Lifenurses

NCP Nursing Care Plan for Dislocated Or Fractured Jaw

Lifenurses — Thu, 24 May 2012 00:37:12 +0000

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NCP Nursing Care Plan for Dislocated or Fractured Jaw. Dislocation and subluxation are terms used to describe the anatomic displacement of a bone from its normal position in the joint. Dislocation is the complete separation of the bone from the articular surfaces of the joint, whereas subluxation is only a partial displacement in the joint. Both dislocations and subluxations refer to the position of the distal bone in relation to its proximal articulation. Displacement of the temporomandibular joint results in a dislocated jaw. A break in one or both of the two maxillae (upper jawbones) or the mandible (lower jawbone) constitutes a fractured jaw. Treatment usually restores jaw alignment and function.

Causes for Dislocated or Fractured Jaw

Simple dislocations or fractures are usually caused by a manual blow along the jawline as may occur in cases of child, spouse, or elder abuse: more serious compound fractures frequently result from motor vehicle accidents.

Complications for Dislocated or Fractured Jaw

Infection can be a serious complication of a fractured jaw. A fracture can cause a large sublingual hematoma, which may compromise the airway. Injury can also traumatize the nerves that innervate the jaw and face.

Complications may include:

• Airway blockage

• Bleeding

• Breathing blood or food into the lungs

• Difficulty eating (temporary)

• Difficulty talking (temporary)

• Infection of the jaw or face

• Jaw joint (TMJ) pain and other problems

• Problems aligning the teeth

Nursing Assessment Nursing Care Plan for Dislocated or Fractured Jaw

Patient’s history reveals an injury to the jaw, and he reports mandibular pain beginning right after the injury. Patient may report Bite that feels “off” or crooked, Difficulty speaking, Drooling because of inability to close the mouth, Inability to close the mouth, Jaw that may protrude forward, Pain in the face or jaw, located in front of the ear on the affected side, and gets worse with movement, Teeth that aren’t normally aligned
Inspection reveals malocclusion (the most obvious sign of dislocation or fracture), swelling, ecchymosed, loss of function, and asymmetry.
Palpation of the injured area reveals pain and swelling. During palpation, note whether the patient experiences any altered sensation. A mandibular fracture that damages the alveolar nerve produces paresthesia or anesthesia of the chin and lower lip.

Diagnostic tests For Dislocated or Fractured Jaw

X-rays usually most accurate confirm the diagnosis

Nursing diagnosis Nursing Care Plan for Dislocated or Fractured Jaw

Acute pain
Ineffective airway clearance
Anxiety
Disturbed body image
Imbalanced nutrition: Less than body requirements
Impaired verbal communication
Risk for aspiration
Risk for deficient fluid volume
Risk for infection

Nursing Key outcomes Nursing Care Plan for Dislocated or Fractured Jaw

Nursing outcomes Nursing Care Plan for Dislocated or Fractured Jaw, Patient will:

Express feelings of comfort and relief of pain.
Demonstrate methods (coughing, suctioning) to maintain a patent airway.
Express that he feels less anxious.
Express positive feelings about self.
Have no further weight loss.
Use an alternative method of communication if unable to communicate with language.
Avoid aspiration.
Fluid volume will remain adequate.
Exhibit no signs or symptoms of infection.

Nursing interventions Nursing Care Plan for Dislocated or Fractured Jaw

Pain Management, Analgesic Administration, and Environmental Management Comfort: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Use of pharmacologic agents to reduce or eliminate pain. Manipulation of the patient’s surroundings for promotion of optimal comfort
Respiratory Monitoring, Airway Management: Facilitation of patency of air passages. Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
Body Image Enhancement: Improving a patient’s conscious and unconscious perceptions and attitudes toward patient body. Self-Esteem Enhancement: Assisting a patient to increase patient personal judgment of self-worth
Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance Facilitating gain of body weight. Eating impairment Management
Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech. Active Listening Attending closely to and attaching significance to a patient’s verbal and nonverbal messages
Aspiration Precautions Prevention or minimization of risk factors in the patient at risk for aspiration
Fluid Monitoring, Hemodynamic Regulation, Bleeding Precautions: Collection and analysis of patient data to regulate fluid balance, Optimization of heart rate, preload, afterload, and contractility, Reduction of stimuli that may indicate bleeding or hemorrhage in at-risk patients
Infection Protection, Infection Control, infection Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making

NCP Nursing Care Plan For Anaphylaxis Shock

Lifenurses — Wed, 23 May 2012 15:17:07 +0000

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NCP Nursing Care Plan for Anaphylaxis Shock. Anaphylaxis is a dramatic, acute atopic reaction marked by the sudden onset of rapidly progressive urticaria and respiratory distress. A severe reaction may initiate vascular collapse, leading to systemic shock and, possibly, death. Anaphylactic shock, or anaphylaxis, is an immediate, life-threatening allergic reaction that is caused by a systemic antigen-antibody immune response to a foreign substance (antigen) introduced into the body.

Causes for Anaphylaxis Shock

Anaphylaxis can result from a variety of causes, but it most commonly occurs in response to food, medications, and insect bites. Anaphylactic reactions result from systemic exposure to sensitizing drugs or other specific antigens.

Complications for Anaphylaxis Shock

Untreated anaphylaxis can cause respiratory obstruction, systemic vascular collapse, and death minutes to hours after the first symptoms.

Nursing Assessment Nursing Care Plan for Anaphylaxis Shock

The patient, a relative, or another responsible person may report the patient’s exposure to an antigen. Immediately after exposure, the patient may complain of a feeling of impending doom or fright and exhibit apprehension, restlessness, cyanosis, cool and clammy skin, erythema, edema, tachypnea, weakness, sweating, sneezing, dyspnea, nasal pruritus, and urticaria.

Patient History: Obtain information about any recent food intake, medication ingestion, outdoor activities and exposure to insects, or known allergies. Symptoms usually begin within 5 to 30 minutes, and the earlier the signs and symptoms begin the more severe the reaction. Often the signs and symptoms begin with skin and respiratory involvement

Physical examination: Note any hives, which appear as well-defined areas of redness with raised borders and blanched centers. On inspection, the patient’s skin may display well-circumscribed, discrete cutaneous wheals with erythematous, raised, serpiginous borders and blanched centers. Angioedema may cause the patient to complain of a lump in his throat, or you may hear hoarseness or stridor. Wheezing, dyspnea, and complaints of chest tightness suggest bronchial obstruction. They are early signs of impending, potentially fatal respiratory failure.

Auscultate the patient’s blood pressure with a high suspicion for hypotension. Auscultate the patient’s heart to identify cardiac dysrhythmias, which may precipitate vascular collapse. Palpate the patient’s extremities for signs of cardiovascular com

Diagnostic tests for Anaphylaxis Shock

Usually No tests are required

Nursing diagnosis Nursing Care Plan for Anaphylaxis Shock

Common nursing diagnosis found in nursing care plan for patient with Anaphylaxis

• Acute confusion

• Acute pain

• Anxiety

• Decreased cardiac output

• Deficient fluid volume

• Deficient knowledge (avoidance strategies)

• Impaired gas exchange

• Impaired skin integrity

• Ineffective airway clearance

• Ineffective breathing pattern

Nursing outcomes for Anaphylaxis Shock

Nursing outcomes Nursing Care Plan for Anaphylaxis, patient will:

Reoriented to the situation and his surroundings.
Express feelings of comfort and decreased pain.
Verbalize measures to reduce his anxiety level.
Cardiac output and heart rate will remain within normal range, and his pulses will remain palpable.
Maintain an adequate fluid volume.
Verbalize measures to avoid allergens.
Ventilation and oxygenation will remain adequate.
Wounds or lesions will heal without complications.
Maintain a patent airway.
Maintain a respiratory rate within five breaths of baseline.

Nursing interventions Nursing Care Plan For Anaphylaxis Shock

Delirium Management Provision of a safe and therapeutic environment for the patient who is experiencing an acute confusional state. Reality Orientation Promotions of patient’s awareness of personal identity, time, and environment. Surveillance Safety Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety
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 and Comfort Management Manipulation of the patient’s surroundings for promotion of optimal comfort
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 chronic confusional state. Calming Technique to Reducing anxiety in patient experiencing acute distress
Hemodynamic Regulation Optimization of heart rate, preload, after load, and contractility. Cardiac Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function. Circulatory Care Mechanical Assist Devices Temporary support of the circulation through the use of mechanical devices or pumps
Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded. Shock Management Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Teaching Individual Planning, implementation, and evaluation of a teaching program designed to address a patient’s particular needs. Learning Facilitation to promoting the ability to process and comprehend information. Learning Readiness Enhancement to Improving the ability and willingness to receive information
Respiratory Monitoring to Collection and analysis of patient data to ensure airway patency and adequate gas exchange. Oxygen Therapy Administration of oxygen and monitoring of its effectiveness. Airway Management Facilitation of patency of air passages
Wound Care Prevention of wound complications and promotion of wound healing Cleansing, monitoring, and promotion of healing in a wound.
Airway Management Facilitation of patency of air passages. Respiratory Monitoring Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Ventilation Assistance: Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs

NCP Nursing Care Plans for Intestinal Obstruction

Lifenurses — Mon, 14 May 2012 11:26:59 +0000

NCP Nursing Care Plans for Intestinal Obstruction. Intestinal obstruction is the partial or complete blockage of the lumen of the small or large bowel. Intestinal obstruction occurs when a blockage obstructs the normal flow of contents through the intestinal tract. It’s commonly a medical emergency. Complete obstruction in any part of the bowel, if untreated, can cause death within hours from shock and vascular collapse. Intestinal obstruction is most likely after abdominal surgery or in people with congenital bowel deformities.

Causes for Intestinal Obstruction

The two major types of intestinal obstruction are mechanical and neurogenic or nonmechanical.

Intestinal obstruction results from mechanical or nonmechanical (neurogenic) blockage of the lumen.

Mechanical obstruction include adhesions and strangulated hernias (Mechanical obstruction usually associated with small-bowel obstruction) chronic, severe constipation or fecal impaction, carcinomas (usually associated with large-bowel obstruction) foreign bodies, such as fruit pits, gallstones, and worms; compression of the bowel wall from stenosis; intussusception; volvulus of the sigmoid or cecum, tumors and atresia.
Nonmechanical obstruction usually results from paralytic ileus, the most common of all intestinal obstructions. Paralytic ileus is a physiological form of intestinal obstruction that usually develops in the small bowel after abdominal surgery. Other nonmechanical causes of obstruction include electrolyte imbalances, toxicity, such as that associated with uremia or generalized infection; neurogenic abnormalities such as spinal cord lesions; and thrombosis or embolism of mesenteric vessels.

Complications for Intestinal Obstruction

Intestinal obstruction can lead to perforation, peritonitis, septicemia, secondary infection, metabolic alkalosis or acidosis, hypovolemia or septic shock and, if untreated, death.

Nursing Assessment Nursing Care Plans for Intestinal Obstruction

Investigation of the patient’s history often reveals predisposing factors, such as surgery (especially abdominal surgery), radiation therapy, and gallstones. The history may also disclose certain illnesses that can lead to obstruction, such as Crohn’s disease, diverticular disease, and ulcerative colitis. Family history may reveal colorectal cancer in one or more relatives. Hiccups are a common complaint in all types of bowel obstruction. Other specific assessment findings depend on the cause of obstruction mechanical or nonmechanical and its location in the bowel

Diagnostic tests for Intestinal Obstruction

Various tests help to establish the diagnosis and pinpoint complications. For example,

Abdominal X-rays.
Barium enema In large-bowel obstruction reveals a distended, air-filled colon or a closed loop of sigmoid with extreme distention
Serum sodium, chloride, and potassium levels may decrease because of vomiting.
White blood cell counts may be normal or slightly elevated if necrosis, peritonitis, or strangulation occurs. Serum amylase level may increase, possibly from irritation of the pancreas by a bowel loop.
Hemoglobin concentration and hematocrit may increase, indicating dehydration.
Sigmoidoscopy, colonoscopy, or a barium enema may be used to help determine the cause of obstruction.

Nursing diagnosis Nursing Care Plans for Intestinal Obstruction

Acute pain
Constipation
Deficient fluid volume
Imbalanced nutrition: Less than body requirements
Ineffective tissue perfusion: GI

Nursing Key outcomes Nursing Care Plans for Intestinal Obstruction

The patient will express feelings of comfort, Report pain is relieved/controlled, Verbalize methods that provide relief.
The patient’s bowel function will return to normal, Participate in bowel program as indicated.
The patient’s fluid volume will remain within normal parameters, Maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, good skin turgor.
The patient will maintain adequate caloric intake. Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.
The patient will exhibit signs of adequate GI perfusion.

Nursing interventions Nursing Care Plans for Intestinal Obstruction

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 Comfort Management Manipulation of the patient’s surroundings for promotion of optimal comfort
Constipation/Impaction Management: Prevention and alleviation of constipation/impaction. Bowel Management: Establishment and maintenance of a regular pattern of bowel elimination
Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance Facilitating gain of body weight.
Fluid/Electrolyte Management Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels. Gastrointestinal Intubation: Insertion of a tube into the gastrointestinal tract

NCP Nursing Care Plan for Abdominal Trauma

Lifenurses — Sun, 13 May 2012 16:13:56 +0000

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NCP Nursing Care Plan for Abdominal Trauma. Blunt and penetrating abdominal injuries may damage major blood vessels and internal organs. Intra-abdominal trauma is usually not a single organ system injury; as more organs are injured, the risks of organ dysfunction and death climb. Such injuries are potentially fatal; the prognosis depends on the extent of injury and the organ damaged but is improved by prompt diagnosis and surgical repair.

Blunt injuries occur when there is no break in the skin; they often occur as multiple injuries. In blunt injuries, the spleen and liver are the most commonly injured organs. Injury occurs from compression, concussive forces that cause tears and hematomas to the solid organs such as the liver, and deceleration forces.

Penetrating injuries are those associated with foreign bodies set into motion. The foreign object penetrates the organ and dissipates energy into the organ and surrounding areas. The most commonly involved abdominal organs with penetrating trauma include the intestines, liver, and spleen.

Causes for Abdominal Trauma

Blunt (nonpenetrating) abdominal injuries usually result from motor vehicle accidents, fights, falls from heights, and sports accidents. Penetrating abdominal injuries usually result from stabbings and gunshots.

Complications for Abdominal Trauma

The abdominal cavity contains solid, gas filled, fluid filled, and encapsulated organs. These organs are at greater risk for injury than are other organs of the body because they have few bony structures to protect them. Immediate life threatening complications include hemorrhage and hypovolemic shock. Later complications include infection and dysfunction of major organs, such as the liver, spleen, pancreas, and kidneys.

Nursing Assessment Nursing Care Plan for Abdominal Trauma

The patient’s history reveals an accidental or forcibly inflicted abdominal injury. Symptoms vary with the degree of injury and the organs damaged. History of the mechanism of injury by including a detailed report from the pre-hospital professionals, witnesses, or significant others. The patient with a blunt or penetrating abdominal injury typically is in obvious discomfort or pain.
Inspection pinpoints the type of abdominal injury and helps determine its severity. Depending on the severity of the injury, the patient may be pale, cyanotic, or dyspneic. Inspection of the patient with a blunt abdominal injury may also reveal bruises, abrasions, contusions and, possibly, distention, For a patient with a penetrating abdominal injury, inspection reveals the type of wound and associated blood loss. Internal bleeding caused by this type of trauma may be further determined by diagnostic tests. Gunshots usually produce both entrance and exit wounds, with variable blood loss, pain, and tenderness. The patient may also exhibit pallor, cyanosis, tachycardia, shortness of breath, and hypotension.
Palpation may reveal the extent of pain and tenderness and, in blunt abdominal injuries, abdominal splinting or rigidity. Rib fractures commonly accompany blunt abdominal injuries.
Auscultation may disclose tachycardia, decreased breath sounds, absent or decreased bowel sounds, or bowel sounds in the chest. Auscultate all four abdominal quadrants for 2 minutes per quadrant to determine the presence of bowel sounds. Although the absence of bowel sounds can indicate underlying bleeding, their absence does not always indicate injury

If the patient is hemorrhaging from a critical abdominal injury, he or she may be profoundly hypotensive with the symptoms of hypovolemic shock.

Diagnostic tests for Abdominal Trauma

Abdominal and Chest X-rays
Computed tomography (CT) scan
Focused abdominal sonogram fortrauma
Arterial blood gas analysis evaluates respiratory status
Excretory urography and cystourethrography show renal and urinary tract damage

Nursing diagnosis Nursing Care Plan for Abdominal Trauma

Common nursing diagnosis found in Nursing Care For Abdominal Trauma

Acute pain
Decreased cardiac output
Deficient fluid volume
Impaired gas exchange
Ineffective tissue perfusion: Renal, cardiopulmonary, gastrointestinal
Imbalanced nutrition: Less than body requirements
Impaired skin integrity
Anxiety
Risk for infection
Risk for post trauma syndrome

Nursing outcomes Nursing Care Plan for Abdominal Trauma

Nursing Key Outcome Nursing care Plan For Abdominal Trauma, Patient Will:

Express feelings of comfort and relief of pain.
Express that he feels less anxious.
Show signs of adequate cardiac output.
Fluid volume will remain within acceptable range.
Express understanding of special dietary needs.
Maintain adequate ventilation.
Regain skin integrity.
Develop effective coping mechanisms.
Show signs of adequate cardiopulmonary, renal, and gastrointestinal perfusion.
Exhibit no further signs or symptoms of infection.
Express his feelings and fears about the traumatic event.

Nursing interventions Nursing Care Plan for Abdominal Trauma

Provide emergency care, as needed, to support the patient’s vital functions, maintain airway and breathing.
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 Comfort Manipulation of the patient’s surroundings for promotion of optimal comfort
Hemodynamic Regulation Optimization of heart rate, preload, afterload, and contractility
Cardiac Care Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
Circulatory Care Mechanical Assist Devices Temporary support of the circulation through the use of mechanical devices or pumps
Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded
Shock Management Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Respiratory Monitoring Collection and analysis of patient data to ensure airway patency and adequate gas exchange
Oxygen Therapy Administration of oxygen and monitoring of its effectiveness
Airway Management Facilitation of patency of air passages
Nutrition Management Assisting with or providing a balanced dietary intake of foods and fluids
Wound Care Prevention of wound complications and promotion of wound healing, Wound Site Care Cleansing, monitoring, and promotion of healing in a wound
Pressure Ulcer Care Facilitation of healing in pressure ulcers
Anxiety Reduction Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger, Calming Technique: Reducing anxiety in patient experiencing acute distress
Infection Protection Prevention and early detection of infection in a patient at risk
Infection Control Minimizing the acquisition and transmission of infectious agents
Infection Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and role, Identify supportive persons for client

Honoring Nurses Around The World 12 May Is International Nurses Day

Lifenurses — Sat, 12 May 2012 12:10:30 +0000

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Honoring Nurses Around The World 12 May Is International Nurses Day. Each year, people around the world celebrate and honor the dedicated and devoted men and women who care for us when we need it most, nurses! International Nurses Day is celebrated around the world every May 12, the anniversary of Florence Nightingale’s birth. Florence Nightingale was one of the most influential women of her time. Born in Italy on May 12, 1820, she was the daughter of a wealthy landowner. She went on to become a nurse. During her nursing career, “The Lady with the Lamp” helped care for thousands of injured and sick soldiers during the Crimean War. In her later years, she went blind and became a “complete invalid.” Ironically, Nightingale required full-time nursing until she died in London in 1910 at the age of 90. May 12th is International Nurses Day (IND), an annual event observed on the anniversary of the birthday of the visionary nurse, Florence Nightingale.
Role of nurses vital in medical profession
Nurses serve as the backbone of the health care system. Because nurses play such a critical role in our lives, Nurses are health care professions who are part of a health care team. No longer the “handmaid” of the doctor, as mentioned by nursing professor Virginia Burggraf, nurses are an integral part of quality patient care.

NCP Nursing Care Plans for Burns Injury

Lifenurses — Fri, 11 May 2012 15:26:58 +0000

NCP Nursing Care Plans for Burns Injury. A major burn is a devastating injury, requiring painful treatment and a long period of rehabilitation. Burns have a catastrophic effect on people in terms of human life, suffering, disability, and financial loss. Burns can be fatal, permanently disfiguring, and incapacitating, both emotionally and physically. Infections are a major cause of morbidity and mortality in seriously burned patients. The skin injury from burns has six different mechanisms of injury: scalds, contact burns, fire, chemical, electrical, and radiation.

Causes for Burns Injury

Thermal burns, the most common type, result from preventable accidents occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkali, or vesicants. Electrical burns commonly occur after contact with faulty electrical wiring or high-voltage power lines. Friction, or abrasion, burns happen when the skin is rubbed harshly against a coarse surface. Sunburn follows excessive exposure to sunlight and improper use of tanning lights.

Complications for Burns Injury

Leading causes of death in burn patients are respiratory complications and sepsis.

Other possible complications include:

Hypovolemic shock
Anemia
Malnutrition
Multisystem organ dysfunction.

Nursing Assessment Nursing Care Plans for Burns Injury

Patient history. Obtain a complete description of the burn injury, including the time, the situation, the burning agent, and the actions of witnesses. The time of injury is extremely important since any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit specific information about the location of the accident, since closed-space injuries are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people who are involved with the child. The injury may be suspect if there is a delay in seeking health care, if there are burns that are not consistent with the story, or if there are bruises at different stages of healing. Note whether the description of the injury changes or differs among family or household members.

Basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine burn severity. First, determine the depth of tissue damage. A partial-thickness burn damages the epidermis and part of the dermis; a full-thickness burn also affects the subcutaneous tissue. The more traditional method is to gauge burns by degree. Most burns include a combination of degrees and thicknesses

RULE OF NINES

The “rule of nines” is a practical technique used to estimate the extent of TBSA total body surface area involved in a burn. The technique divides the major anatomic areas of the body into percentages: in adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portions of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patient’s palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patient’s response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and outpu

Nursing diagnosis Nursing Care Plans for Burns Injury

Impaired gas exchange
Ineffective airway clearance
Acute pain
Decreased cardiac output
Deficient fluid volume
Ineffective tissue perfusion: Peripheral
Hypothermia
Impaired skin integrity
Impaired physical mobility
Disturbed body image
Risk for infection

Nursing outcomes Nursing Care Plans for Burns Injury

Nursing Key outcomes Nursing Care Plans for Burns Injury, Patient will:

Ventilation will remain adequate.
Airway will remain patent
Achieve pain relief with analgesia or other measures.
Maintain adequate cardiac output.
Fluid volume will remain within the acceptable range.
Exhibit signs of adequate peripheral perfusion
Communicate understanding of special dietary needs.
Maintain normal body temperature.
Wounds and incisions will appear clean, pink, and free of purulent drainage.
Attain the highest degree of mobility possible within the confines of the injury.
Express positive feelings about self.
Express that he feels less anxious.
Demonstrate effective coping mechanisms.
Remain free from signs and symptoms of infection.
Express his feelings and fears about the traumatic event.

Nursing interventions Nursing Care Plans for Burns Injury

Provide immediate, aggressive burn treatment to increase the patient’s chance for survival.
Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring
Airway Management Facilitation of patency of air passages
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
Hemodynamic Regulation Optimization of heart rate, preload, afterload, and contractility. Circulatory Care Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps
Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management Reduction in extracellular and/or intracellular fluid volume. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Fluid/Electrolyte Management Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels. Circulatory Care Arterial/Venous Insufficiency: Promotion of arterial/venous circulation
Hypothermia Treatment Rewarming and surveillance of a patient whose core body temperature is below 35C. Temperature Regulation: Attaining and/or maintaining body temperature within a normal range
Wound Care Prevention of wound complications and promotion of wound healing
Exercise Therapy Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement
Body Image Enhancement improving a patient’s conscious and unconscious perceptions and attitudes toward his/her body. Self Esteem Enhancement Assisting a patient to increase his/her personal judgment of self worth.
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

NCP Nursing Care Plan for Irritable Bowel Syndrome

Lifenurses — Fri, 11 May 2012 15:05:15 +0000

NCP Nursing Care Plan for Irritable Bowel Syndrome. Irritable bowel syndrome (IBS), sometimes called spastic, spastic colitis, mucous colitis. Is a common condition marked by chronic or periodic diarrhea alternating with constipation. It’s accompanied by straining and abdominal cramps. Although people with IBS have a gastrointestinal (GI) tract that appears normal, colonic smooth muscle function is often abnormal. The autonomic nervous system, which innervates the large bowel, fails to provide the normal contractions interspaced with relaxations that propel stool smoothly forward. Excessive spasm and peristalsis lead to constipation or diarrhea, or both. Generally patients with IBS have either diarrhea or constipation predominant syndrome. Irritable bowel syndrome occurs mostly in females, with symptoms first emerging before age 40.

Causes for Irritable Bowel Syndrome

Although the precise etiology is unclear, irritable bowel syndrome involves a change in bowel motility, reflecting an abnormality in the neuromuscular control of intestinal smooth muscle.

Contributing or aggravating factors include anxiety and stress. Irritable bowel syndrome may also result from dietary factors, such as fiber, fruits, coffee, alcohol, and foods that are cold, highly seasoned, or laxative in nature. Other possible triggers include hormones, laxative abuse, and allergy to certain foods or drugs.

Complications for Irritable Bowel Syndrome

Irritable bowel syndrome is associated with a higher-than-normal incidence of diverticulitis and colon cancer. Although complications are usually few, the disorder may lead to chronic inflammatory bowel disease.

Nursing Assessment NCP Nursing Care Plan for Irritable Bowel Syndrome

Patient reports a history of chronic constipation, diarrhea, or both. investigate possible contributing psychological factors such as a recent stressful life change that may have triggered or aggravated symptoms.
Inspection, the patient may seem anxious and fatigued, but otherwise normal. Auscultation may reveal normal bowel sounds. Palpation typically discloses a relaxed abdomen. Occasionally, percussion reveals tympany over a gas-filled bowel.
Auscultation of the abdomen, normal bowel sounds may be heard, although they may be quiet during constipation. Tympanic sounds may be heard over loops of filled bowel. Although palpation often discloses a relaxed abdomen, it may reveal diffuse tenderness, which becomes worse if the sigmoid colon is palpable. The patient may have pain on rectal examination but does not usually experience rectal bleeding.

Diagnostic tests for Irritable Bowel Syndrome

No definitive test exists to confirm irritable bowel syndrome, the diagnosis typically involves studies to rule out other, more serious disorders, such as diverticulitis or colon cancer. The most frequently performed tests include barium enema, stool examination and Flexible sigmoidoscopy or colonoscopy

Nursing diagnosis NCP Nursing Care Plan for Irritable Bowel Syndrome

Acute pain
Constipation
Deficient knowledge (diagnosis and treatment)
Diarrhea
Disturbed body image
Ineffective coping

Nursing Key outcomes Nursing Care Plan for Irritable Bowel Syndrome

Nursing outcomes Nursing Care Plan for Irritable Bowel Syndrome, patient will;

Express feelings of comfort.
Patient’s stool will be soft and will pass easily.
Express an understanding of the disease process and treatment regimen.
Bowel function will return to normal.
Express positive feelings about herself.
Demonstrate adaptive coping behaviors.

Nursing interventions NCP Nursing Care Plan for Irritable Bowel Syndrome

Usually Patient isn’t hospitalized; nursing interventions focus on patient teaching and home health care guidance.

Teach to the patient about disease and treatment plan, prescribed drugs, reviewing their desired effects and possible adverse reactions. Diagnostic tests. Review all pretest guidelines. Explain that diagnostic tests can’t specifically diagnose irritable bowel syndrome but do rule out other disorders.
Help the patient to implement lifestyle changes that reduce stress
Remind the patient about regular exercise, Discourage smoking, Explain the need for regular physical examinations

NCP Nursing Care Plan For Nonviral Hepatitis

Lifenurses — Fri, 11 May 2012 14:43:05 +0000

NCP Nursing Care Plans For Nonviral Hepatitis. Hepatitis can be caused by bacteria, by hepatotoxic agents (drugs, alcohol, industrial chemicals), or most commonly, by a virus. In Non viral hepatitis Classified as toxic or drug-induced (idiosyncratic) hepatitis, nonviral hepatitis is an inflammation of the liver. Most patients recover from this illness, although a few develop fulminating hepatitis or cirrhosis

Causes For Nonviral Hepatitis

Alcohol overuse
Direct hepatotoxicity hepatocellular damage and necrosis usually caused by toxins
Cholestatic reactions
Metabolic and autoimmune disorders
Infectious agents

Complications For Nonviral Hepatitis

Complications may include cirrhosis, hepatitis, and liver failure.

Nursing Assessment Nursing Care Plan For Nonviral Hepatitis

Patient history of alcohol use or recent infection. His medication history may include one implicated in causing the disorder, as stated above.

Clinical features of toxic and drug-induced hepatitis vary with the severity of the liver damage and the causative agent. In most patients, symptoms resemble those of viral hepatitis: anorexia, nausea, vomiting, jaundice, dark urine, hepatomegaly, possibly abdominal pain, clay-colored stools, and pruritus with the cholestatic form of hepatitis.

Diagnostic tests For Nonviral Hepatitis

Diagnostic findings include elevations in serum aspartate aminotransferase, alanine aminotransferase, both total and direct bilirubin (with cholestasis), and alkaline phosphatase levels; white blood cell (WBC) count; and eosinophil count (possible in the drug-induced type).

Liver function tests
Liver scan: May be indicated for differential diagnosis, to identify underlying chronic liver disease, or for evaluating organ function.
Liver biopsy: Considered if diagnosis is uncertain or if clinical course is atypical or unduly prolonged.
Urinalysis: Checks the urine for bilirubin for the nonjaundiced client with suspected viral hepatitis.

Nursing diagnosis Nursing Care Plan For Nonviral Hepatitis

Acute pain
Activity intolerance
Anxiety
Deficient knowledge (diagnosis and treatment)
Fear
Imbalanced nutrition: Less than body requirements
Risk for infection
Risk for injury

Nursing Key outcomes NCP Nursing Care Plan For Nonviral Hepatitis

Pain Level Control: Severity of reported or demonstrated pain, Personal actions to control pain, Report pain is relieved/controlled. Demonstrate use of relaxation skills and diversional activities as indicated for individual situation
The patient will perform activities of daily living within the confines of the disease process, Extent of active management of energy to initate and sustain activity.
The patient will identify strategies to reduce anxiety, Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source.
The patient and family will express an understanding of the disease process and treatment regimen Ability to acquire, organize, and use information. Verbalize understanding of condition/disease process and treatment.
The patient will discuss fears and concerns, Acknowledge and discuss fears, recognizing healthy versus unhealthy fears.
The patient will achieve adequate caloric and nutritional intake, Display normalization of laboratory values and be free of signs of malnutrition.
The patient will remain free from signs and symptoms of infection, patient will Identify interventions to prevent/reduce risk of infection.
The patient will avoid complications, Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Nursing interventions NCP Nursing Care Plan For Nonviral Hepatitis

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: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Activity Therapy: Prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual’s (or group’s) activity. Energy Management: Regulating energy use to treat or prevent fatigue and optimize function. Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
Teaching Individual about disease, diagnosis and treatment. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement: Intensifying a patient’s sense of physical and psychological safety. Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
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
Surveillance: Safety: Purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety. Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for an individual or group. Environmental Management Manipulation of the patient’s surroundings for therapeutic benefit

NCP Nursing Care Plan For Colorectal Cancer

Lifenurses — Thu, 10 May 2012 00:17:11 +0000

NCP Nursing Care Plan for Colorectal Cancer, Colorectal cancer accounts for about 15% of all malignancies and for about 11% of cancer mortality in both men and women living in the United States. It is the third most common cause of death from cancer among men and women, combined. Malignant tumors of the colon or rectum are almost always adenocarcinomas. About half of these are sessile lesions of the rectosigmoid area; the rest are polypoid lesions.

Colorectal cancer tends to progress slowly and remains localized for a long time. Consequently, it’s potentially curable in 75% of patients. With early diagnosis, the 5-year survival rate is 50%. It is potentially curable in 75% of patients if an early diagnosis allows resection before nodal involvement

Causes For Colorectal Cancer

The cause of colorectal cancer is largely unknown; however there is much evidence to suggest that incidence increases with age. Risk factors include a family history of colorectal cancer and a personal history of past colorectal cancer, ulcerative colitis, Crohn’s disease, or adenomatous colon polyps. Other factors that magnify the risk of developing colorectal cancer include obesity, diabetes mellitus, alcohol usage, night shift work, and physical inactivity. It has been strongly suggested that diets high in fat and refined carbohydrates play a role in the development of colorectal cancer.

Complications For Colorectal Cancer

As the tumor grows and encroaches on the abdominal organs, abdominal distention and intestinal obstruction occur. Anemia may develop if rectal bleeding isn’t treated

Nursing Assessment Nursing Care Plan For Colorectal Cancer

Signs and symptoms depend on the tumor’s location. If it develops on the colon’s right side, the patient probably won’t have signs and symptoms in the early stages because the stool is still in liquid form in that part of the colon. He may have a history of black, tarry stools, however, and report anemia, abdominal aching, pressure, and dull cramps. As the disease progresses, he may complain of weakness, diarrhea, obstipation, anorexia, weight loss, and vomiting.

Patient History. Seek information about the patient’s usual dietary intake, family history, and the presence of the other major risk factors for colorectal cancer. A change in bowel pattern (diarrhea or constipation) and the presence of blood in the stool are early symptoms and might cause the patient to seek medical attention. Patients may report that the urge to have a bowel movement does not go away with defecation. Cramping, weakness, and fatigue are also reported. As the tumor progresses, symptoms develop that are related to the location of the tumor within the colon. When the tumor is in the right colon, the patient may complain of vague cramping or aching abdominal pain and report symptoms of anorexia, nausea, vomiting, weight loss, and tarrycolored stools. A partial or complete bowel obstruction is often the first manifestation of a tumor in the transverse colon. Tumors in the left colon can cause a feeling of fullness or cramping, constipation or altered bowel habits, acute abdominal pain, bowel obstruction, and bright red bloody stools. In addition, rectal tumors can cause stools to be decreased in caliber, or “pencil-like.” Depending on the tumor size, rectal fullness and a dull, aching perineal or sacral pain may be reported; however, pain is often a late symptom.

Physical Examination. Inspect, auscultate, and palpate the abdomen. Note the presence of any distension, ascites, visible masses, or enlarged veins (a late sign due to portal hypertension and metastatic liver involvement). Bowel sounds may be high-pitched, decreased, or absent in the presence of a bowel obstruction. An abdominal mass may be palpated when tumors of the ascending, transverse, and descending colon have become large. Note the size, location, shape, and tenderness related to any identified mass. Percuss the abdomen to determine the presence of liver enlargement and pain. A rectal tumor can be easily palpated as the physician performs a digital rectal exam.

Diagnostic tests For Colorectal Cancer

Several tests support a diagnosis of colorectal cancer. Digital rectal examination can detect almost 15% of colorectal cancers. Specifically, it can detect suspicious rectal and perianal lesions. Fecal occult blood test can detect blood in stools, a warning sign of rectal cancer.

Digital examination.
Hemoccult test (guaiac).
Proctoscopy or sigmoidoscopy.
Colonoscopy permits visual inspection (and photographs) of the colon up to the ileocecal valve and gives access for polypectomies and biopsies of suspected lesions.
Computed tomography scan.
Barium X-ray. Barium examination should follow endoscopy or excretory urography because the barium sulfate interferes with these tests.
Carcinoembryonic antigen, although not specific or sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastasis or recurrence.

Nursing diagnosis Nursing Care Plan For Colorectal Cancer

Acute pain
Anxiety
Constipation
Deficient fluid volume
Diarrhea
Fear
Imbalanced nutrition: Less than body requirements
Risk for infection

Nursing Key outcomes Nursing Care plan for Colorectal Cancer

The patient will express that he feels less pain.
The patient will express feeling less anxious.
The patient will have soft, formed stools that are easy to pass.
The patient’s fluid volume will be maintained within normal range.
The patient will resume a regular elimination pattern.
The patient will verbalize fears and concerns relating to his diagnosis and condition.
The patient won’t experience further weight loss.
The patient won’t exhibit signs or symptoms of infection.

Nursing interventions Nursing Care Plan for Colorectal Cancer

Pain Management, Analgesic Administration, Environmental Comfort Management, Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient, Use of pharmacologic agents to reduce or eliminate pain, Manipulation of the patient’s surroundings for promotion of optimal comfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress.
Constipation/Impaction Management: Prevention and alleviation of constipation/impaction. Bowel Management: Establishment and maintenance of a regular pattern of bowel elimination.
Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
Diarrhea Management: Management and alleviation of diarrhea. Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance. Perineal Care: Maintenance of perineal skin integrity and relief of perineal discomfort
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Security Enhancement: Intensifying a patient’s sense of physical and psychological safety Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
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

NCP Nursing Care Plan for Liver abscess

Lifenurses — Tue, 08 May 2012 03:22:49 +0000

NCP Nursing Care Plan for Liver abscess. Liver abscess is a relatively uncommon but life-threatening disorder that occurs when bacteria or protozoa destroy hepatic tissue. The damage produces a cavity, which fills with infectious organisms, liquefied hepatic cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver.

A liver abscess occurs when bacteria or protozoa destroy hepatic tissue, producing a cavity, which fills with infectious organisms, liquefied liver cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver. Liver abscess carries a mortality of 10% to 20%, despite treatment. Liver abscess affects both sexes and all age-groups, although it’s slightly more prevalent in hospitalized children (because of a high rate of immunosuppression) and in females (most commonly those between ages 40 and 60).

Causes for Liver abscess

Underlying causes of liver abscess include benign or malignant biliary obstruction along with cholangitis, extrahepatic abdominal sepsis, and trauma or surgery

Certain illnesses or conditions may also lead to abscess development; these include cholecystitis, colon cancer, diverticulitis, peritonitis, regional enteritis, infective endocarditis, pelvic inflammatory disease, pneumonia, trauma, and septicemia.

Nursing Assessment Nursing Care Plan for Liver abscess

Signs and symptoms of liver abscess depend on the degree of involvement. Some patients are acutely ill; in others, the abscess is recognized only at autopsy, after death from another illness.

With a pyogenic abscess, the onset of symptoms is usually sudden; with an amebic abscess, it’s more insidious. Common signs and symptoms include abdominal pain, weight loss, fever, chills, diaphoresis, nausea, vomiting, and anemia. Symptoms of right pleural effusion, such as dyspnea and pleural pain, develop if the abscess extends through the diaphragm. Liver damage may cause jaundice.

The patient may report right abdominal and shoulder pain, chills, fever, diaphoresis, nausea, vomiting, and weight loss. If the abscess extends through the diaphragm, he may complain of dyspnea and chest pain (symptoms of pleural effusion); if he has developed anemia, he may report fatigue. Inspection may disclose jaundice, a sign of liver damage. On palpation, the liver may feel enlarged, indicating hepatic disease.

Diagnostic Tests For Liver Abscess

Ultrasonography and
Computed tomography scan
Blood cultures and percutaneous liver aspiration, Liver biopsy
Urinalysis
Stool

Nursing diagnosis Nursing Care Plan for Liver abscess

Impaired Liver Function
Acute pain
Deficient knowledge (diagnosis and treatment)
Imbalanced nutrition: Less than body requirements
Risk for impaired skin integrity
Risk for infection

Nursing Key outcomes Nursing Care Plan for Liver abscess

Be free of signs of liver failure as evidenced by liver function studies within normal limits (WNL) and absence of jaundice, hepatic enlargement, or altered mental status
The patient will express feelings of comfort.
The patient and family will express an understanding of the disease process and treatment regimen.
The patient will achieve adequate caloric and nutritional intake.
The patient’s skin integrity will remain intact.
The patient will remain free from signs and symptoms of infection.

Nursing interventions Nursing Care Plan for Liver abscess

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: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
Teaching: Individual Planning, implementation, and evaluation of a teaching about Liver abscess. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.
Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity. Pressure Management: Minimizing pressure to body parts. Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them
Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents. Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making