Stress the importance of follow-up visits to the physician’s office. Patient with cerebral contusion may present with a variety of physical and cognitive disabilities, depending on the severity of the injury. Individuals may need treatment by physical, occupational, or speech therapists; neuropsychologists; vocational counselors; and/or social workers. Care for those experiencing moderate to severe Cerebral Contusion progresses along a continuum of care, beginning with acute hospital care and inpatient rehabilitation to sub acute and outpatient rehabilitation, as well as home- and community-based services.

Patient teaching and home healthcare guidance for patient with Cerebral Contusion

• Tell the patient not to cough, sneeze, or blow his nose because these activities can increase ICP.
• Instruct the patient to observe for CSF drainage and to be alert for signs of infection.
• Teach the patient and his family how to observe for mental status changes and to return to the facility or to call the physician if such changes occur.

Although Thyroid cancer occurs in all age groups Incidence increases with age. The average age at time of diagnosis is 45.  There appears to be an association between external radiation to the head and neck in infancy and childhood, and subsequent development of thyroid carcinoma. (Between 1949 and 1960, radiation therapy was commonly given to shrink enlarged tonsil and adenoid tissue, to treat acne, or to reduce an enlarged thymus.) People who have goiters have an increased risk for developing thyroid cancer.
The incidence among such patients is 10–15 percent. A lack of iodine in the diet may lead to thyroid cancer. Because iodine is added to salt in the United States, thyroid cancer is rarely caused by iodine deficiencies in this country. Thyroid cancer may also have a genetic basis. Some researchers have found that an alteration in the RET gene may be transmitted from a parent to a child, causing medullary thyroid cancer. If several people in a family are diagnosed with thyroid cancer, other members may wish to be tested for a mutation of the RET gene. This syndrome, when present, is also called familial medullary thyroid cancer or Multiple Endocrine Neoplasia, type 2 (MEN 2). Individuals who have MEN 2 syndrome are also at risk for developing other types of cancer.

Types characteristics of thyroid cancers

1. Papillary adenocarcinoma  (Most common and least aggressive, Asymptomatic nodule in a normal gland, Starts in childhood or early adult life, remains localized, Metastasizes along the lymphatics if untreated, More aggressive in the elderly, Growth is slow, and spread is confined to lymph nodes that surround thyroid area, Cure rate is excellent after removal of involved areas).  Papillary carcinoma accounts for half of all thyroid cancers in adults; it’s most common in young adult females and metastasizes slowly. It’s the least virulent form of thyroid cancer. Follicular carcinoma is less common but more likely to recur and metastasize to the regional nodes and through blood vessels into the bones, liver, and lungs.
2. Follicular adenocarcinoma (  Appears after 40 years of age, Encapsulated; feels elastic or rubbery on palpation, Spreads through the bloodstream to bone, liver, and lung, Prognosis is not as favorable as for papillary adenocarcinoma, Brief encouraging response may occur with irradiation, Progression of disease is rapid; high mortality )
3. Medullary (Appears after 50 years of age, Occurs as part of multiple endocrine neoplasia MEN), Hormone-producing tumor causing endocrine dysfunction symptoms, Metastasizes by lymphatics and bloodstream, Moderate survival rate, inheritable type of thyroid malignancy, which can be detected early by a radioimmunoassay for calcitonin )
4. Anaplastic (50% of anaplastic thyroid carcinomas occur in patients older than 60 years, Hard, irregular mass that grows quickly and spreads by direct invasion to adjacent tissues, May be painful and tender, Survival for patients with anaplastic cancer is usually less than 6 months, The most aggressive and lethal solid tumor found in humans,  Least common of all thyroid cancers, Usually fatal within months of diagnosis)
5. Thyroid lymphoma (Appears after age 40 years, May have history of goiter, hoarseness, Dyspnea, pain, and pressure, Good prognosis )

Complications For Thyroid Cancers

• Untreated thyroid carcinoma can be fatal.
• Hemorrhage
• Hematoma formation
• Edema of the glottis
• Injury to the recurrent laryngeal nerve
• Hypothyroidism occurs in 5% of patients in first postoperative year; increases at rate of 2% to 3% per year.
• Hypoparathyroidism occurs in about 4% of patients and is usually mild and transient; requires calcium supplements I.V. and orally when more severe.

Clinical Manifestations for Thyroid Cancers

• On palpation of the thyroid, there may be a firm, irregular, fixed, painless mass or nodule.
• The occurrence of signs and symptoms of hyperthyroidism is rare.

Symptoms of Thyroid Cancer

• As with many other forms of cancer, most people in the early stages of thyroid cancer have no symptoms or signs of disease. When symptoms or signs occur, they may include the following:
  • Hoarseness
  • A lump near the Adam’s apple of the neck
  • Swollen lymph nodes in the neck or nearby
  • Dysphagia (difficulty swallowing)
  • Pain in the neck or throat
• Medullary carcinoma of the thyroid secretes CALCITONIN and thus can cause symptoms due to the presence of this hormone, such as flushing, nausea, and diarrhea. In addition, medullary carcinoma of the thyroid is often inherited. Family members can be screened by measuring their calcitonin levels or by looking for abnormal chromosomes, such as RET.
• Anaplastic carcinoma typically presents in older men as a very hard mass in the neck. It is often incurable at the time of diagnosis, as it does not concentrate iodine, and thus radioactive iodine (RAI) therapy cannot be used. It is poorly responsive, if at all, to chemotherapy and external radiation therapy.

Nursing Diagnosis for Thyroid Cancer

Nursing Diagnosis for Thyroid Cancer. Nursing care plan for Thyroid Cancer begins with a detailed assessment as soon as the patient is admitted. In the Assessment phase, information is obtained the patient in a direct and structured manner through observation, interviews and examination. Initial interview includes an evaluation of mental status. Even when the initial assessment is complete, each encounter with the patient involves a continuing assessment .The ongoing assessment involves what patient is saying or doing at that moment.

Focused Nursing Assessment for Thyroid CancerExplore patient’s feelings and concerns regarding the diagnosis, treatment, and prognosis. The first indication of disease may be a painless nodule discovered incidentally or detected during physical examination.If the tumor grows large enough to destroy the thyroid gland.

Patient’s history may include sensitivity to cold and mental apathy (hypothyroidism). If the tumor triggers excess thyroid hormone production, the patient may report sensitivity to heat, restlessness, and overactivity (hyperthyroidism). The patient may also complain of diarrhea, dysphagia, anorexia, irritability, and ear pain. When speaking with the patient, you may hear hoarseness and vocal stridor.

On inspection, you may detect a disfiguring thyroid mass, especially if the patient is in the later stages of anaplastic thyroid cancer. (See Anaplastic thyroid cancer.)

Palpation may disclose a hard nodule in an enlarged thyroid gland or palpable lymph nodes with thyroid enlargement.

By auscultation, you may discover bruits if thyroid enlargement results from an increase in TSH, which increases thyroid vascularity.

Diagnostic Evaluation

• A thyroid scan with ^99mTc will detect a cold  nodule with little uptake
• FNA biopsy
• Surgical exploration
• ultrasound
• MRI
• CT scans
• Thyroid scans
• Radioactive
• Iodine uptake studies
• Thyroid suppression tests

Nursing Diagnosis for Patient with Thyroid Cancer

Commong Nursing Diagnosis That Could Be Found In Patient With Thyroid Cancer:

1. Fear/Anxiety [specify level]
2. Acute/chronic Pain
3. Risk for ineffective Airway Clearance
4. Impaired verbal Communication
5. Risk for Injury, [tetany, thyroid storm]
6. Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs

Nursing Care Plan for Thyroid Cancer. Common Nursing Diagnosis That Could Be Found In Nursing Care Plan Patient With Thyroid Cancer:  Fear/Anxiety, Acute/chronic Pain, Risk for ineffective Airway Clearance, Impaired verbal Communication,  Risk for Injury (tetany because of thyroid storm), Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs

Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer

Nursing Diagnosis Fear/Anxiety

Could be related to:

• Situational crisis cancer Thyroid Cancer
• Threat to, or change in, health, socioeconomic status, role functioning, interaction patterns
• Threat of death
• Separation from family hospitalization, treatments, diagnostic procedures, diagnosis of chronic/life-threatening condition

Nursing Outcomes Evaluation Criteria, Client Will:

Fear or Anxiety Self Control: Display appropriate range of feelings and lessened fear. Appear relaxed and report anxiety is reduced to a manageable level. Demonstrate use of effective coping mechanisms and active participation in treatment regimen.

Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety:

• Review client’s and significant other’s (SO’s) previous experience with cancer. Determine what the doctor has told client and what conclusion client has reached. Rationale Clarifies client’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer.
• Ascertain client/SO(s) perception of what is occurring and how this affects life. Rationale Fear is a natural reaction to frightening events and how client views the event will determine how he or she will react
• Encourage client to share thoughts and feelings. Rationale Provides opportunity to examine realistic fears and misconceptions about diagnosis.
• Provide open environment in which client feels safe to discuss feelings or to refrain from talking. Rationale Helps client feel accepted in present condition without feeling judged and promotes sense of dignity and control.
• Be alert to signs of denial/depression. Indicates need for specific interventions to identify and deal with problems. Rationale Client may deny problems until unable to deal with situation. Depression may accompany problems associated with fear that interfere with daily activities
• Maintain frequent contact with client. Talk with and touch client, as appropriate. Rationale Provides assurance that the client is not alone or rejected; conveys respect for and acceptance of the person, fostering trust.
• Be aware of effects of isolation on client when required by immunosuppression or radiation implant. Limit use of isolation clothing, as possible. Rationale Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety, fear, and alienation.
• Assist client and SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears. Rationale Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control and coping strategies are available.
• Provide accurate, consistent information regarding diagnosis and prognosis. Avoid arguing about client’s perceptions of situation. Rationale Can reduce anxiety and enable client to make decisions and choices based on realities.
• Explain the recommended treatment, its purpose, and potential side effects. Help client prepare for treatments. Rationale The goal of cancer treatment is to destroy malignant cells while minimizing damage to normal ones. Treatment may include curative, preventive, or palliative surgery as well as chemotherapy, internal or external radiation, or newer, organ-specific treatments such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral progenitor cell transplant may be recommended for some types of cancer.
• Note ineffective coping such as poor social interactions, helplessness, giving up everyday functions, and usual sources of gratification. Rationale Identifies individual problems and provides support for client and SO in using effective coping skills.
• Administer anti-anxiety medications, such as lorazepam (Ativan) or alprazolam (Xanax), as indicated. Rationale May be useful for brief periods of time to help client handle feelings of anxiety related to diagnosis or situation during periods of high stress, to assist client with diagnostic procedures, such as lying still during scan, and/or to minimize nausea.
• Refer to additional resources for counseling and support as needed. Rationale May be useful from time to time to assist client and SO in dealing with anxiety.

Nursing Diagnosis Acute pain/Chronic Pain

Related to: Disease process compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation, metastasis to bones. Side effects of various cancer therapy agents

Nursing Outcomes Evaluation Criteria Client Will

• Report maximal pain relief or control with minimal interference with activities of daily living (ADLs).
• Follow prescribed pharmacological regimen.
• Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain

• Determine pain history, for example, location of pain, frequency, duration, and intensity using a rating scale (scale of 0–10), or verbal rating scale “no pain” to “excruciating pain”; and relief measures used. Believe client’s report. Rationale Information provides baseline data to evaluate need for, and effectiveness of, interventions. Pain of more than 6 months’ duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention.
• Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client about what to expect. Rationale A wide range of discomforts are common such as incisional pain, burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer.
• Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV. Rationale Promotes relaxation and helps refocus attention.
• Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck. Rationale Prevents hyperextension of the neck
• Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch. Rationale Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain.
• Provide cutaneous stimulation, such as heat and cold packs, or massage. Rationale May decrease inflammation, muscle spasms, reducing associated pain.
• Be aware of barriers to cancer pain management related to client, as well as the healthcare system. Rationale Clients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; belief that pain has meaning, such as “God wills it,” they should overcome it; or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities.
• Evaluate pain relief at regular intervals. Adjust medication regimen as necessary. Inform client and SO of the expected therapeutic effects and discuss management of side effects. Rationale Goal is maximum pain control with minimum interference with ADLs.
• Develop individualized pain management plan with the client and physician. Provide written copy of plan to client, family and SO, and care providers. Rationale An organized plan beginning with the simplest dosage schedules and least invasive modalities improves chance for pain control. Particularly with chronic pain, client and SO must be active participant in pain management and all care providers need to be consistent.
• Refer to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, as indicated. Rationale May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain.

Nursing Diagnosis Risk for Ineffective Airway Clearance

Related to Tracheal obstruction, swelling, bleeding, laryngeal spasms.

Nursing Outcomes Evaluation Criteria

• Client Will Maintain patent airway, with aspiration prevented.

Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance

• Monitor respiratory rate, depth, and work of breathing. Rationale Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.
• Auscultate breath sounds, noting presence of rhonchi. Rationale Rhonchi may indicate airway obstruction and accumulation of copious thick secretions.
• Assess for Dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice. Rationale Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention.
• Keep head of bed elevated 30 to 45 degrees. Caution client to avoid bending neck; support head with pillows in the immediate postoperative period. Rationale Enhances breathing and reduces likelihood of tension on surgical wound.
• Assist with repositioning, deep breathing exercises, and coughing, as indicated. Rationale Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions.
• Investigate reports of difficulty swallowing and drooling of oral secretions. Rationale May indicate edema and sequestered bleeding in tissues surrounding operative site.
• Keep tracheostomy tray at bedside. Rationale Compromised airway may create a life-threatening situation requiring emergency procedure.
• Provide steam inhalation, humidify room air. Rationale Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.
• Assist with and prepare for procedures, such as: Tracheostomy Rationale although rare, tracheostomy may be necessary to obtain airway if obstructed by edema of glottis or hemorrhage.

Nursing Diagnosis Impaired Verbal Communication

Related to: Vocal cord injury, laryngeal nerve damage. Tissue edema; pain and discomfort

Nursing Outcomes Evaluation Criteria

Client Will Establish method of communication in which needs can be understood.

Nursing Interventions and Rationale:

• Assess speech periodically and encourage voice rest. Rationale Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and or compression of the trachea.
• Keep communication simple. Ask yes and no questions. Rationale Reduces demand for response; promotes voice rest.
• Provide alternative methods of communication as appropriate—slate board, letter and picture board. Place intravenous (IV) line to minimize interference with written communication. Rationale Facilitates expression of needs.
• Anticipate needs as much as possible. Visit client frequently. Rationale Reduces anxiety and client’s need to communicate.
• Post notice of client’s voice limitations at central station and answer call light promptly. Rationale Prevents client from straining voice to make needs known and summon assistance.
• Maintain quiet environment. Rationale Enhances ability to hear whispered communication and reduces necessity for client to raise and strain voice to be heard.

Nursing Diagnosis Risk For Injury

Related to:  tetany, thyroid storm. Chemical imbalance, such as with hypocalcemia, increased release of thyroid hormones, excessive central nervous system (CNS). Stimulation

Nursing Outcomes Evaluation Criteria Client Will Demonstrate absence of injury with complications minimized or controlled.

Nursing Interventions And Rationale

• Monitor vital signs, noting elevated temperature, tachycardia (140 to 200 beats/minute), dysrhythmias, respiratory distress, and cyanosis—developing pulmonary edema or heart failure (HF). Rationale : Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm.
• Evaluate reflexes periodically. Observe for neuromuscular irritability—twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, and seizure activity. Rationale : Hypocalcemia with tetany (usually transient) may occur 1 to 7 days postoperatively and indicates hypoparathyroidism, which can occur because of inadvertent trauma to and partial to total removal of parathyroid gland(s) during surgery.
• Keep side rails raised and padded, bed in low position, and airway at bedside. Avoid use of restraints. Rationale Reduces potential for injury if seizures occur. (Refer to CP: Seizure Disorders, ND: risk for Trauma/Suffocation.)
• Monitor serum calcium levels. Rationale : Clients with levels less than 7.5 mg/100 mL generally require replacement therapy.
• Administer medications, as indicated, for example: IV calcium (gluconate or chloride) Phosphate-binding agents, Sedativesm Anticonvulsants Rationale : Corrects deficiency, which is usually temporary but may be permanent. Note: Use with caution in clients taking digoxin because calcium increases cardiac sensitivity to digoxin, potentiating risk of toxicity. Helpful in lowering elevated phosphorus levels associated with hypocalcemia. Promotes rest, reducing exogenous stimulation. Controls seizure activity associated with thyroid storm until corrective therapy is successful.

Nursing Diagnosis Deficient Knowledge Regarding Condition, Prognosis, Treatment, Self-Care, And Discharge Needs

Related to: Lack of exposure and recall; misinterpretation, Unfamiliarity with information resources

Nursing Outcomes Evaluation Criteria

• Client Will Verbalize understanding of surgical procedure and prognosis and potential complications.
• Verbalize understanding of therapeutic needs.
• Participate in treatment regimen.
• Initiate necessary lifestyle changes.

Nursing Interventions and Rationale

• Review surgical procedure and future expectations. Rationale Provides knowledge base from which client can make informed decisions.
• Discuss need for well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt. Rationale Promotes healing and helps client regain and maintain appropriate weight. Use of iodized salt is often sufficient to meet iodine needs unless salt is restricted for other healthcare problems, such as with HF.
• Identify foods high in calcium, such as dairy products, and vitamin D, such as fortified dairy products, egg yolks, and liver. Rationale Maximizes supply and absorption of calcium if parathyroid function is impaired.
• Encourage progressive general exercise program. Rationale In clients with subtotal thyroidectomy, exercise can stimulate the thyroid gland and production of hormones, facilitating recovery of general well-being.
• Review postoperative exercises to be instituted after incision heals flexion, extension, rotation, and lateral movement of head and neck. Rationale Regular range-of-motion (ROM) exercises strengthen neck muscles and enhance circulation and healing process.
• Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts. Rationale Effects of hyperthyroidism usually subside completely, but it takes some time for the body to recover.
• Instruct in incision care cleansing and dressing application. Rationale Enables client to provide competent self-care. Note: Neck incisions heal rapidly and are watertight within 24 to 36 hours.
• Recommend the use of loose-fitting scarves to cover scar, avoiding the use of jewelry. Rationale Covers the incision without aggravating healing or precipitating infections of suture line.
• Discuss possibility of change in voice. Rationale Normal surgical area swelling and vocal cord dysfunction can cause changes in pitch and quality of voice, which may be temporary or permanent.
• Review drug therapy and the necessity of continuing even when feeling well. Rationale If thyroid hormone replacement is needed because of surgical removal of gland, client needs to understand rationale for replacement therapy and consequences of failure to routinely take medication.
• Identify signs and symptoms requiring medical evaluation: fever, chills, continued and purulent wound drainage, erythema, gaps in wound edges, sudden weight loss, intolerance to heat, nausea and vomiting, diarrhea, insomnia, weight gain, fatigue, intolerance to cold, constipation, and drowsiness. Rationale Early recognition of developing complications, such as infection, hyperthyroidism, or hypothyroidism, may prevent progression to life-threatening situation.
• Stress necessity of continued medical follow-up. Rationale Provides opportunity for evaluating effectiveness of therapy and prevention of complications.

Patient Teaching Thyroid Cancer

Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer. To maintain a euthyroid state, teach family  and patient sign and symptoms of hypothyroidism for early detection of problems: weakness, fatigue, cold intolerance, weight gain, facial puffiness, periorbital edema, bradycardia, and hypothermia. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Explain that the patient needs routine follow-up laboratory tests to check TSH and thyroxine (T4) levels. Be sure the patient knows when the first postoperative physician’s visit is scheduled. Explain any wound care and that the patient should expect to be hoarse for a week or so after the surgical procedure.

Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer:

• Preoperatively, advise the patient to expect temporary voice loss or hoarseness for several days after surgery. Also, explain the operation and postoperative procedures and positioning.
• Instruct the patient on thyroid hormone replacement and follow-up blood tests.
• Stress the need for periodic evaluation for recurrence of malignancy.
• Supply additional information or suggest community resources dealing with cancer prevention and treatment.
• Assist patient in identifying sources of information to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain
• Assist patient in identifying sources of information and support available in the community Refer the patient to resource and support services, such as the social service department, home health care agencies, hospices, and the American Cancer Society
• Before discharge, ensure that the patient knows the date and time of his next appointment. Answer his questions about his treatment and home care. Be sure he understands the purpose of his medications, dosage, administration times, and possible adverse effects

Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. TNM staging system. TNM staging takes the following factors into account. The size of the Lung Cancer (T). Whether Lung Cancer cells have spread into the lymph nodes (N) whether the Lung Cancer has spread anywhere else in the body – secondary cancer or metastases (M)

Stage of Lung cancer TNM (Tumor, Nodes, Metastases) system of staging

TNM Stage of Lung cancer Description:

Primary tumor (T)

• TX; Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy.
• T0 :  No evidence of primary tumor
• Tis :  Carcinoma in situ
• T1 :  Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)
• T2: Tumor with any of the following features of size or extent: 3 cm in greatest dimension. Involves main bronchus, 2 cm distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung.
• T3 : Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinum pleura, parietal pericardium; or          tumor in the main bronchus, 2 cm distal to the carina, but without involvement of          the carina; or associated atelectasis or obstructive pneumonitis of the entire lung
• T4: Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusion, b or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung

Regional lymph nodes (N)

• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor
• N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)
• N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node(s)

Distant Metastasis (M)

• MX Presence of distant metastasis cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis present

Stage grouping (TNM subsets):

• Stage IA (T1 N0 M0), IB (T2 N0 M0). Most common form of early lung cancer located only in the lungs. Detected on routine chest X-ray in patients who present for unrelated medical condition or routine examination. Treatment-surgical resection.
• Stage IIA (T1 N1 M0), IIB (T2 N1 M0, T3 N0 M0). Tumors in the lung and lymph nodes (hilar and bronchopulmonary nodes). Treatment-surgical resection and adjuvant radiation or chemotherapy, or both. Induction chemotherapy before surgery is being investigated. Patients with significant co-morbid disease surgery may not be an option.
• Stage IIIA (T3 N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0) Cancer in the lung and lymph nodes on the same side of the chest.  T3 tumors involving the main stem bronchi produce hemoptysis, Dyspnea, wheezing, atelectasis, and post obstructive pneumonia. T3 tumors involving the pericardium or diaphragm may be symptomatic but those involving the chest wall usually cause pain. Nodal disease is often asymptomatic, if extensive nodal disease may cause compression of the proximal airways and superior vena cava syndrome. Treatment—selected cases surgical resection (T3NO-1), commonly multi-modality therapy with chemotherapy being primary form of treatment; multiple trials of combined chemotherapy, radiation with or without surgery are under investigation.
• Stage IIIB (T4 N0 M0, T4 N1 M0, T4 N2 M0, T1 N3 M0, T2 N3 M0, T3 N3 M0, T4 N3 M0) Cancer has spread to the lymph nodes on the opposite side of the chest. T4 tumors invade the mediastinum structures, and/or malignant pleural effusions. N3—metastases. Treatment—chemotherapy and radiation therapy; in rare exceptions, surgery may be considered.
• Stage IV (Any T Any N M1) Evidence of metastatic disease. Treatment often palliative (to relieve symptoms). Clinical trials may offer some survival benefit.

Like many other neoplasm disease Complications of Lung Cancer occurs when lung cancer metastasized to other organ, outside the Lung. Disease progression and metastasis cause various complications. Early stage and localized disease may be asymptomatic. Symptoms are often medically treated and attributed to conditions such as bronchitis, pneumonia, and chronic obstructive pulmonary disease. Symptoms: cough & wheezing, increased sputum production, hemoptysis, Dyspnea, pneumonia, pleural effusions.

Advanced disease predominant at time of diagnosis related to tumor growth and compression of adjacent structures. When the primary tumor spreads to intrathoracic structures, complications may include tracheal obstruction; esophageal compression with dysphagia; phrenic nerve paralysis with hemidiaphragm elevation and dyspnea; sympathetic nerve paralysis with Horner’s syndrome with ptosis, miosis, hemifacial anhydrosis, clubbing, hypertrophic osteoarthropathy, bone pain, fatigue, dysphagia from esophageal compression, wheezing or stridor, phrenic nerve paralysis with elevated hemidiaphragm, arrhythmias and heart failure (from pericardial involvement), hypoxia related to lymphangitic spread, superior vena cava syndrome (swelling of the face, neck and upper extremities and related to compression of blood vessels in the neck and upper thorax.

Symptoms: chronic cough, Dyspnea, weight loss, increased sputum production, hemoptysis, hoarseness (involvement of the laryngeal nerve), pleural effusions and atelectasis, chronic pain, pain over the shoulder and medial scapula, arm pain with or without muscle wasting along ulnar distribution,

Lung cancer usually cause breathing and heart problems such as:

• Pleural effusion
• Pericardial effusion
• Coughing up large amounts of bloody sputum.
• Collapse of a lung (pneumothorax).
• Blockage of the airway (bronchial obstruction).
• Recurrent infections, such as pneumonia.

Other complications are anorexia and weight loss, sometimes leading to cachexia, digital clubbing, and hypertrophic osteoarthropathy. Endocrine syndromes may involve production of hormones and hormone precursors.

Extra thoracic spread of disease: adrenal glands (50%), liver (30%), brain (20%), bone (20%), kidneys (15%), scalene lymph nodes. Prognosis remains poor and has improved very slightly despite medical advances: <14% combined 5-year survival rate.

A common treatment method of Lung Cancer is Surgery, chemotherapy and radiotherapy is all classified as a treatment for lung cancer. Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer.  Lung cancer accounts for more deaths than prostate, breast, and colon cancer combined. The 1-year survival rate remains approximately 41%, and the 5-year survival rate is 15%. Only 16% of lung cancers are found at an early, localized stage, when the 5-year survival rate is 49%. The survival rate for lung cancer has not improved over the last 10 years.

Common treatment methods of Lung Cancer:

Surgery Treatment for Lung Cancer

The treatment of choice for non-small cell lung cancer, Stage IA, IB, IIA, IIB, and selected cases of stage IIIA : lobectomy (removal of a lobe of the lung), pneumonectomy (removal of one lung), wedge resection or segmentectomy for patients with inadequate pulmonary reserve who cannot tolerate lobectomy, VATS (Video Assisted Thoroscopic Surgery), palliative surgery. Before surgery patient must know the risk factor from Lung Cancer Surgery; Risks from lung cancer surgery include damage to structures in or near the lungs, general risks related to surgery, and risks from general anesthesia

Patient education before surgery: patient understands surgical procedure, incision, placement of chest tubes; smoking cessation before surgery to reduce pulmonary complications pain control; bronchodilators, coughing and deep-breathing exercises, early ambulation after surgery.

After surgery : assess respiratory function (respiratory rate, level of dyspnea, use of accessory muscles, and arterial blood gases); monitor chest tube drainage and air leaks, monitor oxygen saturation at rest and ambulation, assess pain control, chest physical therapy (bronchial drainage positions, deep breathing, coughing)  early ambulation,monitor for atrial arrhythmias ; discharge planning and home care arrangements.

Chemotherapy Treatment for Lung Cancer

Researchers are continually looking at different ways of combining new and old drugs for advanced non-small cell lung cancer.

Chemotherapy Treatment for Non-Small Cell Lung Cancer

1. Customize treatment: Erlotinib (Tarceva) for people whose tumors have epidermal growth factor receptors, a genetic mutation. Gefitinib (Iressa) effective in people whose lung tumors have similar genetic mutations.
2. Targeted treatments for advanced non-small cell lung cancer; Sunitinib (Sutent) works by cutting off blood supply and blockingnthe cancer cells their ability to grow. Sorafenib (Nexavar) suppresses receptors for vascular endothelial growth factor platelet derived growth factor—plays a critical role in the growth of blood vessels that feed the cancer (angiogensis).
3. Combined methods are the treatment of choice for selected cases of stage IIIA and IIIB;  Cispatin, Paclitaxel and Gemcitabine, Gemcitabine and Vinorelbine, Carboplatin and Paclitaxel and radiation, Cisplatin and Vinblastine and radiation
4. Stage IV; Carboplatin and Paclitaxel, Carboplatin and Gemcitabine, Cisplatin and Vinorelbine, Docetaxel and Gemcitabine, Pemetrexed, Chemotherapy combined with Cetuximab (Erbitux): Cetuximab binds to epidermal growth factor receptors (EGFR), preventing a series of reactions in the cell that lead to lung cancer.
5. Progression of disease: Single-agent Docetaxel, Gemcitabine, Paclitaxel
6. Investigational New treatment approaches are being investigated all the time. Mage-A3 vaccine and non-small cell lung cancer, Bortezomib (Velcade) proteasome inhibitors destroys cancer cells

Chemotherapy Treatment for Small-Cell Lung Cancer

1. Limited-stage disease;  Pulmonary resection stage I or stage II, Etoposide and Cisplatin and Radiation, Etoposide and Carboplatin
2. Extensive stage disease: Etoposide and Carboplatin +/− Paclitaxel, Adriamycin, Cyclophosphamide
3. Investigational: Vaccine-autologous dendritic cell-adenovirus p53

Chemotherapy treatment Complications, Myelosuppression (infection, anemia, bleeding), nephrotoxicity, nausea and vomiting, mucositis (inflammation of the mucous membranes), fatigue, SIADH and hyponatremia, hypotension, anaphylaxis, alopecia (hair loss), neurotoxicity (peripheral neuropathies, central nervous system toxicity), cardiomyopathy, arrhythmias, congestive heart failure, myocardial infarction, pneumonitis or pulmonary fibrosis, taste changes.

Patient education (chemotherapy): chemotherapeutic agents, treatment schedule, adverse effects of drugs.

Radiation therapy Treatment for Lung Cancer

1. External beam radiotherapy used as an adjunct to surgery to decrease tumor size, to cure patients considered inoperable for medical or pathologic reasons, or to decrease symptoms. Radiation after surgery: to improve resectability of tumor & to sterilize microscopic disease. Radiation after surgery: to treat disease confined to one hemi thorax with hilar or mediastinum nodal metastasis & to reduce local recurrence (if positive surgical margins exist). Prophylactic cranial irradiation: limited disease small-cell lung cancer to reduce reoccurrence in CNS.
2. Brachytherapy placement of radioactive sources (seeds or catheter) directly into or adjacent to a tumor. Intraoperative: reduce local recurrence. Symptom palliation (relief of pain from bone metastases, hemoptysis, superior vena cave syndrome, airway obstruction).

Complications of radiation therapy: Dyspnea, cough, initial increase in mucus production, and then dry cough, fatigue, skin erythema, esophagitis and dysphagia, pneumonitis, lung fibrosis.

Patient education: radiation therapy: indelible markings, treatment schedule, site-specific adverse effects (within treatment field).

Treatment alternatives

Neoadjuvant is therapy given before the primary therapy to improve effectiveness (e.g., chemotherapy or radiation before surgery). Adjuvant treatments are equally beneficial and often given concurrently or immediately following one another to maximize effectiveness (e.g., surgery and adjuvant chemotherapy after surgery), multimodality is therapy that combines more than one method of treatment (e.g. concurrent chemotherapy and radiation, such as, adjuvant and Neoadjuvant)

Home care considerations

After lung surgery: smoking cessation, control of incision pain, wound care, breathing exercises and coughing, pursed lip breathing exercises, maintain fluid intake, maintaining your nutrition, resume activity, regaining arm and shoulder function.

During and after radiation therapy: monitor side effects of radiation therapy and report any change in.

Symptoms: Dyspnea, fatigue is common lasting 4–6 weeks after therapy, good nutrition, liquid diet supplement during periods of esophagitis, avoid wearing tight clothes, skin care.

During and after chemotherapy, advise patients:

• To identify all treatment related side effects and report changes
• Fatigue may last weeks to months
• To plan their day, and allow for periods of rest
• Try activities such as yoga, exercise, meditation, and guided imagery
• Keep a diary and document symptoms, activity level, nutrition, treatments, and emotions
• To monitor effectiveness of pain medications
• To monitor for any signs of infection, such as an increased temperature, redness or swelling, and that the latter symptoms may not be present during weeks of impaired immunity following chemotherapy administration
• Monitor weight change and appetite
• Nutritional supplements

Pulmonary rehabilitation programs: exercise strengthening, breathing exercises, walking program, nebulizers/aerosol medication delivery, disease specific instruction and support. Support groups: Lung Cancer specific, Better Breathers Club a support group sponsored by the American Lung Association for patients with chronic lung disease. Hospice: dignified dying, pain management, end of life issues, patient/family support.

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

Nursing Assessment 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

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.

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 and patient teaching Nursing care plans Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH

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 and
• 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

Respiratory System

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.

In general, ARDS has two different pathogeneses: a direct ‘pulmonary’ insult to the lung cell or an indirect ‘‘extrapulmonary’ insult resulting in a systemic inflammatory response. ARDS is a progressive disease, with different stages, different mediators, and both inflammatory and anti-inflammatory activity (cellular and humoural). At the beginning of the inflammatory response, changes occur in the alveolar capillary barrier, including the formation of a protein-rich fluid, alteration of surfactant and migration into the lung of neutrophils, lymphocytes and macrophages. Plasma factors, such as complement, and mediators generated by the cells, such as cytokines, oxidants and leucotrienes, are secreted inappropriately and at high levels. Resolution of the disease starts with a decrease in the levels of inflammatory mediators, the migration of fibroblasts into the lung, collagen deposition and the re-absorption of oedema fluid.

In the acute phase of ARDS, damage to the alveolar capillary barrier, including an increase in its permeability, causes the accumulation of a protein-rich fluid. The degree of injury to the epithelium and endothelium influences both the severity of lung injury and the clinical outcome. The protein-rich fluid may gradually become organised, producing the characteristic hyaline membrane that further destroys the alveolar structure.

In the early phases of ARDS, there is an intense alveolar inflammatory process that is characterized by the local accumulation and activation of neutrophils and macrophages. These cells, in turn, release oxidants and inflammatory mediators. The lung per se has a large reservoir of alveolar and interstitial macrophages, both of which come from blood monocytes. Alveolar macrophages release oxygen metabolites, cytokines, hormones, proteases and anti-proteases, all of which are fundamental for normal lung homeostasis and have the ability to eliminate microorganisms. According to an animal model of lung injury, there is an initial accumulation of neutrophils and then macrophages, which is followed by resolution of the inflammatory process. During phagocytosis, macrophages produce oxygen radicals and proteases, which eliminate most particulate matter and microorganism from the distal airways, thus keeping the alveoli ‘clean’. Similar to macrophages, neutrophils secrete several enzymes, such as hydrolases, myeloperoxidate, lysozyme and neutral proteases, which can cause further damage to the injured lung. In the presence of lung injury there is also breakdown of alveolar cells, with the subsequent release of nuclear debris and membrane damage and thus activation of the complement pathway.

Causes of Acute Respiratory Distress Syndrome ARDS

Trauma is the most common cause of ARDS, possibly because trauma-related factors, such as fat emboli, sepsis, shock, pulmonary contusions, and multiple transfusions, increase the likelihood of microemboli developing.

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.

Complications for Acute Respiratory Distress Syndrome (ARDS)
Severe ARDS can lead to metabolic and respiratory acidosis and ensuing cardiac arrest.

Treatment for Acute Respiratory Distress Syndrome ARDS

The primary focus in the management of ARDS includes identification and treatment of the underlying condition.  Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Supplemental oxygen is used as the patient begins the initial spiral of hypoxemia. As the hypoxemia progresses, intubation and mechanical ventilation are instituted. The concentration of oxygen and ventilator settings and modes are determined by the patient’s status. This is monitored by arterial blood gas analysis, pulse oximetry, and bedside pulmonary function testing.

Positive end-expiratory pressure (PEEP) is a critical part of the treatment of ARDS. PEEP usually improves oxygenation, but it does not influence the natural history of the syndrome. Use of PEEP helps to increase functional residual capacity and reverse alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation and a reduction in the severity of the ventilation–perfusion imbalance. By using PEEP, a lower FiO2 may be required. The goal is a PaO2 greater than 60 mm Hg or an oxygen saturation level of greater than 90% at the lowest possible FiO2.

Numerous pharmacologic treatments are under investigation to stop the cascade of events leading to ARDS. These include pulmonary-specific vasodilators, surfactant replacement therapy, antisepsis agents, antioxidant therapy, and corticosteroids.

Nursing Care Plans for Acute Respiratory Distress Syndrome (ARDS)

Common Nursing diagnosis found in nursing care plans for stroke is; Impaired verbal communication, Impaired physical Mobility, Anxiety [specify level], Deficient knowledge regarding diagnosis  prognosis and treatment options, Risk for disturbed Body Image, Risk for ineffective Sexual Pattern, Self-Care Deficit [specify], Disturbed Sensory Perception (specify), Disturbed Thought Processes, Risk for Injury/Trauma

Below is sample of Nursing Outcome, Nursing interventions and evaluation nursing care plans for Stroke

Florence Nightingale taught us that nursing theories describe and explain what is and what is not nursing (Nightingale, 1859/1992). Today knowledge development in nursing is taking place on several fronts, with a variety of scholarly approaches contributing to advances in the discipline.

Nursing practice increasingly takes place in interdisciplinary community settings, and the form of nursing in acute care settings is rapidly changing. Various paradigms and value systems that express perspectives held by several

Groups within the discipline ground the knowledge and practice of nursing. Because the language of nursing is continually being formed and distinguished, it often seems confusing, as does any language that is new to the ears and eyes.  Nurses, who have active commitments to the work of the discipline, whether in nursing practice, research, education, or administration, are essential for the continuing development of nursing theory. This chapter offers an approach to understanding nursing theory within three contexts: nursing knowledge, nursing as a discipline, and nursing as a professional practice.

Definitions of Nursing Theory

Nursing theory is a conceptualization of some aspect of reality (invented or discovered) that pertains to nursing. The conceptualization is articulated for the purpose of describing, explaining, predicting or prescribing nursing care. (Meleis, 1997). Nursing theory is an inductively and/or deductively derived collage of coherent, creative, and focused nursing phenomena that frame, give meaning to, and help explain specific and selective aspects of nursing research and practice. (Silva, 1997)

Types of Nursing Theory

Barnum (1998) divides theories into those that describe and those that explain nursing phenomena. Types of nursing theories generally include grand theory, middle-range theory, and practice theory. These will be described below.

Grand Nursing Theory

Grand theories have the broadest scope and present general concepts and propositions. Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing. This limits the use of grand theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing.  Although there is debate about which nursing theories are grand in scope, the following are usually considered to be at this level:  Leininger’s Theory of Culture Care Diversity and Universality, Newman’s Theory of Health as Expanding Consciousness, Rogers’ Science of Unitary Human Beings, Orem’s Self-Care Deficit Nursing Theory, and Parse’s Theory of Human Becoming.

Middle range Nursing Theory

Nursing scholars proposed using this level of theory because of the difficulty in testing grand theory (Jacox, 1974). Middle-range theories are narrower in scope than grand theories and offer an effective bridge between grand theories and nursing practice. They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies. The methods used for developing middle range theories are many and represent some of the most exciting work being published in nursing today. Many of these new theories are built on content of related disciplines and brought into nursing practice and research (Lenz, Suppe, Gift, Pugh, & Milligan, 1995; Polk, 1997; Eakes, Burke, & Hainsworth, 1998). The literature also offers middle-range nursing theories that are directly related to grand theories of nursing (Olson & Hanchett, 1997; Ducharme, Ricard, Duquette, Levesque, & Lachance, 1998). Reports of nursing theory developed at this level include implications for instrument development, theory testing through research, and nursing practice strategies.

Nursing Practice Theory

Nursing practice theory has the most limited scope and level of abstraction and is developed for use within a specific range of nursing situations. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice. At the same time, nursing questions, actions, and procedures may be described or developed as nursing practice theories. Benner (1984) demonstrated that dialogue with expert nurses in practice is fruitful for discovery and development of practice theory. Research findings on various nursing problems offer data to develop nursing practice theories as nursing engages in research-based development of theory and practice. Nursing practice theory has been articulated using multiple ways of knowing through reflective practice (Johns & Freshwater, 1998). The process includes quiet reflection on practice, remembering and noting features of nursing situations, attending to one’s own feelings, reevaluating the experience, and integrating new knowing with other experience (Gray & Forsstrom, 1991).

Nursing Is a Professional Practice

The major reason for structuring and advancing nursing knowledge is for the sake of nursing practice. The primary purpose of nursing theories is to further the development and understanding of nursing practice. Theory-based research is needed in order to explain and predict nursing outcomes essential to the delivery of nursing care that is both humane and cost-effective (Gioiella, 1996). Because nursing theory exists to improve practice, the test of nursing theory is a test of its usefulness in professional practice (Fitzpatrick, 1997).  From the viewpoint of practice, Gray and Forsstrom (1991) suggest that through use of theory, nurses find different ways of looking at and assessing phenomena, have rationale for their practice and criteria for evaluating outcomes.  Development of nursing knowledge is a result of theory-based nursing inquiry. The circle continues as data, conclusions, and recommendations of nursing research are evaluated and developed for use in practice. Nursing theory must be seen as practical and useful to practice and the insights of practice must in turn continue to enrich nursing theory.